Review Article

The Ochlocratic Trap in Bioethics

Thomas F Heston1,2*
1Department
of Medical Education and Clinical Sciences, Washington State University, Spokane, Washington, USA
2Department of Family Medicine, University of Washington, Seattle, Washington, USA

*Correspondence author: Thomas F Heston, Department of Medical Education and Clinical Sciences, Washington State University, Spokane, Washington,
USA and Department of Family Medicine, University of Washington, Seattle, Washington, USA; Email: theston@uw.edu

Abstract
Citation: Heston TF. The Ochlocratic The ochlocratic trap is the tendency to have moral decisions conform to popular majority
Trap in Bioethics. Jour Clin Med Res.
opinion regardless of their ethical implications. This decision-making method in bioethics can
2023;4(3):1-5.
significantly impede moral progress, weakening the foundation for sustainable healthcare
http://dx.doi.org/10.46889/JCMR.2023.
systems. Instead of allowing popular opinion to form the basis of our morality, the scientific
4305
method can provide a framework for making strong ethical decisions. The consequences of
weak morality are profound, resulting in poorly sustainable systems lacking human empathy
Received Date: 21-09-2023
and economic viability. Treating ethical issues like scientific problems can foster a more
Accepted Date: 14-10-2023
rigorous, evidence-based discussion, leading to better medical care globally.
Published Date: 21-10-2023

Keywords: Ochlocratic Trap; Bioethics; Medical Ethics; Healthcare Providers

Copyright: © 2023 by the authors.

Submitted for possible open access
publication under the terms and
conditions of the Creative Commons
Attribution (CCBY) license
(https://creativecommons.org/li
censes/by/4.0/).
Introduction
The term "ochlocratic trap" is derived from the Greek term "ochlos," which translates to
"crowd." This term refers to the potentially problematic scenario when the majority's views
unduly influence decision-making, potentially leading to ethically compromising situations.
It can occur when public opinion unduly influences decisions or when majority opinion within
the healthcare field results in a herd mentality [1]. This issue becomes especially conspicuous
within medical ethics, where historical incidents are a stark reminder of the disastrous
outcomes that can ensue when the majority's acceptance overrides ethical considerations. The
ochlocratic trap is letting the mob rule moral decision-making.

One of the most poignant instances is the infamous Tuskegee syphilis experiment, conducted between 1932 and 1972. In this
study, hundreds of African-American men were denied treatment for syphilis to study the natural progression of the disease.
Despite the gross violation of ethical principles, including informed consent and non-maleficence, this experiment continued for
an alarming 40 years [2]. A significant portion of the medical community initially overlooked these violations, arguably falling
into the ochlocratic trap, as the study had gained acceptance among the majority. A similar occurrence occurred during the US
government's human radiation experiments during the Cold War era. Under the guise of medical treatment, scientists exposed
unsuspecting patients to radiation to understand its effects. This included injecting pregnant women with radioactive iodine and
feeding mentally disabled children oatmeal laced with radioactive iron, all conducted under the majority's acceptance at the time
[3,4]. The ethical transgressions of these experiments, like the Tuskegee experiment, were initially ignored, demonstrating the
potency of the ochlocratic trap. In both these cases, an ochlocratic mindset allowed the majority's acceptance to justify gross
ethical misconduct. These examples serve as sobering reminders of the detrimental impact of the ochlocratic trap on medical
ethics and the importance of individual critical judgment in healthcare decision-making.

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Morality and Sustainability

A healthcare system that upholds ethical principles is more likely to be sustainable in the long run. When healthcare providers
and policymakers prioritize ethical decision-making, it can lead to better patient outcomes, increased trust in the system and
improved overall quality of care. On the other hand, a lack of ethical considerations, such as corruption or discrimination, can
undermine the sustainability of a healthcare system by eroding public trust and hindering equitable access to care.

Incorporating sustainability into healthcare is a moral principle that requires balancing immediate needs with long-term impacts.
For example, rapid digitization enables more efficient care delivery and risks environmental harm and ethical issues from
excessive reliance on technology [5]. While digitization can increase the performance of healthcare delivery systems, if poorly
implemented, it can create moral hazard through improper implementation or environmental harm [6,7]. On the one hand,
fairness suggests meeting pressing needs and maximizing health benefits now, but sustainability requires conserving resources
for future generations. Resolving this tension is challenging. Short-term procurement logistics can undermine long-term system
stability by wasting resources on ineffective treatments or depleting collective goods like antibiotics. However, discounting
future impacts seems morally questionable, too.

Deliberating these trade-offs openly using accountability for reasonableness principles is essential but complex for sustainability
issues regarding such issues as aging, decentralization and resource utilization [8]. Predicting long-term scientific, economic and
social changes is difficult. Ultimately, sustainability necessitates expanding our moral view beyond today's patients to maintain
a health-enabling environment. However, balancing those duties against immediate needs poses profound philosophical
dilemmas. Still, ignoring sustainability risks the viability of healthcare systems, especially ones that are economically unstable
or unable to meet needs reasonably over time. More interdisciplinary cooperation on ethics and sustainability is critical for
developing healthcare that is morally and environmentally viable [9].

Avoiding the ochlocratic trap by applying a scientific framework to these issues allows a thorough analysis without the flighty
whims of emotion, peer pressure, or cancel culture. While taking into account emotional impacts, solid decision-making requires
a more structured approach. The scientific method provides the foundation for this by starting out with a hypothesis, establishing
a method to test the hypothesis, examining the results and then coming to a conclusion.

The Impact of Popular Opinion on Economic Viability

Popular opinion plays a significant role in shaping public policies [10]. In health care, popular opinion can influence economic
viability by shaping resource allocation, affecting stigma reduction efforts and shaping the cost-effectiveness of healthcare
interventions. While popular opinion can help inform project managers on issues important to the community, it can also run
contrary to sustainable project development [11]. It’s a mixed bag. This implies that a morally just healthcare system needs to
incorporate public opinion yet not let public opinion be the only measure of economic viability or sustainability.

Application of the Scientific Method to Bioethics

Medical ethics, like science, is fundamentally an endeavor to discover truth through rigorous investigation and reasoning.
Practicing clinicians face a diverse array of complex ethical dilemmas that call for decision-making that transcends merely
following the majority opinion of the general public. Applying the scientific method to bioethics is a four-step process as follows:
1. Hypothesis: a hypothesis around the ethical issue of concern is formulated
2. Methods: decisions are made on what data to collect and how to analyze
3. Results: the data and analysis are summarized
4. Conclusions: the final conclusion may be left to the leader or be a team vote

Case Studies
Organ Allocation
The conflict between popular opinion and moral judgment arises in organ allocation, which embodies the need for an evidence-
based approach akin to scientific inquiry. For example, in the US, every day, an average of 17 patients succumb to their illnesses
while waiting for an organ transplant due to a stark mismatch between supply and demand. As of July 2023, over 93,000 people

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are on the national transplant waiting list in the US Yet, in 2022, only about 25,000 transplants were performed. While this was a
new annual record, most patients must wait about 4 years before undergoing renal transplantation [12,13]. Determining which
patients should receive available organs necessitates a delicate balance between fairness (ensuring equal access) and utility
(maximizing the benefits of each organ transplant). While artificial intelligence systems may help, their primary purpose is
prioritizing who will and who won’t get access to limited resources [14].

Mandatory Vaccination
Another ethical dilemma surrounding renal transplantation during the COVID-19 epidemic was whether or not it was ethical to
require vaccination before transplantation. About a third of transplant centers had the requirement. In this case, one analysis of
newspaper articles on the topic found that the pros and cons of vaccination were equally discussed [15]. The authors of this
analysis felt that the popular press gave a “false balance” by presenting both sides equally instead of emphasizing the benefits
of vaccination more heavily. The question remains: are the minority of centers that require vaccination morally correct, or are
they falling into the ochlocratic trap of following the majority opinion of medical professionals? Or, on the other hand, are the
majority of centers that did not institute an absolute vaccination requirement morally correct, or did they fall into the ochlocratic
trap of following majority public opinion? Using the scientific method to resolve this ethical issue requires making a hypothesis,
rigorously collecting data and having an open debate without censorship. Finally, a critical analysis of the points raised by the
debate is carefully analyzed without respect to the majority opinion.

End-of-life Care
Another example that mirrors the meticulous scrutiny demanded in science is the ethical decision-making process in end-of-life
care. Approximately 1.2 million individuals in the US are receiving hospice care as of 2023 and medical professionals grapple
with the responsibility of striking a balance between preserving life and respecting a patient's autonomy, often with significant
quality of life implications. The patient's desires and the medical prognosis must be weighed to reach ethically sound decisions.
While public opinion in specific locales may favor euthanasia in some cases, is the decision to go ahead an ochlocratic trap or
sound ethical practice?

Physician Assisted Euthanasia

Consider the following scenario to illustrate how the scientific method can be applied to an ethical dilemma in healthcare. In this
scenario, a palliative care physician faces a patient diagnosed with terminal cancer suffering severe pain. The patient has
expressed interest in physician-assisted dying-a practice that personally conflicts with the physician's moral stance. To navigate
this complex issue, the physician can engage in the four-step scientific process:
1. Hypothesis: The physician proposes an initial hypothesis: "Despite my beliefs against physician-assisted dying, it may be
ethically permissible if it alleviates the patient's suffering and aligns with their personal autonomy"
2. Methods: The physician sets up a structured method for inquiry. First, data will need to be gathered. The physician begins
by gathering all pertinent information to validate or refute the hypothesis. This encompasses the clinical aspects, such as
patient prognosis and quality of life and extends to ethical guidelines, legal parameters and societal perspectives. The
physician also considers the views of colleagues, the patient's family and the broader medical community. Then, the
physician designs a structured way of analyzing the data. One good way is the six thinking hats method, where a problem
is viewed through several different lenses, including emotional, positive, creative, negative, objective and logical [16,17]. A
decision is made regarding who will make the final judgment
3. Results: Armed with the data and analysis method, the physician follows the process and resolves the ethical dilemma. After
ensuring that accurate data has been collected, participants in the analysis will then look at it from several angles and then
come to a conclusion based on their analysis. While public opinion may be a consideration, it rarely will be the only
consideration
4. Conclusion: The feedback and perspectives from the debate prompt the physician to reassess their initial hypothesis.
Depending on the discourse, they may need to adjust their ethical stance regarding physician-assisted dying in this particular
case

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Resource Allocation
Let's consider another example: the case of prioritizing patients for ICU beds during the COVID-19 pandemic when demand far
exceeded supply.
1. Hypothesis: The healthcare team might hypothesize, "The most critically ill patients should be given priority for ICU beds
to maximize the utility of limited resources"
2. Methods: The team agrees upon what data is most important to gather and how it will be collected. For example, it may
determine patient prognosis, age and comorbidities, along with available resources, are essential. The team will then also
agree on a structured method of analysis. This may include a numerical statistical analysis and an analysis of the ethical
implications
3. Results: The team works through the process. Data is analyzed numerically and the ethical issues undergo a structured
debate. The group considers ethical principles like justice, utility and individual rights
4. Conclusion: Depending upon their agreed-upon methods, the team may have the leader decide on the final conclusion, or
they may have the group vote on a conclusion

These case examples underscore the usefulness of a scientific approach in navigating ethical challenges in healthcare. The
scientific approach to bioethics starts out with a hypothesis, then complex data is collected and the issue is openly discussed.
Finally, the most ethical course of action can be decided. Clinicians must constantly be alert for groupthink bias and ask
themselves if they fall into an ochlocratic trap. These examples underscore that medical ethics requires a depth of analysis and
an evidence-based approach parallel to scientific inquiry that goes beyond merely surveying public opinion. The goal in each
case is to arrive at ethically sound, evidence-based decisions that respect individual rights and overall societal good rather than
merely following the majority's view. Hence, medical ethics, much like science, must guard against the pitfalls of the ochlocratic
trap. While following popular opinion is safe since most people agree with the action, history has shown that blindly following
public opinion can lead to unethical behavior.

The Necessary Evolution of Bioethics

Scientific understanding is fluid, ever-evolving and continuously refined as new evidence emerges. Similarly, ethical
considerations are not static but must adapt and evolve in response to societal changes, new discoveries, technological
advancements and our growing understanding of diverse cultural perspectives and values. This dynamism underpins the
interplay between scientific knowledge and ethics. It's crucial for physicians and healthcare providers to ensure that their ethical
deliberations and actions are evidence-based. As technology advances, it is possible to do many things that may not be ethical.
For example, should we order another CT scan “just to be sure” even when the evidence says not to? Should the standard of care
change and if yes, are we responsible for changing only after an expert position statement is published? Or are we ethically
bound to change earlier? Following the scientific approach to ethics helps resolve these questions. Technology is constantly
evolving and as healthcare professionals, we must take the lead in examining the bioethical implications. For example, how do
we ensure that genetic editing technologies such as CRISPR follow ethical principles? In the case of medical research, we had to
wait over 50 years for bioethical principles to be put in place. With the fast pace of technological advances, we must be able to
address ethical issues faster and with the greater certainty that comes from a scientific approach. There is an urgent need for the
field of medical ethics to remain responsive to evolving scientific advancements. It's not merely about adhering to a fixed set of
ethical principles but requires a scientific approach that continuously reevaluates and refines them in light of new evidence.
Ultimately, the interplay between science and ethics should serve the overarching goal of improving patient care, promoting
health equity and ensuring respect for all individuals' rights and dignity.

Conclusion
By embracing a scientific methodology in medical ethics, physicians and other healthcare workers can effectively navigate and
avoid the pitfalls of the ochlocratic trap. The result is improved morality, better healthcare, more viable economics and increased
long-term sustainability. This approach empowers people to make ethical decisions grounded in evidence. This active readiness
to challenge prevailing norms and beliefs is fundamental to science and ethical inquiry. While the bedrock principles of ethics -
autonomy, beneficence, non-maleficence and justice - remain as guiding lights, the field of bioethics cannot afford to be static. It
must continuously evolve and adapt in response to technological advances, societal changes and expanding medical knowledge.
For instance, the advent of precision medicine, artificial intelligence in healthcare and genetic editing technologies like CRISPR

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have introduced new ethical dilemmas that require thoughtful examination. Incorporating scientific principles into bioethics -
such as formulating hypotheses, gathering data, conducting rigorous analysis and refining beliefs based on evidence -brings a
systematic and rigorous approach to ethical decision-making. It promotes transparency and facilitates the inclusion of diverse
perspectives in ethical discussions, thereby promoting fairness and inclusivity. As we move further into the era of digital
medicine and personalized care, adopting a scientific approach to bioethics becomes increasingly vital. This methodology will
play a key role in upholding and enhancing our commitment to patient-centered care, ensuring that we maintain the highest
standards of medical ethics while adapting to the rapidly changing healthcare landscape. It will guide us in balancing the exciting
possibilities of innovation with the timeless values of compassion, respect and dignity at the heart of the medical profession.

Conflict of Interest
The author has no conflict of interest to declare.

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