Strategic Ambiguity: The Pragmatic Utopianism of Daniel Callahan’s “Bioethics as a Discipline”

Abstract

This article highlights the continuing relevance of a classic bioethical text, “Bioethics as a Discipline,” published by the Hastings Center’s cofounder Daniel Callahan in 1973. Connecting the text’s programmatic recommendations with later reflections and interventions Callahan wrote about the development of bioethics illuminates how the vision Callahan established and the reality this vision helped create were interrelated—just not in the way Callahan had hoped for. Although this portrait relies on an individual perception of the development of bioethics, it might nevertheless, through its unique linkage of different bioethical temporalities, contribute to a broader reassessment of what bioethics became and why.

The question of how bioethics became self-aware, and what has come out of it, has found different answers in the course of the past 30 years, when its (self)-historicization began: As historian Robert Baker phrased it, a consensus could be established regarding the “What, When, Who, and How” of what he called the “bioethics revolution,” whereas the “Why” remained a rather controversial subject of discussion¹—a peculiar differentiation, implying that the questions of process and cause were not necessarily intertwined but different analytical entities. This focus on the “how” and its separation from the “why” of bioethics is still prevalent. Most recently, the Hastings Center Report published a series of articles appreciating “Fifty Years of Bioethics”—an occasion that coincided with the journal’s own 50th anniversary—which highlighted historical publications and their lasting relevance. Rediscovering what scholars such as Hans Jonas, Renée Fox, Paul Ramsey, or the Hastings Center’s cofounder Daniel Callahan had written in the late 1960s and early 1970s about issues such as human subject research, organ donation, abortion, or informed consent encouraged the reader to reflect on bioethics’ past as much as on its present: As two of the series’ authors put it, “one is likely to be struck more by continuity than by change.”² Almost taken for granted by the series and its contributors was the mere existence of something called bioethics, a term that had not even been in use when most of those historical publications were written. Only George Annas pointed to the establishment of the term and its inchoate meaning around 1970.³ As the Hastings Center Report exemplifies, the term was actually applied early on, for example, in a series on “Case Studies in Bioethics,” launched in late 1972, but as an umbrella term for contemporary issues under discussion, rather than endowed with a thought-through, conceptual meaning.⁴ It could be argued that the reason for the term gaining traction was not that it positively represented something specific, but that it was perceived to have such a specific meaning. After all, those who used it early on seem to have done so in a systematically unsystematic fashion and almost against their very intuition—as Warren Reich recalls, when he conceptualized the Encyclopedia of Bioethics in the early 1970s, he originally wanted to name it the Encyclopedia of Medical Ethics, and the aforementioned Daniel Callahan, who was cited by the Library of Congress as the justification to introduce a new category called “bioethics” into its catalog in 1974, clarified in his memoirs that he “was not drawn to the term.”⁵

This ambiguity in adopting the term bioethics was not just a sign of initial indecisiveness. Instead, it can be interpreted as a structural feature of what bioethics has become and how. The fact that the Library of Congress invoked Daniel Callahan as their authoritative witness that bioethics existed while Callahan was reluctant to associate himself with the term was no accident or misunderstanding: It resulted from the interpretation of a short, programmatic essay that Callahan had just published under the title “Bioethics as a Discipline.” ⁶ Although the title hardly seems ambiguous and its interpretation by the Library of Congress was quite understandable, it is actually a much more complicated text that sheds light on a couple of interconnected ambiguities concerning the mission, the operation, and the place in society to which bioethics aspired—productive ambiguities, fueling its establishment, but ambiguities, nevertheless. In this regard, it is worthwhile to reread “Bioethics as a Discipline,” not just as a historical artifact but as the programmatic outline its author intended it to be, and to juxtapose it with Callahan’s many reflections on the development of bioethics from decades later, which appear to contradict many of the arguments he had originally introduced. Such a juxtaposition might help sharpen our understanding of how the present of bioethics has been shaped by its origins and how the ambiguities at its origin keep influencing the shape of bioethics today. Although Callahan himself acknowledged a diversion of bioethics from its roots, which led to his own estrangement from the field, he hardly connected the outcome with the beginning and his own programmatic vision from 1973. ⁷ The text and Callahan’s later interventions form a unique and particularly instructive corpus for analyzing the becoming of bioethics, not because the significance of the author might justify some sort of Callahanist exegesis, but because they connect bioethical temporalities: the perspective on what bioethics was supposed to become and the perspective on what bioethics became, which draw from the same set of ideas and motives, thereby disclosing how these ideas and motives developed an unforeseen, though not necessarily unforeseeable, dynamic of their own.

Narrow and Broad Bioethics

The most blatant indicator of such ambiguity at the foundation of bioethics, as Callahan envisioned it, is a semantic peculiarity, pervasive throughout the text. He spoke of “the utopian goal” ⁸ of bioethical methodology, an “unmanageable sense” ⁹ of the required understanding of ethics, an “impossible list of demands” ¹⁰ confronting the bioethicist, and also of the “unparalleled opportunities” ¹¹ resulting from the uncharted territory that constituted the prospective field. These formulations signify an ambiguity regarding the proclaimed mission of bioethics, which was, at the same time, conceived as very narrow and very broad. Callahan actually used these qualifications to differentiate the classical, analytical, and narrow understanding of academic ethics from the practical, therefore unmanageably broad tasks of bioethics. Bioethicists were supposed to supply practical solutions to practical problems, posed by what was then called the biological revolution, taking the shape of “medical advances coming on fast and furiously.” ¹² Helping “scientists and physicians to make the right decisions” was the bioethicist’s foremost task, and this required an understanding “that at some discrete point in time, all the talk has to end and a choice must be made, a choice which had best be right rather than wrong.” Yet, this “most difficult” of the bioethicist’s tasks had its basis in two other tasks: identifying those moral questions that needed answering and “providing some systematic means of thinking about, and thinking through” them. ¹³ In so many words, his understanding of the tasks bioethics needed to fulfill summed up Callahan’s famous antipathy toward the academic practice of ethics he had experienced at Yale, Georgetown, and especially Harvard, whose proponents did everything in order not to engage with real-life problems. By focusing on those real-life problems that were increasingly being raised by medicine and the life sciences, Callahan set off to free the normative potential of ethics from its encrusted tradition—ten years later, displaying a similar analysis of the state of academic philosophy, Stephen Toulmin famously rephrased this endeavor as the story of “how medicine saved the life of ethics.” ¹⁴

In another striking formulation that highlighted the intrinsic ambiguity at the onset of bioethics, Callahan proclaimed: “Feet will be wet before feet are even in the water.” ¹⁵ Bioethicists had to step down from their armchair in the ivory tower into the messy maelstrom of moral challenges posed by the biological revolution. It was inevitable that bioethics, without possessing a comprehensive scheme of maneuvering those challenges, would be affected by them. The questions connected to this grounding of ethics were not only the ones on which Callahan’s analysis and program centered, that is, “What is the place of the ethicist in medicine and biology? Does he have anything to contribute and, if so, what?” ¹⁶ Linked to the question of what ethics would do in medicine was the question of what medicine would do to ethics, that is, how bioethics would be influenced by the experience of getting its feet wet before even having touched the surface of the moral maelstrom it was supposed to navigate. Although focusing predominantly on the first part of the question, Callahan foreshadowed the second part by closing his article with the observation that bioethics, to become a discipline that was accepted and called upon by physicians and scientists, “should be developed inductively, working at least initially from the kinds of problems scientists and physicians believe they face,” notwithstanding the probability that “they will be wrong about the real nature of the issues with which they have to wrestle.” ¹⁷

Callahan understood this initial convergence as part of a dialectic development of consolidating the often-diametrical perspectives of philosophical analysis and medical practice. However, it bore the risk of unilateral consolidation by overemphasizing the practical necessities of medicine. Indeed, Callahan put a distinct emphasis on “the realities of most medical and much scientific life,” ¹⁸ the risk of failing to adequately address the “psychological reality” ¹⁹ this life entailed and, therefore, to “falsify the reality of the way decisions are and will continue to be made.” ²⁰ This acknowledgment and integration of what presented itself as the “reality” one had to deal with proved to be a double-edged success story, as Callahan phrased it more than twenty years later: “Can that strategy, in the name of reality, actually distort reality? Does ‘reality’ lie in the particularity of individual cases – where most clinicians think it does – or in a more general, abstract, and universal realm, no less real but just more hidden?” ²¹ What set out to accomplish the broadening of narrow-minded academic ethics deviated into a narrowing of the bioethical focus, increasingly fixated on the “how,” rather than on the “why,” or, again in Callahan’s words, “a tide that is more interested in means than in ends.” ²²

This development can be interpreted as an unintended result of the very program Callahan laid out in “Bioethics as a Discipline.” Such unintendedness is highlighted not least by the journal in which the text was published. Strikingly, Callahan did not choose the already established Hastings Center Report, but the first issue of the Hastings Center Studies, which was designed to “complement the Report with a journal capable of reporting fully on original research and carrying longer, more detailed, and more reflective analysis”—the Report was referred to as a mere “newsletter” of bioethics. ²³ The place of publication and its explicit juxtaposition with the Report not only shed light on how Callahan understood his text, that is, as a detailed reflection on the legitimacy and functionality of bioethics as a whole, the “why” or the “end” of bioethics, which was lifted above the fray of bioethics’ “how” or its “means,” the ordinary bioethical routine. It also shed light on the early differentiation of what was deemed a viable path for bioethics, transpiring shortly after the text had been published: The Hastings Center Studies was shut down after only two volumes, in 1974. Decades later, Callahan was frank in sharing his frustration about the greater development this editorial decision represented. What he called the broader stream of bioethics’ initial composition, that is, the reflection on the biological revolution’s implications for society and of society’s possible reactions, was superseded by a narrow, clinical stream—“Consider the contrast between that sort of discussion and improving informed consent forms”—but he was no less frank about its inevitability, given that “it’s been the harder one to get money for or to keep the interest in.” ²⁴

(Un)-Committed Bioethics

Yet, this narrowing of the bioethical mind—as Callahan’s frustration could be summed up—should not simply be interpreted as resulting from extrinsic interest in and support for certain aspects of the bioethical program. Rather, it should be analyzed in correlation with two other ambiguities that this very program, as Callahan laid it out, tried to navigate. Taking up his criticism of academic philosophy, Callahan cautioned against a “disciplinary reductionism” in the approach of bioethical challenges, that is, “a penchant for distilling out of an essentially complex ethical problem one transcendent issue which is promptly labeled the issue. Not coincidentally, this issue usually turns out to be a classic, familiar argument in philosophy or theology.” ²⁵ To Callahan, this tendency was basically one of translating a problem from ordinary language into academic jargon. Such a translation made its discussion inaccessible to the ordinary person confronted with the reality of this problem and saved the ethicist from the reality of having to commit to a resolution. Instead, the bioethicist’s job was to produce clarity, not to increase complexity. His training made him capable “of moving more deeply into the issue than others do, of giving them coherence and clarity, which they may lack in the formulation of ordinary language, and of bringing to them a nuanced methodology.” ²⁶ What should this training, this nuanced methodology, comprise? To Callahan, it had to include “sociological understanding of the medical and biological communities; psychological understanding of the kinds of needs felt by researchers and clinicians, parents and physicians, and the varieties of pressures to which they are subject; historical understanding of the sources of regnant value theories and common practices; awareness of and facility with the usual methods of ethical analysis as understood in the philosophical communities,” ²⁷ without overemphasizing and thereby committing to one or the other, while constantly reflecting on the limitations of each of those methods. Yet, such a definition represented the composition of the Hastings Center’s early working groups, much rather than the individual researcher’s abilities, which remained, in fact, bound by their disciplinary education. ²⁸

No Wonder that Callahan Described such a Methodology as a “Utopian Goal” ²⁹ It had to avert disciplinary reductionism by simultaneously drawing on nondisciplinary and interdisciplinary knowledge and by integrating the individual perspective of the person affected and the plurality of perspectives of the disciplines involved. Therefore, the balancing of disciplinary perspectives remained an explicit task of the Hastings Center, with regard to the composition of fellows as much as the individual appropriation of at least some “amateur knowledge of three or four different fields.” ³⁰ However, what evolved from this precarious, amateurish integration was more of a parallel structure, an “oligopoly of fields” ³¹ that included philosophy, clinical medicine, and law, but quickly pushed out theology and history and produced a strained relationship with the social sciences. Bioethics became, again, much more narrow than what Callahan had proclaimed, although this additional narrowing can already be retraced in his programmatic text: Here, he acknowledged that every ethical system allowing for the pragmatic resolution of real moral problems was essentially a matter of the past, having been based on an overarching cultural consensus, like the “Roman Catholic scholastic tradition and the Jewish responsa tradition,” and that in the absence of such a consensus—an absence that produced the very necessity of bioethical scholarship in the first place—“it has become absolutely urgent that the search for a philosophically viable normative ethic, which can presuppose some commonly shared principles, go forward with all haste. Short of finding that, I do not see how ethical methodologies can be developed which will include methods for reaching quick and viable solutions in specific cases.” ³²

Only a couple of years later, Callahan’s demand would be answered. Out of the urgent necessity of providing real solutions to real problems arose principlism. Callahan later characterized principlism as “a kind of blocking function,” which “short-circuited the opening up of larger, more important issues,” and as “the main reductionist agent” of bioethical thinking. ³³ The reductionism of bioethical methodology, born out of the necessity to quickly find a mode of problem-solving, can be interpreted as coinciding with and reinforcing the tendency of prioritizing the “how” against the “why” and the “means” against the “ends.” Still, Callahan could not deny that this tendency was, indeed, rooted in reality: that is, the American cultural reality and the prevalent understanding of individual rights and freedoms. Bioethics, through its adoption of autonomy as the quintessential guiding principle for decision-making, inevitably reacted to and became part of this reality. Callahan’s allusion to the lack of a common, shared moral framework and to the moral fragmentation of contemporary society as the very reason for bioethics having to approach new paths of ethical deliberation and resolution acknowledged this reality as a main driver for the creation and evolution of bioethics. What can be understood as Callahan’s bioethical initiation, a book about abortion he published in 1970, ³⁴ had already introduced him to the cultural fragmentation accompanying almost all of the issues bioethics came to be involved with. It was no coincidence that he introduced his programmatic vision of “Bioethics as a Discipline” with an example from his personal experience of discussing abortion. ³⁵ Getting drawn into the cultural trench warfare about moral absolutes was a danger he was well aware of, so much so that the Hastings Center, as early as 1976, organized a conference about the increasing use of Nazi analogies in bioethical debate and the question of what such comparisons revealed “about not only the conduct of our discussion in this area but about ethical discourse in our society generally.” ³⁶

Finding individual ethical passages in between the generalizing moral extremes was a mission Callahan took seriously. In his thoughts on “Bioethics as a Discipline,” he foresaw the

“exasperation ethicists arouse in those already committed to an answer to a specific problem, those for whom the intellectual probing is over and dedication to propagating the cause is the only item left on the agenda. The professional diffidence of the ethicist about seeing himself in the role of the advocate (I am less certain about the theologian) can only seem an evasion or a failure to take ethics seriously enough.” ³⁷

On several occasions, he highlighted the necessity of finding such a morally uncommitted ethical passage in clear sight of the irreconcilable absolutes by jokingly juxtaposing “the Joseph Fletcher route of totally blessing everything that came along, or the Paul Ramsey route of seeming to reject everything,” which bioethics had to navigate while appreciating the seriousness of both positions: “somehow the field has to have its own compass.” ³⁸ How seriously the Center took this mission is reflected in Fletcher and Ramsey simultaneously receiving its Henry Knowles Beecher Award in 1981 for their respective lifetime contributions in the field. ³⁹ It seems as if Callahan and the Hastings Center wanted to reiterate that the whole enterprise would be blown off course if this passage could no longer be taken and were drawn to either one of those unreserved positions. At least in retrospect, this is a possible interpretation, given that Callahan later acknowledged self-critically: “It appears that Fletcher won the day,” a development that came along with another trend, “an increasing embrace of strong advocacy as a proper role for those in bioethics.” ⁴⁰

The prioritization of Fletcher over Ramsey can be understood as a stand-in for other directions bioethics took in the course of—and in relation to—its establishment, all of which Callahan simultaneously initiated and dreaded: for the prioritization of the “how” over the “why,” for the prioritization of clinical and legal requirements over theological and historical ruminations, for the prioritization of advocacy over neutrality, in short: for bioethics’ increasing commitment to certain ways of thinking, its narrowing, and reductionism. This stand-in makes sense at least from the perspective of Callahan’s later regret that the “marginalization of religion in bioethics effectively downgraded one potential source of vigor to explore the larger questions,” a regret that was personified in Paul Ramsey who “was thought of as very religious, and also very conservative too.” ⁴¹ It is telling, albeit in a paradoxical way, that this development has been criticized as bioethics’ adoption of a “conservative position,” ⁴² an assessment that does not make much sense analytically, considering which position was adopted and which one was marginalized. However, it makes a lot of sense as an example of “the coming of the culture wars to bioethics,” ⁴³ of bioethics being subjected to increased ideological scrutinizing from both sides of the spectrum, equally tending to interpret everything they disagree with as the expression of their adversary’s cultural hegemony. Callahan was the first to expound on this problem and its consequences for bioethics as much as bioethics’ own liability, an early indication of which had been his own skepticism that religion had a serious role to play in the bioethical endeavor. ⁴⁴

Disciplined Bioethics

Connecting Daniel Callahan’s “Bioethics as a Discipline” to his later reflections about the path bioethics took allows for an interpretation of why bioethics evolved the way it did and how the outcome can be related to the beginnings. To understand the synchrony of historicity and topicality in Callahan’s text, it might help to read “Bioethics as a Discipline” as a strategy, which was designed to overcome a clear and present obstacle, that is, a lack of professional and political legitimacy for bioethics to do what it ought to do. This strategic dimension reveals itself when juxtaposing Callahan’s goal of establishing “Bioethics as a Discipline” not only with his own understanding of what defined a discipline—“too often arrogance, insulation, neurosis, and narrowness”⁴⁵—but also with his understanding of what bioethics actually was—“It’s not a discipline”—and how he saw himself—“In fact, to this day I say, ‘I don’t describe myself as a bioethicist.’”⁴⁶ While envisioning and advocating for “Bioethics as a Discipline,” Callahan did not want bioethics to become a discipline and never felt it had, although he felt that it was trying very hard to acquire its formal features—and he undoubtedly continued to contribute to this ambiguity, for example, by incidentally reminding Georgetown University’s Kennedy Institute of Ethics of the Hastings Center’s superior intradisciplinary status of being “probably the largest” existing bioethical enterprise.⁴⁷ The ambiguity of simultaneously claiming and disputing the status of a discipline can be understood as containing all the other ambiguities of his original text: Bioethics’ “utopian goal,” its “unmanageable sense,” its “impossible list of demands,” and its “unparalleled opportunities” could only be realized if it was, after all, perceived as a useful instrument in medicine and the life sciences, if it “proved itself to be a friendly force within medicine, and brought in principles and ways of thinking quite congenial in a liberal society.”⁴⁸ It had to focus strategically on the specific—professional as well as cultural—realities it came across, it had to implement a workable methodology, and it had to be pragmatic and, to some extent, progressive in order to become something at all. The term discipline entailed all those features and allowed bioethics to be perceived within a familiar range of patterns and norms. The fact that Callahan strategically chose this term to describe what bioethics reached for gave the whole endeavor an unintended but not unpredictable direction, notwithstanding that it stood in stark contrast to many aspects of his overall vision for bioethics. Even more, one could argue that the term fundamentally illustrates his predicament: To become something at all, bioethics, this envisioned container of multitudes, had to become straightforward: It had to discipline itself.