For nearly 30 years, Gregory E. Pence's name has appeared in the by-lines of headlining newspaper articles in bioethics. Pence, one of America's pioneering bioethicists, has never been afraid to go his own way or stir up a little controversy. Brave New Bioethics gathers 35 of his most influential and groundbreaking op-ed pieces and essays into one broad-ranging volume on issues such as cloning, AIDS, dignified death, and test-tube babies. These distinctive, lively commentaries have graced the pages of such publications as The Wall Street Journal, Newsweek, The New York Times, The Los Angeles Times, and The Philadelphia Inquirer.
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About the Author
Gregory E. Pence is a medical ethicist with twenty years of experience reviewing significant cases in bioethics, and is professor in the School of Medicine and the Department of Philosophy at the University of Alabama-Birmingham. He is the author of Who's Afraid of Human Cloning? (1998) and Designer Food (2001).
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Brave New Bioethics
By GREGORY E. PENCE
ROWMAN & LITTLEFIELD PUBLISHERS, INC.Copyright © 2002 Rowman & Littlefield Publishers, Inc.
All right reserved.
Chapter OneMedical Ethics Is Whatever You Say It Is
In what seems like yesterday but was actually a quarter century ago, I stood in the office of the dean of medicine in the huge medical complex that exists in Birmingham, Alabama. I had just been told that I would henceforth have a job on both sides of the campus, a regular one in the Philosophy Department and a special one in the School of Medicine, teaching 165 students a required course in medical ethics once a year.
I was happy not because I had entered an exciting new area of interdisciplinary study but because I had any job at all connected to philosophy. During the previous year, I had come very close to having an alternate career in real estate in New York City.
After getting my Ph.D. in 1974 working under Raziel Abelson and Peter Singer (who visited for a year at NYU), I tried in vain for two years to secure a tenure-track job. Failing to do so, I had quit philosophy. (Looking back at statistics in those years, I now realize that the market was flooded with new Ph.D.s.)
An unexpected opening brought me to Birmingham on January 1, 1976, when the Karen Quinlan case and trials were going on in New Jersey. The dean of medicine had studied philosophy as an undergraduate at Davidson College and, partly because of that and the Quinlan case, thought that medical students should think about such issues before they practiced. So he created a position, searched for an instructor, and ended up hiring me; the next fall I started to teach.
After he offered me the job, I accepted and then asked, "By the way, a lot of people disagree about medical ethics. What do you think it is?" He laughed and responded, "It doesn't matter what I think. From now on, it matters what you say. You're going to teach the course and write the books. Good luck!"
That was not the whole truth by any means, but when it came to teaching the course, it wasn't far off. There were no textbooks. My first year, I patched together readings from the Hastings Center Report, theology journals, Journal of American Medical Association, Time, and Philosophy and Public Affairs. Moreover, rather than embracing an exciting new area of interdisciplinary study, most medical students resented having to take another course (they didn't know when they had it good: since then, four additional courses have been piled on them: medical history, nutrition, neuroscience, and, soon, integrated problem solving).
During the early years, I longed for the safety of teaching traditional courses in philosophy-at least my courses in graduate school had some relation to that! I sometimes longed for my office on the green side of campus, far away from the hospitals where for several months I did daily rounds in oncology and other specialties. What was most uncomfortable was not having a definite role to play in making these rounds (for I was there strictly as an observer, not to advise about ethics; I have never been an ethics consultant in a hospital and, based on my experiences in hospitals, never want to be).
Until I taught in medical school and served on hospital committees, I had never realized the power a professor has in his mini-kingdom, his classroom, especially over the serfs who need a recommendation for medical or professional school. In a hospital or even a medical school, and especially in the early years, I often got the question, "What is a philosopher doing here?" I constantly felt I had to prove I belonged.
Over the years, I wrote a text (so I would have something to teach) and learned to like the constant challenges. Entirely unexpected issues kept arising, such as artificial hearts, AIDS, the Human Genome Project, and cloning. What I didn't like doing was trudging over to the medical library, or badgering physician friends, to try to quickly learn some new field.
I now think medical ethics is today's most exciting academic field. I was very lucky to enter on the ground floor and to help create a field that so well matched my interests and personality. (I am not constitutionally suited to spending decades writing on criteria of justified true belief or on proving to skeptics why I am not a brain in a vat.)
The growth in the number of courses in bioethics offered in North America has been explosive. (I purposefully use the wider term "bioethics" here rather than "medical ethics" to include issues such as genetically modified food and animal rights.) Each year, dozens of my medical and undergraduate students want to become bioethicists, and some have done so. Their interest is both satisfying and alarming-can the world accommodate so many bioethicists?
In September 2001, I attended the International Association of Bioethics meeting in London. What struck me was how bioethics has spread across the globe and is being taught in colleges in places such as Saudi Arabia and Liberia. The meetings also taught me that new issues arise when one takes an international perspective, such as the costs of AIDS drugs and the protection of human rights.
In 1976, the quintessential bioethical issue was death and dying. (There were also some red herrings: psychosurgery, genetic engineering, and behavior control.) What no one could have predicted were the cultural shocks from Louise Brown's in vitro fertilization and birth in 1978, from the failure of the Roe v. Wade ruling in 1973 to end the abortion debate, from the introduction of artificial hearts and xenografts (transplantable organs from other species), from the creation of hordes of homeless people due to deinstitutionalization in the I980s, from surrogate mothers, from the discovery of genes for clinical disease, from thirty years of failure to provide medical coverage for the uninsured, and from the underground prejudice against gays and lesbians that surfaced and, with AIDS, continues.
Extrapolating from the last quarter century, I know that the big issues of the next twenty-five years will be unpredictable. Past experience would dictate that the big issues will be justice in medical coverage, AIDS, genetic discrimination, and expansion of parental choice about traits of children through new techniques in assisted reproduction.
But if the history of bioethics shows anything, it is that the biggest issues ambush the field. As Larry Altman, the physician-reporter of the New York Times, said in a retrospective in July 2001 (twenty years after the first public report of AIDS), every physician thought in 1981 that all infectious agents had been discovered. Altman wrote that at the time no one in medicine seriously considered the hypothesis that an entirely new, lethal agent had emerged.
Just as new infectious agents will emerge in medicine, so will entirely unexpected ethical issues. It is the nature of the beast. If you like to be challenged by unexpected issues (and to have reporters besieging you to take a stand almost instantly), bioethics is for you. Of course, you can always play it safe and inveigh against each new change, citing the mantra of bioethicists, the slippery slope. You can imply that each new way of creating families endangers the traditional family. You can be cautious and side with the American Medical Association (AMA) on most moral issues, but who needs philosopher-ethicists for that?
It is more interesting to take some risks and to back changes you think are reasonable. In any case, and as I wrote in Re-Creating Medicine (2000), medicine needs both "inside" and "outside" bioethicists to understand its problems internally and to critique them externally.
Personally, I believe that philosophers who understand the facts about medicine and science will play an increasingly important role in public policy and in daily medical life because no one else seems both willing and able to do so. If I am correct, then just as philosophy spawned the separate, new field of psychology a century ago, so one day we may look back and say the same about bioethics.
Chapter TwoI Meet the AIDS Bigot
I have always felt like an impostor teaching medical ethics. Fifteen years ago, newly armed with a Ph.D. in philosophy from New York University, I never expected to be teaching medical ethics, much less in a medical school, much less about something like AIDS.
I didn't get the teaching job right away. The year 1974 was the peak of a bell curve for graduation of Ph.D.s in the humanities, and a vast oversupply resulted. After a few years, I grew frustrated, quit philosophy, decided to make big money, and sold real estate in New York City. There I encountered prejudice of all kinds. I made money, but to do so (I'm ashamed to say), I had to go along with the prejudice.
I later got a job teaching philosophy. I would like to say I gave up the big money of real estate because I hated the prejudice and loved philosophy, but this wouldn't be the truth. I couldn't accept failing to become what I had set out to be.
Although New York friends thought me crazy to leave, the job turned out to be better than they expected. During this time, Karen Quinlan's right-to-die case began, and courses in ethics were developed in medical schools, such as the one I was hired to teach. So it is that twelve years later, early on a warm April morning, I am driving on a two-hour trip to another city to talk on medical ethics. My host is a civic club that meets at lunch on a weekday and that often has a visiting guest speaker.
I am to talk about ethical issues concerning AIDS. I am not about to do this because I am a do-gooder. A local program of the National Endowment for the Humanities chose some humanities professors to give talks to nonacademic audiences, and this is mine. The idea is to bring the humanities to people, although sometimes this backfires. I have given this talk a half-dozen times before, and I guess I will give it a dozen times more, although I tire of discussing AIDS. As I crisscross airports and interstates with my carousel of slides (the security blanket of my medical colleagues), note cards, and evaluation forms, I think of myself as a mixture of peripatetic philosopher, sophist (I get paid), and dog and pony show.
When I arrive, I see about fifty middle-aged white men and ten women, dumped in small groups to gossip, a scattering of blacks among them. The young club president helps me set up the slide projector, then everyone has roast beef, potatoes, rolls, apple pie, and coffee.
Before my talk, we pray and pledge allegiance to the flag. New members are inducted, and a club officer explains the club is about friendship and civic duty. Most members seem to work in insurance, local banks, hospital administration, and the law. The president introduces a visiting female assistant district attorney. The city sees itself as progressive.
I feel nervous about this talk, even though it is only twenty minutes long. My problem is that my talk on ethics cannot avoid drug abuse and homosexuality, and I know these are hazardous topics. I soft-pedal the idea that most Americans are prejudiced against homosexuals. I say that, much as with racism and sexism of earlier years, people are still openly unashamed about prejudice to gays. I continue by discussing problems about blood banks, testing, and prevention.
When my talk is over, a powerful-looking man makes some grunting noises as he rises. His face contorts as he begins to speak. "What angers me" he says, "is spending my tax money on cures to save these faggots and drug addicts. I hope they just go away and die."
My face flushes and I stammer. The large man before me is a mass of rage and hate. The black members of the dub look uncomfortable. I watch the big man speak as he continues to make even worse comments. It is impossible to stop him. I feel as if I'm paralyzed, watching a deadly force of nature erupt before me. I shuffle at the podium, feeling strangely surprised, angry, and incompetent. With the name of a well-known medical school behind me, I had expected the usual deferential audience, and here I am being attacked by a bigot. As he rants, several men snicker. I cannot tell whether they snicker with him or at the predicament of someone like me confronted with someone like him.
I debate a finesse, but finally say, "Your comments show the prejudice I am talking about." Unbowed, he instantly replies, "I'm not prejudiced. I just hate queers"
At this there are still snickers, but fewer. His comments are vile. This is an awkward scene. The arrogant, ugly face of prejudice has suddenly appeared; the audience's progressive view of their dub and city has been challenged.
I keep on talking, mentioning that perhaps some people in this audience have gay children. ("Not true," the bigot mutters.) I say that past patients with cholera, syphilis, and plague were victims of similar prejudice. My statement falls on deaf ears. At this point, the younger members of the club rescue me, and for ten minutes I answer their (enlightened) questions. Afterward, a dozen members congratulate me and (in low voices) disparage the bigot. What they most want to tell me is, "Not everyone here feels that way"
Later, and like a lot of people in similar situations, I ask myself whether I could have answered the bigot better. It takes a long time to get home, so I have time to think. Should I have bothered with him at all? Was anything accomplished? It certainly made me feel bad. Certainly most speakers would have passed over the whole thing, pretending it didn't happen, just like when people say "nigger" I imagined myself with Richard Burton's voice and Dick Cavett's wit, refuting him while everyone laughs. It's a nice fantasy.
This confrontation could have happened in any similar club in the United States. Does it do any good to confront these things? Some medical ethicists are so moralistic about their opinions that they are counterproductive. It's certainly safer to play ostrich. I have colleagues who claim that confrontations like mine are never worth it, that they just polarize situations, that real bigots won't change, that on some level I did it to feel superior. Maybe.
Today, whites say that only a small minority of whites supported segregation and that most hated it. Yes, but how many confronted the bigots in our midst then? In New York or Chicago? In real estate, physicians' dining rooms, or civic dubs? I know I wasn't any big hero then.
My students sometimes say they wish they had lived twenty years ago and could have fought segregation because it was an evil without ambiguity and that the fight "merely" required courage. They seem to think there are no similar issues today. I'm not selling real estate anymore, so I'm ignorant about remaining prejudice in that area. But in medicine, AIDS has made one issue clear-cut.
Excerpted from Brave New Bioethics by GREGORY E. PENCE Copyright © 2002 by Rowman & Littlefield Publishers, Inc.. Excerpted by permission.
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Table of Contents
|Events in a Bioethicist's Life|
|1||Medical Ethics Is Whatever You Say It Is||1|
|2||I Meet the AIDS Bigot||6|
|3||Do We Really Value Human Life?||10|
|4||Exercise Is Dangerous to Your Health||13|
|On Bioethics and Bioethicists|
|5||Bioethicists and the Media: Finicky Lovers||17|
|7||Bush's Bioethics Council: Dead on Arrival?||28|
|8||On Reading Shakespeare to Get into Medical School||31|
|9||Happy Twentieth Birthday, Louise Brown||35|
|10||The McCaughey Septuplets: God's Will or Human Choice?||39|
|11||Our New Idol, Life||44|
|12||Twinning Embryos Isn't Cloning||49|
|13||Cloning Michael J. Fox's Embryos||53|
|14||A Sheep Is Cloned, Tah Dah!||57|
|15||Ban Sexual Reproduction!||61|
|16||Please Don't Criminalize Human Cloning||64|
|17||Why Science Fiction Distorts Views of Cloning||70|
|If Parents Expect Bad Things from Cloning, Should We Ban It?||77|
|Death and Dying|
|19||Do Not Go Slowly into That Dark Night: Mercy Killing in Holland||87|
|20||Even with a Living Will, It's Tough to Die Well in America||94|
|21||In Case of Terminal Illness, Call Your Lawyer, Not Your Physician||100|
|Money, Ethics, and Medicine|
|22||Everyone Creates Soaring Medical Costs||104|
|23||How to Say "No More" to Patients||108|
|24||What the Clinton Medical Plan Should Have Emphasized||111|
|Ethics and AIDS|
|25||Should Doctors Treat People with AIDS?||116|
|26||How Politicization of Facts about AIDS Helped Kill People with AIDS||121|
|27||Don't Fear the Human Genome Project||135|
|28||Children's Dissent to Research: A Minor Matter?||141|
|29||Organ Donation Can Kill You||146|
|30||Big Brother Is Watching: The Ethics of Cybermedicine||149|
|Development of New Drugs|
|31||How to Get AIDS Drugs for Africans||153|
|32||Indigenous Peoples Deserve Profits from Drugs from Their Lands||156|
|Food and Ethics|
|33||Norman Borlaug: He Fed a Billion People but You Don't Know His Name||159|
|34||Hating Biotechnology: A Tree with Deep Philosophical Roots||163|
|About the Author||177|
What People are Saying About This
Gregory Pence's lively and very readable essays are sure to provoke discussion and debate. From cloning and genetics to living wills and the value we place on human life, Pence never flinches from raising the tough issues, and letting his readers know what he thinks.
Greg Pence has done a masterful job of taking very complex bioethical issues and making them comprehensible to the average thoughtful person. His arguments are crystal clear, and he's not afraid to take on sacred cows. This will be a very valuable collection for the non-specialist who wants to understand the perplexing problems of modern bioethics.
Combining clarity and remarkable thoughtfulness, Greg Pence has written a timely and accessible guide to some of the most vexing problems in bioethics.
Armed with an admirably clear style, a sharp eye for what's important, low tolerance for hype, demagoguery, or sloppiness with the facts, Pence provokes the reader to think clearly about the major bioethical issues of our time. Along the way, he reveals a refreshingly self-critical attitude, illustrating time and again that, in bioethics, experience is a hard teacher. He gives the test first and the lesson later. Experience has also made Pence a good teacher. He benefits us all by giving us genuinely worthwhile things to think about.