No Easy Answers in Bioethics Podcast

Reflecting on Early Bioethics: Fleck and Tomlinson - Episode 9

May 10, 2018 Len Fleck photoTom Tomlinson photo

What issues were bioethicists concerned with in the early days of the field? This episode features two senior Center faculty members, Director Tom Tomlinson, PhD, and Professor Len Fleck, PhD. Together they discuss and reflect on the accidental ways in which they entered the field of bioethics in the ‘70s and ‘80s, also touching on the creation of the program that became the Center for Ethics around that same time, and the early days of the College of Human Medicine. They discuss the changes they’ve seen around topics such as death and dying, advance directives, and advances in medical technologies. Finally, they speculate on where bioethics may be headed in the future.

This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: "While We Walk (2004)" by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License.

Episode Transcript

Liz McDaniel: Hello and welcome to another episode of No Easy Answers in Bioethics, the podcast from the Center for Ethics and Humanities in the Life Sciences at the Michigan State University College of Human Medicine. This episode features two senior faculty members from the Center, Director Tom Tomlinson and Professor Len Fleck. Together they discuss and reflect on the accidental ways in which they entered the field of bioethics in the 1970s and ‘80s, also touching on the creation of the program that became the Center for Ethics around that same time. They discuss the changes they’ve seen around topics such as death and dying, advance directives, and advances in medical technologies. Finally, they speculate on where bioethics may be headed in the future.

Tom Tomlinson: Okay, well, hello everybody, my name is Tom Tomlinson, I'm the Director of the Center for Ethics and Humanities in the Life Sciences here at Michigan State, and as it happens I’m also an alumnus of MSU, getting my PhD here in 1980.

Len Fleck: And I'm Len Fleck, I'm a professor of philosophy and medical ethics in the Center for Ethics here at Michigan State University, and I came here in 1985.

TT: So, Len and I are like two old bioethicists rocking on the front porch, I think, today. [Laughs] So we thought we, you know, we'd like kind of reminisce, or whatever the right word might be, around a couple of general areas. One is just to talk a little bit about how each of us got into bioethics, in the early days of the field certainly. Not quite the dawn of bioethics, but shortly thereafter. About 10 AM, maybe. I'll also talk a bit about the Center itself, and some of its history and trajectory. And also, and then finally I think, just talking about the field itself, then and now. And, you know, what we see as the similarities, what's the same, and what's different. So, Len, why don't you start and tell us about sort of how you got into this bioethics racket. [Laughs]

LF: My story is probably a story that's repeated by lots of other bioethicists, I got into the field accidentally. In my graduate work I was doing American philosophy and the history of modern European philosophy, and my first teaching position outside of St. Louis University was at St. Mary's College in Notre Dame, Indiana back in 1971. They were supposed to merge with Notre Dame, Notre Dame was going to go co-ed. The merger fell through, a bunch of St. Mary's women transferred over to Notre Dame. St. Mary's was worried about their financial viability and they wanted to offer, again, a nursing program in order to attract more women to the college. And they needed somebody to teach a course in health care ethics. And there were only three of us in the department, and it sounded interesting to me, so that was how I ended up developing a course in bioethics way back in 1972. At a time when the number of books on, that were related to bioethics on a library shelf would have covered no more than one or two feet, nothing more than that, and the Hastings Center Report was about eight pages in length.

TT: Yeah, right. So I think I kind of stumbled also into bioethics, which is not surprising, considering there wasn't really a field, and there wasn't a clear career path. Maybe there's not, oh now there's a much more clear career path at least in some ways. But, I had, when I was discharged from the army, I ended up going to the master's program in philosophy here at Michigan State University, and one of my mentors during my master's program was Martin Benjamin. And Martin Benjamin actually started the first bioethics course at Michigan State in 1975. So that was kind of pioneering, and so he had an interest. And then later when I had, my wife got a job before me because she was the theater major so she had better prospects for employment than I did as a philosopher. Anyway, we went off and then I came back in '78 to finish my dissertation. And it so happened that in 1977, what was then called the medical humanities program had been started. And I ended up being the first graduate assistant for the medical humanities program, and that then involved a lot of work related to the medical humanities and medical ethics, and I think that's kind of what got me really hooked. And then I ended up incorporating medical ethics cases into my dissertation at the time, so that's how I got started. So, you know, it's different though today.

LF: Yes, that's right, it's very different today. Because there are formal programs, a lot of master's degree programs, some PhD programs, that are directly aimed at training bioethicists.

TT: Mmhm. So there are, there are pathways to going into bioethics now, and there weren't really then. You had no idea what the prospects might be for employment--

LF: That's right.

TT: --as a bioethicist.

LF: I mean there were, in my case, there were a lot of accidents along the way in terms of how my own competence in various area of bioethics evolved. And so, there were some early grants I had when I was at Indiana University in South Bend after St. Mary's College, that looked at community dialogues about issues related to death and dying. Because the death and dying issues, those were among the early issues related to bioethics.

TT: Mmhm.

LF: And that's obvious why that would be the case. These are the kinds of problems that health professionals, physicians, and nurses would face on a regular basis. And in that community, and as a result of the community dialogues, we ended up actually creating the 42nd hospice program in the United States, hospice of St. Joseph County, and so that became, that was one way in which I acquired a certain kind of knowledge of, a firsthand knowledge of the problems related to health care ethics. Beyond that, I then got involved in, there were the health planning agencies that were being formed in the late 1970s to do something about controlling health care cost. And the health planning agencies had these very large community boards, typically with 50 or 60 members, for whom there had to be this training. And they wanted ethical issues related to resource allocation as part of the training of these board members. Because that's in effect what they were doing, they were deciding how many CT scanners or MRI scanners or ICU beds they were going to permit in a particular community. And that was what got me launched into thinking about all the issues related to health care justice, and resource allocation, and cost containment, and rationing, and so on.

TT: Yeah. That actually prompts a memory, because between my master's and my PhD there was a period of time when -- well, I take that back. After I got my PhD, there were no prospects for employment in Michigan because it was kind of the height of the recession under Carter, and—people may remember who he was [laughs]—and so I ended up taking a job with the Foreign Agricultural Service at the Department of Agriculture in DC. Because they called me to ask me whether I'd be interested, and since I was facing unemployment here in Michigan, I said yes. And I ended up, one of the things I ended up doing in part of this public relations sort of role is looking at all of the foreign agricultural trade press. So that was part of my job was to clip items of interest to the ag economist in the Foreign Agricultural Service, and at the time there was a lot of furor over animal, so called animal rights. Among people who were raising hogs and cattle and all kinds of things, chickens and so on. And that really prompted an interest of mine, so I acquired a lot of knowledge about the debates around animal rights at that time, and of course, when did Animal Liberation come out, Peter Singer's book?

LF: Late '70s, I think.

TT: Yeah, it's about the same, it was to the same time. And that ended up then, just sort of fast-forwarding a bit, sometime after I got the position on faculty, I remember Bruce Miller and I went around and made presentations to a number of the basic science departments, researchers doing lab animal work, around these questions. And the one, there was a delegation of faculty who went to the then-dean of the College of Human Medicine asking that I be fired.

LF: Oh.

[Both laugh]

TT: And thank God for Don Weston, because he told them to get the hell out of his office, or something to that effect. That’s probably actually what he said. So that was, and you and I were on fixed term appointments.

LF: That’s right. When I came here I was on a fixed, yep.

TT: One year, yearly fixed term appointments for like, what, ten years or something? Or close to that?

LF: No, I think by the early '90s Howard was successful in getting us tenure stream appointments.

TT: Yeah.

LF: I think that's when it was.

TT: Right. But then, if I, because I started in '81.

LF: Yeah.

TT: And you started in '85.

LF: '85.

TT: Yeah, okay.

LF: So, what was the Center doing? How did the Center get started?

TT: Yeah, so Andy Hunt, Andrew Hunt, was the founding dean, he was a pediatrician, was the founding dean of the College of Human Medicine. And I want to sort of underline "human medicine," because one of the philosophies of Andy and the small, relatively small group of other folks, senior faculty who sort of really energized the start of the college, was that they wanted to train physicians who really had a humanistic understanding of health and medical treatment and illness, and so on. Not just scientific, and that was quite deliberate on their part. And so when Andy stepped down as dean, I can't remember, I lose track of exactly when CHM started officially.

LF: '64 I think is the official start.

TT: '64? Really?

LF: Yeah.

TT: Okay. He, as a condition of stepping down he said, “I want to have a medical humanities program.” And so because he was the founding dean they said yes. And so that's how it started. And at the time there were several different tracks in training medical students in CHM, and so in some of those tracks, in fact, we were incorporating small group teaching around cases, you know, the same kind of approach and methodology that's very commonly used today. And we had guest speakers coming in all the time. Sam Gorovitz, for example, I remember is somebody that we brought in. One of the grandfathers, kinda--

LF: He would be a grandfather. His collection of readings was one of the very early collections that was, that would be used in a lot of courses in bioethics.

TT: Yeah, right, that's right. So, and then the Center continued as the medical humanities program for quite a number of years, and, funded, originally funded just through CHM, but then we got a grant actually from the National Endowment of the Humanities, of all things, to create faculty positions, and part of that grant committed us to providing assistance also to the College of Osteopathic Medicine at Michigan State University, and the College of Veterinary Medicine. And so then that would mean that every year, Andy Hunt and then later Howard Brody, would have to go around from dean to dean with hat in hand and say, okay, please cough up this amount of money because we need it to keep going. That was untenable in the long run, and so we persuaded, it must have been Howard and Andy and some others, persuaded the provost to consolidate all this funding into one single funding stream for the Center for Ethics and Humanities. So it then still had this pretty broad mission.

LF: So what were the kinds of issues that were the focus of the work of the Center from early on?

TT: Well I, you know, I was thinking about this the other day, and what was really, one of the things that's really striking to me is how much resistance there was at the time among a number of physicians to withdraw life-sustaining treatment. And, because it was seen as murder.

LF: Yes.

TT: That was actually a word that some people would use. And, at a kind of euthanasia, and so I it was very vigorously resisted, not by all physicians, but certainly by some. And so that was probably, on the clinical ethics side, I'd say, the major issue that animated, that bioethics was focused on. And then I also recalled the vocabulary that was used, there was active euthanasia, which was, you know, actually doing something like injecting someone, and there was passive euthanasia, which was just withdrawing treatment. So the very act of withdrawing treatment from somebody was called a kind of euthanasia.

LF: And the word euthanasia of course had all kinds of bad connotations--

TT: Oh sure.

LF: --because it was associated with Nazi Germany and World War II and so on.

TT: Right.

LF: And the other thing that I'll add historically, you know I mentioned that I had helped to found this hospice program in St. Joseph County. Well, today of course hospice would have a very, very excellent reputation as providing a more thoughtful, peaceful end-of-life care to individuals. But again, at the time, Tom, you're absolutely correct. There was significant resistance to the creation of that hospice program in South Bend, Indiana in St. Joseph County, there were a lot of physicians who thought of this, this is, you're just trying to kill people more quickly for whatever reason, and this is just not acceptable. And so there was a lot of community education that had to be done. And medical education to convince physicians that this, these were reasonable choices, and that individuals should be allowed to make them. I guess, part of the other thing in terms of the history of the emergence of bioethics, is the history of the 1960s. The civil rights movement, consumer rights, feminism, and so on.

TT: Oh yeah.

LF: And so all of that put a lot of emphasis on respect for the choices of individuals, and so that became the principle of respect for patient autonomy. And that sort of helped to facilitate dealing with some of the death and dying issues that were otherwise much more controversial at the time.

TT: Yeah. There are also legal developments, so it was during the '60s and even into the '70s where the doctrine of informed consent, not just plain consent, but informed consent was being developed and solidified, and I think that was also a, there was a lot of energy behind that, which also I think was one of the factors pushing against physicians and others who want to limit the choices that patients had, especially with regard to what was being done to them.

LF: Mmhm, yes. And then if we fast-forward into the later part of the 1980s, part of what's going on is there is much more emphasis on health policy issues and cost issues and so on. There's more emphasis on health reform. You get into the early 1990s and you have the Clinton Task Force.

TT: The Clinton Task Force, yeah.

LF: Yeah, the Clinton Task Force on health reform. So, Howard Brody and I were a part of that, that of course was a failed effort, but at least we gave it a shot. And we learned a lot about some of the challenges that are faced with trying to reform the health care system, and the fact that it is so complex, and that there are so many different points of view regarding what counts as appropriate and cost-worthy kinds of healthcare. At the time, that was, it was relatively complex, it's gotten even more complex since then because of all the emerging medical technologies that you find in the health care system today.

TT: Yeah. Well, you know, it's just an example of how if you want to actually effect change, you have to take bioethical principles and analysis into a political realm. Because no one's going to make a bioethicist king, and--

LF: That's right.

TT: Probably for good reason. [Laughs] And so that's where you really encounter the sheer necessity of developing some political, you know, public relations even, skills. I remember that Howard and I, and maybe you were involved too in this, in the, must of been mid to late '80s when David Hollister, who was later the mayor of Lansing, but was then a legislator, a very active legislator in the Michigan Legislature, wanted to introduce a bill to create advance directives, to legalize advance directives in Michigan. Which, at the time, was something going on elsewhere in the country. And that was a very complicated political negotiation between those of us in the Center on the bioethics side, and Dave himself of course and a number of others, to try to empower patients, people as much as possible to direct their future health care. Against people who were concerned about the possibility that people would be allowed to die prematurely, or that they'd be allowed to die because of, because they had a poor quality of life. And merely because they had a poor quality of life. And so we had numerous negotiations, particularly with Michigan Right to Life, and the Michigan Catholic Conference, around those issues. And it was a very interesting struggle. We were ultimately successful in those discussions, I think, in creating a advance directive statute that has many fewer limitations than the ones found in a number of other states. So, for example, in Florida, you either have to be terminally ill or you have to be in a persistent vegetative state in order to trigger your advance directive. There is no such limitation here in Michigan. So we feel, we felt pretty good about that.

LF: Now if we go beyond the death and dying issues, because the field has evolved over the past 30, 40, 50 years. When you get into the early 1990s, this is when the Human Genome Project gets going. So this is a ten-year project to map the human genome, and so all of a sudden there are all these genetics issues, and an increasing capacity to control the genetic endowment of future possible children. This, all these things that were just sort of science fiction scenarios back in the '70s and '80s are becoming much more real today. And, in part as a result of the research that went on, and that continues to go on through the 1990s and now into the 2000s. Right currently the issues are around CRISPR/Cas9 as a gene editing technology, this has been a focal point of a lot of recent discussion. And of course the ability to do various kinds of genetic manipulation, raises the most difficult kinds of bioethics issues when we start talking about reproductive decision making, the development of pre-implantation genetic diagnosis, the ability to create these 8-cell embryos in vitro and to do genetic analysis of the embryos, and to allow parents then to choose embryos that are free of particular genetic disorders about which the parents might be concerned. All of that is raising a lot of the issues that we're faced with today.

TT: Mmhm. Yeah. And I think, you know, it's just another example of how the creation of new technologies creates new choices where there were no choices. You don't have choices, you don't have an ethical problem.

LF: Right.

TT: You've just got tragedy, or whatever. So, I mean, it's similar in lots of ways to the introduction of dialysis as a technology. And, you know, before dialysis if you had end-stage renal disease, there wasn't anything to really be done. You were going to die. With dialysis, now we've got decisions to make. And at the time, of course, it was because we didn't have enough machines or facilities relative to need. There were also cost issues percolating in the background. And so this is in part the recurring story of bioethics is as advancing technology gives us these new choices, we're faced with ethical question where before we didn't have those problems. I think the question for me is in what regard are those questions different in nature to the ones that were raised previously. Sometimes I see, this where I think, you know, everything that's old is new again.

LF: Yes.

TT: [Laughs] That there, that in bioethics there's a lot of, you see the same kinds of issues, the same kinds of questions occurring over and over again, but being raised in these new contexts.

LF: And, when they're raised in new context, the details often make a difference. So we have to pay attention to the details. We have to pay attention to, in terms of genetics and cancer today, these targeted cancer therapies, and the varying degrees of success that these different drugs have for different individuals with different genetic endowment, or whose cancer is distinguished by the genetic analysis that might be done to their cancer. So you've got those kinds of issues. The other issues that are emerging today have to do with the human brain, and so all the issues of neuroethics and so on. And again, there's a lot of medical scientific detail, there are all kinds of interventions that we're attempting today that, deep brain stimulation in connection with Parkinson's, for example. And potential consequences of doing that and how serious they are, and do you give patients choices on this, or are there some choices that shouldn't even be offered to patients and that physicians should avoid getting involved with. I mean, those are all recurring kinds of themes within bioethics.

TT: Mmhm, yeah, right. Right. I mean, I think one of the things that's, for me, is a little more distinctive about some of the advances in neurological treatment and interventions are the more fundamental, sort of maybe ontological [laughs] that's too fancy a word, questions that they raise about personal identity. So, you know, as more and more, as you create these interventions that do things to my brain, that may affect my behavior, in ways that don't seem to be, seem to be created by a machine, or by some technology rather than me. What is the boundary between me and my brain implant? Can I say, oh, I'm sorry, my brain implant again. Please excuse it. It doesn't know what it's doing. [Laughs] So those, I think, are, maybe they're precedents in bioethics, but for me those are the most, the newest kinds of arenas that are, questions that are being raised by advances in neurotechnologies.

LF: What we're trying, I mean, sometimes we ask the question, how do we identify what someone's real self is? And is it not my real self if there is say some kind of psychiatric disorder that makes me different from the way in which I want to be. And then if we have a drug that can in one way or another correct that disorder, make me more like other people, is that my real self? Or, alternatively, we have Kay [Redfield Jamison] who wrote this book An Unquiet Mind, and in that, and in her story, the story that she tells about herself, and she's a very prominent researcher at Johns Hopkins University, she has to deal with bipolar disorder. And this is something that was really wrecking her life in many ways, and of course we have very good drugs that can help individuals with that disorder to deal with it. But she really loved the manic states, and she sort of felt that this was her real self, and she got all kinds of praise because she would turn out these scientific articles.

TT: Very much more creative.

LF: That’s right, more creative, more productive. She loved that version of herself, and when, when she would take the various medications that would bring her to the more normal psychological level, this was just a dull and uninteresting version of herself. She didn't really want that self, but the alternative was if you want the mania and so on, you also had to take some very bad consequences regarding the kinds of choices that she made. She engaged in, for example, this extraordinarily, these extraordinary spending sprees.

TT: Spending sprees, yeah right.

LF: That resulted in bankruptcy and so on.

TT: Right. Well you need a targeted mania drug.

LF: A targeted mania drug, yes.

TT: Just for the creative part.

LF: Yep, yes, that's right.

TT: I mean I think, you know, of course this, you know, this all edges into, you know, this sort of transhumanist.

LF: Oh yes.

TT: Yes, all these ideas about how we're going to sort of leave our biological selves behind, have ultimate control over every aspect of our lives. That's what some people find kind of frightening.

LF: Well, what's even more frightening and more transhumanist than we might care to accept is the idea that we would create these robots with artificial intelligence, and so future versions of HAL from [2001: A Space Odyssey] who would be smarter than any humans and would ultimately replicate themselves, and kind of push us out of the way.

TT: Yeah.

LF: These of course are, I believe, science fiction scenarios. Interesting reading, but I don't think that stuff like that will really happen.

TT: Yeah. Well, I mean, here's another thing that's coming into medicine, of course, and that is the use of artificial intelligence to be making diagnoses, and prescribing therapies, and providing prognosis, and doing all the things that ordinary human doctors have done for millennia. And. I think that, I think there's interesting work to be done in bioethics there, too. And not just bioethics, but also sociological and psychological studies of what the impact may be on the nature of the doctor patient relationship. And the patient's experience. This is going to be a real revolution that may have consequences -- we should really try to understand as best we can what the consequences of that are going to be. Is it going to be unemployment for physicians, is that going to be one of the consequences?

LF: I don't think physicians worry too much about that. But, the, part of the ideas you were suggesting was you have these massive computers that can manage huge amounts of data about hundreds of thousands or millions of patients, and, in effect, say doctor this is how you outta think about responding to the needs of this particular patient before you now. And the doctor caring for that patient might have what you would call in intuition that I don't think that's quite right for this patient, but if they act on that intuition you get a bad outcome--

TT: His reimbursement's going to drop.

LF: That’s right, yes, that's right.

TT: [Laughs] If he's not following that protocol.

LF: And there are, and there would be legal problems, why did you do that? Why did you trust your one micro brain to make that judgement when we're got this billions of--

TT: Yeah, your one gigibot, your one gigabyte brain. [Laughs]

LF: Yeah, to go against the several terabyte brain that's associated with the computer that produces big data.

TT: Yeah. I think I, this is, now we're kind of wandering a bit but that's okay. So, I, there's something I saw recently that, that said that the biggest problem for artificial intelligence is what we call common sense. So you can build algorithms, you can train, you know, these computers with neural networks and all this kind of stuff, to recognize things or to make decisions better than humans, but when it comes to decisions that revolve a kind of a common sense, or some kind of background knowledge that is highly, highly contextual in its relevance, that's the big challenge as I understand it to something real artificial intelligence that approaches human intelligence. I hope we never cross it.

LF: Yes, me too.

TT: [Laughs]

LF: And on that note, I think need to conclude.

TT: Well this has been fun.

LF: Yes.

TT: Thanks everybody.

LM: Thank you for joining us today on No Easy Answers in Bioethics. Please visit us online at bioethics.msu.edu, and follow us on Twitter @MSUbioethics. This episode of No Easy Answers in Bioethics was produced and edited by Liz McDaniel.