Transcript, Meeting 23, Session 4 and Concluding Remarks

Date

November 17, 2015

Location

Arlington, Va.

Presenters

Member Discussion

Transcript

SESSION 4:  MEMBER DISCUSSION

DR. WAGNER:  I hate to cut you off but you're digging into your next session.

DR. GUTMANN:  Yes.  We're going on.  I'm happy to do it.

Okay.  So we're moving on to consider the relationship between deliberation and bioethics education.  We've already done some of this.  But we have some provisional recommendations on this.

We've heard from experts in education that using deliberation as an educational tool builds the skills that will help students become informed and active participants in their communities.  Diana Hess's work, you structure deliberative activities in the classroom.

And it shows that the students learn how to deliberate, to reach policy consensus on controversial ethical and political issues, and also learn how to respect one another.  They also learn the virtues of listening and responding and respecting.

Bioethics education can be an important forum for introducing deliberative methods into diverse educational settings.  And she actually looks at different educational settings ranging from ones in which the students are diverse and have diverse views, which is optimal for deliberation, to ones where, because of the communities, they're more homogeneous.

And she shows how teachers have to learn different ways of teaching in those settings.  In the first, you draw out the diversity of views.  In the second, you have to actually have students role‑play and the teacher has to play an active role in making sure minority opinions get out there.

We also heard from organizers of and participants in deliberative activities with the general public, such as What's Next California?, Deliberative Poll, and the public dialogue on mitochondrial donation in the United Kingdom, about the important educational function of these activities which fosters a more informed and engaged public.

So we also heard how deliberation is educational, as Dan said, outside of schools, in the public realm.  As a public voice and forum for bioethics on the national level, our efforts to bring deliberative process and values to bear on some of the most pressing bioethical questions and to extend our work through educational materials underscores this mutually reinforcing function of deliberation and ethics education.

And what we believe and what we have demonstrated and what other scholars have demonstrated is this creates a virtuous circle as deliberation facilitates education and bioethics education builds skills and virtues of deliberation.

So with these examples of the intersection of deliberation and bioethics on our minds, here are two recommendations for our consideration.

First, as we've seen in our work on topics as diverse as synthetic biology, whole genome sequencing, and cognitive enhancement, developments in health science and technology can raise significant bioethical questions that need robust and informed public discussion and deliberation.

Those involved in education and deliberation should use the tools in both of these domains to facilitate greater public engagement with these questions.  And I hasten to add we need to give examples of how that works.  Right?

Second, the Bioethics Commission has been a leader in bioethics education by developing publicly available teaching tools that make our work accessible to anyone wanting to study or teach bioethics.  Following our report on the Public Health Service supported research on sexually transmitted diseases in Guatemala in the 1940s, we published a study guide.  It's available in a Spanish translation.  And it uses original sources as well as our analysis to make the ethical elements of this case vivid for teaching.

We developed several case studies around topics of our Ethics in Ebola report that are designed to bring bioethics to life for professionals in public health and other related fields who might have received little if any ethics education.  And these are just two examples from a catalogue of over 50 teaching tools that the Commission has created to date.

National bioethics commissions have an important role to play in supporting public bioethics education and contributing to national discourse and deliberations on health science and technology policy in bioethical areas.

Future bioethics commissions, and this is our recommendation, and other bioethics organizations and organizations that take on bioethical issues should continue to explore in advance their educational and democratic role, and to develop and promote accessible educational tools to enable teachers at all levels to integrate deliberation and bioethics into their classrooms.

And I open that up for our discussion and whether we agree with these recommendations.  There are two levels of questions.  One, do we fundamentally agree with the recommendations?  And two, how would we revise/modify/improve them?  Anyone?

DR. ALLEN:  Fundamentally agree?

DR. GUTMANN:  Fundamentally agree, yes.

DR. ALLEN:  Fundamentally agree, with one small issue.  We talk a lot about analytical reasoning as part of what we want to teach and utilize.  But I'm also wondering about the development of empathy and caring, and maybe we should explicitly integrate in our account of what we're aiming for are these capacities as well.

DR. GUTMANN:  Yes.  So ‑‑

DR. WAGNER:  Dan, you've been worried about that.

DR. GUTMANN:  Yes.

DR. SULMASY:  Yes.  I'm not sure that those are ‑‑ I agree that those are good virtues.  But I think they belong more in the virtues of education, particularly for professionals who are dealing with students or persons who are particularly ill, through medicine and nursing and other professions.

I'm not sure that that's part of the virtues that are specific to democratic deliberation, where I think a public beneficence, those kinds of ‑‑ or benevolence, I guess, would be the virtue associated with it ‑‑ would be more the kinds of equivalence to that sphere.

So I think to the extent that they are teaching to care about your students, to the extent that one is a clinician to care about one's patients would be good.  But I think in the public sphere that it's more at the level of public benevolence, respect, being someone who's able to listen, are more the kinds of virtues I'd think about for this section that schools could teach that would then overlap with public deliberation.  This is similar to your question about the clinical bedside consultation versus public policy.

DR. WAGNER:  Since this again brings up the ‑‑ obviously it's the fusion, deliberation and education.

Not specific to these recommendations, necessarily, but any observation.  I have caught myself using a phrase today, and I've heard others use it.  I've been using the phrase as a shorthand for something I actually do believe.  But the phrase itself I don't believe.  But I just want to make sure.

And it has to do with our notion that deliberation on biomedical ethics and bioethics is not intended to reach an outcome.  I actually don't think I believe that.  I believe that deliberation on ethics may not converge to a single outcome, but the whole reason for doing it is to drive toward an outcome.  Are we comfortable with that?

DR. GUTMANN:  Yes.  Yes.

DR. WAGNER:  And we have said this repeatedly.  Well, it doesn't go to an outcome.  It doesn't come to a single ‑‑ the fact is, it's intended.  We're trying to get to resolution.  But we need to understand that there's value in that process and that the process may not necessarily in every case converge to a single outcome.  I just wanted to add that qualification.

DR. FARAHANY:  So there's education and there's the process of democratic deliberation for a particular policy.  Right?  So I think with respect to a particular policy, there are multiple purposes of democratic deliberation.

One of them, at the end of the process if you were seeking to adopt a policy ‑‑ you were actually recommending adopting a policy ‑‑ but the process of hearing and including viewpoints that influence the outcome and that enables people to be heard, I think, is a value in and of itself that is important toward the process and the outcome.

On the ‑‑

DR. GUTMANN:  So the ‑‑

DR. FARAHANY:  Sorry.

DR. GUTMANN:  No.  Please go ahead.

DR. FARAHANY:  On the education side, what I've been saying repeatedly, which I think is different than in a policy setting, is we're not trying to impart upon students a particular outcome of thinking, meaning we're not trying to impart upon them that they come to believe that ‑‑ pick your topic ‑‑ that X is the right answer.

DR. GUTMANN:  Yes.

DR. FARAHANY:  It's instead to empower them with a set of skills, tools, reasoning capabilities, to be able to think through the process for themselves to be able to come to a pace where they can answer for themselves how they would come out on an issue or how they would reason through it, even if they don't have an ultimate inclusion of where they would come out on an issue.

So I think they're separate issues.  We're not trying to achieve a particular outcome in an educational setting with respect to what a student should think.  We are trying to achieve an outcome in imparting a set of skills that will enable them to think.

DR. WAGNER:  What I'm getting to also, though, is my personal motivation to be involved in the conversation is the possibility that there might be a solution.  But I have to, as you say, value that process, understanding that at the end, we might not come up with a ‑‑

DR. FARAHANY:  A solution to policy, but not for education.  Right?  You don't want to have a particular answer for a student.

DR. WAGNER:  One of the concerns I see in education ‑‑ and you guys all, we all engage students that are so smart that, in fact, I think they know that certain arguments will not converge and they won't engage in them.

And why ruffle feathers?  Why do these things?  What we're advocating is that there's value in pursuit of a solution even if at the outset you don't think there is one and even at the end of the day there isn't one solution.  But still, what drives it is the notion that we should be deliberating toward solutions, even if at the end of the day there isn't one.  I don't think it's a subtle distinction.

DR. GUTMANN:  So let me just address the deliberation and leave the ‑‑ okay.  And Dan will do ‑‑ you can do education.  Let me do the deliberation.

I think it's really important to recognize ‑‑ and we need to say this very clearly in the report; otherwise, it will seem like the report isn't as strong in its recommendations and specific as it is ‑‑ so in some sense, you're both right, but here it is.

Deliberation has two necessary and neither sufficient components.  Deliberation is different than discussion.  Discussion is just you air your views, and you can have ground rules for discussion.

But deliberation seeks an outcome.  It seeks a decision.  And the decision might be ‑‑ deliberation in a classroom, the decision is, we're going to deliberate about, and you name it, who was right in this historical argument?  Who was right in the ‑‑ what was the right thing to ‑‑ we're going to deliberate.  What was the right thing to do on Guatemala?

So it's a deliberation not because it's going to issue in a policy.  It's a deliberation because you're asking your students to come to a decision at the end.  Now, in a policy realm, as Jim says, you're seeking a policy decision.  So that's the number one necessary condition of deliberation.

The other necessary condition is that deliberation values respectful, reasoned giving among people who likely disagree.  And it may not come to a consensus, and it would still be valued because that reasoned giving is valuable.

So that's just a robust and pretty uncontroversial ‑‑ otherwise, you can't distinguish deliberation from discussion.  So that's deliberation.  Now I'll hand off education.  And I think that's what we've been working with.  That's what we've been evidencing.

And if you want, any deliberation in a classroom is in some sense a mock deliberation.  It's modeling where the heart of deliberation is.  The heart of deliberation began in nondemocratic times when a king or head of state brought together ‑‑ and it was usually his counselors and asked them to deliberate with him about what he should do, which was better than him making the decision by himself.  Now democratically, we broaden it.  So education.

DR. SULMASY:  Yes.  Or actually, this may cut across both education and deliberation.  What I think I hear your worry to be, Jim, is that you don't want this to devolve into an endorsement of either moral subjectivism or of cultural or historical relativism.  And so I agree that that's a concern.  But I do not think that democratic deliberation implies that.

What I think we may want to suggest as a virtue both in education and in public discourse is something I call epistemic moral humility.  Right?  Which means that there's no reason to get into the argument unless you are committed to the believe that there might be a right answer to the question.

But you also have to have the virtue of being humble enough to realize you may not have total hegemony on the answer, and that there will be other people who disagree with you ‑‑ you don't know everything; that there may be some cases in which we can all come to agree that it is wrong no matter what one's culture is, no matter what one's historical situation is.  And I would argue that injecting spirochetes into somebody's cisterna magna was wrong if you lived 2,000 years ago or in 1948.  Right?

But there are other questions in which we're going to have lots of controversial objection.  That does not mean at the end of the day that if we have to answer a policy question or have to answer a clinical question, that some people couldn't judge that ultimate decision to be wrong.

So I think it may be important if we want it to be in the report that democratic deliberation does not imply either subjectivism or relativism, if that's the worry, because I think that you have to come to an answer.  There will be disagreements, and maybe the virtue, as I put it, is epistemic moral humility, that I have to admit that I may not be right.  I may not be able to convince you that I'm right.

DR. GUTMANN:  But let me just get to Nita's point, and then let's see if Nita agrees.  So I do want to make sure that we recognize that the goal of educating students in ethics is not ‑‑ the first order goal is not that they agree on the right answer.  That is not the goal.  The goal is for them to reason well towards a conclusion.

Now, obviously, if reasoning well towards a conclusion on a certain issue, an easy issue, means you get to the same answer, that's great because we're not subscribing to relativism on this.  But we know on controversial issues that it's really important in educating that teachers not directly aim at the goal of getting agreement because there are more efficient ways of getting agreement that are bad, that are morally bad ways.

And the primary value in teaching students in a deliberative way is to teach them the skills and virtues of reasoning.  And that's, I think, what you were saying, that the goal, the first order goal, is that teaching.

DR. FARAHANY:  Yes.  Absolutely.  So I agree that the process of deliberation is different than discussion.  There is a tension between deliberation and education sometimes when it comes to bioethics in the educational setting.

There are some cases where everybody will agree, and the process of laying reasons out on the table should lead everybody to basically the same conclusion.  There are some ethically impossible things that we think really one should, through the process of reason, arrive at a particular outcome.

DR. GUTMANN:  Right.  Right.

DR. FARAHANY:  But to the concern that I've echoed a few times, one of the dangers in this area is if a teacher, if an educator, is trying to guide people in the process of deliberation toward a particular outcome and they have a particular ideological agenda, it doesn't teach students that it's okay to have a diversity of views.

And so I want to make sure that we emphasize in this report that the purpose of deliberation in the classroom is to teach skills, not to drive toward a particular set of what to say.

DR. GUTMANN:  Teach skills and the virtues of reasoning together respectfully.  Right?

DR. FARAHANY:  Yes.  Yes.  And it could be debates.  It could be requiring people to take the opposite side of what they might believe in order to engage in that process, not to try to have everybody reach the same conclusion or a particular outcome.

DR. GUTMANN:  Right.  So to teach skills and the virtues of reasoning respectfully together.  Let me just, though, do the ‑‑ if that's the Scylla which we want to avoid, which is the shoals ‑‑ what's the Charybdis?  The Scylla is we want to avoid the idea that everybody has to come to this conclusion.

The Charybdis is ‑‑ I will illustrate it by a real example.  The Charybdis is an assumption of total moral relativism.  Right?  So I had an example ‑‑ this is a real example, no names ‑‑ a high school teacher who assigned a set of readings on some practices of a cultural group in medicine with readings, and some of the practices were clearly, if you had some basic science knowledge, going to let people die rather than use the best science, the best medicine.

And the student wrote a paper saying that some of these practices were really medically ill‑founded.  And the comment that the teacher gave was that the student's views were equivalent to cultural genocide because the student was arguing that it would be good for those practices to change.

So while it is true that some teachers drive a conclusion, other teachers won't allow it if it's contrary to a group.  So we have both issues that need to be avoided.  And what we're recommending avoids both of them.  And what Nita said, there are some places that have extreme relativism and other places that have the opposite.

 We will say goodbye to a wonderful ‑‑ we thank you.  We thank you.

So I think we're all in agreement, but I don't want us to either ‑‑

DR. WAGNER:  I wanted to have the conversation.

DR. GUTMANN:  Yes.  I think we're really in agreement.  Okay?  I think we're set.  We can move on.

DR. ALLEN:  Could I just ‑‑ I didn't respond to Dan's response to you my comments ‑‑

DR. GUTMANN:  Oh, yes, yes.  Please.

DR. ALLEN:  ‑‑ about empathy because I needed to think about it for a minute.  And so I think I get the notion, which we've talked about quite a bit here, that deliberation might be seeking an outcome, education seeking to develop skills like analytic reasoning and the ability to deliberate together respectfully and so forth.

I just puzzle over where all of that leaves empathy and caring.  And I don't think we've, as a group, articulated where those things fit in.  You point out that, well, part of the professional training of doctors might be empathy as a clinical skill and so forth.

DR. GUTMANN:  Yes.  Yes.  I agree.

DR. ALLEN:  But I just think that in ordinary life, we do think that developing empathy and caring are important.

DR. GUTMANN:  Yes.  For sure.

DR. ALLEN:  I just want to have us not forget that we might need to somehow think about or incorporate that in our ‑‑ where we ‑‑

DR. SULMASY:  Moral character.

DR. GUTMANN:  Yes.  No, for sure.  You're right.

DR. SULMASY:  I don't think we're in disagreement in that sense.  It was just where it would be placed.

DR. GUTMANN:  Where we put it.  Yes.

DR. SULMASY:  I think it should be more in education than in the overlap between education and deliberation, that's all.

DR. GUTMANN:  Yes.  I think that's the ‑‑ and I think Ebola and Guatemala both raise the issue of some virtue of empathy, caring, or respect for others.  Any one of those virtues would work.  But they're mutually reinforcing, and they're all extremely important for ethics education.  So I think it's just a matter of where we bring that up, and since it hadn't been brought up, I think it is important to bring it up.

I think we've covered a lot of ground, and unless anybody has any other ground to cover, I want to just reiterate, as I always do, that we invite anyone ‑‑ speakers, people in the audience, those of you watching the webcast ‑‑ to write us with any and all comments.  You can submit your comments on our website, bioethics.gov.

And I want to thank our wonderful Commission members, our staff, the wonderful people who participated today, and our vice chair, Jim, who I will ask if you would like to say any ‑‑

DR. WAGNER:  Only that it's always a pleasure to deliberate with this group.  And Amy, again, thank you for your leadership.

DR. GUTMANN:  Thank you, and safe travels home, everybody.  So thank you.

                       

 

 

 

 

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