The death of Nelson Mandela this week at the age of 95 is a reminder for me, at least, of how powerful human dignity can be in history. The notion of "human dignity" (usually in scare quotes) has been dismissed by a number of bioethicists as " flawed, fuzzy and unhelpful" or as just plain "stupid". Of course dignity is a bit fuzzy; most concepts that do a lot of heavy lifting are. But it is no more fuzzy than the alternative ethical criterion on offer, autonomy.
Mandela was the embodiment of dignity, in all its senses. He was a man who commanded respect and admiration, even veneration, because of the way he comported himself and dealt with others. But he also believed that every human being was worthy of respect because they possessed an inalienable dignity. As he wrote in The Long Walk to Freedom, "Any man that tries to rob me of my dignity will lose". Mandela was a pragmatic politician, but these were more than fine words. His strategy of nation-building through truth and reconciliation demonstrated his consistency. As a slogan, dignity was more powerful than even prosperity or nationalism.
Does this have any relevance for bioethics? Indirectly, yes. Apartheid, the system which Mandela fought and dismantled, led to terrible inequities in health care and created conditions which helped to make South Africa the AIDS capital of the world. All because respect for human dignity had been lost – or rather because the ruling National Party had redefined who is human.
The dreadful, deadening, dreary ideology of apartheid was (almost literally) gospel truth for South Africa's politicians. It was undemocratic, violent, and unjust to the blacks and coloureds, but it was supported by the whites. It was even defended as doctrine of Christianity by the Dutch Reformed Church, in defiance of all other denominations. Apartheid's defenders included intelligent, well-educated, even well-meaning people. But these qualities did not keep them from colluding in what is now regarded as a paradigmatic case of an unjust government.
Human dignity is powerful in the hands of heroes like Mandela, but fragile, oh so fragile, in the hands of ethical pygmies.
Last year BioEdge had a world scoop when it was the first to report the publication of an article about infanticide in the Journal of Medical Ethics. “After-birth abortion: why should the baby live?” was irresistible fodder for the tabloid media. As they say in newsrooms, it had legs.
While some authors might have luxuriated in the publicity, Francesca Minerva, the corresponding author, did not. She received hundreds of abusive emails, including some death threats. Dealing with the fall-out robbed her of precious time and tranquil reflection in the ivory tower.
So she proposes in the journal Bioethics this month that contributors to academic journals should be able to make anonymous contributions. This will spare them the pain of publicity and to foster daring expeditions into the realm of dangerous ideas.
While I am sorry about the abuse, I am surprised by Dr Minerva naiveté. Everyone knows that the internet is a dark jungle of nastiness, of venomous creepy-crawlies and sabre-toothed carnivores. I moderate comments on BioEdge and MercatorNet and I have seen the most innocuous articles bucketed with bile. In her case, she was advancing ideas which have real world consequences. People living in the real world were bound to respond.
More than anything else, it is anonymity that generates the nastiness on the internet. I fail to see how anonymous publication in academic journals will function differently, albeit with Olympian sneers instead of four-letter words. Anonymity brings out the very worst in people. When they do not feel that they will be held to account, they lose their balance and perspective. Are bioethicists really that different?
By one of those strange quirks of fate, John F. Kennedy, Aldous Huxley, and C.S. Lewis and all died on November 22, 1963 – 50 years ago this week. Try as I might, I was unable to wring a bioethical link out of President Kennedy’s life, although the Kennedy Institute of Ethics at Georgetown University owes its existence to the Kennedy family.
Huxley and Lewis, however, have clearly made their mark as sceptical seers.
No student of bioethics can escape reading Huxley’s 1932 novel Brave New World, in which he predicted IVF clinics, cloning, genetic engineering, the separation of sex and reproduction, and the use of mood-altering drugs. Huxley had a way with words and his characters frame arguments which still echo in bioethics debates.
Here, for instance, is Mustapha Mond, one of society’s leaders in the year 632 After Ford, spruiking the benefits of the drug soma:
“There's always soma to calm your anger, to reconcile you to your enemies, to make you patient and long-suffering. In the past you could only accomplish these things by making a great effort and after years of hard moral training. Now, you swallow two or three half-gramme tablets, and there you are. Anybody can be virtuous now. You can carry at least half your morality about in a bottle. Christianity without tears–that's what soma is."
C.S. Lewis has had an enormous, if indirect, influence on bioethics debates. An insightful Christian apologist and novelist, he promoted a natural law approach to ethics, defended traditional Christian sexual morality, and opposed scientism and transhumanism.
His novel That Hideous Strength is an odd combination of science fiction, Christian philosophy and mediaeval legends which he deploys to expose the dangers of scientific materialism. The plot unfolds in the sinister organisation National Institute for Co-ordinated Experiments, or N.I.C.E. (The irony that the UK’s healthcare think tank has the same acronym has not be lost on bioethicists of a conservative bent.)
Long before Ray Kurzweil, Lewis anticipated transhumanist proposals for mind uploading to escape the limitations of having a body. Here is the villain of That Hideous Strength on the future:
“The world I look forward to is the world of perfect purity… What are the things that most offend the dignity of man? Birth and breeding and death. how if we are about to discover that man can live without any of the three?”
What influence do you think these men have had? Was it for better or worse?
The British novelist and playwright Somerset Maugham (1874-1965) never seems to fade completely. His 1925 novel The Painted Veil was made into a film only a couple of years ago -- for the third time. What I liked when I first read him was the geometric precision of his plots and his Edwardian gift for epigrams like, “She plunged into a sea of platitudes, and with the powerful breast stroke of a channel swimmer made her confident way towards the white cliffs of the obvious.” But he had the misfortune to be immensely popular and the critics have not been kind to him.
What I liked less and less as I grew older was his brutality and cynicism, albeit masked by an urbane wit. There is no place for heartfelt and faithful love in his stories. Much of that must be attributed to his tormented emotional life: a very unhappy childhood, a very unhappy marriage, and a succession of gay lovers.
Here was a man, if ever there was one, made for the “anti-love biotechnology” discussed by bioethicists from Oxford University in the latest issue of the American Journal of Bioethics. What if you wanted to fall out of love, as Maugham’s hero in his most famous novel, Of Human Bondage, does? You could simply take a pill and the passion would fade. Of course, this discussion is largely conjectural. The closest treatment at the moment is chemical castration for paedophiles and rapists, which would probably not interest Somerset Maugham, or anyone else, for that matter.
But what if we could turn the well-springs of Eros on and off like a tap? Would a technology to master emotions make us more human – or less? I am a bit sceptical about its feasibility, but it would be a great loss if a future Somerset Maugham solved his personal dramas with a pill and led a humdrum life as a suburban drudge. As John Stuart Mill said, “It is better to be a human dissatisfied than a pig satisfied”.
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A dismaying report on the participation of health care workers in torture at Guantanamo Bay was released this week. An independent panel concluded that doctors and other health professionals had been involved in designing and monitoring torture regimes, including waterboarding and sleep deprivation.
It is scandalous enough that the American government used torture without learning that the members of the medical profession had been corrupted into colluding with it. The vocation of a doctor is to heal, not to harm. Primum non nocere is the centuries-old adage.
As bioethicist Craig Klugman points out (see article below), doctors must be men and women with high principles and moral courage. “We expect health care professionals to do the right thing even when that requires a display of extraordinary moral courage.”
How can this be achieved? More ethics codes and stern policy statements are unlikely to stop doctors from buckling under pressure from their superiors in the military. Dr Klugman suggests that medical courses be changed to discourage bullying and encourage whistleblowing. Amen to that, but will this be enough?
How do we learn how to be virtuous? Perhaps the answer begins long before students enter medical school.
Last week we reported concerns about doctors and social media. There is a steady stream of stories about doctors losing professional detachment by “friending” patients. However, according to a survey by a medical apps company only 8% of doctors engage with patients through social networks, while 82% engage with other doctors.
One thing you wouldn’t expect is the danger of doctors monitoring Facebook discussions for evidence of political incorrectness. But that is what happened in the Australian state of Victoria. In the course of a Facebook discussion with colleagues, an unnamed doctor stated that – hypothetically – he would not refer a patient for an abortion. Since 2008, referral for abortions is mandatory in Victoria. One of his colleagues denounced him to the Medical Board of Australia.
The Board interrogated him for 70 minutes and then left him twisting in the wind for 14 months while it conducted an investigation. Finally it gave him a stern written warning about his unprofessional conduct.
The facts of this particular case are not clear as the Board refuses to comment on the issue. But on the face of it, it seems that Victoria’s abortion law has given birth to thought police. Doctor X had committed no offence whatsoever. He was guilty only of expressing an opinion which would probably be supported by at least half of the electorate.
It is very worrying if the Medical Board of Australia has gone into the business of monitoring doctors’ opinions as well as their conduct.
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Earlier this year, a 33-year-old obstetrician in New York was fed up with one of her patients. She vented to her 470 friends on her Facebook page: "So I have a patient who has chosen to either no-show or be late (sometimes hours) for all of her prenatal visits, ultrasounds and NSTs. She is now 3 hours late for her induction. May I show up late to her delivery?"
She copped it sweet. There were calls for her to be fired, even though she did not reveal the patient’s name.
This is just one anecdote about a growing problem for medicos who can’t live without Facebook.
Should doctors discuss patients on Facebook and Twitter? Or should they spy on them to make decisions about their treatment? In our lead story today, bioethicist Art Caplan recalls another incident in which doctors decided to pass over a candidate for a liver transplant after they trawled through his Twitter feed and found a photo of him downing a can of beer. This raises some ethical dilemmas, doesn’t it?
Just so that we aren’t left out of ethical dilemmas, BioEdge is trying to ramp up our Facebook page. We have spruced it up a bit and over the past week we have nearly doubled the page likes. Why don’t you pay a visit and “like” us? Help us to reach 5,000 ASAP!
I wrote a story below in which I originally mentioned the vomitorium, a well-known feature of Roman imperial banquets, er, well-known to me, because I have discovered that it never existed. There was gluttony, of course, gobs of it, and it is described in emetic detail by some of the classical authors. But there were no vomitoria where satiated guests could disgorge their flamingoes’ tongues and return for a serving of peacock brains (a menu mentioned in the Life of Vitellius, by Suetonius).
However, what the Romans failed to have invented, the Americans have developed – a portable stomach pump attached to a stomach peg so that morbidly obese people can eat but still lose weight. If you respond to this device, called AspireAssist, by saying Yuk, your feelings are shared by some obesity experts. "People often wish they could just eat and make the calories go away," one commented. "It was only a matter of time before someone came up with this.”
What are the bioethics of such a device – and a whole range of remedies which are being developed to treat obesity? It is a complex area, but in many cases, technology is being substituted for human agency. It’s easier to have a stomach pump than to strength one’s will-power to change eating habits. Obesity has been described as one of the most serious public health challenges of the 21st century. My hunch is that it will be a growing area of bioethical debate.
The Google of genetics, a California company called 23andme (after our 23 chromosomes) has denied that it is in the business of providing toolkits for creating designer babies. (See story below.) Instead, it just wants to provide consumers with better ways to manage their health and their children’s health.
Could be. But it’s more likely that it is simply unsure of what the market wants. The company has been re-inventing itself over the past year. It slashed the price of its spit kit, hired a CEO whose expertise is selling luxury goods online and launched a slick TV advertisement. And it is moving heaven and earth to get 1 million people on its database. “With a million people, we become disruptive," says co-founder Anne Wojcicki.
Designing babies may not be a major product, but it will surely be one of them, along with ancestry research and detection of genetic diseases. 23andme is lean, mean and hungry – it will supply whatever the market wants. And if the market wants designer babies, why not?
We are accustomed to think of eugenics as a dark government-run totalitarian program to eliminate people who are regarded as unfit, disabled and racially inferior. But those days are over. Twenty-first Century eugenics will be a pastel-coloured, smiley, do-it-yourself, consumer-driven project. And if it ever happens, I think that it will look a lot like 23andme.
Because autonomy is the central issue of contemporary bioethics, I suppose that it is only natural that euthanasia is a constant theme in BioEdge. Unfortunately there are some weeks – like this one – when it seems to dominate!
I wonder what “lifers” must think about debates over euthanasia. Where assisted suicide and euthanasia are legal, they normally don’t qualify as they are not terminally ill. However, in Belgium, where psychological suffering is a qualification for euthanasia, a prisoner was euthanased last year and five subsequently requested the Minister of Justice for permission to be put down. So there is definitely a market.
As you can read below, a British bioethicist has floated a trial balloon about prisoner euthanasia on Oxford’s blog for utilitarian bioethics. Not only would it reduce the amount of suffering in the world, he argues, but it would also help the government’s bottom line.
This is a cause which Australian euthanasia activist Philip Nitschke has backed for years. He writes in his recent autobiography, Damned If I Do, “if the state is going to engage in this form of torture, it should at least be prepared to offer those incarcerated a peaceful death. Anything less is barbaric.”