What We Talk About When We Talk About Ethics

Dr. John Lantos

Very kind. Kind of you to stay. The few, the proud. Can't get enough ethics.

Dr. John Lantos

This is really going to be the theme of the talk here. Normally in any modern society is a chaos of opinions and of moral attitudes. A reasonable person knows that there is this chaos and those with strong opinions or with fanatical hearts deplore the chaos and hope for a consensus usually for a consensus in which their own opinions and attitudes are dominant.

Dr. John Lantos

So I was recently invited to talk about ethics with the staff of a level three NICU. And they presented a case, full term baby born by emergency C-section after a cord prolapse that caused prolonged anoxia. Initial pH was 6.7. She was intubated and resuscitated in the delivery room. Her Apgar score remained at one for 10 minutes and then her heart rate and color improved. She was treated with hypothermia. Further evaluation over the next two days not surprisingly revealed severe brain damage. She had a gag but no suck or swallow reflexes. She withdrew from painful stimuli. She was able to breathe on her own. Her prognosis was obviously dismal. The best hope would be some minimal neurologic recovery. The doctors recommended a DNR order. The parents agreed. The doctors suggested a gastrostomy tube. The parents disagreed. Instead, they requested that fluid and nutrition be discontinued.

Dr. John Lantos

The parents were college-educated Hindus, first-generation Indian Americans, And they claim that their desire to withhold fluid and nutrition was based on their religious and cultural beliefs. Now, the staff was knowledgeable. They were aware of the policy of the American Academy of Pediatrics permitting withdrawal of artificial nutrition and hydration under certain circumstances, which this case seemed to meet, and after appropriate evaluations and discussions. Some were also aware of certain church and religious teachings, for example, the Catholic Church guidelines, which would probably prohibit withdrawal of fluid and nutrition under these circumstances. And as a group at this NICU, they had not before had a case in which parents had requested withdrawal of fluid and nutrition, and nobody was familiar with Hindu beliefs on these matters. So we talked about ethics.

Dr. John Lantos

What do we talk about when we talk about ethics? It's a case where all choices are bad, where all options are legal, where principles conflict, where reasonable people disagree, and where a decision must be made. There was no neutral position. You either fed or not. The emotions in the room as we started to discuss the case were strong and discordant. Some people thought that the parents alone had the right to make this decision. The job of the doctors and the nurses, they said, was to support the parents in whatever decision they made. Others felt strongly that it was wrong to withhold fluid and nutrition from a baby. One doctor said, it's like taking away a blanket. Would we leave the baby naked on the front steps? The case had taken place some months before our discussion. The staff had decided to respect the parents' preferences. The baby was not fed. He lingered for 11 days. During the 11 days, some nurses refused to care for him, and their conscience-based requests were honored, and they were assigned to other babies. Other nurses then bore the burden, some willingly and some grudgingly. During the 11 days, some staff members made disparaging comments about their colleagues, and the entire nursery was a sad and stressful place. One nurse said, what made it so hard was that it took so long. When we stop a ventilator, babies die quickly. Another said, I didn't object to the parents' decision, but why couldn't they take him home? Why did we have to take care of him?

Dr. John Lantos

One of the nurses who had cared for the dying baby said that it was difficult, but that it was also beautiful. She admired the parents' ability to stay with their baby, holding her and comforting her, even though the baby was unaware of their caring. And this nurse was deeply moved by the parents' decision and by the way they followed up on it. People in the room were saying things that they had never before said to each other. even though they had clearly been thinking about them for a while. Obviously, there were a few ethical issues here. We could have focused on futility or quality of life or parental autonomy or cost of care or conscience-based refusals or moral distress or the best interest of the baby. But the conversation wound down and everybody turned to me expectantly. the visiting bioethicist.

Dr. John Lantos

I wasn't sure what to say. It would have been useless to say that what they did was consistent with the current AAP guidelines or inconsistent with some religious views. Everybody knew that. But what to say instead? It might have been interesting to compare Catholic views with Hindu ones or to speculate about the ways that religious Claims based on religion differ from claims based on philosophy or psychology or family dynamics.

Dr. John Lantos

I could have discussed recent survey results showing that many more neonatologists are uncomfortable with drawing fluid and nutrition than with drawing mechanical ventilation. I could have talked about the Groningen protocol for neonatal euthanasia and whether a lethal injection would be preferable once a decision has been made to withdraw fluid and nutrition. But what interested me most was the ways that those particular people in the room talked about what was at stake for them as individuals and As a result, what was at stake for them collectively as a group of professionals who had worked together on this tough case and who needed to continue to work together? And when talking about the case, it seemed like everybody started with a moral intuition, a gut feeling, a sense of what was right or wrong. And when pushed, they then turned those intuitions into moral claims. But nobody really made moral arguments. Instead, the moral claims were offered as rationales for their gut feelings. They offered these rationales as if they were the reason for their intuitive conclusions. So some said, we should stop feeding because the parents have the right to make these decisions, or we should not stop feeding because the baby has a right to fluid and nutrition. But these because claims didn't cause anybody to change their minds. If anything, as we haltingly put forward reasons and rationales and justifications for one course of action or another, everyone's initial convictions just seemed to grow stronger. Talking about ethics did not move us towards consensus. If anything, it sharpened the disagreements. Now this process would not have surprised Alastair MacIntyre. In his remarkable book, After Virtue, McIntyre discusses his view of the state of contemporary philosophy in the Western world. He writes, the most striking feature of contemporary moral utterance is that so much of it is used to express disagreements. And the most striking feature of the debates in which these disagreements are expressed is their interminable character. I do not mean by this, he goes on, just that such debates go on and on and on, though they do, but also that they apparently can find no terminus. There seems to be no rational way of securing moral agreement in our culture. In MacIntyre's view, this is because moral philosophers in the modern world have an impossible task. They are trying to come up with justifications for different ideas of what is good and right in particular cases without any overall agreement or conception of what is good or right overall. That is, in a human life understood as a whole.

Dr. John Lantos

In fact, modern moral philosophy, particularly political philosophy, is often committed to the idea as a fundamental principle that there can be no universal conception of the good. What is good is good for an individual, an autonomous moral agent who arrives at his or her own conception of what is good and must be respected in those conclusions. In bioethics, this plays out in the way that autonomy trumps beneficence. To have an idea of beneficence, one must have a mutually agreed upon idea of the good, and that is just what we seem to lack. That is what each of the cases that we've been talking about and arguing about for the last day and a half illustrates, or at least the ones that are not just about communication failures. So moral philosophers today, according to MacIntyre, offer only rival and incompatible accounts of the good. He says we have utilitarians competing with Kantians and both with contractarians so that moral judgments become essentially contestable. Such moral systems are each internally consistent. The utilitarians' conclusions follow from their premises. as do the deontologists, but they are useless as a way of adjudicating disputes between two different equally self-contained moral systems. Rival conceptions of the good do not and cannot engage one another's first premises. A Kantian argument will never convince a utilitarian. Protestant arguments mean nothing to a Buddhist. The fact that the Committee on Bioethics of the American Academy of Pediatrics endorses something just means that a particular subset of a particular professional and social class has come to certain conclusions about a particular type of case. We all pick and choose among rival philosophies, rival religions, and rival professional societies, creating our own amalgams. On some issues we go with the AAP, on others with the Catholic Church, on others with the Department of Health and Human Services or the Republican Party or the New York Times. And explaining the logic that leads to the positions of any of these groups will likely not convince anybody who starts from different first principles. But this leads to a trickier question. Where do our gut instincts come from? And why do we respond as we do to a particular moral problem? Why did some people say it would be okay to withdraw fluid and nutrition and others didn't? Carl Elliot wrestles with some of these same issues in his 1992 essay in the Hastings Center Report, Where Ethics Comes From and What to Do About It. He writes, the difficulty with applying ethical theories is that ordinary people pay little attention to theories when they make their moral decisions. Moral decisions are, of course, often influenced by theories of one sort or another, but this influence is usually indirect rather than explicit. And he illustrates this with a personal example. I myself, he writes, refer to no systematic moral theories or doctrines in making moral judgments, but I have no illusions that those judgments are independent of the fact that I grew up Presbyterian in South Carolina.

Dr. John Lantos

So that is one possible explanation. We get our gut feelings from the experiences of early childhood, from the way that we were raised. If we were raised right, we become virtuous people and write thank you notes and do all those things. sorts of good things, we internalize these early on and they shape our world view in a way that comes to seem both intuitive and unquestionable.

Dr. John Lantos

But if that is true, it leads to even deeper questions. We think of ourselves as autonomous moral agents who create our own moral systems. We think of ourselves as having the ability to reason and make choices based on our own deeply held values. We think of ourselves as guided by reason. Bioethicists in particular think that reasons matter. But what if we have no autonomy with regard to the values that we hold most deeply and that shape our intuitive judgments? Are we free to choose our deepest and most fundamental beliefs? And if not, then in what manner can we think of ourselves as autonomous? And if so, how do we decide when and how to change those beliefs? Philosopher Lisek Kolakowski played with such questions in a somewhat tongue-in-cheek essay that he wrote in his book, An Endless Trial. The book, the essay is called From Truth to Truth. And in the essay, he proposes to create something that he calls a conversion agency. The conversion agency will help people change their most deeply held beliefs. Its advertising slogan would be, we convert from anything to anything.

Dr. John Lantos

At Kolakowski's conversion agency, one could, if one chose, be turned into a pious Jew, a committed Maoist, or a secular hedonist. The fees would be determined according to the degree of difficulty of the conversion. It's a lot easier, he claims, to make someone into a Unitarian than into a Sufi mystic.

Dr. John Lantos

How would such conversions be achieved? Kolakowski is a bit coy here, but he notes that rational persuasion would not be used because, he says, it's simply not very effective. Rational persuasion, in his opinion, is only relevant for a very few belief systems. In most, it's neither relevant nor effective in achieving total conversion. True believers, he suggests, use rational arguments not as the basis of their beliefs, but only as weapons against followers of other belief systems, that is, against heretics and skeptics. True beliefs come from somewhere deeper beyond rational systems, from a place in our souls, he claims, where our deepest fears meet our deepest longings for security and reassurance. We long to live our lives in harmony with some transcendental idea, whether it's an idea of God or green environmentalism or patriotic fervor. Kolakowski's

Dr. John Lantos

essay, his

Dr. John Lantos

ironic essay, raises an important and non-ironic question. Can we change our own deepest beliefs? Can an American Christian ever really become a Tibetan Buddhist? This is a fundamental question about character and identity and about those aspects of ourselves that make us who we are. It is, in a sense, the question at the heart of the popular television series Homeland in which the delight and suspense about the main character, Brody, is whether he is ultimately truly an American or whether he has in fact been turned and become an agent of Al-Qaeda. Perhaps it's no surprise that Homeland was created in Israel before being adapted by Hollywood, since Israel is, even more than the US, a land in which identities are shifting and blending, and in which many, most people have multiple allegiances. Those who live there must constantly ask about themselves and their neighbors, who are we? What moral commitments are fundamental? And how malleable are we?

Dr. John Lantos

Some people argue that we are not very malleable at all, that our moral convictions are hardwired into us. Psychologist Jonathan Haidt suggests that all people, and in fact many mammals, feel certain emotions in certain situations in a way that has nothing either voluntary or malleable about it. They feel fear, vulnerability, anger, love, even a desire to help other members of their species. And these biologically-based emotions, according to Haight, become the basis of the moral systems that we articulate to explain our innate feelings. That is, the moral arguments are after-the-fact stories that we tell ourselves to explain feelings that we can't help but having and that may not make sense. That doesn't mean that we all come to the same moral convictions. The feelings can evolve into different moral systems, and Haight makes an analogy between morality and taste. Biologically, he says, we all have the same taste receptors, taste buds. They lead us to perceive and enjoy things that are sweet, salty, sour, bitter, and savory. But from these basic building blocks, we develop many different cuisines. As we grow up with the foods of our culture, we develop tastes for them. By this argument, taste, like morality, is both universal and particularistic, both culture-bound and biologically predetermined. Everybody, it turns out, likes spices. Everybody is repulsed by cruelty. But everybody defines cruelty slightly differently and then has to decide whether some cruelty under some circumstances might taste good, that is, might be morally acceptable. So some cultures find punishment by whipping acceptable, but would find solitary confinement for years unacceptable and inhumane. Other cultures take a different view. To hate, it makes no more sense to ask whether one moral system is superior to another than it does to ask whether one cuisine is somehow intrinsically or objectively better than another. Now, I happen to like Italian food and think that all rational people should prefer

Dr. John Lantos

Italian food, but German people inexplicably seem to prefer German food.

Dr. John Lantos

With food, it seems uncontroversial to claim that there is no right answer. So here's the question. Are our primal moral responses similar to our primal gustatory responses? Both are deeply ingrained. Many people have preferences for the foods they grew up with, and these foods evoke powerful emotions that are not voluntary. Turkish writer Elif Batuman wrote a great essay in The New Yorker about going to eat in a Turkish restaurant in Istanbul called Chia. And the chef, Musa Dagdiviren, is a food anthropologist who has traveled around Turkey and found recipes from small villages and recreated them in his restaurant. And Batuman writes, having read Proust and also neuroscientists on the direct connection from smell and taste receptors to the hippocampus, I had long been aware that eating is for many people an emotionally and mnemonically fraught activity. But that night at Chia, I viscerally understood why someone might use a madeleine dipped in tea as a metaphor for the spiritual content of the material world. While eating the meal, she feels powerful and surprising emotions about her parents, her grandparents, and her place in the world. She is overwhelmed and mystified, and being a graduate student in comparative literature at Stanford, she decides to do research on this. So she goes and interviews other people who ate at Chia, and she found an 85-year-old auntie who noisily burst into

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tears with her first bite, saying, this is the dish my grandmother used to make. She found a man in his 70s who was transported

Dr. John Lantos

back to Emilia to eat at the age of five, and she concluded that Chef Doug de Viren was tapping into a powerful vein of what she called collective food memory. So to get back to the topic at hand,

Dr. John Lantos

Can anybody not raised in Turkey feel the same way about Turkish food? And are there foods that some people like and others find so abhorrent that they would reject them out of hand? What about, oh darn,

Dr. John Lantos

I must have sent an earlier version. I had pictures of this, which was great. What about kasu marzu, a Sardinian cheese with live maggots in it? thought to be a delicacy in Sardinia. Or balut, a developing duck embryo eaten while it's still in the shell. Will our life be richer if we learn to appreciate the fried beetles that are a popular street food in China? In both moral and culinary matters, tastes change. We know that moral systems change over time. Things that were once thought unalterably wrong come to be seen as acceptable and vice versa. One might look at issues like polygamy or slavery or abortion or gay marriage or euthanasia to see moral reevaluation at work. Or more mundane things. It used to be acceptable to smoke in hotel rooms, but you had to go out into the alley to buy pornography.

Dr. John Lantos

Gambling used to be both illegal and morally condemned. Now it's state sponsored. So how do our ideas about right and wrong, our moral tastes, if you will, change? I think that there is only one way, by talking about them out loud to one another, telling the stories of our lives. And in the telling, We try out new ways of thinking and of feeling about things that evoke complex thoughts and emotions. Such conversation is a complicated experience. It is intensely personal, but also interpersonal. As we talk and listen, we make an ongoing series of judgments, moral judgments, about what to say and how to say it, about when to speak and when to listen. about what to share and what to withhold, about when to let disagreements go unremarked and when to argue, about how to interpret what we are hearing. As we listen, we make judgments about the person with whom we are conversing and the micro decisions that we make as we converse shape us and shape the macro conclusions that we reach as individuals and as a moral community. Now the title of this lecture is an homage to Raymond Carver, who wrote a short story called What We Talk About When We Talk About Love. In Carver's story, two couples, Mel and Terry, and Nick and Laura, are drinking together on a summer afternoon and talking about love.

Dr. John Lantos

The story illustrates in a different context the importance of conversation as a way of figuring out who we are as individuals who we are in relationship to one another, and what we mean by vague but important, in fact, central concepts like love or, I would suggest by analogy, ethics. In the story, the most talkative of the four people is Mel, a cardiac surgeon. Before medical school, he studied in seminary. He's smart, driven, opinionated, and somewhat world-weary. He is married to Terry. Both were married before. Terry's first husband, Ed, was physically abusive. Terry says, he beat me up one night. He dragged me around the living room by my ankles. He kept saying, I love you, I love you, you bitch. And he went on dragging me around the living room. My head kept knocking on things. Terry looked around the table. What do you do with a love like that? She knew what to do. She left him. And Ed was so bereft and depressed that he shot himself. He didn't die immediately. And while he lingered for days in the ICU, Terry went and visited him. And she sat at his bedside as he was dying.

Dr. John Lantos

Mel thinks this was crazy. Terry explained that even though he beat her, she still had feelings for him. What's more?

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He had loved her deeply. It was love, Terry said.

Dr. John Lantos

Sure, it's abnormal in most people's eyes, but he was willing to die for it. He did die for it. I sure as hell wouldn't call it love, Mel said. I'm not interested in that kind of love. If that's love, you can have it. Mel was also married before to Marjorie.

Dr. John Lantos

About her, Mel says, sometimes I have a hard time accounting for the fact that I must have loved my first wife too. But I did. I know I did. There was a time when I loved my first wife more than love itself. But now I hate her guts. I do. How do you explain that? What happened to that love? And after a few more drinks, Mel describes his homicidal fantasies about Marjorie. She's allergic to bees, he says. Sometimes I think I'll go up there dressed like a beekeeper. You know, the hat that's like a helmet with the plate that comes down over your face, the big gloves and the padded coat, and I'll knock on our door and I'll let loose a hive of bees in the

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house. And the three friends look at him horrified.

Dr. John Lantos

And he says, I'd make sure the kids were out of the house first.

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Mel isn't done thinking about love. He tells a story about an elderly couple he'd cared for who had been severely injured in a motor vehicle

Dr. John Lantos

accident. And both husband and wife ended up in casts, in bandages, in his ICU. He was their doctor. And Mel says, the husband was very depressed for the longest while. Even after he found out that his wife was going to pull through, he was still very depressed.

Dr. John Lantos

Not about the

Dr. John Lantos

accident, though. I'd go up to his mouth hole, you know, and he'd

Dr. John Lantos

say it wasn't the accident exactly, but it was because he couldn't see her through his eye holes. He said that was what was making him feel so bad. Can you imagine? I'm telling you, the man's heart was breaking because he couldn't turn his goddamn head and see his goddamn wife. I mean, he was killing the old fart just because he couldn't look at the fucking woman. Do you see what I'm saying? Mel said. And the story is about how they do and do not see what

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Mel is

Dr. John Lantos

saying. How he was revealing things about himself that nobody, not his friends, not his wife, had ever seen before. Nick, the narrator, thinks maybe we were a little drunk by then. I know it was hard keeping things in focus. The

Dr. John Lantos

light was draining out of the room, going back through the window where it had come from. Yet nobody made a move to get up from the table to turn on the overhead light. As they talk and drink in the darkness, they come to know one another. And talking about love becomes an enactment of love, just as talking about ethics becomes an enactment of ethics. We reveal ourselves to one another in ways that test the fragile limits of the understandings and commitments that hold us together. Love, though obviously central to each of the lives of the characters in Carver's story, is also fundamentally mysterious to them. It can only be explained through ambiguous stories that they tell each other and listen and interpret. And morality is a bit like that. Just as we needn't agree about what love is in order to try to understand how to love one another, we needn't agree about what is ethical in order to work together on projects that express collective moral values. The cases that haunt us are the ones that demand of us that we interrogate our own deepest beliefs. They challenge our fundamental ideas of who we are and why we do the work that we do. And they test the bonds that hold us together in communities. We find that the same facts and similar moral principles can lead to opposite conclusions. Did Ed love Terry? Can withdrawal of nutrition be not just ethically defensible, but a deep expression of love?

Dr. John Lantos

When we talk about ethics, we are not just trying to come to some universal truth that all can accept. We are also trying to understand the range of disagreements and the limits of our tolerance for one another. We may aspire to a pure and perfect world, but we keep living and working together in this imperfect one. Philosopher Stuart Hampshire, who wrote the book Justice is Conflict,

Dr. John Lantos

I took the quote at the beginning of this talk from, compares the ambivalence that individuals feel when facing a difficult moral choice with the political and legal conflicts that tear societies apart. And he argues that ambivalence and conflict form the essence of human nature and human civilization. There can never be harmony. The best that we can hope for, he claims, is fairness in procedures that we have for resolving conflicts. Fair procedures make for enduring moral communities. And he specifies that he's not just talking about communities as religious communities or even as nation states, but he's also talking about professional communities. He writes, I think the true communities in modern life are to be found in professions and shared pursuits in the communities of people who work together. Most lawyers, most actors, most soldiers and sailors, most athletes, most doctors, and most diplomats feel a certain solidarity in the face of outsiders. And in spite of other differences, they share fragments of a common ethic in their working life and a kind of moral complicity. When we talk about medical ethics in case conferences or in ethics committees, we are talking about creating that complex moral complicity. We are shaping ourselves both as individual members of a moral community and collectively as a moral community. When we talk about ethics, we talk about things we've locked inside, things that are difficult to examine, things that are important to share but difficult to share, things that reveal ourselves to each other, things about which we cannot go on alone but are not sure whether or not we can go on together. The staff in the NICU, in the case that I started with, faced a collective decision. They had to think about how to care for a baby under difficult circumstances. They had to think about Hindus and Christians, doctors and nurses, parents and the law. They had to look at one another and ask, can I still work with you?

Dr. John Lantos

Are we in this together? Can we go on after this baby dies here in our arms because we haven't fed her? We might also ask whether it does any good after the baby is dead to talk together, to talk about ethics. Philosopher Arnold Davidson argues that our understanding of morality must focus on two different aspects. One, the more traditional one, is the focus on codes of behavior. The other one, though, is the way that we think about ourselves and shape ourselves in relation to those codes. We come to these very tough situations, the difficult cases that create moral conflict, as morally formed human beings. We live in worlds in which most codes are well understood, time tested, and well accepted. But we are all code followers as well as code makers. We know the foods we like, but we also want to try new recipes and explore new cuisines. We try to achieve both a dutiful subservience to the codes that we understand and respect, as well as a critical stance towards those codes and towards ourselves as subservient. Because At least in this culture, our most deeply held code is internally contradictory. We have a moral imperative to be free.

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That's a rule that demands to be broken. We must somehow be both ruler and subject at the same time, holding ourselves in subservience as we rebel.

Dr. John Lantos

Davidson borrows ideas he attributes to Foucault and calls the first the mode of subjection, the way the individual establishes his or her relationship to moral obligations and rules. The second he calls the self-forming activity, the ethical work that one performs on oneself in order to transform oneself into an ethical subject. When we talk about ethics, We are telling stories about ourselves. We know the codes. We know the rules. But we also know that true freedom means that we must question the codes and that rules are sometimes made to be broken. And that is a very scary thing. That's why we do it together. It's what we talk about when we talk about ethics. The end of the Carver story could be the end of a good discussion about ethics.

Dr. John Lantos

At the end, Nick notes, I could hear my heart beating. I could hear everyone's heart. I could hear the human noise we sat there making, not one of us moving, not even when the room went dark. Thanks.