The President's Council's important report.

Health and medicine explained.
March 9 2004 2:42 PM

Beyond Politics

Why have bioethicists focused on the President's Council's dismissals and ignored its remarkable work?

Book cover

Leon Kass, the University of Chicago social theorist and bioethicist, has had the misfortune to chair the President's Council on Bioethics under a man who inspires more revulsion among academics than any president since Richard Nixon. Last week, 170 academic bioethicists sent a petition to President Bush protesting the dismissal of two members of the council, the cell biologist Elizabeth Blackburn and the ethicist William May. (To read Timothy Noah on the dismissals, click here.) Blackburn had told the press she was dismissed because she clashed with Kass, and ethicists have been quick to assume that the two members were dismissed for ideological reasons. Perhaps it is a sign of our strange, politically charged times that the composition of the council can generate protests and petitions from bioethicists while its actual work has been largely ignored.

This is a shame. The council, which was formed in 2001 to advise the president on ethical issues surrounding medicine and biotechnology, has recently published the findings of a two-year project in a report titled Beyond Therapy: Biotechnology and the Pursuit of Happiness. As the title suggests, the report concerns the use of drugs and surgery that not only make sick people well but make well people better than well. Americans take Paxil for shyness, Provigil for sleepiness, Adderall for poor concentration, Ativan for anxiety, Humatrope for short stature, Propecia for baldness, Xenical for obesity, beta blockers for stage fright, designer steroids for poor athletic performance, and Viagra for poor sexual performance—and that's not even counting the possible future technologies on the table, from memory managers to genetic enhancement to longevity drugs. Beyond Therapy asks not whether it is right or wrong to use such technologies, but rather, what are the implications of these technologies, what will they mean for us "as individuals, as members of American society, and as human beings eager to live well in an age of biotechnology"?

Advertisement

Journalists have heaped praise on Beyond Therapy for its eloquence, but what little comment bioethicists and scientists have offered has had a decidedly grumpy tone. David Magnus of the Stanford Center for Biomedical Ethics has written that Beyond Therapy fails because the "council members have been too blinded by their own conservative ideology." University of Pennsylvania bioethicist Arthur Caplan told Nature Biotechnology that it was "a politically conservative report" that espouses "the quasi-religious view that the natural is good." Elizabeth Blackburn, the former council member, has objected that the report implies that immortality is the goal of age-retardation research. The editors of Nature Biotechnology, in a mocking editorial titled "Beyond Belief," simply parodied the abstract style of the report and concluded by saying, "There are times for getting to the damn point."

It's difficult to know what to make of these comments. The stated aim of the report is to produce philosophical reflection, not advice. The report issues no guidelines or policy recommendations, which is why it is an odd target for left versus right debates. Instead, it reads like a scholarly book. Beyond Therapy is about 300 pages in length and is divided into four main sections: "Better Children," "Superior Performance," "Ageless Bodies," and "Happy Souls." The careful philosophical style of the report parodied by the editors of Nature Biotechnology is, admittedly, unlike any government document I have ever read, but I count that as a strong point in its favor.

The truly striking thing about Beyond Therapy is how just radically at odds it is with mainstream American culture, right and left alike. The report is skeptical of America's faith in technology, worried about America's radical individualism, alarmed at the transformation of medicine from a profession into a business, and deeply concerned about the role of the market in driving the demand for new medical technologies. Beyond Therapy may not please many bioethicists, but neither will it please the libertarian or the business-conservative wings of the Republican Party. When was the last time you heard a Republican complain, as the council does, that the pharmaceutical industry is expanding diagnostic categories as a way of selling drugs or express concern that it "can manufacture desire as readily as it can manufacture pills"? As much as it pains me to admit that anything worthwhile could come from a council appointed by the Bush administration, Beyond Therapy is a remarkable document: gracefully written, thoroughly researched, ideologically balanced, and philosophically astute. It will be a benchmark for all future work on the topic.

Although Beyond Therapy defies easy summary, one of its larger philosophical themes is the notion of control. Many aspects of our selves are obviously not directly under our conscious control: our memories, our genetic constitution, our physical appearance. What would it mean to think of our own identities, and those of our children, as objects to be shaped and molded? Once we begin thinking of something as an object of control, it begins to look different to us: less like nature and more like art, less a gift than a project. For example, when parents are allowed to choose the genotype of their children—not to prevent disabling illnesses but to satisfy their vision of the child that they want—procreation begins to look uncomfortably like manufacturing and children like products. Beyond Therapy warns of the dangers of seeing our children as instruments of our own desires. "A man and a woman do not produce or choose a particular child, as they might buy a particular brand of soap," writes the council. "Rather, they stand in relation to their child as recipients of a gift. Gifts and blessings we learn to accept as gratefully as we can." (Controlling the genotype of a child may sound like science fiction, but in at least one way, it is already here; some IVF clinics allow parents to choose the sex of their children.)

The council also recognizes that today we are encouraged to use medical technology not merely to improve ourselves but to alter our identities. For the most part, we embrace this possibility. This is America, after all, where self-invention is a way of life. If there were something inherently wrong with self-transformation, we would have to give up on, for example, the idea of rehabilitating criminals. The issue is not whether self-transformation is wrong but under what circumstances it has a moral cost. How would I change as a person if I routinely used psychopharmacology to blunt my memory of trauma and my experience of grief? To what extent is a personality produced and maintained by psychopharmacology my own personality?

Is the council ideologically stacked? The answer isn't as simple as the press has suggested. According to council transcripts, one of the dismissed members, Elizabeth Blackburn, has missed about half of the council's meetings. The other, William May, has issued a statement saying that he had joined the council with the expectation that he would leave when his two-year term had expired. Yet the council does have ties that cannot help but inflame the most paranoid liberal suspicions—for example, to the Ethics and Public Policy Center. The EPPC publishes the journal the New Atlantis, whose editors include council staffers Eric Cohen and Yuval Levin and which has published the work of a number of council members. Until 2001, the EPPC was led by Elliott Abrams, the former Reagan administration official convicted of lying to Congress during the Iran-Contra affair, making the EPPC not merely a right-leaning think tank but one of the rare ethics institutes to be directed by a convicted felon.

The critical ideological divide may be less right versus left than techno-skepticism versus techno-enthusiasm. Americans tend to embrace technology, but it is worth remembering that the history of technology is not one of allayed progress. It is also the history of what Edward Tenner has called "the revenge of unintended consequences"—sophisticated car alarms that erupt so often that nobody trusts them, paperless offices that generate more paper than ever before, kudzu vines introduced to prevent soil erosion that wind up choking trees and enveloping entire farms. When we ourselves become the objects of technological control, the stakes multiply dramatically. As the council understands, we need to approach that prospect not just with caution but with humility.

Carl Elliott is a professor at the Center for Bioethics at the University of Minnesota and author of White Coat, Black Hat: Adventures on the Dark Side of Medicine.