Human Flourishing in the Face of Suffering

In early January 2012, I learned that the title of this year’s bioethics conference was to be “Health and Human Flourishing,” which set my pondering wheels in motion. Human flourishing is a term that has been conscripted into service in the bioethical community—particularly the Evangelical bioethical community–in recent years as a semantic alternative to the Aristotelian notion of “eudaemonia”–“the Good” or “Happiness”–both which have been corrupted in contemporary vernacular. The term has been offered as a framework for understanding and conceptualizing our approach to technological innovation in order to positively promote progress in the health and well-being of the human community, but it’s content is seldom defined. Even in the book Health and Human Flourishing: Religion, Medicine, and Moral Anthropology, a collection of essays edited by Carol Taylor and Robert Dell’Oro (Georgetown, 2007), the meaning of the term is assumed, not defined. But what is flourishing–what does it mean to flourish? How does one flourish? And in particular, how are we, as Christians, to understand flourishing? Querying others outside the ethical and bioethical arena yielded a general response of cluelessness: most seemed unfamiliar with the term, let alone the concept. This launched a one and a half year journey through Scripture in search of a biblical perspective on human flourishing with which to frame and fill the content of the concept.

While the fruits of that labor and journey will be presented at the conference, I want to share a particular insight here. One note that resonated clearly throughout Scripture, although more loudly in the New Testament, is the relationship of suffering to flourishing. Suffering, in Scripture, is not incongruent with flourishing; in fact, not uncommonly, flourishing is by way of suffering. This paradoxical fact is made explicit in Mt 5: 10-12 where those who are persecuted, slandered and insulted are said to be blessed. In this passage, it is suffering that is acknowledged and allowed by God. But in other passages, that suffering is seen to come directly from the hand of God: suffering in the form of discipline or chastisement (Rev 3: 19); suffering that is evidence of God’s love (Prov 3: 11-12); suffering that ultimately leads to flourishing (Job 5: 15-26). The purpose of God in such suffering—pastorally referred to as “pruning”–is to bring about repentance and proper orientation to the Law or Word (Ps 94: 12-14; Ps 119: 71) and to produce holiness and fruitfulness in our lives—fruits of righteousness (John 15:2, Heb 12: 10-11). Suffering therefore keeps us on, or returns us to, the path—the εὐοδόω, or good way– that leads to our ultimate fulfillment, to a fuller revelation of God Himself.

This relationship of suffering and flourishing is contrary to contemporary culture where the old motto “no pain, no gain” has been modified to fit its new conception of the good life: “no pain, no pain.” It is also the orientation of most of biotechnology whose primary objective is painless immortality—the elimination of pain, suffering, and death at all costs–which is objectively measured by quantity of life and visual analog scales. There is no room in such objective calculations for consideration of flourishing as a subjective and relational reality, or for the fact of pain and suffering as means of flourishing, leaving the secular notion of flourishing at odds with the Scriptural concept. Yet it is often suffering that leads us to Christ whereby we can be healed and consequently flourish.

Biotechnology offers us a portrait of human flourishing distinct from that of Scripture, one that entails a “different gospel,” offering us the hope of freedom from suffering and death through technology and biotechnical means. Such freedoms stand in opposition to the role of suffering demonstrated in scripture where suffering is often a means to flourishing. This new gospel of flourishing proclaimed by biotechnology is not grounded in a dependent relationship with a Creator God but in the self-sufficiency of human creativity and ingenuity, in the power, strength, and determination of our will. It is an ill-conceived notion of human good that sees that good as devoid of pain and suffering; it is a gospel for which the means are justified by the ends, the ends of our choosing. Biotechnology, when employed for purposes of self-glorification and salvation is a thief who has come to kill and destroy, whereas abundant life (flourishing) comes from Christ.

This does not require that we reject all that biotechnology has to offer. Human flourishing is not exclusive of health, longer life, ease of life or material prosperity, for God is a God of mercy and redemption, who gifted and enabled us to redeem some of the consequences of our own sinfulness. What is necessary is a proper orientation toward God in the midst of biotechnological pursuits, a discernment of His purposes and plans for human flourishing in this world and the role that biotechnology might play in those purposes. It requires an understanding of the limitations of biotechnology and the positive role of suffering can play in our lives. For God enables our flourishing when we have turned from and been cleansed of the idols, especially the idol which is the work of our own hands. But it is God who is the source of our flourishing–our “eudaemonia”–and not we, ourselves. And it is God who confirms and gives permanence to the work of our hands.

On (Being) “Better than Human” – Part 3D

With apologies in advance to my readers for the length of the recent posts in this series, I finish up here my critique of Allen Buchanan’s argument in Chapter 2 of his Better than Human. This chapter contains a great deal of theoretical machinery, which machinery will prove central to Buchanan’s argument in the rest of the book. For that reason, I have spent considerable time on those details in the last few posts, with a view toward proceeding more economically through the respective arguments of subsequent chapters. I beg the reader’s indulgence.

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First, as we have seen, Buchanan prefers to think of evolution as being more like a “morally blind, fickle, tightly shackled tinkerer” than a “master engineer.” He makes much in particular of the fact that evolution is “morally blind,” using the cruelty of nature—both in the way it selects against certain traits and in the way it selects for other (“beneficial”) traits—as a point of departure for pontificating on the Problem of Evil (pp. 37-39), which he defines as follows: “Given how much human suffering there is in the world—much of it utterly undeserved—how could such a world be the creation of a being that is both all-powerful and supremely good?” (p. 37).

In this context, Buchanan contends that Darwin’s theory of natural selection not only deals a “blow” against the very notion of there being an intelligent designer, but also strikes another, “equally devastating blow against religion: It shows that the Problem of Evil is even worse than we thought” (p. 37). As Buchanan points out, “the whole survival of the fittest thing is astonishingly cruel,” leading him to ask the question: “If God is supremely good, why would he choose such a bloody mode of creation?” To the suggestion that our suffering is “compatible with God’s goodness because suffering enriches our lives, builds character, etc.,” Buchanan rightly points out that “many humans—especially children who die from violence or diseases and the millions of young men who die in war—experience suffering without much opportunity for gaining from it” (p. 38). But, Buchanan objects, “God’s making them suffer so that you and I can have a deeper appreciation of existence seems obscenely unfair” (p. 38). Moreover, “it appears there’s surplus suffering: God seems to have given us more than enough of it to make his point” (p. 38).

Even granting that human suffering might, perhaps, enrich our lives, Buchanan asks, how could it possibly have value for other, non-human creatures? As Buchanan puts it, “[t]he elk that’s devoured by wolves while still alive can’t console itself with the thought that elk life is enriched by character-building suffering. Thinking that the good that humans get from our suffering is so wonderful that we can simply turn a blind eye to the misery of all the other creatures seems a tad anthropocentric to me” (p. 39).

The “central point” of these reflections on the Problem of Evil, for Buchanan, is simply this: “IGM has the potential to achieve the good results of UGM, without the butcher’s bill” (p. 39). If we can, for example, introduce beneficial genetic changes more quickly and with fewer deleterious effects than the (unassisted) process of UGM would otherwise produce, this gives us good reason to consider pursuing IGM. Or, as Buchanan sums it up: “Evolution doesn’t count the cost of its improvements and it doesn’t care how the costs are distributed—it’s morally blind. If IGM can achieve the good that UGM achieves and do it not only more quickly, but without the moral costs, then that counts heavily in favor of it” (p. 40).

All of this is both de rigeur and “par for the course” when it comes to discussions of the Problem of Evil in the contemporary philosophical literature, and a thorough discussion of that problem is beyond the scope of this post. With respect to Buchanan’s attempted foray into the philosophy of religion in this context, suffice it to say that his comments here are less than persuasive. For one thing, we might ask the following question: might a perfectly good, all-powerful Creator have a good reason (or set of reasons) for permitting such suffering/evil to occur—i.e., some reason (or set of reasons) other than, or in addition to, “enriching” our lives? If this is possible, then it will hardly do to simply point out that there is such suffering/evil, intimate that we don’t understand what the good reason for it might happen to be, and then conclude from that fact that, therefore, there is no Creator.

More fundamentally, what if we, too, are not only epistemically but also “morally blind” as well? Given our own epistemic and moral limitations—especially our propensity toward moral evil—is there any good reason to think that we would do any better a job (through IGM) than UGM has done thus far?

One might argue, further, that talking about “suffering” (etc.) makes sense only in a theistic universe, i.e. one in which there is an intelligent designer of some sort. It certainly makes little, if any, sense in a strictly naturalistic universe, at least not in the sense in which Buchanan intends here—namely, that in which such “suffering” is morally significant.

Finally, Buchanan speaks of the ubiquity of “design flaws”—“suboptimal design,” he says, is “everywhere” (pp. 30-31). But speaking of “design flaws” in the products of evolution presupposes some sort of objective standard against which such deviations or “imperfections” are measured. Such a standard, in turn, may also imply the existence of a “species standard.” At the very least, it opens the door conceptually to one: if an objective standard is possible, then why couldn’t there be a full-fledged species design as well? And if a there is such a thing as a “species design” after all, then there may very well be good reason to be wary of the prospect of IGM.

In the end, if all you have just is a strictly naturalistic universe, then all you have just is life, death, development, coming into and going out of existence, etc., of various species. On such a scenario, “design flaws” are such only with reference to purely subjective criteria (individual goals, objectives, etc., of an organism), certainly not with respect to any objective standard of design. So it becomes difficult even to speak coherently of a design flaw.

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In the next post in this series, we will move on to an analysis of Chapter 3 of Better than Human. In that chapter, entitled “Changing Human Nature? Or, Unnatural Acts, and Not Just with Sheep Like Dolly,” Buchanan addresses the “changing human nature” and “changing biology” objections to the enhancement enterprise, respectively.

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Works Cited in this Post:

Buchanan, A. (2011). Better than Human: The Promise and Perils of Enhancing Ourselves (Philosophy in Action Series). New York: Oxford University Press.

In praise of the Myriad Genetics decision—as far as it goes

The U.S. Supreme Court has recently been handing down a series of controversial decisions (as if you hadn’t noticed).  But a less contentious decision, nonetheless meaningful in bioethics, was the unanimous decision two weeks ago in Association for Molecular Pathology et.al. v. Myriad Genetics, Inc., et.al. 

Myriad Genetics has marketed a test for the cancer susceptibility genes BRCA1 and BRCA2, certain mutations of which greatly increase the risks of breast and ovarian cancer in women.  Their patent included the full sequence of these genes, as found in nature.  Enforcing that patent meant that any other company or lab—including a university lab or independent lab—was guilty of infringement if they attempted to test a woman for mutations of these genes in the course of her medical care, regardless of the method of testing used.  That in turn meant that in practice the Myriad Genetics test, along with its high price, had to be used.  The patents were challenged in court.

Myriad Genetics had discovered the naturally occurring gene sequences and claimed them in their patents.  The court held this part of the company’s patents invalid; one may not patent a discovery from nature, without creating a new substance or a new method of using that substance in an invention.  This opens the door for competing tests.  In “bumper sticker” terms, “life,” as it is encountered in nature, is not patentable.

What may be patented, among many other things in biotechnology, is something that Myriad Genetics and many other scientists and companies create from naturally occurring genes; namely, complementary DNA, or “cDNA.”  cDNA is the sequence of coding regions of a gene, with the non-coding regions spliced out, that is “complementary” to that gene’s messenger RNA (mRNA).  (In nature, a gene’s coding regions, called “exons,” are interrupted by noncoding regions called “introns.”  The introns are spiced out in the course of transcription, or reading, of the DNA to form mRNA.)  This part of the ruling limits the overall impact on the patent estates of biotechnology firms, which in turn means that the ruling is unlikely to impair the discovery and development of new treatments or diagnostic tests.  Similarly, the methods used in such discovery and development also may still be patented.

Something else that may still be patented is a genetically engineered organism—for example, a bacterium with a gene inserted so that it will produce a protein of interest that it would not naturally produce.  This represents a lot of activity; many such organisms are patented, including microbes and genetically altered higher animals like mice created for specific experimentation.

What of the future?  Could human tissues, made from adult stem cells for an alternative to organ transplant, be patented?  I would think that they could.  At a minimum, the procedures for growing such tissues could be patented.  If some future human embryo were enhanced with a gene to improve vision, what could be patented then?  My guess is that the process could be, but the actual person could not be.  This seems commonsense but of course one would need to see the actual cases, if and when they arise.

Commodification of life, including human life, remains an urgent concern, but it seems that, even if some altered organisms are patentable, it is unlikely that people, though they may be “made,” could be considered to be “invented.”  My guess is that this decision would help set a limit.  In any event, I think the court got this one right.

More on the “just price” of lifesaving drugs

It’s one thing when academic ethicists complain about drug prices.  It’s another when, as I discussed two weeks ago, physicians raise their voices.  And it’s yet another thing when a major industry scientific journal weighs in.

In the June 2013 issue, the editors of Nature Biotechnology, following on the discussion of the high cost of drugs to treat certain leukemias, broaden the discussion to cover expensive specialty drugs in general.  They are concerned.  A few snippets:

  • “[P]rice tags for drugs entering the US market continue to skyrocket.”
  • “To make matters worse, in the United States, most of this price inflation is being passed on directly to patients, leading to financial hardship.”
  • US drug costs are “increasing twice as fast as other healthcare services.”
  • While “in many cases, new drugs addressing unmet needs or offering major advances…do warrant high price premiums,” “companies also seek price premiums for drugs that have only marginal benefits…[and] industry’s dirty little secret is that the greatest contributors to increases in US spending are not new drugs, but year-on-year price increases for older drugs.”
  • “Thirty percent [a common co-pay rate] of a single $100,000 drug is a crippling burden.”

Read the whole thing.

Sure, the Nature journals originate in the UK, so we might expect a broadside from there aimed at the US.  But this particular journal is directed at biotech scientists and entrepeneurs trying to build successful companies.  So if its editors think industry’s behavior should change, maybe that says something.

Why the mess?  The editors charge that customers (public and private insurance entities) have an “asymmetry of information…that drug companies exploit,” and pharmacy benefit managers make money by selling more drugs at high prices negotiated behind closed doors with industry.  This strikes me as about as anti-free-market as one can get.  Defensible pricing should come as a result of a more open process of price discovery—negotiation and competition for business.

As a possible alternative, the editors suggest industry consider suggestions like one made by Harvard Business Review blogger Rafi Mohammed.   His idea:  differential pricing, with discounts, analogous to the way we buy, oh, just about everything we buy—cars, hotel rooms, airline flights, stuff at J.C. Penney (depending on who their CEO is today), and so on.  A patient’s out-of-pocket payment would be limited by the actual maximum amount a patient “should” pay.  That, in turn, would be determined by income, family size, etc—with an “independent third party agency” making the call.

Hmmm.  That sounds to me too much like eligibility for welfare, or unemployment insurance, or college financial aid.  A “FAFSA” for your medical bills, anyone?

I think I prefer an approach by which different levels of insurance coverage were offered, with different levels of co-pay, perhaps even different “formulary” drugs—and different premium structures.  But for it to work, there would have to be some level of societal/market agreement that the costs for truly effective and expensive drugs would be almost fully covered, and the out-of-pocket payments starkly limited to an absolute dollar amount that contributes to one’s overall out-of-pocket maximum for all coverage under a policy or program.  And, again, I don’t see how we can escape having a more explicit and open payer negotiation of prices and a firmer limit on paying for marginally effective new drugs or allowing previously-introduced drugs to increase in price year-on-year.

But the current state of affairs can’t go on like this, unchanged.

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.

On (Being) Better than Human, Part 3A

As I noted in Part 1 of this series (see my 03/25/13 post), in Better than Human Allen Buchanan considers four major lines of objection to the “enhancement enterprise.” As Buchanan summarizes them, each of these objections claims that biomedical enhancement is “different” in morally significant ways from other kinds of (nonbiomedical) enhancement. Specifically, these objections assert that:

(1) biomedical enhancements are different because they change our biology; (2) biomedical enhancements are different because (some of them) change the human gene pool; (3) biomedical enhancements are different because they could change or destroy human nature; [and] (4) biomedical enhancements are different because they amount to playing God (p. 12).

In Chapter 2, Buchanan takes on the second and third of these objections—that is, the “changing the human gene pool” and “changing human nature” objections, respectively.

The heart of Buchanan’s discussion in this chapter is a consideration of two competing analogies in terms of which one might understand evolutionary biology—or, alternatively, “nature” (p. 29)—and its processes: the “master engineer” and the “grim tinkerer” analogies, respectively. On the former analogy, “organisms are like engineering masterpieces: beautifully designed, harmonious, finished products that are stable and durable (if we leave them alone)” (p. 29). On the latter, evolution is “morally blind,” “fickle,” and “tightly shackled” (p. 49)—it produces “cobbled-together, unstable works in progress, and then discards them” (p. 28).

Evolution is disanalogous to a master engineer, Buchanan says, in two key respects. First, “natural selection never gets the job done” (p. 28). Environments are constantly changing, and organisms are constantly adapting both to their environments and to each other, in “a ceaseless round of adaptation and counteradaptation” (p. 28)—resulting in further changes both to organisms and their environment, in a process that never arrives at a terminus. So rather than being “the end points of a process whereby they climb a ladder to perfect adaptation to their environment,” organisms instead exist in a state of perpetual instability, one that belies the “finely balanced” nature implied by the master engineer analogy (pp. 28-29). Second,

unlike a master engineer, evolution doesn’t design what it produces according to a plan that it draws up in advance. Instead, it modifies organisms in response to short-term problems, with no thought of long-term effects. Evolution has no overall game plan for any species, and the results show it. What’s useful for solving today’s problems can cause new problems—and even extinction—down the line (p. 29).

In the final analysis, Buchanan contends, “evolution is more like a morally blind, fickle, tightly shackled tinkerer” than a master engineer. The burden of the rest of the chapter is to provide reasons why (on Buchanan’s view) we ought to accept this analogy over against the master engineer analogy.

In order to adjudicate between these two analogies, Buchanan says, we need to grasp certain key aspects of the mechanisms of evolution (p. 29). The first thing to notice in this regard is that nature is replete with instances of “suboptimal design” (pp. 30-31), which Buchanan takes to be prima facie evidence that the master engineer analogy is problematic at best. Examples of such “design flaws” include, inter alia, the fact that in male mammals the urinary tract “passes through (rather than being routed around) the prostate gland, which can swell and block urinary function,” and the “hasty shift from quadruped to biped, which resulted in back and knee problems and a birth canal that passes through the pelvis, resulting in greatly increased risks to both mother and child in the birthing process” (p. 30). Numerous additional examples could be cited (and Buchanan cites several other illustrative examples here).[1] “Design flaws” such as these led Darwin to develop his theory of natural selection, with which, Buchanan informs us, “Darwin debunked the argument from intelligent design, one of the traditional arguments for the existence of God, by cataloguing the ‘clumsy, blundering, wasteful’ works of nature” (p. 30).

To show more clearly why nature is not best thought of as a “master engineer,” Buchanan introduces at this point a distinction between what he terms “Unintentional Genetic Modification” (UGM) and “Intentional Genetic Modification” (IGM). UGM is “evolution as usual, what Darwin called ‘descent with modification,’ where a driving force of the modification is natural selection”—in other words, “evolution without intentional modification of human genes by human beings” (p. 31). IGM, then, in the context relevant to our discussion, is intentional modification of human genes by human beings.

Buchanan’s aim here is actually two-fold: first, he wants to provide reasons why we ought to reject the “master engineer” analogy in favor of the “grim tinkerer” analogy, and second, he wants to give us reasons for considering the possibility that it may be preferable, in at least some circumstances, to actively pursue IGM rather than simply leaving the development of the human species entirely to UGM. His subsequent discussion in the remainder of this chapter is designed to accomplish both of these aims simultaneously. To that end, he begins by enumerating some of the built-in limitations of UGM, and then goes on to describe some ways in which IGM might be employed to overcome those limitations.

In the next post in this series, we’ll finish up our explication of Buchanan’s argument, and then develop some critical observations regarding that argument. By way of preview, three major limitations of UGM to which Buchanan draws our attention are the facts that (1) UGM is “insensitive” to post-reproductive quality of life (pp. 32-37); (2) in UGM, beneficial mutations spread only by way of a “nasty, brutish, and long” process (37-45); and (3) UGM selects only for “reproductive fitness, not human good” (pp. 45-48). Critical remarks will focus, in turn, on several epistemological, ontological, and moral issues raised by the way Buchanan frames and develops his argument in this chapter.

 


[1] A bonus for the philosophy buffs out there: In the context of this discussion of “design flaws,” Buchanan offers an arresting image in answer to Nagel’s famous query regarding what it’s like to be a bat. As Buchanan explains, “bats spend a good deal of their time hanging upside down, closely packed together, with their feces pouring down over their bodies to their heads. (Imagine yourself holding a toothpaste tube upright and squeezing it until the contents cover your hands. That’s what it’s like to be a bat.)” (p. 31).

Lies, clones, and stem cells: the language of respectable evil

A breathtaking specimen of obfuscation (or was it just plain ignorance?) was published in the Wall Street Journal (WSJ) this week. The article, entitled, “Experiment Brings Human Cloning One Step Closer,” begins, “Scientists have used cloning technology to transform human skin cells into embryonic stem cells, an experiment that may revive the controversy over human cloning. The researchers stopped well short of creating a human clone.”

A little confusing, but it sounds innocuous, no? Transforming human skin cells into embryonic stem cells: that’s the ethical alternative to cloning a human for the purpose of destroying it and removing stem cells, right? At least they didn’t create a human clone, right?

Not so fast. If one refers to the original article published in the journal Cell this Wednesday, the title alone speaks volumes: “Human Embryonic Stem Cells Derived by Somatic Cell Nuclear Transfer.” Somatic cell nuclear transfer. That’s scientist-speak for cloning.

“The achievement is a long way from creating a cloned human embryo,” the WSJ article says.

Wrong again. The article in Cell describes, and the accompanying diagram shows, a process of creating a cloned human embryo, which at the blastocyst stage is “disaggregated” (destroyed) to remove embryonic stem cells. (If the WSJ didn’t think they created a cloned human embryo, how did they think they got embryonic stem cells from it?)

Not all the press coverage was as slanted/wrong as the WSJ coverage. The BBC, for example, reported it far more clearly.

I don’t know if the inaccurate reporting by the WSJ was motivated by ignorance; or by an ideology that says that “Embryos aren’t human and if you don’t implant it and grow a baby from it it’s not a clone”; or by a desire to confuse people by semantic sleight-of-hand so that they won’t understand what’s happening until it’s too late; or a combination of all of these, or something else altogether.

But just for clarity’s sake, let me paraphrase: We have clearly demonstrated, in a respectable, peer-reviewed journal (no National Enquirer here), that we as a society are willing to facilitate the development of human beings in a Petri dish, and then, when they are at their weakest, smallest, most vulnerable and voiceless, kill them and take their body parts in the hope that they might be useful for others of their species. We deliberately kill our young: not in a gas chamber or oven, as the Nazis did; not tied to an altar, as the Aztecs or Incas did; but in air-conditioned laboratories with bright fluorescent lighting and mild-mannered lab technicians and nice watercolor paintings on the walls in our most prestigious institutions of higher learning.

God help us.

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.

Cesarean Delivery on Maternal Request (CDMR); an ethical option?

A growing phenomenon in recent decades is “Cesarean Delivery on Maternal Request” (CDMR) — the delivery of a baby via a scheduled cesarean section, not for any medical reason, but because the mother desires not to have a vaginal delivery.

Is this an ethically legitimate medical practice? There are different arguments for or against. When one weighs the potential benefits and risks to both mother and baby, the scales don’t tip overwhelmingly towards one side or the other. Not unexpectedly, the principle of autonomy is one justification given in support of the practice: if a woman understands the benefits and the risks, so the argument goes, she should be free to make a decision in accordance with what she wants. (This begs the question of, should doctors be obligated to do an unindicated medical procedure simply because a patient requests it?) The principle of justice is often cited as a reason not to do CDMR; on this account, the increased expenses of surgery and prolonged hospital stays constitute an unjustified use of finite resources.

One of my concerns with CDMR is that it represents another example of our tendency to place faith in a technique or technology, to uncritically accept what is gained by the technique, the good that it promises (e.g., not having to undergo labor; control; the convenience of scheduling); without stopping to consider either the idea embedded in the technique, or what is lost by adopting the technique. One idea embedded in CDMR is that Pregnancy is a Medical Condition, a Disease that needs to be treated and cured. Now it is clear that there are some pregnancies that benefit from medical intervention. However, we extrapolate and make every delivery a techno-medical event, to the detriment of many, performed in hospitals and replete with fetal heart monitors and IVs and all the other indispensables of the modern delivery suite. (We are so inured to this idea of pregnancy-as-disease that most of us are surprised when we hear of a delivery taking place at home; some might even question the sanity of a decision to have a home delivery!) CDMR only reinforces this idea, moving us further away from understanding pregnancy and delivery for the “natural” and very human events that they are. As for what is lost by the practice of CDMR, there is an irreplaceable mother-child bonding time that occurs immediately post-partum. Sometimes, when a cesarean section is medically necessary or the mother or baby are ill, this precious time must necessarily be relinquished; but to forgo it for no necessity minimizes an ineffably important and human experience.

Is this an ethically legitimate practice? It’s perhaps not as clear as some other contested issues. But it seems to take us another step down a path — the medicalization and technicalization of all human experience — a path to a world brave and new, a path we will rue after we have gone too far down it to turn back. Ethically legitimate? Barely, maybe. Wise? I don’t think so.

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.