How will we handle genetic, technological advances?

Commentary. By Leonard J. Marcus, PhD, and Barry C. Dorn, MD, amednews contributors. Sept. 17, 2001.

COMMENTARY

Observations on the state of medical practice and medical life

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Some years into the future -- when the history of our species is written -- the period in which we are now living could very well be labeled among the most momentous and decisive of times.

We humans are now learning to harness and activate our intelligence in ways never before achieved and in ways that will set the tone for much of our future. How we deal with the choices, decisions and conflicts that emerge will determine whether our information and technological explosion will be a trajectory into spectacular possibilities; whether these new powers will reflect the tales of missed opportunities; or whether our choices become the augurs of doom itself.

The decisions regarding our bodies and our health -- advances in the genome project and new biotechnological breakthroughs -- will be among the most difficult to face us: scientifically, technologically and ethically. What we could know and what we could do: the possibilities are incredible. But imagination itself must be tempered by critical concerns for real capabilities and moral correctness.

Future generations could very well chastise us, harshly, if we either ignore or conversely become mired in addressing the ethical dimensions of these choices. It is they who will live with the consequences.

Recent discussions regarding research utilization of stem cells demonstrates how difficult the choices and how contentious the deliberations about them are. The stakes are high, and proponents on each side are ready to fight hard to achieve victory.

Ultimately, it is up to us as a species to manage or resolve the current and impending conflicts that face us. Just because we can do something does not mean that we should. Likewise, just because we do not know the full consequences of a procedure does not mean we should limit exploration that could reap substantial benefit.

Polarized conflict

It is typical of a high-stakes and polarized conflict for sides to portray issues in black-and-white terms. A proponent of one side of the stem-cell debate was quoted as saying, "It's not about science, it's about morality."

In a polarized conflict, the issues are simplified, emotions come into play, and the sides assume an "enemy image" of one another. Each portrays the other as all wrong, rallying the troops to "get them before they get us." Complex issues and choices are reduced to compact ideological assertions and slick slogans. Each side develops an obsession to win. Victory is a singular goal. The complexities, subtleties or nuances of the issues are lost in the process.

There is much at stake in these discussions, and it is only to be expected that advocates will frame their positions in the strongest language possible. Each decries the dire consequences of following the opposition. Each highlights the dramatic and spectacular achievements supported by their stand.

Truth itself often lies somewhere in between and is often a casualty of the process. And yet truth -- as elusive and quixotic as it sometimes appears to be -- must be a singular goal of those who are responsible for deciding just what we will and will not do with our newfound capabilities.

Ultimately, these discussions are not only about matters of substance. They are also a matter of process. There are alternatives to win-lose, adversarial and fight-to-the-finish contests about matters of such great importance. The question is, how do we structure these deliberations to decisively, carefully and yet efficiently enhance the chances that we will make wise and effective choices?

Dealing with conflict

There is no one place at which these decisions will be made. Ours is a pluralistic society in which decision-making is diffuse by design, and in which individuals or constituencies are provided significant freedoms in their influence and power.

This means that the controversies and deliberations will take place in several diverse settings and will be affected by a number of considerations, many of them not a function of pure science, technology or ethics. Much of the push and pull of the decision-making process will be a function of ideologies, politics and the economic implications of various choices.

That is the reality of the process. The challenge is, how can we incorporate some balance in the deliberations to increase the chances of finding the wise course of action?

One method to improve the quality of the decision-making is to construct mediated venues specifically designed to address and synthesize the spectrum of ethical opinions, the breadth of scientific knowledge and the capacities of new technologies.

These neutral venues should be designed to enhance understanding, encourage an exchange of ideas and information and resolve conflicts based on the shared interests and the distinct concerns of different constituencies. Facilitated meetings -- intentionally removed from the spotlight of controversy but involving key leaders -- would be charged with crafting balanced thinking, developing respected advisory statements and constructing the finely tuned language that would be useful to official decision-making bodies. By meeting in less contentious and intentionally constructed settings, participants are more likely to listen to one another, engage in the issues and find constructive ways to move beyond roadblocks to progress.

What principles and practices should guide this decision-making?

These venues should be inclusive, with balanced representation of those who have a stake -- financial, political, moral or otherwise -- in the process and the outcome. Efforts also should be made to ensure that those with a direct stake, for example, patients who could benefit or be hurt, also are represented. And we should recognize global implications. These decisions ultimately are not isolated from other countries and cultures.
Discussions should be premised on a respect for life and lifestyle, and with the intent of finding a balance of ethical, scientific, technological, financial, political and social considerations. The process and participants should have the tenacity and willingness to allow and encourage a diversity of ideas and interests, so that the outcome of the process is realistic, feasible and responsive, and ultimately has a reasonable chance of success.
Certainly, this mediated process should be flexible, timely and results-driven. These are not deliberations just for the sake of talking: These conversations provide the unique opportunity for reasoned, informed and intelligent discussion of complex issues. The hope is that such meetings themselves will generate a synergy of thinking, action and outcome that will benefit a society grappling with momentous and historic decisions.

Resolving conflict

The conflicts facing us today are not simple questions of right and wrong -- as if those matters were simple. There are enormous economic and financial repercussions. There are context issues: Should you be able to decide for your own body or offspring what society cannot decide?

The human dimensions of choosing will determine the dimensions and impact of our uniquely new and wonderfully human capabilities.

The choices are ours. The question is how and if we will make them.

Note: This column originally appeared in print as "Renegotiating Health Care."

Dr. Marcus is director and is associate director of the Program for Health Care Negotiation and Conflict Resolution at the Harvard School of Public Health, 617-496-0867. Dr. Dorn is CEO of Health Care Negotiation Associates 781-861-6116. The paperback version of their book, "Renegotiating Health Care: Resolving Conflict to Build Collaboration," is available for through Jossey-Bass Publishers, 800-956-7739.