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Saturday, August 28, 2010

The Most Dangerous Idea in Bioethics

Professor Margaret Somerville of McGill University argues that the most dangerous idea in the world today is that human beings are not special compared with lower animals and even robots. I believe she has the right idea, but she has argued rather timidly.  She concludes more or less that the danger of denying human specialness stems from what things it leads to—but the idea is designed precisely to lead to those things.  If one does not see those things as dangerous but desirable, then the idea becomes desirable as well.  The idea is dangerous, therefore, for an entirely different reason that hinges on truth, as I will show.

Critics in the combox under her article argue that Prof. Somerville has not adequately proved that human beings are special.  That critique, however, is entirely bogus. Human specialness does not need to be proven because it is self-evident.  It is a simple fact that human beings differ in important ways from all other animals (not to mention robots), even if there are similarities as well.  Take farming for instance. I am not saying that our specialness hinges on farming, but farming serves as one piece of evidence of what a human being is, and how a human being differs from other life.  Whereas every other life form has to find read-to-eat food occurring spontaneously in nature, we do not and can instead purposefully modify and control our environment to make the environment produce our food, and then modify the food to make it look and taste good. Granted, some critters engage in farm-like activities (such as ants that “farm” aphids) but the difference between critter farms and human farms is infinite. Not all humans farm, but any human could; farming is a uniquely human activity. Human specialness is self-evident.

Anyone who demands that human specialness be proven ought to try thinking like an animal, since in his view he is no different from an animal.  Dogs can tell that humans are different from cats, and not merely different but superior as well.  Who ever heard of a dog being a cat’s pet?  Who ever heard of a cat training a dog? Who ever heard of a dog domesticating a human or any other animal for that matter?  Yet, dogs respond well to domestication by humans.  If humans are, in fact, not superior to other animals, what does it mean if other animals who are not inferior to us understand humans to be different from and superior to themselves and other animals?

Also, human specialness is impossible to prove to the satisfaction of everyone.  Who can stop someone from saying, “Sorry, that doesn’t prove it to me” or “I reject that argument; human beings are still no different from other animals”?  These are people who already reject the evidence of their own existence compared to that of their pets, how on earth will a cogent argument sway them?

I say in response, prove that human ingenuity and accomplishments in science, technology, poetry, and the arts are meaningless differences from other animals and robots.  Birds can sing, none has written an opera. Bees build hives, but none has built a pyramid that has survived for millennia. Not all humans can write operas or build pyramids, but only humans can and any human could if he set his mind to it.

Prof. Somerville also mentions many arguments that deny humans specialness. Unfortunately, she doesn’t do anything with them but mention them.  One of these arguments goes like this: Human superiority resides in the ability to reason.  Some human individuals do not have that ability, so they lack the defining trait of human superiority.  These individuals at least are no better than other animals, and other animals would be at least as good as them.  Therefore, there should be parity between our treatment of these individuals and other kinds of animals.  This line of argumentation of course is a red herring.  Individuals lacking in traits proper to their kind are still of that kind.  Cars have two headlights. Some have only one because one is broken.  But it is still a car.  A car may lack wheels, a motor, seats, doors, glass, and be just a rusting piece of junk, but it is a car, a car lacking those things. We can quibble and say it really is just a part of a car or the remains of a car, but not a car—which is a matter of semantics and not ontology.  If your kid asked you, “What is that thing?” your answer will likely be, “It’s a car,” and quibble as much as you like over semantics, your answer would not be wrong. It is a car—one lacking in things proper to being a car, yes, but a car nonetheless.  A car lacking things a car is supposed to have a) doesn’t make it not to be a car, b) doesn’t render cars in general to be non-cars, and c) doesn’t make other things lacking those traits to be no different from a car. Likewise with the lack of human attributes both high and low in some humans: a) it doesn’t render them non-human or non-special, b) it doesn’t render humans in general to be non-special, and c) it doesn’t render other things lacking those traits to be no different from a human.

The fact is, our specialness cannot be pinpointed to DNA or a single power or ability unique to human beings.  Rather, a human being is one thing with several properties, and it is the sum total of what a human being is that makes a human being special in comparison to other animals.  The notion that human specialness hinges on one identifiable thing to the exclusion of all other things is simply a false premise.

Now, why is this idea so dangerous? There are three main reasons.  First, it denies self-evident truth.  Secondly, support for the idea depends on poor logic presented as sound reasoning.  Thirdly, people propose the idea not because it has merit in itself, but to justify to themselves and to others courses of action that they want to engage in. No one who supports the idea does so merely because they believe it to be true and want others to know the truth, too. It is not about the metaphysical, concrete reality of human ontology. It is purely about what doors it opens if it were to be seen as true. Truth should be an end, not a means; but the fact is, the truth is irrelevant to those who support the idea.  It is its acceptance that is important.

So, in a nutshell: The idea that human beings are not significantly different from and superior to other animals and robots is dangerous because it is a patent falsehood masquerading as truth, supported by deviousness, and intended to manipulate the minds and actions of others. Its plausibility to unsuspecting minds makes it the most dangerous idea in bioethics.

Sunday, August 15, 2010

The $93,000 question

In this short case presentation, you might think the difficulty is the age of the patient.  In reality it is the cost of the medication.

Comfort food, revisited

Here's an interesting take on that same NYTimes article about the use of feeding tubes in end-stage Alzheimer's disease.  The author, a doctor who spent the early part of her medical training caring for Alzheimer's patients, appears aghast to learn that feeding tubes were used in the first place, let alone that there is a controversy surrounding their discontinuation in favor of hand feeding.

Some beautiful nuggets in the article.  I was concerned that hand feeding may lead to neglect or quickly giving up by those not dedicated to provide care.  But she had genuine persistence: "What else did they have to do all day and what else was I there for, after all?" I would hope that anyone who provides daily care for such patients would have the same attitude.  I guess the stories of neglect are what we hear about most in the news or from family and friends. And neglect is what we have to be on guard against.  Yet this lady is the real thing, someone who knows what "care" means.

Go take a look and read the article to the end.  Something to think about there.

Wednesday, August 4, 2010

Comfort food

I haven't decided what I think yet about the idea of "comfort feeding" rather than using a feeding tube.  Comfort feeding refers to giving normal food and drink by mouth to someone unable to feed himself, up to his tolerance for the process and the ability to swallow without choking.

Employed in patients with advanced Alzheimer's disease, whose brains are degenerating to the point of them forgetting how to eat and drink, it appears to be a way of providing comfort, nutrition and hydration that does not distress the patient or require sedation or restraints.  It enables the caregiver to feel like she's not starving or dehydrating Dad to death, while at the same time providing direct nurturing care to a loved one.  It would be used instead of a feeding tube.  The tolerance level of the patient, though, virtually ensures that too little nutrition and hydration are given.

The feeding tube has the advantage of ensuring that the patient receives adequate nutrition.  It has the disadvantage of being very uncomfortable and restrictive for someone in the last weeks or months of life as a terminal disease inexorably progresses.

The ethical question for the caregivers -- the patient's loved ones and the health professionals -- is whether their responsibility to the patient involves feeding or nutrition.

The statement by the US Catholic Bishops cited in the article suggests an obligation to nourish and to hydrate the patient.  The NYT points out, however, that feeding tubes do not necessarily prolong life.

The logic is clear: Is there a moral obligation if the outcome -- longevity -- does not improve?

Outcomes are only part of the equation, however.  Human beings need water and nutrition.  These are necessities, not means to any particular end other than to provide what every human being needs without depriving them.  The ability of hydration and nutrition to prolong life seems irrelevant: As long as the patient lives, he needs hydration and nutrition, and we have a duty to provide him with what he needs.

Comfort feeding almost seems more like it comforts the caregiver more than the patient.  I am also concerned about the slippery slope: If food and drink are given in accord with the patient's tolerance to eat and drink, at a certain point it becomes frustrating to continue to give food, whether it be "right now" at a given feeding, or day after day after day. Caregivers can easily give up when they ought to persist, and over years and years with this policy, it eventually morphs into a pro-forma "I tired to give him food but he wouldn't take it so I didn't force him" -- at the slightest resistance -- and then, eventually, getting to the point of asking, "Why bother even trying?"

And, by the way, since when are Alzheimer's patients competent to determine their own care?

I appear to be arguing myself out of comfort feeding, and I have to admit, it makes me, well, uncomfortable.  But I haven't decided yet.

This I know: There is no wrong in giving someone adequate hydration and nutrition.  It's a matter of how best to do that. Each way appears to do well in some respect while falling short in another, albeit in opposite ways.  I need to think about it some more.

If it’s bad, is it an enhancement?

The whole idea that a human “enhancement” can be seen as good or bad just goes to show that the Institute for Ethics and Emerging Technologies has a bit of a difficulty with the “ethics” part of their name.

Yet, it’s true: Newly named Affiliate Scholar at IEET, Richard Eskow, has identified two basic kinds of human enhancements, good and bad.  He actually claims there are three (good, bad, and inevitable), but the diagram in his article shows that inevitable is where the good and the bad enhancements overlap.  The diagram could have been drawn the other way, with “improbable” enhancements as the overlap between the good and the bad, depending on the point one wants to make.  So perhaps there are four kinds of enhancements: Good and bad, and among each kind, improbable and inevitable.

What intrigues me, though, is the notion of “bad enhancements.”  Extreme plastic surgery, he says, is a bad enhancement.  Whatever else may be said of extreme plastic surgery, if it’s bad, it’s not an enhancement.

He goes on to talk about the advent of personal devices such as cell phones, PDAs, and laptop computers, chaining people to their professions.  He said he was at the time “appropriately horrified.” However, what were considered “bad enhancements” became today’s addictions.  Now he feels uneasy when he’s parted from his cellphone.  And he doesn’t appear to mind.  As useful and even necessary a cell phone is, I would hope he would remain “appropriately horrified” at his uneasiness at being parted from it.

So, there are four lines of ethical reasoning at work, none of which are adequately ordered to determining an authentic good or evil in acts that affect human life and health. 

First is the outcomes-based ethics revealed in the example of bad plastic surgery. The word “extreme” implies a bad outcome, surgical “enhancements” that disfigure rather than repair defects or refine good but imperfect traits.  If only good outcomes are attained, who’s to call it “extreme”?  There’s no way to know otherwise what a bad enhancement is, except what happens as a result of it.  Authentic bioethics, however, must go beyond mere outcomes, or at least expand the notion of “outcomes” to include more than just the objective result of the act.  Take massive cosmetic surgery. We must ask, does it make someone to be a better person, or does it merely make him look better (which might actually make him arrogant and selfish, i.e., worse as a person)?

Second is culture-define acceptability: A thing is acceptable if the society wants it.  Accepting the concept that societal and cultural mores change over time, frankly, is just another way of saying we’re on a slippery slope and that’s okay.  How long before we connive ourselves again that slavery is good? It’s unthinkable today, but will it be unthinkable when future humans with their technological enhancements see themselves as ontologically superior to natural, unenhanced humans, whom the supermen of tomorrow find morally indistinguishable from pets or livestock?  Slavery it will be, but it will be called something else.  But it will be slavery.  Can’t happen? Ask Dr. Eskow how he became addicted to the very thing that horrified him a few short years earlier.

Third is the absence of a true concept of what a human being is.  I do not say, “an inadequate idea of what it means to be human,” but of what a human being is.  Eskro says that what it “means” to be human is constantly in flux and defined in the present moment by the prevailing whims of culture and society.  Anything is possible if, for instance, the body is seen as a mere possession rather than a constitutive component of a human person.  A human being is what he is, however, and societal opinions cannot change the concrete reality of a human being.  In this respect, man is an image of God, who also is unchangeable.  Human nature is immutable; human beings individually can be altered, the human gene code modified, but in the one case human nature remains and in the other the result is not really human.  Yet, if man creates a rational animal, it will be a person, a person manufactured for a purpose defined by the humans that bred it. A slave.

Fourth is the notion that the natural functioning of the human body (in the absence of any defect or disorder) is intrinsically defective.  For instance, there is probably a limit as to how fast a human being can run, given the natural development of a person’s muscles and bones. But perhaps if we replace natural leg bones with titanium steel and natural muscles with computer controlled mechanisms, we can break those limits of human speed.  We have to ask, though, is it really a human being who attains that speed, or a man-made machine surgically attached to a remnant of a human person? Is it really an enhancement? Is it really a human enhancement, or a mechanical one with some human elements going along for a ride?

That is the kind of distinction that Dr. Eskow appears unable to make.  These are the questions that need answering that find no resolution in his article.  In a way, it is funny that he calls some enhancements “bad,” since he doesn’t have a concrete way of determining that they are bad.  One must truly wonder about IEET’s first E.

Tuesday, August 3, 2010

Life Support, or a Replacement Part?

When transhumanists equate wearing eyeglasses with replacing healthy flesh and bone with cybernetics, one must not downplay the power of analogy in bioethical reasoning. The simple response to the transhumanst is that eyeglasses do not alter the body at all nor do they become part of the person nor do they consider otherwise healthy eyes as disposable. (We'll not explore all of the ways the analogy limps in this post.)

Analogy is the very heart of the reasoning used by the Mayo Clinic in deciding that physicians can ethically withdraw a left ventricular assist device (LVAD) at a patient's request.  The device keeps the heart going in the cases of heart failure, where left ventricular hypertrophy has diminished the heart's ability to pump blood.  It is often used by patients awaiting a heart transplant.

According to a WSJ article on the topic, some clinicians feel uncomfortable with withdrawing LVAD because the device seems more like a replacement device than life support -- more like an artificial heart that lets a patient engage life than a ventilator that simply forestalls death when there is no life-saving treatment to be had.  Withdrawing LVAD would thus appear to be more like assisted suicide an euthanasia, rather than discontinuing a useless treatment.

The Mayo Clinic saw things in the exact opposite way. Withdrawing LVAD imposes no new pathology, but simply lets underlying pathology run its course. They consider it a treatment that any patient has a right to refuse and they recommend that clinicians respect their patients' wishes.

Yet that is also the weakness of the analogy.  The right to refuse treatment, like every other right, carries with it some responsibility.  No right is absolute -- people do not have the right to say whatever they want, whenever they want.  They have a responsibility to speak truthfully and not to slander, to keep the peace and not to incite a riot, and to keep silent and not to breach a confidence.

Patients can refuse treatments, but they have a responsibility -- to themselves, their loved ones, society and, yes, God -- also to maintain and restore their health.  Allowing existing pathology to run its course can be a form of murder, euthanasia, or assisted suicide -- not saving a savable life is the same as taking it. Circumstances will determine whether withdrawing LVAD means discontinuing a useless treatment that has no benefit, or causing an unethical hastening of death.

The discomfort of advanced heart failure and a life maintained by a mechanical device can make things seem pretty dismal to the patient. The patient needs advice, not obedience.  Above all, bioethics cannot make physicians into obsequious technicians that abdicate all ethical responsibility to others and remain authentic.

Sometimes a physician has to say, "No, it would be wrong." The Mayo Clinic seems to have taken that responsibility away from them.