A “diagnosis” a physician can no longer make?

If you were to follow the trends on gender identity discussion you would be unsurprised to see this article in The Slate:
“Don’t Let the Doctor Do This to Your Newborn”

The author begins by portraying a physician taking a newborn away from a worried mother for a “procedure,” which turns out to be gender “assignment.” This physician, described as stern, masked, dismissive, knuckle-cracking, paternalistic, and judgmental, is charged with executing a “brutal” act within some “power structure.” It is essentially a charge of malpractice.

I am, unfortunately, not surprised that it is necessary today for a physician to justify what is blindingly obvious: calling a boy a boy and a girl a girl. The first step in helping to clarify reality is to refute the author’s narrative. I am usually not the first, second, nor even third person to declare the child’s gender. In the majority of pregnancies the mother and the ultrasound technician have already made the “diagnosis” in the second trimester. In the delivery room, I am often attending to the many details of delivery while observers such as family members and nurses declare the gender before I even notice.
But perhaps what is most instructive in this article is how well it exemplifies six devices of deception commonly used in modernity to undermine confidence in those aspects of society so long taken for granted that we have forgotten their quite logical origin and purpose:

1. Assigning false (and evil) motive;
2. Claiming that human actions can only be the result of collusion within some fantasized power structure instead of the logical result of human nature (that is, reality);
3. Turning a blind eye to the benefits of traditional social arrangements for human flourishing (while relying on a general inability of others to articulate them);
4. Claiming no harm in deviation from traditional social arrangements, perhaps out of willful ignorance that the very existence of society depends upon them;
5. Relying on lack of scrutiny of misleading terms;
6. Relying on hidden presuppositions that actually depend on a reality that disproves the existence of that which they try to describe.

Each of these provides ample basis for future blog discussions. Perhaps one must first decide if there is a reality that exists independent of our own design. If not, then it is pointless for a physician to make any diagnosis before checking with the patient to find out if he or she has already done so.

Jimmy Savile and the Hospitals

This week, a report released by the British government details sexual abuse by Jimmy Savile and its relationship to NHS hospitals.  Remarkably, the blockbuster entertainer went decades escaping investigation.  Even in his later years when he faced some scrutiny, Savile was never prosecuted for any crime.  However, in the three years since his death in 2011 at the age of 84, a ghastly picture of abuse has been uncovered.  And much of it is tied to his charity work with hospitals.

Most notably, Savile’s abuse appears to be tied to that of doctors at Stoke Mandeville, a British hospital which benefited from £40 million of fundraising from Savile.  One doctor, pediatrician Michael Salmon, served three years in jail after admitting to assaulting two girls.  Another doctor said of Savile:

“We all knew [Savile] because he was such a presence at Stoke Mandeville.  I personally had no inkling about Savile’s behavior.  This was all as much as a surprise to me as anyone else.  He wasn’t a person I was mad about but he was a philanthropist and he was responsible for getting an enormous amount of money for the hospital.  He would come into the wards, and I never saw a problem with him doing so—all the doctors knew him.  I am absolutely shocked by all of this.”

For Further Study

Laura Smith-Spark, “Rapes, abuse, possible necrophilia: DJ Jimmy Savile’s hospital horrors detailed,” CNN, June 26, 2014.

Sandra Laville and Lisa O’Carroll, “Jimmy Savile inquiry looking at alleged sexual abuse by three doctors,” The Guardian, October 24, 2012.

“NHS and Department of Health Investigations into Jimmy Savile,” Department of Health, Government of the United Kingdom, June 26, 2014.

Edward Malnick, “Jeremy Hunt Apologises for Jimmy Savile’s ‘Sickening’ Abuse in Hospitals,” The Telegraph, June 26, 2014.

The Fountain of Youth

 “Since by man came death, by man came also the resurrection of the dead. For as in Adam all die, even so in Christ shall all be made alive.”

Two weeks ago, family physician Joe Gibes wrote on the shaky medical footing of low testosterone treatment.  This week, Brian Williams reported on the NBC Nightly News that the FDA has issued warnings about thrombotic events associated with “Low T” treatment.  Dr. Bill Reilly, owner of an expanding chain of “Low T Centers” around the country and a user of testosterone treatment himself, says testosterone treatment is worth the risk.  According to Reilly:

“Once I got on testosterone, boy, it was just back like I was in college.”

At the conclusion of Dr. Nancy Snyderman’s story on Low T and Dr. Reilly’s testosterone centers, Dr. Reilly stated:

“You can age, but you don’t want to grow old as you age.”

I don’t understand that last statement.  I think part of aging is getting older.  Though it is hard for some Americans to imagine, aging, at one point in time, was thought to be accompanied by honor, as younger people looked to their elders as sources of wisdom.  Take the words of the book of Proverbs:

“Gray hair is a crown of glory; it is gained in a righteous life.” – Proverbs 16:31

Of course, today we would use hair-coloring long before “old age” and the proverb would be a moot point.  Gray hair would be a sign of a problem.  We would need a treatment for that.

Low T Tx is one of many maladies in American medicine due to our loss of our Christian context.  There is no need for every physician to be well-schooled in Christian theology, but when a culture becomes removed from its Christian background, well, then we really are left o our own devices (in a very literal sense).  Thus, aging, with its organic decay and immobility, is of no use to us and must be “treated” as a pathology.  What we really lack is the context of a resurrection.  It is completely normal to be dismayed at our own mortality.  However, within the context of a Resurrection we understand that God is good enough to even restore the decaying body.  In the words of the apostle Paul:

“But in fact Christ has been raised from the dead, the firstfruits of those who have fallen asleep.  For as by a man came death, by a man has come also the resurrection of the dead.  For as in Adam all die, so also in Christ shall all be made alive.  But each in his own order: Christ the firstfruits, then at his coming those who belong to Christ.  Then comes the end, when he delivers the kingdom to God the Father after destroying every rule and every authority and power.  For he must reign until he has put all his enemies under his feet.  The last enemy to be destroyed is death.  For ‘God has put all things in subjection under his feet.’”  — 1 Corinthians 15:20-27

Aging reminds us that death is real.  However, in Christ, the new Adam, there is hope of resurrection.



Strengthening from the Supper

I’d like to follow up on a recent post I made on the Lord’s Supper (see “The Body and the Blood” on May 11, 2014).  One of the important things to remember about Communion is that it is for our nourishment.  In fact, it was specifically instituted by Christ for our nourishment.  Baylor professor and Texas pastor of 100 years ago B.H. Carroll preached an interesting sermon on this fact, “The Relation Between the Lord’s Supper and Temptation.”  While I do not know exactly the circumstances surrounding this sermon, Carroll mentions near its conclusion that he sought desperately the Supper that very day because he had been suffering from a “dangerous illness” for at least six weeks.[1]

In this sermon, Carroll mentions that he cannot recall hearing a pastor make the connection between temptation and the Supper as seen in 1 Cor. 10:

“There hath no temptation taken you but such as man can bear: but God is faithful, who will not suffer you to be tempted above that ye are able; but will with the temptation make also the way of escape, that ye may be able to endure it. … The cup of blessing which we bless, is it not a communion of the blood of Christ?” — 1 Cor. 10:13, 16

I can’t either, but it does appear that Paul is making the connection.  And it makes sense.  When we are facing trials and temptations, we need strength.  And if Christ has specifically set aside something for our strengthening, we ought to take advantage of it.  Carroll makes this important point by way of analogy:

“If you knew that a child of yours had before him an arduous duty, requiring toil and persistence, you would want him, before he commenced it, to be well, to be strong, to go out nourished. … That is the precise point of failure in most of the Christian life, the indifference to the great doctrine of the nourishment of the soul, and the soul must draw that nourishment day by day from God.  It is the great teaching of the Lord’s Supper.”[2]

In this day and age, when we are suffering from illness or emotional trauma, our first move is to seek the best medical specialist or spend hours with a psychotherapist.  While the knowledge and skills of medical science and counseling are resources from which we should draw, let us first look to Christ in faith.  He has provided ample means for our help: the preaching of the Word by those called to the pulpit; the Scripture for our own private study as well as its reading among our brothers and sisters in the congregation; prayer, especially as we are led along by His indwelling Spirit; and the sacraments of baptism and His Supper.

Let us especially draw near to His table as we celebrate the Supper together for our nourishment.

For Further Study

Carroll, B.H., “The Relation Between the Lord’s Supper and Temptation” (Chapter V.) from The Supper and Suffering of Our Lord: Sermons.  Compiled by J.W. Crowder, Fort Worth: J.W. Crowder, 1947, pp. 56-71.


[1]Page 69.

[2] Pages 67-8.

International Research Ethics

More and more research funded by high-income countries (HICs, e.g. the US) is taking place in low- and middle-income countries (LMICs). For example, colleagues at my institution have received grants of over $64 million to do research in Ghana. A search of ClinicalTrials.gov shows that 20 of 29 open studies in Ghana involve women, children, and persons with HIV—all considered vulnerable populations. The obvious concern is how to protect human subjects of research from exploitation. For example, the pregnant woman with HIV who is approached by a US-funded researcher who offers to pay for all her prenatal care if she agrees to be randomized into a trial. How can she best be protected from coercion?

Therefore,  HICs are now taking the responsibility of exporting research ethics to LMICs. The question then comes up: Whose ethics? A cynical view is to look at the effort to teach research ethics in LMICs as a form of missionary work: to proselytize those who haven’t heard the good news of the Georgetown mantra and to help them build research ethics committees that can function like a Western IRB. Certainly many of these countries have been colonized by Western countries and have seen missionary work in their borders. Is this just adding insult to injury as rich countries continue another form of imperialism in South America, Africa, the Middle East and Asian sub-continent? Many authors think so, or at least warn against this approach.

But even if we all agree that exporting a Western IRB framework is the ideal, implementation still has a long way to go. A recent survey of research ethics committees in LMICs (that will be published next month in the Journal of Medical Ethics) showed that only 40% of these committees had a budget and only 50% included women on the committee—certainly a few stumbling blocks to effective research regulation.

An ideal model would be to facilitate the articulation of ethical guidelines for research in LMICs that are based on local interpretations of the concept of respect for human dignity. What that looks like and how to sustain protections of human subjects of research in LMICs is still a work in progress.

The Men of Atalissa

Originally, it was a progressive idea that sought to give mentally retarded men a place to earn their own pay.  Eventually, it became a system of servitude where men with intellectual disabilities lived in squalor and barely took home $65 per month.

Please take a moment to watch “The Men of Atalissa,” a short New York Times documentary made as a summary of a larger investigative project.  It traces the history of the Henry Turkey Service, the venture of a two Central Texas ranchers used to get “boys” out of state institutions and provide poultry companies with inexpensive labor.  “The Men of Atalissa” chronicles the story of a group of men from Texas who were moved to Atalissa, Iowa, where they suffered for many years with little notice from their fellow townspeople.

One man’s recollection of “they kicked us around” reminded me of a woman I met in the E.R. one night during a clerkship.  A woman with an intellectual disability and scratches on her arms was brought to the hospital by one of the caregivers at the group home where she lived.  I was the first on the scene, and as I began to talk to her she looked me straight in t he eye and said, “I want to talk to you alone” and gestured for the caregiver to leave.  Taking this as a possible indication of abuse, I notified the resident on call concerning the situation.  We did indeed conduct the interview with her alone and a separate interview with the caregiver out in the hall.  The social workers down the hall were contacted, but it was unclear to me later how well they followed up on the case.

We know what we are to do in the procedural sense.  The right questions are asked.  The right boxes are ticked off.  The chart is handed off to the next healthcare professional.  But do we see the person who is the patient?  Or is he nothing more than Ralph Ellison’s invisible man passing before us?

Maybe we are hurrying to our cubicle in order get our quota of sales calls in for the day.   Or maybe we are rushing to our townhome sandwiched between the families whose members don’t even have first names (to us).  Or maybe accounting or billing is breathing down our throats and there’s just not the time (or money) to speak to the patient in that manner.

Listen to the words of the father in Luke 9 who brought his suffering child to Jesus:

“And behold, a spirit seizes him, and he suddenly cries out. It convulses him so that he foams at the mouth, and shatters him, and will hardly leave him. “ (v.39)

Perhaps this is not the most heart-wrenching part.  Listen to his next sentence:

And I begged your disciples to cast it out, but they could not.” (v.40)

Let us not be called a “faithless and twisted generation” (v.41) and miss the patient in need or neglect to prayerfully consider how we might best treat him.

Ukrainian Bioethics

I returned from Kyiv, Ukraine, last week as part of a team that is working to strengthen a partnership with a Christian seminary there. As we met with various program heads within the school, I asked a few questions about how ethics are taught, and what bioethical issues the Ukrainian people face. Some of the answers were surprising.

Ukraine, of course, is the long-suffering nation to the west of Russia, most often remembered as the breadbasket of the former Soviet Union, as the nation where millions starved to death in Stalin’s effort to break the farmers that resisted collectivization, as a nation where much of the fighting—and death—from World War II occurred, and as the location of the horrific Chernobyl nuclear disaster of 1986, some seventy miles north of Kyiv. Ukrainians know what it means to endure; their national anthem is “Ukraine Is Not Yet Dead.” Ukraine’s history has witnessed many affronts to human dignity, perhaps one most chillingly on display at the “Museum of the Great Patriotic War” (a.k.a., World War II) where gloves made of human skin and a bar of soap made from human fat show just what human beings are capable of doing to each other. The Ukrainian people were saved from the atrocities of the Nazis to be dominated by the Soviets, exchanging one form of tyranny for another.

Years of communist rule still leave their mark on Ukraine. Something especially notable when out and about in Kyiv is the utter absence of physically-challenged people, the handicapped, on the city’s streets. It isn’t that they don’t exist. But communism in the Soviet Union served to create an “ideal society,” free of suffering and disability, filled with “perfect” people. In reality, this meant warehousing the mentally and physically-handicapped—and orphans—into hidden-away institutions. This mindset has been slow to change. Handicapped access is limited, to be charitable, and it is hard to imagine that a shopping trip would be anything but excruciating for anyone in a wheelchair. As much as I groan at some of the excesses, as I perceive them, in our “Americans with Disabilities” Act, I’ll probably now more gladly accept its quirks and demands as a way of affirming the dignity of those who suffer challenges I have yet to face in my own life.

It is easy to criticize the post-Soviet outlook, this vestigial communist view of human beings, as an American. But how much do we sanitize the pursuit of perfection here? What are enhancement technologies but a reflection that we have a need to be free of problems, to be our “best selves?” We tuck away our dying elders in nursing homes so that the inevitability of decline and death don’t confront our pursuit of happiness.

A member of our team wryly reflected that, in Ukraine, their faces are from the West but their minds are from the East. As I mentally checked off the list of bioethical issues we face in the West—challenges with assisted reproductive technologies and pre-implantation genetic testing, with use of technologies for human enhancement, and with limitation of burdensome treatment at the end of life—it became clear in discussing bioethics with the seminary faculty in Kyiv that most of these issues are completely off the radar of the vast majority of Ukrainians. Abortion is still hideously common as a method of birth control in Ukraine, as it is in Russia and elsewhere in the former Soviet Union. But the idea that we would use medicine to end life with physician-assisted suicide or euthanasia, or spend scandalous amounts of financial treasure on cheating the aging and dying process, seem arcane in Ukraine. One director even noted that the people of his country don’t have time to be depressed (even as they have faced generations of addictions) because they are too busy just surviving. A study in contrasts, this nation, where children are forgotten in orphanages and old women, the babushkas, may beg for money to supplement their meager pensions, but where children are bundled for warmth with the smallest hint of chilly air and people give up their seats on crowded buses for the elderly and for women with small children. These are a people acquainted with suffering and sorrow, and they have a certain respect for those who have suffered for more years than most (the elderly) and for those who hold the eternal promise of a better future (the children). A rather elegant ethic there: respect and promise.

Wiser minds than mine have delved into the mystery that, within the crucible of suffering, we may be best equipped to find evidence of grace in daily life. It was a visit to a church in Kyiv that I could best see this illustrated. There is, in Ukraine, a national church that had been suppressed, harassed, and persecuted at every turn, one that has survived communism and the economic anarchy that followed, and today sends workers into other former Soviet republics. It is, in fact, a joyful and beautiful place. It is a church that is ministering to orphans and the mentally and physically handicapped, bringing them out of the shadows to which communism relegated them. Ukrainian bioethics is more, forgive the awful word here, “primitive” in a sense, because the technologies that are such qualified blessings in the West have yet to meet this part of the world. But it is the church that is leading the way toward negotiating the ethical issues in a society in transition and embracing the notion of human dignity, a church that just may impact the course of a nation that is, indeed, not yet dead.


A Genetic “Fix” for Down’s Syndrome?

A couple of weeks ago I mentioned some of the thoughts presented at the July Summer Conference hosted by the Center for Bioethics and Human Dignity—thoughts I am still processing in the afterglow of an enjoyable and stimulating few days. Much has re-shaped my thinking on a host of issues, to which I alluded previously. But there was one nugget that remains with me, nagging at me, even as it was presented as a rather small bit of fresh information in a larger context of bioethical analysis of prenatal diagnosis. In a workshop session led by the estimable David Prentice, formerly a faculty member at Indiana State University and now a Senior Fellow with the Family Research Council, it was mentioned that American scientists have been successful in experiments to eliminate the “third gene” that is found in various “trisomy” disorders. This, of course, is most commonly seen in Trisomy 21, the genetic abnormality responsible for Down’s syndrome. The process, perhaps best described in an article in The Guardian, essentially inactivates the third chromosome, the one that makes a crowd out of an otherwise happy pair, in a process that is similar to what happens in normal meiosis, where the female gametes are formed and a non-functioning Barr body is produced. In typical British style, and in reality, the science is described as “elegant,” and is worth a look.

My first impulse on hearing this news was joyous relief. For as long as amniocentesis has been commonplace, the default position of genetic counselors when guiding those with a diagnosis of Down’s has been one of pregnancy termination, of abortion of the fetus that would suffer the mental and physical tolls of Down’s. Now that we can fix it, I thought, these babies can live. If we view genetic disorders as the fallout from a world where brokenness pervades all of creation as the result of sin, then a “fix” is a manifestation of God’s grace to make straight what has been made crooked by the Fall. It is a good thing, and I can view it as such. But what if we find a way to “eradicate” trisomy 21 and Down’s syndrome, even as the technology is still quite nascent and the fix quite tentative? Is that an altogether good thing, to see a future free of people who suffer Down’s?

I used the word “suffer” when describing someone with Down’s because it is a descriptor that is common, provocative, and almost entirely wrong. Certainly the medical issues associated with Down’s are real, the cardiac and gastrointestinal problems, the increased risks of cancer and dementia. Yes, Down’s syndrome is linked with numerous medical maladies—ones that made a thirty-year old adult with Down’s a rarity just a generation ago. Individuals certainly live longer today, blessed by improved medical technology. But do they flourish? I think of my prayers for my children when they were infants: protect them, of course, but most of all, keep them devoted to God through their lives, let their eternity be inextricably linked with their Savior. I would rather their earthly lives be significant than they be happy, to be completely honest. And I reflect on my experiences with those who have Down’s syndrome. I have yet to meet one who seems to typify “suffering.”

So we may someday, perhaps sooner than we can imagine, be able to eliminate trisomy 21 with a genetic “zap.” Will the child whose chromosome count has been normalized be a very different one from the one who has not had genetic intervention? I think of an 18-month old I met this week, who sat in his stroller as I examined the new puppy his parents just adopted. They looked like many parents of children with a mental disability, who have learned to accept the modification of their dreams for a child and who, so sadly, must somehow justify their decision to even bring this child into a judging world, given the options. But as I do the checkup on this bundle of puppy energy, they could see the same smile I could see, one that is more manifestly beautiful than that from a “normal” child in how it processes the unfolding scene. I can’t quite describe its wonder and delight. This smile was a mark of grace in a seemingly graceless world, one that God has supplied to a youngster created in His image and whom He has declared will someday judge the angels. I would have missed that if this little boy had been “fixed” by a genetic repair.

I think of my cousin, now in his mid-thirties, who has faced so many medical issues, and who has so challenged the lives of his parents. I have, sadly, struggled to connect with him over the years, because I cannot relate to his experiences and cognitive abilities easily. It is only in recent years that I see what I’ve missed. The middle of three brothers, he is the one who has been best able to find a true sense of pure worship toward God, one that has become clouded by cynicism (at least for now) in his high-functioning, articulate siblings. Would I wish an easier ride for my aunt and uncle, and for anyone with a special needs child in a society that values the capabilities of an individual above all else? Of course. But how serious have I been in my prayers that my children develop a deep spiritual devotion—would I exchange their future college and career and social success for it? If they were never to inculcate this devotion, would I sacrifice all the “normal” stuff and hope for a child with a lower IQ, a host of medical challenges, and a heart that embraces God?

None of us will ever know what would have happened spiritually, or in the degree of happiness and earthly success, if those with mental disabilities like Down’s had been rendered “normal.” I initially rejoiced at the happy thought that Down’s syndrome and similar issues would be cured someday. In the weeks that have passed, I have found new ways to grieve the potential loss of these individuals in our world, individuals who have made it a richer place for being here. Is it ethically wrong to wish an end to genetic aberrations? I think not. Is it ethically wrong to appreciate the diversity of God’s blessings that transcend a fallen world? Increasingly, I find it isn’t.

Ethical Bullies, Part I

To the degree that there are any public sins anymore, particularly among the young, “bullying” may be the chief among them, wed as it is to the cardinal vice (in our culture, at least) of intolerance. The bullies of yesteryear, with their lunch-money-stealing, “uncle”-extorting bluster, are now replaced by the sophisticated “cyber-bully,” and with those who replace brawn with “hate-speech.”

Don’t read me wrong here—I think that a focus on the devastation that can come from cruelty from one person or group to potentially weaker individuals is well overdue. Many of us bear more scars from emotional cruelty than physical, and it is right to recognize that cruelty ought not to be regarded as normative, as a rite of passage, that must be endured to toughen us up.

That said, it seems fascinating that two recent issues that directly confront ethical choices seem to have bullying at their core. The first is perhaps more personal to me than the second, the second more consequential than the first.

The Boy Scouts of America (BSA), who count my 10-year old son as a member and me as a den leader, concluded a very public year of angst over the status of their ban on openly gay and lesbian scouts and adult leaders with an announcement last month that such individuals would be accepted (largely on the basis of “orientation”) as scouts, but not as adult leaders. This decision, of course, had the effect of making no-one entirely happy, though some were less unhappy than others.

I could spend countless words on the merits or lack thereof of such a decision. I could spend a lot of time on the issue of homosexuality itself, where the evangelical church has fallen so short of wrestling well with an issue that is deeply complex, that involves behavior springing from desire that vanishingly few feel can be chosen or denied, and where too many seem to declare that an entire group of human beings are not created in the image of God, but are marks of a very broken image. This view, in my mind, has little to support its theology. I have close friends and colleagues who struggle with their faith and their desires, and others who see a Christ presented to them that couldn’t possibly be seen as loving, one who will love sinners who gamble or are drug-addicted or engage in the heterosexual hook-up culture or plunge into materialism wholeheartedly, but not them. On the other hand, we live in a society of sexual entitlement, where full acceptance of anything that affirms our well-being in the pursuit of sexual desire must be embraced. The Jesus who told us to sell everything to buy the pearl of greatest price surely didn’t mean that we remain celibate inside an old-fashioned social construct.

Okay, so I spent some words on that. But none of those things directly address my concern with the position of the Boy Scouts. This decision, in reality, has little to do with the Scouts tackling the ethics of their policy, whatever its faults or merits. Their choice was based on the effective use of a much-shunned, quietly-devastating campaign of bullying by vociferous critics of the long-standing position. While the official words from the BSA reflect a clear sensitivity, the proponents of change spent many hours and much treasure threatening the Scouts, from loss of financial support from businesses that would face boycotts to overt efforts to thwart enrollment of new Cub Scouts. Every scouting manual, from Tiger Cub to Boy Scout, teaches young men to abandon bullying and to help each other stand up in defiance of it. In their national meeting in Grapevine, Texas, in 2013, the leadership of the Boy Scouts of America, facing shrinking enrollment and corporate abandonment, collapsed under the weight of sophisticated bullies, teaching their youth everything and nothing.

There is no small irony here. People who have faced historically awful levels of bullying in the gay and lesbian communities were successful with those same methods. More troubling, the BSA took an ethical position because they were backed into a corner when the numbers stopped adding up. Maybe I am naïve, but it seems that, even with wildly-different ethical groundings, people once brought their best ethical arguments to the table and then worked through them. Today, in a system marked by moral relativism, we are left with the ethical imperative that one choice is wrong because it is not on the “right side of history.” Only in a world that understands ethics and morality poorly, and history even more poorly, could such a weak appeal be made.

The ridiculous and anachronistic feudal system of czarist Russia was replaced by the regimes of Lenin and Stalin. Who was on the “right side of history” there? History may be a better a judge of ethical and moral choices than opinion polls, but the fact that something replaces an antecedent is a rotten marker of its moral worth, however untenable the system it may have replaced. Is this really the best we can bring to ethical conversation today? It is unsurprising, but is disappointing.

So what in the world does this have to do with bioethics? The second of the two issues, that of Internal Revenue Service shenanigans, which I hope to address next week, speaks directly to a concern that ethical choices will sublimate to forces of bullying. The Boy Scouts of America did not succumb to a superior ethical argument, but to an ethic of bullying by stronger cultural forces. When the government is involved, particularly the division assigned to implement our health care policy going forward, things ratchet up a bit, and we will all be wise to take notice.

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).