Where Shall We Go?

This issue of the Hastings Center Report coincides with the annual conference of the American Society for Bioethics and Humanities, whose theme this year is “Where do we stand?” The issue addresses that theme with the article by Debra Mathews and colleagues and the set of brief response essays that follow it. Mathews et al., drawing on work carried out by the Association of Bioethics Program Directors, pose questions about how to understand and evaluate the worth of bioethics research. Those questions require them to think very broadly about what bioethics is, in the first place, and how it is related to medicine, health policy, science, and society generally. In short, they are thinking at the highest level about the question, where do we stand?     

Daniel Callahan (1930–2019)

Daniel Callahan, cofounder of The Hastings Center, prodigious author, and pioneer in bioethics, died on July 16, 2019, three days before his eighty‐ninth birthday. Callahan created The Hastings Center with Willard Gaylin in 1969. He served as its director from 1969 to 1983 and president from 1984 to 1996, and he continued as a scholar and president emeritus until his death, publishing books and essays and leading research projects. Tributes published in the days following Callahan's death celebrated him for his role in creating bioethics, for his challenging questions and unconventional thinking, and for his ability to do incisive scholarship in a way that had a public impact.     

Chinese Bioethicists Speak Out on Covid-19, and Others Follow

Shortly after Wuhan, the city where the novel coronavirus was first identified, was placed on lockdown in January, I received an email from two Hastings Center fellows in China: Renzong Qiu, of Renmin University of China in Beijing, and Ruipeng Lei, of Huazhong University of Science and Technology in Wuhan. Attached was a post for our blog, Hastings Bioethics Forum, that raised ethical and legal questions about China's response. “Hegel says, ‘We learn from history that we do not learn from history,’” their piece began. “The recurrence of the coronavirus epidemic in China proves his insight to be right.” This bold report from bioethicists in China was courageous and eye-opening. It was among the first discussions in bioethics of what has since become a global crisis, and it turned out to be the first in a string of commentaries in Hastings Bioethics Forum with insights about the crisis, the issues it raises, and how the world should respond to it.     

Learning from a Pandemic

The Covid-19 pandemic has highlighted connections between health and social structural phenomena that have long been recognized in bioethics but have never really been front and center—not just access to health care, but fundamental conditions of living that affect public health, from income inequality to political and environmental conditions. In March, as the pandemic spread globally, the field's traditional focus on health care and health policy, medical research, and biotechnology no longer seemed enough. The adequacy of bioethics seemed even less certain after the killing of George Floyd, whose homicide showed in an especially agonizing way how social institutions are in effect (and often intentionally) designed to make the lives of black people go poorly and end early. Whether bioethics needs to be expanded, redirected, and even reconceived is at the heart of the May-June 2020 issue of the Hastings Center Report, which is devoted to questions provoked by and lessons emerging during this pandemic.     

Conservationism and Bioethics

The lead article in this issue of the Hastings Center Report (July‐August 2017) explores the ideas underpinning the Precision Medicine Initiative, the effort announced by President Obama in 2015 to promote the development of treatments adjusted to genetic and other variations. Authors Maya Sabatello and Paul Appelbaum hold that the effort works by appealing to a sense of collective identity and shared commitment—an understanding that they call the “PMI nation.” But what are the moral implications of this idea? Sabatello and Appelbaum's question about the impact of an imagined community is an unusual way of exploring a set of values questions. In the second article, Johann Brännmark defends what is, at least in bioethics, an unusual philosophical framework for moral values. Brännmark starts by calling attention to large, never‐quite‐solved problems with the field's going way of understanding personhood and autonomy, and then argues that the body of tradition, law, and international governance known as the human‐rights framework offers a solution to those problems. And a supplement to this issue offers a set of essays on a topic outside the usual range for bioethics: the prospect of “de‐extinction”—that is, of using genetic and reproductive technologies to construct simulacra of extinct animals that might eventually be introduced into the wild.      

Annual Award for an Essay by an Early‐Career Scholar

As part of the celebrations of The Hastings Center’s fiftieth anniversary, we are launching an annual prize, The David Roscoe Award for an Early‐Career Scholar’s Essay on Science, Ethics, and Society. The award is named in honor of David Roscoe, an accomplished essayist and recent past chair of the Hastings board. The award is intended to highlight the good scholarship that will take the field of bioethics forward into the next fifty years. It will recognize an early‐career scholar—someone who either is currently pursuing a relevant academic degree or has earned one within the last six years—for a published essay on the social and ethical implications of advances in science and technology. More information about the award, along with online submission forms, is available on The Hastings Center’s website.     

A Champion for the Unestablished

As a student in bioethics, I knew that The Hastings Center and its founders were the height of excellence in this field, and therefore I found them both intimidating and intriguing. When I began working there, Dan Callahan was supportive of my endeavors to provide a venue for students and other young writers to express their views on bioethics. I started my own blog called Bioethx under 25 that featured short essays by anyone who wished to submit, generally individuals who had a genuine philosophical interest but were not yet at the level of pursuing a Ph.D. Dan's support of my project culminated in his sponsorship of the Daniel Callahan Young Writer's Prize, an essay contest run through the blog. This was one of the many ways he demonstrated that making theoretical contributions to bioethics should not be limited to a select few.     

Telos versus Praxis in Bioethics

The authors of “A Conceptual Model for the Translation of Bioethics Research and Scholarship” argue that bioethics must respond to institutional pressures by demonstrating that it is having an impact in the world. Any impact, the authors observe, must be “informed” by the goals of the discipline of bioethics. The concept of bioethics as a discipline is central to their argument. They begin by citing an essay that Daniel Callahan wrote in the first issue of Hastings Center Studies. Callahan argued in this 1973 piece that bioethics had yet to attain the status of a discipline, and he lauded the freedom of being able to define a new discipline. Callahan's essay shares with Mathews and colleague's a peculiarity: neither ever defines what it means to refer to something as a “discipline.” To define a discipline does mean attending to the intended end product of scholarly activity, so I concur with Mathews et al.’s focus on outcomes. But I am concerned that in their argument they confusingly entangle their understanding of an academic discipline's internal goals, its telos, with its potential to have an impact on the external world, its praxis. The confusion that this can bring exposes what I believe is a profound problem within bioethics, the discipline's peculiar and at times intellectually hazardous relationship with its institutional hosts.     

An Ethical Obligation for Bioethicists to Utilize Social Media

In this issue of the Hastings Center Report, Mélanie Terrasse, Moti Gorin, and Dominic Sisti respond to recent efforts to address the “digital attention crisis,” arguing that “[b]ioethicists should make their voices heard in the debate on the responsibilities of social media companies toward their consumers and society at large.” I strongly agree. I have frequently been asked by my colleagues why I spend time on social media professionally, on top of all the competing demands associated with my work as a bioethicist and medical educator. There is sometimes a dismissive tone in these questions, a sense that attention to social media is beneath a bioethicist’s proper intellectual pursuits. Such perspectives overlook the extraordinary opportunities of social media and the important role for bioethics, as a field, in examining them.     

Religion and moral meaning in bioethics

Courtney S. Campbell observes that the practical dilemmas of bioethics often presuppose common questions of meaning about human nature, suffering, dying, and human destiny that are central to religious traditions.     

Bioethics and Addiction

Bioethicists have sometimes regarded the opioid epidemic as a problem with obvious answers and thus no need for the field's conceptual analysis. Yet, as three essays in the July-August 2020 issue of the Hastings Center Report demonstrate, the opioid crisis contains a knot of distinctions and puzzles to be sorted out. Travis N. Rieder examines, for example, what is fundamentally driving the crisis—access to the drugs or large societal problems such as poverty and joblessness. The role of choice in addiction, the effects of moral condemnation on approaches to addiction, and what treatment should look like are among the puzzles Hanna Pickard explores, while Daniel S. Goldberg focuses on the common and harmful conflation of the public health problems of substance misuse and pain. These philosophical and bioethical questions point in widely different directions, lying both inside and outside bioethics. They point toward systemic societal factors that determine health and well-being yet have seemed outside bioethics' largely clinical boundaries. And they point toward a deeper look at the very idea of autonomy—an examination of a topic clearly within bioethics yet occurring at the fringes of its usual constructs.     

Decisions and Authority

This issue of the Hastings Center Report (January‐February 2017) features three articles exploring aspects of decision‐making for others. In the first two, the focus is on the limits of surrogate decision‐makers’ authority when the surrogates’ judgments about a patient's treatment conflict with the physicians’. If a physician decides that a patient will not benefit from CPR, for example, but the patient's surrogate insists on it, is the physician obliged to proceed with the procedure? Or can the physician, pointing to a duty to provide good care to the patient and not to cause the patient to suffer, get a do‐not‐resuscitate order for the patient—even in the face of the surrogate's objections? These are the questions that animate the first article, in which a group of authors report on a policy implemented at Massachusetts General Hospital to help doctors who face this dilemma. The second article, by physician Jeffrey Berger, flips the questions. If a physician decides that a patient's intractable suffering requires palliative sedation, may the surrogate prevent it anyway? Or can the physician, pointing to a duty to alleviate the suffering, administer palliative sedation even in the face of the surrogate's objections? Such circumstances, says Berger, show the need for conceptual work delineating the limits of surrogates’ authority and practical work on mechanisms for doing so—protecting patients and giving physicians a clear route to follow.      

Emergence of a Discipline? Growth in U.S. Postsecondary Bioethics Degrees

Teaching competency in bioethics has been a concern of the field since its start. In 1976, The Hastings Center published the first report on the teaching of contemporary bioethics. Graduate programs culminating in an MA or PhD were not needed at the time, concluded the report. “In the future, however,” the report speculated, “the development and/or changing social priorities may at some point allow, or even require, the creation of new academic structures for graduate education in bioethics.” Although that future might be upon us, the creation of a terminal degree in bioethics has its detractors. Scholars have debated whether bioethics is a discipline with its own methods and theoretical grounding, a multidisciplinary field bringing various professional perspectives to bear on particular types of problems, a set of problem‐solving skills to resolve moral disagreements, or something else entirely. Whether or not efforts to develop the methods and theory of bioethics have matured to the point that it is now a discipline in the strictest sense, new bioethics training programs have appeared at all postsecondary levels. In this essay, we examine the number and types of U.S. programs and degrees in this growing field.     

Patient Welfare and Trust

This January-February 2020 issue marks the start of the Hastings Center Report's fiftieth volume. The issue introduces the column Looking Back, Looking Forward, which we plan to run in this volume only. Conceived by Hastings Center fellows Douglas Diekema and Lainie Friedman Ross, the column will explore the significance of landmark publications from the first fifty years of bioethics. For the first installment, Diekema looks at the unconventional moral position Hans Jonas took in his 1969 essay “Philosophical Reflections on Experimenting with Human Subjects.” In the lead article, “Trust, Risk, and Race in American Medicine,” Laura Specker Sullivan contextualizes patient mistrust within a history of racism in general and in the nation's biomedical research and clinical institutions specifically. Specker Sullivan proposes ways for individual clinicians to improve relationships with distrustful patients and their families. Two commentaries provide additional insights and recommendations about the work of earning patient trust.     

On the possibility of a pragmatic discourse bioethics: Putnam, Habermas, and the normative logic of bioethical inquiry

Pragmatic bioethics represents a novel approach to the discipline of bioethics, yet has met with criticisms which have beset the discipline of bioethics in the past. In particular, pragmatic bioethics has been criticized for its excessively fuzzy approach to fundamental questions of normativity, which are crucial to a field like bioethics. Normative questions need answers, and consensus is not always enough. The approach here is to apply elements of the discourse ethics of Habermas and Putnam to the sphere of bioethics, in order to develop a normative structure out of the framework of bioethical inquiry as it stands. The idea here is that the process of inquiry contains its own normative structure as it aims to discover norms. Such an approach, which fuses pragmatic bioethics with discourse ethics (which equally draws on pragmatism), may rightly be called a "Pragmatic Discourse Bioethics."     

Pediatric Drug Labeling and Imperfect Information

I first became aware of bioethics in the spring of 1980. I had spent a thirty-six-hour shift shadowing a medical resident, and I was struck that many of the resident's decisions had ethical dimensions. The next day, I came across the Hastings Center Report, and I realized I wanted to explore ethical issues I found implicit in clinical care, even though I still wanted to become a pediatrician. In September 2019, when I attended my first meeting of the U.S. Food and Drug Administration's Pediatric Advisory Committee, as a pediatric pulmonologist, I had the same sense of awe and curiosity that I had forty years ago. What had appeared initially as somewhat technical decisions about the regulation of drug labeling was suffused with ethical questions. The committee was asked to discuss possible changes to the labeling of two previously approved drugs.     

Reasons of the heart: emotion, rationality, and the "wisdom of repugnance"

Much work in bioethics tries to sidestep bedrock questions about moral values. This is fine if we agree on our values; arguments about human enhancement suggest we do not. One bedrock question underlying these arguments concerns the role of emotion in morality: worries about enhancement are derided as emotional and thus irrational. In fact, both emotion and reason are integral to all moral judgment.     

Why Bioethics Has a Race Problem

In the September‐October 2001 issue of the Hastings Center Report, editor Gregory Kaebnick encouraged bioethicists to turn their attention toward “easily overlooked, relatively little‐talked‐about societal topics” such as race. In 2000 the president of the American Society for Bioethics had called for a more socially conscious bioethics. Race was risky territory, Kaebnick pointed out, but this challenge did not justify avoidance. Over the next fifteen years, the response to this editor's invitation to examine the racial dimensions of medicine in the Report was limited both in quantity and in terms of the range of topics covered. All told, the bioethics community has not responded to the editor's call for bioethicists to engage with the racial dimension of medicine, and the Report has not really come through on the tacit commitment made in 2001. The lack of interest in race matters evidenced in the Report as well as the American Journal of Bioethics has also prevailed in medical humanities journals, whose few pieces on race have tended to remove race relations from our current realities in two ways: some articles locate medical racism in the American past or in colonial Africa, while others analyze the medical disorders of fictional characters. Bioethicists have not embraced the opportunity to create a sociologically and historically informed bioethics that might be applied to the lives of black Americans and their unending health crisis.