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Home > Jeff Ubois > Deepening The Public Conversation Around Bioethics (part 1)

Deepening The Public Conversation Around Bioethics (part 1)

by Redazione FGB [1], 3 July 2008

An Interview with Dr. Thomas Murray [2]

(Thomas Murray is President of The Hastings Center, an independent bioethics research institute founded in 1969 and based in Garrison, NY.)

One of the world's leading institutions in bioethics, the Hastings Center takes an approach characterized by interdisciplinary inquiry, broad public engagement, scenario-based thinking, public service, and engagement with regulators at all levels. Since its founding nearly forty years ago, the Hastings Center has trained and launched the careers of many of today's most prominent bioethicists.

"The founding insight for the Center was simply that the issues that medicine and the life sciences were presenting to society were vastly too complex for any one person, one profession or one discipline to fully comprehend," explains Dr. Thomas Murray, President of the Hastings Center. "And so the only way to get a relatively well-rounded understanding of even the nature of the problem, let alone solutions, was to bring together a variety of expertise and points of view, that together could create something greater than individuals working side by side could accomplish."

As bioethics has become a more universal concern, the Hastings Center has moved to broaden its audience, and to engage the public, and legislators, in new ways. "Bioethics has now become a part of the political discourse, which means that it has become prey to all the sort of spinning and sound biting that people are expert in in that realm, and that's anathema to the Hastings Center," Murray says. "[Our] goal is to…deepen and enrich the public conversation and understanding about these issues."

In this discussion, Murray sheds light on different thinking processes useful in assessing ethical questions and innovation; particular developments in medicine and biotechnology related to sports and human enhancement; and on the Hastings Center's operations and influence.

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Ubois:
Could we start with a little bit about the center and your work and your focus?

Murray:
Sure. The Hastings Center is the world's first institution devoted to ethical issues in health, medicine and the life sciences. We construe that very broadly; it was born before the term bioethics was in currency, and it's mission since the founding has been to create knowledge and share knowledge about ethical issues in health, medicine and the life sciences.
We're a research institute, we're non-profit, non-partisan, and most of our life have been deeply poor. The chair -- the couch you're sitting on used to belong to a psychiatrist who was one of the co-founders. And this is the way of a not-for-profit, right?
For all that, the center has had quite a remarkable impact in the world. It's seen as an intellectual leader or the leading institution in this field. We publish IRB, and we publish the Hastings Center Report. The latter journal is arguably the top journal in the world in bioethics. Paid circulation is now about 5,000, and via Internet [distribution] it looks like about 100,000 people see material from each issue of the Report. We are called upon by people around the world who want to do bioethics.
Since I've come back to the Center, we have had many visitors and much interest from Asia. So we've entertained at least a half dozen delegations from countries in Asia who want to -- in some cases they're government sponsored, but they want to create a Hastings Center for their particular nation.

Ubois:
Do you do project based grants?

Murray:
Yes, if you want, I can give you a copy of our annual report or activities report, but in a typical year, about half of our income will come from grants, and a quarter will come from our publications, and about a quarter will come from donations. Our budget was about $2.5 million a year or so ago, and will be more than $3 million this year. So we're in a growth phase.
So that's it. We fight for grants. We do research projects. We publish. We do a lot of various kinds of communications, including running around the country, and occasionally the world, to talk to different audiences.

Ubois:
I'm particularly interested in your work on human enhancement.

Murray:
It's not that the Center has chosen enhancement as a theme. We don't usually work that way, actually. We try to bring very talented and creative investigators in, and set them loose to follow issues that they think are most interesting and significant and for which we can get funding. It's happened that enhancement issues have crossed a couple of lines. It's been something I've been doing for close to 30 years. And it began here at the Hastings Center, when we got a grant from the National Science Foundation in roughly 1980, and half of it was spent taking a fresh look at the whole concept of drug abuse and what it meant, and the other half was about drug use for enhancement. I took on that half of it, and went out and talked to a number of elite athletes and coaches,to try to understand what was going on and the ethics of the use of drugs for enhancing performance.
I went to sports, because that was the most visible sphere of human activity in which drug aided enhancement seemed to be an important factor. I looked at what philosophers were writing about it, and they tended to take a pretty fact-free view, a context-free view, of philosophical ideas about individual liberty, which are very important and powerful. [But] it was very difficult to find an athlete who thought that anabolic steroids or amphetamines in sport were a good thing. Few of them would actually admit to using them themselves, of course, but they talked about the enormous pressure on athletes not merely to win, but to compete fairly. That is, to compete on what they saw as a level playing field.
The level playing field is a virtually universal metaphor in sports. Even downhill skiers might talk about a level playing field, which is on the one hand completely absurd, but on the other makes perfect sense. They want to have an equal chance to excel in the competition as any other athlete would.
I wrote articles about liberty and sport, what I called the coercive of power of drugs in sport. In a sport where competitors use performance enhancing drugs, and those drugs are effective, the pressure on athletes to use drugs in order to equalize the competition is enormous, very much like an arms race. It's a darn good analogy, and most athletes would much prefer a situation where they could compete without taking anabolic steroids or amphetamines, and be completely confident their competitors weren't taking steroids or stimulants. That was the insight that we gathered from the research. My personal journey [started] when I published these academic articles, thinking that was the end of it, but then I got dragged in by the U.S. Olympic Committee to help them look at their doping program. That was very frustrating, in part, I think, because the leadership of the U.S. Olympic Committee just regarded it as a nuisance. You know, it was just bad publicity, but I'm now the Chair of the Ethical Issues Review Panel of the World Anti-Doping Agency.

Ubois:
One of the things that keeps getting tossed out is the idea that we should just have two Olympics, one where you use whatever enhancement you want, and another that follows traditional rules. How does that idea play inside the medical ethics and Olympic cultures?

Murray:
Well, I think within the Olympic culture it's a non-starter.

Ubois:
Really?

Murray:
Within the leadership of the Olympic movement, yes. There are certainly philosophers who specialize in imagining just about everything, and there are trans-humanists would really embrace and advocate this whole idea. A young voice, but a prominent voice, is Andy Miah. I helped mentor Andy, though I don't agree with many of his views, and he's been a part of our projects on performance enhancement in sports, recent projects we've been running at the Hastings Center.

Ubois:
So how do you approach the problem?

Murray:
There are rare exceptions, but for the most part, our work employs a signature methodology that was developed from the early days of the Center, where the insight, the founding insight for the Center was simply that the issues that medicine and the life sciences were presenting to society were vastly too complex for any one person, one profession or one discipline to fully comprehend. And so the only way to get a relatively well-rounded understanding of even the nature of the problem, let alone solutions, was to bring together a variety of expertise and points of view, that together could create something greater than even those same individuals working side by side could accomplish. So we'd put them in a sustained interaction. We've fine tuned this over the years so we know how to do this. And you will get, at the end, much deeper insights and a much more comprehensive understanding that you could probably by individual scholars working alone or even by commissioning a variety of papers. It's really in the give and take around the table that some of the greatest, most valuable insights emerged.

Ubois:
So back to enhancement. Why is the issue important?

Murray:
Well, it's not because sport is all that important. Although, as an economic engine it is. Enhancement's important because it looks -- it explores the boundaries that society tries to create and understand between medicine as a therapeutic enterprise and biomedical technology, or more broadly, the impact of biomedical technology on human life and human society.
Now that boundary between therapy and enhancement is much more difficult to stake out than many people may assume it is. Nor does it tell you, if you can figure out whether the thing you're looking at is a therapy or an enhancement, whether it's morally or socially desirable or undesirable. The boundary answers certain kinds of questions, but not some of the most fundamental questions.

Ubois:
Can we define enhancement more precisely?

Murray:
Given that the therapy/enhancement boundary is sometimes unclear, and that you don't get all questions answered simply by deciding that something is therapy or enhancement, the distinction has some use. There appears to be a pretty clear difference between, for example, giving someone EPO [used to increase red blood cell count] because they they're on renal dialysis because their kidneys have stopped functioning, and they have chronic anemia, for which EPO is a very effective treatment, versus taking EPO because as a cyclist I want to climb more quickly and with less exhaustion than it otherwise would require.

Ubois:
OK, so this idea of purpose is one of the lines that we can draw here. Are there any other good bright lines that you would point to?

Murray:
Well, the presence of an illness, the presence of some sort of malady or an illness or symptom. In the absence of any illness or symptom, it's hard to see how one could say one is applying therapy. I spend less time worrying about how to draw the distinction than trying to think about what enhancements mean for the realm of human activity.

Ubois:
Can you give some examples of things you're wrestling with?

Murray:
Sure. I've been thinking a lot about sport, because it's a leading edge of enhancement. What does sport tell us about the desirability and the limits of enhancement technologies? One difficulty with completely open use of enhancement technologies in sport is the likelihood that they would find no natural limits; given the kind of arms race quality to performance enhancement in sport, it would likely mean a lot of damage, many casualties. So doping control becomes a kind of public health approach. This is not limiting individual athlete's liberty, per se, it's really standing back and asking what happens systematically if one took off all the rules that would prevent enhancement. So that's one argument, and I think that's a powerful argument. It's one that the public's more likely to be persuaded about. But I'm interested in more subtle ones, as well. And to me it's about the meaning of that kind of activity. It's the meaning of sport. What gives sport its value?

Ubois:
A kind of self transcendence?

Murray:
Well it is - but let's take a step back. Most of us experience our bodies most of the time as things to be on one hand fed and fed, watered and rested. The body is sometimes a bit of am impediment, a nuisance,. I really want to continue to work on this interesting article, but I'm tired and hungry, and so I've just got to do these maintenance chores. It's also the occasion for various kinds of pleasures, from eating and drinking to sex. So the body works in those ways. Participating in sport -- and here I don't mean being an Olympic athlete or professional, I mean for any of us who do any kind of sport, participating in sport is one extraordinary way in which we bring the mind and the body, the will and the physical body together.

Ubois:
Right.

Murray:
Because if you've ever trained to improve at even the most amateurish level in sport you want to improve your skill level, your stamina, your speed, whatever it is you work towards, you have that sense that you are a fully embodied willful, embodied creature. And the mind and body engage with one another in a kind of intensity that's not typical of our daily activities. In other words, the body is [often] the site of pleasure or the body is a nuisance to our other efforts. So sport is where the aim of the activity is the body. I'm just beginning to think and write about this and, I'm not sure where I'm going to take that, but it seems to me that it's an insight worth following up on.

Ubois:
Maybe it heals our sense of subjective multiplicity.

Murray:
Well, it acknowledges our existence as a bodily creature. Thinking about the relationship between mind and body goes back to the very beginning of philosophy and theology. John Robinson talked about the Greek and Hebraic views of mind and body. The Greeks tended to emphasize the split, so they were fascinated with rationality. In the Hebrew cosmos, the mind and body were fundamentally integrated with one another.

Ubois:
Interesting to speculate on how that split might have made sport more of a Greek tradition.

Murray:
But what about drugs? How do things like performance enhancement technologies fit into this?
There are views of the body, of athleticism, that welcome all sorts of enhancements, where the point is maximum performance by whatever means at whatever the cost. You find elements of this in the sport called power lifting, which is like weight lifting. But there are well over a dozen power lifting associations in the United States alone, and they range from those that are adamantly against any kind of performance enhancing drug use, to those that wink, nod and basically say do whatever it takes. So, power lifting offers us a natural experiment of what would happen if we remove all the limits and see what athletes do and how people respond. So I think we should follow power lifting and see what unfolds. But I also believe a very powerful moral case can be made for sport without performance enhancement drugs, where we acknowledge that there are ways of perfecting the human body and our talents, our natural talents, that are admirable. There are ways of maximizing performance that are far from admirable, maybe even far from all that interesting.

Ubois:
What makes them admirable? To exercise our will or. . .

Murray:
It can be a crude classification. There are things that you do to perfect our athletic capacities that are fully admirable. And usually the things we admire in great athletes are things we'd admire about people in general. We admire perseverance. We admire intelligent preparation, so the athlete can train smart. We appreciate that. We admire people who are willing to sacrifice and suffer in the service of some larger cause. We admire tenacity. We admire in sport many of the same things that we would admire in any realm of life.
I've called this the virtuous perfection of our natural talents. Virtue is an old fashioned word, but it's the right word here. It's the virtuous perfection of our natural talents. And people vary enormously in their natural talents…How many runners were there in the New York Marathon last year?

Ubois:
I don't know.

Murray:
It was in the tens of thousands. Not all of those people were going to be elite athletes, but they all had a goal that required great perseverence, and I think every one of them is admirable for that. You don't have to be first across the finish line to find meaning in the kind of training and effort you put forward to compete. In a way, the marathon is the epitome of what sport ought to be: People setting challenges, setting goals and working towards those goals.

Ubois:
That's interesting; it gets back to the purpose of the therapy or enhancement, too.

Murray:
Right, I started out saying there are three categories. There are the things we admire in athletes preparing for excellence. Whatever their level of excellence is in their sport, we probably admire them for those same traits across [many] realms of human endeavor. Then there are the things that we tend to view as, in a sense, undermining or somehow defeating the purpose or meaning of that sport. Examples are the drugs that we disapprove of. And then there's a middle set, those are interventions that are not particularly virtuous, but don't seem to fully undermine the meaning of the sport. So we tolerate them, even if we don't embrace them and celebrate them, like chambers some athletes are using to try to simulate high altitude living as a way of improving their endurance.

Murray:
Athletes can train at low altitude, because they can train more intensely. But then they retreat into these chambers or apartments, which simulate high altitude, and the body adjusts by producing more red blood cells. It's apparently not a very big effect on those people, in fact, some people seem to get no benefit from it. It requires a certain amount of discipline to lock yourself in one of these chambers or sleep in one of these tents, but otherwise it's utterly passive.

Ubois:
Yeah.

Murray:
We don't admire any athlete doing that, in the way that we'd admire an athlete who trains intensively. And if it were incredibly powerful, I think we'd actually be more suspicious of it. But it's not. At this point the evidence indicates it's not -- it's erratically effective and doesn't make a profound difference, so we tolerate it.

Ubois:
If somebody invented it themselves and was using it uniquely, it might be a different. . .

Murray:
And there are other factors. The realities are important. The Hasting Center has a mantra. We have three mantras, but the one that's important here is ‘good ethics begins with good facts.' So you ask, what is the reality? Who's using it? Why? What does it cost? Can everybody get access to it without bankrupting themselves? Does it have a dramatic impact on the outcomes? It doesn't seem to. So when you put all the facts together, the fact pattern suggests that tolerating it would not create a grave injustice or distort the meaning of the sport. Although it does pose the question, what happens if other biomedical technologies come along that are absolutely transformative of the sport that are equally passive. And so I've been pressing people to be thinking about these questions.

Ubois:
That's a grey area. That's where a Pistorius comes into it. In his case it seems like there is sort of a -- there's definitely a therapeutic aspect.

Murray:
There sure is. I mean, what he's doing, his willingness to train intensively, his natural talents as a runner, all are completely admirable. And I celebrate what he's been able to do, for all the same reasons that we celebrate the accomplishments of an athlete who's not wearing a prosthetic, but is running on his own legs. But let's imagine that the cheetas [the paddles worn on his legs] give him a huge advantage over an athlete running with two legs. It would be pretty clear, wouldn't it, if technology transformed the sport by providing such a performance advantage that it simply becomes uncompetitive for people running on their own legs.

Ubois:
I'll get my legs cut off, so that I can compete.

Murray:
When I was serving on the [Olympic] Committee, we had a case presented to us. There was a young man who was in his early 20s. He was ranked as an internationally competitive sailor. This young man had suffered bilateral testicular cancer, so both of his testes had to be surgically removed. Now, when a body that has been accustomed to regular doses of testosterone, which is what the testes make, is deprived of that, it begins to feminize, and the standard treatment for somebody who has had his testosterone supply cut off as a 20 year old would be testosterone injections or patches or some means of providing testosterone to the body. But of course the anabolic steroids are simply chemical knock-offs of testosterone, and testosterone is prohibited for Olympic athletes. So the question posed was, could this young man take testosterone, at what were reputed to be therapeutic levels, replacement levels, or not? And it was an amazing discussion around the table, where some of my experienced, grizzled colleagues in drug testing were opposed. At one point I asked them -- I used a colloquial expression, but I said basically, do you think anybody would have their testes chopped off so that they could take testosterone just for a performance advantage? And several heads around the table nodded yes.

Ubois:
Well, there is the Vienna Boys Choir…

Murray:
And so, in the end, we worked out an accommodation for this young man, supporting his application to the International Olympic Committee Medical Commission to support careful medical monitoring, testing, to make sure he wasn't getting beyond the therapeutic dose of testosterone. And in the end, his appeal was mooted because he didn't qualify.

Ubois:
That was a good edge case.

Murray:
Yes, this is your case of, you know, would you have your legs chopped off to be able to run faster. It sounds crazy, and I don't see large numbers of athletes flocking to the operating table, nor do I see large numbers of doctors agreeing to it.

Ubois:
One of the distinctions that occurred to me on Pistorius, is there is no -- all the calories that propel him along the racetrack are his own.

Murray:
Imagine somebody, an Oscar Pistorius character, maybe with one prosthetic, who wants to do the high jump. His prosthesis is fitted with a huge pogo stick. And let's imagine that the mechanical advantage of the pogo stick is greater than the human leg could ever provide. How would we evaluate that? I think would say well, this has distorted the event.

Ubois:
Shoes distort the event. The Olympics was all about competing nakedly when it started.

Murray:
I'm not a student of the ancient Greek games. But sure, all athletic equipment influences the competition. And every sport evaluates every new significant piece of equipment, asking does this ultimately affect the sport and is its impact a positive transformation, or is its impact to undermine what matters about the sport?

Ubois:
When you do that hill climb on your bicycle, I bet you're faster if you have a cup of coffee.

Murray:
I am, I think. The scientific evidence says that I am.

Ubois:
Another interesting boundary case maybe. And back in the 1930s, people were into recumbent bikes for a little while in the racing world. And the people who got on recumbent bikes just blew everybody else away. And so they said, well, no more recumbent bikes, because it's unfair. And yet, was that a good decision? I mean to freeze the technology.

Murray:
They didn't freeze the technology, they just simply said that you had to have a triangle frame bike, not a recumbent bike. You could have a recumbent Tour de France. You could do that. But sport is, by it's nature, a rule governed activity….But we should get off sport, because enhancement isn't just about sport.

(more on 7th July [3])

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