Monday, October 26, 2009

Brawling Bioethicists? How Health Care Reform is Creating a Schism in the Field of Bioethics.

From MercatorNet, an article on a developing schism among bioethicists. (I refer to this in my latest article for AlterNet on rationing of health care.) According to Michael Cook, the field is in crisis.

This was sparked by an address by Dr Emanuel to the annual conference of the ASBH [American Society for Bioethics and Humanities]. He argued that what bioethics needed was more statistics. Without a solid grounding in quantitative methods, bioethicists simply aren't much good. Ideally, aspiring bioethicists should study behavioral economics, psychology, decision theory or sociology. There should be less public discussion and more number-crunching. And, he implied, it is number-crunching bioethicists who will be getting the precious government funding which enables them to stay in business.

America's best-known bioethicist, Arthur Caplan, of the University of Pennsylvania, was so irritated that he almost immediately posted an open reply. He responded that a bioethicist must be a "moral diagnostician". "A crucial part of the bioethicist's role is to alert, engage and help to illuminate ethical problems and challenges both old and new in the health and life sciences." Empirical data are just one tool in the bioethical toolbox.

Emanuel's address has not been published on the internet yet. But this very public dust-up provides more ammunition for those who believe that the field of bioethics is in crisis. When the most quoted US bioethicist says that the philosophy of the most powerful US bioethicist is "narrow, misguided and wrong", what are laymen to think? It certainly gives them no confidence whatsoever that President Obama is getting the right bioethical advice.

And Cook goes on to explain the schism as a loss of philosophical reasoning in what has become a statistics-focused profession. To make his point, he starts with the definition of bioethics:

For so familiar a word, "bioethics" has a short history. It entered our dictionaries as late as the 1970s. The English word cobbles together the Greek words for life, Bios, and for moral character, or custom, Ethos. So huddled under the umbrella of a single term are two related but distinct intellectual disciplines, metaphysics and ethics. Bioethics is inexplicable without them, just as biochemistry is inexplicable without biology and chemistry.

Let's look at metaphysics first. The ancient Greek philosopher Aristotle coined the word. He wanted to investigate whatever underlies or lies beyond (meta) the physical world of what we can see and touch (physica). So metaphysics deals with the most fundamental questions of experience: what is reality? what does it mean to be? what does it mean to be a person? what is life? Bioethics "works" only if its metaphysics is correct, that is, if its understanding of life, humanity and personhood corresponds to reality. An astrophysicist who bases all of his calculations on the equation e=mc³ will ultimately reach the wrong conclusions, no matter how sophisticated his mathematics.

He concludes that the profession has lost credibility because many in it rely on statistical analysis to come to conclusions.

I humbly disagree. How one parses statistics requires an ethics. How many times do "pro-life" groups use skewed statistics to trumpet that approval of abortion has slipped in the US? Or that abortion is linked to cancers in women? Or that abortion has declined in the US because of their efforts? Statistics, of course, can be - and most often are - used for one's own purposes, in this case control of women's reproduction and role in society. (There are so many more examples of the use of skewed statistics but the "pro-lifers" are currently the most egregious.)

Bioethicists are getting push-back from their own for a number of reasons. No one wants to have their profession vilified in the public square. Many are wary of statistical (and ethical) support for "rationing" of health care. As I write in my latest article for AlterNet, "rationing" exists and will always exist because resources are finite. (I conclude that much of the expense of end of life care can be decreased by simply giving the elderly and terminal patient a choice in how they die.) How to best use those resources in an egalitarian and ethical way is what is at issue. Denial that "rationing" exists (or has to exist) is certainly easier than facing the harder questions of how to mitigate its effects.

The greatest detractors from such a discussion often rely on a faith system, a religious code; or a capitalistic assessment of medical resources. Either God or the free market should decide who gets what treatments, medicines and services. The former relies on a moral system that is dominant in our culture, that adhered to by Catholics and Evangelicals, but is not representative of all society. The latter relies on a cultural value held by fiscal conservatives fearful of a regulating government, the profit-motivated medical industry, and Republicans afraid of "the spread of socialism." Let private companies pick and choose what services individual patients get and the free market, this group says, will take care of the ethics.

For the bioethicist charged with finding an egalitarian way to deliver services, neither code works. The first discludes non-believers or other believers. The second favors the wealthy or entitled. Neither answers the over-all cost question.

Saying that neither of these dominant theories works is not popular nor easy. And this is root of the crisis in bioethics; not a loss of philosophy as Cook contends, but a profession trying to save itself from the criticisms it sustains when wading into a contested arena.

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