Challenging the Conventional WisdomFrom Philosophy to Bioethics
Philosophy is a core discipline that has contributed importantly to bioethics. In this essay, the author traces his trajectory from philosophy to bioethics, oriented around the theme of challenging the conventional wisdom. Three topics are discussed to illustrate this theme: the ethics of randomized trials, determination of death and organ transplantation, and pragmatism as a method of bioethics. In addition, the author offers some general reflections on the relationship between philosophy and bioethics.
Philosophy recovers itself when it ceases to be a device for dealing with the problems of philosophers and becomes a method, cultivated by philosophers, for dealing with the problems of men.—John Dewey (1917)
Kierkegaard famously declared that life is lived forwards but understood backwards. The retrospective look at one's career necessarily takes the form of a narrative reconstruction. Our lives are messier than the stories we tell about them. [End Page 3]
I first took up serious study of philosophy as a sophomore at Columbia College in 1967. The extensive core curriculum at Columbia exposes all students to a sampling of classic texts in philosophy. Some inkling of a more than passing interest in philosophy, which I can't now recall, must have induced me take an elective course devoted to that subject. It was taught in the old-fashioned way of detailed examination of classic texts—the way that I believe it is best to learn about, and kindle enthusiasm for, philosophical inquiry. We studied carefully Descartes's Meditations, Hume's Enquiry Concerning Human Understanding, and Mill's On Liberty. I was hooked. And from that time I can trace a lasting influence: Mill's classic text is one to which I returned nearly 40 years later in a collaboration with the late Alan Wertheimer concerning the paternalistic character of the ethics and regulation of clinical research.
My first course in philosophy led to taking others and eventually to majoring in the discipline. But I almost set it aside after graduating college, as I believed then that I was more interested in graduate studies in the history of ideas. I didn't get into either of the programs to which I applied, which prompted me to sheepishly consult with one of my philosophy professors about what I should do next. Taking a properly directive stance, he encouraged me to apply to the graduate program in philosophy at Columbia, and he was instrumental, I believe, in my getting accepted. This was one of a few twists of contingency or fate that set me on the path to becoming a philosopher-bioethicist.
In graduate school I concentrated on moral and political philosophy, eventually writing a dissertation on the moral obligation to obey the law. In the late 1970s, it was especially difficult to land academic positions in philosophy. I count myself lucky that I failed in that endeavor. It is doubtful that I would have found my way to bioethics had I managed to become a faculty member at some obscure college or university. Instead, I pursued alternative career paths from 1977 to 1990. In the latter half of that period I renewed my love affair with philosophy, but in a purely private way. I fancied myself a "closet philosopher," rereading classic texts, exploring areas of philosophy with which I hadn't been much familiar, and writing unpublished essays, dialogues, and even an unpublished book on the theme of philosophy as a way of life. While pursuing philosophy again, I was in rebellion against academic philosophy, which I took to be essentially an ivory tower discipline. Perhaps there was an element of sour grapes in this perspective, given my failed efforts to become an academic philosopher. Nevertheless, I saw moral philosophy in the Anglo-American world as largely isolated from practical issues of moral concern.
My path to bioethics opened up when I met John Fletcher, a theological scholar and one of the pioneers in the field, who now is probably unknown to most bioethicists. Then a solo bioethicist employed at the National Institutes of Health, Fletcher was an old friend of my stepfather. In 1985, Fletcher persuaded me to become a lay member of the institutional review board (IRB) of the intramural [End Page 4] research program at the National Institute of Child Health and Human Development. This was my first exposure to the ethics and regulation of clinical research, which I later addressed as a major theme in my bioethics scholarship. To get any sense of what the research protocols under review were about, I had to first read the consent documents. I served continuously on IRBs at the NIH until 2015, and I confess that in the last few years of that all-too-long engagement with the regulation of clinical research I had become burned out to the extent that I could barely force myself to read another consent form.
Fletcher left the NIH in 1987 to develop a biomedical ethics program at the University of Virginia (UVA), and he recruited me as a volunteer to help him plan the shape of that program. Working then as a family investment manager, I had time on my hands, and while working on the UVA project I drew on skills developed during an earlier five-year stint as a program planner at a nonprofit organization devoted to research and development in criminal justice and social services. My exposure to Fletcher's world at UVA sparked an interest in bioethics as an intellectual field.
In 1990, I participated in the week-long intensive course in bioethics delivered annually at the Kennedy Institute of Ethics—my one and only experience of formal education in bioethics. Later that year I began team teaching bioethics with Fletcher at UVA, commuting once a week from the Washington, DC, area to Charlottesville. Also that year, after some false starts, I wrote my first published article, which was on the topic of physician-assisted death. At that time Jack Kevorkian, a retired pathologist, was on the rampage, receiving considerable attention in the news media and causing consternation in the medical community for assisting suicides of individuals he engaged with solely for that purpose. Physician-assisted death became for me a major and enduring research interest, one that has continued right up to the present.
Learning by doing has characterized my various careers subsequent to completing graduate school in philosophy. In bioethics I was almost entirely self-taught. Although Fletcher was a mentor who opened doors for me to establish and advance a career in the field, I forged my own path intellectually. I did learn a great deal, however, in the process of collaborating with other bioethics scholars, especially with physician-bioethicists. Because I worked on the margins of academia, in my weekly visits to teach bioethics at UVA, I gravitated towards collaborative scholarship—a way of building my own community of colleagues. But the turn to collaboration also was useful for me as a non-clinician interested in medical ethics. Early on, I aimed at writing for publication in medical journals, where I could reach a much larger audience than for bioethics journals. The fact that most medical journals practice unblinded peer review makes it advantageous for emerging scholars to collaborate with better-known colleagues, especially physicians. [End Page 5]
It is worth pausing to comment on how ill-prepared I was for important aspects of the trajectory of my career in bioethics scholarship by virtue of training in academic philosophy. This is not just a matter of the isolation of academic moral philosophy from practical ethics. Philosophy has remained a discipline of solo scholarship, so I had no experience with collaborative research and writing. Moreover, academic philosophers write for their academic peers, and this writing proceeds generally at a high level of abstraction, with painstaking trappings of rigor in analysis and argumentation that are off-putting to scholars from other disciplines. Bernard Williams (2015) aptly lampoons the style of academic analytical philosophers as one that "tries to remove in advance every conceivable misunderstanding or misinterpretation or objection, including those that would occur only to the malicious or the clinically literal-minded," and notes that the training of these philosophers tend to promote "an intimidatingly nit-picking superego" (330).
To some extent academic philosophers can get away with their distinctive habits of thinking and writing when trying to get their work published in bioethics journals. But even in that forum it is desirable to dial back the high level of abstraction, set aside more fanciful thought experiments, curb philosophical jargon, relax the "nit-picking superego," and connect with concrete issues. Philosopher-bioethicists need to break away from the philosophical style entirely in order to get their work published in medical journals, and in pursuit of that goal they must tolerate the necessary lack of sophisticated analysis and argument that goes along with very short articles addressed to a medical audience. In making the transition to writing for medical journals, it helps for philosopher-bioethicists to work with physicians without philosophical training, as one has to be able to communicate intelligibly and fruitfully with one's colleague before submitting a paper for publication. In my own case, I was probably aided by having spent five years as a program planner, which involved doing a good deal of writing for nonacademic professionals.
My first medical journal publication was unusual in a number of respects. I was the lead author in a team I assembled of five other authors, including Fletcher, three physicians (two of whom were not bioethicists), and a legal scholar. We proposed a model for regulating a legal option of physician-assisted death, before the practice had become legalized in the United States (Miller et al. 1994). This was prior to the internet and the ability to transmit attachments of track-changes documents. We traded drafts back and forth by fax machine, requiring laborious efforts on my part to incorporate changes into successive drafts. Completing the project included a phone conversation with the no-nonsense editor of the New England Journal, Marcia Angell, who insisted on certain changes before the paper was accepted. Anticipating that the publication, coincidentally on Bastille Day 1994, might generate attention from the press, I anxiously awaited a phone call from journalists; none came. [End Page 6]
I considered myself fairly productive as a scholar during my decade of affiliation with UVA. But my productivity ramped up considerably after joining the NIH Department of Bioethics under the energetic leadership of Zeke Emanuel. I was hired for a faculty position in the department, along with an affiliation with the National Institute of Mental Health (NIMH). In the latter capacity I worked with my friend and colleague Don Rosenstein, director of the Consultation-Liaison service of the NIMH intramural research program, as a co-instructor in a seminar on research ethics for psychiatric research fellows. I also served as the bioethics member on the NIMH IRB.
Philosophy and Bioethics
Philosophy etymologically is love of wisdom. More accurate is to characterize it as love of examining critically what passes for wisdom. Challenging the conventional wisdom is a philosophical trope that goes back to Socrates. In Plato's Apology, Socrates describes himself as a "gadfly" irritating his fellow Athenians. Whenever he encountered others making claims to moral knowledge, he subjected them to cross-examination. The claimants were exposed as lacking cogent reasons for their beliefs, which withered in the face of Socrates' relentless critical scrutiny. As is well known, Socrates got into trouble by persisting in his gadfly mission. The Apology dramatizes the prosecution of Socrates and his typically gadfly defense, in which he proclaimed that "the unexamined life is not worth living." He was sentenced to death and died by drinking hemlock—an event that oddly intersects with medical ethics by virtue of the Hemlock Society, which advocates for assisted suicide. Other great philosophers especially known for challenging conventional wisdom are Baruch Spinoza, who published his works anonymously out of fear of legal consequences, and David Hume, who also suppressed the publication of an essay defending suicide as rational. Immanuel Kant declared that reading Hume awoke him from his "dogmatic slumber."
Bioethicists, being human, also can fall into dogmatic slumber. Moreover, there are tendencies within bioethics that lead bioethicists to coalesce around conventional wisdom views, some of which are misguided. Consensus is valued within the medical world—an orientation that also, to a significant extent, characterizes bioethics and marks one of many ways in which it differs from philosophy. While only radical skeptics would hold that all conventional beliefs are mistaken, conventional wisdom in bioethics, I believe, always deserves critical scrutiny. Consensus views that are based on faulty reasoning should be abandoned not only owing to their lack of sound justification, but because they can foster deleterious consequences.
In a somewhat tongue-in-cheek mode, Bob Truog and I wrote an essay we entitled, "An Apology for Socratic Bioethics" (Miller and Truog 2008). It reflected our mutual admiration for provocative critical thinking but recognition that this [End Page 7] stance also should be subject to critical scrutiny. In it we described some of my work challenging conventional wisdom on the ethics of randomized controlled trials and his on the determination of death and organ transplantation. Subsequently, the two of us teamed up on what became a long-term project devoted to the latter topic.
Philosophers contribute to bioethics scholarship in different ways. For the sake of simplicity, they can be divided into two camps. Some primarily identify as philosophers and apply their philosophical theorizing to ethical issues relating to medicine and biomedical research. Others make use of skills in analysis of concepts, critical thinking, and logical argumentation in undertaking bioethics scholarship, often without explicitly invoking philosophical theories or undertaking sophisticated philosophical analysis. By situating my own work within the latter camp, my account of how my philosophical background has contributed to doing bioethics reflects this orientation. But the distinction is not meant to define a dichotomy. Some philosopher-bioethicists in the first camp have demonstrated the ability to travel light as philosophers by writing influential articles for medical journals, as did James Rachels in his classic article, "Active and Passive Euthanasia," published in the New England Journal of Medicine in 1975. On the other hand, I have attempted some (modest) contributions to explicitly applying the philosophical thinking of the American pragmatist John Dewey to bioethics, discussed below. The epigram of this essay—a quote from Dewey—succinctly characterizes in a general way how, I think, philosophy as a discipline can best contribute to bioethics: by cultivating and applying a method of clarifying and helping to resolve ethical problems faced by men and women in the practice of medicine, biomedical research, and public health.
To illustrate how the discipline of philosophy—trained habits of reflective and critical thinking—can contribute to bioethics, I take up two major themes of my bioethics scholarship pursued over the last 17 years: the ethics of randomized controlled clinical trials, and the intersection between the determination of death and organ transplantation. As different as these two themes are, a common philosophical impetus sparked my work on both: challenging the conventional wisdom and analyzing incoherence between theory and practice. Next, I take a critical look at my efforts to advance philosophical pragmatism as a paradigm for bioethics scholarship.
The Ethics of Randomized Trials
Randomized controlled trials are the standard way in which medical treatment interventions are evaluated rigorously. In these studies patients with a given medical condition are invited to be allocated randomly to receive either a novel treatment or a control intervention, which may be a standard treatment or a placebo designed to appear indistinguishable from the treatment under investigation. My work on the ethics of randomized controlled trials began with an invitation [End Page 8] to write a paper in connection with a conference on placebo-controlled trials in psychiatry. Owing to my position as the bioethics member of the NIMH IRB, I was familiar with psychiatric clinical trials that randomized patient-subjects suffering from depression, anxiety disorders, schizophrenia, and even acute mania to placebo controls, despite the existence of proven effective treatments for these conditions. Some of these trials were performed at the NIMH, others at leading academic medical centers. Many, but by no means all, were funded by pharmaceutical companies. Trials for many other medical conditions exhibited this same pattern. These IRB-approved studies flew in the face of a consensus ethical view that no patient should be randomized to placebo when a proven effective treatment exists for the patient's condition. This stance was reflected in the Declaration of Helsinki, which propounded ethical principles for the conduct of medical research, and in the bioethics doctrine known as clinical equipoise, initially articulated by philosopher-bioethicist Benjamin Freedman (1987). Here was an obvious clash between bioethics theory and research practice. Was current research practice unethical in this context, or was the established ethical perspective mistaken?
I knew that in order to do justice to the controversy, I needed to grapple with the methodological rationale for using placebo controls in some conditions despite proven effective treatments. Without going into that rationale here, examined in my initial paper on this topic and in subsequent work, I bring up this point in order to emphasize the importance for philosopher-bioethicists, who may lack any training in science or in a clinical discipline, to educate themselves on the scientific and clinical considerations that are relevant to understanding and resolving ethical problems in biomedicine. Indeed, I had previously shied away from work on this topic because I knew it would take a substantial investment in reading methodological literature and appreciating its relevance to clinical research. It is easy for bioethicists to weigh in on why such clinical trials are thought unethical, as it is apparent that they withhold proven effective treatment from patients. Doctors shouldn't be inviting patients to do that. To be sure, some critical thinking can put into question why this is unethical in clinical research, given that the activity aims to produce valuable generalizable knowledge about the safety and effectiveness of treatments and thereby differs from patient-centered medical care. This recognition proved critical to the position I came to stake out on this topic. Nonetheless, there would be no point in randomizing patient-subjects to placebo despite proven effective treatment if there were no solid methodological reasons for doing so, and if there were no problems posed by active-controlled trials that randomized patient-subjects either to an experimental or a standard treatment.
The investment in background research outside of philosophy and bioethics can pay off in unexpected ways. In studying methodological issues relating to placebo-controlled trials, it became clear that one of the reasons favoring this type of trial design was the propensity of patients to experience placebo effects, especially with respect to subjective outcomes such as psychic distress and pain. [End Page 9] Accordingly, I delved into the literature on placebo effects—positive therapeutic outcomes caused by receiving a placebo intervention, typically under conditions where the patient believes or expects to be receiving a real treatment. I became fascinated with this phenomenon in its neurobiological, psychological, and philosophical dimensions. Contributing to the conceptual and theoretical understanding of placebo effects eventually became a major research focus for me—one that had nothing to do with bioethics. Additionally, this line of research stimulated an interest in, and considerable work on, ethical issues relating to research on placebo effects (focusing on the use of deception in study design) and the ethics of placebo treatments in clinical practice.
Based on my IRB experience and background reading, I concluded that sound reasons of scientific methodology supported the continued use of placebo-controlled trials to evaluate investigational treatments in psychiatry, and that with standard procedures for monitoring trial participants, they would not be exposed to undue risks of harm from withholding proven effective treatment; indeed, those randomized to placebo might experience symptomatic improvement as a result of placebo effects. Of course, these trials could be ethical only with a process of informed consent that adequately explains to trial participants the purpose of the research, the chance of receiving a placebo rather than a drug to treat their condition, and the risks of faring worse than those randomized to the experimental drug. The trials could be justified in essentially the same way as other instances of non-therapeutic research: the use of placebo controls is needed to promote the scientific validity of the research, and the risks to patient-subjects are compensated by the anticipated value of the knowledge to be gained by the research (Miller 2000).
Having staked out that position, my task was to attempt to explain what was wrong with the conventional wisdom view regarding the ethics of placebo-controlled trials. I wasn't ready to take on clinical equipoise systematically at that initial stage, but I did identify what I saw as the normative mistake underlying the conventional view: failure to appreciate the ethical differences between the conduct of clinical research, aimed at generalizable knowledge, and medical care, governed by patient-centered beneficence and nonmaleficence.
My next task was to undertake a frontal assault on the doctrine of clinical equipoise (Miller and Brody 2003). This doctrine asserts that randomized trials are ethical only if there is a state of uncertainty in the medical community about whether a novel treatment is superior to standard treatment. As Freedman and colleagues (1996) wrote:
That principle [of clinical equipoise] can be put into normative or scientific language. As a normative matter, it defines ethical trial design as prohibiting any compromise of a patient's right to medical treatment by enrolling in a study. The same concern is often stated scientifically when we assert that a study must start with an honest null hypothesis, genuine medical uncertainty concerning the [End Page 10] relative merits of the various arms included in the trial's design. These principles allow for testing new agents when sufficient information has accumulated to create a state of clinical equipoise vis-à-vis established methods of treatment. At the same time they foreclose the use of placebos in the face of established treatment, because enrolling in a trial would imply that a proportion of enrollees will receive medical attention currently considered inferior by the expert community.(253)
Some of my fellow bioethicists probably thought I was on a fool's errand in attacking clinical equipoise. Not only did many see it as an obviously sound ethical doctrine, but it was firmly entrenched, at least in theory. But it seemed clear to me that if I was right in seeing placebo-controlled trials as sometimes justified in the face of proven effective treatment, then clinical equipoise, which implied the opposite, had to be mistaken. I argued that the incoherence between bioethical theory and research practice in this domain needed to be resolved by abandoning the theory that unjustly condemned placebo-controlled trials solely on the basis of withholding proven effective treatment.
Furthermore, I detected incoherence within the doctrine of clinical equipoise (Miller and Brody 2007). Proponents of this doctrine saw no ethical problem in the fact that many clinical trials include research procedures that carry some risk of harm to patient-subjects but are implemented for scientific reasons, such as imaging procedures that involve radiation and biopsies for the purpose of measuring study outcomes. These are procedures that can't be justified in the context of clinical medical ethics. If clinical trials can justifiably depart from the ethics of medical care for scientific purposes with respect to these research procedures, then by the same token it can be ethical to use placebo controls despite proven effective treatment. In both cases the risks of these nontherapeutic interventions are to be justified not by the benefits to patient-subjects, but by the anticipated value of the knowledge to be gained from the trial. Moreover, from a scientific perspective, these placebo-controlled trials do not run afoul of the uncertainty principle or honest null hypothesis, because there is uncertainty whether the investigational treatment will be superior to a placebo control. Many experimental treatments for symptomatic conditions that look promising in early phase trials fail to demonstrate superiority to placebo in larger-scale randomized placebo-controlled trials.
Consider once again the passage explicating clinical equipoise by Freedman and colleagues. They state that clinical equipoise can be formulated in either scientific or normative language. Does that mean that these formulations are equivalent? If so, that would seem to imply that a morally neutral rule of scientific inquiry in the medical realm is logically equivalent to a moral norm regarding the physician-patient relationship. Such a stance appears philosophically dubious, as it would have made more sense to explicate clinical equipoise as consisting of scientific and normative components. It is mainly the normative thrust of clinical equipoise that I sought to put into question. Not only did the clinical equipoise doctrine conflate the ethics of clinical trials with the ethics of medical care, but its [End Page 11] defenders failed to explain why patients' right to standard medical care couldn't be waived by them when they became research participants via informed consent.
Might the incoherence between the practice of conducting placebo-controlled trials despite proven effective treatment in some conditions and the normative doctrine of clinical equipoise be resolved by making some adjustments to the latter so that it can accommodate the former? Perhaps. But to invoke a scientific analogy, that looks like the effort to preserve geocentric astronomy by introducing epicycles into the model. Better, I would argue, to dispense with equipoise than to attempt to shore it up, especially in view of its assuming a problematic therapeutic orientation to the ethics of clinical trials.
Insisting on the ethical differences between clinical research and medical care became a major theme of my bioethics research, which I applied not only to the ethics of placebo-controlled drug trials but also to sham-controlled surgery trials and both phase I and randomized controlled trials in oncology (Miller 2012). My first foray into the ethics of placebo-controlled trials was a solo performance, which contained the germ of this approach to research ethics that I pursued for the next 15 years. However, my subsequent work was almost entirely collaborative. It is highly unlikely that I would have had the fortitude to mount a sustained attack on clinical equipoise and the therapeutic orientation to clinical trials, or would enjoy the publication success that derived from this research program, without teamwork with three physician colleagues—Howard Brody, Don Rosenstein, and Steve Joffe—with whom I collaborated separately in a series of papers.
Determination of Death and Organ Transplantation
Incoherence between theory and practice was on my radar screen once again in pursuing a very different area of bioethics, mostly in collaboration with another physician-bioethicist, Bob Truog. In 2007 I read with great interest an article by Truog (2007) with the catchy title "Brain Death: Too Flawed to Endure, Too Ingrained to Abandon." While I was convinced by Truog's analysis of the flaws in the doctrine of "brain death" in this and previous articles he had written, I felt that there was good reason to try to demonstrate more systematically why bioethics and the medical community should abandon the dogma that brain death constitutes the biological death of the human being. That dogma underwrites the procurement of vital organs from these profoundly brain-damaged bodies while hooked up to ventilators, consistent with what is known as the "dead donor rule." (The dead donor rule specifies that vital organs can be procured only from donors legitimately determined to be dead at the time of procurement.) I certainly wasn't opposed to vital organ donations from those diagnosed as brain dead, but I was persuaded that this practice couldn't be justified on the basis that they already were dead at the time of organ procurement. With respect to this area of conflict between theory and practice, one or the other had to be abandoned to achieve intellectual coherence, and once again I felt sure that it was the theory that was [End Page 12] flawed and needed to be attacked, despite its being ingrained as conventional wisdom.
It took some persuading to get Truog on board, as he thought that he was at the end of a long-standing research program relating to this topic. I didn't anticipate writing any more than a single paper aimed at diagnosing and attempting to resolve the incoherence between theory and practice in determination of death and organ transplantation. However, it turned into a collaborative project spanning multiple papers and culminating in a book we wrote together, Death, Dying, and Organ Transplantation: Reconstruction of Medical Ethics at the End of Life (Miller and Truog 2012).
The brain death doctrine was a settled and largely unquestioned fixture of medical ethics from 1968 to around 1990. The consensus rationale supporting this doctrine was articulated in 1981 by the U.S. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. The position of the President's Commission can be summarized in the following argument: (1) death is the irreversible cessation of the functioning of the organism as a whole; (2) the brain is the integrator of functioning of the organism as a whole; (3) the brain has irreversibly ceased to perform all its functions in those diagnosed as brain dead; therefore, (4) the brain dead are dead.
About a decade later, some commentators in the medical and bioethics literature demonstrated that the second and third premises of this argument were false. Individuals who meet the diagnostic criteria for brain death are in an irreversible coma without the ability to breathe spontaneously. Nevertheless, with the maintenance of mechanical ventilation, they display a wide array of integrative, homeo-static functions of the organism as a whole. These include circulation, respiration, elimination of wastes, maintenance of body temperature, wound healing, fighting infections, stress response to incisions connected with organ retrieval, and in the case of brain dead pregnant women, even successful gestation of a fetus. Moreover, some neurohormonal functioning is preserved in a proportion of those diagnosed correctly as brain dead, which makes it false that the whole brain has necessarily ceased to function in this condition. The clear upshot is that the brain dead are not dead in terms of a biological conception of death, defined in terms of the functioning of the organism as a whole (Miller and Truog 2012).
Truog and I argued that the dead donor rule was routinely being violated in the practice of vital organ transplantation. How was this incoherence between theory and practice to be resolved? One approach that would preserve the dead donor rule would be to adopt a consciousness-based standard of death—a move long endorsed by some philosophers and bioethicists. This approach sees the brain dead as dead because by virtue of the irreversible loss of consciousness they are no longer persons with moral standing. However, this perspective had been explicitly rejected by the President's Commission in 1981 and again by the President's Council on Bioethics, which revisited the determination of death in 2008. Furthermore, [End Page 13] we saw a host of theoretical and practical problems with the consciousness-based standard (Miller and Truog 2012).
A good deal of our collaborative work on this topic was devoted to developing an alternative ethical rationale for vital organ donation, which did not rely on the dead donor rule. But how could we justify a practice of transplantation that causes the death of brain dead organ donors? A major part of our argumentative strategy relied on juxtaposing vital organ transplantation with the practice of withdrawing life-sustaining treatment, and we endeavored to demonstrate that death was being caused routinely and much more frequently in medical practice by means of the latter. We argued that, contrary to conventional wisdom in medical ethics, this practice was not merely allowing patients to die from their underlying medical condition, it was causing death. Moreover, the conventional view was based on a moral fiction (Miller, Truog, and Brock 2010). Since everyone agrees that it is ethical to withdraw life-sustaining treatment in order to respect patient autonomy and provide medical care that offers a favorable balance of benefit over harm, there should be no ethical objection to life-ending organ procurement from brain dead donors, provided that this is consistent with valid consent. As mechanical ventilation is withdrawn from the brain dead after the diagnosis is made, unless they are maintained for the purpose of organ procurement, no one would be made dead by organ procurement who otherwise wouldn't soon be made dead by stopping life-sustaining treatment.
Making good on the argument involved an extended foray into the nature of causation—a classic philosophical topic—and its application to treatment withdrawal. We attempted to defend a commonsense understanding of causation, rather than delving deep into philosophical issues. In our more systematic approach to characterizing treatment withdrawal, we slightly toned down our critique of conventional medical ethics, shifting from describing it as embracing an obvious moral fiction to regarding it as morally biased. We analyzed the standard view that withdrawing life-sustaining treatment allows the patient to die and does not cause the patient's death, as driven by commitment to the traditional stance in medical ethics that doctors must not (intentionally) kill their patients. Looking back now, and in the light of some criticism from commentators (McGee 2015), I am less than satisfied with the treatment of causation in our book and its application to life-sustaining treatment. I don't doubt that it makes good sense to describe withdrawing life support as causally contributing to death, but whether that makes treatment withdrawal better characterized as killing or letting die seems more complicated to me now.
Nonetheless, based on other elements of our justification for vital organ transplantation without the dead donor rule, I believe that we could have developed a fully adequate account without invoking the argumentative strategy that relied on characterizing withdrawal of life-sustaining treatment as causing the death of patients. As we contended, the still-living brain dead individuals who donate vital [End Page 14] organs with valid consent are not harmed or wronged by organ procurement, despite the fact that the intervention to procure organs causes their death; and they would become dead if they were not organ donors following the cessation of life-sustaining treatment. It follows that nothing is lost by procuring vital organs from patients in an irreversible coma before they are dead, and something important is gained: life-saving transplants for desperately ill patients. In other words, even if withdrawing life support is seen as allowing patients to die and not killing them, a sound independent argument could be developed in support of vital organ transplantation from still-living donors in an irreversible coma.
Pragmatism and Bioethics
I became interested in American pragmatism, especially the thought of John Dewey, as a graduate student in philosophy. Although at that time it had long been eclipsed by the so-called "analytical" movement in Anglo-American philosophy, pragmatism seemed to me a refreshing alternative to academic philosophy. My interest in pragmatism lay dormant for the next 20 years, but revived as I became engaged with thinking about the theoretical foundations of bioethics and method in bioethics analysis. I intensively revisited Dewey's philosophy, which I saw as pointing to an alternative to the prevailing theoretical orientation and method in bioethics, known as "principlism." This orientation was progressively developed by Tom Beauchamp and James Childress (2009) in multiple editions of their now classic text, Principles of Biomedical Ethics. I saw principlism, especially as applied by others, as an often mechanical, top-down approach to bioethics analysis, simplistically invoking fixed principles without paying due attention to the concrete contexts of problematic situations in biomedicine that posed ethical issues. Principlism as the reigning theoretical paradigm in bioethics was being attacked from a variety of perspectives, including casuistic, feminist, and narrative approaches to ethics. Working with my physician colleague Joe Fins, we argued that what we called "clinical pragmatism" offered a better method for analyzing ethical issues in clinical contexts (Fins, Bacchetta, and Miller 1997; Miller, Fins, and Bacchetta 1996). In doing so, we contended that it could, and should, constitute a new paradigm to replace principlism.
The project failed not only because it got little traction in the bioethics literature; more significantly, it failed because, as philosopher-bioethicist John Arras (2002) cogently argued, the approach to pragmatism in bioethics that we developed fell short in offering a bona fide alternative to principlism. Arras's critique of our work in this domain, written with his characteristic panache, appeared in an article entitled "Pragmatism in Bioethics: Been There, Done That." The title reflected his major contention that our formulation of pragmatism, when subjected to critical examination, did not succeed in identifying any tools of ethical analysis that were not already being deployed in mainstream bioethics. As Arras put it: "Thus, if pragmatists believe that moral principles are both action-guiding and [End Page 15] the products of refinement in the crucible of concrete cases, then Beauchamp and Childress are pragmatists. For all its verisimilitude, then, the 'clinical pragmatist' theory of principles advanced by Miller et al. turns out to be a mere restatement of principlism as presently understood by its chief exponents" (47–48).
I didn't have a good counterargument to Arras's critique at the time, and it wasn't long before I gave up the project of defining method in bioethics from the perspective of pragmatism. Pragmatism in bioethics, as I understood it, turned out to be no more than a label for effective tools of bioethics analysis put to good use by bioethicists with divergent theoretical orientations. Despite my affinity for philosophical pragmatism, as I look back at my career in bioethics I doubt that my work would have been any different analytically or substantively if I had never been exposed to the thought of John Dewey. In sum, this effort to challenge the conventional wisdom in bioethics at the level of method didn't make the grade.
As a bittersweet aside, I note that Arras had planned to include the thrust of that essay on pragmatism in a book he had long been writing on method in bioethics. Several years ago I was scheduled to meet with the bioethics editor of Oxford University Press at an annual meeting of the American Society for Bioethics and the Humanities. Immediately before my meeting, he was talking with John Arras. Arras concluded the conversation by thundering, "I'm going to finish that fucking book!" Sadly, he died before he could complete it.
Philosophers see themselves as practicing a rational discipline of logically rigorous, systematic thinking. To a large extent, that self-perception is accurate. But the history of philosophy is replete with logically incompatible theoretical orientations. William James (1907), a great psychologist and significant philosopher, diagnosed this fact provocatively:
The history of philosophy is to a great extent that of a certain clash of human temperaments. … Of whatever temperament a professional philosopher is, he tries, when philosophizing, to sink the fact of his temperament. Temperament is no conventionally recognized reason, so he urges impersonal reasons only for his conclusions. Yet his temperament really gives him a stronger bias than any of his more strictly objective premises.(488–89)
Many philosophers would regard this diagnosis as an unwarranted psychologism. However, I believe that James advanced an important perspective, albeit perhaps with some exaggeration. Challenging the conventional wisdom, which I have highlighted in this essay, is a logically optional philosophical stance—one that appeals to certain temperaments. In contrast, some philosophers endeavor to show how traditional or commonsense views regarding knowledge or morality can be grounded on a systematic foundation. Both philosophical orientations can make important contributions to bioethics. [End Page 16]
Critique of conventional wisdom views in bioethics is not self-justifying. Obviously, its value depends on the critique being accurate and cogent. Hence, critics of the conventional wisdom deserve critical scrutiny. But even if accurate and cogent, such critique may fail to make a difference. The inertia of dogmatic slumber may persist. Critics of entrenched views need to look to the long term for vindication, but it is to be hoped that in the short run critique of the conventional wisdom may prompt its defenders to rethink their views and search for a better defense.
Training in philosophy promotes critical inquiry and analytical rigor. Because theoretical stances in bioethics draw on traditions of moral philosophy emanating from Kant and the classical utilitarians, it helps in doing bioethics to have at least some basic familiarity with these general ethical theories. Accordingly, the study of philosophy is excellent training for becoming a bioethicist. But it is not sufficient. Indeed, Bernard Williams (1995) noted a paradox regarding the role of philosophers in bioethics: "it invites us to appeal in matters of life and death to someone who has a PhD in ethical theory but whose judgment, quite possibly, we would not trust on any serious practical question" (206). As this quote by Williams suggests, competence in bioethics calls for practical judgment, which has nothing to do with philosophical training. In any case, bioethics is not an inherently philosophical field of scholarship, and philosophy has no valid claim to be the master discipline behind bioethics. Bioethics is inherently interdisciplinary, and it aims to shed light on ethical issues in medicine, biomedical research, and public health in ways that are intelligible to practitioners of these professional domains. Bioethics also addresses the educated public in the form of the work performed by public bioethics commissions, and bioethicists are frequently interviewed by journalists writing stories on ethical issues in biomedicine. As bioethics scholars with backgrounds in philosophy, we are most effective when we travel light as philosophical theorists, deploying our skills in analysis and argument (and practical judgment) in service of diagnosing ethical problems in the biomedical arena and contributing to thinking about how to resolve them satisfactorily.
This essay is dedicated to the memory of the author's late colleague and friend Alan Wertheimer. The author regrets that he couldn't discuss the themes of this essay with him and profit from his critical comments. Thanks to Anne Barnhill and Martha Montello for valuable comments on previous drafts.