On Technology, Bullying and Compassion Fatigue

Technology has been described variously in theological terms (a “qualified blessing” from a God who gives of grace creatively) and ethical terms (generally neutral of itself, with potential for good or bad outcomes, depending on how it’s used). Most medical professionals (at least those who cling to some moral and ethical footing in their view of such things) hold certain technologies in high regard, like therapeutic tools that allow their patients to live longer, healthier lives. Yet they struggle with those things that push the envelope, which may sacrifice the judicious for the temporal.

It’s not these ethical dilemmas of which I speak. Technology has the ability to be a tremendous force for democratization of everyday life. People have access to information that is unfiltered, and can express themselves with a freedom that goes beyond even the seeming anonymity of road rage. The past few weeks have shown me the challenge that this technology creates for those in medicine, both human and in my own veterinary medical professions.

I am entering an unlikeable phase in life where I will start to lose friends and contemporaries to cancer and heart disease and strokes. I attended the funeral of a friend that left this life sooner than many of us felt ready. We know the right theology, we face reality, but it still stings. One of our other friends, who has lost a parent in recent years, commented that, near the end, there seems a need for blame to be assigned. She had maintained vigils at her own mother’s side as she slipped away, and still felt herself recoiling from the sight of hospital beds and fluid pumps. She remembers how she almost hated the nurses and doctors that couldn’t fix her mother, and who seemed almost as baffled at the deterioration of their patient as she did. All she could see was her mother worsen with no apparent plan by her caregivers to turn things around. That anger, fully known to be irrational in hindsight, is no less real in her memories.

As a veterinarian, I also know of another very sad case, this time of a colleague in New York. Her story can be found here, but it is heart-wrenching to hear its specifics. Briefly, this doctor had done what many veterinarians before her have done, which is to avoid the personal and professional pain of what is called “economic euthanasia,” where a pet is taken in by the doctor after the individual bringing it to the office expresses a financial inability (or unwillingness) to have treatment performed that would save its life. Dr. Shirley Sara Koshi successfully nursed a cat back to health, on her own time and at her own expense, after it had been turned over to her in such fashion by an individual who brought various cats to Dr. Koshi after they were removed from a New York City park. After its recovery, the individual attempted to reclaim the cat and was rebuffed unless and until the medical expenses were paid. Legally, the cat had been relinquished to Dr. Koshi and there were no ethical obligations (and, indeed, should have generated ethical objections) to return the cat to the individual who brought it to her in the first place.

Technology and emotion can supplant when legal options are scant. Enter social networking, specifically a pair of Facebook pages. The first, called “Regret-a-vet,” offers disgruntled consumers of veterinary services a forum to air their grievances, complete with lots of “Likes” and supportive comments. The second, and more venomous, is called “Veterinary Abuse Network,” and, in this case, ratcheted things up a bit. A full-tilt assault on Dr. Koshi ensued. The veterinarian did respond, regrettably pulling herself into the same mud as her opponents, but the social networking diatribe continued, unabated, for weeks and weeks.

When the body of Dr. Sochi was discovered after her suicide, a brief note on the “Veterinary Abuse Network” page found justice in the freedom that the cat had won, free of this imperialistic animal doctor. There was cheering at the death of this veterinarian. The Facebook destruction of a medical professional was complete.

Now to be sure, I don’t know all the specifics of this case, nor do I know all the factors that led to the suicide of a 55-year old veterinarian. But I do remember the brute honesty of my friend who admitted that her family needed a scapegoat when her mother died, and medical professionals served that role. The freedom to “rate” our physicians and veterinarians and others, via the anonymity of the Internet, is a technology that is fearsome to me and, I suspect, some of my friends in human medicine. The narcissism fueled by Facebook and other venues can destroy someone, and fast. I have never had to deal with it; someday I surely will.

Jean Bethke Elshtain once wrote that we must think of our political figures as being made of “flesh and bone,” not just as unfeeling figureheads in a political system. I think this relates to our medical professionals as well, a staggering percentage of whom are still (and often inexplicably) idealistic and face emotional and ethical issues head-on, and who must maintain a deep compassion for their patients and family members (and, yes, this means veterinarians as well as physicians; as one of the former, I can tell you how the short lifespan of my patients and their role in the family make my job and the job of my staff that much more exhausting). This compassion is exhausting, and we all seem to take it personally when a patient dies, no matter the reason. Jesus modeled well how to get away to a “lonely place” to regroup in communion with the Father when acts of compassion could be so, soulfully tiring. We have no room for that in medicine. The standard for an online review of a physician ought to differ from one made for an Italian restaurant or a carpet cleaning service, but the democratization of the Internet lumps them all together.

What a shame. What a tragic story. What a reminder that technology can be our friend, and can be used to bully us all. And that bullying can hit us in our weakest place—the place that says we just don’t care. Be ready.

Erasing Inequality?

It is 2014 and, heaven help us, it is another election year in America. The talking points are already taking shape in our own political Yugoslavia, where dialogue was long ago supplanted by lecturing. On the right, one cannot hiccup without the word “Obamacare” coming out. Comparisons to the Hindenburg and Titanic are considered too tame; at least the former made it across the Atlantic and the latter had a few lovely days at sea. It has been intriguing to me that this blog, with contributors of strong opinion and willingness to express such, has left untouched commentary on the October 2013 rollout of the Affordable Care Act (ACA for short; “Obamacare “ as a term has gone from pejorative to badge of honor to pejorative again, and “ACA” is quicker to type, so thus it is…). I do wonder if, among its supporters and detractors alike, the difficult launch of the ACA has created some sense of grief, where the laudable aims of medicine to help all who suffer, and where there should be no affirmation that “everything is just fine the way it is,” should be considered acceptable. If this reform fails, perhaps we will never get any kind of reform. I won’t put words in the mouths of my blogging colleagues, but there has to be, at some humanitarian level, a bid of sadness at the initial difficulties of the ACA for those at the margins of society. On the right, I think it legitimate that there needs to be some expression of that, even within a firm critique of the legislation itself.

On the left, that all-American response to adversity—change the subject—has brought us to the “Message of 2014: Economic Inequality Must Not Stand.” This is, to some degree, laudable: recessions tend to ensure that winners win big and losers lose badly. Jesus told us that the poor would always be with us, but he didn’t seem especially happy about that whenever he encountered poverty. A sorrow about poverty is not the exclusive domain of a single political ideology, though how to deal with it varies greatly between the two American political parties. Solutions abound…just today came a piece by a former Bush Press Secretary, Ari Fleischer (can’t get the hyperlink to work, just Google it), about the social roots of economic inequality. At least we are all talking about it…

But is economic inequality sufficient as an ethical imperative? It seems there are lots of other kinds of inequality that should have principles of distributive justice applied as well. There is a thought that economic inequality is often a product of the “lucky versus the unlucky.” Some have advantages, things that allow them to win at life’s financial lottery. Others hold pieces of paper with losing lottery numbers and work on to beat the odds next time. I have not spent long periods of time studying economics, but it seems that there are a lot of lucky and unlucky people out there, too, beyond those who play the lottery for money.  My athletic prowess is revealed with many a “came in just before the guy with a heart attack” finishes in 5K races. Perhaps (and believably) I am not well-trained, but maybe I’m just not lucky to be gifted as an athlete.  But it would sure be great to be the top finisher in my age group!

Lots of other examples abound. Some seem to come down to the lottery of good fortune, or abundant blessing for the Calvinists out there. An advocate of the ACA, MIT’s Jonathan Gruber, sent the conservative blogosphere into hysterics this past fall when he declared that “genetic lottery winners” have paid “artificially low” insurance rates up until the advent of the ACA, where the playing field would now be leveled. There is more than a kernel of truth to that—it has genuinely paid to be healthy. But is that itself a form of inequality, a distributive injustice? Much can be said about what a social contract should include—what provides for the majority who didn’t “win the lottery,” and what means should exist to allow them to flourish. But is genetic fairness even a good thing?

Intellectually, economic injustice should mean that the many that are economically disadvantaged are not made “less poor” or the well-off made “less rich.” Each should make marked strides toward the middle, with the result that many get much richer and few get slightly poorer. In the perception of most, though, and with only a passing glance at the claims of the rich who are to be “soaked,” the standard becomes one that all should consider themselves rich. It is the mark of the human heart to find that no level of riches is completely satisfying, and so “good enough” is, alas, not good enough.

Does that perception apply to those who are not winners in the genetic lottery? If so, that means that there is an ethical imperative to be as close as possible to the best and brightest. Fortunately, we think, technology when applied to biology can do what economics cannot and even the playing field without the “genetic winners” giving up much more than their exclusivity. We all can be the best! Here there is more than a passing dalliance with eugenics, all in the name of equality.

I am an advocate of care for the poor, for helping those who are suffering economically, whether from mistakes they have made or through no fault of their own. Justice and grace are about that. But I know that humans have sought to be better than they are, to reach greater heights, and that life in a fallen world cannot erase the inequalities that arise as a natural phenomenon. So when we look at a more even playing field, in “economic inequality” or in human health and flourishing, have we really considered what most people find that to be, and whether erasing inequality in all its forms is a worthy objective for us to pursue?

The Alzheimer’s Epidemic and the Developing World

Headlines of “Alzheimer’s Epidemics” have been prevalent for several years now, with an uptick, it seems, in the past year. I am often reluctant to read further when I see one, largely because it seems something we can’t do much about and because such news is often sensationalized, with several crackpots offering “guaranteed natural cures” and others spewing conspiracy theories that implicate “Big Pharma” and other sinister types as the reason for the increase in cases.

Several days ago, an article ran in a Hong Kong newspaper declaring “Alzheimer’s Disease International Warns of Dementia Epidemic.” The article stated: “Many governments are woefully unprepared for an epidemic of dementia currently affecting 44 million people worldwide and set to more than treble (sic) to 135 million people by 2050, health experts and campaigners said yesterday. Fresh estimates from the advocacy group Alzheimer’s Disease International (ADI) showed a 17 per cent increase in the number of people with the incurable mind-robbing condition compared with 2010, and warned that by 2050 more than 70 per cent of dementia sufferers will be living in poorer countries.” Few of the previous articles seemed to reference this geopolitical angle.

We still don’t really know exactly what causes, or how to prevent, Alzheimer’s dementia, crackpot theories aside. And the increase in cases is the ironic result of a longer lifespan. People are not dying from prostate cancer and heart disease in the same numbers they did in the past; we’re healthy enough and living long enough to die of disorders associated with dementia instead.

What is different now is the idea that the developing world may see such an increase in cases. Somehow I always think of Alzheimer’s disease as a uniquely Western disorder, where we face ethical issues that seem to contrast sharply: How do we avoid going too long and how do we avoid the impulse to ignore the dignity of individuals who are “just a shell of their former selves?” Here we deal with fears that our healthcare system, already dealing with systemic traumas from unfolding government policy changes, will face the crushing burden of millions of baby-boomers with dementia in the not-so-distant future. Will the care of these individuals bankrupt the system for future generations? Will we find that these people, who are “no longer themselves,” be granted a “death with dignity” when their memories fail and their caregivers’ burdens increase? These are the questions of the West.

But what about the rest of the world? We have grieved the dismal lifespan statistics of many in sub-equatorial Africa who suffer the scourge of HIV and leave scores of orphans in their wake. Suppose we find that the many initiatives underway there really do improve the stats, and we start to find people living long enough to join the ranks of Alzheimer’s. The article quotes Martin Prince, a professor at King’s College London’s Institute of Psychiatry, who says “most governments are woefully unprepared for the dementia epidemic,” and that “only 13 countries have national dementia plans.”

But here we look at cultures. The HIV epidemic in Africa is a tragic result of certain cultural phenomena, with many, many innocent victims, and its prevention and treatment must be addressed within this cultural crucible. The way we look at dementia in the West is likely quite different than how it is regarded in other parts of the world. The way we view the elderly and infirmed, the aged parent for whom it is exhausting to provide basic care and who cannot even recognize us or remind us of what they used to be, may be quite different in places like Africa or Asia, where the elderly are often revered. Sure, the medical resources to care for scores of dementia-sufferers will be challenges of distributive justice. But at its most basic, Alzheimer’s isn’t about technology or medical marvels, but about dedicated caregiving to members of society that Jesus must surely have considered among “the least of these” in his teaching. I don’t look forward to an “Alzheimer’s epidemic,” because I may well be one of its victims someday. But perhaps there will be some perspective, some grace, shown by other cultures that suffer through it, too, and, perhaps, we will look to the developing world to see just how it’s done. These “national dementia plans,” however they play out, may be quite elegant in their own way, and offer some guidance to the “developed” world.

Pro-Life Vegetarians: Can’t We All Just Get Along?

I broached the ethical linkage between the pro-life and vegetarian movements in a blog post a couple of weeks ago, where I introduced an essay by Matthew Scully that purports to make a case for vegetarianism on ethical grounds. I have mentioned before my dislike of the moniker “pro-life,” though I have yet to find a more politically-palatable name when “anti-choice” is offered as its replacement. Given my options, I’ll run with “pro-life” henceforth. I have also mentioned my dislike for the manner in which Scully makes this argument, appealing less to rationality than engaging a PETA-like appeal to theatrics.

In this second overview of the issue, I reference an article in First Things from over four years ago written by Mary Eberstadt, an author and research fellow at the Hoover Institution, and someone for whom I have a high regard. She finds herself in agreement with Scully’s overall principles, with a more intellectually cautious, less bombastic approach than his, but carries the moral imperative for vegetarianism further, connecting it to the defense of human life. That the proponents of each appear to find little common ground today she finds less an issue of intellectual and moral acrimony than a failure of competing ethical frameworks to engage one another. This dedication to the ethical agenda of various groups has essentially led (as I quite loosely paraphrase) to people that can’t play well together in the sandbox.

She describes the principal proponents of ethical vegetarianism (if I can call it that; it suggests that people like Bill Clinton who have essentially embraced veganism to avoid an imminent death from cardiovascular disease are “unethical vegetarians;” I will leave it to political non-partisans to parse those terms). They are a group of utilitarians like Peter Singer and postmodern eco-feminists like Carol J. Adams. Neither group is especially amenable to the views from an alliance of conservative Catholics and evangelicals that make up much of the pro-life movement. Evangelical Christians and conservative Catholics put away their differences in a conjoined white-hot lather against people like the utilitarians and eco-feminists who do the same against them. It’s like the 1980s where the Moral Majority and People for the American Way largely existed to antagonize each other and finally just got tired of it. But these groups aren’t tired yet.

Eberstadt notes that, among the “pro-animal” (again, I dislike the term, but will stick with it) adherents within utilitarianism and feminism, “both are hostile to the idea of admitting unborn human life to their circle of approved moral sympathy.” In the case of utilitarianism, animals can suffer pain in ways that unborn humans cannot, so they “trump” the unborn ethically. Eco-feminists find that both women and animals have been victimized, by rape and slaughter, respectively. Protection for animals means that they should not be killed for food; the protection of women means that all rights, including reproductive rights like abortion, must be preserved at all costs. Add that to an open hostility of both groups to matters of religious faith and you have created a very inhospitable sandbox indeed.

The pro-life forces, in Eberstadt’s view, are largely against vegetarianism because it is so often associated with wackos. We’re against it because they’re for it. This defensive crouch, she finds, is counter to the long history in the church of vegetarians like Francis of Assisi and John Chrysostom. Unfortunately this is where her explanation of this position ends, failing to address Biblical scholarship that permits meat-eating, in moderation like most things, as morally-acceptable.

Her solution rests upon an appeal to moral intuition (she avoids the term “natural law” for whatever reason). The comparison is made between those who joined the pro-life or pro-animal (i.e., vegetarian) cause as a consequence of a moral epiphany. Something happens, and we realize that our prior position is wrong. Certainly pro-life supporters use ultrasound images to sway the thinking of those who don’t seem to fully comprehend the moral significance of an unborn human. Likewise, images from grievous practices in some commercial farming or slaughter operations can create a moral reprehension toward the eating of livestock. Eberstadt now finds that we really are all playing in the same sandbox, one where our deepest, most intuitive assessments will prevail to embrace the value of all life, human and animal.

But this is where natural law, or moral intuition, loses me. Moral intuition is a terrific system in the absence of sin, when separated from the realities of the fall. It is still with us in some form, as the notion of “common grace” would have it, but it isn’t perfect. Our moral intuition may change with a compelling argument, perhaps a morally-invalid one. Moral intuition is not disembodied from our feelings at any given time.

During a recent time-wasting exercise of clicking-on-a-link-from-another-link, I was led to an advice column in Salon magazine, that sentinel of moral rectitude. I didn’t expect a lot, but was taken aback by the comment of what should prevail in moral decision-making:

“I think, within certain limits, in our social arrangements, it is right for us to behave according to how we feel. Feeling is a great regulator of human behavior.”

I won’t go further in how ghastly that idea is; I’m glad flash mobs are so in touch with their feelings. Fallen human beings can and do fall prey to their feelings and emotions when setting a moral compass. There need to be deeper principles than just profound moral intuition when processing ethical claims.

More importantly, frankly there are frankly moral issues that trump others. It is not necessary to make false equivalencies to justify moral repugnance to meat-eating and taking the lives of unborn humans. Both are substantial moral quandaries, but they aren’t the same. To make them so is little better than how the utilitarianism of Peter Singer or the rights-theory of Tom Regan sentimentalize all life, with no distinctions made for the moral weight of human beings. At some point, there needs to be recognition that there are indeed two very different games being played in the sandbox.

Pro-Life Equals Pro-Animal

There is some buzz being generated within the political and religious blogosphere these days about animal welfare issues, and it is standing out because of its appeal to an unusual audience of perceived kindred spirits. It makes the argument that “pro-lifers” are the intellectual and spiritual brethren of “pro-animal” advocates. To some this would seem an interesting, if somewhat opaque, syllogism, perhaps akin to Knights of Columbus who are also Master Gardeners.

But it has some intellectually-serious proponents. I must admit to being a fan of one of them, Matthew Scully, a former political speechwriter for figures including George W. Bush and Sarah Palin, in large measure because his writing is eloquent and compelling. I’m a sucker for both, and I freely confess that I would be a model of Stockholm syndrome for anyone making an argument in such a way as Mr. Scully typically does. I have to tread cautiously when I read people whom I like stylistically so as not to be easily persuaded by their prose alone.

So Mr. Scully has posted an intellectually rigorous and rather long post in the National Review Online entitled “Pro-life, Pro-Animal,” which links the issues of respect for human life and the welfare of animals. He starts off well-enough, with an argument that I can support in the context acquitting responsible animal stewardship as a hazard to the notion of human dignity:

“Far from presenting any threat to human dignity, animals and their moral claims upon us — the basic obligation never to be cruel, not just the option to be kind when it suits our purposes — are a constant hindrance to human presumption. What is the mark of that special status of ours, anyway, if not precisely the ability to be just instead of merely dominant, to be the creature of conscience and bring mercy into the world? A loving concern for humanity that stops there, instead of spreading outward in a sense of fellowship and active respect toward ‘our companions in creation,’ to borrow a lovely phrase from Pope Benedict, is too close to self-worship, and bad things come of it.”

I agree with this; human dignity is affirmed, not threatened, when we reflect the compassionate God in whose image we are made. The animals over which we have been granted dominion, in the Judeo-Christian conception at least, offer abundant opportunites to display the full measure of our humanity as stewards of God’s creation.

Where I part company with my erudite friend begins when he starts to wander into the weeds of anti-scientism. I am insulated in small animal practice, a practice filled with animals that are pets and where I am able to totally ignore the fact that the meat my patients and I eat is not harvested from “steak trees” but involves the death of animals to get it. Understood. But I have also spent time on the “kill floor” of a slaughterhouse, and I have colleagues who are intellectually-serious and ethically-motivated as they fulfill their oaths in family farms and within large commercial operations alike. They use moral reasoning as they care for their porcine and bovine patients. Veterinarians are grudging philosophers, generally a sort with a practical bent and a love for scientific proofs. But we are often moral idealists, ones that use the science of animal behavior and physiology to undergird our practice. It is science that recognizes that most livestock don’t lead a charmed life in most environments, that there are dangers in seemingly-idyllic settings, and that safety is an appropriate motivator for their appropriate care. This is why a statement like this from Scully is so difficult to take:

“No matter what new perversion of animal husbandry the industry might devise, it can always count on the sign-off of friendly veterinarians, as true to their oath (“to promote animal health and welfare, to relieve animal suffering”) as Dr. Gosnell was to the Hippocratic oath.”

This is an ad hominem attack and, sadly, reveals a growing divergence between livestock veterinarians and groups like the Humane Society for The United States, formerly natural allies. There are bad characters in the food animal industry, without a doubt. Scully paints a picture in his piece of some of the bad ones, and reminds us of the worst practices in some of the large-scale food operations. Yet the idea that all veterinarians involved in this industry (for Scully doesn’t narrow down his condemnation) are morally-equivalent to the reprehensible abortionist Kermit Gosnell loses me rhetorically from then on. No thinking anti-abortion advocate considers all those who perform abortions to be the equivalent of a Gosnell, despite a profound dislike of their work. To paint livestock veterinarians with the same brush as a convicted murderer is offensive, and careless in its symbolism.

He notes, as he references other authors that are making the case for moral equivalency between the pro-life cause and vegetarianism (or, less dramatically, the pro-animal cause), that “author Mary Eberstadt writes that factory farming and similar abuses of the animal world are ‘simultaneously morally urgent and widely ignored by many people, including and inexplicably by many well-meaning but hitherto under-informed Christians.’” On this I suspect he is mostly right (as, then, is she) and Christians need to better engage the issue before a watching world. I am hopeful that we can be in agreement where they have good points and criticize them when their arguments seem to fall short. There is much to be mined in both areas.

Ukrainian Bioethics

I returned from Kyiv, Ukraine, last week as part of a team that is working to strengthen a partnership with a Christian seminary there. As we met with various program heads within the school, I asked a few questions about how ethics are taught, and what bioethical issues the Ukrainian people face. Some of the answers were surprising.

Ukraine, of course, is the long-suffering nation to the west of Russia, most often remembered as the breadbasket of the former Soviet Union, as the nation where millions starved to death in Stalin’s effort to break the farmers that resisted collectivization, as a nation where much of the fighting—and death—from World War II occurred, and as the location of the horrific Chernobyl nuclear disaster of 1986, some seventy miles north of Kyiv. Ukrainians know what it means to endure; their national anthem is “Ukraine Is Not Yet Dead.” Ukraine’s history has witnessed many affronts to human dignity, perhaps one most chillingly on display at the “Museum of the Great Patriotic War” (a.k.a., World War II) where gloves made of human skin and a bar of soap made from human fat show just what human beings are capable of doing to each other. The Ukrainian people were saved from the atrocities of the Nazis to be dominated by the Soviets, exchanging one form of tyranny for another.

Years of communist rule still leave their mark on Ukraine. Something especially notable when out and about in Kyiv is the utter absence of physically-challenged people, the handicapped, on the city’s streets. It isn’t that they don’t exist. But communism in the Soviet Union served to create an “ideal society,” free of suffering and disability, filled with “perfect” people. In reality, this meant warehousing the mentally and physically-handicapped—and orphans—into hidden-away institutions. This mindset has been slow to change. Handicapped access is limited, to be charitable, and it is hard to imagine that a shopping trip would be anything but excruciating for anyone in a wheelchair. As much as I groan at some of the excesses, as I perceive them, in our “Americans with Disabilities” Act, I’ll probably now more gladly accept its quirks and demands as a way of affirming the dignity of those who suffer challenges I have yet to face in my own life.

It is easy to criticize the post-Soviet outlook, this vestigial communist view of human beings, as an American. But how much do we sanitize the pursuit of perfection here? What are enhancement technologies but a reflection that we have a need to be free of problems, to be our “best selves?” We tuck away our dying elders in nursing homes so that the inevitability of decline and death don’t confront our pursuit of happiness.

A member of our team wryly reflected that, in Ukraine, their faces are from the West but their minds are from the East. As I mentally checked off the list of bioethical issues we face in the West—challenges with assisted reproductive technologies and pre-implantation genetic testing, with use of technologies for human enhancement, and with limitation of burdensome treatment at the end of life—it became clear in discussing bioethics with the seminary faculty in Kyiv that most of these issues are completely off the radar of the vast majority of Ukrainians. Abortion is still hideously common as a method of birth control in Ukraine, as it is in Russia and elsewhere in the former Soviet Union. But the idea that we would use medicine to end life with physician-assisted suicide or euthanasia, or spend scandalous amounts of financial treasure on cheating the aging and dying process, seem arcane in Ukraine. One director even noted that the people of his country don’t have time to be depressed (even as they have faced generations of addictions) because they are too busy just surviving. A study in contrasts, this nation, where children are forgotten in orphanages and old women, the babushkas, may beg for money to supplement their meager pensions, but where children are bundled for warmth with the smallest hint of chilly air and people give up their seats on crowded buses for the elderly and for women with small children. These are a people acquainted with suffering and sorrow, and they have a certain respect for those who have suffered for more years than most (the elderly) and for those who hold the eternal promise of a better future (the children). A rather elegant ethic there: respect and promise.

Wiser minds than mine have delved into the mystery that, within the crucible of suffering, we may be best equipped to find evidence of grace in daily life. It was a visit to a church in Kyiv that I could best see this illustrated. There is, in Ukraine, a national church that had been suppressed, harassed, and persecuted at every turn, one that has survived communism and the economic anarchy that followed, and today sends workers into other former Soviet republics. It is, in fact, a joyful and beautiful place. It is a church that is ministering to orphans and the mentally and physically handicapped, bringing them out of the shadows to which communism relegated them. Ukrainian bioethics is more, forgive the awful word here, “primitive” in a sense, because the technologies that are such qualified blessings in the West have yet to meet this part of the world. But it is the church that is leading the way toward negotiating the ethical issues in a society in transition and embracing the notion of human dignity, a church that just may impact the course of a nation that is, indeed, not yet dead.

 

Implementation Day!

As this posts, on the day of the rollout of the Affordable Care Act, a.k.a. Obamacare, we have the makings of high political theater. As with the implementation of most things (federal laws included), Wagnerian music fills the background of what proves to be a change that will likely fail to live up to apocalyptic expectations. Ditto the government “shutdown.” Nor are we ushering in a new era of universal health and wellness, with songs of praise to the federal bureaucracy breaking out.

I have little of substance to add to what Jon Holmund said in his excellent blog post last week. All I will do is add some reflections from my own vantage point.

Much is written about the trend toward part-time hires and diminishment of hours for existing employees in businesses, which include an eclectic mix from Home Depot to Trader Joe’s to Forever 21. United Parcel Service (UPS) will curtail family benefits. This was all, by some accounts, unexpected among the planners of the legislation. By other accounts, it was part of a conspiratorial plan to make the law unworkable and (Wagnerian music cue here…) force an even more Draconian plan on a stodgy America toward a Canadian/European model. Again, good theater, but I have worked with people that are crafting legislation that they consider essential; they expect all good things will come from it, not that it will be a speed bump on the road to something really good. The president didn’t want to attach his name to a law that would be quickly supplanted because of its inadequacies.

My veterinary practice is small potatoes. I am nowhere close to the fifty-employee threshold that is ostensibly impacted by the new law (see Trader Joe’s, et al. above). So why am I hiring a new receptionist, one who will replace a full-time employee that had health care benefits, one that will work a 28-hour week? It saddens me to do it, because I thoroughly appreciate the fact that my business (like other kinds of medical practices) has traditionally cared for staff that don’t make outstanding wages and that feels some sense of ministry to patients and staff alike. I am just too worried to hire another full-time staff member.

My unscientific talks with other “safe” small businesses (under fifty employees) finds that we all fear what happens if things go terribly wrong—if young, healthy people ignore the mandate to buy health insurance (and thereby subsidize the sick and old). What if these people just pay the penalty (or “tax” as the Supreme Court has determined it) or otherwise feel that a government that sometimes seems incapable of much that would be deemed “competent” will never “find them” to force enrollment in one of the healthcare exchanges? A quick fib on a 1040EZ may be enough to keep Uncle Sam at bay.

If this happens, the premiums we pay, the ones small businesses will face, could be awful. This potentially means eliminating insurance for our staff, people who are struggling to get by as it is, and that is a grievous thing. Will it happen? No-one knows. But fear of the unknown, fear of promises from political figures that have themselves fallen into disrepute, urges caution. I am hopeful that all fears are proven too great, that small businesses, including my practice, will find that it is of little real consequence and that we can go back to hiring full-time employees and letting them join health insurance plans. It’s my Pollyannaish side.

Ironically, I think there may be little appetite to delay the onset of Obamacare, even among its critics in the world of business. Perhaps citizens of the United States feel like we’re on a 9-foot cliff waiting to jump into a cold lake below. We could stand there longer and fear the result a little more, or we could just jump in and then deal with what we will then know. Sink or swim, just don’t keep us hanging. Another year of waiting is hardly something to cheer.

Over the weekend I did a 37-mile bike tour (with my energetic 10-year old son) that offered several things for me to process. One of the things I like about cycling is the way it slows things down. Certainly it lets me face my own mortality—there are parts of me that hurt that I hadn’t expected. But it also makes a rider look at each house we pass, each farm and orchard and lake cottage, and think about those who live inside. Sometimes the people look back, and then the narrative in your mind has faces to connect with it. I thought of my staff, present and future, and I thought of what would happen to my body that is aging (perhaps faster after my ride!) and is now facing the loss of the insurance that my wife’s employer has felt the need to give up in January (one I understand all too well). What do I expect will come of us, and them?

This ride took us past small towns with tiny homes and rural areas with aging mobile homes, past elaborate horse farms and Lake Michigan “cottages” that were worth millions. What happens to the inhabitants of each when cancer strikes? Do I really want a system where the former are denied care and the latter can circumvent the system to get it? Where does my family fit? My sense of distributive justice is stymied by the sense that fallen humanity can’t have it all, and that the gulf between the haves and have-nots has, if anything, been heightened in recent years.

But cycling also helps me face my own idolatry. I can easily ride 100 miles when studying a route on my computer screen. Hills, pedals, knees and rough pavement humble me to reality. And I can fear the consequences of health care policy that could kill me, kill my family, kill my business, pull the safety net out from under me, take away the care I “deserve” as much as the rich weekenders on the Lake Michigan beaches.

And then I have lost trust in a God that I have promised to trust with everything, who has given me a life of which I am only a weak steward. I fear jumping into a cold lake from which I will ultimately be rescued, no matter what, and yet my anxiety ignores my rescuer. Yes, I am to be dedicated to justice and wholeness among human beings while I am on Earth. But I am not to be so lost in the process that I cannot recognize who is in charge, if I am swept up in the drama and fail to appreciate in whose hands my healthcare ultimately lies.

On Animal Welfare and Professional Consensus

The original reason I become involved with organized veterinary medicine, first the local association and then the state, was because I had become a solo practitioner in a start-up practice. This is a lonely business, where you can’t bounce ideas off colleagues within your own practice and where the struggles of being a veterinarian can only be recognized by others who live a similar professional life, people who you don’t see a lot as a solo doc.  Thus came an entry into the veterinary political process, the innocuous-sounding “Member-at-Large” position in the local association. I would seek out relationships with my colleagues, and work together to strengthen my profession. Since relatively few seek out such spots anymore, and with a modicum of competence in my role, an ascent was assured. On to the state association!

The American Veterinary Medical Association (AVMA) is a group that has struggled mightily to make statements of substance on a wide variety of issues that reflect a remarkably disparate group of veterinarians in a very diverse profession. It is, pardon the pun, herding cats.  Their job is not enviable, and they seek to hold us all together as a kumbaya group of animal medical professionals.  So the result of this has been a philosophical foray into the gradations of vanilla, with position statements that have the strength of a triple A battery.

The states are the laboratories of democracy in the political process, and incubators of thought in the taking of positions. In my state of Indiana, we are not blessed with or burdened by the same forces that make public policy in California or Vermont or Alabama. We are Hoosiers, people who live and work in a hotbed of practicality in the epicenter of common sense. And I am a member of the Animal Welfare Committee for the state association, the perfect place for an ethics dilettante like myself to engage the big issues. It was our task to arrive at a consensus statement about animal welfare that captured Hoosier values and I was excited about the chance to help shape things.

Yes, this is a bit “tongue-in-cheek.” I am actually quite pleased with the abilities to engage bioethical issues that my education has afforded, so I am not altogether a dilettante. My ability to address issues of animal rights and appropriate stewardship ethics has come from the expert teaching I received in my degree program. As I worked (on a fast deadline) to offer up an introductory statement that sought to secure the rights (or at least “interests”) of all human beings to be considered distinct from animals—a view under increasing attack from the Singers and Regans, the PETAs and the HSUSAs that are gaining traction, I consulted with Trinity faculty and others who helped crystallize my thoughts. Here is what I submitted to others on the committee, themselves bright and thoughtful veterinarians in small animal and swine and equine and regulatory medicine practice. It isn’t perfect (and actually was not even completely vetted by those who I wanted to have read it before the deadline), but here it is nonetheless:

“Human beings, in their essence as a species and in the degree of sophistication of their various capacities, should be considered to have rights, and maintain a significance of moral status and moral agency, that non-human animals cannot possess. However, humans have great power toward animals for compassion and harm alike, and therefore bear a unique responsibility for wise stewardship of animals, particularly for those animals that have been domesticated. This relates to how we care for the environment we share with wildlife, and to the husbandry of domestic animals used for food, clothing, and companionship.

Many issues of human welfare should be considered separately from animals, because they are different kinds of beings. But there are significant areas of overlap in the welfare of humans and animals that necessitate a focus on the latter, in knowledge that to be good stewards of animal welfare is also to provide benefits to human health and flourishing.

To the extent that animals may be considered sentient beings, there is variation between species. The level of mental, neurologic, emotional, and social sophistication ranges widely, and must be considered in how welfare can be optimized in a practical way and to an appropriate degree toward different species. These considerations should be based on the best science available, not on sweeping generalizations or sentimentality. They should also reflect the unique ability of human beings to process and comprehend the available data from biology, behavioral science, and other disciplines, and to make legitimate welfare determinations for animals.”

This began one of the most fascinating back-and-forth electronic conversations in which I have ever been privileged to find myself included. Comments ranged from “too long, too philosophical” to the conclusion that “humans have what they deem to be moral agency only because they happen to be the dominant species (at least vertebrate mammalian) on the planet presently.” Consensus is not so certain, even in the Midwest.

After much chatter, and upon review and acceptance from the full Board, this was the final result for the introductory statement:
 “Humans have a unique responsibility to be wise stewards of animals. This relates to how we care for the environment we share with wildlife and to the husbandry of domestic animals used for food, fiber and companionship. The best science available from the fields of biology, behavioral science and other disciplines should be used to make legitimate welfare determinations for animals.”

Yes, this is a significant paring-down of the prose I offered. But it’s also has some key items that I think are important. Among those, the fact that an introductory statement even survived is notable. The idea that humans have a stewardship role over animals is significant, and that we have the ability to determine animal welfare is not to be assumed in all philosophical contexts today.

I’ll share the rest of what points followed in our full statement soon. But there is a lot to be learned here. Achieving consensus from those who aren’t part of the philosophical (or theological) “home team” may mean some small, but hopefully substantive, victories. And, I dare say, putting out what may be contentious words in a pluralistic society may lead to review from others that may be made by scalpel or hatchet, but is (hopefully) worth the effort nonetheless.

An Update on the Bei Bei Shuai Case

A few months ago I mentioned a trial that was set to begin here in my hometown of Indianapolis this September. It involved Bei Bei Shuai, a Chinese immigrant facing charges of murder and feticide whose story I recounted, with a few observations about its potential significance.

Recently the case was settled out of court, with a plea deal that gave her a much lesser charge of “criminal recklessness” instead of murder and feticide. By pleading guilty to this misdemeanor, the year-plus in which she had already served in prison before bonding out was applied to the sentence she was given, and Bei Bei Shuai is now a free woman. She and her attorney had rejected a plea deal a year ago that would have had her plead guilty to feticide, but not murder, charges, punishable by up to 65 years in prison. The choice appears to have been a wise one for her.

I have read the scuttlebutt from this outcome throughout the world (a side note: the British take a far more intense interest in the goings-on in America than their former colonists do in those of the United Kingdom; could anyone tell me the last time among the American media we read of an intriguing case in, say, the Yorkshire Dales?). The general consensus was palpable relief among those in the abortion rights camp (also found under such nomenclature as “reproductive rights proponents” and “champions of women’s health”). The winner for most unctuous of these was on the “RH Reality Check” site, dedicated to “Reproductive and Sexual Health and Justice.” Here the Indiana case was depicted as the latest among the efforts of “anti-abortion activists toward criminalizing pregnancy to both attack reproductive rights and punish pregnant women for failed pregnancies.” It is curious that it omits the fact that ingestion of rat poison by Miss Shuai in her eighth month of pregnancy led to this pregnancy “failure.”

A conviction would have potentially devastating consequences for them, and they knew it. Indiana is a socially-conservative bastion among the Great Lakes states, and is not the state in which they wanted this case tried. That said, an acquittal on all charges would have been a blow to the prosecution, though likely not all that crushing to the overall movement toward protection of the unborn. There are some glimmers of encouragement for those who grieve abortion, about which others have spoken, and there is a faint sense that the tide may be turning. The Bei Bei Shuai case was a tragedy for all involved, and speaks more to the damage that the Fall has inflicted on humanity than to wider legal precedents. I have a sense that Bei Bei’s friends and supporters may have a bit less need for her now, and I have a hopeful (if perhaps Pollyannaish) image of the Body of Christ reaching out to Bei Bei Shuai, at once the criminal and the victim, with the love of God that transcends an agenda.

A Genetic “Fix” for Down’s Syndrome?

A couple of weeks ago I mentioned some of the thoughts presented at the July Summer Conference hosted by the Center for Bioethics and Human Dignity—thoughts I am still processing in the afterglow of an enjoyable and stimulating few days. Much has re-shaped my thinking on a host of issues, to which I alluded previously. But there was one nugget that remains with me, nagging at me, even as it was presented as a rather small bit of fresh information in a larger context of bioethical analysis of prenatal diagnosis. In a workshop session led by the estimable David Prentice, formerly a faculty member at Indiana State University and now a Senior Fellow with the Family Research Council, it was mentioned that American scientists have been successful in experiments to eliminate the “third gene” that is found in various “trisomy” disorders. This, of course, is most commonly seen in Trisomy 21, the genetic abnormality responsible for Down’s syndrome. The process, perhaps best described in an article in The Guardian, essentially inactivates the third chromosome, the one that makes a crowd out of an otherwise happy pair, in a process that is similar to what happens in normal meiosis, where the female gametes are formed and a non-functioning Barr body is produced. In typical British style, and in reality, the science is described as “elegant,” and is worth a look.

My first impulse on hearing this news was joyous relief. For as long as amniocentesis has been commonplace, the default position of genetic counselors when guiding those with a diagnosis of Down’s has been one of pregnancy termination, of abortion of the fetus that would suffer the mental and physical tolls of Down’s. Now that we can fix it, I thought, these babies can live. If we view genetic disorders as the fallout from a world where brokenness pervades all of creation as the result of sin, then a “fix” is a manifestation of God’s grace to make straight what has been made crooked by the Fall. It is a good thing, and I can view it as such. But what if we find a way to “eradicate” trisomy 21 and Down’s syndrome, even as the technology is still quite nascent and the fix quite tentative? Is that an altogether good thing, to see a future free of people who suffer Down’s?

I used the word “suffer” when describing someone with Down’s because it is a descriptor that is common, provocative, and almost entirely wrong. Certainly the medical issues associated with Down’s are real, the cardiac and gastrointestinal problems, the increased risks of cancer and dementia. Yes, Down’s syndrome is linked with numerous medical maladies—ones that made a thirty-year old adult with Down’s a rarity just a generation ago. Individuals certainly live longer today, blessed by improved medical technology. But do they flourish? I think of my prayers for my children when they were infants: protect them, of course, but most of all, keep them devoted to God through their lives, let their eternity be inextricably linked with their Savior. I would rather their earthly lives be significant than they be happy, to be completely honest. And I reflect on my experiences with those who have Down’s syndrome. I have yet to meet one who seems to typify “suffering.”

So we may someday, perhaps sooner than we can imagine, be able to eliminate trisomy 21 with a genetic “zap.” Will the child whose chromosome count has been normalized be a very different one from the one who has not had genetic intervention? I think of an 18-month old I met this week, who sat in his stroller as I examined the new puppy his parents just adopted. They looked like many parents of children with a mental disability, who have learned to accept the modification of their dreams for a child and who, so sadly, must somehow justify their decision to even bring this child into a judging world, given the options. But as I do the checkup on this bundle of puppy energy, they could see the same smile I could see, one that is more manifestly beautiful than that from a “normal” child in how it processes the unfolding scene. I can’t quite describe its wonder and delight. This smile was a mark of grace in a seemingly graceless world, one that God has supplied to a youngster created in His image and whom He has declared will someday judge the angels. I would have missed that if this little boy had been “fixed” by a genetic repair.

I think of my cousin, now in his mid-thirties, who has faced so many medical issues, and who has so challenged the lives of his parents. I have, sadly, struggled to connect with him over the years, because I cannot relate to his experiences and cognitive abilities easily. It is only in recent years that I see what I’ve missed. The middle of three brothers, he is the one who has been best able to find a true sense of pure worship toward God, one that has become clouded by cynicism (at least for now) in his high-functioning, articulate siblings. Would I wish an easier ride for my aunt and uncle, and for anyone with a special needs child in a society that values the capabilities of an individual above all else? Of course. But how serious have I been in my prayers that my children develop a deep spiritual devotion—would I exchange their future college and career and social success for it? If they were never to inculcate this devotion, would I sacrifice all the “normal” stuff and hope for a child with a lower IQ, a host of medical challenges, and a heart that embraces God?

None of us will ever know what would have happened spiritually, or in the degree of happiness and earthly success, if those with mental disabilities like Down’s had been rendered “normal.” I initially rejoiced at the happy thought that Down’s syndrome and similar issues would be cured someday. In the weeks that have passed, I have found new ways to grieve the potential loss of these individuals in our world, individuals who have made it a richer place for being here. Is it ethically wrong to wish an end to genetic aberrations? I think not. Is it ethically wrong to appreciate the diversity of God’s blessings that transcend a fallen world? Increasingly, I find it isn’t.