Jul 8, 2008

HEALTH MATTERS: Bioethicists aim to strike medical, moral balance

LJ Anderson / Daily News columnist

Since the 1970s, the field of bioethics, a term coined independently by two professors, has dealt with ethical and moral questions resulting from advances in science and medicine. Its theoretical framework and approach, drawing from various disciplines, has tried to provide greater clarity in ambiguous and emotionally charged areas such as genetic engineering and euthanasia. This so-called "clarity" has not always been welcomed by its detractors, often the disabled, who resist suggestions that might categorize people in terms of their worth. The discipline of bioethics is often as controversial as the topics it tackles.

David Magnus, Ph.D., is director of the Stanford Center for Biomedical Ethics (http://bioethics.stanford.edu), and co-chair of the Stanford Hospital and Clinics Ethics Committee. Magnus is widely published in the areas of genetic testing, stem cell technology and organ transplantation, and has a Ph.D. in philosophy from Stanford University.



Q: How does a background in philosophy prepare you for this role?

A: My job encompasses several different kinds of activity, and philosophy plays a different role in each. Some of the issues that I teach are philosophical in nature or build on philosophical concepts, from ethical theories to conceptual, metaphysical or epistemological issues. For example, in human embryonic stem cell research, a key issue in policy formation is the moral status of the embryo. Similarly, my philosophy background informs my research, whether I am doing a conceptual analysis ("what is a genetic disease?") to more policy oriented work ("should we list developmentally delayed children for organ transplantation?"). I also do a significant amount of clinical ethics work - mostly dealing with end-of-life issues. Here, philosophy can be helpful in understanding and helping to articulate the value systems that people bring to their clinical situation, which can often be the key to resolving dilemmas.



Q: How complicated do bioethical issues get, and what's a good example?

A: They can range from fairly straightforward issues that are a matter of settled law or policy, or where we have ethical consensus, to very complex problems where intelligent people can genuinely disagree. For example, the issue of transplant-listing decisions for developmentally disabled children is very challenging. We have an obligation to be good stewards of a scarce resource. For everyone who receives an organ, there are other individuals who will not receive that same organ. Added to this should be concerns that the causes of developmental delay are often associated with co-morbidities that may reduce the probability of survival. On the other hand, individuals who are disabled are entitled to the same consideration as anyone else, and it is clear that listing decisions are sometimes made out of a sense that such children's lives have "less worth," which would be morally objectionable.



Q: What are the ways in which people like you help others approach bioethical dilemmas?

A: It varies depending on the kind of issue and which "others." When teaching students, we try to provide them with a set of tools, including theoretical tools, but also some law, policy and empirical tools, and work with them to begin to develop the judgment necessary to see what tools are applicable in a particular case. In the clinical setting, we have to make decisions about a concrete problem. This can be a disagreement between the family of a patient and the treating team. In these kinds of cases, we try to listen to what the family and the team are saying, and to place the disagreement into a context. In these cases, empirical data can be relevant. For example, if a family requests treatments that are not medically effective, based upon good data, then we try to first make the family understand that and reach agreement, and second, advise clinicians on what their obligations are in light of our policies and what the literature says. In some cases, such as the issue of pediatric transplant listing decisions for developmentally delayed children, we may recognize gaps in the literature and attempt to fill them. For example, we conducted a survey of transplant programs to try to find out more about what sorts of things programs are actually doing before moving on to developing normative guidance for how listing decisions should be made. We often integrate interdisciplinary perspectives from social science, philosophy, law, medicine and science in the way we conduct research into these problems. In the research realm, including high-tech areas like genomics or stem cell research, there may also be concrete problems that arise that we can help with. For example, do researchers have an obligation to return research results to participants, and what happens when there are incidental findings that may have clinical significance? Again, we often engage in interdisciplinary research to help solve these problems, and in each case, produce scholarship out of trying to help solve practical problems.



Q: Has the field of bioethics changed in the time that you've been in this field, and how?

A: Yes, and the biggest change is the explosion of interest in the field from young people. There are now bioethics courses in high school! Most of us in the field came to it from our disciplinary starting points. There is a new generation that is saying that they want to be bioethicists before deciding what they are going to major in.

In addition, the field continues to grow and to become more of a profession, though that is still a work in progress.



LJ Anderson writes on health matters every Tuesday. She can be reached at lj.anderson@yahoo.com.