Dr. Arthur L. Caplan is Professor of Bioethics at New York University Langone Medical Center and the founding director of the Division of Medical Ethics. He has made numerous contributions to public policy including helping to found the National Marrow Donor Program, creating the policy of required request in cadaver organ donation adopted throughout the United States, helping to create the system for distributing organs in the U.S., and advising on the content of the National Organ Transplant Act of 1984. Dr. Caplan is a regular commentator on bioethics and health care issues for WebMD/Medscape, for WGBH radio in Boston and WMNF public radio in Tampa. He appears frequently as a guest and commentator on various national and international media outlets.
Dr. Kadish: The United States continues to be mired in disagreements about abortion and, as you know, there are some restrictive abortion laws that have been passed in certain states. I’d like to ask you to comment, not from a political standpoint, but from a purely ethical standpoint. How do you deal with the issue of “when life begins” and the controversies about abortion?
Dr. Caplan: Well, that is a very interesting question. For decades, the scientific and medical communities did not weigh in on the question of when life begins. They basically put the issue aside and said, look, it’s not a science question; it’s a legal issue, an ethical issue, a philosophical issue, even a political issue. I don’t accept that, at all. I agree that you can’t get a line based on facts about when life begins, but facts are absolutely relevant to the philosophical view or theological view or legal view about where we should say life begins.
Here’s what I mean by that: It is true that every human life begins with conception. It is not true that every conception, however, begins a human life. Many fail. There’s particularly a high rate of failure when fertilized eggs fail to implant and probably post fertilization, you see failure rates, as we know from scientific studies, as high as 40%. So I am loathe to say that life begins at conception as a legal matter when, if you will, many things that are conceived either abort spontaneously, don’t implant, and don’t work right… and occasionally there are extra-uterine problems in terms of where the implantation takes place. So, I don’t believe conception always creates a person. I think the failure rate is too high.
I think, however, that when we start talking about when does life begin, what we’re really asking is when does personhood begin, when can we say there is an entity worthy of moral standing. And I’ll answer it this way: we agree that people are dead and no longer exist when their brains have ceased to function. So, I think a key landmark is when a brain is able to totally function, as an integrated unit. For me, that probably happens around 24 or 25 weeks—again, where the science seems to say that you’re starting to get the brain fully functional, not just cells firing, but integrative function. That overlaps as it happens where the Roe v. Wade decision is. In sum, I don’t think personhood is when conception begins. I do grant that life may begin there, but it’s a sketchy, difficult matter in terms of whether the conceptus is likely to work. I think using symmetry, when we call ourselves dead, when our brains cease integrative function, is probably a good landmark to use to say that’s when we become persons.
Dr. Kadish: That’s a fascinating and novel approach, and I think an unusual one. But it seems great in some ways because, as you say, it uses symmetry. What about the issue of fetal viability? I know that’s a moving target.
Dr. Caplan: The Roe v. Wade decision is linked up very closely to fetal viability, for a slightly different reason. It’s not really hinging on when is there a person there. What it’s saying is if the woman does not have to support the fetus in her body, if it can function independently, then the woman loses control, if you will, over the fetus and it should be treated at that point as beyond abortion, because it can live on its own. Historically, in neonatology, the cutoff has been 24 or 23 weeks, and the reason is very simple. There are no lungs in the fetus before that. It can’t survive in the air—it can’t survive outside the amniotic fluid, so if you’re going to use the women’s right to control what happens, based on independent viability, that seems appropriate as a line.
However, there is research going on with artificial wombs, with artificial amniotic fluids. I think that it is likely that that the age of independent survival is going to push down because you may find that you can support the developing fetus at 19, 20, or 21 weeks in an artificial environment. So the moral question, really, divides them into two parts: 1) What would we not let happen to a person, and if a person emerges with a functioning brain, then that’s probably the 24 or 25 week cut off to doing anything that might terminate a pregnancy. If it’s viability, because the women’s right to control what happens is ended when the fetus doesn’t need her body to exist in any more, then we’re probably soon going to be talking 19 or 20 weeks.
Dr. Kadish: Do you believe that as ethicists and physicians we have a responsibility to weigh-in on this—a responsibility that exceeds that of the average citizen, assuming we’re not involved in performing abortions and therefore it doesn’t apply to our practice directly?
Dr. Caplan: Well, you’d hardly find an American who doesn’t have an opinion on abortion. It’s not as if theologians have to come along and say, “Here’s something for you to think about!” There is often a role for an ethicist to be more of a prophet; to try and raise awareness of an issue or something that’s emerging that’s not recognized yet. With abortion, on the other hand, yes, I do think people in ethics—people who study ethical problems in medicine—have more of an obligation to get involved. I would not say that my peers do it to the extent to which I wish they would. They bring expertise. They’ve considered a lot of the arguments that people have made and had time to reflect on them.
I think it’s possible for the ethicists to work with the scientists to understand embryology, to understand neonatal development, to get some of the facts straight about key landmarks in embryo development, and so on, that the ordinary citizen may not have time to get involved in. Politicly, it may still be that for whatever personal reason, someone wants to say from the moment of conception, that’s going to be a person and they could argue that politically they might not be moved, but I think that abortion can be a little more nuanced and we may see situations where people might say, “I permit it under some circumstances, but only up until a certain point.” That’s where I think bioethics can help shape the debate. As heated and as frenzied as arguments are about abortion, I still think there is room to try and find areas where, if you spend some time thinking about it, you could point toward some compromise.
Dr. Kadish: Obviously I think this country and women’s health would be better off if we could do that. I would suggest that one of the roles that ethicists could play would be simply listening to other people, and to their points of view. Showing sensitivity is also an important part of what ought to be included in an ethical system.
Dr. Caplan: I very much agree with that, and even though I am more on the pro-choice side of the issue, in terms of allowing some abortions in some circumstances, I’m not open-ended about it. I think there are immoral abortions—people regularly using abortions for birth control is not a sound moral position. That said, I do have respect for the right to life, a pro-life position. It’s an admirable stance to wish to protect human potentiality and life. I think it deserves acknowledgement that it’s coming from an honest desire to protect what may be seen as an innocent fetal life. You can argue though whether it pays enough attention to women and their rights… Nonetheless, it’s a position I take seriously, and I think we should in these debates. It’s not as if we have one good and one evil position.