Medical Ethics Community Out of Step With New Administration: Ethicist

This transcript has been edited for clarity. 

Hi, I'm Art Caplan. I'm at the Division of Medical Ethics at NYU Grossman School of Medicine in New York City. 

Post the election, the Trump administration is moving to make its appointments at the level of the Cabinet. For many of the agencies that Trump is appointing people to, the appointments have turned out to be very controversial.

Probably the most visible and widely discussed is the nomination of RFK Jr to be the head of Health and Human Services. There are many other people moving into positions at the CDC, NIH, and FDA, that if confirmed, they bring a large amount of debate about the merits of having those individuals in charge. They are certainly bringing a large amount of debate into my area of medical ethics.

I think many medical ethicists are concerned about these appointments, and I think it raises some important questions about the future of ethics in healthcare. Where will that go in a new Trump administration? 

Before I make a little prediction about that, I want to point out that a survey was recently done of the professional side of medical ethics, including people who identify as doing medical ethics or doing it part-time. These are not just people who are ethicists, but doctors, lawyers, and nurses, who say, “I am running a program, teaching a program, heading an ethics committee, or running an IRB.” They are part of the apparatus, if you will, of medical ethics. 

The survey, which was done both of bioethics programs and at the big national bioethics meeting, turned out some findings that I don't think are surprising. When surveyed, the establishment in medical ethics is pretty male, pretty white, leans liberal left, isn't especially associated with strong religious practices or beliefs, and is somewhat not in step with views that many in American society hold about key issues.

For example, most of the medical ethics community, at least the ones with formal roles and jobs, are supportive of women's rights, including abortion. Obviously, there are many sectors of American society and many states that do not support abortion rights and want it either eliminated or restricted.

There are many bioethicists who fully support the use of infertility treatments. That's something that many Americans support. There are many bioethicists who support transgender rights, the right of a family to decide to transition a young child to a different sex, if that is what the doctor, the family, and the individual believe is best. It's clear that Trump and many other Americans do not support that at all. 

In a way, the community of medical ethics is somewhat out of step with what the election results produced, and it is going to be a health field that is led by people who represent those more — and I'll say with broad intent — conservative views, somewhat religiously driven in some cases, than you're going to see in the bioethics community.

What does that portend? What's likely to be going on? I'll make a few predictions. First, I think funding for bioethics activities that are linked up to transgender issues, linked up to promoting diversity, or linked up to reproductive rights is going to be cut back. 

It's just going to be harder to launch studies to see whether people who go through transgender procedures are happy, and what we think about the use of infertility when somebody might be older or single. Bioethicists like to study those things and report the findings. I don't think that empirical information is going to be as easy to get. 

I think in some areas of the country, such as Texas, empirical information about who's using abortion or what's going on with adverse events because you couldn't get an abortion is going to be suppressed. It already is a little bit.

I think we're going to see, in other words, less empirical data available to ground an argument. It doesn't surprise me all the time that ethicists are out of step with where society is. Sometimes the ethicists want to move society or the medical profession or a practitioner in a different direction. That's going to be harder to do because the support for that out of government funding is not going to be there. 

Similarly, bioethics likes to think about world problems, such as pandemics. I don't think this administration with a make-America-great-again, more isolationist stance is going to be in any way interested in funding work on relationships, trying to figure out how to distribute resources and vaccines overseas in a pandemic, what to do about restricting travel, and this sort of thing.

I think the administration is going to say we protect ourselves. We're not as concerned about what goes on elsewhere, even if factually, it's very important to pay attention early to outbreaks in other places if you want to control any type of pandemic infectious disease outbreak. 

There could be tension and there could be problems coming in terms of public health policy in spaces like vaccines and the distribution of resources that might be in our self-interest to tamp down pandemics.

I think, again, this administration is not in any way — and many American people are not — supportive of any type of mandates about masks or vaccines. I think those issues are going to come under critical scrutiny and start to lose support at the federal level. 

I think, overall, this administration also is very supportive of market solutions in healthcare. I think that the commission that was drawn up with Elon Musk to advise on these matters is going to take a position that may startle some, but I would predict they're going to go after the VA and try to privatize it — that is, outsource everything. 

There's a large amount of VA care that is now outsourced, but if you're looking to make a big budget cut and you like free market ideas, I would tell you to watch what might happen at the VA. That means people with special needs, special requirements, veterans who have spinal cord injuries, severe burns, or mental health issues that are very tough to outsource. I'm not saying you couldn't privatize more of the VA. It'll be a debate we're going to see, but the biggest publicly funded healthcare system in the world is about to get subjected to more pressure to go to market forces.

Market forces have not done well in bringing us the most efficient, cheap, high-quality healthcare in the world. Nonetheless, in Congress and in the administration, there is big support for moving the government out of healthcare, saving money, perhaps even taking a hard look at Medicare, and certainly taking a hard look at Medicaid, with maybe less people covered.

Regarding the ethical consequences of the new administration, personally, I oppose some of them, but that's neither here nor there. What's important is to realize that change is coming, and it isn't just coming in our ideas about defense or national security. It's coming to healthcare, I would predict, in a big way.

Many major institutions, such as the VA and Medicaid, are probably in for some readjustments that are going to be very controversial, and also in some substantive areas, such as transgender care, abortion policy, infertility care. I think we're going to see very little support coming from the administration and Congress for broadening or defending rights in those areas.

I think the future means speaking up and trying to fight when something looks like it is being eliminated or attacked that ought not be. I think bioethics, including the medical ethicists and people who are interested in the ethics of healthcare, should get louder, not retreat, and not go into the corner. I do think change is afoot and we better pay attention.

I'm Art Caplan, at the Division of Medical Ethics at the NYU Grossman School of Medicine. Thanks for watching.