Bioethics Discussion Blog: December 2005





Saturday, December 31, 2005

Do You Really Want the Longevity of Methuselah and Beyond?

Let's continue to contemplate longevity and immortality. Longevity is hallmarked by the 969 years of life of the biblical character Methuselah (Book of Genesis 5:27: And all the days of Methuselah were nine hundred sixty and nine years: and he died.) Methuselah was said to have died in the year of the Great Flood.

Know'st Thou What Gray Methuselah
by Konstantin Nikolaevich Batiushkov (1787-1855)

Know'st thou what gray Methuselah
Pronounced when parting with this life?
Man's born a slave,
He dies a slave,
And death will never tell him why
He walked this lovely vale of tears,
Suffered, wept, endured, and disappeared.

And on a more cheerful note:


- Unknown Author

Methuselah ate what he found on his plate,
And never as people do now;
Did he note the account of the calorie count.
He ate it because it was chow.
He wasn't disturbed as at dinner he sat,
Devouring a stew or a pie
To think it was lacking in granular fat,
Or a couple of vitamins shy;
He cheerfully chewed every species of food,
Unmindful of troubles or fears
Lest his health might be hurt
By some fancy dessert,
And he lived over nine hundred years.

More on longevity including some interesting speculation on biblical longevity from Wikipedia


Our current knowledge on cellular lifespan hypothesizes that the natural limit on modern human longevity is well below 150 years. Guinness Records for the oldest living person have long remained within the range from age 112 to the all-time record of 122 years held by Jeanne Calment, but the process of sorting genuine supercentenarians from longevity myths is hampered by the often questionable birth certification records from the late 19th century. Guinness Record statistics are soon likely to reveal the approximate true longest natural human lifespan yet achieved in modern times.

Today some maintain that the unusually high longevity of Biblical patriarchs is the result of an error in translation: lunar cycles were mistaken for the solar ones, and the actual ages are 12.37 times less. This gives 78 years for Methuselah, which is still an impressive number, bearing in mind the life expectancy of Biblical times. Methuselah's fathering of Lamech would correspondingly have occurred at solar age 15 (187÷12.37). (This theory however, seems doubtful to others since patriarchs such as Mahalalel (Book of Genesis 5:15) and Enoch (Book of Genesis 5:21) were said to have become fathers after 65 "years." If the lunar cycle theory were accepted this would translate to an age of about 5 years and 2 months. Creationists have proposed a number of ideas for the dramatic decrease in lifespans following the flood of Noah's time. One was that conditions before the flood caused much less ultraviolet light from the sun to impact the earth, and that this allowed for longer life spans. The latest proposal is that it is due to the genetic bottleneck that would have been caused by the flood, causing loss of longevity genes.

What would we worry about if we all had the potential to live nine hundred years or forever. I guess it would be not to get killed in an accident, a homicide, a war or a natural disaster (a flood as perhaps Methuselah?). Would we worry that we might get bored with life?: “Not new. Already seen this, done this.” Is this, the longevity of Methuselah or beyond,that which people alive in this world of ours really want? ..Maurice.

Wednesday, December 28, 2005

Immorality,Immortality: Just One Letter Apart or Something More?

There is much discussion in society and ethical circles today about the morality of cloning and the issues of the destruction of embryos. This discourse is about the morality of procedures at the beginning of life and how a personhood begins. After this beginning, the term immortality is often used as recognition of a person’s accomplishments beyond death. This immortality is usually ascribed to artists, writers, poets and others whose acts in life are preserved through future generations. Woody Allen allegedly said "I don't want to achieve immortality through my work, I want to achieve it through not dying." The other use of the term immortality is that of living forever. Therefore what should also be discussed in society is about the morality of the goal of attempting to live or maintaining life perhaps forever. What is the morality of attempting immortality? This consideration becomes pertinent if one considers that the current studies on the genetic factors that cause everyone to die could eventually lead to developing genetic changes so that everyone could live and live and live. Is it ethically wrong to want or make it possible to live forever? Moral considerations might include who or which groups of people would be given the chance to live forever or would this be available to all persons? Where would the increasing numbers of people live and what resources would be available to all so that their lives would be worth living? There could be more questions. And what do the answers say to the question could immortality be immoral? ..Maurice.

Tuesday, December 27, 2005

Unprofessional Physicians Grow from Unprofessional Medical Students

Students are accepted into medical school, taught and then sent out. But do we really know what happens to each student years later? Not really. Unless a study is done which has statistical power, we can’t really be sure the followup will provide us with any help in establishing cause and effect relationships needed for improving the medical education system. With numbers of physicians being subjected to disciplinary action by state medical boards for unprofessional behavior, it is important to look for relationships of medical student misbehavior to later problems that could give early warning and hopefully lead to corrective measures.

Such a statistical study regarding the disciplinary action by medical boards and prior behavior in medical school was published in the December 22, 2005 issue of the New England Journal of Medicine by Maxine A. Papadakis, M.D.,et al. (p.2673). The following is an abstract of the article.

Evidence supporting professionalism as a critical measure of competence in medical
education is limited. In this case-control study, we investigated the association
of disciplinary action against practicing physicians with prior unprofessional behavior
in medical school. We also examined the specific types of behavior that are
most predictive of disciplinary action against practicing physicians with unprofessional
behavior in medical school.


The study included 235 graduates of three medical schools who were disciplined by
one of 40 state medical boards between 1990 and 2003 (case physicians). The 469
control physicians were matched with the case physicians according to medical
school and graduation year. Predictor variables from medical school included the
presence or absence of narratives describing unprofessional behavior, grades, standardized-
test scores, and demographic characteristics. Narratives were assigned an
overall rating for unprofessional behavior. Those that met the threshold for unprofessional
behavior were further classified among eight types of behavior and assigned
a severity rating (moderate to severe).


Disciplinary action by a medical board was strongly associated with prior unprofessional
behavior in medical school (odds ratio, 3.0; 95 percent confidence interval,
1.9 to 4.8), for a population attributable risk of disciplinary action of 26 percent.
The types of unprofessional behavior most strongly linked with disciplinary action
were severe irresponsibility (odds ratio, 8.5; 95 percent confidence interval, 1.8 to
40.1) and severely diminished capacity for self-improvement (odds ratio, 3.1; 95 percent
confidence interval, 1.2 to 8.2). Disciplinary action by a medical board was also
associated with low scores on the Medical College Admission Test and poor grades
in the first two years of medical school (1 percent and 7 percent population attributable
risk, respectively), but the association with these variables was less strong
than that with unprofessional behavior.


In this case-control study, disciplinary action among practicing physicians by medical
boards was strongly associated with unprofessional behavior in medical school.
Students with the strongest association were those who were described as irresponsible
or as having diminished ability to improve their behavior. Professionalism should
have a central role in medical academics and throughout one’s medical career.


As medical school teachers and as supervisors in internships and residencies, we should not look casually at unprofessional behaviors in those we are supervising but based on studies such as this and hopefully others to come, consider the behaviors as warnings of future behavior and establish systems to act on them at the time. ..Maurice.

ADDENDUM 12-28-2005:
One of the excuses a medical school may give on being shy to remove an unprofessional student from the medical school is their concern about being sued by the student for their action. No one, not even a medical school enjoys a legal suit. However,with statistically significant studies like this one in the current NEJM, suits from students will be "no prob..llem". It is going to be the law suits from injured patients later on who, with this documentation in the literature, coming back to the medical schools with their suits that then will be a problem! ..Maurice.

Monday, December 26, 2005

More on Human Dignity (4)

Despite its varying history and application, concluding the working paper written by Adam Schulman, Ph.D. for the December 2005 meeting of the President’s Council on Bioethics, Schulman attempts to find a meaning or significance to the term human dignity and our need eventually to take a stand on its definition. . Again, I will include the disclaimer that the paper was prepared by staff solely to aid discussion and it does not represent the official views of the Council or of the United States Government. ..Maurice.

3. Dignity understood as humanity—an indispensable concept for bioethics?

Having disentangled some of the roots of the modern concept of human dignity, can we make a compelling case for the usefulness of this concept in present-day and future bioethics? Only a tentative answer to this question can be hazarded here.
There is a strong temptation to say no, for the following reason. The fundamental question we have alluded to several times in this paper—the question of the specific excellence or dignity of man—has proved sufficiently daunting that a long line of great modern thinkers, from Hobbes and Locke to the American founders, have found it prudent, for political purposes, to assert that all human beings have rights and freedoms that must be respected equally, without spelling out too clearly the ground of that assertion.18 And such deliberate reticence as to the foundation and content of human dignity has arguably served liberal democracy well, fostering tolerance, freedom, equality, and peace. In the particular context of medical ethics, it must be acknowledged that for a long time the liberal principle of “respect for persons”—including the rights of voluntary, informed consent and confidentiality, as well as protection from discrimination and abuse—has proved serviceable in resolving many (though by no means all) ethical problems.

But in this extraordinary and unprecedented era of biotechnological progress, whose fruits we have scarcely begun to harvest, the campaign to conquer nature has at long last begun to turn inward toward human nature itself. In the coming decades we will increasingly acquire the power to isolate and modify the biological determinants of human attributes that hitherto have been all but immune to manipulation. For example, we are learning to control the development of human embryos in vitro, and this may one day make possible the cloning of human beings, the creation of animal-human chimeras, and the gestation of human fetuses in animal or artificial wombs. We are assembling a growing arsenal of psychoactive drugs that modulate not only behavior but also attention, memory, cognition, emotion, mood, personality, and other aspects of our inner life. We are acquiring the ability to screen out unwanted gene combinations in preimplantation embryos and may in future be capable of direct germline genetic modification. We may one day be able to modify the human genome so as to increase resistance to diseases, optimize height and weight, augment muscle strength, extend the lifespan, sharpen the senses, boost intelligence, adjust personality, and who knows what else. Some of these changes may amount to unobjectionable enhancements to our imperfect nature; but surely not all forms of biomedical engineering are equally benign and acceptable.

Our ever-increasing facility at tinkering with human nature itself poses an acute challenge to any easygoing agnosticism on the question of the ground and content of human dignity. As we become more and more adept at modifying human nature at will, it may well prove impossible to avoid a direct confrontation with the question posed by the Psalmist, “What is man that thou art mindful of him?” That is, among all the features of human nature susceptible to biotechnological enhancement, modification, or elimination, which ones are so essential to our humanity that they are rightly considered inviolable? For example, if gestation of fetuses in artificial wombs should become feasible, would it not be a severe distortion of our humanity and an affront to our dignity to develop assembly lines for the mass production of cloned human beings without mothers or fathers? Would it not be degrading to our humanity and an affront to human dignity to produce animal-human chimeras with some human features and some features of lower animals? Would it not be a corruption of our humanity and an affront to human dignity to modify the brain so as to make a person incapable of love, or of sympathy, or of curiosity, or even of selfishness?19

In short, the march of scientific progress that now promises to give us manipulative power over human nature itself—a coercive power mostly exercised, as C. S. Lewis presciently noted, by some men over other men, and especially by one generation over future generations20 —will eventually compel us to take a stand on the meaning of human dignity, understood as our essential and inviolable humanity. If the necessity of taking that stand is today not yet widely appreciated, there will come a time when it surely will be. With luck, it will not be too late.

[References for this section of the Working Paper:

18. Hobbes, however, was somewhat less reserved than the others: in chapter 13 of Leviathan (1651) he indicates that our equal rights are derived ultimately from our roughly equal ability to kill one another. Note that, for Hobbes, dignity is not intrinsic to human beings but is merely “the public worth of a man, which is the value set on him by the Commonwealth.” (Leviathan, ch 10).

19. In the novel White Noise (1985) by Don DeLillo, a drug is invented whose specific effect on the human brain is apparently to suppress the fear of death. Would it be compatible with human dignity for all of us to start taking such a drug?
20. C. S. Lewis, The Abolition of Man (Oxford: Oxford University Press, 1943), chapter 3: “From this point of view, what we call Man’s power over Nature turns out to be a power exercised by some men over other men with Nature as its instrument…. There neither is nor can be any simple increase of power on Man’s side. Each new power won by man is a power over man as well. Each advance leaves him weaker as well as stronger. In every victory, besides being the general who triumphs, he is also the prisoner who follows the triumphal car.”]

Friday, December 23, 2005

More on Human Dignity (3)

So now.. what is the history of the definition and concept of human dignity and its application over the ages? As you will see, it is an ambiguous concept as I suggested in the last post but it is frequently used in discussions of morality. For a good historical review, I would now like to return to the working paper written by Adam Schulman, Ph.D. for the December 2005 meeting of the President’s Council on Bioethics. Again, I should include the disclaimer that the paper was prepared by staff solely to aid discussion and it does not represent the official views of the Council or of the United States Government. If you have the time, read about the history of human dignity as presented below. It has given me insight about the concept. ..Maurice.

2. The tangled sources of human dignity

If human dignity seems a malleable concept of uncertain application in bioethics, that is partly because the idea of human dignity comes to bioethics from several disparate sources. Each of these sources contributes something of value for bioethics; yet each source also brings its own peculiar difficulties to the application of the concept of human dignity to bioethical controversies. At least four such sources of human dignity seem worth mentioning:

a. Classical antiquity: The word “dignity” comes to us, via the Latin dignus and dignitas, from Greek and Roman antiquity, in whose literature it means something like “worthiness for honor and esteem”. This classical notion of dignity as something rare and exceptional retains some of its power even in our egalitarian age: witness the admiration we bestow on outstanding athletic and musical performance, on heroism in war, on courageous statesmanship, or on the selflessness of those who make sacrifices or undergo hardships for the sake of their young children, or their aging parents, or their neighbors stricken by misfortune or tragedy. But if dignity implies excellence and distinction, then to speak of “human dignity” raises the question, what is it about human beings as such that we find distinctive and admirable, that raises them in our estimation above other animals? Is there some one attribute or capacity that makes man worthy of respect, such as reason, or conscience, or freedom? Or is it a complex of traits, no one of which is sufficient to earn our esteem? These are not easy questions to answer; yet most would acknowledge that there must be something about humankind that entitles us to the special regard implicit in this sense of human dignity.4

One problem with the classical notion of dignity that has only grown more acute in our age of rapid biomedical progress is the complicated relationship between technology and human dignity (understood as grounded in excellence). Is the dignity of the soldier enhanced by the invention of modern weapons? Is the dignity of the athlete enhanced by drugs that improve his performance, or even by his reliance on trainers, nutritionists, and other experts? Some might argue that new technologies (“bio” and otherwise) serve human dignity by augmenting those traits that make human beings worthy of esteem; yet others might view such inventions as undermining human dignity, by making our excellence depend too much on the artifice of others.

A second problem with dignity in its classical sense is that it lends itself to invidious distinctions between one human being and another; it is not fully at home in democratic times, where it keeps uneasy company with the more characteristic democratic ideals of equality, freedom, easygoingness, and tolerance.5 Now for that very reason one might argue that human dignity is especially vulnerable and worth defending in democratic times. But to make the case for human dignity as a robust bioethical concept for our age, one would have to show that dignity can be something universal and accessible to all human beings as such.

There was in fact a school of philosophy in ancient Greece and Rome, the Stoics, who believed in dignity as a genuine possibility for all human beings, regardless of their circumstances, social standing, or accomplishments. For the Stoics, human beings have dignity because they possess reason, and the best life, the life according to nature, is available to anyone who chooses to live in a thoughtful or reflective way. And what our reason dictates, above all, is that everything necessary for our happiness and peace of mind is within our control; despite poverty, illness, or oppression it is always possible to live in a dignified way. Nothing that anyone can say or do to you can rob you of your dignity and integrity. For the Stoics, dignity is a profoundly democratic idea, in that it is just as likely to be found among the wretched as among the lofty: as possible for the slave Epictetus as for the emperor Marcus Aurelius.6

Yet while dignity as the Stoics conceived it is a universal possibility for all human beings everywhere, it nonetheless sets a rigorous and exacting standard that few of us, in practice, manage to attain. And while the Stoic teaching of indifference to bodily suffering might well prove to be a valuable discipline for those who have to live with pain, illness, or infirmity, the Stoic attitude of detachment from the things of this world—embodied in the principle that “nothing that can be taken from you is good”—means that particular bioethical questions are ultimately of little significance from the Stoic point of view.

b. Biblical religion: Another powerful source of a broader, shared notion of human dignity is the Biblical account of man as “made in the image of God.” This teaching, together with its further elaborations in Jewish and Christian scripture, has been interpreted in many different ways, but the central implication seems to be that human beings, because they are in some respects godlike, possess an inherent and inalienable dignity. One part of that dignity, suggested by the Book of Genesis, has to do with the special position of man in the natural world: within that realm man is like God in having stewardship or dominion over all things, because he alone can comprehend the whole and he alone concerns himself with the good of the whole.7 In this sense, “being made in God’s image” could even be taken to imply a special responsibility on our part to perfect nature in order to finish God’s creation. Interpreted in this way, the idea of human dignity could lend support not only to the practice of healing and medicine in general, but also, some might argue, to a defense of such activities as in vitro fertilization or even cloning, here understood as fixing nature in a godlike way.

Yet if man’s mastery of nature has some sanction in the Biblical teaching on human dignity, that teaching also points in another, humbler direction: for although made in God’s image, we are not ourselves divine; we are creatures, not creators. In this sense, “made in God’s image” has the implication that all human beings, not only those healthy and upright but also those broken in body or soul, have a share in this God-given dignity. Dignity in this sense would give ethical guidance to us in answering the question of what we owe to those at the very beginning of life, to those at the end, to those with severe disability or dementia, and even to tiny embryos. Seeing human beings as created in the image of God means, in some sense, valuing other human beings in the way a just or loving God would value them. It means seeing dignity where some might see only disability, and perhaps seeing human life where others might see only a clump of cells.

Yet because the Biblical account of human dignity points in different directions, its implications for bioethics are not always clear and unambiguous. In the controversy over stem cell research, for example, would the inherent dignity of man mean that human life at every stage is sacred, and that the destruction of human embryos is therefore forbidden? Or would it mean that healing and preserving human life is our preeminent duty, justifying all kinds of otherwise morally questionable research?
Some will argue that a concept of human dignity derived from the Bible (or other religious texts) is inherently unreliable, a mask for religious dogmas that have no legitimate place in secular bioethics. Thus Ruth Macklin, who advocates banishing the term “dignity” from medical ethics entirely, suspects that religious sources, especially Roman Catholic writings on human dignity, may explain why so many articles and reports appeal to human dignity “as if it means something over and above respect for persons or for their autonomy.”8 More recently, Dieter Birnbacher has suggested that the idea of human dignity, when invoked (as it has been in the cloning debate) to defend the natural order of human procreation against biotechnical manipulation, is nothing more than camouflage for a theological tradition that sees “the order of nature as divinely sanctioned.”9 Yet, while it might be problematic to rely on religious texts for authoritative guidance on bioethical questions, such texts may still be quite valuable in helping all of us—whether believers or not—to articulate and think through our deepest intuitions about human beings, their distinctive powers and activities, and the rights and responsibilities we believe them to possess. Furthermore, those who would dismiss all religious grounds for the belief in human dignity have the burden of showing, in purely secular terms, what it is about human beings that obliges us to treat them with respect. If not because they are “endowed by their Creator with certain unalienable rights,” then why are all men entitled to “life, liberty, and the pursuit of happiness”?10

c. Kantian moral philosophy: A daring attempt to set universal human dignity on a strictly rational foundation was made in the eighteenth century by the German philosopher Immanuel Kant. Kant’s primary purpose was to show how moral freedom and responsibility could still be possible in a world governed by the laws of mathematical physics. For Kant, in agreement with the Stoics, dignity is the intrinsic worth that belongs to all human beings and to no other beings in the natural world. All men possess dignity because of their rational autonomy, i.e., their capacity for free obedience to the moral law of which they themselves are the authors. Kant’s doctrine of human dignity demands equal respect for all persons and forbids the use of another person merely as a means to one’s own ends. Kant’s celebration of autonomy and his prohibition of the “instrumentalization” of human subjects have certainly had a lasting impact on modern ethical thought and on bioethics in particular (especially in the ethics of human experimentation and in the principle of voluntary, informed consent). And it cannot be denied that Kant’s account of what the moral law demands of us (his various formulations of “the categorical imperative”) has a certain austere majesty and logical economy that compel grudging respect if not wholehearted allegiance. Yet the application of Kant’s moral theory to bioethics remains problematic for a number of reasons.

First, Kant’s achievement in reconciling morality with mathematical physics was won at a great price: in locating human dignity entirely in rational autonomy, Kant was forced to deny any moral significance to other aspects of our humanity, including our family life, our loves, loyalties, and other emotions, as well as our way of coming into the world and all other merely biological facts about the human organism.11 His exclusive focus on rational autonomy leaves Kant with a rather narrow and constricted account of our moral life, one that has precious little to say about the moral significance of a whole range of biomedical interventions that currently arouse ethical controversy. If the rational will alone is the seat of human dignity, why should it matter if we are born of cloned embryos, or if we enhance our muscles and control our moods with drugs, or if we sell our organs on the open market?

Second, the doctrine of rational autonomy itself, clear and unambiguous though it may be in theory, can be difficult to apply in practice, especially in a biomedical context. Consider these examples: If dignity depends on the rational will, must we conclude that those human beings who do not yet have the powers of rational autonomy (infants), or who have lost them (those with dementia), or who never had them (those with congenital mental impairment) are beneath human dignity? How far can a person go in the use of mood- and mind-altering drugs before rational autonomy is compromised? Are choices made under the influence of such drugs less than free? On such basic questions in bioethics Kant’s account of human dignity does not offer clear moral guidance.

Third, Kant’s moral philosophy has bequeathed to later ethical thought a deplorable legacy in the form of the rigid distinction between deontology and consequentialism, i.e., between a morality (such as Kant’s) of absolute imperatives and one (such as utilitarianism) that considers the good and bad results of our actions. Nowadays, if human dignity is invoked in the discussion of some bioethical issue, the first question that is usually raised is whether the term is being used as a categorical moral principle (e.g., “human cloning is wrong in principle, because it violates some inalienable right of the child”) or as an argument based on consequences (e.g., “human cloning is wrong because of the degrading effects it is likely to have on the child, the family, and society at large”). Bioethics in practice requires a healthy measure of old-fashioned prudence and is not well served by a dogmatic adherence to the artificial division between an ethics of principles and an ethics of consequences.

d. 20th century constitutions and international declarations: Finally, another prominent yet problematic source for the introduction of “human dignity” into contemporary bioethical discussions is the frequent use of that phrase in national constitutions and international declarations ratified in the aftermath of the Second World War. By proclaiming a belief in “human dignity”, such documents would seem, at first blush, to point beyond the prosaic safeguarding of “rights” advocated in the American founding (“life, liberty, and the pursuit of happiness”) or in the writings of John Locke (“life, liberty, and property”) and other modern natural right theorists.

The preamble to the Charter of the United Nations (1945) begins:
We the people of the United Nations, determined to save succeeding generations from the scourge of war, which twice in our lifetime has brought untold sorrow to mankind, and to reaffirm faith in fundamental human rights, in the dignity and worth of the human person, in the rights of men and women and of nations large and small….

In the Universal Declaration of Human Rights (1948), recognition “of the inherent dignity and of the equal and inalienable rights of all members of the human family” is said to be “the foundation of freedom, justice, and peace in the world.” At least thirty-seven national constitutions ratified since 1945 refer explicitly to human dignity, including the Basic Law (Grundgesetz) of Germany (1949), which begins: “Human dignity is inviolable. To respect and protect it is the duty of all state authority.”12

As Doron Shultziner has emphasized,13 while human dignity in these documents plays the role of a supreme value on which all human rights and duties are said to depend, the meaning, content, and foundations of human dignity are never explicitly defined. Instead, the affirmation of human dignity in these documents reflects a political consensus among groups that may well have quite different beliefs about what human dignity means, where it comes from, and what it entails. In effect, “human dignity” serves here as a placeholder for “whatever it is about human beings that entitles them to basic human rights and freedoms.” This practice makes a good deal of sense. After all, what mattered most after 1945 was not reaching agreement as to the theoretical foundations of human dignity but ensuring, as a practical matter, that the worst atrocities inflicted on large populations during the war (i.e., concentration camps, mass murder, slave labor), would not be repeated. In short, “the inviolability of human dignity” was enshrined in at least some of these documents chiefly in order to prevent a second Holocaust.

Yet because of its formal and indeterminate character, the notion of human dignity espoused in these constitutions and international declarations does not offer clear and unambiguous guidance in bioethical controversies.14 Certainly the fact that human dignity is mentioned prominently in these documents is to be welcomed as an invitation to explore the question, “What is the ground of human dignity?” And the sensible idea of invoking universal human dignity in order to establish a baseline of inviolable rights—in effect, a floor of decency beneath which no treatment of human beings should ever sink—may well prove to be of some value in holding the line against the most egregious abuses of the new biotechnologies (e.g., the deliberate creation of animal-human chimeras). Yet if we are content to regard human dignity as nothing more than an unspecified “Factor X”15 in virtue of which we are obliged to treat all persons with respect, then some bioethicists have wondered why we should bother invoking it at all. Why not dispense with dignity and simply spell out precisely what “respect for persons” demands of us? Ruth Macklin adopts this viewpoint, arguing that respect for persons is a sufficient principle for bioethics, one that entails “the need to obtain voluntary, informed consent; the requirement to protect confidentiality; and the need to avoid discrimination and abusive practices.”16 Her approach may have the virtue of simplicity, but it does not explain why all persons are entitled to respect;17 and it is far from clear that all present and future controversies in bioethics can be resolved merely by providing informed consent, honoring confidentiality, avoiding discrimination, and refraining from abuse.

e. Summary: To recapitulate the findings of this section: Important notions of human dignity are to be found both in classical antiquity and in Biblical scripture, each with lasting influence on modern thought. Yet the classical conception of dignity (in the general sense of human worth, grounded in excellence) is of problematic relevance to present-day bioethics, in part because of its ambiguous relationship to technological progress and in part because of its aristocratic and inegalitarian tendencies; while the specifically Stoic notion of human dignity is of limited use in bioethics both because of the severe and exacting standard it sets and because of the basic Stoic attitude of indifference to the external world, including the suffering of the body. And although the Biblical teachings on human dignity are rich and evocative, they have ambiguous implications for bioethics, pointing both toward godlike mastery of nature and toward humble acknowledgment of the sanctity of human life in all its forms. Turning to the modern era, both the moral philosophy of Kant and various constitutions and international declarations of the twentieth century appear to provide support for a belief in the equal dignity of all human beings. Yet Kant’s idea of human dignity carries certain theoretical baggage that limits its utility for bioethics, while the recently ratified constitutions and declarations tend to invoke dignity without clearly specifying either its ground or its content, suggesting that the concept itself might well be superfluous. On the other hand, it is hard to see how ethical standards for the treatment of human beings can be maintained without relying on some conception of what human beings are and what they therefore deserve.

[References for this section of the Working Paper:

4. Of course there are some sophisticated thinkers who, in the name of animal rights, assail the very idea of a special status for man as an expression of naïvely anthropocentric “speciesism,” a word coined by analogy with racism and sexism. See Peter Singer, Animal Liberation, 2nd edition, New York: Avon, 1990; see also Bernard Williams, Ethics and the Limits of Philosophy, Cambridge: Harvard University Press, 1985.

5. That “dignity” retains an aura of Roman exclusivity even in modern times is suggested by a quotation attributed to humorist James Thurber: “Human Dignity has gleamed only now and then and here and there, in lonely splendor, throughout the ages, a hope of the better men, never an achievement of the majority.”

6. That the Stoic conception of human dignity might not be entirely incompatible with our lax American culture is suggested by the recent popular success of the Ridley Scott movie Gladiator (2000) and the Tom Wolfe novel A Man in Full (1998), both of which explore Stoic responses to misfortune. Consider also the example of Admiral James Stockdale, whose education in Stoic principles helped him survive with dignity through seven harrowing years as a prisoner of war in Vietnam.

7. See Leon Kass, The Beginning of Wisdom: Reading Genesis (New York: The Free Press, 2003), pp. 36 ff.

8. Ruth Macklin, “Dignity is a useless concept.”

9. Dieter Birnbacher, “Human cloning and human dignity.”
10. Whether the rights proclaimed in the Declaration of Independence rest ultimately on a religious or a secular foundation is, of course, a complex question that cannot be settled here.

11. One will not, for example, find much hint of human dignity in Kant’s definition of marriage as “the association of two persons of different sex for the lifelong reciprocal possession of their sexual faculties.” [quoted from Part I of the Metaphysics of Morals (1797).]

12. See Teresa Iglesias, “Bedrock Truths and the Dignity of the Individual,” Logos 4: 1, 114-134, 2001.

13. See Shultziner’s helpful review article, “Human dignity—functions and meanings,” Global Jurist Topics 3:3, 2003.

14. UNESCO’s recently adopted (though still provisional) Universal Declaration on Bioethics and Human Rights refers to “human dignity” or “the dignity of the human person” (in close conjunction with “human rights” and “fundamental freedoms”) eleven times but does not spell out what that dignity is or why human beings have it. Reflecting its status as a consensus statement among many nations, the draft suggests that “due regard” should be paid to “cultural diversity and pluralism,” but not so as to infringe upon or limit the scope of “human dignity, human rights and fundamental freedoms.” The text of the Declaration may be found online at

15. See Frank Fukuyama, Our Posthuman Future: Consequences of the Biotechnology Revolution (New York: Farrar, Straus and Giroux, 2002), chapter 9, “Human Dignity.”

16. Ruth Macklin, “Dignity is a useless concept.”

17. One recognizes, in the various principles of autonomy or “respect for persons” that populate contemporary bioethics, the remote and enfeebled descendants of Kant’s categorical moral imperative; yet the devotees of autonomy today are seldom willing to embrace anything like the metaphysical system Kant felt obliged to supply as the ground for his moral principles.]


More on Human Dignity (2)

Another poem by another poet about dignity before and after death. This poem, for me, emphasizes the ambiguity of who deserves human dignity and should it be qualitatively more in one human being than another? ..Maurice.

One Dignity Delays for All
by Emily Dickinson

One dignity delays for all --
One mitred Afternoon --
None can avoid this purple --
None evade this Crown!

Coach, it insures, and footmen --
Chamber, and state, and throng --
Bells, also, in the village
As we ride grand along!

What dignified Attendants!
What service when we pause!
How loyally at parting
Their hundred hats they raise!

Her pomp surpassing ermine
When simple You, and I,
Present our meek escutheon
And claim the rank to die!

Thursday, December 22, 2005

More On Human Dignity (1)

I have discussed something about human dignity and “death with dignity” in October 2005 postings. A Working Paperwas written by Adam Schulman, Ph.D. for the December 2005 meeting of the President’s Council on Bioethics. While it was prepared by staff solely to aid discussion and does not represent the official views of the Council or of the United States Government,nevertheless, the portion I have reproduced here helps to point to the conflicts people have in explaining what behaviors or acts support or deface human dignity. This can be the start of further discussion.


“Human dignity”: is it a useful concept in bioethics, one that sheds important light on the whole range of bioethical issues, from embryo research and assisted reproduction, to biomedical enhancement, to care of the disabled and the dying? Or is it, on the contrary, a useless concept—at best a vague substitute for other, more precise notions, at worst a mere slogan that camouflages unconvincing arguments and unarticulated biases?
Although the Council has itself made frequent use of this notion in its writings, it has not undertaken a thematic exploration of human dignity, its meanings, its foundations, and its relevance for bioethics. In the meantime, at least one critic, noting that “appeals to human dignity populate the landscape of medical ethics,” has recently called into question whether human dignity has any place in bioethical discourse at all.1 It would seem timely, then, for the Council to take up the question of human dignity squarely, with the aim of clarifying whether and how it might be a useful concept in bioethics.
The purpose of this working paper is to help the Council focus its discussion of human dignity and its proper place in bioethics. To that end, it will first give some examples of how human dignity can be a difficult concept to apply in bioethical controversies. It will then explore some of the complex roots of the modern notion of human dignity, in order to shed light on why its application to bioethics is so problematic. Finally, it will suggest, tentatively, that a certain conception of human dignity—dignity understood as humanity—has an important role to play in bioethics, both now and especially in the future.

1. The problem of human dignity in bioethics: some examples

That human dignity might be at least problematic as a bioethical concept is suggested by the many ways it gets invoked in bioethical debates, often on different sides of the same issue. Consider, for example, a question raised in the Council’s recent exploration of ethical caregiving at the end of life:2 Is it morally acceptable for an elderly patient, diagnosed with early Alzheimer’s disease and facing an inexorable decline into dementia and dependency, to stop taking his heart medicine, in the hope of a quicker exit, one less distressing to himself and his family? One possible answer discussed in our report is that it is morally permissible (and perhaps even admirable) for such a patient, who finds the prospect of years of dementia humiliating or repellent and who is reluctant to become a burden to his family, to forgo medication and allow heart disease to carry him off in a more dignified and humane way. Another possible answer is that it is morally impermissible, because deliberately hastening the end of one’s life, even by an act of omission, is incompatible with the equal dignity and respect owed to all human life. A third answer is that respect for the dignity and autonomy of all persons requires us to defer to the personal choice of a competent individual in such intimate matters, regardless of how he or she might decide. Note that all three answers (and perhaps others that could be given) are grounded in part in some appeal to human dignity, though they reach quite different conclusions.

Or, to take an example from the beginning of human life, consider a question that might arise in a neonatal intensive care unit: What medical interventions are appropriate to save the life of a critically ill premature infant who is likely to survive, if at all, only with severe mental defects? One possible answer is that, because human dignity rests on our higher mental capacities, it is wrong to bring a person into the world burdened with a devastating lifelong mental incapacity. Another answer might be that every reasonable measure should be taken, because the equal dignity of all human life forbids us to declare some lives “not worth living.” Yet a third answer might be that, out of respect for their dignity and autonomy, the parents must be left free to resolve this moral dilemma for themselves.

Or, again, consider an example of biomedical “enhancement” examined in the fifth chapter of Beyond Therapy:3 If science were to develop memory-blunting drugs that could free us from the emotional burdens of intrusive and painful memories, would it be ethically permissible to give such drugs freely to people who have suffered grievous disappointments or witnessed horrifying events? One answer might be that such an invention, with its promise of liberating miserable people from the emotional tyranny of past misfortunes, ought to be embraced as an unqualified enhancement to human freedom, autonomy, and dignity. But another answer might be that human integrity and dignity require of us that we confront our painful memories and learn to deal with them (if possible) and not just “flush” them away by taking a pill. A third answer would be that this decision is properly left to the individual, whose dignity and autonomy entail the right of voluntary, informed consent.

In each of these examples, a variety of strong convictions can be derived from powerful but conflicting intuitions about what human dignity demands of us. Little wonder, then, that some bioethicists are inclined to wash their hands of “dignity” entirely, in favor of clearer and less ambiguous ethical concepts.

[References for this section of the Working Paper:

1. Ruth Macklin, “Dignity is a useless concept,” BMJ 327: 1419-1420, 2003. Dieter Birnbacher, another skeptic on the usefulness of human dignity as a bioethical concept, observes that there is a “nearly worldwide consensus that reproductive cloning is incompatible with human dignity and should be prohibited by law.” See his “Human cloning and human dignity,” Reproductive BioMedicine Online 10(Suppl. 1): 50-55, 2005.

2. The President’s Council on Bioethics, Taking Care: Ethical Caregiving in Our Aging Society, Washington, D.C.: Government Printing Office, 2005, chapter 4, pp. 154 ff.

3. The President’s Council on Bioethics, Beyond Therapy: Biotechnology and the Pursuit of Happiness, Washington, D.C.: Government Printing Office, 2003, chapter 5, pp. 214 ff.]


I plan to present this paper in piecemeal segments so that we can cone down on the information presented to us. Looking at the conflicting examples suggested in the paper, I wonder how my visitors might accept one view but reject the other. Would anyone want to comment on which view of the examples given above the visitor accepts and why? ..Maurice.

Wednesday, December 21, 2005

The Morality of America Through the Eyes of Harold Pinter

On Dec 7 2005, the British playwright,screen writer and director was presented the Nobel Prize in literature. He is also known as a longtime political activist with some very strong views. Though not everybody might agree with the ferocity of his expressions and some might want to challenge some facts, I thought it would, nevertheless, be proper to document his thoughts and speech here on this ethics blog for further discussion. As noted on a previous posting, there is concern that philosophers and ethicists are not speaking out on social issues forcefully enough. Should they follow the lead of Pinter? ..Maurice.

© THE NOBEL FOUNDATION 2005General permission is granted for the publication in newspapers in any language after December 7, 2005, 5:30 p.m. (Swedish time). Publication in periodicals or books otherwise than in summary requires the consent of the Foundation. On all publications in full or in major parts the above underlined copyright notice must be applied.

Harold Pinter – Nobel Lecture
Art, Truth & Politics

In 1958 I wrote the following:
'There are no hard distinctions between what is real and what is unreal, nor between what is true and what is false. A thing is not necessarily either true or false; it can be both true and false.'
I believe that these assertions still make sense and do still apply to the exploration of reality through art. So as a writer I stand by them but as a citizen I cannot. As a citizen I must ask: What is true? What is false?
Truth in drama is forever elusive. You never quite find it but the search for it is compulsive. The search is clearly what drives the endeavour. The search is your task. More often than not you stumble upon the truth in the dark, colliding with it or just glimpsing an image or a shape which seems to correspond to the truth, often without realising that you have done so. But the real truth is that there never is any such thing as one truth to be found in dramatic art. There are many. These truths challenge each other, recoil from each other, reflect each other, ignore each other, tease each other, are blind to each other. Sometimes you feel you have the truth of a moment in your hand, then it slips through your fingers and is lost.
I have often been asked how my plays come about. I cannot say. Nor can I ever sum up my plays, except to say that this is what happened. That is what they said. That is what they did.
Most of the plays are engendered by a line, a word or an image. The given word is often shortly followed by the image. I shall give two examples of two lines which came right out of the blue into my head, followed by an image, followed by me.
The plays are The Homecoming and Old Times. The first line of The Homecoming is 'What have you done with the scissors?' The first line of Old Times is 'Dark.'
In each case I had no further information.
In the first case someone was obviously looking for a pair of scissors and was demanding their whereabouts of someone else he suspected had probably stolen them. But I somehow knew that the person addressed didn't give a damn about the scissors or about the questioner either, for that matter.
'Dark' I took to be a description of someone's hair, the hair of a woman, and was the answer to a question. In each case I found myself compelled to pursue the matter. This happened visually, a very slow fade, through shadow into light.
I always start a play by calling the characters A, B and C.
In the play that became The Homecoming I saw a man enter a stark room and ask his question of a younger man sitting on an ugly sofa reading a racing paper. I somehow suspected that A was a father and that B was his son, but I had no proof. This was however confirmed a short time later when B (later to become Lenny) says to A (later to become Max), 'Dad, do you mind if I change the subject? I want to ask you something. The dinner we had before, what was the name of it? What do you call it? Why don't you buy a dog? You're a dog cook. Honest. You think you're cooking for a lot of dogs.' So since B calls A 'Dad' it seemed to me reasonable to assume that they were father and son. A was also clearly the cook and his cooking did not seem to be held in high regard. Did this mean that there was no mother? I didn't know. But, as I told myself at the time, our beginnings never know our ends.
'Dark.' A large window. Evening sky. A man, A (later to become Deeley), and a woman, B (later to become Kate), sitting with drinks. 'Fat or thin?' the man asks. Who are they talking about? But I then see, standing at the window, a woman, C (later to become Anna), in another condition of light, her back to them, her hair dark.
It's a strange moment, the moment of creating characters who up to that moment have had no existence. What follows is fitful, uncertain, even hallucinatory, although sometimes it can be an unstoppable avalanche. The author's position is an odd one. In a sense he is not welcomed by the characters. The characters resist him, they are not easy to live with, they are impossible to define. You certainly can't dictate to them. To a certain extent you play a never-ending game with them, cat and mouse, blind man's buff, hide and seek. But finally you find that you have people of flesh and blood on your hands, people with will and an individual sensibility of their own, made out of component parts you are unable to change, manipulate or distort.
So language in art remains a highly ambiguous transaction, a quicksand, a trampoline, a frozen pool which might give way under you, the author, at any time.
But as I have said, the search for the truth can never stop. It cannot be adjourned, it cannot be postponed. It has to be faced, right there, on the spot.
Political theatre presents an entirely different set of problems. Sermonising has to be avoided at all cost. Objectivity is essential. The characters must be allowed to breathe their own air. The author cannot confine and constrict them to satisfy his own taste or disposition or prejudice. He must be prepared to approach them from a variety of angles, from a full and uninhibited range of perspectives, take them by surprise, perhaps, occasionally, but nevertheless give them the freedom to go which way they will. This does not always work. And political satire, of course, adheres to none of these precepts, in fact does precisely the opposite, which is its proper function.
In my play The Birthday Party I think I allow a whole range of options to operate in a dense forest of possibility before finally focussing on an act of subjugation.
Mountain Language pretends to no such range of operation. It remains brutal, short and ugly. But the soldiers in the play do get some fun out of it. One sometimes forgets that torturers become easily bored. They need a bit of a laugh to keep their spirits up. This has been confirmed of course by the events at Abu Ghraib in Baghdad. Mountain Language lasts only 20 minutes, but it could go on for hour after hour, on and on and on, the same pattern repeated over and over again, on and on, hour after hour.
Ashes to Ashes, on the other hand, seems to me to be taking place under water. A drowning woman, her hand reaching up through the waves, dropping down out of sight, reaching for others, but finding nobody there, either above or under the water, finding only shadows, reflections, floating; the woman a lost figure in a drowning landscape, a woman unable to escape the doom that seemed to belong only to others.
But as they died, she must die too.
Political language, as used by politicians, does not venture into any of this territory since the majority of politicians, on the evidence available to us, are interested not in truth but in power and in the maintenance of that power. To maintain that power it is essential that people remain in ignorance, that they live in ignorance of the truth, even the truth of their own lives. What surrounds us therefore is a vast tapestry of lies, upon which we feed.
As every single person here knows, the justification for the invasion of Iraq was that Saddam Hussein possessed a highly dangerous body of weapons of mass destruction, some of which could be fired in 45 minutes, bringing about appalling devastation. We were assured that was true. It was not true. We were told that Iraq had a relationship with Al Quaeda and shared responsibility for the atrocity in New York of September 11th 2001. We were assured that this was true. It was not true. We were told that Iraq threatened the security of the world. We were assured it was true. It was not true.
The truth is something entirely different. The truth is to do with how the United States understands its role in the world and how it chooses to embody it.
But before I come back to the present I would like to look at the recent past, by which I mean United States foreign policy since the end of the Second World War. I believe it is obligatory upon us to subject this period to at least some kind of even limited scrutiny, which is all that time will allow here.
Everyone knows what happened in the Soviet Union and throughout Eastern Europe during the post-war period: the systematic brutality, the widespread atrocities, the ruthless suppression of independent thought. All this has been fully documented and verified.
But my contention here is that the US crimes in the same period have only been superficially recorded, let alone documented, let alone acknowledged, let alone recognised as crimes at all. I believe this must be addressed and that the truth has considerable bearing on where the world stands now. Although constrained, to a certain extent, by the existence of the Soviet Union, the United States' actions throughout the world made it clear that it had concluded it had carte blanche to do what it liked.
Direct invasion of a sovereign state has never in fact been America's favoured method. In the main, it has preferred what it has described as 'low intensity conflict'. Low intensity conflict means that thousands of people die but slower than if you dropped a bomb on them in one fell swoop. It means that you infect the heart of the country, that you establish a malignant growth and watch the gangrene bloom. When the populace has been subdued – or beaten to death – the same thing – and your own friends, the military and the great corporations, sit comfortably in power, you go before the camera and say that democracy has prevailed. This was a commonplace in US foreign policy in the years to which I refer.
The tragedy of Nicaragua was a highly significant case. I choose to offer it here as a potent example of America's view of its role in the world, both then and now.
I was present at a meeting at the US embassy in London in the late 1980s.
The United States Congress was about to decide whether to give more money to the Contras in their campaign against the state of Nicaragua. I was a member of a delegation speaking on behalf of Nicaragua but the most important member of this delegation was a Father John Metcalf. The leader of the US body was Raymond Seitz (then number two to the ambassador, later ambassador himself). Father Metcalf said: 'Sir, I am in charge of a parish in the north of Nicaragua. My parishioners built a school, a health centre, a cultural centre. We have lived in peace. A few months ago a Contra force attacked the parish. They destroyed everything: the school, the health centre, the cultural centre. They raped nurses and teachers, slaughtered doctors, in the most brutal manner. They behaved like savages. Please demand that the US government withdraw its support from this shocking terrorist activity.'
Raymond Seitz had a very good reputation as a rational, responsible and highly sophisticated man. He was greatly respected in diplomatic circles. He listened, paused and then spoke with some gravity. 'Father,' he said, 'let me tell you something. In war, innocent people always suffer.' There was a frozen silence. We stared at him. He did not flinch.
Innocent people, indeed, always suffer.
Finally somebody said: 'But in this case “innocent people” were the victims of a gruesome atrocity subsidised by your government, one among many. If Congress allows the Contras more money further atrocities of this kind will take place. Is this not the case? Is your government not therefore guilty of supporting acts of murder and destruction upon the citizens of a sovereign state?'
Seitz was imperturbable. 'I don't agree that the facts as presented support your assertions,' he said.
As we were leaving the Embassy a US aide told me that he enjoyed my plays. I did not reply.
I should remind you that at the time President Reagan made the following statement: 'The Contras are the moral equivalent of our Founding Fathers.'
The United States supported the brutal Somoza dictatorship in Nicaragua for over 40 years. The Nicaraguan people, led by the Sandinistas, overthrew this regime in 1979, a breathtaking popular revolution.
The Sandinistas weren't perfect. They possessed their fair share of arrogance and their political philosophy contained a number of contradictory elements. But they were intelligent, rational and civilised. They set out to establish a stable, decent, pluralistic society. The death penalty was abolished. Hundreds of thousands of poverty-stricken peasants were brought back from the dead. Over 100,000 families were given title to land. Two thousand schools were built. A quite remarkable literacy campaign reduced illiteracy in the country to less than one seventh. Free education was established and a free health service. Infant mortality was reduced by a third. Polio was eradicated.
The United States denounced these achievements as Marxist/Leninist subversion. In the view of the US government, a dangerous example was being set. If Nicaragua was allowed to establish basic norms of social and economic justice, if it was allowed to raise the standards of health care and education and achieve social unity and national self respect, neighbouring countries would ask the same questions and do the same things. There was of course at the time fierce resistance to the status quo in El Salvador.
I spoke earlier about 'a tapestry of lies' which surrounds us. President Reagan commonly described Nicaragua as a 'totalitarian dungeon'. This was taken generally by the media, and certainly by the British government, as accurate and fair comment. But there was in fact no record of death squads under the Sandinista government. There was no record of torture. There was no record of systematic or official military brutality. No priests were ever murdered in Nicaragua. There were in fact three priests in the government, two Jesuits and a Maryknoll missionary. The totalitarian dungeons were actually next door, in El Salvador and Guatemala. The United States had brought down the democratically elected government of Guatemala in 1954 and it is estimated that over 200,000 people had been victims of successive military dictatorships.
Six of the most distinguished Jesuits in the world were viciously murdered at the Central American University in San Salvador in 1989 by a battalion of the Alcatl regiment trained at Fort Benning, Georgia, USA. That extremely brave man Archbishop Romero was assassinated while saying mass. It is estimated that 75,000 people died. Why were they killed? They were killed because they believed a better life was possible and should be achieved. That belief immediately qualified them as communists. They died because they dared to question the status quo, the endless plateau of poverty, disease, degradation and oppression, which had been their birthright.
The United States finally brought down the Sandinista government. It took some years and considerable resistance but relentless economic persecution and 30,000 dead finally undermined the spirit of the Nicaraguan people. They were exhausted and poverty stricken once again. The casinos moved back into the country. Free health and free education were over. Big business returned with a vengeance. 'Democracy' had prevailed.
But this 'policy' was by no means restricted to Central America. It was conducted throughout the world. It was never-ending. And it is as if it never happened.
The United States supported and in many cases engendered every right wing military dictatorship in the world after the end of the Second World War. I refer to Indonesia, Greece, Uruguay, Brazil, Paraguay, Haiti, Turkey, the Philippines, Guatemala, El Salvador, and, of course, Chile. The horror the United States inflicted upon Chile in 1973 can never be purged and can never be forgiven.
Hundreds of thousands of deaths took place throughout these countries. Did they take place? And are they in all cases attributable to US foreign policy? The answer is yes they did take place and they are attributable to American foreign policy. But you wouldn't know it.
It never happened. Nothing ever happened. Even while it was happening it wasn't happening. It didn't matter. It was of no interest. The crimes of the United States have been systematic, constant, vicious, remorseless, but very few people have actually talked about them. You have to hand it to America. It has exercised a quite clinical manipulation of power worldwide while masquerading as a force for universal good. It's a brilliant, even witty, highly successful act of hypnosis.
I put to you that the United States is without doubt the greatest show on the road. Brutal, indifferent, scornful and ruthless it may be but it is also very clever. As a salesman it is out on its own and its most saleable commodity is self love. It's a winner. Listen to all American presidents on television say the words, 'the American people', as in the sentence, 'I say to the American people it is time to pray and to defend the rights of the American people and I ask the American people to trust their president in the action he is about to take on behalf of the American people.'
It's a scintillating stratagem. Language is actually employed to keep thought at bay. The words 'the American people' provide a truly voluptuous cushion of reassurance. You don't need to think. Just lie back on the cushion. The cushion may be suffocating your intelligence and your critical faculties but it's very comfortable. This does not apply of course to the 40 million people living below the poverty line and the 2 million men and women imprisoned in the vast gulag of prisons, which extends across the US.
The United States no longer bothers about low intensity conflict. It no longer sees any point in being reticent or even devious. It puts its cards on the table without fear or favour. It quite simply doesn't give a damn about the United Nations, international law or critical dissent, which it regards as impotent and irrelevant. It also has its own bleating little lamb tagging behind it on a lead, the pathetic and supine Great Britain.
What has happened to our moral sensibility? Did we ever have any? What do these words mean? Do they refer to a term very rarely employed these days – conscience? A conscience to do not only with our own acts but to do with our shared responsibility in the acts of others? Is all this dead? Look at Guantanamo Bay. Hundreds of people detained without charge for over three years, with no legal representation or due process, technically detained forever. This totally illegitimate structure is maintained in defiance of the Geneva Convention. It is not only tolerated but hardly thought about by what's called the 'international community'. This criminal outrage is being committed by a country, which declares itself to be 'the leader of the free world'. Do we think about the inhabitants of Guantanamo Bay? What does the media say about them? They pop up occasionally – a small item on page six. They have been consigned to a no man's land from which indeed they may never return. At present many are on hunger strike, being force-fed, including British residents. No niceties in these force-feeding procedures. No sedative or anaesthetic. Just a tube stuck up your nose and into your throat. You vomit blood. This is torture. What has the British Foreign Secretary said about this? Nothing. What has the British Prime Minister said about this? Nothing. Why not? Because the United States has said: to criticise our conduct in Guantanamo Bay constitutes an unfriendly act. You're either with us or against us. So Blair shuts up.
The invasion of Iraq was a bandit act, an act of blatant state terrorism, demonstrating absolute contempt for the concept of international law. The invasion was an arbitrary military action inspired by a series of lies upon lies and gross manipulation of the media and therefore of the public; an act intended to consolidate American military and economic control of the Middle East masquerading – as a last resort – all other justifications having failed to justify themselves – as liberation. A formidable assertion of military force responsible for the death and mutilation of thousands and thousands of innocent people.
We have brought torture, cluster bombs, depleted uranium, innumerable acts of random murder, misery, degradation and death to the Iraqi people and call it 'bringing freedom and democracy to the Middle East'.
How many people do you have to kill before you qualify to be described as a mass murderer and a war criminal? One hundred thousand? More than enough, I would have thought. Therefore it is just that Bush and Blair be arraigned before the International Criminal Court of Justice. But Bush has been clever. He has not ratified the International Criminal Court of Justice. Therefore if any American soldier or for that matter politician finds himself in the dock Bush has warned that he will send in the marines. But Tony Blair has ratified the Court and is therefore available for prosecution. We can let the Court have his address if they're interested. It is Number 10, Downing Street, London.
Death in this context is irrelevant. Both Bush and Blair place death well away on the back burner. At least 100,000 Iraqis were killed by American bombs and missiles before the Iraq insurgency began. These people are of no moment. Their deaths don't exist. They are blank. They are not even recorded as being dead. 'We don't do body counts,' said the American general Tommy Franks.
Early in the invasion there was a photograph published on the front page of British newspapers of Tony Blair kissing the cheek of a little Iraqi boy. 'A grateful child,' said the caption. A few days later there was a story and photograph, on an inside page, of another four-year-old boy with no arms. His family had been blown up by a missile. He was the only survivor. 'When do I get my arms back?' he asked. The story was dropped. Well, Tony Blair wasn't holding him in his arms, nor the body of any other mutilated child, nor the body of any bloody corpse. Blood is dirty. It dirties your shirt and tie when you're making a sincere speech on television.
The 2,000 American dead are an embarrassment. They are transported to their graves in the dark. Funerals are unobtrusive, out of harm's way. The mutilated rot in their beds, some for the rest of their lives. So the dead and the mutilated both rot, in different kinds of graves.
Here is an extract from a poem by Pablo Neruda, 'I'm Explaining a Few Things':
And one morning all that was burning,
one morning the bonfires
leapt out of the earth
devouring human beings
and from then on fire,
gunpowder from then on,
and from then on blood.
Bandits with planes and Moors,
bandits with finger-rings and duchesses,
bandits with black friars spattering blessings
came through the sky to kill children
and the blood of children ran through the streets
without fuss, like children's blood.
Jackals that the jackals would despise
stones that the dry thistle would bite on and spit out,
vipers that the vipers would abominate.
Face to face with you I have seen the blood
of Spain tower like a tide
to drown you in one wave
of pride and knives.
see my dead house,
look at broken Spain:
from every house burning metal flows
instead of flowers
from every socket of Spain
Spain emerges
and from every dead child a rifle with eyes
and from every crime bullets are born
which will one day find
the bull's eye of your hearts.
And you will ask: why doesn't his poetry
speak of dreams and leaves
and the great volcanoes of his native land.
Come and see the blood in the streets.
Come and see
the blood in the streets.
Come and see the blood
in the streets!*
Let me make it quite clear that in quoting from Neruda's poem I am in no way comparing Republican Spain to Saddam Hussein's Iraq. I quote Neruda because nowhere in contemporary poetry have I read such a powerful visceral description of the bombing of civilians.
I have said earlier that the United States is now totally frank about putting its cards on the table. That is the case. Its official declared policy is now defined as 'full spectrum dominance'. That is not my term, it is theirs. 'Full spectrum dominance' means control of land, sea, air and space and all attendant resources.
The United States now occupies 702 military installations throughout the world in 132 countries, with the honourable exception of Sweden, of course. We don't quite know how they got there but they are there all right.
The United States possesses 8,000 active and operational nuclear warheads. Two thousand are on hair trigger alert, ready to be launched with 15 minutes warning. It is developing new systems of nuclear force, known as bunker busters. The British, ever cooperative, are intending to replace their own nuclear missile, Trident. Who, I wonder, are they aiming at? Osama bin Laden? You? Me? Joe Dokes? China? Paris? Who knows? What we do know is that this infantile insanity – the possession and threatened use of nuclear weapons – is at the heart of present American political philosophy. We must remind ourselves that the United States is on a permanent military footing and shows no sign of relaxing it.
Many thousands, if not millions, of people in the United States itself are demonstrably sickened, shamed and angered by their government's actions, but as things stand they are not a coherent political force – yet. But the anxiety, uncertainty and fear which we can see growing daily in the United States is unlikely to diminish.
I know that President Bush has many extremely competent speech writers but I would like to volunteer for the job myself. I propose the following short address which he can make on television to the nation. I see him grave, hair carefully combed, serious, winning, sincere, often beguiling, sometimes employing a wry smile, curiously attractive, a man's man.
'God is good. God is great. God is good. My God is good. Bin Laden's God is bad. His is a bad God. Saddam's God was bad, except he didn't have one. He was a barbarian. We are not barbarians. We don't chop people's heads off. We believe in freedom. So does God. I am not a barbarian. I am the democratically elected leader of a freedom-loving democracy. We are a compassionate society. We give compassionate electrocution and compassionate lethal injection. We are a great nation. I am not a dictator. He is. I am not a barbarian. He is. And he is. They all are. I possess moral authority. You see this fist? This is my moral authority. And don't you forget it.'
A writer's life is a highly vulnerable, almost naked activity. We don't have to weep about that. The writer makes his choice and is stuck with it. But it is true to say that you are open to all the winds, some of them icy indeed. You are out on your own, out on a limb. You find no shelter, no protection – unless you lie – in which case of course you have constructed your own protection and, it could be argued, become a politician.
I have referred to death quite a few times this evening. I shall now quote a poem of my own called 'Death'.
Where was the dead body found?
Who found the dead body?
Was the dead body dead when found?
How was the dead body found?
Who was the dead body?
Who was the father or daughter or brother
Or uncle or sister or mother or son
Of the dead and abandoned body?
Was the body dead when abandoned?
Was the body abandoned?
By whom had it been abandoned?
Was the dead body naked or dressed for a journey?
What made you declare the dead body dead?
Did you declare the dead body dead?
How well did you know the dead body?
How did you know the dead body was dead?
Did you wash the dead body
Did you close both its eyes
Did you bury the body
Did you leave it abandoned
Did you kiss the dead body
When we look into a mirror we think the image that confronts us is accurate. But move a millimetre and the image changes. We are actually looking at a never-ending range of reflections. But sometimes a writer has to smash the mirror – for it is on the other side of that mirror that the truth stares at us.
I believe that despite the enormous odds which exist, unflinching, unswerving, fierce intellectual determination, as citizens, to define the real truth of our lives and our societies is a crucial obligation which devolves upon us all. It is in fact mandatory.
If such a determination is not embodied in our political vision we have no hope of restoring what is so nearly lost to us – the dignity of man.

Saturday, December 17, 2005

Moral Status of Embryos vs Human Victims of War

I was reading in the current issue of American Journal of Bioethics regarding the view of the President's Council on Bioethics describing the Majority members view expressing full moral status to the extra-corporeal human 14 cell embryo and arguing against the "routinely and large scale" destruction of these embryos for therapeutic stem cell research. I suspect our President, based on his statements and actions, agrees with that view. What I was wondering is whether there is some philosophical explanation or rationalization of his view for full moral status and protection against destruction of the embryos when our President can initiate a war which involves the gross destruction of innocent born sentient humans, including perhaps unborn embryos, all of whom by the view of the Majority have full and highest moral status. The President might argue that he initiated the war for a good. One can also argue that destruction of embryos for stem cell research is also for a good. Is there something, from a philosophical aspect that I am missing in attempting to understand our President? Does one good trump the other good? If there are some philosophers out in blogland who can explain what seems to me to be an inconsistency, I would most appreciate it. ..Maurice.

Wednesday, December 14, 2005

Ethics:Treating a Patient for the Benefit of Others (1)

A decision by a physician about any medical treatment of a patient should be based on a risk vs benefit assessment. The possible risks and chance of risk may be fully or just partially known. The benefit can be a known patho-physiologic benefit (directly affecting the underlying disease) or it may include a quality of life or life goals or values consideration that is usually poorly known by the physician but best determined by the patient. When the patient is unconscious and/or does not have the mental capacity to inform or decide, then the physician will look to a surrogate. But the physician must make some degree of assessment before the medical treatment is offered or carried out.

How does one look at a clinical scenario where there is no direct benefit of treatment to the patient? And what if, in addition, there are physical or emotional risks? Why would a patient be treated without benefit? Well, one answer would be that the treatment of the patient was primarily to benefit others. One example in which the act doesn’t involve a drug or medical procedure would be the isolation of a communicable disease patient so that others would not be exposed to the disease. Another might be the current consideration regarding isolation of known pedophiles beyond the period of punishment again for safety concern for others.

Beyond these custodial treatments, there are medical pharmacologic or medical procedural treatments which occur which again do not medically benefit the patient but primarily benefits others. Treating those who have committed sexual crimes by castration or hormone injections in an attempt to protect others might be an example. Another which has been carried out in the past was the castration or tubal ligation of a mentally defective female to prevent her from becoming pregnant. Some of the sedation or tranquilization of Alzheimer’s patients might be prescribed by physician primarily to try to make the patient easier to manage by the caregiver and perhaps ease the emotional burden suffered by the caregiver. In this example one might argue that this patient therapy may be beneficial to the patient by hoping to prevent injury but also it might not.

A good example of the kind of treatment which occurs in medical practice which one can wonder about the ethics and the medical propriety is that of administering increasing doses of a narcotic such as IV morphine to a patient who is nearing the end of life from a serious illness such as strokes or cancer and who is already unconscious and clinically not in pain or in discomfort in order to satisfy the concerns of the bedside family. In terminally ill patients, occasional respiratory or muscular behavior can occur which will frighten the observing family members but clinically does not represent a comfort issue for the unconscious patient. If further morphine is administered, for example, the respiratory rate may be slowed to the point where respiration stops and the patient will die as a consequence of the administration. If the patient had been conscious or stuperous and was in frank discomfort, then the benefit of treating such a terminal patient with morphine would be medically and ethically appropriate despite the risk of death from the drug. Ethical support for this conclusion would come on the basis of the “double effect” principle.

The principle balances the good effect of the act (benefit) against the bad effect (risk). For an act to be ethical it must meet all 5 parts of the principle: 1) The act must be good or morally neutral, 2) Only the good effect is intended, 3) The good effect is not achieved through the bad effect, 4) There is no alternative way to achieve the good effect and 5) There is a proportionally good reason for running the risk. The question becomes is it ethical for an unconscious patient who clinically appears comfortable and in no distress be treated with a narcotic to further depress the patient’s nervous system to try to prevent a behavior which is unsettling only for the unsophisticated family watching and to provide them comfort while at the same time possibly risking and causing the premature death of the patient? More on this issue in a later posting. ..Maurice.

Monday, December 12, 2005

The Ethics of the Execution Participation:Why a Physician and Why Not the Jury?

I heard on the news that it would be a physician who is to determine if Stanley Williams is dead after given the IV chemicals. If the news report is correct, this represents the unethical use of a physician. Think.. what happens if the physician finds that Williams is not dead? Then the physician's evaluation is going to be used as the basis to administer more poison to insure death. Thus the physician is not simply confirming death but participating in the completion of the death sentence. It's plain wrong! If the death sentence is a morally correct act then why is it that at virtually every step in the final minutes of the process including the pressing of the three buttons to administer each chemical, a different person is to carry out each step so that no single person can assume responsibility for the end result. If the act was morally virtuous, certainly only one person would be necessary to claim the virtuousness. My other question involves those who are participating beyond the physician. Why is it that the very persons who have legally established that Williams should die, such as the judge, members of the jury and the Governor amongst others shouldn't be the ones to actually perform the execution? Is it really another way to avoid "dirtying" their hands from consequence of their decisions? You can see which way I stand on the whole ethics of this business. ..Maurice.

Saturday, December 10, 2005

Withholding/Withdrawal Life Support:Killing vs Letting Die

A topic which I have posed on my currently not updated "Bioethics Discussion Pages" is one of whether patient or surrogate requested removal of life support or to withhold life supportive treatment represents forms of "killing" or is it really a process of "letting" the patient die from the underlying disease for which the life support was being or was to be used. A visitor to that web site wrote me the following response which I thought was so well written that I would put it up on this blog. What do you think are the distinctions? ..Maurice.

Your question important for all of us. My father-in-law chose death at his
own hand when confronted with a diagnosis of terminal liver cancer which
would have lead to a slow death by starvation and the likelihood of
institutional care. My own father died a "natural" death from congestive
heart failure. His multiple organ failures (kidney, heart, and lungs) lead
to hallucinations and increasing levels of frustration and angst as his
periods of lucidity waned. He was "made comfortable" with high levels of
morphine derivatives to enable him to rest "comfortably". In both cases
their deaths were hastened either by overt means or decisions not to intrude
with life supporting machines (kidney dialysis in my dad's case).

Is the refusal to utilize treatments that might cheat death for a period of
time any different from the decision to remove such life support when the
individual involved no longer can enjoy any quality from the "life" such
machines and intrusions provide? I don't think so. We all share one
commonality in this life - we will die. While few of us want to reach the
termination of life, the reality is that we all must.

When the death knell tolls we should each have the option to pursue
treatments that will delay our demise and also the ability to express
through living wills or direct discussions with our attending physicians and
our loved ones the circumstances under which we do not wish to continue with
life sustaining efforts. The question regarding removal of life sustaining
equipment begs a simpler question for me: has the life sustaining equipment
really replaced the failed organ meaning I can live my life in the same
manner as I did before the organ failed, or has it merely replaced the basic
function of the failed organ and in so doing has irreparably changed my
quality of life by either restricting my mobility or my ability to live

My dad suffered from congestive heart failure for several years after
successfully battling lymphoma with an aggressive chemotherapy regimen.
Basically, the patient was cured but at the expense of his heart function.
For a time he was able to live a fairly normal life through the
administration of several drugs to assist his heart in removing fluids from
his body. We enjoyed family vacations to Alaska and Europe with him after
his successful lymphoma treatments. His stamina wasn't 100%, but he was able
to enjoy his life. However, when he sustained major organ failure he was
sentenced to a bedridden existence. Kidney dialysis might have prolonged his
life, but it wouldn't have enabled him to walk, live in his home and enjoy
family gatherings ever again. In short, his lifestyle was altered in a way
that was unacceptable to him.

I wish as a society we could step back from our religious views, our
political posturing and our belief in the sanctity of life and consider for
just a moment that each of us will one day face our own moment of truth. How
do we want to pass from this existence? With compassionate medical care that
can be tailored to our own wishes or with archaic handwringing that leaves
everyone dissatisfied and puts medical practitioners in the position of
"playing god" or, perhaps worse, risking legal and criminal complaints for
compassionate actions?

In the ideal, the patient's wishes should be clearly communicated to family
and medical practitioners so the level and duration of care administered
will be consistent with those wishes. In this scenario your question is
easily answered. The doctor who "pulls the plug" has done so at the
patient's request and is merely allowing to take place what would have
already happened were it not for the medical intercession.

I came to your site from your blog and appreciate the opportunity to express
my opinion.

Sincerely yours,

Ric Enge

Sunday, December 04, 2005

Transition from College Student to Physician: “How am I doing?”

I just wanted to briefly explain why I have no time in this week or so to post here as often as usual. I am facilitating two groups of medical students, first and second year, their first learning of what it is like and what skills and behavior are necessary to become a doctor. The course is called “Introduction to Clinical Medicine”. It is an experiential course, no lectures. It is “hands on” with regard to learning how to understand and how to intellectually, empathetically and in a humanistic way connect with patients, take a history and perform a physical exam. It is now mid-term for the students, they are asking me “how am I doing?” and since there are no exams but simply (or perhaps not so simply) my observation, it is time for me to provide the feedback that will help to guide them as the year progresses and beyond. I have to prepare to say the most productive suggestions specific to each student and that takes time. So this posting will be it for a week. If you are looking for postings about medical ethics and the practice of medicine to read, there are still over 250 on this blog. ..Maurice.