"Technology," says Daniel Callahan in this autobiography, "had been for my entire career in bioethics, the thread connecting almost all of the ethical problems I worked on." (p. 137) Technology creates problems of service and delivery that amateurs in science but skilled in moral philosophy are, somehow, uniquely equipped to answer.
In Search of the Good: A Life in Bioethics (MIT Press, 2012), read carefully, evidences the failure, or at the least the inadequacy of that thesis.
Callahan: The history
By his own admission, Callahan was an indifferent high school student but a decent swimmer accepted by Yale because its swimming team was a source of university pride. There he had a middling career, failing biology early on, drifting into philosophy after enjoying a course on the writings of Thomas Aquinas. A stint in the army and an MA in philosophy from Georgetown University earned him entry to Harvard's doctoral program in philosophy.
At Harvard he found analytic philosophy mostly dry and largely irrelevant: "I thought the theologians had all the interesting questions." He was less enamored with his dissertation subject's (George Berkeley) philosophy -- "to be is either to perceive or be perceived" -- than his insistence that religion and ethics "should move the person to action and feeling" (p. 18). Callahan liked that. He wanted to be a player.
He found his place not in academia but as a writer for the liberal Catholic magazine, Commonweal. But as his sense of religious commitment waned Commonweal became a less agreeable environment. Callahan then decided to open an ethical think-tank. His neighbor, psychiatrist Willard Gaylin, thought it a fine idea and together they founded what became the Hastings Center.
Turns out that while at best a disinterested philosopher -- Callahan found academia somewhat tedious -- he was a natural entrepreneur. "At a meeting with [Senator] Ted Kennedy, Sargent Shriver, and Eunice Kennedy, we were asked if we did deep, slow, and serous work," Callahan writes. Absolutely, he replied. They then asked, "Well, what if the senator asked you for some fast, even overnight, work: could you do that? Easily, I said" (p. 55-56).
Deep serious work or ethics couriered on the fly... Callahan was available.
It was his Ph.D. in moral philosophy that served as Callahan's entrée into the ethical consultant's world. But, as he cheerfully admits, that did not mean there were any rigorous standards of judgment, any sure method by which dilemmas might be resolved. There were, instead "many contending versions of moral theory... [and] no decisive way of judging those differences" (p. 71). That meant Callahan and his expanding staff could make almost any judgment they wished and call it morally correct.
He and they were more than willing to "projected a wisdom about large moral puzzles we did not yet have" (p. 76). No matter... sooner or later wisdom presumably would accrue.
Callahan became a national figure in 1987 with a book arguing society could not afford currative care for superannuated seniors without bankrupting the nation and denying the young. Setting Limits: Medical Goals in an Aging Society presented as settled moral theory the dubious argument that seniors owe care to younger generations, even at the cost of their own continuance. If greedy geezers, as they were then called, choose to cling to life, demanding curative treatments, well, bioethicists were there to say governments could morally deny them their unreasonable demands.
The real villain, Callahan argued, was Medicare and new medical technologies. The government had taken on entitlements it couldn't afford and medical technology permitted the extension of life for those who would otherwise have died in an affordable way.
The left-leaning Roman Catholic writer had morphed into a right-of-center defender of the economic status quo.
The problem was never technology. It was, and remains, a health care system that makes care and survival a matter of economic convenience rather one of social necessity. In 1975 he and Gaylin were asked by Senators Ed Kennedy and Jacob Javits to take on the issue of a right to health care, to develop a language in which it could be at least discussed. Here was deep, slow, serious work to challenge the Harvard-trained moral philosopher. Callahan, while flattered by the suggestion, declined to take on the problem (p. 62).
Across his career Callahan shied away from that type of question, instead assuming scarcity was a natural limit that required ethical adjudicators, like him, to decide who might live and who would die when technology introduced and there was not enough for all.
Thus with others he dates bioethics beginnings from the early 1960s debate over the allocation of then limited dialysis beds in U.S. hospital facilities. The new technologies promised life to those who otherwise would die within months without treatments. But demand far outstripped supply. The problem was solved not in 1972 not by moral philosophers but by a Congressional act that made dialysis a national endowment. A wealthy nation, Indiana Senator Vance Hartke told his colleagues, should be able to "set our national priorities through a national effort to bring kidney disease treatment within reach of all those in need." The problem of scarcity in dialysis disappeared.
It was left to a politician to find an ethical solution to a problem that launched folk like Daniel Callahan into the business of triaging the status quo.
Callahan never identifies what he thinks "the good" is. Nor, really, do we read in this autobiography about a search for its essence. It appears to have been lost in the business of the Center, and of Callahan's own life. He does, here and there, lament the direction of bioethics and its failure to see the effects of economic policies on issues of treatment or care. These are not critiques, however, but largely disconnected musings.
We are left with a very honest memoir but a very decent fellow whose lack of serious reflection or self-criticism provides unexpected insights into the business of bioethics and its failure to address fundamental issues of ethics rooted in social policy and social structures. For that we can thank him wholeheartedly.
Tom Koch is a bioethicist, medical geography and medical historian. He is the author of Thieves of Virtue: When Bioethics Stole Medicine (MIT Press: 2012).
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