Bioethics is much larger than the sum of its parts. The discipline isn’t “only” about how patients are treated in hospitals or the arcane details of public health policy. Rather, because many leading bioethicists reject intrinsic human dignity and seek to remake medical ethics and public policy to reflect that nihilistic worldview, the bioethics movement (as I call it) threatens to subvert human freedom. Indeed, if we reject human exceptionalism in bioethics—and the danger here is acute—the principle of universal human rights could buckle.
Bioethicists don’t see themselves as undermining freedom, of course. Many believe they champion liberty by focusing intently on patient autonomy as the fundamental underpinning of bioethical analysis. Moreover, they note, bioethical advocacy helped bring an end to the bad old days of medical paternalism under which dying patients were often “hooked up to machines against their will,” when they wanted to die naturally, at home, surrounded by family.
The Belief in Human Dignity Led to Better End-of-Life Care
Bioethics—along with the hospice movement—did indeed spark a revolution in the humane care of dying people. But the decades that have since passed have obscured why that great humanitarian reform was achieved: The most prominent leaders of these efforts were inspired by a robust Christian faith and a strong adherence to the sanctity/equality of human life.
The late English physician Dame Cecily Saunders, whose dedication to dying patients drove her over several decades to create the modern hospice movement, is a perfect example. In a 1998 interview for a book I was writing, she described how her work as a hospital social worker led to an epiphany: “I realized that we needed not only better pain control but better overall care. People needed the space to be themselves. I coined the term ‘total pain,’ from my understanding that dying people have physical, spiritual, psychological, and social pain that must be treated. I have been working on that ever since.”1
This insight—and her great calling to reform end-of-life care—arose directly from her deep Anglican faith, as I recounted in my book Culture of Death (citations omitted):
Saunders’ epiphany was not “rational,” but spiritual, coming from a deep empathy inspired by her religious faith. Her work was a “personal calling, underpinned by a powerful religious commitment,” wrote David Clark, an English medical school professor of palliative care and Saunders’ biographer, to whom she has entrusted the organization of her archives. So strong was Saunders’ faith in what she perceived as her divine call: “I have thought for a number of years that God was calling me to try to found a home for patients dying of cancer,” she wrote to a correspondent. Saunders’ initial idea was for St. Christopher’s hospice to be a “sequestered religious community solely concerned with caring for the dying.” But the idea soon expanded from a strictly religious vision into a broader secular application, in Clark’s words, “a full-blown medical project acting in the world.”2
Similarly, the bioethics pioneer, the Christian theologian Paul Ramsey, was the first leader in the then-nascent movement to focus on methods by which dying patients could be treated more humanely within the medical system. He called it treating “the patient as a person,” and indeed wrote a book by that title, arguing that patients should be allowed to refuse unwanted life-extending treatment even if it resulted in their deaths.
Ramsey was not motivated by a belief that a dying or profoundly disabled patient is somehow less valuable than those who are healthy and able-bodied—a prominent view in contemporary bioethics. (As we shall see, the problem today is that many in bioethics want to treat some patients as “non persons.”) To the contrary, in The Patient as a Person, he clearly foresaw the nexus between upholding the sanctity of human life on one hand, and preserving human freedom on the other (my emphasis):
Just as man is a sacredness in the social and political order, so he is a sacredness in the natural and biological order. He is a sacredness in bodily life. He is a person who within the ambience of the flesh claims our care. He is an embodied soul or ensouled body. He is therefore a sacredness in illness and in his dying. . . . Only a being who is a sacredness in the social order can withstand complete dominion by “society” for the sake of engineering civilization’s goals—withstand in the sense that the engineering of civilizational goals cannot be accomplished without denying the sacredness of the human being. So also in the use of medical or scientific technics.3
Ramsey considered this point to be so fundamental, he even thought that the term “dignity of human life” was a mere “sliver of the shield in comparison with the awesome respect required of men in all their dealings with men if man has “a touch of sanctity in this his fetal, mortal, bodily, living and dying life.”4
Contemporary Bioethical Advocacy for Human Dignity
The belief in the equality/sanctity of human life in bioethics, as we shall see, has waned since those early days. But thankfully, it has not yet been eradicated. For example, Leon Kass—who headed the President’s Council on Bioethics under President George W. Bush—explained the importance of human dignity in the context of bioethics while serving on the Council. Note how he correctly tied that principle to the promotion of liberty:
[W]e Americans . . . care a great deal about human dignity, even if the term comes not easily to our lips. In times past, our successful battles against slavery, sweatshops, and segregation, although fought in the name of civil rights, were at bottom campaigns for human dignity—for treating human beings as they deserve to be treated, solely because of their humanity. . . . Today, human dignity is of paramount importance especially in matters bioethical. As we come more and more immersed in a world of biotechnology, we increasingly sense that we neglect human dignity at our peril, especially in light of gathering powers to intervene in human bodies and minds in ways that will affect our very humanity, like threatening things, that everyone, whatever their view of human dignity, holds dear. Truth to tell, it is beneath our human dignity to be indifferent to it.5
Similarly, in their 2008 book, Embryo: A Defense of Human Life, Princeton University professor of jurisprudence Robert P. George and University of South Carolina philosophy professor Christopher Tollefsen argue for a “natural rights” understanding of the intrinsic value of human life that supports a “universal personhood”—a dramatically different concept from the usual meaning of personhood in contemporary bioethical discourse. They write:
For . . . if we are persons, then as bodily beings we have human dignity. And that dignity is served or disrespected by our attitude, and the attitudes of others, toward the basic human goods, including the good of human life. So our dignity is violated when the basic goods are deliberately damaged or destroyed in our person, as when someone intentionally takes another human being’s life. That action, as an assault on human life, is an assault on human dignity no matter the victim’s age or size or stage of development. We become subjects of human dignity, in other words, from the point at which we begin to exist as human beings, and we are, for the same reasons, the subjects of absolute human rights from precisely that point as well.6
Alas, the equality/sanctity of life understandings of Saunders, Ramsey, Kass, and George/Tollefsen represent a distinct minority view in contemporary bioethics, having been generally supplanted by the so-called “quality of life ethic”—that presumes to invidiously declare differing moral values for human life based on measurements of individual capacities or abilities.7
Attacking Human Dignity in Bioethics
The idea that human life should be accorded relative value isn’t new in bioethics. Indeed, its genesis can be traced back to the very beginning of the field as a modern discourse. For example, in 1973, the late utilitarian philosopher Joseph Fletcher—whom bioethics historian Albert R. Jonsen once called the “patriarch of bioethics”8—opined in the first edition of the Hastings Center Report that “criteria for humanhood” should be adopted within bioethics to measure the moral worth of individual human beings in order to determine how they should be treated in medicine, by science, and within society.9
In his essay, Fletcher callously dismissed medical “reverence for life,” sniffing that “nobody in his right mind regards life as sacrosanct.” What matters, he wrote, was not membership in the human race, but one’s capacities and capabilities. “What is critical is personal status, not merely human status.”
Toward that end, and to show that “we mean business,” he proposed a list of “criteria or indicators,” by which bioethicists could judge the existence of what he called “humanhood,” in order to eugenically (my term) divide “truly human beings” (in Fletcher’s parlance) from those who were merely “subpersonal.”10 These criteria or indicators11 included “minimum intelligence,” “self awareness,” “self control,” a “sense of futurity,” “memory,” and the ability to communicate, writing bluntly with regard to the latter, “disconnection from others, if it is irreparable, is dehumanization.”12
The Fletcher School (if you will) predominates in today’s bioethical discourse—either explicitly, or sometimes, based on practical effect. This anti-human-exceptionalism meme is most commonly expressed around a distorted concept of personhood, in which that status is not viewed as intrinsic, but rather, must be earned by possessing minimal capacities, such as being self aware or able to value one’s own life. In this view of personhood theory, some humans—all unborn life, infants, and people with serious cognitive disabilities or diseases such as late-stage Alzheimer’s—are human non-persons, and hence, possess lesser value than other humans (and, perhaps, than some animals).
The implications of personhood theory to the most vulnerable among us could not be more pronounced. For example, writing in the Kennedy Institute of Ethics Journal, the influential United Kingdom bioethicist John Harris wrote that non-persons are not wronged if they are killed, because nothing is taken from them “that they can value.”13 Similarly, in the same edition of the KIEJ, the American bioethicist Tom L. Beauchamp suggested that human non-persons might one day be used instrumentally, based on their purported lower moral worth:
. . . because many humans lack properties of personhood or are less than full persons, they are thereby rendered equal or inferior in moral standing to some nonhumans. If this conclusion is defensible, we will need to rethink our traditional view that these unlucky humans cannot be treated in ways we treat relevantly similar non humans. For example, they might be aggressively used as human research subjects or sources of organs.14
The anti-universal-human-rights implications of these views, which are commonly expressed in bioethics discourse, are obvious—but often go unremarked upon directly. That is why a recent article entitled “Undignified Bioethics,” published in the journal Bioethics, was so notable.15 Rather than ignore the clear adverse liberty import of viewing human life in a relativistic fashion, English bioethicist Alasdair Cochrane (who, ironically, works out of the Centre for the Study of Human Rights) acknowledged the explicit human-rights implications of denying human dignity in bioethics—but embraced such policies anyway.
Cochrane first discusses dignity as a way of behaving, which is immaterial to moral value. Then he gets to the heart of the matter (my emphasis):
The second important conception of dignity that we need to consider does not see dignity as a form of behaviour, but as a property. Under this conception, the possession of dignity by humans signifies that they have an inherent moral worth. In other words, because human beings possess dignity we cannot do what we like to them, but instead have direct moral obligations towards them. Indeed, this understanding of dignity is also usually considered to serve as the grounding for human rights. As Article 1 of the Universal Declaration of Human Rights states: ‘All human beings are born free and equal in dignity and rights.’16
Exactly right. Cochrane vividly—and succinctly—highlighted the liberty stakes at risk in embracing a human-unexceptionalist bioethics. If humans do not have intrinsic equal moral value, the philosophical bases of all human-rights documents, e.g., the U.S. Declaration of Independence (“We hold these truths to be self evident, that all men are created equal . . .”) are rendered impotent. Making matters worse, we open the door to exploiting human beings as mere natural resources, a point that Cochrane acknowledges:
This conception of dignity as inherent moral worth certainly seems coherent enough as an idea. Indeed, we can also see why this conception of dignity is employed in certain debates around bioethics. For if all individual human beings possess dignity, then they should not be viewed simply as resources that we can treat however we please. To take an example then, it may be that we could achieve rapid and significant progress in medical science if we were to conduct wide-ranging medical experiments on groups of human beings. However, because human beings have dignity, so it is argued, this means that they possess a particular quality that grounds certain moral obligations and rights.17
Again, right on. It is the principle that undergirds crucial protections of the vulnerable such as the Nuremberg Code’s ethical ruling governing human-subject research. Bluntly put, without robust support for human exceptionalism in medicine, health policy, and bioethics generally—across the gamut of human differences, distinctions, and capacities—the door opens to tyranny.
But even though Cochrane sees, he doesn’t care. He writes:
When we start looking at particular characteristics that might ground dignity—language-use, moral action, sociality, sentience, self-consciousness, and so on—we soon see that none of these qualities are in fact possessed by each and every human. We are therefore left wondering why all human beings actually do possess dignity.18
Thus, like Fletcher, Singer, Harris, and others before him, Cochrane argues that we should look to each individual to determine moral worth rather than accepting intrinsic human dignity.
Cochrane supports his thesis by arguing that the only truly cogent bases for embracing inherent human moral worth are religious, such as the belief that we are made in the image and likeness of God.19 Ironically, some Christians further Cochrane’s cause by agreeing with the false premise that only a metaphysical understanding of human nature justifies intrinsic human dignity. That is dangerous in a society in which even devout believers accept that public policy should rest on secular foundations, because it surrenders the field to the human unexceptionalists. It is also completely unnecessary. Human dignity can be well defended from secular bases. Indeed, in order to protect universal human rights, we must earnestly engage that intellectual challenge.
Defending Human Dignity in the Secular Public Square
Happily, human exceptionalism does not require belief in a transcendent God, or indeed, spiritual allusions of any kind if we understand that what matters morally is not the capacities of the individual—which, after all, are transitory—but our intrinsic natures as human beings—which are innate. We, and only we, in the known physical universe, are hard-wired—whether through creation, intelligent design, or random evolution—to be moral beings.
Consider: Animals certainly have exceptional capabilities, e.g., the bat’s sonar or the gorilla’s strength. But these are mere physical distinctions that have no more significant moral implications than my having less value than someone with 20/20 vision because I wear glasses. In contrast, humans are exceptional in ways that separate us morally—rather than physically—from fauna, e.g., rationality, creativity, abstract thinking, moral agency and accountability—the list is long—which arise from our natures and are possessed by all of us unless interfered with by immaturity, illness, or disability. As the philosopher Hans Jonas put it so well, “something like an ‘ought to’ can issue only from man and is alien to everything outside him.”20
Because our essential human natures do not change if we are injured or too young to fully express them, none of us should be denied equality. The philosopher Carl Cohen put it this way:
It is not individual persons who qualify (or are disqualified) from the possession of rights because of the presence or absence in them of some special capacity, thus resulting in the award of rights to some, but not to others. Rights are universally human; they arise in the human moral world, in a moral sphere. In the human world moral judgments are pervasive; it is the fact that all humans including infants and the senile are members of that moral community—not the fact that as individuals they have or do not have certain special capacities, or merits—that makes humans bearers of rights.21
Moreover, refusing to segregate ourselves into different moral castes is philosophically essential to maintaining universal human rights. As the noted philosopher Mortimer J. Adler wrote, if we ever came to believe that all humans do not possess equal moral status, the intellectual foundation of liberty would collapse:
Those who now oppose injurious discrimination on the moral ground that all human beings, being equal in their humanity, should be treated equally in all those respects that concern their common humanity, would have no solid basis in fact to support their normative principle. A social and political ideal that has operated with revolutionary force in human history could be validly dismissed as a hollow illusion that should become defunct.22
Adler then explained why knocking humans off the pedestal of exceptionalism could lead to tyranny:
On the psychological plane, we would have only a scale of degrees in which superior human beings might be separated from inferior men by a wider gap than separated the latter from non-human animals. Why, then, should not groups of superior men be able to justify their enslavement, exploitation, or even genocide of inferior human groups, on factual and moral grounds akin to those that we now rely on to justify our treatment of the animals we harness as beasts of burden, that we butcher for food and clothing, or that we destroy as disease-bearing pests or as dangerous predators? 23
That isn’t an overstatement. In bioethics, we are already seeing advocacy for just such courses.
The Potential Bioethical Oppression
In the West, oppression would not look like history’s previous great evils, such as American slavery or the Holocaust. Rather, it would most likely be imposed, in the name of reducing suffering, around issues and activities that come under the general heading of bioethics. For proof, we need merely look at the following partial list of current bioethical policies or proposals that (would) exploit, harvest, and kill the most weak and vulnerable among us:
1) Infanticide: Peter Singer and other bioethicists have long argued that because infants lack personal capacities, they should be allowed to be killed to benefit themselves (stop suffering), family (to ease emotional or financial burdens), or society (reducing health care costs).24 This isn’t just theoretical. Dutch doctors now openly euthanize infants born with disabling or terminal conditions under what is known as the “Groningen Protocol” (named after the Groningen University Medical Center, where many infanticides have taken place).25 Repeated studies in The Lancet indicate that 8 percent of all infants who die in the Netherlands are euthanized.26
2) Human Cloning/Fetal Farming: Discarding human exceptionalism in bioethics enables the pursuit of human cloning and the growing of cloned fetuses in artificial uteri for use in organ harvesting or medical experiments, even paying women to gestate fetuses into late term before aborting so the remains could be usable. Such a crass course has already been seriously proposed by bioethicist Jacob M. Appel: “Someday, if we are fortunate, scientific research may make possible farms of artificial ‘wombs’ breeding fetuses for their organs. . . . That day remains far off. However the prospect of fetal-adult organ transplantation is a more realistic near term possibility. A market in such organs might benefit both society and the women who choose to take advantage of it.”27
3) Redefining Death for Organ Harvesting: Some of the most notable and respected bioethicists and organ-transplant professionals have openly advocated changing the “dead donor rule” to include people with persistent unconsciousness, so that the organs of patients diagnosed to be in a persistent vegetative state could be harvested. Even though this would amount to killing for organs, such proposals are commonly made in the world’s most prestigious medical and bioethical journals. For example, several physicians writing “for the International Forum for Transplant Ethics,” opined: “If the legal definition of death were to be changed to include comprehensive irreversible loss of higher brain function, it would be possible to take the life of the patient (or more accurately to stop the heart, since the patient would be defined as dead) by a ‘lethal’ injection, and then remove the organs . . . subject to the usual criteria for consent.”28 Others have urged that such people be used in medical experimentation. Thus several Belgian bioethicists argued that permanently unconscious patients should be considered mere “living cadavers,” as a consequence of which they could be used ethically in xenotransplantation experiments in which their own kidneys would be replaced by those from pigs.29
4) Euthanasia/Organ Harvesting: Belgium has begun tying euthanasia of seriously disabled patients with organ procurement, which was documented in an international medical journal: “This case of two separate requests, first euthanasia and second, organ donation after death, demonstrates that organ harvesting after euthanasia may be considered and accepted from ethical, legal and practical viewpoints in countries where euthanasia is legally accepted. This possibility may increase the number of transplantable organs and may also provide some comfort to the donor and his (her) family, considering that the termination of the patient’s life may somehow help other human beings in need of organ transplantation.”30
Babies can’t choose to be killed. Ending the lives of the cognitively disabled for their organs would amount to a profound human-rights violation. Treating the unborn as so many tissue lines—which is a distinct issue from the usual abortion-rights-liberty claim of women controlling their own bodies—would send an insidious message that human life has no moral value based on being human whatsoever.
And that is just the beginning of the threat. As science advances and we assume the power to literally remake genomes, the possibilities for intentionally creating Brave New World-type oppressed castes could leave the realm of science fiction. Indeed, in his last book, Joseph Fletcher advocated engineering a part-ape chimeric “parahuman” to “do dangerous or demeaning jobs.”31 More recently, from the other direction, Princeton biologist Lee Silver foresaw the establishment of a two-tiered caste-based system made up of genetically enhanced and superior post-humans, whom he calls the “Gen Rich,” and the unmodified human “Naturals,” who would be forced into menial pursuits. He writes: “Now, Natural children are only taught the basic skills they need to perform the kinds of tasks they’ll encounter in the jobs available to members of their class.” 32 And here you thought that “untouchables” were supposed to be a relic of the past.
Conclusion: A Human Dignified Bioethics Is Essential to Maintaining Human Freedom
This is why bioethics matters. Bioethical discourse and policies grapple with the essential question of human meaning. Such debates aren’t merely philosophical, but—given that bioethical policies have the potential to impact every living and future human being on the planet—have very practical, real-world consequence. The stakes could not be higher. Cochrane sees this potential too, writing: “Obviously, given controversies over abortion, stem cell research, genetic interventions, animal experimentation, euthanasia and so on, bioethics does need to engage in debates over which entities possess moral worth and why.” 33
One last important point: We often hear that politics is the art of compromise. But that only works when there is general agreement about values and ends, but debatable differences over means. That is not where we find ourselves in bioethical controversies, where the disagreements are fundamental and will determine the core governing values of society.
We cannot fashion a principled compromise around the existence of human dignity—it either exists or it doesn’t. But while that precludes debate in the usual sense of the term, we can, nay, must, hold up these diametrically conflicting world views to intense public scrutiny. And we must make people understand that the contest over a “dignified” or “undignified” bioethics is too important to leave to academics and public intellectuals. All must be engaged, for the bioethics we choose to follow will determine whether our society stands for human equality and the guarantee of truly universal human rights.
1. Cecily Saunders, Interview with Author, December 8, 1998.
2. Wesley J. Smith, Culture of Death: The Assault on Medical Ethics in America (San Francisco, Encounter Books, 2000), p. 24.
3. Paul Ramsey, The Patient as Person: Explorations in Medical Ethics, 2nd ed. (New Haven, Yale University Press, 2002), p. xlvi. (First edition published by Yale University Press, 1970.)
5. Leon R. Kass, “Defending Human Dignity,” Ch. Human Dignity and Bioethics: Essays Commissioned by the President’s Council on Bioethics (Washington D.C., President’s Council on Bioethics, 2008), p. 298.
6. Robert P. George and Christopher Tollefsen, Embryo: A Defense of Human Life (New York, Doubleday, 2008,), p. 108.
7. See for example, Peter Singer, Rethinking Life and Death: The Collapse of Our Traditional Ethics (New York, St. Martin’s Press, 1994 ), p. 118.
8. “O Brave New World: Rationality in Reproduction,” by Albert R. Jonsen, David C. Thomasma, and Thomasine Kushner, eds., Birth to Death: Science and Bioethics, p. 50.
9. Joseph Fletcher, Humanhood: Essays in Biomedical Ethics (Prometheus Books, Buffalo, N.Y., 1979), p. 85.
10. Id., p. 11.
11. Id., pp. 12-16.
12. Id., pp. 16-17.
13. John Harris, “The Concept of the Person and the Value of Life,” Kennedy Institute of Ethics Journal (Baltimore, Johns Hopkins University Press), Vol. 9, No. 4, December 1999, p. 307.
14. Thomas L. Beauchamp, “The Failure of Theories of Personhood,” Kennedy Institute of Ethics Journal, supra, p. 320.
15. Alasdair Cochrane, “Undignified Bioethics,” Bioethics, 2009, Vol. 4, Issue 5, pp. 234-241.
16. Id., p. 236.
19. Id., pp. 236-237.
20. Hans Jonas, The Phenomenon of Life: Toward a Philosophical Biology (Evanston, Northwestern University Press, 1966), p. 283.
21. Carl Cohen, “Do Animals Have Rights?” Ethics and Behavior, Vol. 7, No. 2, 1997, p. 95. 97.
22. Mortimer J. Adler, The Difference of Man and the Difference it Makes (New York, Fordham University Press, 1993), p. 264.
23. Id., p. 265.
24. See for example, Wesley J. Smith, “Infanticide Must be Combated—Carefully,” Human Life Review, Fall 2010.
25. Eduard Verhagen, M.D., J.D., and Pieter J. J. Sauer, M.D., Ph.D., “The Groningen Protocol—Euthanasia in Severely Ill Newborns,” New England Journal of Medicine, 352:959-962, March 10, 2005.
26. For example, see Agnes van der Heide et al., “Medical End-of Life Decisions Made for Neonates and Infants in the Netherlands,” Lancet, Vol. 350, 1997, pp. 251-55.
27. Jacob M. Appel, “Are We Ready for a Market in Fetal Organs?” Huffington Post, March 17, 2009, http://www.huffingtonpost.com/jacob-m-appel/are-we-ready-for-a-market_b_175900.html.
28. See, for example, “Should Organs from Patients in Permanent Vegetative State Be Used for Transplantation,” R. Huffenberg, et al., Lancet, Vol. 350, November 1, 1997, p. 1321.
29. An Ravelingien, et al, “Proceeding with Clinical Trials of Animal to Human Organ Transplantation: A Way Out of the Dilemma,” Journal of Medical Ethics, February 2004; 30(1): 92–98.
30. Oliver Detry, et al., “Organ Donation After Physician-Assisted Suicide,” Transplant International, 21 (2008) p. 915.
31. Joseph Fletcher, The Ethics of Genetic Control: Ending Reproduction Roulette (Buffalo, Prometheus Books, 1988), p. 172.
32. Lee M. Silver, Remaking Eden: Cloning and Beyond in a Brave New World (New York, Avon Books, 1997), p. 6.
33. Cochrane, “Undignified Bioethics,” supra., p. 237.