Anne Zimmerman 0:04
Welcome to the voices in bioethics podcast. Kaitlin Puccio is with us today. Kaitlin’s a lawyer bioethicists and podcaster. She brings common sense approaches to hotly debated bioethics issues, defusing controversy and identifying the reason for certain claims actions and behaviors, considering social norms. Her podcast, Grey Matter, is about bioethics, culture and law. Hi, Kaitlin, thanks so much for joining us.
Kaitlin Puccio 0:30
Thank you for having me.
Anne Zimmerman 0:33
So I want to start off by asking you about a general concept that you address in your podcast, you suggest that too much emphasis on an issue can be harmful. I find that a little similar to good hearts law that that relying on a single metric will eventually make that metric go bad or lose its value. In bioethics in particular, there are some hot button issues that seem really divisive at first glance, and the constant discussion can sometimes fan the flames or just lead to a constant cultural discussion that makes an issue maybe come to light and be over emphasized socially and culturally.
Kaitlin Puccio 1:10
So, I think discussion is always a good thing, right? It’s the problem is, when the discussion turns into just two sides, proposing conclusions at each other, it’s less of a discussion than you because with a discussion, you need people to listen to what you’re saying, right? So what it seems that we have now is that there’s two sides of an argument, pick any argument you want, right? And there are just conclusions being thrown from both sides, no one is really listening to the other side, no one is presenting an argument that the other side can latch on to, and then respond to. So discussion is always a good thing. The issue again, is that what we have right now is not really a discussion. So this throwing conclusion sort of becomes overplayed, and then everyone stops paying attention to it. So but to your your larger point about everything being overplayed, or it being too much of something in the culture, and that being harmful. Some psychologists have proposed that idea. I’m not sure if it’s widely accepted at this point. But there are some psychologists who say, for example, there are certain disorders that will emerge and disappear in society in waves. So it’s sort of like a fad, right? But the problem is, some people– in getting caught up in that fad will actually start to manifest some sort of symptoms of this disorder. So let’s take gender dysphoria, for example, which is a big one today. If you have so much discussion about it, and so many people talking about it and normalizing it, when it’s really something that affects a minority of the population, you might be harming two sets of people here, people who actually have gender dysphoria, because the issue becomes, again so overplayed that people stop paying attention to it and don’t take it as seriously. And then those who are maybe a little bit confused, because they keep hearing this thing that’s been hammered into them over and over again. And they start thinking, “Oh, well, maybe that’s what’s going on with me” when it might be just something completely different that’s manifesting as fleeting transgenderism, in a sense. So that’s the idea behind things coming up in waves and disappearing and waves maybe being harmful to a lot of people.
Anne Zimmerman 3:50
Sure, and I think in the gender arena, sometimes gender stereotypes can change a lot as well. So it might have made sense to think you have dysphoria when people are defining certain things as gender related, when really those things are cultural. You know, girls don’t have to behave a certain way or wear dresses or something like that. And–
Kaitlin Puccio 4:10
Yes
Anne Zimmerman 4:10
So maybe some of it is just about how society and culture changes. I’m interested in your references to the word zeitgeist, which I think is a really relevant and good cultural term. How is gender really approached differently in the current culture? And how do you think the ways in which gender is discussed in society might be pulling people apart, or leading to policies and actions that could undermine the transgender community?
Kaitlin Puccio 4:36
Yeah, so if you think if you replace the word Zeitgeist with culture, right, it’s just it’s become part of our culture. We’re seeing this transgender movement which originated with individuals, activists, other people who are interested in raising awareness about trans rights, which is a totally normal thing to do. You know, you have an issue, you want to raise awareness about it, you talk about it, you do something about it. The way that it’s become so pervasive in every aspect of our lives, again, it’s a minority issue, which doesn’t mean it’s any less important. But it is interesting that it’s become so widely disseminated, that it’s in our corporations. I mean, we have the whole Bud Light issue happening right now, we have a lot of other sort of controversial things going on. We have Disney movies, making casting changes, and putting out casting calls specifically for transgender individuals to play transgender roles, which is great for opening up the playing field to a lot of people, but it also might be seen as excluding certain people, because what if you are not out as transgender yet? Do you have to come out to say, “Yes, I’m transgender, I can play this role.” That aside, it is almost impossible to not be involved in the conversation in today’s world. And what’s interesting to me is that the issues started to get really big when we started talking about pronouns and do you call an individual he or she or they, and that’s where things started to get a little bit confusing for people because it became a language issue rather than a trans rights issue. Because, the question that certain people have is, you know, someone says, trans rights are human rights, okay? What rights do you not have that you feel that you should have right now, which is not being articulated satisfactorily to a lot of individuals, because they are hearing over and over again, speaking of hammering the same conclusions, you must call me, she or some people have said it should be a crime to misgender, someone intentionally. The issue there is that it buries the real question behind language. So the argument becomes about whether using the term “they” to refer to a single individual is acceptable, versus what that person is actually asking of society by asking to be called “they” instead of “he” or “she”?
Speaker 2 7:30
Yeah, I think that rights and social acceptance are really what people are aiming for. So that question of whether language is going to answer that question. I think language is a little bit too small to answer the question of equal rights.
Kaitlin Puccio 7:45
Yes.
Anne Zimmerman 7:45
And then just to have another question on gender as well. Used suggests that a false positive may be very harmful. That’s my big takeaway from listening to some of your podcast episodes. I know you don’t use the phrase false positive. But do you think that the scientific and medical communities worry more about a true negative than they do about a false positive? And do you think that that’s partly due to this social and cultural narrative?
Speaker 1 8:14
Right, so I think they will become a lot more worried about false positives when lawsuits start coming down from D transitioners. who transitioned when they were minors, they’ll start suing their medical teams, or trying to sue their medical teams, etc. But right now, I think they’re in a difficult place because they’re trying to be socially conscious, be medically conscious. They don’t want to discriminate, or jump to any sort of conclusions. They’re being told something by a patient. And I think they don’t know how to balance the issue right now. Because, in my view, we don’t have enough information to make a move, meaning the medical community probably need some sort of guidance as to if a person comes to you and says, I’m a woman and it’s a biological man, and she wants to transition. What sort of psychological testing do we have to do to make sure that this individual is transgender, and will not be harmed by medical intervention in the future whether this person has other psychological issues that are manifesting again as transgenderism? Or if the person will be able to thrive in society as a transgender individual, there’s a lot of questions, not only about the physical aspect of medical intervention, but evaluating people mentally we do the same thing when we evaluate people for plastic surgery. There’s a psychological evaluation. If you’re good, you’re good to go. You can get your implants, you can get your nose job, whatever it is. For this, for some reason, it’s sort of a yes or no. And we’re very quick to jump to either yes or no, because whether it’s some people in the community want to show that they’re supporting this community, which is great. But you also want to make sure that you’re not harming anyone, potentially. But you also don’t want to just go and say, No, this is not happening. Because, you know, whatever reason you want to say all this is not normal, or no, you are not really transgender, you need to wait. You need to find a way to actually evaluate the individual and make sure that this is a path that will be beneficial to them and not harmful to them.
Speaker 2 10:51
Yeah, I think that the DSM-5 tried to come up with sort of a test. And I think part of the problem with defining gender in a thoroughly medicalized way, is that you can’t evaluate some of the other things that might have to do with social acceptance. And the very same person might seek medical care, if they lived in a different household or a different place, their transition might have been really, really accepted, just by making some social changes and environmental changes.
Speaker 1 11:23
Yes, and also, the DSM-5 recently updated its language, such that they’re no longer talking about being transgender quotes, “as a disorder”, they’re calling it gender dysphoria, as sort of a state of being, right? So they are trying actively to make sure that they are not stigmatizing this condition. And some trans individuals will say, Well, no, it’s not a disorder. And some medical individuals might say, well, you know, it’s it’s not a bad thing, that it’s a disorder. People in the United States all over the world have all sorts of disorders, it’s you know, it’s part of life, you have anxiety, you have depression, it’s not a bad thing. That shouldn’t be a stigmatized thing. It’s just how we have to talk about certain things. But to your point, the DSM-5, now changing the way that it talks about these conditions, you kind of have to ask yourself, what is the goal? Who are the people reading this? Who are the people reading this new language? How are they interpreting the new language? How are they interpreting the change in the language? So if a transgender individual is seeking psychological help, that individual might come across two completely different sets of medical providers with different perspectives and different viewpoints on the issue. And that’s why the guidance is, I think, a good thing to have, because there’s a little bit more uniformity than yes, every individual is different. But there’s something to latch on to. And you know, that you’re not just going to a person who has a political agenda.
Speaker 2 13:10
Right, I think the DSM-5 does have that benefit of being universally recognized in our country, not necessarily–
Kaitlin Puccio 13:18
Right.
Anne Zimmerman 13:19
that is helpful. It gives a profession some professional standards, then in general, I think a lot of this comes back to rights. And you and I are both lawyers. I generally think of a lot of these Bioethical Issues in general in terms of law and rights and human rights and the US Constitution. And I just wonder how you see the relationship between law and bioethics. And whether you see bioethics as helping rights or sort of standing in the way of some legal rights.
Speaker 1 13:48
Yeah, so I think law and bioethics are complementary to each other. So, ethics are not fully encapsulated in the law, you might come to an ethical conclusion that is not necessarily codified as law. And some laws, you might say lead to unethical outcomes. So though they’re complimentary, they might not neatly overlay one another. I think of ethics, bioethics, in particular and law as vertical. Let’s say you start with ethics. You have no legal constraints, if you’re thinking about an ethical issue, a bioethical issue. You can think about it in perfect terms, again, because you don’t have legal constraints. So you come to a perfect conclusion. Then you look at the law. So you take the next step, you bring it from the abstract to the practical world, and you say, Okay, this is the ideal outcome. Can we get there? How do we get there? Is it feasible to get there and then is it legal? Are we stepping on anyone’s individual rights? Are we stepping on any group of individuals rights? How does it look in practice? And then you kind of have to look back at your ethical conclusion and say, Okay, well, that’s not going to work because X, Y and Z would happen in the practical world. How do we make this work? So I think, when you have just laws without considering bioethics, especially now with all the technology we have at our fingertips, we can’t act so quickly to make policy without considering the bioethics from all perspectives, which is not a quick and easy task. But you also can’t have bioethics without bringing it back down to earth. Because it’s very nice to talk in abstracts. It’s a lot of fun to do your armchair thinking. But we live on planet Earth and these ethics, because we do not have pure forms of answers for objective ethical answers, we have to think about it, but then we have to think about it in our real context.
Speaker 2 16:12
So, you often in your podcast refer to things from a utilitarian standpoint, looking at the most benefit for the most people. Sometimes I find that that might pull something away from rights. And I sometimes wonder whether the bioethics community doesn’t always follow through to that endpoint and say, this might be the best thing for lots of people. But all those people have the right to refuse to engage in it, or must engage in it for some other legal reason. And to me, there is sort of that relationship. I don’t mean to say that law trumps bioethics, but I do sometimes wonder whether you find that you sort of organize and think about bioethical dilemmas differently because in the back of your mind, you do have that legal background.
Speaker 1 16:55
I think that having the legal background certainly helps. Because as lawyers, you’re trained to not only think about issues from all sides, but to anticipate arguments on the other side. So you really have to make sure that your arguments and the way you’re thinking things through before you open your mouth are spot on, and that they are bulletproof. It’s very difficult to make a real world bioethical argument that is bulletproof because there are new things happening every day. New technology, new issues, new disease, new pandemics, I mean, we have all sorts of things that you can’t possibly even conceive of, or else you would just be paralyzed in thought. So I think that a utilitarian perspective is just one perspective, sometimes the greatest good for the greatest number of people tramples on a lot of individual rights. And I think that might be a little bit of what you’re getting at. And bioethics is not necessarily meant to be a dictator. So when you’re thinking of bioethics, you sort of have to also think of a meta ethics. And so we have this bioethical conclusion, we think it’s great for everyone, and we’re going to impose it upon people. But, then you have to think is that ethical, because what we think is right for someone else, for a group of people might not be what they think is right for them. And this is why you try to get a lot of people at the table and have lots of roundtable discussions, it’s impossible to get every voice, it’s impossible to please every voice. But you do have to think again before just acting and before codifying your bioethical essentially opinion as law, how this will affect individuals. Because when you bring things back, when you zoom in, from a larger perspective, and you say, there’s this group of people, it’s very dehumanizing. It’s a group of people. Look at one individual and see how it affects that one individual. And does that look ethical? Your perspective might change a little bit from there. So I think that utilitarianism, again, is one way of looking at it. I also think that you have to consider other ways of looking at it, even if you don’t subscribe to those ways of thinking, because it might illuminate some holes in your argument.
Anne Zimmerman 19:32
And you have tools that you recommend to sort of elicit more ethical argumentation from people to really get down to the issues and to avoid what you spoke about in the beginning, which is two sides that already have conclusions and are just kind of at odds with each other.
Kaitlin Puccio 19:52
Yes, I think that’s one of the biggest issues and frankly, the easiest issue that we have to fix. We’re just not doing it. So civil does discourse is sort of a lost art. And listening is a lost art. And questioning instead of just responding. There’s a the Socratic method, which I’m sure you’re familiar with, and you ask someone a question, they’ll give you a response, you’ll ask them another question that digs a little bit deeper into what they initially proposed. And in doing so by asking them these questions, sometimes they come to realize the flaws in their own argument. But it also you as a questioner, these are real questions that you have? So you are responding, yes. But you’re listening, and you’re trying to really understand what the other side is saying? And then you can pick up on say, okay, but you just said this and logically, that doesn’t make sense with how you responded to the second question. So enlighten me, you know, not in a sarcastic way, but actually enlightened me, because it’s not making sense to me. And it’s not just a response, oh, you know, it’s not a gotcha. You just, you know, you’re a hypocrite, whatever, whatever names you want to call people actually try to get the individual to make a logical argument that flows. You know, I use Boolean logic a lot. It goes from A to B, and B to C. And then there’s a conclusion, right, I talked about this in one of my early Grey Matter podcasts, it’s just people need to start thinking in logical terms and really drill down the terms that they’re using to make their arguments because language is really important. Ambiguity is a huge disadvantage to an argument. So thinking about your argument in logical terms, anticipating what counter arguments there might be, anticipating the holes that people might try to poke in your argument before presenting an argument is very helpful, but then also, being willing to listen and say, you know, I didn’t think of that. But let me rephrase, because this is what I actually meant to say. And then you know, what, if your end argument doesn’t actually support the conclusion, you thought it’s supported, it’s not a big deal, you haven’t lost. It’s not a competition. But that’s how it’s presented. It’s very combative. And it doesn’t need to be if your conclusion isn’t supported, you go back. And you support the conclusion, you find a way to support the conclusion. Because if you’re trying to support your belief, and your opinion, there’s a way to do it. And if there’s not a way to do it, why do you actually have that belief?
Anne Zimmerman 22:47
Yeah, I think respectful disagreement and logic are two things that are really crucial to argumentation and to ethical argumentation in particular. And I think harnessing logic can help you sometimes come up with a good compromise as well. It isn’t always about just proving your side and the other person being wrong. But sometimes something politically centrist, for example, could come from good argumentation on both sides. I also think words are used incorrectly. Some people throw out the word “therefore” or the word “because” because it’s a causal connection, and that sometimes takes research or it takes logical reasoning. And people need to really choose those words carefully when they engage in ethical argumentation.
Kaitlin Puccio 23:31
Yes, I talked about this in my episode on abortion in using the proper words and not presenting your full argument as a premise if it’s actually a conclusion, because then you can’t actually have a discussion then. It is important to be able to discuss these things. And like you just alluded to, I don’t think that we’re, in general, really that far apart on certain issues. It’s just the way that it’s being presented and understood. And if it were made clear in an argument, what one side is thinking about abortion, if you can look at the logical steps that were taken to support that conclusion, and the other side says, oh, no, it’s step three. That’s the one I disagree with, because you said this, but it’s really this, then you know, which argument is the actual argument. It’s not the conclusion that’s the issue, it’s the premise that you disagree with. And if we have scientific facts, wonderful, because that makes a very easy premise. Some premises are not based in science, and there may be based on language where you know, when is life? What is life? Things like that? Yes, there’s a scientific element, but a lot of it is perception. So if you have a premise and someone can point to it and say we disagree about this, then you can dig into the question of what is life, rather than should we’d be able to abort babies at X weeks or something like that you can actually get to the heart of the problem instead of just yelling at each other.
Anne Zimmerman 25:09
I think opinions sometimes look like fact. And sometimes it’s important for both sides in an argument to understand what is their opinion to sometimes start their sentence saying, “in my opinion” this, and I think that really draws attention to what is an opinion versus fact I think that helps the conversation flow, and it helps people understand again, an element of ethical argumentation.
Kaitlin Puccio 25:36
Sure. And that begs the question, okay, why is that your opinion? And then you get to know the person’s thought process, which is very helpful to being able to have a conversation.
Anne Zimmerman 25:47
Yeah, I think some of the conversations we have in bioethics also kind of center on people being either pro medicine and science entirely or anti and so skeptical that they can’t participate in mainstream medicine as a patient who’s sick. And I think there’s so much changing in medicine, where medicine is operating in some avenues where it didn’t used to be, some of which are in sort of the psychology and psychiatry arena where maybe we’re treating mild emotional distress, that at one time was not considered medical. And I guess I just wonder how bioethics can push back on medicine when it overreaches, but also encourage trust and confidence in medicine in its traditional roles of treating and curing disease.
Kaitlin Puccio 26:35
Yeah, I think that point speaks to where we are in society right now in particular, and that we are very much black and white, there is no gray, we’re either for or against, and we can’t get anywhere near the middle, we can’t even look at where the middle might be. I think part of the problem may stem from, there might be two things here. So if you have a patient who goes in to see a doctor, that doctor might be pressured by insurance, our health insurance to spend absolutely no time speaking with the patient, if the patient has a question, the doctor might answer very curtly, because the doctor has 15 minutes to spend on three patients. That gives the impression to the patient, that the doctor is either disinterested or doesn’t know or doesn’t care, or thinks that he or she knows more than the patient, and then the patient might start to feel like okay, well, I’m gonna go consult WebMD, instead. And that’s where the doctors have problems, because they have patients coming in then saying, I read on the Internet, that I have cancer. And that’s true. And therefore you need to treat me and the doctor says, Okay, no, the Internet says everything is cancer. So it’s frustrating on both sides, because the doctor feels as if they are no longer being considered the expert competing with WebMD. And the patient feels like they are no longer being treated by an expert because they’re not seen as a person. So I think, and again, that might stem from insurance, it might also just be the doctor who knows. But I think the problem got a lot worse when insurance came around and said, “You have no time to talk to patients, they’re just money factories, let’s go.” So I think where bioethics comes in, is, you know, if you have five minutes to spend with a patient, okay, fine. We have to deal within those parameters right now, until we can change the law, if that’s what we want to do. Or the medical health insurance regulations, or whatever it is, if you have five minutes, make sure to hit these points, because it’s important for patients to feel like they are human and heard. So you need to listen to their question, perhaps offer a follow up phone call if they have other questions, which is not something that was unheard of back when doctors worked for themselves or in smaller, individual practices. It doesn’t take that much time to listen to a patient and respond. I understand that it’s extra time and not every doctor has the time to do that with every patient. But there are certain patients who were happy to just get the facts and be gone and be done and go on with their way. And then there are some other patients who you need to treat differently and that’s just the nature of being human. And as a doctor, you’re in a profession treating humans and we can’t forget that. So I think with bioethics again, going back to where bioethics comes in, it’s going back into Okay, we have the umbrella, the utopia of the umbrella and what that looks like. But how does it work for the individual, and if it’s not working, and you have individuals who are going home and consulting WebMD, instead, we have a problem.
Anne Zimmerman 30:11
The Internet I’m sure, has caused in many ways a lot of problems for doctors, although interestingly for correct medical information it is a great source. So it’s been this source of misinformation and a source of good information. It hasn’t, to your point, made it really easy to self diagnose everything and people who have a little bit have a fear of disease or maybe constantly think they’re sick will stumble on things that almost ensure them that they are sick.
Kaitlin Puccio 30:39
And there’s also, we have, like you said, access to all sorts of information on the Internet. It’s not always comprehensible or fun to read, to be honest. I mean, we do have access in a lot of cases to certain medical studies. what do we read in general, what do layman read? Most likely the conclusion, not necessarily the discussion, not necessarily the way the study was carried out. So understanding the study, is a whole different world. And that’s why you want to rely on the doctors, you want to feel like you can rely on the doctors, say “Hey, you know I saw this study what does it mean for me?” But there’s also, the doctors are supposed to be the experts but it seems that everyone on the Internet is an expert these days. You can start a website and you know, call yourself Jane Does Medicine and you can put out blog posts, they might become popular, they might be read by millions of people who were just looking for some sort of entertainment. Because you know what is news? What is information if it’s not entertaining it’s just not gonna be read. So there’s a lot going into it. The Internet can be used in very beneficial ways, you kind of have to know how to use it and it’s very difficult to weed through the experts and the non-experts who pose as experts and, who knows what the algorithms are pushing forth these days, who knows how they even work? I’m sure some people do, I have no idea but, it’s a whole deal.
Anne Zimmerman 32:22
Yeah, and the Clay Shirky book Here Comes Everyone, kind of explains how we’re all journalists and then we all look like doctors and we’re all sort of armchair experts on everything now.
Because once you have these social media accounts you’re able to chime in on things that are really important to people’s health, and you could be undermining health altogether when you think you know better about certain things including disease.
Kaitlin Puccio 32:45
Yes, and that’s why it’s important to also listen to people. Because if someone says something that might be contrary to what you’ve said, maybe think OK, instead of thinking well they’re just stupid they have no idea what they’re talking about I definitely know better, you might sure but also you might not. So maybe think, is what I know all there is to know? Is how I’m understanding something the right way to understand something? There are obviously, especially on social media, going to be comments from people that are just not worth thinking about but if someone is presenting again, it’s not just that argument that just says no you’re wrong it’s someone presenting an alternative viewpoint that you can look back and say OK, maybe this is something to consider. And if it turns out that they are in fact wrong, fine it’s not an issue, they weren’t out to get you, right, for the most part? But you’ve improved your own knowledge then, and you can be more sure of your information and maybe you’ve even learned something along the way, in doing your research and trying to find out how that person was either right or wrong.
Anne Zimmerman 33:55
I find social media can sometimes validate your viewpoint, not by offering correct validation or factually correct information, but just by offering you more of the same. Because the algorithms tend to attract you to something that you already believe.
Kaitlin Puccio 34:10
Yes.
Anne Zimmerman 34:11
It can sort of confirm your beliefs without offering justification. Which really makes trust in the source much more important, and the trust in the source brings us back full circle to the actual doctor. So when you are gathering your information on the Internet you should be able to have a trusted person who is taking the time to spend time with you and discuss the elements of a certain disease or aspect of health and wellness.
Kaitlin Puccio 34:36
Yes, exactly that’s right. And then on the other side of that, the doctor needs to be given the opportunity to listen to his or her patients and address those concerns.
Anne Zimmerman 34:47
I’m sure doctors love it when you always walk in with the information from the Internet and you already
Kaitlin Puccio 34:53
Oh yeah.
Anne Zimmerman 34:56
I’m sure doctors don’t like that much.
Well Kaitlin, thank you so much for joining us today this is Kaitlin Puccio and I’m Anne Zimmerman and this was the Voices in Bioethics podcast. Thanks for listening.
Kaitlin Puccio 35:09
Thank You.
Anne Zimmerman 35:10
Thank You.