few areas of public policy have been fraught with as much controversy as bioethics. Each novel development in biomedical technology seems to spark rancorous disputes. Those averse to new technologies often express the concern that the new technology is 'unnatural' or requires us to 'play God'. Slogans such as 'Frankenfoods' and 'sanctity of life' substitute for reasoned argument. This is an ambitious book that seeks to reframe the debates surrounding current controversies in bioethics. Carefully examining and dissecting claims made by many policy-makers and ethicists on topics such as assistance in dying, genetic engineering, and embryonic stem cell research, bioethicist Ronald A Lindsay shows that all too often these claims are based on instinctive reactions, beliefs that lack factual support, and religious or ideological dogma. After describing in detail the proper way to approach and resolve a dispute in bioethics, Lindsay proceeds to analyse several different cutting-edge issues. Through his insightful analysis, Lindsay demonstrates how to achieve pragmatic, progressive solutions to these controversies. An antidote for misguided thinking, "Future Bioethics" illuminates the way forward to bioethics policies appropriate for the 21st century.

FUTURE BIOETHICS

OVERCOMING TABOOS, MYTHS, AND DOGMASBy Ronald A. Lindsay

Prometheus Books

Copyright © 2008 Ronald A. Lindsay
All right reserved.
ISBN: 978-1-59102-624-2

Contents

PREFACE....................................................................................................11ACKNOWLEDGMENTS............................................................................................151. The Problem and the Cure................................................................................192. How to Decide Which Policies to Adopt...................................................................29Common Morality............................................................................................30Rules of Reasoning.........................................................................................32Understanding the Rationale for Our Norms..................................................................38The Use of the Law in Crafting Public Policy...............................................................423. Legalizing Physician Assistance In Dying For The Terminally Ill.........................................51Terminology................................................................................................53The Importance of Assistance in Dying for the Terminally Ill...............................................55The Experience in Oregon: Individual Choice and Effective Prevention of Abuse..............................64Mistaken Diagnoses.........................................................................................68Risks of Abuse.............................................................................................70Opposition to Assistance in Dying Based on the Sanctity of Life............................................78Confusion about Causation and Intention....................................................................79Why Do We Prohibit Killing?................................................................................85The Best Argument for the Sanctity-of-Life Principle.......................................................90The Argument against Legalization Based on Disparate Impact................................................99Dopes and Slopes...........................................................................................1084. My Choices-Your Conscience?.............................................................................131Norms and Facts Relating to Conscientious Objection........................................................134Conscientious Objection by Healthcare Workers..............................................................138Conscientious Objection by Employees in Other Occupations..................................................145Conscientious Objection by Institutions....................................................................1475. Food Fears versus Food Facts-The Need for Appropriate Risk Assessment...................................153A Fact-Rich Diet...........................................................................................154Appropriate Risk Assessment................................................................................165Dessert....................................................................................................1806. "How Horrible! You've Become More Intelligent!"-Is Self-Improvement Wrong?..............................187Moral and Factual Background...............................................................................195What Is Wrong with Trying to Alter the World and Improve One's Life?.......................................198A Quick Review of Some Additional Objections to Enhancements...............................................205Enhancements and Justice...................................................................................2137. Saving Embryos for the Trash-Our Illogical Policies on Embryonic Stem Cell Research.....................227Chronology of the Embryonic Stem Cell Funding Dispute......................................................228Scientific Background for Stem Cell Research...............................................................232Moral and Factual Premises for Resolving the Dispute over Federal Funding..................................239The Position That Embryos Are Entitled to the Same Rights as Human Persons.................................241The Early Embryo Is Not an Individual......................................................................243The "Potential" of the Embryo Does Not Make It a Human Person..............................................246The Unacceptable Consequences of the View That the Embryo Is a Human Person................................248The Failure to Provide an Adequate Theory of Moral Status..................................................250Conclusion: A Reasonable Policy on Stem Cell Research......................................................253CONCLUDING OBSERVATIONS-And an Outline of a Theory of Moral Status.........................................261BIBLIOGRAPHY...............................................................................................277INDEX......................................................................................................293

Chapter One

The Problem and the Cure

This is a book about issues that directly affect your life and the lives of your loved ones. For example, among the issues discussed in this book are whether we should legalize physician assistance in dying for terminally ill patients, whether we should allow pharmacists to refuse to dispense medication to which they have an objection, and whether the federal government should fund embryonic stem cell research-research that may produce valuable therapies but will require use of human embryos.

Controversies such as these have received an enormous amount of attention in recent decades. It is not difficult to understand why. First, as indicated, how these disputes are resolved will have significant consequences for all of us. Second, to a large extent, these controversies present ethical questions that prior generations did not have to confront. In fact, bioethics as a specialized discipline has been around only since the early 1970s. (I use the term "bioethics" as it is commonly understood, that is, a field of study focusing on ethical and legal controversies arising out of healthcare, the practice of medicine, and biomedical research.) One of the principal controversies that helped spur the development of bioethics was the litigation over the withdrawal of treatment from Karen Ann Quinlan, the unfortunate New Jersey woman who fell into a persistent vegetative state in 1975. The condition of a "persistent vegetative state" had itself been expressly recognized and defined only a few years before. Prior to that time, there was no need to define that condition or to resolve controversies over maintaining someone in that condition because the technology to keep such patients alive indefinitely simply was not available. Similarly, medical procedures and treatments such as in vitro fertilization, organ transplantation, "morning-after" contraception, and gene therapies are all relatively recent developments and have all sparked ethical and legal disputes.

The novelty of some of the ethical and legal issues presented by the recent rapid advances in biomedical technologies is underscored by the fact that both federal and state governments have created commissions and other advisory bodies to study and discuss these issues and recommend policies. For example, the Quinlan case and other controversies over patient care resulted in the creation in 1978 of the President's Commission for the Study of Ethical Problems in Medicine and Biomedical Behavioral Research. Prior to the 1970s there was scant precedent for the creation of government advisories to study moral as opposed to social or economic issues.

Nonetheless, despite the development of bioethics as a specialized discipline and the investment of substantial public resources to study bioethical issues, all too often our policies continue to reflect myths, taboos, and dogmas rather than reasoned analysis and an appropriate understanding of the implications of these new technologies. Part of the explanation for this is again attributable to the novelty of these technologies. There is an aversion that many instinctively feel to the new and unfamiliar. Virtually every new medical procedure and technology has been opposed on the ground that it is somehow "unnatural." Those old enough to remember the 1960s may recall the shock and horror experienced by some at news of the first heart transplant; many condemned the procedure as unnatural and inherently immoral. Today, few would oppose heart transplants, or organ transplants in general, as immoral. (The current ethical debates surrounding transplants usually focus on legitimate ways to encourage organ donation.)

Although one frequently sees the terms "natural" and "unnatural" thrown around in debates about bioethical issues, these terms actually explain little and obscure much. They function as substitutes for meaningful reasons and arguments. Almost anything can be described as "natural" or "unnatural." Using wheeled vehicles as a mode of transportation and obtaining milk from cows are unnatural actions in the sense that our human ancestors were not born with rotating disks on their feet nor were they initially in a world in which tame animals supplied some of their nourishment-and the use of these techniques were undoubtedly opposed at first by some who found these innovations frightening or abhorrent. (Debating point from 10,000 BCE: "If we drink milk from cows, we're on a slippery slope to making cheese.") The point is that saying something is "unnatural" is simply a superficially more impressive way of saying, "I don't like this, but I can't tell you why." Yet new technologies continue to be opposed by some merely on the ground that they are somehow unnatural.

A related objection to new biomedical procedures or techniques is that they require us to "play God." How often have we heard that phrase in the last forty years? Any attempt by humans to control and shape their lives in ways not previously contemplated by some religious tradition results in the claim that we are trying to "play God." This objection appeared when birth control pills were introduced, when organ transplants were first attempted, when patients were first placed on or removed from respirators, and so on. But this objection is not very informative; indeed, it is not clear whether it has any specific meaning at all or is simply an emphatic way of indicating opposition. To the extent this objection has any core meaning, it seems to suggest that it is improper for us to use our own cognitive and emotional resources to come to a decision about right and wrong. Certain decisions are God's prerogative. If that is the meaning of this objection, then it is incoherent, because every time we do something because it is morally required or permissible and every time we refrain from doing something because it is morally impermissible, we "play God." This includes both the acceptance and rejection of new biomedical procedures or techniques.

We cannot avoid making decisions on an issue allegedly reserved for God because a decision not to undertake an action is itself a decision. If I decide not to undergo a heart transplant because undergoing such a procedure would be to "play God," I am playing God by deciding to forego the procedure. Even if we assume there is a God and that God takes an interest in human affairs, we have no option but to rely on our own reason, understanding, and experience to determine what is and is not morally acceptable. This is not usurping God's authority. If there is a God, we are simply using the means that She/He/It has given us to consider and resolve moral problems.

Some readers may react negatively to this assertion and claim that we know something is good because God commands it and something is bad because God forbids it. But how do we know when God has commanded something or forbidden it? If someone informed you that God has commanded us to kill every other female newborn and shoved some "holy" writings in your face to prove this, would you accept this supposed commandment? Obviously not. Presumably you would consider this person to be morally deranged. If God is supremely benevolent and would only require us to do what is good, as nearly all religious persons claim, then as a matter of logic, we must first determine what is morally good and bad before we decide what constitutes an authentic commandment from God and what represents a counterfeit revelation. There is no shirking your moral responsibility. In rejecting (or accepting) some new technology or procedure, you may pretend that you are only following God's commandments, but you have at least implicitly made a decision about which moral principles are good and, therefore, endorsed by God's commandments. Either that or you are simply slavishly following someone else's interpretation of what constitutes a commandment from God.

Nonetheless, the conviction held by many that morality must be based upon religion and that we can discern what is morally acceptable by consulting religious writings or dogma results in deeply misguided attempts to mine the Bible, the Koran, or other writings deemed sacred for insights on bioethical controversies. This occurs repeatedly despite the fact that these writings were generated at a time when there were no respirators, no organ transplants, no gene therapies, no embryos available for research, and so on. Not surprisingly, these writings are utterly silent on the issues presented by these innovations, unless these writings are very imaginatively interpreted-and then we are again back to the question of what constitutes a correct interpretation of God's word. Blind adherence to religious dogma has proven a serious impediment to progressive policies, as I will demonstrate in this book.

However, this book should not be interpreted as some sort of thinly veiled attack on religion. Given the popularity of some recent books with that theme, perhaps it would improve sales if it were, but that is not my focus. This is a book about bioethics, not metaphysics. Many bioethicists who are religious have made valuable contributions to moral inquiry. They have done so by offering reasons, not religious dogma, for their positions-reasons that can be assessed and evaluated by anyone regardless of their religious background. Just as someone's religious beliefs or lack thereof are a bad predictor of that person's character (there are thoroughly odious atheists just as there are thoroughly odious Christians, Muslims, Jews, etc.), similarly, religious beliefs or lack thereof are not necessarily correlated with an insightful understanding of bioethics.

Certainly, it would be incorrect to infer that instinctive rejection of innovation and misguided reliance on religious dogma are the only impediments to ethically sound bioethics policies. Secular ethicists can have ideological commitments that result in stubborn adherence to positions that are incoherent, irrational, or devoid of factual support. One example is the assertion that if a policy might have a "disparate impact" on some allegedly vulnerable group (typically, women, racial minorities, and the disabled are cited as examples of vulnerable groups), then this by itself is a sufficient reason to reject this policy. ("Disparate impact" here means that the policy has a disproportionate adverse effect on some group, such as African Americans being denied appropriate medical treatment more often than whites.) Invoking disparate impact as the basis for objecting to some policy is very fashionable among bioethicists, to the point that all too often they do not consider whether a policy's alleged disparate impact actually provides a reasonable basis for objecting to this policy. The classic example is the claim that we cannot legalize assistance in dying because it would have a disparate impact on women and racial minorities since members of these groups are more likely to be pressured into requesting assistance in dying. Leaving aside the point that there is zero empirical evidence to support such a claim, does such a claim even make ethical sense? Effectively, those who raise this objection are implying that if white men were pressured into choosing assistance in dying at rates that reflect their proportion of the population, then it would be permissible to legalize assistance in dying. But this is absurd. A coerced request for assistance in dying is morally objectionable no matter what the race or gender of the person being coerced. Evidence that we cannot legalize assistance in dying without placing large numbers of individuals at risk of coercion would be a legitimate argument against legalization, but it is the overall number of individuals who are placed at risk, not their race or gender that counts.

For the issue of assistance in dying and for all bioethical controversies, we need to have a clear understanding of the rationale for our policies. All too often we fail to ask the fundamental questions: What precisely are we trying to accomplish through our policies? How will our policies further human interests? Do our policies strike an appropriate balance between the rights of the individual and the community's interests? Are our policies consistent with our policies and ethical views on other issues?

In this book, I will analyze the flaws in the various taboos, myths, and dogmas that continue to influence our policies-to the detriment of our health and well-being.

I will begin with a topic that has been the subject of much debate in the United States and in other countries, namely, the legalization of assistance in dying. Despite a decade of evidence from Oregon (where assistance in dying has been legal since 1997) that confirms legalizing assistance in dying does not place patients at risk, opposition to legalization remains adamant in some circles. This opposition has no basis in reason or fact; in the final analysis, it is predicated on a taboo mentality. Several of the principal arguments against legalization-based on the alleged inability to control abuses, the sanctity of life, and the disparate impact that assistance in dying will have on vulnerable groups-will be examined and found wanting. In the process, I will show the profound inconsistency between our policies on cessation of life-sustaining treatment, which any competent patient may refuse, and our policies on assistance in dying, which remains illegal outside of Oregon. I will devote more space to this topic than others because the flaws in reasoning of the opponents of assistance in dying are indicative of the more common flaws in bioethical arguments generally.

In recent decades, federal and state laws have provided that various healthcare professionals, ranging from physicians to nurses' aides, can refuse to participate in certain healthcare procedures based on their "conscientious objection" while still retaining their jobs. The latest group to join this parade consists of pharmacists who refuse to dispense certain forms of contraception. Are healthcare professionals there to help patients or are patients there to secure a livelihood for individuals who want to be able to pick and choose the services they provide and obstruct patients' choices? I will demonstrate why the category of "conscientious objector" is misapplied in almost every case involving healthcare professionals.

Many individuals suffer from the misperception that organic food is not only healthier for them, but is also morally preferable to food cultivated with the use of conventional methods or scientifically enhanced methods, such as genetic engineering. But organic farming methods typically consume more land than other methods, resulting in more harm to the environment and feeding fewer people. In addition, no study has demonstrated that organic produce is overall healthier for humans than conventional or genetically enhanced produce. Some of the attraction to organic foods is based on misinformation. Many consumers believe organic foods must be grown without pesticides. Wrong. Organic farmers may use pesticides derived from organisms and various minerals-you see, these pesticides are supposedly "natural." If the misperceptions that many have about organic farming resulted simply in a mistaken understanding of its methods, this probably would not be a significant issue. However, myths about organic farming also contribute to unjustified suspicion of food produced in part by bioengineering. This is a serious issue because calls for banning or onerous regulation of bioengineered products not only lack any scientific justification, but prevent our reaping the benefits of these new technologies, which could result in greater agricultural yields and a substantial decrease in the use of pesticides. Fears and fantasies about the "unnatural" pose a much more serious threat to your well-being than genetically engineered corn.

(Continues...)

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