Daniel Callahan, In Search of the Good: A Life in Bioethics, Cambridge, MA, MIT Press, 2012, 232 pages. $ 29.00, £ 19.95, hardcover, ISBN: 9780262018487.

Environmental planners seldom think of ethics as a lynch pin of the world they would order. With rare exceptions, the moral possibilities of the city, or the immoralities of environmental choices, are rarely considered seriously. Conversely, few ethicists consider seriously the environmental structure of the things they seek to judge, the complex realities that provoke the dilemmas they self-confidently assess.

That is the unavoidable if unintended lesson of Daniel Callahan’s biography, In Search of the Good: A Life in Bioethics. A co-founder of the prestigious Hastings Center bioethics think tank, and for two decades its influential president, Callahan was a seminal player  in the production of bioethics as a philosophically grounded ethic of medical practice, planning and research. The virtue of Callahan's autobiography lies in its total lack of doubt or self-criticism. Its reminiscences are devoid of serious self-reflection. In recounting his role as a progenitor of bioethics he never asks, "Where did I go wrong?" He never doubts an argument he has made. And thus we have not history revised but history bared, its failures available for all to see.

Callahan: a brief history

Born in Washington, DC, in 1930 Callahan was, by his own admission a middling high school student with unexceptional SAT scores. He was accepted to Yale University because he was both a competitive swimmer and, perhaps, because he was Roman Catholic (page 6). The university had a strong competitive swim team and was "making amends" for its historic discrimination against non-protestant Catholics.

Good but not good enough, his swimming career ended in his junior year. Academically his record was scarcely more stellar. He failed undergraduate biology, for example, a fact he looks back on with amusement. After a course in Thomas Aquinas, he drifted into philosophy. After graduation he served in the army, entered a masters program in philosophy at Georgetown University and later a PhD program at Harvard. "Why Harvard? The Yale department, considered the best at the time, turned me down" (page 11).

Callahan found philosophy dry and pedantic in the main, and lacking interesting subjects: "I thought the theologians had all the interesting questions", he now remembers. He graduated with a dissertation on the Irish-English philosopher and Anglican bishop, George Berkeley. It was not Berkeley’s belief that "to be is either to perceive or be perceived (esse est percipi aut percipere)" that interested Callahan but Berkeley’s argument that religion and ethics "should move the person to action and felling" (page 18).

From the start Callahan sought, as Berkeley would have encouraged, perhaps, not the quiet of the academy but a position in the mix of current events. In 1961 Callahan began writing for Commonweal, a liberal magazine for Roman Catholic intellectuals. There he wrote about religion and its changes, publishing three or four books on religion along the way.

The disaffected philosopher became an increasingly disinterested Roman Catholic who, he suggests, came to believe in morality more than in the church. Commonweal had taught Callahan that what he loved best, perhaps, was public writing on current events. In 1967 Callahan decided to open a research center that would focus on issues of morality in public affairs. His neighbor, the psychiatrist Willard Gaylin, embraced the idea and became a cofounder of The Hastings Center.

The evolving world of medicine, as he understood it, would be the focus of the Center’s activities and Callahan’s own career. It worked because the failed biology student and disinterested philosopher turned out to be a terrific entrepreneur. In its first years The Center was mostly a fiction existing in Callahan’s living room. A $15,000 grant from the National Endowment for the Humanities (and a matching grant from the Rockefeller Foundation) began its rapid transformation into a well-funded, prestigious think tank with generous endowments (page 54). Callahan’s autobiography is replete with stories of famous people he met while selling his and his Center’s expertise.

"At a meeting with [Senator] Ted Kennedy, Sargent Shriver, and Eunice Kennedy, we were asked if we did deep, slow, and serious work", Callahan writes. "Absolutely, he replied. They then asked, Well, what if the senator asked you for some fast, even overnight, work: could you do that? Easily, I said" (pages 55-56). Callahan was ready to close the deal and if that meant ethics on the fly, couriered overnight… no problem.

Callahan was more than willing to pronounce authoritatively on subjects about which he and his Center-mates knew little. As he writes, they cheerfully  "projected a wisdom about large moral puzzles we did not yet have" (page 76).

After all, there was no single, generally accepted moral standard to apply to any of these problems but instead at "many contending versions of moral theory … [and] no decisive way of judging those differences" (page 71). That meant the field was open for almost anything he and his staff chose to pronounce as ethical or decry as immoral.

Nowhere was this more evident than in Callahan famous declaration that advancing medical technologies had created an unaffordable class of expensive, superannuated seniors (Callahan, 1987; 1990). Technology kept people alive and older people were too expensive to maintain. Physicians who kept oldsters alive were villains who would not only beggar the nation but also younger folk who needed treatment and, unlike seniors, were needed to man the factor floor and the military.

Callahan’s argument married the philosopher’s veneer of moral authority with a politician’s half-truths to mask his ignorance of both gerontology (see, for example, Binstock and Post, 1991; Katz, 1996) and health economics (Arrow 1963). Seniors, he declared, had a duty to abjure care, so scarce health resources could be focused upon the productive young. Since they were probably tired of life anyway why wouldn’t they give up their own care, so the nation’s younger folk could thrive? And if those greedy geezers, as they were called, demurred, well, bioethicists like him were prepared to empower governments to ethically deny senior care. They were, after all, trained as moral philosophers.

Environment and planning

The result was fundamental. Governments loved Callahan’s argument. Programs were begun that would limit "futile," or "unnecessary," care to seniors even if a family thought their patriarch or matriarch deserved a few more years. All this was, as fellow bioethicist and philosopher Dave Thomasma put it in defending one such policy, simply "rational" (Thomasma, 1997).

It is no exaggeration to say that Callahan helped create an environment in which seniors were seen as expendable citizens whose care was to be at best grudgingly given where not denied. In recent years, that argument has been expanded to include persons with differences (Down syndrome, for example) whose erasure, if not in utero then with a "post-birth abortion"—is seen as economically practical and morally acceptable in a world where scarcity reigns (Giubilini and Minerva, 2012).

Callahan seems blissfully unaware of the effect of his writing in creating an environment in which humans are judged on the basis of potential performance, one in which the elderly, disabled, or otherwise unemployable are assumed to be unproductive burdens. The problem is that Callahan (and by extension his bioethical successors) has been blissfully ignorant of the social environment and the manner in which its structures create the problems that seemed to him so urgent. "Technology had been," he writes, "for my entire career in bioethics, the thread connecting almost all of the ethical problems I worked on" (page 137). That is at best a shady half-truth. It is scarcity that has been at the center of his work, and of the bioethics he helped create. Technology creates expense and that creates resource scarcities, he argues, as if scarcity were a natural and inevitable condition. But scarcity is rarely natural and his failure to recognize this is, I argue elsewhere, Callahan’s and bioethics’s greatest failure (Koch, 2012).

For example, Callahan follows common practice in dating bioethics beginnings in the public debate of the early 1960s over the triaging of dialysis patients in the United States when there were too few treatment facilities for needy patients. It was the type of problem Callahan loved—Who do we save when some must die—and  one that ever since has propelled medical amateurs with training in moral philosophy into the public arena as adjudicators.

This example of "lifeboat ethics" was not, however, either a necessary consequence of new technologies or a natural, inevitable dilemma. It was, instead, a direct result of US policies of hospital and medical funding. The problem was not technology but the economic and social environment in which care is provided or withheld in the US.

This was proven when in 1972 the US Congress made dialysis a national entitlement, funding care for all renal dialysis patients (Social Security Amendments, 1972). A wealthy nation, Indiana Senator Vance Hartke told his colleagues, should be able to "set our national priorities through a national effort to bring kidney disease treatment within reach of all those in need" (Congressional Record, 1972; Koch, 2002: 56). The economic environment changed on the basis of a politician’s ethical insistence that people should not die of preventable renal failure for want of treatment facilities.

It was left to politicians to make an ethical argument that, one would think, a moral philosopher trained at Harvard would engage. But Callahan has always accepted the structure as ethical, or at least inevitable. His judgments took the status quo as a given. In 1975 Senators Kennedy and Jacob Javits asked Callahan and Gaylin to take on the ethical right to care. Callahan demurred because he lacked the staff.

But really, Callahan never understood the question: "It would be ten years before I returned to cost control," he writes (page 62). The question, however, was not the cost of care but healthcare as a human right, a subject that, one thinks, a moral philosopher would have at least understood, even if he did not wish to engage it.

Discussion

An ethical and moral center in the analysis of not only medical care but also environmental science and social issues is needed. But that requires an ethic that focuses first on the social context and its environments of inclusion and exclusion (Koch, 2008: 116). But ethics is about what is right, not what is politically acceptable. The bioethics Callahan created is one where scarcity and the status quo together reign and, as a result, all good solutions are taken off the table from the start.

Callahan’s bioethics succeeded because it was fundable. It was fundable because it was simplistic, carefully avoiding the hard, structural issues whose consideration would have angered, perhaps, the agencies that supported Callahan and his Center. The issue was never technology. Focusing on it as if it created the dilemma was, in the end, the problem.

As Callahan himself notes, "the market was treated as a moral, not just an efficiency value little interested in the idea of the common good" (page 132). It is, however, that good, in theory if not practice, the focus of moral philosophy. It is where critical thinking must begin. For environmental and social planners, in health and in every other venue, it is this idea—that of a common good irrespective of short-term efficiency values—that must be the starting point for critical moral analysis (see, for example, Jennings, 2008). What constitutes that good—its resolution and scale of its definition—is the question we need to address.

Callahan’s autobiography becomes, in this reading, a cautionary tale. This is what happens when business as usual becomes the model for business that will be. There is nothing necessarily ethical or moral about that result whatever the pedigree of the author. We can, and must, do better. 

References

Arrow K (1963) Uncertainty and the welfare economics of medical care. American Economic Review 53(5): 941–73.

Binstock R and Stephen G (eds) (1991) Too Old for Health Care? Controversies in Medicine, Law, Economics, and Ethics. Baltimore: Johns Hopkins University Press.

Callahan D (1987) Setting Limits: Medical Goals in an Aging Society. New York: Simon and Schuster.

Callahan D (1990) What Kind of Life? The Limits of Medical Progress. Washington, DC: Georgetown University Press.

Congressional Record (1972) 30 September, 33, 004-33, 008.

Giubilini A and Minerva F (2012) After birth abortion: why should the baby live? Journal of Medical Ethics 10.1136/medethics-2011-100411.

Jennings B (2001) From the urban to the civic: the moral possibilities of the city. Journal of Urban Health: Bulletin of the New York Academy of Medicine 78(1): 88-103.

Katz S (1996) Disciplining Old Age: The Formation of Gerontological Knowledge. Charlottesville, VA: University of Virginia Press.

Koch T (2002) Scarce Goods: Justice, Fairness, and Organ Transplantation. Westport, CT: Praeger Books.

Koch T (2008) Bioethics? A grand idea. Canadian Medical Association Journal 178(1): 116.

Koch T (2012) Thieves of Virtue: When Bioethics Stole Medicine. Cambridge, MA: MIT Press.

Social Security Amendments (1972) § 2991, Pub. L. No. 92-603, 86 Stat. 1329.

Thomasma D (1997) The Asbury draft policy on ethical use of resources. Cambridge Quarterly of Healthcare Ethics 8: 249.