Abandoning “Futility” for Bioethical Discourse

Of the four principles of bioethics as enumerated by Beauchamp and Childress (autonomy, beneficence, nonmaleficence, and justice), autonomy tends to get the most attention from bioethicists. A central feature of the principle of autonomy is the right to refuse treatment, and the courts have consistently upheld the right of competent adult patients to refuse treatment. Even patients who are severely obtunded or unconscious have the right to refuse treatment through an advanced directive or a surrogate. The right of doctors to refuse to provide treatment, for any reason, is generally recognized as well as no one can compel a doctor to enter a contract. Even when doctors have agreed to enter a contract with a patient, they can choose to terminate the relationship. Problems arise when doctors refuse to provide treatment for patients who are no longer able to seek other health care providers. When doctors do this, they usually claim the treatment is inappropriate or futile. I will claim that the concept of futility is only useful when a treatment is known to be ineffective for achieving the goals of the patient and should not be used to resolve conflicts between patients and physicians. In cases of conflict, what is referred to as “futility” generally either involves a quality of life judgment or a cost/benefit judgment. The use of the word “futility” obscures significant ethical and legal issues that should be confronted in a forthright manner.
Some treatments are clearly inappropriate. If a patient demanded pectoral enhancement as a treatment for his tennis elbow merely so he can claim his cosmetic surgery on his insurance, the doctor would likely, one would hope, tell his patient to accept a reasonable treatment or find a new doctor. Even in cases where the patient does not ask the doctor to participate in fraud, the doctor may not wish to provide a particular treatment for various reasons. A surgeon may not offer a patient any other treatments than surgery, not because the treatments are inappropriate in themselves, but because it is inappropriate for a surgeon to provide treatments better administered by a non-surgical specialist. The problem of a doctor’s refusal to provide treatment typically only arises in cases where the patient cannot easily find alternative treatment and is near death. The doctor’s refusal to treat is a death sentence, and doctor’s in such cases will typically justify their refusal by claiming medical futility. I assert that in such cases, discussion should focus on the actual issues of the quality of life of the patient, cost of the treatment, and the likelihood that the patient might benefit from the treatment. Simply declaring a treatment futile obscures the value conflicts inherent in any conflict.
There are three classifications of medical futility: physiologic futility, qualitative futility, and quantitative futility. Cases of physiologic futility are the least controversial as they entail a patient requesting a treatment that is known to not be effective for the patient’s condition. Jerry Menikoff gives the example of a patient requesting an antibiotic for a viral infection, which would not respond to antibiotics. While antibiotics will have a physiologic effect, it is an effect desired by neither the patient nor the doctor. In other cases, however, the goal of treatment is not so clear. Qualitative futility is more controversial; on occasion a patient or the patient’s family will request a treatment that may achieve the patient’s physiologic goals while the doctor feels the patient’s condition is too poor for the patient to benefit from the treatment. These cases tend to center on quality of life judgments, even when no one will admit to it, and can be extremely controversial. With quantitative futility, a patient is requesting a treatment that has a slim chance of being effective. The doctor may feel that the chance of benefit is too low to justify the expense.
In re Wanglie is a case of a woman eighty-six years old (Helga Wanglie) who fractures her hip, suffers a respiratory arrest, and becomes ventilator dependent. She later suffers a cardiorespiratory arrest and falls into a persistent vegetative state. Her husband, Oliver Wanglie will not agree to cessation of treatment in spite of the opinion of her doctors that her treatment provided no benefit to her. It is clear that her doctors did not feel her quality of life was worth sustaining. Rather than arguing before the court that the hospital was not obligated to provide treatment that provided no benefit or that her life was of insufficient quality to prolong, the hospital sought to have Oliver Wanglie declared incompetent to make decisions about her medical care. As a result, the the court did not address questions of benefit and quality of life. The opinion by Judge Belois stated, “No Court order to continue or stop any medical treatment for Helga Wanglie has been made or requested at this time. Whether such a request will be made, or such an order is proper, or this Court would make such an order, and whether Oliver Wanglie would execute such an order are speculative matters not now before this court.”
The Wanglie case raised complex issues with no hope of resolving them. Claiming that Oliver Wanglie was incompetent only directed attention away from the issue of non-beneficial treatment. Had the court been eager to make a decision regarding physician autonomy or a patient’s right to non-beneficial treatment, it would have been frustrated in its desires. Judge Belois’s comments suggest the court may have felt eager to make a more definitive decision. At the least, the court was frustrated by the claim of the hospital. In addition to preventing any kind of court decision on futility, the hospital alienated the family of Helga Wanglie. The hospital had argued that her treatment was not beneficial to her not to show that it was not obligated to provide treatment but to claim that any conservator disagreeing with its judgment was not competent. In addition to alienating the family of Helga Wanglie, the publicity of the case likely made members of the public less trusting of the decisions their doctors or hospitals might make.
In an analysis of the case and of medical futility, Daniel Callahan argues that a joint lay-medical process should be developed to help resolve disputes before going to court. He says, “I happen to agree with [the Medical Center’s] judgment. But I also believe we should not override the moral values of the Wanglie family, whose judgment is different from both mine and the Medical Center. To allow the judgment of the Medical Center and its staff to triumph over that of the Wanglie family before a joint lay-medical process has been developed to make the combined medical-moral judgments is at least unwise and perhaps unfair.” While Callahan is correct to point to the complexity of the problem and suggest more attention be paid to joint decision-making, it is not at all clear that a lay-medical process would have resolved the issue. Nonetheless, more communication and respect for the beliefs and desires of patient’s families is always welcome and is often imperative.
The hospital did not describe Helga Wanglie’s treatment at futile. It refrain from claiming futility in light of the fact that the respirator could indeed prolong her life. Rather, the hospital claimed the treatment offered her no benefit. In actuality, the hospital had made a quality-of-life judgment and determined that Helga’s life was not worth prolonging. While it could be argued that saying her treatment offered her no benefit is tantamount to saying her quality of life is so poor that it is not worth living, a direct statement of the actual issues involved would, at least, promote legal and public discourse on whether physicians (or taxpayers) should be required to expend resources on someone whose life is deemed of no value by her physicians.
Another case that involved a claim of medical futility but did not yield a legal opinion on futility is the case of Causey v. Francis Medical Center. Sonya Causey was transferred to St. Francis Medical Center after suffering a cardiorespiratory arrest at a nursing home. She was a quadriplegic who was comatose and in end-stage renal failure. Her physician did not feel she would benefit from dialysis in spite of the fact that dialysis and ventilator support could keep her alive for another two years. The physician’s opinion rested on the fact he felt the treatment was quantitatively futile as she had only a one to five percent chance of regaining consciousness. The court in this case spent a fair amount of time discussing the concepts of futility in its opinion, authored by Judge Brown, but ended up concluding only that the case must be submitted to a medical review panel as the Medical Malpractice Act was applicable.
This case differed from Wanglie in significant ways. The action was brought by the patient’s family rather than by the physicians, and the physicians had argued that treatment offered no benefit to Sonya as it was quantitatively futile. The physician in this case attempted to find an alternative medical center to provide the treatment and consulted with the hospital’s ethics board. What was not stated clearly but was almost certainly a consideration was the cost of the treatment. The physician, Dr. Harter, claimed dialysis was not worth offering as Sonya had only a one to five percent chance of regaining consciousness by his estimate. If one of twenty people would regain consciousness by administering a treatment costing 10 dollars each day, few health care providers would deny the treatment.
Judge Brown’s opinion remarks that futility in this case is a matter of subjective value. It is clear that Sonya’s life was worth much more to the Causeys than to Dr. Harter. Judge Brown notes that arguments regarding the definition of “futility” result in polemical discussions, so the court turns instead to standards of medical care. Many ethicists feel that following the standard of medical care is the best guide to handling cases of futility when disagreements arise between physician and the patient or patient’s family. This is the approach Eric Gampel supports. He says,
“Health care providers need to follow norms established in the medical community regarding appropriate care: norms defined by a combination of actual medical practice, expert opinion, laws, and explicit guidelines promulgated by professional societies. So if there is argument for health care provider’s refusal of futile treatment, it is grounded not in the self-governance of individuals, but in the self-governance of the medical community.”
Gampel’s suggestion would give physicians a sense of physician autonomy while also preventing rogue physicians from denying appropriate care without fearing any consequences. However, it is likely that patients might feel distrust of the medical community to govern itself, especially in the wake of publicity from cases such as Wanglie. Callahan’s suggestion of a lay-medical process for establishing overall guidelines rather than resolving individual cases might help both patients and physicians feel a sense of autonomy, even if the autonomy is collective rather than individual autonomy.
While it is unlikely that consensus could be reached on every case where quantitative futility is asserted, a plurality of opinion of a representative group of lay and medical individuals might help avoid some confusion facing physicians and patients. Once again, the issue will be less confusing if the language of futility is avoided all together. This case is better presented as a cost/benefit analysis of the treatment given the probability of a desirable outcome. If this language sounds too blunt and offensive, it is only because the language of futility is the language of subterfuge and obfuscation. It does not appear that Dr. Harper mentioned the cost of dialysis to the Causey family, but it is impossible to imagine that cost was not a motivating factor for his decision.
One of the most discussed cases of futility in bioethics literature is In re Baby K. In this case, the hospital sought a declaration from the court that it was not required under the Emergency Medical Treatment and Active Labor Act (EMTALA) to provide more than warmth, nutrition, and hydration to an anencephalic infant. In this case, the hospital claimed that any care beyond so-called “comfort” care was futile, as it provided no chance of medical recovery for Baby K. Unlike the Causey case, where the chance of regaining consciousness was estimated to be between one and five percent, the chance of physiologic improvement for an anencephalic infant is zero percent. The hospital argued that the standard of care for infants with anencephaly was to provide only warmth, nutrition, and hydration. In this case, “futility” does not disguise the actual concerns of the health care providers. Although Baby K’s mother is an obvious exception, few would dispute the claim of physiological futility in this case, but a conflict of values is still present.
Baby K’s mother is an exception because her religious beliefs place a value on all human life, no matter how limited that life may be. Ms. H holds the sanctity of life principle, which prohibits anyone from killing a patient or letting a patient die. Stephen Post argues that we must respect the sanctity of life view even when a case is futile and expensive. He says:
“A religious rejection of medical futility judgments is neither sufficiently harmful nor socially repulsive to warrant the restriction of freedom, except when the burdens of treatment for the patient are clearly inhumane (that is, cause pain and suffering). While I lament overtreatment of Baby K, such treatment does not thwart the purposes of civil government, such as peace and tranquility, articulated in the Preamble of the Constitution.”
He argues that refusal to respect the religious liberty of patients and their families trivializes religious belief. Although he sets the question of cost aside in the beginning of his essay, Post eventually discusses the difference between asserting a negative right such as when a patient rejects treatment on religious grounds and asserting a positive right as Ms. H does with Baby K. If someone has a positive right to any treatment called for by religion, then society must be forced to provide the treatment. Post confounds the issue somewhat by considering the possibility of special (and more expensive) insurance pools for those holding the sanctity of life view. If the economic burden is shifted in this manner, it is no longer a matter of asserting a positive right, it is a libertarian concern of making free trades in an open market; one receives the treatment one can afford.
Post further confuses the issue by asserting, “No physician who dissents from ventilator support in the name of futility should be required to act against his or her personal convictions. The freedom of physicians also deserves respect.” It is quite likely that Ms. H would not find any physician willing to provide treatment to Baby K. If her religious freedom is respected along with respect for the doctor’s autonomy, the case will end up in court just as it did. Post is somewhat convincing in his argument that religious convictions ought to be respected and taken seriously, but he leaves us without resolution to the issue of treatment in a clear case of futility.
Alexander Morga Capron takes quite a different approach to the Baby K case. Capron argues that futility is not a necessary concept to curb patient autonomy in any circumstance, as patients do not have the right to demand treatment of physicians. With regard to Baby K, he says decision to provide medical intervention must “always involve the complete circumstances of the patient and the treatment setting. This principle applies as much to emergency treatments as to any other, and it can only be hoped that if other courts fail to incorporate this understanding into their interpretation of EMTALA, Congress will clarify that the act is intended to outlaw discrimination against poor patients, not command that patients be equated with their symptoms and be provided with every medical intervention known to have any physiologic effect on those symptoms regardless of the prospect of truly benefiting the patient.” He claims that use of the word “futility” is a way of hiding what is usually a value judgment; the quotation just cited refers to treatments that offer no chance of improving the patient’s chance of survival for more than a short time. A treatment that offers no hope of improving the medical condition of the patient is a case of physiologic futility, but a value judgment has entered the discussion once again. While there is a conflict of religious value in this case, there is no conflict of opinion of whether treating Baby K will cure her anencephaly. The court differed from the physicians in its opinion because it considered apnea to be the presenting condition rather than anencephaly. In this case, the doctors did not want to refuse treatment because they did not value Baby K’s life; they refused treatment because they felt Baby K had no life to value and that treatment provided no chance of recovery or improvement. Ms. H, however, valued any life of her baby, no matter what its limitations.
In 1999, Texas became the first state to address the problem of futility legislatively through the Texas Advance Directives Act. Under this law, when a health care provider wishes to withdraw or withhold life-sustaining treatment against the wishes of a patient or the patient’s family, the provider must follow several steps. The family must be notified of the decision and the provider’s ethics consultation process, the family must be invited to participate in the process, and the hospital must try to arrange transfer of the patient to a provider willing to continue the treatment. If the provider is able to find other providers willing to offer the treatment, then the provider is obligated to continue treatment until the transfer can be arranged. If no alternative provider can be found after 10 days, the provider may withdraw treatment against the wishes of the patient or the patient’s family.
Although people will sometimes refer to the Advanced Directives Act as the Texas futility law, the law avoids discussions of futility and essentially leaves the question to the standard of medical care in Texas. If any facility can be found that will accept the patient and offer requested treatment, then the treatment must be offered; only when no facility can be found may treatment be withdrawn. In a case such as Baby K, it seems unlikely that an alternative facility could be found, and the standard non-treatment of anencephalic babies would be supported by the law, an outcome quite different from the actual case. In 1995, Texas Children’s Hospital sought to withdraw treatment from Sun Hudson, who was born with a fatal form of dwarfism. This became the first case in which a judge permitted a hospital to discontinue care over the wishes of a child’s mother. As a result of a procedural error and appeals, Hudson’s care was extended four months after the judge made the initial decision.
While the Texas law has been criticized for some procedural issues, many in the medical community are relieved to have some legal definition for when care may be withdrawn or withheld. The law does not make exceptions for those who believe in the absolute sanctity of all life, and will most likely face challenges from vitalists for as long as it is in effect. The law requires a registry of agencies willing to assist in the transfer of patients, but the list of agencies in the registry is distressingly small. Patients challenging an institution are unlikely to find another institution willing to accept a patient that is using resources with little or no hope of recovery or benefit. If the law provided resources for the transfer of a patient that would protect institutions accepting such patients from financial loss, more successful transfers might take place.
Hudson’s case is again one of physiological futility as his condition is fatal without exception, and he died within moments of withdrawal of ventilator support as expected, but it is a value judgment as well. His mother may argue that his ventilator support is not a futile treatment as it can keep him alive; it does have a physiological effect. Thus, even in this case, the determination of futility is based on a value judgment. Just as in the case of Baby K, Hudson’s mother valued his life, in whatever state he was in, more than the hospital and his care providers. In response to the death of Sun Hudson, Dr. William Winslade, lawyer and professor at the Institute for Medical Humanities at the University of Texas Medical Branch, said, “This isn’t murder, it’s mercy, and it’s appropriate to be merciful in that way. It’s not killing. It’s stopping pointless treatment.” The treatment was not deemed futile because it could not extend life; it was deemed futile because it could not improve Hudson’s condition nor provide him with a chance for living a meaningful life as defined by his care providers against his mother’s definition of a meaningful life.
In his book, The Healer’s Power, Dr. Howard Brody anticipated that definitions of physiologic futility would not be value free. He says, “That no sense of futility can ever be value-free in the required sense is driven home by the goal-relativity stipulation. One can always ask, ‘Futile relative to what goal?’ and some values will have to be employed in the selection of the relevant goal from among a set of all possible or conceivable goals. Applied to the physiologic definition, it means that virtually no ‘futile’ intervention produces no physiologic change at all; but it does fail to produce the physiologic change that is desired.” The value judgment enters the discussion when the physiologic change desired by the patient or family is different from the physiologic change sought by the care providers.
Cases of health care providers wishing to withdraw or withhold treatment over the objections of patients are relatively rare, but they produce powerful emotions generated by love, religious devotion, and grief. Respect for such powerful emotions is a moral imperative. Respect does not, however, entail that care providers become enslaved to the emotions or values of patients and their families. Care providers should not mask their value judgments by invoking futility to resolve disputes between patients and care providers when patients demand treatment that seems to be of insufficient benefit or causes too much suffering to warrant its cost or effort.
William Harper offers a critique of Lawrence Schneidermans’ and Nancy Jeckers’ arguments in Wrong Medicine that physicians are obligated to withhold treatments that are futile. Harper points out that doctors already recognize a duty to withhold futile treatments in the sense that treatments have no hope of achieving the goals of the patient or physician. As an example, Harper says that no physician should offer copper bracelets to patients to cure arthritis because there is no evidence that copper bracelets have any effect on arthritis. Harper’s claim is that Schneiderman and Jecker are not really arguing for the duty to withhold useless treatments; they are actually trying to expand the number of treatments regarded as futile. He says their “position on withholding treatment is best advanced by arguments that directly support their intuitions that certain treatments (which they label ‘futile’) do not benefit the patient.” In most of the cases Harper cites in his article, conflict arises when doctors feel a patient can receive no benefit from a treatment that family members want to continue. As in the cases I’ve discussed above, family members often place a much greater value on the life of a loved one than do some health care providers. In some cases, the issue appears to result from an unequal distribution of knowledge. In such cases, patient education is sometimes effective. Indeed, thoughtful and compassionate family meetings avoid many conflicts over withdrawal of treatment. In Harper’s conclusion, he says, “Any successful treatment of these issues will have to include a determination of what counts as benefit to the patient. This will require a determination of the kinds of lives worth living, and this, in turn, an identification of the sources of worth for human life.” Except in cases where a treatment simply cannot help either the patient or the physician achieve their medical goals, discussions of futility almost always rest on either a misunderstanding or conflicting values. Harper’s argument is that discussions of conflicting values must take place in open and frank discussions and not behind the veil of futility. To determine whether it is worthwhile to keep an anencephalic baby alive for a week with a ventilator requires a determination of the value of that baby’s life. Determining the value of such life requires discourse that may include representative health care providers, religious and spiritual leaders, secular philosophers, and bioethicists.
In a constructivist analysis of the “utility of futility” language, Franco Carnevale uncovers similar issues. He says, “What emerges is not a debate about the permissibility of futile intervention but, rather, struggles over differing conceptions of a ‘good enough life,’ as well as tensions over trust, respect, and power among the many agents. Framing these issues in terms of futility discourse disregards this inherent strife over trust, respect, and power; indeed, futility talk seems to perpetuate these problems further.” In the cases examined in this paper, the assertion of physician autonomy resulted in power struggles where the patients’ families felt their values had been trivialized or ignored. In these cases, futility was asserted as a fact, concealing the real source of dispute. The use of futility by physicians diverted attention away from the issues of the religious values of patients, the financial costs of treatment, and the value of enabling families to take time to adjust to the passing of a loved one. No source of discourse or communication will eliminate disagreement, but an honest and straightforward statement of what values are in conflict is more likely to preserve trust in professional health care providers than a blanket appeal to futility.
This is more than a mere discussion of semantics. Paul Hofmann and Lawrence J. Schneiderman quote Edmund Pelligrino saying that “some operative way of making a decision when ‘enough is enough’ is necessary. . . . Some determination of futility by any other name will become a reality.” It is misleading to say that a determination of futility will become a reality. Rather, a determination of when life should be prolonged will be made a reality. A discussion of what kind of life is of value to a patient, to a patient’s family, to society, or to God is quite different from a discussion of what treatments are futile. In the cases of Helga Wanglie, Sonya Causey, Baby K, and Sun Hudson, the health care providers had deemed their lives to be worth less than the cost of extending them. In some of the cases, one can imagine that if the families had opposed treatment, they would probably argue that the treatments were burdensome and painful. Providers often attempt to avoid difficult conversations by invoking futility, but their refusal to acknowledge the real motivations for their actions only produces distrust and resentment.
Issues
Several issues seem to be shrouded repeatedly by discussions of futility. I will discuss these below.
Autonomy—Neither patients nor physicians have unlimited autonomy. Patients are sometimes rescued against their will, and their rescuers are not liable for malpractice or even lack of professionalism. Patients also do not have the right to demand any treatment they think might benefit them. Physicians have an obligation to protect patients from inappropriate treatments. Refusing to provide such treatments is a part of professional responsibility, not physician autonomy. Nonetheless, physicians do have a great deal of autonomy. Physicians are not obligated to treat patients under most circumstances. Patients may not be excluded as a result of illegal discrimination, but may be excluded for most other reasons. Physicians also have the power to terminate their relationships with patients under most conditions. All four cases in this paper involve patients who are dependent on life support and have no alternative means of sustaining life. This is a rare restriction on physician autonomy just as there are rare restrictions on patient autonomy. It is misleading to construct debates of futility as debates of physician autonomy.
Rationing—Often, when health care providers claim that a treatment is futile, they mean that it is not worth the cost. Less expensive treatments offering no better outcomes would likely be offered. It appears this was the issue in the case of Sonya Causey, but the issue of cost was not discussed directly. When a physician says outright that a patient’s life is worth less than the money it would take to preserve it, families and others may be offended by the harshness of the language. Such harshness is needed, however, if doctor’s, patients, and society are ever to come to terms with the real issues of rising health care costs and the expense of offering treatments that offer little benefit to patients and may even be a burden to them.
Religion—It is said that we should avoid discussion of religion and politics in polite company, but many cases such as Baby K involve a conflict of religious values. Some physicians are strict vitalists, and some patients are strict vitalists. These lead to physicians sometimes wanting to impose unwanted treatments while in other cases physicians want to withhold wanted treatments. Simply claiming that a treatment is medically futile can obscure the differences among physicians regarding what care is appropriate and what care is not. Neither physicians nor patients should feel the need to obscure their religious feelings when discussing whether treatment is beneficial or burdensome. Of particular concern are issues of the sanctity of life. Even those who hold that human life is sacred and that all human lives are of equal value usually recognize exceptions. Compassion tends to motivate even the most religious to choose to let people die when their continued life causes extreme pain and suffering. Given that almost everyone recognizes exceptions, conversations about the value of a patient’s life may not be in vain. Open discussion is not likely to end all conflicts, but it will expand understanding.
Quality of Life—Saying that a life worth living creates powerful emotions in many, especially as it is reminiscent of the words of Nazi doctors. Nonetheless, many claims of futility are centered around whether the patient’s life is a life that anyone would want to live. In the case of unconscious patients, it is impossible to tell whether they are receiving benefit from their lives. Sometimes, it is their families or loved ones who are receiving benefit from their lives. This does not justify keeping them alive, but it helps to frame questions of quality of life. Someone’s life may be valuable because it is in that person’s interest to stay alive, or it may be valuable because someone else is interested in keeping that person alive. Disputes over quality of life should be stated as such.
Conclusion
The concept of physiological futility is useful when discussing whether a particular treatment will help a patient meet particular health goals. Menikoff’s example of the futility of using antibiotics to treat viral infections is a workable example. It is futile to give antibiotics for viral infections because they will have no effect. This kind of futility is not an issue for the law, however, as doctors are completely free to refuse to prescribe antibiotics for viral infections without any fear of legal challenges from patients, who are free to seek other medical opinions. Instead, legal problems arise when doctors invoke futility to withdraw or withhold treatment that is achieving some result, usually the prolongation of a seriously impaired life. The treatment may be futile in curing the patient’s condition or even improving it, but it is not futile in sustaining life. The real question is not over futility but over whether the life is worth sustaining. When legal problems arise, discussions of “futility” should be avoided, and issues of quality of life, costs, benefits, and religious value should be discussed openly.

Ethics of Life

In 1971, Van Rensselaer Potter published Bioethics: Bridge to the Future and defined “bioethics” as an ethics based on biological survival. In his first book, he dealt with subjects such as stress, toxic hazards, ecology, biotechnology, and population growth. In his 1988 book, Global Bioethics, Potter added topics discussed by more mainstream bioethicists: disabled newborns, organ transplantation, euthanasia, and contraception. However, the later book maintained an interest in ecology, population change, and an emphasis on human survival. Potter’s vision of bioethics concerns healthcare and healthcare providers, but it also encompasses ethical duties of all members of society. The fact that he did not write specifically on the ethics in medical care facilities may explain why his work is little more than a footnote in most bioethics texts.

Potter poses two challenges to bioethics as generally practiced or presented. First, he presents bioethical duties as human duties rather than professional duties, although some duties or specific actions are of course related to one’s profession. Second, bioethical duties extend beyond health care to care for the living earth. He challenges doctors to look beyond the bedside, and enjoins lay people to accept responsibility for improving the chances for biological survival. Had his work been taken more seriously, bioethics may have reached beyond topics related to medical dilemmas and instead have comprised diverse subjects such as war, famine, genetically modified food, corporate responsibility, and individual responsibility. Such an approach may have better prepared us for substantial threats to global health in the twenty-first century.

Christian Frei’s 2001 film, War Photographer, is a documentary of the work of photographer James Nachtwey. The film depicts scenes of suffering resulting from poverty, famine and war: the sorts of issues Potter would define as bioethical concerns. In a sense, the film poses a sort of double aesthetic; it is beautifully filmed and exposes the viewer to the achingly attractive photography of James Nactwey. The aesthetic qualities of the film place the viewer in a bind, however, as the images are generally of horrific events of human cruelty and suffering. Nachtwey has made a career of filming the effects of famine, war, disease, and poverty. To his mind, this is a moral act, but his narration reveals ambivalence. He assures his interviewer that he only photographs with the complicity of his subjects, that he only shows his subjects in a respectful manner, and that his only motivation is to improve the plight of humans in this world as Potter exhorts us to do when he says, “I will try to adopt a lifestyle and to influence the lifestyle of others so as to promote the evolution of a better world for future generations of the human species.”

Nachtwey’s attempts to explain and justify his career only highlight the underlying issues. How can a person dying of cholera or starvation give consent to be photographed? Is it possible for a mother who has just learned of the death of her son or husband to make an informed decision about how images of her might be used in the media? Nachtwey wants his subjects to be joint contributors to his cause of publicizing events in the world and, with a bit of luck, bringing some relief. Indeed, he tells us he will only film victims of famine when relief workers are present. Nachtwey clearly would hate to make his fame and fortune exploiting the suffering of his fellow human beings. The film does not reveal Nachtwey’s net worth or his contributions to relief in the form of donations or volunteering, but he is presented as a dedicated individual with little concern for his personal comfort or safety.

The fact remains that Nachtwey has garnered fame[1] and attention for his photographs, and he may well violate Kant’s injunction against using others as a means to one’s own ends. Without dealing with Kant explicitly, Nachtwey claims that his goal is merely to help his subjects meet their own ends. He assumes his subjects do not want to be victims of war, poverty, and famine, so he makes every effort to publicize their plight in hopes of securing relief. If we fault Nachtwey for his project, then we may also fault writers (bioethicists among them) who publicize tragic events in order to publish in journals and advance their careers. It may be that Nachtwey is merely a more effective bioethicist (at least in the sense intended by Potter) than those who publish in journals or even the popular press. Publishing in internationally distributed magazines such as Geo and Time Magazine, Nachtwey reaches millions of affluent individuals and confronts them with compelling images.

Nachtwey’s work could be compared to that of philosopher and ethicist Peter Unger. Author of Living High and Letting Die: Our Illusion of Innocence, Unger is a successful academic whose work has reached somewhat beyond the walls of the academy. Unger shares Nachtwey’s desire to motivate action to relieve the world’s suffering. Unger begins with an optimistic assumption that any rational reader would agree that it would be morally repugnant to stand by and let someone lose a limb when such a loss could be prevented by a relatively small sacrifice. For example, if I could prevent the loss of limb by giving someone a dollar, I would be morally wrong to keep my dollar. Unger realizes, however, that there is a point where we will no longer give up our dollars. Even if I agree that a child’s life is worth more than $200, I may not be willing to give up $200 each week even if I can afford it by abstaining from all luxury and recreational spending. We are left with a form of the sorites paradox. Anyone who would give up a dollar to save a child would probably give up two dollars. Finding the point where moral motivation encounters selfish (egoistic) resistance is the challenge of ethicists and relief agencies. Unger and others leave us with a challenge that we must make greater demands on ourselves than most of us are currently making.

Nachtwey appears to assume, also, that most of his viewers in affluent societies will feel it is inappropriate to witness preventable suffering and take no action to alleviate it. He enters no debate as to how much any one person should do; he merely attempts to make suffering visible and personal. He believes this is an action required of him by basic morality. In this sense, Nachtwey is both moral agent and ethicist. He is attempting to both act morally and to motivate others to adopt his moral position. The endeavor is somewhat risky. Some individuals involved in attempting to provide relief to the poorest people in the world warn against the use of “disaster porn.” One fear is that some viewers will feel that by watching the images they have somehow done something significant on the face of it without actually taking action to alleviate suffering. Affluent people may watch the images, comment on the beauty of the photography, praise the dignity of those suffering, cry a few tears, exhort others to view the images, and then go about their normal routine.

Another concern is that the photographer, film makers, and viewers are all using the individuals depicted to their own ends. From a consequentialist, or Utilitarian, perspective, the ends may seem to justify the means. If distribution of disturbing images brings relief to victims of war, famine, and poverty, then the use of the images seems not only justified but noble. Complications arise, however, if we cannot be sure the images are bringing relief. We may feel the effort is good, but it is only a good if it has a good result, and verification of such results is difficult at best. More troubling is the fact that we may be viewing (or making) the images for reasons that have nothing to do with relieving suffering. The images are beautiful and bring some pleasure to those viewing. As a result, the images sell movies, books, and magazines in addition to winning awards.

In War Photographer, Nachtwey reads letters he received from some of his viewers who were moved to help the individuals depicted in published photographs. Viewers of the film are reassured that the images are having a positive effect. We do not know, however, whether profits from Nachtwey’s images and Frei’s film are used to help the individuals depicted in the film and the photographs. One would guess not as the people in refuge camps, famine relief camps, and battles are most likely anonymous to Nachtwey and the filmmakers. Even if they are not anonymous, many are too ill or too busy fighting to give consent to be filmed, have their images displayed internationally, or to even support relief efforts. As mentioned above, Nachtwey says in the film’s narration that he could not do his work without the collaboration of his subjects. At times, it seems he is trying as hard to convince himself as he is to convince his viewers. One particularly disturbing scene is of a man in Indonesia who is being murdered for no real reason. While taking the photographs, Nachtwey pleas with the aggressors to stop their violence. He tells them there is no reason to kill the man, and he continues taking pictures. It is impossible to imagine that the victim of this senseless violence consented to have his murder filmed and sold. Nachtwey is not the only one who recorded the event, and other photographers probably did not consider their actions unethical. In fact, they were probably glad of their good fortune to be present for the event. Nachtwey, however, suffers some moral crises and invites his viewers to suffer these moral crises with him.

In the end, we must all decide the value of recording and viewing extreme suffering with or without the consent of those suffering. We may view victims of famine as objects of care more than as moral agents. They have lost the ability to make autonomous decisions regarding their images and have also lost the ability to be joint collaborators in the projects of Nachtwey and Frei. We may use surrogate judgment and claim that they would want to be given a voice to the outside world, and this conclusion seems reasonable. If affluent citizens will respond to the suffering, they will be motivated by their knowledge of the suffering, and the disturbing images are likely to provoke at least some people to take positive action. While watching the film or simply viewing Nachtwey’s photographs, we may feel guilty for not doing more to end suffering, for violating the privacy and dignity of those depicted, and for taking pleasure in the beauty of the photographs. Our guilt may motivate us to examine our moral impulses and actions, and we may become better as a result.

Bioethics is not simply medical ethics, and the obligations of bioethics apply to everyone. Potter, Unger, Nachtwey, and Frei have a single message in this regard: improving the conditions for human life requires a collective will, not just the concern of healthcare providers. At the same time, healthcare providers have the same obligation to look beyond the walls of the clinic or hospital to the suffering, preventable or not, that exists in the world. They are not obligated to do so out of professional duty; they are obligated to do so out of human duty. If bioethicists generally recognized this shared duty to recognize and respond to suffering, public and professional views on moral responses to public health, infectious diseases, pandemics, pollution, and poverty might be framed quite differently. If a global community of moral agents does not exist, it may be imperative to make an effort to form one.

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[1] His wesite, www.jamesnachtwey.com, lists the following awards, “the Common Wealth Award, Martin Luther King Award, Dr. Jean Mayer Global Citizenship Award, Henry Luce Award, Robert Capa Gold Medal (five times), the World Press Photo Award (twice), Magazine Photographer of the Year (seven times), the International Center of Photography Infinity Award (three times), the Leica Award (twice), the Bayeaux Award for War Correspondents (twice), the Alfred Eisenstaedt Award, the Canon Photo essayist Award and the W. Eugene Smith Memorial Grant in Humanistic Photography. He is a fellow of the Royal Photographic Society and has an Honorary Doctorate of Fine Arts from the Massachusetts College of Arts.

Genetics and the Alterable Course Toward Fascism

Genetics and the Alterable Course Toward Fascism

Given that theories of heritability arose before eugenic plans and that those eugenics plans preceded fascism, it is easy to understand why some would infer that hereditary thinking in Western cultural settings may have caused both the eugenics programs and the fascist movements that followed. On the face of it, of course, this is a clear example of the post hoc ergo propter hoc fallacy. On the other hand, it is possible that beneath the surface is a clear causal link between hereditary theory and fascism, but it is equally possible to imagine a different course of events unfolding given only slight changes in the historical record or in human nature. In one sense, all events are caused by those that precede them, or so the determinist will claim. If this is true, then the path of history is unalterable regardless of the subject at hand. For the purposes of this essay, though, I will assume that humans have free will and that cultures have differing goals and values. I will also assume that the motives of at least some early geneticists were devoid of the values of later fascists in Germany and elsewhere. Given that most people familiar with western science accept the heritability of personality and other traits as scientific fact, I will also question whether science must be concerned with the possible applications of its theories, even when they seem almost certain to be correct.

The work of Mendel, in particular, seems to fly the flag of Objective Truth. Scientists still accept the basic laws of genetics discovered by Mendel, and most would say these truths are separate from any social programs or ideological agendas they may be used to support. Mendel’s laws are more easily verified and categorized than Darwin’s, but it was Darwin who originally captured the public imagination in the nineteenth century, with the importance of Mendelian genetics being asserted decades after their original publication. Both Darwin and Mendel were “scientific” in the sense that they collected data based on observation and recorded it with care, even if Mendel’s data now seem to be a bit more consistent than nature itself (meaning that some have suggested Mendel manipulated the data to fit his theory with greater exactness than one would expect). To state that someone’s methods are “scientific,” though, is to say almost nothing. Many methods of doing science have been employed over the years, and no Scientific Method has presented itself. The best science, it is claimed, is science that is based on mathematical models, makes predictions, is simple, can be observed repeatedly, is instrumental in producing results, or is accepted by a community of scientists.

Various theories of genetics, evolution, and social degeneration all could be classified as “scientific” by one of the methods mentioned above. What scientific method does not yield, however, is Truth (or, even, truth). One need only look to the constant modifications to scientific theory to see that the truth of science is ever changing. One must not be skeptical only of science practiced by those with a social agenda. One must be skeptical of all scientific truth. That many scientists practicing in genetics, eugenics, sociology, anthropology, and psychology did have a social agenda is not evidence in itself of bad science, though it may be evidence of bad social agendas. On the other hand, scientist such as Mendel did not appear to have an obvious social agenda, and it seems unreasonable to expect a scientist doing research in good faith to predict the abuses of his discoveries. If Foucault is correct in asserting that the nineteenth century gave rise to the study of Man, then we would expect the nineteenth century to produce a plethora of work in the so-called social sciences. Indeed, Foucault listed sciences such as economics, anthropology, and sociology as examples of fields of study that arose as men turned to study Man. Physicists and chemists and other “hard” scientists would be likely to question Foucault’s concept of science and deride the social sciences as rife with unsupportable assertions. On the other hand, Foucault’s claim that humans turned to the study of Man as subject in the nineteenth century is noteworthy.

The scientists in the new fields were not unaware that their work may be seen as unscientific, and they made every effort to produce claims objectively verifiable by relying on the universal under girding of objective science: mathematics or, at the least, quantification. These scientists observed, counted, and recorded with fervor in an effort to gain acceptance for their theories. They were in luck, in a sense, as many in society were eager for their “discoveries.” Social reformers of the nineteenth century were no different from social reformers of the twenty-first century in one respect: they felt they had given their claims credibility when they could begin their arguments with the words “studies show.” When looking for the cause (or someone to blame) for social ills, it gives great force to one’s arguments to claim scientific proof . Errors are made in all branches of science, but the social sciences are particularly vulnerable to abuses for social ends.

If fascism is defined broadly as an attempt to improve society through the elimination of undesirable elements, then many of the social sciences were born of the effort to identify and eliminate causes of social ills. For some, social ills were caused by poverty and injustice, and such individuals advocated the elimination of slavery, oppression of women, exploitation of children, and abuse of animals. For others, the ills of society stemmed from the existence of dangerous persons, and those who believed dangerous persons caused such problems advocated more government intervention to imprison or even destroy those found to be defective. It is the latter mode of thinking that leads to to the sort of autocratic and despotic fascism that most of us imagine when we hear the word “Fascism.” Hereditarianism was certainly incorporated into the arguments of fascists, but it was also used by social reformers seeking more humane treatment of prisoners, the mentally ill, and the poor. The anarchist, socialist, liberal democrat, communist, and fascist may all agree that certain personality traits are inherited. One person will see it as a reason to show compassion to individuals while another will see it as a reason to eliminate such individuals or declare them to be less than human. If hereditarianism leads inevitably to fascism, it reveals not a feature of the theory but a feature of human beings. In the struggle between acceptance and blame, acceptance seems always to lose. Before we give up in despair, however, we should remember that social reformers of a more benevolent nature have continued to use genetic research in an effort to ease suffering while recognizing the value of diverse individuals. Over the last 150 years, acceptance of the mentally ill and the disabled has increased dramatically. In addition, genetic research has helped identify the causes of some disorders and helped us cope or even find superior treatments in some cases.

Before the eugenics movement gained momentum, Hervey Backus Wilbur, Samuel Gridley Howe, and Dorothea Dix were all advocates for improved treatment of those with mental disabilities. Before eugenics the attitudes were quite different, but similar arguments were used for quite different ends. Nicole Hahn Rafter says:

Supporters of idiot education drew on two rhetorical strategies that, Joel Best has shown, are utilized frequently during campaigns to identify social problems: they argued that it would be immoral to further ignore members of this class (what Best calls ‘the rhetoric of rectitude’) and that it was socially beneficial to help them (Best’s ‘rhetoric of rationality’). Eugenic criminologists later used the same strategies to define the retarded as deviant and socially dangerous.[1]

Wilbur and his contemporaries intended to use their facilities to reduce deviance and improve the lives of the disabled. They shared the view of eugenicists that reducing deviance was a social good, but felt it could be achieved through humane treatment and education. Dix was particularly strident in her advocacy of reform for poor houses. She complained of country institutions that isolated inmates in “close, unventilated rooms; narrow dark cells; cheerless dungeons, cold and damp.”[2] It is quite conceivable that later hereditarians could have followed the compassionate lead of Wilbur, Howe, and Dix in seeking improved care and education of the disabled, rather than their elimination.

In 1925, Judge Harry Olson delivered an address on crime and heredity. Judge Olson’s address was highly acclaimed and included an impassioned plea for eugenics. Olson argues that crime is a product of heredity and, in effect, that criminals are not able to choose differently. His argument calls for compassion but also a deprivation of freedom for criminals. Rather than harsh punishment, however, he calls for farm colonies to provide segregation for delinquents. For his time, he was calling for a relatively humane treatment of such individuals. He says of the inmate on such a farm, “The need of the individual defective is likewise met, for he is given an opportunity to live to the limit of his powers, whatever their limit may be in each individual case. He will have all his worries and troubles removed, existence will no longer be anguish and agony for him, but a sensible balancing of work and play.”[3] Olson’s argument is a strange mélange of compassion and indifference, but it is not far from the approach taken today, even if the terms we use are different. Today, individuals who are severely disabled are often cared for in residential care facilities, and reproduction, when it happens, is seen as a great tragedy. It is seen as a tragedy because it is usually the result of rape committed by a staff member as residents are still not permitted sexual or reproductive freedom. Facilities today will also claim to be providing the most compassionate care possible.

Geneticists and hereditarians made every attempt to be positivistic in their claims, reporting only what could be observed, measured, counted, or deduced. From craniometry to psychometrics, the inferiority of certain races, genders, nationalities, and even families was confirmed again and again. In retrospect, it is easy to see that positivism was a cloak for prejudice, but many saw this as a way of ascertaining truth with a high degree of certainty, just as many do now.

The positivism taken by the social scientists was not what it could have been. Karl Popper claimed in 1919 that he was dubious about the claims of three specific kinds of science: Marxist theory, psychoanalysis, and individual psychology. He claimed that in order for a scientific theory to be an actual scientific theory it had to make certain kinds of claims. The riskier the claims, the more scientific the theory. The theory should, according to Popper, make a prediction and make a claim that could possibly be shown to be false. Most theories in the social sciences (psychometrics, for example) fail to make predictions or falsifiable claims. For Popper, no scientific theory is ever proven to be true. Tests of the theory can only prove it false or fail to prove it false. Theories that pass all tests are only theories that have not yet been proven false. Such theories may have instrumental value, but no one should ever be brazen enough to speak of scientific fact. In contrast, theories such as those in the social sciences posit a hypothesis and then researchers seek confirmation through observation. Popper calls this process pseudo-science.[4] Most of the sciences Foucault describes as the science of Man are pseudoscience by Popper’s reckoning. Popper was also a strong critic of totalitarian governments and the author The Open Society and Its Enemies. He was opposed to the theories of Marx, Hegel, and Plato.

In opposition to Popper, Thomas Kuhn argues that science is the product of social interaction of communities of scientists. Kuhn argues that normal science proceeds according to past achievements and evidence that is accepted by most scientists in the field. When evidence that a theory needs modification, the community must accept a paradigm shift that results in a scientific revolution. For Kuhn, scientific revolution occurs when scientists encounter unexpected anomalies that create a crisis within the community.[5] An example he does not give might involve craniometry; when it was discovered that extremely intelligent people sometimes had smaller skulls than the unintelligent, craniometrists were faced with a crisis and were forced to shift to a new paradigm such as intelligence testing. Although Kuhn gives the discovery of oxygen as an example, his theory seems particularly applicable to the social sciences, which Popper would deem pseudoscience in the first place.

It is impossible to say whether the outcome would have been different if the science practiced by many hereditarians had been more reliable and accurate, but I am skeptical of any improved results. Fascists are just biased individuals who are likely to seek the science that suits their aims rather than survey a wide array of data. In other words, fascists had a social agenda and sought any possible support for their agenda; they did not base their agenda after becoming familiar with scientific theories of their time. Of course, seeking alternative scientific views would have proven difficult as objections to the conclusions of hereditarians were few. Some did question the results they were finding, but most forged ahead emboldened by the authority of science.

Even when scientists were careful to articulate the limits of their research, as Binet did with intelligence testing, their theories were used to support and reinforce prejudices and biases. While Binet sought to help all children learn to their fullest potential, his test was eventually used to deny education to children who were not fully adapted to the educational settings in which they found themselves.

Centuries before Darwin, Galton, or Mendel, Plato’s Republic provided a model for a possible meritocracy and eugenic society. Plato advocated rule by the fittest (meaning those with the greatest intellectual powers) members of society and also a selective breeding program to produce more rulers. In this breeding program, pairs would be matched according to their native intelligence, which would be determined by elder rulers. Plato did not see a need to extinguish all of the less intelligent members of society as they, driven by their bodily appetites, would become motivated workers struggling daily to produce goods in order to earn enough to satisfy their baser desires. Those unable to achieve this level of productivity independently would be slaves. Plato assumed that intellectual ability was the product of good parentage, and he was certain that both parents played a role in producing the best possible offspring.

In the nineteenth century, Hegel proposed another view of political philosophy without reference to eugenics. In fact, Hegel said that individuals are powerless to effect change in society. On the contrary, history makes progress toward what he called freedom through the rational movement of the Absolute Spirit. The movement of the Absolute Spirit is rational but can only be understood by humans when it is too late to change it. He famously claimed the “Owl of Minerva” flies only at dusk. Historical progress proceeded, in Hegel’s mind, at the “slaughter bench of history.” Through progress, one nation would overthrow another nation and bring synthesis of the two. The eventual result of such progress would be that all individuals would share a single will that would be in accord with the Absolute Spirit, which is embodied in the State. Any struggle against the State would be a struggle against the Absolute Spirit and would therefore be immoral. Absolute freedom, in Hegel’s mind, would be a state where no individual would have any desire to behave in a way contrary to the national will. As the most popular intellectual in Germany and perhaps all of Europe, Hegel’s philosophy had a profound influence on his generation and the generations that followed. Though Hegel claimed the Absolute Spirit acted according to Reason in a manner that was unalterable, he also said that the actions of the Absolute Spirit would be driven by world-historical individuals. For his time, he noted that Napoleon was such an individual. It is easy to imagine Hegel also identifying Mussolini, Hitler, and Stalin as such individuals as well. While fascist propagandists and defenders may have used genetic research to bolster their movements, the drive toward fascism existed independently of genetics and eugenics.

Hegels most famous student and disciple, Karl Marx, altered his teacher’s theory in significant ways, but many of the elements remained the same. The Absolute Spirit, in Marx’s view (based on the philosophy of Feuerbach) was actually the spirit of Man. Also, although the actions of the Absolute Spirit are inevitable, Marx advocated direct action to effectuate change in society. Rather than one nation overthrowing another nation, Marx claimed that capitalism must be overthrown by communism. I would aver that Marx’s vision of communism has much in common with fascism and had nothing to do with eugenics.

The theories of Darwin, Mendel, Galton, and others were certainly used by fascists to justify some of their actions. The theories of eugenics also helped motivate people with the best of intentions to advocate actions that were cruel and hopelessly flawed. This is in part due to strong biases that were reinforced by inaccurate claims of scientists. Theories of genetics and evolution are not value-free, but they also do not lead to any inevitable conclusions. Where one person sees genetic theory as a means to improve the lives of individuals, another will see genetics as a way of identifying scapegoats. Skepticism of scientific claims of inferiority (or of anything else, really) and a bit of humility would go a long way toward inoculating society from the excesses and cruelty of both fascists and eugenicists. Those who are too certain of their claims are prone to irremediable, rash, and dangerous action.

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[1] Nicole Hahn Rafter, Creating Born Criminals. (Chicago: University of Illinois Press), 25.

[2] Dorothea Dix, qtd. in Rafter, 25.

[3] Harry Olson, Research Studies of Crime as Related to Heredity (Chicaco: Municipal Court of Chicago, 1925) 28.

[4] Karl Popper, “Science: Conjectures and Refutations” in G. Lee Bowie, Meredith W. Michaels, and Robert C. Solomon, eds. Twenty Questions (Belmont: Thomson-Wadsworth, 2005), 98 – 106.

[5] Thomas Kuhn, The Structure of Scientific Revolution (Chicago: University of Chicago Press, 1972).

Can we talk?

In recent months (perhaps years, now), it seems the religious and irreligious are divided more severely than ever. In response to demands that intelligent design be taught in schools or that evolution not be taught, writers such as Sam Harris, Daniel Dennett, and Richard Dawkins have taken religious thinkers and writers to task, attacking religious thought with unbridled enthusiasm. Their writings serve more as a rallying cry than as discourse and, as such, probably exaggerate the true gap between believers and non-believers in our society. Some of the religious seem equally enamored of raising arms against the other side. The Terry Schaivo “debate” quickly devolved into nothing more than grandstanding, posturing, and provocation for combat. With no background knowledge of our society, one would think pluralism had only happened moments ago and that any kind of discourse between the two sides (indeed, there are far more than two sides, but such nuance is invisible at the moment) is impossible. A little reflection, however, will remind us that the United States, while not quite the rich and diverse mosaic some dream it has been, is a country that has managed discussion between divergent groups in the past. The founders of our country were both religious and secular. Although a fair amount of strife resulted, discussion and compromise were always seen as real possibilities. It is possible that a way forward still exists.

When asked who would be an authority on matters of morality, most members of the public, in the United States at least, would first mention members of the clergy. More sophisticated individuals might know to mention theologians specifically. Few people would think to mention philosophers, especially not secular or, worse, atheistic philosophers. In The Elements of Moral Philosophy, James Rachels says:

“It is not unusual for priests and ministers to be treated as moral experts. Most hospitals, for example, have ethics committees, and these committees usually include three types of members: healthcare professionals to advise about technical matters, lawyers to handle legal issues, and religious representatives to address moral questions.”

So, most people in the U.S. believe morality and religion are inseparable. Rachels refers to Plato’s Euthyphro to question whether God’s morality is arbitrary or rational. If actions or values are good only because God commanded them, then morality is arbitrary, or so the argument goes. If God commanded actions and values because they are good, then God’s morality is rational. Rachels quotes Leibniz saying that the latter must be true. He says, “For why praise him for what he has done if he would be equally praiseworthy in doing exactly the contrary.” If God’s actions are rational and not arbitrary, then any rational person should have an equal ability to examine moral questions on the basis of reasoned argument. Rachels’ argument is that atheists and secularists should be included in moral discourse.

It is surprising, then, to find that the theologians Rachels felt have an undeserved place of privilege in moral discourse should complain that they have been left out of moral discussions, particularly with regard to bioethics. Courtney Campbell writes, “One unfortunate aspect of civic bioethics . . . is its incivility, including incivility toward religiously grounded opinions.” He also warns that religious bioethicists cannot retreat to the academy as, “the academy exhibits its own forms of intolerance toward religious expression.” Rachels and Campbell appear to be living in two different worlds, one hostile toward the secular and one hostile toward the religious. Authors on both sides declare that they must fight to be included in the discussion and be heard over the tyrannical forces of the opposing side.

Certainly, each side is correct in at least a surface view of discourse in the United States. Most people in the United States are religious, and their religious values are reflected in the public sphere. Some religious groups have shown clear forms of intolerance for opposing views. On the other hand, many professional philosophers are secular or atheistic, and a condescending attitude toward religion is perceptible to even beginning students in philosophy. Philosophers are a small minority, indeed, but their voices are disproportionately loud in the debates over bioethics, at least in part because they have made some provocative claims. How is a religious person to speak to a philosopher who claims it is permissible to kill babies and disabled adults but not animals? The fact that such a question is even asked must be enough to make some religious writers feel dialogue is hopeless.

James Gustafson describes three styles of religious discussion in medical ethics. The first is based on autonomy of religious views; most people would generally associate this view with an assertion of religious authority. When asserting authority, one is likely only to sway those of the same faith who feel compelled to follow the authority of its leaders. This is, of course, an important part of the moral work of many theologians, but it does not engage the wider community. The second style stresses continuity with the wider community. This style seeks to make religious positions intelligible both to those within and beyond a specific religious community. For example, a Catholic theologian may publish and article or give a speech intending to make the Catholic position on social welfare or just war comprehensible to non-Catholics. In doing so, some non-Catholics may come to agree and join with Catholics in support of or opposition to public policies. The final style is interaction, which is the only style in which the religious interlocutor is open to revising his or her original position. The interactive style is not for every writer or every occasion, but Gustafson notes that it is possible and can provide a space where the religious and the secular can converse about matters of medical morality.

J. Bryan Hehir discusses the role of the “public church.” In examining the proper role of Catholic bioethics, he notes that the Catholic Church “defines civil society as both an audience for its teaching and an object of its pastoral care.” From this prospective, theologians and others are obligated to engage the wider, pluralistic public on important matters of morality. He says that religious writers must be prepared to contend with a pluralistic society, a secular state, and a liberal philosophy of law. He notes the success of Martin Luther King in addressing the public on moral matters using rational argument that was not free from religious significance. However, biomedical issues seem especially intractable, particularly with regard to issues related to sanctity of life (e.g., abortion, suicide, euthanasia).

Given the steadfast opinions of individuals on both sides of the abortion debate, many have advised Catholic writers to focus attention on the ecclesial community. Hehir finds this dissatisfying as he advocates a public church, not a church that restricts its reach to its own enclave. He says, with some apparent pride, “The strategy may ultimately fail, but the failure will be that of a public church, rather than a decision by a once-public church to retreat within a purely ecclesial definition of its role.” The question is not whether the church succeeds or fails but whether it fulfills its duty to society as an object of pastoral care.
Hehir moves to another issue that may seem to be less of a problem for discussion between the church and the secular public: public access to health care. While religious language may be used to discuss health care, the general public can certainly understand the positions of the church, and the issues are not nearly so intractable as discussions of abortion, for example. On the surface, it seems that the church would be obligated to support efforts at providing heath care to all, but Hehir sees a problem. Many proposals for public access to health care include provisions for publicly funded abortions. He suggests that multiple strategies could be adopted but not in his short essay. Fortunately, Andrew Lustig expands on the discussion of health care rationing and reform, but the problem remains frustrating. Lustig recalls Christian teaching that demands universalizing love and care for one another, which would seem to require support for public access to health care, perhaps even globally. Nonetheless, he notes that U.S. bishops oppose any health care package that includes abortion. He calls for religious writers and others to invite their religious values to drive arguments expressed in non-parochial, or public, terms. He sees a possibility that religious values will “work their leaven upon the world” indirectly. How is a secularist to respond?

Two secular philosophers, Peter Singer and Peter Unger, have devoted much of their attention to the ethical use of the world’s resources. Both are motivated by a value shared by all Christian writer’s I am aware of: a value of preserving the lives of those who wish to live. Admittedly, some Christian writers would want to preserve lives in cases where someone might want to die, but it is possible to bracket that concern while discussing our individual obligation to others who do want to live. Singer and Unger both argue that taking care of the world’s most vulnerable people is an individual responsibility for everyone. While they both eschew religious language, others have pointed out that only Jesus seemed to have an ethic as demanding as Utilitarianism, requiring all in affluence to give to any who need assistance. Singer and Unger are both Utilitarians (a frequent straw man for non-Utilitarian ethicists) and argue that the interests of all must be considered equally (for Singer, the interest of animals must also be part of the calculus).

On the point of health care in particular, Singer questions the claim of Christians to value all lives equally. He challenges the notion, saying that to value all lives equally would mean spending as much money to save the lives of the world’s desperately poor as we spend saving premature infants and those in the last stages of life. Many of Singer’s positions are anathema to Christian thought and tradition, but on this point common ground seems possible. While not responding specifically to Singer and Unger, Edward Langerak gives an example of a kind of language that is distinctively religious yet still capable of engaging secular philosophers. He notes that religious covenant requires individuals to love their neighbors. He acknowledges that “the problem has usually been that people’s sense of obligation is too minimal for covenantal flourishing.” He quickly adds, “But some special covenants seem especially prone to encourage a ‘savior’ mentality in which persons lose themselves in a bottomless pit of others’ needs.” His language is decidedly religious, but it echoes secular arguments against the Utilitarian calculus. Both the Utilitarian and covenantal ethicist can “bury the self in the bottomless needs of others.”

James B. Tubbs grapples with the question of obligation to strangers. Tubbs exclaims, “Yet Jesus goes beyond the claim that needy strangers should be regarded in the manner in which God regards them. He suggests, in fact, that the needy stranger be regarded as the Son of Man himself!” Tubbs emphasizes this point further by admonishing that the encounter with the stranger should be seen as an encounter with the divine. He then moves to an examination of what it means to be a neighbor. He declares that our moral life is dependent on relationships with others, but he leaves off the discussion of what this relationship demands of us. It would not be difficult for the Utilitarian to agree that strangers shape our moral lives, but it seems more difficult for Utilitarians to turn away from what our relationships demand of us. In any case, it is not religious language or hostility to religious thought that prevents Utilitarians and religious writers from becoming interlocutors. One has no difficulty imagining a discourse on our obligations to strangers between the secular and the sectarian. A certain degree of consistency is of value in any moral tradition.

I have focused so far on obligations to strangers as it seems to me to be the most pressing medical issue for everyone. More than four million people die each year from starvation. Millions more die from treatable or preventable diseases. While academic bioethicists grapple with deep quandaries regarding patients and the role of the doctor at the bedside, most of the world would be improved greatly by having the luxury of becoming a patient rather than another statistic. War and its always-attendant famine kills far more people than withdrawal of treatment from impaired newborns or cessation of treatment for the cognitively impaired. This is not to dismiss the importance of discussions over transplantation and other hard questions, but the easy questions may be a good place for secular and sectarian interlocutors to begin a discussion. An infinitesimally small number of people discussing bioethics and medical humanities would claim that the loss of life is insignificant. Whether the author values life because it is a gift from God or because it is something individuals have developed an interest in maintaining, life is something to be preserved, at least in the cases where the living person values his or her life. Given the almost universal agreement with this statement, it seems that philosophers, theologians, and bioethicists of every stripe could work together not on whether life should be preserved but on how public policy can be shaped to help those who need medical care and cannot procure it. It has perhaps been avoided too often because the task is more daunting than deciding at what moment a dying person becomes a corpse with organs suitable for donation. Nonetheless, if we are to encounter strangers as our neighbors, we must gird ourselves for the struggle and prepare for a significant shift in how we view our fellow sufferers in the world.

If a discussion of helping the world’s neediest individuals seems possible among people of many faiths and philosophical dispositions, Leigh Turner’s example of blood transfusions will have us despair that no discussion is possible in other areas. To be sure, people from many backgrounds would agree that blood transfusions are often required to prolong lives. Many would see providing transfusions to be an obligation of the highest order. Turner points out that none of this rhetoric or consensus of most bioethicists will be of interest to Jehovah’s Witnesses. Turner warns, “Principlist and case-based approaches to moral deliberation typically exaggerate notions of common morality.” The point deserves consideration. It is naïve for any bioethicist to assume that any argument, no matter how well reasoned, will be accepted by all. Turner accuses bioethicists of ignoring the elephant in the room, but this conclusion may be rash. It could be that bioethicists, aware of the elephant in the room, persevere in the hope of lighting one candle rather than cursing the darkness.

It is no question that philosophers and theologians often talk past one another. Many religious concepts cannot be put into a language common enough for the secular and the sectarian. This should not mean, however, that the conversation should not begin. The “public church” should make its beliefs as clear as possible to even an unreceptive audience. The public intellectual should do the same. Resistance should come from all who have the strength of their convictions regardless of whether those convictions come from religious moral traditions or reasoned argument and reflection. Speaking one’s conviction publicly and arguing for it is itself a moral act. Tolerance and respect for diversity do not require us to stifle our voices. They require us to accept that other individuals have the same right and obligation we have to express their deeply held convictions and beliefs.

Public policy, on the other hand, must reflect the greatest respect for individual beliefs and convictions that cause no harm to others. To be sure, it is not easy to decide what beliefs cause harm to others. The case of blood transfusions from the Jehovah’s Witnesses’ point of view is a reminder that sometimes harm seems quite different when seen from different vantages. I personally am concerned about harm done to animals. I realize that most do not consider harm to animals to be harm at all. I join the relatively small group of individuals, mostly but not exclusively secular philosophers, in explaining why much of the harm to animals seems not only cruel but unnecessary. I have learned that the stronger claim that animals should not be harmed or used in research is almost universally rejected, but many people of various faiths and backgrounds accept that cruelty is an evil. Deontologists and virtue ethicists both reject cruelty to animals as a bad habit that could lead to cruelty to humans. Thus, Kant and Aquinas both reject direct obligations to animals but see humane treatment of animals as an indirect obligation to humans. Those with sufficient openness have been able to discuss this subject with respect and results. Globally, a shift toward more humane farming is underway even as factory farming continues to be the most profitable means of producing food.
We can and must engage one another in discourse with respect, tolerance, and courage. The debate will not always produce an answer that is accepted by all, but the lack of debate will always produce frustration and power struggles. Bioethicists are in a position to model such discourse for the larger society. This will require leaving the enclaves of institutions and entering the public sphere in a more visible manner. We must take care to live by the principles we espouse. Peter Singer has been criticized for donating only 20 percent of his salary. He admits he could do more but also points out that it would not be necessary if everyone living in affluence would give only one percent of her or his income. We have achieved nothing near this level of giving, but aid organizations did see a spike in donations after Singer’s essay on world poverty appeared in the New York Times. It is certain that atheist Singer managed to engage the religious with his argument. Discourse can have positive results.

Ronald Carson writes, “In covenant, one receives others as one receives a gift—in trust—and one passes the gift on in response to need, with due regard for the recipient, and without calculation.” Our fellow ethicists are in need of respectful interlocutors just as our fellow humans are in need of medical assistance. As bioethicists, medical humanists, and responsible human beings, we can help provide insight, assistance, and advocacy. We can join and be fully engaged in a moral community. This is the task at hand.