Government agencies and professionals who deal with damage claims are literally trying to determine the dollars-and-cents worth of human life. How do we decide what is an efficient annual cost for a nursing home? Or the cost for a new liver? And who is going to pay? Dr. Willard Gaylin was a psychiatrist and president of the Hastings Center, an institute devoted to studying the relationships between biology and ethics. In this episode of World of Ideas, Gaylin explored the growing conflict between the survival of communities and the survival of the individual.
BILL MOYERS: [on camera] Good evening, I’m Bill Moyers. When I was growing up in Texas no Fourth of July oratory was complete without references to the “dignity and worth of the individual.” The phrase became a cliché, true but boring. Now it’s taking on a new meaning. Government agencies and professionals who deal with damage claims are literally trying to determine the dollars-and-cents worth of a human life. The numbers range anywhere from $70,000 to $132 million. With the proliferation of expensive medical treatments we’re all going to be punching the calculator to assess – well, perhaps to assess the value of the life sitting there next to you right now, your grandmother or grandchild. How do we decide if $30,000 a year for a nursing home is cost-efficient? Or a quarter of a million for a new liver? And who is going to pay? In this broadcast we’ll talk about economics and ethics with Willard Gaylin.
[voice-over] Caring, anger, love, despair. Dr. Willard Gaylin has spent his life exploring the feelings and emotions that bless and bedevil us all. He is an author, a practicing psychiatrist and president of the Hastings Center, where he studies the relationship between biology and ethics. At his home in New York’s Hudson River Valley, we talked about some hard choices facing America.
[interviewing] Here we are, just 12 years away from the 21st century. What do you think is the most pressing ethical issue we have to face between now and then?
BILL MOYERS: Another way of saying what you’re saying is, Americans have to begin to accept some limits on their personal, individual autonomy?
WILLARD GAYLIN: Absolutely. We began to do it and we’re capable of doing it in crisis. Certainly, we did it during The Great War when people were mobilized. But you see the gas shortage, no one takes it seriously, no one wants to take it seriously. At a time of a real crisis, I think Americans not only could do it but would enjoy doing it. One of the most incredible things, really, is to see the typical middle-class kid who’s given everything he wants, everything, except the privilege of service, the privilege of self-sacrifice and the joy of being a giver. We’ve become a passive society that sees everything in terms of our open mouth — fill it with something — and the whole idea that we can actually do things for something broader, a community, is lost. Now, partly, communities have broken down. Most people don’t really take religious communities that seriously anymore. It’s very tough to identify with something called New York City, I mean, you can identify with your block, maybe, or a community, et cetera, but communities have broken down. And I think we have to pay much more attention to the nature of that.
BILL MOYERS: What does this mean in terms of some hard choices? For example – and you’ve written a lot about this – are we going to be able to help everybody who wants to stay alive stay alive?
WILLARD GAYLIN: No, and I think this is the next crisis. Perhaps I’m thinking more of the collective good now than I would have 15 or 20 years ago or when I- certainly when I was in medical school, because we are now on the threshold of a giant success in medicine. And, while most people may not realize it, it’s always our successes that get us in trouble, because successes give us choices. At one time, medicine couldn’t do anything except give you comfort. It sure couldn’t save lives. My professor of physiology once said that medical intervention probably took more lives than it saved, and he was right; and he claimed that almost up to the year of training. That, I don’t believe. I think World War II, the ’30s was the change, with the antibiotics. But now that we’re getting into genetic engineering, now that we’re getting into molecular medicine where we actually get down to the level of the cell, we are going to be able to do extraordinary things. Now, with those choices that we have – and all of them are expensive choices – Americans are going to have to face a dreadful thing, the whole world is, but we particularly – that now we are not going to be able to afford the most important thing there is, and that’s life. And that’s the irony, that the thing we’re going to run out of, that is going to force us to think collectively, are lifesaving devices. They are simply too expensive.
BILL MOYERS: In other words, we cannot afford for everybody a kidney dialysis machine or an artificial heart. Is that what you’re saying?
WILLARD GAYLIN: Yes. You know, it’s an interesting point. People say, well, we’re spending 11 percent of the gross national product – that’s a staggering amount – and who says that it’s too much? So let’s say it’s not too much. Let’s say 15 percent. Let’s say that I’m a total pacifist, I don’t believe in Star Wars, I don’t believe in any- I don’t believe in Star Wars but- so we’re free to say that. But sooner or later, we’re going to run out of bad guys. Sooner or later, it’s going to be good guys versus good guys. The rising cost of medicine is going to be medicine versus education, medicine versus public safety. We’re going to have to have some kind of a defense establishment somewhere along the line. We certainly don’t want to see the decay of our cities.
So we are going to have to limit medical costs and it’s a hard thing for people to realize, that the costs of medicine are not due, again, to the easy answers: greedy physicians, sloppy techniques. Now, we do have greedy physicians, we have sloppy techniques, there is a lot of fat in the system. That’s all hogwash, that is not what causes expensive medicine. What causes expensive medicine is our successes. What most people don’t realize is that good medicine increases morbidity. There’s more sickness. There are more diabetics alive in the United States than there are in Libya. I mean, I don’t have those figures but I’ll bet on it.
BILL MOYERS: I get the point, right.
WILLARD GAYLIN: So that what we do is we keep sick people alive. Also, they say, well, then we should do preventive medicine. There is no such thing as preventive medicine ultimately, in that we’re all going to die. It means that you prevent a child from dying of a childhood disease, which has a humanitarian purpose but not an economy purpose because he will then live to be a very expensive old man. Or, if you save him at the beginning of life, it will be very, very expensive. So here we’re going to be faced with this terrible irony. Now that medicine can really do something, really deliver what we used to con people into thinking we could deliver, and that is life-saving, we can’t afford to do it.
BILL MOYERS: The implication of what you’re saying is that we will have to decide that some lives have a greater claim on us than other lives.
WILLARD GAYLIN: Absolutely. Here’s what happened. Those choices used to be made by physicians because they occurred in the house of medicine, with the language of medicine, using the metaphors of medicine, but they are not medical decisions. Those decisions are human decisions, philosophical point of view decisions. Now, I think we do have a point-of-view. People try to avoid it by saying, “Let’s make enough of everything.” Well, we’ve gone through that. You’re not going to be able– we did it with the dialysis machine, and we cannot with each new succeeding generation of technology. Impossible. We will bankrupt ourselves. So then they say, “Do it by chance.” Chance is somewhat immoral, it seems to me.
BILL MOYERS: This would be a lottery. I’ve actually heard suggestions that we do a lottery to decide whose life is-
WILLARD GAYLIN: And wouldn’t that be strange if I’m 96, dying of terminal cancer, praying to God that I don’t wake up in the morning and it’s against my moral principles to take poison or something like that, and there’s a child that’s brought in with an acute intoxication, swallowed a bottle of aspirin or something and we both go into a kind of emergency status. Is it not immoral to put his name and my name into a hat and pull one of them? We can’t do it that way.
BILL MOYERS: But as long as you have the power of choice, you could say, “I don’t want my name in the hat.”
WILLARD GAYLIN: Yes, you could. But what I’m saying is we may get down, after we’ve made certain broad values, to a kind of lottery system. I certainly don’t want to sell it and that’s what we’re doing now.
BILL MOYERS: We are selling-
WILLARD GAYLIN: Oh, and how we are.
BILL MOYERS: It’s a marketplace.
WILLARD GAYLIN: Oh, and how it’s a marketplace. I remember – I want to be a little protective – talking to a — let’s just say a distinguished transplant surgeon who didn’t know I was a bioethicist. And we were both sitting there — I was going to speak –on the dais, but he didn’t know my name. He said, “You’re a doc, aren’t you?” And he said, “What’s all this baloney about” – baloney was not his words – ” bioethics?” And I wasn’t going to answer him, a big tough looking guy, and I asked him what he did and he said he was a transplant surgeon. I knew what he did, he was a very famous man. And when he talked about it, he became gentle and tender, described what it is to put a liver into a child and see all systems light up. It was like Genesis, I mean, it was poetry, it was so romantic and touching. And I said to him, “How much does it cost’!” He said, “$200,000.” I said, “How do these kids pay for it?” And it was the shortest, briefest answer I ever got: “Up front.” And I gave him a look and he said, “Well, you don’t expect the University of X to subsidize this. We couldn’t afford it.” I said, “Does that bother you?” He said, “What do you think I am? I’m a human being.” I said, “That’s maybe what we mean by bioethics,” and I ran up the dais to give my speech.
BILL MOYERS: But he was saying that the market determines it there.
WILLARD GAYLIN: Oh, absolutely.
BILL MOYERS: Those parents could pay. The parents of a child down the block or up the street couldn’t pay, that child dies.
WILLARD GAYLIN: Yes, and even if it isn’t pay, it’s often things like getting on television, having access. There has to be a better system, and we are going to have to do dreadful, dreadful Sophie’s Choice kind of things.
BILL MOYERS: How do we do that, Gaylin? I understand when you say the imperative, there has to be a system, but how do we devise a system?
WILLARD GAYLIN: I think it’s collective wisdom again. I’ll give you some extremes and then you can fill in the tough cases. It seems to me that if I were to name a three-day-old zygote — it just happened, three nights ago, you made love to your wife and it’s there — a three-month-old fetus, a nine-month-old fetus, a one-second-old child — just one second changed that fetus to a child — a nine-year-old, child and an 80-year-old man. I think, if I gave that to you and me, our collective audience, we would have a massive consensus. There might be some that say, “I refuse to judge,” but most of us would say that the nine-month fetus is a different thing from a three-day old zygote and has a different claim on life. Most of us, if it were our child, would say that even the nine-month-old fetus is not to be put –his name is not to be put in the lottery with our nine-year-old child. And most of us would say that the nine-year-old child has a greater claim than the 80-year-old man. Now, I leave the distance between the nine-year-old child and the 80-year-old man, those are very, very difficult. And it may be that, as we squeeze down, then we may go to some kind of a lottery system, if necessary. But we must moral judgments first.
BILL MOYERS: If you were knowing of your condition and the choice were yours, do you think you would take your name out of the lottery?
WILLARD GAYLIN: I’ve often said if my name were in with my grandchild, let’s say, and my name were picked and I survived, I would — my first act on survival would be to throttle the person who did it. I’m not a conventionally religious person, I’m a romantic, which may be another way of saying it. My grandchild, or -children — I said this first, I thought of this first at the birth of my first grandchild — is my immortality. That’s my future. That’s not just my biology, it’s that future, too, but one of the things that astounds me is I find my grandson behaving like my father whom he never met. Now, that’s a kind of miracle. That means that something went from that father to his son to my daughter to that grandchild. And that’s my immortality, that’s my reputation. To destroy that would be to destroy me.
I’ve lived my 60 years. I’ve had a good life. I’ve had kids. I don’t want to die but there’s no great tragedy, but it would be a tragedy if you took away one of my children before they’d had this opportunity, one of my grandchildren, and I hope I’m unselfish enough to say other people’s children.
BILL MOYERS: Doesn’t fate run the biggest lottery of all? Circumstance, happenstance?
WILLARD GAYLIN: Well, I suppose, in the sense that my children were lucky to be born in Hastings — on Hudson, not in Calcutta — and that’s one of the biggest lotteries — or in North Africa, let’s say.
And that does raise other questions. I mean, if we stick even with our medical model, is medical
humanism something like an export-import product in which you reserve it to the borders of
your country? You know, if we spent piddling amounts of money on tropical diseases which kill millions and millions and millions of people — much, much more than the cancer or hypertension that we’re dealing with now — children, young people. But no one who lives there is terribly important. It’s an area that doesn’t attract attention. We could have had a cure for malaria, we could have had a cure for schistosomiasis, all these horrible parasitic diseases, but that isn’t a terribly important area of the globe. So we do tend to think about our own problems and I — look, that’s human nature.
BILL MOYERS: But the other side of it is that you make life more tolerable when they are at the fragile state of youth and they grow up to become childbearing parents, you get what is in The Times this morning; India’s population is shooting up again at a horrific rate that has all the public officials there frightened that if they don’t find some way to bring birth control under control in India, the population’s going to be rampant and out of control.
WILLARD GAYLIN: Oh, I think that’s absolutely true. I think population control is one of the major ethical questions and those who are opposed to population control have to then face, in their own
mind — I have no problem with that because I consider that a primary concern, international
population control. I have no problem with that at all, but those who do feel that there’s something immoral have to then face up to the fact of how they’re going to allocate the limited resources we have. The hard choices are going to be beyond that, too. They are going to be in valuing life and, you know, people say, well, you’re on a slippery slope. You going to allow it here and not there. And we are going to have be on a slippery slope and we’re going to have to draw a line. And I’ll tell you what happens because I’ve done this. You draw a line and someone says, “Hey, wait a second. You mean that the person this side of the line is that different from that side?” And they can make you look like a fool. Now, of course, a person who is 17 years old, 11 months and 29 days and can’t vote isn’t much different from a person who’s 18 years old. But you draw a line or else you go through life slopping through real problems and making no decisions and taking a passive approach.
BILL MOYERS: But don’t Americans prefer sloppiness in their moral and ethical situations?
WILLARD GAYLIN: Well, what really-
BILL MOYERS: Each one makes his or her own call, as you said earlier on.
WILLARD GAYLIN: What they really prefer is optimism and denial. They don’t- that’s what America’s all about. They don’t want to believe there’s a problem. We don’t like- I mean- you know, I used to talk about running out of things and I used to make a joke. I’d say, “No one believes we’re running out of anything. I think we’re running out of everything.” And I used to say, “We’re running out of out.” Out is where my parents threw their garbage. You threw the garbage out. You can’t throw the garbage out anymore. Out is where your children are going to live, where your grandchildren are going to live, but Americans can’t face it, and I never understood why — Europeans can face limitations, shortages, et cetera — until I heard a friend of mine, a historian, giving an entirely different lecture. And he explained that Europeans are raised with boundaries, with frontiers. You can only drive your motorcycle up to the frontier, then you stop. You can only sow the grain to the frontier and then you stop. You only cut timber to the frontier. Americans, even though most of us weren’t pioneers, are raised in a tradition shaped by an open frontier. You run out of timber-
BILL MOYERS: You can always run somewhere-
WILLARD GAYLIN: -there’s always more. Go get it. It’s not here? Dump it, move on to the next frontier. So we don’t like to think of limits. We’re also on the go. You were raised in the South, I was raised in the Midwest. I mean, I was panting by the time I was 16 to get into the car. I knew how to drive by the time I was 12, you know. My father’d let me sneak a ride in here or there. We’re mobile people, and so we want to go. So, I think the problem with Americans is that one, they deny. Two, they cannot accept the concept of limits and three, the fact that there has been simply too much emphasis on the individual rather than the group. And even speaking biologically, it’s just such nonsense because we — one of the things we’ve learned — it’s a fascinating thing. You deprive a child — I wouldn’t do this experimentally — but you deprive a child by accident of contact with human beings and give him perfect nourishment, and he becomes an incomplete adult. He loses those qualities that are most identified with being human: the capacity to form attachments, the capacity to have guilt, the capacity to foresee the future, in other words, the capacity to have conscience and love.
BILL MOYERS: Do you believe that we are, as you once did, biologically endowed with the faculty for caring?
WILLARD GAYLIN: Absolutely, absolutely.
BILL MOYERS: Is there any evidence for that?
WILLARD GAYLIN: There’s plenty of evidence. There’s the evidence of the fact that — look, you know, knowledge and culture are a very short time, 20,000, 30,000, 40,000 years. The fact is that we had to exist before culture and not gobble up; during periods of hunger, little babies. The human infant is born so helpless, it’s unique among animals. It’s partly the explanation –the brain is so big, we’re upright, the pelvis is so small. What comes out is an unformed child like no other mammal. After all, a little foal comes and runs away. A baby can neither run from danger, or fight it off. It’s totally helpless. So we have the most prolonged dependency period possible. If we didn’t have a caring tendency in us, no species so constructed with this prolonged dependency period could possibly survive.
BILL MOYERS: Well, I can see that the species, that the organism has within it this need of dependence. But what I don’t understand is, if there is this caring faculty in us, why is there so much child abuse, so much family violence, which is the opposite, of course, of care?
WILLARD GAYLIN: Because this extraordinary, wonderful, terrifying creature, homo sapiens, with which I’ve had a lifelong love affair, is unique among all creatures. There’s a wonderful Talmudic quotation which, in a sense, says if God had intended man to be circumcised, why didn’t he make him that way in the first place? And the answer, with the wisdom of the sages, is that man alone among creatures is created incomplete, with the privilege of sharing with his Maker in his own design. And that is true. Of all the animals, we are the one least dictated to by genetics or by nature. And we have the capacity to shape ourselves for good, or for evil. So that, while we are endowed with certain caring features, we can create a corrupt human being, we can create a corrupt race of human beings and eventually destroy ourselves. Because we are incomplete, we have the capacity — through the way we’re brought up, through the way we’re raised, through the way we’re treated — to become that which we choose, or even that which we do not choose, that which we’re made of.
BILL MOYERS: Well, how do we connect these as we head toward this 21st century? This obvious necessity of beginning to make choices that are more fair than unfair, to distinguish between who can and cannot live, who we will and will not pay for, in a caring way that somehow makes the stresses and strains of the modem world, which are in many respects more stressful and more frustrating than in a long time, how do we make this a more benevolent and fair and just society as we move toward these terrible problems?
WILLARD GAYLIN: Well, I would start — when I said that we’ve lost the sense of community, let me start from what I consider the most fundamental community, the one from which all other communities started, and that’s the family. It’s intriguing to me how people will get all exercised about high-tech things when it’s low-tech things which really should concern us.
BILL MOYERS: What do you mean?
WILLARD GAYLIN: Well, the surrogate mother.
BILL MOYERS: Right.
WILLARD GAYLIN: The surrogate mother is an interesting problem, but it’s no threat to our society. The illegitimate teenage mother is a threat to our society. If we destroy that last nuclear cement of community, the family — and we are well on our way to it, between the illegitimacy rates as they are, the fact that they’re being born to teenagers, the fact that there’s only one parent in the household, the fact that even — and we’re talking now about poor, underprivileged groups, black urban groups — but then you have in the middle-class groups, divorce rates what they are, with children, particularly, not taken care of — if we destroy the nucleus of the family, I really think we are in trouble.
BILL MOYERS: But it is destroyed, Gaylin, I mean, I don’t think society can will back the idea of the family that existed when you and I were growing up. I don’t think society can order — I mean, if it could, I think I would be inclined to do so, but I don’t see realistically how society can order a husband and a wife, when they’re not there.
WILLARD GAYLIN: Well, you know, we’ve discovered that the family when I was young isn’t the family it is now anyway. The family had an awful lot of cousins who showed up at grandma’s house every Sunday and uncles and aunts and there were six children and one of my grandparents had seven children and the other one had nine, I think, altogether. I can’t keep track. Today, no one has more than two. It’s considered a little vulgar to have more than two children and, in many ways, going back to the question of population control, maybe it’s immoral to have more than two. Now, it doesn’t mean that we’d have to have the old kind of family, but it may be that when we talk about priorities and allocation of scarce resources, such things as respecting the time that a parent spends with a child, allowing some funding from the government for that, so that we recognize that a child simply can’t be cast out like a kitten to mend its ways. It can, but what you’ll get is a wildcat. You won’t get an adult human being. So it may be, as we budget our priorities – and here we may come right back to the election year — we ought to begin thinking about new ways to produce a kind of collective environment. I don’t care what you call it, if it isn’t the family you knew, you’d better invent something, because if you’re going to have a working mother and a working father and neither of them are going to have time for the child, you are going to get a different kind of person, a noncaring person and you may get, if it’s bad enough, an incomplete person.
BILL MOYERS: What I hear you saying is that our society’s going to change. That in order to grapple with, and sort out these very tough choices, we have to act in a way that will impinge upon the autonomy of the individual.
WILLARD GAYLIN: Absolutely.
BILL MOYERS: We have to act more as a community.
WILLARD GAYLIN: Absolutely. And one of the intriguing things, I think, is just as ethics got a rebirth with technology — you know, Science was going to kill God. It turned out that Science rediscovered Him because of all these questions we had then — I think that all these high tech-things which scare us are forcing us to reexamine things that slid by, and I think that when we begin to look at our resources and the fact that they’re limited — and maybe we don’t want a left ventricular pump, either, or maybe we do want it, or an artificial heart — we’re going to begin to have to look at all of our institutions, because the choices are so massive, and look at some of the things we’ve lost and maybe not replicate them the way they were in the past, but find some creative alternatives.
BILL MOYERS: [voice-over] From his home in Hastings, New York, this has been a conversation with Dr. Willard Gaylin. I’m Bill Moyers.
This transcript was entered on March 25, 2015.