What is Bioethics? Commentary on Harris & Sass on The Eubios Declaration, Biswas on Holistic Health Care, Yu Kam Por on Futile Medical Treatment
- Frank J. Leavitt, Ph.D.
Chairman, The Centre for International Bioethics
Faculty of Health Sciences
Ben Gurion University of the Negev, Beer Sheva, Israel
Fax: + 972-8-6477633
Eubios Journal of Asian and International Bioethics 12 (2002), 162-4.
I would like to comment on some items which appeared in the July 2002 issue of EJAIB.
I. Harris on the Eubios Declaration:
I have had a number of debates with John Harris in our work on the Board of the International Association of Bioethics. So I was pleasantly surprised to see that I do not totally disagree with his first point of criticism of the Eubios Declaration for International Bioethics. (EJAIB 2002; 12:122) John opposes "off the cuff declarations" which he says: "add compromise to compromise in pursuit of consensus". It is unfair to call the Declaration "off the cuff". We worked hard on it. On the other hand, I have my own doubts about the value of "consensus". Almost every time I have co-authored an article on ethics, I have had regrets afterwards I once published an article on human growth hormone for healthy, short stature children, with Dina Pilpel, an epidemiologist, and Esther Elizur-Lieberman, a pediatric endocrinologist. I was against. Esther was in favour. Dina was in the middle. In trying to agree, we ended up publishing something so insipid that we would have done better if we'd each published our views individually, no matter how one-sided. Then at least we might have said something interesting. I am also skeptical about the value of consensus or uniformity in clinical ethics. Life, which is what bioethics is about, contains so many deep unknowns -- and each case is so different from the others -- that it is futile to expect everyone to agree. I would not try to impose a uniform DNR policy, for example, on all the internal medicine wards in one hospital, let alone an entire country or the world. On the other hand, sometimes the process of trying to achieve consensus, even if the goal is never achieved, can be a valuable educational game for sharpening our thinking and clarifying our ideas. The journey-- as Leonard Wolff entitled his autobiography -- and not the arrival matters.
All in all, however, I do not think that consensus is a goal worthy of a great deal of effort. We can disagree and still be friends. I think that the UNESCO - IUBS - EUBIOS Bioethics Dictionary is therefore a better vehicle for encouraging us to think together, than is the declaration. In the dictionary, I am happy to say, we made no effort at consistency, neither between entries written by different authors, nor between entries written by the same author at different times. This is part, I think, of why it is called a "Living Dictionary". Existence is just too deep to expect anybody, let alone a group of people, to say much about it without entailing some contradictions. Look at the great philosophical systems -- Descartes, Spinoza, Kant, etc. The philosophers tried to be consistent, but the scholars are always finding contradictions. And look at the difference of stature! Maybe this is why my former boss, Velvl Green, used to say that consistency is a mark of a small mind. The great philosopher, Bertrand Russell, tried for consistency within individual books, but he didn't mind changing his mind from book to book, and article to article. When he found a contradiction within his mathematical logic, his German colleague, Frege, who believed in the same mathematical logic, got quite upset. But Russell did not mind. He happily regarded the contradiction as an inspiration to go on and study more deeply. Bioethicists should read some of Russell's writings as an inspiration to put such ideas as "consensus" and "consistency" into proper perspective.
Paragraph 16: John says that sales of bodies and body products "can be ethical". I say that it can not. Philosophers used to have what they called the "Principle of Verification" according to which a statement is meaningful only if you have a way to decide conclusively whether it is true or false. Otherwise it is nonsense. I am unaware of any decision procedure to decide who is right: John or I. Indeed I am not sure that the purpose of bioethics should be to imitate Halacha or Canon Law, and to decree what is permitted and what is forbidden. I think we should be spending more time thinking about the meaning of life. But, again, the process of somebody saying that something is ethical, and somebody else saying that it isn't, can lead to some deep communication.
John says: "Perhaps we ought to exploit someone in order to save life". If we take this out of context, it makes sense. I would steal a car (exploiting the owner who invested in it) in order to rush a wounded person to hospital. But in the context of organ transplants, we are talking about poor people who have been tricked into undergoing "medical examinations" for purposes of employment, who have been anaesthetized (for the sake of the "examination") and had kidneys removed, and have then been sent home with a few coins, after being declared "unfit for employment". We are talking about mental patients who have been killed for their organs. In this context, it is hard to take John's statement seriously.
Paragraph 22: John says: "Why add this burdensome qualification to germ line therapy but not to somatic line therapy?" I am not a biologist, but I think I am right to say that there is no such thing as a "somatic line". Somatic therapy means that it stops with this body. It does not get passed on. But this is exactly the point. If I give informed consent, then maybe it is alright to try anything on my body, if it is not going to affect my generations. Another question, however, is whether a gene therapy can really be kept "somatic". Can we be sure that a somatic therapy won't get to sperm? That is a question for the biologists.
Paragraph 24: I agree with John, and favour including him in the moral community, even though he does not wish to work towards the love of others. I also agree that love is probably neither necessary nor sufficient for morality. A really nasty guy can be quite moral, while one can make many moral mistakes out of love. Indeed loving someone does not ensure we shall do the best for that person. How many people have been made miserable by misguided love? I remember a female student who was made miserable by an older male student who fell in love with her. He made her life so unpleasant that he had to be expelled from university. And consider a terminal patient. The statements: "I love this patient; so I shall do everything to save his life", and "I love this patient; so I shall help him end his suffering by dying", can both be right. But although love does not solve all bioethical questions, it is certainly not a bad thing. With everything considered, it is probably better for more people to love, than for less. A pluralistic ethic should give love an important place.
Paragraph 15: John asks: "What does 'life is the common heritage of life' mean?" Before answering, I want to tell a story which was told by American philosophers in the 1950's and l960's. Two American philosophy professors were discussing a colleague. One said: "He used to be a good philosopher. But then he went to Oxford for a sabbatical. Now he doesn't understand what anything means any more."
The point is that in those days, under the influence of Wittgenstein, Austin and the "Ordinary Language Philosophy" movement, philosophers got into the habit of asking "What does that mean?" (with a sort of derogatory tone to the word that), rather than sitting down and making a genuine effort to understand one another. (I have a right to be critical, because I did my own PhD in philosophy in Britain in the 1960's. So I am one of the guys whom I am criticizing.) In this case the meaning of the phrase is obvious, if you think about it. The phrase: "Life is the common heritage of life" is a way of expressing the feeling many of us have that there is something wrong with patenting a genome, or part of one. Genetics has taken a lot of mystery out of the "secret of life". It is beginning to look like just another mechanical process. But some of us are not ready to relinquish the miraculous that quickly. Giving someone an exclusive right to a form of life seems like going too far too soon. Have I given the phrase a clear meaning? No. But a meaning does not have to be clear, to be a meaning.
Not everything which can be thought can also be said. Not everything which can be said can also be said clearly. Nor do we have to be silent about everything which we have not yet figured out quite how to say. Biology and medicine have changed the world. The old concepts don't work any more. This is the point which I believe John misses. I want to give some examples to explain. All religion, literature, myth, all over the world, contain the assumption that people are creatures which come into existence as a result of sexual intercourse. The counterexamples: Adam, Hava, Jesus, Athena, are poignant and effective myths only because they are so impossible. And think of how much of our psychological makeup is supposed to result from our relationships with our fathers. And your father is somebody who lay in bed with your mother, and did what men and women like to do in bed. And we come into existence from that act. The Oedipus complex is a well know example of how this fundamental fact of existence is said to influence who we are. But since the first human artificial insemination, we have had to grapple with a new fact: people who do not have fathers, in the old sense of the word: father. The debates about human reproductive cloning are really too late. All the questions should have been asked before the first human AI. This is a new situation, which requires us to grope for a new language. The loving man, who raises, and is the male figure in the home of, an AI baby, if he is called the father, is called such through a metaphorical extension of the meaning of the word. Perhaps another word should be found for that loving relationship. We are groping for a new language, appropriate for a new world.
It is as a result of this groping that bioethics has come into existence. The old modes of dealing with our world are inadequate. Consider as another example, Halacha, Jewish Law. On such important matters as abortion and brain death, two rabbis can come to quite opposite conclusions, while they base themselves on exactly the same traditional sources. Using the same sources, some orthodox rabbis forbid aborting a baby with a serious genetic anomaly, and others, equally orthodox, permit it; some accept that brain death is death, and others deny it. This shows that the traditional sources are not what decide the issue, they are no longer adequate. (I believe the same sort of thing can be said about Christianity, Islam and Buddhism. But I know more about Judaism, so am using it as my example.) I do not deny the profundity of traditional spiritual sources. Bioethics should and does consult them. It should and does consult philosophy as well. But none of these sources is quite adequate.
The situation is not exactly as if we once knew what life and existence were, but biology and medicine have changed life and existence so much that we no longer know what they are. The situation is rather that we never knew what life and existence are. When I used to teach formal logic, I would write backwards "E", meaning: "there exists something such that....", and thought I knew what I meant. And if asked to explain, I would define existence in terms of truth, or the satisfaction of a sentential function. But I never knew what these things were either. I am not saying anything new here. Philosophers always admitted that if these things could be defined at all, the definition had to be circular. But we did not see that this admission had much relevance to life outside of the lecture hall and the library. The great contribution of medicine and biology to spirituality and bioethics is that they forced us to take seriously the fact that the most basic things are the greatest mysteries. And they must be thought about when we make decisions about life and death.
It is because of the inadequacies of old language and old sources, that bioethicists sometimes have to resort to unclear ways of saying things (like "life is the common heritage of life"), simply because what we are trying to talk about, life, is so unclear itself. This calls for a sympathetic effort to work together to make sense of our new world, rather than getting derogatory. This sympathetic effort is what I call bioethics.
Paragraph 27 John says: "People are not equally diverse -- what rot! Some must be more diverse than others unless this is not an empirical but a religious point" This is what I mean by getting derogatory. I shall, however, resist the temptation to pass over it all with some analytic philosopher's phrase, like "What does what rot mean?" Instead, since John is a philosopher, I will try to give him a philosopher's answer. I must ask the non-philosophers among our readers to forgive some technical language. Assume, now, that there are N particles in the world. We need not specify whether N is infinite or finite. Now if we think like mathematical logicians, it is easy to accept that every person participates in at least one relationship with each of these particles. But given the unique spatio-temporal history of each person, the relationship(s) which one person has to any given particle must be different from the relationship(s) which another person has. So everybody is diverse from everybody else in exactly the same way. So people are equally diverse, quod erat demonstrandum. Nor is this trivial, because you really cannot say what effect any given particle is having on one's genetic or environmental makeup.
II. Sass on the Eubios Declaration
On the other hand, I want to express my agreement with Hans-Martin Sass's suggestions for revisions, especially his suggestion to add to Section 7, the words: "and to respect the moral choices made by fellow humans." It is important to emphasize that life and existence are so deep and complicated that only a pluralistic bioethics can be realistic. Indeed, maybe the reason we say bioethics, rather than bioethic, is to recognize that there must be not just one ethic but many ethics. I would like to go a little further than Hans-Martin and to suggest we add a section recognizing the importance of respecting the moral choices of others, even when they differ from our own. But I am not yet ready to try to formulate such a section, because I do not yet know how far to go in tolerating views and behavior which are obviously morally odious. If some people, for example, have chosen in favour of genocide, and are acting to carry out their choice, can we respect them? It may sound strange and paradoxical, but I must say that if we are fighting against such fiends, trying to prevent them from carrying out their aims, then
we must respect them as professional soldiers. If we do not respect their dedication and their ability to carry out their evil goals, then we cannot hope to defeat them. But this is professional respect, not moral respect. We cannot respect them morally. But to what extent can we morally respect decisions of those with whom we strongly disagree? It seems obvious that someone who decides in favour of genocide does not deserve moral respect, while someone who differs from me on a decision as to whether to comply with a specific request for DNR in an internal medicine ward, might very well deserve moral respect. But I am not yet sure how to explain the difference philosophically. This is a complex issue on which we should have a seminar some day.
III. Biswas on holistic health care.
The article by Rakesh Biswas and colleagues, from Nepal, also in the last issue, (Developing holistic health care in the third world: A working study proposal. EJAIB 2002; 12: 143-147) is more to the point of bioethics. They attempt to apply the method of "narrative" to understand their patients in the context of their lives and cultures. A statement by their student, Binod Dhakal, who took part in the study, sums up, in my opinion, the central point of global bioethics: "Medicine," Dhakal says, "might take greatest pride in itself in taking a giant step from cloning to designer babies but it must take into account that there are still a large fraction like this who because of poor access to health are forced to an untimely and undeserved death."
The one critical point which might be made about the paper is what I am sure a number of my physician friends would say. All this cultural and personal narrative is interesting, they would say, but once you know the disease the patient has, and the drug that can cure it, who cares about the cultural context? Just give the drug, and be done with it.
This kind of objection has some truth to it, but it lacks an understanding of what Binod Dhakal calls the "poor access to health [care]", which is probably the situation of most people in the world. Once someone is already sick, if you don't have the drugs then cultural narrative probably won't help very much. But a lot can be done for prevention, especially through low-tech education. And you need to know about local culture and habits for this. To teach STD prevention, it helps to know about sexual behavior. To try to change toilet habits, to prevent infectious diseases, it is good to know about current toilet habits. To try to influence nutrition, it is good to know about eating habits.
The paper by Rakesh Biswas and colleagues is definitely in the direction of what bioethics should be about: implementing the principle of distributive justice, developing the concepts necessary to improving the health of the medically deprived people of the world. I hope they will write more for the Eubios Journal, and I would like to encourage them to focus more on prevention next time.
IV. Yu Kam Por on Futile Medical Treatment and Passive Euthanasia:
The article by Yu Kam Por, (Terminating futile medical treatment and passive euthanasia: is there a difference? EJAIB 2002; 12: 137-138) in the last issue, is an example of what I mean by bioethics, grappling with the inadequacies of old language, and with the challenge which bioethics has of developing new concepts and terms in the fact of new developments in medicine and biology. Yu Kan Por comes "to the conclusion that the two are substantially the same thing". But I would like to suggest that Por misses an important difference. The Oxford English Dictionary, internet edition, defines "futile" as "incapable of producing any result; failing utterly of the desired end through intrinsic defect; useless, ineffectual, vain". I am not going to argue that what the OED says is always right. As I have suggested in at least one earlier editorial commentary in Eubios, I believe that anyone has the right to use words any way they like. Language is a developing thing, and there are no authorities. But this does not mean that the OED is always wrong. And it does have a point here. Keeping an unconscious or a suffering terminal patient on life support systems may, in certain circumstances, be undesirable or even cruel. But it is not futile. That is just not a good word for it. It achieves a result, or an end, which is keeping the patient alive. Whether this end is the ethically good end or not is irrelevant to whether or not the action is futile. On the other hand, taking a patient to an operation, when you know that the operation will not help, is not totally futile if your desired end is to make the family think you have done your best. But it is medically futile. It is also medically futile -- outside of the context of terminal patients -- to prescribe antibiotics for flu, when every well informed doctor knows this will not help. So I propose keeping the phrase," terminating medically futile treatment" for stopping any treatment which serves no medical purpose, in contrast to "passive euthanasia" which has to do with withholding or withdrawing life sustaining treatment.
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