Michael Tooley’s “package deal”

Further to the May 2013 JME discussion of infanticide was a fairly gymnastic article by Michael Tooley that was in essence given central prominence in the issue.  I say “gymnastic” because, partly by his own admission, Tooley tried to cover, albeit superficially, a lot of ground in a brief essay.  But given that there is so much written, and so much information out there, that one cannot review it all in detail—Tooley himself admits as much vis-à-vis his position—one is often forced to perform similar gymnastics to form a provisional judgment of a series of claims.  And thus do I take to the trapeze for a brief discussion of Tooley’s essay.

Tooley writes that he wants to replace emotional claims with critical thinking, and yet I could not help be irritated by his tone: “pedantic” seems too strong a word, but “tendentious” and “condescending” might fit.  After lecturing non-philosophers on how they ignore critical thinking and eschew calm, dispassionate argument, and in essence telling doctors that they should defer to the wise judgment of professional philosophers (who really are the only ones who have thought long and hard about things) on ethical matters, he urges the reader to accept the “Socratic challenge” that all held beliefs are potentially suspect, and that resistance to some ideas betrays commitment to a “package deal” that includes some basic belief that one is determined to hold despite the evidence.  Of course, opposition to abortion is one such package deal because Tooley apparently has found that all abortion opponents cling to the notion that there is a God.  (He does, in passing, also say that some feminists include abortion support in their own package deal but he does not say anything further about them.)

More substantively, Tooley briefly addresses two strategies supporting “the extreme antiabortion view according to which abortion is always, at the very least, prima facie seriously wrong,” as he puts it:

  • Membership in the biologically defined species Homo sapiens is a suspect ground of moral status because, were we confronted with a lovable extraterrestrial creature that is rational, we would ascribe similar privileged moral status to that being.  We wouldn’t approve of serving him up a la Kentucky Fried Chicken, for example.  (Or, if you prefer, think of the horror of the Narnian visitors eating talking animals in Lewis’s The Silver Chair.)  So, the ground of moral status would be something like possession of “an immaterial, rational soul,” and membership in the species would not be a basic ground for a life to right (the rational soul would be a more basic ground).   But it seems to me that Tooley misses the point here. Humans are the sort of beings which have the ultimate capacity for not just thought but moral judgment, self-awareness, awareness of self-awareness, and so on.  And they are unique within the creation, or the biosphere if you will, as we encounter it.  Were Tooley’s ET to visit us, perhaps we would have another example of the sort of being with ultimate capacities such that it ought to be accorded privileged moral status simply by virtue of being one of that sort of being—a member of that “kind,” or species.  Christopher Kaczor, for one, has defended this position rather more substantially than Tooley seems to be willing to allow.
  • Possession of an immaterial, rational mind or soul is not just suspect, but patently false, for Tooley, because he thinks science has established that the mind and the brain are one and the same.  He calls out Moreland, Beckwith, and Scott Rae (among others) by name—Thomistic substance dualists all.   He may correctly identify their view but he makes it too Cartesian by identifying soul with mind, and he fails to engage the dualist argument with more than a list of science-writer level examples.  Also, in my (limited, to be sure) reading of philosophy of mind, I don’t see people considering Tooley a significant contributor.  So I take his claims against substance dualism as little more than rhetoric.  And substance dualism appears to me to be rather robust in philosophy than Tooley will allow.

Instead, Tooley asserts that “[o]nly neo-Lockean persons have a right to continued existence.”  The “neo-Lockean” person is “an entity that has conscious states at different times, and that are psychologically connected by such things as memories, desires or intentions.”  These are the states that “make for personal identity.”  They persist through temporary losses of consciousness, and so get around one objection (which Tooley considers a “straw man”) about approaches to personhood as consciousness.  And, for him, a right to life is grounded not in an essential characteristic of a being, but in something that is acquired at some point in development.

But it’s not clear why actual rather than anticipatable acquisition of capacities should ground moral status.  If we take care of a baby properly, he or she will quite predictably become Tooley’s neo-Lockean person.  In cases when that is not going to happen, we can still argue, at a minimum, that respect for the sort of beings humans are ought to stay our hand against active killing.  Yet that is not where Tooley is headed.  Because we are talking not just about abortion here, we are talking about infanticide.  And returning to the latter point, Tooley closes by mentioning that, while he thinks human fetuses and neonates “probably” have the same moral status, he seems to be questioning his earlier position that humans acquire capacity for thought episodes only some time after birth.  He says that he doubts that most philosophers are conversant in the relevant science, and that he has not been able to catch up with it.  And so the “crucial underlying scientific premise” that would support killing healthy newborn humans on purpose—viz., that neonates lack the capacity for thought—“has not yet been scientifically, firmly established.”

Well.  And if it is “scientifically, firmly established” that neonates DO have the capacity for thought—as I bet most new mothers would claim, and as I think we ought to assume for the purposes of our moral reasoning—then how established is it that there is NO capacity for thought late term in utero?  And how do we distinguish the unborn healthy 30-weeker from the post-natal 30-week preemie?  And if there is anything whatsoever to the notion that our thoughts have a private character, accessible only to us, how confident ought we to be of our ability to measure the onset of that actualized capacity in tiny humans?  The potential for pseudoscience seems substantial.

And this, finally, underscores Tooley’s own “package deal”—skepticism about the moral status of newborns comes with a firm commitment to naturalism and a physicalist approach to the philosophy of mind, at all costs.  We all start with basic beliefs that we change very slowly, if at all.  And so, rather than think that every belief ought to be held with radical skepticism, we ought to beware lines of reasoning that wind up contradicting the deepest human intuitions and experience—kind of like questioning our work when the answer to a math problem doesn’t make sense.  (I should add that Tooley’s arguments reinforce my conviction—or, in our pluralistic, secular society, should I say “despair”—that naturalism can ground any stable sense of moral obligation.)

In the meantime, while you are catching up with all that Tooley and others have written, I recommend that, rather than abandoning your most basic beliefs, you resist his reading of the Socratic challenge.  Tooley’s approach sounds less like a search for truth than a demolition job.

I wonder whether Socrates would approve.

Physicians call for the “just price” of lifesaving drugs

A group of over 100 physicians who specialize in the treatment of chronic myelogenous leukemia (CML) have published a commentary in the journal Blood, decrying the high price of highly effective drugs, like Gleevec, for the treatment of CML.   The article was spearheaded by Dr. Hagop Kantarjian of M.D. Anderson Cancer Center, an oncologist who has become an articulate and authoritative voice in matters related to drug availability.  (He was prominent in discussions of the drug scarcity problems encountered in 2012.)  Their argument demands serious consideration by anyone—especially economic conservatives and pharmaceutical industry workers like me—concerned about the affordability of modern medicine.

Before 2001, the average survival of someone with CML was 5-6 years, and only about 20% lived for 10 years.  Long-term survival was possible for the subset of patients who were able to undergo a bone marrow transplant.  Otherwise, standard treatment was interferon (the protein drug that disappointed as the putative “cure for cancer” after its introduction in the 1980’s).  But CML has a specific molecular abnormality that can be targeted with a drug, and since 2001, several drugs have been approved.   With these drugs, 10-year survival is over 80%, and people with the disease generally live normal life spans—if they take these pills continuously.

And that’s where the problem arises.  In the US, the price of each of these drugs is about $100,000 or more every year, year in and year out.  Because of the way we pay for drugs supplied by a pharmacist, the patient—who needs these highly effective drugs to live—is on the hook for 20-30% of that.  That’s more than most people can afford, so they may skip doses or not take the drug altogether, greatly reducing the chance of benefit.  Actual survival results for CML in the U.S. are less than they might be, indicating that patients are not all getting the full benefit of treatment.  The CML doctors estimate that only about a quarter of all people with CML are getting these new drugs at all, and that only about 1 in 6 of those benefit from financial support programs, from foundations or the drug companies that make the drugs, to defray the costs.  In other countries, the drugs’ prices are about one-half of the U.S. prices (grossly approximating for the sake of brevity here), lower in countries with stronger government price controls or better competition in the marketplace.

Ah, yes, “competition.”  Regular readers of this blog know that I am an outspoken advocate of more “market-oriented” approaches to medical costs, on the grounds that top-down rigid controls will tend to create scarcity and limit options for individual patients and their physicians, and that insulating people from the costs of their medical care—i.e., socializing every dollar—would inflate those costs (the “skin in the game” argument).  But this last argument clearly does not apply in this case, and as for competition—well.  When it was introduced in 2001, the annual price of Gleevec was $30,000, compared to $22,000 for interferon—seemingly reasonable, given the huge leap in effectiveness.  But newer—and similar—drugs come for the more astronomical prices cited, and in that time, the price of Gleevec has tripled, rather than decrease.  So we have the exact opposite of the normal price competition that we are used to with just about everything else we buy.  Nobody can claim that this state of affairs is acceptable.

How on earth did we get here?  The etiology is multifactorial, as it were:  a process driven by insurers and industry; a “pass-through” mentality by which every new drug gets priced based on the prior similar drugs plus a mark-up; many details and issues related to patents, patent life, and the timing and requirements for generic competition; limits (at least in the U.S.) on price negotiation by payers (out of concern that the 800-pound gorilla, Medicare, will effectively dictate prices, an approach that generally fails for goods and services overall).   After discussing all of these, the CML doctors actually soften their concluding statements to an invitation to “dialogue” about all the factors involved.

This is a problem of justice.  I submit that it is not so much a matter of bioethics or medical ethics than of the intersection between those areas and business ethics.  I do not think that one can wedge the matter of drug pricing into Belmont principalism (except peripherally as a matter of justice), nor can one apply the ethical demands on physicians to pharmaceutical companies as entities, or to their employees.  But we can claim that the industry properly serves the proper ends of medicine, meaning that it takes its signals from what doctors need to help sick people.  And certainly it is basic business ethics to provide high quality products at fair prices.  And it is naturally incumbent on drug companies to adhere to ethical treatment of human research subjects (a non-controversial point).

But the CML doctors—quite understandably, I suppose—call for a (neo-medieval?) search for the “just price” of these drugs.  This seems misguided to me.  They claim that market prices really apply only to luxuries, but “when a commodity affects the lives or health of individuals, the just price should prevail because of moral considerations.”  But food, clothing, housing, automobiles, even computers affect our lives and/or our health, yet we don’t search for the just price for those.  The CML doctors’ claim has clear heuristic value but, if applied generally, runs into the issue of how big an umbrella to unfurl.  Also, I understand the search for the just price to have failed because value does not inhere in a product or service.  Rather, the value is in the judgment of the informed buyer.  Now, for a fair transaction to occur, the buyer must be on fairly equal footing with the seller.  That’s relatively easy when buying a shirt or a loaf of bread or even an iPhone, harder when buying a car or a house, and daunting or impossible when buying medicine.

In this case, however, the buyer is the payer—Medicare, or Aetna, or Anthem Blue Cross, or UnitedHealth, or some other insurer.  And so it seems to me that a somehow-improved improved approach to price negotiation between those entities and the sellers (industry) is in order.   That, in turn, means affecting how the buyers value drugs like the new CML drugs.  And that, further, means that this is an exercise in what costs we are willing to socialize (distribute across a large population), and what outcomes do we—most of whom do not have the disease in question—value on behalf of people who do have that disease?  As I have argued in this space, we should be willing to pay for somebody else’s life-saving drug when that drug is the real deal, as in this case.  While we’re at it, we should not make someone come up with 20-30% of that cost, but reduce those copays.  In the process, we might all accept that we have to pay a bit larger fraction of the costs of our own routine checkups and generic drugs and blood tests and maybe even our birth control pills.  If that means higher insurance premiums to cover truly effective drugs (not marginally effective ones), so be it.  If the whole process creates substantial downward pressure on new drug prices, will that stifle innovation?  I imagine it will reduce the number of new drug candidates in development.  I am not sure that it will reduce the number of safe and effective new drugs.  And I’m less sure that the overall public health or commonweal will be harmed.  Maybe we have to give it a try.

Finally, the CML doctors are right to advocate, aggressively, for their patients in this matter.  Doctors should not have the only “vote” in this discussion, but their collective professional opinion should carry great weight.  This is one of the proper “ends” of medicine, I think.

Gosnell, the Journal of Medical Ethics, and Infanticide

On May 13, Kermit Gosnell was convicted of three counts of first-degree murder—for infanticide.  Some news reports said that the convicted man looked stunned, as if he couldn’t understand why anyone would think he did anything wrong.

The May 2013 issue of the Journal of Medical Ethics was devoted to a serious discussion of the notion that infanticide—as in, the intentional killing not only of handicapped but also healthy infants—is morally acceptable, for the same reasons that abortion, including late-term abortion, is accepted in the West.  That issue of the JME expanded on the prior online publication, in January of 2012, of an article by Giubilini and Minerva.  I found the contents of this issue available online for free (for which I was thankful, because nobody should have to pay for this tripe).  Read it, and it will be clear that the authors, and the editors of the journal, don’t understand why anyone could have been upset that it was published in the first place.

In an editorial, Julian Savulescu states that the Giubilini-Minerva article was published because of “the quality of [the] argument, the contribution to the existing literature, and the relevance to current medicine.”  But the article failed the first two criteria, and ought to fail—at least, in a decent and human society, ought to fail—the third criterion as well.

Giubilini and Minerva argue poorly in their piece.  Two key sentences:  “both a fetus and a newborn certainly are human beings and potential persons, but neither is a ‘person’ in the sense of ‘subject of a moral right to life.’  We take ‘person’ to mean an individual who is capable of attributing to her own existence some (at least) basic value such that being deprived of this existence means a loss to her.”  In a reply, Francis Beckwith points out that this position has been carefully refuted on numerous occasions in recent years, and criticizes the notion of a “potential person” as misguided.  An unborn or newborn baby is not a “potential” person in the way that, for example, a piece of wood is a potential desk or Michael Tooley’s cat is potentially smart if only it is injected with the right potion.  Rather, the fetal or newborn human is a being so ordered that it essentially has the capacity to express, when fully developed, the range of higher capabilities that Giubilini, Minerva, and other like-minded people say confers moral status only when realized—either fully, or fully enough.  What would constitute “fully enough” they are unwilling to venture.  They also claim that refusing the burden of caring for a baby is reason enough to warrant infancitide (as it is, de facto, sufficient justification for abortion under our current legal regime).  But Beckwith demonstrates that, for them, infanticide is morally permissible even in the absence of any burdens—so an appeal to “burden” is irrelevant.

At bottom, Giubilini and Minerva’s paper is nothing more than a rehash of old arguments for abortion and infanticide, without proper regard for substantial criticisms that have been previously and extensively published and discussed.  Accordingly, their article adds nothing whatsoever to the current literature save provocation.  It does have one merit: it serves as a reminder that if abortion is morally permissible, it is difficult if not impossible to declare, on the merits, that infanticide—or, for that matter, the elective murder of children of some indeterminate older age—is not morally permissible.  Several contributors to the May 2013 JME point this out in one way or another.

Finally, the relevance to modern medicine:  In his contribution, Robert George states that “killing an infant because he or she is unwanted is evil” and that advocating it, or its moral permissibility, is “madness.”  And so it is.  To ask seriously, “is it permissible to kill an infant because he or she is unwanted?” or “under what circumstances is it permissible to kill an infant because he or she is unwanted?” is to speak from a heart desperately twisted by evil.  We must forcefully reject the premises of such questions.  They can never be relevant to modern medicine.  They are considered relevant only because we live in the days of the Groningen protocol for neonatal euthanasia—which, we are told, is decreasing euthanasia (or so it is believed) in favor or more abortions, for things like spina bifida.  (An “updated report” is due later this year.)

Apparently, after the online publication of their article, Giubilini and Minerva received death threats.  Such a response is also evil.  That is it was affirmed explicitly by several contributors—both pro- and anti-infanticide, or pro- or anti-abortion—to the May 2013 JME.  But again, the authors and editors don’t appear to understand why there should be such outrage, and some of them seem (rather sanctimoniously, to my ear) to cloak themselves in a sense of martyrdom.   Outrage must be controlled, and supported by proper warranted belief and sound argument.  But correctly-directed outrage cannot be replaced by a cool rationalism.

And so, indeed, in responding to what George has properly called this “madness,” we must be civil but we must not be gentle.  Academic freedom and the First Amendment demand that we abide such talk, at least to a point.  However, serious advocacy of killing healthy infants or children by choice ought not to be acceptable in decent, humane conversation, and we should aggressively press the point that this one has been “asked and answered.”  Daniel Dennett has said that people who believe in God should be dismissed with derision from intelligent conversation.  We must be more patient, but I am tempted to ask whether sauce for the goose is sauce for the gander here.

It is said that Hippocratism arose as a counter-cultural protest movement, and that early Christians bore reproach for their opposition to infanticide.  Those of us who consider ourselves “neo-Hippocratists,” if you will, may be facing such a time again.  I wonder: just how many of our fellow citizens think that Gosnell did something wrong?  Or that he didn’t?  And would not most frankly reject infanticide?  I suspect that most people in the general public don’t realize this discussion of infanticide is going on.  We must educate them.  And we must be polite—but not too nice—in opposing the “experts” pushing infanticide.

Emergent Dualism and the Sanctity of Human Life

My wife and I spent May 10-11 at the annual conference of Biola’s Center for Christian Thought (CCT), where the theme for 2012-2013 has been “Neuroscience and the Soul.”  The plenary talks are not all on the web, yet, although some are on Facebook, but a number of discussions on the general topic may be accessed here.  I encourage readers of this blog to spend some time knocking around the CCT website.

The weekend (though perhaps not the year, more broadly) didn’t have much neuroscience in it.  Most of the time was spent talking about philosophical and theological anthropology—in particular, what is the soul?  As I have previously written on this blog, I am most attracted to a “Thomistic substance dualism” (after Thomas Aquinas) of the sort advocated by J.P. Moreland of Biola, who argues that the “soul” is a simple (it doesn’t have parts) nonmaterial substantial entity that contains all the ultimate capacities of an organism and which is intimately involved in directing that organism’s development and expression of those capacities.  The word “ultimate” is critical here, because, as we all know, not all members of the human race realize all capacities at all times.  Moreland’s development shores up some shortcomings of Aquinas’s dualism (e.g., the notion that human embryos acquire souls at either 40 [males] or 80 [females] days of prenatal development), while attempting to retain its merits.  It, and other approaches that reject equating mind with brain function, appeal to certain Cartesian intuitions, like those of self-awareness, the sense of “what it is like” to have an inward experience, and others.  The philosophers call these “qualia” of mental events, which make them non-identical with physical/biologic events.  At the same time, Moreland and those of like mind reject the radical Cartesian distinction between mind and body in favor of a more wholistic, as it were, view of what the soul is and does.

Now, this fits nicely with the biblical notion of the image of God, even if one rejects Moreland’s view that the image is what man is, not just what man does (tend the earth), or the relationship between man and God, or the “status and standard” of man relative to God, creation, and the ultimate perfection man.  But I would argue that Moreland’s Thomistic substance dualism is not just faith-based, but also supported by formidable philosophic arguments and accessible on the terms of general revelation.   As such, I think it provides the strongest support available for the sanctity of individual and collective human life.  One sees this in arguments most commonly employed (perhaps not surprisingly) by Roman Catholic thinkers like Robert George; to wit, “humans are the kind or sort of being that….”

Two criticisms of Moreland’s view are:

  1. It amounts to vitalism, an otiose idea long-ago relegated to the biology’s scrap heap of history.   Moreland’s rejoinder to this is to claim that bad, old-fashioned vitalism was too crude, and that a more modern view, “organicism,” is more promising.  (I can’t carry on about that, yet.)
  2. Evolution is irreconcilable with the Thomist view of the soul, because the latter requires that genus and species not be degreed properties, but be in a real sense, immutable.  I agree that the Thomist view pushes one there, and I think that (along with Moreland, I believe), as these critics claim, the Thomist view requires one to accept that God is progressively active in creation.  But these points are said to be unacceptable because of the science of human evolution.

So, as an alternative, some philosophers who remain sympathetic to the idea that mental phenomena are not reducible to physical processes, and in fact are different in ways that cannot be fully explained by appealing to physical processes, nonetheless inescapably depend on those processes and “emerge” from them.  However, they would hold, what is emergent is not just mental properties but an actual, and in a meaningful sense, substantial self.  So they are dualists about human nature—even, in a sense, “substance dualists,” but they are less ready to allow that the human soul might exist independently of bodily life and processes—particularly those of the brain.

Now, there is more to be said about this than I can say, here or elsewhere, but it seems to me that the appeal to a “degreed” nature of life or consciousness disallows categorical distinctions of moral status between individual people, or people in general, and other beings.  (It seems to me that the emergent dualist also conceives “soul” as too readily identified with higher mental properties than the Thomist view would insist on.)  It risks making “personhood,” or “dignity” or moral status a degreed property.  Should we be more concerned about an anencephalic baby, or a fetus with Down syndrome, than a fully-endowed and functioning gorilla, and if so, why?  Should we be troubled about creating a human/non-human hybrid, and if so, why?  Would a super-intelligent robot, if there could be such a thing, potentially be a rival of “natural” humans in competing claims for concern?

I tried this out on a prominent Christian emergent dualist at the conference, and he quickly dismissed my objections.  To be fair, I hit him with a “drive by” on the coffee break, but as it happened, when I pushed, he responded, in effect, we can’t base all our moral appeals on rational argument.  Sometimes we have to just demonstrate the truth of the gospel, and show people the choice between worldviews and their consequences, and ask them what do they really prefer?  And, as unfairly as this brief post may be posing the issues, that kind of rejoinder worries me.

Ultimately, some appeal to a “givenness” of human nature is necessary to defend boundaries in bioethics.  We might indeed appeal to the naturalist by counseling caution—evolution has, over millions of years, presented us with ourselves, including our common intuitions—and we ought to have a “default” position of “no-go” on the most “out there” ideas.  We might indeed present a “two views” picture, and ask people to choose what kind of world they really want and what sort of people they ought to be.  We might argue, as I take the German philosopher Jürgen Habermas to argue, that the interplay of human autonomy, human language, and human social relationships lead us to conclude that some technological interventions would tend fundamentally to destroy who we are in community, and so ought to be avoided.  But I think it’s harder to identify, on emergent dualist grounds, what if any specific maneuvers ought to be proscribed with “thou shalt not,” or words to that effect.

The emergent dualists might be right.  (I tend to agree with Moreland that the position is unstable, tending toward either his dualism on the one hand or functionalism on the other.)  If so, we should, as the philosopher I challenged told me, follow the inquiry where it leads.  (One approach that could be called into question is Francis Schaeffer’s approach of asking whether one can live with the consequences of one’s philosophy.)  But my efforts, at least, are still awfully preliminary.

The Egg-Freezing Express

Oh, my.

The “Review” section of last Saturday’s Wall Street Journal (my paper of record) carried a piece by one Sarah Elizabeth Richards, entitled, “Why I Froze My Eggs (And You Should, Too).”  (Of course, she’s written a whole book about it.)

Egg cryopreservation has progressed to the point where human eggs do well enough in a freeze-thaw that subsequent success rates with IVF are, apparently, at least competitive with IVF using freshly-harvested eggs.  So a woman who doesn’t want to risk compromising her career, or who is having trouble finding a mate, can alleviate at least some of the pressure of the “biological clock” for procreation, and have her own eggs frozen and saved for future IVF when said mate has been found.  Ms. Richards reports that freezing her eggs helped her relax, seek a man interested in marriage, and look forward to raising a family within the bounds of what sounds like her hoped-for traditional marriage.  Apparently she has friends with similar experiences and intentions.  And she rejects the tyranny of the biological clock, while acknowledging that nothing is foolproof and motherhood can’t be postponed indefinitely in a woman’s life.

So, insofar as preserving fertility of, say, a young female cancer patient receiving chemotherapy, or—assuming you agree that IVF within the bounds of marriage is ethically acceptable—helping infertile couples, one might argue that egg freezing is a welcome development, a relatively small step that will enhance reasonable family planning and might actually discourage some couples from seeking eggs from a third-party donor.  So far, so good—or, maybe, “so far, so OK.”  (Oh, there was nothing much in the article about the process of inducing ovulation or hyperovulation with drugs, which is tacitly assumed to be risk-free.)

But of course there is no reason in principle for it to stop there.  Ms. Richards acknowledges that egg freezing can help single-mothers-by-choice, and, if a woman’s own eggs don’t survive the process, then “instead of paying tens of thousands of dollars [to an egg donor], [a woman] can buy her eggs piecemeal for a couple of thousand dollars each,” online, from one of several clinics selling eggs provided by some 300 donors.  Gee, I wonder how long before one can get a really great deal at Costco.

It all gives women power over the last area of their lives that limits their opportunity.  What’s not to like?

In an accompanying article, “The Ethics of Egg Freezing,” Christine Rosen of the New America Foundation raises concerns about complications of workplace accommodations for women and families, and she points out that the likely accompanying increase in the use of preimplantation genetic diagnosis will have people seeking “just the child [they] want by choosing its sex” or some other genetic traits.   The greater sense of control brings with it different expectations; viz., people will want the resulting child to match their expectations.  Ms. Rosen would not ban egg freezing, but she worries that if young women routinely freeze their eggs then our society “could develop very different attitudes about children and the arc of a human life.  The danger lies not in a particular technology but how it might allow us to indulge our hubris and pretend that we and our families are not subject to the relentless march of time.”

Check, check, check, check, and check.  Ms. Rosen is correct on all points.   Most people don’t believe in the providence of God anymore, but they do believe in the providence of man (and woman).  (Oh, BTW, over at his “Human Exceptionalism” blog, Wesley Smith recently took to task a recent New England Journal of Medicine piece promoting the sale of made to order embryos.  And Ms. Rosen didn’t comment—as well she might have—that such control, such ‘autonomy,’ could readily come under control of the state someday.  “Ms. Smith, do you have your government-approved pregnancy permit?”)

I don’t pretend that this freight train will stop.  And I would not try to ban egg freezing—for eventual use in, say, gamete intrafallopian transfer.  Old fashioned and inefficient, I know.  But I am convinced that human IVF was a line we ought never to have crossed.  Having crossed it, I agree with the Roman Catholic commentators who argue it is a practice of which followers of Christ ought to repent.  (I know I am at odds with received evangelical opinion here.)   And we must promote an attitude that children are a gift, not a product.  And we must raise our kids and encourage people in general that procreation is properly limited to true marriage—as describe by Robert George’s group, a complete union of husband and wife, body and soul, uniquely ordered for procreation and the raising of children, necessarily exclusive and permanent.

Let’s lean into that.

What Should We Want?

At a biotech industry conference last week, I sat in on a panel discussion entitled “The Affordable Care Act is Here to Stay.”  The upshot:  black crepe all around—biotech-driven research and development of new drugs is going to get squeezed.  And so, it seems, it clearly will be.  And a panelist representing patient advocacy organizations said, “What do patients want?  We want access to all new drugs, we want the drugs to be ever better, and we don’t want to pay for them.”

Okay.

I’ll limit my comments here to oncology, because it’s the area I know best.  There appears to be an emerging sentiment among cancer clinical researchers that a tactical reassessment of the 40+-year-old “War on Cancer” is in order.  To wit:  the story thus far has been to throw money at the problem, rush every possible development forward, and try to piece together every incremental development, no matter how small, to make gradual progress.  (And to hold no end of events “for the cure” in the process.)  And, indeed, this is how progress in cancer treatment has been made; some thunderbolts of discovery have struck, but progress just as often has been slow, and truly apparent only over a number of years, even decades.

Now, however, because the new consensus is that doctors should be paid by the patient instead of by the test, procedure, or encounter; because it’s clear that payment arrangements that reward more and more treatment create incentives for physicians that are questionable at best and frankly unethical at worst; and because the public, through government or through private insurance (and what can be gargantuan out-of-pocket payments), is increasingly unwilling or unable to pay for certain expensive new drugs—for all those reasons, cancer doctors are thinking that good medicine, human decency, and common sense demand more effectiveness from every new drug, and they’re trying to define what they mean by that.  “How high should we set the bar?”

To that end, the American Society of Clinical Oncology (ASCO) has put out for public comment a draft proposal defining “clinically meaningful outcomes.”  I wish I would have been watching this more closely; the deadline for public comment is tomorrow, May 1.  But that notwithstanding, and even if you are not a doctor, I encourage you to look at and see what you think.  Note that however the recommendations come out, what is “clinically meaningful” will be defined by “evidence;” i.e., data from controlled clinical trials, not what worked for Aunt Agnes.  And the recommendations will be an example of doctors raising an authoritative voice on behalf of their patients—what they think they ought to insist a drug do to warrant putting their patients through the risk and trouble of getting them.  As a matter of process, both points are as they should be, I think.

And what should we, the public, consider “clinically meaningful?”  Well, that’s what ASCO is inviting comment on.  The doctors’ voice is authoritative but not dictatorial.   And how should we comment?  From a perspective that realizes that this life is not all that there is, that realizes that death is a conquered enemy, and that understands that human dignity may be challenged by, but is not obliterated by, terminal illness.  And, above all, we in the church should remember that bringing the gospel of eternal life to all is our most urgent task.

A Place Where We Ought to Fear to Tread

The current issue of World magazine includes a brief article about this work going on in the United Kingdom: attempting to circumvent certain inheritable diseases by replacing the mitochondrial DNA in a mother’s oocyte with mitochondria from an oocyte of another woman.  The re-engineered oocyte is then fertilized in vitro, with subsequent implantation of the embryo, etc, etc.  The article’s provocative title was, “Heather has two mommies.”

If one accepts IVF and is inclined to observe the “therapeutic boundary” as placing limits on what genetic manipulations we should be willing to undertake, then this project would seem to qualify as treatment, rather than enhancement, before a new individual person is conceived, and could qualify as an acceptable use of reproductive technology.  And one can argue that the risk/benefit analysis, in a case like this, is clearly positive (perhaps requiring that all embryos so created are implanted with the intent to carry them to term).

But I’m not so sure that a line has not been crossed here.  Still, to object on grounds of “repugnance”—as I would—would seem to succeed only if said repugnance reflects deep, universal moral sentiments and intuitions that are expressions of a natural moral law.  And a lot of people would not find the case here repugnant.  To object—as, again, I would—on the grounds that the undertaking here is part of the transformation of procreation (and receiving of new life as a gift) into manufacturing seems to require that there is an objective, given, human nature and order of human life that must not be tampered with.  If life is God-given and humans are in His image, then it is more natural to make that kind of assertion, but by so doing I think we (I) accept the task of saying what that human nature is.  The image, in that case, needs to be more than just a “status and standard,” or to say that it grounds the human nature we shouldn’t mess with seems tautological.  Alternatively, on more naturalistic grounds, one might argue that evolution “gave” us a core genetic nature (“in its wisdom??”) that “ought not be disposed with,” a tack the German philosopher Jürgen Habermas seems to take in opposing PGD.  Or, we could even invoke a form of the much-maligned “precautionary principle” and claim that, when we start mixing and matching pieces of genomes in newly-conceived people, we don’t know what difficulties we might be wandering into, so we can’t define a risk-benefit ratio in the first place.

Anyway, I think a line something like this—there is, in a meaningful sense, a “core human nature” that must not be altered, and a natural moral law that grounds at least the most basic, primary moral precepts setting that limit—is the line that is necessary if one wants to claim that our biotechnologic grasp must stop somewhere.  And so I want to hold.  None of it suggests that the march of biotech will be slowed—it seems that somebody will try anything that becomes feasible—but it is a basis for asking people to stop and think, and getting perhaps some to turn back.  It is a basis for articulating a “presumption to forbear.”

We Should All Be Cognitivists

I mean that title without irony…

I have repeatedly described myself as a moral realist, and urged that position on readers of this blog.  Again, a “moral realist” thinks that moral statements—statements like, “setting off bombs at the Boston Marathon is wrong”—are intended to report facts (and hence are the sort of utterance that can be true or false), and that, if we have the facts right, at least some of these statements are true.

Not long ago, I wrote on this blog of a naturalist, atheist friend who I thought was nonetheless a moral realist.  Boy, was I all wet.  I hadn’t been listening to him all this time.  He told me that, after some investigation, he could be “taxonomized” (a pejorative term in his view) as a “non-cognitivist, moral irrealist, naturalist.”  That string of terms is internally consistent, anyway.  Non-cognitivism is a form of moral irrealism (while the moral realist must necessarily be a cognitivist).

To approach these matters invokes about a century (plus a shout back to David Hume, at least) of metaethics.  As I have also blogged here, being an amateur philosopher is dangerous business, but I think that some foray into the field is necessary for those of us who style ourselves as thoughtful members of the general public, on bioethical matters.

I am 180-degrees opposite from my friend on all three of his self-characterizations.  For the moment, I want to make a few sketchy comments limited to cognitivism.  Cognitivism holds that moral statements do express beliefs and make assertions that can be true or false.  Non-cognitivists say that moral statements express attitudes such as desires, approval, or disapproval.  A primitive form of non-cognitivism used to be called “yah/boo” theory—as in, “yah” for courage, “boo” for bomb-setting.  But my very limited study indicates that there are now several variants of non-cognitivism, some of which seem hard to distinguish from cognitivist counterparts.  I’m still learning about those.  (Non-cognitivism has come a long way from what I understand to have been the failed initial attempts of the likes of A.J. Ayer to ground the meaning of language in scientific experiment.)

But in a first approximation, I can’t accept a non-cognitivist approach to ethics for several reasons:

1)      Non-cognitivism rests on a prior (and I assert, pretheoretical) commitment to naturalism.  To be sure, it arises in large part in response to the “naturalistic fallacy”—a statement of what ought to be cannot be deduced from a statement of what is without a prior “ought” premise (following Hume).  Or, as G.E. Moore put it, for any natural property it was always an open question whether that property is good.  But I understand the core tenet of naturalism to be that the only facts are those accessible to the various sciences (physical and social), and I reject that tenet.  It seems to me there are mental facts that are not identical to naturalistic events, for example.  Here we get into the complex arguments about supervenience in metaethics and philosophy of mind, and “naturalistic moral realists” make sophisticated arguments along these lines—arguments that I think ultimately fail—but space prohibits writing more about that now.

2)      Intuitively, we act as if moral claims are true or false all the time, and it appears to me that even my friend (for example) appears not to hold just attitudes about what is praiseworthy or deplorable, but real beliefs about justice and injustice.  Or, as Arthur Holmes put it, moral terms we use express evaluative concepts with real cognitive content.

3)      Full-blown moral relativism seems to me an inescapable consequence of non-cognitivism. If there is no moral fact of the case, at any level, in any matter, then to what can one appeal except a test of wills?  Justice becomes “the will of the stronger,” does it not?  Or doesn’t a dispute require, in the end, just a shrug of the shoulders?

4)      “Bomb setting is wrong,” might just be an expression of my attitude, but what about, “I believe that bomb setting is wrong,” or “I wonder whether bomb setting is wrong?”  The latter two examples suggest that cognition is involved in assessing the normative relationship between bomb setting and moral turpitude.  (This is an example of “the embedding problem,” discussed at length in “Moral Cognitivism vs. Non-Cognitivism” in the online Stanford Encyclopedia of Philosophy.  That article seems to me to demonstrate that non-cognitivism is on an inexorably melting ice floe.)

The above are but superficial comments on a beginner’s level, but we have to start somewhere, and I think these matters are terribly important the more I think about them.  “Everyday” bioethicists should be thinking in cognitivist, realist terms, and training our children to do likewise.

Forgiveness, “Everyday Bioethics,” and the Church

A recent email message directed me to a warm and personal post entitled “Forgiveness and Aging,” by Dr. Al Martin over at the Hastings Center’s “Over 65 Blog.” (Dr. Martin, an academic physician who has also been Chief Medical Officer of Blue Shield of California, writes a blog called Age with Spirit that looks worth periodic visits.)

Check it out.  Dr. Martin’s thoughts, and the initial comments posted in response, are fine reflections on what it means to forgive.  Dr. Martin’s big point is that, as one’s life on earth winds down, one should seek to forgive, and not carry destructive anger or resentments all the way to the grave.  Amen to that.

My response, as a Christian layman and amateur bioethicist, is that this topic is right in the Church’s wheelhouse.  I remember Pastor John MacArthur once preaching that forgiving another person is the most God-like act one can perform.  Surely the ability to forgive is accessible to people in general, as part of common grace.  But as I recall the Lord Jesus Christ’s command to forgive “seventy times seven,” I’m also reminded (especially right after Holy Week) that he forgives to the nth degree, and calls us by the power of the Holy Spirit to do likewise—to exceed “normal” human capabilities.  And surely demonstrating and preaching forgiveness should be at the forefront of Christian bioethics.  I, for one, can get so wound up in arguments that I risk forgetting that living and preaching the Gospel comes first.

Further, I’ve found that bioethics can take me into a sort of echo chamber that is foreign to my fellow churchmen and –women.  Frankly, a lot of what we talk about, and the way we talk about it, goes over the heads of most people, doesn’t touch their daily lives, or can get too easily separated from critical spiritual concerns.  Last summer I spoke to my congregation about end-of-life issues, and I was quickly drawn to base my reflections in how we view, hold to, and, eventually, must relinquish this life, in light of the hope of eternal life with Christ.  And I was drawn back to the Scripture of course, but also to the medieval ars moriendi.  By them, the believer is encouraged to practice five “Christian graces”—reaffirmation of faith, hope for forgiveness, charity and patience, humility and recollection of sins, and detachment—to counter five parallel temptations:  lack of faith, despair, impatience, complacency, and greed.  The big aim, of course is for us, as we approach the end of life, to prepare for that, and, indeed, to prepare to meet our Maker.  (Oswald Chambers said that we should be ready to meet Jesus “at every turn.”)  This clearly includes forgiving others and seeking reconciliation (and being willing to pursue it when sought by a dying relative or acquaintance).  It also clearly includes consistently pointing to Christ, and what it means to be forgiven and to forgive.

The writers at the “Over 65 Blog” are thinking a lot about end of life care, “futility,” and public policy, to be sure, but they are also reflecting on the challenges of getting older.  As I get older, I hope I can link up with that effort.

Three Stem Cell Developments

The news this past week carried three reports related to developments in stem cell research.  Briefly, starting with the farfetched and ending with the “nearfetched”:

First, the Wall Street Journal reported on efforts to “grow” human organs in the lab.   People who try to “keep score” of therapeutic results with adult vs. embryonic stem cells may recall a case in recent years in which surgeons (in Germany, I believe) fashioned a new trachea, or windpipe, for a patient using that patient’s own adult stem cells.  The current report follows this track.  In its most daring application, a heart is “grown” in the lab.  Well, not exactly: it’s not like researchers expect a clump of cells to magically take on the full, functional form of a human heart in a Petri dish.  (I’m sorry, I should be serious, but I cannot but recall my late, lamented Weekly World News carrying the front page story that Hitler’s nose had been cloned in a Petri dish—complete with a photo of the darn thing, mustache included.)  Seriously, these researches take an approach similar to the windpipe case.  They obtain a donated heart from someone who has died (i.e., a cadaver heart), and strip off all the cells, leaving only the foundation of connective tissue, the scaffold on which the functional heart cells had rested.  Then, they take adult stem cells—the idea is that these come from a patient whose heart is failing, who ordinarily would need a transplant—and place those on the scaffold, taking steps to induce the cells to differentiate into heart cells.  It’s still very early, but in concept this approach to organ engineering looks promising.  The cadaver heart need not be fresh, as it must for a transplant as currently practiced.  That means that there is no urgency to harvest the heart immediately after death, and there would be no pressure on the definition of death, and no concern about over-eager transplant surgeons jumping the gun.  Also, the “scaffold” is not particularly immunogenic, so the patient’s immune system would “see” the immunologic type of the patient’s own cells.

Now, there are years—10, at least—of research needed to find out whether this will work, but the approach appears promising.  If it does pan out, it seems to me the principal ethical issue invoked will be justice:  how much will it cost, and who will be able to get it (i.e., will we socialize the cost)?  That is for another day.

Second, a federal court let stand a decision favoring the FDA over Cytori Therapeutics, in a case involving the company’s device that allows surgeons to separate out adult stem cells from a patient’s fat.  The initial application has been in breast reconstructive surgery, and I believe the device is approved in at least one country outside the U.S.  In the U.S., however, the FDA is going to insist that the company prove, in a large, randomized clinical trial (at least one of which is in progress) that the device is safe and effective.  This places the device in a high-risk regulatory category (like, for example, cardiac defibrillators), not a lower risk category that would allow the company to get fast approval simply by showing that the device is similar to a prior, or as the FDA calls it, a “predicate” device.  (There are further nuances, because in some cases, if the risk is low enough, FDA lets a new device without a predecessor serve as its own “predicate” device, but that is too far into the weeds for this post.)  In any event, the court sided with the FDA, and the company was not surprised—this has been going on for a while.  But it is consistent with FDA’s approach to adult stem cells in general, which is that the Agency views them as sufficiently manipulated to require full-blown development, as for new drugs—even if all a doctor does is take tissue from a patient, spin it in a centrifuge to pull out the stem cells, then re-inject the same stem cells, with no other doctoring, back into the same patient.  That, in turn, is what lay behind the State of Texas trying to circumvent the FDA in recent past, to let doctors use adult stem cells in some ways for their own patients.  But the FDA will win this, in the end.  The net effect will be to slow down the availability of treatments using adult stem cells, and to make it necessary that deep-pocket companies bear the costs of the research.  On the margin, as I have blogged in the past, I think the FDA’s maybe being a bit too conservative, but “it is what it is.”

Third, the California Institute of Regenerative Medicine (CIRM), the body that was created with several million dollars’ funding a few years ago, largely for the purpose of promoting research with embryonic stem cells—which require destruction of one or more embryos to be obtained—is establishing a stem cell bank—not with embryonic stem cells, but with induced pluripotent stem cells (iPSCs) and adult stem cells derived from them.  Cells will be obtained from people with a variety of chronic diseases that are priority areas for research supported by the CIRM.  Makes all the sense in the world from the standpoint of basic and translational (applied) research.  The takeaways?  The CIRM is following the science, and not all of the research it supports is ethically questionable (although some still is, and there are other issues with how the CIRM operates that I won’t go into here).

To close, a reminder to scientifically uninitiated social conservative types:  we are not “against stem cell research.”  We are against unethical research, including research that does not adequately protect human subjects (including the unborn), wherever it is proposed.