After a lengthy wait, the request is inexplicably denied. After some investigation, the generals and engineers are shocked to learn that a special interest group, the Wagon Wheel Trade Organization (fictitious dramatization!), has managed to kill the request because it would hurt sales of wagon wheels and parts.

Although this scenario is fictitious, powerful special interests are often a real and present danger in many areas of public life, including healthcare. If this had actually happened during the civil war, many more lives would have been lost.

Defeat leads to opportunity

The leaders of Confederate troops on the Mississippi River had a choice to make, be captured by Union forces or abandon and burn their vessel. They burned their vessel.

The Battle of Island Number 10 (the Kentucky bend on the Mississippi River) ended in defeat for Confederate forces on April 8, 1862. It also left a charred ship. The timing could not have been better for the Union.

Transporting the wounded

The Battle of Fort Donelson in February 1862 resulted in thousands of wounded on the Kentucky-Tennessee border. They needed to be moved off the battlefield and to hospitals to receive professional care and hope to live. Transporting them by wagon over land was difficult, took time, and would likely result in more deaths or permanent disabilities.

The nearby Cumberland River provided an answer. The federal government leased private steamboats to transport the wounded along the river systems to Cairo and Mound City, Illinois, and sometimes other points north.

An estimated 15-25 commercial steamboats were jammed with the battle wounded. Although it resulted in more rapid transport, it was a disaster. Wounded soldiers were everywhere: decks, cabins, improvised bedding. The boats were not equipped to provide medical care, only transport. With overcrowding, lack of sanitation and medical care, many soldiers became sick and died before reaching a hospital.

The Battle of Shiloh in April 1862 resulted in even more casualties. The battle was near Pittsburgh Landing on the Tennessee River in southwestern Tennessee. It is important to note that the Tennessee empties into the Ohio River only miles from the Mississippi.

Steamboats were again used to transport the wounded, but with similar results to Fort Donelson. Not only were the wounded dying on the battlefield, but also during transport. The rivers often became clogged, delaying medical care for the wounded by days, even as long as a week.

Innovation in medical transport is born

In April 1862, Union leaders decided to convert the charred hull of the Confederate vessel into a hospital ship. It was outfitted not only to transport wounded, but also to treat them. It was commissioned in December 1862. From idea of transforming a burnt ship into a state-of-the-art medical facility to a functioning floating hospital took only eight months.

The USS Red Rover

The Red Rover had separate wards for patients, ventilation systems for disease control, onboard laundry and other hygiene methods, along with ice storage for preserving food and medicine. In addition, this floating hospital had Navy surgeons, nurses, including the Sisters of the Holy Cross (Catholic sisters), and other workers to care for the sick and keep the ship clean.

Critically, the hospital ship was not just a transport method like the steamboats; it evacuated the wounded and treated them on the way to land-based medical facilities. The staff onboard was able to stabilize and treat gunshot wounds, amputations, and treatment of infectious diseases, such as dysentery, malaria, and typhoid, along with providing comfort.

By early 1863, the Red Rover was active along the Mississippi River during Union campaigns. Other floating hospitals were commissioned soon after. The Mississippi and its connecting waterways functioned as a well-oiled evacuation chain.

The Wagon Wheel Trade Organization

If a powerful special interest had intercepted the creation of floating hospitals because they would cost them market share, we may not have seen the developments during the Civil War, or they may have been too little, too late. Obviously, this is an exaggerated and imperfect example, but it is meant to make a point.

Perhaps they would have released a press statement resembling this:

“The wagon is a safe, proven, and effective form a transportation for the wounded. We care deeply for the wounded and their families, as well as the safety of medical personnel. A hospital ship is unproven and risky. There are too many unknowns.”

The next story will discuss the massive Civil War medical operation in Paducah, Kentucky, a strategic city at the intersection of the Mississippi, Ohio, and Tennessee Rivers.

J. Steven Bromwich founded 1690 Media to explore the soul of healthcare. He tells the stories of heroes and villains of historical healthcare, connecting these moral lessons to modern medicine. He is a bioethicist, criminal investigator, and RN.

Lucia[1], like too many children in 2010 post-earthquake Haiti, was orphaned. Buildings collapsed, injuries went untreated until help could arrive, and diseases spread. First responders dealt with death, destruction, treating the wounded, and helping people cope with loss and trauma. Many people lost nearly everything, including their families.

This was reality. The people of Haiti had to deal with a frightening reality, including an uncertain future. Most of them already suffered abject poverty, and the earthquake compounded their difficult lives.

First responders were confronted with concentrated misery on a scale many had never experienced. We used our physical and emotional skills the best we could to care for people in crisis.

An orphaned girl and the community

Lucia’s situation unfolded quickly. First, she was dropped off at our hospital, was alone at 6 or 7 years old, and needed medical treatment. I am not sure about her exact medical needs, but I believe she had head injuries from falling debris. She sat on a blanket hugging a stuffed animal someone had given her. At that moment it was everything to her.

She was evaluated by one of our pediatric nurses and a physician. By the time they had completed their evaluation, two women had arrived from the community and were sitting with her. We vetted them, and they were approved by our trusted local community leader. They were ladies from a local church. More women arrived. The girl was now being comforted and cared for by four or five women.

The power of trusted members of a local community cannot be overstated. Physicians, nurses, social workers, administrators, and chaplains can only do so much. The vulnerable sick need support from their local communities and churches. This is an important lesson for modern American healthcare, a system that has moved from community hospitals to corporate conglomerates. This will be the topic of a future article.

Organized compassion in chaos

Working as healthcare professionals in post-earthquake Haiti was a roller coaster of emotions for most of us. It was sometimes adrenaline driven, and always physically exhausting.

The hospital out of which we worked and the neighboring school we used as a triage center and spillover hospital were far enough away from the epicenter of the earthquake in Port-au-Prince that no damage was incurred. Shortly after arrival a few of us immediately got to work organizing a triage center, pharmacy, supply chain, staff duties and the like.

We knew that what was about to hit us required intricate organization, but also human resilience and compassion. This was made clear the moment we arrived from the airport. No sooner had we stepped out of the vehicles that someone yelled “incoming.” We had not even had a chance to unpack or change into scrubs when we were shown where to go (run) to meet the helicopters. Ready or not, more injured were arriving.

The U.S. Navy (primarily) flew helicopters with the wounded from Port-au-Prince to our hospital because we had an intact hospital and plans to open several hundred more beds. They landed on the soccer field down the bumpy dirt road from the hospital and triage center.

Those assigned to incoming helicopters ran out to the choppers with stretchers in hand to unload the injured. We then ran the patients secured on top of stretchers to the awaiting ambulances and loaded them on. As many as six wounded could fit into the ambulance truck stacked three high on each side. One or two of us rode with the patients on the ambulance to the triage center where they were unloaded, triaged, treated and/or prepped for surgery, often amputations. This process was repeated multiple times most days.

This did not feel like a job. It felt like a calling, a mission. We did not punch a clock. People needed care. Often the sound of an incoming chopper and “incoming” was our timeclock.

Healthcare is a calling, not just a job

If caring for the sick is merely a job, and healthcare is only a business enterprise, then those who are sick, elderly, and dying are commodities, objects we use to increase profit and market share. They cease being human beings. Moreover, if we treat human beings in need like objects we not only disrespect their dignity, but we also reduce our own. We will have missed an amazing opportunity.

The word compassion means “to suffer with.” This is a high and challenging calling. To suffer with someone requires much more than “resiliency,” a word often empty of real meaning. It requires a deep spiritual understanding of who we are and who we are meant to be as humans. It requires us to acknowledge a reality about being human: we have all been created in the image and likeness of God and share a common nature and a common purpose.

Even if a healthcare professional does not believe in God, it is possible to recognize that there is more that connects us as humans than mere flesh and blood. We are more than material beings. We long to love and be loved, to be connected to others, to be good and encounter goodness. These realities transcend materiality.

Many of us entered healthcare to connect with people in need on a deeper level than mere sick bodies. Those of us who went to Haiti did so because we had a deep desire to help suffering fellow human beings, to do good for them in their darkest moments.

Getting back to basics is the only way to reform healthcare

Few people would argue that healthcare in the United States needs reform. The situation is complicated and beyond the scope of this article to address it in its entirety (this is part of the purpose of this newsletter).

The foundational reform needed, however, is a human one. The vulnerable sick, elderly, and dying must be at the center of reform discussions. The calling of healthcare professionals needs to be discussed openly. Human dignity and compassion should be the foundations of every healthcare business model. If these are not at the center, we are engaged in exploitation, not healthcare.

J. Steven Bromwich founded 1690 Media to explore the soul of healthcare. He tells the stories of heroes and villains of historical healthcare, connecting these moral lessons to modern medicine. He is a bioethicist, criminal investigator, and RN.

[1] Names and details have been changed to protect privacy

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(Public domain image, 2010 Haiti).

Medicine at the heart of humanity

When she arrived unaccompanied on the back of a motorcycle we did not wonder why a six-year old was alone. It was 2010 Haiti. The effects of the disaster, including orphaned children, were widespread.

Children often survived while their parents were killed by the devastating earthquake that took the lives of over a quarter of a million people in Haiti, especially in and around the highly populated capital of Port-au-Prince.

Lucia (not her real name) was sitting on a blanket in our traige unit when I spotted her. She was hugging a stuffed animal. Now what?

I served as a first responder in post-earthquake Haiti as a nurse, administrator, and ethicist. The soul of healthcare was pulsating every minute of every day among our staff, patients, families, and the community surrounding the hospital.

In next week’s article I will unpack the story of this little girl and those who cared for her. The experiences are instructive.

J. Steven Bromwich founded 1690 Media to explore the soul of healthcare. He tells the stories of heroes and villains of historical healthcare, connecting these moral lessons to modern medicine. He is a bioethicist, criminal investigator, and RN.

Healthcare: saints and sinners

The soul of healthcare is service. It includes the stories of heroes and villains. These stories are inspiring, infuriating, thought-provoking, humbling, and even life-changing.

The stories that comprise this drama, both past and present, need to be told and recounted from the perspective of what it means to care for the sick, dying, disabled, and otherwise vulnerable human beings. Every one of us will encounter medicine. Hopefully, we are cared for by the heroes and saints, those who embrace the high calling of serving those needing care.

Why start with an article about silencing the freedom of speech?

Imagine you are a doctor, a researcher, or other healthcare professional. You have just discovered a new way to prevent or treat an otherwise intractable disease or infection. Your discovery, although effective, differs from current medical norms. This is amazing news and will be welcomed with enthusiasm by your professional colleagues, right? Maybe not.

What if your discovery threatened reputations, an existing financial pipeline, even the careers of your professional colleagues? You might encounter resistance. It is possible you would be silenced by not having your papers published, not receiving grants, perhaps being fired and blackballed from your profession. Even worse, your new discovery, a treatment that could save lives, may never reach those in need.

Don’t believe it? This has happened repeatedly throughout the history of medicine. Silencing, cancelling, name-calling, skewing algorithms happen today, as well. This kind of darkness, one that would crush lifesaving treatment in favor of personal gain, is a symptom of the darker side of human nature.

I named this publication “1690 Media” because without the freedom to speak and share our ideas, including the freedom to disagree with others, all other freedoms are threatened. In healthcare, the lack of freedom to share research results, debate the research of others, have open discussions, is dangerous. We all suffer. 1690 Media is named for the year Publick Occurrences was both published and shut down.

The first page of Publick Occurrences. Public domain. https://archive.org/details/publickoccurrenc1169unse/mode/2up

First American newspaper censored, cancelled, and destroyed

Publick Occurrences Both Forreign and Domestick, the first multi-page colonial publication in 1690 Massachusetts was cancelled by the government. Colonial authorities (the British Crown) disapproved of content that criticized the government, the British military, and tattled on royals. It only took colonial authorities four days to put an end to the newspaper.

Benjamin Harris first published Publick Occurrences on September 25, 1690, and was officially banned and shuttered on September 29, 1690. Authorities ordered the destruction of every copy. None survive except one currently located at the British Library.

This did not stop Harris, a publisher and tireless supporter of free expression and free press. He forged ahead despite official government opposition. In addition to coffee house gatherings, Harris went on to print and circulate content for the public in the form of discreet fliers. He did not, however, attempt to publish another newspaper in the colonies.

Is it “free” if it is censored or needs government approval?

In 1704 the Boston News-Letter became the first continuously published newspaper, but at a price. John Campbell, its publisher, obtained government approval. The front page prominently displayed, “Published by Authority.”

If a media outlet needs government approval to publish content with its materials passing through a censor, is it free? Are we free people if information about public affairs has been scrubbed by a government bureaucrat before we see it, meaning vital information is missing? Do government authorities have the right to terminate a publication’s existence (or cancel a writer) even if it publishes unsubstantiated rumors, inaccurate content, or content that opposes official government positions? What if government uses proxies, like tech companies, to limit speech?

The First Amendment of the United States Constitution, ratified in 1791, resoundingly says, “no” to all these questions. The First Amendment exists to protect free speech from government oversight and threat.

“Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the Government for a redress of grievances.”

About a century after the colonial authorities shut Benjamin Harris’ Publick Occurrences down, the founders put these forty-five words into law intended to protect the right to speak and publish freely without fear of government censorship and other consequences. It is likely the American founders knew of his newspaper and what government authorities did to it.

The need for objectivity and free expression is also true of medical and scientific organizations. This is not only part of the American way of life, but also the scientific method. Neither the government nor media organizations, including tech companies, should silence and censor medical science and debate.

Our Mission

The mission of 1690 Media is to tell both inspiring and disturbing stories of the heroes and villains of healthcare. There are magnificent achievements and monumental failures. There are people who gave up comfort, even their lives, to serve the sick and suffering. There are others who gave up the sick and suffering to serve their own greed.

Subscribe and never miss a new story! A new story will be published every Monday.

For more details on Publick Occurrences Forreign and Domestik see https://www.history.com/articles/first-colonial-american-newspaper-1690

J. Steven Bromwich founded 1690 Media to explore the soul of healthcare. He tells the stories of heroes and villains of historical healthcare, connecting these moral lessons to modern medicine. He is an ethicist, criminal investigator, and RN.

Targets of public health

Between 1965 and 1975 Native American women of child-bearing age were targeted for mass sterilization by federal and local public officials, with the Indian Health Service (IHS) as the central agency involved. They had the cooperation of many local doctors and hospitals. For example, just between 1973 and 1976, 3,406 Native American women were sterilized by IHS facilities. (Government Accountability Office 1976 investigation).

Why target these women? Some scholars argue that federal officials sought sterilization to reduce poverty and long-term dependency. (Lawrence, Jane. 2000. “The Indian Health Service and the Sterilization of Native American Women,” American Indian Quarterly 24(3): 400–419).

The sterilization of Native American women was the continuation of the eugenics movement of the previous 50 years, a movement that some argue continues today. The eugenics movement sought to “improve” the population, the gene pool, if you will, by reducing “less desirable” humans while increasing those who had more desirable traits. (Stern, Alexandra Minna. Eugenic Nation, 2005).

State laws around the nation, beginning with Indiana in 1907, began forced and coerced sterilization as one means of achieving these public health goals. Federal sterilization abuses led to new consent regulations in 1978 that legally ended widespread coercive sterilization practices. (HEW sterilization regulations, 1978).

Estimates vary widely; some activists and researchers suggested rates as high as 25–50% of child-bearing age women were sterilized without consent, either through coercion or without their knowledge during other procedures.

AI could make eugenics programs more efficient and devastating

AI acts as a force multiplier for the intent of its users. AI is not a moral agent. It augments the moral agency of those who design and deploy it.

The intent of many public health officials in the 1960s and 1970s was unethical, violating well-established medical consent standards and targeting a vulnerable population despite contemporaneous objections and regulatory requirements. By the time these sterilizations were occurring, the principles of voluntary informed consent had already been firmly established in international medical ethics through the Nuremberg Code and the 1964 Declaration of Helsinki.

If public health officials in 1965 had access to AI tools how might the eugenics program against these women have been different? I argue it would have been more efficient and more devastating for the women and communities being targeted because those utilizing such tools were already violating established ethical and regulatory norms intended to protect the rights of these women.

Predictive targeting: AI algorithms

AI algorithms could have been used to scan medical records and census data to flag women who met specific socio-economic criteria (e.g., those with multiple children or receiving federal aid). This would have significantly scaled the eugenics process.

The 1970 Family Planning Services and Population Research Act (Title X) expanded federal funding for family planning services, including sterilization, which increased access to the procedure through Medicaid and IHS. Federal reimbursement made sterilization financially feasible for providers and institutions. In the context of Native American women and eugenics, this could have incentivized providers and health facilities to perform more sterilizations.

Algorithmic bias and dehumanization

Data in the 1960s was often filtered through a lens of poverty as a pathology. The intellectual foundation underpinning this lens was the “Culture of Poverty” theory, popularized by anthropologist Oscar Lewis in his 1961 book The Children of Sánchez. The theory effectively blamed poor people and poor families for poverty. Through this lens poverty is a moral and hereditary failure. (Lewis, O. 1966. The Culture of Poverty. Scientific American, 215(4), 19-25).

An AI model trained on such biased data and supported by this underlying belief-system would have scored Native American communities as high-cost or unfit. With the “scientific” evidence justifying forced sterilization as a cost-saving measure for the government and a good for society, an AI governance team would likely give the model a green light for deployment.

“The common good” is language that repeatedly emerges to justify unethical practices. This language suggests that it is ethical, even obligatory, to sacrifice the rights and health of certain individuals, even entire communities, for the good of the larger society.

Why waste resources on the hopeless poor, the reasoning goes, when that money can be spent on programs for people who will be productive members of society? If we must sterilize thousands of women for the good of millions, then so be it. The “common good,” otherwise known as utilitarian ethics, is not a relic of the past, it is a staple of ethical reasoning today.

The efficiency algorithm

Federal agencies like HEW (Health, Education, and Welfare) could have used predictive modeling to estimate long-term fiscal burdens associated with poverty. AI would have generated a “Sterilization Priority List,” identifying women for forced sterilization based on their projected cost to taxpayers.

Federal funds could then be used to reward those who meet and exceed performance targets and punish those who do not. The coerced sterilization of Native American women could then have become an optimized business objective.

Value-based eugenics

In contemporary healthcare, “value-based care” is meant to communicate the prioritization of patient outcomes, but it often translates to minimizing high-cost patients. (My previous article on Predictive Mortality Tools highlights one method used to minimize costs).

AI excels at risk stratification. In this case study’s overlay, the AI would identify Native American women not just by race, but by predicted lifetime cost. If the algorithm determines that a specific demographic has a high probability of chronic illness (often due to poverty), it will flag sterilization as the most cost-effective clinical intervention to prevent future high-cost dependents.

If a private healthcare contractor managed IHS facilities, their AI would optimize for “throughput.” Short procedural interventions are typically reimbursed more per encounter than longitudinal primary care. The AI would create productivity dashboards for doctors, pushing them to “convert” patients to permanent procedures to meet quarterly financial targets.

The ethics of AI depends on the ethics of humans

This article has highlighted how artificial intelligence would have likely amplified the unethical sterilization practices carried out against Native American women in the 1960s and 1970s. AI does not manufacture injustice, but it can scale the intentions of those who design and deploy it. AI can transform ethical violations into efficient and systematized abuses.

Although AI might have intensified these abuses, transparent systems and auditable data could also have helped whistleblowers, journalists, and investigators identify, quantify, and challenge the abuses earlier and more efficiently. This is dependent, however, on data and intent being transparent and accessible for scrutiny.

Those who design, implement, and oversee AI systems in healthcare and public policy must be grounded in medical and research ethics. Models optimized solely for efficiency, cost reduction, or productivity risk committing new historical injustices. Behind every dataset, prediction, and performance metric is a patient, a human being, whose dignity and rights must remain central to developers, caregivers and institutions.

About the author

J. Steven Bromwich is an RN, clinical ethicist, and investigator. With a background spanning bedside care, bioethics, and criminal investigation, he founded The Standard of Care Report to bring the dignity of patients and the vocation of caregiving to the foreground amid AI advances and the systemic challenges in healthcare.

Artificial intelligence in healthcare must be evaluated in light of fundamental principles about the human person. Among these, autonomy and informed consent are central.

A case study

Although fictional, this scenario is clinically routine in American ICUs. For this reason, you may recognize it. Neither the names nor the conditions are from a real patient.

Susan, a 73-year-old married woman, suffered a hemorrhagic stroke. She has been in the ICU for 5 days. Her husband, Joe, and two of her three children are present, praying and hoping she will recover.

The prognosis for hemorrhagic stroke is usually poor. There have been good signs in Susan’s case, however. Even though Susan is on the ventilator, she has begun “breathing over the vent,” which means she is breathing in a limited way on her own. Susan has started responding to stimuli.

The entire process is overwhelming for the family because it was so unexpected. Susan was healthy and active before the stroke.

The medical team arrives in Susan’s room. The neurologist tells the family that continuing medical treatment for the stroke is futile, and it is time to think about keeping her comfortable. He then introduces the topic of palliative care, but the family does not hear anything past “futile.”

Susan’s husband, Joe, asks, “Why? What has happened? She seems to be making progress.” This seems so sudden.

The doctor replies that her lab values, scans, and other metrics indicate no improvement and, in fact, may indicate she is declining. He then suggests making her a DNR (Do Not Resuscitate). He also says palliative care will be in to discuss options with the family.

Mortality prediction tools are AI tools built into the electronic medical record. These tools “read” the patient’s medical data. They are frequently intended to prompt earlier goals-of-care conversations. Most clinicians use them thoughtfully and with good intentions. It is the experience of many clinicians in critical care that patients may suffer longer than necessary when the burdens caused by treatments outweigh the benefits.

The family is overwhelmed with grief and confusion. A short time later, the palliative care team arrives. They express care for the patient and family. They, too, explain that Susan’s care appears futile and explain what “comfort care” would mean for Susan.

Of data, doctors, and algorithms

On day five in the ICU an alert appeared in the corner of Susan’s electronic medical record (EMR). These alerts are based on what is sometimes referred to as a predictive mortality score or a prognostic score. They tell the medical team if a patient has a high chance of mortality in the next x amount of time (30 days, for example). Susan’s score indicates she has a high probability of death in the near term. The alert did not make the decision, but it shaped the frame through which the decision was discussed by the medical team.

The mortality prediction alert goes to the attending physician, the palliative care team, and others who need to know. The alert, if the mortality score is high, may also prompt the physician to change the plan of care.

The AI “learns” from large datasets of prior patients with similar diagnoses and clinical features. Using supervised learning methods, the model analyzes patterns between physiological variables and outcomes such as 30-day mortality.

It does not simply look for a small group of identical patients and calculate a percentage. Rather, it identifies statistical relationships across thousands of cases and applies those learned patterns to the current patient. Based on how Susan’s lab values, imaging, vital signs, age, and diagnoses align with those patterns, the system may generate a prediction, for example, a 90% estimated probability of death within 30 days.

This is a probabilistic forecast, not a certainty, and it depends heavily on the quality and representativeness of the data on which the model was trained.

Hospitals are expected to validate these tools against their own patient populations to improve accuracy and mitigate bias. Even well-validated models can suffer calibration drift when deployed in new clinical settings, meaning their predicted mortality risk may systematically overestimate or underestimate real-world outcomes.

Based on these data, the algorithm generates a mortality prediction for Susan and every other patient in the ICU. While datasets can be audited for bias, the models themselves are often proprietary, limiting transparency for both clinicians and patients. Even when the model is not proprietary, clinicians may not understand how it produces its estimate and therefore may be unable to explain it to families. This lack of explainability is not merely a technical limitation; it is an ethical concern.

Patient autonomy and the new paternalism

Medicine has a long history of paternalism. In recent decades it has been identified and attempts have been made to limit it. Paternalism essentially says, “I am the doctor and I know what’s best for you. You do not need to know the details of your illness or the treatments.” One especially troubling feature of this paternalism was the withholding of a terminal diagnosis from patients for “their own good.”

In more recent years, paternalism has become more institutionalized. The patient may be seen as just another data point in a huge sea of datasets. Put another way, patients can easily become commodities of large corporate health.

While autonomy is intrinsic to the human person, its central place in modern medical ethics developed in response to this history. Patients have a right to know the nature of their illness, the risks and benefits of proposed treatments, and the alternatives available to them, subject to rare exceptions. Over time, this commitment has reshaped medical practice: patients can access their medical records, seek second opinions, and participate meaningfully in decisions about their care.

When a prognostic recommendation originates in a model the patient cannot examine, and the clinician cannot explain, autonomy becomes procedural rather than substantive. The authority of the physician risks becoming derivative, borrowed from an opaque statistical system rather than grounded in clinical judgment.

These concerns intensify if a physician feels pressure, from institutional quality metrics, documentation expectations, or liability concern, to act on the AI prompt embedded in the medical record.

Restoring autonomy in the AI hospital

In moments like this, preparation matters. Difficult questions should be discussed in advance as a family and, when possible, written down before crisis arrives. Asking questions of the medical team is not confrontational; it is an exercise of informed consent.

“What information brought you to the conclusion that mom’s care is futile, especially considering the positive signs we have witnessed?” “Did an AI alert prompt you to recommend this new course of care?” “How did the AI arrive at that conclusion?” “Do you agree with it?” “Are there alternatives?”

Overcoming algorithm-mediated clinical authority requires making these systems explainable and accountable for the decisions they prompt. Clinical judgment must remain primary, not derivative.

To maintain robust patient autonomy and informed consent, AI alerts must be explainable. If patients are unaware that these systems are shaping recommendations behind the scenes, they cannot ask the right questions or meaningfully participate in decisions about their care. Autonomy will erode one alert at a time.

About the author

J. Steven Bromwich is an RN, clinical ethicist, and investigator. With a background spanning bedside care, bioethics, and criminal investigation, he founded The Standard of Care Report to bring the dignity of patients and the vocation of caregiving to the foreground amid AI advances and the systemic challenges in healthcare.

I started my nursing career in bone marrow transplant and oncology. In such high acuity and often high stakes practice areas, it is common to encounter patients who do not fit neatly into an average. Skilled nurses and physicians in such units develop a clinical intuition for medicine that doesn’t fit a recognizable pattern until hindsight illuminates it.

In my previous article, I looked at the tension between the utility of AI and the trust (or lack of trust) patients place in it. Today, I will take a look into the mechanics behind that trust, specifically, what happens when the math decides a patient is merely “noise.”

The tyranny of averages

Artificial Intelligence loves averages. It lives in the “mean.” In data science, outliers, or “edge cases,” (sometimes also called “tails”) are the data points that don’t make the cut. They are discarded to make the model cleaner.

But in healthcare, an “edge case” is a human being. It is the patient with the rare drug reaction, the one who survives a life-threatening diagnosis, or the person whose physiological markers are ignored because they don’t match the majority dataset.

Marketing brochures often boast 95% accuracy for healthcare AI. To an administrator, that sounds like a miracle. To a clinician, 95% accuracy can mean a 100% failure for the patient who doesn’t fit the mold. If an AI predicts “no complications” for every patient because complications only happen 5% of the time, the algorithm is statistically accurate but clinically unhelpful. This is called the accuracy paradox. It describes a model that has high accuracy but low sensitivity (the ability to detect the positive case). It misses the very thing it was hired to find.

This isn’t a theoretical concern; it is a documented clinical failure. An audit published by Wong et al. in JAMA Internal Medicine (2021) examined a widely used AI tool designed to predict sepsis, a leading cause of death in hospitals.

The tool claimed high accuracy. However, when independent researchers examined the patients who fell outside the dominant pattern, they found the AI failed to flag approximately two-thirds of those who went on to develop sepsis.

The model was considered “accurate” because it correctly identified the thousands of patients who remained healthy, but it was dangerously blind to the ones it missed. This is the accuracy paradox in action.
(Wong A, Otles E, Donnelly JP, et al. External Validation of a Widely Implemented Proprietary Sepsis Prediction Model in Hospitalized Patients. JAMA Intern Med. 2021;181(8):1065–1070. doi:10.1001/jamainternmed.2021.2626)

AI models are based on recognizable patterns

Machine learning models are trained to minimize “loss.” In plain terms, they are built to make the fewest mistakes across all patients.

When an algorithm must choose between a prediction that fits the majority and one that identifies a rare outlier, it usually favors the majority. That choice keeps the model’s overall accuracy score high. Statistically, betting on what happens most often is the safest move for the software, even when it means missing the patient who is different. In medicine, that can be a dangerous trade-off.

AI systems are essentially prediction machines trained on past data. They learn what “normal” looks like by finding repeating patterns in large groups of people. When a patient falls outside those patterns, perhaps because of a rare reaction, an unusual presentation, or a combination of factors the model has rarely seen, the AI tends to pull the prediction back toward what is most common. This isn’t because the patient is average, but because the model has learned far more about the middle than the margins.

The result is subtle but consequential: the further a patient is from the statistical norm, the less confident the system become, and the more likely their signal is treated as noise.

The cost of algorithmic erasure

AI needs thousands of data points to “learn” a pattern. While the “90%” provides a mountain of data, the edge cases may only contribute a neglible amount.

Imagine an AI trained to paint portraits. If asked to paint a family whose faces are scarred by a house fire, the model might fail. Because it was trained on “average” faces, it may not recognize the scarred faces and be unable to properly reproduce them.

In healthcare, this isn’t just a false portrait; it is algorithmic erasure. It erases essential realities about outlier patients. If the AI cannot see the exception, the healthcare system may fail to treat the exception. When the edges fall off, outlier patients can suffer.

Forensic reasoning for AI in healthcare: what clinicians must ask

This work is not an argument against artificial intelligence, nor is it driven by fear of technology. It is an exercise in clinical and forensic reasoning. When an algorithm enters patient care, the questions are the same ones clinicians ask at the bedside and investigators ask after harm occurs. What did the system see? What did it miss? Why did it miss it? And who bears responsibility when it does? AI holds real promise in medicine, but only if it is examined with the same rigor we expect of any other high-stakes clinical tool.

Reference: Wong et al., 2021

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Previous article: J. Steven Bromwich

About the Author

J. Steven Bromwich is an RN, clinical ethicist, and investigator. With a background spanning bedside care, bioethics, and criminal investigation, he founded The Standard of Care Report to bring the dignity of patients and the vocation of caregiving to the foreground amid AI advances and the systemic challenges in healthcare.

Safety, guardrails, and AI experimentation

Although I am enthusiastic about the successes and potential of AI in healthcare, I am also a realist. In medicine, we don’t judge a new intervention by its potential; we judge it by its performance at the bedside, adherence to the Standard of Care, and its compiance to ethics.

We are currently being inundated not only by new AI uses, but also enthusiasts. Are these AI improving care and closing healthcare gaps? At what cost? Are they creating new gaps? Are they worsening care for vulnerable people? How are we measuring these results and creating the necessary guardrails to protect patients against harm? Are clinicans and systems left in an ambiguous liability moment?

To trust or not to trust?

People now query AI agents for information about symptoms, diagnoses, treatments, and pharmaceuticals as a matter of daily habit. Earlier this month, OpenAI reported that 40 million people worldwide use ChatGPT daily for health information. Many of these searches are patients trying to navigate the complex labyrinth of insurance coverage and billing, others are researching health conditions and treatment.

There is an interesting and instructive paradox. According to a survey by the Annenberg Public Policy Center (APPC), 63% of Americans find AI-generated health information reliable, yet 49% are uncomfortable with their own providers using AI in making care decisions for them. People are comfortable searching for information and options in the privacy of the AI but have increased distrust for the provider using it in real-time medical decisions and care. (Physicians and other clinicians are, in fact, using AI at the bedside. This topic will be covered in another article).

Perhaps these statistics point to a different challenge in healthcare: being disconnected and uninformed. Patients want to be involved in their healthcare, yet healthcare has become less personalized and less educative. “Big health” has left many patients feeling like metrics and “throughputs.”

The KPI failure

If we view these survey results about people’s experience with AI search results and feelings about their use in the clinical setting through the lens of a clinical audit, we are witnessing a performance crisis masquerading as a technology revolution in healthcare. In any other clinical setting, the following metrics would be considered abysmal KPIs (Key Performance Indicators):

• Functional success rate (31%): Only about three in ten searchers “often or always” receive a satisfactory answer from AI.

• The reliability gap (69%): Nearly seven out of ten users walk away without the reliable guidance they need.

• Consumer sentiment: 75% of the public believes AI is being integrated into medicine too quickly, without accounting for the risks.

Auditing the results

These numbers reveal a trust gap of 32%. This is the distance between the 63% of Americans who believe the tool is reliable and the 31% for whom it works. There exists a disturbing “false positive” in trust, a gap between aspirational hope and functional utility.

This gap is where the danger resides. If the functional failure metric is not substantially repaired, the aspirational trust could eventually turn into a systemic liability, especially if consumer expectations are conflated with the standard of care used by providers and healthcare systems.

Success tempered by reality

AI in healthcare is already improving care and promises more advances in diagnostics, treatments, and clinical breakthroughs. Trust is not built through marketing or hype, however; it is built through transparency, accountability, and the rigorous training of the clinicians who act as the final safety net.

AI needs guardrails. I know, everyone is saying this, but it needs more than the hype of a headline; it needs teeth. We must treat algorithmic logic with the same “chain of custody” standards we use for medical evidence and evidence in a criminal case. It should be rigorous. Patients and families need to know these exist.

Patients want to be informed and involved in their healthcare. It is the responsibility of healthcare systems and providers to properly engage and educate patients and their families about the reality, both the advantages and limitations of artificial intelligence in their care. Systems should not limit implementation to technology experts. Clinical-AI translators are needed to explain and build trust with patients, families, and staff.

About the Author

J. Steven Bromwich is an RN, clinical ethicist, and investigator. With a background spanning bedside care, bioethics, and criminal investigation, he founded The Standard of Care Report to bring the dignity of patients and the vocation of caregiving to the foreground amid AI advances and the systemic challenges in healthcare.

All mouth and no ears

Have you ever felt like people with whom you were speaking were not listening? When it happens you can almost see the busyness on their faces as they think about what they will say next.

Living in our heads, interrupting, sound-bite conversations, or old-fashioned shouting all hinder relationships and problem-solving. We can do better.

If we are honest, we have all been that person. Each of us has at one point or another failed to listen, talked too much, formulated our positions and responses while the other person was talking and interrupted in conversations. We have all been a bit self-absorbed at some point.

Communicating when we have different values can be especially challenging. It can be difficult not to attempt to force our opinions onto others. Even when our values clash, the person standing before us should feel heard. After all, we want the same respect in return. Moreover, if we are trying to convince someone of our viewpoint, showing respect is the first step to a mutual and productive dialogue.

In the workplace, not listening to and talking over others can have deleterious consequences. Healthcare settings, for example, need an environment of listening and learning to promote patient safety.

Human dignity flourishes in curiosity

We might be right about our position in a particular meeting or conversation but relentlessly pushing it onto other people not only disrespects our own dignity, but theirs as well. It hurts relationships and fails to address, much less resolve, our interpersonal, professional, and cultural challenges.

Setting up fortresses around our opinions, especially if they are wrong, closes us to new ideas and new approaches to thinking and living. On the other hand, cultivating intellectual curiosity enriches us.

Some people think if they listen to ideas that do not align with their values they are compromising their integrity. This is not true. We can be intellectually curious about another’s positions, and thus take an interest in them as people, while maintaining our own principles.

Demonstrating respect for others, even when we disagree, not only preserves our own dignity, but it can also help build or preserve relationships. People who disagree on major issues can and should strive to be civil.

Intellectual humility and dialogue

Intellectual humility is the recognition that we do not know everything there is to know in the universe. It opens the way to new knowledge and fresh eyes in which to view the world. Intellectual humility is necessary for curiosity and learning.

Everyone has experienced the know-it-all who never stops talking, right? Frankly, I have sometimes been that person. Maybe you have, as well. In those unfortunate moments we slip into a state of intellectual pride, where we stare into that mirror of self-doom, admiring every word that drips out of our mouths. Often, though, these are moments when we are not fully present to ourselves or others. We get lost in our own mental and verbal momentum. Frankly, it is a frightening loss of self-awareness and self-control.

How to have better civil discourse and cultivate better relationships

Listening, watching more, and speaking less are the shortest routes to being better at respectful and curious communication. We have two ears, two eyes, and one mouth. It seems like a perfect recipe for listening and watching at least twice as much as we talk.

Imagine if everyone took a deep breath and listened to an entire thought before deciding to speak? The dynamics of conversation would change dramatically for the better. There would certainly be more silence, which would create necessary space for thoughtful contemplation. We would also have time to reconsider what we might have said in haste.

Listen and watch for understanding. Take a deep breath, listen to what is being said, watch the other person’s expressions and emotions, and ask yourself, “What is being communicated, both in words and in emotion?” Perhaps ask for clarification. Acknowledge what was said, and ask, “Am I understanding what you are saying?”

This thoughtful, attentive approach to conversation respects the dignity of the other person, and it will be noticed. Imagine how this dynamic could positively impact people and processes, whether in business and civic meetings, with patients and families, in conversations among friends and political debates.

In addition to preserving and building relationships, attentive dialogue enables transformation. It provides space for all involved to consider new ideas and new approaches to problem solving. When this happens, we all win.

A Final Note:

I am shifting my focus to a topic increasingly impacting every one of us: the profound transformation taking place in healthcare. Artificial intelligence holds much promise, but it must be understood and monitored with clinical rigor.

My background as an RN, bioethicist and administrator, combined with my expertise in criminal investigation, positions me to provide a unique level of oversight for this new era.

On January 19 I will be launching the first Standard of Care Report. It will be a bi-weekly newsletter exploring the ethical and clinical implications of AI in healthcare, ensuring that as technology evolves, the patient remains our top priority. We are all being impacted by AI, but in healthcare these impacts can be life and death. Subscribe and be informed.

About the Author

J. Steven Bromwich is an RN, clinical ethicist, and investigator. With a background spanning bedside care, bioethics, and criminal investigation, he founded The Standard of Care Report to bring the dignity of patients and the vocation of caregiving to the foreground amid AI advances and the systemic challenges in healthcare.

A woman of action. A beacon of hope.

Public domain image.

Dear Miss Wells:

Let me give you thanks for your faithful paper on the lynch abomination now generally practiced against colored people in the South. There has been no word equal to it in convincing power. I have spoken, but my word is feeble in comparison. You give us what you know and testify from actual knowledge. You have dealt with the facts with cool, painstaking fidelity and left those naked and uncontradicted facts to speak for themselves.

Very truly and gratefully yours,
FREDERICK DOUGLASS
Cedar Hill, Anacostia, D.C., Oct. 25, 1892

(Public Domain: https://www.gutenberg.org/files/14975/14975-h/14975-h.htm)

Several decades before Rosa Parks refused to give up her seat on a city bus in Montgomery, Alabama, Ida B. Wells sat in a train car reserved for white ladies in 1880s Tennessee. When the conductor told her to move to the smoking car, she refused. She was forcibly carried out of the car by several men. This experience triggered her tireless and courageous life.

Born into slavery, raised with hope

Ida B. Wells was born into slavery in 1862 in Holly Springs, Mississippi. After emancipation, her father, James Wells, was politically active, despite often violent opposition. Both her father and mother, Elizabeth Wells, worked diligently to make a better future for their children through political activity, education and faith.

Ida’s parents and youngest brother died from yellow fever when she was only 16 years old in 1878. She took a job as a schoolteacher to support her surviving siblings and keep the family together.

Ida Wells’ spirit was formed by the example of her parents, formed in faith and education, and forged in hardship. Not surprisingly, Ida B. Wells became a successful journalist and formidable civil rights activist.

By the 1890s she began documenting, investigating and reporting lynchings. In 1895, she published The Red Record, Tabulated Statistics and Alleged Causes of Lynching in the United States. It provides a detailed account of her investigations.

Public Domain. Retrieved from https://digitalcollections.nypl.org/items/9cb8c600-c609-012f-2e71-58d385a7bc34

Ms. Wells goes to Bardwell, Kentucky to investigate a lynching

Seay Miller (sometimes referred to as CJ Miller) of Springfield, Illinois was accused of brutally murdering two children, Mary and Ruby Ray, on July 5, 1893. A mob, deciding to play prosecutor, judge and jury lynched him without an investigation or due process. In fact, several key pieces of exculpatory evidence were ignored and at least one witness tampered with.

A search party was formed the same day to find the killer. In The Red Record Wells reports that two members of the search party, the Clark brothers, spotted a man running into a cornfield. The brothers fired at him, presumably assuming he was the killer, but the man escaped. The brothers reported he was likely a white man or mulatto.

Wells reports that the search continued all day. Blood hounds were secured and utilized in the search beginning at the scene of the crime. Interestingly, it was the use of the dog that began to solidify evidence favoring Miller’s innocence, facts that were ultimately ignored.

The investigation, timeline and evidence

The bloodhound led the search party to a fisherman named Gordon. Gordon stated he ferried a white man (or “bright” mulatto) across the Mississippi River at Wickliffe, Kentucky at 6:30 P.M. on July 5. The search party resumed the search with the bloodhound across the river at a place called Bird’s Point on the Missouri side. The dog ran to a farmhouse a few hundred yards from the river, stopped in front of a cottage, lay down and refused to move from that spot. The cottage belonged to a white farmer named Grant.

Wells recounts that a worker on a train in Sikeston, over 40 miles from Wickliffe, KY, discovered Seay (CJ) Miller stealing a ride on the train. There was a confrontation between Miller and the worker that resulted in Miller’s arrest at around 11:00 A.M. on Thursday, July 6.

Law enforcement claimed they found four rings on him, along with a knife and a razor, both of which were rusted and stained. It was claimed the rings belonged to the girls and had their initials on them. The authorities assumed he was the killer of the Ray girls.

The authorities in Sikeston, Missouri informed the Kentucky authorities they had captured Miller, describing his clothing, knives and rings. The Sheriffs from Bardwell and Carlisle Counties and a group of armed residents went to Missouri to retrieve him. Without a warrant, the Sheriff in Sikeston turned Miller over to Kentucky law enforcement when the group arrived on July 6. Miller told the Sheriffs and the posse that came for him that he had never been to Kentucky.

When the group and Miller arrived back in Wickliffe, Kentucky they called Gordon the fisherman to identify him. Before the identification, the Ballard Sheriff gave Gordon a warning that if the prisoner (Miller) was not the man, he would hold Gorden responsible for whoever committed the murders. Gordon stood looking at Miller from behind for a long time. According to Wells’ investigation, even though Gordon had previously said the man he ferried was white, he identified Miller, a dark, brown-skinned man, as the one he ferried across the river.

The crowd was ready to execute Miller immediately in Wickliffe, but John Ray, the father of the murdered girls, wanted Miller taken to Bardwell for justice. Ray stated he believed a white man murdered his daughters, not Miller. The mob took Miller to Bardwell but decided to skip due process and determine guilt themselves.

One of the Clark brothers, the brothers who spotted and shot at a white man running into a cornfield, changed his story. He identified Miller as the man they encountered, whereas the other brother said he was not. The testimony of the brother who identified Miller was accepted as the true account. Mr. Ray stated the rings found on Mr. Miller did not belong to his daughters, nor did they have the girls’ initials on them as previously asserted.

While the questioning was occurring, a crowd had been preparing for Miller’s execution, complete with a funeral pyre for burning Miller to death. They fully intended to torture and kill him. The biased investigation only had one conclusion. Confirmation bias assured only “evidence” of Miller’s guilt would be found. The mob was hot with passion and eager for an execution.

Miller was taken to the jail and stripped. No blood was found on his clothing or body. Even a red stain on the underside of his shirt was determined to be red paint.

The mob came to the jail to force a confession from Miller. He refused to speak to them except to continue asserting his innocence.

Even the mob’s rudimentary investigation revealed there was not even probable cause. First, the rings he possessed did not belong to the murdered girls. Second, the fisherman falsely identified him after being threatened by the Sheriff. Third, one of the Clark brothers changed his story (that the possible killer was white) and positively identified Miller, while the other disagreed with him. Fourth, there was no blood on Miller’s clothing. If he had cut two girls’ throats it seems likely their blood would be on him. Finally, Miller continued to declare his innocence and that he had not even been to Kentucky, much less to Bardwell, Kentucky, which is a full 51 miles from where he was found in Sikeston, Missouri.

Innocence, faith and the death penalty

Execution was inevitable and predetermined by the mob and those afraid of it. Miller requested a priest and when one was unavailable, a Methodist minister went to the jail and prayed with and baptized him. The minister encouraged Miller to confess. Rumors went around the inpatient mob that Miller confessed to the murders, but Wells reported that the minister, the Chief of Police and a leading editor, all with Miller at the time, said he never confessed.

The crowd descended upon the jail and dragged Miller out into the street. Mr. Ray implored the crowd not to burn him, as he was not convinced of his guilt. The mob compromised and decided to hang him instead.

A one-hundred-pound log chain was placed around Miller’s neck. He was paraded through the streets followed by a crowd of thousands. When he passed out (more than once) the mob dragged him. He was then hanged, shot, mutilated, and burned. Body parts were taken as souvenirs.

According to the reporting of Ida B. Wells in The Red Record, Miller stated: “My name is CJ Miller. I am from Springfield, Illinois; my wife lives at 716 N. 2d Street. I am among you today, looked upon as one of the most brutal men before the people. I stand surrounded by men who are excited, men who are not willing to let the law take its course, and as far as the crime is concerned, I have committed no crime, certainly no crime gross enough to deprive me of my life and liberty to walk upon the green earth.”

For more details on the life and work of Ida B. Wells see the collection at the University of Chicago library: https://www.lib.uchicago.edu/e/scrc/findingaids/view.php?eadid=ICU.SPCL.IBWELLS

J. Steven Bromwich is a writer, criminal investigator, and ethicist. He is the founder of 1690 Media, where he explores stories of American culture, history, ethics, and faith.

By J. Steven Bromwich

The morning life changed

You did not expect this morning to be different than any other. You pour coffee, scroll your phone... and your world collapses. Messages from family, friends, co-workers, and your son fill the inboxes. Your heart begins racing so fast it might jump out of your chest. You feel cornered by a mob, an angry digital mob you cannot see.

The news of your son’s arrest has spread far and wide, before you even had a chance to wake up. You hesitate, but open Facebook. It is all there. When you look at the police blotter, you see more than a hundred comments, many with a similar theme: “Lock him up,” “I hope he dies,” “Loser,” “Jerk,” and worse, much worse. You have only been away from your phone for eight hours.

You run a search for your son’s name. His mug shot is plastered everywhere with the caption, “Arrested for assault and resisting arrest.” It looks bad. It sounds bad. But is he guilty?

It is all so overwhelming. Your only thought is to find and protect your son. “This accusation does not sound like my son,” you think to yourself. It cannot be true, but the digital mob and the storm are gathering.

They seem to not care whether he is guilty or innocent. They have no use for due process; their emotions have reached a verdict.

Who needs due process?

Similar scenarios unfold everyday across America. Once someone is arrested for a crime, law enforcement agencies often publish the arrest online where the media picks it up as part of local crime reporting. A sketchy looking mugshot sometimes accompanies the announcement of the arrest. The story and your mugshot follow you forever (or years), even if your case is dismissed or you are acquitted.

People check these sites sometimes for entertainment purposes, or perhaps to see if a neighbor or co-worker has been naughty, or maybe just to feel validated in their own virtue in the face of “evil.” Then the outraged mob rapidly gathers, like vultures circling a dying animal. People often have their reputations destroyed and graves dug long before they get a probable cause hearing in court.

This is not new behavior. What happens online today once unfolded on courthouse lawns, outside jails, and in public squares in towns and cities across the United States.

Vigilante justice is ruled by emotions. Due process is [most often] governed by reason.

The Haymarket Riot, Chicago, 1886. Illustration from Harper’s Weekly. Public domain via the Library of Congress.

When the mob descended on Bardwell, Kentucky

Two young girls, Mary and Ruby Ray, were brutally assaulted and murdered while picking berries by their home near Bardwell, Kentucky. Their distraught mother found the older girl, believed to be 16 years old, with her throat slit. The children’s father, John Ray, found the body of his younger daughter, believed to be 12 years old, a short time later, also sexually assaulted and murdered.

The assaults and murders, not surprisingly, shocked and outraged the small town of Bardwell and surrounding area. The family and community rightly wanted to find whoever committed the heinous crime. The hunt was on.

Two witnesses gave a minimally helpful description: a white man running from the area near where the bodies were found. A posse assembled and proceeded to track the suspect with the help of a bloodhound. The group made their way from Carlisle County, Kentucky to Sikeston, Missouri. (Atlanta Constitution, July 11, 1893).

Outrage vs. due process

Despite the earlier witness description of a white man, Seay (CJ) Miller, a black man, was apprehended on a train car in Sikeston. Those who apprehended Seay Miller claimed he possessed a bloody razor blade, a knife and five gold rings, rings that supposedly belonged to the murdered girls.

Miller insisted he had not been to Kentucky. Evidence would later emerge substantiating his claim. According to accounts, there was a struggle, but Miller was overpowered by the group and transported by steamer to Wickliffe, Kentucky and then by train to Bardwell, Kentucky.

There are mixed reports of what happened to Seay Miller once he arrived in Bardwell. Some reports indicate he was in the custody of the sheriff for a brief time before being handed over to a mob that was demanding the accused man. Other accounts claim the mob never turned him over to the sheriff despite the sheriff demanding custody of him.

The precise details of the events are unclear, perhaps because the people spreading the news to neighbors and giving accounts to the newspapers were filled with rage and/or trying to justify the killing of the man they assumed was the perpetrator of violence against two little girls.

It is possible the authorities involved were reluctant to implicate themselves or anger their neighbors. Stories involving high emotions and drama tend to morph while spreading through small communities. Most of us have played the telephone game and have experienced this phenomenon.

What we do know is his arrest was questionable, there was a rush to judgment, an assumption of guilt, and a quick and violent execution. There was no due process.

Is it possible the real killer for whom they stopped looking got away and killed again? Were other little girls murdered because law enforcement failed to investigate and an irrational mob halted justice? There are consequences when an investigation is overcome by confirmation bias (only looking for evidence that confirms your belief) and justice ruled by an emotional mob. (Atlanta Constitution, July 11, 1893).

A crowd without faces

The mob was thirsty for retribution. Some arrived for the entertainment.

A reported 5000 people from Kentucky, Illinois, Missouri and Tennessee watched as Seay Miller was hanged, shot, mutilated, and burned despite his repeated protestations of innocence. Miller had no opportunity to defend himself. No one seemed to be listening. He was assumed guilty. No deliberation, just a quick, celebratory execution.

The mob was angry, irrational, and perhaps made assumptions about a black man assaulting and killing two white girls. Someone had to pay.

Immediately before he was hanged, Miller said, “I am not guilty.” Other accounts say he admitted to partial guilt and named an accomplice to the murders. Ida B. Wells, an investigative journalist who investigated the incident soon after the execution, discovered he never confessed. Again, there is a possibility the newspapers did not verify the information before publishing. This resulted in one-sided, self-justifying accounts of the events. (Atlanta Constitution, July 11, 1893).

Imagine standing on the scaffold, noose around your neck, a mob yelling, even celebrating, knowing you are innocent of the crime for which they are seeking vengeance? If only they really knew me, he may have thought. You may think of your spouse and children, as Miller likely thought of his family in Springfield, Illinois before his death.

Seay Miller’s wife and children in Illinois may not have heard the news of the accusation and execution of Miller for some time. They never had a chance to see him again, nor bury his body. It had been burned. There are reports that Mrs. Miller later had a mental breakdown.

Public domain. Accessed at https://digital.lib.niu.edu/islandora/object/niu-gildedage%3A19817

Are we so different? Is there a lesson?

There is a lesson in the tragic story of Seay Miller. John Ray, the man whose daughters were assaulted and murdered, reportedly asked that Seay Miller receive due process. He apparently wanted a pause in the rush to execution to determine the truth, although there are differing accounts of what exactly he requested. It would be amazing if the man whose daughters were raped and murdered asked for restraint when most people would be consumed by blue hot rage. The was solid evidence, however, that indicated Miller was not the killer, and perhaps John Ray suspected someone else.

If the mob had listened to Ray, reason may have prevailed over passion. Seay Miller would have received a hearing. Would it have been fair? That is another question.

Crime and the public’s response

Is there a better way to report crime, one that does not destroy an “innocent until proven guilty” individual? Law enforcement usually puts a disclaimer related to this at the bottom of an arrest post, but does this make much difference?

Why do we so often assume that the accusation we hear or read is true? What is it about us that drives us toward condemning a person before we have heard the evidence? We want others to believe the best about us, yet we so often believe the worst about others.

Ida B. Wells: investigation of the lynching

Ida B. Wells was one of the bravest investigative journalists of her time. She travelled to Bardwell, Kentucky to investigate the accusation and execution of Seay Miller. She was a black woman investigating a white mob who executed a black man in rural Kentucky in the 1890s. She was driven by a desire for truth, despite the danger.

Ida B. Wells went where few dared go to seek and report truth. Did telling the truth about injustice and shining a light on human nature make a difference? It did.

In the next story we will present Ida B. Wells and the details of her investigation. Her investigation was thorough and vindicated Seay Miller.

J. Steven Bromwich is a writer, criminal investigator, and ethicist. He is the founder of 1690 Media, where he explores stories of American culture, history, justice, and faith.

By J. Steven Bromwich

The Evolution of Silencing: From Literal Mobs to Digital Censorship

The desire to silence opponents is nothing new; it merely takes on different forms in new eras. Suppression of difficult truths happens on the macro and micro levels in everyday life. Suppression techniques are not new but have evolved with technology. Today, silencing, cancelling and reputation bombing of people and organizations that people find disagreeable occur in daily discourse, online digital hit squads (digital mobs), big tech, big media and old-fashioned mob violence.

Utilizing digital suppression through algorithms and account suspensions is also common, but less visible. Many people are unaware when information is omitted from searches or excluded from their feeds. This is censorship by other means. It is a form of manipulation by augmenting “desirable” political and social content while minimizing exposure to alternative viewpoints that do not align with the ideologies of the big tech of the day. It is the opposite of civil dialogue and antithetical to promoting a flourishing democratic republic.

Elijah Lovejoy, 1802-1837. Public domain. (https://commons.wikimedia.org/wiki/Category:Elijah_P._Lovejoy)

Elijah Lovejoy’s evolving life of ministry and advocacy

The story of Elijah Lovejoy is an amazing story of zeal, personal transformation and the price he paid telling the truth and advocating freedom for enslaved black Americans. Lovejoy not only called for change, often in fiery rhetorical fashion, but became the change.

The power of Elijah Lovejoy lies in his own personal transformation, both as a man of faith and as an editor, and how it influenced his approach to addressing societal change. A horrifying event had a profound effect on Lovejoy was the brutal burning of the black riverboat man, Francis McIntosh, in 1836.

Elijah Lovejoy was born in Maine in 1802 and started his career as a teacher after completing college. After only one year of teaching, he moved to St. Louis, MO and worked as a journalist for various local newspapers. In 1832 he attended seminary in Princeton, NJ, and then returned to St. Louis, was ordained a Presbyterian minister and became a pastor in 1834. A short time later, both his activism and trouble began.

The most monumental events of Lovejoy’s life unfolded in turbulent 1830s America while he lived in Missouri and Illinois and worked as an editor of the St. Louis Observer and eventually the owner of the Alton Observer in Illinois. Violent mobs were erupting throughout the United States. There were many causes and targets, but abolition and race were central issues. Elijah Lovejoy’s abolitionist zeal made him a target.

The attempts to silence Lovejoy’s opposition to slavery speak directly to many of the challenges we face in contemporary society. For example, the use of mobs and riots as a means of political activism and fear. The mobs today are often more insidious, such as people hiding behind screennames, but physical street mobs and rioting have been on the rise.

Elijah Lovejoy’s pivot: from sectarian minister to abolitionist martyr

Early in his career as pastor and editor, Elijah Lovejoy used his pulpit and pen to call for moral reform, temperance, and to denounce the Catholic Church. For example, one article in the St. Louis Observer, Popery in America, published in February of 1835, attacked the Church and Catholics saying,

Popery is a system of darkness. It substitutes priestly domination for the liberty wherewith Christ hath made us free. It spreads ignorance, superstition, and vice wherever its influence prevails.

Lovejoy’s combative rhetoric infuriated many people, especially Catholics. St. Louis at the time was called the “Rome of the West” because of the size of the new Catholic Diocese of St. Louis and the number of Catholics living in the region. His attacks were not limited to Catholics. He also targeted Baptists and Episcopalians.

Elijah Lovejoy was an abolitionist. He knew slavery was against God’s will and violated the dignity of enslaved human beings made in God’s image.

The Catholic Church in St. Louis, including members of the clergy, religious orders and the seminary, owned slaves, a reality which no doubt fueled his disillusionment with and rants against the Catholic regime. Lovejoy understood it was hypocritical to profess faith in Christ and view and treat other human beings as less than human.

Lovejoy aggressively and repeatedly denounced slavery despite having an audience that was overwhelmingly favorable to it. Missouri was a slave state, having just joined the Union in 1821 after the negotiation of the Missouri Compromise.

In June of 1835 in the St. Louis Observer he condemned slavery, saying in part, “slavery is a sin — a heinous crime in the sight of God.” Lovejoy set himself on a collision course with many members of the community.

The murder that changed Lovejoy

Francis McIntosh, a 26-year-old free black man from Pittsburgh, PA, worked as a steward on a riverboat on the Mississippi River. According to contemporary reports and the 1836 grand jury record, a quarrel erupted onboard a boat while in St. Louis that resulted in his being detained by law enforcement. He was arrested for breach of peace. When they attempted to take him to jail, he allegedly stabbed two officers while attempting to escape. One of the officers, a deputy sheriff, died, while the other was injured.

(Public Domain. https://commons.wikimedia.org/wiki/File:Burning_of_McIntosh.jpg)

A mob of several hundred arrived at the jail, seized McIntosh, chained him to a tree and burned him alive while he begged for mercy. During the brutal 15–20-minute ordeal no city official intervened. No one was ultimately brought to justice. Elijah Lovejoy witnessed at least the aftermath of the immolation.

This event was a major personal and professional turning point for Eijah Lovejoy. Outraged by the extrajudicial execution of McIntosh, in May 1836 he published an editorial in the St. Louis Observer denouncing those who killed McIntosh and those who did nothing:

When human life is thus wantonly taken—when the laws are set at defiance by a mob, and the cry of the innocent is disregarded—it is time for the friends of order to awake.

This editorial inflamed many in the city, who accused him of sympathizing with a murderer. The month he wrote the editorial his printing press was destroyed.

Lovejoy then moved his abolitionist paper to Alton, IL and named it the Alton Observer. His troubles, however, were just beginning. Illinois was not a slave state but that area of the state was dependent on the slave economy.

Although Lovejoy’s anti-slavery activism was inflamed by the McIntosh murder and he continued to demand the immediate end to slavery, his tone changed in other ways. For example, his anti-Catholic rhetoric significantly softened. In May 1837 he wrote in the Alton Observer,

Let not Protestants and Catholics contend as enemies. We differ—yes—but let the difference be discussed in charity. Violence and bitterness never convinced the mind nor converted the heart.

The inflamed mob ended Lovejoy’s life and advocacy

Lovejoy sensed the storm clouds gathering around him. In the weeks before his death he often spoke of martyrdom. He frequently referred to the words of Jesus regarding the need to sacrifice everything, even one’s life, to follow Jesus. As a man of faith Lovejoy was committed to losing his life for the sake of the dignity and liberty of black Americans and his own integrity.

Citizens and public officials tried to convince Lovejoy to leave Alton, Illinois, or to at least stop his anti-slavery rhetoric. In response, he gave a speech to a group of citizens in the fall of 1837 saying,

If I fall, my grave shall be made in Alton. It is not that I love strife, but peace founded on righteousness. I cannot yield the liberty of conscience and of speech which I hold from God.

The destroying of the Alton Observer by a mob, 1837.

Public Domain: (https://en.wikipedia.org/wiki/Alton_Observer)

The tensions escalated to a climactic armed standoff at the Alton Observer on November 7, 1837. Elijah Lovejoy and his followers were defending the press against citizens who came to destroy it. Ultimately, the fourth and final printing press was burned, and Elijah Parish Lovejoy was shot to death.

Lovejoy’s final stand was a powerful demonstration of personal integrity and living the Gospel he preached, despite the ultimate consequence. His willingness to change, as evidenced by the softening of sectarian rhetoric and encouraging dialogue, is a testament to his commitment to Christian love.

Unfortunately, an angry mob, instead of accepting the invitation to dialogue and truth, chose violence and murder. Elijah Lovejoy’s final act was a culmination of a life lived for others, especially the most marginalized of his time.

The unfolding of the story of Elijah Lovejoy is simultaneously tragic and inspiring. It contains within it a core reality about human nature: we are capable of great good and profound evil. These collided in Lovejoy’s story. If we were in this story today, who would we be?

Further Reading

A more detailed discussion and analysis of the life and work of Elijah P. Lovejoy as a champion of the free press and civil liberties can be found in this comprehensive academic analysis.

J. Steven Bromwich is an investigative journalist who writes about culture, crime and human nature to help readers navigate modern problems with historical perspective and first principles. His background includes training and experience in criminal defense investigation, clinical ethics, nursing, and diplomatic studies. He is the founder of 1690 Media.

Who decides if you need to be cancelled?

Imagine you have just launched your first Substack or blog. The first days attract more readership than you ever dreamed possible. Your hard work is starting to pay off.

Then, four days after hitting the “post” button, the government shuts you down. Your writing dreams are shattered. What did you do wrong? Some anonymous bureaucrat disapproved of your content and cancelled you. You feel violated and for good reasons.

There is a greater likelihood today that your post or video will be directly censored by a private company, not the government. For example, social media companies may put a warning on your post or suspend your account for violating their “community standards.” Algorithms may engage in censorship. You may even be “fact checked” by a self-appointed media department. None of these are accountable to voters.

If not the government, tech or media companies, it is not too far-fetched to imagine a mob showing up at the door to intimidate you into silence.

The first page of Publick Occurrences. Public domain. https://archive.org/details/publickoccurrenc1169unse/mode/2up

First American newspaper censored, cancelled and destroyed

Publick Occurrences Both Forreign and Domestick, the first multi-page colonial publication in 1690 Massachusetts was cancelled by the government. Colonial authorities (the British Crown) disapproved of content that criticized the government and the British military, and tattled on royals. It only took colonial authorities four days to put an end to the newspaper.

Benjamin Harris first published Publick Occurrences on September 25, 1690, and was officially banned and shuttered on September 29, 1690. Authorities ordered the destruction of every copy. None survive except one currently located at the British Library.

This did not stop Harris, a publisher and tireless supporter of free expression and free press. He forged ahead despite official government opposition. In addition to coffee house gatherings, Harris went on to print and circulate content for the public in the form of discreet fliers. He did not, however, attempt to publish another newspaper in the colonies.

Is it “free” if it is censored or needs government approval?

In 1704 the Boston News-Letter became the first continuously published newspaper, but at a price. John Campbell, its publisher, obtained government approval. The front page prominently displayed, “Published by Authority.”

If a media outlet needs government approval to publish content with its materials passing through a censor, is it free? Are we free people if information about public affairs has been scrubbed by a government bureaucrat before we see it, meaning vital information is missing? Do government authorities have the right to terminate a publication’s existence (or cancel a writer) even if it publishes unsubstantiated rumors, inaccurate content, or content that opposes official government positions? What if government uses proxies, like tech companies, to limit speech?

The First Amendment of the United States Constitution, ratified in 1791, resoundingly says, “no” to all these questions. The First Amendment exists to protect free speech from government oversight and threat.

“Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the Government for a redress of grievances.”

About a century after the colonial authorities shut Benjamin Harris’ Publick Occurrences down, the founders put these forty-five words into law intended to protect the right to speak and publish freely without fear of government censorship and other consequences. It is likely the American founders knew of his newspaper and what government authorities did to it.

1690 Media is named for the year Publick Occurrences was both published and shut down. Good public policy and the preservation of our republic require the ability of citizens to speak freely without fear of retaliation.

Historical struggles for freedom of the press continue

More than three hundred years later, the temptation and attempts to silence opposition voices and inconvenient speech endure. Attempts by the government to curtail free expression, including silencing the press, have been an ongoing struggle and debate throughout the history of the United States of America.

We will address the topic of free speech in upcoming stories. Relatedly, we will also address the recurring theme of the government, political parties, and the press colluding with each other to suppress opposing viewpoints.

A free republic must have free and honest media. Media that has lost its objectivity and colludes with political parties or corporate interests is not serving the public interest. Citizens need objective information. Government and State officials need to be held accountable. If we lose this freedom and accountability, we will spiral into corruption and cease to be free people.

Maintaining a free democratic republic requires knowledge, memory and vigilance

What we find throughout history is that nearly every new dispute over public policy, including government attempts to suppress speech, civil unrest, administrative overreach, homelessness, mental illness, political violence and others, have historical analogues. We examine these.

What is also true is that claims have frequently been made about human nature and founding principles by politicians, judicial actors, educators, media, activists and others that are false. These need to be corrected through objective evaluation and public conversations. Good policy decisions cannot be made without good information.

The mission of 1690 Media is to help readers recognize patterns in cultural upheaval and public policy challenges. We also commit to bring ethics to bear in the analysis of and writing about cultural issues and policy decisions. The good of the human person must always be at the center of policy discussions.

For more details on Publick Occurrences Forreign and Domestik see https://www.history.com/articles/first-colonial-american-newspaper-1690

Next week we will feature Elijah Lovejoy, often called the first martyr for freedom of the press. More importantly, however, he is a martyr for the dignity of the human person. He was willing to die for the most vulnerable and oppressed people of his era.

We invite you to join our mission by reading, subscribing, and engaging with our content.

J. Steven Bromwich is an investigative journalist who writes about culture, crime and human nature to help readers navigate modern problems with historical perspective and first principles. His background includes training and experience in criminal defense investigation, clinical ethics, nursing, history, and diplomatic studies. He is the founder of 1690 Media.

Fear of retaliation and exclusion is often the deterrent to voicing a differing or unpopular viewpoint to a ruling narrative. Many people walk on egg shells.

“What did you do for Christmas?” a co-worker might ask. Many people will list anything but “We went to Church,” lest they ignite a firestorm or provoke a snarky remark. There is no point, one might reason, in stirring that pot, especially in an environment with a narrative hostile to religious belief and practice. People are then left editing out important aspects of their lives.

We are social creatures and the desire to talk over the fence or cubicle about daily events is natural. We obviously should not impose our viewpoints.

We will not agree with everything others believe or think, and that's okay. We can learn when we engage in civil discourse, but it takes humility and respect for others. Admittedly, it may be wise at times to refrain from conversation.

1690 Media officially launches on December 8. Our mission is to bring context to current affairs by analyzing their historical precendents along with the reality of human nature.

This month, press freedom and courage will be the overarching themes, ones that will continue to emerge. A long-form essay on human nature will be released later this month.

I hope you join us!

J. Steven Bromwich

There is truth to both of these statements. On the one hand, this is the time and place in which I live, so they are the worst of times and the best of times. Moreover, nostalgia can improve how we perceive the past, while living in the present moment can increase our experience of pain. One fact, however, is certain: the best of times are never the best for everyone and in everyway. Perspective is important.

History is littered with the worst times and the best times. When we look at a current challenge it is often wise to ask, “Have we been here before?” How can we learn from that experience, either our own or another’s, so as to act with more wisdom and prudence today? I once added Karo syrup instead of oil to a cake recipe when I was a teenager. It was painfull, especially since it was for my mother’s birthday. She laughed. I learned from history!

We rely on historical grounding all the time in learning new tasks. Mom’s or grandma’s recipes are saved for a reason, especially if they include tips they learned along the way. Science provides a historical road map on which we build or correct.

Many cultural issues, such as crime and punishment, mental health, homelessness, and race have historical dos and don’ts from which to learn. Why keep ad libbing a recipe or public policy when we can draw on experience?

1690 media provides stories that take both deep dives and quick glances at the good and bad recipes of the past. We focus on researching past policy and practice and their outcomes so as to make better decisions today. Subcribe and join us on the journey.

A significant, self-limiting intellectual challenge we often encounter is the assumption that we are better, smarter and all-around more advanced than our ancestors, as though Aristotle, Galileo, Blaise Pascal, Harriet Tubman, Frederick Douglass, or any other figure from history were less intelligent than us. Often, the simplest person in the smallest town can teach us a lesson about living and problem-solving.

The overarching mission of 1690 media is to explore how our ancestors wrestled with the same challenges we face. The stories we tell are exciting, infuriating, heart warming, heart breaking, sometimes confusing, but always full of insights.

Subscribe and join us for 1690’s inaugural article on December 8th and weekly thereafter.

J. Steven Bromwich, investigative journalist, criminal investigator, ethicist, historian

Pressing current affairs need to be understood in context. Too often contemporary media misses vital historical connections to reported stories.

We pair “then and now” stories to better understand and solve pressing issues, especially involving crime, governance, and civil liberties.

Subscribe today and be better informed and equipped to be a solution.