Covid-19, Economics and Bioethics

Bioethics, in its essence, is multi-disciplinary. It involves medicine, philosophy, theology, political science, and supernumerary other scholarly fields. And, of course and, perhaps, unfortunately, economics. Bioethics is blessed, and plagued, by its confluence of academic influences, and operates within their inevitable, intersecting, conflicting, uncomfortable gray areas. The Covid-19 pandemic speaks to the bioethical implications that go beyond who gets ventilators and when do we get a vaccine to even more elemental questions. Can we survive the economic paralysis that comes from a quarantine designed to arrest or slow the spread of the novel coronavirus in the United States? Was it “worth it” to force a government shutdown of many industries in an effort to keep our population as safe as possible….and, perhaps, forestall further economic devastation…and, even if so, what is our endgame?

I write this as a veterinarian, a bioethicist, a small business owner, a father of three high schoolers suddenly thrust into “e-learning,” and the son and son-in-law of octogenarians. If those seem conflicting interests, then they are indeed representative of just what a mess this pandemic finds our society. We aren’t unique but, in so many ways American, have managed to find ourselves the world leaders in Covid-19 deaths, infections, tests and are the economic “canary-in-the coal-mine” for the industrial world.

The Atlantic, hardly a shill for the Trump administration or its apologists, has a sober assessment, two months into the general national “quarantine” zeitgeist that has been our reality in most of America. The complex effects of the coronavirus on our economics are described in this piece, one that also looks at what those economic effects have on other nations and, yes, the mental and physical health of our own citizens. It isn’t pretty. Macroeconomics is a bioethics issue.

Americans have now been forced to face, and decide between, our competing ethics of safety (a biggie in contemporary society), personal liberty (autonomy, in ethical lingo, another biggie) and self-sacrifice for a greater civic good (mostly read about in vintage World War II texts, but bringing on a new significance). And it seems we can’t begin to reconcile them, so we just retreat into support of one of the first two, claiming the third as its moral anchor. As we are seeing, this is no way to orchestrate a response to a pandemic that has left (as of this writing) over 80,000 Americans dead and an economy that currently can only be measured by the Great Depression levels of unemployed, but really should only begin to be assessed the way we do tornado damage…when the sun comes up and the clouds lift.

There are no numbers to encourage us. Yet, reports tell us that there are available hospital beds and ventilators, and that the navy ships brought in to our urban “hot spots” to offer more space were (thankfully) never needed. We succeeded in “flattening the curve,” that goal that was always our fundamental one when we paralyzed our economy and society many weeks ago. So what is the goal now? Is it avoiding a new wave that will create a curve that needs flattening again? Is it a quick or gradual reversal of the paralysis of the economy that lets us eat out, shop in malls, have gatherings with friends, play sports and see marching bands perform, and worship in community again? Governors have played a primary role here, perhaps an illustration of the wisdom of federalism to some, the limitations of the same when dealing with a pandemic across fifty free borders to others. It is inescapably political in an election year…do you want to see people die or go bankrupt? That is our apparent binary choice, and our political polarization has already entrenched the position of each side.

I reinforce to my clients who are making decisions for my patients, their pets, as well as to my own children, should they be listening, that every decision we make has consequences, and virtually none makes everyone a winner. The Atlantic article mentions the profound economic devastation that comes to our health if we enter an economic abyss. Some of that is already realized. That bioethical decisions are inextricably economic should be painfully obvious to all. It has always been the “elephant in the room,” sometimes at a micro- and others at a macro-level. We have viewed economics as, at best, a stern taskmaster who wants to ruin a good thing and, at worst, the archenemy of bioethics. In the West at least, we have been blessed by wealth to make high-level bioethical decisions. The challenge of who gets dialysis was answered by “everyone,” because we found a way to pay for it without creating economic devastation. When that wealth erodes, we are on a different playing field. Covid-19 shows us what happens when a bioethical decision runs headlong into economics. Again, it isn’t pretty.

Fundamentally, we need to decide what human dignity and human flourishing look like in a modern society. Justice for all, and with particular attention paid to those at the margins, always dictate this. The margins we face in Covid-19 are, of course, the elderly, the immune-compromised, the chronically ill. But they are also those who struggle in good times to make financial ends meet and who are suddenly out of work weeks after the highest level of employment in recent history. Some are facing mental health and addiction crises. Global poverty, and its accompanying hunger and death, will rise. Whether one out of five or one out of ten, whether in North America or sub-Saharan Africa, we have a group of people at the margins. The number will inevitably widen as the storm damage is fully assessed. To fail to account for them in our public health decisions is inept and insensitive. To ignore the power of a disease caused by a novel virus for which no nation in the world has yet achieved “herd immunity” is no better.

Be careful how strongly you support either position. Those who lead, ultimately, are successful when they disappoint those who follow them equally. This is not a Solomonic baby-splitting, but the hard work of public policy and personal behavior. We will give up (and already have given up, to a great extent) some things that are excruciatingly painful losses. Our Western obsession with safety, with the quest for immortality that cannot be realized, for choosing death on our own terms and in our own time, has come under attack. Now we can be safer, but lose our prosperity, or remain wealthy but sacrifice many more thousands of our own. We can’t have both. Our public health decisions must recognize that national and global economics are bioethical, human flourishing, epidemiological decisions that cannot be ignored. A cavalier approach to loss of human life is ghastly, and an economy that fails means a health care system that fails.

Gender-Optional Birth Certifcates: A Parental Lesson

I’ve been parenting for over fourteen years now, and I’d think it should offer some seasoning and an accumulation of wisdom. Yet the parental “goalposts” are continually being moved as my own children grow into young adults, and (to throw in another metaphor) I enter uncharted waters every day. Current parenting choices are often met with rejoinders by myself and others, and regrets mount over past choices. Cheerfully, based on reports from those who preceded me, I find that it’s entirely expected. Parenting means making mistakes. And as my older children enter high school, I catch myself living vicariously through their triumphs, joys, and agonies. The tension is great to give them space to be their own people, not enlightened versions of me that will triumph over that which I never could. But it’s a struggle.

At the same time, and I don’t know if it’s advancing age or a sign of our times, I think I appreciate the satirical more now than ever. It seems that, if we can laugh about ourselves, we may be able to put our differences in perspective and not take ourselves quite so seriously. Sometimes “hard news” even reads like satire. It has been a few months now, but I thought that a friend who linked me to an article in the Canadian Broadcasting Company’s story was sharing a satirical piece. He was not.

My high school English teacher would read the pronouns and capitalization choices in that piece as an aneurism-inducing affront to all she held dear. I’m not sure I’ll be able to comment without upsetting her, me, and many others, in grammatical terms alone. In short, a transgender Canadian, Kori Doty, fought to keep the gender identification on their (grammatical groan) child, Searyl Atli, unspecified, stipulating that the child would not…and should not be expected to…have fully formed a gender identity until later in life. Gender identity is fluid, and a birth certificate should recognize that. According to Kori’s attorney, “assigning gender at birth is a violation of a child’s human rights to freely express their gender identity.” Cis-entitlement is not a satirical construct, but a point of great contention and injustice, and the violation of a basic human right, to those included in this piece.

A few months of pondering later, as a parent I can, in some ways, relate to Kori, who is making a choice with which I disagree, with some sympathy. Kori wants baby Searyl to be empowered to overcome the pain that gender identity struggles have already been lived in their life. Yes, there is also a clear political agenda, in the creation of a human right that society has never recognized, and I have far less respect for that. But I know the evangelical church has a history of poor responses to issues of sexual identity, on a political and relational level. I have limited personal experience with transgender individuals, and recognize that ethical decisions are not best made anecdotally, but even that limited experience has revealed that they have complex and challenging, and often extraordinarily painful, life stories. None have seemed capricious in their decisions. Some have been born with undetermined genitalia that truly weren’t clearly determinative of their gender. Others struggled with the very essence of who they were, even as anatomy would have seemed determinative.

The complexity of this issue should be sobering to us all, and particularly to those who embrace the Christian message that fully recognizes the devastation of a fallen world and the remarkable promise of grace that is not yet fully realized. I encourage the church to look at a complex issue with cautious, winsome eyes. The evangelical church lost its place at the table on the discussions of homosexuality (one where its voice could and should have been compelling) because too many showed graceless insensitivity. The high suicide rate of those who identify as transgender should be heartbreaking to the church. I am convicted as I initially read the article as unintentional satire.

Yet this is another issue where the complexity of medicine and social science is subordinated to a cultural agenda. There is, frankly, nothing wrong with asking for time and space to better study and understand the many pieces of the puzzle that transgenderism includes. The cry to “affirm” that which I can’t yet understand is unreasonable, even in the name of compassion. The appeal of bioethics is the way it synthesizes the disciplines of medicine, social science, theology, philosophy, and public policy, and recognizes the importance of each. I would like to think parents are the best arbiters of their children’s interests. Sadly, this story, and my own vicarious desires for my children, remind me otherwise. This parent has instrumentalized a child. The choice, if repeated on a mass scale, leads to social chaos and places a staggering stress on children whose developmental biology already faces challenges in our culture. Even now, we see gender reassignment surgery performed on young people. A sobering piece from a bit ago in The Federalist likens these surgeries with the frontal lobotomies of the 1930’s. Medicine needs to be exceedingly cautious as it encounters the “human right” that is gender identity. May bioethicists recognize the great complexity of transgenderism through eyes of compassion and grace, yet not submit medical and ethical wisdom to a cultural agenda. And may parents be wise enough to realize when we place the burdens of our agendas upon our children, whatever those agendas may be.

An IVF Keepsake?

As a father of two teenagers (and one who will join that esteemed company in a month), I am fluent in “sarcasm,” the native tongue of this group. Mine only use English sparingly, to do business. So, I often read headlines of stories in newspapers (remember those?) and online as sarcastic, and the articles they lead as spoofs. This one, in the “Parenting” section of an Australian web journal called “Kidspot,” immediately led me there. It speaks of a company that will take embryos from in vitro fertilization (IVF) that have not been implanted, and for which the biological parents have no plans of implanting, and turn them into keepsake jewelry. But this is no spoof.

The couple interviewed in the piece, having completed a 6-year journey through infertility and IVF, has a 4-year old son and twin toddlers. With seven remaining embryos, they had a decision to make. For them, “Donation wasn’t an option, the annual storage fee was an added financial strain, and disposing of them unimaginable.” Enter a company called “Baby Bee Hummingbirds,” who placed the embryos in a heart-shaped pendant.

My first impulse, not without some merit, was to find this all a rather ghastly business. Each of these embryos is a unique genetic human created in the image of God. I find myself critical of parents who don’t seem to have fully thought out the ramifications of fertilizing ten or more eggs. If these are genuinely human beings, then the creation (if that’s the right word) of “leftovers” is itself deeply problematic. It takes a great deal of restraint for a mother, who must have eggs harvested after a somewhat risky hyperovulatory cycle, and the physician, who will be judged on the success rates of achieving pregnancy, to fertilize only enough embryos to be implanted once. That is understood. But the ethical choice usually follows the more difficult path of restraint, and that includes the decision on how many embryos are to be made.

On another level, one which is a bit more gracious, perhaps, I try to see some redemptive value in this. Presumably “donation” was for medical research, for which I would commend the parents’ avoidance. It does not mention embryo adoption, which could fall under “donation” and would be ethically the best decision. But, with hundreds of thousands of human embryos in liquid nitrogen in fertility clinics across the United States alone, this is no full solution to the problem, and shouldn’t be seen as an easy “out” ethically. In the parents, there is a reflection that these are more than just unwanted clumps of cells, as something beautiful is being attempted to serve as a kind of memorial to the lives that could have fully developed. Maybe this is some effort to take something, quite literally ashes, and redeem it. Maybe it is a message to the world that we should all think a lot harder about what assisted reproduction fully means, and to what it speaks of human life. We sometimes carry the cremated ashes of loved ones with us as a reminder of their significance, after all. Perhaps this helps affirm the humanity of these embryonic humans?

Yet…this ultimately shows us what kind of a mess we have created. We feel better about children that we never gave the opportunity to breathe and walk and talk because we have made something pretty to carry them around “close to our hearts.” That the parents made the choice that these embryos will not live on can’t be lost here.

From the mother interviewed:

“Finding this has brought me so much comfort and joy.
I [am] finally at peace and my journey complete.
My embryos were my babies – frozen in time.
When we completed our family, it wasn’t in my heart to destroy them.
Now they are forever with me in a beautiful keepsake.”

Assisted reproduction has been described as the “wild, wild West” ethically…there is little regulation of the industry worldwide, it exists in (to use another metaphor) “uncharted waters,” and it has offered hope to people who desperately dream of loving a child…and may spare no expense or physical burden to achieve it. I can speak to the difficult journey of infertility because my wife and I traveled it. We set our boundaries early and held to them, but could easily see how each step leads to the next, and how gut-wrenching it is to say, “done.” This is not a critique of IVF per se. It is a reminder that anyone who undertakes the process (or, indeed, makes the decision to bring children into the world) should reflect on the motives behind and consequences associated with it.

This industry, this process, at its worst, instrumentalizes children. It takes a beautiful desire that has been met with profound pain and somehow convinces us that we have a right to children…children who look like us, will give us an ideal-sized family, and (ultimately and chillingly) will be the best that science can make. It is when children become a means, maybe the means to our fulfillment, that we lose sight of the sacrificial love that parenting represents. In a world of idols, this is another, and it is one that is consequential.

March for Science

If anything can be gleaned from the early days of the new administration in Washington, it is that a lot of Americans appear eager to march. The sheer numbers of marches chronicled since the election and into the nascent days of the victors’ succession would impress John Philip Sousa. The newest entry is the “March for Science,” an event to be held on April 22nd, a day now also known as “Earth Day.”

The march, like virtually all of the marches, is a reflection on the new administration. “The mischaracterization of science as a partisan issue, which has given policymakers permission to reject overwhelming evidence, is a critical and urgent matter.” So states the website, with rhetoric that heats up from there. Its organizers plan worldwide marches with a “Teach-in” along the National Mall in America’s apparent scientific capital, Washington, D.C. It would seem unlikely that this venue will protect it from partisanship.

It is, of course, ludicrous to believe that science is ever truly separated from politics. From before Newton to the Scopes trial, science has been linked to the political dialogue. In our age, science still carries great weight in any argument (perhaps second only to empathy), and politicians, corporations, and just about every one else will use science as needed to advance an agenda. And we should not think scientists are dispassionate about the work they do, or free of political impulses. And certainly federal funding of research, awarded broadly by politicians and specifically by government agencies, necessitates a tighter relationship than most scientists would have traditionally found comfortable.

I don’t want to be misconstrued as being overly critical of the concerns expressed in the call for the march. The principal issue with which the organizers are united is not particularly veiled. While this is not the forum, and a suburban small animal veterinarian is hardly the description of someone whose opinion on climate change should be sought, I do grieve the polarization on this issue that seems to fall along political lines. The left-versus-right divide would make some absolute enemies of the free market and others absolute enemies of science. We have lost the ability to have a nonpartisan discussion on this issue (or many scientific issues) in the public square, because to do so means we must accept an agenda. Whether you agree with it or not, the organizers of this march certainly have one, and it would not be fully embraced by many scientists (nor does some of it have much to do with science).

Beyond this, part of what I see missing in the aims of such a march is any reflection on what science can and cannot do. Science, at its core, ought to be a deeply humbling endeavor. Science uses empirical evidence to help show us how things work, from the cosmos to the quark. And sometimes new empirical evidence shows us that the earlier evidence was insufficient or outright wrong. Science tells us about the world around us and gives us tools to make new things possible, but cannot tell us if something is ethical. Bioethics emerged as a discipline, in large part, to evaluate and make judgments on the consequences of scientific discovery. Science is not itself a good or bad thing (though it can be done well or badly), and it cannot effectively determine either from within. Modernity taught us wrongly that science was its own arbiter, and we are not soon to recover.

I don’t know how to get all that on a placard, so I won’t find a way to attend the march. Marches don’t lend themselves to nuance. That’s a pity. I’d proudly march in celebration of scientific discovery that is ethical and recognizes its own limitations, its promise and its risks. I have spent twenty-five years in practice using science to try to bring health and happiness to my animal patients and their human companions. I often find it frustrating when a long-standing treatment is shown to be ineffective based on new scientific evidence. But I am compelled to respect that, and I change what I have done. Science is one of the greatest means for revelation that God has granted us. My faith in general, and my eschatology in particular, tell me that I have have profound responsibilities to care for the Earth and its inhabitants. The “March for Science” reminds me that agreement on the means of doing so remains supremely difficult.

Can We Be Okay With Chimeras?

In a post yesterday, Jon Holmlund, in typically erudite fashion, addressed the ethical issues that arise from the findings of a published study which looked at the potential use of genome technologies to (someday) produce human organs in animals. I will begin by saying that I have no particular disagreement with Jon’s assessment. There is a lot that is troubling in this research, as much good as it could eventually do, and we need not embrace it just because it has the chance to help people. Many of us have have taken an ethical stand against embryonic stem cell research, for example, because it ultimately violates the dignity of human beings, regardless of its intended benefits.

Yet I do find myself troubled, aesthetically and emotionally, at least, by the contention of the esteemed Charles Krauthammer that this research would ultimately provide “spare parts.” I suspect that, to the parent of a child with a congenital liver disease, a donor organ would hardly be considered such. That doesn’t constitute an ethical argument, for there are many unethical ways to procure organs and we invent more all the time. But it is a reminder that these discussions aren’t restricted to the theoretical firmament of the molecular biologists.

It’s in the public forum now. A recent article in the New York Times addressed this research and spoke to the continued disparity between the tremendous need for healthy human organs in waiting patients and the great scarcity of those organs available from donors. The article estimates 76,000 people are currently on a waiting list. Stem cell therapy, for all its successes in treating a host of diseases by way of human adult stem cells, has not had success with in vitro development of human organs for transplantation. Enter “chimeras.”

To be honest, there is much about the very notion of “chimeras” (which are a blend of the cells of two or more species, in this case: human and non-human animal, which this post addresses) and “human-animal hybrids (a blending of the DNA of both species) that I find troublesome, or even “creepy,” in an Island of Doctor Moreau-kind of way. And concern is warranted. Much of the research for which some scientists are seeking advocacy would do exactly what Jon (and Dr. Krauthammer) expressed: place pluripotent stem cells into another species (likely pigs or, less likely, sheep) and “pull the trigger.” In the article there is an implicit assumption that we must be cautious. The Times tries to be clever here: “No-one wants a talking pig.” But even a slight risk that this could place human cells into the central nervous system or reproductive germline of animals should be chilling.  And yes, we need to have a compelling explanation of this concern to offer the suffering and those who wait with them for new organs.  This is a risk not worth taking.

But I am also haunted by a bit of an escape clause: there is technology that could avoid the bulk of what I find ethically problematic. I have less fear of some mix of human and animal tissue…certainly “xenotransplantation,” like implanting a pig’s heart into a human being, whatever its successes or failures, isn’t really an ethical problem to most. What if the use of  the “CRISPR-Cas” gene editing system, which would allow for specific genes that code for targeted organs, could be used?

This technology, to which the original Cell (and NYT) article alludes, would mean that the animal embryo with implanted human stem cells did indeed avoid involving any human tissue in the non-specific organs of the host animal, particularly the brain and reproductive systems. Could that blunt much of our argument against this…one that says that the brain and germline are “off-limits,” but that we could find ethically-acceptable ways to provide organs for waiting patients using animals we already use for human food?

To be honest, I have my own qualms about CRISPR-Cas, largely because I don’t know a lot about it. It may indeed involve its own ethical problems, despite any protestations from its proponents. And once we go down this road, it makes it harder to say that, in particular, brain tissue is “off limits.” I get that. I would need to be convinced that this technology would do exactly what it is supposed to do. But I want to be sure my acceptance or rejection of any technology is soundly rooted in a consistent ethic that is appropriately nuanced.

I say all this to open the conversation…perhaps more to have the wiser inform me. But I do wonder…in this very specific way, are we able to keep the door slightly ajar without rejecting the technology outright? Does that keep us in the conversation? Within strict boundaries, can we be, indeed, be okay with chimeras?

Atul Gawande’s Look at Mortality, Part 2

I was invited to write a review of the book, Being Mortal, by Atul Gawande recently. While not a Christian book, it addresses end of life issues of interest to all involved with bioethics. This is the second half of the review, the first of which can be found here.

Nearly half of Gawande’s book reflects on final things, on letting go of life in the face of the limits of mortality. In this way, it supplements the excellent book by another physician, Ira Byock, called Dying Well: Peace and Possibilities at the End of Life. Through stories of real people, including his patients and even his own dying father, Gawande offers a harsh critique of the role modern physicians play as the chance for cure slips away with terminal diseases. That so many people die in a hospital setting, undergoing treatments inconsistent with their deepest convictions and in conflict with their ultimate goals, he finds disturbing. True, he is not at all unique in this assessment. He is also not unique in the celebration of the value of palliative and hospice care in decreasing the numbers of patients who face the end of their lives in hospitals, and who actually find the length and quality of their lives substantially improved over those who do not receive such care. Where Gawande is especially effective is in the way he can tell a story…one that links the crux of the patient’s own narrative with the medical realities (and innate struggle of the physician and the caregiving team) in the cases he uses for illustration. He lays bare the error of many within modern medicine who have transitioned from a paternalistic model that would tell patients what is best for them to one where patient autonomy dictates all medical choices of the physician. The former makes the physician a god, the latter, a technician. Neither is right, but concerns abound that the latter model is becoming the norm in modern medicine. He writes:

“All-out treatment, we tell the incurably ill, is a train you can get off any time—just say when. But for most we ask too much. They remain riven by doubt and fear and desperation; some are deluded by a fantasy of what science can achieve. Our responsibility, in medicine, is to deal with human beings as they are. People die only once. They have no experience to draw on. They need doctors and nurses who are willing to have the hard discussions and say what they have seen, who will help people prepare for what is to come—and escape a warehoused oblivion that few really want.”

The nature of such conversations, those that we should all have with our families, that physicians should have whenever they provide a difficult diagnosis, complete Gawande’s analysis. The goals that people have for their lives, how intensely they feel they must continue a life that may be devoid of what they consider most important, must be discussed by physicians who see care for their patients as more than fixing an emergent problem to keep them alive. It is a treatise against a paradigm of vitalism, one that would declare that life must be sustained at all costs.

Gawande has written a commendable work, one that would benefit everyone from healthcare professionals, to those imminently facing their own mortality, to the generation who will be part of making decisions for aging family members. His prose is elegant and engaging, full of facts but rich in narrative that makes it very readable, even as difficult subjects are broached. The reader can be brought to tears from the emotional intensity of those it chronicles, yet called to action within a caregiving system that is rapidly improving but still has much work to do.

The author was raised Hindu, but has essentially renounced that religious system. It is unclear that any other religious system has supplanted it in his life. Despite the substantial wisdom that the book imparts, Evangelicals will likely find a vexing lack of the transcendent in the conclusions Gawande reaches. While he is not antithetical to religious faith, rather linking it in with other activities that the elderly find significant, like playing bridge or eating chocolate ice cream, he certainly does not dwell on the vital role faith can play in the lies of the dying. The reader must look elsewhere for this discussion.

He does reflect on the bioethical principle of autonomy as distinct from living a life of complete independence, “free of coercion and limitation.” In his view, a more compelling sense of autonomy lies in the ability “to be the authors of our own lives.” This is, in a sense, a very human need, one with which we can all identify. But the Christian life is one marked by the gradual death to self that leads to true life, so that Paul could declare, “To live is Christ and to die is to gain.” We are ultimately confronted with the life of the cross, one that places our worth within the story of God, not ourselves. God is our author, though Jesus Christ, and our hope lies in the role we play in His grand narrative. Gawande’s analysis is not so much incorrect as it is lacking. We crave eternal meaning that only God can give, and we are weak authors of even our own stories within this much larger one.

The ears of Evangelical bioethicists will be pricked as Gawande broaches the subjects of euthanasia and physician-assisted suicide. While I am not in agreement with his view that physicians should have the ability to prescribe drugs to allow the terminally-ill to end their own lives, within a tepid acknowledgement that these pills can offer some peace and comfort to the dying, who rarely use them, he makes it clear he does not see a role for euthanasia in medicine. In fact, he reports the quality of hospice and palliative care in the Netherlands, the prototype nation for euthanasia policies, is notably inferior to that of the United States. It would be nice to see a stronger analysis of why such policies are antithetical to the practice of medicine, but perhaps that is asking too much from an author without an explicit theological conviction to express. Frankly, I had far greater worries that, in a secular book, an even-handed response to the excesses of “live-at-all-costs” he decries would be achieved at all.

With these criticisms aside, Atul Gawande has succeeded in writing a book that is highly readable and richly applicable to physicians, ethicists, and those who must face the difficult realities of our own mortality. It is not Christian, to be sure, and is therefore incomplete in how Christian believers would view mortality, but the wisdom he presents has great application (with a few exceptions) within an Evangelical ethic. As society works to erode a sense of our own mortality, Dr. Gawande has authored a must-read analysis of how we must rethink that paradigm.

Atul Gawande’s Look at Mortality

I was invited to write a review of the book Being Mortal by Atul Gawande recently. While not a Christian book, it addresses end of life issues of interest to all involved with bioethics. This is part one of two.

Evidence of humankind’s tendency to avoid the inevitable surrounds us in our culture. Burgeoning numbers of technological and surgical enhancements, from Botox to Nano therapy, promise us long, beautiful, pain-free lives. A recent headline shouted “The First Person to Live for 1,000 Years Is Probably Already Alive!” Transhumanism believes genetic technology will indeed eliminate death altogether. American culture in particular seems to reflect a people who have an uncanny ability to live as though the aims of the transhumanists have already been accomplished, and we will never die.

Against that backdrop, the blunt title of surgeon and Harvard Medical School professor Atul Gawande’s newest book, Being Mortal, seems more striking. Modern medicine has made tremendous advances in the elimination of once-deadly diseases and has allowed humans to live longer lives. But Gawande’s premise in writing this book reflects the idea that the very gifts to humanity that modern medicine brings also create a direct conflict with the reality of our own mortality. Many may long for a life free of death in this world, but our intellect, experience with family and friends who die, and (for Christians) words like Hebrews 9:27, “and just as it is appointed for man to die once, and after that comes judgment…” temper any delusions otherwise. Gawande celebrates the advances of medicine, but also laments that, in a healing profession designed to find a problem and fix it, medicine may be worsening the lives of the very patients it seeks to help. At some point, the fix may not be worth the cost as it butts up against the inevitability of death. We crave independence, as human beings and, indeed, as modern Americans, but our own mortality is its greatest threat. It was once thought that a speedy death was not to be desired…the Book of Common Prayer includes an explicit petition to avoid one, presumably in order that we may have time to make our peace with our God and others before we die. In fact, until recent years, a “fast death” was far more likely to occur than it is today, with technology that can sustain life beyond what could have been imagined a few generations ago. We are more likely to die over an extended period of time today, and that is rarely answers our prayer, but feeds our fear. We do not fear death so much as we fear the loss of the life we want to lead, which is made manifest in in a slow death.

Gawande does an extremely effective job describing the physiological effects of aging…the losses that begin before we know they have happened and that reach an inevitable end point when we die. Our ability to cheat death through whatever measures we choose must be reconciled with these realities, in a chapter labeled simply, “Things Fall Apart.” He then goes on to connect the losses of aging with the loss of our independence, which is considered the most painful loss of all, and then begins an extended critique of our society’s efforts to look after the increasingly-dependent as these losses mount. The modern nursing home, which has “…come a long way from the firetrap warehouses of neglect they used to be,” still are found lacking. “[I]t seems we’ve succumbed to a belief that, once you lose your physical independence, a life of worth and freedom is simply not possible.” He is critical of the modern system that allows the safety of patients to trump all other concerns, including their sense of purpose, their freedom, and which seems to assail their very dignity as humans.

Assisted living, which is a concept that has been extremely popular and profitable (at least as indicated by the mushrooming numbers of such facilities being constructed where I live), offers, in Gawande’s view, some improvements in the life of the increasingly-dependent over the nursing home model. These facilities certainly seem to assuage the greatest concerns of the children of their residents, perhaps the greatest reason for their appeal and success. But these, too, seem to view the safety of their residents, such as whether or not they get every one of their medications, or whether they can avoid foods and activities that could lead to harm, over their mental and emotional health. He laments a “life designed to be safe but empty of anything they care about.”

Gawande goes on to describe, in a chapter called “A Better Life,” what could improve these models. He illustrates the way nursing home and assisted living could work for their residents, through stories of those who have actually done so. These are stories of facilities that offered enriched environments, that stretched the conventional notions of what was safe and seemed appropriate for their residents to allow them to live lives more in line with what they wished. These stories were notable for both their remarkable effectiveness and, sadly, their rarity. While specifics of public policy are not explicitly addressed, it would be intriguing to see how Gawande would suggest these stories be applied to the broader context.

(Part 2 of this review to follow)

Ethical Hysteria

This is a blog that I had no desire to write, and concerns a matter for which I have been troubled for a few days now.

I am a Hoosier, a resident (and native) of Indiana, which is a state that is either, depending on your perspective, the epicenter of common sense or a new hotbed of hatred. The week just passed was marked by the private signing of a law named “The Religious Freedom Restoration Act” in Indiana, by Governor Mike Pence. This came out of a legislative session that had, up to now, been considered rather tame and even dull to most who work within Indiana politics. The windup to this has been nothing compared to its national response, which has been abundant and vociferous.

Indiana has a sort of curious pride in its ability to be neither the first nor last to do much of anything. Hoosiers are a people who survey the passing scene, dwell on it awhile, and then decide to join when the water seems tepid enough. We continue to celebrate such things as a dessert item that can be deep fried at our State Fair, we crown a “Pork Queen” at an annual festival thirty miles north of our Capitol, and shake our head at the corruption in parts of the state while we mow our lawns and lay down fresh mulch on our flower beds every Spring, undeterred. If you move here you’ll probably receive a pie from someone, and a recommendation to the best steakhouse around. Indiana is generally a delightful, non-threatening place. One law seems to have changed some of that.

I actually have a complicated view of the legislation just passed, as many Evangelicals do. This is not especially personally commendable, as it should be no surprise; our faith inherently makes the sausage-making of legislation in a secular government complex. I own a small business; I am the president of a professional organization; I have clients and friends and colleagues that have a wide range of beliefs, life experiences, and moral positions. I can see the concerns that all sides have with the passage of this law.

What troubles me is the weight given to hysterics. And this is where we must all be troubled in the era of moral and ethical relativism. And yet it is hysteria, often promulgated by well-meaning people who are swept up in a sea of compassion, which seems to win the day. It isn’t even very good ethical relativism, where all views are to be held equal…the most valid ethical opinion is the loudest one. Perhaps it is my age or (hopefully) advancing wisdom that finds hysterical arguments so odious. I almost don’t care what position you take; I will discount it ten-fold if you resort to hysterical means to defend it. This, by the way, is not limited to any one side of most issues. People of faith are as capable of resorting to histrionics as anyone else.

I love to come to conclusions, and, sadly, my temperament must be satisfied with more musings than solutions this time. As those who seek to follow Christ, in His difficult teachings and astonishing sacrifice for those who didn’t deserve it, do we look at (and influence!) legislation, bad or good, and social evolution, similarly, with a winsome response, or a hysterical one? In an era of 24-7 news cycles and social media, where “he (or she) with the most ‘likes’ triumphs,” is hysteria the way to win? My darker angels are rather inclined to think that it is. What is maddening to me is how often hysteria is passed off as enlightenment. And this should continue to worry us in Bioethics because the “optics” and the “narrative” that surround an issue are what rule the argument. Can we continue to compete in the arena of ideas with elegant arguments but restrained by that darn Christian civility?

In fact we must. The price to win some battles with bluster is too great, for it may damage the cause of the very Gospel we seek to advance. We know that. Jeremiah wrote to the exiles held captive in Babylon that they should “pray for the welfare of the city” where they lived, for “in its welfare you will find your own welfare.” For each People spread that glorifies the values of the Hemlock Society, that find their object lesson in Brittany Maynard, a quiet Kara Tippets response is less flashy but exactly right. If “our side” on this issue eventually loses, I will find such means the most affirming way to have lost. Let us be wise in how we manage the optics and the narrative, to be certain, but in that process, defend our ethics in a way that is consistent with them.

I’ve not given my position on the law because, frankly, I consider it entirely irrelevant to the big picture of God’s ultimate plan, what the late Dallas Willard called the “Divine Conspiracy.” In six weeks I will travel with a team of eight to meet with fellow believers in war-torn Ukraine. One of them is a pastor from Donestk whose church was burned to the ground by rebels backed by a Russian madman who wishes to see the nation of Ukraine crushed into subservience, and who have already killed thousands and driven the church there into a Soviet-style bunker mentality. This pastor is now ministering to other refugees in Kiev. I do not expect to ask for their prayers for me to attain either greater religious liberty or freedom from persecution from anyone. The Ukrainian Christians have a perspective that I cannot fathom. My Ukrainian brothers and sisters are not hysterical; they are surviving. No legislation in America or anywhere else will stop God’s relentless conspiracy to make right that which was wrong. I hope many of His people will ultimately be marked by diligence and faithfulness, and less by how hysterically they defended our ethics in His name.

The Indignity of a Death with Dignity

The story of Brittany Maynard, a 29-year old newlywed who has been given the diagnosis of terminal glioblastoma, an especially aggressive brain tumor, has gone viral over the past week. Many know the story already, but it centers on her decision to end her life by taking an oral medication prescribed by her physician, who will be sitting at her bedside with her husband and other members of her family at the end, at a date she has selected to coincide with her husband’s birthday later this month. The details are chronicled in People magazine, which is significant because of the role the magazine plays as gatekeeper for what is to be considered culturally-normative, and because it is where you can see the heart-wrenching video she and her husband prepared to explain her decisions.

I will not attempt to mount a thorough rebuttal to her choice of physician-assisted suicide, one made to avoid the certain-suffering that will face her as cancer ravages her mind and body. Perhaps the best, most elegant response I have seen can be found here, the words of a fellow traveler on the awful road of terminal glioblastoma. Other responses, including a Matt Walsh blog and even a debate on the Blaze, offer great commentary as well.

But so much of what Brittany says needs to be answered by many more, those who have profound objections to what she is saying, because she is sharing this difficult and intimate season of her life for reasons of advocacy. She, her husband, family and doctor support the causes of the “Death with Dignity” movement with the organization “Compassion and Choices.” After her diagnosis, Brittany specifically moved to Oregon where the process of physician-assisted suicide (PAS) is legal. Within the People article itself, there are plenty of opportunities to see how semantics will be used in the future to argue for PAS.

Brittany makes it clear that, in her view, this is not suicide…she does not wish to die, but her life is to be taken from her by cancer and “it’s a terrible, terrible way to die.” I don’t disagree with the latter sentiment…I pray that it will not be the way I leave this life, either. But I believe that my life is not my own…I ceased believing it was long ago…and I have no authority to decide how I leave it. I trust a Lord who has never ceased to be my advocate for what is best for me, and I will trust that same Lord with my eternity. But those who attempt suicide, or succeed, rarely think that ending life is what they really want, but that the “terrible, terrible” pain they face makes death the better answer. If the pain (emotional or physical) would end, suicide would be unnecessary.

She addresses ethics: “I believe this choice is ethical, and what makes it ethical is it is a choice.” Again, I don’t want to be cruel to someone who is suffering in a way in which I have no way to relate, but this argument is both insipid and dangerous. It is the latter because it is supported by little ethical framework than that of radical autonomy. She believes that, because she can ostensibly change her mind at any time (and many pray that she will), all is right with her choice. Never mind that it seems unlikely that someone so committed to the cause as she will join many (nearly half) of those who sign on with the “Death with Dignity” provisions, getting prescriptions written…and never follow through. Perhaps she will not find herself as free as she thinks. As resources become scarcer, some with the “choice” will find other subtle (or not-so-subtle) pressures to follow through. Beyond coercion, “choice,” as an ethical paradigm, also fails to account for collateral damage to others.

Brittany has had a remarkable life in her 29 years. Her accomplishments, including climbing Mount Kilimanjaro, show someone who has been in control of her life. The beautiful photos attest to a young woman that seems to be dying in her prime. There is a sense that she fears the pain that accompanies death from a terrible disease, but the greater sense is that she will lose control. Pain can be controlled by medication; control of one’s fate, once lost, is irrecoverable.

Her final sentiments are spoken thusly: “I’m dying, but I’m choosing to suffer less,” she says, “to put myself through less physical and emotional pain and my family as well.” This last part makes me want to cry. I have no idea what her faith system is, but I see that it isn’t one that can find the redemptive value in suffering, in the “ministry of dependency” that comes from letting others love us well when we leave this life. I am not a vitalist; I don’t want to live my life for as long as possible and at all costs. But I do want to let my faith be revealed in the trust I place in God and the people with who I have been blessed to share my sojourn on this Earth. It’s a trust that means that as I lose lucidity and seem less dignified, I will know that my true dignity as a being created in the very Image of my God, one undiminished by a time of mental and physical incapacity that occurs before I pass into an eternity that bids pain and sorrow goodbye forever. The indignity of a rotten death pales in comparison to that inherent dignity. I wish Brittany that same knowledge.

Google Maps and Moral Authority

At a recent conference held for the leadership of state veterinary medical associations, I had the opportunity to listen to the sobering economic statistics that veterinary medicine faces. These are not, by the way, altogether new or shocking (I’ve listened to them and read them well before the average new graduate entered the profession with the 2.7:1 debt to income ratio of the Class of 2014), and my profession always seems to endure. When care for the equine-based transportation infrastructure was supplanted by Fords and Chryslers a century ago, veterinarians began a focus on pets that now dominates the profession. So we contend today in practice with few patients named “Trigger” and more named “Toonces,” a paradigm shift of the first order, and, increasingly, with our medical expertise supplanted by the opinions of “Dr. Google.” It is a reminder that, whatever the intensity of the human-animal bond, much of our profession is supported exclusively by the discretionary income of others. We’re not unique among professions who consider the practice of their craft a fragile thing indeed. The palpable angst of the many physicians who blog in this site, those who face challenges in the human medical profession far more revolutionary than evolutionary, sometimes seem to blunt the big professional worries faced in my field.

But common to all of us is a sensed need to practice defensively. No one wants to offer low-hanging fruit to the trial lawyers, or to spend depressing amounts of time dealing with liability cases. We all document things assiduously. When the dust settles in a case, I may ultimately look like an idiot, but it sure better not be because of a failure to accurately chronicle what I was saying or thinking.

But now, according to a bright veterinarian who is a marketing guru and speaker (and, curiously, about whom I say all those things without sarcasm and with notable reverence), we have new fears. In a competitive marketplace for services, we need to stand out; we need to offer something that others do not. Any medical professional knows that already seems to be stamped on our DNA—we got to medical or dental or veterinary or whatever school because we were driven to be the best, to stand out, and we have the emotional scars and empty Prilosec bottles to prove it. It’s what makes us all, not just DVMs, think, as American Veterinary Medical Association (AVMA) Executive Vice President Ron Dehaven recently stated, that “ninety-nine percent of veterinarians think they communicate better than their peers.” We crave excellence in what we do, and how we communicate it, and have reasonable expectations that the work we do and the hours we sacrifice will make us just a bit different than our peers. We will offer that optimal “experience” that the gurus say we must.

So often the way we stand out has nothing to do with our medical or surgical competence, but has everything to do with how we are perceived in the public. Dr. Google, and his cousin, Professor Yelp, and what seem like a host of other sites can give us star ratings that appear whenever someone in the public just seeks our phone number online and is automatically shown a “Google Map” of our location, complete with our reviews. These can build up our professional egos, or crush our spirits. Chillingly, statistics say that 69 percent of the population would place as much stock in an online review of a medical professional as they would from the personal recommendation of a friend. We have become, as Tristam Englehardt, Jr., has commented, a society of “moral strangers.” The online opinions of a disgruntled former employee or the supportive golfing buddy of a doctor, neither of whom has to particularly identify as such, are granted the same authority for help in making significant and important and often difficult medical choices as a trusted friend. How awful.

I’ve written of the consequences of online bullying of a veterinary colleague before, bullying that seemed to have contributed to her suicide. Medical professionals have long had to worry about what happens if the outcome of a case is not optimal. Now they (we) must monitor the Internet as sentinels waiting for the poor rating from a client or patient we may have inadvertently offended, from any number of rating sites. I say this as someone whose practice has great online reviews; hooray for me. But popularity, and especially online popularity, is ephemeral. Does this change how we practice? Does it change how we share the truth or protect our staff or other patients from toxic people? Does it mean that standard medical ethics are replaced by the business model of “the customer is always right”? How do we even try to change the cultural authority of anonymous (or nearly so) online reviews? I don’t like how it may impact the way I now practice, but I must accept its presence and deal with its ramifications. For those who face remarkable burdens to practice ethically and honestly within their professions, it offers one more sobering burden to doing just that.