Transcript for Episode 92

Grant: My guest today on the podcast is Dr. Michael Deem. Michael is an Associate Professor in Human Genetics at the University of Pittsburgh. He's a bioethicist who writes on a variety of issues related to clinical practice, vaccines, philosophy of medicine, and he's especially interested in the bioethics education of clinicians.

So Michael is also a deacon-in-training in the Catholic Church. So we'll be talking about issues of contemporary bioethics, but also issues related to Catholicism.

He's a friend of mine, a friend of the Beatrice Institute, and I'm especially excited for this conversation for many reasons. But one is that we're actually live in a studio together. Every single podcast I've done has been over the internet, so this is the first time we've been able to do it together. So welcome to the Beatrice Institute Podcast.

Michael Deem: Thanks.

Grant: So I'm going to start our conversation today by reading a quote from Richard John Neuhaus in an article he wrote in 1989 called “The Return of Eugenics.” And this was in Commentary Magazine. Richard John Neuhaus, for folks who don't know, was the editor of First Things. I've read this quote on a podcast before, but here it goes. So this is Richard John Neuhaus.

“Thousands of medical ethicists and bioethicists, as they're called professionally, guide the unthinkable on its passage through the debatable on the way to becoming the justifiable until it is finally established as unexceptionable.”

So in what ways does Neuhaus accurately describe the current state of bioethics?

Michael Deem: So it's interesting. So, that article… when it came out, there were some interesting studies that are being performed at Loma Linda University, and that's actually what he's commenting on there is a research project where they were looking at whether or not they could have good transplantation allocation outcomes from anencephalic infants.

So anencephalic infants are infants who during fetal development are missing part or almost entirely their brain, usually lacking a skull as well. Most infants with anencephaly die before birth. Many are stillbirth. And the small proportion that are born live usually die within hours to days.

And so one question that was looming at the time in the late 80s and through the early 90s was whether or not we could approach parents of anencephalic infants and request that they donate their dying infant’s organs. Now one of the problems that was encountered here is that it can sometimes take, as I noted, hours or days for anencephalic infants to die. During this process, as their breathing shallows, their blood oxygen saturation diminishes, many of the solid organs that we’d like to transplant become damaged, and so they would be useless for transplantation purposes. We could still get things like parts from the eye, we could use heart valves, but livers, hearts, lungs: those would suffer ischemic injury from the lower oxygen saturations in the blood as the event was dying.

So Loma Linda University dealt a protocol where they were looking at the possibility of providing some anencephalic infants with what would be considered aggressive life sustaining treatment, so intubating, providing oxygen in those waning hours of their life to sort of maximize the utility of their organs. Of course, this raised a lot of ethical questions because what do we typically use aggressive life sustaining treatment for? Well, we use it to extend life. But in this case, the intention is to get the most use out of these organs. And they compared the study arm of that group with, control arms, right? So just procuring organs from anesthetic infants who die naturally. And this raised a firestorm and it ended up getting shut down.

But what Fr. Newhouse is referring to there is the fact that we probably never would have thought about this application of aggressive life sustaining treatment simply for the purpose of procuring organs.

And of course, another question looming in the background that wasn't being considered by these studies is what does this mean to parents? How do parents experience the request to enroll their child in a study to see whether or not aggressive life sustaining treatment will increase the utility of their child's organs after they die?

Another sort of ancillary question that wasn't fully researched was: well, could we procure these organs while anencephalic infants are still alive, right? I'll get to that in a moment.

So this is all on Fr. Newhouse's radar, but I think his point with that quote was they were doing the unthinkable at Loma Linda university. Now, the unthinkable doesn't need to be the immoral. It's just, we hadn't thought about these applications. But the unthinkable also needn’t be morally neutral, right? It can be wrong. And many people, including, I would say, more progressively-minded bioethicists were very troubled. Because this portended, I think, what we're looking at decades later and what I think Father Newhouse predicted with that quote, and that is the use of medical technologies for things that we would have ordinarily considered harmful, wrong, problematic, or at least underexplored. And we're just marching on and using these technologies in ways that suggest that human dignity is no longer relevant consideration in research studies.

The irony of course being that the Loma Linda study was simply decades after the conclusion of the Tuskegee syphilis study when we went through these very issues about human dignity, injustice, unfairness, withholding information, one would argue systemic racism. And so we didn't learn our lessons for very long.

And so I think that there is something accurate about the quote. Whether we have a return to eugenics wholescale like that, I don't know, but I do think that what Father Neuhaus was referring to with Loma Linda was a symptom of a greater illness within medical research and I think in bioethics today, and that is a lack of courage to speak out, to affirm what looks like a foregone marching on technology.

So in the Loma Linda case, I think he's right. Where were the clinical ethicists and the bioethicists at Loma Linda? Why did it take so many external critiques of what was happening there with those anencephalic infants to get it shut down? It's a puzzle.

And so I think what he's predicting there, and I think it's come true in many large respects, is that clinical ethicists, particularly those that are working in the very institutions that hopefully their expertise can guide, and in some senses, check, aren't speaking up fast enough, coherently enough, or they're being stipled in some way.

Grant: Do you know of an actual scenario under which a bioethicist said, “Stop, this is wrong” and a physician change course away from what they wanted to do? Or is this a sense – and I think this is part of what Newhouse is getting at – is maybe there's a sense in which the job of the contemporary bioethicist is to baptize and justify what physicians and health care professionals want to do anyway?

Michael Deem: I definitely don't think it's the latter; I don't think investigators that's the role of the bioethicist. Whether or not some bioethicists and clinical ethicists – and we can talk about the distinction there in a moment – I don't think that's what they take themselves to be doing or were called to do.

I can't disclose too many details because I was part of some of these cases, but when I worked in a pediatric hospital in Kansas City as a fellow, I participated in ethics committee conversations and discussions, and I did learn that there are often physicians who are willing to listen to a committee-wide recommendation. They will change course. How often that happens, whether that was sort of an anomaly in the field, I'm uncertain. And I don't want to be unfair to clinicians who seek ethics consultation services in hospital settings or research settings and really do want to listen in good faith to what ethicists have to say. So I've been in committees and I've been in consultations where there was a change of course or a change of mind on the part of the physician or the clinical team after an ethics consult.

But I do think that there's a real concern… a twofold concern. One, I worry about clinical ethicists who provide these consultation services within institutions they're hired. So you take something like a large health system like UPMC, right? Just to use that as an example. They employ clinical ethicists. Do those clinical ethicists have the sorts of protections that, say, professors like you and I enjoy, where, with academic freedom, we're permitted to sort of explore where the evidence goes, marshal reasons for unpopular views. I mean, there are abuses of academic freedom, but largely what we're given is license within the scope of our expertise to explore difficult, tough questions and issue answers that are well-reasoned or well-backed that may be unpopular or might be part of a minority view. Do clinical ethicists enjoy that sort of protection? I don't think so. I don't think that they're told explicitly by their institutions that they have these protections, that they can truly look at a difficult ethical challenge in a hospital or health system setting and give a thoughtful, good faith analysis and issue recommendation that may challenge status quo or may suggest that institutional policy be revised on certain questions. I hope that they are offered that opportunity. And I don't know if UPMC – I use that as one example – I don't know if UPMC provides those protections, but I'm thinking about systems like UPMC that hire clinical ethicists, people with credentials. Do they have those protections to pursue really where the inquiry analysis goes?

That’s one concern I have. The second question is what sorts of people are we giving those credentials to. So we do have a national accreditation, call it certification process through the American Society for Bioethics and Humanities, ASBH. And we have a number of people, academic bioethicists and clinical ethicists, who pursue this credentialing. It requires some time in hospital settings, giving consultation services to clinical teams who are facing ethical questions, but also some academic formation. They take a test, which will measure, I suppose, whether or not they're to be credentialed or not. But the field of bioethics itself is so nonstandardized and it's not clear what our academic standards are. I mean, one of its strengths is its interdisciplinarity. One of its weaknesses is its interdisciplinarity, because we have all of these different fields converging and there's no clear ordering within our field. Does one field, say philosophy, take priority as foundational such that to do good bioethics we need to have people train in such a way that they can critically analyze, deploy certain logical and analytical methods, to really look at questions. Or, is it just some sort of amalgam of people from different fields who are just interested in medical questions or policy questions related to health and we don’t have standards, and so we let the doors be so wide open that we compromise, I think in an important way, the integrity and coherence of the field.

So are the clinical ethicists that are being credentialed, and then after that, the clinical ethicists that are being hired, what is their expertise? What is their status? And those are legitimate questions to ask. And I think if you're a physician or you're on a clinical team, you're facing an ethical problem, an ethical dilemma, and you're seeking the guidance of a clinical ethicist, do you have reason to be worried that this person truly has an expertise to tell you something new or informative? Are they in a better position than you are as a physician to understand and evaluate the various principles, values, preferences, and interests at stake? I think it's a legitimate question.

Grant: I recently read ethical arguments for the moral legitimacy of pedophilia. One thing that I noticed was that the arguments were relatively clean. At least in terms of forms of logic and reason, right? They made sense, and if you started here and use the tools of logic and reason, I can see why you get to this conclusion. It struck me that what was really driving whether or not pedophilia is right or wrong was the what I think of as the assumption architecture. So to what extent can we justify basically anything within bioethics as long as we structure the assumption architecture correctly?

Michael Deem: Yeah, I mean, that's a great question. This is a perennial question for logic. So we know that logical validity… So if you're talking about clean arguments, logical validity in deductive logic is just this property of an argument that if the premises are true, then the conclusion must be true, under pain of contradiction.

But that's again, hypothetically, if the premises are true. So we could construct something like – this is a very common argument that you find in Logic 101 textbooks – “All ducks eat dirt. Grant Martsolf is a duck. Therefore, Grant Martsolf eats dirt.” Logically valid, airtight, if the premises are true.

So, and this gets to this question about pedophilia, but I think it actually gets to every single bioethical argument, or any argument really, in any field in philosophy, ethics, sociology, law. Is that if we accept or assume the truth of the premises and we are hoping for something like deductively valid argumentation, then yeah, we can fix the premises in such a way that the conclusion just simply falls out of them.

So I think some of these arguments that you see that are shocking, it's hard to point at the logical error. Fortunately, most people, rightly so, find pedophilia to be morally offensive. They may not have ever thought why; It may just be an ick response. But ick responses and disgust responses only get us so far. This gets right to your question about Fr. Neuhaus. I guarantee that most people, most clinicians, most researchers, most ethicists who first heard about the Loma Linda studies would've had an ick or disgust factor. In fact, I think that's what largely ended up shutting it down. Because that just seemed wrong. It seemed exploitative. It seemed cruel.

That only goes so far because we're actually now opening up that very question that Fr. Neuhaus was commenting on today, a few decades after Loma Linda. The question about procuring organs from anencephalic infants is back on the bioethic table.

Disgust reactions only get us so far. We need to question not just whether we have logical validity, but are our premises good premises? Are they actually true? And in ethics, what do we need in our premises? We need values. You need value terms like oughts, ought nots, goods, evils or bads, virtues, vices. We need to have a reckoning, I think, in bioethics, where we're willing to actually consider whether or not premises that begin arguments that include these value terms are true.

And I think that's exactly where bioethics as a field, whether we're talking about clinical ethics, that is, ethics that's done on the floor in the clinic or in health institutions but also academic bioethicists and to a large extent academic bioethics has shied away from, this sort of honest evaluation of: what are the presuppositions, what are the theories that tacitly inform what we take to be virtue-vice, good-bad, oughts and oughts-nots?

Grant: Is that how we end up collapsing into autonomy above all else?

Michael Deem: I think in part, right? I think in part. So you're making reference to what many just assume is the primary principle of bioethics, and that is respect for patient autonomy. And what's interesting, again, is that the autonomy theorists, which gave rise to our thinking and philosophy and ethics about autonomy, so you're thinking about figures like Immanuel Kant, and though not explicitly using the term, it's certainly operating there in the more liberal theorists like John Locke and even J. S. Mill. They didn't think of autonomy as just this blank canvas where there's no values painted, no preferences, no interests. It's just simply the atomistic individual who's a chooser.

Even J. S. Mill's libertarianism included something like a harm principle to put a check on what we choose. So he's thinking in terms of political arrangements, when you have individuals whose exercise of basic liberties may infringe upon the consistent practice of those basic liberties by other individuals, so state involvement. But he had a very specific understanding of what he meant by harm. And on the other side, he also had a very clear understanding of what he meant by utility or the good, based on things like pleasure and pain.

Immanuel Kant had a very, very strict standard for what he counted as a truly autonomous choice, and it was choosing in such a way that one could will that the maxim of one’s action, that is, the principle of action being proposed, could be universalized and be consistently practiced by all individuals. Then he reformulated that in terms of treating humanity as an end in itself and never as a mere means.

So even the great autonomy theories of the Enlightenment packed into their understanding of autonomy values. My sense is there are several bioethicists that do that today. So I'm not going to pooh-pooh autonomy and the importance it should hold in any normative theory being applied in bioethics. But one does get the sense that the dominant views of autonomy in bioethics today have that picture of the criterionless choice. It doesn't matter what's being chosen if it's an autonomous choice. It's a good choice or it's the right choice, period.

And so I think that reluctance to think about, well, what is human freedom? Is it just freedom from constraint? Or does it also involve the freedom or the ability or the empowerment to choose what is good or what is virtuous rather than being prevented from doing so?

I think the reluctance to consider those questions has led us to this very empty, vacuous notion of autonomy, of just choice.

Grant: So do you think new natural law reasoning when it comes to bioethics is dishonest? Are we sneaking Catholicism into our reasoning? Or does that even matter? Should we just openly admit that we're sneaking Catholicism in, everyone has their values, you value autonomy, I value the natural law… Because part of the premise of the natural law thinking is that it doesn't presuppose any metaphysics. Is that a dishonest claim?

Michael Deem: Is which claim dishonest?

Grant: That natural law thinking doesn't require Judeo Christian presupposition.

Michael Deem: Oh, I absolutely think that what is called the New Natural Law Theory, and it's really a cluster of viewpoints sort of united against a conception of basic human goods and their self-evidence.

As an aside, the New Natural Law, I think that the philosophers, legal theorists clinicians who identify with this view aren’t comfortable being called New Natural Law Theorists. It was actually a derogatory term kind of foisted on a group of really excellent philosophers and legal theorists, so Germain Grisez and then John Finnis. These were individuals who thought that there was something that needed to be recovered, not because they were nostalgic or wistful for a bygone era, but that in contemporary discussions in law, jurisprudence, in moral theology, and in ethical theory, that these conceptions of the good had largely either been foregone or that they would be sort of waved off as, “Well, we are now partakers of a multicultural, interdisciplinary, multi-ethnic, multi-religious, democratic system.” And so bringing a particular conception of the good into our law or into our government, our governing, into the hospitals would be unjust or unfair. They looked at those responses to modern, democratic, liberal social contexts and thought “We can still meaningfully talk about human good without relativizing it to a particular era or a particular culture.”

So when Finnis and Boyle and Grisez began to recover this idea of the good, it t was largely rooted in the writings of Aquinas. But Aquinas himself noted that our knowledge of human goods need not be dependent upon our theology. So in his development of what's called natural law, Aquinas does hold that we have self-evident knowledge of the basic principles of practical reasoning.

And this is a position that people who do not espouse Natural Law Theory also hold. So in contemporary philosophy, we have the ethical intuitionists, right? People like Robert Audi, who have no theological commitment behind this ethical view, who argue that, yes, through the power of reason, if we understand the concepts that are at work within certain ethical principles, we will see that they are true. And that’s just what it is to be self-evident.

So I think that what's going under the New Natural :aw descriptor is not at all based on a certain theological conception of what the good is, at least as far as what we can know about the good. And it just so happens that these natural law theorists are Catholic – although with some exceptions, right? So Farr Curlin, for example, has written with Christopher Tollefsen. Farr Curlin is not a Catholic. He's a Protestant Christian. – but it need not be tied to Christianity or a theological view.

So a fancy term for this is that the basic principles of practical reasoning, which includes certain obligations or deontic principles, like the good ought to be pursued and the evil avoided, but also then our knowledge of certain goods, goods for humans, like knowledge is a good, that leisure or play is a good, right? That friendship or social relationships are good, are self-evident. We call that epistemic independence. In other words, we're hitting bedrock with our knowledge, that these require no further justification, that somebody who understands the concept X, so put in there knowledge, leisure, play, and the concept is good, and we embed those in our proposition, like knowledge is good, we will see that that is true. That's all it means to say that that proposition or that statement is self-evident. That doesn't require any religious perspective. It doesn't rely on any theological commitment.

Now, when you get to explaining, well, why are those the basic human goods? Well, then you could tell a theological account, right? You could, and Aquinas does, for example, he grounds this ontologically in the existence of God and God's plan for Creation. But Aquinas also notes that to know that these are goods and to know these basic principles of practical reasoning, one need not ground that knowledge in one's knowledge of God or God's revelation.

Grant: Sometimes I find that bioethicists sometimes stack the ethical deck, so to speak, by embedding within their arguments a certainty of future events.

So for example, before I converted to Catholicism, I was a very strict pacifist because I was very influenced by Stanley Hauerwas. And he works a lot with the work of John Howard Yoder, who made this observation that oftentimes someone would say to him, “Well, what would you do if someone broke into your house there to rape your daughter and kill your wife and kill your son?”

And he pointed out that this is actually a totally unfair argument because you're already presuming what the outcome is right? You're saying that they are there in your home to rape your daughter and kill the rest of your family. But in reality, the way that this thing actually plays out is you hear something downstairs. It could be an animal. It could be a human being. They could be there to steal your stereo. It could be that you shout down the stairs and they leave the house, right? So as they break in, actually, the future is totally open in the raping and the killing is probably, in many ways, a relatively small probability, right?

So sometimes we hear some of the logic about abortion, like we need to keep it legal because if we don't have medicalized abortion, people will necessarily get back alley abortions and die.

So this is a long lead to this question: How should future unknown probabilities factor into ethical thinking? Particularly, how should we understand the use of ethically problematic practices now to potentially stave off future unknown possibilities?

Michael Deem: Yeah, the Hauerwas example is interesting because I think it's a bad faith argument, first of all.

So if you come to me – say I'm a pacifist. I take that you're not simply saying that I'm committed to nonviolence in every circumstance, but you're also recommending passivism as the correct view of response to harm or violence done to others. So it's not just that you're saying, “I'm a pacifist;” you're saying, well, “We ought to be pacifists.” Right? Or you might say something like, war is wrong, or military response to aggression is wrong, or something like that.

This little trick where you try to make it personal is a bad faith response. Because what you're really asking how our loss in that situation is what you're asking him, if all this happened to your family, wouldn't you have anger or rage? Would you not be infected with resentment? Would you not have the desire for vindication of your family? And putting all those things together, surely that's going to justify a violent response. And that's what they're trying to get Hauerwas to say or anybody who faces these sorts of objections.

And that's a different question about whether or not being a pacifist is good or if pacifism is true, is that the correct view of war and aggression or retaliation. It's asking: would you be consistent with your own views? And so that's why I think it's a bad faith argument.

I can say to you and our listeners, “We all ought to be honest.” But what if I found myself in such a situation where if I were to be honest in this particular instance, in this moment, it might lead to great harm to somebody. And in that moment, in my troubled mind, my difficulty, because of the emotionally charged situation, seeing all the relevant values, I have a moment of weakness of will and I lie. Have I therefore shown that I'm not really committed to the view that we all ought to be honest or honesty is a virtue? No.

We're appealing to this hypothetical question on how would my emotions dictate my actions in a given situation. That's why I think that these are bad faith arguments.

But they are effective on the political stage. Right? We're familiar with this, this sort of question was posed, I think, to Jimmy Carter about his view on the death penalty in a presidential debate. I heard it recently in a political debate about abortion laws and abortion restrictions, bringing out the really tragic case, of a young girl, I think she was ten or eleven, who had been impregnated through sexual assault. And whether or not a commitment to restriction on abortion in, say, the state of Indiana –I think that's where it took place – if we really committed to that, then you're okay forcing this young girl to be pregnant and to give birth to a child.

And I think that these arguments they do put pressure, I think, on our intellectual commitment and they do push us to be nuanced, but I don't think that they're intended to do that. I think they're intended to shock. I think they're designed to embarrass. I think they're just sort of bad faith arguments. They get a lot of political points, though, in these sort of stages that I'm describing.

So back to your question about future unknown possibilities or probabilities. I mean, they should factor into our ethical decision making, right? I think that utilitarians have – we talk about proper nuance – have really nuanced their view. Now, I'm not a utilitarian. I think it actually misses the entire purpose of what a normative theory should do when it tries to explain what fundamental ethical principles are or why we make certain ethical judgments. I think that utilitarianism gets this mostly wrong. But a lot of utilitarians have taken seriously this issue about future probability. How could you possibly have an ethical theory committed to the right action being that which produces the most good when we have no idea how future events will play out, particularly those that are in the remote future?

But nonetheless, they should be considered, right? So when we sat down for this podcast, maybe I put a paperclip in one of the wheels of the chair you're sitting on. So you're in one of those chairs that's got a swivel, but it also has wheels to move across the floor. And I guessed; I thought, “Well, I know Grant shifts a lot when he's working the computer and the microphone. And so there's a good probability that he'll move that chair in just such a way that that wheel will catch on the paperclip and he'll stumble or fall out of his chair.” Will that happen with certainty? No. So it's unknown probability. Could I put a probability number on that? No. But was it wrong? Yeah, but it's wrong because not just the outcome, the possible outcome, but really that's a vicious action, right? That's not something that a virtuous person would do, particularly to a friend but also to strangers.

So I do think that future probabilities do matter in moral action. We should be considering how particular actions or you mentioned things like abortions, certain policies will impact future events or how they may place individuals in situations that don't have an altogether good outcome, right? So they do matter for our considerations. What I think the problem is, and you said it well, you said “necessarily.”

So looking at the abortion argument, whether one is endorsing of abortion restrictions or one is not. No one in good faith can argue that we know with certainty that we're going to have women seeking abortions in back alleys because they live in a state that has restricted abortion access in some way, whether totally or to such an extent that you'll have individuals who will not be able to have an abortion in that state. That they will go to the back alley: do we have any reason to believe that's true?

And let's suppose for a moment that we do think that abortion restrictions are permissible. Much like we think that a lot of restrictions at the state level are permissible, right? So are citizens forced by these restrictions to go and perform the actions that are restricted in dark alleys or behind the scenes in nefarious ways? You can think about things like restrictions on gambling. You can think about prohibition. What I think really is animating such arguments isn't that, “Indeed, how horrible it will be that this will all take place illegally while black markets will have back alley abortions, et cetera.” I think it's still, it's a tacit acknowledgement about whether or not abortion is good or not, because that's what it comes down to. Because the same people that argue that would say, “Well, we don't want to lift restrictions on murders because now murders are going to be taking place in dark alleys and by ambush and people will try to get away with them.” People who would worry about the back alley abortions will say, “Of course we should keep murder restrictions in place,” right? We shouldn't have citizens murdering other citizens, even if it's going to be done now in sort of really unfortunate ways. Bodies will be hidden, right? People will be putting barrels and put out to the sea to cover up.

I think we're just avoiding that question again about whether or not abortion is good or at least permissible or whether abortion is bad. Is it an evil? Is it an offense to human life and human dignity? We're not willing to have those conversations. So we invent these shocking hypotheticals to do the hard work of argument. So there's no argument there at all.

Going back to what we were talking about earlier, they're to elicit a certain disgust reaction from us. Like how horrible or how disgusting if people have to do this; therefore we can't put them in that position.

Of course we also – now I won't belabor this point – we also take away their agency as well. So if there is a certain restriction on an action, we're not even positing, well, what might an agent do other than seeking to perform that action in a licit or illegal way? Do we channel them in certain other agential ways where they can accomplish other aims or other ends, or see the value of something, right?

Grant: All right. I want to turn a little bit to philosophy of medicine. I know you teach a philosophy of medicine course because you invited me to give a lecture, which was a lot of fun.

So is hormonal birth control healthcare? And if not, who should provide it to those that want it? If it's not going to be physicians and nurse practitioners and PAs.

Michael Deem: Yeah. And this is one of the questions that we're grappling with right now in Philosophy of Medicine. And interestingly, in my course, I – just as sort of a side note for our audience – I assigned a new book called The Way of Medicine, written by Farr Curlin and Christopher Tollefsen. Farr Curlin is a clinician, specializing in palliative care at Duke University. He's also a bioethicist. And Christopher Tollefsen is one of these New Natural Law folks that we were talking about earlier, sort of the second generation, who's done a lot of really good work, I think, teasing out the implications of natural law for contemporary ethical issues. He's at the University of South Carolina. Their book, I think, is extraordinarily useful for showing the stark contrasts in at least two understandings of what healthcare is.

So the question you asked is prescribing hormonal birth control healthcare? The answer is it depends. And this is again where we need to have the more fundamental questions – and this is where philosophers can be very helpful, I think – in bioethics, in medicine, is: what do we mean by health and what do we mean by health care?

So just to use their distinction – so I'm going to completely tip my hat to them and say I'm ripping this off from their book – I think they do a really nice job of sort of diagnosing the state of play in health care. That there are at least two broad views of what health care is. One is traditional, traditional in the historical Western medicine sense.

But I would also argue that it's also animating a lot of what we would call Eastern medicine as well. And that is that medicine is a particular practice, that it has particular aims and those aims primarily are the health and wellbeing of the patient. With health understood as well functioning. And I think they kind of lean towards a physiological functioning idea of health.

So I mean, it makes it sort of uncomfortable to fit in things like mental health: is mental health actually, this healthcare or is it something else? I don't see a problem with it being something else that's also aimed at patient wellbeing, but in a different way than, say, medicine, which is focused on physiological health.

Grant: The care of the soul.

Michael Deem: Maybe so. So there'd be more to it than just simply a clinician at work in mental health. And I think that's actually how it plays out, right? We have therapists, we have social workers as well as clinicians contributing to –

Grant: Friends.

Michael Deem: Friends. That's it. Communities. – to mental health. Whereas physiological health, that's something that's a little bit more constrained to a particular practice for promotion. Now, of course we have our responsibilities for our physiological health. So the, the physician's role is not – something like Curlin and Tollefsen's account: to govern all aspects of a patient's physiological health. This further narrows for what the physician does. It's restoration of physiological function.

So you and I are still responsible morally, of course, but also agentially for our own physiological health, right? Whether you and I throw on our running shoes after this podcast and hit the trail is up to us. And that would probably be good. If you and I go get beers after this, maybe not as good for our physiological health, but we'd be promoting some other value like friendship and –  

Grant: Mental health.

Michael Deem: Mental health. Yeah. So this idea of restoration and healing really animated much of what is now called Western medicine for centuries, millennia, but also Eastern medicine. They contrast that with what they see is sort of a dominant current in what we call medicine today and that is they have called it, I think helpfully, the provider of services model. Because it's so open ended too. That's why I think they really did a nice job diagnosing it. They didn't over diagnose, they didn't over specify, they just said that one gets the sense that modern contemporary Western medicine is largely governed by what patients want, what their preferences are as they're stated or expressed, and that medicine's role is to adapt insofar as it has the competence to do so, adapt itself to meet or satisfy those preferences or those desires.

And what you have then is sort of a loosening now, of what it is that the clinician does, what the clinician's identity is. It's almost like they just become a dispenser of the things that a patient wants and knows that at least in principle is within the power expertise of the clinician.

So the birth control question is going to probably be answered in different ways depending on what model of healthcare you're looking at.

Now, you didn't say what the prescribing of hormonal birth control is for. If the question is, is the prescription of hormonal birth control for the prevention of pregnancy health care? I think the answer is no on the more traditional healing side of medicine. Because, however we want to cut it, at the physiological level, hormonal birth control creates dysfunction within the body, it suppresses and it actually – we have really good evidence now – it actually makes ill certain systems of the human body, irrespective of what the purpose or reason behind creating the dysfunction is. And so this traditional notion of medicine is an art of healing, a practice of healing. Hormonal birth control for the purpose of simply preventing pregnancy is not healing.

Another question might be, though, but what about prescription of hormonal birth control because it may provide some other secondary effect, right?

Create regular periods.

Create regular periods, reduction of extraordinary pain. I'll leave it to you – you're a nurse by training – whether or not controlling acne would be a good secondary use of hormonal birth control.

So in that sense, we're asking, “Well, what is the clinician aiming at it? What's the clinician doing?” And there it might be relief of certain other symptoms, whether you're saying pain or regulation of periods. That could have a healing orientation. So that might be compatible on certain understandings of traditional medicine.

But I take it that your question is really like, what about prescribing hormone birth control for the prevention of pregnancy? It seems strange to suggest that creating dysfunction in the body is healthcare. But on the provider of services model, it is certainly something that a clinician can do. It's something that we have the pharmaceutical technology to accomplish, that is the suppression of ovulation or as a secondary effect of hormonal birth control, making the uterus inhospitable to implantation by thinning the lining in which a blastocyst or embryo would embed. If that contributes to – and these questions are even asked – but presumably this is going to contribute to some other goals or aims that a patient has in their life. Maybe it is, “I have career aspirations and I know that having a child right now would prevent me from pursuing this particular path, to this career aspiration.” Or, it could just be simply “I'm sexually active. I don't want to be pregnant right now. I don't have any other goals other than just not being pregnant right now.” Those questions probably don't need to be asked of the patient on the provider of service model.

So I think that for a lot of the PSM, provider of service model, clinicians, it's sort of a no-brainer. Of course it's healthcare, because it's what I can do and my job is largely, at least for physiological and arguably, now, social wellbeing of the patient. It is part of what I do, it is healthcare. So it's going to depend. It's really going to depend.

One thing I will say is that I have noticed this and this is not just anecdotal. My wife and I, we have five children. We lost one recently to miscarriage. We have a lot of experience with prenatal care. We have a lot of experience of being asked if we want to receive genetic testing, we've had emergency c-sections, we've had natural births: we've really run the gamut with modern healthcare when it comes to pregnancy and labor and delivery.

Postpartum care hasn’t been great, I will say that, sort of an aside. That's one thing we probably need to get better at, period, right, is acknowledging that aspect of labor and delivery in a pregnancy.

But we have felt, we have noticed in our conversations with friends, my conversations with colleagues in medicine, in nursing, in bioethics, is that, again, using this sort of provider of services model to diagnose what's happening in medicine right now, there's a real diminishment of communication between clinician and patient because it cuts that out. It's not about, “Well, we're trying to contribute to your healing or to your wellbeing. How do you understand that? How are you feeling? What are our mutually endorsed goals together in this clinical relationship? What do I owe you as your clinician?” The PSM model does a lot of work to cut out those conversations. If it's just about satisfying your preference, why does it matter to the clinician why you have this preference? Is it the clinician's role to suggest that, “Well, maybe we can think about that preference and how this might not be good for you?”

And that's not just with birth control. It could be in any area. But I think it's especially key right now in women's health. We see it most acutely, I think, when we're talking about contraception itself with these sort of natural methods of pregnancy prevention, which don't create dysfunction in the body, they don't require a pharmaceutical regimen or an implantation, some invasive procedure to prevent pregnancy. They I think they at least tacitly promote the wellbeing of the patient in so far as they involve conversations about how one's body works. It puts a lot of empowerment, I think, in the hands of the patient, if they want to take it, to understand themselves, to understand how they, their body, their physiology naturally works. And interestingly, at least with committed relationships, if you're talking about long-term or stable monogamous relationships, it pushes the couple to talk to each other about this as well. And indirectly, then, I think it contributes to a broader sense of wellbeing.

But those conversations, as far as I can tell, are not happening very often in the clinic. That PSM, particularly in Women's Health, has shortcutted those conversations, the relationship between the provider and the patient, where all the options are not presented for accomplishing just the aim if it's just, “I would prefer to prevent pregnancy.” “Well, let's have a conversation about the various ways that that happens.” Yeah, go ahead.

Grant: So is your sense that that is – I've puzzled about this a lot – is your sense that this is a function of the field not catching up with what's going on scientifically? Because in 1975, the options for fertility-based awareness methods were pretty rudimentary? And you had the pill that was relatively easy. So do you think the providers just haven't caught up with what's going on? Do you think this is just the easiest thing to do, because all you’ve got to do is pop a pill, you don't have to chart anything? Or do you think it's an act of hostility towards this approach to “family planning,” for lack of a better word. I know the term “family planning” has a lot of baggage behind it. But what's your sense? What was driving that?

Michael Deem: Well, I think we don't want to just look at women's health. I think how we train clinicians: so we have a handful of options that we can teach clinicians in medical school or nursing school, various techniques, various pharmaceutical options. So it's largely going to be shaped by how we teach to our clinicians of the future. And so what possibilities there are that one could pursue with a patient. So it's largely constrained by health professional education.

I think there are social factors as well, like you said. But again, it's not just women's health. I think that we have a pharmaceutical industry that has encroached quite a bit on the clinician and patient relationship, where incentives are provided to clinicians or health systems to promote certain pharmaceutical options. And I think that external good, that is, the profit of the pharmaceutical company, and the external good to the practice of medicine, that is whatever incentive might be being offered to the clinician, invades the space of the clinic. And so it can become a pursuit within medicine that is not healing, but rather a pursuit of goals that are not necessarily the patient's, but they might be the clinician's goals, or it might be a certain sociological or industry forces that are seeking their own good as well, then they've encroached and they've sort of coopted in certain ways this practice.

So I think that those factors are there. I think the ease with which it is to take a pill. I think that there's also an ignorance that, wow, we actually may not be living up to the standards of informed consent that have been drilled into us, right, when it comes to providing a patient with quality care.

So one of those is the disclosure of the rationale behind a particular recommendation. So if, going back to contraception, is there a conversation about, “Well, here's why I'm recommending this particular oral hormonal birth control pill,” or, “Here's why I'm recommending this hormonal implantation device for you”? Maybe those conversations are happening, maybe they're not.

Are the risks discussed? So that's one of the main reasons why autonomy became such a central principle. First in medical research, and then it kind of got offloaded into the clinic as well, is the risks that any given treatment or intervention may pose for the patient. I don't know whether or not those conversations are happening.

And then alternatives. Are there alternatives that could achieve the same aim that are still within the purview of health care that could also be considered? I don't know that, you mentioned, fertility awareness-based methods are being offered or discussed all that often. I mean, the CDC has an entire webpage on fertility awareness-based methods. I don't know that that's trickled down to medical schools or nursing schools. I don't know if it's in the classroom. So I'm hesitant to say that there's an overt hostility towards them. I think it's largely ignorance.

One, it's going to be ignorance that these methods exist, that they, when utilized correctly – which is the same thing with a pill; you still have to utilize the pill correctly, follow the regimen; if you don't, the pill will be less and less effective – well, same with these sort of fertility awareness-based methods that when they're practiced correctly that they are as good at accomplishing the aim of preventing pregnancy or planning pregnancy as the most reliable hormonal birth control methods. I think there's ignorance about that. 

And I also think that there's a failure – I said ignorance earlier; maybe I'll revise that. I think maybe there's a failure to really think critically about how our standards of informed consent connect to these clinical conversations.

So again, I use that anecdotal experience. When I go to the clinician for various things, whether it's a wellness visit, I've gone to dermatologists, I've gone to other specialists. I've always had good conversations with them. And there’s never been something imposed upon me and or just simply, “Here’s what I’m going to do. We’re going to put you on this medication.” Or, “No, I want to perform this procedure.” There’s always a rationale given to me.” My wife has said, largely it happens with her in wellness visits, but we notice that within the context of women’s health, there’s very little conversation – and this is anecdotal – about why certain things are recommended.

I mean, case in point, when we moved to Pittsburgh, we had our first child here in Pittsburgh. We went to a new hospital. We didn't have a relationship with those clinicians, previously like we did in Indiana where we had our first three children. And my wife was shocked when shortly after delivering our fourth child one of the nurse practitioners came into the room and said, “Okay, so we're going to put you on birth control.”

Grant: I hear that story so frequently. It's the third time this week I've actually heard that from a woman who recently gave birth.

Michael Deem: So why? So we're not even at a point in that context about my wife expressing a preference. Like we've gone beyond that. It's now my preference for you. Or “This is just what we do now.”

So this disconnect between what we take to be very thin… Informed consent standards. I mean, it's very thin. There's a lot of different ways to check consent, right? We might pat ourselves on the back when we've checked the boxes of what we consider necessary conditions for adequately informed consent. That requires very little overall communication just to get that minimum baseline standard met. We're not even doing that anymore.

And again, anecdotally talking with friends, with colleagues, a lot of the same sorts of accounts, that for some reason in women's health, there's less and less conversation about why certain things are recommended and why they're done, why certain tests are ordered, why certain labels are given to women, like “advanced maternal age.” They're just given or they're just proposed or they're just simply stated, like in my wife's case, “We're going to put you on birth control.” And she had to say no, right? Now she didn't have to fulfill the prescription if she didn't want to. But just the fact that it wasn't even a question of, “Well, is this what you want? Is this what you prefer?”

There was a good reason though, right? Why did the nurse practitioner come in and say, “We're going to put you on birth control”? Well, because becoming pregnant shortly after delivering an infant can be very risky. The uterus still needs time to fully contract and heal. We talk a lot about replenishing the lining of the uterus, making it more hospitable to an implanting embryo, but it's also important for the woman because there can be hemorrhaging, there can be postpartum physiological complications.

But that's where we're at, where it's not even: “Here are various options.” She wasn't being hostile. One, perhaps she didn't know that there were other options that we could practice ourselves as a couple, like fertility awareness-based methods. Or two, it's become so routine, particularly within the context of women's health, that this is just what you do. Like almost as if we've come to believe that this is what's good for women patients, irrespective of what their preferences might be, whether or not it was like the sort of hostility described, I don't know. We had our fourth child. Maybe there was a tacit judgment, like, “Wow, we need to pump the brakes here a little bit.” I don't know.

Grant: Our friend told us a story – this is a mutual friend of ours – that as they were sewing her up, because she had a tear, literally the physician said, “Well, this is the last one, right?” Yeah. As they were sewing her up, which is really interesting.

Michael Deem: And we're so conscious now, I mean, in bioethics, I think for the most part in medical education or education still about how important communication is and how framing questions or framing statements to our patients can have these subtle psychosocial harms that may go undetected by the clinician, to the wording we choose when we talk to patients. And that just sometimes just goes right out the door. So what, what sort of psychosocial effect does that have on a patient who just gave birth, is being sewed up because of either cesarean section or maybe because the perineal tore during delivery. What effect does the framing of that statement have? Not just like the statement itself, but in the context, in the moment, right? I don't know why these things are not thought of more, or why they've just been let go as just sort of a matter of course, “It's just what we do.” I really see it as a problem.

And I think that going back to, to Curlin and Tollefsen, I think they've gotten the diagnosis right that if it's just about meeting preferences, it's just a hop, skip and a jump from actually listening to what your patient's preferences are to simply saying, “Well, most patients prefer this, so I'm just going to do it.” And what are we back to now? We're back to paternalism, the very thing that the provider services method was supposed to avoid.

Grant: I'd be remiss if we didn't talk about Catholicism, because in our real life, this is what we argue about most, or discuss most, let's just say. And as a deacon in training you obviously have an institutional relationship to the Church, and you're a thoughtful commentator on the Church.

So, you talk a lot about the continuity between Pope Francis and St. John Paul II. As you know, my confirmation saint was John Paul II. We both have a particular devotion to John Paul II. And one of the themes of your discussions, particularly as you talk in marriage prep, is the continuity between Pope Francis and St. John Paul II. But what is the most basic difference between Pope Francis and St. John Paul II in your estimation?

Michael Deem: So there are a lot of differences, and one could argue that they're basic.

So one obvious one, let's just start there. One obvious, basic difference, I think, between Pope Francis and Pope St. John Paul II is style. And I won't go with… both were very animated. I mean, Pope St. John Paul II was an actor in university. He was extraordinarily charismatic. People love talking to him. He probably talked to the press as much, if not more, than Pope Francis. We just, in the eighties and early nineties, we just didn't have the dissemination of digital media like we do today, where virtually anything the Pope says is almost instantaneously transmitted across a number of media outlets, not without commentary as well, in most cases.

But an obvious difference, I think, isn't there. I think it's actually writing. So when one reads Pope Francis's encyclicals – and I'm thinking particularly the style of “Lumen Fidei,” which was his first encyclical, and then “Laudato Si” –  I think you see a difference in style. And one's not better than the other.

Pope II was dealing at a time, I think, where on a global scale there was a lot of despair. There was a lot of uncertainty. I know he certainly experienced that growing up and as a young priest and then as a bishop in Poland; the political instability, the question about how there could be a God when you've gone through a second world war, the atrocities of the Nazis, and at the time when St. John Paul II became Pope, you still had the Soviet Union, it's still a communist country. And so I think St. John Paul II was very attuned to those global currents. He was also very attuned, I think, because he himself was an academic. He earned a doctorate in philosophy, taught philosophy. He was very concerned about certain directions of theology, and in particular, moral theology.

So, aside from his first three encyclicals, which are wonderful, and I think you could read them, and if you get rid of some of the autobiographical references in them, you might be thinking you're reading Francis. Those first three encyclicals that he wrote on the Trinity, he wrote on “Redemptor Hominis” was his first encyclical, which is just, if you haven't read it, that is, I mean, that's one of the most beautiful things, I think, and most hopeful things that Pope John Paul II wrote.

But once he began to address, I think, the political, economic, and social upheavals across the globe at the time, and he began to address problems in both philosophical and theological morality, he had a real academic turn in his encyclicals. So, right about the time that he starts writing about moral theology in a really authoritative papal way, “Veritatis Splendor.” It's a difficult encyclical. So I pride myself on being a professional ethicist, right? But even I can get puzzled at times and have to take a second and think, “Whoa, what's the argumentative thread here?” It's always coherent. I mean, the deficiency is mine. It's not the Pope's, Pope St. John Paul II’s.

That string of encyclicals after “Veritatis Splendor,” they became dense. They became a little academic, but with a purpose. Because he was writing for a really particular sort of audience, right? Politicians, economists. With his social encyclicals – he wrote three social encyclicals – and a number of philosophical and moral encyclicals.

Pope Francis is not an academic. People made a big deal about his master’s in chemistry, I think, that he had, when he was first elected pope, but he's not, he didn't move in philosophical circles like John Paul II did prior to becoming a bishop. And he didn't move into academic theological circles like Pope Benedict XVI, his predecessor. So he has a very pastoral way of writing. I know pastoral can carry negative connotations. I mean, in the true sense, a shepherding way. When you read Pope Francis's official documents from his papacy, you get the sense that he's writing for you, whoever you happen to be. It can be the academic like two of us here, but he's talking to my mother. And he writes in such a way that maybe with just a little bit of aid from a dictionary or asking her son, “What does this word mean?” my mother can get through a Pope Francis encyclical. So I think that style of teaching is very different.

So I see Pope Francis's encyclicals as trying to reach everyone in the pew, whereas Pope John Paul II became more and more intentional with respect to who his audiences were. And that can make those encyclicals very difficult to get through.

So that's one difference, but I think he wants something more thrilling, something more…

Grant: He wants some more red meat.

Michael Deem: Red meat. Yeah.

So I actually, I think there's a bigger contrast between Pope Benedict XVI and Pope Francis.

But back to the other difference between John Paul II and Francis. And this is again, not a criticism of either one of them. But while Pope John Paul II – he was often called the World's Pope and appropriately so. He traveled everywhere; he was the most traveled pope in history. Of course, there may have been other popes that wanted to travel too, but they didn't have airplanes in the 16th century, for example. Which probably would have helped with the Protestant Reformation. One, if we had a Pope that was actually motivated to address Luther's concerns, right?

Grant: He could have flown up to Germany and had a little conversation.

Michael Deem: Yeah. Instead of relying on Tetzel and others who were selling indulgences to try to put out the fire over there. No, I mean, the Reformation wasn't just a theological issue. That was also a geopolitical issue as well with the revolt against the Holy Roman Empire by the princes.

But, but John Paul II, he was a globe setting pope; he went everywhere and he really saw himself as universal pastor of the Church.  And he put people in charge of the Curia, the Roman Curia, which is sort of the doctrinal and advisory offices of the Vatican tasked with – of course, under the Pope's authority – governing liturgy, doctrine, political statements and guidance religious life, priests for the Church. And he was very hands-off with what the Curia was doing, at least as far as we can tell from his biographers, that he put men that he trusted in places in the Vatican. And so when it came to things like appointment of bishops, the story was that by the time Pope Saint John Paul II would get a list of three or recommend or just a recommendation of one, it already gone through the Curial channels. And the Curia at the time, it was a huge bureaucratic machine John Paul II trusted. And that's an admirable trait: to trust in that way that we are shepherds of the Church, that he looked at his brother bishops and his priests at the Vatican and trusted that they had the good of the Flock in mind.

Pope Francis, on the other hand – and I think this is where he's really in continuity with Pope Benedict XVI – Pope Francis was very distressed by what was happening in the Curia. First, he thought it was a bloated bureaucracy like Benedict did. But he was also concerned about the sorts of men who had positioned themselves to take that power in the Curia. And again, under Pope John Paul II, you, again, you had the unprecedented travel. You also then had an unprecedented lack of oversight of the day-to-day of the Curia. So Pope Benedict XVI began to undertake reforms in the Curia: removing people from certain positions, trimming down offices. Pope Francis is much in the line of Pope Benedict on this. Francis sort of completed what Pope Benedict XVI started with the reform of the Curia. So it's a much thinner, more trimmed, and I think it's actually a less honorific job than it was in the past.

And Pope Francis shows an invested concern with who's in which offices, congregations and dicasteries in the Curia. And he's far more hands-on, it seems, with the appointment of Bishops and Cardinals than Pope Saint John Paul II. So that's a major difference there.

Grant: You know, it's interesting. In some ways that actually turns the understanding of Saint John Paul II and Pope Francis on its head, where you get the sense that that Pope Francis is much more pastoral and John Paul II is much more controlling.

But that's, that's actually opposite of what you're saying. Pope St. John Paul II was out there with the people, was traveling, sort of let the Curia go and the clerical offices do their own thing. Whereas Pope Francis seems to be less pastoral in that way, going out to the people and much more about the Institution of the Church. That seems opposite of our impressions of those two men.

Michael Deem: Yeah. You know, it's funny. I think the answer is yes and no. There were some ways in which John Paul II was very, you said, controlling. Again, you're not using any sort of negative connotation there.

So you see, like, the promotion of certain orders within the Church and certain apostolates. What comes to mind is that he would champion some movements and ignore others that he thought were not contributing well to the life of the Church. So Opus Dei enjoyed a huge favor and sort of an explosion, I think, of notoriety, in the positive sense, under Pope John Paul II. That he favored that movement that was directed to the lay people, which was a dear to his heart. And so he was, in a sense, a kingmaker of certain orders, certain movements. And so that's a bit of a sort of controlling, hands-on shaping of the Church.

And, of course, we know that in retrospect, in hindsight, it wasn't always the right choices, right? So the Legionaries of Christ, it would be wrong not to mention that. But again, it was St. John Paul II gets accused a lot of missing this or ignoring it. And again, that's certainly not the most charitable understanding of what was going on. Again, he trusted his Curia and the promotion of certain movements and priests as they were recommended to him by people he trusted there. And unfortunately with Father Maciel Legionaries, you had people in the Curia who vouched for them and John Paul II trusted them. So I actually don't think that John Paul II was aware at all of what Father Maciel was doing. In fact, I don't think Pope Benedict XVI really understood until he became Pope and actually began to reform the Curia that he realized how bad it was, because that's when you have the discipline.

So John Paul II was very much a kingmaker. He was very controlling as to which movements, I think, made the biggest impact on the Church. But it was always with an aim of the good of the Church. And particularly the laity and, and families. But Pope Francis has shown himself to be less concerned about movements, it seems, and far more controlling about the structures of the Church, authority within the Church and liturgical practice than his predecessors.

Grant: I wish I could follow this up with a hundred questions, but unfortunately we're out of time. We got someone knocking at the door who needs the needs the studio. So I just want to thank you so much for coming on. This is a lot of fun. Maybe we'll have you on again and we'll actually really dive into these questions of the Church. But thanks so much for coming on. This was a lot of fun.

Michael Deem: My pleasure.