Death panel dudgeon

A very public disagreement between two prominent American bioethicists shows that they have only themselves to blame for attacks on their profession.
Michael Cook | Oct 26 2009 | comment  

Dr Ezechiel EmanuelBack in August, the American Society for Bioethics and Humanities took the unusual step of publicly complaining about “unfair attacks” upon bioethicists. The ASBH was incensed at the shellacking its members has been receiving in the media over the “death panels” issue.

Failed vice-presidential candidate Sarah Palin was the first to ring alarm bells about "death panels" of bioethicists who would have divine powers of life and death in President Obama's health care plan. Palin highlighted the "Orwellian thinking" of President Obama's chief health care adviser, Ezechiel Emanuel, and basically accused him of introducing euthanasia by stealth. If she didn't name other bioethicists, the media did.

This infuriated the ASBH. Portraying the work of these thoughtful people as an attempt to hasten the deaths of patients was "a heinous form of intellectual violence" and contemptible dishonesty. This inflammatory rhetoric not only defamed individuals, but also "denigrate[d] bioethics as a profession," the ASBH said. The “death panels” – however absurd they were – became a public relations nightmare for the bioethics industry. "Bioethics" had become something sticky and malodorous on the sole of your shoe.

Weeks later, the situation hasn't changed much. Dr Emanuel is still in the cross-hairs of critics of Obamacare. Earlier this month the head of the Southern Baptist Convention Ethics & Religious Liberty Commission had to apologise for bestowing an imaginary "Dr Josef Mengele Award" upon him in a rabble-rousing speech.

But the most recent attack on Dr Emanuel, who is also the head of bioethics at the National Institutes of Health and the brother of President Obama's chief of staff, came not from the right-wingers, the tabloid press or the internet wackos, but from a leading bioethicist colleague.

This was sparked by an address by Dr Emanuel to the annual conference of the ASBH. He argued that what bioethics needed was more statistics. Without a solid grounding in quantitative methods, bioethicists simply aren't much good. Ideally, aspiring bioethicists should study behavioral economics, psychology, decision theory or sociology. There should be less public discussion and more number-crunching. And, he implied, it is number-crunching bioethicists who will be getting the precious government funding which enables them to stay in business.

America's best-known bioethicist, Arthur Caplan, of the University of Pennsylvania, was so irritated that he almost immediately posted an open reply. He responded that a bioethicist must be a "moral diagnostician". "A crucial part of the bioethicist's role is to alert, engage and help to illuminate ethical problems and challenges both old and new in the health and life sciences." Empirical data are just one tool in the bioethical toolbox.

Emanuel's address has not been published on the internet yet. But this very public dust-up provides more ammunition for those who believe that the field of bioethics is in crisis. When the most quoted US bioethicist says that the philosophy of the most powerful US bioethicist is "narrow, misguided and wrong", what are laymen to think? It certainly gives them no confidence whatsoever that President Obama is getting the right bioethical advice.

The problem is deeply rooted in American bioethics, at least the kind represented by Dr Emanuel, and to some extent, Dr Caplan himself. Americans have every right to think that bioethics is about clarifying and defending human dignity. But to their surprise, when these mysterious seers emerge from their academic caves, all they hear is talk about statistics, efficiency and quality-adjusted life years.

There's a reason for this. Bioethics is meant to be a practical philosophy, but the brand represented by Dr Emanuel has become so practical that it is no longer philosophy. This is a tragedy. Without philosophy, bioethics becomes detached from human dignity.

Here's why.

For so familiar a word, "bioethics" has a short history. It entered our dictionaries as late as the 1970s. The English word cobbles together the Greek words for life, Bios, and for moral character, or custom, Ethos. So huddled under the umbrella of a single term are two related but distinct intellectual disciplines, metaphysics and ethics. Bioethics is inexplicable without them, just as biochemistry is inexplicable without biology and chemistry.

Let's look at metaphysics first. The ancient Greek philosopher Aristotle coined the word. He wanted to investigate whatever underlies or lies beyond (meta) the physical world of what we can see and touch (physica). So metaphysics deals with the most fundamental questions of experience: what is reality? what does it mean to be? what does it mean to be a person? what is life? Bioethics "works" only if its metaphysics is correct, that is, if its understanding of life, humanity and personhood corresponds to reality. An astrophysicist who bases all of his calculations on the equation e=mc³ will ultimately reach the wrong conclusions, no matter how sophisticated his mathematics.

This is not just airy-fairy, pie-in-the-sky theorising, either. Many bioethical issues which hit the front page are fundamentally metaphysical. Is a human embryo a human person? Did Terri Schiavo have a right to life? When does a person with Alzheimer's become so disabled that she no longer has human dignity?

Bioethics also depends upon the ethical systems which underlie them. Is what I do ethical because I have a good intention? Or is it good because God says so? Or is it good because a majority says so? Or is it good because its consequences are good? Or are questions of right and wrong meaningless and is all ethics basically a waste of time? Should bioethicists give up and get PhDs in behavioural economics?

Unfortunately, many American bioethicists give the impression that they have never given the philosophy or ethics which underpins their work much thought. One British philosopher has even complained that they are simply too stupid:

... it is all too evident that very many, perhaps the majority, of bioethicists are, to put it frankly, less than competent. I believe that this is a view a good number of philosophers share. The bioethics industry is, unfortunately, populated by many individuals whom one might even call second-rate philosophers. They have found themselves unable to grapple with the more technical or abstract areas of philosophy--or at least to make a name for themselves in such areas--but have found that it is relatively easy to forge a name for oneself in the bioethics business.

If this is true of second-rate philosopher-bioethicists, what about decision-theory bioethicists?

No one should subscribe to the reasoning of a bioethicist, even one as eminent as Dr Emanuel, without kicking the tyres. He should be asked two questions: what makes us human and what makes right right and wrong wrong. If we can agree on the philosophical bits, it is much more likely that we will agree on the practical consequences which flow from them.

Let's say that your mother has Alzheimer's and breaks her hip. Let's say that all the bioethicists on the hospital ethics committee have degrees in behavioral economics, psychology, decision theory or sociology. Would you find that reassuring? When tough decisions have to be made about her future, would you expect them to treat your mother as a unique human being with inalienable dignity? Probably not. Probably the thought would cross your mind that these guys may know a lot about quality-adjusted life years, but not a lot about how precious a human life is. In fact, the thought might cross your mind that this looks more like a death panel than an ethics committee.

No doubt the ASBH would respond, “Trust us! We are honourable men. Decent people like us would never ignore your mother's dignity.” Hopefully this is true of most members of the ASBH. But “trust us” is not a very persuasive argument. (Just watch this hilarious Apple attack on Windows 7 to see why.)

Dr Caplan's stoush with Dr Emanuel is more than an academic bunfight. It has exposed the shallow foundations of American bioethics. If American bioethicists really want to put a stop to the hysteria about death panels, they will have to return to bioethics' roots in human dignity.

Michael Cook is editor of MercatorNet and the bioethics newsletter BioEdge

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