The Virtue of Human Development

New York University bioethicist S. Matthew Liao has recently proposed giving people drugs to predispose them to make decisions in favor of programs working toward climate change:

Yes. It’s certainly ethically problematic to insert beliefs into people, and so we want to be clear that’s not something we’re proposing. What we have in mind has more to do with weakness of will. For example, I might know that I ought to send a check to Oxfam, but because of a weakness of will I might never write that check. But if we increase my empathetic capacities with drugs, then maybe I might overcome my weakness of will and write that check. (1)

What Liao is talking about is something still closely tied to beliefs: the will.  Jonathan Edwards spent a good bit of his time writing about the close relationship between these two aspects of human character.  If all that was needed was a little perk-me-up to help out a sleepy donor, then we would prescribe a cup of coffee.  However, beliefs and the will are both components of human character and therefore are changed and molded by the process of maturation.  And the maturing of a person takes place in relationship with other persons, in relationship to God and in relationship to other human beings.  This is the heart and soul (literally) of the human experience.  Theologians oftentimes use the term sanctification to describe this change within the person as a result of the action of God.  This process is ultimately directed toward Jesus, the Mediator who opens the door for making the human heart living and the One who is the New Adam—the One who is human in the truest sense.  Pharmacological manipulation of human behavior seeks to short-circuit the process of human development, thereby essentially taking away that which is truly human.  Just think: if the literature describing the story of human struggle and development were eliminated, our libraries would be largely empty.  A person no longer growing in relationship with God and with others would be less human.  The manipulative means would have done great harm in pursuit of the end behavior.

The renewed interest in virtue ethics in recent years may serve to steer us away from further attempts at manipulation in favor of choosing a path of maturity.

I have always marveled at how Meda Pharmeceuticals markets their version of the muscle relaxant carisoprodol as Soma because of the name’s negative connotations.   Maybe it has no negative connotations at all.

By this time the soma had begun to work. Eyes shone, cheeks were flushed, the inner light of universal benevolence broke out on every face in happy, friendly smiles. (2)

1.  Anderson, Ross.  “How Engineering the Human Body Could Combat Climate Change.” The Atlantic,  March 12, 2012.

2.  Huxley, Aldous. Brave New World.  HarperCollins, 1932 (2006).

Cyborgs and Design Constraints

A recent article in BBC News asks the question: Can we build a “Six-Million-Dollar man”? If that reference is lost on you, the Six-Million-Dollar Man was a made-for-TV movie and television show that aired in the 1970s based on a book, Cyborg. The main character was an astronaut who was in a debilitating accident. He was equipped with bionic legs, left arm, and left eye and with these bionic features was able to save the world using his super-human abilities.  The underlying point of the reference is to ask if we can go beyond prosthetics and enhance the human body beyond its normal capabilities.

Ironically, many cyborgs in film, television, and literature are people who suffered from some sort of trauma causing their bodies to become vulnerable, or to operate as sub-standard levels. Examples include Darth Vader/Anakin Skywalker, who became a cyborg after almost dying in an epic battle; Luke Skywalker, who lost his hand in another epic battle between him and his cyborg father; Robocop, who was a cop that almost died at the hands of a gang; Ironman/Tony Stark, whose heart was irrevocably damaged when he was kidnapped; and the already mentioned Six-Million-Dollar Man. Rather than restoring their bodies to their previous level of mobility and functionality, these characters are enhanced to amazing levels. (Although Luke Skywalker’s enhanced abilities do not come from technology but from mastering the Force, an important point in Lucas’ films).

The article asks whether we are at a point where enhancement to super-human abilities is possible, and offers the example of humans being able to run at 60mph. While this may have every science fiction fan salivating, there’s this small problem of design constraints:

Bipedalism was not really designed for that kind of running. There’s considerably more efficient ways of moving at 60mph. I don’t know if there’s enough benefit to overcome the difficulties of 60mph running speed…It might be possible to attach a bionic arm with enough strength to lift a car. However, actually doing so could cripple the rest of the body. Falling over while running at 60mph could be equally damaging.

 

The human body is a work of engineering with all of its integrated parts interacting as a functioning whole. One does not need an anatomy and physiology class to understand this; just throw out your back or injure your hamstring and see how integrated your body really is. Or run in a pair of bad running shoes and see what happens to your feet, ankles, knees, hips, and back. Every movement employs a series of muscles, tendons and joints, not to mention the neural networking required to tell your body to make those movements. It is an interacting whole, and like any piece of engineering, there are design constraints.

Our culture has an obsession with enhancement. In this sense medicine is not about healing; it is about conquering. But what is it that we are conquering? The transhumanists would say that we are raising our fists at Nature by taking control of our own evolution. No longer are we going to be the products of chance and necessity; we will take it from here and will be the products of our own making.

I think if we are honest with ourselves, what we’re fighting against is our own frailty. We want to watch athletes conquer world records. We want superheroes that are stronger than all of the bad guys. We want to see man on the top of the tallest mountain or on the moon or surviving in the wilderness. We want to feel like we are not nearly as vulnerable as we really are.

Perhaps for some of us, we want solace that maybe someone has conquered the very thing that horrifies us the most about our frailty: Death. Death is confounding. Why do creatures like us die like an animal? We can create, have consciousness, are individually unique yet also relationally connected, have ideas, and contemplate our own mortality.  With every world record, every amazing feat of ingenuity, achievement, and technological advancement that pushes our design constraints, there is a background hope that we are one step closer to overcoming our ultimate enemy.

Of course, the BBC article is not talking about immortality. It is only speculating on running faster or lifting heavier objects. But the subject is so tantalizing because, “Eventually you reach the point where you can start doing things that normal people can’t do…” The point isn’t to be “normal” or to restore normal function. Normal people can get in a car wreck, can lose an arm, can go blind, and can hurt themselves doing mundane things. Normal people die.* The point is to be anything but normal. But design constraints place limits on just how far from “normal” we can go. We will never be able to out-run or “out-react” or out-smart every danger. Even if we somehow overcame one design constraint, another becomes more pronounced to the point that what may have started as an enhancement in one sense becomes a detriment in another sense.

The “Six-Million-Dollar-Man” idea is only feasible to a point. It will not save us and it will not give us the resurrected body that we ultimately desire.

 

 

*See Isaac Asimov’s Bicentennial Man for an interesting take on this concept in regards to robots with human qualities, the opposite of a cyborg, perhaps.

Technology and health care reform

 

A couple of letters in this week’s Archives of Internal Medicine provide a picture of some of the more perverse incentives to overuse technology that are built into our current health care delivery “system.” One letter describes a study of proton beam therapy for treatment of prostate cancer. Proton beam therapy has never been shown to be superior to standard photon-based therapy for the treatment of prostate cancer; it is, however, novel, high-tech, “cool,” and way more expensive. The study showed that the mere availability of the technology, rather than any clinical indication, drove its utilization: “If you build it,they will come” (and spend!).

Another letter addressed the systemic factors that influence physicians to use more technology, whether clinically warranted or not: “The sheer amount of technology available may lead some [doctors] to look askance at the value of their clinical skill and bypass them in favor of testing. This can lead to a technological addiction that is every bit as difficult to break as a substance addiction.”  In the reply to this letter, the authors wrote of “several systemic factors that promote a ‘more is better’ approach: a reimbursement system that rewards diagnostic testing while failing to provide physicians enough time with patients to avoid it; performance measures that reward doing more with no attempt to measure doing too much; and a malpractice system perceived to expose physicians to legal punishment for doing too little but not for doing too much.”

The incentive to use more technology is not only inherent in the nature of technology itself (see Jacques Ellul’s The Technological Society), but is built into the fabric of our health care “system.” The cost of that technology is a large part of what is making health care unaffordable for all except the healthy. Any health care reform scheme that does nothing to change these structural incentives is so much wind. The reform schemes put forth by the two major political parties are pathetic, cosmetic band-aids that do nothing to get even close to the root of the problem (“Uh, let’s find different ways for people to buy insurance!”). Such band-aids amount to a joke; only it’s hard to laugh when so much is at stake.

 

Sources:  Aaronson et al., “Proton Beam Therapy and Treatment for Localized Prostate Cancer: If You Build It, They Will Come,” pp. 280-282; letter from Volpintesta, “Training in Uncertainty Has Value for Primary Care Physicians: Overreliance on Technology Can be Remedied,” p. 297; and the reply by Sirovich et al., p.297, Archives of Internal Medicine, Vol 172 (No. 3), Feb 13, 2012.

The ethics of mind-reading

 

A study that sounds like the stuff of science fiction was recently published in PLoS biology (If you don’t speak Scientific Gobbledygook, it is translated here). In the study, scientists were able to identify the words that human subjects were thinking by analyzing the electrical patterns in certain parts of their brain. Scientists hope that some day this line of study may lead to techniques that would allow people who cannot speak, because of some type of brain damage, to communicate by direct neural control of devices that would, literally, read their minds and speak for them.

In his book The Technological Society Jacques Ellul described the characteristics of technology in modern society. (Actually, he wrote about technique, of which technology is a subset.) One characteristic, which he termed monism, is that a technology tends to spread and be applied everywhere it can be applied without regard as to whether it is a “good” or “bad” use, because monism “imposes the bad with the good uses of technique.” Ellul provides many examples to back up his assertion.

The type of “mind-reading” described in the PLoS article is in its infancy, and may never progress beyond the stage of interesting but not very practical experiments. But it is not difficult to imagine the sort of pernicious ends for which such technology might be used if it lives up to the hope of researchers and ends up in the wrong hands — say, the paranoid rulers of a modern security state. It is not difficult to imagine what someone with wrong intent or motives could do with the power to see into another’s mind. And if Ellul is right, there will be a natural tendency for the technology to be put to such uses.

Rather than simply be reactive, the job of bioethics must be proactive, to even now, in the infancy stage of such technology, be placing safeguards around its uses to try to ensure that its potential benefit is realized while its potential threats to human thriving and dignity are thwarted. The attempt to limit technology’s application, to shepherd it into what we consider ethical uses, will go against all of the inherent tendencies of technology. It will go against all of our society’s unquestioned faith in the benefit and rule of technology. But it is necessary if such technologies are not to be used in the hands of some to wield a terrible power over others.

 

Eight is Enough

 

In response to a family’s having eight babies by IVF and gestational surrogacy:

“In this society, if you have money, you can have miracles!”

“Having children is now a luxurious game for the rich!”

“This completely topples the traditional meaning of parents.”

“From the sound of it, they just tried to have some kind of baby machine.”

“Gestational surrogacy is the business of renting out organs.”

“Why did they have to hire so many people to have babies for them? Did they think they had the right to bear children just because they were rich? Secondly, what respect to life did they show? Multiple pregnancies are super risky.”

These are reactions from the public, press, and government officials to a wealthy couple having two sets of triplets and one set of twins via IVF and two surrogates in China, where there has been an official one-child-per-family policy since 1978. Last month a southern Chinese newspaper broke the story of this family, and you can sense the angry reaction of their society in the quotes above.

(There is apparently a large surrogacy industry in China, despite a 2001 ban on Chinese hospitals doing the procedures. The manager of one surrogacy agency reports being overwhelmed with applications from aspiring surrogate mothers, most of whom are having emergencies and “need a large sum of money.”)

In the uproar, we can see erupting some of the tensions surrounding these technologies that are still somewhat under the surface in our own society: What about the divide between those who can and can’t afford reproductive technology? What does it mean to be a parent, especially where surrogacy is involved? Is surrogacy the commodification of women, the reduction of woman to womb?

There is a lot of worrying that China will catch up and surpass western economy and culture. It seems that in some areas they have already caught up with us: pushing the envelope of societal norms with the use of reproductive technologies, and the commodification of women in the process. In another area they are still far behind us: they have not yet lost the ability to be uncomfortable, shocked, even a little disgusted at the ethical implications of these technologies for families and society.

 

(Sources: Here and Here)

How private enhancement decisions led to a public health crisis

 

The proponents of using medical techniques not just for treating disease and dysfunction, but also for enhancing normal form or function, often appeal to privacy. Since most public and private insurance schemes do not pay for enhancement technologies, people who desire such “treatments” pay out of their own pockets; so, the argument goes, if they’re not hurting anybody, and they’re paying for it themselves, what’s the problem?

One of the more popular enhancement technologies worldwide is the cosmetic surgical procedure of breast augmentation. In the last few weeks a crisis of sorts has erupted around a particular brand of silicone breast implant, manufactured by the now-defunct French company Poly Implant Prothese (PIP) and exported all over Europe and South America. It turns out that the silicone used in PIP’s implants was not medical-grade, but industrial-grade, made to be used in mattresses; this may make the implants more prone to rupture. Rupture can lead to increases in inflammation and scar tissue formation.

About 300,000 of PIP breast implants are thought to have been used worldwide. This week, France and Venezuela took the step of offering to pay for the removal (but not the replacement) of all PIP implants. “We have to remove all these implants,” said Dr Laurent Lantieri, a French plastic surgeon “We’re facing a health crisis …” France will pay for ultrasounds every six months for those women who opt not to have the surgery.

Two things to note: first, removal of an implant is not like taking out a splinter. It is a major surgery, under general anesthesia, with all of the attendant risks — and expenses — of surgery. Second, other than those women who had implants inserted after breast cancer surgery, all of the women involved paid for their augmentation themselves. But now the state — that is, the citizens of France and Venezuela — will be paying for the corrective surgeries.

All techniques and technologies carry unintended and unforeseeable consequences. Even with the best planning and forecasting, all techniques will surprise us in some way. Medical techniques, because they work directly on the human body, have the potential and power to do very great unintended harm. The silicone breast implant crisis is an example of how choices made in private can have significant unforeseen consequences and costs for the public. The argument that using medicine for enhancement is merely an individual and private decision is simply not valid. How many more individuals will be hurt, and how much more will society pay, as enhancement techniques — and their unforeseen consequences — proliferate?

Losing control at Christmas

 

Throughout most of history, having children was not a matter of exerting control, but of accepting uncertainty. Whether and how the act of making love resulted in children was a mystery. In the pages of Scripture, having children — especially when one had been considered barren — was most often seen as a sign of God’s blessing: think of Eve, Sarah, Rachel and Leah, Hannah, Elizabeth …

Somewhere in the modern epoch the mindset changed. Children are still a blessing, but now they are also a liability, and we calculate how many hundreds of thousands of dollars it costs to raise a child. In the modern purview, since childbirth brings liability, it must be brought under control. The most portentous embodiment of this mindset change is the development of contraception. We now speak of “planned” and “unplanned” pregnancies — another way of saying “controlled” vs. “uncontrolled.”

But this is not enough control for moderns, for all contraception, other than abstinence, is imperfect. So when contraception fails, when we lose control, we establish the option of abortion, by which we re-assert control, by which we affirm the supreme modern value of control over life.

But even this degree of control is not enough. Why should we stop at merely preventing children, when we can control their conception? Thus we pursue reproductive technologies, by which the woman barren, like Rachel, or too-old-to-have-children, like Elizabeth, can produce a child. Yet this is still not enough; there is still too great an element of uncertainty, so we assert an ever-greater control over the process of conception by testing these children of reproductive technology before they are born or even en-wombed, in order to control who will live and who will not. Again, the mindset changes: children now are not only a blessing and a liability, but a product, manufactured to certain specifications and precise tolerances.

“Control” is not a bad thing. There are many in this world who would be much better off if they had a greater degree of control over their lives. But since we are a fallen race, the more we seize control of something, the more we ruin it in the process. We see this in our physical environment as we have increasingly asserted control over it; we will see it in our humanity if we continue in the path of controlling ourselves through enhancement and controlling our offspring through genetic manipulation.  One of the most vexing questions bioethics must answer is, How much control is right? And when have we gone too far?

Contrast the modern techno-birth with the most important birth in all of history, which was not a matter of control, but of surrender, surrendering control over birth. In the process, the “perfect” contraception — abstinence — fails! Yet from this act of surrendering comes the greatest gift the world has ever received. Is there a lesson here? Does our greatest good always lie not in grasping for greater and greater control, but in knowing when to relinquish control and surrender?

 

Of IOM, IT, EMRs, patient safety, and quality

 

If your doctor’s not looking you in the eye quite as much as he or she used to, it may be partially the fault of the Institute of Medicine (IOM).

In 1999, the IOM published a report entitled “To Err is Human: Building a Safer Health System,” which famously concluded that preventable medical errors cause up to 98,000 patient deaths annually. This was followed by the 2001 report, “Crossing the Quality Chasm: A New Health System for the 21st Century.” These reports touted, among other things, the power of health information technology (IT), including Electronic Medical Records (EMRs), to reduce medical errors, increase patient safety, and increase the quality of medical care. Subsequently, the federal government has stepped in, providing financial incentives for physicians who can demonstrate “meaningful use” of an EMR, and will soon be imposing financial penalties on those physicians who don’t climb onto the EMR bandwagon. Thus, the IOM is directly or indirectly responsible if your doctor isn’t looking you in the eye because she’s gazing into a computer screen instead.

Upon what evidence did the IOM base its assertion that EMR’s would improve safety and quality? Well … you know … it’s just kinda obvious, isn’t it? I mean, after all, it’s technology, and it’s gotta be better than paper, and it just makes sense that using more technology is better, right?

In fact, there was no data to suggest that health IT would improve either the quality or the safety of medical care. In the intervening years, as health IT implementation has exploded, there continues to be a paucity of data to suggest that health IT improves either the quality or the safety of medical care. There is good data that it introduces new errors and quality problems into health care.

Last month the IOM released a new report, calling for the formation of an independent federal body to investigate patient deaths and other adverse events caused by … drumroll, please … health information technology.

Dr. Richard I. Cook, an associate professor of anesthesia and critical care at the University of Chicago, said, “It’s not surprising that such adverse events are being found related to health IT, and it’s not surprising that those promoting these systems have neither looked for them nor anticipated them. To make large-scale investments in these systems and only now be looking at the impact on patient safety borders on recklessness.” Dr. Scot M. Silverstein, a consultant in medical informatics at the Drexel University College of Information Science and Technology in Pennsylvania, said that it is “unethical” to expand health IT so dramatically without understanding the precise nature of the risks it poses to patients.

“Reckless” … “unethical” …

Meanwhile, my doctor’s still not looking me in the eye because he’s trying to find something in the computer. Sheesh! This is quality improvement?? Have we simply created a new “Quality chasm”?

 

(The quotes above are from this story which was published in the AMA news.)

Knowing too little about too much

 

With the ability to map the human genome, we find ourselves in the bewildering position of knowing too much and knowing too little at the same time.

Consider this scenario: The year is 2015. You, being the modern that you are, want to know your future, so that you can have some degree of control over it. You’re pretty sure astrology isn’t very helpful; but you’ve been keeping up with Time and Newsweek, and you’re thinking from what you’ve read there that genetic testing offers the scientific equivalent of what astrology promises. So you go down to the local Genetics-R-Us and for a mere $99 have your entire genome analyzed in 15 minutes. You then sit down with one of their genetic consultants, who reveals that you have a 64% likelihood of developing diabetes and a 43% chance of developing colon cancer. You go on a vegan diet, exercise three hours a day, and start a regular regimen of bowel cleansing and weekly colonoscopies. You have your genome analysis results sent to your primary care provider (PCP) to be part of your medical record.

Fast forward to 2025, when you are diagnosed with a rare cancer of the nose. After a little research, you discover that this particular type of cancer can be predicted by genetic testing. Genetics-R-Us went out of business, so you go to your PCP and demand to know why she didn’t warn you about the possibility of this cancer. She steps out to do a little research and comes back into the room:

“It turns out that the gene that predisposes you to this kind of cancer wasn’t discovered until 2019, and you had this test done in 2015.”

“But when that information became available, why didn’t you go back and recheck my genome?” you reply.

“That’s the responsibility of the company that tested you,” she says, as she gets her defense lawyer on the phone.

“But Genetics-R-Us went bankrupt! You’re the only one who has the data!”

“We have thousands of these genome maps in our records, each consisting of six billion base-pairs. They are encoded in various formats, none of which are compatible with each other, and some of which are so outdated we can’t access them anymore. Plus, a 200-page update of the latest new gene dicoveries is published every month. We simply don’t have the resources to go back through everybody’s individual genome and check for all of these genetic abnormalities that are constantly being discovered.”

***

With the capability to map an individual’s genome, we can gather lots of data, but we do not yet have the knowledge of how to apply that data (much less the wisdom with which to use it!). We know too little about all that we know. As genome testing becomes more affordable and widely available, some of the ethical questions that arise are, Is there an ethical obligation to go back an re-analyze data in light of new findings? If so, whose is the responsibility?

A busy week for stem cells

Two bits of news from the world of stem cells this week:

First, Geron, the California company conducting the first ever official study using embryonic stem cells in humans, has suddenly terminated the study. Geron cited economic factors as the reason for stopping the trial. The study involved spine injury patients; Geron said only that the therapy was well tolerated, with no serious adverse events.

Second, a study using “adult” stem cells from patients’ own hearts to repair their own damaged heart tissue has produced promising results. The study’s purpose was not to show that the use of the cardiac stem cells was effective, but to make sure that the process is safe (the Geron study was also a test of safety); but study subjects receiving their own stem cells have already shown improvement in heart function.

Daniel Heumann, of the Christopher and Dana Reeve Foundation, said of the halted Geron study, “I’m disgusted. It makes me sick. To get people’s hopes up and then do this for financial reasons is despicable. They’re treating us like lab rats.”

The authors of the adult stem cell study, while warning that the results of the trial needed confirmation in larger trials, called the initial improvement in cardiac function “very encouraging.”

Geron has invested tens of millions of dollars in embryonic stem cell therapy in the past decade.

Even if one does not believe that it is unethical to destroy our offspring to find cures for our diseases, one should at least acknowledge that spending tens of millions of finite research dollars for an agenda that repeatedly uses reckless hype to gets people’s hopes up, only to dash them, is an unethical option when compared with funding “encouraging” research with a proven track record of producing successful treatments.