Daniel Callahan is one of the most influential thinkers in contemporary bioethics. He is the founder and president emeritus of the Hastings Center, and has written or edited more than 40 books. Most recently he published a memoir, In Search of the Good: A Life in Bioethics (MIT Press), and The Roots of Bioethics: Health, Progress, Technology, Death (Oxford University Press). He also has a forthcoming work, Five Horsemen of the Modern World: Disease, Food, Water, Chronic Illness, Obesity (Columbia University Press, 2016).
Recently he spoke with BioEdge about the state of the discipline today.
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Xavier Symons: You were present at the creation, so to speak, of “bioethics” in the 1970s. Are you surprised at how prominent the field has become? Where will bioethics be in another 50 year’s time? Will it defy sceptics and survive and thrive?
Daniel Callahan: When my psychiatrist colleague Willard Gaylin and I created the world’s first research center on bioethics in 1969, the Hastings Center--even before the term bioethics had been invented—we were confident it would survive and flourish. By the 1960s research advances in medicine and biology were creating a surge of ethical problems and dilemmas, from the beginning of life to its end, and much in between. At the same time health care costs were rising and straining national government budgets. Not only did the new technologies that generated most of the dilemmas improve health and extended life they no less raised costs, creating ethical issues of allocation.
We were welcomed by a number of prominent doctors and biology researchers, urging us on, but also with some worry and suspicion from others. Yes, the latter said, our issues were real but could be handled perfectly well within the fields themselves; philosophers, social scientists and lawyers were not welcome or needed. Many also expressed the belief that ethics itself is a weak field, either dogmatically religious in nature or wholly soft and indecisive, unlike science.
Much of that reaction faded as time went on, but still surfaces on occasion. A prominent Harvard scientist at Harvard, Steven Pinker, recently wrote an article with the title “Bioethics, Get Out of The Way,” rather nastily attacking a group of bioethicist and a few scientists who called for a moratorium on some genetic research.
Once underway in the 1970s, bioethics flourished. While only a handful of American universities and medical schools had courses or programs in the late 1960s, by the beginning of the 1980s almost all did. Undergraduate courses proliferated as well. The Institute of Medical Ethics in the UK, a few years ahead of my Center, set the movement afoot there. By the 1980s we were receiving requests from all over the world for help in getting government programs and courses in medical schools underway. The media, moreover, began to note the field of bioethics and to follow the many debates taking place, often ending in important court decisions.
Within bioethics itself, a strong cadre of philosophers took interest in its issues. They succeeded in pushing aside the theologians, most working within a long- standing tradition of interest in medical ethics, the predecessor of bioethics. There was a resolutely secular, and usually liberal, ideological commitment among many of them which came to flavor the field, often in a way biased against conservative values. While secular myself, I felt that bias did not help the field, one which claims to be open to debate and different views. In any case, bioethics has made its mark in American society and around the world.
What I have most noted over the years has been an interesting mixture of old and new issues. Every one of the problems we bit into with our baby teeth in our earliest days is still with us: end-of-life care, genetic screening and procreation dilemmas, cost of health care, behavioral problems, human subject research, and human enhancement beyond ordinary good health. Early on, I think, we naively believed we could solve those problems once and for all.
No, they have all turned out to be chronic in nature, constantly affected by new knowledge and technologies, new generations of doctors and researchers, and new public interests. And all kinds of new interests have appeared: for instance, neuroethics as a topic and feminist bioethics as an angle of vision.
The field will exist 50 years from now, but maybe with a different name, if only because medical and scientific knowledge does not stand still, and because human beings will still take a dim view of finitude, illness and death, never likely to be overcome. Just how prominent the field will be is less certain. Will it simply be one of many interdisciplinary academic sub-disciplines of a kind now common in American universities (urban studies, black studies, women studies, international studies)--but always a kind of second –string team as it is now--always dominated by long-standing single disciplines (physics, philosophy, biology)? I have no idea, but I know some bioethicists have that ambition for the field.
XS: At least in the American media, “bioethics” is often equated with utilitarian ethics, with Peter Singer as its guiding spirit. What do you think of the utilitarian strain of the bioethical enterprise?
Callahan: Perhaps 15 to 20 years ago Peter Singer might have been called our “guiding spirit,” but that time has long past. It was mainly due to a great deal of publicity he received in the media, mainly for his writings on animal welfare and the killing of newborn, defective children. Moreover, for those who thought bioethics an excessively liberal field, he was taken as embodying all that is obnoxious about it.
It was the outside society in short, it was not those in the field, that elected him as our leader. Since then he has written on many topics beyond bioethics and has not remained a highly visible presence in the field. Nor was utilitarianism ever a strong strain in the American field even though many philosophers early on debated the pertinence of utilitarian versus deontological theories. Utilitarianism is much more noticeable in, say, the UK Journal of Medical Ethics than of the Hastings Center Report or other American journals of bioethics.
Much more American is the appeal of autonomy as a central value, reflecting an important ideological strain in our society. It was the hallmark of our 1776 revolution, “give me liberty or give me death” as one of our patriots said. It helps explain our cultural resistance to the dominant welfare state in the UK and other European countries, most notable of late in struggles over the role of government in health care. The idea of “solidarity,” strong in those countries, has little purchase in the US. Principlism, however, gained a strong foothold. It represents for the philosophers who devised it a way of moving beyond theoretical debates of utilitarianism and ontology more directly in rules and procedures for individual ethical choices and policy formulation. And that is what many of those in the domain of medicine and health policy seek from us, not theoretical analysis of a kind common in the traditional work of moral philosophy.
It is no accident that the principle of respect for persons (usually understood as individual autonomy) comes first in the list of the four principles, nor (as I understand them) that the other three principles are meant implicitly to serve that autonomy, including that of justice, whose ultimate aim is the fair treatment of individuals. Moreover, principlism seems to offer a clear road map for decision making, which those who are not ethicists find attractive and understandable. It relieved them of the need to find their way put of the thicket of ethics, with some 2500 years of religious philosophical argument and disagreement.
XS: Most bioethicists in the US subscribe to the principlist approach. What attracted you to the counter-cultural notion of communitarian ethics? Is such an ethics paternalistic, as some have charged?
Callahan: Here’s where the story of bioethics, in my reading, begins to get complicated. I see four parts to be understood: (1) the changing role of ethical theory in the field; (2) broadening the scope of bioethics from that of clinical ethics to cultural and health policy issues, and expanded to encompass empirical ethics for all of them; (3) bringing communitarian approaches into the field to balance the heavy emphasis on autonomy as the core of ethics; (4) the move to greater specialist research in the field and declining interest in broader and deeper problems , a major feature of classical studies in the humanities.
The changing role of ethical theory
In the early years of bioethics and with the advent of a flood of philosophers into the field--soon coming to have a dominant role--concern and debates about ethical foundations were common. They had two prominent and overlapping features, one of them common to interdisciplinary fields, and the other to the philosophical foundations of bioethics. If bioethics is understood to be interdisciplinary, what is the glue or foundation perspective that it holds it together, and how is the fact of disciplinary differences among the partners to be navigated in some integrated way? I will not take that question on here, but move instead to the philosophical foundations of bioethics.
An early debate, soon passing, was whether bioethics should draw its foundation from the history and traditions of medicine, from within so to speak. The philosophers had little interest in that approach, and quickly moved on, seeking a theory in moral philosophy that would serve as bioethics as its basis. How could the field have any credibility if it had no such foundation? As is the case with standard disciplines, what are the canonical texts of the field, necessary for all novice to understand, and what is the established methodology for assessing pertinent issues? Not only was no such theory ever found, much less a standard methodology--or even a few put in competition with each other--it was a topic that seems to have all but disappeared from general discussion.
I suspect it was not just the futility of that search that led to its decline. It was most likely also because the growing presence of doctors and nurses, social and political scientists, and assorted others, coming into bioethics with little or no interest in philosophical foundations—nor any willingness to cede special prestige or leadership to philosophy as the disciplinary king of the mountain. My own informal survey found that physicians are now the dominant teachers of bioethics in medical schools, with those from the humanities and social scientists on the decline. Yet the latter do seem to remain dominant in teaching undergraduates courses, and they are now common and popular with students.
Broadening the scope of bioethics
If some kind of search for a grounding philosophical theory had a short life in bioethics, it gradually was replaced by an interest in what came known as “empirical bioethics.” The meaning of that term is somewhat vague. It does not mean that moral rules and principles can be derived from scientific evidence--an ought from an is--known as the naturalistic fallacy. But it does mean that evidence should be sought about the practices, folkways, and values of those who make moral decisions, and about the cultural and political values that help shape health policy.
The addition of health policy as a legitimate part of bioethics has been an important expansion of the field even if it still remains a minority interest. By including justice as one of the four principles that was a stimulus to do so. But, save for work on justice, there is little interest among political scientists, economists, and health policy analysts in bioethics. In my experience, that is a closed shop. And interestingly, those who are in that shop tend only rarely to talk the language of justice and rights.
The emphasis is on cost-benefit calculations, access disparities, the need for safety nets, and market forces for research and health care deliveries. There are a great number of ethical issues hidden in that focus, but rarely described as such. Empirical data has a central kind of role that is less at play in bioethics. There is a dark side to all of this, at least from the perspective of those or us in the humanities, that of science as the real king of the mountain now. The decline of the humanities in American higher education is a symptom of that shift.
Communitarian perspectives on bioethics
I was never satisfied with principlism, put off by the dominance of autonomy, representing a kind of cultural captivity, and altogether too narrow to deal with the social dimensions of human life. I take the good of society to be as important as the good of the individual. Aristotle was right to note that “man is a social animal,” someone who lives with others and is dependent for his or her welfare on them.
Principlism also seems to me mainly an external kind of ethics, focused on what we owe others, not that of the kind of person we should ethically be to even care about others, or to ethically shape a personal life , what I call an internal ethics. Aristotelian virtue ethics tries to shape that inner life, at the same time making clear that prudence is a key feature of individual decision making, not standing in the way of moral rules and principles but giving them a secondary role.
Bioethics American style seems a bit too enamored of John Stuart Mill’s “harm principle” that we may act as we please as well as we do no harm to others. “The sole end for which mankind are warranted,” he wrote, “individually or collectively, in interfering with the liberty of action of any of their number is self-protection” seems to leave little room for determining what we owe to others to advance their good and that of the society in which we all live. American society is now caught up in a deep ideological struggle, pitting the idea of a common good and social solidarity against an individualist market view of life that stresses freedom of choice and a minimizing of the common good, both economically and culturally.
Mill’s principle lends itself to that side of the argument, a curious kind of convergence of the politically right and left. Margaret Thatcher famously caught the flavor of libertarian individualism when she said “that there is no such thing as society.” The absence of any serious sense in the US of the concept of solidarity reveals not only an impoverished view of the human community as a whole but a chilling embrace of individual freedom as the hallmark of a good society. Indeed it is but only if joined by a no less strong embrace of community. That latter embrace has been weak in bioethics, not altogether absent but wavering.
While it may not directly bear on communitarianism, there has been of late in what I think of a noticeable shift in a bellwether axiom of bioethics, that of the centrality of autonomy in the doctor-patient relationship. A better balance with traditional physician paternal, once declared anathema, is now being sought. Does communitarianism encourage paternalism? I see no reason to think it does. The good of a society requires democracy, which requires the free voice of its citizens. It also requires the well-off to come to the rescue of those in need, not as their moral and civic superiors, but as their more fortunate equals.
The move to specialized research
As noted above, a strong push for bioethics in the 1960s came from scientists, hardly all by any means, but by a few who saw the power of advances in medicine and biology to bring unprecedented change to the way we understand life and live it. Their interest was deep and broad. That spirit animated the earlier years of the field, but did not last with its early force. The field flourished because of the challenge of specific ethical decisions that had to be made, at both the clinical and policy level. The emphasis came to focus on concrete solutions to concrete dilemmas. That is what attracted public and professional interest, and the media, not age-old plunging into the deeper issues of the meaning and ends of life lying just below the surface. That shift was important in raising money for research and publications. They had to show practical results. It was understood from the outset that the many government commissions set up over the years were not to be academic seminars, musing about the good life, but fact-finding and policy analytic bodies.
As the field moved along the range of issues proliferated, the number of publications grew, and the problems themselves became more perplexing. Prenatal screening for a few deadly genetic disease gave way to dreams of ever more genetic information, radically expanding the possibilities of predictive genetic screening and what has come to be called “precision medicine,” that of treatments tailored to the genetic makeup of individual patients. End-of-life decisions have if anything become more complex over the years because or constant technological innovation, removing any sharp line between living and dying.
Those developments brought about increased specialization. In the early days we moved easily back and forth from one issue to another, but that is not common these days. That shift made the need to keep returning to the deeper questions harder and harder. The early discussion of the meaning and appropriate definition of “health,” or a special interest of mine, “the goals of medicine,” gained little purchase: interesting, but not useful for making decisions.
While that overall shift is understandable, the enduring and underlying questions need as much attention now as they ever did. For me, there are three enduring questions. What do the scientific and related social developments mean for our ideas about health, about the role and ends of medicine, about their impact on the way we live our lives. They have been there since the beginning and will be there 50 years from now. We should help to understand those questions, to find helpful approaches to deal with specific decisions, but no less to be loyal dissenters when the sugar plums of endless progress are allowed to dance too seductively before our eyes. Not everything new is good, and not everything old is bad.
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CEBID - Centro de Estudos em Biodireito
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