Bioethics at America250 

Editor’s Note: As Americans celebrate the 250th anniversary of the Declaration of Independence, it’s a good moment to celebrate our history and accomplishments while also thinking ahead to our future. Politics is dominated by four-year election cycles, but short-term thinking is insufficient for those interested in the flourishing of a civilization. Obviously some problems and opportunities resolve quickly, but serious cultural and social issues require foresight. In this series, four different Public Discourse authors consider what we should be deliberating about and acting upon in the next twenty-five years to make ours a more perfect union. 

This will be neither the first nor the last time this year that the following words of the Declaration of Independence are quoted: 

We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness. 

They are, admittedly, unlikely to be often quoted in a discussion of the future of bioethics at America’s semiquincentennial celebration. Yet they can provide a platform for thinking about what the bioethics of our future should look like over its next fifty, and, it is to be hoped, 250 years. 

We Hold These Truths 

I will be briefest about what is, in one way, the most important requirement for our bioethics: it must be a bioethics of truth. We—bioethicists and those who take bioethics seriously—must not abandon the idea that there are truths to be discovered about the human person, about right and wrong, about human health and human flourishing, and about the divine, and that these truths matter to bioethics. If bioethics abandons the idea of and aspiration to truth, then no future bioethics will be adequate to the further desiderata I identify below. 

All Men Are Created Equal 

Our future bioethics must take the problem of equality more seriously than it currently does. Of course, contemporary bioethicists will reply that they take the issue very seriously. But they do not always identify the most significant failures of equality where they should. 

For example, bioethicists worry that genetic enhancement will exacerbate existing inequalities or create new ones. They worry that future generations of enhanced babies will have better life prospects than those who are unenhanced, and that the two categories will track current class differences. 

These concerns are reasonable. But they fail to address the inequality already built into our current practices of assisted reproduction, an inequality much deeper than any class difference. As I have argued before in these pages, artificial reproductive technologies (ARTs) are attempts to make human babies by asserting as much mastery over natural materials as is possible in order to satisfy a person’s, or a couple’s, or perhaps even a “throuple’s” desire to have a child. 

And this just is for such persons, couples, or throuples to appropriate for themselves the kind of dominance over another person’s existence that is characteristic of a master-slave relationship. Such attempts at making assert a profound inequality between parent and child thoroughly incompatible with the founding claims of the Declaration. 

Might we look back at America250 as at least roughly marking the moment when reproduction in the West took an even sharper turn toward such baby-making and away from equality? Ross Douthat’s interview of Noor Siddiqui, the founder of Orchid, is bleakly illuminating here (Glenn Stanton has previously discussed this interview here). 

Siddiqui is blunt about the separation between sex and babies that she foresees in the future and unshakable in her sense that although women should be given a “choice,” nevertheless, the weight of moral obligation tilts strongly toward making sure that only the best babies are born. She does not bat an eye at the thought that perhaps up to 90 percent of future babies might go through a genetic screening process in vitro. 

Of course, this procedure overlooks the inherent worth of the many hundreds of thousands and eventually millions of embryos that will be discarded. It similarly overlooks the contingency of the value of each baby approved for implantation and birth: they are valuable only if they measure up. And that kind of value is, to reiterate, also incompatible with equality.  

So bioethics at America250 is faced with its first challenge: how to ensure that the equality of the Declaration is more than a myth, a noble lie. Equality must play a meaningful role in how we think of the future of humanity.  

Life 

Let us pass over, until the end, questions about the Creator and creation to address the three unalienable rights identified in the Declaration. The first, the right to life, will be familiar as a touchstone of bioethical controversies over the past fifty and more years. 

That right is most clearly implicated, and threatened, in abortion. The bioethics of our future must continue to prosecute the case for unborn human life with all necessary vigor. Like Abraham Lincoln and Martin Luther King, Jr., pro-life bioethicists can rightly say that they seek to attain—not for themselves, but for the most vulnerable among us—what is promised in the Declaration. We cannot be satisfied until the day when every human life is treated with the respect it deserves, whether that day is tomorrow or 250 years from now. 

Our bioethics must likewise recognize that physician-assisted suicide and euthanasia are a stain on medicine and medical ethics. 

The corruption of both law and medicine intrinsic in these practices threatens many an innocent life. Widespread adoption of “medical assistance in dying” will, as is already the case in Canada, put pressure on those who do not want to be euthanized to “consent” to their death because they are offered no other options for care. It will put pressure on families and medical professionals to likewise opt for the one choice that will save money and seemingly limit human suffering: the choice of death.

These pressures will be intensified by the failure of the young to marry and have children. Is that failure a problem for bioethics? It is if we put the emphasis on the root: bios. Life. Any moral failure with regard to the good of life is a kind of bioethical issue. And this particular one has deep implications even for bioethics as narrowly understood, since one impetus for baby-making outside the context of marital sexuality, seen in the Trump administration’s emphasis on widespread availability of IVF, is the plunge in fertility worldwide.  

Liberty 

Bioethics at America250 wants to have it both ways where the medical profession is concerned. “Autonomy, autonomy, autonomy!” is its battle cry on every front. This is true of patient autonomy to be sure, as I will discuss shortly. But the autonomy and liberty of physicians and physician conscience is increasingly threatened, in a way enthusiastically anticipated by Julian Savulescu more than twenty years ago when he wrote that physicians unwilling to provide legally approved medical services should leave the profession, and our future bioethics needs an understanding of physician conscience that avoids the intellectual failings of critics of conscientious medicine. 

Liberty of physician conscience is portrayed, by its detractors, as a matter of a physician’s private values being allowed to trump their professional responsibilities. This is entirely mistaken. In all the important cases, the dissent made by the physician to this or that demand emerges precisely from the physician’s conception of the nature and requirements of medicine: that if medicine is for the sake of health, then this or that action is not to be done, or is not required, because it does not fit within the vocational requirements of medicine.  

A physician who will not treat a Muslim because of his religion, or a black woman because of her race or sex, may properly be said to be violating his or her professional obligations. But a physician who will not perform an elective abortion, or assist in the death of a patient, or suppress the puberty of a healthy boy or girl, or surgically remove functional reproductive organs of a man or woman, refuses these because they are contrary to the purpose of medicine and thus to the health-related good of the patient. 

Thus the attempt to hive off claims of physician conscience as mere matters of “private” belief is a red herring, an attempt to distract from the need for bioethicists to ask deep questions not just about the nature of conscience, but also about the nature of medicine. 

The Pursuit of Happiness 

We arrive at a question that will surely vex, as it vexes now, the profession of medicine and medical ethicists well into the future. What is medicine; that is, what is medicine for? Our future bioethics, no less than our future physicians, must determine, as we look past America250, which of two models of medicine we will profess and commit to. 

With the physician Farr Curlin, I have characterized one of those models as the Way of Medicine, which understands medicine as oriented toward the basic good of human health, not in the abstract, but in the health that a physician can pursue for his or her patients. 

Against such a common sense understanding of the nature of medicine stands the Provider of Services model (PSM). In the PSM, physicians possess a sophisticated set of skills that may be deployed in service of the satisfaction of patient desires, so long as the patient consents to what is offered, and what is offered is both legal and possible. Medicine in such a conception is deeply de-moralized, and physicians are reduced to the role of instruments for the pursuit of the well-being of others. 

This question about the nature of medicine is in reality a question about the nature of the happiness whose pursuit the Declaration guarantees. Is that happiness no more than the satisfaction of autonomously held desires? Or is it to be found instead in objective goods, including, for the patient, the good of health and, for the physician, the goods of health, work, and solidarity? 

These questions will be sharpened by the increasing role played in medicine by AI, a role that threatens to reduce the opportunity for meaningful work and solidarity in the medical profession by taking over core physician tasks such as diagnosis and prescription, while serving “neutrally” to aid patients in pursuing their autonomous interests. 

The “care” that patients can receive from AI, from therapy chatbots, and from automated technologies more generally often seems but a simulacrum of what real medicine can and should offer. But its appeal is manifest, and like euthanasia, abortion, and delayed or refused procreation, it offers an inexpensive and efficient route to a thinly understood form of well-being. These are all issues that our future bioethics must grapple with. 

Let me mention a related issue that I believe will, or should, emerge as central to the practice of medicine at America250, to those who seek medicine, and to those bioethicists who attempt to grapple with the challenges of the age.  

The powers of medicine extend radically beyond the provision of care for human health; this is what makes the PSM so attractive. Medicine can seek to resolve infertility, which is clearly a health deficit. But it can also seek to suppress fertility—which appears contrary to health—or to make a baby, which is not a matter of health care as such. 

Put another way, the tools of medicine enable it to offer “solutions” to many forms of suffering that do not restore or even address health deficits. Asking what forms of suffering should, and what should not, be medicalized is an important way that our future bioethics can contribute to a responsible pursuit of happiness, a responsibility that surely accompanies the Declaration’s announced right. 

Endowed by Their Creator 

Our nation’s first founding document announces the origin of both the human person and the person’s unalienable rights, in an act of divine creation. The Declaration thereby acknowledges the existence of a being who transcends and is the ultimate source of human existence and meaning. Man is not the measure in the Declaration’s ontology; rather, human endeavors must be measured against that which the Creator has ordained. 

This is not a vision in which human beings are instrumental to some set of extrinsic divine purposes, for what role could unalienable human rights play in such an instrumental vision? Rather, the Declaration seems at least compatible with the traditional Christian view that God creates for the good of his creation. But, to reiterate: neither man’s desires nor man’s will is the measure of that good any more than they are the measure of human worth. God’s goodness and his loving creative activity stand as a deeper than merely human source of meaning and value. 

Can a fully human bioethics be possible that turns its back on this divine transcendence? I have my doubts. Yet bioethics at America250 is deeply secular, deeply naturalist and materialist, and often deeply hostile to religious belief of any sort. A bioethics that looks back, to the insights of America’s founding, and forward, to a humane and humanistic future, is one that must avoid what John Paul II called the eclipse of man in the eclipse of God. 

There is no guarantee that the bioethics of our future will live up to America’s founding promises and insights. Those of us concerned that such a bioethics should exist must, as Lincoln said in honoring the dead of Gettysburg, “be dedicated to the unfinished work” of creating, sustaining, and defending that bioethics. It will be no small task, but I hope to have given some sense of what the shape of that task must be.

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