Genetic enhancement. Abortion. Assisted suicide. Informed consent.
These are among the most contentious topics in medicine, because they force us to ask ourselves, “What does it mean to be human?” When does human life begin, and end? Do we have the ultimate authority to dictate how and when our lives come to a close? What if we’re incapacitated? Could that render us less than human?
These questions keep presenting themselves to Nicolae Morar in new contexts.
Morar, an assistant professor of environmental studies and philosophy, specializes in bioethics—the study of ethical issues emerging from advances in biology and medicine. His exploration of the philosophical arguments underlying life and how we care for it has taken him from UO biology laboratories to bedside at the largest hospital in the region.
Morar has been selected to receive a prestigious UO teaching fellowship—the Robert F. and Evelyn Nelson Wulf Professorship in the Humanities—which he will use to design a new course in clinical ethics. This 10-week program will take students into Springfield-based PeaceHealth Sacred Heart Medical Center at RiverBend to explore, in a clinical setting, ethical dilemmas as they emerge in real life.
Q What abuses led to the founding of bioethics?
Nicolae Morar: Bioethics emerged in part as a response to some of the most morally egregious cases of human experimentation, not just during the time of the Nazi camps but also the Tuskegee (Alabama) syphilis experiment, where physicians were experimenting on human beings under absolutely deplorable ethical conditions. Bioethics offers a position from which we will always protect human dignity and personal autonomy.
Generally, people understand bioethics as medical ethics. But it also tracks relations between humans and their environment—for example, how living around sources of pollution affects health or how human impact could irremediably destroy nature. I’m part of a group advocating for an environmental understanding of bioethics as well, to think of questions of health more holistically, from human to ecosystem health.
Q What’s been in the news lately that intrigues you?
NM: It’s very interesting how the assisted suicide debate evolves. If human life is a gift from God, then it’s probably not something over which I should have the final decision of how to dispose of it or what to do in those final moments. But if we think of human beings as rational entities that can self-determine their behavior, that takes you in a different direction. And physicians—their vocation is to heal and to “do no harm,” but what’s harm? Isn’t there harm in letting someone go through months of suffering when the quality of life is diminished?
Q What will your students be doing in the clinical ethics course?
NM: The goal is to provide students ways to think about bioethical dilemmas and then expose them to real cases in the hospital. When we talk about stress in the medical profession, they’ll talk directly to a nurse because nurses experience that every day. When we talk about emergency medicine, we’ll hear from the physician who says, “Yes, we’ve got 30 patients coming in, it’s very hard for us, I’m always trying to do the moral thing, here’s how I try to think critically about these decisions.”
With my students, if we’re talking about assisted suicide or informed consent, they relate rationally to the cases, but it’s very different when you start relating emotionally. You cannot understand bioethics until you face the suffering that goes on in a hospital—then you can say, “Yes, informed consent truly matters.” Until you see a family completely split over the decisions to be made for a patient, or how difficult it is for health-care personnel when a cousin and a mother go in completely different directions regarding consent, you don’t realize what informed consent is.
This course starts in winter 2017—a 10-week program, one week in the classroom, one week in the hospital, alternating. It would not be possible without the help of John Holmes (the hospital’s director of ethics) and the Oregon Humanities Center.
Q I understand your thinking about human health has expanded to include microbes?
NM: Historically, we have thought of the human organism as made only of human DNA—half from my mom, half from my dad, and the way I function is supported by this cellular material. That’s the concept that I came to the UO with, and then I met microbiologist Brendan Bohannan. And he said, “That’s probably false.” (Morar laughs). He showed me that in terms of biological diversity, what makes us human, in a lot of ways, is the number of genes that microbes are adding to us—adding to our body, microbes on our skin and especially in our gut.
We are mainly made of microbial cells. Most digestion is done by microbes, and the ways in which they achieve this affects who you are as a human organism. Which ones are in your gut, for example, really matters as far as whether or not you’re at risk to become obese.
I thought, “This is amazing, the question of what it means to be human comes back to me in one of the most interesting and challenging ways.” Microbiologists are saying, “Stop thinking of microbes just in terms of germs that you fight; they do more good for us than you can imagine.” If we think of our microbes as an organ, that could affect therapies. If you have heart failure, we’ll try to find you a heart transplant; if you have a failure with the function of your microbiome, there is now a procedure to “transplant” microbiota into your system. The notion of health is much more dynamic than we thought previously.
Q How does the human micro-biome relate to philosophy?
NM: Scientists often believe there is an overarching framework that explains the whole story about a certain phenomenon, such as the human microbiome. Philosophers can highlight the assumptions that scientific knowledge is based upon and show the limitations of certain scientific claims. As a result, there are five or six competing views that explain our relationship with the microbes that have made a home of our bodies.
Brendan and I are evaluating those concepts and the ways in which each fails, in some way, to tell the whole story. We’re saying, “Don’t rush this process.” There are numerous concepts trying to capture this phenomenon—that shows the complexity of the phenomenon and that no single framework could capture it on its own.
Q Another medical debate: What have you learned about Big Pharma giving gifts to physicians?
NM: In an effort to promote drugs, pharmaceutical companies invest tremendous amounts of money in gift-giving to physicians. Working with Natalia Washington (of Washington University in Saint Louis), we asked, “Why have legislative restrictions against physicians for receiving gifts had zero—or limited—effect?”
Physicians have been required to report gifts over a specified value, toward discouraging them from accepting lavish gifts that would be embarrassing to disclose. But pharmaceutical companies continue to spend more and more money on gift-giving—the practice continues unabated. The restrictions didn’t work because they’re based on the assumption that, as rational beings, we will consider the pros and cons of our actions.
Social psychology tells us that there are other parts of our cognition at play here. For example, if a physician is repeatedly presented small gifts that carry the label of a new drug, he or she is more likely to decide that that’s the best drug, even without the evidence to support that belief. Those thought processes are largely unconscious. Physicians need to know that this is how the brain functions in that situation, and that they’re likely to prescribe those drugs disproportionately.