Archive for the ‘Bioethics’ Category
A great article in the NYTimes illustrates a major problem in contemporary psychiatric practice–its mind/body dualism. The author Daniel Carlat, who has a book coming out on the subject next month, describes how psychiatric practice has moved over the last fifty years from an exclusive focus on the mind to an exclusive focus on the brain:
Leon Eisenberg, an early pioneer in psychopharmacology at Harvard, once made the notable historical observation that “in the first half of the 20th century, American psychiatry was virtually ‘brainless.’ . . . In the second half of the 20th century, psychiatry became virtually ‘mindless.’ ” The brainless period was a reference to psychiatry’s early infatuation with psychoanalysis; the mindless period, to our current love affair with pills.
More specifically, writes Carlan, “psychiatry has been transformed from a profession in which we talk to people and help them understand their problems into one in which we diagnose disorders and medicate them.”
This is due to a number of factors including the fact that insurance companies “pay nearly the same amount for a 20-minute medication visit as for 50 minutes of therapy” as well as the fact that patients in today’s busy culture are unlikely to want to commit valuable time to weekly therapy. But a big reason for the move to meds over therapy is that the drugs seem to work. But appearances can be deceiving. Carlat writes,
But over the past few years, research studies have shown that therapy is just as effective as medications for many conditions, and that medications themselves often work through the power of placebo. In one study, for example, researchers did a meta-analysis of studies submitted by drug companies to the F.D.A. on seven new antidepressants, involving more than 19,000 patients. It turned out that antidepressants are, indeed, effective, because on average patients taking the pills showed a 40 percent drop in depression scores. But placebo was also a powerful antidepressant, causing a 30 percent drop in depression scores. This meant that about three-quarters of the apparent response to antidepressants pills is actually due to the placebo effect.
Nobody knows exactly how the mysterious placebo effect works, but it is clear that it has impacts on the brain that can be seen as clearly as medication effects. In one study conducted by pain researchers at the University of Michigan, subjects were given an ache-inducing injection of saline into their jaws and were placed in a PET scanner. They were then told that they would be given an intravenous pain treatment, but the “treatment” was merely more saline solution, acting as a placebo. The PET scan showed that the endogenous endorphin system in the brains of the subjects was activated. The patients believed so strongly that they were receiving effective treatment that their brains followed suit. Presumably, a corresponding brain change occurs when depressed patients are given placebo pills.
Therapy, you may be surprised to discover, also leads to empirical changes in the brain.
n an experiment conducted at U.C.L.A. several years ago, with subjects suffering from obsessive-compulsive disorder, researchers assigned some patients to treatment with Prozac and others to cognitive behavior therapy. They found that patients improved about equally well with the two treatments. Each patient’s brain was PET-scanned before and after treatment, and patients showed identical changes in their brain circuits regardless of the treatment.
What this article points out is that the dualistic distinction between mind and matter does not correspond to reality. The “mind” is not some metaphysical entity distinct from and trapped inside the material trappings of the brain. Rather, the mind is matter, or perhaps more specifically, the mind is consubstantial with matter. As scientists like Steven Pinker and Antonio Damasio have illustrated, the legacy of Descartes that there is some sort of “ghost in the machine” is false. The metaphysical “mind,” complete with values, personality, and character, exists substantially in the material components of synapses, axons, and cortex.
We might consider this a development from a more Platonic to a more Aristotelian psychology and biology. Ethically, it challenges us to see how care for the soul cannot be separated from care for the body. We are not spiritual beings who can somehow transcend the trappings of the body with all of its inconveniences, but nor are we purely material beings, as transparent and obedient to the laws of nature as a stone. What is metaphysical in our nature influences and is influenced by what is material.
This new understanding of the nature of the human person, what we might call a philosophical anthropology, needs to influence the way we think of medicine. As Carlat writes,
Clearly, mental illness is a brain disease, though we are still far from working out the details. But just as clearly, these problems in neurobiology can respond to what have traditionally been considered “nonbiological” treatments, like psychotherapy. The split between mind and body may be a fallacy, but the split between those who practice psychopharmacology and those specializing in therapy remains all too real.
For him practically, this has meant a shift to what he calls “supportive therapy” which involves not only prescribing drugs, but also listening to patients, helping them solve basic problems, and offering emotional support. The implications, however, extend beyond just psychiatry to all of medicine. Carlat concludes that good doctoring “involves perfecting all the skills relevant to healing and deploying them when needed.”
This will be a challenge in upcoming years as our health care system becomes more systematized, more reliant on complex care networks dependent largely on electronic patient records rather than a simpler primary care provider/patient relationship. In an of itself, this is not a bad thing and a more efficient system will allow more patients to receive and benefit from healthcare. But doctors need not forget the value of that standard question “how are you feeling?” and most importantly, cultivating a disposition to listen to the response. They may find themselves prescribing fewer meds and getting healthier and happier patients as a result.
On November 11, Andrea Vicini, S.J. the Gasson Chair professor at Boston College, presented the annual Gasson Chair lecture on “The Future of Bioethics.” Vicini has a unique vantage point in presenting a lecture on such a topic. He possesses two doctorates, one from Boston College in moral theology, and one from Italy, and he is also an M.D. Moreover, he possesses a larger global perspective that many North American bioethicists lack.
Vicini first identified three major areas of concern for contemporary bioethical inquiry. The first, health care, is an obvious concern, but Vicini pointed out the global dimension of this issue, noting that 70% of the world’s population cannot afford health care.
The second concern, research, is a familiar topic for bioethical inquiry, and developments in biomedical and biotechnological research always raises new moral dilemmas that ethicists need to be aware of. Vicini pointed out specifically the ethical challenges raised by the new discipline, synthetic biology, which combines elements of engineering, chemistry, biology, and computer science to redesign life as we know it at the molecular level. The immediate implications of this new discipline were described in a New Yorker article documenting how synthetic biology is changing the face of malaria treatment. Artemisinin, an herb, when taken with other drugs, is the only consistently successful treatment for malaria. However, this plant is difficult to cultivate. Using the tools of synthetic biology to create a new metabolic pathway that did not exist naturally by inserting artemisini genes into E. Coli bacteria, scientists were able to create organisms that produce the drug necessary to treat malaria, potentially saving millions of lives. While the language that accompanies such advances is often triumphant, as Vicini pointed out, we need to also be aware how these new advances are impacting human evolution, and potentially creating new biological and ecological threats for future generations.
The third area of concern Vicini addressed is the problems created by global emergencies like HIV, which have not only biological and medical dimensions, but also social dimensions. Does bioethics have a future in addressing such complex issues?
Vicini thinks that bioethics, a relatively new discipline, historically a branch of applied philosophical ethics, does have a future in addressing these and other issues, but to do so, the discipline must evolve. First, bioethics can no longer be seen as a mere area of philosophical inquiry with implications for policy, but must be understood as a practice. Quoting Baruch Brody, Vicini noted that the future of bioethics must be regarded as a “working practice, not solely a collection of arguments and ideals.”
The practice-oriented vision of bioethics has three dimensions, according to Vicini. First, it is interdisciplinary in mode. Everydaythomist has written about the necessity of interdisciplinary work in both the sciences and the humanities, a point Vicini confirmed. “Interdisciplinary work makes us grow morally and intellectually,” he noted. Moreover, interdisciplinary work has a theological foundation. God in the Christian understanding is triune, and thus eminently in relationship. So too must God’s creation be in relationship, recognizing and reaching out to the other in order to forge relationships on both a practical and a scholarly level that are themselves foundational for truth.
More practically, interdisciplinary work demands that science acknowledge its limits and that the humanities acknowledge their dependence on the sciences. While the natural sciences like neuroscience and medicine can provide a strong empirical foundation for the future of bioethics, a necessity especially emphasized by bioethicist Ezekiel Emmanuel, such empirical foundations are necessary but not sufficient to achieve the telos of the bioethics discipline. Understanding what it means to be human requires not only empirical data, but also narrative from literary studies, an understanding of causation from philosophical studies, an understanding of sociality and group dynamics from sociology and economics, and an understanding of grace from theology. Because human beings cannot possibly master all of these disciplines, the task of bioethics is necessarily collaborative, both on a scholarly and a practical level.
The second dimension of Vicini’s vision of the future of bioethics is the discipline’s prophetic nature. By “prophetic,” Vicini is referring to a human capacity to “speak truth to power.” Bioethicists have to be ready to make ethical proposals, to challenge the status quo, and to have the courage themselves to live out their ethical beliefs. A prophet is inspiring not only in word, but also in example. Future bioethicists have an extraordinary responsibility to live in a way worthy of their calling.
Finally, Vicini’s vision of the future of bioethics sees the discipline as transformative, not only on the level of public policy, but on an individual level. Genetic developments are allowing us to transform human nature on a biological level, but Vicini also thinks that bioethics has the power to transform on an ontological and existential level. Bioethics allows us to see concretely the relational dimension of human nature, and the discipline should proceed in such a way according to Vicini that strengthens those relationships, allowing us to extend those relationships to a universal level, whereby human beings see their connection not only with other human beings, but also with the natural world around them. Bioethics should help human beings identify their place in the cosmos.
Of course, a lecture at this level is necessarily vague, but Vicini’s overall point I take it is that bioethics should transform the way people live. Bioethicists have typically worked on a grand scale, working to transform public policy and weighing in on controversial moral quandaries like the Terri Schiavo debate. While there is a place for such ethical reflection, we must ask ourselves how transformative this mode of bioethical practice really has been. Leon Kass, when asked if bioethics makes a difference in people’s lives, answered in the negative. Vicini’s point is that if bioethics is to have a future, it must find its power on an individual level.
What Vicini neglected in his lecture is the necessity of an adequate moral psychology for his vision of the future of bioethics. Until we can learn how to translate an intellectual ideal into an appetite and an action, bioethics, and all ethics, will fall short. I currently teach a bioethics class for nursing students and we most recently raised the question of the morality of in vitro fertilization (IVF). I had my students read an article from the NYTimes on the larger societal implications of IVF, especially on the cost of health care for children born prematurely due to fertility treatments.
Surprisingly, almost all of my students concluded that from a utilitarian perspective, IVF was not a morally sound practice. There were various comments about how the benefits of IVF are limited to the rich while the burdens more strongly affect the poor, a violation of the principles of beneficence and justice. However, when asked if they themselves would undergo IVF if unable to conceive naturally and practically every student said that she would. The understanding of an ethical ideal was not strong enough to change the actual practices of those holding this ideal.
So without such a moral psychology, bioethics will still fall short of its goals. It will find it easier to get bogged down in quandaries than transform people’s lives. It will find it easier to talk big and act small. Without an adequate moral psychology, bioethics will, I think, become obsolete.