Introduction to Bioethics: Bioethics at the Bedside

[APPLAUSE] So about 20 years ago, I

found the field of bioethics, which is a field that asks

philosophers, along with lawyers, public policy folk, medicine,

nursing, medical anthropology, to come together to look at some of

the most challenging moral issues and policy issues that

our generation faces. Well, what do I mean by bioethics? So, one of the ways I think about it

is sort of what angels wouldn't have. So if you think about it, if there are

angels, they're incorporeal, immortal. I don't know, maybe they had

incredible ethical conundra, trying to figure out their

answers to moral questions. But it's not "bio"-ethics. So bioethics looks at

ethical issues that arise in virtue of

our biological nature, in virtue of the fact that we

are embodied and not just minds, and then we have the kinds of bodies,

that we are this kind of animal. It's a field that started in the

United States back in the 1970s. And cast your mind back

to history, this was a time of the Civil Rights Movement,

the time of the Women's Movement, when groups of people came

forward with new voices to assert that they had rights

that weren't being respected. And at just this time, another group

came along and said, we're patients, or we're clinical research participants. And we have certain

fundamental rights of autonomy that are not being respected. So some of this was due

to incredible abuses, to be honest, in clinical research. So the Tuskegee experiments, where

members of the United States Public Health Service actually enrolled

black, poor men who had syphilis, told them they were treating them, and

then intentionally withheld treatment even after it was

discovered, so that they could chart the course of the disease. Patients, who would

arrive ill and vulnerable, dealing with a physician, who out

of beneficence-- right? the desire to do good for the patient-- would

withhold information about a diagnosis. So you wouldn't know

that you were actually dying and able to share that with

your loved ones and make final plans, because the doctor was afraid that that

information would be too distressing. Or you would have surgery done

to you, far more extensive than you might have

understood at the time. For instance, a surgery with a

cesarean, if you were giving birth. And it turns out they just decided

it was time for a hysterectomy too, because you already had four kids. OK, so very fundamental sort of abuses. It gave rise, then, to a conversation

that, again, brought together philosophers, lawyers, humanities folks,

and medicine, and nursing, arguing that paternalism, the idea that doctors

know best or researchers know best, because they're benevolent,

that that might not be really the right model

for a couple of reasons. One is what is best

for you is actually not just a function of medical knowledge. It's also what you value. Right? With the chemotherapy,

are you more interested, if you face a difficult

diagnosis, having aggressive chemo so that you have lower quality of life

but longer quantity, or vice versa? Not surprisingly, people differ,

so you might want to ask. And second, even if the physicians

did know exactly what was best for you, if they're going

to intervene on this body, if they're going to

cut it open for surgery or hook it up to a machine, that is the

sort of decision that should be yours, that should belong to the

person who lives in that body, even if it's a terrible decision. Right? So even if the doctor

were right, you should have had the surgery, at the end of

the day, it's your decision to make. The appellate court in the United

States reached a landmark decision that said surgery on your body,

even if it's in your best interests, relative even to your values,

without your informed consent, is battery, a crime. You have to make the

decision, not the doctor. So bioethics was born in the '70s

in this crucible of patients' rights and the rights of those

participating in research. It's also evolved in

an incredibly rich way. So a second topic that

bioethics has turned to has to do with fundamental

issues about the environment. So as we begin to learn

that what humans have done, sometimes intentionally and

sometimes unintentionally, have led to profound challenges

for the survival of the planet-- not the stakes are very high-- it is

the moral issue of our generation. And the issue isn't just what

can we do scientifically? What can we do politically? There are also bioethical

issues, namely, issues about environmental justice. So one issue, who bears the burden

of pollution where it happens? OK, spoiler alert, it's not the

well-resourced and the rich. Here's a third topic

that bioethics looks at-- the fast-paced, crazy,

amazing world of biotechnology. So any of you who study

science likely have encountered some of the

really cool stuff we can do and stuff that's on the horizon. How about growing human

organs inside of pigs? I mean, after all, there's a

huge organ shortage, right? People are dying, waiting for a

kidney or a liver or a pancreas. Huge, worldwide crisis, also

yielding black market sales of organs, another bioethical issue. Some researchers have recently

accomplished the following. So they take a pig. They took a pig that was a white pig. And while it was an

embryo, they switched off the gene that's responsible for

developing the pancreas in the pig embryo. OK? Switched it off. They then inserted stem cells

from a black pig into that embryo, and let it grow. And what was born was a

really cute little piglet that was a white pig through and

through, except with a black pig pancreas. So researchers are wondering we could

do the same thing if we inserted human stem cells after turning off the

pancreas or the liver or the kidney. But bioethics also wants to

ask a different question. Do we want to start mixing

and matching in this way? So these animals are

called chimeras, which is simply a biological

creatures that has genetic material from two

different individuals. It actually occurs naturally

under that description. Sometimes, early nonidentical twin

zygotes, sometimes in early pregnancy, fuse together. Isn't that weird? And you'll get a baby,

a human baby, born with parts that are comprised

of different genomes. But we're talking about chimeras in the

more ambitious sense of actually doing a mash-up between two different species. So what should we think? How about transplanting human

brain cells into great apes so we can finally talk more? So as you can see, the world of

bioethics is a rich and broad one. And some of the issues

really are dealing with things that are

moving very quickly. But let's return to that first issue

I mentioned, that kind of founding question for bioethics. The issue about how patients

and physicians or nurses should understand their relationship,

one of paternalism or something else. That's a question that

isn't about technology. That's a question that's born of a

fundamental existential fact about us, and the fact that we're not

angels, that we get sick, that we die, that we need other

people's help and expertise, that when we are vulnerable to

illness, we have to present ourselves to a provider who belongs

to a profession, which comes from "professing," which is to make an

oath to act in the best interest of you and not her. But how much is it fair

to ask of that doctor? Here's a sobering fact, for those of

you who live in the United States. Less than half of American

physicians would recommend the career to their children. They worry that we

have so far swung away from paternalism, which was

a very problematic model, way over to a sort of consumer model

of medicine, where the patient is now a "client" and the doctor

or nurse is a "provider," and we want to optimize productivity. We're optimizing

productivity as measured in things like how much of

the surgical theater is used. And how many of the beds are

taken, as opposed to what patients and providers describe as

the most meaningful, both humanly and in healing terms, which is

having an interaction in human terms. So bioethics ranges from

almost sci-fi issues, all the way back to issues that are as

old as the human condition themselves. And all tracing back to the fact that

we are embodied creatures, embodied creatures who need one another,

face illness, give birth, manipulate our environment, explore new answers,

change ourselves, change the world, and the ethical issues

that arise from it. Thank you. [APPLAUSE]