Science / Medicine : Bioethicist Takes His Cases Public : Health policy: Unlike many in the field, he thrives on publicity. And when he thinks a topic should be covered, he does not wait for the reporters to call him.
Articulate, knowledgeable and never at a loss for a quote or an opinion, Arthur Caplan of the University of Minnesota is probably America’s best-known bioethicist.
Caplan is director of the university’s Center for Biomedical Ethics, where he teaches and pursues research. He contributes to professional journals, lectures widely, writes a weekly newspaper column, and advises state and federal government officials.
Unlike many colleagues who shun the media, the 41-year-old professor of philosophy and surgery thrives on pithy sentences and sound bites.
The field of bioethics has taken off over the last 25 years. Its growth has been fueled by technological advances in medicine and increased attention to the rights of patients to make decisions about their medical care. Increasingly, academic medical centers are setting up programs in medical ethics and community hospitals are hiring ethicists to advise them on difficult issues.
But Caplan and, to a lesser extent, a handful of others have become bioethics advisers to the public as well. Whether the topic is euthanasia, new reproductive technologies or experimental AIDS treatments, Caplan is likely to be called--and often quoted.
Journalists seek him out because they know that he will return their phone calls. But Caplan often does not wait for reporters to call him. When he thinks something ought to be covered, he does not hesitate to pick up the phone and let reporters know.
Caplan says he makes these phone calls because he puts a high priority on educating the public and influencing policy. He also suggests other ethicists and specialists for reporters to talk to, including those whose views may not match his own.
Caplan has communicated his views on such controversial topics as Oregon’s plan for health care rationing (he’s against it) and organ transplantation (he still thinks that using babies born without brains as organ donors is a good idea).
He has been a strong critic of racial and socioeconomic inequities in access to health care as well as of medical experiments in which he believes that the rights of patients are not protected. He was critical of the early tests of the artificial heart and the 1985 “Baby Fae” baboon-to-human heart transplant at Loma Linda University Medical Center.
His high profile and aggressiveness make Caplan controversial. Some bioethicists, while perhaps envious of his success in the public arena, consider him overextended, lacking in scholarly heft and a bit of a self-promoter.
His curriculum vitae runs to 43 pages, including 10 pages of articles and a 24-page list of his public lectures over a 17-year period. There are 48 lecture entries for 1990.
Caplan “is viewed as someone who is colorful, interesting and a good colleague who contributes ideas to the field, but does not contribute much in the way of theory and broad perspective,” said Daniel Callahan, director of the Hastings Center, a bioethics research center in Briarcliff Manor, N.Y.
Callahan, for whom Caplan worked at Hastings from 1977 to 1987, added: “He is better known as a public figure than as a scholarly figure. . . . I don’t think there is an Arthur Caplan theory of things.”
Alexander M. Capron of the USC Law Center, another well-known and widely quoted bioethicist, said that “Art’s eagerness to comment publicly on things illustrates some of the pitfalls we all face in discussing bioethics in the media.”
Capron added that “there are risks of trying to be quotable,” particularly on complex issues that require a “nuanced understanding” of the facts. Too often, he said, bioethicists take “something where the gray is the most interesting shade in the whole discussion and turn it into the sharp shadow of black and white.”
Caplan readily admits that there is not “a Caplan theory or a Caplan stance.” But he considers this to be a virtue, not a vice.
He views bioethics as a practical endeavor, where a key goal is to “improve the welfare and protect the interests of people,” not simply to achieve an “academic understanding.”
“If there are problems that patients or doctors have, then you ought to come up with advice that makes a difference to how health care is done,” he said. “People might not know what a Caplan world view is but I bet you that there is no one you will run into who will say, gosh, I don’t know what Caplan thinks about that. I am probably as opinionated as they come in the bioethics field.”
Callahan takes a different view. “Our job (as bioethicists) is not so much rendering opinions on everything that comes along but to help people have some organized way of thinking about things.”
There is no set background or training for bioethicists. Many in the field have degrees in philosophy. Others have degrees in medicine, law or religion.
According to Caplan, the minimum requirements for expertise are knowledge of the major religious and secular ethical traditions and theories and the law as related to health care practice, as well as a broad understanding of how the health care system works, both at the bedside and in organizational terms.
Bioethicists are more likely to be advisers to physicians or other health care officials, who usually pay their salaries, than to patients. Some of their advice is offered at the bedside, such as when disagreements arise as to when to discontinue treatment in a hopeless case. But an increasing number of cases involve structural and organizational issues, such as whether health insurers should pay for experimental treatments for cancer or AIDS.
Early in his career, Caplan says, he learned the value of defining the problem and offering practical advice. One of his cases when he was in New York City began as a discussion of how to decide which asthma patients should be given priority in the emergency room on hot summer days, when the deluge of asthmatics was often overwhelming.
Caplan’s suggestion was that physicians should prescribe air conditioners for their asthmatic patients who did not have them. Because many of the patients were poor, he found out that such a prescription was covered by the state’s Medicaid program.
“It is easier to buy somebody an air conditioner than it is to fight over slots in the emergency room to suck oxygen out of a tank,” he said. “You always want to ask why is this problem happening and is there anything you can do to anticipate it and maybe stop it from being a problem.”
These days, Caplan says his primary audience is often policy-makers, who make the far-reaching decisions about when the government will pay for new forms of organ transplants and whether it will fund experiments involving the use of fetal tissue. When new issues arise, he is impatient with traditional routes of academic communications, such as medical journals.
“I am proactive,” he said. “I want to try to get there early, just because I think better public policy will get made that way.
“Sometimes the fastest and most powerful route to influence public policy is to go directly to the media and try to get someone to cover or write about or pay attention to a particular topic. The source of sustenance for American politicians is media attention. If you want their attention, then you have got to use the medium to which they pay attention.”
Caplan’s public role grew out of very traditional studies in the philosophy of science. After receiving his bachelor’s degree in 1971 from Brandeis University in Waltham, Mass., Caplan entered graduate school at Columbia University in New York City.
He described his Ph.D. dissertation as a “hypertraditional” study of evolutionary theory. Caplan said he was “100%” planning a career teaching the philosophy of science, until an opportunity arose in the late 1970s for him to advise physicians at Columbia’s medical school on some of the newly emerging bioethics issues.
Caplan said his first reaction was to tell the dean of the medical school “that I was not interested and didn’t care about this ethics of health care stuff at all. I was interested in trying to understand theories of science. I wasn’t interested in watching people try to do plumbing, that’s what medicine was.”
But Caplan quickly changed his mind. Lured by “money more than anything else,” as jobs for philosophy graduate students were scarce, Caplan entered the world of medicine. His first assignment was to spend several weeks observing a kidney dialysis unit.
Intrigued, Caplan got himself admitted to Columbia’s medical school as a special student for a year. He took courses in physiology and pathology and did rotations in such specialties as neurology and psychiatry. “In that year, I got hooked on the idea of doing bioethics,” he said.
For a few years, Caplan split his time between Columbia and the Hastings Center. He moved to the Hastings Center full time in 1981. In 1987, he took his current position at the University of Minnesota.
Caplan says he is less sensitive than he used to be to “the criticism that too much exposure and too much visibility is a bad thing.” He says it is fair for a colleague to criticize him if he does not know what he is talking about but not simply for being visible.
“I don’t think there are eight people from bioethics who agree with me about my approach to the media but I think more bioethicists ought to feel comfortable about taking a more active public role.”
Key Issues in Medical Ethics
These are some of the issues that Arthur Caplan expects will dominate bioethical discussions in the 1990s:
* Health care rationing. As medical costs continue to increase, more proposals are likely that will place limits on medical services because of financial constraints. One such plan is being considered in Oregon.
* Termination-of-treatment issues, such as euthanasia. This issue will be fueled by the aging of the population, AIDS and technological advances in the ability to forestall death.
* The Human Genome Project. The federally sponsored effort to determine the genetic blueprint of human chromosomes is likely to yield significant new knowledge, raising questions about screening for inherited conditions and challenging current views of what is normal and what is diseased.
* Doctor-patient relationships. Structural changes in health care, such as the continued growth of health maintenance organizations and managed health care, are likely to renew discussion of many topics in medical ethics, such as patient confidentiality and informed consent.
* New reproductive technologies. Building on in-vitro fertilization advances, Caplan foresees the advent of embryo biopsies and embryo lavage, in which human embryos would be washed out of the mother’s uterus, checked into the laboratory to see if they are normal, and then returned to the uterus.
