There have been three large themes in my recent published research and professional presentations: (1) abortion and the Dobbs decision; (2) public reason and bioethics; and (3) precision medicine, priority setting, and health care justice. All these themes represent engaged philosophy that aims to manage respectfully and thoughtfully the public discussion of controversial ethical and political issues.
No one doubts that the Dobbs decision has roiled the political environment at every level. What is less well known are the broader effects on medical practice and medical education. I came to Michigan State University and the College of Human medicine in 1985. Over the years some number of medical students would ask me why the abortion issue was not being discussed as part of the curriculum. The short answer was that many medical schools saw that as divisive and unnecessary (because Roe was in place). The Dobbs decision changed that dramatically as the effects of that decision began to play out in medical practice in various states that put in place very restrictive laws.
In Emergency Rooms, for example, a woman might present with a partially completed spontaneous abortion at four months. At that point it would be impossible to tell whether this was an unfortunate natural event or the result of a botched effort at self-abortion. If the physician intervened to complete the abortion and avoid any risk to the woman’s life from bleeding out, that physician in several states would be at legal (criminal) risk for assisting in completing an abortion. To avoid that legal risk, the physician would have to allow the woman to bleed out to the point where her life was at risk, at which point the physician could safely legally intervene (having sacrificed the best interests of that patient and their own medical integrity).
The most recent example of consequences from the Dobbs decision is the Alabama Supreme Court declaring, as a matter of law, that the embryo was a person from the moment of conception. “Alabama rules frozen embryos are children, raising questions about fertility care,” headline from the New York Times [2/21/24]. As philosophers, it would be reasonable to ask the broader public to consider what the rational and scientific considerations would be that would justify thinking of an eight-cell embryo as a child with a distinct personal identity. Am “I” fully contained as “I” in the DNA of the eight-cell embryo?
The second theme in my recent writing pertains to public reason and bioethics. Life would be a lot simpler and more peaceful if ethical judgments regarding numerous emerging controversial medical technologies were confined to the inner practices of various religious or ideological groups. However, many of these technologies are seen as subversive challenges to what various groups believe are fundamental social values (at least fundamental to their belief systems). Examples include abortion, physician aid-in-dying, and medical research with embryos. They want to completely exclude access to these medical technologies for the larger society because that represents a threat to their belief system. And they wish to use public policy as the means for curtailing access to those technologies. As I argue, and as Rawls argues, such efforts are not congruent with the larger, deeper political values that define a liberal, pluralistic, democratic society.
How can such disagreements be respectfully addressed? That requires reliance on public reason, the detailed application of which I address in various recent publications and presentations. Public reason requires that we adopt the role of being a citizen for purposes of formulating and legitimating public policy. It requires our putting aside our religious, philosophical, and ideological beliefs that might shape our private lives but that can only yield illiberal results if used to justify public policies. Public policies are justified by appeals to public interests and public values in a liberal, pluralistic society as well as the best relevant scientific evidence. The clearest recent example of illiberal public judgment is represented by the Alabama Supreme Court which invoked several passages from Scripture to justify their legal claim that the embryo was a human child from the moment of conception. Other state legislative bodies are pursuing efforts to outlaw contraceptives on the grounds that they contribute to excess sexual activity, including sexual activity outside marriage. In both cases no public interest would justify outlawing contraceptives. Likewise, no public interest requires regarding embryos as mini children.
The third thematic focus of my recent research and professional presentation pertains to precision medicine and these very expensive targeted cancer therapies. For the benefit of readers not familiar with precision medicine, there are now about 150 of these targeted cancer therapies and immunotherapies. They are termed “targeted” therapies because they target the distinctive genetic features of various tumors. Immunotherapies, on the other hand, seek to alter the immune system in one of several ways in order to improve its ability to recognize and attack cancer cells. Both these therapeutic options are used with patients who have metastatic cancer, which is essentially a terminal disease. Virtually none of these therapies are curative. For the vast majority of metastatic cancer patients these therapies promise extra months of life, not extra years.
These targeted cancer therapies generally have costs of $150,000 to $200,000 per year. The immunotherapies, specifically, CAR-T cell therapies, have one-time costs in excess of $500,000. From an ethical perspective, these drugs are problematic as matters of health care justice in the United States and as matters of solidarity in most of the European Union. One term that is used to capture the justice-relevant criticism is onco-exceptionalism, i.e., the idea that cancer is ethically special and may justifiably claim unlimited public resources compared to all other diseases.
To further complicate matters, there is now a company called GRAIL pushing a cancer screening test called Galleri that costs $950 that promises to screen for more than fifty different cancers. GRAIL wants every American over age 50 to have access to this test annually at public expense. There are 110 million Americans over age 50, which would represent an annual cost of $100 billion in extra health care costs. Over 106 million of those Americans would be told each year they had no sign of cancer. This would be another example of ethically problematic onco-exceptionalism. That is a very high price for a little anxiety relief that could have been more economically achieved with a fine glass of wine.
List of Recent Publications:
1. “The Dobbs Decision: Can It be Justified by Public Reason?” Cambridge Quarterly of Healthcare Ethics 32 (July 2023), 310-22. I served as editor for this symposium on the Dobbs Supreme Court decision. I edited the nine articles that comprised this symposium.
2. “Abortion and ‘Zombie’ Laws: Who is Accountable?” Cambridge Quarterly of Healthcare Ethics 32 (July 2023), 307-08.
3. “Teaching Bioethics Today: Waking from Dogmatic Curricular Slumbers,” Cambridge Quarterly of Healthcare Ethics Cambridge Quarterly of Healthcare Ethics (Nov., 2023), pp. 1–8 doi:10.1017/S0963180123000178. This article addressed the challenges associated with discussing the abortion issue as part of the medical school curriculum. Many medical schools saw that as divisive and unnecessary (because Roe was in place). The Dobbs decision changed that dramatically as the effects of that decision began to play out in medical practice in various states that put in place very restrictive laws. The most recent example is the Alabama Supreme Court declaring, as a matter of law, that the embryo was a person from the moment of conception. “Alabama rules frozen embryos are children, raising questions about fertility care,” headline from the New York Times [2/21/24].
4. “Abortion, Artificial Wombs, and the ‘No Difference’ Argument,” American Journal of Bioethics 23 (May, 2023): 94-97.
5. “The Dobbs Decision: Did the Supreme Court Get It Right? Essay for Ethics in Practice 6th edition, edited by Hugh LaFollette, London: Blackwell, late 2024. 25pp. (forthcoming).
6. “Public Reason and Bioethics: A Seductive Delusion or Ambitious Aspiration?” Cambridge Quarterly of Healthcare Ethics (introductory essay for symposium on this issue for which I am the editor). (31 pp.) The symposium will be published in mid-2024.
7. “Can Public Reason Yield Legitimacy and Justice in Health Care?” presentation for European Philosophy and Medicine conference in Riga, Latvia (August, 2023).
8. “In Defense of Public Reason in Bioethics and Related Public Policy,” Part of panel presentation titled “Defending and Evolving Secular Bioethics in Response to Religious Critiques,” at the ASBH conference in Baltimore (Oct., 2023).
9. “Public Reason, Bioethics, and Religion,” brown bag presentation for MSU Philosophy department (Oct., 2023).
10. “Precision Medicine and Rough Justice: Wicked Problems,” Cambridge Quarterly of Healthcare Ethics (Oct. 2023), Jun 16;1-4. doi: 10.1017/S0963180123000312.
11. “Precision Public Health Equity: Another Utopian Mirage?” American Journal of Bioethics 24 (March, 2024) (forthcoming).
12. “Precision Medicine: Wicked Problems for Democratic Deliberation,” keynote address for conference sponsored by Erasmus University titled “Precision Medicine: Ethical and Legal challenges” (March, 2023) Lisbon, Portugal.
13. “Just Caring: Meeting the Challenges of Extraordinarily Expensive Treatments with Uncertain Outcomes,” Presentation for Ethics, Policy, and Law faculty at Erasmus University (Rotterdam), June 2023.
14. “Multi-Cancer Early Detection Screening Tools: A Dream Come True or a Nightmare in the Offing?” presentation for annual ethics conference sponsored by the University of Michigan Ethics and Health Policy Center (May, 2023).
15. “Multi-Cancer Early Detection Screening: Can We Afford to Do This?” presentation for “Brews and Views” session sponsored by the Institute for Quantitative Health Science and Engineering and the Center for Bioethics and Social Justice, MSU (Sept., 2023).
16. “Just Caring: Ethical Challenges for Physicians Facing Patients Demanding Low-Value Care,” presentation for annual Family Medicine conference in Bad Axe Michigan (Oct. 2023).
17. “Precision Medicine/ Distributive Justice: Are Some Human Lives Priceless,” public lecture for University of Detroit-Mercy (Oct. 2023).
18. “Multi-Cancer Early Detection Screening Tools: Emerging Ethical Challenges (in the clinic and in policy forums,” Medicine Grand Rounds, Sparrow Hospital, Lansing MI (Nov. 2023).
19. “Multi-Cancer Early Detection Screening Tools: Emerging Ethical Challenges (in the clinic and in policy forums,” Medicine Grand Rounds, Corewell Health Care System, Grand Rapids, MI (Dec. 2023).
20. “Is Two-Tiered Solidarity an Oxymoron…or Just Awkward,” presentation for annual conference sponsored by the European Society of Philosophy, Medicine, and Health, Frankfurt Germany (August, 2024).
21. “Precision Medicine and Distributive Justice: Wicked Problems for Democratic Deliberation,” keynote presentation for the Thomas A. Pitts Lectureship in Medical Ethics, Medical University of South Carolina (April, 2024).
