This book review is excerpted from a detailed forthcoming review in the American Philosophical Association Newsletter on Medicine and Philosophy, v. 10, n. 1, Fall 2010.

Jonathan D. Moreno and Sam Berger (eds.)
MIT Press, Cambridge, 2010
286 pp., with Index
Foreword by Harold Shapiro
Introduction and Afterword by Jonathan D. Moreno and Sam Berger
ISBN: 9780262134880

Bioethics addresses issues shaped by abstruse empirical fact and the technical parameters of the technologized controversies of contemporary culture. It is tempting to imagine that our philosophy must be as technologically-informed as our understanding of our lives has now become – that human flourishing must be in some ways dependent upon technological problem-solving, that the range of values and possibilities accommodated within the morally good life is wider than previously imagined, and that these observations define a particular stance, critical but welcoming, toward the prospect of aggressive engagement with the future through the tools and products of science.

Something like that is the position ascribed to “progressive bioethics” by the authors of the just-issued essay collection, Progress in Bioethics: Science, Policy, and Politics. The volume collects almost 20 essays on questions of the nature of bioethics as a field, its relationship to progressive ideology, and the ways that relationship plays out in particular issues and controversies characteristic of the field now and in the past. The authors are a roll-call of respected and influential figures in contemporary bioethics, not all of them academics, subscribing to a wide range of perspectives on progressivism and the task of progressive bioethics. The impression they give is of a fluid and open-minded community, engaged in a searching and sometimes indeterminate discourse with itself and the wider world.

The Foreword, Introduction, and essays of both Section I: “Bioethics as Politics” and Section II: “The Sociology of Political Bioethics” investigate the nature of progressivism, the issues that are or should be of interest to progressive bioethics, and the practicalities of politics and policy that bioethics is often involved in. Section III: “The Sociology of Political Bioethics”, addresses questions of the professional identity of bioethics, and how progressive ideology meshes with other personal and professional values. Section IV: “Conflicting Views of Biotechnology” contains one unabashedly pro-technology piece, and another warning against an uncritical stance on science. The concluding Section V: “Progress Beyond Politics”, offers higher-level reflections on the field of bioethics in general. In the “Afterword”, the editors remark upon the prospects for progressivism and healthcare reform in the advent of the Obama administration – a question that could not be more timely.

Necessarily, there are gaps: the definition of progressivism needs further exploration, and it remains unclear why progressivism should have any of the content suggested for it; at times the content or scope of bioethics also seem taken for granted. Even the role of science in progressive bioethics awaits further examination. These are not faults in a collection of diverse viewpoints; however, much remains to be discussed. This volume opens that discussion insightfully, searchingly, and provocatively.

Progress in Bioethics is must-reading for political progressives interested in biomedical issues, bioethicists who identify as political progressives, bioethicists in general who are interested in the conceptual landscape of contemporary biomedical policy and cultural controversy, and for those who seek to develop a humanitarian pro-science viewpoint, whether on biotechnology or other complexities of our technologized modernity.

Afghanistan’s President, Hamid Karzai, has signed a law which “legalises” rape, women’s groups and the United Nations warn. Critics claim the president helped rush the bill through parliament in a bid to appease Islamic fundamentalists ahead of elections in August.

In a massive blow for women’s rights, the new Shia Family Law negates the need for sexual consent between married couples, tacitly approves child marriage and restricts a woman’s right to leave the home, according to UN papers seen by The Independent. . . .
The most controversial parts of the law deal explicitly with sexual relations. Article 132 requires women to obey their husband’s sexual demands and stipulates that a man can expect to have sex with his wife at least “once every four nights” when travelling, unless they are ill. The law also gives men preferential inheritance rights, easier access to divorce, and priority in court. . . .

Even the law’s sponsors admit Mr Karzai rushed it through to win their votes. Ustad Mohammad Akbari, a prominent Shia political leader, said: “It’s electioneering. Most of the Hazara people are unhappy with Mr Karzai.”

The fault in this case lies squarely with the Afghani men, of course. (British officials, rushing to the defense of women, have “raised concerns at a senior level”. Thank God!) But it’s worth noting that this government is America’s “ally” – in the sense that if we don’t acquiesce in their doing these things, and pay them a lot of money besides, they’ll . . . be even less cooperative against Al Qaeda. One might also note that this sort of thing is once more on the rise in Iraq, where women had once had full legal equality under Sadam, now that de facto separatist governments under religious extremists have been established, with American approval, in parts of the country.

It has to be acknowledged how disastrous the situation has always been for women in most of the world, and how little leverage the nascent democracy movements in the most backward countries are. Except in places like Iraq and Iran, where modernist governments have been fully or partially replaced by theocracies, it’s not clear that, however horrendous conditions are, things are getting much worse for women, even in the worst countries. In a practical sense, the new Afghan law may not change anything, since the practices in question are widespread there anyway. The fact that there is even a tiny amount of freedom for women in the capital city is a – very depressing – step forward.

But those facts, inescapbable as they are, do not tell the real story. What’s most galling is not that conditions for women are so bad, but that that is regarded as a negligible problem. Women’s rights, and women’s freedom, are simply not issues worth caring about, to virtually any government or any influential group of (male) people.

We’ll go to war over oil, land, religion, vaguely-articulated political and economic beliefs, other countries’ refusals to do our bidding, or a soccer match. We’ll claim as justification for our wars other people’s freedom to vote for the candidates we approve, be Christian whether they want to or not, and buy American consumer goods. The one thing we’ll never fight for, or even claim as justification for fighting, is women’s freedom to live their own lives. It’s simply not an issue. The idea that we should invade Iraq to establish a quasi-democracy in some parts of the country while igniting an indigenous religious war and all but completely destroying the country’s economy and material infrastructure is somehow not seen as ludicrous. The idea that we would invade Afghanistan – or refrain from invading Afghanistan – because it’s women are subject to widespread, organized rape and open murder – legally – now that is seen as ludicrous. The idea that we would threaten preemptive nuclear war with Iran because they might someday have one warhead to our current 10,000 is not absurd; the idea that we would threaten any serious engagement of Iran because the women of that country have virtually no legal rights and are subject to arbitrary imprisonment, rape, abuse, and murder by the religious police, is beyond absurd – it is unthinkable.

The idea that women’s rights and women’s freedom is an issue that commands our involvement – that it is one of the things we must pursue and protect, among the many things we accept as justification for our adventures and misadventures around the globe – that it would constitute any kind of reason at all for any kind of action at all, let alone aggressive engagement or sacrifice on our part – is quit obviously a joke. Of all the places we’ve invaded, bombed, or threatened over the past few decades – Nicaragua, Grenada, North Korea, Panama, Iran, Iraq, Lebanon, Russia, and on and on and on . . . – and usually on the most ridiculous pretenses (Reagan invaded Grenada because they were building a runway, which he then continued building after occupying the island), in which of these is it even imaginable that the same things could have been done because the women of that country did not have full equality, or even basic rights?

Women’s interests are negligible. Whatever misery, oppression, or lack of freedom motivates political concern, in the US or anywhere else, it is not women’s misery or oppression that provides that motivation. The US courted Afghanistan for decades without any overt action on the basis of the grinding, indescribable misery and abuse of the women of that country, and we continue to tolerate those same conditions while occupying that country and propping up its government. But that occupation was prompted – on little notice and with little debate – by the fleeting presence there of a small group of terrorists we still haven’t managed to locate. That minor military problem was sufficient justification for occupying and remaking the country; the horrific abuse of its female population for all time up to that moment was not such a motivation, and its continuation during our presence there is not motivation for any proportional expenditure of energy on their behalf. Women are not a reason for doing anything, in Afghanistan, though smaller groups of people who catch our male leaders’ attentions are more than enough reason. The US invaded Iraq, twice, on the pretext of its supposed military ambitions; in the process we eliminated the freedom for women that existed there at the time, and returned them to the insecurities of religious politics, and for many of them outright partriarcal theocracy. The oppression of a small percentage of its population who were political opponents of its leader was justification for destroying that country and its government; that that government was the only source of liberty for more than half its population – the female half – was not justification for not doing so. Women simply didn’t count, in that equation. And they never do.

Until women count – until women in and of themselves are a reason for doing anything – until the oppression and misery of women is seen as human oppression and human misery, the sort of thing we say we care about and act on – there will be no progress. And until we powerful nations, nations who shake the world and make and unmake governments and laws and wars, do what we do because women matter at least as much as oil, or land, or religion, or markets, or men, women will not count where it counts.

The most entrenched redoubt of medical power (though least well-grounded in research and knowledge) was psychiatry. Not only did the head-shrinkers lay claim to the most occult knowledge of human functioning and health, but they stood against a patient population that was inherently and societally almost unable to defend itself. Members of, possibly, the most severely and unsympathetically stigmatized stratum of society, mental patients were given no credence, and often had no recognized legal standing, to assert their own values and choices in treatment. And it is true that in many cases, patients with mental illness could not in fact act for their own interests or competently manage their own treatment and caretaking. But the presumption that no such patient could have a valid opinion about their own care, coupled with the prejudice that they were unfit for “normal” society, and likely dangerous, meant that virtually anything could be done to anyone, if advocated by a doctor armed with a diagnosis of mental illness. The things that were done were in many cases almost unthinkable.

Howard Dully spent over 40 years thinking about what was done to him. It took him a full life of hardship and failure to finally understand his own fate, and to come to terms with it. That anyone could have survived, let alone found peace and stability, after having lived his story, is an amazement in itself.

Dully is the author (with a professional co-writer) of My Lobotomy: A Memoir. The subject of the book is exactly what the title suggests. The story it contains is heartbreaking.

Dully’s life is difficult to summarize, except to say that it was unremittingly harsh almost from birth. Dully was born in California in 1948; his father was a hard and unemotional man who was driven to work excruciating hours, sometimes at as many as 4 or 5 low-skill physical labor jobs at the same time, partly by the need to support his family, partly by his own obsessive work ethic. Howard grew up a big kid (he’s now 6’7″, 350 lbs) who picked on his younger brother; when he was 4 his mother died after giving birth to a baby brother with a severe neurological deformation – the baby was placed with relatives and never spoken of again within the family. Howard and his family bounced around various friends’ and relatives’ homes as his father struggled to earn a living, and Howard suffered constantly both from missing his mother and from the severe discipline he suffered in some of these homes. Things really got bad when his father married again, to a woman with two sons of her own. Dully claims that she simply resented and hated him; from reading both his own stories of his home life, and some of his doctors’ notes, it is easy to believe he is correct. Howard, in the meantime, was legitimately a handful for any parent: he was apparently flightly and unreliable to an extreme degree, was aversive to school work, discipline, and hygiene, and often fought with his brothers, though they had a generally good relationship. As he got older he began doing stupid kid pranks – shoplifting and stealing items from cars, and playing hooky. As a huge and growing boy, he was constantly hungry, but was not allowed to eat between meals and was beaten for taking snacks. His step-mother also had some sort of obsession with her furniture and household trinkets, and would beat Howard for touching anything in the house, sitting on the parlor furniture, or using the front door. His step-mother would beat him for any infraction, and for things that weren’t infractions; later his brothers confirmed that she did indeed beat him for things she did not mind when done by her own sons, and would rave at him for no reason at all. When his father got home, he would get another beating – his father made him choose a piece of firewood to be beaten with, and Howard developed the skill of picking ones that were flexible enough to hurt less but strong enough not to break (which would encourage his father to continue the beating with his bare hand). Between his actual behavioral problems, his pre-adolescent awkwardness, the fact that his step-mother did seem to truly want him dead, and his father’s absence and emotionally and physically violent treatment, Howard seemed doomed to a life of misery no matter what might have happened. What actually did happen is unbelievable.

Howard’s step-mother apparently conceived the idea that she could get rid of Howard if she got the weight of professional opinion on her side. She began visiting a series of psychiatrists to complain about her son’s behavior, but none of them would agree he had to be institutionalized or removed from the home. Several wrote consulting notes to the effect that they were convinced her harsh treatment was the problem and that she should moderate her behavior toward the boy. She moved from doctor to doctor trying to find one that would agree with her. Finally she stumbled onto Dr. Walter Freeman.

Freeman was the pioneer, in the US, of the new treatment of psycho-surgery. He actually coined the word “lobotomy”, and popularized the use of that treatment in this country. He was the first US physician to see the procedure, after it was developed in Europe just before WWII; Freeman brought it back to the States and traveled the country in specially-modified vans or station wagons that he called his “Lobotomobiles”, giving demonstrations of both electro-convulsive therapy (using a machine he built himself; when it broke down, he simply held the bare wires against the patient’s head for as long as he felt was appropriate, with no mechanism for monitoring voltage or current) and lobotomy. According to the Dully, relating reports of academic researchers who studied Freeman’s career, Freeman was a constant self-promoter and showman: he would perform several lobotomies in a day, every day, in front of medical audiences, liked to demonstrate how easy it was by sometimes using ordinary household implements rather than surgical tools, and developed a signature two-handed bilateral technique in which he would insert “leucotomes” (the lobtomy knife) into both lobes of a patient’s brain and then simultaneously jerk them both through the tissue with a flourish. At times, his death rate ranged upward of 20%. Nobody seemed to think this was cause for alarm. Patients were operated on without their own knowledge or consent, and authorization was freely obtained from courts or patient guardians after reassurances from Freeman that the procedure would solve all the patients’ problems. Often, no precise psychiatric diagnosis was attempted before the lobotomy was performed; lobotomies were used for conditions ranging from headaches to schizophrenia. More than a few were performed on minors, even pre-teens; there were questions about such cases, but little organized opposition. Freeman was profiled in popular magazines, and sometimes hailed as a god, delivering sufferers from their misery. There were many detractors in the medical community, but the great benefit of lobotomy was that it often made patients docile enough to live with their families without monitoring, meaning they could be discharged from the large state mental institutions that were commonplace then. This made the procedure wildly popular with the managers of those institutions, whose patients had no effective representation to oppose the treatment plans made for them by others.

After a few years, Freeman heard about, and again pioneered, a variation of the lobotomy procedure called “trans-orbital lobotomy”, often referred to as “ice-pick lobotomy”. In that procedure, a long, sharp, thin instrument was pushed along the eyeball parallel to the nose, and through the back of the eye socket (“orbit”) into the skull, and into the frontal lobe of the brain. The instrument could then be levered back and forth, and up and down, to tear through the frontal lobes and disrupt their neural circuitry. There was no method for visualizing the exact placement of the instrument in the brain, or the location, depth, or extent of the lesions created; the method was simply to stick the metal rod in through the eye socket and wiggle it back and forth to tear the brain tissue randomly. The effect was almost as dramatic as an open-skull lobotomy, but there was no external wound, and it could be performed under mild anaesthesia. The procedure could be done in an ordinary doctor’s office, and took about ten minutes. In many cases, the surgical instrument used was, in fact, an ice pick. (Freeman’s personal lobotomy instrument was labled “Uline Ice Company”.) Patients were sometimes sent home afterward in a taxi cab.

Freeman began popularizing the trans-orbital lobotomy, sometimes performing as many as two dozen procedures a day on patients in mental institutions and hospitals. In some cases, patients were operated on against their consent; after the procedure, they lacked the drive and wherewithal to sue. After some years traveling the country in his Lobotomobile, he finally settled in the South San Francisco Bay Area, near where Howard Dully’s family were living. Eventually, Dully’s step-mother asked to see him.

Freeman met with her a number of times over a period of two months, duly recording her wild stories of Howard’s unmanageable behavior (some of which later turned out to be pure fabrications – such as the story that he had beaten his brain-damaged baby brother almost to death). From the beginning the step-mother openly solicited some kind of dramatic professional intervention. Freeman hesitated at first, insisting he would have to meet the patient and interview the other family members before coming to any conclusion. (What seems incredible is that he began formulating treatment plans with the mother for weeks before ever once meeting Howard.) He interviewed Howard’s father one time; the father gave a much more balanced report of Howard’s behavior, but Freeman didn’t pick up on the clue. He began to meet with Howard himself, and found him reasonably normal though somewhat uncommunicative (who wouldn’t be?). But he kept meeting with Howard’s step-mother, who still filled him with tales of how afraid she was of Howard, how her other sons were afraid of him and were constantly beaten up by him (they deny this), and finally how Howard had beaten up his baby brother in infancy (his entire family denies this – and note that the step-mother was not part of the family at that time). Freeman seems to have accepted everything she said, and viewed Howard’s truancy and other bad behavior through this fictionalized and delusional lens. After four meetings with the step-mother, only one meeting (ever) with Howard’s father, and four visits with Howard himself, Freeman recommended that they should attempt to “change his personality” with a trans-orbital lobotomy. Howard’s step-mother immediately agreed, and took the papers home for his father to sign, which he did without ever speaking to the doctor again. Freeman cautioned the parents not to tell Howard what would happen – only that he would be admitted to the hospital for “tests”. Howard excitedly looked forward to his night in the hospital, because he had heard they gave you Jell-O there. And they did. It was two weeks after his 12th birthday.

Freeman lobotomized Howard the next day. Howard has no memory of any of the events of that day. He contracted a fever and an apparent infection (Freeman was infamous for not sterilizing his instruments before surgery; you can see, in the actual photograph of Howard’s procedure, [see photo at end, below the jump] that he is not wearing gloves), but recovered soon enough.

The rest of his life was a disaster.

To make a long story short, the lobotomy did not placate Howard’s step-mother. She continued to persecute him, and to complain to Dr. Freeman about Howard’s behavior. Freeman claimed that Howard was improved after the surgery. His step-mother began demanding that he leave the house – at the age of 12 – and so he was sent around to a variety of relatives and foster-home settings. He found one family he liked, and who doted on him, but who were very religious. His father objected to their religion, and took him from the home. He continued to get into trouble at school, and was eventually sent to a local psychiatric evaluation facility, who found him normal and discharged him. He spent about a year on an adult psychiatric ward at the age of 14. At one point his parents seriously discussed simply giving him an allowance and telling him he would have to find his own apartment and take care of himself – at the age of 15. He began a downward spiral of increasingly anti-social behavior and lack of discipline, resulting in juvenile hall, then a state psychiatric facility for observation, then a children’s psychiatric residential facility, then a long-term state psychiatric locked facility – all before the age of 17. He was repeatedly told by the staff of these facilities that they knew he was not mentally ill – there was just no procedure for discharging him, and nowhere for him to go. His family refused to have him at home, and only his father visited, at intervals.

After reaching adulthood, he was discharged to a halfway house in San Jose, and began 4 decades of aimlessness, petty crime, and continual inability to maintain any semblance of a stable life. The lacunae and byways of his distorted life were too many to recount here, but the bottom line is that he suffered from two crippling problems: one is that his brain had been severely damaged by the horrendous procedure he endured, and the other is that he had never been socialized into living a responsible life. His development was cut off at the age of 12. He simply did not know how to do any of the things you have to do to live normally – how to feed himself, how to handle money, how to work at a job. He invented a “brilliant” check-kiting scheme that involved stealing other people’s tax refund checks, depositing them in a bank account under his own name, then writing checks on that account to buy merchandise which he would then pawn for 1/3 its value, giving his real name and address as security on the checks he had written; he was amazed when they caught him. He was homeless for long intervals, drank too much, had a succession of terrible relationships with people equally as strung-out and fucked up as himself, started businesses that he bankrupted by partying with the money out of the cash register, and in general had no way of planning for any future further away than his next bad decision. Weighing over 300 lbs and smoking three packs a day, he had a heart attack in his 40s. After many long, bad years, he fell in love with a woman who realized she had to get them both clean and sober, and into some kind of stable lifestyle, if they were going to survive – and, miraculously, they managed it together. He eventually found a job as a bus driver, and has worked consistently in that field for some years now.

A few years back, when Dully was well into his 50s and finally finding some (imperfect) stability, an NPR radio producer contacted him, saying he was putting together a program on the life of Walter Freeman, and had contacted a few of his old patients; they wanted to interview Dully for the spot. He agreed – but after he talked for some time with the producer and his assistant, they became so enthralled by Dully’s story that they changed their minds. They wanted to do the show about him – to get Dully himself to actually narrate the show and interview the other patients and participants, including his own father. They also told him that they had located Freeman’s personal archives – which he had donated to George Washington University in anticipation of the professional acclaim he was sure would come; as a former patient, Dully was entitled to ask to see his own medical records.

Dully desperately wanted closure on the pain and bewilderment that had haunted him his entire life. He was also terrified to, but eventually agreed to, interview his father for the show. He began travelling the country, interviewing former lobotomy patients or their surviving family members. Some said they did feel the operations had been beneficial; most said the results were debilitating or horrifying. One woman broke down in recalling that the operation had made her mother so childlike that she, her daughter, had never thought of her mother as her mother, or as the grand-mother of her children; she had never introduced her own daughter to her mother. Dully spent extensive time with his own father, trying to elicit some reaction to the fact that he had been lobotomized at the age of 12, and his father had signed the consent to allow it. At no point does his father offer anything that seems genuinely humanly emotional or authentic, and at no point does he acknowledge what was done to his son or how momentous it was.

The radio show was a smash. It was previewed to a select audience in New York, including experts in medicine and the work of Walter Freeman; they were left in tears, and responded with a standing ovation. Dully replayed the interview when he appeared as keynote speaker for the National Guardianship Association (a group for those who serve as legal guardians of mental patients); they had the same reaction, and he was mobbed for autographs and questions. When it finally aired on NPR, the station’s server immediately crashed with e-mail messages expressing how moved and admiring the listeners were. (I can’t imagine this book isn’t going to be made into a fantastic movie soon. It needs to be.) The show remains available on the NPR Web site; it is moving and at times horrifying. Dully’s book contains more material, and more elaborate context, for the interviews and sound bites heard on the program, which is only 20 minutes long. (His description of being awed by Frank Freeman, Walter’s son, describing in technical clinical terms his father’s brilliant successes, and claiming that he himself could perform lobotomies with the same instruments – and then seeing Frank pop out of his bedroom in his “work clothes” – a rent-a-cop security guard’s uniform – is priceless.) The aural impact of the people’s actual voices is unforgettable, however. You hear one poor woman chirpily singing “You Are My Sunshine” with her lobotomized mother who remained a little girl to the age of 93; she explains that, until that day, she had never brought her husband of 19 years to meet her mother, because she couldn’t face the fact of her mother’s debility. When Howard asks her what made her change her mind that day, she answers, “You. Do you know how many people you are championing?”

Howard Dully is still a bus driver in San Jose, CA. He is also a noted speaker on lobotomy and patients’ rights issues. He remains a champion. His greatest victory is summed up in his own final words from the book and the radio program: “I did feel, at last, truly at peace. . . . I had found my place. I was no longer ashamed.”

* * * * *

This story resonated strangely with me, when I realized that I could have met Howard Dully during his wandering years. I grew up in the Bay Area and attended San Jose State University, in San Jose, California, during the period that Walter was living in the same town at the lowest ebb of his life. I worked for a year in juvenile residential psychiatric facility similar to the one he lived in, and, as an EMT, I transported mental patients to Napa and Agnews State Hospitals, where Howard was incarcerated for long periods. (Basically minimum-security prisons for people who got on the wrong side of a psychiatrist, I wouldn’t wish those places on anyone – and sometimes felt conflicted about my role in placing people there, though I remember angrily defending myself against a radical professor who criticized my participation in the system.) I was there just after the great wave of “de-institutionalization” – patients’ rights advocates found an unexpected friend in Governor Ronald Reagan during the 1960s, who was perfectly willing to empty the large state mental facilities and dump patients on the streets with almost no support. The large concentration of halfway houses like the one Howard lived in, near the San Jose State campus, was the result of the closure of the long-term institutional centers. Just as Howard describes, the patients were forced to leave the halfway houses during the day to “socialize”, but were provided with no employment, therapy, or job training, and so would simply congregate downtown or on the college campus; I saw many of them in the vicinity as a student and later an EMT. Though it’s unlikely, one of them could have been Howard. I certainly recognize many of the places he mentions in the book (though I was never brave enough to go into the Saddle Rack – the redneck bar he frequented in those days). At one point we apparently lived within a few blocks of each other. I knew the rough outlines of that world, but Howard’s book lays bare the inside of the system, and the ease with which people can get caught up in it.

It has to be said that it’s hard, throughout the story Dully tells in his biography, to see exactly where the lobotomy fits into the picture. As he himself reports, his behavior was not well controlled even before the lobotomy – though it hardly seems like anything more than the usual ne’er-do-well kid stuff. His step-mother truly seems to be an unmitigated evil, and even if she hadn’t had him lobotomized, nobody would have come out of that situation whole and well, but his father’s seemingly soulless and disingenuous relationship to his own culpability, and his son’s desperate need for affirmation, can be understood as the product of his weird Christian Science upbringing (where he apparently learned that you don’t dwell on “negatives”, or show strong emotion). Howard’s later troubles, though harrowing, don’t seem that atypical of the lives of more than a few people who found they just couldn’t make it in the straight world, and wound up down and out, living hand to mouth and having trouble with the law. It doesn’t take a lobotomy to get into that position. But Dully had all that and a lobotomy – which complicates the picture, and also underscores what a triumph his life has finally become.

More than anything, this book illustrates how grinding, and how merciless, the system of antagonistic medical power can be. On the radio show, while reading, live, for the first time, Walter Freeman’s summary of his step mother’s libelous “case report”, and his father’s complacent acquiescence in their plans to cut his mind, Dully says heartbreakingly: “I was supposed to fight all this, huh? No way. A twelve-year-old couldn’t stand against all this. It wasn’t fair.” It surely isn’t.

The strange and harrowing history of psycho-surgery was a brief one. At one time it transfixed medical ethics as a paradigm case of the clash of values and the appropriate limits of medical authority. But as the horror stories began to seep out and the bizarrely unscientific nature of the procedures became more apparent, and especially as the patients’ rights movement grew some teeth, the issue simply disappeared. Such procedures came to a halt in the late 70s, about the time of Freeman’s own death (and that of his last hapless patient). In some jurisdictions they were banned outright, or placed under stringent safeguards of patient interest. The rise of effective psychological medications – not without their own significant side effects – also made the crudeness and destructiveness of the surgeries seem unnecessary. (To this day there is no known method for guiding or controlling the specific pathways, or predicting the consequences, of large-scale brain lesions like lobotomy.) They are simply not performed anymore, and the patient-autonomy pendulum has swung far enough, even in mental health, that such free and easy invasions, on such a scale, are not likely to recur. My own first textbook in medical ethics – the 1981 original edition of Mappes and Zembatty’s Biomedical Ethics – devoted two full sections to behavior modification and psycho-surgery; the current edition contains no mention of either topic.

But the larger issue this tale raises remains germane. The tension between expert opinion and patient values remains as acute as ever, even as patient-centered decisionmaking and autonomy have come to be watchwords in healthcare. And the terrible vulnerability of the mentally ill, or even anyone simply labeled mentally ill, remains. Once that label has been put on, it becomes impossible to get anyone – still less medical professionals – to see one’s behavior, values, or decisions through any other lens. And the temptation to substitute judgment for the mentally ill becomes insurmountable for too many people – a temptation that is indulged and ratified too easily by both the health and legal systems. We are unlikely to see many more 12-year-old lobotomy victims, but we are in no way unlikely to see more people caught in power struggles with doctors, parents, administrators, judges, and family members who “know best”.

UPDATE: The blog Neurophilosophy has an excellent review of the history of lobotomy as a procedure. Howard Dully himself contributes in the comments thread.

SECOND UPDATE: Moved photo per reader’s request.

Robert has been documenting, step-by-step, the pathway he, his equally-admirable wife Julie, and Schuyler (pr. “SKY-ler”) herself have followed, first coming to terms with Schuyler’s developmental difficulties, then battling the public schools’ broken and indifferent system for educating special-needs children until finally moving to a city (Plano, TX, of all places) that offered what Schuyler needed. At the urging of his growing base of enthralled fans and well-wishers, he turned the blog into a book that hit the market just this week. It has already received considerable word of mouth and small-market press attention even before release; I am convinced it is just about to explode into a real sensation, and deservedly so.

Robert has an ability to communicate the pathos and humor of his family’s situation, and even more strongly Schuyler’s unbelievably spunky and winning personality, and her brilliantly unique triumph over the multiple dirty tricks life has played her. Schuyler is without question the star of his blog (which, he says, she still has not read, nor has she the book, either, though she is fully aware that she is a media queen). It is impossible to read their story without falling in love with Schuyler (and indeed she is regularly showered with largesse by fans, often anonymous, who have visited the family’s Amazon wish-lists). “Schuyler has a posse!”, I told Rob, and he agreed that one of the most satisfying side-effects of blogging about her condition is that she has garnered such a wide-spread support base. That is due to Rob’s ability to make her come alive through his words – though it’s obvious Schuyler is giving him a lot of great material to work with.

In person, Rob comes across just as you’d imagine from his blog: funny, personable, thoughtful, fiercely dedicated to Schuyler and her needs, worried about her future, and laceratingly honest about his own uncertainties and shortcomings (which I think he overestimates). It was great fun meeting him, and I was glad to see the St. Martin’s Press staff just as enthused about the book as were the many fans who turned out to meet the author.

I mention all this simply to add this plug for a book that deserves to be read, and will break your heart and change your viewpoint when you have done so. I can’t communicate the impact of Rob’s blog or the book it gave rise to, but I urge everyone to experience them for themselves.

(1) Go buy this book:

(2) Go read this blog.

You can thank me later.

UPDATE: Fixed an editing mistake.

Nabokov left a manuscript on index cards, apparently totaling about 30 pages’ worth of text, for an unfinished book titled The Original of Laura. No one outside his family knows what is in the text, or what the title means. Nabokov left unambiguous instructions, at the time of his death, that the manuscript was to be destroyed without publication. This jibes with ideas he expressed elsewhere about refusing to publish imperfect works. His wife, the legendary (infamous?) Vera Nabokov, was his literary executor; she indicated she would follow his wishes but never got around to destroying the cards. When she died in 1991, the cards, and Nabokov’s imprecation, fell to his son Dimitri, who has otherwise actively defended his father’s literary legacy. Dimitri has indicated that he is ambivalent about destroying the work, but is apparently leaning in the direction of carrying out his father’s wishes. Rosenbaum has corresponded with Dimitri over the years, encouraging him to publish the material; in his Slate article, he broadcasts a call for input from readers, promising to forward the best responses to Dimitri, who is apparently finally nearing a decision.

Well. By itself all very interesting, no doubt, and arguably very thinly connected to bioethics by way of Nabokov’s background in biology. (Rosenbaum even tries to link Nabokov’s Laura to Petrarch’s Laura by way of a bird image in the latter and one of Nabokov’s ubiquitous butterfly images in Pale Fire; Dimitri scoffs at this.) But it really doesn’t seem to be an immediate issue in bioethics itself. Or is it?

Rosenbaum and Dimitri Nabokov both seem deeply conflicted by competing obligations of artistry, as it were: respecting Nabokov’s wishes as an artist vs. giving the world its last best look at the scope and breadth of his talent. (Dimitri has upped the ante by suggesting that Laura is simultaneously a “distillation” of Nabokov’s body of work and “a brilliant, original, and potentially totally radical book”.) Dimitri is further conflicted by his feeling that his father’s work has been mistreated by ignorant critics in the past: he thus faces the question whether publishing a partial manuscript his father wanted destroyed would correct or exacerbate that problem; there is also his filial duty to follow instructions. Rosenbaum addresses the question of the artistic standing of Nabokov’s work, and its relevance to this decision, in an insightful passage:

Does it matter what V.N. would feel, since he’s long dead? Do we owe no respect to his last wishes because we greedily want some “key” to his work, or just more of it for our own selfish reasons? Does the lust for aesthetic beauty always allow us to rationalize trampling on the artist’s grave? Does the greatness of an artist diminish his right to dispose of his own unfinished work?

I think this focus on artistic legacy misses the central point, however. The real question, as in so many disputes over conflicting wishes or values, is, I think, the familiar one: “who decides?” And that makes this dispute relevant to bioethics in a vital way. If there is a clear and unambiguous answer to the question of whose decisions should be determinative, and an answer that carries compelling or overwhelming moral force, then the questions of artistic intent and value fall by the wayside. If Nabokov has a moral claim to dispense with his own literary legacy entirely as he sees fit – a claim that is compulsory upon others even after his death – then it doesn’t matter how good this work might be, or how helpful in illuminating Nabokov’s other works. If, on the other hand, one has no moral claims that extend beyond death, or no interests that survive, and can potentially be harmed, after death, then the issue becomes one of prudential decision-making, or perhaps personal obligation, on the part of Nabokov’s executors, and only then does the issue of artistic merit enter into consideration.

Problems such as this arise whenever the handling of controversial legacies comes up (eccentrics who leave a fortune to their cats, for instance), but they are perennial in bioethics, which treats of issues that approach and cross the threshold between life and death. Organ donation, termination of life support, the definition of death, and other such borderland issues often generate conflict between the expressed wishes of the dying or dead and the perceptions and preferences of others left behind to carry out those wishes. While prudential and other values can be conscripted on both sides of such arguments, to the effect that one or the other resolution would be a good thing, autonomy as a trumping power overrides such considerations if autonomy is the controlling value in enacting the wishes of agents who no longer exist as autonomous persons. (That is, it is understood in this discussion that the decisions in question are ones of which the agent’s autonomy would unquestionably be determinative while the agent was alive: you can certainly agree to donate your own [non-vital] organs without interference by others, while you are alive; you can spend as much money as you like on your cats, while you are alive; Nabokov would have had an absolute right to destroy his own manuscript, while he was alive. The question is whether those powers or rights persist beyond death, such that others who agree to accept the responsibility for carrying out one’s wishes after death must thereby agree to carry them out in full and without modification.)

From this perspective, the discussion of Dimitri Nabokov’s dilemma, or of the benefits of either preserving or destroying Vladimir Nabokov’s last work, is premature. It doesn’t matter what Dimitri wants to do, or how valuable that manuscript might be, if Vladimir’s wish that it be destroyed commands the same moral force after his death as that same wish would before his death. That is the question that must be resolved, not only to decide the fate of Nabokov’s Laura, but of so many issues involving the death-transcending desires of the dead and dying.

Often, among the last conscious acts of an elderly or dying person is to “get their affairs in order” – including by expressing their wishes for the disposition of various worldly concerns at the time of or after their deaths. One of the strongest arguments in favor of a persistent interest in the affairs of one’s lifetime, after death, is that much of our lives is shaped by our expectations that those interests will be respected and our postvital wishes will be carried out. Traducing the interests of the living as soon as they are dead may not be a morally-neutral act: though it does not affect the dead directly, it, arguably, retroactively ruins their previous lives by emptying or dismissing the goals and projects that gave those lives purpose, and in some way perhaps steals the products of their lives (whether monetary or otherwise) by diverting them to ends not chosen by the decedent themselves but by others after the fact. On the other hand, it must be admitted that the dead themselves will never know this, and so never be anguished by it. Either way, it is a non-trivial issue, and, as the Nabokov case, and the medical cases, show, one that has considerable practical implications.

I’ll leave the argument at this point. I confess to always having been ambivalent about its resolution. Perhaps my vast readership may have some input?

Honestly, I have no idea what to think about this business, but . . . here goes:

Rant is a pseudo oral history of the life and exploits of the title character, Buster “Rant” Casey. Palahniuk delivers over 300 pages of short-paragraph-length observations from peripheral characters describing their interactions with him from overlapping and mismatching perspectives. (The book reads quickly because, given the large amount of white space between the “recollections”, it’s probably closer to 250 pages of real text.) We’re supposed to reconstruct the events described on the basis of which stories we believe. When you solve the puzzle, you get a picture of a dysfunctional and paranoid society suspiciously like our own, in which the government has vacated all civil liberties, imposed lifetime detention without trial for undesirable elements, and sequestered half the population in a dark underworld in which they are doomed to menial, marginal existences, receive a grudging minimum of social services, and can be shot on sight for being caught in the wrong place with the wrong paperwork; the justification for all this is . . . (wait for it) . . . the security of the nation, in the face of an existential threat from an invisible but omnipresent enemy. Young people respond to this with desperate nihilism, engrossing themselves in bizarre and self-destructive practices, as well as drugs, mindless sex, and violence. Behind the scenes are shadowy conspiracies enacted by powerful individuals who maintain the danger and the resulting oppression for their own interests: corporate, political, or religious.

Palahniuk’s take on this otherwise none-too-fictional theme is that the danger in question is not terrorists or traitors, or weapons of mass destruction, but biology. The world is driven to the brink of collapse by an unstoppable epidemic of rabies, passed mouth-to-mouth through close, casual contact, through sex between unknowing partners, and sometimes by those who deliberately seek infection as an act of rebellion. Rant Casey is the source of the infection, and of much else that goes on in this strained and tortured world.

[Spoilers Follow]

Casey, it appears, has always been a kind of human disease vector, and he possesses an unusual closeness of connection with other living things. Growing up in the country, he has an affinity for animals of all kinds – and women of all kinds. From childhood on, he deliberately seeks bites from wild animals, because, he says, that moment of pain is the only one in which he feels truly alive; later, he finds sex offers the same benefit. He can taste a person’s entire life history, their menstrual cycle stage, and what they had to eat at any point in the past, from a kiss, or cunnilingus – and he gets many opportunities to do so. Here, Palahniuk introduces the theme that is most recognizable from his other works, and which underlies much of Rant: the search for authentic experience.

This desperation for authenticity drives even the parts of his life in which he is not giving oral sex or sticking his hand down rattlesnake dens. Casey sends the entire town into hysterics one Halloween by substituting real blood and brains for the pretend exhibits in the community “haunted house” (thereby earning his nickname: “rant!” is supposedly the sound a child makes when vomiting in disgust); his explanation is that he wanted it to be real – that he couldn’t stand the thought that the fake tricks usually used were a lie. When he reaches puberty, he discovers that spider bites are the only thing that give him an erection, which he then puts to use after wielding his persuasive charms on all the women and girls in the town. He stages stunts that disrupt the order of things in his environment, at one point suspiciously discovering an immense fortune in gold coins that he distributes among the children in the town, who instantly subvert the local economy and social order. Business profits are driven by the whims of children, parents steal from their children, the local market devotes entire shelves to stocking toys and water pistols costing hundreds of dollars; one narrator comments that the episode reveals the “consensual reality” nature of the capitalist economy (things are only valuable because people agree they are). Taking advantage of the the erection-on-command potential of his affinity for spiders, Rant stages a boner rebellion in his high school, encouraging the boys to disrupt classrooms by displaying fake erections that teachers cannot punish for fear of lawsuits, until the authorities are finally forced to negotiate with him to put an end to it, thereby freeing himself from the terrors of a haughty math teacher (and demonstrating that authority, like market value, is consensual). He deliberately seeks infection with rabies, and repeatedly catches the diseases, takes injections to cure it when the symptoms approach the danger point, and then re-infects himself – passing the infection to all the women he sleeps with as well.

This search for excitement and authenticity guides every step of his path through life – nothing matters to Rant, and nothing feels to him, except his few moments of transcendental sensation. The biological theme – closeness with people and animals, seductive persuasiveness, obsessive sex, disease, infection and transmission – also defines Rant’s life, and his actions in moving through it.

In response to the breakdown of their society and their marginalized place in it, young members of the subculture – known as “Nighttimers” for their nocturnal ghettoization and dawn curfew in a society organized into two camps on opposite sides of the clock – invent a thrill-seeking game called “Party Crashing”. They acquire used cars and decorate them with a specific recognition signal keyed to the theme of each night’s adventure (“Wedding Night” sees the cars decorated with “Just Married” signs, the drivers and crew wearing tuxedos and wedding gowns; on “Student Driver Night” they all sport traffic-school warning signs, with hilarious results for one hapless actual student driver who wanders in by mistake); they then drive around in a specified zone until they spot another car with the recognition signal, whereupon they deliberately crash into it, rating themselves on the quality and artistry of the wreckage. The most popular radio station broadcasts live descriptions of drivers’ injuries and probabilities of survival after each crash. Most crashes are minor; occasionally someone dies in a spectacular inferno, and, rarely, after such an episode, the wrecked car is then found empty. After Rant Casey flees the farm, he hooks up with the Party Crashers; the authentic moments – focus, excitement, danger, pain – they provide satisfy some of his needs. Through casual and non-casual contact, he introduces rabies into the wider urban society, sparking an epidemic that rages across the nation and leads to the civil-liberties crackdowns and perpetual-quarantine prisons that further fracture society. Some observers speculate that Rant is the worst mass-murderer in history, but it is not at first clear why he knowingly does this.

We see other aspects of this somewhat manic and desperate society. Media culture is centered around “boosting” – electronic recordings of direct neurosensory experiences that are downloaded by those having the experience, and uploaded by those wishing to experience it vicariously, through a connection port at the base of the skull. Boost artists can edit the neural traces by replaying for a viewer and recording the experience of having the experience from that second-generation viewer – boosting a recording through a blind person enhances appreciation of the sound, while boosting it through a dog gives a vivid sense of smell. One can experience the influence of drugs by merely boosting a drug trip rather than taking it; the most euphoric experience comes from boosting experience tapes through a port installed in a new-born infant’s perfectly innocent brain. Rabies-caused neurodegeneration, however, wipes out the ability to experience the recordings.

Throughout the book, cryptic references are made to mysterious strangers who reappear at intervals in the history of the Casey family, and to how Rant’s mother became pregnant with him, and who his “for real father” may be. The source of the wealth that Rant stumbles on, and then spends without care, is also obscure. Certain characters, including Rant, make vague and portentous prophecies; often they come true. For most of the story, these hints and complications are kept dark.

Toward the end, the narrative (if it can be called that) takes a turn, and an explicit time-travel theme is introduced. One character proposes a wild and vague solution to the infamous “Grandfather Paradox” – he claims that you can kill your own grandfather, if you go back in time before you were born, but that the effect is not to kill yourself as well, but to cut you loose from all history – to set you outside of time, as a kind of immortal. Along with this theory, it is suggested that you could be your own grandfather – go back in time and seduce (or rape) your own grandmother, thus fathering the man who will father you. And, of course, if you can be your own grandfather, you can be your own father, thus you would be the man who fathers the man who is you who fathers the man who is you – one person, reappearing over and over through history, coupling with each member of the same line of daughters and sequentially raising himself as his own son who is also his own father who is also himself. And each such generational re-charge, it is asserted, reinforces and concentrates whatever special powers that individual might have – an affinity for animals, maybe, and the ability to withstand disease. Of course, such a person could also ensure his own wealth simply by going back in time and hiding something ordinary that it was known would be very valuable later – for example, gold coins.

All this, however, requires some mechanism for actually going through time. Palahniuk supplies one: when someone of precisely the right frame of mind, freed of all external influence (a mind, for instance, at the moment of a transcendently authentic experience and that is also incapable of boosting neural stimulation, as a result of rabies), suffers a sudden and violent death, that person may be transported back in time – from whence to start (re-start?) the cycle of fertilizations and rebirths that will eventually give rise to themselves in the present age. (This then gives them the opportunity not only to spark their own lineage but then kill its first-generation member – themselves in an earlier age – allowing their later self to ascend to the “Liminal Space” – the out-of-time realm where they become effectively immortal, able to reappear in Earth time when they choose. Such immortals, of course, would have no emotional connection to ordinary humans. A human life would be a flicker in time to them; humans, born to die, would have no intrinsic value. These immortals could toy with humans, alter their societies for amusement, kill them simply as a way of passing time, for instance by starting an epidemic . . .)

Whew.

As I said, I have absolutely no idea what to make of all this.

Some critics complain that Palahniuk has recycled themes from much of his other work. I have not read any of his other books, but I did see the movie version of Fight Club, and the parallels seem glaring. Though many reviewers draw a link between the fistfights of the previous work and the car crashes of this one – violent events undertaken for amusement by social misfits – I think the parallel runs deeper than that. Violence is what Fight Club and Rant have in common in only the superficial sense; in both cases, it is the rejection of stultifying social convention and the search for authentically felt experience that matters. In the present work, that search motivates all aspects of the main character’s life: deliberatey seeking bites from wild animals and poisonous snakes and spiders, constant sex, car crashes, and his obsession with his own ancestry. It is not coincidental that in both books the main character sparks a social upheaval that destroys conventional society while causing thousands of deaths. Along with the desire for authenticity comes hatred for those who deny or corrupt it.
With its hodgepode of self-destructive contempt for phoniness, rejectionist desperation for authenticity, cultural despair, violence, sex, neurocyberpunkish science fiction, dystopian time travel, and a literal deus ex machina ending in which central characters become gods through fatal car crashes, Rant is nothing if not a mess. It reads like Catcher in the Rye meets Last Tango in Paris while the Neuromancer rides The Time Machine to meet Lazarus Long so they can all go watch Fight Club and cheer for the Brad Pitt side of things. But there are other cultural touchpoints to be aware of.

Rabies, in this book, is a clear metaphor for the AIDS crisis; Palahniuk at one point explicity compares Rant Casey to Gaetan Dugas (and to other “superspreaders”, including Typhoid Mary). The asymptomatic infectious period found in both diseases contributes to their epidemic nature (though Palahniuk posits an unrealistically infectious form of rabies). But the progression of the rabies epidemic is not described in Rant; it is merely stated in passing that it had been devastating and resulted in the crackdown on civil liberties and the imposition of quarantine without due process. Here, Palahniuk widens the metaphor, from rabies-as-AIDS to AIDS-as-terrorism: the quarantine and isolation regimen imposed in the wake of the rabies epidemic has elements of both the AIDS hysteria of the 1980s (bars and bathhouses are named among places shut down due to rabies; disease transmission is mostly sexual, though this is not the case in real rabies infections) and the terrorism scare and “homeland security” crackdown seen under the Bush administration (indefinite detention, summary execution, mob violence against suspected threatening individuals). But, given the limited focus on the specifics of the epidemic, he is clearly not trying to replay the AIDS scare; his interest is the effect such intrusions have on social interaction, not on the civil liberties battles that took place to prevent them.

The nihilist youth culture Palahniuk describes may be a commentary on contemporary society: everyone constantly tied into multimedia players with wires leading directly into their skulls; lives devoted to unreal online experiences and commodified sensation; experience itself packaged and edited for commercial consumption; product ads infiltrated into the sensory media to create external, but real, desires for products; “extreme sports”, drugs, and sex filling the void left by dead-end lives in the corporate hive-state. If this isn’t the world we’ve given ourselves with our iPods, X-Boxes, product placements and incessant, pervasive, howling consumerist huckstering, then we’re just one product upgrade away from it.

From that perspective, Palahniuk’s familiar quest for authenticity seems to make sense: in a fake world carefully crafted to constrain and mold human lives, anything real and primordial – sex, here, a punch in the face, in Fight Club – may be a relief, and a chance to break into the “liminal world”, the world outside those constraints. The death-and-resurrection theme carries the motif forward: the authenticity of violent relief (pain, orgasm, fiery death) does take the initiates through to the other side. The quasi-Christian aspect of that transcendence cannot be accidental, either – escape is achievable only in an immortal afterlife, and only after they have renounced the consumerist culture (“be in the world, but not of the world”), cleansed themselves (searing the inauthentic from their minds with the rabies virus), mortified their flesh (with bites, poisonings, and automobile accidents), and become first hermits (Nighttimers), then martyrs. It’s at this point, though, that the story seems to go off the rails. The authenticity motif becomes muddied and confused just at the point that the immortality/time-loop theme is clarified; once we are told that Rant, and certain others, are living their lives over again, it becomes clear that what they are seeking is not the liminal experience, but some procedural method to access another state of being – one that just happens to involve snakebite, rabies, and car crashes. Rant’s poetic rhapsodies about feeling “truly alive” while being chomped by a groundhog are robbed of their significance. And why this has to take on such explicitly Christian form is also not clear – the book is anything but an endorsement of Christianity, yet there are older and better versions of the transcendence and immortality theme.

The book makes little sense throughout. During the last quarter or so of its pages, however, when Palahniuk lets the other shoe drop regarding the coy hints about past lives he has been leaving, its tenuously-connected themes – authenticity, transcendence, sex, pain, consumerism, isolation, time travel, immortality – whirl apart; it becomes impossible to say what the book is actually about. Its biological motifs, however – sex, death, life, rebirth, rabies, AIDS, pain, pleasure, viral transmission, the connectedness of bodies – seem even more non-literal than the demands of fiction would make them. Ironically, they don’t seem to be . . . authentic. He’s not talking about a real viral epidemic, or for that matter real sex, real pain, or real life and death; they are convenient MacGuffins to be chased on his road to, well, wherever it is he wound up. So the book has less to say even about those pregnant topics than it at first seems.

For all this, I was not disappointed to read the work – though I did not find it entirely pleasant to do so. But I found it works better as “mere fiction” than as literature, and better as fiction – of whatever kind – than as fact.

The article generated a fascinating discussion thread, however (with minimal, but nonzero, trollage) - one that I only stumbled across today by following a visitor link (thanks!). I’m sorry to be so late on this but I encourage everyone to run over there; the discussion is interesting and, collectively, it includes a fascinating list of resources on the history of abortion, abortion and race, and sexual autonomy as seen from a variety of times and places, and presented in a variety of media (the rock-opera version of a 19th-century German play about the link between lack of sex ed and unplanned pregnancy sounds . . . wild – and I had no idea there was a whole list of early silent movies on the same topic!). Now I’ve got a lot more reading to do! So do you.

Most of the discussion centered on the phenomenon of reporters seeking quotes from ethicists – which then are distorted, reduced to sound-bite meaninglessness, or, worst of all, used as “balance” in the kind of he said/she said articles that present the most outrageous or false statements on an equal footing with informed or rational commentary. Many session participants complained of their bad experiences in that regard, and there was talk of how to get reasoned approaches to ethical issues better represented in the news media.

There was also some discussion of whether ethicists should take “educational” or “advocacy” roles in dealing with the media – whether they should speak in a neutral, explanatory voice, or take a clear position on controversies and use their knowledge and insight to advocate for that position. There are good arguments on both sides. (The most compelling one for the “advocacy” position, to me, is that the enemies of reasoned discourse have no compunction about explicit advocacy in the guise of “expert opinion” – meaning that only one side of the argument is being presented in a forceful way, while real ethicists are constrained to a neutral role that leaves intellectually dishonest advocacy unopposed.)

These are important issues, but I think the matter has broader significance. My concern is that there is very little effective public discourse on ethical issues at all. Many at the conference session bemoaned the low level of public knowledge about controversial topics of all kinds, but there was no consensus on what scholars or professionals should do about that. The public simply does not seem to have a taste for knowledge on those subjects. In a conversation after the session, I and some other members agreed we were confounded by the lack of active public-level publishing on bioethical topics. There is a very active popular-science publishing genre – good authors regularly have best-sellers on very abstruse scientific topics, and the last few years have been a golden age for science writing. There seems to me no reason the same phenomenon can’t take place in bioethics, but where is our Natalie Angiers, our Matt Ridley, our Stephen Jay Gould? The closest thing seems to me to be execrably argued – or simply dishonest – tomes of complaint by the likes of Leon Kass, or freakin’ Dinesh D’Souza. (That’s not entirely true. For one thing, virtually the entire President’s Council have published tomes of complaint, not just Kass, and it’s also true that there has been some good work on cloning, genetic engineering, and life extension. But that’s the tip of the iceberg to what could and should be done.)

That is the kind of thing I would like to see bioethics doing in the media – and not just the print publication media, either. Where is our Cosmos, our Ascent of Man, our E.R. or Medical Investigation? (Actually, that’s an intriguing thought! What kind of medical-ethics-based dramas could we create for TV? Many of the popular medical shows introduce controversial issues in some episodes, but what about one that centered on them as a theme? We could have, say, I.R.B., in which intrepid and remarkably good-looking research-safety committee members forcefully cite the Belmont Report in committee hearings, and then race into laboratories in slow motion just in time to fling themselves between evil researchers and subjects who didn’t read the fine print on their consent forms. Or, say, House, Ph.D., in which a grumpy and iconoclastic ethicist antagonizes the academic establishment with his cynicism, while simultaneously enlightening them with his brilliant displays of symbolic logic. And, of course, there’s an obvious opening for Medical Forensics, in which bioethicists engage in formal debates over clinical cases while working around the clock on dazzling, cutting-edge position papers with really hard-hitting footnotes.) At any rate, there’s room for effective public education, and for engaging the public in the excitement and intellectual reality of the controversies they are currently being misled on. A public that snaps up intellligent popularizations on relativity theory, black holes, or evolution science will, I keep thinking, read equally accessible, but uncompromising, books on social and ethical controversies.

Who will write them, and how should they be written? What would good work of this kind look like, and why is what is already available so bad?

Robert J. Sawyer is a hugely creative sci-fi author (Hugo, Nebula multi-nominee and winner, slews of other awards) with a fascination for issues touching on human personhood and human nature. He has a widely-read series that posits a parallel universe in which H. neanderthalensis evolved to become the dominant species, with a distinctly different human nature from that of H. sapiens, and a number of similar books in which human nature and the science/religion conflict are examined from a perspective slightly removed – by the license granted to science fiction – from our own. His most recent book is Mindscan, an examination of the possibility of cognition “uploads” – the copying of memory and thought from the human mind into a permanently-rebuildable (hence immortal) synthetic substrate. The fact that the copying process does not destroy the original – that it creates two cognitively-identical minds housed one in its original organic body and the other in an indefinitely long-lived synthetic one, which then vie for recognition as the “real” person – gives the plot its tension.

Sawyer recognizes the most significant problem with this scenario: it does not grant immortality to the entity actually choosing to undergo the copying process. Most sci-fi stories involving mind copies seem to forget this entirely. (The Sixth Day seemed to grasp it dimly, but awkwardly. Others blithely assume that “you” are the new you, and the old you is . . . no longer a factor. Not so.) Sawyer’s main (organic) character, in this story, wants to undergo copying to evade an unavoidably fatal congenital neurovascular defect, and hence extend his life; he enters the MRI-like copying machine, endures some blinkenlichten, and . . . emerges exactly as he was before, and just as doomed. For some reason, the fool seems to have believed his – organic – consciousness would be transferred to the synthetic body, even though it was explained it would be copied instead (and that there is an elaborate quasi-legal process by which legal personhood is transferred to the new body, and the old bodies are whisked off to mandatory lifelong retirement in a senior-citizens’ colony on the far side of the moon). He remarks in disappointment that he had hoped to wake up “somewhere else”, and had expected it would be “a fifty-fifty shot” whether he was the new person or the old one. He only realizes at that moment that his consciousness, as an artefact of his brain, stays with his brain; the new body gets its own consciousness, resident in its synthetic brain, which picks up with the exact memories and thoughts the old one had had and then branches off on its own path, but the old one just remains what it was. Oops.

This raises the salient question why anyone would want to undergo such a process: you’re not buying anything extra for “you”, you’re just creating a new person who happens to share all your memories up to that instant (and presumably your personality traits as well), but then becomes its own entity and lives its own life. A good deal for that new person, of course, but why would “you” care? Simply kick-starting new lives so they can go off and experience the joys of being you is all well and good, but “you” get nothing out of it. Sawyer implicitly answers this by way of the fact that most of his characters are intellectuals who have something to contribute to the world in their synthetic form – a civil-rights lawyer, a novelist – and who appear to be copying themselves to give the world the benefit of “their” continued existence. That’s a bit arrogant, but it makes sense. For the person who wants continued benefits for themselves, copying offers nothing. As a potential (though not in the foreseeable future) “body enhancement” technology, copying is thus much less desirable in general than simple organic life extension, or life extension of the original organism via cybernetics.

By introducing the persistence of the original mind, Sawyer shifts the frame of discussion from the most obvious benefit of copying – immortality – to its less obvious corollary: the personhood of the copy vis a’ vis the original. The main conflict in the story arises as the synthetic clones assert their humanity against hostile organics: the synthetic male character is challenged by his organic original for status as the “real” person, and the synthetic female character (who has taken over the property of the wealthy original, per the transfer of legal personhood) is challenged by her son, who attempts to probate his mother’s will after the organic original dies.

The story then becomes an impressively detailed and carefully wrought debate over the meaning of personhood and personal identity. Sawyer is versed in the philosophical literature on these concepts, and conducts the discussion as a reasonably well-informed survey of the traditional positions. His limitations as a writer become painfully obvious, here. In general, Sawyer’s books, like most “genre” fiction, are “plot-driven” – they depend on setting up interesting scenarios and working them through, rather than particularly subtle depictions of human character. His dialogue is rather stagey, and clunkily presented. In Mindscan, his probing of the conflicting schools of thought on personhood takes the place of set speeches put in the mouths of characters representing traditional fields: he sets up a court scene in which various expert witnesses – a neurologist, a philosopher, a religious believer – plump for different positions using straightforward recitations of the standard scholarly arguments. There’s a whiff of Cliff’s Notes about it. Even so, Sawyer manages to drag sci-fi into the realm of the “novel of ideas”; if it is a reluctant introduction, we can acknowledge that Sawyer is not the first to make it, and, in his defense, his awkwardness in the job in some ways recalls Tolstoy, who had the same penchant for long speeches by cardboard characters. Sawyer breaks down a bit trying to extend that discussion into his hypothetical scenario (in particular, the crucial parallel he draws between fetal personhood and copied-mind personhood makes little sense, I think), but he tries gamely and produces some interesting theoretical twists. At any rate, he throws it out there, and puts the conflicts he uncovers into realistic-enough scenarios that you can see how these issues would play out in real lives. It’s a creditable job of illustrating the complexities of major technological shifts impacting the traditional parameters defining human nature; I kept thinking, as I read along, “But what about . . . ?!”, only to find he introduced exactly that concept as the plot unfolded. The book does a fine job presenting some aspects of philosophy of mind and personhood, as well as dramatizing their implications. (He also sets the book in a near future – 2045 – in which US President Pat Buchanan has overseen the complete criminalization of abortion and the finalization of the right-wing backlash in American society. Liberals flee to Canada, but global warming drives the US closer to the northern border, leaving even less breathing room for normal society. If you don’t care about mirror-mind robots, the book will scare the pants off of you with that alone.) It’s worth a read.

So much for Sawyer. I’m interested in some of the actual issues he touches on, however.

One of the sticking points of the book is the identity of the individual who has undergone the copying process. Even granting that the new synthetic copy is identical to the old mind at the moment of its creation, that isn’t sufficient to declare it the same person - a problem made only more acute by the persistence of the original mind. The issue obviously touches on the definition of personhood (hinging on mental performance, or corporeal existence), but everyone recognizes that personhood is only an enabling factor in personal identity. Obviously – and especially so given the continual renewal and replacement of our bodily tissues – personal identity depends upon some sort of persistence argument, the continued and unbroken link, Ship of Theseus-style, of momentary identities of almost-indistinguishable entities that form a life history. And, heretofore, every person who experienced persistence of personal identity also experienced persistence of bodily identity – the mind is the brain, so the mind persists only because the brain persists. We do see brains without minds, and there we – the rational we, that is – have no difficulty discerning that the brain persists but the person has terminated its existence; thus, these examples do not challenge the correlation of mind with brain, other than to make it clear the implication of that correlation is one-sided – if there is a mind, there will be a brain, but not vice versa. We thus conclude – perfectly reasonably – that personal identity is a function of the persistence of mind (or, persistence of a functionally adequate organization of the brain, to put it in non-mental-realist terms), not of body. But Sawyer gives us a satisfyingly confounding hypothetical. If persistence of mind is the key, and body is essentially irrelevant, and if two copies of the mind can exist at the same moment, how do we decide which is “the real one”. It is natural to think of the mind in the original body as the “original mind”, and hence the “real one”, and the other merely its backup, like a tape made from a music-studio master reel. But we just got done saying that the body doesn’t matter. We would agree that that mind, copied in a sole and single version into a computer or other device, was “the real one” even if its organic body was destroyed – why isn’t the synthetically-based copy of the mind in the robot body “the real one” if the organic original is not destroyed? Why is possessing that irrelevant carbon-based housing enough to make that individual “the real person”, compared to the one in the synthetic body, if we don’t think that organic housing is vital to being “the real person” under other circumstances? Alternatively, how can we call the copy “the real person” – even if the body does not matter, and the minds are essentially identical, surely the mind in the synthetic body is further removed from the original than is the mind occupying exactly the same material substrate without disjunction?

Sawyer does not satisfactorily resolve these issues, though he elucidates some of the conflict. Part of the problem is his continued discussion of the two entities as “copy” and “original” – a framework none of the characters challenges. (He gives himself an easy out by setting up the conflict over personhood between a “live” robot and a dead organic, not between organic and synthetic copies of the same individual. Thus it is clear from the outset that there is only one person present; the only question is who it is, not which one of them is “it”.) In fact, I think this perspective is flawed. The “copy” individual is not like the duplicate made from an original master tape; it is (in Sawyer’s technological milieu, at least) more like a digital copy of a piece of software: indistinguishable in its information content. There is not then an “original” and a “copy” – there are just two distinct copies of the same content, which instantly begin to diverge as they accumulate different experiences from that point forward. And the question of body is utterly irrelevant. It is true that the synthetic copy has memories that were accumulated within an organic body that it never inhabited – but the same is largely true of the organic copy within that body. We grant identity – we say the body is “the same body” – over time to organic bodies on the basis of the Ship of Theseus model, but it is not literally true that the material of the body at any moment is the same as that at all previous moments. (For one thing, bodies grow, adding material that was not previously incorporated; for another, living bodies replace their substance continuously, and at some point are composed virtually entirely of new matter that was not part of the same body at some earlier point.) So the mind in the organic body inhabits the “original” body only in respect of the last few years of that body’s life – both minds otherwise bear the same (non-)relation to the “original” body in every sense but that of Ship of Theseus continuity. It seems obvious, then, that at the moment of copying we merely have two distinct individuals who happen to share some mental history. This is no different from the case of identical twins, who prior to the splitting of the embryo would have to be regarded as one entity, and afterwards as two different entities derived from a common stalk. (Note: I did not say “person”.) I see no reason, in principle, to think we cannot have such a splitting mentally as well as physically (making allowances for the hypothetical nature of Sawyer’s example). That would suggest that neither daughter entity was “the original” or “the real one” – that both are new entities each with an equal claim to being a continuation of the prior, and thus, presumably, neither one of them actually identical with that prior.

This leads to the other sticky point: the transfer of legal personhood from the “original” to one chosen daughter entity (the synthetic copy). Sawyer accomplishes this with a simple declaration that the synthetic copy is to be accepted as the survivor personality – he acknowledges that this has no known legal basis, and that fact becomes the central point in the legal case that occupies much of the second half of the book. If we were actually to accomplish mind transfers – with or without persistence of the original copy – this issue would have to be addressed. I have argued above that persistence of personal identity does not depend upon persistence of body; I would think that a mind transferred into a computer, or a robot body, should be recognized as the same person as its original manifestation, and have the same rights – and own the same property, and occupy the same legal status - as the original. But I have also argued that two minds, one copied from the original in the same way as previously but with persistence of the original as well, should be regarded as distinct entities, neither of which is the original. This elucidates a significant conflict arising from my earlier argument. By that argument, neither the organic body nor the synthetic body houses the “real” original person, and neither is that original person – they are each distinct persons set off at the moment of the copying into brand new, sui nominus (if that’s at all a reasonable term) personal identities. But this means that in each case it is the existence of the other copy that determines whether the individual is or is not the original person. A normal person who is not copied is obviously the original person. A normal person who is copied becomes someone else, because of the copy? A copy whose original is destroyed is the original – in though, memory, and personality, and therefore in all relevant respects – and should be recognized as such. A copy whose original is not destroyed becomes someone else, because of the original? These are very difficult contradictions – yet they seem unavoidable on the seemingly-obvious fact that a copied mind, by itself, bears no relevant disjunction from the original mind. The problem becomes worse when you consider that, even if copy-with-persistence technology became available (a’ la Sawyer), there is no reason why a copy has to be accompanied by persistence of the original (the original might happen to die immediately after the copy was made, or you could build some sort of death ray into the copying machine); some copies would then have original “twins”, and thus no clear personal identity, while some would have no twins and would assume the identity of their originals, a rather reclkless contingency which does tremendous violence to the notion of attempting to find the “real” person at all. Deciding who should inherit the legal identity of the original is thus much more problematic than finding a legal mechanism for doing so.

Despite the seeming absurdity of hanging one person’s identity on the existence of another person, I am still inclined to assert my original analysis. (At least until I’ve had more time to think about it and figure out something that doesn’t sound quite as stupid.) As counterintuitive as it may be (and here comes yet another good reason for never trusting intuitive arguments), there is really nothing wrong with saying the identity of a person depends on contingent facts such as the existence of another person. Certain parts of one’s identity – “brother of”, “husband of”, “Prince of Wales” – depend entirely on the existence or non-existence of other people, and change as those people go into or out of existence. More to the point, our persistence-of-identity schemes – on which all personal identity arguments are based – are predicated upon a pre-supposition of non-forking identity histories: the idea that a person, once come into being, either is or isn’t one and the same person, literally, to the end of their days. For this reason we say that personal identity persists across huge, and even quite sudden, personality changes, such as due to brain injury; we even say it persists across the loss of the mental contents that define a person. We strongly resist the notion that a given person could ever become some other person, or even just plain not the same person, other than by being dead. But the possibility of bifurcating mental histories requires that we broaden our understanding of cognition-based definitions of personhood, and therefore personal identity. And the most obvious way is by the adoption of theories encompassing bifurcating personal identities.

Sawyer touches on the much-abused notion of “zombies” as well, but we will leave those for another day. The book is provocative enough – and has forced me far enough out on much too thin a limb – as it is. Good fun.