Promethean medicine: spirituality, stem cells, and cloning.

Abstract: Every ethos implies a mythos. That is, every ethical system depends upon some fundamental story disclosing its assumptions about human nature, freedom, good and evil, and the workings of the universe. A romanticized version of the myth of Prometheus, who stole fire from the gods and was punished by being chained to a rock and having his liver plucked out by vultures, seems to undergird much of contemporary healthcare. Christianity offers a different view--one in which the universe is not a zero sum game and human beings do not need to steal fire because God has already freely given them all the fire they need in Christ and in his spirit. A critical virtue for physicians, taught by Christianity, is sagacious engagement--the ability to engage the world practically, discerning what can and should be changed and what should be accepted as unchangeable and given. The illusory quest for immortality through the practice of regenerative medicine using stem cells is a gross violation of that virtue.

Key Words: medical ethics, spirituality, Christianity, stem cells

**********

The relationship between spirituality and ethics is complex. Even for a nonreligious person, one is not reducible to the other. Yet if spirituality concerns how one lives one's life in relationship to the deepest questions that confront humanity, one's spirituality, however it is construed, is bound to affect one's ethical stance in the world. Whether secular or religious, every ethos implies a mythos. (1) That is to say, every ethical viewpoint requires a set of deeply held, originating beliefs about such matters as the meaning of being human, the place of human beings within the cosmos, and the nature of human freedom.

Much has been written about the ethics of cloning and stem cell research. However, little has been written about the spiritual questions that might lie beneath the surface of the controversies that surround these procedures. In this brief essay, I would like to express how a Christian might view questions about cloning and stem cell research as spiritual questions.

It is of no small interest that in 2003 a scientist wrote an editorial in the New England Journal of Medicine lauding the possibility of cloning human embryos for the purpose of creating a pool of genetically identical stem cells for each human being. (2) The dream of so-called "regenerative medicine" is to use such stem cells to replace damaged, worn out or aging body parts, leading us the brink of immortality.

The author of this editorial, Nadia Rosenthal, evoked the myth of Prometheus to support her romantic stem cell idyll. The reader will recall that according to the ancient Greek myth, Prometheus stole fire from the gods. As a punishment for this transgression, Prometheus was chained to a rock where vultures ate away at his liver, which the gods caused to grow back every day only to have the cycle repeated. Rosenthal, however, presents a different Prometheus. According to her myth, Prometheus is the great hero of regenerative medicine, defying the gods and the death they would impose on us poor mortals. The Prometheus she heralds has the power to regenerate his own liver through cloning!

I suggest that Rosenthal's version of the Prometheus myth is a perfect expression of the spirituality that underlies contemporary attempts at human cloning and characterizes much of stem cell research. Whether ancient Greeks or contemporary cell biologists, people want control of the fire. And despite all protestations of scientific atheism, Rosenthal's myth demonstrates that even an avowedly secular culture still believes strongly in the gods who would keep that fire from us. Even the culture of scientific atheism apparently believes in a jealous, zero-sum spiritual universe in which the gods can be diminished if people can steal their fire. That is why a scientist who wants to clone human beings can see a Prometheus who regenerates his own liver as a romantic hero rather than a pathetic creature. Despite the fact that our livers might be plucked at by vultures, we can now revel at the prospect that the regenerative fire that perpetuates our pain might soon belong to us. We imagine ourselves happier if we could control even our own punishment.

Control

For many persons today, control is central to the meaning of life. We want to be in control. Many bioethicists believe that the central goal of ethics is to promote people's life plans and to maximize the control they have over their own futures. (3) Bioethicists think the control of one's own future is the philosophical foundation of informed consent. (4) Empirical studies have shown that it is far more common for patients to seek assisted suicide because of loss of control than because of pain. (5,6)

Control is an issue for biomedical scientists, physicians, and patients, and is a social ideal. Physicians, especially, have three distinct but related attachments:

* The need to be in control.

* The need to be effective.

* The need to be right. (7)

Clinicians often abhor patients who are noncompliant. They are often frustrated by those diseases that resist the power of their increasingly sophisticated potions. Medical school faculty often sneer superciliously at local physicians who miss the obscure diagnoses that the learned professors make in their medical Meccas. For many physicians, professional accomplishment becomes the chief source of meaning and purpose in life. Twenty-first century physicians cure some diseases, attenuate the effects of others, and conduct research that they promise themselves will one day eliminate all injury and illness. They appear to hold the fire in their hands.

Of course, all this belief in control as the eternal flame of life's meaning appears very odd if one takes a few steps back and begins to look at the larger picture. To begin with, we have no control over the fact of our existence. We did not, in any literal way, create ourselves. And this lack of control cannot be overcome through genetic engineering. It is metaphysically impossible to choose one's own biologic parents. Even the wildest proponents of so-called regenerative medicine talk only of indefinite life extension, not true immortality.

And perhaps most importantly, we cannot control whether someone else loves us. So, if the quest for control is the meaning of life, life's meaning would necessarily exclude existence, family, death, and love. Even if life's meaning were more cleverly defined as the quest for control over the things one could control, and existence, family, death, and love were considered mere givens of which everyone partakes, what remained would seem rather paltry, not to mention boringly bereft of spontaneity. It would hardly seem to make life meaningful.

And yet, despite all this profound lack of control, we know and experience ourselves as free agents. We do things. We make choices that change us, change others, and change the world. We do make plans. We are expected to do so. We are responsible for what we do.

This is especially true for healthcare professionals; people who have pledged to help the sick and conduct research aimed at curing disease. Healthcare professionals do want to exert control over the world, and to exert that control for good. We have the power and the opportunity to do so. We know that doing so is right.

Perhaps our problem then is just that too often we lose sight of the limits of our control. These limits are imposed by the nature of who and what we are, and by the nature of the universe. Accordingly, one must examine one's mythos to know how to act.

What are the limits of the human? We are limited by our own finitude. Physically, intellectually, and morally, we are finite. We are limited by birth and death--our own and that of others. We are limited by a universe that is given to us, not created by us. We are limited by the freedom of others.

So what, then, do we control?

Virtue

We dispose of our own freedom in the context of our limits: this is one way of describing the moral life. As Aristotle puts it, ethical deliberation consists of responsibility and choice. (8) The moral life, then, is really human freedom deployed precisely at the point of intersection between possibility and necessity; between malleability and resistance. It is where we live our lives as human. And the choices we make as physicians, nurses, and other health care professionals are the moral choices that make our professions human.

We can dispose of our freedom both with respect to our inner lives and with respect to the world around us. Two of the cardinal virtues correspond to these "vectors" of human freedom: sophrosune (or temperance) and phronesis (or practical wisdom).

The internal disposition of our freedom concerns our desires and inclinations. This is the provenance of the classical cardinal virtue of sophrosune (temperance). Temperance is the virtue of proper self-control. It is the mean between self-indulgence and being repressed. As Aristotle noted in the Nichomachean Ethics, self-indulgence is very common. Being repressed, Aristotle said, is such an uncommon vice that it barely has a name. (9) He would seem even more correct in making this observation today.

But there is also a temperance with respect to our control over the external world--how we dispose of our freedom with respect to our families, our communities, our environment, our colleagues, our patients. In our encounter with the world, we need to discern what is within our power and what is not. The virtue that operates in this field of human experience appears at the intersection between sophrosune and phronesis. It has never had a separate name, but I would call this part of wisdom the virtue of sagacious engagement--temperance regarding our exertion of control in our practical deliberations as agents active in the world. It is a vitally important part of the virtue of practical wisdom. The vices opposed to this virtue would be fatalistic docility on the one hand, and controlling, contumacious, sometimes even Machiavellian manipulativeness on the other.

I think it is fair to say that we live in a culture dominated by intemperance. Contemporary Westerners err toward a lack of control internally and err toward over control externally. That is, the people of our society tend to be both self-indulgent and controlling at the same time. These vices lead to a myriad of illnesses in patients. But it would be profoundly naive to think that health professionals hew to lives of temperance

and sagacious engagement and are completely free of these vices.

Medical Vices and Virtues

Older physicians are beginning to complain about younger physicians' emphasis on "lifestyle" in their career choices. One can certainly make the case that several previous generations of physicians led overly controlled, repressed lives, sacrificing too much, even damaging their own families through overzealous dedication. But one can ask whether the pendulum has begun to swing too far in the opposite direction. We certainly need clinicians in those subsubspecialties that have few emergencies and little overnight call. Nonetheless, should the medical profession not question itself if the best and the brightest medical students compete most vigorously for these subsubspecialties precisely because they offer the best salaries and lifestyles? Are hospitalized patients now losing too much continuity of care to a succession of covering physicians arranged to assure more acceptable schedules of night duty? And while the majority of healthcare inflation is not due to physicians' fees and salaries, should any physician be making one million dollars per year off the predicament of the sick? These questions should at least be raised.

The biggest questions for physicians with respect to control, however, are not the classical, internal aspects of temperance, but the external aspects. A lust to control, dominate, and conquer disease still leads far too many physicians to overtreat their patients. Sometimes, however, the confluence of the attempt to control what cannot be controlled and the belief that control gives life its meaning leads to a different but equally noxious place. Some physicians suffer from a sense of helplessness when they cannot cure, when the disease is beyond their control. Sharing with their patients the belief that control itself gives life its meaning, they engage in the following logic: Control is the meaning of life. If the disease is beyond the physician's control, and the disease has robbed the patient of control, the search for meaning becomes the search for a way to re-establish control. The logical solution appears to be either assisted suicide or euthanasia.

Assisted suicide, however, is just as ironic a statement of control as is the regeneration of livers through stem cells. In regenerating his own liver, the Prometheus of the stem cell researcher shouts out at the gods in whom he professes not to believe, "So, I can't be immortal and you've punished me for trying, eh? All right, then, I'll show you. I'll punish myself!" In assisted suicide, the patient shouts out at the gods in whom he professes not to believe, "So, I can't be immortal, eh? All right then, I'll show you--I'll kill myself." Both over treatment and assisted suicide are born of the attempt to control what cannot be controlled. Both are conspiracies of mutual self-delusion between practitioners and patients. Superficially, the oncologist who refuses to stop treating patients who are beyond the reach of biomedical therapy, the internist-psychiatrist who dispenses prescriptions for assisted suicide, and the scientist passionately pursuing immortality through regenerative medicine all appear very different. They all subscribe to a similar spirituality, however. They all want to steal fire from the gods. They all want to be in control.

The lust for control is so great that physicians sometimes take delight in manipulating patients. I recall with horror an experience I had as a first year medical student in a small group clinical experience with a psychiatrist. Donning his white coat and eager to inspire a group of eight fresh new medical students, he said, "I can bring any patient to tears in ten minutes." He then asked that an arbitrary patient be selected from the ward to demonstrate. He accomplished his psychiatric rape in less than five minutes. We were supposed to be impressed.

The Christian Mythos

I have heard it said that the central theme of Dante's Divine Comedy is that, in the end, each of us gets what each of us wants. Dante's message is that whatever one wants most deeply in life is precisely what one gets--forever and ever and ever. If what one really most wants out of life is money, that's what one gets--one drowns in piles of it forever. If what one really most wants is pleasure, all one gets is pleasure--which ceases to be a source of happiness very quickly if it never stops. And if what one really wants is the power and control to regenerate one's body, one becomes the new medical Prometheus--producing one's own stem cells to feed the vultures who will pluck them out of one's liver, forever and ever and ever.

Christianity offers a profoundly different mythos and a profoundly different ethos, however. St. Paul tells the Philippians (2:1-11):

If there is any encouragement in Christ, any solace in love, any participation in the Spirit, any compassion and mercy, complete my joy by being of the same mind, with the same love, united in heart, thinking one thing.

Do nothing out of selfishness or out of vainglory; rather, humbly regard others as more important than yourselves, each looking out not for his own interests, but (also) everyone for those of others.

Have among yourselves the same attitude that is also yours in Christ Jesus, Who, though he was in the form of God, did not regard equality with God something to be grasped.

Rather, he emptied himself, taking the form of a slave, coming in human likeness; and found human in appearance, he humbled himself, becoming obedient to death, even death on a cross.

Because of this, God greatly exalted him and bestowed on him the name that is above every name, that at the name of Jesus every knee should bend, of those in heaven and on earth and under the earth, and every tongue confess that Jesus Christ is Lord, to the glory of God the Father.

The Christian message is that one does not need to steal fire from the gods. The Christian message is that God has already freely given fire to the world. One can use this fire for treating the sick, in compassion and mercy, being of the same mind, united in heart, thinking one thing. The Christian message is that human beings need not vainly and desperately try to make themselves into gods, because God has already reached out in love and has become human.

The spiritual economy of the Christian universe is not a zero-sum game. The fact that one can cure pneumonia does nothing to add to one's personal greatness, nor does it subtract from God's greatness. A Christian does not need vainly to try to show that she is in control or vainly to try to make herself into something she is not. In Christ, one's freedom is God's freedom.

Human beings can do this, Christians believe, as Christ did--by plunging into the depths of their humanity, into the reality of their humanity, into the humility of their humanity. Salvation comes not from trying to be like gods, but from allowing oneself to be more completely what one was created to be--a human being.

So, for the Christian, the virtues have a radically different meaning. Augustine defines temperance as "love giving itself entirely to what is loved." (10) He defines practical wisdom as "love distinguishing with sagacity between what hinders it and what helps it." For a Christian, this sagacious engagement, this temperance in action, is the wisdom of which Niebuhr (11) wrote in his famous serenity prayer--the wisdom love requires to give itself entirely over to love in all of its actions, knowing the difference between what hinders love and what helps it. This sagacious engagement is the wisdom by which one judges between the things one cannot change and the things one ought to change.

This virtue, in turn, depends entirely upon the love that is the "one thing" of which St. Paul wrote in his letter to the Philippians. Christians are asked to believe with all their hearts in this one true thing--the love of God made manifest in Jesus Christ. And if that's what one really wants, Christianity teaches that this is what one will really get--forever and ever and ever.

It is also Christian faith that any physician, nurse, chaplain, or social worker who believes in this one true thing need not always be in control; need not always be effective; need not always be right.

Those who believe in this one true thing know that only One is really in control; only One makes our meager human efforts effective; only One is always right. And none of us is that One.

In that truth, the virtue of sagacious engagement with the world--our temperance with respect to all the choices we make with respect to the world--is what Christians mean by the virtue of obedience. Christian obedience is not a form of slavery that treats human beings as God's commodities. Obedience comes from the Latin root, obedire, to listen. To be obedient is to listen. To be obedient is to be willing to serve in response to what one hears. To be obedient is to hear the call from beyond one's self.

Christian Virtue and Medicine

To be an obedient physician requires one to listen to one's patients and the wisdom of the stories they tell; to listen to one's colleagues and the wisdom of the stories they tell; to listen to God, and the wisdom of the story God tells.

Sagacious engagement with the patient is a dialogue. This is how one learns when to press and when to let go; when to persuade and when to exercise deference. This is how one learns to be concerned about the results without being overly anxious or defined by them; how to be discerning without being judgmental. One listens.

Hans Georg Gadamer believes that even the physical examination is a dialogue--a way of listening to the patient's body. He describes the physical examination as, "carefully and responsively feeling the patient's body so as to detect strains and tensions which can perhaps help to confirm or correct the patient's own subjective localization, that is, the patient's experience of pain." (12)

Similarly, the wise therapeutic decision is one that neither exerts too much control nor fails to assert enough. When we err in the 21st century, it is generally on the side of too much control. This happens when we fail to be obedient to the situation before us, fail to listen attentively, fail to engage the clinical circumstances sagaciously. Again, Gadamer puts it beautifully, arguing that when a medical intervention goes wrong, "it would not be because physical force or power was lacking or too little was exerted, but rather because there was actually too much force in play. But when the act works, suddenly everything seems to happen spontaneously, lightly and effortlessly.... Genuine success is accomplished in medical practice at just that point where intervention is rendered superfluous and dispensable. All medical efforts at healing are already conceived from the outset in light of the fact that the doctor's contribution consummates itself by disappearing as soon as the equilibrium of health is restored." (13)

A Christian need not grasp at equality with God. A Christian need not steal anything from God. God has already given us everything that we need. One need not claim power or control or knowledge for oneself.

If one makes some obscure diagnosis or effects some wonderful cure, one may be tempted to wonder whether this comes from one's own power or from God's? For the Christian, this distinction ceases to matter. On the one hand, in a sense, it all comes from the God who created us and created the patient and created everything that constitutes the art and science of medicine. No doctor, regardless of religious or nonreligious preference, can claim to have created herself, the patient, or the art and science of medicine. All must be experienced as gifts. All are given. (14) Each clinician, however, is a free and intelligent, even if fallible, being. The clinician is inextricable from the healing act. In this sense, it is always 'I' who heal. But in Christ, this 'I' can be liberated from worrying about how much of a role is 'mine', liberated from trying to possess the fire or control the situation or control the patient. It makes no sense for Christians to jockey for control with a God who has already given himself completely to them. What should matter to Christians is what matters to Christ. It is the healing that matters. Or rather, it is the giving over of oneself to the love that subsumes the process of healing that matters.

The right amount of control is what the situation--as it is engaged by the physician in a spirit of obedient service--demands. A Christian physician need not try to be in complete control, whether in the examining room or in the laboratory. What happens as a result of his ministrations is not his to determine. If his therapy or the experiment fails, he must listen again, sagaciously engaging the new situation that presents itself to him, humbly plumbing the depths of his own humanity and that of the reality before him. He tries to be effective, he educates himself so that he will be effective, he acts with the intention of being effective, but he does not delude himself with the need to be effective. And if some consultant offers another opinion, he does not feel diminished. He realizes that he is not God. Sadly, clinicians often hurt patients by not letting go of their original diagnoses, or by acting defensively when the patient asks about the wisdom of a second opinion. Even more sadly, as we have learned from recent reports about cloning experiments in Korea, some medical scientists seem so driven by their need to be "effective," to be "in control of the fire" that they fall into all sorts of ethical and intellectual traps, including the self-delusion of convincing themselves that they have been effective when plainly they have not. (15) By contrast, the Christian physician, whether an investigator, a clinician, or both, listens attentively in a spirit of obedient service, knowing that the effectiveness belongs to someone else.

The real sin of Simon Magus, the magician whose story is recounted in the Acts of the Apostles (8:9-25), was not that he wanted to pay money for the power to heal but that he wanted to have the healing power and authority of the Apostles without their faith. The true disciples of Jesus Christ knew that they could only heal in the Name that is above every other name. Christians understand that the power to heal in its truest and deepest sense is really only given to those who know that they are never in complete control. That sort of healing can never be effected through cloning, stem cells, or a Promethean understanding of medicine.

References

1. Sulmasy DP. Every ethos implies a mythos: bioethics and faith. In Davis DS, Zoloth L, eds: Notes From a Narrow Ridge: Religion and Bioethics. Frederick, University Publishing Group, 1999, pp 227-246.

2. Rosenthal N. Prometheus's vulture and the stem-cell promise. N Engl J Med 2003;349:267-274.

3. Brock DW. Life and Death: Philosophical Essays in Biomedical Ethics. New York, Cambridge University Press, 1993, pp 28-33.

4. Faden RR, Beauchamp TL. A History and Theory of Informed Consent. New York, Oxford University Press, 1986, pp 235-287.

5. Sullivan AD, Hedberg K, Fleming DW. Legalized physician-assisted suicide in Oregon-the second year. N Engl J Med 2000;342:598-604.

6. Back AL, Wallace JI, Starks HE, et al. Physician-assisted suicide and euthanasia in Washington State. Patient requests and physician responses. JAMA 1996;275:919-925.

7. Kurtz E, Ketcham K. The Spirituality of Imperfection: Storytelling and the Search for Meaning. New York, Bantam, 1994, p 173.

8. Aristotle. Nichomachean ethics 1112a. Irwin T, trans. Indianapolis, Hackett, 1985, pp 61-62.

9. Aristotle. Nichomachean ethics 1119a. Irwin T, trans. Indianapolis, Hackett, 1985, p 83.

10. Augustine. The Catholic and Manichean ways of life [de moribus ecclesiae Catholicae et de moribus manichaeorum]. Gallagher DA, Gallagher IJ, trans. Washington, DC, Catholic University of America Press, 1966, pp 22-23. Available at http://www.ccel.org/ccel/schaff/npnf104.iv.iv.xvii.html. Accessed Jan. 5, 2006.

11. Sifton E. The Serenity Prayer: Faith and Politics in Times of War and Peace. New York, W. W. Norton, 2005.

12. Gadamer HG. The Enigma of Health: The Art of Healing in a Scientific Age. J Gaiger, N Walker, trans. Stanford, Stanford University Press, 1996, p 108.

13. Gadamer HG. The Enigma of Health: The Art of Healing in a Scientific Age. J Gaiger, N Walker, trans. Stanford, Stanford University Press, 1996, p 37.

14. Sulmasy DP. The Rebirth of the Clinic: An Introduction to Spirituality in Health Care. Washington, DC, Georgetown University Press, 2006.

15. Wade N. Clone scientist relied on peers and Korean pride. New York Times Sunday, December 25, 2005:A1.

Daniel P. Sulmasy, OFM, MD, PhD

From the John J. Conley Department of Ethics, St. Vincent's Hospital, Manhattan and New York Medical College, New York, NY.

Reprint requests to Daniel P. Sulmasy, OFM, MD, PhD, the John J. Conley Department of Ethics, Saint Vincent's Hospital Manhattan, 153 W. 11th Street, New York, NY 10011. Email: [e-mail]

RELATED ARTICLE: Key Points

* There is a "spirituality" undergirding every ethical system.

* Contemporary research and practice, particularly stem cell research, appears to be guided by the myth of Prometheus.

* Christianity, by contrast, teaches a virtue of "sagacious engagement."