Voices in Bioethics (Mar 2016)
An Interview with Dr. Daniel Callahan, Bioethics Pioneer
Abstract
Daniel Callahan, PhD, is an internationally recognized thought leader in bioethics. A philosopher by training, Callahan co-founded the Hastings Center, a nonpartisan bioethics research institution, in 1969, and has contributed prolifically to the field ever since. His most recent book, The Five Horsemen of the Modern World, is due out in May 2016. At eighty-five years old, Callahan serves as Senior Research Scholar and President Emeritus of the Hastings Center. [1] I interviewed Callahan at his home in a densely settled neighborhood just off the center of town in Hastings-on-Hudson. He invited me to join him and his wife, Sidney Callahan, PhD, for lunch after our conversation. The Callahans’ warmth and hospitality made me feel as though I was catching a glimpse of the early Hastings “style” he talked about. In the interview, we touched on older issues such as abortion, newer issues like CRISPR, and some of the themes that Callahan is best known for: limits to what can or should be spent on medical technologies and the downsides of scientific progress. As Callahan has acknowledged, not everyone has responded to his work favorably. In a review of Callahan’s 2012 memoir,In Search of the Good,[2] bioethicist Tom Koch argues, “The bioethics Callahan created is one where scarcity and the status quo together reign and, as a result, all good solutions are taken off the table from the start.”[3] Koch’s criticism certainly deserves consideration. But after spending time with Callahan, I believe his ideology goes deeper than simply warning about scarcity. He is not just worried about the economics of technology; he is questioning the research imperative itself. Callahan challenges the widely held assumptions that there is an absolute moral obligation to conduct scientific research, and that new technologies will always better our world. What follows is an edited and condensed version of the conversation we shared. I was going to start off by asking you to highlight parts of your career that you are most proud of… I suppose that the most interesting part of my career in a way was starting the Hastings Center—an idea that occurred to me after I had decided I did not like academic philosophy very much. I also decided I didn’t like universities very much. I found I really was the interdisciplinary type and I found universities rather stifling. I had spent seven years as an editor for this magazine, Commonweal, in New York, and I spent a lot of time with people who were journalists, writers, and editors, and I just found them more interesting. They were just a livelier kind of bunch. I was inspired by the magazine world to do some serious intellectual work outside of universities. I liked that particular style so the idea of starting my own place seemed to fit. This colleague, Willard Gaylin, who is still going at age ninety-one at Hastings, was someone I just knew socially in town at a time when people used to have many more dinner parties than seems to be the case these days. I met him and I said, look, here’s my idea of doing this, I’m interested in these issues and would you be interested in helping me and he said sure. So that was it. Then we got started. The first year we spent in our house, and then we just moved up gradually. We did things rather differently in the sense that we wanted the Hastings Center to be distinct—most of the people in bioethics to this day are in academics—and we wanted a different kind of atmosphere from a) the university and b) sort of the professionalization. People from academia, they all belong to associations; they go to annual meetings with people in their field. We held lots of small meetings, but we did a lot in our homes. We said bring your wife; bring your children. We’d have dinner parties, or sit around the pool. We got to know everyone personally very much that way. We developed a certain style. We felt these issues are complex. We did one project once on behavior control; those days I was interested in psychosurgery and such things. There was a big split between psychiatrists and people doing brain work, and we knew that they really disliked each other. We were going to have a big meeting and get all these people together. We were going to get them all drunk the night before, and all sit around and talk with each other; and by the time the next day, they’ll be different—and it really worked. They got to know the people. We did a lot of that sort of stuff because we were dealing with controversial things. The question is how to deal with controversial subjects. Rule number one is don’t get the leader, because they are usually single-minded types; get someone who is the sort of second or third string, who is still open to talking about everything and they’re not pushing a line. It seems to me that it was very brave to start… Well, I don’t know … that’s really interesting. The point is, we felt we couldn’t possibly fail … these issues were going to be so important, that if the Hastings Center didn’t make it, it would be because were just incompetent. It would just be our faults. We took the attitude: of course we could do it. We were just good salesman. The word bioethics hadn’t even been invented when we first started. We’d have to go to foundations. We told them issues we were working on in a general way. And they said we don’t have any programs that deal with any of that. So we found, something I did over and over that really worked—I asked these middle-aged people, I would say, do any of you have problems caring for some elderly parents, problems dealing with difficulties at end of life? Yeah, yeah, that rings a bell. Or: Do you have adult children that have trouble having babies? Yeah. I didn’t even mention ethics. I said, that’s the kind of stuff we do. And often they’d say, well, it’s not part of our regular program, but I have a little side fund. That worked four or five times very effectively. Find something in their own lives that could connect what was in the field, which was just a bunch of issues floating around. If somebody read the newspaper they would hear about them but they weren’t dominant in the media. These were all bubbling below the surface. In terms of methodologies…do you find approaching a bioethical question is best addressed from different viewpoints? What bioethical methodology works best? See that book right behind you? Which one? Go to the left—Abortion [Abortion: Law, Choice & Morality]—that’s the first big book I did in this field. It’s 300 pages of data in a 500-page book. I didn’t know anything about abortion. It was being talked about in the papers, of course. States were beginning to pass bills and I said that’s an interesting issue. But I didn’t know anything; there was nothing in the ethics literature to speak of at all. Since I didn’t know anything, I said, I’ve got to learn about this field, the issues, what’s going on in the world. Fortunately the Ford Foundation gave me—these were the good old days—they said, would you like to go around the world and talk with people in different parts of the world? I said, sure, and they said, just go down to our travel office and go wherever you want. So I went around the world in one big trip and about seven different countries—I went to Latin America, and I collected all this information. So I learned about abortion from the ground up—not by starting with ethical stuff on abortion. That’s the way I’ve done everything since that time—and that’s what I think is important. Almost like a social scientist? I start out like a social scientist and it’s very striking because over the years … Do you see the British [BMJ]Journal of Medical Ethics ever? There it is, right before your eyes. It’s very much in the Oxford analytic style. And they don’t immerse themselves in the subject. They do it all by thought experiments and other games that some philosophers play. But I like to start from the ground up. Find out what’s the reality and work from there. And that shaped my views on abortion in a funny way, more so than anything theoretical I read. I’m going to write an article with somebody about bioethics as an interdisciplinary field. It’s interesting because I think bioethicists should appreciate what anthropologists do. When you talk about abortion, what you need to know is what’s the culture. There’s one culture from very liberal feminist women who don’t want to have children; you have to understand that culture. And you have to understand the right-wing culture that wants to shut down Planned Parenthood. That’s a different crowd altogether. That’s the kind of thing that I think that you have to get alert to. I think there are different layers. One layer would be, you start with philosophical theories. Then you get to Beauchamp and Childress—rules and principles. Then go down one more and sort of be the good anthropologist and do what I did with this Abortion [book]. Then sop yourself up with the realities. Then do your ethics. It struck me that one thing that influenced you was that the countries that had laws against abortion still had illegal abortions. What I think was most interesting was that whatever country I went to, nobody liked their own system. There was either too many abortions—that was in Japan and Eastern Europe—versus the ones where it was all forbidden and they didn’t like that. And then you had the Scandinavian countries, where you had to pass certain tests, and they didn’t like that. It was fascinating in itself. But I guess what most came across is I really came to appreciate the situation of women, but mainly poor women in poor countries, having seven, eight children and they were getting all these illegal abortions, which was killing them. It was a real mess. In this country, too, there were a lot of poor people getting abortions. There was a whole other stream of affluent, middle-class women, feminist types, and abortion was still part of the deliberation. I mention in the book itself, I got to know these people off duty and they just turned me off. It was pretty clear on the whole, the main thing they objected to was calling this an ethical issue in the first place. I don’t know if you know the name Katha Pollitt for The Nationmagazine—she’s a super hotshot feminist. For her, this is not … they get mad as hell if you say it’s an ethical issue. It’s a personal issue by God—chocolate or vanilla ice cream. What’s a good or bad choice? They don’t want to go near that topic at all. The point is to get rid of morality, get it out of the moral arena altogether and that bothered me a lot. I lost pro-life people because I came out in favor of legal abortion and the feminists didn’t like me for taking it seriously as a moral issue. I think there was a People magazine article discussion about you and Sidney on this issue. Where’d you ever find that? Yes, I think there was … Sidney ended up pro-life—but she’s very liberal—she’s one hundred percent feminist except for abortion. For many feminists, if you don’t have a right to abortion, you’re not part of the team at all, you’re just thrown off. In your book, you spoke to the fact there are two sides that don’t speak to the gray area in between. Does that still go on today? I find when I hear abortion mentioned, it sounds the same. I would say that’s the most static area of all in bioethics. The arguments are all familiar. It’s very hard to come up with any new moral reasoning on the issues. When does life begin? Well, everybody’s running around that bush since Aristotle took that one on. By and large, most of the feminists never mention it, but it’s still a fifty/fifty split among females for and against it too. Over the years that’s one of those little facts. The backstory and rhetoric turns me off. Sidney and I used to debate publically on this until we got sick of the whole topic. One of the rules was we each had to say what were the weaknesses of our own position, and that was interesting. We gave a big lecture, crowded, at Harvard Medical School, and a couple people came up afterwards and said, you know, your wife is the first time I’ve ever met any rational person that’s against abortion. We said, where’ve you been? The first rational person that’s against abortion? But this was Harvard… You talk about how you generated your viewpoint on abortion—taking the “bottoms-up” approach.[4] How does that contrast with your position on stem cells? [Callahan met with President George W. Bush, Karl Rove, and Karen Hughes in 2001[5] and testified before Bush’s Council on Bioethics in 2003 to discuss stem cell research. Callahan’s position was that we do not have an obligation to pursue stem cell research.[6]] You know, I never really wrote much on stem cells when you got down to it. But I guess the difference is I was leery of messing around with embryos that much. I really did not like the idea of using embryos for research purposes or extracting stem cells either from it … that was pushing things just a bit too far. But I never really wrote any articles developing all that. You ask about my Catholic background—they used to say when I was pro-choice on abortion … they knew about my book, they’d say, well, only a Catholic could write that much stuff about the embryo. OK, you came down on our side, Callahan, but you spent so much space worrying about the status of embryo; only a Catholic would even have that problem in the first place. So I thought that was an interesting comment, too. So do you agree that your Catholic background had some influence? [Callahan became an agnostic in the late 1960s.[7]] Sure, it makes some difference. Here’s the interesting part. I don’t remember any discussion growing up in the Catholic world of any of these issues. When I was growing up, abortion wasn’t anything; it was not a big public issue at that time, much less stem cell research … or even contraception. It just never came up. So it wasn’t as if I was brainwashed in anyway. All these issues really came to the fore once I left the church, but people somehow saw some traces of it in there somewhere. The religion of science is nothing I associated with Catholics very much, but for many people, science is thething. I never got that. There is nothing wrong with science, science is good, but it’s not like religion—but for many people it is religion. That is almost a theme for you—science is not something we always have to do… Well, to me I have no problem, this whole CRISPR debate—I have been [assembling] a small bunch of people who really are now figuring out how can we find a way to do something to stop or slow down science, which we believe is really going to end up with a bad result. We have a situation now: the scientists do the research by and large. If you follow the journals you might find out what’s going on, but it’s done all quietly and then—suddenly bammo, we have something in our laps. And we said, how do we get that? Now we have to deal with it, and we set up commissions, and everybody says, how can we regulate it and watch over it? But the question is, well, that’s often too late, by the time it’s there. And I’ve been interested in radical life extensions; that’s one of my pet issues these days. A bunch of people want to get people living up to an average of 125 years ... but I think it’s altogether a bad idea. We shouldn’t do it. But how can you stop it—these entrepreneurs are putting a lot of money into life extension. I look around the world. We already have a huge population problem, where the population itself is the problem, to which you are going to add a lot more older people. If you are going to add twenty years to everyone’s life, you haven’t increased the population, but you sure have increased the expense of the population by virtue of keeping them alive much longer. Anyway, I’ve always been wary—a lot of my books have been wary of technology and progress. I wrote one book on medical technology and all the problems it raises; another on medicine and the market. The worst problem is when you get the combination in our healthcare system: government on one hand, market on the other. Well, the market is out to make money. That’s their game. Healthcare is a great thing to make money off of. Everyone loves all this high-tech stuff. We touched a little bit on CRISPR. I’ve been trying to find a group of people to figure out how do we stop some of this stuff early on. I use the analogy of the Hudson River one hundred years ago: companies just did what they want. They threw all the junk in the river, down the pipe. After a while, people said we need to start cleaning up the river, and then after a while, people said we have to stop what’s going in the pipe in the first place. It’s too late by the time it’s in the river—then we’re just stuck with it. I have a small group that’s saying, how do we find ways of stopping things before we’re stuck with them? Are we too late? We’re often too late. With CRISPR? Probably so. At least as I talk with people, they say this is really the big, big stuff. Would you agree—is this a real major turning point? From what I’ve read it’s a transforming capability. That’s exactly right, including the germ cell possibilities. So the question is, what do we do now? It’s already out there. We’ll find lots of commissions studying it. David Baltimore, by the way, was one of the people early involved with the Hastings Center before he won the Nobel Prize. In terms of CRISPR, do you see a positive use for it? Oh, I’m sure there’s going to be positive uses. That’s the trouble with all of this, most of these advances. Steven Pinker wrote a very nasty op-ed piece in the Boston Globelast summer.[8] Basically, the message was, bioethicists: get out of the way. He was very critical of people beginning to raise questions about CRISPR and the research. He basically blamed the bioethicists but it was basically a bunch of scientists who raised the issues before bioethicists, so I don’t know how he somehow managed to ignore them. But he was basically saying it’s already too heavy with regulation, the science. The last things we need is people raising all these questions. He puts in questions of justice and the like. What worries you the most with CRISPR? Well, I suppose the germ cells would be the side that would—if we really mess around, we’re going to be changing things. What it will be like to have children if whatever way you fix your children will be passed down through the generations. Particularly since you don’t know what long-term consequences will be. How do you act in the face of uncertainty about long-term consequences? Along those lines, with as something as high stakes as this, would you side with the gambler’s principle or the precautionary principle[9]? I guess, let me put it this way: the reality principle would suggest you aren’t going to stop this. The standard argument is well, we stop it there. But you know the Chinese are not going to stop. You can’t stop it anyway. The best you can do is maybe regulate it. But I would want to say don’t use the gambler’s principle. Use some kind of a precautionary principle; be very careful about it. To me what’s important is to make sure scientists are telling us what’s really going on, too. One of the best books I’ve ever read on ethics is The Making of the Atomic Bomb by Richard Rhodes. They were wrestling ethically with the whole thing as it went along in a very serious way. He wanted to really see the ethics being played out. One of my favorite quotes is from Robert Oppenheimer [a scientist who helped develop the atom bomb]. There’s a quote I want to find… [we find the quote in his memoir[10]]: “When you see something that is technically sweet, you go ahead and do it and you argue about it only after you have had your technical success. That is the way it was with the atom bomb.” OK, that’s the CRISPR debate. My concern is it certainly happened with IVF when the people did it—they just went underground. I can see in this case that scientists may decide to keep it quiet amongst themselves. Don’t talk to the press, just do it. You have talked about limits to healthcare… I got interested in that on aging. I think the first book that I really got a lot of attention for was my book on aging [Setting Limits: Medical Goals in an Aging Society]. That was in 1987; that sold 36,000 copies. It got a huge amount of attention, most of it negative. I was attacked by everybody on the right and the left. This I found, when your book really got attention, they don’t read the books, they only read the media stories. What I talked about having some limits of aging, I’m talking about in the future, not now. I’m using government projections. It will get bad twenty years from now. They thought I was going to kill grandma right now. Somebody asked Sidney, what’s it like being married to a Nazi? However, for an author, I got the best of both worlds, because we got a lot of attention, mainly attacks. But even the attackers said you probably should read the book. That’s better than, hmm, it’s an interesting book, and put it aside. But that got me fascinated: If we accept the reality that one way or another we are going to die at some point, if we accept the reality that if we keep going down the high technology path we are just going to find more expensive ways to keep sick people alive longer and for longer periods of time—is that progress? What’s my big solution to all this? Well, change the whole culture. The whole enterprise needs to be rethought. So you’re not just saying there should be limits—perhaps there might be better ways that money can be spent? That would certainly be part of it: you may want to spend a lot less on high tech for the elderly and put money into schools, more prevention. Yes, that’s one consequence. But the point is you don’t just keep looking. Basically, you have a model, which in itself is limited. This is why I got interested in my other book—this is the global warming thing. It’s the same thing. How do we learn to live within the finite resources of earth? Right now, we are learning we are ruining our planet. That’s the vital argument of the environmentalists. All the economic growth has been terrific except we are getting too much carbon in the atmosphere as a result of the economic growth. Economic growth has also ended up giving us obesity because we get better food, but a lot of the better food also makes us fatter. The environmentalists talk about sustainability. That’s the term. One of my books I wanted to call sustainable medicine [False Hopes: Why America’s Quest for Perfect Health is a Recipe for Failure (1998)]. By sustainable medicine, I meant medicine that is affordable in the long run—satisfies the population. Those would be the two main things. What does “satisfies the population” mean? Namely, some of the European countries where they do have some limits: people accept the fact that you have to have some limits. For example, the British National healthcare service said, we’re not going to pay for some expensive new cancer drugs. Of course, they’re going to get in a lot of trouble and go to court—there will be fights there. The point is we can’t spend $200,000 on a patient in order to give them six extra months of life. It’s not affordable. By and large, Europeans are in general more willing. They’re less technology driven than we are. But even there, apparently every time they set limits they get a backlash, but it’s usually accepted in the long run. But the hook between the environmental movement: they use the word sustainability too. How in the future can we have an Earth that can afford to feed people we already have; that can [supply] clean water for all those people? Sustainability—you’ve kept it in a manageable form, instead of just constantly more and more and more. Even though we spend so much on healthcare here, it’s not necessarily with best results. We don’t get a good outcome, absolutely. What about the transparency? I think where the whole debate about rationing became a fascinating one … I started writing about rationing way back a long time ago. Basically, over the years, gradually, a lot of people didn’t want to talk about it. But it crept into the medical literature and social science literature, but it never crept into the public debate on this. There have been three big debates over the last fifty years on healthcare reform: one was in the mid-1970s, which didn’t get anywhere, didn’t get out of the Senate; the other was a big push by the Clinton administration in the mid-’80s, which failed also; and then finally Obama and Obamacare—that one succeeded. But one thing they did not want to talk about … I think I mention in the book that Senators Kennedy and Javits, who we met with, they were in those days talking about a right to healthcare … but they said we can’t talk about limits to rights in public. They said to us—our big Hastings Center with a three-person staff—you guys should really take that one on. I thought, oh, this is bizarre, the US Senate … they admit it’s a huge problem but that they can’t talk about it. That was a revelation to me. Even when the debate on the ACA was going on, we were told in Washington—in fact, we were going to work with a group in Washington. Gee, I’m really interested in talking about limits and rationing. They said, we can’t talk about that in Washington. Democrats and Republicans can’t go near that topic. You can’t use the word rationing. Do you believe there is a basic right to healthcare? Let me give you a funny answer. I’ve never seen a good argument for a right to healthcare. After the Kennedy effort, neither Clinton [n]or the ACA talked about the right to healthcare at all. And they didn’t use the word justice either. Neither political party, even the people pushing for it, used that language. That’s a perfect case of academics talking one way, and the rest of world—politicians—talking another. I think probably they felt that was not going to fly. Once you get outside of academia, they can understand justice toward blacks or negative rights, namely, “don’t harm others.” But the idea of positive rights—if you actually owe something … I find it very hard. To me, the Europeans have the concept of solidarity; their view is you provide universal healthcare because we’re all finite creatures, we’re all going to die and need healthcare, and you do it out of empathy for fellow citizens, and we’re all in same boat together. That’s why they pay for universal healthcare and let the government have a stronger role. That’s the solidarity argument as distinguished as dealing with it from the basis of individual rights. Americans want to work up from individualism. But it’s very hard to get from American individualism into solidarity; we’re not big on solidarity. Your most recent project is what you call The Five Horsemen[11]—the challenges of global warming, food shortages, water quality and shortages, obesity, and chronic illness. Those are huge issues to take on. After all your research, what do you think bioethics can do? I wouldn’t claim this to be a bioethics topic at all. I got interested in it because the five areas I picked were ones where they are all getting worse, not better. There’s a fair amount of literature that would argue that over the past one hundred years, things in general things have gotten better. Poverty has gone down, fewer women are dying in childbirth, more babies are surviving … but these five are all getting worse. What is there about these five that makes them so intractable? They are sort of interlocked in some—not all—respects, but they interact with each other. Basically what I found at the root bottom was the problem of progress. All of them represented what I call progress going sour, going too far. Global warming comes to that because of GDP, growth of industrialization. Why is China coming out of poverty? Because they’ve industrialized like crazy, but they used a lot of cheap coal to do it. So what you get is global warming. The Chinese—a perfectly great case—they reduced their death rates radically so they are only eight or ten years behind us in average life expectancy. But obesity has also increased, because diets have improved in some ways, but the diets also improved by eating more meat. More meat takes a lot more water and so forth. So you start to see these funny interconnections. In each case what started out as something very good and beneficial, but then after a while, as with healthcare for the elderly, we don’t know where to stop it. How do you turn back and how do you get people to stop? Coal is still the cheapest way to get energy. How are you going to tell very poor countries, folks, you have to stop doing that? And they say, you’re telling us? Half our population can’t read. I figured, I’m a smart guy, but now I’ve decided I see why they haven’t been solved. But at least I’ve offered what I call a good diagnosis. We have a culture now used to eating what we eat, manufacturing the way we manufacture. Getting it back to the idea of progress … how do you change a culture? References: [1] Daniel Callahan, PhD, (biography), The Hastings Center,http://www.thehastingscenter.org/About/Staff/Detail.aspx?id=1282. [2] Daniel Callahan, In Search of the Good: A Life in Bioethics(Cambridge, MA: MIT Press, 2012). [3] Tom Koch, "Callahan, Daniel 2012 in Search of the Good: A Life in Bioethics, Reviewed by Tom Koch," Society & Space, July 2013, http://societyandspace.com/reviews/reviews-archive/callahan/. [4] Callahan, In Search of the Good, pp. 38–41; 73–74. [5] Callahan, In Search of the Good. [6] Paul Lauritzen, “Daniel Callahan & Bioethics: Where the Best Arguments Take Him,” Commonweal, May 28, 2007,https://www.commonwealmagazine.org/daniel-callahan-bioethics-0. [7] Callahan, In Search of the Good, pp. 33–34; Lauritzen,Commonweal. [8] Steven Pinker, “The moral imperative for bioethics.” The Boston Globe, August 1, 2015,https://www.bostonglobe.com/opinion/2015/07/31/the-moral-imperative-for-bioethics/JmEkoyzlTAu9oQV76JrK9N/story.html. [9] Callahan, In Search of the Good, p. 66. See also Daniel Callahan, "Rejecting the Gambler's Principle," Nature Biotechnology 23, no. 10 (2005): 1220. To paraphrase, the gambler’s principle holds that despite uncertainties, the benefits of certain actions (e.g., research) warrant taking risks; conversely, the precautionary principle holds that actions should not be taken unless risks are understood and minimized. [10] Callahan, In Search of the Good, p. 171. [11] Daniel Callahan, The Five Horsemen of the Modern World: Climate, Food, Water, Disease, and Obesity, (Columbia University Press, May 2016),http://cup.columbia.edu/book/the-five-horsemen-of-the-modern-world/9780231170024.
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