Assisted Suicide and Disability

On October 9th, the National Council on Disability (NCD) released a report on the dangers of assisted suicide laws as they relate to persons with disabilities. The report provides a nice background on the history and justification of the Council’s position against assisted suicide as far back as 1997. The present report, available here, provides an update on its rationale for its continued opposition to assisted suicide laws. The report, and its references, provide an excellent resource for those of us who argue against assisted suicide regardless of the presence or absence of a disability.

Eight states and the District of Columbia have legalized assisted suicide in some form since Oregon led the way in 1994. Additionally, while lacking a specific assisted suicide statute, a state supreme court decision in Montana in 2009 is believed to provide a defense for physicians who practice assisted suicide. Oregon has provided the statutory framework for existing assisted suicide laws as well as proposed or pending legislation in states moving in this direction. As a result, every state where assisted suicide is legal claims that a primary need for the law is to preserve a person’s dignity, a claim that NCD finds particularly troublesome for people with disability:

The idea that hastened death is a pathway to dignity for people facing physical decline reveals the public’s extreme disparagement of functional limitations and a perception that “dignity” is not possible for people who rely on supports, technology, or caregivers to be independent or alive. Many hold the attitude that a person with a disability may be better off dead than alive.

Assisted suicide is often the cheapest “treatment” for many chronic medical problems affecting those with disability, a fact not lost on those responsible for state Medicaid budgets. NCD provided example after example of patients in Oregon who were denied treatment for their chronic or terminal medical care only to be offered coverage for assisted suicide within the same denial letter. Such crass efficiency was too much even for California, who in 2015, passed a law correcting this behavior: “[a]ny [insurance carrier] communication shall not include both the denial of treatment and information as to the availability of aid-in-dying drug coverage.” Many patients or their physicians eventually were provided the information on assisted suicide by the very same insurance carrier in a follow-up phone call.

Another major issue discussed within the NCD report was the relationship of depression and suicidal ideation in patients with a new disability:

Research overwhelmingly shows that people with new disabilities frequently go through initial despondency and suicidal feelings, but later adapt well and find great satisfaction in their lives. However, adaptation takes considerably longer than the mere 15-day waiting period required by Oregon-model assisted suicide laws.

Perhaps the most persistent concern by NCD since 1997 continues to be “the major gap between informing the patient of alternative options [such as palliative care programs and long term-term services/supports] and those alternatives actually being available and provided.” All statutes legalizing assisted suicide include provisions that require a full explanation of all of the programs, resources, and options available to assist the patient if he or she does not decide to pursue suicide. However:

Many people with disabilities find this to be a very shallow promise when they know that all too often the programs are too few, the resources are too limited, and the options . . . often nonexistent.

The concerns articulated in the NCD report warning of the dangers of assisted suicide apply just as forcefully for those without disability. We should join their efforts to educate law makers on a better way forward without assisted suicide.

More on Physicians’ Conscience Rights

Yesterday’s post to this blog addressed physicians’ conscience rights.  The standard shape of arguments about preserving individual physicians’ conscience rights goes, broadly, like this:  certain actions now sanctioned by society (e.g., abortion, assisted suicide) have been embraced by the medical profession as standard medical care which all physicians should be willing to perform, but this stance runs counter to the long tradition of medicine and to the proper ethical stances of some individual physicians.  Therefore, objecting physicians should be free to decline to perform them, without fear of professional or legal reprisal.  In this vein, the current U.S. Administration had promulgated a regulatory rule in May of this year attempting to ensure that, consistent with existing statute, such conscience rights are protected.  This week, a federal judge struck down the rule in its entirety, arguing that a) the propose rule, which, like all regulations, would have had the force of law, went beyond the statute behind it by making unwarranted interpretations and expansions of the statute’s wording; b) the government’s process of promulgating the rule violated other laws governing such rule-making; c) that it was unconstitutional, violating not only the separation of powers but also the Fifth Amendment because the rule was too vague, and the First Amendment because it would have “required employers to conform their business practices to the religious practices of their employees.” 

One might wonder whether at least some of the court’s reasoning—especially the separation of powers and Fifth Amendment arguments, and the concern (“a” above) about bureaucratic overreach—might not in fact apply to a wide range of government regulations.  That notwithstanding, the Christian Medical and Dental Associations, which has been particularly vigilant to protect conscience rights when it comes to abortion and assisted suicide, vowed to fight on.

The Journal of the American Medical Association (JAMA) cites a different case, involving assisted suicide in Colorado.  There, assisted suicide was made legal, with only limited restrictions, by a public referendum.  Notably for the present case, while health care organizations such as hospitals may opt out, and decline to provide assisted suicide, they may not enforce a blanket prohibition against their physician-employees doing so on their own initiative.  Such a prohibition could only be enforced on the organizations’ actual premises. 

So apparently a physician who worked for a Catholic hospital wrote (on her own time, outside hospital premises, and of her own volition) a prescription for a lethal prescription for a cancer patient.  The physician cited judgment of her own conscience.  The hospital cited its moral reasoning, its own freedom of religion, and, it appears, a claim that the physician was, or should have been, considered to be acting as an agent of the hospital.  The matter is the subject of a lawsuit.

The hospital fired the physician.  It is said she found another job.  But that of course is not the point, is it?  If a physician, who has a covenantal relationship with the patient, finds in her moral judgment that, in a given case, assisting suicide is ethically permissible, why does the hospital system have a right to override that judgment—especially if it was exercised, as it is argued here, in accordance with existing civil law?  One can certainly argue, as I would, that the physician has erred in her moral reasoning, and misapplied the physician-patient relationship. 

But I wonder whether, as the saying goes, “what is sauce for the goose is sauce for the gander,” in this case.  We might consider: the hospital could employ the physician based on an upfront, written agreement that the latter would act in accordance with certain moral stances of the former.  Absent such an upfront agreement, it’s hard to agree with disciplining the physician as was done in this case.  But even then, such insistence on upfront agreements seems to run counter to much of the spirit of much discussion about conscience rights, setting up a regime in which the relative power of available employers of physicians determines the constraints on medical practice.  Even then, if medicine remains a learned profession at all, perhaps insistence on conscience rights should be understood to cut both ways.

Drs. Stephanie Harman and Abraham Verghese seem to lean in this direction in an accompanying editorial in JAMA—but by emphasizing physician autonomy.  Their examples betray their preferred value judgments, but the overarching concern still seems relevant and valid.

Rights of conscience and the distinction between needed and desired treatment

Rights of conscience, the moral concept that physicians or other medical providers should be able to choose not to provide or participate in medical treatments which they believe to be morally wrong, continues to be widely debated in our society. A recent article in Vox titled “He needed a gender-affirming procedure. The hospital said no.” Expresses some things that I think are misunderstandings of what this debate is about.

Although it mentions other faith-based institutions, the article is primarily about the types of procedures which Roman Catholic hospitals in the United States do not provide under the Ethical and Religious Directives for Catholic Health Care Services. Throughout the article it is stated that Roman Catholic hospitals have refused needed care to persons seeking care in those hospitals. It also raises the concern that people may die because they are not provided necessary emergency care and care from another hospital willing to provide the care may be too far away. My main concern with this article is that there appears to be a misunderstanding about the distinction between needed and desired treatment. Among the things listed as needed care are “fertility treatment, gender-affirming care, or tubal ligations.” The article begins with the case in which a Roman Catholic hospital would not provide an elective hysterectomy to a biologically female person who identified as being male. The hospital’s reason for not providing this elective surgery was not because it was desired as a part of the person’s gender transition. They chose not to provide the surgery because of their belief that removing a healthy uterus impairs fertility in a way that should not be done.

There is a difference between desired elective treatments that people may choose to do even though there is no medical reason why they need to be done and treatment that is either life-saving or needed for other medical reasons. Such things as fertility treatments, gender affirming surgeries, tubal ligations, and abortions are elective treatments that an individual may choose to do but are not medically necessary. There is an appropriate difference between the obligation of a physician or hospital to provide medically necessary and life-saving care and the presumed obligation to provide elective medical treatments that are desired but not medically necessary.

I am not Roman Catholic, but I practiced in a Roman Catholic hospital for about 30 years. I served on the ethics committee at that hospital as well. I became very familiar with the ethical and religious directives and the type of things they direct Catholic hospitals not to do. These things are elective treatments or procedures that a person may desire, but which are not medically necessary. I also became familiar with the important role that Roman Catholic hospitals play in providing care for the poor and marginalized, many times providing care for people that other hospitals and physicians would not. Those who think that our society would be better without Roman Catholic and other faith-based hospitals are quite mistaken. If those hospitals are forced out of our society by those who would require them to do anything that anyone requests even when they believe that those things are wrong, the poor and marginalized in our society will suffer greatly.

“Why did you make me this way?!”

Recently, Jon Holmlund brought us up to date on an effort in Russia to proceed with CRISPR gene editing aimed at eliminating deafness. Coincidently, a recent MedPage article was posted regarding the ethics of using pre-implantation genetic diagnosis and IVF to purposefully select FOR an embryo with genetic deafness for a couple, both of whom were deaf. Both links discuss some of the ethical problems with using medical reproductive and genetic technology for these purposes. While we presently lack the ability to use polygene scoring to accurately “produce” the babies we want, I want to use the remainder of today’s blog to consider what obligations, if any, a genetic engineer (or parents that use their skills) may have toward future children designed using these growing array of genetic technologies.

Deafness seems to me to be rather curious in that it is considered either a serious disability or a desirable trait, depending upon your cultural worldview. No one in any culture would purposefully select for cystic fibrosis or Tay-Sachs diseases for their child. In fact, most want to use medical reproductive and genetic technologies to eliminate these diseases. On the other end of the genetic trait spectrum, some parents want to use these same technologies to purposefully select for more trivial traits for their children – hair and eye color, for instance. Given the triviality of these traits, I hear no one mounting an effort to genetically eliminate any particular hair and eye color. Perhaps I am living a sheltered life?

Nonetheless, with regard to deafness, prior to the promises of our new reproductive technologies, if you were born deaf and did not like it, you could only shake your fist at God or Nature. Now (or very soon), you can shake your fist directly at another human, such as your regional genetic engineer (or your parents who purposefully used her technological skills) and demand a direct answer as to why they purposefully made (or did not make) you deaf. Maybe this angst will be more widespread for the many more trivial traits such as eye or hair color rather than something more significant like deafness?

Building a child is about to become much harder for parents as they become directly responsible for both interior (genetic illnesses) and exterior (hair and eye color) design issues.

“Why DID you make me this way?!”

“Why did YOU make me this way?!”

I wonder how many genetic designers (or the parents that will ultimately bear the direct responsibility for having used the technology) really want that type of responsibility?

Is there already fine print in PGD-IVF contracts holding the doctors/scientists/geneticists harmless for the choices the parents make?

I can’t wait for the late night TV commercials: “Were you born with brown eyes and feel emotionally scarred because you have always wanted blue? Call our law offices as you may be entitled to financial compensation …”

Racial Bias in Algorithms?

Can algorithms show racial bias?   That is the conclusion of a recent article published in Science by Obermeyer, et al., entitled, “Dissecting racial bias in an algorithm used to manage the health of populations.”  

According to Science, the algorithm’s goal is “to predict complex health needs for the purpose of targeting an intervention that manages those needs.”  Fair enough.  That certainly sounds like a worthy goal, especially in these days of complex medical conditions, with equally complex treatments.  However, the problem raised by the research done by Obermeyer, et al., is that “the algorithm predicts health care costs rather than illness, but unequal access to care means that we spend less money caring for Black patients than for White patients.  Thus, despite health care cost appearing to be an effective proxy for health by some measures of predictive accuracy, large racial biases arise.”   The study concluded that with a reduction of bias in the algorithm, a much larger percentage of Black patients would receive the advanced interventions that the health care system offers.

In addition, the Minneapolis Star-Tribune reports that “New York regulators are calling on Minnetonka-based UnitedHealth Group to either stop using or show there’s no problem with a company-made algorithm that researchers say exhibited significant racial bias in a study.”

In its note on the research, Nature  states that Optum (the algorithm’s developer) raised questions about the study’s conclusions:  “The cost model is just one of many data elements intended to be used to select patients for clinical engagement programs, including, most importantly, the doctor’s expertise.”  Nature also reports that “Obermeyer is working with the firm without salary to improve the algorithm.”

The results of this study deserve to be examined closely.  If we truly want to affirm the dignity of each individual, bioethics must address these areas of disparity whenever possible.  It’s not likely that we will ever achieve a bias-free world, but it is surely helpful to be made aware of our biases so that we can better serve those in need.

Regulating New Technologies

History’s lessons applied to Artificial Intelligence (AI) regulation is the subject of a recent Brookings article by Tom Wheeler.  He writes

Societies impose government oversight for the protection of old principles in a time of new technology. Foremost among those principles is each individual’s right to a future; and it comes in multiple manifestations. In the educational realm, it means adequate training to be meaningfully employed. Economically, it means maintaining the benefits of capitalism through checks on its inherent incentive to excess.

Most importantly, the right to a future begins with the belief that there is a future, and that national leaders care about whether individuals affected by new technologies participate in that future.

Although the author has AI in mind, it is interesting to consider his words in relationship to the regulation of human gene editing. Now is certainly “a time of new technology,” particularly regarding human germline gene editing.  The “old principles” of experimentation on human research subjects ethically done and informed consent, along with the restrictions/bans in many countries heretofore prohibiting human germline modification, come to mind.  Additionally and importantly, in Greely’s extensive review of how “CRISPR’d babies” came to be, he includes a welcome overview of the state of affairs regarding regulation (or not) of human germline genome editing, in the October 2019 Journal of Law and the Biosciences. 

An upcoming meeting (London, November 14-5) of the International Commission on the Clinical Use of Human Germline Genome Editing is slated to discuss more than governance of the technology. Their agenda is available here.  In addition to a discussion of issues and perspectives relayed by various parties in their evidence submitted to the Commission, there is a planned discussion of “how the rights of future people have been considered and established in other medical and nonmedical scenarios, and how consenting to any necessary or preferred long term follow up on behalf of future generations could be established.”

Exactly how does one generation prescribe the “necessary or preferred long term follow up” of succeeding generations? How does one generation assure consent of future generations? When Wheeler penned the Brookings article about AI regulation (quoted above), he wrote about the right to a future, which rests in part on the fact that “national leaders care about whether individuals affected by new technologies participate in that future.” It certainly seems reasonable that those who are affected by a project be allowed to participate in it – as something more than research subjects. If such is true for AI, how much truer should it be for those whose very selves are affected by the research! There has to date been no compelling reason to go forward with human germline genome editing, and there are many reasons not to proceed. The most appropriate regulation is a ban.        

Skepticism about polygene scores to select for IQ and height

One caution when objecting to the prospect of heritable human gene editing is to take care not to overestimate what it technically possible.  That is, an all-too-easy argument is that attempts to edit a disease gene will lead, by momentum if nothing else, to “designer babies,” with children not just being genetically selected but in fact engineered in great detail for traits like attractiveness, athletic prowess, height, and intelligence.  This contributor to this blog has repeatedly taken the position that heritable human gene editing is a project that fundamentally alters the way we see ourselves and each other; that divides the human race into “actors” and “acted upons;” that has no prospect of prospectively assessing long-term, unintended consequences, to an individual subject, subsequent generations, or society at large; and that fortifies a perspective of admitting to the human race only those members we want to admit.

Along the way, we must keep in mind that “designer babies” are not likely to be feasible in the foreseeable future.  One recently-reported case in point is a study by scientists at the Hebrew University of Jerusalem.  A preprint (in advance of publication in a peer-reviewed journal, it is said) is publicly available here.  I daresay the details will be inaccessible to all but specialists in genetics, but a summary of key points is provided by a technical writer at a website called GenomeWeb.  In brief, some of those points:

  • A score based on assessment of multiple genes has previously been suggested to explain only about 5% of the difference between individuals in IQ (300,000 people genetically tested) or 25% in height (700,000 people tested).
  • These researchers tested about 1000 people, and considered about 15,000 genetic variations.
  • They looked at offspring of actual couples and also “simulated” matches for about 500 would-be couples made from individuals for whom they had genomic data.
  • Of note, they appear to have looked at “SNPs,” or “single nucleotide polymorphisms,” which are relatively easy to catalog across the 30,000 or so human genes, and which themselves run into the hundreds of thousands across those genes, but SNPs are far from the whole genetic story.  Larger differences in genes, or how those genes are translated into biological traits, is much more complex to assess.
  • They surmised that, if their score were used to try to predict height, the average gain would be about 2.5 cm (about one inch), with a range of 1-6 cm.  If used to predict IQ, the average gain would be about 2.5 points, with a range of 1-7 points.
  • Then they also looked at 28 actual families with lots of kids, from 3 to 20 (!).
  • For the actual families, the score predicted to cause the tallest child did so for only 7 of the 28 families, and the highest scoring child was actually shorter than average in the family in 5 of the 28 families.  No attempt to assess IQ for these real families, apparently.
  • They point out other reasons why trying to select for IQ might be problematic—potential association with autism and anorexia, for example, as well as just general complexity.
  • They suggest that for most people undergoing IVF, and creating fewer than 10 embryos in the process with less than 100% success after implantation in the womb, the odds are not good for making a reliable forecast of an offspring’s height or IQ.
  • They make these points without commenting more broadly on the ethics or policy wisdom of allowing or encouraging heritable genome editing to proceed.

A complex story, and a developing one, to be sure, but one should not be too quick to accept grandiose promises for predicting complex traits based on genetics.  At least for now, those appear to be rather “ahead of the puck,” shall we say.

Future new CRISPR baby in Russia?

Nature reports that Russian scientist Denis Rebrikov has started experiments intended to lead to editing a gene, in human oocytes (egg cells) associated with human deafness.  Prior reports had claimed that he was working on eggs from deaf women in an attempt to repair the defect and, presumably, provide a normal egg for IVF.  This apparently is not the case—yet.  At the moment, he is using eggs donated by women who can hear, to do experiments on editing the gene in question and ferret out what might go wrong in the process—that is, is the right gene edited, is only the right gene edited, and related questions.   

He says he has had discussions with deaf women, but has not yet sought approval from the Russian regulators to try IVF with a gene-edited egg.  The regulators appear reluctant, and Rebrikov says he will not proceed without prior approval.  He had previously said he wants to edit the same HIV-susceptibility gene that was edited in twin babies born in China last year, but it looks like there aren’t too many candidates for that approaching him, and that attempt has not gone forward—yet.

He’s clearly impatient.  Other scientists working in the gene editing field—which has broad applications short of making “gene-edited babies”—are urging patience, and saying that it is at a minimum rashly irresponsible to rush ahead with the effort, particularly for non-fatal conditions like deafness.  And they are right—too little is known to justify the effort—yet—even if one thinks there are conditions for which it ethically could or even should be attempted.

But “the field” is working hard to define a path forward.  The second meeting of an international panel discussing how to move ahead meets in London November 14-15.

Nature includes a brief Q+A with Dr. Rebrikov.  Forgive me, but some of it is chilling, reflecting blindness to the deeper issues.  Paraphrasing selected questions, quoting the answers, offering italicized commentary:

  • Question:  don’t the risks of trying this outweigh the benefits, for a non-life-threatening condition like deafness?  Answer: “Any new drug carries certain risks. The deafness model is the most appropriate for applying genomic editing at the zygote [newly fertilized egg] stage. And it is only for deaf parents to decide whether … deafness is enough to not expect the same for their child.”  Beg pardon:  heritable gene editing is NOT A DRUG, and the risk-benefit decision is NOT solely the province of private decisions about reproductive-related risks.
  • Question:  the regulators point out that editing people is currently not permitted.  Answer: “Laws are written to change them. As soon as we demonstrate the safety of technology, the rule will change.”  Ahem: some laws are enduring, even eternal—cf. divine law. Recognizing that the regulators’ judgment is not divine, eternal law, reverent attention to the latter should be a paramount concern.  And ‘safety’ appears to be narrowly defined here, blissfully ignoring the deeper human questions posed by modifying people’s genes permanently.
  • Question: people trying to build a regulatory framework for human genome editing think researchers should slow down until the framework is agreed upon. What do you say?  Answer: “Are you serious? Where did you see the researcher willing to slow down?”  Hello!  McFly!  We are not ASKING you to slow down.
  • Question: Russian regulators and the World Health Organization say it is too soon to create edited children.  What do you say?  Answer:  “What does it mean, too soon? Lenin said ‘yesterday was too early, tomorrow it will be too late.”.

Lenin?? LENIN?!  For real??

Addressing gene editing with “thin” bioethics

Yesterday’s post on this blog, by Steve Phillips, warned that a narrow, “rules limited” approach to bioethics reduces ethics in science and medicine to matters of regulatory compliance and risks making thoroughly logical conclusions based on faulty premises that are adopted without regarding “deeper ethical thinking” for which scientists’ thinking must be brought under the discipline of broader humanitarian reflection if correct basic notions of what it is to be human, and what humans should be up to, are to be arrived at.

A different but closely related way to look at this was suggested by John Evans of the University of California, San Diego in his contribution to Human Flourishing in an Age of Gene Editing, a new collection of essays, edited by Erik Parens and Josephine Johnson.  In brief, Prof. Evans commented that too much of bioethics is “thin,” reduced to the Belmont principalism (respect for persons/autonomy; beneficence/nonmalificence; justice) governs human subject research.  This “thin” bioethics is convenient for regulators to use to derive a manageable set of rules, and for scientists to, if you will, hide behind (my expression, not Prof. Evans’s).  Rather, he writes, we must be willing to criticize the assumption that all we need to ask about technology is how to use it, and seek a deeper wisdom about what is a good or worthy human life, for individuals or communities.  In making this argument, he appeals to “critics of technology,” both politically conservative (Leon Kass) and politically liberal (Jacques Ellul).  Jacques Ellul!  How often does anyone hear him mentioned anymore?  How many of us have read him?  (I venture fewer than should!) 

This criticism of worshipping at the Belmont altar, if you will, is hardly new, but it’s critical, especially when something as profound as heritable human gene editing is being considered.  You see, Belmont principalism is quite robust when asking how to deal with clinical trials.  But it really most closely applies to things like regulated drug development, and germline gene editing goes far beyond drug development.  It isn’t drug development at all, and cramming it into the conceptual framework of drug development is fundamentally misguided.

Nonetheless, the International Commission on the Clinical Use of Human Germline Genome Editing appears to be proceeding merrily along the drug development path. The second meeting, in London, is next month; one can sign up for a webcast. Just check out the agenda, especially day 2’s planned sessions on risk-benefit analysis and defining “a translational pathway.”  That language applies to new therapy development, not fundamental alterations of human inheritance.

One should keep in mind also that the assumption one can assess risks and benefits is only as good as one’s data.  This week it is reported that scientists have retracted an analysis suggesting that babies edited for an HIV-susceptibility gene might be at risk of relatively short life spans, something this blog poster readily jumped on in his June 6, 2019 post.   But, then again, so did the prestigious journal Nature Medicine, so I guess I shouldn’t beat myself up too much.  Seems the researchers didn’t define matters carefully enough.  Even if this particular analysis, from a large database of human genetic data, was flawed, similar analyses in the future might be helpful, it is argued.  Until more is known, it is further argued, one should not seize on a retracted analysis to infer a full “green light” to edit unborn babies’ genes.  But that may take “thicker” bioethics than whatever risk-benefit analysis we think we can muster now.

The importance of premises

In an interesting article in the Hastings Center Bioethics Forum, titled “Hannah Arendt in St. Peter’s Square,” Joseph Fins and Jenny Reardon write about the importance of deep ethical reflection in dealing with the ethical challenges of biomedical research. They point out that when ethics becomes a matter of simply following a set of rules we can end up in the wrong place. Even such fundamentally good concepts as informed consent and the need to have research proposals reviewed to be sure that they are ethically sound can lead to a mindset of regulatory compliance, essentially following the letter of the law, while leading to poor conclusions about what we ought to do. In the end they suggest that in order to facilitate deeper ethical thinking regarding new areas of biomedical research we need more interdisciplinary conversation between the sciences and engineering on one hand and the humanities and social sciences on the other. I think this is quite true and is a strong argument for a liberal education in its classic sense.

However, I find it particularly interesting how the thinking of Hannah Arendt enters into their discussion. Arendt was a German Jew who fled from Europe to the US in the Nazi era. She wrote about the kind of thinking that allowed the totalitarian regimes of Hitler and Stalin to gain control. Fins and Reardon focus on her idea that logical thinking can lead from a seemingly self-evident statement to a replacement of common sense with thinking that leads in a direction that is very wrong. They see a culture in medicine and science that considers ethics as a matter of regulatory compliance rather than deep reflection an example of this.

What I find most interesting in Arendt’s thinking is the idea that logic will lead to faulty conclusions if the premise is not true. The problem that she saw in the thinking leading to totalitarian regimes was not that the thinking was illogical. The problem was that the seemingly self-evident statements which were used as the premises were false. When we apply that to ethics it means that we will only reach sound ethical conclusions when we begin with moral premises that are true. A liberal education with interplay between the humanities and the sciences is one way to seek true premises for our ethical thinking in the wisdom that can be found in the interplay of academic disciplines. Another is to recognize that the existence of common sense morality suggests a source of moral wisdom that is beyond human wisdom. Christian ethics finds its premises in that higher source of moral wisdom. A Christian liberal education integrates them both.