the Electric Monk

Yesterday was the kick-off of yet another bioethics conference. From the perspective of an outsider like me–and a journalist to boot–”Ethical Issues in the Prioritization of Health Resources” seems like a hard sell. I struggle to imagine a less sexy title. (Perhaps “Academics Arguing about the Rights/Wrongs of Divvying Up Drugs and Doctors”?) But my prejudice was toppled by the following bizarre scene.

About 200 academics sat silently like parishioners in pews. Floating over their heads was a disembodied voice with a lilting Hispanic accent. It was Mexico’s Vice-Minister of Health, Mauricio Hernández, calling from his office to describe the difficult decision of how to stretch his limited budget to administer pneumococcal vaccines to his country’s children. The vaccine manufacturer recommends 3 doses, but it seemed to be more cost-effective to cut a corner from the standard of care and give only 2 doses. This is certainly the first time I’ve witnessed a politician on the phone with a packed room of academics, seeking their advice on a real-world, life and death dilemma.

Of course, deciding who should be given access to limited health resources is by definition a matter of life and death. But traditionally, philosophers who deal with the underlying ethics have not gotten their hands dirty with the real-world details. “Philosophers like us often say that we should learn about the issues from the experts who actually deal with them,” said Oxford bioethicist Roger Crisp. And rather than stopping there, “we should go on to try to make a positive difference.” This conference is supposed to be an opportunity for exactly this.

Crisp was the first speaker in a 3-man panel of academics who took the floor after the Vice-Minister. (Besides the Mexican vaccine dilemma, the conference learned about a dialysis machine shortage in Thailand and a new cancer drug that can extend life by a few months for an exorbitant cost. But more on those in a later post.) In contrast to the nitty-gritty of these real-world cases, the panelists battled it out on a very different plane–the abstract and esoteric world of moral theory. To give a sense of the flavor: Crisp added a new term to the menagerie of philosophical ‘isms (“sufficientarianism”); Alex Voorhoeve pondered whether it would be right or wrong to use a “philosophical laser” to prevent harm to one person from a plummeting meteor if not doing so would result in a greater benefit to another person; and JP Sevilla argued that redistributing people’s health (rather than money) was tricky because health is so “chunky”.

These are just caricatures of their arguments, of course. Abstraction is a necessary tool for teasing ethical issues apart. But the contrast between academic argument and real-world dilemma was dramatic. So I posed a real-world meta-question to the panel: Why does your work matter?

Voorhoeve considered his work in terms of national healthcare policies. “NICE is making some wrong decisions,” he said, referring to the ironically acronymed National Institute for Health and Clinical Excellence, the body that decides which drugs and treatments are not worth paying for in the UK. According to Voorhoeve, those decisions seem to derive ultimately from arguments made by another philosopher, All Souls don Derek Parfitt. So aside from the benefits to “mental hygiene,” he said, there are very practical reasons to get these philosophical arguments right.

With exquisite British self-deprecation, Crisp considered himself in the context of “all the philosophers over the centuries whose work is read and taken seriously.” Considering how vanishingly small that number is, he concluded, “I don’t think I matter.” But he went on to mount a poetic defense for the role of bioethics. “It’s like astronomy,” he said. The sky is filled with stars too dim to make out. “We’re trying to look deeper, helping each other to see a little farther.”

I was most touched by Sevilla’s reply. “What should I do to make the biggest difference for the benefit of all?” he wondered out loud. Public policy? Business? Even activism can have a more direct impact than academic bioethics. “The reason I do it is probably just that this is what I am best at,” he said. “Do I make a difference with these ideas?” He hopes so.

–John Bohannon

Countries such as China and India have prospered with the help of jobs outsourced from the US. When there is an excess of need in one country and an excess of supply in another, both sides benefit–or so goes the economic mantra. But what about the trade of human organs?

There are some obvious problems with organ markets: the potential for coercion, exploitation, and bodily harm to the seller, just to name a few. Vigilant policing in a legalized system could (at least theoretically) keep these harms in check. But according to Nir Eyal, an ethicist at Harvard Medical School, we should consider a more fundamental problem: Organ markets treat the human body as a commodity.

Selling your kidney can yield quick cash, but you may feel shame and humiliation for the rest of your life. Eyal points out that sellers may also experience social stigma from their community, a diminished sense of self esteem, and a sense of victimhood. And for society as a whole, organ markets may compromise human dignity, leading to the view that one group of people are sub-human. (See Europe 1939 – 1945 for possible consequences.)

However, if you believe that global organ markets are not morally acceptable, you have a difficult case to argue. Some 200,000 people are waiting for a kidney transplant–and they are dying by the hour. On the other side, kidney donation is not a life-threatening procedure. You can live a full life with just one kidney. And for the absolute poor of the world–those living on less than $1 per day–the sale of a kidney could lift their entire community out of poverty and save yet more lives from preventable disease.

Can the eventual risks of a global organ market outweigh these benefits? Also, might banning the organ market only drive it underground, resulting in even more harm?

–Daphne Ezer & Kelly Dakin

After the final dinner of the NUBC conference, Peter Singer spoke about global poverty. (There was a vegan option on the menu, of course.) The world’s most famous bioethicist came full circle to the idea that launched his career. His 1972 article “Famine, Affluence, and Morality” challenged readers with the following tale:  You come across a child drowning in a pond. You can easily wade in and save the child, but you will have to sacrifice your brand new expensive shoes. What should you do? “If you just walk on by,” Singer told us last night, “we consider you a monster.” But is that really so different from what you’re doing right now by not helping any of the millions of children around the world dying needlessly of poverty-related illnesses?

Singer has a new book out–The Life You Can Save–and a new strategy for convincing affluent people to help the poor: Encourage everyone to give a very small amount of their disposable income. Singer admits that the amount is far less, according to his theory, than people are morally obliged to give. “But as a utilitarian,” he said, his goal is to obtain the best outcome possible. Ask people to be saints, and only a few will step forward. Ask them to be slightly generous and far more people will give, adding up to a far greater total effect. At the time of this writing, his website lists 1,570 people who have pledged to donate the charity he requests, which is adjusted according to the donater’s income. He even provides a global map of where these generous people reside. (It’s an impressive distribution.)

After the talk, I asked Singer about his wrangle with Stephen Colbert. “For the record, how much of the cost of your book is going to save the world’s poor?” Singer’s answer would have been a good reply to Colbert’s jab. “100% of the profits I receive from the sale of the book go to charity,” he said, adding with a note of disappointment that his share only amounts to about 10% of its $22 price. The rest goes to Random House. Singer tried to convince the publishing company to donate a portion of its profits to charity as well, but they refused.

So for the record, Singer is clearly not a hypocrite. He walks the walk. But I wonder, is he doing the right thing by asking the world to give far less to the poor than they should? Or is it better for a radical leader to stick to his radical message? Imagine if Jesus, instead of telling people to “turn the other cheek” when wronged, said, “Take your revenge, but don’t hit back quite as hard as you usually do.”

Is the world worse off in some way, even if Singer’s pragmatic strategy pays off?

–John Bohannon

At the end of his address at the National Undergraduate Bioethics Conference, Dr. Daniel Wikler posed a tough question to the audience. Two people need a liver transplant, one who is blind and one who is not. If there is only one liver available, who should receive the transplant?

According to a global health mantra, the sighted person should receive the transplant. This would amount to progress in global health, a small reduction in the burden of disease: A population of equal size that has one less person suffering from blindness is a healthier population.

Something about this answer feels repugnant, even for many who agree with the logic. There is no clearly desirable outcome in this situation. A human being will die regardless of the decision that is made. When facing such circumstances, perhaps the best we can do is to seek the lesser evil.

How would you decide who gets the liver? Save the blind person or the sighted? Or flip a coin?
–Kavin Sundaram

The field of bioethics is growing. More and more universities are incorporating bioethics into their programs and the exposure of major bioethical issues in the media is now a regular occurrence. Prenatal testing, new life-saving technologies, clinical testing of pharmaceuticals–these are just a few of the bioethical issues that we in the West hear about every day.

But Sarah Alsamarai of Boston College wonders: Are these the most important issues? Sarah emphasized that case-based bioethics often “applies primarily to wealthier, insured communities.” If people feel that both local and global bioethical issues are important, why is there so much focus on what Paul Farmer, American anthropologist and physician at Harvard, calls “quandaries of the fortunate?” The fact is that while there are many public health issues that are discussed within the bioethical community, they are often overtaken and overshadowed by topics that are more “popular” but an impact on far fewer lives–for example, preimplantation genetic testing.

As Sarah repeatedly noted, this tension does not imply that such case-based bioethical issues are not worth attention. Mainstream bioethics issues such as pharmaceutical testing need to be discussed. But collective bioethical issues, such as global health disparities, need to be brought to light. But journalists face the problem of a lack of interest on the part of media consumers.

Is this inequality of attention even something that can be fixed? What’s truly important to us, and what is there to be done about it?
–Richard Blissett

How much should a really rich guy give to the poor in order to not seem like “a complete A-hole?” Colbert asked last night. Singer’s answer: I don’t know, maybe 10%… Then Colbert notes that Singer’s book costs $22 and asks him how many lives that money could save.

I think Singer held his own. (It’s not his first time on the Colbert Report.) But what if he hadn’t? What if instead he came across as a hypocrite for not living up to his own philosophy? Should it matter for you and me? An idea should be considered on its own merits, not by the popularity or integrity of the person who puts words to it. Then again, most people have a different intuition, that you should “walk the walk” if you want to convince anyone of a radical idea, such as Singer’s claim that we should all be vegans who give away most of our disposable income to help those in the greatest need. (I’ll be checking what he eats tomorrow evening at the conference here.) [Editor:  See for yourself whether Singer is a hypocrite.]

But would it matter if Peter Singer turned out to be a meat-eating scrooge? Would his arguments be any less convincing?

–John Bohannon

I used to think journalists—especially when they cover tough topics like bioethics—get a bad rap for fumbling stories. Not today. Nope, today at the NUBC conference I haven’t heard a single person criticize the media for getting facts wrong, or sensationalizing a story, or explaining complex issues poorly.

Instead, at every turn, someone is lamenting that writers have missed a story altogether.

In his talk this morning on the tricky issues in treating adolescents with antidepressants, Steven Hyman noted how surprisingly prevalent suicide is: each year in the U.S. there are 20,000 homicides, but 30,000 suicides. Not what you’d expect by reading the papers, he said.

Of course: a murder and its investigation occasions a barrage of news coverage; a suicide does not. And surely it shouldn’t. Perhaps there, the complexity, and tragedy, demands instead a fuller treatment—a meaty feature story, an in-depth documentary.

Or maybe not. “People want to read about crises,” said Bonnie Steinbock, whom I talked to later in the morning. “And they want it made simple.”

Do we always tune out the substantive and the sticky in favor of the sexy?

Almost on cue, Dan Wikler sprinkled his talk this evening with assertions that the biggest bioethical conundrums around—the so-called “New Issues”—are the ones we’ve never heard about. We aren’t told about a disease unless it’s going to reach us in the privileged Western world. We aren’t made privy to the quantitative analysis undertaken in setting global public health priorities, because it’s just too mind-boggling.

Are there exceptions? Have you found yourself reading an article about a complex health issue so compelling that you couldn’t put it down?

—Megan Talkington

From where we stand in America, Africa seems so far away – an ocean and plagues of malaria, tuberculosis and tropical diseases away. Yet merely a hundred years ago, the southern United States had similar rates of malaria running rampant through its warm climate.

So what happened? The US eradicated malaria through mosquito nets and draining the swamps that bred infected mosquitoes. But what of Africa?  Dr. Lachlan Forrow discussed the issue in his seminar “Moral Responsibility and Health Disparities in the U.S. and Africa: Lessons from Dr. Albert Schweitzer” this afternoon.

Economically, it’s relatively cheap to prevent malaria using the same techniques that we used in America, and these techniques are known to be effective. So we have the measures to eradicate it – Dr. Forrow even mentioned a malaria vaccine that will be tested in a randomized clinical trial on March 31 – but the progress in Africa has not been anything like that experienced in the southern US.

So what is limiting us from helping Africa eradicate malaria? Are we morally obligated at all to help them?
–Asra Shaik