[Overview remarks at the March 2005 conference on the Global State of Stem Cells and Cloning in Science, Ethics, and Law.]
My task here this morning is to provide a broad overview of the stem cell question, and especially an account of what is ethically at stake. And I think it is fair to say, without exaggeration, that we are discussing one of the great ethical issues of our time—an issue that raises questions about the meaning of human equality, the sting of human suffering, the nature of human origins, and the spirit of human progress. Of course, stem cells come from many different sources, both embryonic and non-embryonic. And much of our discussion today will involve the search for ethical alternatives to embryo destruction in the procurement of pluripotent stem cells. But the embryo lies at the heart of our debate—it is why there is such an ethical quandary. And thus it makes sense for us to begin with the beginning, with the tiniest human organism, which sets before us the biggest human questions.
It is useful to remember that our encounter with the human embryo—living and dividing outside the human womb, there to be seen with human eyes and held with human hands—is remarkably novel. And our confusions about it go back to the beginning—indeed, back to Robert Edwards himself, one of the pioneers of in vitro fertilization. Permit me, then, to read two quotes, both from Dr. Edwards, and both quite remarkable. The first was his reaction to the birth of Louis Brown in 1978: “The last time I saw her,” he said, “she was just eight cells in a test-tube. She was beautiful then, and she is still beautiful now!” In other words, he was awestruck at the continuity of the person he knew “then” and the person he knows “now”; at the continuity of her beauty, her presence, and her being.
But now let me read a second quote from Dr. Edwards, written only a few years later in 1980, in his memoir about the birth of IVF. “Will we,” he asked, “be able to extract the stem cells of various organs from the embryo, the precious foundation cells of all the body’s organs and then use them therapeutically? Will it ever be possible to use the cells to correct deficiencies in other human beings—to replace one deficient tissue with another that functions normally? For instance, will we be able to use the blood-forming cells of an embryo to re-colonize defective blood-forming tissue in an adult or child? And will these notions be met with pursed lips and frowning faces?” Now Dr. Edwards, we should be clear, was endorsing this prospect of destroying embryos for stem cells, and he saw such “pursed lips” as a kind of backwardness, indeed as a religious rejection of progress itself.
And so in only two years, this beautiful being—the embryo he knew as Louise Brown—was now a potential resource for us, there to be exploited and destroyed. The embryo’s meaning now depended entirely on its destiny—a destiny held entirely in our hands. What was once beautiful was now merely useful—if useful in the noble end of easing suffering and combating disease.
Since this group is well-familiar with the basic ethical terrain of the stem cell question, I thought I would use my remarks this morning to probe more deeply: to examine how we got here; how the embryo came to exist outside the human body; and how we came to desire it as a source of useful cells. And there are, I think, three original human desires—or human problems—that we must consider.
First, the embryo only exists outside the body, certainly historically, because of the human drive to overcome infertility. This is, you might say, a primordial drive—the desire to have a child of one’s own, flesh of one’s flesh. This desire surely has biological roots—though the low birth rates in Europe and Japan suggest that biology is not enough. This desire also has biblical roots—exemplified in God’s answer to Sarah and Abraham, in the miracle of the first child of the covenant, in the fulfilling of God’s promise of perpetuation. The technological answer and the divine answer are surely different in meaning. But we all recognize the powerful desire for a child, and understand how the drive to give birth to our own replacements moved us to initiate life in the laboratory.
The second origin, you might say, of the embryo question is the relentless drive of human curiosity—especially the desire to understand how we came to be, to understand our own human origins. In this sense, bringing the embryo outside the body is the quintessential scientific act of bringing what is in darkness into light, of bringing the embryo from the darkness of the womb to the light of the laboratory. In acting upon such curiosity, the scientist always lives daringly on the narrow ridge between the holy and the profane—between seeing reality as God sees it (if God in fact exists), and usurping those boundaries of reverence that preserve our humanity as neither beasts nor gods. Not everything, after all, is meant to be seen by everybody, or anybody. The preservation of the sacred—especially when it comes to the body, and to the nakedness of the flesh—requires a certain modesty, a certain reluctance, even a certain shame.
And yet, the reason science seeks to uncover darkness is not curiosity alone, but the desire to ease suffering and cure disease; it is the desire to answer mortality through medicine. Throughout history, we have shattered many old taboos in the name of healing—as with organ transplantation—and mostly for the better. But not always for the better. And so the question before us now is whether the shattering of yet two more taboos—by initiating embryonic life in the laboratory as an answer to infertility, and by destroying embryonic life in the laboratory as an answer to mortality—is progress, regress, or a mixed blessing. This is, in the deepest sense, the heart of the question before us. And our challenge is to see where human reason can take us in sorting it out.
To do so, one must begin with the experience of suffering and disease that drives many scientists to engage in embryo research in the first place. Disease is not entirely rational, of course. Every day, parents shuttle their sick children to the hospital, and some of these children are diagnosed with the flu and others discover that they have incurable cancer. In the age of modern biology, we can rationally explain how their situations are different. We can explain how the relevant genes and cells and proteins work or fail, at least within the limits of current medical knowledge. But we cannot really explain why one child gets deathly ill and another does not. Sickness is often guiltless. It is not jumping off a cliff but being struck by a bolt of lightning. To blame bad genes does not answer the fundamental existential question: Why are my genes bad, and not his? Or why am I still alive, and not my child? The biologist has no real answers to these questions. He can explain how the disease happened, but not why it happened.
In the age of modern science, therefore, we confront the fact that nature is both orderly and absurd: Nature is orderly, in the sense that we can understand how many biological systems work and how they fail, and we can often use this rational knowledge to fix them. But nature is absurd, in the sense that sickness strikes some individuals and not others for no apparent reason—a fact made dramatically clear by the young faces in the cancer ward. Disease does not strike bad children and spare good children. Disease simply strikes. Nature is amoral, and seemingly immoral. All of us—but especially doctors, who are trained in the most rational techniques—are thrown into a world that is often irrational. We must live with the absurdity of disease, especially the absurdity of the sweet, sick child. And the sick child is the best reason to engage in embryo research, if not finally a morally compelling reason to treat nascent human life as merely an experimental resource.
Turning the tables, some might argue that it is irrational to devote so much energy to fighting disease, since in the end all victories are temporary and all losses are final. Faced with the inevitability of suffering and death, a rational person might pursue instead a life of preparation, not resistance—a life spent preparing to die, even from childhood. Perhaps such mystic detachment is the most rational response to the death sentence that is birth. Perhaps we’d be better off spending less money on basic research and more money on death education.
But such a dark view of life is not the modern view of life, or the Jewish view of life, or even the Christian view of life. It belittles the many goods of this world to see all of life as one long preparation for death. The danger comes when we come to see partial goods as absolute, or secondary goods as primary, or temporary goods as eternal. In the clinical setting, doctors just want to help people. They want to make the sick feel better. But in a deeper sense, modern medicine is an effort to impose rationality on an often irrational world—an effort to meet the absurdity of nature with the orderliness of nature; an effort to give every child a fair chance to live a full and flourishing life. In this sense, science and medicine might be understood as redemptive activities: as the restoration of justice in a world where biological nature often seems unjust. Doctors want people to get what they deserve, and they do not believe anyone deserves to be sick. Medicine is the taming of errant nature by human morality, using nature’s laws as its instrument. But like any this-worldly effort at redemption, modern medicine lives nervously between godliness and godlessness, between imitating God and seeking to replace Him.
In our public debates, it is sometimes hard to remember that the pursuit of health and the rejection of death are not the whole of human morality—even if being healthy is, as Descartes claimed, “the foundation of all other blessings in this life.” Perhaps no one deserves to be sick, but it is also true that no one deserves to live forever. And if extending life were the only or highest goal of being human, then civilization would be in peril—because we would be too cowardly to confront murderous tyrants, or so blood-thirsty for life that we would use the dying to save the living, or so narcissistic that we would never have children.
As biotechnology improves, medicine will achieve more partial victories over nature; we will cure many terrible diseases. But medical science will never achieve its ultimate aim of reversing the death sentence that comes with being born. And so doctors will continue to play the dual role they have always played: they will cure as long as possible and they will care when cures are no longer possible.
But what happens, we must ask, when curing and caring come into conflict? What if caring for people with terminal illness interferes with curing people who might yet be saved? To put the question more sharply: Why not harvest organs from a patient who is dying to save three other patients who have a chance to continue living? If the purpose of medicine is to mitigate the absurdity of disease as much as possible, is it rational to let a teenager die rather than use tissues from a dying sixty-year-old to save him? Should the obligation to care for this terminal patient stand in the way of finding cures for the many patients who might suffer in the future?
And here we see the other side of our existential predicament: While the death sentence of nature is often amoral, the acceptance of death is often necessary in order to prevent being immoral, at least as we usually understand it. Perhaps it is morally obvious that we should accept death rather than harvest vital organs from the living. Surely there is an aesthetic objection to disaggregating those who look like us, even if their days are numbered and their lives are miserable. But should we accept death rather than harvest stem cells from destroyed human embryos, which do not look like us at all? And would accepting death for this reason be rational or irrational?
To answer this hard question—perhaps the great bioethics question of our time—we need to examine the first principles upon which our ideas of moral obligation rest, especially the principle of human equality. The reason we do not use some individuals as raw materials to help others is because we believe that every living person possesses an equal dignity, including those who are weak, disabled, dependent, and dying. We believe everyone possesses an inviolable right to be cared for, at least in the minimal sense of not being exploited. Even prisoners on death row get medical care, and no civilized society would use them as ready sources of organs. This equal dignity is not a function of what we do, but intrinsic to who we are; it is not an attribute that can be measured according to our deeds, but an unchanging characteristic of our very being.
This commitment to equality is not, I should say, the only view of human dignity. Aristotle seemed to have little problem leaving deformed infants out in the wilderness to die; the dignity he sought to defend was the dignity of human excellence, which the disabled could never achieve. But the belief in the equality of all human beings is the democratic view of human dignity, with roots that trace back to biblical religion. And while there is much to learn from Aristotle about the nobility we often lack, the democratic idea of dignity is, as Tocqueville soberly concluded, more just. So long as we are alive, we are not things and we are more than animals—even when our rational faculties decline, and even when we behave in beastly ways. This democratic belief in human equality can be rationally defended, but it cannot be proved by human reason. It is a commandment we obey or a proposition we seek to uphold, not an indisputable natural fact like gravity.
For those who accept this first principle—the equal dignity of all individuals—the embryo research question centers on whether an embryo is a person or something less than a person. Now, if deciding this question were just a mathematical or even ontological problem—if we were interested simply in the best scientific answer, not the answer that was most expedient for doing science—then it seems to me that the religious opponents of embryo research are the most rational voices in the stem cell debate. If the question is—When does an individual life begin?—then the conclusion that life begins at fertilization is the most rational conclusion. If we trace an individual life backwards biologically—from adulthood to adolescence to infancy to birth to the fetal stage to the embryonic stage—there is only one bright line—fertilization—that separates being from non-being. Before fertilization, we have an egg and many sperm; we have many possibilities and no person. After fertilization, we have an individual human life in-process. I was once a zygote, but I was never a sperm or an egg, since the gametes that produced me could have produced someone else.
To be sure, there are other key moments in embryological development, moments that some people believe are more significant than fertilization for conferring human worth: There are the moments when certain powers—like brain activity or the capacity to feel pain—manifest themselves. There is the moment when the discernible human form first becomes visible. But these moments do not mark the arrival of a new person; they mark the arrival of certain attributes in an existing person. To believe that crossing these hurdles is the prerequisite for human dignity is to deny the first principle that all individuals are equal. It makes our equality conditional, and thus weakened. But for those who really believe that all human individuals have equal worth—regardless of size, or intelligence, or level of dependence—then the most rational conclusion is the view held by many religious believers: the conclusion that life begins at conception. Put differently: To oppose embryo research is to act rationally on the belief that human beings are inherently equal. This position is strictly religious only inasmuch as the belief in human equality is strictly religious.
Of course, destroying embryos and harvesting stem cells is also a very rational activity. It involves testing hypotheses about how nature works and seeking to use natural knowledge to develop rational techniques. It also involves a goal—curing disease—that can be rationally defended. But the moral theories that justify embryo destruction—the theories that most stem cell scientists embrace, whether implicitly or explicitly—are either mystical or revolutionary.
The mystics argue that “personhood” arrives at some murky point along the continuum of development. They appeal to our moral sentiments in claiming that 8-cell embryos should be available for research while 8-pound babies should not be. And they assert that somewhere along the way usable embryos become inviolable infants, even if we cannot say exactly when. But this sensibility—which may be true—is not very rational. It is surely not a scientific argument grounded in biology, but a moral feeling about who is equal and who is not. The scientists are often the mystics, even if they would never admit it.
The more revolutionary defense of embryo research involves the rejection of the very principle that all human beings possess equal worth, and the assertion that human dignity depends on possessing certain attributes—like a developed neurological capacity or a certain number of cells. This view does not abandon reason to follow sentiment; rather, it attacks the original premise that dignity is intrinsic rather than conditional. It attacks the first principle of equality upon which modern democracy is based. It dissents from the idea that “all men are created equal.”
And why not question this founding democratic faith? After all, the belief that all human beings possess equal worth is not the only rational conclusion one might draw from lived experience. In many important ways, human beings are clearly not equal, either at birth or through life: some are healthy and some are sick; some are saints and some are knaves; some are independent and some are needy; some are excellent and some are average. Is it really so obvious that a retarded child or a demented grandparent is equal to the rest of us? Or that Einstein is equal in dignity to Einstein’s maid? And is it really so obvious that we should sacrifice our plans and projects to care for the retarded, the demented, and the terminally ill? Or that we should abandon our hopes of medical progress to care for frozen embryos?
And so the principle of equality may be true, but it is hardly obvious. Some people argue, quite rationally, that it is senseless to devote medical resources to individuals who are beyond repair or not fully conscious, and that we should focus instead on helping those who are sick today but who might flourish again in the future. Rather than holding the belief that all human beings are inherently equal, these prophets of utility seek to help as many people as possible to enjoy the fruits of equality, while dealing ruthlessly with those who will never enjoy the fruits of equality, such as retarded children or people with dementia. They are at war with nature’s absurdities, but they also know when to cut their losses. They know that some cases are futile, that nature has won her nasty victory.
If the goal of medicine is to correct nature, then curing must always trump caring. The possibility of making human beings equal by making the sick healthy must always trump treating human beings as equals by caring for the dependent. And even though embryos are not beyond repair but on-the-way, their very lack of certain powers apparently makes them usable as raw materials in the effort to restore the powers of health to those who have lost them. This is both a radical rejection and a radical pursuit of human equality. In the name of the sick whose inequality we lament, we would embrace discriminatory litmus tests for human dignity. In the pursuit of medical justice, we would become unjust. This is true not only in the case of embryo research, but in the case of screening-and-aborting fetuses with genetic disabilities, like Down Syndrome. In the name of health, we would discard the sick; in the name of gaining strength, we would exploit the weak. Whether this is because of our blindness, or coldness, or well-meaning humanitarianism, the result is still the same: the pursuit of equality requires the sacrifice of equality. The pursuit of a rational world, where nature’s absurdities are conquered, requires the retreat from moral reason in the name of sentimental science, or the rejection of the inherent equality of all human beings in the pursuit of a more egalitarian future.
And this leaves us with one final question, especially for those who believe in the inherent equality of all human beings and the rational conclusions that follow from it. Let us suppose in the future that embryo research or “therapeutic cloning” works as advertised, and that parents one day face the choice between saving their sick child by destroying an embryo or letting their sick child die because embryo destruction is unethical. No parent would ask his doctor to procure fresh organs by dissecting one of the babies in the maternity ward. Familial love in this case is checked by neighborly love—a premise, for now, that everyone accepts. But are embryos our neighbors, in the sense of being inviolable? For those who believe that all human beings are equal regardless of their attributes, the rational answer is unequivocally yes. Even tiny embryos are our neighbors, because each tiny embryo is a life in-process.
But on the precipice between a beloved child’s life and death, the ethical commitment to reason and equality will be put on trial. Indeed, while we began with Abraham and Sarah’s desire for the child that became Isaac, we now end with a modern-day version of Abraham and Isaac’s trip up the mountain, with the apparent absurdity of faith. Parents will face the ultimate existential predicament: the absurdity of a sick child, the obligation to treat all human beings equally, and the apparent absurdity of letting their child die rather than deliberately destroying an embryo to save him. Believing in the “culture of life” means accepting the concrete reality of death. And acting rationally in defense of equality requires a faith in reason that ends in blood—the blood of the child we could not save in the name of the embryo we can barely see.
Such an act—the act of letting die—will probably make no sense to the world. But it may be what is required to live the commandment of equality in a world where nature does not treat us equally, and to follow the dictates of moral reason in a world that is often irrational. Thrown into a condition that is absurd—being the parents of a dying child—neighborly love and moral reason require enduring what seems absurd. And perhaps only those who believe in divine redemption—who believe that this world’s irrationality will be set right in the next, by God rather than science—can endure the painful witness that reason and equality may require. Perhaps only religious people can see the weak the way God does, and see equality where uncorrected human eyes see only a clump of cells.
But in the end, I do not believe that modern democracies would ever tolerate the death of children in the name of embryos. If such therapies ever really exist, the state will mandate embryo-based medicine for underage persons. It will force parents to act in ways that seem more reasonable. But in doing so, the democratic state may cannibalize the very principle of equality on which it rests. It will compel people to act in inegalitarian ways. It will seek a course that seems more reasonable, but one that requires adopting the irrational view that embryos are not persons or the inegalitarian view that some persons possess dignity but others do not. And while I doubt that I could ever be the parent who lets his child die, even if the law still allowed me to do so, I’m not sure I’d want to live in a world where the commandment to treat everyone equally has been abandoned, and where moral sentimentality trumps moral reason.
And this is why God needs politics: to set limits on embryo research before we have to make the impossible choice between the child and the embryo. It is because most of us lack the faith of Abraham that we need the law of Moses—to prevent us from doing evil, even in the name of very great goods. Or better yet, maybe our prayers will be answered with non-embryonic stem cells—a good place for me to end and the next scientists to begin. Thank you.