The Way It Used To Be
If you are like me--a baby boomer; the first generation raised by TV--then you are sure to remember Drs. Kildare, Ben Casey, and Marcus Welby. They were TV icons of what doctors had become for us: dependable, trustworthy, wise, and virtuous. Fr. Schmemann liked to tell the story of how after preaching for many years about the promise of eternal life, a parishioner came to him to declare that it was true after all! Doctors,--"doctors! no less," Fr. Alexander would groan--had recently conceded that there might be life after death. Only now could his parishioner believe. Jesus and all of the saints might be doubted, but a doctor is trusted! And there you have it. After more than two-thousand years of medical history, after many trials and setbacks, doctors had won such respect. That success story, should you have the time to read it, is well and amply told in The Greatest Benefit to Mankind: A Medical History of Humanity by Roy Porter (W.W. Norton and Company, 1997). After over 700 pages documenting the ascent of medicine, Porter concludes--rightly, as I see it--that today medicine's "triumphs are dissolving in disorientation" (p. 718). Something revolutionary has recently occurred in medicine and in medical ethics that can only be described as disorientation. In the following paragraphs I will try to describe all too briefly what has happened to generate such disorientation and what it means for ethics and for us.
From Medical Ethics to Bioethics
It will help at the start to make a distinction between medical ethics and bioethics. While such a distinction is not made or maintained by all ethicists, "bioethics," a term coined in the '70s, was created just so as to mark a real difference. Changes have occurred in the last thirty-or-so years that have dramatically and essentially revolutionized the practice of ethics in relation to medicine. The change is of such a magnitude that some scholars claim that what is being done today is so unlike the medical ethics of the last few thousand years, that a new name is appropriate. A helpful, and not so dated, overview of these changes is "The Metamorphosis of Medical Ethics: A 30 Year Retrospective" by Ed Pellegrino (I recommend anything written by Dr. Pellegrino. This article is found in JAMA 1993, pp. 1158-1162. JAMA, Journal of the American Medical Association, may be found in most public libraries). A longer, book-length account would be The Birth of Bioethics by Albert R. Jonsen (Oxford University Press, 1998), from whom I draw freely. So, what has happened? A revolution, nothing less, has occurred--and is, perhaps, still in progress--in at least three areas. There has been a crisis in medicine. There is a social revolution in progress. Lastly we are undergoing a dramatic transformation in how we conceive of and grasp being a self, of how we understand what it is to be a person.
Three Revolutions that have changed us
The first crisis was one of trust. The post W.W.II years were a time when the trust and confidence won by doctors eroded. For centuries doctors have been essentially those who cared, there was little that could be cured. A wound might be closed, a broken bone could be set, but care and not cure was the doctor's strength. An explosion of new technology seemed, at first, to be a boon for doctors. Not just care but cure was now within reach. But was modern medicine to be trusted with the new technology? Was it and the doctor always a friend? Nazi medicine and the Nuremberg Trials of 1945 suggested that medicine could be cruel and callous. It was revealed that at Tuskegee, physicians were infecting African-Americans with syphilis just to observe the course of the malady. In November of 1962, Life magazine published an article, "They Decide Who Lives, Who Dies." The article's title says it all. Few my age will ever forget the drug thalidomide, aggressively marketed by Merrell Pharmaceuticals. Dr. Christian Barnard ('67) transplanted a human heart from a dead person, but was the donor really dead, we wondered? From Karen Ann Quinlan's respirator ('76) to Dr. Barney Clark's artificial heart ('82), we were forced to ask if doctors brought us relief or more pain?
If we began to doubt medicine and doctors, we did so from out of a rejection of paternalism and in favor of individualism. Marcus Welby was only one show removed from "Father Knows Best," but did they always know and do what was best for us? African-Americans and women, among others, began to ask if merely being black or female resulted in different and inferior treatment. In 1973 the book Our Bodies, Our Selves sold no less than 350,000 copies.
A third change, no less revolutionary, has been a change in how we view ourselves. Americans--using a metaphor borrowed from business and the free market--began to demand that all relating be free, informed, and uncoerced. Doctors could not do what they thought best, but rather must enter into a contractual relationship. We expected results to be guaranteed and would turn to the law for recourse. Patterns of trust had dissolved and Americans turned to the ways of the market place, a place that was familiar and thus navigable, for guidance. As we had discovered with marriage--and recently with children--we were (and still are) to discover about medicine: Once surrendered to the ways of the market place, things could never be the same.
The Responses of Bioethicists
When all of this began there was no college degree in bioethics to be got and no bioethicists. The first responses came from theologians. Theologians had their ancient traditions of morality and, so, were the first with resources that would allow them to engage the new questions. Joseph Fletcher (the author of "Situation Ethics"), Paul Ramsey (from Princeton University), and Fr. Richard McCormick, S.J., all made significant contributions. Some notions first found in Catholic moral theology have found an enduring place in contemporary secular medical ethics. For example, the principle of double effect (that one can intend a good act that might also have another unintended bad effect) and the distinction between extraordinary and ordinary (that one need take ordinary but not extraordinary steps) are a commonplace in contemporary bioethics, to include Orthodox ethics.
Soon, however, religious responses seemed inadequate. Something was needed that was not so particular, so sectarian, but could be employed to resolve the bioethical dilemmas of those who were neither Catholic nor Protestant. In short, we needed some principles to guide us that all could accept. Soon religious ethics would be subordinated to medical ethics. (Not everyone is happy with this change: Read "How Christian Ethics Became Medical Ethics" in Wilderness Wanderings, Westview Press, 1997, by the brilliant Methodist Theological Ethicist Stanley Hauerwas.)
The next step in bioethics might be called the "Turn to Principles." James F. Childress and Tom Beauchamp published Principles of Biomedical Ethics ('79). To greatly simplify their work, it might be said that, according to Childress and Beauchamp, we need only four principles to make decisions in medical ethics. These principles are: beneficence, nonmalficience, justice, and autonomy. It would seem that this model of applying principles to medical problems has won the day. There are those who suspect, however, that all of the guiding principles actually collapse in American practice into just one, autonomy.
While other models for doing medical ethics are being suggested, it would seem for now that the ascendant model is one of principles. This means that in America medical ethics is thought of in terms of acts, problems, and rules. This need not be so: Ethics might be imagined not as act-oriented but person-oriented (i.e., asking what sort of person are we becoming); not simply problem-oriented but whole-life-oriented (which is to claim that not just an occasional problem, but all that we do has to do with morals); and not rules- but skills-oriented (which means that knowing the rules isn't enough, but that we need to gain wisdom). Not only is there little in the current and dominant model for doing medical ethics that encourages us to reflect on questions of moral development, but there is scant room for concerns over relationships and our institutions. For example if a patient claiming autonomy--the right to do whatever she/he wants to do--demands euthanasia, can we require that effort be spent asking what such a demand does to the doctor-patient relationship? Can we insist that we must also consider how such a demand alters our institutions? As a problem-solving, rules-governed approach, contemporary medical ethics of the sort described above is the "tool" that we have hammered out to do the job, but it may not be so rich and nuanced a device as to allow us to engage the richer concerns of virtue, wisdom and community.
Every day, new questions
New areas of bioethical concern seem to appear almost every day. Topics that we might examine include issues surrounding death and dying, health care, human reproduction, transplantation, artificial organs, genetics, and cell therapy. And that wouldn't come near to exhausting the possible list. If I were to select one topic that, for the moment at least, illustrates both the dangers and the promise of recent research, it would be research centering on the human cell.
Attempts to manipulate the next generation (a sort of "genetic engineering") are at least as old as herdsmen. There is ample evidence that early in human history cattle were bred and plants crossed so as to direct and even improve the next generation. At the risk of being indelicate, royal families--but perhaps not only they--might on occasion entertain similar considerations. But the recent history of genetics began when Gregor Mendel in 1865 described the rules for inherited traits. As early as 1902, Walter Sutton demonstrated that chromosomes hold genetic information, and, in the same year, Hans Spemann divided a salamander embryo to demonstrate that early cells already had all of the needed information for a new salamander. Frogs were cloned in 1952 by Robert Briggs and Thomas King. Watson and Crick in 1953 discovered the double helix structure of DNA and received the Nobel Prize for their work in 1962. The British biologist J.B.S. Haldane coined the term "clone" in 1963. By 1969 the first gene had been isolated. In 1980, the U.S. Supreme Court ruled that one could get a patent for organisms designed in the laboratory. The project to map every human gene (the Human Genome Project) began in 1990--it is now near completion. Dolly, the first animal cloned from adult cells, was "born" in 1996 as a result of the work of Ian Wilmot. New and more efficient methods of cloning have since been developed by Teruhiko Wakayama and his colleagues at the Univ. of Hawaii. Their technique will probably be used to make transgenic cattle, allowing cattle to produce human proteins and drugs.
More complicated than cloning is using knowledge of the genetic code to correct "defects" that cause disease. Religious ethicists (to include Orthodox) seem somewhat more comfortable with the idea of somatic cell than with germ cell interventions. The difference is that an inherited disease (like cystic fibrosis) might be alleviated by correcting the genetic code in a body or somatic cell, but influencing germ or reproductive cells would entail whole generations of change. To many, germ cell therapy raises the specter of eugenics, engineering for the perfect race.
Even more current is the subject of stem cells. Stem cells are those cells present early in embryo development that seem to be "pluripotent." They are able to grow into almost any sort of cell. Stem cells might be able to grow into liver cells, heart cells, etc. Research in this area, according to some, promises the possibility of growing cells to cure Alzheimer's, Parkinson's, osteoporosis, spinal cord injuries, as well as most cancers. Since these cells are most often derived from human embryos, the National Bioethics Advisory Commission had recommended that such research not be funded. This year the commission reversed itself and recommended funding research involving stem cells derived from unused embryos made by in vitro fertilization, since, the commission reasoned, these would be discarded anyway. Orthodox, of course, would oppose the use of human embryos for such purposes. However, a researcher at the University of Massachusetts has announced that he made an organism by merging a cell from his cheek with a cow egg. He claims to have found stem cells in this... well, what was it?
A Few Conclusions
The disorienting whirl of recent research might prompt us to seek easy shelter, a retreat where such burdens do not exist. Already voices in the Orthodox community encourage us to back away from, as they see it, a de-Christianized world with which we have nothing in common. But if creation now has nothing in it of God, then we have managed to destroy God's will. The claim that God can be altogether forced from His creation by us is a heresy, because without grace there can be no nature. Let me suggest an area of promise where I had expected none.
A few years ago I would have said that we were well on the way to mercy-killing shops, euthanasia centers presided over by the likes of Jack Kevorkian, but I was wrong. While the Oregon initiative passed and while there is legalized euthanasia there, it is not the case that there has been a rush to euthanasia in Oregon or elsewhere. Rather, as I see it, and if recent congressional hearings and statements by the AMA and others is any indication, there has been a realization that the widespread fear by the ill and elderly of suffering and abandonment prompted the widespread support of Americans for legalized euthanasia. Medical associations across the country have testified that proper palliative (pain-killing) care is what has been missing. Pain management is actually available so that no one need experience the person-destroying burden of unrelieved pain. Daniel Callahan (of the Hastings Center) has written that death "requires a spiritual, not scientific, remedy" (First Things 42). To die, even of cancer, being cared for by others, with pain controlled, loved, is not something to be ashamed of but an example of a spiritual remedy, medicine of the soul. Orthodox, rightly, claim that death is an enemy, but we mean death understood as any separation from God. Dying can be filled with God's transforming Spirit in Christ, when such happens then dying is a sacrament. The Spirit is not confined to our churches, to be sure. It is our work to find the "all things new" even in recent bioethics. We will not remedy the "poverty" of recent bioethics by turning from it.
What resources have we? Let me suggest some Orthodox authors: You might read Fr. John Breck's recently published The Sacred Gift of Life: Orthodox Christianity and Bioethics. Any of the many works by Fr. Stanley Harakas will repay your study with a firm foundation in Orthodox ethics. Vigen Guroian, a professor of theology at Loyola, Baltimore, publishes works using Armenian and other Orthodox sources. I find that the works of Christos Yannaras--translated, unless you read Greek--tough reading but full of insights. Fr. Alexander F.C. Webster, while not working in bioethics, will also engage the reader in moral debate. H. Tristram Engelhardt--a newly converted "Orthodox Catholic," but well-known in bioethics--puts his MD and Ph.D. to work in The Foundations of Bioethics (Oxford, 1996). These authors are available at seminary bookstores.
Fr. Joseph Woodill earned the Ph.D. in ethics from Fordham University, and he is the author of The Fellowship of Life: Virtue Ethics and Orthodox Christianity (Georgetown University Press, 1998). He is the Acting Rector of St. Mary Orthodox Church in Waterbury, Connecticut. This article was published in Jacob's Well.