A conversation with the bioethicist.

Question: Why should we drug our drinking water?

Jacob Appel: I think when you ask questions about whether or not any pharmaceutical or any products be added to the drinking water, you’re really asking two sets of questions.  One is: should any product that might be beneficial be added to the drinking water?  And secondly, should the specific product be added.  The first question I think can be dismissed fairly easily.  People who oppose adding enhancement to the drinking water in the way people opposed adding fluoride to the drinking water half a century ago rely on the false premise of naturalism that if something occurs naturally, it must be better. 

Now many things that occur naturally are better, but that's correlational, not causational.  Pain is natural, anesthetics are synthetic.  Most people would prefer anesthesia to pain.  By the same logic, there are many things that naturally occur in the drinking water that are beneficial.  In some parts of the country that don’t cover other parts of the country.  One of those items happens to be lithium.  People who oppose adding lithium to the drinking water in trace amounts don’t go around advocating to strain the lithium from the drinking water in the areas where it does exist. 

The specifics of lithium are rather interesting and I should add, I am not the first person to propose this idea.  Peter Kramer floated this idea in the New York Times over a year ago; the Brown University Psychiatrist, the author of Listening to Prozac.  In areas where Lithium in trace amounts is in the drinking water, there seems to be a lower level of suicidality and in the Texas counties that we’re studying, there’s actually a lower crime rate.  The same studies were repeated in Japan, a completely different culture and they had the same result. 

I should add that we are not talking about adding therapeutic levels of lithium to the drinking water.  It’s worth noting that if you wanted to get a therapeutic level than the trace amounts that currently exist in the area where there is already lithium, you would have to drink several Olympic size swimming pools every minute to reach that level of concern.  That level of therapeutics.  So the reality is, these are very low levels and there’s no reason to think they are not safe in the areas they already exist, so why not give everybody that benefit?

Question: Is lithium the drug different from lithium the element?

Jacob Appel:  Actually it is the element.  It’s the ionic form of the element.  Unlike many pharmaceuticals, which are complex compound synthesized in laboratories, lithium is simply an ion that occurs naturally in the environment.  I am not a geologist, I don’t know exactly the process by which the lithium leaches into the water, but it does.  And I think it is also worth noting that the mechanism by which the lithium works in the body is probably very different in the treatment of diseases like bipolar disorder, or mood disorders, mania being it is in the much lower levels where it seems to prevent suicidality. 

And the theory is that very low or trace amounts of lithium enhance connectivity between neurons.  And doing that over the course of a lifetime, a lifetime exposure makes the brain more healthy.

Question: Why stop at lithium? Are there other enhancements that we should add to the water?

Jacob Appel: Well I think the first thing to point out is fluoride, which is widely available in the United States, the Surgeon General has determined that it is possibly the most cost effective health intervention in the history of the United States.  That has saved hundreds of dollars, if not thousands of dollars per person in dental care over the course of lifetimes.  And it’s the reason why Americans tend to have very good teeth.  And if you go abroad to some countries people tend not to have as good teeth with the same other dental hygiene care.  Because our fluoride protects our teeth and there is no evidence that that fluoride – no credible evidence, does any damage.  So this has been an experiment that has been tried. 

I think the other most interesting area to look at would be in basic nutrients added to the drinking water to protect specific populations.  A good example might be alcoholics who are at risk of certain neurogenic disorders, for example, from lack of thiamin and adding a trace amount of thiamin to the drinking water.  I could be done relatively cost effectively.  It might prevent an alcoholic from developing what’s called Wernicke-Korsakoff Syndrome.  The other benefit of this would be every emergency room that treats alcoholics wouldn’t instantly have to treat them with thiamin because they would know these people are exposed to thiamin.  Not that different from adding Vitamin A to rice.

Question: Should parents be allowed to euthanize severely disabled children?

Jacob Appel:  Absolutely.  I think the Dutch have used a system called the Hornussen Protocol for almost a decade now.  And under this principle, they evaluate children that are born with either severe defects or in severe pain and assess their likelihood of surviving into meaningful adulthood, and if the answer is no and two physicians a the parents agree upon this, then the baby can be euthanized and they do it very pain-free and very quickly in the first few days of life. 

Only in our culture is the obsession with keeping life going at all costs, even when the pain is immense and the likelihood of survival is very low come to the fore.  In many cultures historically, the ancient Romans, for example, didn’t view life as a whole in it’s beginning until well into childhood.  Understanding that infant mortality was high and that sometimes the suffering an infant went through made it not worth the **** alive. 

The real interesting ethical question is if our goal to prevent the childhood suffering.  Where their parents should actually have a say in this process.  Whether, and I’ve written about this in the past, if a child is going to suffer immensely over the course of several weeks and die, would the parents have the right to say, we want this process to occur rather than injecting the baby with Potassium instantly, or whether **** itself is a form of child abuse.  If an older child was to need a medical intervention or medical procedure and without it they would suffer severe pain, we wouldn’t let adults make that choice.  Why do we let them make the choice the other way with infants?

Question: Is it tantamount to child abuse to let such disabled children live? 

Jacob Appel: I think it can be.  I think we are very reluctant to condemn parents in those situations, in part because it is a very stressful situation.  These parents themselves have suffered.  I wouldn’t want, for example, criminal penalties to punish parents in this situation.  But I think in terms of determining what should be done with a child, the best interests of the child’s standard should be the standard we use.

Question: Why do you think life should begin after seven days?

Jacob Appel: Well I should emphasize, I don’t think there is much value in having an arbitrary hard and fast rule.  One of the reasons I’ve actually said the law should use birth, for the most part as the standard would it would be very easy to figure out whether the baby is born or not born.  Figuring out whether an infant is six days old, or eight days old is a much harder project to endeavor.  Particularly, in situations where the baby has been abandoned or the origins of the baby are unknown. 

The larger point I am trying to make, and I’m not the only person that’s made this, Peter Singer at Princeton has made this for years, is that life should be divined by cognizance, by sentience, by ability to interact with the world.  And infants who can’t do that in the same way adults do should have their lives evaluated in very different ways.  And the potentiality of fulfilling life is a factor to consider.  But the suffering that an infant may undergo if they aren’t going to lead a meaningful fulfilling life is also a valid concern to think about.

Question: Who should be allowed to commit suicide?

Jacob Appel: The short answer, I would say, is anyone.  But the real answer I think is, almost anyone.  I am very comfortable with the system that for a very acute period of time protects from their own worst instincts.  But I do mean for a very acute period of time.  I think the paradigmatic example of someone you might want to prevent from committing suicide is the teenager who breaks up with a boyfriend or girlfriend and tries to overdose on Tylenol.  And to tell them, for a few days, we’re going to hospitalize you against your will doesn’t seem that reasonable to me. 

In contrast, someone who has suffered from chronic depression throughout their life with multiple suicide attempts clearly, modern medicine and modern psychiatry has been unable to help this person.  While I wouldn’t necessarily choose to end my life under those circumstances, I would respect someone else’s right to do so.  So the real standard I would use is, does this person on the one hand have the capacity to make this decision.  Are they thinking clearly, are they thinking rationally?  And secondly, can they demonstrate this capacity over a prolonged period of several days rather than in an instant? And I think the vast majority of people who wish to commit suicide wouldn’t meet most of those criteria.

Question: Why should prostitution, polygamy, incest, and bestiality be legalized?

Jacob Appel: I would argue that all of them should be legal.  Overarchingly for the same reason that the state has very little interest controlling what people do in their own private lives in their own bedrooms unless it directly and negatively affects other people in a tangible way.  And I’m not convinced that any of those particular items, whether it’s bestiality, polygamy, incest do have that affect on consenting adults or between human beings, animals where consent is not really a meaningful question. 

I think you have to assess each of these phenomena on its own terms though.  And I’ve written fairly extensively on each.  I think the concerns about polygamy are structural.  While it is entirely not my concern if people want to have three or four wives, or 30 or 40 husbands, and it all comes – some cultures they do, and cultures survive quite well.  My one concern would be, for example, the person who decides they’re going to have 40 wives and will let social Security pay benefits to all of them after their demise.  And we have to set up a system to balance the rights of people to marry who and how many people they choose with one that controls funding of this in a way that the rest of society can function. 

In the same manner, while I think bestiality, per se, should be legal, I think there may be forms of bestiality that transcends into animal cruelty and there the government might want to step in.   I think the important distinction to make is, it is not inherently clear that sex between animals and humans is unpleasurable for the animals, and in fact there are documented cases where clearly it is the opposite.  There is a man who, off the coast of England masturbates with the Dolphins.  Not something I would particularly choose to do, but he seems to find it fulfilling.  And we know the Dolphins find it fulfilling is they keep coming back for more.  I think you’re hard pressed to argue is this fundamentally unethical.  People talk about animals not being able to consent.  You’re dog can’t consent when you play Frisbee with it either.  Nobody evaluates the question in that term. 

Prostitution, we often hear the object here is this leads to vice, this leads to crime we’d be undermining the social fabric of the community.  In countries that have legalized or decriminalize prostitution, Amsterdam comes to mind, Sweden comes to mind; crime rates have actually gone down.  The prostitutes, rather than being victims can lead stable middle-class lives and they are protected.  So in some ways, it’s suspicious argument. 

The objections to all of these phenomena are really not what people say they are.  People say they are concerned about the welfare of the individuals, but what they are really interested in doing is imposing their own social values, or their own religious values on other people.  And that’s what really concerns me.

Question: Why should all medicine be available over the counter?

Jacob Appel: Well it’s interesting you ask that because historically in the United States, all medicine was available over the counter without a prescription.  It’s interesting to note one of the first “medications” that you needed a prescription for in the United States was beer.  Because beer was prescribed at Prohibition and doctors would prescribe beer for various ailments, for small pox, for rabies, for measles.  I should add, not effectively.  This is not a good remedy.  And from that, from the interest in protecting the rights of doctors, over time, the prescription right of doctors, which is really what it’s about. 

The theory is we should protect from themselves.  People don’t know the consequences of the medication.  The reality is, in the world of the internet, in the world of the educated consumer, most people go to the doctor and say, “This is what I want medically, and there are enough doctors out there that honor this request anyway.  That the harm of not letting some people buy medication over the counter and forcing them to have a doctor’s appointment with the added cost will keep certain people from getting the medical care they need.  Which in my opinion is far greater a risk than the small number of people who might not be educated enough or informed themselves enough to use medicine in a dangerous way.  I think it’s important to keep in mind there are many people out there, and I see them every day who really do need medication.  Medical medication, psychiatric medication, who know they need it, who don’t get it because they haven’t been able to get to a doctor, or can’t afford a doctor, or have time to see a doctor to get the prescription.

Question: What is the most pressing ethical issue of our time?

Jacob Appel: I think it is, to phrase it bluntly, the rights of foreigners.  It is the arbitrary distinction that people have more or fewer rights because they were born on one side of the border of another side of a border.  Once you accept the premise that all human beings are endowed with equal rights and of equal value, then there’s no moral or ethical justification treating them differently simply they were born in different countries. 

We can’t grant everybody rights by invading all the countries in the world and forcing our values upon them.  What we can do is grant anybody who has the wherewithal or power to come within our borders the same set of rights that we grant the people that are already here. 

I should add that was the American tradition up until the 1920’s with the exception of Asian Americans, all other groups until the 1920’s who came here volitionally were granted a certain set of basic rights and the borders were open to them.  And that really was the fundamental difference between the United States and the countries of Europe.  You came to America, you had the opportunity to become a citizen, you had an opportunity to take part in “The American Dream.”  That’s what the Statute of Liberty is all about.  The people who waved their American flags and shout about patriotism and at the same time don’t want immigrants to come across our borders or are concerned about illegal immigrants have missed the entire point of America.

Question: Wouldn't such a massive influx of immigrants overtax government entitlement programs?

Jacob Appel: It’s not at all clear that having more immigrants coming to the country wouldn’t generate more revenue and make more revenue available to provide the entitlements that people seek.  Immigrants tend to be among the most productive members of our society.  And historically, people have studied this.  It’s second generation, third generation Americans, the children of immigrants who are the powerhouse to the American economy.  If you were really concerned about expenditures on entitlements, you would take people whose families have lived here for a very long time and weren’t being economically productive and you would deport them and then you have more money for entitlement programs or you would spend less on entitlements in relation to economic progress.  I think it’s a terrible idea, but I think it’s worth noting that many of those same people or of people who have waived their flags complaining about the criminality of illegal immigrants. 

Question: Why should parents be allowed to choose the sexual orientation of their child?

Jacob Appel: I think there are two reasons for this:  one, people who oppose the possibility.  I mean, technology for the most part really isn’t there yet.  Letting people choose the sexual orientation of their children assume that this will lead to more straight children and fewer gay children.  I’m not at all convinced that this is the case.  If a small percentage of people choose to have straight children because they would otherwise be bigoted – or they otherwise are bigoted and don’t want to have gay children, but a large percentage of gay people choose to have gay children and the average of likelihood of randomly being gay is somewhere between 2% and 10%.  On the whole, the number of gay people will actually increase rather than decrease.  So I think that’s a red herring argument. 

The real concern I have is I want people to be born into families that want them.  On an individual basis, as a utilitarian philosopher, I think the least suffering we have the better.  And my concern is for the potential gay child born into the bigoted family who mistreats that child, who disowns that child, who drives that child to suicide.  And that to me, that suffering is far more concerning than the possibility that we won’t force more progressive cultural values on people who don’t want them. 

While I wouldn’t necessarily make that choice personally, I can also understand why a parent might say, “I’m deeply opposed to homophobia, I think the world should be a fair and equal place, but the reality is I want the best for my children.  And I understand that people discriminate against gays and lesbians.  I don’t want my child to be discriminated against.  Until the revolution occurs and there is equality, I want my children to have the best opportunities.”  And I wouldn’t necessarily justify that sexual orientation.  I think that’s a reasonable philosophy to apply to race, religion, ethnicity, and characteristic. 

I should add that I don’t think many will make that choice.  I don’t think it will, on the whole lower social diversity.  What I think it will do is guarantee that people who do have children who are more diverse want those children.  

Question: How much of sexual orientation do you think is genetically determined?

Jacob Appel: I think the research on this is still rapidly evolving.  But there will be some genetic component to sexuality.  There clearly is some hormonal component in the womb.  While there maybe some environmental component too.  We simply don’t know yet.  I do think over the course of time, we will be able to unravel whatever the complex web of causes of homosexuality, or for that matter whatever the complex web of causes of heterosexuality are.  And once we can do that, then parents are going to have to face the choice, and they should be able to make the choice what kind of child they want. 

I should add, I’ve already written in the past, that I think parents should be able to choose whether they want to have male children or female children.  I think in this country, not many people would do that, and I think the only limitation on that should be, if there is a mass structural dislocation.  So I can understand why India might require parents to – might prevent parents from making a choice because of the fear of having a overwhelming number of men in relation to women, I would be far more pressed to say Sweden without those same cultural concerns should be allowed to do this.  I would also add for what it’s worth that in cultures where there may be people who choose male children or straight children, they’re outliers like me where if they did make a choice, might choose to have female children or gay children that would balance things out.