Research
Peer-Reviewed Publications
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Mehl, Kayla R., Stephanie R. Morain, & Jeremy Sugarman. 2025. "Empirical research related to the ethics of pragmatic clinical trials: A scoping review." LearnIng Health SysTems. 2025;e70041. doi: 10.1002/lrh2.70041.
Background Pragmatic clinical trials (PCTs) offer insights into real-world intervention effectiveness, but they may involve challenging ethical issues. Empirical ethics research may inform deliberations about them. Methods We conducted a scoping review of empirical ethics research related to PCTs. This involved searching in PubMed and Embase, charting findings, and analyzing themes to identify trends and gaps. Results Eighty-two publications were included, which examined a vast number of issues encompassing 22 themes. The five most prominent were: consent/disclosure; risk assessment; trust and transparency; burdens, barriers, and costs; and engagement. Written consent is often impractical, prompting interest in opt-out or general notification approaches. Challenges in risk assessment include variability in defining minimal risk, thereby complicating regulatory determinations for the appropriateness of particular participant protections and communicating research risks. Trust-building practices, such as result-sharing and data-use disclosure, can foster confidence. Stakeholder engagement can address logistical barriers, improve recruitment, and align research with participant needs. Time, financial, and regulatory burdens are significant obstacles to implementing PCTs. Conclusion There has been progress in understanding many ethical issues encountered in PCTs, including appropriately navigating alternatives to obtaining written informed consent, trust-building, and the operational role of stakeholder engagement. However, critical gaps remain, with research concentrated in Western contexts and reliant on surveys and hypothetical scenarios, limiting generalizability and real-world insights. Addressing these gaps with geographically inclusive studies, innovative methods, and nested empirical work will be important for more comprehensively understanding the ethical issues in PCTs and developing appropriate approaches to mitigating them. Mehl, Kayla R., Stephanie R. Morain, & Emily A. Largent. 2025. "The Importance of Including Underserved Populations in Research." Pharmaceutical MedicinE 39, 59–71. https://doi.org/10.1007/s40290-025-00562-1
This paper provides an overview of the ethical considerations surrounding the inclusion of underserved populations in later-phase clinical trials. Underserved populations, defined here as those with restricted access to or limited benefits from healthcare, often face systemic, logistical, and social barriers that limit their participation in research. This results in a lack of representation that undermines fairness in research and also hampers the development of effective inclusive healthcare practices. This paper argues that including underserved populations in research is crucial for promoting justice, increasing the generalizability of research findings, and building trust in medical institutions. It differentiates underserved populations from other populations of interest, including vulnerable, minority, and underrepresented groups. It then explores barriers to research participation and targeted solutions for four underserved populations: rural residents, racial and ethnic minorities, low-income individuals, and older adults. Strategies for improving participation include expanding trial sites to accessible locations, lowering financial and logistical barriers, broadening eligibility criteria, and fostering culturally tailored outreach and engagement. While some interventions may apply broadly across groups, effective solutions will often require intersectional and context-specific strategies tailored to each population’s unique needs as well as coordinated efforts from multiple stakeholders. While these interventions alone cannot resolve healthcare inequities — as underrepresentation of underserved populations in research is just one contributing factor — their widespread implementation would represent meaningful steps toward advancing health equity. PRopes, CAleigh, Kayla MEhl, and STephanie R. Morain. 2024. "Untapped Potential? Representativeness in Pragmatic Trials." JAMA. doi:10.1001/jama.2024.22983.
Morain, Stephanie R., Abigail Brickler, Joseph Ali, Pearl O’Rourke, Kayte Spector-Bagdady, Benjamin Wilfond, Vasiliki Rahimzadeh, Kayla Mehl, Caleigh Propes, & David Wendler. 2024. "Ethical Considerations for Sharing Aggregate Results from Pragmatic Clinical Trials." Clinical Trials. doi: 10.1177/17407745241290782.
A growing literature has explored the ethical obligations and current practices related to sharing aggregate results. However, no prior work has examined these issues in the context of pragmatic clinical trials (PCTs). Several characteristics of PCTs may complicate both the ethics and the logistics of sharing aggregate results. Among these characteristics include that PCTs may affect the rights, welfare, and interests of not only patient-subjects, but also clinicians and others, meaning that results may be owed to a broader range of groups than typically considered in other research contexts. Additionally, some PCTs are conducted under a waiver of informed consent, meaning sharing results may alert participants that they were enrolled without their consent. This paper explores the ethical dimensions that can inform decision-making about sharing aggregate results from PCTs, and provides recommendations for that sharing. A key insight is that healthcare institutions—as key partners for the conduct of PCTS—must therefore also be key partners in decision-making about sharing aggregate PCT results. We conclude with insights for future research. Mehl, Kayla R. & Paul A. Tubig. 2025. “Challenging Anti-Fatness Amid the Climate Crisis,” IJFAB: International Journal of Feminist Approaches to Bioethics 18(1): 113–146. doi:10.3138/ijfab-2024-0022.
This paper critically interrogates the anti-fat beliefs that are employed in environmental bioethics, particularly in response to climate change. Fat bodies have been associated with climate change because they are presumed to consume more resources and produce more greenhouse gas emissions. In this paper, we argue that such interpretations employ mistaken assumptions to justify placing disproportionate blame on already oppressed individuals, reinforcing weight stigma, which increases the vulnerability of fat people to a range of harms and disproportionately affects communities of color. For these reasons, conceiving fat bodies as harmful to the environment is both misguided and unjust. Mehl, Kayla R. 2023. "The Medical Model and the Values Behind the Guise of Health," Synthese 201(215): 1 – 28. https://doi.org/10.1007/s11229-023-04209-z.
Assumptions about obesity – e.g., its connection to ill health, its causes, etc. – are still prevalent today, and they make up what I call the medical model of fatness. In this paper, I argue that the medical model was established on the basis of insufficient evidence and has nevertheless continued to be relied upon to justify methodological choices that further entrench the assumptions of the medical model. These choices are illegitimate in so far as they conflict with both the epistemic and social aims of obesity research. I conclude the paper with a partial solution to these epistemic and social shortcomings. Marshall, Colin & Kayla R. Mehl. 2023. "Schopenhauer’s Five-Dimensional Normative Ethics," David Bather Woods and Timothy Stoll (eds.), The Schopenhauerian Mind. Routledge. https://doi.org/10.4324/9781003048992.
Most Anglophone commentators either ignore Schopenhauer's normative ethics or dismiss it as simplistic. This chapter argues that Schopenhauer in fact offers a rich normative ethics. Taking a cue from Scanlon, it offers a reading of Schopenhauer on which actions are subject to five distinct dimensions of ethical assessment. The resulting view is nuanced and, in many respects, attractive. The chapter concludes, however, by arguing that none of the evaluative dimensions equip Schopenhauer to condemn actions that are motivated by misplaced compassion, as when a member of an oppressive class self-sacrifices in order to maintain the status quo. |
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Shorter Commentaries, Reviews, & Case Studies
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Mehl, Kayla R. 2025. “Loosening the Straitjacket,” Radical Philosophy Review. (Book Review)
Mehl, Kayla R. (Forthcoming). “Allowable Deaths: Anorexia and Suicide by Starvation,” Fritz Allhoff (ed.), Bioethics: New Directions. Oxford University Press.
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Public-Facing Publications
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Mehl, Kayla R. 2024. “BMI Restrictions & Reproductive Justice in the 'Ozempic Baby' Era” [Blog]. Bioethics Series: American Philosophy Association, November 15, 2024.
Mehl, Kayla R. 2023. “Is Improving Health Really the Goal? A Criticism of the American Academy of Pediatrics Guidelines for Treating Obesity” [Blog]. Bioethics Today, April 17, 2023.
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Works in Progress
The Extrapolation Illusion: Rethinking Generalizability in Pragmatic Clinical Trials
Pragmatic clinical trials (PCTs) are often promoted by funders, trialists, and policy organizations as producing “real-world” evidence whose results are broadly generalizable to everyday practice. Because they are embedded in routine care and use usual comparators and outcomes, stakeholders frequently describe PCTs as if their design features themselves secure applicability across settings. My project argues that this framing is philosophically and epistemically mistaken. Generalizability is not a property of design but an inference that requires warrant. I call the conflation of resemblance with relevance the extrapolation illusion.
The philosophical contribution is twofold. First, it clarifies the epistemic status of generalizability claims, situating them alongside broader debates in philosophy of science about external validity, mechanistic reasoning, and extrapolation. Second, it exposes how institutional incentives and rhetorical habits sustain an illusion of applicability, with downstream ethical stakes for policy, implementation, and equity. In reframing generalizability as an argument rather than a design deliverable, this project brings conceptual precision to a set of claims widely used in medicine but rarely examined philosophically.
This paper will be presented at ASBH 2025.
The philosophical contribution is twofold. First, it clarifies the epistemic status of generalizability claims, situating them alongside broader debates in philosophy of science about external validity, mechanistic reasoning, and extrapolation. Second, it exposes how institutional incentives and rhetorical habits sustain an illusion of applicability, with downstream ethical stakes for policy, implementation, and equity. In reframing generalizability as an argument rather than a design deliverable, this project brings conceptual precision to a set of claims widely used in medicine but rarely examined philosophically.
This paper will be presented at ASBH 2025.
Promoting Equity without Sacrificing Pragmatism?: Tough Choices for Pragmatic Clinical Trials (In Preparation)
Pragmatic clinical trials (PCTs) have been proposed as a solution to address the shortcomings of traditional clinical trials, which are often expensive, underpowered, and unrepresentative of diverse patient populations. By embedding research in routine care settings and leveraging existing healthcare infrastructure, PCTs aim to generate practical, real-world evidence more efficiently and at a lower cost. However, the pursuit of pragmatism in these trials can sometimes conflict with efforts to promote health equity. In this presentation, I explore these tensions and argue that trial design choices must carefully balance the objectives of pragmatism and equity, depending on the trial’s goals.
I highlight key areas where these tensions arise, such as participant recruitment, trial settings, and primary analysis. For example, while a pragmatic approach to recruitment focuses on streamlining the process through routine care visits, this may inadvertently exclude marginalized populations who are less likely to seek routine care. Similarly, highly pragmatic trials often prioritize existing resources and infrastructure, but this can overlook the needs of underserved clinics that lack the capacity to implement standardized interventions. Finally, while intention-to-treat analysis supports the goal of inclusivity, conducting additional subgroup analyses to address health disparities may introduce complexity and require larger sample sizes, which can make the trial less pragmatic.
Ultimately, I argue that while highly pragmatic PCTs hold significant value, especially when generalizable evidence is needed, efforts to promote health equity may require trade-offs in trial design. These tensions are critical for investigators, institutions, funders, and regulatory bodies to consider as they shape the future of clinical research.
I presented a draft this paper at the American Society for Bioethics and Humanities (ASBH) conference (2024).
I highlight key areas where these tensions arise, such as participant recruitment, trial settings, and primary analysis. For example, while a pragmatic approach to recruitment focuses on streamlining the process through routine care visits, this may inadvertently exclude marginalized populations who are less likely to seek routine care. Similarly, highly pragmatic trials often prioritize existing resources and infrastructure, but this can overlook the needs of underserved clinics that lack the capacity to implement standardized interventions. Finally, while intention-to-treat analysis supports the goal of inclusivity, conducting additional subgroup analyses to address health disparities may introduce complexity and require larger sample sizes, which can make the trial less pragmatic.
Ultimately, I argue that while highly pragmatic PCTs hold significant value, especially when generalizable evidence is needed, efforts to promote health equity may require trade-offs in trial design. These tensions are critical for investigators, institutions, funders, and regulatory bodies to consider as they shape the future of clinical research.
I presented a draft this paper at the American Society for Bioethics and Humanities (ASBH) conference (2024).
Fatness & Well-Being: Why Body Size Is Not Itself a Harm (In Preparation)
This project challenges the assumption, common in medicine and public health, that higher body fat inherently diminishes well-being. I argue that most harms attributed to fatness—such as pain, restricted capability, or reduced quality of life—are better explained by co-occurring conditions (e.g., osteoarthritis, diabetes, depression), exclusionary environments and tools designed around smaller bodies, and the pervasive effects of stigma. Once these factors are addressed, any residual penalty tied to body size itself is minimal and varies across individuals.
Philosophically, this analysis advances two claims. First, health and well-being must be distinguished: biomedical classifications describe functions and risks, but do not, on their own, determine how a life goes overall. Second, judgments of harm should turn on functioning in context rather than deviation from statistical norms, since “normal function” is not value-neutral. By examining evidence on pain, capability, and valuation, I show that apparent decrements to well-being often stem from biased measurement and social meanings rather than from adiposity itself.
The broader contribution is to debates about naturalism, normativism, and the scope of health concepts. Like disability theory, fat embodiment demonstrates that well-being is compatible with bodily difference once stigma and structural barriers are removed. This supports a functioning-first, participatory account of health that resists pathologizing fatness and directs justice toward addressing remediable causes of harm—pain, access, and stigma—rather than treating body size as the problem.
Philosophically, this analysis advances two claims. First, health and well-being must be distinguished: biomedical classifications describe functions and risks, but do not, on their own, determine how a life goes overall. Second, judgments of harm should turn on functioning in context rather than deviation from statistical norms, since “normal function” is not value-neutral. By examining evidence on pain, capability, and valuation, I show that apparent decrements to well-being often stem from biased measurement and social meanings rather than from adiposity itself.
The broader contribution is to debates about naturalism, normativism, and the scope of health concepts. Like disability theory, fat embodiment demonstrates that well-being is compatible with bodily difference once stigma and structural barriers are removed. This supports a functioning-first, participatory account of health that resists pathologizing fatness and directs justice toward addressing remediable causes of harm—pain, access, and stigma—rather than treating body size as the problem.
Future Projects
Avoidability = Amenability: A Semantics and Decision Rule for Health Inequity
This project develops a philosophically rigorous account of “avoidability” in health equity, a concept often invoked but inconsistently understood in public health and bioethics. Whereas existing debates oscillate between prevention, remediation, and compensation, my account defines avoidability as amenability to intervention: a health inequality is avoidable if and only if it can be prevented or reduced through a feasible intervention relative to a clear baseline. This reframing resists collapsing avoidability into fairness or feasibility, and it excludes compensation, which may address well-being but does not change the inequality itself.
The philosophical contribution lies in both semantics and normative structure. First, I clarify the meaning of “avoidable” so that it marks a substantive boundary between preventable/remediable inequities and those that cannot be changed. Second, I propose a decision rule that disciplines usage by requiring explicit baselines, mechanisms, cost tests, and an all-things-considered judgment that situates health within Rawlsian and hybrid theories of justice. By fixing the semantics and connecting avoidability to recognizable philosophical frameworks, the project transforms a vague slogan into a defensible normative criterion—one that philosophers can debate, but also one that public health researchers and policymakers can operationalize without conflating correlation with causation or relying on compensation as a surrogate for equity.
The philosophical contribution lies in both semantics and normative structure. First, I clarify the meaning of “avoidable” so that it marks a substantive boundary between preventable/remediable inequities and those that cannot be changed. Second, I propose a decision rule that disciplines usage by requiring explicit baselines, mechanisms, cost tests, and an all-things-considered judgment that situates health within Rawlsian and hybrid theories of justice. By fixing the semantics and connecting avoidability to recognizable philosophical frameworks, the project transforms a vague slogan into a defensible normative criterion—one that philosophers can debate, but also one that public health researchers and policymakers can operationalize without conflating correlation with causation or relying on compensation as a surrogate for equity.
Epigenetic Justice: Rethinking Luck and Inequality in Political Philosophy
A central question in political philosophy is when health inequalities count as injustices rather than misfortunes. Luck egalitarianism famously draws a line between brute luck (unjust) and option luck (not unjust), while other approaches focus on the distribution of social determinants of health. Yet recent debates have increasingly emphasized the limits of these frameworks, highlighting relational equality, capabilities, and feminist critiques of liberal individualism. This project brings new evidence from epigenetics to bear on these debates. Epigenetic research shows that social conditions such as poverty, racism, and chronic stress alter biological processes—through mechanisms like DNA methylation, stress regulation, and inflammation—in ways that increase vulnerability to disease. These findings demonstrate that structural injustice is not merely external but becomes biologically embodied across the life course, with effects that may persist across generations. Epigenetic embodiment exposes the inadequacy of luck egalitarian distinctions between choice and chance, since outcomes shaped by social adversity are neither fully voluntary nor reducible to brute misfortune. Instead, these findings reinforce relational and feminist accounts of justice, which emphasize how oppression and domination are embedded in social meanings, institutions, and now in bodies themselves. They also complement capability approaches by showing how health disadvantages constrain substantive opportunities, and they connect to contemporary work on collective responsibility by underscoring the need for institutional rather than individual remedies. The result is a political philosophy of health justice that reframes embodied disadvantage not as private misfortune but as a political wrong demanding collective redress.
Who Owes What for Embodied Injustice? Forward-Looking Collective Responsibility in Health and Disability
Structural injustices often leave biological traces—through chronic stress, disability, malnutrition, or environmental exposure—producing harms that are at once bodily and social. Yet political philosophy offers little guidance on how collective responsibility should be allocated when injustice becomes embodied. Existing theories emphasize blame for past wrongs or general duties of aid, not the forward-looking question of who owes what when causal pathways are diffuse and trans-institutional.
This project develops a normative framework for collective responsibility for embodied harms. Building on relational equality, structural injustice theory, and health-justice work, it extends forward-looking responsibility models to cases where oppression becomes biologically sedimented. The framework integrates four principles—capacity, role, benefit, and complicity—each tracking a different moral basis for remedial duty: the ability to act, structural position, receipt of unjust advantage, and participation in harmful systems. Together they yield a fair allocation of obligations across states, health systems, employers, and industries.
Applied to environmental racism, disabling infrastructures, and the physiological effects of weight stigma, the account shows how justice requires institutional redesign rather than individual adaptation. By grounding responsibility in forward-looking fairness instead of backward-looking blame, it specifies what collective redress demands once social inequality has taken root in bodies. The broader contribution is a decision procedure for assigning collective duties in health justice, linking feminist and egalitarian theories of responsibility to the moral realities of embodied life.
This project develops a normative framework for collective responsibility for embodied harms. Building on relational equality, structural injustice theory, and health-justice work, it extends forward-looking responsibility models to cases where oppression becomes biologically sedimented. The framework integrates four principles—capacity, role, benefit, and complicity—each tracking a different moral basis for remedial duty: the ability to act, structural position, receipt of unjust advantage, and participation in harmful systems. Together they yield a fair allocation of obligations across states, health systems, employers, and industries.
Applied to environmental racism, disabling infrastructures, and the physiological effects of weight stigma, the account shows how justice requires institutional redesign rather than individual adaptation. By grounding responsibility in forward-looking fairness instead of backward-looking blame, it specifies what collective redress demands once social inequality has taken root in bodies. The broader contribution is a decision procedure for assigning collective duties in health justice, linking feminist and egalitarian theories of responsibility to the moral realities of embodied life.
Legitimacy Tests for State PathologizatioN
States routinely use classificatory frameworks that define certain traits, behaviors, or populations as public harms—by labeling them diseases, disorders, or risk factors. Once such designations are embedded in law, policy, or administration, they authorize medical, coercive, and distributive interventions that shape civic status and access to resources. Yet political philosophy lacks a normative account of when these acts of state pathologization are themselves unjust. This project develops legitimacy tests for state harm-classification: principles for determining when the state’s interpretations of harm reinforce, rather than repair, structural injustice.
Drawing on relational and feminist theories of justice and responsibility-sensitive egalitarianism, I argue that legitimacy depends not on isolating biological causes but on how the state distributes causal and moral responsibility across persons and structures. (1) Interpretive accountability: the state must treat health conditions as socially and biologically co-constituted, ensuring that interventions reflect the full causal landscape rather than individualizing risk. (2) Recognitional integrity: classifications must not reproduce racialized, gendered, or ableist hierarchies, nor convert socially mediated disadvantage into personal defect. (3) Remedial alignment: policies arising from pathologization must prioritize structural reform and collective responsibility before behavioral correction.
Pathologization, on this view, is a political act of interpretation—not a neutral discovery of disease but a decision about where society locates harm and how it chooses to repair it. Through cases such as fatness, neurodivergence, and chronic illness, I show how prevailing frameworks misdirect remedies toward bodies when justice demands institutional change. The project offers a normative framework for evaluating the legitimacy of state authority over human variation, grounding health governance in principles of structural accountability, recognition, and equality.
Drawing on relational and feminist theories of justice and responsibility-sensitive egalitarianism, I argue that legitimacy depends not on isolating biological causes but on how the state distributes causal and moral responsibility across persons and structures. (1) Interpretive accountability: the state must treat health conditions as socially and biologically co-constituted, ensuring that interventions reflect the full causal landscape rather than individualizing risk. (2) Recognitional integrity: classifications must not reproduce racialized, gendered, or ableist hierarchies, nor convert socially mediated disadvantage into personal defect. (3) Remedial alignment: policies arising from pathologization must prioritize structural reform and collective responsibility before behavioral correction.
Pathologization, on this view, is a political act of interpretation—not a neutral discovery of disease but a decision about where society locates harm and how it chooses to repair it. Through cases such as fatness, neurodivergence, and chronic illness, I show how prevailing frameworks misdirect remedies toward bodies when justice demands institutional change. The project offers a normative framework for evaluating the legitimacy of state authority over human variation, grounding health governance in principles of structural accountability, recognition, and equality.
Talks
“Promoting Equity without Sacrificing Pragmatism?: Tough Choices for Pragmatic Clinical Trials,” American Society for Bioethics and Humanities, St. Louis, MO, September 18–21, 2024.
“The Incompatibility of the 'Obesity Epidemic' Framework and Eating Disorder Recovery,” Canadian Society for the History and Philosophy of Science, Toronto, Canada, May 27–29, 2023.
“Reconceptualizing Fat Oppression as a Form of Cultural Imperialism,” American Philosophical Association Pacific Division, San Francisco, CA, April 5–8, 2023.
“The Medical Model and the Values Behind the Guise of Health,” Values in Medicine, Science and Technology Conference, University of Texas at Dallas, May 19–21, 2022.
“An Adaptive Preference for Fatness: A Concern for Health or an Epistemic Injustice?” American Philosophical Association Central Division, Chicago, IL, February 23–26, 2022.
“An Adaptive Preference for Fatness: A Concern for Health or an Epistemic Injustice?” 2nd Annual Arizona Feminist Philosophy Graduate Conference, University of Arizona, May 1–2, 2021.
“A Feminist Critique: The Education of Children in Latinx Communities,”Asociaciόn de Filosofía y Liberaciόn (Philosophy of Liberation Conference), Universidad Autόnoma de Cuidad Juárez, Cuidad Juárez, México, September 2017.
“Contemporary Challenges and Solutions to Established Feminist Philosophies on Race and Gender: Racial Barriers as a Lived Experience,” The 8th Annual Women's History Month Conference, the University of Texas at El Paso, El Paso, Texas, April 2017.
“The Incompatibility of the 'Obesity Epidemic' Framework and Eating Disorder Recovery,” Canadian Society for the History and Philosophy of Science, Toronto, Canada, May 27–29, 2023.
“Reconceptualizing Fat Oppression as a Form of Cultural Imperialism,” American Philosophical Association Pacific Division, San Francisco, CA, April 5–8, 2023.
“The Medical Model and the Values Behind the Guise of Health,” Values in Medicine, Science and Technology Conference, University of Texas at Dallas, May 19–21, 2022.
“An Adaptive Preference for Fatness: A Concern for Health or an Epistemic Injustice?” American Philosophical Association Central Division, Chicago, IL, February 23–26, 2022.
“An Adaptive Preference for Fatness: A Concern for Health or an Epistemic Injustice?” 2nd Annual Arizona Feminist Philosophy Graduate Conference, University of Arizona, May 1–2, 2021.
“A Feminist Critique: The Education of Children in Latinx Communities,”Asociaciόn de Filosofía y Liberaciόn (Philosophy of Liberation Conference), Universidad Autόnoma de Cuidad Juárez, Cuidad Juárez, México, September 2017.
“Contemporary Challenges and Solutions to Established Feminist Philosophies on Race and Gender: Racial Barriers as a Lived Experience,” The 8th Annual Women's History Month Conference, the University of Texas at El Paso, El Paso, Texas, April 2017.