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11/02/2015

A Bioethicist on Mars

by Craig Klugman, Ph.D.

The film, The Martian, is an exciting Robinson Crusoe space adventure. Based on the book of the same name by Andrew Weir, the film stays fairly close to the original source. Astronaut Mark Watney is stranded on Mars when he is impaled by a metal rod in the middle of a sudden and violent storm. Thought dead due to a malfunction of his suit, his fellow astronauts leave him and make an emergency evacuation to return to Earth.

Once regaining consciousness, Watney has to find oxygen and repair his injury. He manages to crawl to the ground habitat and realizing he has been abandoned, he sets to fix himself. Watney needs to remove the metal rod, stop the bleeding, suture his abdomen, and bandage himself. In one grueling scene, Watney uses a mirror to be able to see his stitchwork while he sews himself back together.

This is the inverse of the hero epic—instead of crossing into another realm, he’s been abandoned in one and needs to find his way home against impossible odds. The boon is not knowledge of himself nor an amulet but rather that he simply arrives home at all.

The rest of the movie follows a familiar pattern: Watney encounters an obstacle or setback, he finds a way to overcome it, and moves to the next challenge. He figures out he doesn’t have enough food so he brings in Martian soil to the habitat and mixes it with the accumulated freeze-dried waste of the astronauts. Then he finds preserved potatoes that he can use to seed the new ground and grow a crop. In another example his communication equipment is damaged and so he manages to set up a system of communicating with Earth through a rover and a tied-on antennae that can point at letters.

So why should this film be viewed through a bioethics lens? After all, except for his self-doctoring there is not much in here about medicine or even health policy. What there is though is a heroic tale where a strong, American male who should have died many times over, somehow miraculously makes it home when science and pure pluck come together. From a bioethics perspective he has ultimate autonomy—he is literally a man on an island unto himself. His choices affect only him (since the whole world already thinks he’s dead). He is individualism taken to the extreme. His life is in his own hands. Even once he regains contact with Earth, he sometimes listens and sometimes does what he wants, similar to the patient who picks and chooses from a doctor’s advice.

Think of Watney as a patient with cancer who has had several rounds of chemotherapy to no avail but wants to try a clinical trial that is unlikely to help him. Or the patient who has been in a persistent vegetative state for years with no signs of change, meaningful movement, or recovery. Or think of the October 29 Republican debate where Candidate Huckabee said that we need to cure chronic disease the same way we cured polio because once you eradicate a disease then it doesn’t cost money anymore. In all of these cases there is a magical thinking that if you work hard enough, if you are ingenious enough, and if you believe enough, the impossible will happen. You will be the 1 in a million who may be helped by the trial drug. Or your loved one will wake up from PVS. Or you can cure heart disease and Alzheimer’s because you think these diseases are like the poliovirus (which is a virus and has no host other than humans). It’s because we’d rather see what we believe than see the truth.

Americans are optimists. Ever since Tocqueville visited these shores and noted our stubborn individualism, we have believed that there is nothing we can’t do. Even when faced with economic recessions, poverty, income disparity, gun shootings, high debt levels, and the increasing cost of foreign invasions, we smile and look forward to a brighter future. This does not make us happy, just optimistic. So we believe the long shot is one that we can win. A chance is as good as a sure thing.

In describing clinical trials, the FDA website presents a long list of warnings and caveats (including risking permanent injury from unapproved compounds) about research: “While it’s true that clinical trials offer no guarantees, when standard treatments fail, or none exist, clinical research trials sometimes can offer hope.” It offers hope. So the message is either that we should hold onto that hope even when faced with impossible odds or that the FDA is manipulating our tendency toward hope to get us to enroll in trials. Facing reality is not an American option.

Why do we love hope and optimism so much? “They’re tools for managing our expectations when faced by uncertainty.” When we don’t know, it’s easier to think that things will get better than to prepare for a worse case scenario.

And that’s why we cheer for Watney, because he always has hope, he is always optimistic, and he never gives up. He has a plan. Thus, he never prepares for the good chance that there will be a leak in the hub, or that he might starve (which he does to an extent), or that some important system will cease to work, and he never doubts that he will get home. In the world of bioethics, we know that hope is important to help people cope. But we also know that hope can lead to unrealistic expectations that a loved one who is brain dead is still alive, or that a long-time PVS patient will wake up with the right treatment. When offered a risky surgery or a costly pill that will bankrupt the family, we take it because it provides hope. But for the 1 in a million person who will be helped, 999,999 won’t be helped. And yet we prepare for that one and neglect to prepare the 999,999.

The Martian is a great yarn and an entertaining way to spend a couple of hours. But it also feeds into some American tropes that prevent us from seeing the facts in certain cases. Sometimes we need to face reality. Sometimes a situation isn’t good. And sometimes we have to hope for the best but prepare for the worst.

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