I was particularly impressed at last year's conference by two speakers. One, Dr. Thomasma, came armed with a formidable array of cartoons to aid him in making his arguments (otherwise known as the "sugar-coated pill"). Another, Diane Hoffman, successfully relayed a full 60 minute, all-inclusive topic in precisely 25 minutes - requiring her to speak at an astonishing rate of approximately 350 words/minute! Unfortunately, I am one of those who can never remember the punch-line of a joke. And most of my papers usually take closer to two hours. Thus to say what I really want to say in 20 minutes would require me to speak at a clip approximating 675 words/minute. I decided instead, therefore, to begin my remarks with a different technique - the fairytale.
"Once upon a time there was a poor new graduate student in the Department of Philosophy who - having no idea where to begin her studies - inquired of the Department's Great Wizard as to which courses in philosophy she should take first. 'For God's sake', growled the cantankerous but very sage Great Wizard, 'don't waste your time in studying any philosophers before Kant and Mill. All you need to know is recorded from Kant and Mill onward. These are the only philosophers who are relevant to bioethics.'
"Well, this particular student was known to sometimes disregard even sublime purveyors of advice - especially when it somehow seemed counter-intuitive. And so with this Great Decree. Something was wrong, somehow, somewhere, she mused - but what? Immediately she signed up for ancient and mediaeval philosophy. And trusting her instincts she plodded for numerous semesters chronologically through the history of philosophy - just past Kant and Mill. Aha!, she gleaned - what a ploy! It was all too clear and distinct - one cannot effectively analyze or critique modern or contemporary philosophy from within modern or contemporary philosophy itself. One must be able to stand outside of it in order to see its flaws. What a shame the Great Wizard did not know that!"
I often find myself quoting from one of Aristotle's famous passages: "A small error in the beginning leads to a multitude of errors in the end". I will suggest in this short paper that from the beginning something was wrong in bioethics. Autonomy - and the other principles - soon took on a life of their own, and more importantly, the inability in daily clinical practice to "balance" them or to realistically resolve the constant and complex conflicts among them when applied to real patients and real situations, gradually led over the years to a growing uneasiness about these very basic, fundamental and by now institutionalized groundings of the bioethics enterprise itself. If this is true, then bioethics, as it has been largely taught and practiced here in the States, is beginning to loose its credibility.
More importantly, if this by now "classic" framework of autonomy-based bioethics is incorrect, how many thousands of innocent patients have been harmed by its application? Individual "theories" are exciting, and sell books - but when these theories are applied to real live human beings, we should legitimately expect that they are as "right" as they can be. Someone, somewhere, ought to be accountable. In this rising sea of abusive relativism in which we now find ourselves, what about responsibility for our choices and actions? What about the consequences of our choices and actions on our spouses, children, parents, grandparents, neighbors, communities - including the professional health care community - on our environment? Are there really no limits to autonomous choices and actions? Is there really any such thing as pure autonomy; or pure freedom?
What I will argue is that basic to any ethical theory (and therefore its constitutive principles) is the correct definition of a human being or a human person. Using the history of philosophy as an analytical tool I will try to - quickly - demonstrate what I would argue is at least one of the sources of our difficulties with the presently understood and applied principle of autonomy. That source is the inherent and problematic philosophical presupposition of a mind/body split - that pre-dates either Kant or Mill, and which was identified and refuted pre-Kant and Mill! This philosophically problematic definition of a human being or human person, combined with recent trends of integrating what is, in fact, incorrect science into the primary premises of the arguments on "personhood", will lead to even further very real and serious negative consequences for human beings at both ends of the life spectrum, including the majority of patients entering the health care system. If automony alone is definitive of human beings or human persons, then many human populations and patients have, in effect, been redefined out of existence, possessing no legal or ethical protections - all gratuitous references to beneficience not withstanding. For, if what essentially characterizes and defines a human person is pure autonomous choices and actions, then most of us, I would argue, are not persons - and are therefore only objects.
One way to explain how this could have come about, and to evaluate the validity of an autonomy-based ethics, is to trace the evolution of the relevant operative definitions of a human being or a human person so dominant in bioethics today. I will then address just one example, because of time, of the recent use of science to ground an argument that certain human populations are not autonomous, or not human, and therefore are not persons.
One of the first observations in studying the history of philosophy is that each major philosopher defines "being" or reality differently. It is critical for us to realize that if one defines "being" differently, then one defines "human being" differently - and therefore one's ethics and bioethics will be different. What I want to demonstrate is that different ethical theories contain different definitions of a "human being" - a definition central to any theories of bioethics. I would also like to suggest that the original definition of the bioethical principle of "Respect for Persons" (in the Kantian sense) - meant to protect the inalienable integrity and value of each human being - shifted ever so gradually to be understood instead as "Respect for Persons" - where "person" came to be understood as someone who was purely autonomous - in the Millsian sense. From the beginning, then, the selection of basically only Kant's (a rationalist) and Mill's (an empiricist) definitions of a human being or human person precluded a realistic and correct definition of autonomy. Human beings were equated with human persons which were equated with autonomous choices and autonomous actions. The rest of the human being, as well as the rest of humanity was, then, a forteriori, left out of consideration in any real sense.
Briefly sketching the history of philosophy then, some philosophers defined "being" as matter only (e.g., the pre-Socratic Milesians); and therefore a human being was defined in terms of matter only. Some philosophers (e.g., the pre-Socratic Pythagoreans or Parmenides) defined "being" in terms of form only. And it is interesting to note that for them the forms were material, and that they were actually physical, and numbers - a basic tenet of the controversial Pythagorean religious cult. The One, for example, was really the physical number one!
Plato attempted to synthesize his predecessors by defining "being" in terms of non-material Forms, and non-being, or matter. However, Plato's Forms were also actually numbers, as was his One. His major difficulty was that what was really real, i.e., his Forms, or the Essences, or Universals, subsisted in a transcendental world of their own, apart from the material things of which they were suppose to be the essence - causing a split or separation or gap between the Form and the matter. Also, matter for Plato was non-Being - and thus non-real. So, a human being was defined deductively and theoretically as two things - soul (but only the rational part of the soul was immortal or valuable), and body. Yet the soul of a human being was real or even existed only insofar as it participated in the Form of Nous - which existed apart from the material human body. And the material body was, theoretically non-being - or unreal. Hence Plato could not explain the existence or reality of the human body, nor any interaction between that non-real body and the soul - whose rational part was really only an image of the real Soul - and separated from it. Here, I would argue, is one of the earliest formulations of a mind/body split - and one which even Plato himself eventually agreed and concluded wouldn't work. And I ask you - if even Plato thought it wouldn't work, then why should we use it? Plato is also one of the earliest philosophers who separated the rational part of the soul from the other parts of the soul - as well as from the body - thus laying the groundwork for an absolute, isolated, atomistic principle of autonomy as definitive all by itself of a human being or a human person.
Aristotle argued vehemently against Plato's metaphysics, epistemology and anthropology. He defined "being" as both non-material and material, and a human being (at least in the majority of his treatises) as a composite of soul and body, constituting one concrete substance. I will call this Aristotle I. No mind/body split - and no split between the parts of the soul (except, e.g., in his De Anima, where he proposed a definition of a human being much as Plato had - i.e., in terms of the rational part of the soul alone. I will call this Aristotle II, or a Platonized Aristotle). Because Aristotle I defined a human being as only one substance - with two aspects (soul and body) - interaction between them was possible and explainable. The rational aspect of the soul could not be separated from the other aspects of the soul - nor from the human body which it informed. Consequently, the soul was in every part of the human body - not just the brain; and in the experience of knowing, the whole man knows - not just the intellect but also the senses. It is this realistic inductively acquired ball-park of anthropology that, I would argue, we need to reinvestigate. Especially significant for bioethics is Aristotle's remarkable analysis of moral decision-making - an analysis which cannot be properly understood without a clear grasp of his metaphysical, epistemological and anthropological groundings.
In the first few centuries A.D., a series of major philosophical aberrations took place which further set the stage for modern and contemporary philosophy. First, Plotinus developed a theory of "being" which combined, confused and even equated the philosophies of Plato and Aristotle II - taking bits and pieces of each, out of context. This mixed theory, along with that of the Stoics and Neoplatonists, was picked up by several of the major Arabic philosophers between the 7th and 11th century (who added to and mixed with it their own Islamic metaphysics). Finally this philosophy was carried into the medieval scholastic universities of Paris and Oxford, being offered as "genuine" interpretations and expositions of both Plato and Aristotle. These works were accepted as genuine in the lower faculties of arts well into the 18th century.
Aquinas, like Aristotle I, also defined "being" as form, or as form and matter - but articulated a third constituent - the act of existing (esse). Thus a human being or human person was defined (again based on inductive information) as one substance composed of soul (vegetative, sensitive and rational), body, and existing. Because a human being or human person is only one substance, again, there is no mind/body split, and interaction between the soul and the body is possible and explainable.
And finally we meet up with Rene Descartes. Descartes defined "being" in terms of two different - and separate - substances, e.g., Mind and Extension (or matter). A human being was, like Plato, theoretically defined as composed of these two substances, but ultimately as "a thinking thing", distinct and separate from his body. This is the modern source of the mind/body split - although its roots go back at least as far as Plato - and the immediate source of our present concern about "autonomy". What is really definitive of a human being is his active mind - the source of present-day so-called "rational attributes" of personhood, e.g., self-consciousness, reasoning, willing, choosing, sensing (which was a "mode of thought" for Descartes, as he, like Plato, had rejected the validity of physical sense data or physical sense powers). And because he defined a human being deductively as two separate substances, Descartes, like Plato, cannot explain any interaction between his Mind and his Body. His famous attempt with the pineal gland as the "mediator" simply doesn't work, since the pineal gland is also part of the body - and is therefore also separate from the Mind. Descartes, the scientist, is even precluded from doing science because of the problematic metaphysical presuppositions inherent in his definitions.
For example, the validity of the fundamental laws of physics and mathematics depended on Descartes proving the truth of the "cogito" and the existence of God - which he was not able to do. He rejected the existence of a void, and therefore his material substance, i.e., Extension, is continuous. This had serious consequences in his scientific theory of the vortex. The material world is not composed of ultimate atoms, but only volumes, which must then move as a whole, i.e., a simultaneous movement of matter in some closed curve. Planetary motion, then, is explained as one infinite 3-D continuous and homogenous extended body. If there is only one continuous extended substance which constitutes the whole material universe, then he can only distinguish one body from another body in terms of differential volumes and secondary qualities. Therefore he cannot have a definition for density or for viscosity. He omits "matter", therefore, from his definition of motion. Motion = speed x size, but "size" for him is a continuous volume of body! Therefore his laws of impact are, in fact, in error. Also, he cannot isolate a particular force (e.g., gravity) in terms of how a body would move if it were free from resistance, because to imagine it moving without resistance is to imagine it in a void (the existence of which he had rejected). For Descartes, animals have no Minds, no pineal glands, and no souls. Therefore they cannot feel any pain, or any other kinds of sensations - which were only modes of thought. Animals are only bodies, i.e., "machines", and the only sense in which they can be hurt is to "damage" them.
Thus Cartesian philosophy and much of his science was soon discredited and rejected. Many later philosophers took one or the other of his "substances" and claimed either one to be "being". The rationalists (Kant, Fichte, Schelling, Hegel) basically defined "being" in terms of Reason only - including human beings. And the empiricists (Locke, Berkeley, Hume) defined "being" in terms of Matter only - including human beings.
All of these philosophies have major theoretical problems - especially those with a mind/body split. Again, if these philosophies don't work - why use them? Shouldn't we at least learn something from these theoretical and conceptual mistakes from the history of philosophy? Why apply them to innocent human beings, and even ground public policy on them? Where have all of the philosophers who know the difference been? Yet through the years the theoretical impasses of these philosophies have been ignored, these philosophers and their problematic theories are often turned into mini-gods, and even now bioethics theories and public policies are based on them - or useful bits and pieces of them.
My point is this: The Cartesian/rationalist type of philosophical definition of a human being - as well as the Kantian rationalistic, (and the Humean-Lockean-Millsian empiricist philosophical definitions), - in terms of "rational attributes" alone is one of the major bases and sources of our present problematic concept of autonomy. If a human being is defined only in terms of reason, ("rational attributes") or "sentience" (nerve-brain related criteria), and the exercising of rational attributes or brain related criteria alone are definitive of an autonomous human being. And if only autonomous human beings are persons and bearers of ethical and legal rights and protections - then non-autonomous human beings are not persons, and therefore not bearers of ethical and legal rights and protections.
Note that empirically we know that full "rational attributes" and full "sentience" or brain integration are not present until well after birth (about 24 years). And conversely, the precondition for all "preconditions" of "rational attributes" and "sentience" is the single-cell human zygote. What I am arguing, then, is that the present bioethics principle of autonomy has been isolated, separated, split off from the rest of the human being, becoming, analogously, a "thing" or "substance" or "value" all unto itself, with no interaction possible with other principles - taking on a bioethics life of its own.
Are, then, non-autonomous human beings really not persons? Are non-autonomous patients not persons? What, now, is personhood - who is included within this conference's "envelope of concern" - and who is excluded? Consider what is at stake. In fact, consider that in this very conference, the participants in Group I are discussing at this very moment, "Do pre-persons and post persons have rights or interests?" Based on the problematic philosophies I have just addressed, I would reject the very framing of that conference question.
What is interesting is that the current arguments on fetal personhood line up along the Cartesian-rationalist-empiricist pattern in the history of philosophy. What is also critical to understand is how these arguments are linked or integrally connected with many other present arguments concerning similar issues during the course of and at the end of life. Important overlap exists with, e.g., IVF human embryo research, regulations on research with human subjects (especially the mentally ill, human embryos and human fetuses, and children), anencephalic newborns, genetic screening, the genome project, organ transplants, rationing or allocation of scarce medical resources (especially those based on "quality of life" criteria), persons in a comatose or in a "persistent vegetative state", and euthanasia. All of these issues depend directly on how one defines a human person, or "personhood". The theoretical framework and conclusions from the fetal personhood arguments are setting precedents, being "institutionalized", and being applied rapidly to all of these other bioethics issues. It is to these arguments on fetal personhood I want to now briefly turn. The theoretical philosophical presuppositions inherent in each of these arguments I have analyzed elsewhere. For the purposes of this conference, what I want to indicate now is how in each and every argument for a biological marker event of fetal personhood, the science being used as the major premise, the starting point in the argument, is incorrect science.
All embryologists know that by the end of fertilization the "23" chromosomes of the sperm, and the "23" chromosomes of the ovum, have combined to produce a human being possessing "46" chromosomes. However, combined with bits and pieces of theory from the major philosophical systems just indicated, some scientists, philosophers, bioethicists (they are not necessarily philosophers), theologians and public policy analysts have recently argued that there is a difference between a human being and a human person. Immediately one should be able to sense that this very framing of the question implies a mind/body split of some sort. I have argued elsewhere that one cannot realistically or successfully split the human being from the human person - philosophically or scientifically. But several writers, using scientific data as their starting points, or major premises, argue that personhood appears at different biological marker events during human embryogenesis.
For example, it is argued that the human embryo is only a "blob", a lump of the mother's tissues; that the human zygote is not specifically a human being; or that the completion of the genetic input is at the 2-cell stage. Also, hydatidiform moles and teratomas are often produced which are not human beings, thus the zygote from which they developed itself cannot be a human being.
In response, however, after the "23" chromosomes of the male sperm and the "23" chromosomes of the female ovum have combined to form the one-cell human zygote containing "46" chromosomes, clearly only half of those chromosomes come from the mother, and are thus not genetically the same as any of her tissues. The zygote contains "46" chromosomes - the kind and number which is specific for the human species. Immediately, specifically human enzymes and proteins are produced. And the completion of the human genetic input is then already complete. The zygote will not gain or loose any genetic information throughout all of human development. This genetic information contains virtually all of the instructions for differentiation, totipotency, and all of the developmental stages. Genes will be turned on and off to cause the production of molecular information which cascades throughout development. And hydatidiform moles and teratomas proceed from abnormal "zygotes" to begin with, e.g., from dispermy.
Again it has been written that there is only a "pre-embryo" present up to the 14th day, because all of the cells from the earlier trophoblast layer are discarded after birth, and after the formation of the primitive streak twinning does not take place (and then we have a developmental individual - i.e., a person). Or, after 14 days, full differentiation has taken place; or the matter is appropriately organized to receive the human soul.
In response, however, all of the cells from the trophoblast layer are not discarded after birth, but become part of the later fetus and adult gut, median umbilical ligament (which extends from the apex of the urinary bladder to the umbilicus), and its cells are part of early human blood formation. Twinning does take place after 14 days, e.g., in fetus-in-fetu and Siamese twins; and sometimes it is even genetically determined in the original zygote. Full differentiation, in fact, is not complete until early adulthood. And the matter is appropriately organized as human and producing human proteins from the zygote stage (it does not produce cabbage or giraffe proteins).
(Fig. 5) Others argue for some sort of brain-related criteria - either "rational attributes" or "sentience" - symptomatic of either rationalists or empiricists. All of these theories are simply posited, and many scientists have argued that there is absolutely no scientific evidence which demonstrates the supposed correlation between "brain death" and "brain birth", pre-person and person, consciousness and self-consciousness. And if one defines a human person in terms of rational attributes only, or sentience only, one will eventually have to argue also for infanticide of normal healthy infants, since full rationality, or full brain integration or sentience are not present until well after birth. Many well-known writers have, indeed, argued for infanticide for many years in the literature. Where are all of the scientists who know that such scientific arguments are incorrect - more like fairytales than reality?
The over-all theme of this conference, I think, is certainly instinctively correct. We will hear many examples of "pure" autonomous choices which somehow seem off the mark. What I have tried to do from a philosophical point of view is tease out the problematic philosophical presuppositions inherent in the definitions of a human being or human person, which have led to a too abstract and isolated principle of autonomy. I have also tried to indicate how just one group of persons has been redefined with the additional help of incorrect science (and one wonders who is next to be redefined out of personhood, with the aid of incorrect science) - and I have indicated that many other issues prominent in bioethics today are theoretically and intimately related to the issue of fetal personhood. The conclusions of the one are being applied to the conclusions of the other.
And at least we should understand that there is no such thing as a "neutral" ethics, including Kant's deontological and Mill's utilitarian theories, which are normative ethical theories, i.e., they take a non-neutral stand on what is ethically right and what is ethically wrong. In a democratic society, why should these ethical theories be forced on the American people - especially with such inherent theoretical problems? And how many bioethicists, health care workers, theologians and public policy analysts - much less voters - know about these inherent theoretical problems? How can anyone be expected to make an "autonomous" or well-informed or democratic decision based on such philosophical and scientific misinformation?
Nor is there any such thing as a "neutral" definition of any kind. Definitions are always virtually drenched with metaphysical, epistemological and anthropological presuppositions. Indeed, most philosophers know that there is even no such thing as a "neutral" logic (there are many different kinds of each of the "schools" of logic, e.g., Greek, Arabic, Chinese, Buddhist, scholastic, etc), each one coming to a different conclusion. This is why it is critical for well-informed dialogue and open and impartial communication to be protected and insisted upon - especially in a democracy.
What I want to do with the seconds remaining is simply point to a more realistic, inductively derived source of a definition of a human being and of an ethical theory - that is, the objective reality and common facts about the individual human being, and his/her need to live and flourish - and survive - in society. This requires an objectively-based, inductively derived definition of the human being, including all of his "parts" or aspects - not just Reason; and not just Body. Here a human being is always a human person - and should be respected entoto - not just from the point of view of one of his "parts". One then respects a human being who is a human person by respecting his autonomy (if he happens to be autonomous and capable of exercising it), by being beneficient, and by being just.
Within this made-whole again individual human being, decision-making is not just based on his/her pure autonomous choices, but in consort with the rest of his/her "parts", as well as in consort with his/her neighbors and environment. True "human" decision-making starts with, and requires correct theoretical information (including philosophical, scientific and medical facts), and correct practical information, the ability to weigh and measure or deliberate well about this information rightly in light of truly good human goals (or those goals which will ultimately perfect him/her as a human being and allow him/her to flourish), the ability to choose the proper means to reach those proper human goals, and the occasion to actually act in light of that correct information, good deliberation and proper human choice. These are the rough outlines of a more holistic, inductively acquired, objectively-based ethical theory which integrates the real human being with his/her real self, with the real society and with the real environment which we really know to be empirically true.
Autonomy, then, is only one of many ingredients in decision-making, which more realistically takes place in a fluid matrix of relationships - not in an absolute, isolated, atomistic, almost autistic vacuum of self-interests and self-concern. I would suggest that we all come together to pool our stores of collective wisdom, to fill in the objective details of such a system, and to take seriously the consequences of how we ourselves as bioethicists and health care workers deliberate, and what information we use with which to do it. Fairytales are great for children - but not for serious bioethicists or health care workers. There is too much at stake.
1 For very extensive philosophical and scientific references supporting the following comments, please see D. N. Irving, "Scientific and philosophical expertise: An evaluation of the arguments on 'personhood'", Linacre Quarterly February 1993, 60:1:18-46; at http://www.lifeissues.net/writers/irv/irv_04person1.html. This article is a mini-version of my 400-page doctoral dissertation, Philosophical and Scientific Analysis of the Nature of the Early Human Embryo (Washington, D.C.: Georgetown University, 1991). [Back]