Medical writer Daniel Callahan discusses ethics.
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GUEST: Daniel Callahan
I’m Richard Heffner, your host on The Open Mind. And my guest again today is Daniel Callahan, Co-founder and for a long time Director of the prestigious Hastings Center, everywhere renowned for its examination of ethical issues.
So today, not out of any meanness of spirit, mind you, but really out of just plain intellectual curiosity, I want to start off by asking my guest what may seem a perfectly impossible question: just which are the ethical issues that over the years have proven most intractable, most frustratingly difficult to resolve … if any such issues can ever be “resolved”. Then, too, what is the view of human nature, of what it means to be a human being that has informed my guest’s own approach to ethical issues. Dan?
CALLAHAN: Which have been the toughest questions over the years?
CALLAHAN: Well, I think I would make a distinction. You know there are two categories of tough questions. One category would be those issues that seem enormously difficult to get any agreement about what we ought to do in the first place. Abortion would be the classic case. Abortion is, of all the issues, I’ve looked at over the years, I wrote my first book in this field on abortion, it’s the one where the public has remained really utterly at odds and the public opinion polls have it … really utterly divided in our society on that topic. And it hasn’t changed much in the 35 years since I started looking at it. There aren’t … I don’t think there are any other issues that have been quite as intractable as that one. When most of … an awful lot of the problems that are difficult, are of another kind that is where you get a fair amount of agreement on where we want to go, but endless disagreement about the best means of getting there. For instance, the whole problem of getting decent universal health care in this country. I think everyone would say “yes” we certainly want good health care for everyone including the poor, but then you get in a million arguments about how to do it, how to pay for it, and so forth and so on.
HEFFNER: Ethical issues.
CALLAHAN: Well, ethical issues because you have … well, I understand ethics rather broadly. You have some people that say, “my gosh, the government should do it.” And then you have a lot of people of a more conservative bent or very suspicious of the government, and they would like to see the market do it. Or just say, “well let’s get …”, they’re not very good at actually finding … coming up with a totally helpful solution. But in any case we then get into political and ideological arguments about the best way to deal with this problem. So that one has been … a lot of agreement on the goal, but impossible to get any agreement on the means, so therefore we’ve had no health care reform, the situation get worse and worse. I think the questions then that we dealt with in the previous program on the care of the dying … is that everybody says “yes, it would be wonderful to have a peaceful death”. But there’s a lot of disagreement as to whether we’d say want euthanasia and physician assisted suicide is one way to get a peaceful death. And there seem to be all sorts of other psychological and technological obstacles to a peaceful death, so that even though we agree it’d be a great thing, we don’t … haven’t really totally found, by any means found the way to get there in any reasonably consistent way. I think there are going to be some … there have been a lot of interesting struggles that haven’t been quite so important, say … where research should go. Should research try, for instance, to increase average life expectancy significantly. There have been some debate on that one. Again, some say “yes”, some say “no”. But it hasn’t … it’s had a little science fiction flavor so it hasn’t been quite the … it’s been a somewhat more speculative kind of debate.
HEFFNER: Explain yourself.
CALLAHAN: Well …
HEFFNER: The science fiction aspect.
CALLAHAN: Well, the science fiction aspect … people have been talking, actually for centuries about the possibility of science discovering the secret of human aging. Why is it that we grow old and we die? And then recently because of genetic research there has been more, more speculation, “well, maybe we’ll eventually find the genetic causes of aging and we’ll eventually find out a way to intervene within those causes and significantly increase average life expectancy. Right now it’s up around 80, at least in the most developed countries. And the thought is we might get it to average up to 100 or 150, and there were some people that said, “well, great, let’s go for it”. And others, like myself say, “that’s not a great way to … that’s not really a very sensible sort of goal”. So, it … we’ll certainly get debates on issues like … I think the whole genetics movement is going to bring lots of interesting debates. Again, right now they’re a little on the speculative side. For instance, how much choice should parents have over the genetic qualities of their children? I mean again, the people … they’re either visionaries or science fiction addicts. Who say at some point parents are going to say “Well, I want a child that tall, I want that child to have blue eyes. I want a child who wont’ get very fat over life. I want a child who’s smart, I want a child who’s got a good memories. And here, here doctor, is my list of specifications”. And the doctor says “fine, we can genetically do that”. And this … I mean this is not a crazy idea. It may, indeed, be possible.
HEFFNER: You say many say that. Are there a very great many who say that?
CALLAHAN: Well, I think many … many … well, let’s put it this way. The whole research in genetics has working below it the idea that an awful lot of human life is determined in great part, not totally, but is determined by our genetic make up. And certainly our predisposition to disease is genetically, I mean, very important. Our … obviously we know just a … you didn’t need modern genetics that if two tall people married, they’re more than likely to have a tall, rather than a short child. If two intelligent people are probably going to have a somewhat more intelligent child and so forth and so on. So, we’ve had some inkling of the importance of genetics. But now since we’re really going to have the tools pretty soon to, to directly get in there, directly manipulate things, and perhaps begin sort of producing babies on specification and then do a lot of other … once we understand the genetic basis of disease, we’re in a position to really begin seriously eradicating disease in a way that has not been possible to date. So, it’s still … it hasn’t been done. It’s still talk, so to speak. But the scientists are increasingly confident that they are getting the knowledge that will enable. Will it happen? Who knows, we’ll see.
HEFFNER: And the theologians on this issue?
CALLAHAN: Well, you get an interesting split. I would … there are some, it’s sort of a liberal … ??? interestingly these issues to it, is a kind of Liberal/Conservative split.
HEFFNER: How so in this area?
CALLAHAN: Well, in this area … well, I would say there’s a rather common Conservative response, I probably represent that to some extent. Of saying “well, is our problem that we haven’t had enough genetic control?”. I mean after all, it is well known that all of … Nazi leaders … they have IQS over … they were very smart. So if we want to genetically improve average intelligence, is there any evidence that the great human woes come from being dumb, as somebody … one of my colleagues … Leon Casselman(???), as far as we know, no one with Down’s Syndrome has ever started a war or gone out and created massacres … it usually … often it smart people who got who’ve got bad moral ends and goals that create these problems.
HEFFNER: So we manipulate those.
CALLAHAN: Well, the thing is … if we … unfortunately there’s been a lot of speculation about manipulating aggression. The problem there is that certain aspects of aggression are very helpful, they keep us alive. They help us to defend ourselves and how to begin to figuring out how to tinker with that in a way that you would keep the things that we want with aggressive … the valuable part of aggressiveness and get rid of the part that isn’t valuable. I think that … many would say, well, that’s a little … then you’re going to do very delicate kind of balancing. And I don’t know of … it’s interesting … of all the speculation around … a lot of speculation about improving intelligence, improving memory, improving health. I don’t see much talk about improving dealing with aggressiveness and those traits. There used to be … twenty, thirty years ago … there were people pushing that idea very much. But it turned out to be awfully difficult, even theoretically to decide what would be the right balance between some aggressiveness is protective of human life. And how to get the right balance and not get too much or too little, one way or the other.
HEFFNER: You say, Dan, twenty, thirty years ago, this was more of an issue.
CALLAHAN: Well, it was. You may remember the psychologist Kenneth Clark …
CALLAHAN: … and Kenneth Clark was a great, great proponent of that idea, he said that’s where research should go. And we really should find out what is the basis for human aggressiveness? And then the critics really came back and said, “well, aggressiveness is a very complex kind of thing”. There are probably evolutionary reason why we’re aggressive. This is probably, it’s probably something very fundamental to our nature, and if you begin changing that, you may change a lot of other things. And in any case, what we know is that we don’t like people that star wars. But when you think of wars, they … wars are usually started by people who, I think, classically, because they’ve got some bad … some bad moral ideas … they’ve got some idea of a) what they want, and somebody else has and they want it. That’s one reason, or because they have some theory of the world, as with Communism … you know … “we know how the world should be run”. And I would say this is a kind of moral feeling rather than a genetic feeling. And so … and even with aggressiveness, we know some countries are quite … the US has a terrible problem with aggressiveness, and guns and the like. But other countries, English, Japanese … you know they have much lower murder violence rates. So, it’s not clear just what the genetic component here is anyway, so …
HEFFNER: Do you think that the lessened interest in aggression … concern about aggression could in any way be equated with a, an “anything goes economic” marketplace philosophy that has come to prevail certainly in these last 24 years?
CALLAHAN: I, I … I’m not sure about that. I suspect … when I say that, let me … I don’t think there’s a lesson in ??? aggressiveness, but there’s lesson … there’s lessened drive to think that science is going to come up with the ultimate answer to that question. I think the emphasis now is much more on shaping values that people … trying to educate people and inculturate them in a fashion that will make them less aggressive. That it’s not, it’s not going to be medicine that’s going to find the cure to aggressiveness, it’s going to be a social practice, a social policy, moral values.
HEFFNER: Dan, what about this question of marketplace values?
CALLAHAN: Well …
HEFFNER: Ethical questions. Have they proved to be of concern?
CALLAHAN: Well, I … well, I actually am now managing an International Project entitled “Medicine and The market”, I’m very interested in how market thinking and practices are influencing health care. And certainly in this country, the great development over the past ten years have been the large movement to commercialize a lot of medicine. Health maintenance organizations which most of us are part of, the majority are now “for profit”. Medicine thirty or forty years ago was almost all non-profit. You had religious hospitals, and public hospitals, and community hospitals, but the whole move now to turn these into, to make money off of this … has been a powerful move, and I think this has had a shaping, very seriously, the values of medicine and the practice of medicine. Why is this happening? I think it’s partly because it’s been very difficult. Modern medicine is very expensive, it gets more expensive … governments find it hard to pay for. Employers, there’s a limit to how much they can spend. So there’s a tendency to sort of throw out into the private sphere and make it another commodity. The problem, though, is … I think it’s the very nature of medicine to think of medicine as simply any other … as somebody one said, “it’s like selling shoes”. I mean some people want one kind of shoe and one others, and you have the same rule. Well, medicine traditionally has been an altruistic institution. It’s purpose is to serve other people, it’s not to serve oneself. The market, at least at part of its philosophical foundation is that people act out of self-interest and you should play to that self interest. Well, medicine, certainly at least in its ideals with physicians has said, “you’re not in this for you, you’re in this to help your patient”. But when you begin … you bring in money and you begin attracting people to behave certain ways on the basis of whether to make more or less money, you inevitably shape the values a different way.
HEFFNER: Well, certainly at this table there’s been a lot of talk about “the professions” … medicine … law … journalism. And the marketplace. And that’s why I guess I, I asked the question.
CALLAHAN: Well, I think it’s … I think it’s been an interesting phenomenon over twenty years to see how we’ve commercialized more and more … I was once a swimmer in my youth. But in those days you really had such a thing as amateur sports. Gone. I mean the Olympics, you had to be an amateur. Now, it doesn’t matter, you can … and there’s no such thing as amateur sports essentially any more. And there, because I think everybody said, “well, people are always getting a little money under the table, and why shouldn’t people, why shouldn’t college athletes … now there’s much more open talk”. We should understand that we’re hiring athletes to be entertainers in colleges, and don’t pretend, this is not an educational venture at all. So, I, I … and of course, even the interesting debates in journalism as to the extent to which people in journalism should go on the lecture circuits, should sort of sell themselves as celebrities and personalities. And of course, the basic concern that an awful lot of television even in the news department is too much oriented toward the entertainment rather than the hard news. And, so it’s, it’s out there. And medicine, particularly, since it’s a … I think it’s probably, it used to be the second largest industry or something, after the auto industry in the country. There’s a huge amount of money at stake. Of great concern now is in the universities where people in medicine and biology, who one time basically was a non-profit business, but now they take … start up companies … they take stock in things … they work for pharmaceutical companies and a whole different way of thinking about medicine and thinking about research as well has crept in, and this has only been over a relatively short time.
HEFFNER: What’s your own ethical fix on that question?
CALLAHAN: I think it’s … I think it’s both inevitable and hazardous. I think it’s very difficult in an affluent society which believes it’s perfectly okay to make money, to tell one group of people, “no, you have to live a sort of a monastic life, you have to have much higher ideals than everyone else”. I think it, in short I think a lot of physicians, very strikingly after the Second World War … before the War it was understood that you didn’t make much money in medicine, it had that certain social prestige. But you didn’t get wealthy. But by the time the seventies and eighties came around you had physicians in some specialties making $500,000, $750,000, a million dollars a year. And everybody thought “well, that’s you, why not? They’re saving lives, they’re doing good things”. Now, so I think it was partly the times and but, also they’re just … when you have a lot of money floating around I think things tend to get corrupted and it’s very hard for people to resist it. And you combine that with a certain social attitude, which I think came in with the Reagan years and then we, “why not make money? Why not do good at … both …
HEFFNER: Do well and do good?
CALLAHAN: If you’re doing good, you might as well do well. I used to joke that I’d been lecturing in medical school … I said I’d been in every … with the exception of Rolls Royce, I’ve been in every luxury car made because I was usually picked up by the Chairman of some department or other who had the latest BMW, Mercedes, what-have-you, it was really wonderful.
HEFFNER: Because of this new belief.
CALLAHAN: Because of this new belief. And they … and physicians are well paid. Now if you’re in a family practice or primary care, you may not … I mean you do okay, $110,000, $120,000, $130,000. But if you’re in some of the sub-specialties, you’re likely, almost certain to make over $300,000 … a big difference.
HEFFNER: Dan, as alluring as that is, I’m not going to go to medical school at this stage of my life.
HEFFNER: But I am going to ask you a question that I raised at the very beginning. What do you see as the personal imperatives that inform your own position as you’ve examined these ethical issues? What does it mean to be a human being?
CALLAHAN: Well, I think I’m very much in the camp of those who, who really start with the notion of community. I think part of the human life, and a fundamental part is living a life with other people. That’s how we get shaped by it. We’re raised by other people, we’re raised by our parents, we’re influenced by our culture, by our society.
HEFFNER: But does that mean that your concerns are for the community, or that your concerns are for you and yours and living in the community.
CALLAHAN: Well, I think they’re a little of both. It seems to me that one of the powerful values in this country is our individualism. We really … and in medicine the great … there’s been autonomy … people should have choice about everything. How they are born … parents should have choice about their children … you should have choice about how you die, you should have choice which doctors you go to, and choice about which treatments they offer you. So very powerful value. The problem for me is that that value is so strong that we, we fail … it pushes aside the fact that we are interdependent people, we are interdependent as a species, we’re interdependent as a culture. So I … my approach is always to ask the question … of particularly of medicine and medical advances … not “Will this help me or my family? But what will this do for the community as a whole? What is going to be the social benefit of this?” The issue I alluded to earlier, extend average life expectancy. Well, I might want this and maybe I could life a happy life that way. But the more important question is, is this something that society needs. Will we socially benefit from this advance? And there … and I want to keep asking that question all the time. Because I don’t think I can … myself or my family can live a good life unless I’m in a culture and a society which sort of wants us all to life a good life. So if we … and that’s what I like about Europe. In Europe, where they have universal health care … every body has a guaranteed good health care. Their great value is not a right to health, but solidarity, the notion that we’re all in this together, we all are subject to disease and illness. And everybody should be protected against it as far as possible by the government. And in Europe … in this country we believe everybody should have fire protection, police protection and Defense Department to ward off our enemies. In Europe they would say, of course, “why wouldn’t you put in health care? Health care is as fundamentally important as a social benefit, as any of those other things?” We don’t do it here because I think we are too individualistic and we’ve resisted that.
HEFFNER: But then I still h ave to ask you, what informs that attitude? It’s not “I’m alright, Jack, the devil take the hindmost”. Just the opposite.
CALLAHAN: You mean, where does it come from?
HEFFNER: Where does it come from?
CALLAHAN: Well, I suppose it’s my own … I suppose it’s my own perception of, of my own thinking about what it takes for individuals to live well and what it takes to have decent well functioning societies. Plus my observations of going to countries …and I’ve spent a lot to time traveling to different countries and I’ve been particularly interested in what … seeing what kind of general philosophy, so to speak, pervades those countries and begins to shape the social and cultural life of those countries. So it’s a combination of trying to think about what, what we as individuals need, and at the same time, which kind of societies seemed to have functioned most effectively and in a way most conducive to the happiness and satisfaction of their citizens.
HEFFNER: Looking back at all your years at Hastings. Do you think that concept of ones responsibility, of who I am, what I am, what I should be doing is more dominant, less dominant … more prevalent …
CALLAHAN: I think it’s …
HEFFNER: … less prevalent.
CALLAHAN: I think it’s less prevalent today. I remember one very distinguished physician who was among the early founders of The Hastings Center, who said … he said the greatest change he had seen in his lifetime was … he was Protestant, New Englander, patrician New Englander. He said, “I was raised in my family and by my culture with the notion of my obligations to society” And he said the great change is the switch to ‘what society owes me” as distinct from “what I owe the society”. And I think and I said that was a profound insight. And I think that’s very powerful now. I think that’s one of the reasons we don’t have universal health care. We, since the majority of the people in this country get pretty decent care through their employer, there’s not much concern about the 45 million who don’t get care. It’s “I am doing okay, Jack”, so why … and if we reform the whole health care system to help them, I may lose, so I’d better stick with what I’ve got. And I’m sorry about them, but that’s just the way life is.
HEFFNER: What happens to us, then if that … the observation of that older, patrician physician was true then, and you feel it’s become even truer. What happens to us as a people?
CALLAHAN: Well, I, I think we do become more selfish and do become more self-centered. We do become, I think, become poorer citizens. I, I suspect … I mean the general … phenomenal decline in the number of people who vote. I think they don’t feel they have a stake in this society. They don’t have a sense of being a part of a community any longer. A symbol of this is the gated residential community where people … basically you have enough money, you move into a suburb and you have guards and you have walls and you live a happy life. And hope that all that other world doesn’t come over the fence and get in the gate. And I think when you have more and more people who … I think a lot of people do have that attitude. That this is a … that life is a fairly competitive situation. You’ve got to do the best you can. You don’t want to pay taxes because that helps a lot of other people, or leads to big government. So you want to have … minimize your social obligations and maximize your personal desires and interests.
HEFFNER: You get around a lot. Around the world. Is that the trend now, or do you differentiate between them and us on that level?
CALLAHAN: I do differentiate. I think there are lots … I mean there are some countries which really just have terrible cultures and it’s still nasty, and they don’t seem to have any values at all, there are certainly some of them around. But, I would say my strong sense, at least of Western Europe, Australia, some … a number .. and some of the central European countries even, they really are community oriented. I mean very striking differences. For instance, we here in New York City … you want a public toilet, there are no public toilets. We don’t have them on the streets. And a lot of restaurants won’t let you in to use their. The Europeans … the question of whether you can go in the restaurant and they’ll have public toilets, and they’re clean public toilets. And, of course, public transportation is much stronger. I’m fascinated by a common phenomenon … in Europe if you go into a restaurant and it’s very crowded and there’s a table for four people … and there are two people sitting there, you go and sit at their table. Doesn’t happen in the U.S. So there … and they absolutely believe you have to … everybody has to have good health care, and they’re willing to … they don’t like to pay taxes any more than we do, and there’s a ???? and the taxes increase. But they say, “but that’s one thing you give everybody.” So they do have a sense that in order to have a good society you have to have more solidarity, you have to make sure that you’ve got a sort of a decent base for everybody. It’s fine if you want to get rich, but make sure that the poor people get, get … have a pretty good deal as well.
HEFFNER: What’s the future … in the minute or so that we have remaining … what’s the future of the kinds of concerns that the Hastings Center has had?
CALLAHAN: Well, essentially we’ve been concerned with the ethical problems of modern medicine and its progress the technology generates. I think there’s a lot of concern about those problems. I think, though, we are a very pluralistic … we’re a very divided society, and we’ll probably end up arguing about a lot of these matters. But it’s very difficult, I think, forever. So my own inclination … we’ll probably solve many of these issues, we’ll probably go … drift one way or the other and the question’s will we drift in good ways or bad ways. And that’s still an open question. Because it’s one thing to raise the ethical issues and debate them. Buy people differ on the ethics as they differ on … as they do with politics. And there’s no way to control any of this.
HEFFNER: And you wouldn’t, if you could.
CALLAHAN: No, I wouldn’t if I could.
HEFFNER: Dan Callahan, thanks so much for joining me again on The Open Mind.
CALLAHAN: Nice to be here, Dick.
HEFFNER: And thanks, too, to you in the audience. I hope you join us again next time. If you would like a transcript of today’s program, please send four dollars in check or money order to: The Open Mind, P. O. Box 7977, F.D.R. Station, New York, New York 10150
Meanwhile, as an old friend used to say, “Good night and good luck”.
N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.