What Makes Doctors Happy

The Rand Corporation recently published a study of determinants of physician professional satisfaction, and their implications for patient care. One of the “most novel and important findings” related to electronic health records (EHRs).

The study found that EHRs affected physician satisfaction both positively and negatively. Physicians like the idea of EHRs, and appreciate their “promise” to improve patient care and thus professional satisfaction. However, the current reality of EHRs significantly detracted from physician satisfaction for multiple reasons,including, “Poor EHR usability, time-consuming data entry, interference with face-to-face patient care, inefficient and less fulfilling work content, inability to exchange health information between EHR products, and degradation of clinical documentation.”

I can personally testify to the validity of these findings. I have had the opportunity as a family practice doc to work extensively with two EHR systems. One is considered the “Cadillac” of EHRs, and the reputation fits: a bloated, lumbering, energy-guzzling EHR with lots of bells and whistles and a hefty price tag. The other one—well, let’s just say that using it, one gets the impression that the programmers made sure there were no physicians within 100 miles of them who might contaminate their EHR design with concepts of how actual physicians function.

Both of these EHRs are certified for something called “Meaningful Use.” This is a set of practices that EHRs must be capable of, and physician offices and hospitals have to implement, in order to receive bonus payments from the federal government and avoid penalties. The practices include things like E-prescribing, providing patients with an electronic copy of their health information, and generating patient lists for specific conditions.

But some things are absent from the requirements for Meaningful Use, like usability, and doesn’t detract from patient-physician interactions. A new report documents what most doctors already feel: that increased use of EHRs means less face-time with patients. For many if not most physicians, it means lots of time gazing into a screen and keyboarding that used to be spent face-to-face with patients. We spend time tending charts that used to be spent tending patients. I can confidently assert that most doctors did not go into the clinical practice of medicine because they prefer data-entry over relationships with patients; but this is what the current generation of EHRs has handed us.

The federal government defines “Meaningful Use” as “Use of EHRs in a way that positively affects patient care.” Positive effects on patient care can (theoretically, at least) come about by the data storage and manipulation capabilities that computers offer. But if they come about at the expense of that which is central to every human relationship—looking into the other’s face, body language that says, “What you are expressing to me is so important that I will give you my complete attention,” not multitasking—then perhaps the negative effects have overbalanced any theoretical positive effects. One of the dangers of EHRs is the old “To a patient with a hammer, everything looks like a nail” conundrum; to a person with a computer, everything looks like data. When we define “Quality medical care” solely in terms of what we can count and measure, when we value data over relationship, then “Meaningful Use” becomes a meaningless slogan.

 

On Technology, Bullying and Compassion Fatigue

Technology has been described variously in theological terms (a “qualified blessing” from a God who gives of grace creatively) and ethical terms (generally neutral of itself, with potential for good or bad outcomes, depending on how it’s used). Most medical professionals (at least those who cling to some moral and ethical footing in their view of such things) hold certain technologies in high regard, like therapeutic tools that allow their patients to live longer, healthier lives. Yet they struggle with those things that push the envelope, which may sacrifice the judicious for the temporal.

It’s not these ethical dilemmas of which I speak. Technology has the ability to be a tremendous force for democratization of everyday life. People have access to information that is unfiltered, and can express themselves with a freedom that goes beyond even the seeming anonymity of road rage. The past few weeks have shown me the challenge that this technology creates for those in medicine, both human and in my own veterinary medical professions.

I am entering an unlikeable phase in life where I will start to lose friends and contemporaries to cancer and heart disease and strokes. I attended the funeral of a friend that left this life sooner than many of us felt ready. We know the right theology, we face reality, but it still stings. One of our other friends, who has lost a parent in recent years, commented that, near the end, there seems a need for blame to be assigned. She had maintained vigils at her own mother’s side as she slipped away, and still felt herself recoiling from the sight of hospital beds and fluid pumps. She remembers how she almost hated the nurses and doctors that couldn’t fix her mother, and who seemed almost as baffled at the deterioration of their patient as she did. All she could see was her mother worsen with no apparent plan by her caregivers to turn things around. That anger, fully known to be irrational in hindsight, is no less real in her memories.

As a veterinarian, I also know of another very sad case, this time of a colleague in New York. Her story can be found here, but it is heart-wrenching to hear its specifics. Briefly, this doctor had done what many veterinarians before her have done, which is to avoid the personal and professional pain of what is called “economic euthanasia,” where a pet is taken in by the doctor after the individual bringing it to the office expresses a financial inability (or unwillingness) to have treatment performed that would save its life. Dr. Shirley Sara Koshi successfully nursed a cat back to health, on her own time and at her own expense, after it had been turned over to her in such fashion by an individual who brought various cats to Dr. Koshi after they were removed from a New York City park. After its recovery, the individual attempted to reclaim the cat and was rebuffed unless and until the medical expenses were paid. Legally, the cat had been relinquished to Dr. Koshi and there were no ethical obligations (and, indeed, should have generated ethical objections) to return the cat to the individual who brought it to her in the first place.

Technology and emotion can supplant when legal options are scant. Enter social networking, specifically a pair of Facebook pages. The first, called “Regret-a-vet,” offers disgruntled consumers of veterinary services a forum to air their grievances, complete with lots of “Likes” and supportive comments. The second, and more venomous, is called “Veterinary Abuse Network,” and, in this case, ratcheted things up a bit. A full-tilt assault on Dr. Koshi ensued. The veterinarian did respond, regrettably pulling herself into the same mud as her opponents, but the social networking diatribe continued, unabated, for weeks and weeks.

When the body of Dr. Sochi was discovered after her suicide, a brief note on the “Veterinary Abuse Network” page found justice in the freedom that the cat had won, free of this imperialistic animal doctor. There was cheering at the death of this veterinarian. The Facebook destruction of a medical professional was complete.

Now to be sure, I don’t know all the specifics of this case, nor do I know all the factors that led to the suicide of a 55-year old veterinarian. But I do remember the brute honesty of my friend who admitted that her family needed a scapegoat when her mother died, and medical professionals served that role. The freedom to “rate” our physicians and veterinarians and others, via the anonymity of the Internet, is a technology that is fearsome to me and, I suspect, some of my friends in human medicine. The narcissism fueled by Facebook and other venues can destroy someone, and fast. I have never had to deal with it; someday I surely will.

Jean Bethke Elshtain once wrote that we must think of our political figures as being made of “flesh and bone,” not just as unfeeling figureheads in a political system. I think this relates to our medical professionals as well, a staggering percentage of whom are still (and often inexplicably) idealistic and face emotional and ethical issues head-on, and who must maintain a deep compassion for their patients and family members (and, yes, this means veterinarians as well as physicians; as one of the former, I can tell you how the short lifespan of my patients and their role in the family make my job and the job of my staff that much more exhausting). This compassion is exhausting, and we all seem to take it personally when a patient dies, no matter the reason. Jesus modeled well how to get away to a “lonely place” to regroup in communion with the Father when acts of compassion could be so, soulfully tiring. We have no room for that in medicine. The standard for an online review of a physician ought to differ from one made for an Italian restaurant or a carpet cleaning service, but the democratization of the Internet lumps them all together.

What a shame. What a tragic story. What a reminder that technology can be our friend, and can be used to bully us all. And that bullying can hit us in our weakest place—the place that says we just don’t care. Be ready.

Monitoring the Health IT industry

Should electronic medical records (EMRs) be regulated for safety just like any other medical device?

At first glance, the answer seems to be, “No.” After all, EMRs are just computer versions of the old paper chart, right? Nobody regulated paper charts for safety, so why should we be questioning EMRs?

On closer scrutiny, however, the answer is not so clear, because EMRs are more than simple repositories of clinical data. They are used to enter and transmit orders for things like procedures, tests, and medications, as well as to transmit results back to physicians.  While errors due to bad doctor handwriting have diminished, there is a growing body of data documenting new errors and harms to patients caused by EMRs. The Institute of Medicine (IOM) catalyzed the headlong rush to adopt EMRs with its 1999 report asserting that increasing the use of information technology (IT) would lead to decreased patient errors and increased safety; in 2011 it published a report calling for the formation of an independent federal body to investigate patient deaths and other adverse events caused by health IT.

Now the large industry that has grown up around EMRs is fighting federal regulation that would treat EMRs like any other medical device and monitor their effect on patient safety. As the IOM’s 2011 report points out, the precise effect EMRs have had on patient safety is difficult to quantify because of “contractual barriers (e.g., nondisclosure, confidentiality clauses) that can prevent users from sharing information about health IT–related adverse events . . . these types of contractual restrictions limit transparency, which significantly contributes to the gaps in knowledge of health IT–related patient safety risks. These barriers to generating evidence pose unacceptable risks to safety.”

It appears that the Health IT industry believes that it is not in its best interest to gather data on how its products might adversely affect patients. On the other hand, it appears that gathering such data and using it to improve systems is in the best interests of patients. In this conflict of interests, the patients’ interests should clearly prevail.

This is not to say that it should necessarily be the FDA that regulates the industry. In fact, I believe a transparent and trustworthy private body would be a better option. But the Federal Government has spent literally billions of dollars (our dollars) to induce physicians and hospitals to adopt EMRs. Most of that money is ultimately finding its way into the coffers of the Health IT industry. The government has not only the right to determine what harms that money may be causing, but the responsibility to do so.

 

What we can learn from the Amish about technology

The stereotype of the Amish is that they are Luddites, unsophisticated rustics resolutely refusing to use technology because they perceive it as evil. However, if anything, their approach to technology is more sophisticated than the surrounding culture’s, and we could learn much from their approach, especially in medicine.

Contrary to the stereotype, the Amish do not categorically refuse to use technology; it only appears that way in contrast to those of us around them who avidly and unreflectingly adopt new technologies as soon as they are advertised. To the Amish, technology is not sinful or immoral, just potentially dangerous: like a knife, which can be used to cut bread or inflict mortal injury. They are also keenly aware that often, when we adopt new technologies to serve some purpose of ours, the technology insidiously becomes the master and we its servant. Therefore, they have consciously and collectively tried to tame and domesticate technology so that its brute force does not overwhelm their culture and values. They understand that technology requires careful evaluation before it is adopted (this necessarily involves selectivity and sometimes rejection!), and careful limit-setting once it is adopted. This has led them to be scrupulous about what technologies they adopt, and how they adopt them. They “modify and adapt technology in creative ways to fit their cultural values and shared goals.”* The Amish default mode towards technology, in contrast to ours, is to go slow, be careful, and check with the community. They remember the truth that we seem to forget (despite innumerable and painful examples): technology has the potential to change and destroy in ways that we may not realize until it is too late to undo the damage. How many times have we suffered this, without learning? From the antibiotic resistance resulting from the inordinate and thoughtless prescribing of antibiotics for anything that even looks like an infection, to the deforming of the patient-physician relationship by the interposition of the computer, to the cancers caused by excessive and knee-jerk CT scans, we find too late the damage done by the technology we have embraced with such ardor and haste, seeing only the good that it promised without taking thought for its potential to undermine the ends of medicine it was supposed to serve.

The Amish ask, as should we, “Can humans tame technology, or does it control our destiny? Has the enormity and cleverness of our creation overwhelmed our ability to control or guide it?”* This question is important as we evaluate existing technologies (as is happening, for example, albeit belatedly, in the Choosing Wisely campaign); it will be even more important as we approach technologies whose power to act upon humans dwarfs anything we have seen yet, such as nanotechnology and gene therapy. Will we, like the Amish, be willing to go slow, be careful, and check with the community? Or will we find that our technology has taken control, overwhelming our ability to control or guide it?

 

* These quotes, and much of the background information for this post, come from The Amish, a fascinating study by Kraybill, Johnson-Weiner and Nolt, published last year by The Johns Hopkins University Press. Other information for the post came from discussions with several of my own Amish patients.

The givenness of human nature

In his article in the Fall 2013 issue of Ethics and Medicine, Dennis Hollinger writes about how a Christian understanding of human nature impacts how we understand the limits that biotechnology needs to stay within to avoid changing things about humanity that should not be changed and how we understand what are the essential features of humans that ought to be preserved. He suggests that a Christian anthropology says that we should preserve the integrity and uniqueness of the human species, accept and not try to escape our finitude, maintain the unity of material and non-material dimensions of human beings as embodied souls, and respect the dual creation of human beings as male and female. All of these aspects of humanity are presented as “features of human nature that are divine givens that ought to be acknowledged and guarded.”

Hollinger is asserting that there is a givenness of human nature that we can understand theologically. It is essential in understanding what the limits of biotechnology ought to be. However, the idea of givenness is the key in this. One definition of the word givenness is the quality of being granted as a supposition or acknowledged. But the idea that there is a givenness of human nature is not a given in contemporary thought. Many who advocate relatively unlimited use of biotechnology and desire the transformation of human beings into a post human or transhuman state start with a position of philosophic naturalism and see human nature as the malleable result of unguided evolution. As Hollinger states, if one believes that there is no human nature that is normative or given then there is no need to be concerned about what should be preserved and not altered.

We need to recognize that a robust understanding of who we are as human beings is essential to bioethics and requires a solid foundation in the understanding that we are indeed created and have a nature given to us by our creator. Without that foundation all ethics is adrift. While we ought to be able to understand that we are created by looking at creation and can build some foundation from what God has generally revealed to all humanity in what he has made, it is through his written revelation that we can best understand who we are and what the nature of human beings is that we should shudder to alter.

My thanks to Dr. Hollinger for so effectively expressing an understanding of what those divine givens of human nature are that we need to preserve.

Life, death, technology, and really hard questions

A tragedy is unfolding in Texas, unfortunately in the public eye, of a 33-year old woman who suffered a severe injury to her brain on November 26th, when she was 14 weeks pregnant. Her brain, we are told, has stopped functioning; her other bodily functions are being maintained artificially. Her now 20-week old fetus is still alive. Her family has asked the hospital that, in accordance with the woman’s previously expressed wishes, her bodily functions no longer be maintained mechanically. The hospital has refused, citing a Texas law that prohibits the removal of life-support for a pregnant woman; the husband has sued the hospital to have the life-support removed.

Here is a tragedy in which all choices are fraught with deep sorrow, and in which difficult questions are legion; if we think we have answered one, seven more spring up to take its place. Before I discuss them any further, let me lay my cards on table: First, I am pro-life. This implies far more than that I am simply against abortion! But I do believe that in most situations, abortion is not the right or best option. Among other reasons, I believe this because I am a physician still enamored of the Hippocratic tradition, and because I am a Christian — that is, I believe Christ’s claims that he is divine, and that therefore his statements such as “Do unto others as you would be done by,” and “Whatever you do to the least of these you do to me,” are more than just suggestions, and apply to how I treat all people, whether in utero or ex utero. However, there are rare instances in which abortion is the “least bad” alternative, such as when continuing a pregnancy places the mother at risk of serious harm or even death (and while this is indeed rare, I have known patients for whom this was judged to be true).

Second, I have some pretty strong beliefs about technology, which readers of this blog may have divined. I do not believe in the technological imperative which states that “Because we can do such-and-such, we are obligated to do it.” I strongly hold that people should be free to choose not to have technological interventions performed upon themselves. Related to this, I believe “Technology creep” is a rampant problem in medicine: techniques designed for one application are indiscriminately generalized and applied everywhere they can be applied, just because they can be, just because they are technology, and because we assume that technology always makes things better — when often all it does is dehumanize the situation.

That said — of all the questions this tragedy raises, the two questions I pose today are, Is stopping life support for the mother equivalent to abortion? And a related question, Does the pro-life position necessitate holding that this woman should be kept on life support for the sake of her unborn baby? The reasons to answer Yes are compelling. There are two people on life support: one who will almost certainly never get off of it alive, and another who has the potential to get off of it alive if the other stays on a little while longer. If the machines are disconnected, two people will die. As far as we can tell, the machines are not a burden to the mother (if she is indeed “brain-dead,” then by definition she isn’t suffering). When she said that she would never want to be maintained on machines, she probably wasn’t considering being pregnant and on machines, and who knows what she would have wanted in that case? It seems it would be better to err on the side of temporarily maintaining her bodily functions for the sake of her unborn child.

And yet there are enough caveats here to make me wonder. Is stopping the life support in this situation tantamount to abortion? I am not sure that it is. By withdrawing the life support, we withdraw a technique and allow the natural course of events to take place; the intention is not to kill the fetus (although that is what surely will happen as a result).  By induced abortion, we introduce a technique to change the natural course of events, with the intention to kill a human being. It seems to me that there is enough of a difference between the two that we should not conflate them. Again – it is well-accepted that there is no ethical difference between withholding treatment and withdrawing treatment. If we are to say that withdrawing the treatment in this case is abortion, does that not imply that withholding (not starting) the treatment in the first place would also be abortion? That smacks of a tyrannical technological imperative, a place I don’t think we want to go. Again –  The second formulation of Kant’s categorical imperative runs something like, “We should never use someone only as a means to someone else’s ends.” I am no philosophy major, but it sure feels like keeping this woman on life support against her express wishes is making her a means without considering her as an end.

If one were to abstract this situation from its context, consider it as a theoretical problem, the “least bad” outcome would be for the woman to be supported until her baby is born. But this is not an abstract, theoretical problem. I have sat at the bedsides of many, many patients who have been trapped in webs woven by dubious uses of technology. I have seen many, many people enduring the “living hell” that this woman’s husband has described experiencing over the last few months. Granted, these experiences of mine don’t carry the weight of rational arguments; but they remind me that these decisions are not carried out in the academic ether. I do not believe that withdrawing the life support for this woman is equivalent to abortion; and, related to that, I don’t believe the pro-life position necessitates holding that keeping this woman’s body functioning in order to allow her baby to reach viability, against the express wishes of her and her family, is the only ethical solution. There are those who will disagree with me, some vehemently; I understand their positions and respect them. (I am not speaking for Trinity International University, so don’t get mad at them!)

I don’t have space to go into all of the other issues this situation raises (one of them being the definition of “brain death” — see here for a thoughtful reflection on the matter). But one more issue I will address: There are a lot of people who have written and said uncharitable and judgmental things about this woman’s husband and family. While I am uncertain about what is the right thing to do in this situation, I’m quite certain that passing judgment on the family is wrong.

A New Year’s Wish for You: a Period of Disconnection

My recent hiatus from posting has been due to travels. For 3 weeks my husband and I were travelling overseas, and for those 3 weeks we were disconnected–without phone or Internet access. I am currently in Florida with aging and ailing parents and in-laws and am again without Internet access. But one of the things gained in those losses is time to ponder.

While I am more of a Luddite than a technophile, my life, like that of everyone else, is increasingly invaded and controlled by technology, despite my futile efforts to control and contain it. I am often burdened by the conviction that I have to see and respond or react to every email that comes my way for fear of missing some crucial information or a important opportunity to speak something cogent into a situation. But I gained some invaluable insights during these periods of disconnection: the world did not end—and neither did my life—because of my disconnection. As a matter of fact, of the 300 emails I eventually downloaded, only 4 were personal; and of 6 messages on my phone, 4 were from my mother who has mild cognitive dysfunction and couldn’t figure out where I was or why I wasn’t answering her calls (despite having her write down the dates of my absence before I left; and now she remembers neither that she called nor that I wasn’t available).

Moreover, during that period of disconnection–when I was not continually bombarded by electronic demands–I had the opportunity to experience the beauty and majesty of another portion of God’s incredible creation, to learn of other peoples and cultures, to spend time hiking and in meaningful conversation with my husband, and to meet and engage new friends. In other words, I was more fully connected than previously, a fact that put life in a different perspective and raised, once again, the profound issue of what is truly meaningful in life…

It became readily apparent that the superficial electronic connectedness of our lives, fueled in part by an overweening voyeurism, has fed an inordinate sense of self-importance. But in our striving to maintain our global connectedness—and our importance–we no longer have time to connect to the person present before us—or their needs–and so in fact are less connected in ways that really matter. It is indeed a Facebook world, where the impersonal posting of personal experiences constitutes friendship, and possession of health data constitutes a medical relationship. How ironic this is during a season in which we celebrate that fact that the Eternal Word became incarnate—embodied in a particular body in a particular place and time—in order to relate to us. In terms of logic and efficiency—by which we humans measure the worth of almost everything—it would have been more profitable for the Christ to remain unembodied; the Word unencumbered by a body could have reached many more people much more efficiently. But that is not how God chose to relate to us, and that should give us pause to ponder and reflect.

A book by Crystal Downing entitled, Changing Signs of Truth: A Christian Introduction to the Semiotics of Communication, left me feeling quite convic

First, do (no harm)

A fascinating, troubling article in the August Mayo Clinic Proceedings examines ten years of research articles from the New England Journal of Medicine (NEJM), perhaps the most prestigious and highest-impact medical journal around. During that period of time, the authors found 363 articles in the NEJM that described studies which tested an established medical practice to see whether it was actually helpful or not; of those, 146 (40%) found that the practice in question was either no better than doing nothing, or worse than doing nothing. An accompanying editorial asserts that “. . . ineffective, harmful, expensive medical practices are being introduced more frequently now than at any other time in the history of medicine. Under the current mode of evidence collection, most of these new practices may never be challenged.”

Our ability to do things to people has run far ahead of our ability to evaluate or think ethically about what we do. This doesn’t apply just to high-profile procedures like IVF and genetic testing, but also to more mundane procedures such as the treatment of urinary tract infections, inner ear infections, allergies, and asthma. In a techno-medicine world that views the human mechanistically, places starry-eyed (and frequently unwarranted) faith in medical technology, and sees all human problems as techno-medical problems that need a technical medical intervention, these results are perhaps to be expected. Ominously, they will likely only worsen.

A reasonable solution would be to wait and consider more thoughtfully and thoroughly our interventions — procedures, tests, drugs — before we foist them onto an unsuspecting populace. But to even suggest such a thing in some circles is to elicit rolled eyes and to be labeled an obstructionist, or a technophobe, a Luddite afraid of progress (as well as economically unrealistic). However, as we gain increasing power to alter the human organism, our potential to harm will increase proportionally. When it comes to power that we do not yet know how to use wisely, we should take as our example Frodo Baggins, and realize that in these cases, as in so many others, the solution to the problem of power is to refuse to use it.

Technics and Civilization and Medicine

I am reading an old book, Technics and Civilization, written by Lewis Mumford and published in 1934. Mumford traces the history of technics or technique (of which technology is a subset) and divides it into three phases: the eotechnic phase, which stretches roughly from A.D. 1000 to 1750; the paleotechnic phase, covering the years 1750 to 1900; and the neotechnic phase, which Mumford identified as starting approximately 1900 and extending into his present, the 1930s.

Mumford doesn’t have a lot good to say about the paleotechnic phase. This was the time when the values of the machine took over, when all areas of life were subjugated to machines and to machine-like regularity and standardization in the name of progress, profit, and bettering the species; in the brutal process, humans were frequently treated with anything but respect and dignity, reduced to mere commodities, means for someone else’s ends. Mumford rightly describes this as “barbarism.”

As I read Mumford’s indictments of the barbarism of the paleotects, I am disquieted by the parallels to current trends in some quarters of medical practice and research, in which it is considered humane to help kill the very old and sick, and good and beneficial to disaggregate embryonic humans for the good of other humans. As Mumford writes about the paleotechnic phase — and which, with little modification, could be applied to today’s “phase” in the history of medicine — “Here was something almost without parallel in the history of civiliation: not a lapse into barbarism through the enfeeblement of a higher civilization, but an upthrust into barbarism, aided by the very forces and interests which originally had been directed toward the conquest of the environment and the perfection of human culture . . . And how, when it represented in fact the lowest point in social development Europe had known since the Dark Ages did it come to be looked upon as a humane and beneficial advance?” (p. 154)

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).