Conservative bioethics' latest, most dangerous ploy.
This spring, the President's Council on Bioethics released a 555-page report, titled Human Dignity and Bioethics. The Council, created in 2001 by George W. Bush, is a panel of scholars charged with advising the president and exploring policy issues related to the ethics of biomedical innovation, including drugs that would enhance cognition, genetic manipulation of animals or humans, therapies that could extend the lifespan, and embryonic stem cells and so-called "therapeutic cloning" that could furnish replacements for diseased tissue and organs. Advances like these, if translated into freely undertaken treatments, could make millions of people better off and no one worse off. So what's not to like? The advances do not raise the traditional concerns of bioethics, which focuses on potential harm and coercion of patients or research subjects. What, then, are the ethical concerns that call for a presidential council?
Many people are vaguely disquieted by developments (real or imagined) that could alter minds and bodies in novel ways. Romantics and Greens tend to idealize the natural and demonize technology. Traditionalists and conservatives by temperament distrust radical change. Egalitarians worry about an arms race in enhancement techniques. And anyone is likely to have a "yuck" response when contemplating unprecedented manipulations of our biology. The President's Council has become a forum for the airing of this disquiet, and the concept of "dignity" a rubric for expounding on it. This collection of essays is the culmination of a long effort by the Council to place dignity at the center of bioethics. The general feeling is that, even if a new technology would improve life and health and decrease suffering and waste, it might have to be rejected, or even outlawed, if it affronted human dignity.
Whatever that is. The problem is that "dignity" is a squishy, subjective notion, hardly up to the heavyweight moral demands assigned to it. The bioethicist Ruth Macklin, who had been fed up with loose talk about dignity intended to squelch research and therapy, threw down the gauntlet in a 2003 editorial, "Dignity Is a Useless Concept." Macklin argued that bioethics has done just fine with the principle of personal autonomy--the idea that, because all humans have the same minimum capacity to suffer, prosper, reason, and choose, no human has the right to impinge on the life, body, or freedom of another. This is why informed consent serves as the bedrock of ethical research and practice, and it clearly rules out the kinds of abuses that led to the birth of bioethics in the first place, such as Mengele's sadistic pseudoexperiments in Nazi Germany and the withholding of treatment to indigent black patients in the infamous Tuskegee syphilis study. Once you recognize the principle of autonomy, Macklin argued, "dignity" adds nothing.
Goaded by Macklin's essay, the Council acknowledged the need to put dignity on a firmer conceptual foundation. This volume of 28 essays and commentaries by Council members and invited contributors is their deliverable, addressed directly to President Bush. The report does not, the editors admit, settle the question of what dignity is or how it should guide our policies. It does, however, reveal a great deal about the approach to bioethics represented by the Council. And what it reveals should alarm anyone concerned with American biomedicine and its promise to improve human welfare. For this government-sponsored bioethics does not want medical practice to maximize health and flourishing; it considers that quest to be a bad thing, not a good thing.
To understand the source of this topsy-turvy value system, one has to look more deeply at the currents that underlie the Council. Although the Dignity report presents itself as a scholarly deliberation of universal moral concerns, it springs from a movement to impose a radical political agenda, fed by fervent religious impulses, onto American biomedicine.
The report's oddness begins with its list of contributors. Two (Adam Schulman and Daniel Davis) are Council staffers, and wrote superb introductory pieces. Of the remaining 21, four (Leon R. Kass, David Gelernter, Robert George, and Robert Kraynak) are vociferous advocates of a central role for religion in morality and public life, and another eleven work for Christian institutions (all but two of the institutions Catholic). Of course, institutional affiliation does not entail partiality, but, with three-quarters of the invited contributors having religious entanglements, one gets a sense that the fix is in. A deeper look confirms it.
Conspicuous by their absence are several fields of expertise that one might have thought would have something to offer any discussion of dignity and biomedicine. None of the contributors is a life scientist--or a psychologist, an anthropologist, a sociologist, or a historian. According to one of the introductory chapters, the Council takes a "critical view of contemporary academic bioethics and of the way bioethical questions are debated in the public square"--so critical, it seems, that Macklin (the villain of almost every piece) was not invited to expand on her argument, nor were mainstream bioethicists (who tend to be sympathetic to Macklin's viewpoint) given an opportunity to defend it.
Despite these exclusions, the volume finds room for seven essays that align their arguments with Judeo-Christian doctrine. We read passages that assume the divine authorship of the Bible, that accept the literal truth of the miracles narrated in Genesis (such as the notion that the biblical patriarchs lived up to 900 years), that claim that divine revelation is a source of truth, that argue for the existence of an immaterial soul separate from the physiology of the brain, and that assert that the Old Testament is the only grounds for morality (for example, the article by Kass claims that respect for human life is rooted in Genesis 9:6, in which God instructs the survivors of his Flood in the code of vendetta: "Whoso sheddeth man's blood, by man shall his blood be shed, for in the image of God was man made").
The Judeo-Christian--in some cases, explicitly biblical--arguments found in essay after essay in this volume are quite extraordinary. Yet, aside from two paragraphs in a commentary by Daniel Dennett, the volume contains no critical examination of any of its religious claims.
How did the United States, the world's scientific powerhouse, reach a point at which it grapples with the ethical challenges of twenty-first-century biomedicine using Bible stories, Catholic doctrine, and woolly rabbinical allegory? Part of the answer lies with the outsize influence of Kass, the Council's founding director (and an occasional contributor to TNR), who came to prominence in the 1970s with his moralistic condemnation of in vitro fertilization, then popularly known as "test-tube babies." As soon as the procedure became feasible, the country swiftly left Kass behind, and, for most people today, it is an ethical no-brainer. That did not stop Kass from subsequently assailing a broad swath of other medical practices as ethically troubling, including organ transplants, autopsies, contraception, antidepressants, even the dissection of cadavers.
Kass frequently makes his case using appeals to "human dignity" (and related expressions like "fundamental aspects of human existence" and "the central core of our humanity"). In an essay with the revealing title "L'Chaim and Its Limits, " Kass voiced his frustration that the rabbis he spoke with just couldn't see what was so terrible about technologies that would extend life, health, and fertility. "The desire to prolong youthfulness," he wrote in reply, is "an expression of a childish and narcissistic wish incompatible with devotion to posterity." The years that would be added to other people's lives, he judged, were not worth living: "Would professional tennis players really enjoy playing 25 percent more games of tennis?" And, as empirical evidence that "mortality makes life matter," he notes that the Greek gods lived "shallow and frivolous lives"--an example of his disconcerting habit of treating fiction as fact. (Kass cites Brave New World five times in his Dignity essay.)
Kass has a problem not just with longevity and health but with the modern conception of freedom. There is a "mortal danger," he writes, in the notion "that a person has a right over his body, a right that allows him to do whatever he wants to do with it." He is troubled by cosmetic surgery, by gender reassignment, and by women who postpone motherhood or choose to remain single in their twenties. Sometimes his fixation on dignity takes him right off the deep end:
Worst of all from this point of view are those more uncivilized forms of eating, like licking an ice cream cone--a catlike activity that has been made acceptable in informal America but that still offends those who know eating in public is offensive. ... Eating on the street--even when undertaken, say, because one is between appointments and has no other time to eat--displays [a] lack of self-control: It beckons enslavement to the belly. ... Lacking utensils for cutting and lifting to mouth, he will often be seen using his teeth for tearing off chewable portions, just like any animal. ... This doglike feeding, if one must engage in it, ought to be kept from public view, where, even if we feel no shame, others are compelled to witness our shameful behavior.
And, in 2001, this man, whose pro-death, anti-freedom views put him well outside the American mainstream, became the President's adviser on bioethics--a position from which he convinced the president to outlaw federally funded research that used new stem-cell lines. In his speech announcing the stem-cell policy, Bush invited Kass to form the Council. Kass packed it with conservative scholars and pundits, advocates of religious (particularly Catholic) principles in the public sphere, and writers with a paper trail of skittishness toward biomedical advances, together with a smattering of scientists (mostly with a reputation for being religious or politically conservative). After several members opposed Kass on embryonic stem-cell research, on therapeutic cloning (which Kass was in favor of criminalizing), and on the distortions of science that kept finding their way into Council reports, Kass fired two of them (biologist Elizabeth Blackburn and philosopher William May) and replaced them with Christian-affiliated scholars.
Though Kass has jawboned his version of bioethics into governmental deliberation and policy, it is not just a personal obsession of his but part of a larger movement, one that is increasingly associated with Catholic institutions. (In 2005, Kass relinquished the Council chairmanship to Edmund Pellegrino, an 85-year-old medical ethicist and former president of the Catholic University of America.) Everyone knows about the Bush administration's alliance with evangelical Protestantism. But the pervasive Catholic flavoring of the Council, particularly its Dignity report, is at first glance puzzling. In fact, it is part of a powerful but little-known development in American politics, recently documented by Damon Linker in his book The Theocons.
For two decades, a group of intellectual activists, many of whom had jumped from the radical left to the radical right, has urged that we rethink the Enlightenment roots of the American social order. The recognition of a right to life, liberty, and the pursuit of happiness and the mandate of government to secure these rights are too tepid, they argue, for a morally worthy society. This impoverished vision has only led to anomie, hedonism, and rampant immoral behavior such as illegitimacy, pornography, and abortion. Society should aim higher than this bare-bones individualism and promote conformity to more rigorous moral standards, ones that could be applied to our behavior by an authority larger than ourselves.
Since episodes of divine revelation seem to have decreased in recent millennia, the problem becomes who will formulate and interpret these standards. Most of today's denominations are not up to the task: Evangelical Protestantism is too anti-intellectual, and mainstream Protestantism and Judaism too humanistic. The Catholic Church, with its long tradition of scholarship and its rock-solid moral precepts, became the natural home for this movement, and the journal First Things, under the leadership of Father Richard John Neuhaus, its mouthpiece. Catholicism now provides the intellectual muscle behind a movement that embraces socially conservative Jewish and Protestant intellectuals as well. When Neuhaus met with Bush in 1998 as he was planning his run for the presidency, they immediately hit it off.
Three of the original Council members (including Kass) are board members of First Things, and Neuhaus himself contributed an essay to the Dignity volume. In addition, five other members have contributed articles to First Things over the years. The concept of dignity is natural ground on which to build an obstructionist bioethics. An alleged breach of dignity provides a way for third parties to pass judgment on actions that are knowingly and willingly chosen by the affected individuals. It thus offers a moralistic justification for expanded government regulation of science, medicine, and private life. And the Church's franchise to guide people in the most profound events of their lives--birth, death, and reproduction--is in danger of being undermined when biomedicine scrambles the rules. It's not surprising, then, that "dignity" is a recurring theme in Catholic doctrine: The word appears more than 100 times in the 1997 edition of the Catechism and is a leitmotif in the Vatican's recent pronouncements on biomedicine.
To be fair, most of the chapters in the Dignity volume don't appeal directly to Catholic doctrine, and of course the validity of an argument cannot be judged from the motives or affiliations of its champions. Judged solely on the merits of their arguments, how well do the essayists clarify the concept of dignity?
By their own admission, not very well. Almost every essayist concedes that the concept remains slippery and ambiguous. In fact, it spawns outright contradictions at every turn. We read that slavery and degradation are morally wrong because they take someone's dignity away. But we also read that nothing you can do to a person, including enslaving or degrading him, can take his dignity away. We read that dignity reflects excellence, striving, and conscience, so that only some people achieve it by dint of effort and character. We also read that everyone, no matter how lazy, evil, or mentally impaired, has dignity in full measure. Several essayists play the genocide card and claim that the horrors of the twentieth century are what you get when you fail to hold dignity sacrosanct. But one hardly needs the notion of "dignity" to say why it's wrong to gas six million Jews or to send Russian dissidents to the gulag.
So, despite the best efforts of the contributors, the concept of dignity remains a mess. The reason, I think, is that dignity has three features that undermine any possibility of using it as a foundation for bioethics.
First, dignity is relative. One doesn't have to be a scientific or moral relativist to notice that ascriptions of dignity vary radically with the time, place, and beholder. In olden days, a glimpse of stocking was looked on as something shocking. We chuckle at the photographs of Victorians in starched collars and wool suits hiking in the woods on a sweltering day, or at the Brahmins and patriarchs of countless societies who consider it beneath their dignity to pick up a dish or play with a child. Thorstein Veblen wrote of a French king who considered it beneath his dignity to move his throne back from the fireplace, and one night roasted to death when his attendant failed to show up. Kass finds other people licking an ice-cream cone to be shamefully undignified; I have no problem with it.
Second, dignity is fungible. The Council and Vatican treat dignity as a sacred value, never to be compromised. In fact, every one of us voluntarily and repeatedly relinquishes dignity for other goods in life. Getting out of a small car is undignified. Having sex is undignified. Doffing your belt and spread- eagling to allow a security guard to slide a wand up your crotch is undignified. Most pointedly, modern medicine is a gantlet of indignities. Most readers of this article have undergone a pelvic or rectal examination, and many have had the pleasure of a colonoscopy as well. We repeatedly vote with our feet (and other body parts) that dignity is a trivial value, well worth trading off for life, health, and safety.
Third, dignity can be harmful. In her comments on the Dignity volume, Jean Bethke Elshtain rhetorically asked, "Has anything good ever come from denying or constricting human dignity?" The answer is an emphatic "yes." Every sashed and be-medaled despot reviewing his troops from a lofty platform seeks to command respect through ostentatious displays of dignity. Political and religious repressions are often rationalized as a defense of the dignity of a state, leader, or creed: Just think of the Salman Rushdie fatwa, the Danish cartoon riots, or the British schoolteacher in Sudan who faced flogging and a lynch mob because her class named a teddy bear Mohammed. Indeed, totalitarianism is often the imposition of a leader's conception of dignity on a population, such as the identical uniforms in Maoist China or the burqas of the Taliban.
A free society disempowers the state from enforcing a conception of dignity on its citizens. Democratic governments allow satirists to poke fun at their leaders, institutions, and social mores. And they abjure any mandate to define "some vision of 'the good life'" or the "dignity of using [freedom] well" (two quotes from the Council's volume). The price of freedom is tolerating behavior by others that may be undignified by our own lights. I would be happy if Britney Spears and "American Idol" would go away, but I put up with them in return for not having to worry about being arrested by the ice-cream police. This trade-off is very much in America's DNA and is one of its great contributions to civilization: my country 'tis of thee, sweet land of liberty.
So is dignity a useless concept? Almost. The word does have an identifiable sense, which gives it a claim, though a limited one, on our moral consideration.
Dignity is a phenomenon of human perception. Certain signals from the world trigger an attribution in the mind of a perceiver. Just as converging lines in a drawing are a cue for the perception of depth, and differences in loudness between the two ears cue us to the position of a sound, certain features in another human being trigger ascriptions of worth. These features include signs of composure, cleanliness, maturity, attractiveness, and control of the body. The perception of dignity in turn elicits a response in the perceiver. Just as the smell of baking bread triggers a desire to eat it, and the sight of a baby's face triggers a desire to protect it, the appearance of dignity triggers a desire to esteem and respect the dignified person.
This explains why dignity is morally significant: We should not ignore a phenomenon that causes one person to respect the rights and interests of another. But it also explains why dignity is relative, fungible, and often harmful. Dignity is skin-deep: it's the sizzle, not the steak; the cover, not the book. What ultimately matters is respect for the person, not the perceptual signals that typically trigger it. Indeed, the gap between perception and reality makes us vulnerable to dignity illusions. We may be impressed by signs of dignity without underlying merit, as in the tin-pot dictator, and fail to recognize merit in a person who has been stripped of the signs of dignity, such as a pauper or refugee.
Exactly what aspects of dignity should we respect? For one thing, people generally want to be seen as dignified. Dignity is thus one of the interests of a person, alongside bodily integrity and personal property, that other people are obligated to respect. We don't want anyone to stomp on our toes; we don't want anyone to steal our hubcaps; and we don't want anyone to open the bathroom door when we're sitting on the john. A value on dignity in this precise sense does have an application to biomedicine, namely greater attention to the dignity of patients when it does not compromise their medical treatment. The volume contains fine discussions by Pellegrino and by Rebecca Dresser on the avoidable humiliations that today's patients are often forced to endure (like those hideous hospital smocks that are open at the back). No one could object to valuing dignity in this sense, and that's the point. When the concept of dignity is precisely specified, it becomes a mundane matter of thoughtfulness pushing against callousness and bureaucratic inertia, not a contentious moral conundrum. And, because it amounts to treating people in the way that they wish to be treated, ultimately it's just another application of the principle of autonomy.
There is a second reason to give dignity a measure of cautious respect. Reductions in dignity may harden the perceiver's heart and loosen his inhibitions against mistreating the person. When people are degraded and humiliated, such as Jews in Nazi Germany being forced to wear yellow armbands or dissidents in the Cultural Revolution being forced to wear grotesque haircuts and costumes, onlookers find it easier to despise them. Similarly, when refugees, prisoners, and other pariahs are forced to live in squalor, it can set off a spiral of dehumanization and mistreatment. This was demonstrated in the famous Stanford prison experiment, in which volunteers assigned to be "prisoners" had to wear smocks and leg irons and were referred to by serial numbers instead of names. The volunteers assigned to be "guards" spontaneously began to brutalize them. Note, though, that all these cases involve coercion, so once again they are ruled out by autonomy and respect for persons. So, even when breaches of dignity lead to an identifiable harm, it's ultimately autonomy and respect for persons that gives us the grounds for condemning it.
Could there be cases in which a voluntary relinquishing of dignity leads to callousness in onlookers and harm to third parties--what economists call negative externalities? In theory, yes. Perhaps if people allowed their corpses to be publicly desecrated, it would encourage violence against the bodies of the living. Perhaps the sport of dwarf-tossing encourages people to mistreat all dwarves. Perhaps violent pornography encourages violence against women. But, for such hypotheses to justify restrictive laws, they need empirical support. In one's imagination, anything can lead to anything else: Allowing people to skip church can lead to indolence; letting women drive can lead to sexual licentiousness. In a free society, one cannot empower the government to outlaw any behavior that offends someone just because the offendee can pull a hypothetical future injury out of the air. No doubt Mao, Savonarola, and Cotton Mather could provide plenty of reasons why letting people do what they wanted would lead to the breakdown of society.
The sickness in theocon bioethics goes beyond imposing a Catholic agenda on a secular democracy and using "dignity" to condemn anything that gives someone the creeps. Ever since the cloning of Dolly the sheep a decade ago, the panic sown by conservative bioethicists, amplified by a sensationalist press, has turned the public discussion of bioethics into a miasma of scientific illiteracy. Brave New World, a work of fiction, is treated as inerrant prophesy. Cloning is confused with resurrecting the dead or mass-producing babies. Longevity becomes "immortality," improvement becomes "perfection," the screening for disease genes becomes "designer babies" or even "reshaping the species." The reality is that biomedical research is a Sisyphean struggle to eke small increments in health from a staggeringly complex, entropy-beset human body. It is not, and probably never will be, a runaway train.
A major sin of theocon bioethics is exactly the one that it sees in biomedical research: overweening hubris. In every age, prophets foresee dystopias that never materialize, while failing to anticipate the real revolutions. Had there been a President's Council on Cyberethics in the 1960s, no doubt it would have decried the threat of the Internet, since it would inexorably lead to 1984, or to computers "taking over" like HAL in 2001. Conservative bioethicists presume to soothsay the outcome of the quintessentially unpredictable endeavor called scientific research. And they would stage-manage the kinds of social change that, in a free society, only emerge as hundreds of millions of people weigh the costs and benefits of new developments for themselves, adjusting their mores and dealing with specific harms as they arise, as they did with in vitro fertilization and the Internet.
Worst of all, theocon bioethics flaunts a callousness toward the billions of non-geriatric people, born and unborn, whose lives or health could be saved by biomedical advances. Even if progress were delayed a mere decade by moratoria, red tape, and funding taboos (to say nothing of the threat of criminal prosecution), millions of people with degenerative diseases and failing organs would needlessly suffer and die. And that would be the biggest affront to human dignity of all.
Steven Pinker is Johnstone Professor of Psychology at Harvard and the author of The Stuff of Thought.