EP60 Bioethical Decision-making in Healthcare with Jamie Webb

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I AM GPH EP60 Bioethical Decision-making in Healthcare with Jamie Webb

EP60 Bioethical Decision-making in Healthcare with Jamie Webb

Alexandra Arriaga: Hello everyone and welcome to I AM GPH. My name is Alexandra Arriaga, and today we have a very special episode because we're going to be talking to one of our students, Jamie Webb, who is completing his MA in the bioethics program here at NYU. This program was founded through NYU Center for Bioethics, and it actually lives under the GPH umbrella. It was one of the first programs in the world to promote a broad conception of bioethics encompassing both medical and environmental ethics. We're also going to talk about the bioethics field, Jamie's experience as a student here at NYU, and finally, he's going to run us through some exercises in which we will be discussing some pretty controversial ethical issues. So, if you would like to learn more, please stay tuned. Hello Jamie, how are you doing today? 

Jamie Webb: I'm very well Alex, how are you? Nice to speak to you. 

Alexandra Arriaga: So, for everyone that does not know you, can you please tell us a little bit about your background? 

Jamie Webb: Okay. So, my name is Jamie Webb. I'm a student in the bioethics masters program here at the School of Global Public Health, NYU. In terms of my background, it's kind of been a bit of a circuitous route to this point. I did my undergraduate in philosophy at Cambridge University in the U.K. I then did a fourth year in history and philosophy of science. That then led to the entirely unrelated job of being a secondary school English teacher with an organization called Teach First, which is kind of like the British equivalent of Teach for America here. 

Alexandra Arriaga: Okay. 

Jamie Webb: So, I ended up teaching at a school on the south coast of England. A kind of rural-ish area. I taught English there to secondary school students, so sort of 11 to 18, for two and a half years, which was really fantastic, but then kind of wanted a change of scene, I suppose, and wanted to go back into more academic work. So, then I applied here to NYU, managed to get here on a Fulbright scholarship from the U.K. So, that's how I ended up here, yeah. 

Alexandra Arriaga: Amazing. I don't know if you can tell, but Jamie is from England. And so, what inspired you to pursue the bioethics concentration here at NYU? 

Jamie Webb: So, it's a really lovely little department in the School of Global Public Health. I'd say that it has a really nice mixture of practical applications and practical focus, with some really great philosophers working in the department. The teaching is excellent, especially because it's quite a young department of academics. They're really passionate about bioethics, about philosophy, and the cohort size is kind of reasonably small. There's probably like, I don't know, about 30 of us in the department. We have lots of the same lectures together. It's all very seminar, discussion based. It's really dynamic. All of the classes are a lot of fun, and you get to know everyone within the cohort really well. The department has really close links to the philosophy department, and for anyone kind of interested in philosophy, the philosophy department at NYU, it's kind of like The Avengers of philosophy. You read down the list of names and you're like, "Oh my God, it's Thor and Captain America and David Chalmers." It's crazy how many great philosophers work here, so that's very exciting. They have very close links with them. The best moment of my entire year was when David Chalmers said, "Hello," to me in a lift in the philosophy department. That was pretty amazing. 

Alexandra Arriaga: Lift is elevator, right? 

Jamie Webb: Oh, sorry, lift meaning elevator, yeah. But then also, as well as how great the department is, how great the philosophy that we do within there, and the greats links to the philosophy department, there's also really great links to obviously areas of concentration in the School of Global Public Health. Things like public health policy, there's lots of ethical issues arising here, and departments like the medical ethics department. There's really close links with that, which gives a really nice, practical and healthcare focused branch of bioethics, because obviously that's where a lot of the really interesting stuff gets done. 

Alexandra Arriaga: So, speaking about that interesting stuff, what type of jobs do bioethics professionals do?

Jamie Webb: Oh, well, obviously there's been lots of philosophy factories opening up recently. There is a big, booming industry and there's lots of jobs in the field. But it's actually ... So, I think if people here, you know, bioethics being a lot of philosophy, then that can give people the impression that basically, there are no jobs because you're doing philosophy. Like, why are you doing philosophy? Why aren't you doing something practical? This is useless. That, I would argue, is not true. 

Alexandra Arriaga: As a good philosopher would. 

Jamie Webb: As a good philosopher, I would argue that is not true. I think bioethics ... I mean, basically, if you're in philosophy and you're into mathematical and philosophical logic, then probably your jobs are going to be like being a philosophy professor, or maybe something, I guess, like techy or something like that. But bioethics is actually a really good concentration for careers. So, obviously there are academic paths, so lots of the people that do the bioethics MA go onto either philosophy ... So, some people do philosophy PhDs, and then become academics. Bioethics is a really good concentration to have if you want to go into academia because it's really popular amongst undergraduates especially, which means that within philosophy departments, if you can teach bioethics, that's a really employable thing because lots of undergraduates take bioethics courses. For some reason, they find reproductive ethics more interesting than intro to formal logic. I mean, don't know why that is. Probably because it's significantly more interesting. 

Alexandra Arriaga: Yeah. 

Jamie Webb: So, that's a really good career choice. Also, lots of schools now are getting dedicated bioethics departments, like NYU has its own dedicated bioethics departments, so that's really good for that branch. Also, people often combine it with medical degrees, and if you're studying a bioethics MA as part of a medical degree, that's a really great thing because as you get working in a clinical context, one of the big areas of bioethics concern is what you might call sort of clinical ethics, so ethics within clinical healthcare practice. As you can imagine, ethical issues arise in hospitals every day. You know? A doctor recommends a course of treatment for a patient who refuses it. The doctor isn't sure whether that patient has the capacity to make that decision because they seem to have false beliefs about what that treatment entails, or the treatment seems so obviously beneficial that the doctor is confused as to why the patient will refuse it, so they have to have a clinical ethics consultation about, what are the situations where imposing treatment, maybe against someone's wishes, is ever, if at all, permissible. Issues where parents are wanting different treatments for their children than what the doctors will recommend. There's often lots of kinds of clinical ethics issues there. 

Alexandra Arriaga: I've heard the classic case of the patient that comes into the hospital, he's unconscious, he's brought in completely unconscious. They open up his chest to resuscitate him, and he has the Do Not Resuscitate tattoo. 

Jamie Webb: Yeah, yeah. I mean, I think generally hospitals will err on the side of resuscitation. I mean, how long has that tattoo been there? He could have got that 15 years ago and his views might have changed since then. In those kind of emergency contexts it's very hard to know exactly what to do. But there might be a case where there's a bit more thinking time where a 17 year old person refuses life extending treatment. There was a case in the news a couple of years ago of a 17 year old ... I mean, I guess whether you call her a 17 year old girl or a 17 year old woman is kind of relevant in this case in terms of how much control they should have over their medical decisions ... Who refused chemotherapy for their cancer. The doctors judged that, if pursued, that course of treatment, 85% likelihood of getting rid of that cancer entirely. The patient refused that treatment on the basis they did not want to go through chemotherapy. They had very strong views about chemotherapy would be poisoning her body and she would prefer to have more natural, kind of holistic therapies, rather than more traditional medical interventions. Now, she was 17. She was about three months short of her 18th birthday. Very strong principle in medical ethics that if you are an adult with capacity, you have autonomy over your medical decisions. No one can force you to undergo a treatment that you do not want to engage in, even if it seems definitely in your best interests. But we have that cut off point of 18 where you are assumed to have that capacity to make that decision. In three months, there would be no question as to whether doctors could impose that treatment on her, but there was a question of, at 17 she's not an adult. She's not at that age where she is legally allowed to make those decisions. Can that treatment be imposed? It's tempting to say that ... I mean, it's a tricky issue, because she was very much lucid, very much understood the details of her illness, wasn't denying the fact that she was ill, but just thought that homeopathic remedies was going to be the best way to treat her condition. Now, I don't want to be too controversial to say that's probably, almost certainly, based on the evidence we have a false belief. 

Alexandra Arriaga: I feel very strongly about homeopathy in the sense that it's based on, quotation marks, “scientific principles” that are actually not true. I think they believe in potentiation, which means by diluting a substance multiple, multiple times until it's almost parts per billion, it somehow intensifies the effect. 

Jamie Webb: Yeah, that seems strange. 

Alexandra Arriaga: Yes. I'm a chemist, so to me, I know that's not how it works. 

Jamie Webb: Yeah, I often think that it's true that natural ingredients and natural remedies can be beneficial in terms of people's health, but once they're proved to be beneficial, they just start being called medicine. That is then part of the package of care that doctors will offer their patients. But nevertheless, if this has happened in three months when she was 18, the fact that she had this, what the doctors and most people might view as sort of strange and incorrect belief would not preclude her from refusing that treatment. So, did the doctors have some duty of care to a child which meant they could overrule that decision? I mean, we actually looked at what happened to her and she kind of went off the grid. 

Alexandra Arriaga: I was about to ask what happened. 

Jamie Webb: Yeah, she went off the grid. She received treatment for a short while, and it was proving effective, and then stopped, kind of, yeah, ran away, and then a few years later there was a Go Fund Me page for her saying, "The cancer has returned and it's worse. The homeopathic remedies didn't work. Can we get some funding for this treatment?" 

Alexandra Arriaga: That's sad. That's so sad. 

Jamie Webb: Yeah. But that's the kind of stuff that comes up in clinical ethics contexts, and lots of different stuff, often around whether a patient has a capacity to make a particular decision, or whether treatment in the best interests of the patient should be provided even if they're not entirely with their consent. And if you're doing a medical degree and you do bioethics, then you'll end up having the opportunity to do clinical ethics consultations where healthcare professionals will ask you, you know, "Here's this ethical issue that has arisen in the course of our clinical practice. Can you help us think about how it should best be resolved?" If you're doing it, combined with a law degree, there's lots of policy around, say, what's the just way to distribute organs? That involves the creation and the interpretation of laws. Research ethics is another really booming area. Lots of companies or institutions have ethics review boards to check that the research being conducted is ethical and following the ethical principles of research ethics. And if you have a background in bioethics, you can be involved in those IRBs, they're called. So there's actually, yeah, there's lots of stuff actually that you can do with a bioethics background. 

Alexandra Arriaga: Very nice. And clearly there's a lot of applications in the healthcare field. But I'm curious, what projects are you working on and are they related to healthcare?

Jamie Webb: Yeah. So, one of the projects I'm working on right now in one of my classes is related to some quite sort of novel technology and healthcare. So, I don't know if you're familiar with IBM Watson for Oncology?

Alexandra Arriaga: No, not really. 

Jamie Webb: So, IBM Watson for Oncology is an AI program, and one of the things that it does is that it can provide treatment recommendations for cancer patients, theoretically kind of supplementing and helping doctors in making clinical recommendations for their patients. It takes in the details of a patient, like their background, their demographic, the state of their illness. It can scour thousands, millions of journal entries and its database of recommendations, and come up with a recommendation for a treatment option for that particular patient. So, IBM Watson makes its recommendations because it was designed out of Memorial Sloan Kettering Hospital up in New York. Some of the world's cancer specialists operate out of there, and they train the algorithm based on cases that the physicians at that hospital have seen and the recommendations that they would provide based on those symptoms. It gets that as its input, and then it trains itself on thousands of millions of test cases, and giving recommendations based on those, so it makes itself better at giving the recommendations that would be inline with the recommendations that these specialists would offer. And then having used all that training, it gives you a recommendation based on your particular case. So, it's a very novel technology. It's being increasingly used in hospitals. And there's some debate in the literature about how much that technology is able to respond to patient's particular values. So, it's kind of an idea in clinical ethics that treatment recommendations should be based not just on what the doctor thinks is the best thing for the patient, but on what values that the patient has for their treatment. So, maybe one patient values some particular form of functioning, like they want to be able to carry on playing tennis for as long as possible, or they value being really lucid and communicative with their family, or they value comfort, so not being in pain, or they value life extension above all else, or the best chance of a full recovery, even if it's a really painful treatment. So, at the moment, Watson makes its recommendations based on disease-free sort of life extension, and that's obviously a very mainstream value that lots of people have. But there's the question of whether it should be giving those recommendations just based on that, or whether it should be doing it more responsive to the values of particular patients. 

Alexandra Arriaga: Could that be included in the algorithm?

Jamie Webb: Well, that's a question in terms of its practicality. At the current form, it's at quite early stages of development and that is quite a challenging task, getting AI algorithms to be value responsive. In general as well as in this particular case. I mean, there's lots of really famous and fun examples of AI ... Concerns that AI might misinterpret what we suggest that it should be valuing in its recommendations. So, let's say ... There's famous examples of, let's say you want to design an AI that's made to maximize human happiness, like it's made to do whatever will produce the best outcomes in terms of human wellbeing and it creates a system where it hooks us all up intravenously to these mood enhancing drugs, and we live in a blissful stupor for the rest of our lives. That's not necessarily what we intended it to do, but it might be a way of maximizing that value function. Now, in a more prosaic treatment recommendation case, it might be really hard to design an AI program to have the kind of background understanding and contextual knowledge of human life to be able to make those kind of fine grain, value based decisions. So, it's a really practical, challenging issue in of itself. 

Alexandra Arriaga: Yeah. I'm just thinking about this system you're talking about for cancer treatment options. It literally just made me think about Google, when you tell Google, "Okay, I need to get to this place." But then you have these options. I don't want to walk because it's raining, so I want to be on the Subway as long as possible. And then I also don't want to take this train, so can you just route me? I mean, it could be implemented, but the question, of course, I think would be, who is going to give value to these different things, and how do you measure, for example, the level of pain of a treatment? Because it's such a subjective thing, right? 

Jamie Webb: Yeah, a very subjective thing that might be quite hard for a system that does not have those experiences to kind of quantify and factor into its treatment recommendations. 

Alexandra Arriaga: Yeah. 

Jamie Webb: I mean, that's just one small issue in AI ethics in healthcare. A lot of issues around responsibility for who's to blame if an AI treatment recommendation program gives a wrong recommendation, or a wrong diagnosis? Is it the doctor who used that tool? Is it the designers of that algorithm? Is it the hospital that instructed the doctors to use it? Are there worries around transparency around these things? Because these algorithms often sort of operate as black boxes where you can't exactly tell why it came to a decision that it did. 

Alexandra Arriaga: Right. 

Jamie Webb: And is that a problem? Do we need explainability in healthcare decision making? So, there's lots of really interesting, novel questions that is arising because of these new technologies, which is definitely right for people in bioethics to be thinking about. 

Alexandra Arriaga: Definitely. And in terms of bioethics, what would you say are the most relevant topics and challenges that bioethics professionals are facing? 

Jamie Webb: So, a lot of them I think are to do with the ethics of those new technologies. So, the increasing role of AI in healthcare would be one. Other things might be related to our increasing abilities to engage in genetic modification, and kind of the ethical issues that might arise in terms of what it is permissible to adjust embryos, or whatever, based on it might be permissible to adjust an embryo so it doesn't have Tay-Sachs syndrome, for example, but you might not want to adjust an embryo so that it has greater intelligence, or greater sporting ability, or whatever. So, that's an issue that's arising now. I mean recently there was a big scandal where the first genetically modified twins were born in China where a doctor kind of went completely rogue and edited this embryo without kind of ethical oversight, or even his hospital being aware of it. There was a big ethical debate about whether that technology, whether this CRISPR gene editing technology should be used in those contexts. So, that is now a lot of those questions that traditionally have been thought of as arising in the future are now actually-

Alexandra Arriaga: Yeah, like sci-fi. 

Jamie Webb: Yeah, the kind of sci-fi scenarios are actually happening a lot more now, so those kind of emerging technologies are very pressing. Then there are issues in environmental ethics, so what is the correct and just way to respond to things like global warming? Is quite a big issue now. About how far are individuals responsible for these issues and addressing them, as opposed to either corporations or governments where the burdens could justly fall, in terms of how should the Division of Responsibility have responded to global warming be divided up? Should it be the responsibility primarily of developed countries because they're responsible for the vast majority of historical emissions, or should it be just done on an equal per capita basis? Currently, that's quite a pressing issue. New reproductive technologies mean there are sort of emerging issues in reproductive ethics, so even just things like the ethics of IVF, in terms of the discarding of embryos, or issues about how ethically appropriate it is to have children at a later age if you know you might not be around for as long in that child's life. Those are the kind of issues that maybe didn't exist 30, 40 years ago, are now a lot more pressing. I think bioethics in particular, compared to maybe some other areas of philosophy, is very responsive to societal change and technological advancement, and therefore brings with it new and pressing questions all the time for ethical consideration. 

Alexandra Arriaga: So, speaking of IVF and discarding embryos, I thought we could do a little, fun exercise. So, what I want you to do is I'm going to present you with a situation, and I kind of want you to guide us through the thinking process of a bioethics student. Basically, this is the classic pro-life, pro-choice, abortion debate. Here's the test. So, I'm holding a baby in one hand, and a Petri dish with an embryo in the other. I'm going to drop one. I want you to choose which one I should drop. The assumption here, of course, is that pro-life supporters don't think there's a difference between a fertilized egg and a baby since they're both already alive and technically human. 

Jamie Webb: Thank you. That's a nice, uncontroversial topic to talk about. That's great. 

Alexandra Arriaga: Yeah, no pressure. 

Jamie Webb: Yeah, okay, so this is the kind of case we might discuss in a seminar. And you know, in philosophy, I guess it's a really common mode of argument, these kind of thought experiments. So like, "Imagine we're in this situation. What would be the ethical thing to do?" And what these thought experiments often are trying to bring out is our intuitive responses. So, what do you kind of feel as a result of that question? What do you think is the right course of action? The idea being, at least, that you have that intuition and you are attempting to justify that intuition. Think about if there are any moral principles that can justify that response? So, I suppose in that case, my moral intuition naturally is that it would be obviously impermissible to drop the baby. You should really hold onto the baby and drop the embryos, right? Okay. But sometimes our intuitions are unreliable. They're notoriously unreliable. People's intuitive responses based on things vary on the time of day, whether they've just eaten, what kind of mood they're in, what their demographic is. So, maybe intuitions aren't that reliable. 

Alexandra Arriaga: Yeah. 

Jamie Webb: I guess that's what the pro-life person would say in this case. They'd say, "Well, look, you think there's a difference between this embryo and this baby, but what is the difference? There's no difference. They are both members of the human species," seems to be the kind of way you were presenting their case: because they're both human beings, they both have the same rights, so the Petri dish with the embryo in it, well, the embryo, has just the same rights as a human baby. 

Alexandra Arriaga: But does it? 

Jamie Webb: I don't know what you should do in that situation. I guess you should not drop either. Probably don't drop either of them. 

Alexandra Arriaga: Ideally. 

Jamie Webb: But ideally, if you had to drop one, who knows what they would suggest? So again, you've now got this feature. You've identified this shared feature, that they're both members of the human species. Now, it's still an open question from there what moral relevance that has. So, the argument can't just end there. They have to sort of say, "Right, what's the morally important thing that belonging to the human species has that gives the same moral status as a baby?" On first glance, there doesn't really seem ... Well, on first glance you then have to ask, "Why is being a member of the human species important, morally speaking?" Naturally then, you start to think, "Well, it's because humans have certain qualities. They have capacities for higher order thinking that certain other animals don't have. Or they have kind of rich, emotional lives which grants them certain rights. Or they have interests in their own wellbeing and their own futures, which means you can't do certain things to them. Or they have rights of bodily autonomy, which means you can't interfere with them in certain ways."

Alexandra Arriaga: Yeah, but it's a baby. 

Jamie Webb: Well, okay, here we go. So, you can say, "Well, neither the baby or the fetus has those." But the baby might still have qualities that the fetus doesn't. This embryo, sorry. This embryo doesn't have the capacity to feel pain or suffering, so that might grant the baby greater moral status than the fetus does at that point. Maybe you think that the fetus doesn't have personhood, but the baby has personhood. Of course, again, then you need ask what are the conditions necessary for personhood? Does a baby have all those conditions? In many ways, a baby seems less like a person than certain other non-human primates might, if you're thinking about it in terms of qualities of intellectual capacity, or whatever. But nevertheless, you could try and draw some morally relevant distinctions between a human baby and an embryo, which means that although dropping the embryo would be permissible because of certain capacities of either suffering or cognitive capacity or development, that's not permissible with a baby. The differences between a baby and an embryo, and that makes a moral difference. But, you know, the pro-life person could come back and say, "Well, what matters isn't the fact that those features exist already, it's that the embryo has the potential to grow into a full person, just like the baby has the potential to grow into a full person." So, it's just the potentiality that matters there, and so that makes a morally significant difference. So again, then you've got to have a debate. Is having the potential to develop into something enough to give it moral status? Some people think it does, like the pro-life people. Some people might not think it does. So intuitively, there's a difference between an acorn and an oak tree. Just because an acorn has the potential to develop into an oak tree, doesn't make it an oak tree already. Just because a fetus has the ability to develop into a person, doesn't make it a person already. It doesn't necessarily mean it has all the same rights of non-interference, the right to life that a full person might have. To give a sort of science fiction example, another kind of thought experience you might use, if you thought that the potential to develop into a person was all that mattered for moral status, and it then meant that that fetus, that embryo, had a right to life, consider a scenario where we develop a pill that is like a kind of Planet of the Apes style treatment, that if you gave it to any animal, it would be able to develop the full cognitive capacities of a human being. It might seem counterintuitive to suggest that then meant that all animals in the world have the same moral status of people because they now have the potential to develop into someone with those capacities and whatever. 

Alexandra Arriaga: Interesting. 

Jamie Webb: It might seem strange to say, "Well, now they have the same moral status because we developed this novel technology. Nothing about them has changed, but now they have the potential to become something different," might seem kind of weird. Again, you might bite the bullet and say, "Yeah, in that case, they would have the same moral status," if potentiality is all that matters. But lots of people won't want to accept that, so then they'll say, "Okay, so potential isn't enough." The final thing ... I mean, not the final thing. Thousands of articles have been written on this. One other thing to take into consideration would be that unlike a baby, an embryo, if it's going to develop into a person, is going to be reliant on another person's body, a woman's body, to develop into a full person. You might think that's morally relevant because-

Alexandra Arriaga: The woman has life too. 

Jamie Webb: Exactly. The woman's rights to bodily autonomy can trump that embryo's right to life. There's a really famous example in the philosophical literature of Judith Thomson's violinist example. So, this is another thought experiment designed to bring out our intuitions. So, Judith Thomson writes in this article. She says, "Right, let's just assume, most people seem to think that the debate around abortion reduces to a debate around personhood." So, if you can prove that, in this case, a fetus is a person, then abortion would be impermissible. And then, if a fetus isn't a person, then abortion is permissible. Well, Judith Thomson says, "Let's assume that a fetus is a person. Would it ever be permissible to abort a fetus, even if we assumed that?" Most people say, "No, of course not. If it's a person, it has a right to life and that's invariable. You've got to preserve it." Judith Thomson gives the example of, "Okay, imagine this. Imagine this violinist example. You wake up in a hospital bed. You wake up and you're hooked up to all these tubes. You look to the bed on your left and there's this unconscious man lying there. You're like, 'What's going on?' And this doctor comes in and they go, 'Oh, thank goodness, you're awake. While you were asleep, this violinist was rushed in with a serious illness. She's a world famous violinist. She's this incredible impresario. The world would be such a better place if this violinist lived, but they've got a really serious condition and the only way for them to survive is for that violinist to be hooked up to you for nine months. Basically, for that nine months you've got a huge amount of restrictions. You can't really move around as much, can't really do all of the things that you'd like to be because your body is sustaining the life of this violinist. But, you know, that's the only way that this violinist can survive. The violinist has a right to life that is kind of more important than anything else. You're going to have to stay hooked up to them for nine months, and then you can come off and then you can carry on living your normal life and it'll be fine." What are your intuitions about that case? 

Alexandra Arriaga: Well, my intuition is that the violinist is going to stand up and go and do his own thing and play violin, but the baby, you need to take care of the baby. The baby needs the mother. Okay, besides the nine months, you can't just ... I guess you could put the baby up for adoption, but then that's also a psychological issue. Wow. It's complex.

Jamie Webb: But this is great. I mean, if you're Thomson, that's great for your purposes, because do you think it would be permissible, like allowed, for you to say, "No, I'm sorry. Nine months against my consent? I'm going to unhook myself here. I don't need to stay hooked up." Do you think they should stay hooked up, or not stay hooked up?

Alexandra Arriaga: I think they should be able to choose. 

Jamie Webb: Okay. So, even in that case when after nine months that guy's going to get up and going to wander off and live their life, isn't going to be reliant on you, you can make the choice that your bodily autonomy trumps their right to life and so you should be able to unhook. If you can in that case, then Thomson would argue, "Surely you can when even after that nine months, that child is still going to be extremely reliant on you for everything." So, the philosophical literature is filled with these kinds of thought experiments to try and work out, what are the correct moral principles governing these kind of issues? A final example, a really juicy example which is like, I think you get a long way in philosophy if you have really exciting article titles. So, there's a quite famous article in the literature called Abortion and Infanticide, which kind of goes, "Yeah, there are lots of reasons why aborting your fetus is completely permissible because it doesn't have all these qualities.It doesn't have capacity of thought, or complex intellectual capacities that grant it a really invariable right to life that say a fully grown person has. It doesn't have hopes for its future, and that matters. It doesn't have complex interests, and that matters." And then they go, "Okay, but all those same things apply to a newborn child. So, if you think abortion is permissible, you should also think infanticide is permissible," which is kind of messed up.

Alexandra Arriaga: It's messed up, yeah. 

Jamie Webb: And most people think that's really messed up and disagree with it, but there's a lot of hard thinking in there about trying to work out if there's a morally relevant difference, what it is. Obviously, sometimes it can seem really abstract and divorced from the reality of how people make these decisions, but to give an example, you know that J.J Thomson article, the violinist article came out in the early 1970s, before Roe versus Wade, when this was a really hot topic, a really important topic and was quite influential in shaping people's thinking about the permissibility of that at that point. Obviously, with that now, sadly, becoming with the make up of the Supreme Court and whether they'll become a challenge to Roe versus Wade, these kind of arguments are being had all over again about personhood, about moral status of embryos, about the balance between the rights of a mother and the rights of the fetus. There's a big place for bioethics in there to have a really big impact. 

Alexandra Arriaga: Mm-hmm (affirmative). It's super interesting and I can see where all the complications arise. Finally Jamie, I would like to know, what motivates you to keep working in the field even when faced with difficult challenges? 

Jamie Webb: Yeah, ask me that in like a couple of hours when I'm reading this impenetrable book and trying to come up with some argument about it. No, I think it's a really intellectually challenging subject, bioethics and philosophy generally. It can be really frustrating and really hard, like you're beating your head against a wall and you're like, "No one cares. No one cares. Why am I even writing this? This is really difficult. Will anyone ever think it matters?"It can be really tough, but at the same time, it's really intellectually satisfying when you're thinking through these different arguments and you have those kind of breakthrough moments where you think, "Okay, this is important. This is a good argument. Now I can try and put it forward." Particularly with bioethics as well, it always has such a clear relevance in the way people live their lives, in the way research is conducted and the way clinical practice is conducted, in the way that the technology that is developing is going to shape the future that we live in, that you're always aware that, "Yeah, even if this does seem really tough, it is always a super important thing to think about." That's nice to have on those really tough days. 

Alexandra Arriaga: There's definitely a big purpose behind it. 

Jamie Webb: Yeah. 

Alexandra Arriaga: So, before we leave, we thought that it would be a really fun exercise to just this almost like a lightning round of bioethical conundrums. 

Jamie Webb: And this is how it works; people come with these ethical problems and you just have to answer straight off, and then that's how the solutions get made. This is how bioethics is done, it's like a lightning round quiz with buzzers. Yeah. 

Alexandra Arriaga: Okay. Here are the rules. I will invite you, the listener, to participate. It's all yes or no questions, and basically we're just going to go with our first instinct. Jamie and I are both going to answer at the same time. Feel free to join in. Are you ready? 

Jamie Webb: Intuition testing. 

Alexandra Arriaga: Okay, here we go. In the case of the baby versus the embryo or the Petri dish, would you drop the Petri dish? Yes. 

Jamie Webb: No. Wait, no, no, that's the wrong way round. I mean yes. I mean yes. Sorry, that was the wrong way around. Yes you would drop the ... Oh God, yes. That's a good start. 

Alexandra Arriaga: Okay. Would you have stayed hooked to the violinist? Yes or no? No. 

Jamie Webb: No. 

Alexandra Arriaga: Would you kill one person to give organs to five people? No. 

Jamie Webb: No. 

Alexandra Arriaga: Would you force a patient to have a beneficial treatment they don't want? No. 

Jamie Webb: No. This is wonderfully straightforward. 

Alexandra Arriaga: Should IVF children find out who their fathers are? Yes. 

Jamie Webb: Yes. 

Alexandra Arriaga: That wasn't lightning. 

Jamie Webb: That wasn't lightning, but this is, you know ... I want to give it, "Oh, this is really complicated. Let's talk about this for 15 minutes." But yes. Lightning yes. 

Alexandra Arriaga: Okay. Should genetic testing be mandatory? Yes. 

Jamie Webb: No. Ooh, that's interesting. And we shall move on. 

Alexandra Arriaga: Should we edit human embryos to get rid of disabilities? No. 

Jamie Webb: Sometimes.

Alexandra Arriaga: Ooh, that's not yes or no though. 

Jamie Webb: I know. Okay, yes. Yes. 

Alexandra Arriaga: Okay. If you have only one dose of treatment, should you give it to the youngest person? No. 

Jamie Webb: Yes. 

Alexandra Arriaga: I've got to say, it depends on so many things. 

Jamie Webb: Yeah. I mean, you can think maybe people have a right to a reasonable lifespan, and if that's not been fulfilled, they should have priority. They're going to get more life years out of it, maybe, thank someone that's-

Alexandra Arriaga: What if it's one day difference? 

Jamie Webb: Then, I mean, all bets are off. 

Alexanara Arriaga: I mean, they don't specify how young the other person is. 

Jamie Webb: Yeah, that could be ... If it's the embryo in the Petri dish, then no. No. 

Alexandra Arriaga: There you go. Okay. Is it worse to kill the last animal of a species, than a hundred animals of a species with a large population? Yes. 

Jamie Webb: Yes. But why?

Alexandra Arriaga: Because the other species would be extinct. The other ones will still thrive. 

Jamie Webb: It's true, but where's the extra ... What's the value in a species existing, above an beyond the individual members of it? 

Alexandra Arriaga: Actually, I just found a flaw with this. If it's the last animal, how's it going to reproduce? What if it's a male? 

Jamie Webb: All right, like the last number of sustainable population densities, whatever. 

Alexandra Arriaga: Okay. Fine, fine. No, because then you would literally lose that species. If you have tons of the other ... 

Jamie Webb: But why is that a bad thing? What is the value of the species that isn't just like the value of the individual members? 

Alexandra Arriaga: Well, now I'm confused. Now I want to ... 

Jamie Webb: Your head hurts all the time.

Alexandra Arriaga: No, I just want to rethink this for many hours. I don't know guys. For those of you who are listening, what would you do? It's hard. It's very complicated topics. Finally, Jamie would like to invite you to think about a very interesting topic. 

Jamie Webb: It's a cool topic and it comes up all the time in bioethics, and every time it comes up, we sort of groan and go, "Here we go again." So, there's this idea in philosophy called the non-identity problem and it's really relevant in things like global warming. So, it's basically the idea that you can make very small changes in the way we behave, the way we act will result in potentially different people being born in the future than would have been born if you hadn't made those changes. So, it's kind of like The Butterfly Effect; you make a very small change and big consequences follow, but has real lots of bioethical implications. So, it makes a lot of sense to say, "We should stop. We should make changes to stop global warming being as bad as it will by reducing our emissions, because if we don't, that's going to harm future generations because it's going to make the planet less inhabitable." Okay, but let's say we do make those steps. That means people fly less, people take different jobs, people live their lives very differently. That means people meet different people, they conceive children on different days. Those small changes mean that it's going to be a vastly different population that is born as a result of those changes, if we make those changes. So, if we don't, in what sense can you be said to harm the people that live in that future where the planet is less habitable? Because if they said, "Look, you've harmed me by not making those changes. The world is a much less hospitable place because you didn't fight climate change." They could say, "Well, if I had done those things to fight climate change, you wouldn't exist because the world would be a completely different place, I would have had different children, and it would be completely different people that would exist in the future." Right? "So, I haven't harmed you because if I'd acted differently, you wouldn't exist at all." That's super relevant for things like reproductive decisions, so if you choose to conceive a child when you know you're at greater risk of having the Zika virus, maybe in an area where the mosquitoes are around and you conceive a child then and your child is affected by the Zika virus, can that child say, "You've harmed me by doing that?" Because you could turn around and say, "Well, if I'd waited three weeks until I'd left the country to have my baby, then you wouldn't exist." So, where's the harm there? Can you commit harms against people, even if that individual couldn't have been made better off by you acting differently if it would have been a completely different individual that existed?

Alexandra Arriaga: Well, the Zika baby maybe could have been born with microcephaly and probably wouldn't have been able to talk and it would have never asked you, "Why did you harm me?"

Jamie Webb: Oh yeah. But does it matter whether ... I mean, it's not so much whether they can ask you, but whether they have a claim against you. Does that baby have a claim to say, "You have wronged me in some way," when if the mother or the parents had acted differently, that child would not have existed at all? 

Alexandra Arriaga: But then I raise you; that person couldn't control getting Zika. I mean, you can go to, for example, Venezuela where we have Zika and still not get Zika, but it's not up to you to get Zika. But for example, a woman can choose to not smoke and not drink while being pregnant. 

Jamie Webb: Okay, so the difference between those cases, right, would be-

Alexandra Arriaga: Will? 

Jamie Webb: Well, kind of will in a sense. Okay, so let's you're going to an area where you know the mosquitoes are and you could get the Zika virus, right? That parent, let's say they're only there for a short amount of time ... If they live there all their lives it's a bit different and then they don't have so much control over it. But if it's like, "I conceive my child on holiday now in South America where I could get the Zika virus, or I wait three weeks and conceive my child at home when I know they won't get the Zika virus-"

Alexandra Arriaga: South America's more fun. 

Jamie Webb: That's probably true. I'm sure. I’ve gone on holiday in South America, that's another matter. Yeah. More right for ... Nevermind. Then it seems like you've done something wrong, right? You could have waited and had a child without the Zika virus, but there's no individual person that you have harmed because that child, if they have a life worth living, even if they have the consequences of having the Zika virus, that child could not have been made better off because if you had different decisions, they would not have existed. The difference between having a child and then, say, drinking or smoking while that child is in the womb is that, if you'd made different decisions, that child could have been better off. Because it's like the order in which you're doing things. You get the child, you drink and smoke, that child becomes worse off, as opposed to your choice to conceive while in a Zika infected area is a thing that creates that child in the first place. If you'd have made a different choice, that child wouldn't exist, so there's no one there who has actually been made worse off by your decisions. Nevertheless, we kind of think that both are kind of wrong. But where's the harm? 

Alexandra Arriaga: Where is the harm? 

Jamie Webb: Where's the harm? 

Alexandra Arriaga: What do you think guys? What would you say? And with that thought, we will leave you to think about all these issues that we discussed. Hopefully we have sparked in you an interest in bioethics. Well, thank you so much for sharing your thoughts. 

Jamie Webb: My pleasure. It's been lovely to speak to you. Thank you for having me. 

Alexandra Arriaga: Of course, and we cannot wait to see what you do next. 

Jamie Webb: Neither can I. I have no idea. 

Alexandra Arriaga: Well, thank you so much Jamie.