EURESCO
Biomedicine within the Limits of Human Existence. Bioethics – an Interdisciplinary Challenge and a Cultural Project
Davos, 8 – 13 September 2001<\/p>\n\n\n\n
\u201eThe energies and possibilities of medicine must be given direction.\u201c And this, as H.Tristram Engelhardt stresses, in a situation where \u201eunexpected possibilities are becoming real\u201c while it seems impossible to elaborate a common foundational intellectual response to that challenge. (1991, XVI).<\/p>\n\n\n\n
The thesis I am going to argue has two points:
1) that by explicitly reconsidering the existential finitude of human beings, we may gain at least part of a common ground, on which to become moral relatives (not necessarily moral friends), and
2) that by analyzing the practical implications of existential finitude we might elaborate some criteria that will allow us to reasonably tackle some moral dilemmas in biomedical practice.<\/p>\n\n\n\n
In biomedical ethics, the concept of finitude of human existence rarely shows up. In case it does, it is more used as a declaration than made transparent in its practical consequences. There are exceptions, and I shall come back to some of them. It is astonishing that the implications of human finitude for biomedical ethics have not been generally analysed. For human existence and well being, their prerequisites, and enhancement are key concerns of biomedicine. And when we strive after widening and hopefully abolishing limitations within human existence, such as disease, suffering and mortality, finitude is the existential and factual presupposition. This fact may be too evident, and perhaps this is why it escapes from in-depth investigation. In contrast, I hold that anthropological reflection stressing human finitude provides a perspective from which we may gain criteria and solutions when engaging in moral and ethical controversies. And this without having recourse to religious or metaphysical anchoring, remaining within the philosophical framework H. Tristram Engelhardt has named secular humanism\u2018 (1991. XI, XV, passim). Yet while he stresses finitude as an ontological limitation to bioethics, I would try to analyze it as a chance for a secular understanding of what might be considered meaningful aims and goals of biomedicine.<\/p>\n\n\n\n
But let us first clarify the notion of finitude, since this term, rarely used, may create irritation when introduced into ethical debate. I consider this a fact worthy of ideological critique, since \u201afinitude\u2018 refers to something we daily and personally and often enough severely experience. Yet this is not the place to go into such critique; I content myself with stating that neglecting existential finitude belongs to the realm of psychological repression. It is part of that current attitude which Martin Heidegger so aptly described as the lack of existential authenticity (1927\/1963, \u00a7\u00a7 26 f.).<\/p>\n\n\n\n
It is indeed by referring to Martin Heidegger\u2018s existential analysis of human being (1927) that I wish to clarify the notion of finitude. This notion does not directly relate to any particular limits human beings encounter inside or outside themselves, and it must be well distinguished from scarcity. The term signifies a constitutive trait of human existence. Today Engelhardt speaks of our \u201eontological infirmity\u201c (1991, XI) or of \u201ean inescapable element of our ontological condition\u201c (ib., XIII). Heidegger calls it an existential. I shall briefly dwell upon two aspects of that existential constitution (for more details cf. Sitter(-Liver) 1975, part. 31-36, 64f., 150 f., 236f).<\/p>\n\n\n\n
1) Human being exists as being-in-the-world with or better: in possibilities. Whenever choosing one of them, it discards others. While being the source of concrete realizations, it is the cause of non-existence of others. There could always be more than what it is in a position to achieve. Moreover, human being is never self-sufficient in so far as its pure existence is not its doing: it has been thrown into the world – destined to be a not self-supporting entity and the cause of lost realizations. It is thus thoroughly finite, and there is no remedy to that ontological fact.<\/p>\n\n\n\n
2) The second aspect concerns the personal finiteness of human existence. Death is not just something that unfortunately happens to humans; much rather their being-in-the-world is constituted as being to its proper end. Dying and death may be neglected or repressed, but again this is an offspring of lacking existential authenticity. We cannot choose the fact of our death, for we exist as dying entities. The seal of our finitude is our existing as beings with and to their end (\u201eSein-zum-Tode\u201c, cf. 1927, \u00a7\u00a7 49-53). There is no sense in trying to change this ontological condition, for any attempt to do so is already impregnated with existential finitude. Paul Kurtz presents it as \u201ethe brute finitude of existence, the contingent and precarious, often tragic, character of human life\u201c (1983). Let me add right away that the various ways of searching immortality we have been hearing of do not escape the ontological constitution of<\/p>\n\n\n\n
It is this existential meaning I have in mind when using the term \u201afinitude\u2018. Limitations in intellectual power, moral capacity, strengths of will, empathy and sympathy, and so on are grounded in the existential human constitution and thus not to be overcome. This does not mean that they are not to be tackled, quite to the contrary: only then do we live up to possible authenticity and true autonomy when, driven by pressing reasons, we engage in overcoming controversies and tensions while keeping in mind that our findings will remain finite, and thus provisional and ever open to modification. Findings are steps of a staircase, which does not end before death.<\/p>\n\n\n\n
Markus Zimmermann-Aklin, one of the authors in bioethics who explicitly consider human finitude (2000, 30-32) distinguishes three levels of discussion in today\u2018s bioethics: practical decisions, theoretical work in ethics, and the level where meaning and interpretation of expressions of human finitude are at stake (16-32). On the third level, fundamental intentions, moral convictions, images or visions of human being, of world, and God fashion the effort to find sense in painful experiences such as disease, suffering, dying and death. Zimmermann-Acklin holds that third level issues will be intensely studied in the years to come (43) with the Baconian optimism concerning the power of reason, of material progress, and moral enhancement of humanity giving way to a more adequate, comprehensive understanding of human existence. He comments some ideas displayed by Gerald P. McKenny (1997) where the author insists on medicine getting inhumane when it turns a deaf ear to human borderline experiences (op. cit., 30f.). Zimmermann-Acklin recalls that the topics at hand are situated in the centre of theologies and religions, a fact which explains to a certain extent the ongoing processes of re-theologizing the bioethical discussion (2000, 32).<\/p>\n\n\n\n
While being far from underestimating this approach, I wish to emphasize that when talking about existential finitude we do not raise the question of the meaning of particular human limitations. Our approach is ontological and thus remains formal, or as it were, secular. For all that it does not lack practical relevance. Existential finitude is the transcendental as well as factual key to freedom. If the realization of possibilities were in no way restricted, choice would not exist, freedom were of no relevance, nor could the phenomenon of responsibility appear. However, in order to fully understand the phenomenon of responsibility we have to<\/p>\n\n\n\n
When insisting on the formal character of existential finitude I find myself in good company with Dietmar Mieth, yet another bioethical expert tackling human finitude. His tune reminds us of what we heard from McKenny, but it was played years earlier and on different instruments. Progress in genetic engineering says Dietmar Mieth, teaches us that the solutions of problems the sciences propose are solutions found by neglecting contexts (1999, 196). In this way, the knowledge of human finitude as elaborated by philosophical and Christian theological traditions has simply been forgotten (147). But the human being is \u201ea finite, limited, socially dependent being capable of mistakes. Finitude, limitations, and proneness to mistakes or
the openness to failure lie beyond human control and power. Even though one tries hard to act in the best possible way applying all one\u2018s knowledge and consciousness, a life project may simply fail and break down\u201c (204). The corollary is evident: Whatever we do – biomedical research and clinical application included – will turn into an abortive and inhumane undertaking, if we refuse to recapture existential finitude and its manifold impacts. We ought to make \u201eNew Finitude\u201c a practical slogan as Mieth suggests (209). This slogan might set us free from all too hectic efforts of optimising human being \u2013 efforts which tend do run into sheer instrumentalization of those we pretend to serve.<\/p>\n\n\n\n
As I said, although existential finitude is not a general concern in bioethics, there is a number of authors who have looked into it in a more or less in-depth manner. I mentioned Engelhardt, Mieth, Zimmermann-Acklin, I might add Lazare Benaroyo, Alberto Bondolfi, Michel Doucet, Eva-Maria Engels, Florianne Koechlin and others. But as far as I see, it is H.T. Engelhardt who made finitude a key concept supporting his comprehensive study on \u201eBioethics and Secular Humanism\u201c. While he attaches great importance to the historical reconstruction of post-modern secularism – an expression in which the epithet \u201epost-modern\u201c signals the unamendable failure of the project of modernity with its belief in the power of reason and human moral capacity \u2013, he presents finitude as an ontological trait of human being. He draws from it the few normative principles that remain universal – in any case for those willing to accept the moral point of view and to resolve controversies without recourse to force. The grammar of controversy resolution for such ethically engaging moral strangers contains the principle of mutual respect and the unconditional prohibition to use others without their consent. Although Engelhardt firmly maintains that it \u201eis not possible rationally to discover a canonical moral account with content\u201c (1991, 110) – an outflow of the ontologically rooted finitude of knowledge, evaluation, and widsom (119) – he aptly shows that involuntary euthanasia, use in research without consent, treatment without permission and a few more norms can be justified starting from the gained platform. Such norms are of course common with the routine bioethical discourse. However, Engelhardt thinks that in secular humanism they do not involve any supreme value or particular moral content (119-122). I think this is correct, for the will to engage in ethics may be a pure prudential act where respect for others is merely functional, and not grounded in acknowledging their inherent worth or dignity. One ultimate value remains, of course, and this is the value of individual existence proper to every moral stranger. But this value has no moral significance, since it remains irrelevant beyond the individual human being. As such it may become the foundational element of egoism as an ethical theory. We may therefore conclude that although existential finitude might extinguish moral reasoning, it does not affect the possibility of ethical reflection and construction. The conclusions Engelhardt reaches, also in the field of political ethics, are viable and open to meaningful public debate. Let me state but one example: If in a given political community there persist unresolved controversies as to the ethical acceptability of particular biomedical research projects or therapeutical practice, public goods provided by that community may not be engaged in supporting either of them (133). Existential finitude expressing itself in moral limitations will always lead to inequalities and presumably also to inequalities through multiple systems of health care (132 f.)..).<\/p>\n\n\n\n
For all that, their is also a positive side with the \u201efinitude of human moral arguments\u201c (133). It leads to tolerance and to accepting \u201ecollateral, competing, or supplementary health care systems, supported from private funds\u201c (ib.). Tolerance is indeed promoted, but it is doubtful whether it will persist if not complemented by solidarity. For obvious and pressing discrimination might cause social uproar. It is doubtful whether a prudential approach in securing solidarity will suffice. Yet this would be a matter to deal with on an other occasion.<\/p>\n\n\n\n
The duty to help those in need and to heal disease and suffering has been lying at the heart of medical ethics right from its beginning. The obligation is precious, and yet it can be misused. If it is made absolute, it risks to be turned into absurdity. Considering existential finitude may amend its misplaced use and disclose that the physician\u2018s vow to heal does have its limits. By this consideration we affirm that only in critical situations the principle may be correctly interpreted.<\/p>\n\n\n\n
This does have consequences for the sometimes undifferentiated appeal to the hippocratic oath meant to ethically justify whatever research project and clinical experiment are at hand. Existential finitude taken seriously obliges the different actors to scrutinize and evaluate the goals and intentions that guide their practice. Only if these aims prove reasonable in the perspective of finitude they might be ethically sufficient. I shall come back to this issue in the next section – when discussing some examples. Let me just say that finitude made practical in this way provides us with an antidote against the normative power of routine and medical paternalism. For patients it establishes the moral right not to surrender to social constraints and pressures nor to scientific and therapeutical expertise and interest. It withstands conceiving and financing the helpless efforts to produce the perfect human being. In contrast, it fosters the readiness to accept and support those who suffer from heavier imperfections than the average members of the communities in which we live.<\/p>\n\n\n\n
In this section I wish to illustrate the role of considering existential finitude by applying it to the field of gene technology. This technology, particularly when related to human beings, is, as we know, at the forefront of biomedical queries.<\/p>\n\n\n\n
Today, it is widely praised and propagated by visions and promises referring to heavy and deadly diseases. Truthfulness and authenticity would request that legitimate hope for new and effective therapies does not veil what fashions human existence: feebleness, sickness, and death, but also frailty and lack of knowledge, skills, and risk assessment. When anticipating and evaluating hoped for achievements of gene technology, finitude ought to serve as a criterion to examine the meaning \u2013 and if necessary to establish the absurdity \u2013 of objectives, ways and means followed in research and medical practice. Difficulties and problems ought to be publicity laid open, e.g. the fact that actual research is still far from understanding the<\/p>\n\n\n\n
Finally, looking at existential finitude may help us to cope with another and widespread argument. It stresses that not only performing an action, but also renouncing it entails responsibility. Formally correct, the argument leaves finitude out and hastily identifies what is quite different. When acting in an ethically sound way, we do our best to anticipate and evaluate certain
probable and possible consequences, and for that we may be hold to answer. Should we renounce action on the same premises, our full responsibility would not be questioned. But this is not the situation at hand, for if we abstain from concrete action or plead for a moratorium, we do it precisely because consequences of whatever sort cannot clearly be established or satisfactorily evaluated.<\/p>\n\n\n\n
When existential finitude expresses itself in such a dilemma, we are ethically free not to act. More than that: We are ethically relieved from responsibility. It were morally wrong to force us into a proactive decision, and be it with the argument I just discussed.<\/p>\n\n\n\n
Markus Zimmermann-Acklin holds that debates about phenomena such as suffering, dying, and death as well as hermeneutical inquiries into the images of nature and of human beings are significant, but will not help us to solve practical controversies. He restricts their function to disclosing the backgrounds of moral positions with a view to facilitate the process of mutual understanding (2000, 34). I would maintain that the potential of ontological or, as it were, existential consideration in ethics reaches farther. To argue for my position and to descend from my somewhat general and abstract considerations, I am going to test their ethical potential on five roughly sketched examples.<\/p>\n\n\n\n
You may remember the case of Karen Ann Quinlan, a young lady who took tranquillisers together with alcoholic beverages and then fell into persistent unconsciousness. She was ta-ken to the intensive care station. Her state deteriorated continuously but feeble brain activity was still observed. She obviously suffered from the apallic syndrome. After three months her adoptive father demanded that she were taken from the respirator arguing that her life depen-ded entirely on extraordinary arti\ufb01cial devices and that she should be granted death in dignity. His demand was rejected. A \ufb01rst law suit ended with the verdict that professional ethics and competence stood against the father\u2019s will. The court of appeal gave him right. The respira-tor was taken off \u2013 and Karen continued to breathe by herself. The parents took her to their home. Only ten years later Karen left this world, without ever having regained consciousness (Dulitz\/Kattmann 1990, 45 f.). Finitude had been at least twice disconsidered in the process, 1) by those responsible at the hospital and 2) by the \ufb01rst judge. A narrow deontological re-asoning was given priority over the consideration of an inescapable existential condition. The principle not to kill \u2013 which is not identical with the principle not to do any harm \u2013 was made absolute and turned into existential absurdity. Due consideration of existential \ufb01nitude would have lead to disconnecting the respirator at the father\u2019s demand.<\/p>\n\n\n\n
The second example concerns a seventy-one year old patient suffering from a progressive bi-lateral renal sclerosis. He is refused both haemodialysis as well as being put on the waiting list for an allotransplant. Budgetary reasons imposing other priorities were put forward in order to legitimate the decision. The example is cited in a collection of cases published by the Euro-pean network \u201cMedicine and human rights\u201d (1996, 381 ff.). The ethical comment the editor provides is sharp: The case is interpreted as an example of euthanasia for economic reasons. Since such an act discriminates the poor, it is judged entirely contrary to ethics. In so far as the verdict is rooted in the principles 1) forbidding unjusti\ufb01ed discrimination, and 2) securing equitable access to medical treatment and, moreover, refers to international covenants sup-porting fundamental personal rights, it sounds reasonable. Yet again the perspective of finitude is lacking, with formal juridical and ethical arguments prevailing. A critical stance permits to inquire whether the meaning of equity or the criterion of justi\ufb01cation in the case of discrimina-tion are as clear as it appears. Of course they are not. Taking existential \ufb01nitude into account might help to sharpen both issues on a case by case basis, and this even before considering economic and other external constraints. Later, such constraints might render the aspect of \ufb01nitude even more signi\ufb01cant in the process of weighing of goods and interests at stake. Alt-hough I have not yet scrutinized the matter, I would not exclude the possibility of constructing an ethically sound obligation to renounce treatment. Appealing to fundamental rights without considering fundamental obligations as well is one-sided. For the time being, I would start further investigation from the heuristic basis that the decision concerning the 71-years old renal patient might be ethically defended.<\/p>\n\n\n\n
Xenotransplantation of tissues and organs is still a lively project with researchers, medical ex-perts, politicians, and pharmaceutical \ufb01rms. Intensive research has shown that it is accompa-nied by the hardly rateable risk of heavy, if not deadly infections, particularly by porcine endo-genous retroviruses (PERV). The risk not only touches the patient, but also the care personnel and all those with whom he or she gets into close physical contact. Even the danger of a pandemic has been considered. Arguments taken from animal ethics speak as well against the production of xenografts, among them the high number of animals used to produce the transgenic individuals needed, furthermore pain, suffering, and death in\ufb02icted on animals by xenograft research, and by the conditions of breeding and keeping. Thus arguments drawn from human as well as from animal ethics oppose the project of xenotransplantation. The project is meant to alleviate the lack of human organs; it should serve heavily affected per-sons bound to die if not grafted. The obligation to help and heal is called upon to justify the continuation of the project. Yet one may ask whether shedding heavy risks on many persons and in\ufb02icting suffering and death on numerous animals are outweighed by the possible help for comparatively few patients who are near the consumption of their physical existence. The aspect of \ufb01nitude might relativize the physician\u2019s vow to heal and help and give more weight to another obligation that burdens him: the obligation to protect (cf. Sitter-Liver 2000).<\/p>\n\n\n\n
The next example refers to the actually much discussed use of human embryonic stem cells, either taken from surplus embryos or speci\ufb01cally produced. It will serve to understand that the relevance of existential \ufb01nitude is limited, too. A decision concerning the ethical accep-tability of the use of embryonic stem cells depends of course on the moral status we award embryos. But even if these go for humans in the biological process of their existence, one might ask how it is possible to explain to a full-grown and heavily affected person that his wish to survive is outweighed by the claim to live assigned to embryos who must be destroy-ed in any case. Could we not have recourse to the aspect of \ufb01nitude and thus release the embryos for research and applications, supporting our decision by saying that while dying anyway, they will serve to help and heal others?
The argument is tempting, but inadequate. For with respect to the patient, we do speak of dying; as to the embryos we correctly speak of killing, independent of the certainty of their death. And it is quantitatively important killing in the interest of yet uncertain and unknown third parties. If we consider embryos not just as a heap of cells, but as human beings in their development and therefore as entities endowed with human dignity (a controversial and not easily coherent standpoint [cf. Spaemann and Merkel, both 2001] but which we may assume in the present context without any further inquiry), the perspective of existential \ufb01nitude will not help us clear the situation. It is, of course, utterly irrelevant where embryos go simply for a cluster of cells.<\/p>\n\n\n\n
My last example seems to belong to science-\ufb01ction, yet it touches actual reality. In a recent article published by \u201cLe Monde diplomatique\u201d (Vol. 7, No 8, August 2001, p. 19), Mariano Sigman, neuroscientist at Rochester University in New York, comments on the general pro-gramme of the Japanese Riken Institute, \u201cthe rising sun of neurobiology\u201d. The institute has set its overall aim at 1) understanding, 2) protecting, and 3) creating the human brain. The third goal includes the construction of robots endowed with the intellectual and emotional capaci-ties necessary for participating in human intellectual controversies and discourse. In the year 2020, the programme will have led us to the disclosure of the mystery of human thinking; it will have rendered the brain immortal, providing it with the necessary technical devices. The consequences of the scienti\ufb01c and technological progress will by far outdo the implications of genetic engineering. \u201cThey launch\u201d says Mariano Sigmann, \u201cthe most important attack at human identity ever tried. And they threaten to make human beings vanish in a \u2018posthuman\u2019 epoch\u201d.
We may leave that prognosis open and content ourselves with the fact that the institute\u2019s goals and programmes are supported by public as well as private funds. The goal of creating external human brains independent of human beings as we know them is, to my mind, clearly a product of the eternal longing for redemption and the ensuing ever renewed strive for over-coming human \ufb01nitude. It is rooted in a truly religious motive (Mutschler 1998\/99, particularly pp. 72-74). If from a bioethical position taking existential \ufb01nitude seriously, we may approve the institute\u2019s \ufb01rst and second goals as endeavours to enhance human well-being, we must judge the third goal ethically wrong. For by trying to overcome human \ufb01niteness it works to-wards abolishing human existence. It is bioethically evident that public funds must not be in-vested in such an enterprise; and one may raise the question whether private funding should not be legally prohibited. Of course, this conclusion has a normative premise: it is valid only as far as we deny the third goal ethical legitimation on the ground that we oppose scienti\ufb01c and technological developments which tend to set an end to humane existence in this world. <\/p>\n\n\n\n
We may close this section by acknowledging that some of the examples are controversial. I simply intended to illustrate that the perspective of human \ufb01nitude may be helpful in tackling moral dilemmas. But if so, then decisions on biomedical issues claiming to be taken in an ethically responsible way must not forego existential finitude.<\/p>\n\n\n\n
I hope to have shown that considering human \ufb01nitude might help to clear and resolve cont-roversial issues in biomedical ethics. H. Tristram Engelhardt\u2019s effort to construct a platform for moral strangers so as to allow them to meet in a rudimentary common moral world has been very instructive indeed (1991, 42). I would, however, maintain that making human \ufb01nitude a concern of bioethics might enrich the instruments offered by his secular analysis of human nature. He does aim, to recall this again, at \ufb01nding interests all humans share with a view to construct \u201ca basis for secular cooperation excellence\u201d (ib.).
This aspiration is essential. Compared to the range Engelhardt offers, it may yet be extended, without having recourse to religious or metaphysical premises. Introducing the perspective of human \ufb01nitude into bioethical discourse is an effort to draw from an ontological (or existential, or anthropological) study conclusions which help to tackle moral dilemmas and to guide sci-enti\ufb01c as well as content-full political practice \u2013 without falling into the trap of the naturalistic fallacy.<\/p>\n\n\n\n
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EURESCOBiomedicine within the Limits of Human Existence. Bioethics – an Interdisciplinary Challenge and a Cultural ProjectDavos, 8 – 13 September 2001 1. Main thesis and introduction \u201eThe energies and possibilities…<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[3],"tags":[],"yoast_head":"\n