by Craig Klugman, Ph.D.
From the title, you probably assumed I’m going to talk about the fast changing pace of medical technology, whether we should be working on human embryos, claims that scientists will be able to do head transplants within 2 years, or even whether the Olympics should be postponed because of Zika. This blog has also paid attention to some of the orphan issues of bioethics: public health, social justice, health disparities, climate change and medicine in war, torture and guns. My interest today, though, is not on the content of bioethics, but rather on its methods of discourse.
This past week has been a challenging one on my campus. A conservative speaker, Milo Yiannopoulos, was invited to campus by the College Republicans. Though his ideas are not mainstream, and much of what he says is not supported by fact, he was an invited speaker. Students who disagreed with the speakers’ politics and his views protested, as is their right. But they also entered the hall where he spoke and shut down the event. (You can read more at Washington Post blog, Huffington Post blog, and campus newspaper).
Whether one believes that the speaker should not have been invited to a liberal arts university, or whether the protest against his politics and views was justified, or whether free speech was limited, the online response has been toxic and decidedly uncivil. One of the student protesters tweeted that she learned about activism and standing up from one of her political science professors. That professor is an accomplished and celebrated scholar who has recently joined the ranks of bloggers and opinion-makers. However, on Breitbart, her integrity, reputation, and values were shredded. The result of that article is that she has received phone calls, emails, and tweets filled with not only hatred, but racist, misogynistic and violent language.
This series of incidents demonstrates why America needs bioethics right now. Some say that we live in an age of intolerance where candidates for President can spread messages of distrust and unwelcomeness to people based on their religion and race. Some media studies have found that we only read news material that come from sources and people who already believe as we do. I live in a state that has not passed a budget in nearly 11 months because the Democrats and the Republicans cannot talk to one another or compromise in any way.
Bioethics was born out of a need to have careful consideration of controversial issues in a public manner. In its earliest days, The Hastings Center taught it’s associates how to work with the media in order to raise awareness of the institution (and money), but also to engage in societal conversations about important issues. The basic rules of bioethics, specifically clinical ethics, may be a light in the very polarized times in which we find ourselves. Toward that end, I offer these 9 lessons from bioethics:
- Good ethics starts with good facts. I recently received a submission for this blog space which was a list of opinions held by the writer. There were no citations or references even though allegedly empirical “facts” were stated. To defend a position and to make an argument requires empirical facts. In a clinical consult, the first step after receiving the request is to gather data—read the record, and talk to the people involved (family, patient, health care professionals). More and more these days, it seems that publicized arguments are based on emotion, hearsay, and belief more than they are on facts and reality. We can debate an issue supported by good facts, but when a debate is “he thinks this” and “she believes that” there can be no movement.
- A corollary is that good arguments are based in good logic. Saying something does not make it true. You need to use logic to prove that your argument makes sense.
- Identify and include all perspectives. Part of gathering facts is making sure that everyone who needs to have a voice is identified. If a family meeting is necessary, then all involved should ideally be present. This makes sure that there is inclusiveness from all sides and that various constituencies are represented. Is the patient’s voice present? The family? The different factions of the family? The views of health care providers? What the law requires and hospital policy prefers? One reason for the College Republicans having a speaker is their feeling that the conservative voice on campus is not well represented.
- Facilitate and mediate. The ASBH Codes of Ethics and Responsibilities talks about a clinical ethicist “facilitating” communication and “respectful interactions.” The first edition of “Core Competencies in Healthcare Ethics Consultation” listed “facilitation” as a preferred method for doing ethics consults. The second edition encourages education in mediation. This is an alternative dispute method of conflict resolution where parties come together in good faith to be heard and perhaps to reach a resolution. Both methods are about allowing different perspectives to be heard, acknowledged, and respected. No voice is shut out; no voice is shut down. This is the basis of civil discourse—we give each other the courtesy of hearing one another out. I may not want to hear what a “hate monger” has to say, but I should know what he or she is saying so that I can compose arguments and advocate for other points of view. The goal in a consult as in civil debate is to reach understanding if not compromise, future plans, and a way forward.
- Agree to disagree. As Tris Englehardt is known for saying, sometimes we can’t come to agreement but then we agree to disagree. In political and social debate we are not all going to agree. Many individuals are joining a growing chorus in support of one Presidential candidate or another who argues for being wary of certain groups, or fights for perceived current and historic injustice. The two sides are unlikely to come together and suddenly believe the other side. Most people are not convinced to change their minds: We tend to stick with our long held beliefs. But it is important to reach a space where we can respect that the other position may have merits and is a voice in our public debate. We will probably never agree on some topics and ideas, but we have to respect our right to say them.
- Engage the public and own our ideas. As I stated above, from its founding bioethics has been engaged in public life from working with the media to serving on government commissions and task forces. When we have ideas, we own them. We put our name on the byline and take full credit (and blame) for them. With internet trolling the opposite occurs—the anonymity the internet can provide seems to give people a pass to spew hatred and poison that they never would if a name was attached. If you are not proud enough of your words and ideas to own them, then perhaps you should not be sharing them in public, or trying to attack and hurt others.
- All ideas have value (even when they don’t). In a consult, there will be several suggestions and options that do not make sense or are unrealistic. But, we still make space to allow them to be heard and debated. We let those who propose them listen to the arguments and reach a conclusion about why the idea will or will not work. I know that in many consults I think to myself that someone’s idea is not a good one, but I do not say that and I allow the process of moral deliberation to work. At DePaul, an invited speaker has a right to speak. Protesters have the right protest (though not to disrupt or shut down an event—that’s against liberal arts ideals). Whether someone should have been invited in the first place is another question, but once invited and here, that person should have space to speak. Those against the ideas should then have their own speakers on campus, have protests outside the venue, write letters and OpEd pieces speaking out. In two words, there should be civil discourse.
- Don’t take positions (except when we do). One of the more controversial aspects of bioethics, especially with the American Society for Bioethics & Humanities, is whether a bioethicist should take a public position on an issue. The idea against taking positions is that if we are seen as aligning ourselves with certain groups or “sides” then we lose our ability to be neutral facilitators of conversation. There are exceptions to this rule: The association does advocate on behalf of academic freedom. Others in bioethics take an opposing viewpoint that we have an obligation or duty to take a position and then to argue logically for its adoption. Those scholars are usually not advocating for small things, but for the big ideas—in favor of social justice, action on climate change, speaking out on war and torture. We stay neutral in general, except when an injustice is so great that we feel a need to speak truth to power. When the National Socialist Party (i.e. Nazis) wanted to march in the Village of Skokie (IL)—a largely Jewish community—the US Supreme Court found that though you may disagree with their ideas, they have a right to state them. That’s what democracy is about—everyone has a voice, even if you disagree with them.
- We are not moral experts. Bioethicists have no greater access to knowledge about what is right and wrong in the world than any other person. We have knowledge of ethical theories, means of communication (facilitation and mediation), and information on law, policy, and history. It is rare that an ethicist will tell a patient or family, “You are wrong.” We guide and remain open to possibility. For true civil discourse we must be willing to see and admit that we are wrong. We must see the merit in different perspectives and points of view because if we do not try, then we will not respect the human beings who state those ideas. When respect and dignity fall, then it becomes easy to see each other as less than human and to act less than humanely toward one another. The protesters at DePaul could have continued their outside protest or sat quietly through the speech and then asked critical questions afterwards and held their own talk and written their own words countering the speakers points, logically and with good facts. Change agents listen to their haters and try to understand them, especially if they disagree.
The tools and methods of bioethics that help health care professionals and health institutions to navigate ethical quandaries have wider application. We have developed ways of promoting civil discourse, of helping polarized sides to come to understanding if not agreement, and to take action when there seems to be no way forward. Perhaps our experience can help the U.S. return to a place of civility in this difficult age.