Moral Oneupmanship

Moral oneupmanship.

"How can you," I was indignantly asked, "worry about something like medical ethics when the world is faced with a nuclear holocaust?" Someone else, with no less indignation, asserted that the Arab-Israeli conflict was far more important than American medical problems: "Why don't you work on that!" Those conversations took place in 1969, when Willard Gaylin and I were organizing The Hastings Center.

Ever since then there have been, from time to time, comparable accusations, and we are going through another phase of it right now. The kinds of issues the Center—and the field of bioethics—works on are said to be elitist (affecting the affluent only), precious (how many moral distinctions can dance on the head of a pin?), and evasive (averting our eyes from the suffering of the poor in developing countries).

I have puzzled for years about such charges, not taking them too seriously. I have tended to see them as a form of moral oneupmanship: whatever the issue, some other issue is more important. For liberals it is characteristically problems of the poor, or global warming, or inequitable distribution of wealth. For conservatives it is more likely to be moral relativism, scientific hubris and its threats to our dignity, or a neglect of the deeper, classical questions of human meaning and fate.

My usual response is probably too insouciant, but the puzzle remains. As individuals we have to determine how best to use our skills and interests; not all of us would be skilled enough for clinical work in Haiti or for the politics of global health reform. Should some of us seek training to develop such skills? That might well be a good thing to do, but it is hardly evident that each of us has a moral obligation to do so—particularly if we are doing otherwise laudable work (even if not the most laudable by some heroic standards). We can legitimately lament if no one is drawn to such vocations, but not that everyone is not so drawn.

Should the field itself have some ethical priorities? I doubt it, but in any case it is hard to answer that question without some notion of what it is to do work in ethics—as distinguished, say, from bedside medicine, social work, political reform, or anthropology. Bioethics as a field customarily focuses, most appropriately, on ethical analysis and on devising standards for moral judgments. I have written in favor of single-payer universal health care, providing ethical reasons in its favor, but I have not gone to Washington to lobby for it. The latter seems to me a different kind of role, no less important, just different.

As for The Hastings Center, consider the diversity of our present work: continuing work on end of life care and crafting standards of "quality" in health care; development of an international project on long-term care; assistance to international agencies on ethical issues of HIV vaccine trials in Haiti; a project in East Africa on ethical problems in treating those with AIDS; the impact of market theory and practice on health care in developing countries; highly speculative work on a new scientific frontier, neu-roimaging; and research on performance-enhancing drugs and sports. That seems to me a fairly rich mix.