Bioethics for Everyone

By Norman Fost

Arthur Caplan is the Babe Ruth of medical ethics. He looks like the Babe—a healthy, affable, stout man, who enjoys life, and is universally liked. Like the Babe, he is prodigiously productive, with a curriculum vitae that must have more pages than many academics have publications. To most Americans, he is the best known player in the field and has done more than anyone to make bioethics a household word. Just as the Yankees built a giant stadium to house the Babe’s activities, the University of Pennsylvania established a major program to lure Caplan from the University of Minnesota. He does not wear a number on his back, but if he did, it would surely be retired when he steps down.

There are other parallels between Caplan and the Babe. Just as the Babe could do many things well (he was a record-breaking pitcher before he decided to concentrate on hitting), Caplan can write and talk to the ivory tower academic and the layman with equal ease. He is the undisputed master of the sound bite, but he is also a well-trained philosopher of science who has written finely argued analytic articles. He has also done empirical work, joining with social scientists to define the facts that are essential to making responsible policy.

Like most popularizers of complex subjects, Caplan is often criticized by experts in his field. Some of this is mere envy. Some of the criticism, however, is based on a more serious concern about the role of the ethicist—an ill-defined title—in public policy and public education. There are legitimate questions about the nature or even existence of expertise in ethics. (Caplan, in fact, has written one of the better essays on this subject.) The worst suspicion is that ethicists are little more than sophists, spinmeisters whose major expertise is in articulating clever arguments to support their personal views, which are ultimately as subjective as anyone else’s.

Although it is self-serving to say so, I think that there is more to ethics than that, particularly in the case of bioethics. For those who want to take bioethical issues seriously, whether for personal or policy reasons, there are better and worse ways of making decisions. One of the better ways is to know the relevant facts, have a full appreciation of the competing interests, have a clear understanding of opposing points of view, and be able to support one’s decision with arguments that are at least understandable to others. Caplan’s writings offer major assistance to those who share these goals.

This book is a collection of essays and articles, some previously published, most appearing for the first time, on a wide array of current controversies in ethical issues in health care, from Auschwitz to the XYY syndrome. At an average length of 11 pages, these are more than sound bites but something less than analytic philosophy. They are a useful starting point for the educated person who wants an accessible entree to thinking about questions such as: “What, if anything, is wrong with transplanting organs from animals to humans?” “What rules should govern the dissemination of useful data obtained by immoral experiments?” “Are there moral issues in fetal research that should trouble those who are liberal on abortion?”

As with most controversies in bioethics, intelligent consideration of these questions requires knowledge or skills from several disciplines, including medicine, law, analytic philosophy, and social sciences. Part of Caplan’s success as an educator is his firm grasp of all these elements and his ability to collect critical thinking from experts in those fields and weave them into a coherent essay. He also succeeds because of his extensive experience among clinicians, philosophers, lawyers, and policymakers. He is fully capable of being an academic, whether writing a finely reasoned argument in a scholarly ethics journal or joining with social scientists in explicating public attitudes on important policy issues. Although some of these essays are adapted from leading academic journals, the intended audience is not primarily scholars but the general reader, health professional, or policymaker who wants an introduction to a particular issue.

For every person who is suspicious of the glib, opinionated ethicist, there is someone else who is weary of the “two-handed” ethicist who presents all the relevant facts and arguments but scrupulously avoids judgment. Not to worry. Although Caplan is capable of presenting both sides of an argument, his own views are almost always in plain view. He is at his most enjoyable when he is most confident about the rightness of his position. In a piece about Dr. Jack Kevorkian and assisted suicide, he raises the familiar point that a major cause of Kevorkian’s success is the failure of physicians to offer adequate pain management. The point has been made by many but rarely as pungently as this: “The failure has nothing to do with a lack of general knowledge about pain control. It has to do with inadequate training, callous indifference to patient requests for relief, and culpable stupidity about addiction.”

Naturally, it is when he is most assertive (for example, “I believe that any form of compensation for cadaver organs and tissues is immoral”) that scholars will be most critical of his failure to present the issue in sufficient nuance or depth. It is impossible for anyone as prolific as Caplan to be completely consistent. One of his arguments against incentives for organ donation is that “No factual support has been advanced for the hypothesis that payment will increase cadaver donation.” Critics might point out that the policy he is most associated with—a federal law requiring that relatives be asked if they want to donate organs when it is medically appropriate—became national policy without much evidence that it would achieve the desired result. To his credit, Caplan has acknowledged the disappointing results of this policy elsewhere.

The essays vary along the spectrum from one-handed opinion to two-handed balance. Both can be effective. Sometimes it is the highly opinionated teacher who stimulates the most thinking, provoking the student to come up with counter-arguments. When Caplan is at his most opinionated, the clarity and pungency of his writing provide a useful template for organizing one’s own thinking. On the other hand, perhaps the most impressive essay in this collection is a short but lucid discussion of the increasing skepticism among some scholars regarding the definition of death. This is an extremely complicated issue, highly susceptible to opaque metaphysical discourse as well as oversimplification. Caplan does a remarkable job of explaining the issues in a balanced way, conveying the complexity, and offering a sensible political justification for the status quo.

Another reason for Caplan’s appeal is that he is not easily pigeon-holed into traditional political categories. He is sometimes libertarian, believing, for example, that competent people should have considerable latitude to use the new reproductive technologies; but there is a paternalistic element to his insistence on more regulation of infertility clinics. His views are generally centrist and reflect an attempt to find the middle ground. He argues against publication of results that were obtained from immoral experiments but supports the use of ill-gotten data that is already in the public domain, provided certain additional requirements are met, including disclosure that the information was obtained immorally. He is troubled about the spread of assisted suicide but understands that “legalization may be a good even for those who choose not to take this path. The mere fact that the opportunity for help in dying exists may help some persons to endure more disability or dysfunction than they otherwise might have been willing to face.”

An educated friend with no background in medicine, law, or ethics asked me to recommend a book that would introduce him to rational discourse in bioethics without putting him to sleep. I can recommend this book to such a novice at the same time as I find it informative and thought-provoking for someone such as myself who has spent most of his adult life thinking about these issues.