Philosophy and the Mirror of Technology: Interview with Christopher Tollefsen

One of the goals of this series is to explore the impact of technology on ordinary lives, especially the underappreciated negative aspects of the inexorable march of scientific advancement.  A very practical example is the accelerating use of medical advice and technology to terminate life.  A related question is the extent to which, by artificial means, we extend life.  To explore the bioethical implications of technology, I reached out to Professor Christopher Tollefsen of the University of South Carolina.  His upcoming book, The Way of Medicine, Ethics and the Healing Profession, co-written with Farr Curlin, calls for important change in the medical approach.  They propose to move away from an agnostic service model – which resembles an economic exchange with the patient – and provide more concrete guidance, conscientiously advising on health.  Rather than adopt a neutral stance, to proactively seek good outcomes from the beginning of life to its end.  The objective is to contribute to human flourishing, organizing a life and its virtues, rather than serially satisfying patient desires.  In this interview, we talk about the challenge of euthanasia, as well as the thesis of his new book.

Thank you so much for your willingness to contribute to this series, exploring the important issue of intervening in life’s course.  Let me start with a few general questions.  First, can we trace the issues you discuss in bioethics to a broader ascension of materialism in our culture and thinking?  In essence, we venerate observation and objectivity at the expense of the subject – and are left with material prerogatives.  An economic example might be the invisible hand of the free market, automatically generating the right result vs. some defined common good.  That is to say, is the medical profession part of a wider agnostic proceduralism, where neutrality has become a beneficial end in itself?

On the side of both the medical profession and the medical patient, the turn to materialism means the loss of a certain kind of meaning, the kind that comes from final causes. From the materialist standpoint, the body, as mere matter in motion, has no proper teleology for medicine to track, or serve.  So medicine itself is left without a proper finality and comes to occupy what we call in our book the Provider of Services Model.  On this model, medical professionals are ultimately at the service of patient desires, and must provide what is asked for so long as it is legal, feasible, and autonomously requested.

On the side of the patient, there is likewise no teleology, no ends or goods whose claims on the human person transcend their subjective desires.  And so the patient feels a kind of entitlement to use medicine and medical practitioners as expressive tools, as ways of realizing their individuality and manifesting their authentic selves.  If an individual chooses to use medicine in a certain way—to manipulate their body in some way or even to cause their own death—the choosing itself is taken to make that use of medical technology ethical.

To situate our materialist culture in the philosophical discipline, might we go back to, say, Francis Bacon, where the technological mindset is to overcome our deficiencies with the rational control of nature.  Where the medical profession altering the course of life is part of a larger project of dominion over the world, at the expense of other goods.  Can our comfort with euthanasia be seen as a logical extension of this “enlightened” framework?

I think that is correct. Bacon saw in modern science the means to “relieve and benefit the condition of man” by reducing suffering and expanding the realm of human choice, ostensibly noble goals. Unfortunately, as Gerald McKenney has observed, this imperative to relieve suffering and expand choice finds in contemporary culture no larger framework of meaning in which to discern which suffering should be relieved and which choices should be accommodated. In the resulting moral vacuum, medicine comes to relieve any condition that an individual experiences as a burden. It is a quick step from that to the idea that if life itself is the burden, then individuals may, or must, be relieved of it. That is a radically changed mission from medicine’s traditional calling to heal when possible, to care always, and never to harm. 

To frame the question in a way that you talk about it, can you expand on your view that human life is a fundamental or basic good and that medicine should not be an instrumental question or service?

Our basic idea – intuitive to most people! – is that the end or purpose of medicine is human health. The medical profession exists in order to restore, preserve, and promote that health. We think this conception of medicine is made possible by a two-fold objectivity that health has.  First, health is an objective norm for the well-working of any organism.  There is a fact of the matter as to whether some particular cat, or dog, or human being, is healthy or not. The health of an individual organism is relative to the kind of organism it is, and to its age and condition, but health is not a mere social construct.

Second, health must be an objective good; it is an aspect of human well-being and flourishing which provides basic reasons for action to human persons. That is, you or I, or any other human being can act simply in order to bring about or restore health. Unlike medicine or money, which can only be pursued for the sake of some further end, health is intrinsically desirable and can be pursued for its own sake.

That twofold objectivity matters to medicine. The first kind of objectivity means that medical practitioners can be, and must be, experts in what it means to be healthy. And the second kind means that in serving patient health they are, first, contributing to genuine human flourishing, and, second, engaged in a kind of community with their patients that has a genuinely common good, human health. In principle this means that the medical profession has a kind of nobility to it that is lost when physicians see themselves merely as technicians satisfying patient desires.

Further exploring euthanasia in how you’ve framed it, can you discuss how infirmity or disability – effectively limitations – should not be the basis to change the trajectory of life?  How life itself is not a means and is valuable for its own sake.  Can you expand on your point that human organisms are not disembodied minds, but have intrinsic value and we shouldn’t use technology to destroy or damage life?

Both Descartes and Locke, in slightly different ways, set philosophy down a mistaken path in considering what you and I, as human persons, essentially are.  Descartes thought that you and I are essentially immaterial thinking things, and that body, extended matter, is not essential to what we are. Locke thought that you and I are persons, and that the person you or I are is different from the living organism that is typing or reading this interview.

Both views are radically mistaken: you and I are animal organisms, living beings of a particular species, who are essentially embodied. But for philosophy, this would be a natural view to have: when you hit my body, you hit me, and when I look in the mirror, I see a reflection of me.

Getting this right, though, has important consequences. Most of us believe that, as personal beings, our lives have intrinsic worth or dignity – our value is not reducible to the mere wants or desires of anyone.  But if we are of intrinsic value, then it seems that anything that is constitutive of what we are shares in that intrinsic value.  So our bodily existence has, I would argue, intrinsic worth, and is essential to our dignity as persons.

A further important consequence of our bodily nature is this: infirmity and dependence are natural to us. Again, but for philosophy, this would be easily grasped: we begin as children, we end, typically, as increasingly dependent aged and infirm human beings, and we often spend considerable periods of our lives in between birth and death in disability and dependence. These periods of dependence do not detract from our worth or dignity, yet a considerable amount of work in bioethics is dedicated to arguing that human beings who cannot autonomously choose and act are no longer (or not yet) persons and are of less than personal worth.

When you put all these truths together – we are bodily beings, whose bodily existence has intrinsic worth, yet for whom dependence and disability are natural – then you have the resources to push back against the idea that loss of control, or loss of independence, or loss of autonomy are adequate reasons for ending human life. Still less are they reasons for encouraging physicians to abandon their commitment to the good of bodily life and health so as to choose to destroy the life and health of their patients by euthanasia.

For an important recent intervention on the topic of “public bioethics” and its failure to acknowledge our bodily nature, I’d recommend O. Carter Snead’s What It Means to Be Human.

You have also raised an interesting point about how the power to end life ultimately erodes the devotion to care.  Can you discuss how, if euthanizing is an option, it inhibits trust with palliative steps? 

This is really an important insight that emerged in part from my co-author, Farr Curlin’s, clinical work. We give an example in our book of a patient in his care, suffering from dementia and near death, whose family did not want him to enter hospice because they associated palliative care with intentional hastening of death.

The basic point is this: if patients think that you might intentionally hasten their death, then they are not in a good position at all to trust you with potentially death-hastening or lethal medicines. And when trust breaks down in that way, it is an obstacle to providing patients with genuinely needed pain relief.  

But when both patients and physicians are confident that death will not be intentionally hastened, this not only gives patients a reason to trust physicians but also gives physicians the freedom they need to do their work. The commitment to never hasten or cause a patient’s death intentionally creates a space in which physicians can act decisively to palliate distressing symptoms—for example, by using morphine to alleviate breathlessness, or sedatives to relieve a state of restlessness and agitation. 

Without the boundary established by that commitment, patients and their families have good reasons to worry that the morphine that leads to sedation is dosed not in proportion to the patient’s pain or breathlessness, but in an effort to hurry along the dying process. We think this is deeply detrimental to the physician-patient relationship at the end of life.

What distinctions would you draw, if any, with your arguments against euthanasia vs. a religious or Thomistic natural law case? 

Throughout our book, we operate along two parallel paths which we argue converge on the same answers.  The first emerges from the nature of medicine as a healing practice for which health is the central value. That generates an argument that euthanasia runs directly contrary to a physician’s calling: it involves a violation of the good that is constitutive of the medical profession.  

The second path is established by the requirements of practical reason.  One could call the demands of practical reason the natural law, as Thomas Aquinas did, or the Tao, as C.S. Lewis did. Either way, reason’s requirements can be known without a religious foundation, and, we argue, those requirements include a norm against intending the death of an innocent human person. So euthanasia is ruled out both from the standpoint of the nature of medicine, and from the standpoint of the moral demands made by practical reason.

Our arguments are, in principle, open to all persons of good will and open mind, and we hope some of them will take root.  But it would not be surprising if those arguments resonate in a special way with proponents of the major Abrahamic religions, for all, it seems to us, place a great value on human life and the human person, and make room for the idea that human persons are called by their Creator to certain tasks for the promotion of human goods and human persons, and we think this describes the experience of many physicians as they travel their vocational paths.

Acknowledging your view that one should not directly or indirectly assist in destroying life, can you address the right of the individual to end their own life without, say, significant assistance?  Is the appropriate distinction whether an individual or profession is somehow complicit?  Can holistic medical counsel in any way include the individual choice to avoid suffering and end life? 

There are at least three important domains in which the questions of self-killing and euthanasia need to be addressed. One is the individual ethical question: ought one ever to intend one’s own death? We think the answer to that is no, and that this answer emerges from considerations of the basic good of life.  But that does not adequately settle the other two questions.

The second is: should medical professionals be permitted to end the lives of their patients, at the request of patients, or to relieve the suffering of patients who are incompetent to request. We think that question should be answered in the negative even if one thinks that it is in principle permissible for someone to take his or her own life. Encompassing this within the range of permissible medical action radically reconstructs the nature of the medical profession; it threatens to divide the physician’s heart, as it were, so that she is no longer single-mindedly devoted to the health of her patients, but now must take her cue from the patient’s desires on the matter. 

And we should not fail to note that permitting physicians to kill gives them a power that no other private citizens have; license to kill is granted only to those acting with state authority. As a culture, we are right now more mindful than ever of the ways in which that authority can be abused due to imbalances of power, racial or ethnic animus, or unconscious biases. We should not want to expand the reach of that power to physicians.

Third, there is the question of law, a question related to the previous two, but raising additional issues.  The judicious lawmaker should be concerned that institutionalizing the practice poses a threat to patients incapable of full consent, or suffering from depression; or to patients who are under pressure from physicians or families to move things along; or to patients who do not wish to be a burden and are encouraged by society to think of themselves as such. These considerations indicate that even if individuals should not be forbidden from taking their own lives, they should not be thought to have a right to do so in the sense of an entitlement to aid from those dedicated to the healing profession.

Alternatively, how far should medical advice and technology reach to extend life? How do you feel about pushing the envelope of a natural life?  

This is certainly the important flip side. We think there is a helpful distinction to be made between, as John Keown puts it, the view that life is inviolable – ought never to be intentionally ended – and two competing mistaken views, the first, which we’ve just been discussing, that human life can be intentionally ended, and the second, the vitalist view that it must be always preserved and prolonged, using whatever technological means are available.

There are many reasons to resist vitalism. Prolonging life through medical technology can bring many burdens: high costs, intrusive interventions, a loss of privacy; and it sometimes does so in the face of rather minimal benefits: prolonging life (a real good) without any possibility of further restoring health. It is important for patients, or their caregivers, to consider these benefits and burdens in light of some standard.  In the book, Curlin and I argue that this standard should be the patient’s vocation, roughly, the shape of his or her life overall, with its core commitments, obligations, and relationships. In light of a patient’s vocation, it can be seen in many cases that the burdens of medical intervention are too heavy and the benefits too diminished, to justify further medical steps. 

In turn, when the patient is incompetent, then the caregiver’s vocation, which includes fundamental responsibilities towards the patient’s welfare, provides the standard for considering the benefits and burdens of continued intervention.

But importantly, when the choice is to refuse such interventions, that is not a choice to kill, even when death is a consequence. This kind of case shows, we think, the continuing and inevitable relevance of “double effect” thinking in medicine.  If there is to be no intentional killing, still, it is important to recognize that sometimes death will inevitably follow from a decision that was not aiming at death.

Turning to your exciting new book, can you frame the case for a path out of the service model for medicine – where there is an agnostic array of options and it’s a form of economic exchange?  What is the alternative?

We call the alternative The Way of Medicine; as I described earlier, The Way of Medicine operates along two complementary paths.  One emerges from the nature of medicine as a practice and indeed a profession aimed at human health. Understood in this way, it is the task of the physician to act for the sake of patient health out of solidarity for the patient – a concern for the patient’s genuine good.  It emerges from the “internal ethics” of medicine that physicians need not pursue goods other than health for their patients, and should never act against their patient’s health, even when their patients strongly desire them to.

The second path is determined by practical reason, or the natural law, or the Tao. We think this part of the story is important because there might well be a practice, with its own internal ethics, that was nevertheless barbarous and unjust – the practice of torture, for example. So the practice of medicine needs further validation and sometimes guidance from practical reason.

In the end, these two paths converge on similar claims: for the physician on The Way of Medicine, medicine is a calling, a way to organize a life and its virtues; that calling is to solidarity with particular patients, each of whose good is honored and pursued by the physician in the particular domain of health. 

This approach contrasts with contemporary autonomy-centered medicine, where a patient’s autonomous choice governs what the physician must and must not do. We propose instead a conception of patient authority: patients have authority over what may or may not be done to them in light of a physician’s health-oriented recommendations.  But unlike autonomy (on some views), patient authority is not self-ratifying: patients can authoritatively make poor choices. Moreover, authority always has limits, and patients exceed those when they demand something that their physician believes in good conscience is contrary to or irrelevant to their bodily health. And finally, authority is often best exercised in a collaborative way; so patients will best serve their own needs by entering into dialogue with their physicians about what their physicians think is reasonably called for on behalf of their health.

In the introduction of the book, the Amazon framing suggests that “today’s medicine is spiritually deflated and morally adrift”.  Can you expand on the moral norms that you hope will shape the medical practice?

Our recommendation in The Way of Medicine is that healthcare professionals need to recommit themselves to the central good of medicine: patient health. They should do nothing contrary to that good, and they should align their practice to be in harmony with that good. Physicians should cultivate the virtues of good medicine, including solidarity and trustworthiness. They should be physicians and healers, not merely technicians or providers.

Adopting the norms of the Way of Medicine will, we think, function not only to the good of patients but thereby also to the good of doctors and other healthcare professionals, whose own personal flourishing is bound up with their being good doctors and practicing good medicine. This is what it means to be a member of a community serving a common good: that your own good and flourishing is bound up with the good and flourishing of those in the community whose good and flourishing you serve.

Finally, in the same vein, can you place this new vision in the broad history of the ethics generally?  In other words, can you ground this approach in the history of the philosophy?

Although the phrase “The Way of Medicine” has a somewhat idealized quality to it, I think it does identify a discernible tradition with characteristic practices along with ideas that make sense of those practices. This tradition gave rise to what I’ve referred to here as the “internal morality of medicine,” whereby the norms that govern physicians as physicians emerge from the particular needs to which the practice of medicine responds and the goods toward which the practice aims. 

But, to repeat, the internal morality of medicine is not self-vindicating. As the example of torture mentioned above reveals, practices can be unreasonable in themselves—intrinsically contrary to human good and human flourishing. Or, as seems to have happened to medicine at various points in its history, otherwise reasonable practices can grow corrupt, unreflective, or shallow. So one must engage in critical reflection to discern whether, to what extent, and in what dimensions a practice is in fact reasonable. Such reflection, however, is simply a form of attending to the requirements of practical reason, the natural law, or the Tao.

Fortunately, we do not need to attempt the task on our own. Just as the practice of medicine has been deeply shaped by healers such as Hippocrates, Jesus, Maimonides, Avicenna, Hildegard von Bingen, Galen, Thomas Percival, and Dame Cicely Saunders, so have a host of philosophers, theologians, legal scholars, and clinicians given deep consideration to the requirements of practical reason in the medical context. The list would begin with Plato, Aristotle, Augustine, Aquinas, and several of the healers just mentioned, but it would include, and not end with, twentieth-century thinkers such as Edmund Pellegrino, Leon Kass, Alasdair MacIntyre, and John Finnis, to all of whom we were deeply indebted in working on our book. 

And the reference to MacIntyre allows me to make one final point.  “The Way of Medicine” does identify a tradition, but, crucially, not understood as an unbroken continuity between the past and the present. Rather, “tradition” is used here in the sense articulated by MacIntyre, as a “historically extended, socially embodied argument.” The Way of Medicine is intended to be but one intervention, and we hope not the last, in that argument.