Art Caplan’s dissertation in philosophy – examining why evolutionary theory is scientific and creationism is not – didn’t make it to the bestseller’s list when he wrote it 25 or so years ago. But the field he ended up in, bioethics, has put him front and center in the discussions of issues such as transplantation, end of life, and reproductive technologies that are now making headlines in the popular media.
Caplan, chair of the department of medical ethics and director of the Center for Bioethics at the University of Pennsylvania, will speak about the ethical concerns surrounding avian flu and other pandemic threats on Thursday, February 7, at the Princeton Friends School.
Caplan will address ethical issues surrounding rationing and allocating scarce resources, such as flu shots, when a pandemic comes. Who, for example, gets access to respirators? Before flu vaccines are available, says Caplan, "we will want to figure out how to save the most lives and quality of life." The questions that will emerge are whether, for example, to take an 80-year-old off a ventilator in favor of a child of six or whether to treat people who live in a region before either those passing through it or illegal immigrants. "They will probably lean toward children and an efficacy standard – who is likely to benefit most," he says.
Who gets the flu vaccine? At this stage the goal is not just helping the people who get sick but also trying to prevent the epidemic from spreading. The decision here is likely to give shots first to people who have a lot of contact with others – doctors, food deliverers, daycare-center workers, policemen, and military people.
What about people in other countries? Even if the smartest approach might be to control the epidemic in other countries, Americans might be unwilling to send a scarce supply of flu shots, say, to Thailand. But the result may be that the people in Thailand, sick or not, infectious or not, will travel wherever they please.
Caplan found his way to bioethics a bit circuitously. While a pre-med at Brandeis University, he became interested in philosophy and decided to pursue a graduate program at Columbia University after graduating from UPenn in 1971. Then in 1978 Columbia’s medical school approached the philosophy department, looking for a philosopher with an interest in medicine to teach a class in medical ethics. With his pre-med background, Caplan got the job. And that turned out to be the start of a long career in bioethics.
That first class Caplan taught to medical students didn’t go so well. As he remembers it: "It was horrible, and everyone hated it." And indeed people stopped coming. When he sought advice from the pros, they said he had been too theoretical and taught it too much like a straight philosophy course. Instead the dean of students suggested that he teach cases and he then offered Caplan the chance to enroll in the medical school for a year but with a little more freedom than normal med students.
He ended up taking three first-year medical school classes and sat in on two rotations, neonatology and rehabilitation. Rehab, although not a very prestigious part of medicine, turned out to be particularly interesting – a place where lots of things go wrong, with ethical decisions galore.
A bit of an outsider and an observer, Caplan was often privy to what people were really thinking. "People who were not willing to openly discuss their views of right and wrong with patients and colleagues would discuss them with me," he says.
He did one more year of observation and then redesigned his course. After finishing his dissertation in 1979, he continued to work at Columbia as an instructor in medical ethics until 1982.
While at Columbia, he heard about the Hastings Center, an early think tank on medical ethics – from someone sitting next to him on a plane. He visited, and they offered him a job. It was definitely a diversion from the cookie cutter academic path and "it was also crazy, because they had no money and no budget," he says.
Everybody who was anybody in medical ethics came through the door at Hastings, and Caplan got increasingly interested in neonatal issues. When Ronald Reagan was pushing to mandate treatment for every infant, Caplan opposed it. "Some infants are not viable," he says, "and in some cases you are prolonging dying." Caplan’s first TV appearance was an argument with C. Everett Koop, Reagan’s surgeon general, on this issue.
Another issue he became interested in surrounded treatment of people with kidney failure. As Caplan listened to people at Columbia and Hastings argue about how to handle the shortage of dialysis spots, he pushed for the idea of getting more donor organs. Since there were not enough organs available, Caplan worked with the New York State legislature on a law requiring hospitals to ask families about donating organs when a patient died. This Required Request law, he says, is now on the books in every state.
After working his way up to associate director of the Hastings Center, Caplan moved in 1987 to the University of Minnesota to start a program in medical ethics. While building the program, he also brought medical ethics out of academia into the community. "Part of the reason we do this is to empower people," he says, and he has spoken on radio and television, to church groups and civic associations, and he even wrote a column for the St. Paul Pioneer Press," which was syndicated and picked up by over 100 papers.
Yet again, his path was not the prescribed one. He says, "It’s not for the faint of heart – bucking university culture, which is to generate new knowledge that is useful for other academics." During this period, he also became interested in end-of-life care and the rights of people to refuse treatment, including feeding tubes.
In 1994 he came to the University of Pennsylvania to set up the first department of medical ethics, and today it has eight faculty and 150 students.
As for whether we will really see an avian flu pandemic, Caplan is definitive: "It will be a pretty nutty time if there is a pandemic," he says, adding this warning: "Bird flu is still there, churning along. It will come."
Art Caplan, medical ethicist, Thursday, February 7, 7 p.m., Princeton Friends School, Quaker Road. For more information, contact Jill Feldman at 683-1194, extension 16, or E-mail firstname.lastname@example.org. To reserve seats, ask for extension 70, or E-mail email@example.com