Bioethics

I remember that when I first heard of Jack Marshall, who blogs at Ethics Alarms, my opinion of him was colored by the fact that he claimed to be a professional “ethicist.” I had a strong negative reaction to that word. It sounded to me like a self-aggrandizing title that someone would make up for themselves in the hope that it would make people take their opinions and moralizing condemnations more seriously. I later realized that my low opinion of ethicists was influenced by my low opinion of some prominent bioethicists. In particular, I was disturbed by the views of bioethicist Leon Kass, who was chairman of the President’s Council on Bioethics during the Bush administration.

I first heard about him in connection with human cloning, which he opposed. There are a number of good practical reasons to oppose human cloning, such as the high likelihood of birth defects, but Kass’s reasons — once stripped of their vague references to nebulous concepts of human dignity — amounted to little more than his vigorous assertion that “it’s icky.” He not only acknowledged this, but even exulted in it, titling his most famous anti-cloning article “The Wisdom of Repugnance.”

We are repelled by the prospect of cloning human beings not because of the strangeness or novelty of the undertaking, but because we intuit and feel, immediately and without argument, the violation of things that we rightfully hold dear. Repugnance, here as elsewhere, revolts against the excesses of human willfulness, warning us not to transgress what is unspeakably profound.

In other words, he doesn’t like human cloning for reasons he can’t really explain rationally, but he’s sure that his personal disgust is the correct reaction. That’s little more than an appeal to ignorance and bigotry. I’m sure that many homophobes “intuit and feel, immediately and without argument” that gay marriage is a violation of things they hold dear. And I have no reason to believe that the folks at Stormfront are lying when they say that they are disgusted by interracial sex. (Although, in both cases, see reaction formation.) But the problem with Kass’s position is not just his disgust, but his attempt to hold up his personal disgust as a higher form of truth.

It’s not just cloning that bothers him. Kass has this to say about the general effort to extend human life:

Laboratory assisted reproduction, artificial organs, genetic manipulation, psychoactive drugs, computer implants in the brain, and techniques to conquer aging — these and other present and projected techniques for altering our bodies and minds pose challenges to the very meaning of our humanity.

[…]

I wish to make the case for the virtues of mortality. Against my own strong love of life, and against my even stronger wish that no more of my loved ones should die, I aspire to speak truth to my desires by showing that the finitude of human life is a blessing for every human individual, whether he knows it or not.

[…]

Confronted with the growing moral challenges posed by biomedical technology, let us resist the siren song of the conquest of aging and death.

That’s not the attitude toward medicine that I want to hear from a man who had the ear of a President.

I do realize Kass is not representative of most bioethicists — he acknowledges as much with his criticism of other bioethicists — and I know that bioethicists give a lot of practical policy advice…but for a while there it seemed like every time I heard the word “bioethicist” in the news, some self-important twit was opposing medical progress or personal medical freedom in the name of vague ethical concerns.

All of which brings me to a story that Jeff Gamso posted about a few weeks ago about a death row inmate named Ronald Phillips who wanted to donate his organs after his execution to help out a sick relative.

This raises a bunch of thorny ethical issues: Is his consent to the donation truly voluntary? Does using organs from executed criminals create an incentive to execute people for their organs? Can the execution procedure and the organ harvesting procedure be combined without violating medical ethics?

Personally, I think that last issue is an insurmountable hurdle, at least the way executions are carried out today. They’d have to find a way to make Phillips so decisively dead that a surgeon would have no ethical reason not to take his organs but not so completely dead that it would damage any of those organs. And this careful killing would likely have to be done in a sterile operating room with medical personnel standing by so that the surgeons can start work immediately after he dies, but no medical personnel could be involved in the killing itself. That’s so different from how executions are done today that I don’t think we could get there from here.

But I’m hardly an expert, and this seems like exactly the sort of issue where bioethicists could make a valuable contribution. If we take it as a given that the state is going to execute Phillips — that he’s going to die regardless of any doctor’s wishes and regardless of what happens to his organs — it seems like there ought to be some way to achieve the entirely ethical goal of saving an innocent life that the condemned man himself wants his organs used to save. Perhaps there’s a way to design a careful protocol for an execution and an organ harvest that would work around the state’s killing and allow the doctors to save a life without contributing to a death. This seems like something a thoughtful bioethics expert could figure it out.

Unfortunately, the bioethicist interviewed for the AP wire story isn’t that thoughtful. He apparently opposes Phillips’s organ donation for the dumbest and most unethical reason I’ve ever heard of:

Medical ethicist Arthur Caplan of New York University said organ donation is incompatible with the goals of punishment.

“It’s unethical because this guy who’s being executed raped and killed a 3-year-old. When you donate your organs, there’s a kind of redemption,” Caplan said. “Punishment and organ donation don’t go well together. I don’t think the kinds of people we’re executing we want to make in any way heroic.”

Phillips wants to donate a kidney and his heart to save two of his relatives. I don’t know what will happen to them if they don’t get his organs. Perhaps they are high enough on the waiting lists that they will get organs from someone else, but that just means that someone else won’t get those organs and will have to wait. Organ transplants are life-saving procedures, and there is a nationwide shortage of both hearts and kidneys, so if Phillips can’t donate his organs, there will be an inevitable cascade down through the waiting lists, and at some point somewhere, two people will die.

That’s an awful high price that Caplan wants a pair of unknown strangers to pay, all because he doesn’t want anyone to mistake a child murderer for a hero. It’s this kind of thinking that makes me cringe when I hear the word “bioethicist.”

(To be fair to Caplan, much of his writing seems thoughtful, and he points out that using untested drugs for execution is arguably a form of human experimentation that likely wouldn’t pass IRB review, which strikes me as a pretty good point. Also, in a more scholarly piece in The American Journal of Bioethics he gives a brief survey of many of the issues related to using prisoners — condemned or not — as sources of organs, and although he mentions the conflict between the goals of execution and organ donation again, he clearly describes it as only one issue among many.)

A few months ago I saw squirrel get hit by a car. I had just noticed it starting to cross the street when it spotted an approaching car and froze on the pavement. It was probably safe where it was, but I could see it was overwhelmed by fear and I knew, a second before it happened, that the squirrel was going to panic and run the wrong way, right under the wheels of the oncoming car.

I don’t know why that squirrel stuck in my mind. It’s not like I haven’t seen roadkill before. I guess I’m a little haunted by the fear and the panic and the seeming inevitability of failure.

Which brings me back to the subject of our economy. I have that exact same feeling of watching a horrible mistake being made when I see how our leaders are reacting to the current crisis.

It’s not that I can predict what’s going to happen. Unlike the situation with the squirrel and the car, I’m not smart enough to foresee the details of how the folks in D.C. will screw this up. No one is. That’s kind of the problem.

Economists refer to it by the vague term unintended consequences. That’s what you get when you try to control the behavior of a complex system: The system responds to your control inputs in unexpected ways. It’s not that the system behaves randomly (which is a separate issue) it’s that the system’s behavior is more complicated than you are capable of understanding. This makes it difficult for you to make productive changes to the system.

Let me try an analogy: If you’re in charge of the control room in a nuclear power plant that’s going critical, your response has to be based on a thorough understanding of how the reactor works, what’s going wrong, and how the reactor will respond to the controls. If you just start throwing all the switches you can reach, it’s probably not going to make things better.

Our economy is far more complicated than a nuclear reactor. That’s why this is such dangerous time: With major economic turmoil right before a presidential election, everyone in D.C. is trying to make their party look good by frantically throwing the levers that control our economy. It’s a perfect storm of political economy

Both presidential candidates have essentially the same plan: Take over the economy to save us all. Obama’s talking about the need to “reregulate” and who knows what crazy schemes McCain will think of next.

Unfortunately for all of us, a large national economy is probably the worst case when it comes to complexity because the rules governing the components are not the rigid and essentially simple laws of nature but the flexible intellects of millions of people, many of whom will actively react to all attempts at control.

The people who think of themselves as our leaders will feel the urge to seize control in a crisis. In doing so, they risk following following a well-worn path…No, wait, that’s not right. The problem is the unpredictable complexity of the system, so the path is not well-worn at all. Nevertheless, their attempts to follow it will invoke a familiar pattern.

Think rent control. It all starts when politicians in a city decide they can get a lot of good publicity—and maybe some votes—by “stabilizing” rent prices to protect renters from greedy landlords. It makes a certain amount of sense: Renters can’t afford to pay so much, so don’t allow landlords to charge so much.

(For purposes of discussion, I’ll take it as given that for some reason we care more about the fortunes of renters than the fortunes of property owners.)

Since landlords can’t increase the profits on their property by charging more, they try to make money by spending less. They simplify the landscaping, postpone maintenance, stop replacing the carpets, dismiss the doorman, reduce the temperature of the hot water, let the hallway lights burn out. Nice apartments decline into mediocre apartments. Low-income rental properties become uninhabitable, creating a housing shortage.

The government responds by setting more detailed housing standards, and then hiring more housing inspectors to check them, more lawyers to enforce them, and more internal inspectors to keep the housing inspectors from taking bribes.

Landlords may not be able to charge tenants more, but with the housing shortage, they can look for better tenants. They start kicking out troublesome tenants at the slightest provocation, and they stop allowing pets or waterbeds or pianos…or children or minorities or homosexuals, if they can get away with it. Complaints skyrocket, evictions skyrocket.

With rental properties less profitable, investors stop building them, and the housing shortage intensifies. The governments respond with an exception to rent control for new housing. In the next year, thousands of landlords kick out their tenants, tear down their buildings, and put up new ones. The city sets limits on teardowns for new construction, so owners allow rental property to become so dilapidated that they have to be replaced.

A similar battle is fought over remodeling, complete with detailed legal definitions of the difference between maintaining a property, remodeling a property, and replacing a property.

It keeps on going. Renters start secretly subletting to other people, allowing them to earn the profits the landlords aren’t allowed to earn. Landlords spend more time trying to catch cheaters than maintaining their buildings. Entire apartment buildings are converted to condominiums, forcing out renters who can’t afford to buy. Small, mostly-empty apartment buildings just burn down one night, and arson is suspected.

That may be about as bad as it gets in this country, but in some authoritarian countries (Robert Mugabe, call your office) it doesn’t stop until the government has soldiers everywhere and is forcing landlords to repair the plumbing under threat of death.

I don’t know what the financial markets will look like when nice folks from the government start showing up to help in record numbers, but it’s hard to imagine that there will be less chaos. In fact, a lot of the current problem is due to prior government involvement: Mark-to-market accounting, credit-default swaps, inflexible reserve requirements. A few perverse results seem likely.

For example, I can’t see how they can possibly enforce limits on executive compensation. If the CEO is earning $5 million per year, and the rules say he can only earn $500,000, then he’ll quit and be replaced by a junior executive. The former CEO will then start a consulting firm that receives a $5.1 million contract from his former employer, and the new CEO will take his advice about everything. For the next few years, business consulting will be the fastest growing industry in the country.

One of the things that makes regulation of the financial industry harder than rent control is that landlords can’t take their ball and go home, but financial experts can. Maybe the previous CEO and some of the other executives and their friends will form a new company in Hong Kong that does a friendly leveraged buyout of the original company. The American CEO will earn the legal maximum, but the CEO of the Hong Kong holding company will still earn his $5 million. Within a decade, the 10,000 most productive people on Wall Street will have moved to Hong Kong, taking our entire finance industry with them.

On the other hand, what about all the other banks? There must be thousands of small community banks that were careful about the loans they made. They’re not too happy that their big, stupid competition is getting bailed out. They were looking forward to picking over the corpses for more business. Bailing out the Wall Street banks could cause hard time for the Main Street banks.

There’s also talk of making it harder for banks to foreclose on homes (I guess because of our unsupported belief that home ownership is more important than other financial goals). Aside from the cost and the moral hazard of rewarding irresponsible financial decisions, this is also bad for future home buyers.

If the restrictions on foreclosures apply to future home loans—or if banks expect that congress will apply them to future home loans in the future—banks will be reluctant to make home loans. After all, the point of a traditional mortgage is that the money is safe because the bank can always sell the house to recover its money. That may not be how it’s working out right now, but we’ll never get that kind of mortgage back if banks have trouble foreclosing…at least not at a reasonable price: Expect limits on foreclosures to lead to higher interest for home loans.

And just as with rent control, expect the home loan industry to come up with novel new approaches to home financing. How about stealing an idea from the car leasing business and create a rent-to-own housing contract? Instead of making $2500/month mortgage payments for 15 years, the bank owns the house and you agree to a 15-year lease at $2500/month with an option to buy at a price that decreases slightly every month. Or maybe you use your down payment to become a co-investor with your bank in a real-estate deal that buys a house and rents it to you, but allows you to buy out your partner on a fixed schedule.

Both of those ideas are probably unworkable without a lot more detail, but if you doubt the ability of financiers to work around the regulations, just remember that in Islamic countries it is illegal to charge interest, but their bankers have figured out how to make loans anyway. I’m sure we’ll think of something.

If those predictions seem too easy to fix in regulation, then I predict the response will be something harder to predict and regulate.

We’re already seeing signs of unintended consequences. I’m convinced that most of the giganic swings in the stock market are due to the bailout. If the bailout was a totally done deal, and therefore predictable, the market would already have incorporated it into asset prices. But as long as the bailout is subject to political arguments and the whims of Treasury Secretary Paulson, traders have to keep guessing. If Paulson is spotted in a coffee shop with a sour look on his face, the Dow loses 300 points.

It doesn’t help that the U.S. Treasury is now deep into the financial markets. There are already stories of other financial players taking a wait-and-see attitude, because they don’t want to take an equity position in a bank that the Treasury will take over the next week, especially with Paulson’s offer-you-can’t-refuse style.

There’s no reason to believe the panic has stopped at the bailout. Everyone in D.C. is talking about doing more to save us, from another stimulous package to even more regulation on financial activities. Even if we ignore the poor financial record of our government—$10 trillion in debt and counting—I don’t see how this could help. Free markets are flexible and highly adaptive, making our economy less flexible will only make it worse.

…growth hormone to make children taller; pre-implantation genetic screening of embryos; stimulants to boost performance on exams and at work; anti-depressants to improve moods; and medicines such as Viagra and anabolic steroids that restore some of the powers of youth. Just over the horizon, he foresees drugs to erase painful or shameful memories or to simulate falling in love; gene therapy to increase the size and strength of muscles; treatments to slow aging and increase the maximum human lifespan. “Thanks to these and other innovations, venerable human desires-for better children, superior performance, ageless bodies, and happy souls-may increasingly be satisfied with the aid of biotechnology,”

…and Leon Kass, former chairman of the President’s Council on Bioethics, somehow thinks that would be a bad thing.

In Best of the Web Today for October 28, James Taranto quotes from a Larry King interview with Michael Schiavo, who is trying to get the hospital to stop feeding his wife Terri, who is in a vegetative state, so that she will die:

Schiavo: […] This is Terri’s wish. This is Terri’s choice.

King: It’s not written anywhere, right?

[…]

King: How old was she when this happened?

Schiavo: Twenty-five.

King: A 25-year-old said to you, if I die, if I’m in this kind of state–most 25-year-olds wouldn’t think of something like that?

Geez Larry, these sorts of pull-the-plug situations are in the news quite often (somewhat less so now that Jack Kevorkian has a new address), and they’re a staple of television drama. Hell, thousands of people have probably talked this over with their friends and families just because of coverage of the Terri Schiavo story, perhaps even just from this broadcast.

25-year-olds may not expect it to really matter in their own lives, but people talk about these things all the time because the issue comes up a lot in our society. I’m sure that even most high-school kids have discussed what they’d want done.

Michael Schiavo pretty much said what I was thinking:

Schiavo: It was a comment from watching certain programs. She said, we were watching some programs, and she says, I don’t want anything artificial like that. I don’t want any tubes. Don’t let me live like that. I don’t want to be a burden to anybody. She’s also made comments to other people about different stories.

Taranto then comments:

If Terri really felt that way, she could have put her wishes into a living will, a legal document that stipulates the conditions under which treatment is to be withheld and specifies a “health care agent” who is authorized to interpret the will’s provisions. (The New York State Bar Association Web site has a sample will.) […] Michael Schiavo and his partisans seem to be arguing that secondhand reports of offhand comments that Mrs. Schiavo supposedly after a television show have the same weight as a living will. This seems irresponsible to say the least.

Contrary to Larry King, young people do discuss these sorts of things, but contrary to James Taranto, they don’t usually bother to do anything about it.

My wife has expressed her wishes about this situation on several occasions, and yes, it was often after seeing a TV program on the subject. I know her well enough to know that despite the casual situation, she had thought about it and meant what she said. If something were to happen to her, I would feel confident that I know her wishes and I would try to follow them. My wife doesn’t have to notify me in writing when she wants me to do something for her.

Perhaps the state of Florida shouldn’t be willing to take Michael Schiavo’s word about his wife’s wishes, but Taranto is wrong to suggest that Schiavo is a bad guy just because his wife’s wishes aren’t documented well enough.