Posted on October 13, 2020 at 2:37 AM
by Nir Eyal, DPhil
When you pick up an article or a book by Dan Brock, you know that you will find rigor, common sense, imagination, and warranted authority. You never encounter preachiness, frills, overstatement, or demagogy.
Dan was at the forefront of two revolutions in bioethics—one in the 1970s and 1980s, and another in the 1990s and 2000s. The first created the best of Anglo-American clinical bioethics as we now recognize it. Dan, who started his writing career in the 1970s by publishing on normative ethics, started around 1980 to apply the same analytical scrupulousness and lucid writing to medical ethics. Part of a generation inspired both by Rawls’s rigorous philosophical analysis of practical dilemmas and by anti-Vietnam war protests, Dan’s work was liberal bioethics at its very best. it was characterized by uncompromising integrity, critical inquiry, and straightforward writing. Personal autonomy and fairness were particularly dear to his heart. Dan’s bioethics articles and the President’s Commission for the Study of Ethical Problems in Medicine, in which he took part in 1981-82, helped wrest American bioethics from the clutch of the vague theological writing that characterized the field in the 1960s. Bioethics became, in a good sense, more professional.
Dan’s work in those years helped entrench commitment to informed consent (in that presidential commission’s report and then in a 1989 book with Allen Buchanan), a new scholarly openness to death with dignity (partly collated in Life and Death: Philosophical Essays in Biomedical Ethics, 2000), and to their meeting point, in Dan’s inventive work on advance directives. The manner in which his work addressed emergent technologies for reproduction was a beacon of analytical rigor, an open mind, and level-headedness (most centrally, in From Chance to Choice: Genetics and Justice, 2000, co-authored with Allen Buchanan, Dan Wikler, and Norman Daniels).
A classical move from Dan’s work of that period: Some had argued that beneficent and voluntary active euthanasia (e.g. injecting poison to help a person die, beneficently) is impermissible, because it is killing an innocent person. Yet both they and most everyone else agrees: doctors’ withdrawal of life-sustaining treatment from similar patients (e.g. removal of the breathing tube that artificially keeps them alive) would be permissible. These opponents of voluntary active euthanasia explain that withdrawal of life-sustaining treatment is not killing, just allowing the patient to be killed by her underlying condition. Dan provides a powerful thought experiment in response. The patient’s greedy son removes her breathing tube in order to ensure that he inherits her riches. When challenged for that action, he replies, “I didn’t kill her, I merely allowed her to die. It was her… disease that caused her death.” Dan points out the physical resemblance of the greedy son’s action to doctors’ potential removal of the same breathing tube and concludes that both cases involve active killing of an innocent. The main difference is that when doctors withdraw life-sustaining treatment to help a person die, their action is beneficent. We judge that action permissible, but that’s not because doctors did not kill an innocent. It is because killing an innocent can be permissible when done upon the patient’s request and beneficently. So can killing an innocent through beneficent and voluntary active euthanasia.
Dan’s thoughtfulness, careful attention to clinical and legal detail, and professionalism made him, in that period, a rare authority both with philosophers and with clinicians and health policy leaders. He served on the Ethics Working Group of the Clinton Task Force on National Health Reform (1993), the successes and ultimate failure of which were a blueprint for the later Obamacare. Dan also advised the Office of Technology Assessment of the U.S. Congress, the Institute of Medicine, the National Bioethics Advisory Commission, and the World Health Organization. He was President of the American Association of Bioethics and a founding Board Member of the American Society for Bioethics and Humanities.
In the late 1990s and the new millennium, Dan became part of an even smaller group that ushered in a new subfield, population-level bioethics. As he wrote with close friend Dan Wikler,
The bird’s-eye perspective of… population-level bioethics includes consideration not only of health care but of other social determinants of health, including socio-economic standing, environmental and working conditions, and social exclusion. Its subject therefore is health rather than health care alone… The focus of population-level bioethics… is extended in both space and time. It extends naturally to a global focus… The least-healthy populations, most of which are in developing countries, become especially prominent… Population-level bioethics is also extended temporally, taking into account the consequences of present day events that affect the health of future generations, and their size and makeup.
In that era, he wrote on how to make cost-benefit analysis and cost-effectiveness analysis more ethical, on egalitarianism and prioritarianism in health resource allocation, on dilemmas of population ethics, and on other questions at the level of populations and its relation to the obligations of individual clinicians.
During this later period Dan continued to publish on normative clinical questions, but his first love was now macro-level. This work allowed Dan to combine his understanding of economics (in which he held a degree, and years of Wall Street experience— last month he told me he never looked back to those years); his early appreciation of the genius of Derek Parfit (which nearly made him abandon philosophy when they met in Dan’s first graduate school seminar); and interest in normative work beyond bioethics.
Dan was also an institutional leader. After having moved from Brown to NIH, where he was planning to spend the rest of his professional life, under the GW Bush administration Dan encountered political pressures and lack of institutional backup. When he sensed that he might self-censor, he left for Harvard (a reflection of his intellectual integrity and how seriously Dan took his liberal philosophy). There, he started the pioneering Program in Ethics and Health. That interfaculty program, dedicated to bioethics at the level of populations, allowed him to work with other leading lights in that new subfield, and to train students, postdocs, and visitors who now comprise some of the foremost global contributors to it. My job interview for the Program looked like full disclosure of the risks and burdens of working at Harvard, toward ensuring autonomous choice, more than like the typical sales pitch. Dan did take his philosophy seriously. He was the nicest boss one could wish for. We were never a “lab” servicing his projects, always a group of respected individual researchers encouraged to disagree.
But Harvard’s endowment shrunk during the 2008 economic recession, and the University rushed to defund that Program. Dan remained Director of Medical Ethics at Harvard Medical School but at that point his heart was with population-level bioethics. The progression of his Multiple Sclerosis expedited his 2014 retirement. For years he continued to give talks and contribute to an important expert panel on cost-effectiveness analysis. In 2018 he won The Hastings Center’s Beecher lifetime achievement award. He also remained an avid book reader and a frequent visitor of New York City’s museums. Notwithstanding the occasional glass of wine in breach of doctor’s orders, Dan held up better than his original prognosis had portended. He died last month, still faithful to the values of his own philosophical writing. He will be sorely missed by his wife Chon, daughter Kate, and sons David and Darrell, and many loving friends, colleagues, and mentees permanently marked by his high intellectual standards, personal integrity, and amicable and even-keeled nature.