What is Bioethics? Environmental and Economic Justice

Like many people, Peter Singer was the first bioethicist to occupy any space in my consciousness. He first got my attention with his concern for animal welfare and calls for vegetarianism. I suppose he is best known for saying we should not eat animals but that it is sometimes acceptable to kill our babies, which many people find upside down, especially if they haven’t actually read all his arguments, and few of his critics seem to have read his arguments.

But Singer has also spent a great deal of effort offering suggestions on relieving the problems of globalization, wealth inequality, and further destruction of the planet. One can offer reasoned objections to his suggestions, of course, but his choice of topics and concerns helped define what bioethics was for me.

Singer’s concerns fit nicely with the term “bioethics” as originally conceived by Van Rensselaer Potter in 1970. Potter said bioethics should be “a new discipline that combines biological knowledge of human value systems.” Potter saw bioethics as a systematic attempt to ensure the survival of the planet and all the people on it. One of Potter’s goals was to eliminate “needless suffering among humankind as a whole.”

Van Rensselaer Potter

Unfortunately, by the middle of the 1970s, the term “bioethics” had already been co-opted by the medical establishment and applied primarily to medical ethics. Concerns for ensuring the well-being of humankind were replaced by concerns for patients and doctors, with a strong emphasis on patient autonomy. Today’s bioethicists tend to ignore problems that have nothing to do with healthcare or medical research, but millions of people in the world have no access to healthcare and so escape any attention from bioethicists at all, which is itself an injustice.

To be sure, bioethicists are still in the world working for justice and, in some notable cases, the survival of the planet, but those working on themes outside of healthcare or medical research are outsiders at best. (For a couple of examples, see Martha Nussbaum and Thomas Pogge.)

I will continue to argue that this is the wrong approach to bioethics. Potter’s and Singer’s concern for promoting the health of the earth and all its inhabitants is the only reasonable way to think of bioethics, and those who disagree are the ones who should defend their positions.

What are some of the issues we need to address? Just to get us started, we can look at environmental justice, war, climate change, worker’s rights, wealth inequality, access to water, human rights abuses, women’s equality, and children’s welfare. Too broad? The problems that threaten life and health are vast. Medical practice requires an enormous cadre of professional ethicists to develop policy and practice guidelines, of course, but bioethicists following the vision of Potter should be welcome at the table as well.

Glenn Beck is shocked by bioethics blog about an article saying killing isn’t really wrong.

By now, commentary on Glenn Beck seems superfluous—his views are so patently divorced from reality, but this topic could use some discussion anyway. In this clip, he responds to a blog titled “Is it morally wrong to take a life? Not really, say bioethicists” by Michael Cook. Beck seems unaware that his comments are actually about an article titled “What Makes Killing Wrong?” by Walter Sinnott-Armstrong and Franklin G. Miller in the Journal of Medical Ethics. Cook, of course, is just commenting on the original article. Although the full article by Sinnott-Armstrong and Miller is available online, Beck obviously did not take the time to read it. Or, if he read it, he certainly does not want his listeners to.

Here’s the problem: Hospital Ethics Committees (or other hospital entities) must develop extremely precise procedures for organ harvesting. They do this because they do not believe it is ethical to kill patients for their organs, nor do they want others to believe, rightly or wrongly, that they kill patients for their organs. Sometimes, when someone is dying from an extreme and irreversible injury (such as a gunshot wound to the head), doctors will begin to remove organs only to have a monitor show a heartbeat or two. This event can be disconcerting.

I can see three alternatives here: 1. Turn off the monitors and declare the patient dead (changing the definition of death, if necessary). 2. Wait till there is no chance the heart may beat again and risk losing organs that could save another life. 3. Declare that the patient is alive but that killing the patient is acceptable.

Most ethicists have tended to suggest some variation of the first two options, but Sinnott-Armstrong and Miller think it is more honest to accept the third. If the heart may still beat, they argue that the patient is not dead but that it is morally permissible to kill that patient. The authors also make it more challenging by imagining a patient in this state for an extended time (on a ventilator or other artificial life support).

Unfortunately, their term for a patient in this state is “universally and totally disabled,” meaning that the patient cannot suffer, feel, think, or have any other function associated with being a living human being. Beck seizes on the term “disabled” and suggests they want to kill all the disabled people in the world. Is Beck being dishonest or did he just miss the point? Does it matter to you?

The final issue for Beck is that the authors said mere life is not sacred or we would not be able to pull weeds without violating the sanctity of life. So, Beck and his followers are incensed that they authors compared human life to weeds. But, of course, they did not.

No, Sinnott-Armstrong and Miller went on to distinguish between the sanctity of “life” and of “human life.” They follow the weed comment with this explanation:

 “Of course, what people mean when they say ‘Don’t kill’ is ‘Don’t kill humans’ (or maybe ‘Don’t kill sentient animals’). But why then are humans (or sentient animals) singled out for moral protection? The natural answer is that humans (and sentient animals) have greater abilities than plants, and those abilities give human lives more value. Humans can think and make decisions as well as feel (an ability that they share with sentient animals). But if these abilities are what make it immoral to kill humans (but not weeds), then what really matters is the loss of ability when humans (but not weeds) are killed. And then the view that human life is sacred does not conflict with—and might even depend on—the view that what makes life sacred (if it is) is ability, so the basic moral rule is not ‘Don’t kill’ but is instead ‘Don’t disable’.”

To be sure, the article in the Journal of Medical Ethics is provocative, and articles in ethics journals should be provocative. Many bioethicists, doctors, and lay people will disagree that killing is ever acceptable. Discussion of this issue is needed and welcome. Distortions, flag waving, and hysteria are not.

Can justice be utilitarian?

I have always been fond of Utilitarianism and, quite frankly, impressed by the arguments of all the major Utilitarian writers. Criticisms of Utilitarianism also make sense, but they don’t seem consistent with the views of major Utilitarians. I suppose I most commonly hear Utilitarianism dismissed as a cruel philosophy that would accept sacrificing individuals so long as a larger number of people drew some advantage from the sacrifice.

This argument affects me strongly as I feel a society that is unjust to only one person is an unjust and unacceptable society. Yet, I still find myself in great admiration for Bentham, Mill, Hare, Singer, and others. What I admire about these Utilitarians is that they never ignored the plight of people (or even non-human animals) who were marginalized by society. It is precisely this inclusiveness of Utilitarianism that attracts me.

For example, in one of my bioethics classes, we had a discussion of how to respond to a pandemic. Some of my colleagues said that doctors must deal with the person in front of them with full attention. To toss this person aside, they said, would just be Utilitarian. They pronounced “Utilitarian” as if they were saying, “pure evil.” Utilitarianism seems heartless to them. Doctors making calculations as to what actions would benefit the most people. I object, however, and say that it seems more heartless to ignore the 10 people dying in the street than it does to step away from one hopeless case in the hospital. I am biased, but I happen to think the person in the hospital is likely to be more privileged than the people who are in the street, and I feel we should give priority to the poor and dispossessed.

I also noted that everyone, doctors and non-doctors, was obligated to help as many people as possible. In this way, no one should be left to die alone with no one showing concern for him or her. Utilitarians such as Peter Singer and Peter Unger make powerful arguments for devoting more attention to those dying of starvation in the world. They do not advocate, as you might expect from the criticisms leveled against them, ignoring the suffering of the poor so long as it benefits the rich. Rather, they suggest that everyone has an obligation to try to relieve the suffering of everyone else, with no one being left out of the mix. I realize things don’t happen this way, but ethicists attempt to describe how things ought to happen, not how things are likely to happen.

So, all this leaves my question about justice open. I want to say that everyone will be happier if we all live in a state that is perfectly just.* For this reason, we cannot ignore injustice inflicted on any one person. When I make this assertion, I’m taking the line that we should all follow a rule, and some will say that so-called “Rule Utilitarianism” is just another form of deontology. I think the two may be compatible. It may that I have misunderstood Utilitarianism. If that is the case, I think most Utilitarians have also misunderstood it.

*Yes, I know, we are not likely to agree on what is meant by “perfectly just.”

The limits of client autonomy in psychotherapy

In the movie, Analyze This, a psychiatrist has to deal with treating a criminal whose anxiety interferes with his ability to do his job, which includes killing people. The movie is a preposterous and rather horrifying scenario, but it doesn’t challenge accepted ethical guidelines on client autonomy—clients do not have a right to request treatment to enable them to harm others. Such demands are well outside of the scope of client autonomy.

While no one (all right, so I can’t promise there is not some sick exception out there) thinks clients should have unlimited autonomy, maximizing autonomy has been particular focus of bioethics since its inception in the 1970s. This, combined with movements in psychotherapy and feminism to empower both clients generally and women in particular, gives way to some perplexing situations. This is particularly true, to my mind, in cases of so-called “internalized oppression.”

In the 1980s, feminist philosopher Dale Spender rejected the idea of singular truths as being too oppressive, claiming instead, “Only within a multidimensional framework is it possible for the analysis and explanation of everyone to avoid the pitfalls of being rejected, of being classified as wrong.” Spender was specifically advocating a multidimensional view of reality as a way of empowering women.

Similarly, collaborative therapy intends to empower clients by rejecting preconceived notions of truth and meaning, or even of therapeutic goals. In her 1997 book, Conversation, Language, and Abilities, Harlene Anderson writes, “A therapist is not a detective who discovers the truth, or what is true or truer, false or falser.” She goes on to say, “A therapist does not control the conversation, for instance, by setting its agenda or moving it in a particular direction of content or outcome. The goal is not to take charge or intervene.”

So, what is to be done with a client who embraces and fails to question a system that is oppressive, hierarchical, and one-dimensional? If a client has embraced a system that devalues the worth of the client, it would seem honorable and right for the therapist to guide the client to question a system that is degrading and demoralizing, rather than helping the client explore ways to function more effectively within that system. Of course, a therapist may simply open a conversation and hope the client with find liberation on his or her own, but this is a disingenuous respect for multiple truths.

Commenting on the goals of multidimensional feminism, Jean Grismshaw said, “The fact that one group has power over and exploits another, cannot be reduced to anyone’s belief that this is so; nor does the fact that someone does not understand their own experience in terms of oppression or exploitation necessarily mean that they are not oppressed or exploited.”

A belief in moral progress entails a conviction that some truths are better than others. We must believe that changing what we believe can make the world better. In Plato’s allegory of the cave, the philosopher who has become enlightened will not want to return to improve the affairs of men, but it is a duty to do so. If those who are in chains do not realize they are in chains, those who are free must help them.

William James, who I believe is one of the greatest psychological theorists of all time, also rejected the certainty of truth, but he noted that when we give up certainty, we “do not thereby give up the quest for truth itself. We still pin our faith on its existence, and still believe that we gain an ever better position towards it by systematically continuing to roll up our experiences and think.” James also believed in progress—epistemic progress and social progress. A commitment to truth does not demand that we discount the knowledge or experience of others, but it does demand that we constantly seek what is better in our lives.

While we may not pass judgment on someone who does not share our values, the values we hold most deeply must remain important to us. If our own values mean nothing to us, our lives have no meaning. The postmodern therapist has values and wants others to share them; otherwise there is no point in seeking healing. If we don’t seek more valuable lives, there is no point in living.

Corporate funding of research.

Many of us are suspicious of health and safety claims based on research funded by corporations that get rich off public confidence in the health and safety of their products. I don’t really trust manufacturers of drugs or genetically modified foods to tell me that they are safe. I also would feel better hearing that an oil spill is no threat to life or environment from someone other than the company that spilled the oil. (Many people seem to have made one inexplicable exception to this rule, which I will mention in the postscript.)

Further, when corporations fund research projects or labs, they gain control over what information is published. The scientists involved may have enough integrity to conduct rigorous research, but unwanted results are likely to be suppressed, especially if they will hurt the bottom line. This may be justified by claiming that only “useful” data need be published, but negative data can also be useful and can avoid wasted money and energy. If one researcher finds that something doesn’t work, publishing that data can help others avoid the same mistakes. Of course, researchers do share data, but some studies are also suppressed. Publication of misleading data and suppression of useful data are two possible hazards of corporations funding research that will affect their bottom line.

On the other hand, if corporations are the ones to benefit from research, it seems they should bear the cost of supporting labs, scientists, and related endeavors. Of course, some research is in the public interest, and I believe the public should fund it, which may be the topic of another blog. To avoid obvious conflicts of interest in research, companies should not be permitted to hire and promote researchers directly. Funding should go in to a pool and be dispersed anonymously to research labs, scientists, and universities. For profit labs could still exist, but researchers should not be beholden to a specific entity. It was not that long ago that much university research was conducted in this manner. In that sense my proposal is regressive, not progressive.

Postscript: When people get sick, many of them demand the latest drug available, even if it hasn’t been tested thoroughly. They seem to feel that their suffering from the disease is always going to be worse than the effects of the drug. I recently had a student (not a medical student) argue vehemently with me that no one had ever died during a drug trial. For those who know anything about drug trials, this over confidence is baffling, but I fear many share his optimism regarding the safety and effectiveness of experimental drugs. If you don’t know this already, let me tell you that drug testing is there for a reason; not every drug tested turns out to be safe and effective.

My question for Ron Paul: Autonomy and health care

Earlier this year at the Tea Party debate, Wolf Blitzer asked Ron Paul if a person who chose not to buy health care should be left to die. Paul responded that this person’s friends and community could support him and pay his bills. Many in the audience seemed to be all right with letting this person die.

Conservatives and libertarians both express a strong commitment to autonomy, which they sometimes refer to as freedom. The new health care law is unacceptable they say, because it requires individuals to purchase insurance. People should not be required to purchase insurance, but they should be responsible for the consequences if they do not have insurance. Of course, this scenario is rarely a problem for anyone, and Blitzer asked the wrong question.

I would want to ask a different question. I want to know about the person who has worked all her life and been successful. After 20 or 30 years, she decides to expand her opportunities by starting her own business. Remarkably, her business is profitable in its first year. She can afford to buy insurance, but she cannot buy adequate coverage because she has preexisting conditions that every major insurance carrier refuses to cover. When she contracts a serious illness, she is driven into bankruptcy because of medical bills that are astronomical but quite common. Should our country let her die? Should she be permitted to slide into bankruptcy?

Autonomy is not quite as simple a question as it apparently seems to Republicans and libertarians. Philosopher Isaiah Berlin described two types of liberty: one is negative and the other is positive. For conservatives, it is imperative that individuals not be forced to do something they may not want to do and no government intrusion is acceptable. This is negative liberty. For liberals, such liberty is meaningless if one is unable to make the choices he or she desires, which is positive liberty.

Describing the liberal view of positive liberty, Berlin says,

“It is true that to offer political rights, or safeguards, against intervention by the state, to men who are half-naked, illiterate, underfed, and diseased is to mock their condition; they need medical help or education before they can understand, or make use of, an increase in their freedom. ”

While conservatives will not force someone to purchase insurance, liberals want to ensure that everyone has the option to have health care. Everyone who needs health care and cannot obtain it becomes a liberal in an instant.

The number of uninsured in the United States is said to be around 50 million, but many more than that have inadequate insurance. Unfortunately, most people do not realize they are underinsured until it is too late. Many people only learn that their treatment will not be covered by insurance after they have received the treatment. What kind of autonomy is this? What is the value of liberty if it leaves one with no options to avoid bankruptcy, untreated illness, and death? Is this really what we want to be?

Can we talk?

In recent months (perhaps years, now), it seems the religious and irreligious are divided more severely than ever. In response to demands that intelligent design be taught in schools or that evolution not be taught, writers such as Sam Harris, Daniel Dennett, and Richard Dawkins have taken religious thinkers and writers to task, attacking religious thought with unbridled enthusiasm. Their writings serve more as a rallying cry than as discourse and, as such, probably exaggerate the true gap between believers and non-believers in our society. Some of the religious seem equally enamored of raising arms against the other side. The Terri Schaivo “debate” quickly devolved into nothing more than grandstanding, posturing, and provocation for combat. With no background knowledge of our society, one would think pluralism had only happened moments ago and that any kind of discourse between the two sides (indeed, there are far more than two sides, but such nuance is invisible at the moment) is impossible. A little reflection, however, will remind us that the United States, while not quite the rich and diverse mosaic some dream it has been, is a country that has managed discussion between divergent groups in the past. The founders of our country were both religious and secular. Although a fair amount of strife resulted, discussion and compromise were always seen as real possibilities. It is possible that a way forward still exists.

When asked who would be an authority on matters of morality, most members of the public, in the United States at least, would first mention members of the clergy. More sophisticated individuals might know to mention theologians specifically. Few people would think to mention philosophers, especially not secular or, worse, atheistic philosophers. In The Elements of Moral Philosophy, James Rachels says:
“It is not unusual for priests and ministers to be treated as moral experts. Most hospitals, for example, have ethics committees, and these committees usually include three types of members: healthcare professionals to advise about technical matters, lawyers to handle legal issues, and religious representatives to address moral questions.”
So, most people in the U.S. believe morality and religion are inseparable. Rachels refers to Plato’s Euthyphro to question whether God’s morality is arbitrary or rational. If actions or values are good only because God commanded them, then morality is arbitrary, or so the argument goes. If God commanded actions and values because they are good, then God’s morality is rational. Rachels quotes Gottfried Leibniz saying that the latter must be true. He says, “For why praise him for what he has done if he would be equally praiseworthy in doing exactly the contrary.” If God’s actions are rational and not arbitrary, then any rational person should have an equal ability to examine moral questions on the basis of reasoned argument. Rachels’ argument is that atheists and secularists should be included in moral discourse.
It is surprising, then, to find that the theologians Rachels felt have an undeserved place of privilege in moral discourse should complain that they have been left out of moral discussions, particularly with regard to bioethics. Courtney Campbell writes, “One unfortunate aspect of civic bioethics . . . is its incivility, including incivility toward religiously grounded opinions.” He also warns that religious bioethicists cannot retreat to the academy as, “the academy exhibits its own forms of intolerance toward religious expression.” Rachels and Campbell appear to be living in two different worlds, one hostile toward the secular and one hostile toward the religious. Authors on both sides declare that they must fight to be included in the discussion and be heard over the tyrannical forces of the opposing side.
Certainly, each side is correct in at least a surface view of discourse in the United States. Most people in the United States are religious, and their religious values are reflected in the public sphere. Some religious groups have shown clear forms of intolerance for opposing views. On the other hand, many professional philosophers are secular or atheistic, and a condescending attitude toward religion is perceptible to even beginning students in philosophy. Philosophers are a small minority, indeed, but their voices are disproportionately loud in the debates over bioethics, at least in part because they have made some provocative claims. How is a religious person to speak to a philosopher who claims it is permissible to kill babies and disabled adults but not animals? The fact that such a question is even asked must be enough to make some religious writers feel dialogue is hopeless.
James Gustafson describes three styles of religious discussion in medical ethics. The first is based on autonomy of religious views; most people would generally associate this view with an assertion of religious authority. When asserting authority, one is likely only to sway those of the same faith who feel compelled to follow the authority of its leaders. This is, of course, an important part of the moral work of many theologians, but it does not engage the wider community. The second style stresses continuity with the wider community. This style seeks to make religious positions intelligible both to those within and beyond a specific religious community. For example, a Catholic theologian may publish and article or give a speech intending to make the Catholic position on social welfare or just war comprehensible to non-Catholics. In doing so, some non-Catholics may come to agree and join with Catholics in support of or opposition to public policies. The final style is interaction, which is the only style in which the religious interlocutor is open to revising his or her original position. The interactive style is not for every writer or every occasion, but Gustafson notes that it is possible and can provide a space where the religious and the secular can converse about matters of medical morality.
J. Bryan Hehir discusses the role of the “public church.” In examining the proper role of Catholic bioethics, he notes that the Catholic Church “defines civil society as both an audience for its teaching and an object of its pastoral care.” From this prospective, theologians and others are obligated to engage the wider, pluralistic public on important matters of morality. He says that religious writers must be prepared to contend with a pluralistic society, a secular state, and a liberal philosophy of law. He notes the success of Martin Luther King in addressing the public on moral matters using rational argument that was not free from religious significance. However, biomedical issues seem especially intractable, particularly with regard to issues related to sanctity of life (e.g., abortion, suicide, euthanasia).
Given the steadfast opinions of individuals on both sides of the abortion debate, many have advised Catholic writers to focus attention on the ecclesial community. Hehir finds this dissatisfying as he advocates a public church, not a church that restricts its reach to its own enclave. He says, with some apparent pride, “The strategy may ultimately fail, but the failure will be that of a public church, rather than a decision by a once-public church to retreat within a purely ecclesial definition of its role.” The question is not whether the church succeeds or fails but whether it fulfills its duty to society as an object of pastoral care.
Hehir moves to another issue that may seem to be less of a problem for discussion between the church and the secular public: public access to health care. While religious language may be used to discuss health care, the general public can certainly understand the positions of the church, and the issues are not nearly so intractable as discussions of abortion, for example. On the surface, it seems that the church would be obligated to support efforts at providing heath care to all, but Hehir sees a problem. Many proposals for public access to health care include provisions for publicly funded abortions. He suggests that multiple strategies could be adopted but not in his short essay. Fortunately, Andrew Lustig expands on the discussion of health care rationing and reform, but the problem remains frustrating. Lustig recalls Christian teaching that demands universalizing love and care for one another, which would seem to require support for public access to health care, perhaps even globally. Nonetheless, he notes that U.S. bishops oppose any health care package that includes abortion. He calls for religious writers and others to invite their religious values to drive arguments expressed in non-parochial, or public, terms. He sees a possibility that religious values will “work their leaven upon the world” indirectly. How is a secularist to respond?
Two secular philosophers, Peter Singer and Peter Unger, have devoted much of their attention to the ethical use of the world’s resources. Both are motivated by a value shared by all Christian writer’s I am aware of: a value of preserving the lives of those who wish to live. Admittedly, some Christian writers would want to preserve lives in cases where someone might want to die, but it is possible to bracket that concern while discussing our individual obligation to others who do want to live. Singer and Unger both argue that taking care of the world’s most vulnerable people is an individual responsibility for everyone. While they both eschew religious language, others have pointed out that only Jesus seemed to have an ethic as demanding as Utilitarianism, requiring all in affluence to give to any who need assistance. Singer and Unger are both Utilitarians (a frequent straw man for non-Utilitarian ethicists) and argue that the interests of all must be considered equally (for Singer, the interest of animals must also be part of the calculus).
On the point of health care in particular, Singer questions the claim of Christians to value all lives equally. He challenges the notion, saying that to value all lives equally would mean spending as much money to save the lives of the world’s desperately poor as we spend saving premature infants and those in the last stages of life. Many of Singer’s positions are anathema to Christian thought and tradition, but on this point common ground seems possible. While not responding specifically to Singer and Unger, Edward Langerak gives an example of a kind of language that is distinctively religious yet still capable of engaging secular philosophers. He notes that religious covenant requires individuals to love their neighbors. He acknowledges that “the problem has usually been that people’s sense of obligation is too minimal for covenantal flourishing.” He quickly adds, “But some special covenants seem especially prone to encourage a ‘savior’ mentality in which persons lose themselves in a bottomless pit of others’ needs.” His language is decidedly religious, but it echoes secular arguments against the Utilitarian calculus. Both the Utilitarian and covenantal ethicist can “bury the self in the bottomless needs of others.”
James B. Tubbs grapples with the question of obligation to strangers. Tubbs exclaims, “Yet Jesus goes beyond the claim that needy strangers should be regarded in the manner in which God regards them. He suggests, in fact, that the needy stranger be regarded as the Son of Man himself!” Tubbs emphasizes this point further by admonishing that the encounter with the stranger should be seen as an encounter with the divine. He then moves to an examination of what it means to be a neighbor. He declares that our moral life is dependent on relationships with others, but he leaves off the discussion of what this relationship demands of us. It would not be difficult for the Utilitarian to agree that strangers shape our moral lives, but it seems more difficult for Utilitarians to turn away from what our relationships demand of us. In any case, it is not religious language or hostility to religious thought that prevents Utilitarians and religious writers from becoming interlocutors. One has no difficulty imagining a discourse on our obligations to strangers between the secular and the sectarian. A certain degree of consistency is of value in any moral tradition.
I have focused so far on obligations to strangers as it seems to me to be the most pressing medical issue for everyone. More than four million people die each year from starvation. Millions more die from treatable or preventable diseases. While academic bioethicists grapple with deep quandaries regarding patients and the role of the doctor at the bedside, most of the world would be improved greatly by having the luxury of becoming a patient rather than another statistic. War and its always-attendant famine kills far more people than withdrawal of treatment from impaired newborns or cessation of treatment for the cognitively impaired. This is not to dismiss the importance of discussions over transplantation and other hard questions, but the easy questions may be a good place for secular and sectarian interlocutors to begin a discussion. An infinitesimally small number of people discussing bioethics and medical humanities would claim that the loss of life is insignificant. Whether the author values life because it is a gift from God or because it is something individuals have developed an interest in maintaining, life is something to be preserved, at least in the cases where the living person values his or her life. Given the almost universal agreement with this statement, it seems that philosophers, theologians, and bioethicists of every stripe could work together not on whether life should be preserved but on how public policy can be shaped to help those who need medical care and cannot procure it. It has perhaps been avoided too often because the task is more daunting than deciding at what moment a dying person becomes a corpse with organs suitable for donation. Nonetheless, if we are to encounter strangers as our neighbors, we must gird ourselves for the struggle and prepare for a significant shift in how we view our fellow sufferers in the world.
If a discussion of helping the world’s neediest individuals seems possible among people of many faiths and philosophical dispositions, Leigh Turner’s example of blood transfusions will have us despair that no discussion is possible in other areas. To be sure, people from many backgrounds would agree that blood transfusions are often required to prolong lives. Many would see providing transfusions to be an obligation of the highest order. Turner points out that none of this rhetoric or consensus of most bioethicists will be of interest to Jehovah’s Witnesses. Turner warns, “Principlist and case-based approaches to moral deliberation typically exaggerate notions of common morality.” The point deserves consideration. It is naïve for any bioethicist to assume that any argument, no matter how well reasoned, will be accepted by all. Turner accuses bioethicists of ignoring the elephant in the room, but this conclusion may be rash. It could be that bioethicists, aware of the elephant in the room, persevere in the hope of lighting one candle rather than cursing the darkness.
It is no question that philosophers and theologians often talk past one another. Many religious concepts cannot be put into a language common enough for the secular and the sectarian. This should not mean, however, that the conversation should not begin. The “public church” should make its beliefs as clear as possible to even an unreceptive audience. The public intellectual should do the same. Resistance should come from all who have the strength of their convictions regardless of whether those convictions come from religious moral traditions or reasoned argument and reflection. Speaking one’s conviction publicly and arguing for it is itself a moral act. Tolerance and respect for diversity do not require us to stifle our voices. They require us to accept that other individuals have the same right and obligation we have to express their deeply held convictions and beliefs.
Public policy, on the other hand, must reflect the greatest respect for individual beliefs and convictions that cause no harm to others. To be sure, it is not easy to decide what beliefs cause harm to others. The case of blood transfusions from the Jehovah’s Witnesses’ point of view is a reminder that sometimes harm seems quite different when seen from different vantages. I personally am concerned about harm done to animals. I realize that most do not consider harm to animals to be harm at all. I join the relatively small group of individuals, mostly but not exclusively secular philosophers, in explaining why much of the harm to animals seems not only cruel but unnecessary. I have learned that the stronger claim that animals should not be harmed or used in research is almost universally rejected, but many people of various faiths and backgrounds accept that cruelty is an evil. Deontologists and virtue ethicists both reject cruelty to animals as a bad habit that could lead to cruelty to humans. Thus, Kant and Aquinas both reject direct obligations to animals but see humane treatment of animals as an indirect obligation to humans. Those with sufficient openness have been able to discuss this subject with respect and results. Globally, a shift toward more humane farming is underway even as factory farming continues to be the most profitable means of producing food.
We can and must engage one another in discourse with respect, tolerance, and courage. The debate will not always produce an answer that is accepted by all, but the lack of debate will always produce frustration and power struggles. Bioethicists are in a position to model such discourse for the larger society. This will require leaving the enclaves of institutions and entering the public sphere in a more visible manner. We must take care to live by the principles we espouse. Peter Singer has been criticized for donating only 20 percent of his salary. He admits he could do more but also points out that it would not be necessary if everyone living in affluence would give only one percent of her or his income. We have achieved nothing near this level of giving, but aid organizations did see a spike in donations after Singer’s essay on world poverty appeared in the New York Times. It is certain that atheist Singer managed to engage the religious with his argument. Discourse can have positive results.
Ronald Carson writes, “In covenant, one receives others as one receives a gift—in trust—and one passes the gift on in response to need, with due regard for the recipient, and without calculation.” Our fellow ethicists are in need of respectful interlocutors just as our fellow humans are in need of medical assistance. As bioethicists, medical humanists, and responsible human beings, we can help provide insight, assistance, and advocacy. We can join and be fully engaged in a moral community. This is the task at hand.

When doctor’s hate informed patients

A doctor, Scott Haig, published an essay in time magazine titled “When the Patient is a Googler” on November 8. The doctor describes a prospective patient who is “well spoken and in good shape, an attractive woman in her mid-40s.” He then says that she “launched into me with a barrage of excrutiatingly well-informed questions.”

In the course of the essay, Dr. Haig describes Susan’s child as a “little monster” and her as a “brainsucker.” He says patients like Susan are full of “half-baked ideas” and are suspicious and distrustful. He also says that patients like Susan are full of “misused, mispronounced words and half-baked ideas” (what happened to her being “well spoken” and informed?) He knew these things about patients like Susan not because of anything she said (she was well spoken, after all) but because “a seasoned doc gets good at sizing up what kind of patient he’s got.” He decides not to treat Susan but to refer her to another doctor. When he declined to treat her, he says she was “disappointed and annoyed,” but she already had an appointment with the doctor he planned to suggest.

It is obvious to anyone but the doctor that she was vetting prospective doctors just as he was vetting prospective patients. It may be that knowledgeable patients get good at sizing up what kind of doctor they have. Based on the essay, her questions were a good way to ferret out a megalomaniacal doctor who could not handle a patient who may know a little too much. He asks whether such patients exist in countries where doctors are in short supply. It is possible that Susan is a selfish prig who wants everything in life on her own terms.

It does not appear, however, that Dr. Haig is one of those doctors who travels to a war-torn country to give his services to those who need them most. Nor does it appear that Dr. Haig has any humility in the face of patients who may know more about their own pain than he. Susan isn’t the only patient Dr. Haig doesn’t like, you see. He describes others as “non-compliant Bozos.” This is a doctor who gives orders and expects them to be followed.

Paternalism, indeed, is not dead.

The Ethics of Medication

Yesterday, I went to the doctor, and he prescribed medication for reflux disease. When I went to pick up my prescription, the cashier told me the pharmacy could not fill it until they received authorization from the doctor. I asked whether the doctor’s prescription was not authorization. It turns out, according to the pharmacist, that the insurance company will not pay for the medication without a written justification from the doctor.

Rather than needing doctor’s authorization, the insurance company was rejecting his authorization. So, I get no treatment for my reflux, which hardly seems fair, but the situation is exasperatingly complicated.

It could be that my doctor, under the influence of pharmaceutical reps, prescribed an expensive medication that is no more effective than cheaper alternatives. If so, it may be in the best interest of everyone, except the doctor and pharmaceutical company, to reject payment for an expensive medication that offers no additional benefits over other medications. Praise to the insurance company for holding the line on costs.

It may be that the doctor knows that the new and expensive medication is more effective and has fewer side effects than alternatives. He may have prescribed what he feels will promote my health and healing better than any other treatment available. In this case, all thanks go to my doctor, and the insurance company is really quite evil.

Or, it could be that the insurance company rejects any expensive treatment with the hope that patients will give up and find cheaper treatments or go without treatment. This, of course, might save money in the short run, although rejecting claims costs money in itself. Sometimes, rejecting a claim is more costly than simply paying it. the amount of staff time and resources tied up on this one prescription is enough to give one pause. The pharmacy says the insurance company won’t pay for the prescription, but I did not press them on how they know this. It is possible they simply consulted a list of preferred medications. It may be that they checked a computer database. Or, they may have actually made a phone call. Any of these options require employee time.

After determining that the drug was not a “preferred” drug, the pharmacy faxed a form to my doctor. If things go as planned, a member of the doctor’s staff will obtain a statement and signature from him before completing the form and faxing it back to the pharmacy. This is an inefficient system at best.

In this case, the patient, me, is going without treatment for reflux, which is causing real problems and can lead, if untreated, to serious problems such as esophageal cancer, which frequently terminates in death. So, who is to blame for the suffering of the patient? Greedy pharmaceutical companies? Doctors under the influence of greedy pharmaceutical companies? Greedy private insurance companies? Or pharmacists who raise problems when there is no problem? I really don’t know the answer.

Is health care better when you pay more?

In a New York Times article today, Reed Abelson makes the bold statement that a new hospital study provides “stark evidence” that higher payments do not translate to better medical care. He is citing a Pennsylvania government study of the 60 hospitals in Pennsylvania that perform heart bypass surgery. Two of the highest paid hospitals also had the highest death rates. This could be for many reasons. These hospitals might take the most difficult cases or the most costly. Either example would cause higher costs and poorer results.

So, the study is too narrow to make sweeping generalizations about health care costs, but it does raise some questions. Noting that this particular study does not prove much, Abelson goes on to say, “Still, the Pennsylvania findings support a growing national consensus that as consumers, insurers and employers pay more for care, they are not necessarily getting better care. Expensive medicine may, in fact, be poor medicine.”

Implied in the article is a call to adopt a pay-for-performance model for health care. The idea is that physicians and hospitals with better outcomes would receive higher pay. On the surface, this seems like a good idea, but there are potential problems. One way to improve outcomes is to deny service to high-risk patients. Abelson’s article notes that Geisinger Health Care is offering a 30-day warranty on its cardiac surgery. Private hospitals are able to choose the best candidates for surgery and have a much better chance of making good on the warranty.

Public hospitals face other dilemmas. Hahnemann University Hospital now says that its record keeping probably did not give an accurate picture of how sick its patients were before coming for surgery. Public hospitals and teaching hospitals take all patients and do their best to save them. Those with the sickest patients are likely to have the worst outcomes. This is not proof of poor care.

The question of how to compare care at different facilities or among different doctors is not one easily answered. Most will agree that better performance should be rewarded, but getting an accurate picture of care quality will require more than counting deaths and dollars. Dr. Richard Snyder of Independence Blue Cross, is quoted as saying, “Philosophically, you’re not going to get an argument from us. We believe we should pay more for high quality than poor quality.” Implicit in his statement is frustration over how to measure quality. Recognizing the complexity of the question is the first step to formulating possible answers.