International Commission on HHGE Channels Warnock Committee

In various ways, the International Commission on Heritable Human Genome Editing (HHGE) is built on the same grounds as the former Committee of Inquiry into Human Fertilisation and Embryology (Great Britain).  That committee was charged to “consider recent and potential developments in medicine and science related to human fertilisation and embryology; to consider what policies and safeguards should be applied, including consideration of the social, ethical and legal implications of these developments; and to make recommendations.”[1] 

The Committee of Inquiry into Human Fertilisation and Embryology became known as the Warnock Committee, named for its chair, philosopher (later, Baroness) Mary Warnock.  The  “recent” development of concern was a reference to the birth of Louise Joy Brown on July 25, 1978:  the world’s first baby born through in vitro fertilization (IVF).  “Potential” developments the committee addressed during their two-year stint included the use of human embryos in drug testing; nucleus substitution (cloning) to provide replacement organs; and the insertion of “replacement gene(s)” for genetic defects.[2]  These all have in common the use of embryos for research.  The majority of the Warnock Committee argued that if the embryo could not feel pain, and “there were no absolute outrage of general moral sentiment,” then “the embryo might be used for research”[3] In her memoir, Warnock wrote that, in the Warnock Committee deliberations, the “disputes were on the whole civilized:  we did not have any rampaging pro-lifers on the committee . . .”[4]


The recommendations made by the Warnock Committee became Britain’s Human Fertilisation and Embryology Act of 1990 (HFE Act) and gave rise to the regulatory agency, the Human Fertilisation and Embryology Authority (HFEA), established 1991.  The latter is the body responsible for the licensing and inspection of all labs in the U.K. that deal with IVF, donor insemination, and human embryo research, as well as the storage of sperm or eggs.  The HFEA also regulates and oversees the use of mitochondrial replacement techniques (MRT) in the United Kingdom.  The International Commission on Heritable Human Genome Editing (HHGE) used the MRT example to design it own “translational pathway”:

By a “translational pathway’ for HHGE, the Commission means the steps that would be needed to enable a proposed clinical use to proceed from preclinical research to application in humans. Elements that formed the pathway leading to clinical use of mitochondrial replacement techniques in the U.K. have informed the Commission’s development of a clinical pathway toward HHGE, presented in this report. (p 39/225)

The HHGE has, as a portion of its task,

a need for a framework to inform the development of a potential pathway from research to clinical use, recognizing that components of this framework may need to be periodically revised in response to our rapidly evolving knowledge. In addition, other important discussions are ongoing internationally about the implications for society of human germline genome editing and include issues such as access, equity, and consistency with religious views. (p 44/225)


Here’s hoping the HHGE will do a better job of listening than the Warnock Committee did.  Natasha Hammond-Browning, evaluating the Warnock Committee’s handling of the pieces of evidence submitted to it, concluded this:

. . . the Warnock Committee adopted a utilitarian approach in drawing up its recommendations, and it could be assumed that any evidence that adopted this approach would have been favoured over other bright line viewpoints; for example, the view that the embryo must be protected from conception, or the view that the embryo/foetus should not be protected at any stage of development.[5]



[1] Mary Warnock, A Question of Life:  The Warnock Report on Human Fertilisation & Embryology, (Oxford, UK: Basil Blackwell, 1985), 4.

[2] Ibid., 71-4.

[3] Ibid., xv.

[4] Mary Warnock, A Memoir – People & Places (London: Duckbacks, 2002), 33.

[5] Natasha Hammond-Browning, “Ethics, Embryos, and Evidence:  A Look Back at Warnock,” Medical Law Review 23(4): 588-619; doi: 10.1093/medlaw/fwv028.


A contemporary reprise of theories of justice

This blog’s being sponsored by an evangelical Christian university means, among other things, that at least some contributors, notably the current writer, tend to adopt a set of basic Christian assumptions (monotheism, tenets of historic Christianity, biblicism) in approaching matters of bioethics, including justice.  In that light, a recent summary of a Christian framework for justice, by the Presbyterian pastor Timothy Keller, is worth a careful read.  It is a concise and erudite summary of the different secular approaches to justice in pluralistic American society, contrasting them with a Christian approach.  (It does not attempt to address frameworks specifically grounded in other religious traditions.)

Drawing on the teachings of the Bible, especially the example of Old Testament Israel as embodying universal, enduring principles of justice intended by God, Keller characterizes biblical justice as encompassing concern for community that entails a moral imperative to generosity; equity in treatment of all human beings; corporate responsibility, meaning that sometimes, people bear responsibility for sins of others; but also individual responsibility, meaning “I am finally responsible for my sins, but not all my outcomes”; and an imperative to advocate for poor and marginalized people.  Of these, the contours of corporate vs individual responsibility will certainly spark debate among Christians, but living out these principals is, Keller argues, the responsibility of the Church in a secular world.

The big contrast is with atheistic, secular approaches to justice, which must and do fail because they neglect, avoid, or despise appreciation for human teleology—what are people for, what is their purpose?  Keller invokes Alastair MacIntyre’s Whose Justice?  Which Rationality? and, with MacIntyre, takes the position that “behind every understanding of justice is a set of philosophical beliefs about (a) human nature and purpose (b) morality, and (c) practical rationality—how we know things and justify true beliefs.”  Disagreement about these, particularly about human nature and purpose, leaves the prospect for secular agreement about justice well-nigh hopeless.  The rationality of the Enlightenment failed in this regard, and the popular current secular default that morality springs from common sense begs the question, assuming a common moral intuition that need not and does not pertain.

The current American secular landscape is dominated by four theories, which lie, progressively, on a spectrum of sorts, from individualist to collectivist, in order:

  • libertarianism, the position that justice is the maximization of individual freedom, which fails to appreciate the importance of community and the depths to which sin distorts human affairs, and which is too grounded in individual self-interest;
  • modern liberalism, which focuses on fairness, most recently following John Rawls’s A Theory of Justice, and emphasizes rights or entitlements, often to be guaranteed by the state.  It fails for reasons that have been well-rehearsed many times elsewhere: an enthronement of individual autonomy, a lack of a standard for adjudicating conflicting rights-claims, and an unwarranted faith in reason (notably in cost-benefit analyses), attempting to exclude religious values, but, in America at least, assuming Judaeo-Christian principals and values to support fairness judgments;
  • utilitarianism—justice is what produces the greatest good for the greatest number—which, for all its usefulness in individual judgments, fails as an overarching approach for many well-known reasons, including incommensurability of goods, potential to embrace mistreatment of minorities, insufficient criteria for what is “good” in the first place, and over-reliance on the language of “harm” to ground judgments;
  • postmodernism, the notion that “a just society subverts the power of dominant groups in favor of the oppressed.”  This may be the loudest current voice, and it draws the lion’s share of Keller’s attention.  This approach, Marxist in its foundations, starts from the presupposition that human affairs are the product of impersonal social or historical forces—the old “scientific theory of history.”  Keller provides an excellent, quick digest and explanation of what the current radicals, articulating Critical Theory (or Critical Race Theory when applied to racial relations), are talking about when they invoke “dominant discourses,” “intersectionality,” and “checking one’s privilege.”

Let us be clear—Critical Theory is rubbish, and Keller hits it hard.  Among its defects: deep incoherence—if everyone is blinded by their circumstances, so are the Critical Theorists; it reduces humans to automatons and fails to account for universal sin, moral agency, and the union of soul and body (I suppose if you deny that people have souls, and think they are just bodies, you just might be a  Marxist materialist); it denies human sinfulness and common humanity and makes forgiveness and reconciliation impossible; it invites extreme self-righteousness on the part of its adherents; and it sets the stage for oppression under the disguise of opposing oppression.  (Memo to the young: we just spent a century battling the various demons of totalitarianism, and you get to decide what you think of the second coming of Mao.  Study well.  Read attentively.  Choose carefully.)

Read the whole thing.

Human Fetal Tissue — Considerations

The NIH Human Fetal Tissue Research Ethics Advisory Board met on 31 July 2020 to “make recommendations regarding the ethics of research involving human fetal tissue (HFT) proposed in NIH grant and cooperative agreement applications and R&D contract proposals, as set forth in the NIH Guide Notice NOT-OD-19-128.” The meeting agenda included a brief time set aside for public comment. Additionally, written comment could be submitted within a prescribed time frame prior to the meeting.

It is my hope that the advisory board seriously considered the following comment penned by this writer, on behalf of the educational non-profit Tennessee Center for Bioethics & Culture:

All human beings belong to one another.  Whatever our genetic constitution, our ethnicity, our color, our femaleness or maleness, our geographic location, or stage of life:  we are part of the human family.   That membership is not bounded by a cradle-to-grave timeline.  As human mammals, our beginnings begin before the exodus from our mothers’ wombs.  From the fertilization of the egg by the sperm, a new human being arises (and sometimes, multiples).  How we treat that human zygote, embryo, fetus, newborn, baby, toddler, preschooler, child, adolescent, adult, and elder, has effects on that human being – as well as on ourselves.  How we treat other human beings, especially vulnerable ones, tells future generations and civilizations about what kind of people we are.

In 1993, President Bill Clinton signed into law the NIH Revitalization Act.  That Act charged the NIH to conduct or support research that reduced the number of animals used in research, and that produced less pain and distress in those animals (https://grants.nih.gov/grants/olaw/pl103-43.pdf). Those are laudable goals.  That same 1993 NIH Revitalization Act authorized the use of human fetuses for research, including fetuses from induced abortion (www.hhs.gov/ohrp/regulations-and-policy/guidance/public-law-103-43/index.html).  The same law that sought to reduce pain and suffering in animals opened the door wider to using nascent human beings as research subjects.  Utilizing tissue that becomes available by virtue of spontaneous abortion (miscarriage) does not actively convert living beings into research subjects/objects.  It is not a planned procedure that can be scheduled around tissue procurement firms.  That is not the case, however, with the use of fetal tissue from induced abortion.  The willful taking of tiny, live human beings from their mothers’ wombs, followed by the use of them in whole or in part, as research subjects/objects, sets up a human market.  Abortionists and abortion facilities are paid to render a living being into products or parts.  Then they are paid again to yield up these beings or parts to research.  Money is exchanged for parts or labor, even if said payment is labeled “handling charges.” This is a market, and it is a market in human flesh:  a stain upon our culture and our civilization.

More—with trepidation—on COVID

Let us stipulate at the outset: first, that so much—far too much? –is being written on the COVID-19 outbreak, and wisdom is a precious commodity; second, that although your correspondent is an MD, he is as bewildered as anyone by the storm of reports, claims, data, projections, arguments; and third, that whatever public comity may appear to pertain now, in due time we likely will be at one another’s throats with blame about who should have been better prepared or done what when, and there will be plenty of blame to go around.  Our leaders, national and regional, are especially to blame, but the evidence abounds that too many of us took this too lightly throughout January and February.

This being a bioethics blog, however, a few comments about some ethical issues in an outbreak, from a 2018 paper on the subject.  The paper in question raised three major topics: ethics of treatment research, triage, and the duty (by doctors and other health professionals) to provide care.

The last point first: it is well established that the covenantal duty of doctors in particular is a willingness to efface self-interest for the interests of the patient.  There is no dispute that this duty is being followed faithfully by the doctors, nurses, and others who are caring for people sick from COVID-19.  But a related duty of society is to do what it can to limit the risk to the caregivers themselves.  This is clearly pressured by, for example, the limitation on personal protective equipment (PPE) supplies.  We owe it to the medical community to provide them with what they need.

Next, triage:  try as we might, and fail as we might (and always seem to) to prepare in advance for a possible outbreak, surprise never fails to assert itself, and shortages of things that really matter loom.  At this writing, I have no idea whether New York City’s capacity to care for the sick is destined to, or is already, hopelessly overrun “under any scenario,” as Gov. Cuomo said this morning, or whether we can take any comfort in the assertion this evening by Dr. Birx that “there are still ICU beds and ventilators” in New York.  In early March, an infamous discussion at the American Hospital Association projected as many as 1.9 million people needing ICU care nationwide, and about half of those needing ventilator care, and it is further widely said that the typical ICU stay, even for someone relatively young, is 2-3 weeks.  Numbers far fewer than that would outstrip our national capacity, it appears.   Then again, the real shortage may not be ventilators, but the doctors to manage them.

These concerns also arose in the first Ebola outbreak a few years ago, and much-discussed principles of allocating scarce resources apply.  First and foremost is to try to alleviate the shortage through the best possible resource management.  Failing that, if hard choices must be made, then the likelihood of achieving clinical success is a top criterion.  But that requires clinical judgment that may be uncertain, requiring a lottery system, or a registry (as is done for organ transplantation).  Perhaps most controversial is to make an attempt to prefer treating people who are judged, if treatment succeeds, to have more life to live or more potential lifetime contribution to society to offer.  In that case, who decides, and how one decides, become very dubious judgments to make.

In the moment, there may not be enough critical care resources to go around, and doctors have to make a hard choice to treat one person but not another.  Physicians in Italy are reported to have faced exactly this choice this month.  Another principle, easy to say but hard to follow (talk is cheap!), is that triage “should not be a bedside decision,” that is, the treating doctor should not be forced to make a choice, but a previously-settled decision process should be applied.  I do not know whether that was or is possible in Italy, or in New York, or elsewhere in the U.S. or the world during this outbreak.

If we indeed are committed to care for and conserve our most precious care resource, our doctors, then that, in addition to limits on the number of available beds, might be adduced in favor of a so-called “universal” or “unilateral” decision that resuscitation (CPR) of some patients—which will increase the risk of the doctors and nurses getting infected—simply will not be attempted if their heart stops, regardless of whether the patient desires the attempt.  I know of no evidence that this is being done anywhere, but it is the subject of some speculation in the press.  The proper process is for a careful end-of-life conversation to happen between doctor and patient, before being confronted with the need, so that the patient’s wishes and the doctor’s professional recommendation can be considered.  But if that did not happen for people seriously ill with COVID-19, it may be too late when the illness strikes.  Those of us “of a certain age” are wise to consider this question in advance—viral outbreak or no.

Finally, the ethics of experimental treatment during a disease outbreak are governed by a well-defined regime of human subject research.  The key principles follow the Belmont principles reviewed by Mark McQuain on this blog on March 17, and include that risks to subjects must be limited as much as possible; that the necessary research risks not be excessive compared to the potential benefit to the subject at hand or society at large; that informed consent be properly obtained and documented; and that vulnerable people or those less advantaged not be denied access to potentially promising treatment nor be disproportionately placed at risk or have their vulnerabilities taken advantage of.

In the case of this present outbreak, research ethics also require that experimental treatments be properly studied in adequately designed clinical trials.  Implications, IMO, include that people be randomly assigned to treatment alternatives.   It is true that “off-label” use of drugs that are available for other uses is legal when prescribed by a licensed physician, and such off-label use is not on its face evidence of malpractice.  However, society stands to benefit by collection of data about the COVID-19 disease and outcomes of treatment, and so even off-label use should be done in a clinical trial, not in a “right to try” approach.  Because COVID-19 can be so severe, and the need for treatment is so great, I am inclined to think that random assignment to a placebo is a suspect requirement, I must admit that the need to learn more about the natural course of COVID-19 infection probably requires a placebo group in most, if not every, clinical trial.  There is not enough prior knowledge to rely on comparing a past group with a current, treated group, to conclude whether a new treatment works.  But requiring a placebo further requires that the trial get done fast and carefully, so results are as clear as possible, and made pubic immediately.  We should have no doubt at all that everyone doing the trials wants that.

I note that the public registry of clinical trials includes several in the U.S., including a national, 3000-person study of whether hydroxychloroquine may prevent disease in people exposed to others with COVID-19 disease.

Is personhood a biased term?

In ethics it is very important to communicate with clearly defined terms. This becomes especially important when dealing with a very divisive topic such as abortion. Fifty years ago, in the ethical debates about abortion, some expressed concern about how the term human being was used by those who claimed that abortion was wrong. The basic argument for the position that abortion was wrong went like this: It is wrong to kill an innocent human being. A human fetus is an innocent human being. Abortion involves killing a human fetus. Therefore, abortion is wrong. It was claimed that this was not a proper argument because the term human being meant different things in two of the premises. In the first premise human being means an individual with full moral status, but in the second premise human being is used in its biological sense. The claim was made that not everyone believes that every member of the human species has full moral status, so we should not use the term human being in this argument. It was proposed that everyone involved in the discussion abortion use the term person to represent those individuals who have full moral status. Since this discussion in the 1970s the term person has been used in the ethics literature as a technical term which is defined as those individuals who have full moral status.

However, it seems to me that the term person has the same problem as the term human being. In common usage it means other things than individuals with full moral status. It is commonly used to refer to adult human beings although children are sometimes included in who we think of as persons. It many times means those with whom we communicate and have a relationship. In legal terms it means something different. It refers to those who have certain rights and responsibilities under the law. It involves those who can be held accountable for their actions and those who can do such things as owning property and entering into contracts. The legal definition a person can include entities that are not human beings such as corporations. This becomes a problem when we look at how we define who is a person. Instead of looking at how we should understand who has full moral status, we tend to look at who fits with how we commonly use the term person. The Supreme Court in Roe v. Wade stated that “the unborn have never been recognized in the law as persons in the whole sense,” but that does not necessarily mean that the unborn do not have full moral status. Mary Ann Warren asserted that it is those who we consider to be persons rather than those who are genetic human beings who make up the “set of beings with full and equal moral rights.” However, she defined personhood based on cognitive capacities that are characteristic of fully healthy adult human beings who are moral agents and leaves out many, such as infants and those with cognitive disabilities, who we would commonly consider to have full moral status.

Using the terms human or human being to represent those who have full moral status assumes that all biological human beings have full moral status. Using the term person to represent those who have full moral status assumes that having full moral status is based on something other than being a biological human being. But that is the question. What we are trying to decide is whether it is correct to decide who has full moral status based on being a member of the biological category of beings we call human beings or based on having certain cognitive attributes or capacities. Since both terms essentially beg the question, it would be better to use neither. In discussing whether a fetus or some other individual has full moral status we need to focus on how we decide who has full moral status and recognize that using the terms human being or person in a moral sense represent positions on that issue.

Chastening and enthusiasm about genome editing

A writer in Nature says that China sent a “strong signal” by punishing He Jiankui and two colleagues with fines, jail times, and bans against working again in human reproductive technology or applying for research funding.  (They lost their jobs as well and may not be able to do research work, presumably in any field, in a Chinese institution again.)  It is encouraging, this writer says, that China took this action demonstrating a commitment to human research ethics.  He and other researchers doing gene-editing work that is not ethically objectionable worry that there may be collateral damage, so to speak, against ANY gene-editing research in China.

Another writer in Nature says cites progress under “appropriate caution” for using gene editing techniques for so-called “somatic” gene editing; that is, editing disease genes in an existing person with that disease, to treat it.  This is, in essence, a form of gene therapy and is ethically permissible under proper research ethical guidelines.  Some clinical trials in progress involve injecting the gene-editing apparatus into a person, while most such trials remove the person’s blood cells, edit them in the laboratory, then re-introduce them into the bloodstream, after which the edited cells are left to mature normally.  The latter approach is particularly attractive to treat genetic blood diseases such as sickle cell anemia.

Both perspectives seem correct, as far as they go—never mind whether Dr. He’s jail sentence fits the crime, as Joy Riley asked on this blog last weekend.  Never mind also whether Dr. He’s research should be published; as Mark McQuain commented, it’s a bit incongruous to want to assess the technical merits of work that should not have been done in the first place.  He linked an opinion in Technology Review that argued, briefly, that because the ethics of editing genes in human embryos is under societal debate, people trying to decide on the ethical merits should be able to assess for themselves whether Dr. He succeeded, technically at what he set out to do.  (The consensus to date seems to be, no, he did not.)   But the role of technical success in assessing the ethical merits of a medical intervention—or, better, an intervention made in the name of medicine—depends on the degree to which the ethical judgment is a matter of making a reasonably reliable of risk and benefit, and the degree to which risk-benefit is a criterion for judging the ethical merits.  And therein, as they say, lies the rub—which I hope to revisit in coming posts.

2020, or 20/20?

Near the end of 2018, He Jiankui was on the world’s stage announcing that he had edited the genome of twin girls, in the hope of making them resistant to HIV. On Tuesday, December 31, 2019, the Wall Street Journal (WSJ) printed a report that Dr. He and two others have been convicted of “illegally practicing medicine related to carrying out human-embryo gene-editing intended for reproduction.” (online version here).

A court in Shenzhen concluded that the defendants had acted for “fame and profit,” when they “deliberately violated the relevant national regulations, and crossed the bottom lines of scientific and medical ethics.” For the crime committed, He received the most severe sentence. In addition to the three-year prison sentence, He is banned for life from “working in the field of reproductive life sciences and from applying for related research grants, “ according to the WSJ.

The Xinhua News Agency also noted that a third genome-edited baby had been born, and that this child, along with the previously born twins, “would be monitored by government health departments.” The WSJ did not state for how long the monitoring would continue. Not only were the children experimental subjects as embryos, but they continue to be subjects as well. Further, these genome effects will affect their progeny, potentially into perpetuity. Additionally, the Smithsonian Magazine reports that in the summer of 2019, He met with “investors to discuss a potential commercial genetic modification clinic in Hainan, which aims to become a ‘world-class medical tourism hub’.”  One might reasonably call this “a crime against humanity,” even if it does not include genocide of humans already born. (For further reading, see David Luban, “A Theory of Crimes Against Humanity”)

In the print edition of the WSJ, alongside the article on He is an article about Pastor Wang Yi of the Early Rain Covenant Church. Pastor Wang was sentenced on 30 December to nine years in prison. His crime was “incitement of subversion of state power and illegal business operations” (online article here).

Consider that a pastor receives a nine-year sentence for an offense against the State; and a scientist, a sentence of three years for a crime against multiple generations, and indeed, humanity. In the year 2020, we could use a check of our understanding of what is important in the life of the world. Would that our vision were 20/20 also.

Good news

The angel who surprised some shepherds outside of Bethlehem brought them good news. They were told that a baby had been born who would be a savior and that they were being invited to go and see him. I suspect the shepherds thought they deserved some good news. Things were not going very well. They were living in a nation that had been conquered by Rome and the recent requirement that everyone be registered in their hometown was for the good of Rome, not for them. It is likely that the kind of savior they were looking for was one who would save them from their Roman oppressors.

The shepherds answered the invitation and went to see this baby who was going to be a savior and told Mary what the angel had told them. Mary pondered this in her heart. She knew something the shepherds did not. She knew that this baby, who the angel said would be the Messiah and Savior, was not an ordinary child. He had been conceived miraculously by the Holy Spirit. She also knew that an angel had told Joseph that they should name the baby Jesus because he would save his people from their sins. That was a deeper good news than the shepherds probably understood.

When we think of good news in medicine it commonly means that a new more effective treatment has been developed or possibly that a disease that previously had no effective treatment can now be cured. Those things are good news, but however many new treatments are developed, we still all die.

The good news of Christmas gets at something deeper. The Bible helps us understand that the reason that the diseases and death that medicine battles exist in this world is because we and the world we live in are broken by sin. No matter how many new treatments we develop, medicine cannot address the underlying problem. The angel told the shepherds about the ultimate cure. A savior had been born who could reverse the effects of sin and death and save us from our sin. He could bring us eternal life. He did that by going to the cross and showed his victory over sin and death by his resurrection. That is good news.

Merry Christmas!

Determining Fairness in Healthcare

The New England Journal of Medicine (NEJM) had a recent Perspective on proposed bill H.R. 3 aimed at reducing federal spending on prescription drugs. A main component in the bill authorizes the Secretary of Health and Human Services to establish a “Fair Price Negotiation Program” that, beginning in 2023, would permit the secretary to negotiate with pharmaceutical companies the price paid by the federal government on 25 drugs each year. The article provides a broad overview of the bill as it discusses some of the economic pros and cons as well as the political back and forth that would be required to allow this bill to become law. The link is behind a subscription firewall but provides an option for free access to a limited number of articles with registration.

Call me cynical but anytime I see the word “fair” associated with a bill in Congress, I immediately wonder “for whom?” The article is quick to point out that the “negotiation” effectively means “price regulation and severe penalty for noncompliance” by the drug manufacturers. The article describes in general the method that will be used to set the maximum price of a given drug. How or why did Congress determine that method as the best for determining the Fair Price? Also, not all drugs will be included in the group subjected to negotiation. If it is good or fair (as determined by Congress) for drug prices to be determined/set/negotiated by our government, should not all drugs be negotiated similarly so they are fairly priced?

Bills like H.R. 3 are part of the larger discussion of what I call the ultimate “Rights vs. Obligations” in the delivery of healthcare. If healthcare is a human right, who is obliged to provide that right? In the present case of medication pricing, if the present cost of a drug is too high, who is obliged to offset that cost (read – pay the difference between “too high” and “fair”)? The provision of healthcare, generally, and the creation, testing and production of medications, specifically, have real costs. Are these costs fair? Who will pay these costs? The patient? The doctor? The hospital? The pharmaceutical industry? Should healthcare be for-profit? If so, how much profit? Should healthcare become a utility with strict(er) oversight? Can the market decide a fair cost or price? Can a utility board? Can our elected representatives? How about a group of really (and I mean really) smart, unelected bureaucrats?

Thoughtful answers to any one of these questions should be submitted immediately to your local congressperson. Collectively, they are presently the ones determining fairness (in a real bioethical sense) in healthcare.

The importance of premises

In an interesting article in the Hastings Center Bioethics Forum, titled “Hannah Arendt in St. Peter’s Square,” Joseph Fins and Jenny Reardon write about the importance of deep ethical reflection in dealing with the ethical challenges of biomedical research. They point out that when ethics becomes a matter of simply following a set of rules we can end up in the wrong place. Even such fundamentally good concepts as informed consent and the need to have research proposals reviewed to be sure that they are ethically sound can lead to a mindset of regulatory compliance, essentially following the letter of the law, while leading to poor conclusions about what we ought to do. In the end they suggest that in order to facilitate deeper ethical thinking regarding new areas of biomedical research we need more interdisciplinary conversation between the sciences and engineering on one hand and the humanities and social sciences on the other. I think this is quite true and is a strong argument for a liberal education in its classic sense.

However, I find it particularly interesting how the thinking of Hannah Arendt enters into their discussion. Arendt was a German Jew who fled from Europe to the US in the Nazi era. She wrote about the kind of thinking that allowed the totalitarian regimes of Hitler and Stalin to gain control. Fins and Reardon focus on her idea that logical thinking can lead from a seemingly self-evident statement to a replacement of common sense with thinking that leads in a direction that is very wrong. They see a culture in medicine and science that considers ethics as a matter of regulatory compliance rather than deep reflection an example of this.

What I find most interesting in Arendt’s thinking is the idea that logic will lead to faulty conclusions if the premise is not true. The problem that she saw in the thinking leading to totalitarian regimes was not that the thinking was illogical. The problem was that the seemingly self-evident statements which were used as the premises were false. When we apply that to ethics it means that we will only reach sound ethical conclusions when we begin with moral premises that are true. A liberal education with interplay between the humanities and the sciences is one way to seek true premises for our ethical thinking in the wisdom that can be found in the interplay of academic disciplines. Another is to recognize that the existence of common sense morality suggests a source of moral wisdom that is beyond human wisdom. Christian ethics finds its premises in that higher source of moral wisdom. A Christian liberal education integrates them both.