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Medicine, Politics & Atrocities

Jonathan Glover is one of the leading figures in medical ethics, but he is also interested in political philosophy. Paul Sheehy interviewed him recently at King’s College London.

Professor Jonathan Glover is Director of the Centre For Medical Law and Ethics at King’s College London. The author of numerous books and articles, his best-known work is the medical ethics classic Causing Death and Saving Lives.

A world in which technologies such as pre-implantation genetic diagnosis (PGD) and nuclear replacement based cloning are realities may seem to many like a eugenics adventure playground. What is the role of philosophy – to discern the dangers and to suggest ways of addressing them?

I think that’s right about the role of philosophy. When new technologies are first developed we get a polarisation between a few scientists who are very excited, and gravitate towards the technological imperative – if we can do it we should – and members of the public who are at first appalled. Philosophy stands between these two responses. What we need to do is to work out what the dangers and the possible benefits are. If there are no benefits, then there’s no reason for going ahead at all. Then we should look for a set of principles reflecting our deepest values, to guide us and set limits on the use of these kinds of technologies.

So it’s a form of reflective equilibrium?

Yes, that’s Rawls’ phrase. I prefer the analogy with Socrates, and the idea of Socratic argument. We put forward conjectures about what might be a plausible principle, and then reflect on it to see if it does capture what we most deeply feel when we consider it under all manner of imaginary circumstances. Philosophy is one of a number of disciplines which overlap. Law, sociology, anthropology, psychology, to name some, may often concern themselves with the same area or phenomena. The interesting and abstract cases beloved of philosophers are important in clarifying the principles at stake in a particular case, and also in indicating how matters may develop. At the same time, we must always have in mind how principles and thought experiments map onto the dilemmas faced by practitioners. At King’s I’ve been learning a huge amount from the people I’ve been teaching.

If the technology is available one might see its development and implementation as inevitable. What are the main dangers?

In the first place, if there are medical benefits from, say, cloning then that’s a major plus point in its favour. Against this, though, we must bear in mind the twentieth century experience of Nazi eugenics. The principles which are desirable are those which generate the benefits without that kind of risk. For example, individual couples, or potential parents, can look after the interests of their future child – say if they do not want the child to have a terrible disability. What we must avoid is the move towards a state blueprint for the best kind of person. On the whole, I trust parents, whereas I do not want the state to determine what kind of people are acceptable.

So, you advocate freedom of choice in the private sphere and strict limits on the state?

I want to allow a negative role for the state. In a democracy it is appropriate that limits be imposed on parental choice. For example, in the matter of sex selection, unrestrained free choice might lead to a huge imbalance in the numbers of men and women in the next generation. Whilst there should be no state blueprint, the question of the desirability of the freedom to select a child’s sex should be open to public debate, and certain limits can legitimately be imposed on choice.

In some societies a complex combination of culture, economics and political structures promote the value of male children to a family. This is partly manifested in high rates of female infanticide. Is there any scope for arguing that the kind of technologies we are discussing be utilised to allow more ‘efficient’ reproduction within such a culture’s own terms?

Of course this raises major and deep issues of cultural relativism, and whether there are indeed universal human values. I suppose what particularly worries me is the sexism which motivates many in the Third World to prefer having a male rather than a female child. The important thing is not to do anything that reinforces the lower position of women. A state programme to enable mothers to have boys rather than girls would just be reinforcing the cycle of discrimination. In saying this, I am aware that sitting here in the 1990’s talking in terms of a Western language of ‘sexism’, that there may be people in China or India who would regard my views as laden with a kind of cultural imperialism. I am inclined to believe, though, that there are universal human values, and that it is not a sign of cultural imperialism to oppose the subjection of women in a society. Equally I acknowledge that there are difficulties in establishing these claims.

What of those infants born as a result of pre-natal diagnosis when the diagnosis proves to have been faulty: those who are not as expected, whose handicaps or disabilities were not successfully identified?

There’s a real difficulty here. On balance I’m in favour of PGD, but not for the reason often given that it is unfair on a child to live a life with a disability. A few disabilities are so severe that we might think it would be a mercy not to have to lead a life like that. On the whole, though, these techniques pick up things like Down’s Syndrome, and there’s no reason to think that such a life is remotely near being so bad that one might think it better not to live it. Except for the very rare severe cases, one defends PGD on the basis of parental autonomy. That’s the value at stake in favour of the diagnosis. The value that is threatened is equality of respect, not just of the child born when the diagnosis goes wrong, but also the already living people with those disabilities. They rightly feel sometimes that their greatest disability is other peoples’ attitudes. It can’t help their self respect to know that a lot of parents would choose, if possible, not to have children like them. It’s a question of weighing up these two values, and there may not be a right answer. I am inclined to go with the parental autonomy line, but those of us who do so have an obligation to push as hard as possible for as much bolstering of equality and respect in our society for people who do have disabilities. There is a risk that PGD can turn into a tidying up of the world, of people who do not fit with some stereotype.

In a litigious society should we expect those born as a result of a faulty diagnosis to look for damages? Against whom?

Here a claim would be one of wrongful life, and it would only be a justifiable claim if the life were so bad that it would be better not to live. There’s something highly problematic, and a question of its social desirability, about whether wrongful life claims should be pursued. A person is only likely to have a good claim in extremis, and the claim would be against the doctor rather than parents, who would have simply been acting on advice.

Indeed. What about the claims of parents who feel that they have not taken delivery of the package they thought they were purchasing?

One aspect of the real danger of this technology is turning children into commodities. This is a worrying development which we should watch. It’s not enough to justify banning the technology, but we have to be careful about a commercial attitude to relationships getting a foot in the door.

Given how well established surrogacy and the procurement of ‘orphans’ from Eastern Europe and elsewhere have become, that door is ajar anyway.

With surrogacy we already have a degree of regulation which restricts the role of commerce. That seems to be the model we ought to pursue. It’s not always right to ban the thing that worries you. We need to devise a regulatory framework which allows us the benefits with as little of the downside as possible.

Moving on from bio-ethical concerns, you have recently been writing about nationalism and are working on a book on the lessons to be drawn from the atrocities of this century. What motivates your interest in it?

Those of us who write on ethics have written in a way that has not much reflected the great man-made catastrophes of the twentieth century. There is still something in the way people write that is remarkably similar to the way J.S. Mill wrote on ethics. Now, I’m a huge admirer of Mill, but it’s as though the twentieth century hadn’t happened, at least in the analytic philosophy practised in the Englishspeaking world. In countries such as France or Germany, where they have experienced the Nazis, and further east where Nazism was followed by Stalinism, there is sometimes a sense of philosophy being engaged with the great events of the twentieth century. I can’t believe that in writing about ethics there is nothing to learn from what has happened in the wars, in atrocities and genocide. What I’ve been doing is considering twentieth century atrocities, in order to look for psychological patterns. One of the pressing questions for anyone who thinks about Auschwitz is how it is possible for human beings to have done this. That’s something we ought to think about; if one’s writing about ethics it seems odd to leave out any reference to the fact that such appalling things have been done by human beings.

After fifty years of analysis of the instability and breakdown of peace in the thirties and forties, and the conflict and atrocities since, what lessons should we draw?

There is an argument which is much overused in medical ethics – the slippery slope. It is said that if one allows abortion, then one allows infanticide, and so on to allowing mass murder; or if one allows voluntary euthanasia one ends up with death camps. In the context of current medical practice these arguments seem to be wildly overused. But in politics slippery slopes are more powerful. The Nazi so-called euthanasia programme, involving the extermination of thousands of defenceless mental and psychiatric patients, developed techniques to be used later, and many of the same people went to run the camps. In politics we need to be wary of the slippery slope; early resistance is called for.

An important political or practical lesson is the need for a genuine international authority of the kind the UN is supposed to be, but is in fact unable to be as it stands. Nationalist conflict seems to be on the rise, especially with the collapse of the old Soviet Union and the ending of the Cold War. We need an international police force so that a Milosovic can’t just attack smaller places in what used to be Yugoslavia. Such a force needs a properly constituted authority, and the model here is Kant’s Perpetual Peace, rather than Hobbes’ Leviathan. At the moment we have a rather Hobbesian arrangement, in which the most powerful nation, the USA, keeps the order by bullying of a rather selective kind. We also need a proper international court which can authorise a strong and well funded police, and that’s what we don’t have. We require it in order to prevent nationalist conflict and genocide of the kind we witnessed recently in Rwanda.

So these new international bodies act as the barrier on the slippery slope?

Yes, and it’s needed because the autonomy of the nation state needs to be toned down in two respects. First, a police force could stop nations from doing what they like to each other. Secondly, the idea that what goes on in a state is no-one else’s business must be abandoned. When genocide is occurring, then someone ought to protect the people in that state.

Nationalism is often explained as ‘modern’ phenomenon, which I am inclined to take as linking it to the rise of industrialisation, the bureaucratisation of state institutions and administrations, the establishment of recognised territorial boundaries and the adoption of popular forms of government.

I am prepared to believe that the nation state has relatively recent origins. But it is a worry that the historians and social scientists who tell this kind of story do not agree on when the nation state and nationalism begin to arise. For example, Gellner explains the development of the European nation state and of nationalism as a product of the late eighteenth century Industrial Revolution with its need for a standardised educated workforce capable of operating large scale production methods. Anderson dates the development of the nation state two-three hundred years earlier from the decline of Mediaeval Christendom, the demise of Latin as a lingua franca and the rise of printing. Nonetheless, the nation state is in some sense a modern phenomenon. The psychology which is worrying in nationalism goes deeper. I suspect there is a tribalism, a tendency to identify with a certain group and to feel hostility to others, which vastly pre-dates the nation state.

Are there features of the twentieth century state that have encouraged a particular virulence in tribalism, or is it just that with an increased technological and administrative capacity tribalism is better able to express itself?

Considering a region like the Balkans, we tend to be a little historically short sighted, for instance ascribing the recent disasters to the death of Tito or the rise of Milosevic. The hostilities in the region predate the Balkan war which preceded the First World War. They can be traced through the last century and back to the conflict with and Serbian defeat by the Turks in the fourteenth century. Tribal conflict is not a phenomenon of this century, but it has been reinforced by weapons and communications technology. Broadcasting and a mass circulation press have made it easier to manipulate public opinion. We may now be emerging from that era, because people in places like Serbia do not just watch state TV, but have access to CNN and BBC World Service.

Is it too optimistic to see cultural autonomy, which may be valued by a group, as being separable from tribalism?

It’s probably hard to have one without the other, and that’s one of the problems. Part of the Enlightenment idea of a world citizenship was that nationalism would fade away. That now looks rather implausible. Nationalism is often so tied to the things which are valued. Cultural variety is valued, and we would be sorry if the world turned out to be utterly homogenous, but it’s hard to see how we can get it without people holding this form of tribal identity, which if not carefully controlled spills over into conflicts.

You’ve written previously about the importance of constructing a narrative for oneself, of the need to place one’s life in a context or story. It does not seem a priori that tribalism is an essential element in one’s narrative or self-creation.

I have in mind two kinds of narrative. The roots of tribalism go deep into the personal narrative, the story we tell about our own lives, which in part makes sense in the context of relationships located within a particular culture and language. Tribalism is bound up with what gives our lives sense and meaning. This is possibly why it will not be practical to eradicate it. The other type of narrative is the national or tribal one. For example the Serbs and Croats have stories to tell about themselves and each other, in which the history is always one of betrayal by the other side. People may be able to regard such narratives with an increasing scepticism as they see how they are constructed and see the role they play in trapping groups into a cycle of vendetta.

For those of us who do not live in an ethnic war zone, our experience of tribalism may be through knowledge and confrontation of racism.

Nationalism was certainly apparent in Britain during the Falklands Conflict, and today it may be latent in much of the opposition to European Monetary Union. Nationalism is a version of tribalism that says we must have our own nation state. For many states the century commenced with a largely ethnically homogenous population. In 1914 people in Britain were mainly ethnically English, Scottish or Welsh. In 1940 Churchill could refer in several of his speeches to the ‘British Race’. Today, the idea that to be British is to have a particular ethnicity seems strange. We are clearly a highly pluralistic society. Racism reflects, partly, a deep tribal psychology, and, partly, a discomfort felt when there is a perceived threat to the traditional unity of the nation state by ethnic and religious fragmentation. Something of this fear may have been reflected, for instance, when Margaret Thatcher spoke of peoples’ concerns at being ‘swamped’ through immigration. One can not be totally confident that such tensions will subside over time, as the experience of the USA may illustrate. On the other hand, a sense of cultural identity need not amount to hostility to others. Brian Keenan in writing about his experience as a hostage in Beirut relates how he, from the Nationalist community in Belfast, established a close friendship with John McCarthy, a ‘typical’ Englishman. It did not involve a pragmatic move to neutral ground, or only the recognition of the humanity of the other and the respect due, but an embracing of their differences. Friendship can make reference to different and hostile backgrounds.

On that relatively optimistic note we shall conclude. Thank you.

© Paul Sheehy 1998

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