In December 2010, Sherif Girgis sat down with Arthur Caplan, a professor at the University of Pennsylvania and unofficial “dean” of liberal bioethicists, and Robert P. George, a professor at Princeton University and a conservative member of President Bush’s Council on Bioethics, to discuss the current state of bioethics in America.
People sometimes contrast those who go on evidence, facts, science, and reason, with those who “politicize the science.” But both of you seem to think that besides scientific findings, moral norms have to govern scientific inquiry and medical practice…
AC: That’s why Robby and I can get along. We’re just fighting about the norms. But we both know that you have to have normativity. Bioethics without norms is completely blind!
…and that those norms are not going to come from science.
RG: No. Bioethics is ethics, and ethics is about right and wrong. We know you can’t go about figuring out what’s right and wrong by scientific methods. So the norms have to come from somewhere else. And since we are a democratically constituted people, we are going to have to resolve by democratic procedures disputes about what the norms are, and how they apply in particular cases. Now that, I’m afraid, is politics. Not in some pejorative sense—rather in a good sense, in the democratic sense. Together, we deliberate, debate, and decide. So I think the juxtaposition that you mentioned is just phony. It’s not a dispute between the people “who believe in reason and evidence” and people who “are opposed to science.”
AC: You can pile up evidence to the size of the Jungfrau, but if you don’t have norms, evidence does you no good. But some out there believe that the evidence speaks for itself.
The scientific evidence speaks for itself?
AC: Yes, there are adherents of what might be called logical positivism, or scientism.
They are out there! They believe the facts alone dictate moral choices.
RG: I agree. I would add that it is highly ironic that the scientism that Professor Caplan observes out there, and rightly condemns, is often embraced by people who regard themselves as especially sophisticated and even enlightened.
AC: Yes, yes. As an exemplar, take some of the writings recently of Zeke Emanuel, the doctor who’s been whispering in the ear of Obama. Rahm Emanuel’s brother.
RG: He was the Director of the Bioethics Council under President Clinton.
AC: Zeke and I actually have been arguing more contentiously than Robby and I over the past few years because Zeke is an exemplar of scientism: “If we all collect enough evidence, it will be clear we should do X.” I disagree. You need normativity to do both ethics and bioethics.
So in light of what you’re both saying, is there a way of separating science and religion—or of walling off the influence of religious views from the settlement of these policy issues, in a country where many get moral guidance from their faith traditions?
AC: That isn’t going to happen. But the religious communities have to engage one another, too. I think what science does, relative to the religious discourse, is it tries to protect its self-interest. So scientists generally have a very strong commitment to freedom of inquiry, no matter what the heck they’re doing. I have to say it’s not quite my view. Freedom of inquiry is a great thing. But most scientists also want NIH money, or tax money. Science needs public funds; it’s a hugely expensive public endeavor. So scientists have to make their case to the public. They’re used to doing what they want, under the idea that freedom of inquiry will bring the public the most returns. They also have an advantage over religion in that they can deliver shorter term but more immediate rewards. You can at least turn on your heater due to physics. Where your soul is in the afterlife…
Jury’s still out. [Laughter]
AC: But at the end of the day, they’ve got to convince the polity and the religious traditions. Sometimes, if you’re trying to make room for scientific advance, you try to play into the divisions of religious opinion. But the most powerful thing that happened in the stem-cell debates was not arguments by Robby or by me. It was patient advocacy groups speaking up. You come in and say, “I’m in a wheelchair, or my child has diabetes…” Very, very powerful. It’s not religion, but let’s call it a normative stance that is enormously forceful. You must help those in desperate need. That’s how things get settled—not science alone.
Let’s talk more about that bioethics debate. Leading up to 9/11, public funding of stem-cell research in which human embryos are destroyed was a huge issue in American politics, and it deeply polarized the country. There was a very long and public deliberation by the president. To some degree it antagonized some people in the scientific community against some people in the religious community. Was it worth the polarization, the social and political costs?
RG: To me, at stake was our fidelity to the principle of the sanctity of human life. So I could not have yielded and said, “Well, that’s not important.” At the level of principle, I think probably both sides would say that it’s a big issue. But my sense is that it got blown enormously out of proportion as far as the practical significance of a policy one way or another was concerned. First, because it became useful politically. It was a way for Democrats to marshal their base against Bush in 2004. Ron Reagan, the late president’s very liberal son, to my mind just wildly hyped the potential therapeutic promise of embryonic stem cells. I think a lot of people were led to believe—and to what extent scientists were responsible for this is an interesting question—that if only the regulations were relaxed, embryonic stem-cell science would be central to our medical research and practice going into the future, and that it would massively alleviate suffering and produce cures for dreaded diseases. But it wasn’t true. Prescinding from the ethical questions, my own view is that there are scientifically interesting things that can come of embryonic stem-cell research, but that even without regulation, it wouldn’t be central. It doesn’t promise anytime soon, if ever, the amelioration of suffering or cures for dreaded diseases.
AC: So far I don’t disagree with that too much. Embryonic stem-cell research was completely overhyped, in terms of its promise. And people knew it at the time. I tried to say so myself at different times myself, even though I support embryonic stem-cell research. But this notion that people would be out of their wheelchairs within a year if we could just get embryonic stem-cell research funded was just ludicrous. Just simply silly.
RG: They knew it at the time?
AC: Yes, those saying it had to know it at the time. The scientists had to have known that. Who has ever delivered a cure in a year from something that’s basically a dish? That’s never happened. Gene therapy was promised as a cure for everything, and it is now starting to cure things, 15 years after the initial gene therapy experiments in dishes were being done. I think embryonic stem-cell research—if it works out, if you can control stem cells derived from embryos, if they don’t revert back… but we don’t know what chemicals to put around them, to get them to become what we want. We don’t know where to put them. But the politics of that issue were abortion politics, meaning that one side had as a principle, “Don’t kill.” The other side had as a principle, “You’ve got to cure.” And that escalated the rhetoric. So I think the science got hyped in response to the politics. Norms drove the debate. Embryonic stem-cell research for me is one of what I might list as 20 scientific frontiers that you might want to pursue. It’s not the frontier, but it’s one of a number of them.
RG: But it sounds to me like a niche.
AC: Oh it’s a niche, absolutely. Bio-banking, synthetic biology, bioagriculture, regenerative medicine at the adult stem cell level… There’s a bunch of areas of science with equal promise—
RG: If scientists knew that what they were doing was hyping it, then—even laying aside the ethical question about the status of human embryos—it seems to be deeply dishonest, clearly wrong.
AC: Here’s an assertion that you hear all the time: “Stem-cell research will help Alzheimer’s.” But stem cell research has no possibility of helping Alzheimer’s. Alzheimer’s is a gunk-up-the-brain disease, where every cell is affected. You can’t fix it by any sort of stem cell research. Model it? Maybe. Cure it? Never.
RG: In 2003 or 2004, a major Washington Post article quoting the central authorities on this made exactly the same point. Now that’s the kind of dishonesty that threatens to alienate the public from science. Because even if the public buys it in the beginning, and the scientists win the political debate, when they can’t deliver on the promises they made, people’s faith in scientists—crucial for the funding of science—is placed in jeopardy.
AC: I think it’s worse. There’s a clinical trial going on in California with private funding, for a spinal cord study. That study is poorly designed, shouldn’t go on—I’ve said so. The model that you want to use on stem cells is in your eyes: if you wreck one, you still have the other, and they’re easy to access. But trying to shoot cells—and you don’t know what they’re going to do—into someone’s spinal cord on the basis of a few rat experiments… If that goes wrong, the hype has been such that when critics come in and say, “it shouldn’t have been done,” it will set the field back to zero. I’ve tried to tell my science colleagues, “If you make a mistake on this first trial, and kill somebody? You can hang it up.”
RG: I think there was a warning that should have been heeded that came as a result of the exposure of the fraud committed by the South Korean scientist Woo Suk Hwang in 2004. If I recall correctly, his paper had been published in Science, and it had been fast-tracked in what seemed transparently to be part of a political effort to sell the public on human cloning to produce patient-specific embryonic stem cells. Since this would serve the political cause, normal checks that would have prevented the publication of a fraudulent paper were not observed, and it turned out to be fraudulent.
AC: And a little less lofty: “Give it to us, because if you give it to, say, Nature, they might slow it down!”
RG: [Laughter] Is that what happened? Well, the cutting of corners for political reasons is such a dangerous thing to do—to science. But when Ron Reagan was trotted out at the 2004 Democratic National Convention to make these preposterous claims about Alzheimer’s, of course you spoke out—but were there others?
AC: There were and there weren’t. Because at that point, I think what happened was that the polarization of the politics got so bad that it was a team philosophy.
So it would look like you betrayed your side if you spoke out with the truth?
AC: Definitely… It’s a little harder to be a moderate in the middle of that. I can give you a parallel: Terri Schiavo. I was vociferous in my insistence that the husband should make the call in the case of Terri Schiavo [about whether to continue her artificial nourishment after her severe brain damage]. But one thing I knew was that she was absolutely permanently vegetative. She had two heart attacks; she wasn’t getting oxygen to the brain. People were saying, “I could hear things in PVS.” Doctors said, “I can make her better.” And no one on the other side would say that was bull. So certain factual claims get laid aside in the heat, when bioethical disputes move up to culture war level. I can moan about this. “Alzheimer’s disease? Really, a systematic disease of the brain? You’re going to replace every cell in the brain with embryonic stem cells?” But you know, the price of entering into that arena is you can lose or be put in the service of what you know to be purely politicized debate.
RG: Art and I disagreed about the Terri Schiavo case, but the fundamental point he is making here is absolutely right. Back on the embryonic stem-cell debate, there were people on my side of the ethical question who contended that there was absolutely no reason to pursue embryonic stem-cell research even if the stem cells could be obtained without destroying embryos, because (they said) everything that could be done with embryonic stem cells could be done with adult stem cells and we knew it. Well, I knew that we knew no such thing. To admit the truth that there very well may be uses for embryonic stem cells—not therapeutic uses at any time soon or perhaps ever, but in basic science, or perhaps in the construction of disease models—one needn’t abandon one’s principled position against the destruction of embryos.
AC: In the early days of bioethics, we had these conferences at the Hastings Center, where I began my bioethics career, where Alasdair MacIntyre, Paul Ramsey, Leon Kass would come and talk about issues. And I began to form an idea of what bioethics’ role was—and I still believe it to this day: My philosophical idol is Socrates. He worked frequently in the public sphere. I think as a bioethicist you try to alert the public, you warn people, you push to see what’s true, but at the end of the day, bioethics gets out of the way. You don’t issue final judgment; you must resolve issues in the political sphere. If Robby’s guys get elected all the time, and they ban embryonic stem-cell research, I’ll scream and yell, but if that’s what people decide, that’s what people decide. I favor bioethics commissions that raise issues, clarify them, and then give them to the polity to resolve.
RG: Well, it’s true that President Bush’s council on bioethics, on which I had the honor to serve, sometimes went beyond advising the president of the United States himself. But it’s worth remembering that the Executive Order creating the Council included a mandate to “provide a forum for a national discussion of bioethical issues.” The collected readings we published were an effort at large-scale public education. I think that kind of work can easily be defended, and the best defense is that by doing it under the auspices of a commission, and especially an ideologically diverse commission like ours, it is possible to draw attention to the basic values issues that Americans should think about when they consider bioethical questions. I doubt that it would be possible to do it as well in reports issued by, say, Princeton University, or even the premier center for bioethics here at the University of Pennsylvania. If the commission is not the place, where, then? Because the universities aren’t doing it very well, and perhaps can’t.
AC: So it’s funny you should say that, because I’ve also thought—and I don’t know how to make this happen, exactly—but if I had a politician ask me for advice on something, I’d like to be able to bring Robby in—really—and say, “I’ll tell you my advice, and you can listen to the minority, distorted, bizarro other opinion…”
RG: Soon to be the majority! [Laughter]
AC: But here it is, listen to the other view, and you’ll get more from a conversation than you might from me just talking to you.
RG: Art is absolutely right on this. I was asked by three Republican presidential candidates in the run-up to the 2008 election for briefings on embryonic stem-cell research. Senator McCain, Governor Romney, and Mayor Giuliani. Mayor Giuliani did it differently than the other two. He invited me and an advocate of embryonic stem-cell research from one of the New York-based patient advocacy groups to discuss the question with him. Essentially, it was a debate in front of Mayor Giuliani. And I do think that it was more fruitful than the other two briefings, where I had my little captive audience, but would just give my best answer when they asked, “Well, why do the people on the other side think what they think?” And I’d try to give the argument, but I think I was probably less effective in giving the argument than someone who actually believed it.
Let’s have one of those exchanges now about a big issue in bioethics: eugenics. You have people like Professor Kass, who are warning that it is popping up again in the availability of certain options for improving the gene pool or selecting for or against early human life that has certain defects and so on—but that the “new eugenics” are disguised as opportunities for practicing autonomy, and that, as a result, they are viewed as morally okay. Do you think that’s happening, as a factual matter? And is even uncoerced eugenics wrong in principle? Was eugenics in the 1930s, say, wrong only because it was coercive, or also because it was eugenics?
RG: You’ve heard me make the argument about human dignity without any appeal to religious authority or biblical revelation or theological premises. But the most vivid expression of that idea is that man is made in the image and likeness of God. Whether or not that’s literally true, I would still hold that human beings have a certain dignity that distinguishes them from other material objects that we know about. There may be other creatures in the universe that possess a rational nature, and I would say that if there are such beings, they too are of inherent and equal dignity and cannot be reduced to the status of mere means or property. In the end, this is really the only reason to oppose something like slavery, or to consider that domination and conquest are a bad thing. So people who oppose these evils have to embrace some notion of the special worth—we can use the word “dignity” or “sanctity”—of a human being. But that means there are some ways you can’t treat human beings. You can’t treat them as instruments, or just the way you treat cows and horses. That is true even when it comes to breeding, or to improving the quality of the race. Or treating them like products—this is what Leon Kass is so worried about. He’s worried about reducing human beings to the status of products of manufacture. And he’s absolutely right to be concerned about that. That is incompatible with our dignity as human beings. Which leads me to think that the problem with eugenics is eugenics itself. It’s not just that the eugenics practiced by the Nazis was coercive. The idea predated the Nazis. The book Die Freigabe der Vernichtung Lebensunwerten Lebens (Allowing the Destruction of Life Unworthy of Life) was not written by the Nazis. It was written by German progressives in the Weimar period, Karl Binding and Alfred Hoche, who were, respectively (as I recall), a jurist and a medical doctor. And they weren’t thugs like the Nazis; they were well-educated, well-intentioned, polite people—the kind of people that you’d be pleased to have dinner with. But I believe they embraced a very bad idea that was easily taken by the Nazis as a justification for the atrocities that they committed. So I would like to see eugenics itself, and not just the Nazi version of it, relegated to the ash-heap of history. Today we are seeing a revival in eugenics, this time under the cover of (and often in the name of) autonomy. People say, for example, that so long as it is parents who are choosing to abort a Down syndrome baby, or failing to treat a handicapped newborn, and it’s not the state mandating it, then it’s okay. That, I believe, represents the abandonment of something precious in our civilization and in our polity. And that’s the idea of the equality and dignity of all human beings. This treasure of our civilization is the idea that, in some fundamental sense, all of us are created equal.
AC: So, I think that the coercion is, historically, really what made the Nazis’ position absolutely wrong. They practiced government-mandated negative eugenics. They killed involuntarily as social policy to improve the German genome. So put that aside, that’s just an issue of making sure you know when you’re going to use the metaphor—it’s not just eugenics, it’s that kind of eugenics. So to me, I think that intervening to try to improve health and function is part of what medicine does. And there’s some role for medical engineering and cellular engineering to achieve those goals. I think when you start to slide into the aesthetic and cosmetic improvements—I’m not sure that’s something that society or the public has to fulfill. But do I think we will someday try to alter a genetic message to get rid of certain diseases? Yes. Do I think that we’re likely to see the selection of certain types of gametes that might avoid certain clear-cut disease states? Yes. Do I think that the state has to be in the business of affording the opportunity for everyone to have a 6’5” basketball-playing mathematician? No. For me, there is some role for what I’ll concede as eugenics—if you want to take eugenics as just trying to improve the overall hereditary health of the public. For example, if you could fix the child with Tay-Sachs, I don’t think it takes away from the dignity of the child with Tay-Sachs.
RG: I agree. But would you draw the line at trying to enhance intelligence—
AC: I do. I think intelligence is so complicated that you don’t know what the hell you’re doing. If someone came to me and said, “Well, I’m going to try to enhance memory,” that may be good and that may be bad. It’s tricky business, number one. And number two, that isn’t a disease. So I’ve never been a proponent of allowing sex selection. We don’t allow it at Penn, actually. We could do it instantly. It’s not that hard. And other places do it. But gender is not a disease. If you come to us and say, “Could I use gene therapy”—as I said, “for Tay-Sachs, or to try to improve muscular dystrophy”—I’d be first in line to say, “I think that’s great, and we have to test it, and there may be some risk to that, but I’m okay with it,” even though some in the disability community might say, “Well, then, your goal is to get rid of disability, isn’t it?” And I might concede at that point, “Yes—if I could do it.”
RG: But not by getting rid of the disabled.
AC: Oh, no, no, no.
RG: Because that’s the key distinction.
AC: I agree, but some in the disability community hear inferiority, lack of respect, when you say, “I’d prefer people who could function more.” I’ve heard this with the deaf community. To me, hearing is better than not hearing. And it’s pretty clearly a function you’re supposed to have. It’s true that you can sign, and that there is a deaf community. And I get that there’s Gallaudet College. I’m not proposing to close them; I think you should fund them. But at the end of the day, if I’m the child of a deaf couple, I’d rather be able to hear and sign, and decide what I’m going to do from there. I’m not going to make a deaf baby because the couple says, “We want a kid like us.” No steps should be made to honor that kind of autonomy—things that will harm or set back people. I’m worried for that reason about things like intelligence or athletic ability. You’re narrowing futures, deciding what the kid is going to be, raising expectations, instead of allowing them to be more open. So I favor, if you will, ‘eugenics’ on the disease-elimination front, but I am not so crazy about performance-enhancement or the behavioral meliorism.
So it sounds like both of you have two distinctions you want to draw. One is between enhancement and therapy—
AC: Right. And many say you can’t, but I think you can at the extremes.
And the other is between negative and positive, between destroying life that has the therapeutic problems versus—
AC: Trying to engineer it away. Medicine does that now, right?
RG: I think Art’s reminding us of the ends of medicine: the goal of medicine is the restoration of healthy functioning of the organism and its parts, within the bounds of ethical norms. I mean, you don’t restore health by murdering someone conveniently to get a heart for somebody else who happens to need a heart transplant. We understand that. That’s just a plain violation. But my point is that when we treat medical professionals as people who are supposed to enhance our lifestyle choices—the kind of kids we want to have, whether our kids are good at math, whether they’re basketball players and 6’5”—it causes medicine to lose track of its mission and places at risk its commitment to ethical norms shaped by that mission.
LifeNews.com Note: Sherif Girgis is a Ph.D. candidate in philosophy at Princeton University.