Mama, encourage your kids to grow up to be journalists

Once again, we are being treated to the blind spots (or bias, take your pick) of much of what is called “reporting” these days, in the coverage of the Texas legislature’s attempt to pass a bill restricting late-term abortions.  A “heroic” Texas state Democrat wore a back brace to keep herself upright for a “courageous” 11-hour filibuster, only to be “silenced” by fellow senators who were “pro-life extremists.”  (Never mind the rather vociferous champions of “choice” in the gallery who shouted down the proceedings, preventing a vote before the end of the session, prompting, in turn, the governor to call an extra session to complete the work properly.)  Oh, those knee-walking, knuckle-dragging troglodyte stumblebums of the apocalypse.  It was duly reported that advocates for abortion choice pronounce the bill “anti-woman.”

From some reporting, you would never know about the role of the throng in the gallery, and some reports I saw on CNBC left the impression the shouting spectators supported the bill and were shouting down the filibustering Democrat—the exact opposite of the truth.

Never mind that states are increasingly moving to restrict abortion of otherwise viable babies who are at or near the point where modern neonatal care can give them a chance at life.  We didn’t hear that.  Nor did we hear that public opinion polls increasingly show strong support for restricting abortion after the first trimester.

We also heard that this draconian bill would shut down many abortion clinics in Texas by holding them too much too high a standard of medical/surgical care.  But we hold every other medical/surgical care venue to high standards, do we not?  Or is abortion some sort of lower-tier medical service?  And never mind that the drafters of the Texas bill apparently took their cues from—where?—the Philadelphia grand jury indictment of the subsequently-convicted baby murderer Kermit Gosnell.  “Oh, that was an aberration, we don’t need to think about that.”  Pay no attention to that provider behind the curtain!

Oh, I forgot—most of the media didn’t report on the Gosnell trial.  The media chairs in the courtroom were empty.  The Grey Lady buried what stories it did carry on, let’s see, about page 12, while leading with the Keeling curve of global CO2 levels.   Surely climate change is more important.  Then again, if one of the overarching lessons of climate change is that there are just too many people in the world….  (I actually am hearing that one recently.)

Whether it’s the Texas bill, or the Gosnell trial, or getting it right w/r/t what actually is an embryo (cf. the recent posts on this blog), or reporting on euthanasia and infanticide, the conceits of the educated elite have gotten insufferable.  (Goodness, it makes me nostalgic for Spiro Agnew—I can’t help but thinking that, in general, he was right—apart from the self-serving purpose to which he spoke.)

We need more Christians committed to human dignity in journalism.  Educate them classically.  Please be sure they learn some real science.  And help them understand, as Ben Mitchell put it so nicely in a recent issue of Ethics in Medicine, that bioethics is about adopting a virtuous stance toward life, not just about ethical conundrums.

I confess—my paintbrush is broad.  There are good Christian journalists out there.  For example, I think of solid, clearly left-of-center commentators like Bob Beckel and Kirsten Powers, both of whom have confessed Christian faith on camera.  I thank God for them.

And I thank God for Marvin Olasky and World magazine.  If you don’t get that, go to www.worldmag.com and subscribe.  Or do someone else a favor and give a gift subscription.

In praise of the Myriad Genetics decision—as far as it goes

The U.S. Supreme Court has recently been handing down a series of controversial decisions (as if you hadn’t noticed).  But a less contentious decision, nonetheless meaningful in bioethics, was the unanimous decision two weeks ago in Association for Molecular Pathology et.al. v. Myriad Genetics, Inc., et.al. 

Myriad Genetics has marketed a test for the cancer susceptibility genes BRCA1 and BRCA2, certain mutations of which greatly increase the risks of breast and ovarian cancer in women.  Their patent included the full sequence of these genes, as found in nature.  Enforcing that patent meant that any other company or lab—including a university lab or independent lab—was guilty of infringement if they attempted to test a woman for mutations of these genes in the course of her medical care, regardless of the method of testing used.  That in turn meant that in practice the Myriad Genetics test, along with its high price, had to be used.  The patents were challenged in court.

Myriad Genetics had discovered the naturally occurring gene sequences and claimed them in their patents.  The court held this part of the company’s patents invalid; one may not patent a discovery from nature, without creating a new substance or a new method of using that substance in an invention.  This opens the door for competing tests.  In “bumper sticker” terms, “life,” as it is encountered in nature, is not patentable.

What may be patented, among many other things in biotechnology, is something that Myriad Genetics and many other scientists and companies create from naturally occurring genes; namely, complementary DNA, or “cDNA.”  cDNA is the sequence of coding regions of a gene, with the non-coding regions spliced out, that is “complementary” to that gene’s messenger RNA (mRNA).  (In nature, a gene’s coding regions, called “exons,” are interrupted by noncoding regions called “introns.”  The introns are spiced out in the course of transcription, or reading, of the DNA to form mRNA.)  This part of the ruling limits the overall impact on the patent estates of biotechnology firms, which in turn means that the ruling is unlikely to impair the discovery and development of new treatments or diagnostic tests.  Similarly, the methods used in such discovery and development also may still be patented.

Something else that may still be patented is a genetically engineered organism—for example, a bacterium with a gene inserted so that it will produce a protein of interest that it would not naturally produce.  This represents a lot of activity; many such organisms are patented, including microbes and genetically altered higher animals like mice created for specific experimentation.

What of the future?  Could human tissues, made from adult stem cells for an alternative to organ transplant, be patented?  I would think that they could.  At a minimum, the procedures for growing such tissues could be patented.  If some future human embryo were enhanced with a gene to improve vision, what could be patented then?  My guess is that the process could be, but the actual person could not be.  This seems commonsense but of course one would need to see the actual cases, if and when they arise.

Commodification of life, including human life, remains an urgent concern, but it seems that, even if some altered organisms are patentable, it is unlikely that people, though they may be “made,” could be considered to be “invented.”  My guess is that this decision would help set a limit.  In any event, I think the court got this one right.

Connecting the dots on euthanasia

Last weekend’s Wall Street Journal—ever the source of interesting reading—carried a page 1 article under the headline, “For Belgium’s Tormented Souls, Euthanasia-Made-Easy Beckons.”  The main anecdote was of a pair of identical, deaf twins who had a “genetic disorder” that was making them blind.  Belgium’s euthanasia law allows one to request active euthanasia—i.e., performed by a physician—for suffering that need not be related to physical discomfort or terminal illness.  Apparently, about 1% of Belgian deaths each year are from euthanasia.  Some prominent Belgians have exited earthly existence in this way, and their cases are portrayed as positive, dignity-affirming choices, with loved ones at their side for an event described as a “party.”  Sometimes, a person requesting euthanasia doesn’t tell her family, and demands that the doctor not tell, and the doctor, not surprisingly, honors that insistence, so the news comes as a bit of shock to the euthanized person’s survivors.  Belgian doctors interviewed for the story insist that people are not and cannot be buffaloed into being euthanized, but must request it and “really be desperate,” or words to that effect.  People wanting euthanasia sometimes have to doctor-shop; the Catholic physicians won’t do it.  It’s not clear to me what sort of documentation, or consent process, is required of a person’s decision for euthanasia.

But get this—liberalization of the law is being considered by the Belgian parliament.  One change would allow minors with a “capacity for discernment” to request euthanasia, if their parents agree.  Another would let patients with early Alzheimer’s disease request, in writing, to be euthanized at a future date when a doctor determines that they are no longer interacting with the outside world.

And the article describes how euthanasia is being mainstreamed into the entertainment culture of the West.  In Britain, a TV series called “Way to Go” is planned.  It is described as “a black comedy about three ordinary guys who find themselves forced by an extraordinary set of circumstances into setting up an assisted-suicide business.”  (And the merry mix-ups that occur when a depressed girlfriend asks to be a customer, I suppose.  Yuk-yuk.) “Forced by an extraordinary set of circumstances????”  (“Oh, but it’s only assisted suicide, not euthanasia.”)  Goodness!  What sort of imagination conjures up such a premise?

Where is this headed?  Let me count the ways.  But I’ll just mention a couple:

For one, making assisted suicide and euthanasia a matter of a sitcom is to trivialize human life, quite simply.  We must encourage our youth, in particular, and people entering the arts and entertainment industry, to develop better, more godly, imaginations—and we must turn our hearts, thoughts, and eyes (and entertainment dollars) away from more deranged projects.

An advance directive for euthanasia will be seen as mirroring other discussions surrounding advance directives.

Euthanasia for minors will press the issue of informed consent.  I can imagine that this will be framed substantially like the decision to forgo life-prolonging treatment, with older children having a recognized autonomy interest in making their own call, and the process and documentation will follow current regulations for informed consent by minors who are considered candidates for human subject research; i.e., parental consent will be required with a less-detailed “assent” form, varying by age range of the child, presented to and in some way executed by the child.  Even in our world, euthanasia of minors without parental consent, much less notification, seems like it would be a bridge too far even for our sick world.  (Anyone who objects to my use of “sick” in that sentence should just read the epigraph of Paul Tournier’s The Whole Person in a Broken World.)  I can’t begin to guess how many lives will be prematurely foreclosed.

And performance of euthanasia, wherever the practice is accepted at all in the West, will eventually be considered just one more medical procedure which physicians are bound to agree to perform as a condition of being allowed to practice medicine at all.  At least, that’s what our wiser-than-thou philosophers, who pooh-pooh issues of conscience in medicine, will insist on.

And I think it’s obvious that all neo-Hippocratic physicians, and those who stand with them, must tell our neighbors with a strong voice, “We must not,” and if pressed to participate, “We shall not.”

Finally, let us all memorize the statement by the great anthropologist Margaret Mead, cited by Nigel Cameron in The New Medicine: Life and Death After Hippocrates:

[With Hippocrates, “f]or the first time in our tradition there was a complete separation between killing and curing.  Throughout the primitive world the doctor and the sorcerer tended to be the same person.  He with the power to kill had power to cure…He who had power to cure would necessarily also be able to kill.  With the Greeks, the distinction was made clear.  One profession…were to be dedicated completely to life under all circumstances, regardless of rank, age, or intellect—the life of a slave, the life of the Emperor, the life of a foreign man, the life of a defective child…but society is always attempting to make the physician into a killer—to kill the defective child at birth, to leave the sleeping pills beside the bed of the cancer patient.  [It is] the duty of society to protect the physician from such requests.”

More on the “just price” of lifesaving drugs

It’s one thing when academic ethicists complain about drug prices.  It’s another when, as I discussed two weeks ago, physicians raise their voices.  And it’s yet another thing when a major industry scientific journal weighs in.

In the June 2013 issue, the editors of Nature Biotechnology, following on the discussion of the high cost of drugs to treat certain leukemias, broaden the discussion to cover expensive specialty drugs in general.  They are concerned.  A few snippets:

  • “[P]rice tags for drugs entering the US market continue to skyrocket.”
  • “To make matters worse, in the United States, most of this price inflation is being passed on directly to patients, leading to financial hardship.”
  • US drug costs are “increasing twice as fast as other healthcare services.”
  • While “in many cases, new drugs addressing unmet needs or offering major advances…do warrant high price premiums,” “companies also seek price premiums for drugs that have only marginal benefits…[and] industry’s dirty little secret is that the greatest contributors to increases in US spending are not new drugs, but year-on-year price increases for older drugs.”
  • “Thirty percent [a common co-pay rate] of a single $100,000 drug is a crippling burden.”

Read the whole thing.

Sure, the Nature journals originate in the UK, so we might expect a broadside from there aimed at the US.  But this particular journal is directed at biotech scientists and entrepeneurs trying to build successful companies.  So if its editors think industry’s behavior should change, maybe that says something.

Why the mess?  The editors charge that customers (public and private insurance entities) have an “asymmetry of information…that drug companies exploit,” and pharmacy benefit managers make money by selling more drugs at high prices negotiated behind closed doors with industry.  This strikes me as about as anti-free-market as one can get.  Defensible pricing should come as a result of a more open process of price discovery—negotiation and competition for business.

As a possible alternative, the editors suggest industry consider suggestions like one made by Harvard Business Review blogger Rafi Mohammed.   His idea:  differential pricing, with discounts, analogous to the way we buy, oh, just about everything we buy—cars, hotel rooms, airline flights, stuff at J.C. Penney (depending on who their CEO is today), and so on.  A patient’s out-of-pocket payment would be limited by the actual maximum amount a patient “should” pay.  That, in turn, would be determined by income, family size, etc—with an “independent third party agency” making the call.

Hmmm.  That sounds to me too much like eligibility for welfare, or unemployment insurance, or college financial aid.  A “FAFSA” for your medical bills, anyone?

I think I prefer an approach by which different levels of insurance coverage were offered, with different levels of co-pay, perhaps even different “formulary” drugs—and different premium structures.  But for it to work, there would have to be some level of societal/market agreement that the costs for truly effective and expensive drugs would be almost fully covered, and the out-of-pocket payments starkly limited to an absolute dollar amount that contributes to one’s overall out-of-pocket maximum for all coverage under a policy or program.  And, again, I don’t see how we can escape having a more explicit and open payer negotiation of prices and a firmer limit on paying for marginally effective new drugs or allowing previously-introduced drugs to increase in price year-on-year.

But the current state of affairs can’t go on like this, unchanged.

Michael Tooley’s “package deal”

Further to the May 2013 JME discussion of infanticide was a fairly gymnastic article by Michael Tooley that was in essence given central prominence in the issue.  I say “gymnastic” because, partly by his own admission, Tooley tried to cover, albeit superficially, a lot of ground in a brief essay.  But given that there is so much written, and so much information out there, that one cannot review it all in detail—Tooley himself admits as much vis-à-vis his position—one is often forced to perform similar gymnastics to form a provisional judgment of a series of claims.  And thus do I take to the trapeze for a brief discussion of Tooley’s essay.

Tooley writes that he wants to replace emotional claims with critical thinking, and yet I could not help be irritated by his tone: “pedantic” seems too strong a word, but “tendentious” and “condescending” might fit.  After lecturing non-philosophers on how they ignore critical thinking and eschew calm, dispassionate argument, and in essence telling doctors that they should defer to the wise judgment of professional philosophers (who really are the only ones who have thought long and hard about things) on ethical matters, he urges the reader to accept the “Socratic challenge” that all held beliefs are potentially suspect, and that resistance to some ideas betrays commitment to a “package deal” that includes some basic belief that one is determined to hold despite the evidence.  Of course, opposition to abortion is one such package deal because Tooley apparently has found that all abortion opponents cling to the notion that there is a God.  (He does, in passing, also say that some feminists include abortion support in their own package deal but he does not say anything further about them.)

More substantively, Tooley briefly addresses two strategies supporting “the extreme antiabortion view according to which abortion is always, at the very least, prima facie seriously wrong,” as he puts it:

  • Membership in the biologically defined species Homo sapiens is a suspect ground of moral status because, were we confronted with a lovable extraterrestrial creature that is rational, we would ascribe similar privileged moral status to that being.  We wouldn’t approve of serving him up a la Kentucky Fried Chicken, for example.  (Or, if you prefer, think of the horror of the Narnian visitors eating talking animals in Lewis’s The Silver Chair.)  So, the ground of moral status would be something like possession of “an immaterial, rational soul,” and membership in the species would not be a basic ground for a life to right (the rational soul would be a more basic ground).   But it seems to me that Tooley misses the point here. Humans are the sort of beings which have the ultimate capacity for not just thought but moral judgment, self-awareness, awareness of self-awareness, and so on.  And they are unique within the creation, or the biosphere if you will, as we encounter it.  Were Tooley’s ET to visit us, perhaps we would have another example of the sort of being with ultimate capacities such that it ought to be accorded privileged moral status simply by virtue of being one of that sort of being—a member of that “kind,” or species.  Christopher Kaczor, for one, has defended this position rather more substantially than Tooley seems to be willing to allow.
  • Possession of an immaterial, rational mind or soul is not just suspect, but patently false, for Tooley, because he thinks science has established that the mind and the brain are one and the same.  He calls out Moreland, Beckwith, and Scott Rae (among others) by name—Thomistic substance dualists all.   He may correctly identify their view but he makes it too Cartesian by identifying soul with mind, and he fails to engage the dualist argument with more than a list of science-writer level examples.  Also, in my (limited, to be sure) reading of philosophy of mind, I don’t see people considering Tooley a significant contributor.  So I take his claims against substance dualism as little more than rhetoric.  And substance dualism appears to me to be rather robust in philosophy than Tooley will allow.

Instead, Tooley asserts that “[o]nly neo-Lockean persons have a right to continued existence.”  The “neo-Lockean” person is “an entity that has conscious states at different times, and that are psychologically connected by such things as memories, desires or intentions.”  These are the states that “make for personal identity.”  They persist through temporary losses of consciousness, and so get around one objection (which Tooley considers a “straw man”) about approaches to personhood as consciousness.  And, for him, a right to life is grounded not in an essential characteristic of a being, but in something that is acquired at some point in development.

But it’s not clear why actual rather than anticipatable acquisition of capacities should ground moral status.  If we take care of a baby properly, he or she will quite predictably become Tooley’s neo-Lockean person.  In cases when that is not going to happen, we can still argue, at a minimum, that respect for the sort of beings humans are ought to stay our hand against active killing.  Yet that is not where Tooley is headed.  Because we are talking not just about abortion here, we are talking about infanticide.  And returning to the latter point, Tooley closes by mentioning that, while he thinks human fetuses and neonates “probably” have the same moral status, he seems to be questioning his earlier position that humans acquire capacity for thought episodes only some time after birth.  He says that he doubts that most philosophers are conversant in the relevant science, and that he has not been able to catch up with it.  And so the “crucial underlying scientific premise” that would support killing healthy newborn humans on purpose—viz., that neonates lack the capacity for thought—“has not yet been scientifically, firmly established.”

Well.  And if it is “scientifically, firmly established” that neonates DO have the capacity for thought—as I bet most new mothers would claim, and as I think we ought to assume for the purposes of our moral reasoning—then how established is it that there is NO capacity for thought late term in utero?  And how do we distinguish the unborn healthy 30-weeker from the post-natal 30-week preemie?  And if there is anything whatsoever to the notion that our thoughts have a private character, accessible only to us, how confident ought we to be of our ability to measure the onset of that actualized capacity in tiny humans?  The potential for pseudoscience seems substantial.

And this, finally, underscores Tooley’s own “package deal”—skepticism about the moral status of newborns comes with a firm commitment to naturalism and a physicalist approach to the philosophy of mind, at all costs.  We all start with basic beliefs that we change very slowly, if at all.  And so, rather than think that every belief ought to be held with radical skepticism, we ought to beware lines of reasoning that wind up contradicting the deepest human intuitions and experience—kind of like questioning our work when the answer to a math problem doesn’t make sense.  (I should add that Tooley’s arguments reinforce my conviction—or, in our pluralistic, secular society, should I say “despair”—that naturalism can ground any stable sense of moral obligation.)

In the meantime, while you are catching up with all that Tooley and others have written, I recommend that, rather than abandoning your most basic beliefs, you resist his reading of the Socratic challenge.  Tooley’s approach sounds less like a search for truth than a demolition job.

I wonder whether Socrates would approve.

Physicians call for the “just price” of lifesaving drugs

A group of over 100 physicians who specialize in the treatment of chronic myelogenous leukemia (CML) have published a commentary in the journal Blood, decrying the high price of highly effective drugs, like Gleevec, for the treatment of CML.   The article was spearheaded by Dr. Hagop Kantarjian of M.D. Anderson Cancer Center, an oncologist who has become an articulate and authoritative voice in matters related to drug availability.  (He was prominent in discussions of the drug scarcity problems encountered in 2012.)  Their argument demands serious consideration by anyone—especially economic conservatives and pharmaceutical industry workers like me—concerned about the affordability of modern medicine.

Before 2001, the average survival of someone with CML was 5-6 years, and only about 20% lived for 10 years.  Long-term survival was possible for the subset of patients who were able to undergo a bone marrow transplant.  Otherwise, standard treatment was interferon (the protein drug that disappointed as the putative “cure for cancer” after its introduction in the 1980’s).  But CML has a specific molecular abnormality that can be targeted with a drug, and since 2001, several drugs have been approved.   With these drugs, 10-year survival is over 80%, and people with the disease generally live normal life spans—if they take these pills continuously.

And that’s where the problem arises.  In the US, the price of each of these drugs is about $100,000 or more every year, year in and year out.  Because of the way we pay for drugs supplied by a pharmacist, the patient—who needs these highly effective drugs to live—is on the hook for 20-30% of that.  That’s more than most people can afford, so they may skip doses or not take the drug altogether, greatly reducing the chance of benefit.  Actual survival results for CML in the U.S. are less than they might be, indicating that patients are not all getting the full benefit of treatment.  The CML doctors estimate that only about a quarter of all people with CML are getting these new drugs at all, and that only about 1 in 6 of those benefit from financial support programs, from foundations or the drug companies that make the drugs, to defray the costs.  In other countries, the drugs’ prices are about one-half of the U.S. prices (grossly approximating for the sake of brevity here), lower in countries with stronger government price controls or better competition in the marketplace.

Ah, yes, “competition.”  Regular readers of this blog know that I am an outspoken advocate of more “market-oriented” approaches to medical costs, on the grounds that top-down rigid controls will tend to create scarcity and limit options for individual patients and their physicians, and that insulating people from the costs of their medical care—i.e., socializing every dollar—would inflate those costs (the “skin in the game” argument).  But this last argument clearly does not apply in this case, and as for competition—well.  When it was introduced in 2001, the annual price of Gleevec was $30,000, compared to $22,000 for interferon—seemingly reasonable, given the huge leap in effectiveness.  But newer—and similar—drugs come for the more astronomical prices cited, and in that time, the price of Gleevec has tripled, rather than decrease.  So we have the exact opposite of the normal price competition that we are used to with just about everything else we buy.  Nobody can claim that this state of affairs is acceptable.

How on earth did we get here?  The etiology is multifactorial, as it were:  a process driven by insurers and industry; a “pass-through” mentality by which every new drug gets priced based on the prior similar drugs plus a mark-up; many details and issues related to patents, patent life, and the timing and requirements for generic competition; limits (at least in the U.S.) on price negotiation by payers (out of concern that the 800-pound gorilla, Medicare, will effectively dictate prices, an approach that generally fails for goods and services overall).   After discussing all of these, the CML doctors actually soften their concluding statements to an invitation to “dialogue” about all the factors involved.

This is a problem of justice.  I submit that it is not so much a matter of bioethics or medical ethics than of the intersection between those areas and business ethics.  I do not think that one can wedge the matter of drug pricing into Belmont principalism (except peripherally as a matter of justice), nor can one apply the ethical demands on physicians to pharmaceutical companies as entities, or to their employees.  But we can claim that the industry properly serves the proper ends of medicine, meaning that it takes its signals from what doctors need to help sick people.  And certainly it is basic business ethics to provide high quality products at fair prices.  And it is naturally incumbent on drug companies to adhere to ethical treatment of human research subjects (a non-controversial point).

But the CML doctors—quite understandably, I suppose—call for a (neo-medieval?) search for the “just price” of these drugs.  This seems misguided to me.  They claim that market prices really apply only to luxuries, but “when a commodity affects the lives or health of individuals, the just price should prevail because of moral considerations.”  But food, clothing, housing, automobiles, even computers affect our lives and/or our health, yet we don’t search for the just price for those.  The CML doctors’ claim has clear heuristic value but, if applied generally, runs into the issue of how big an umbrella to unfurl.  Also, I understand the search for the just price to have failed because value does not inhere in a product or service.  Rather, the value is in the judgment of the informed buyer.  Now, for a fair transaction to occur, the buyer must be on fairly equal footing with the seller.  That’s relatively easy when buying a shirt or a loaf of bread or even an iPhone, harder when buying a car or a house, and daunting or impossible when buying medicine.

In this case, however, the buyer is the payer—Medicare, or Aetna, or Anthem Blue Cross, or UnitedHealth, or some other insurer.  And so it seems to me that a somehow-improved improved approach to price negotiation between those entities and the sellers (industry) is in order.   That, in turn, means affecting how the buyers value drugs like the new CML drugs.  And that, further, means that this is an exercise in what costs we are willing to socialize (distribute across a large population), and what outcomes do we—most of whom do not have the disease in question—value on behalf of people who do have that disease?  As I have argued in this space, we should be willing to pay for somebody else’s life-saving drug when that drug is the real deal, as in this case.  While we’re at it, we should not make someone come up with 20-30% of that cost, but reduce those copays.  In the process, we might all accept that we have to pay a bit larger fraction of the costs of our own routine checkups and generic drugs and blood tests and maybe even our birth control pills.  If that means higher insurance premiums to cover truly effective drugs (not marginally effective ones), so be it.  If the whole process creates substantial downward pressure on new drug prices, will that stifle innovation?  I imagine it will reduce the number of new drug candidates in development.  I am not sure that it will reduce the number of safe and effective new drugs.  And I’m less sure that the overall public health or commonweal will be harmed.  Maybe we have to give it a try.

Finally, the CML doctors are right to advocate, aggressively, for their patients in this matter.  Doctors should not have the only “vote” in this discussion, but their collective professional opinion should carry great weight.  This is one of the proper “ends” of medicine, I think.

Gosnell, the Journal of Medical Ethics, and Infanticide

On May 13, Kermit Gosnell was convicted of three counts of first-degree murder—for infanticide.  Some news reports said that the convicted man looked stunned, as if he couldn’t understand why anyone would think he did anything wrong.

The May 2013 issue of the Journal of Medical Ethics was devoted to a serious discussion of the notion that infanticide—as in, the intentional killing not only of handicapped but also healthy infants—is morally acceptable, for the same reasons that abortion, including late-term abortion, is accepted in the West.  That issue of the JME expanded on the prior online publication, in January of 2012, of an article by Giubilini and Minerva.  I found the contents of this issue available online for free (for which I was thankful, because nobody should have to pay for this tripe).  Read it, and it will be clear that the authors, and the editors of the journal, don’t understand why anyone could have been upset that it was published in the first place.

In an editorial, Julian Savulescu states that the Giubilini-Minerva article was published because of “the quality of [the] argument, the contribution to the existing literature, and the relevance to current medicine.”  But the article failed the first two criteria, and ought to fail—at least, in a decent and human society, ought to fail—the third criterion as well.

Giubilini and Minerva argue poorly in their piece.  Two key sentences:  “both a fetus and a newborn certainly are human beings and potential persons, but neither is a ‘person’ in the sense of ‘subject of a moral right to life.’  We take ‘person’ to mean an individual who is capable of attributing to her own existence some (at least) basic value such that being deprived of this existence means a loss to her.”  In a reply, Francis Beckwith points out that this position has been carefully refuted on numerous occasions in recent years, and criticizes the notion of a “potential person” as misguided.  An unborn or newborn baby is not a “potential” person in the way that, for example, a piece of wood is a potential desk or Michael Tooley’s cat is potentially smart if only it is injected with the right potion.  Rather, the fetal or newborn human is a being so ordered that it essentially has the capacity to express, when fully developed, the range of higher capabilities that Giubilini, Minerva, and other like-minded people say confers moral status only when realized—either fully, or fully enough.  What would constitute “fully enough” they are unwilling to venture.  They also claim that refusing the burden of caring for a baby is reason enough to warrant infancitide (as it is, de facto, sufficient justification for abortion under our current legal regime).  But Beckwith demonstrates that, for them, infanticide is morally permissible even in the absence of any burdens—so an appeal to “burden” is irrelevant.

At bottom, Giubilini and Minerva’s paper is nothing more than a rehash of old arguments for abortion and infanticide, without proper regard for substantial criticisms that have been previously and extensively published and discussed.  Accordingly, their article adds nothing whatsoever to the current literature save provocation.  It does have one merit: it serves as a reminder that if abortion is morally permissible, it is difficult if not impossible to declare, on the merits, that infanticide—or, for that matter, the elective murder of children of some indeterminate older age—is not morally permissible.  Several contributors to the May 2013 JME point this out in one way or another.

Finally, the relevance to modern medicine:  In his contribution, Robert George states that “killing an infant because he or she is unwanted is evil” and that advocating it, or its moral permissibility, is “madness.”  And so it is.  To ask seriously, “is it permissible to kill an infant because he or she is unwanted?” or “under what circumstances is it permissible to kill an infant because he or she is unwanted?” is to speak from a heart desperately twisted by evil.  We must forcefully reject the premises of such questions.  They can never be relevant to modern medicine.  They are considered relevant only because we live in the days of the Groningen protocol for neonatal euthanasia—which, we are told, is decreasing euthanasia (or so it is believed) in favor or more abortions, for things like spina bifida.  (An “updated report” is due later this year.)

Apparently, after the online publication of their article, Giubilini and Minerva received death threats.  Such a response is also evil.  That is it was affirmed explicitly by several contributors—both pro- and anti-infanticide, or pro- or anti-abortion—to the May 2013 JME.  But again, the authors and editors don’t appear to understand why there should be such outrage, and some of them seem (rather sanctimoniously, to my ear) to cloak themselves in a sense of martyrdom.   Outrage must be controlled, and supported by proper warranted belief and sound argument.  But correctly-directed outrage cannot be replaced by a cool rationalism.

And so, indeed, in responding to what George has properly called this “madness,” we must be civil but we must not be gentle.  Academic freedom and the First Amendment demand that we abide such talk, at least to a point.  However, serious advocacy of killing healthy infants or children by choice ought not to be acceptable in decent, humane conversation, and we should aggressively press the point that this one has been “asked and answered.”  Daniel Dennett has said that people who believe in God should be dismissed with derision from intelligent conversation.  We must be more patient, but I am tempted to ask whether sauce for the goose is sauce for the gander here.

It is said that Hippocratism arose as a counter-cultural protest movement, and that early Christians bore reproach for their opposition to infanticide.  Those of us who consider ourselves “neo-Hippocratists,” if you will, may be facing such a time again.  I wonder: just how many of our fellow citizens think that Gosnell did something wrong?  Or that he didn’t?  And would not most frankly reject infanticide?  I suspect that most people in the general public don’t realize this discussion of infanticide is going on.  We must educate them.  And we must be polite—but not too nice—in opposing the “experts” pushing infanticide.

Emergent Dualism and the Sanctity of Human Life

My wife and I spent May 10-11 at the annual conference of Biola’s Center for Christian Thought (CCT), where the theme for 2012-2013 has been “Neuroscience and the Soul.”  The plenary talks are not all on the web, yet, although some are on Facebook, but a number of discussions on the general topic may be accessed here.  I encourage readers of this blog to spend some time knocking around the CCT website.

The weekend (though perhaps not the year, more broadly) didn’t have much neuroscience in it.  Most of the time was spent talking about philosophical and theological anthropology—in particular, what is the soul?  As I have previously written on this blog, I am most attracted to a “Thomistic substance dualism” (after Thomas Aquinas) of the sort advocated by J.P. Moreland of Biola, who argues that the “soul” is a simple (it doesn’t have parts) nonmaterial substantial entity that contains all the ultimate capacities of an organism and which is intimately involved in directing that organism’s development and expression of those capacities.  The word “ultimate” is critical here, because, as we all know, not all members of the human race realize all capacities at all times.  Moreland’s development shores up some shortcomings of Aquinas’s dualism (e.g., the notion that human embryos acquire souls at either 40 [males] or 80 [females] days of prenatal development), while attempting to retain its merits.  It, and other approaches that reject equating mind with brain function, appeal to certain Cartesian intuitions, like those of self-awareness, the sense of “what it is like” to have an inward experience, and others.  The philosophers call these “qualia” of mental events, which make them non-identical with physical/biologic events.  At the same time, Moreland and those of like mind reject the radical Cartesian distinction between mind and body in favor of a more wholistic, as it were, view of what the soul is and does.

Now, this fits nicely with the biblical notion of the image of God, even if one rejects Moreland’s view that the image is what man is, not just what man does (tend the earth), or the relationship between man and God, or the “status and standard” of man relative to God, creation, and the ultimate perfection man.  But I would argue that Moreland’s Thomistic substance dualism is not just faith-based, but also supported by formidable philosophic arguments and accessible on the terms of general revelation.   As such, I think it provides the strongest support available for the sanctity of individual and collective human life.  One sees this in arguments most commonly employed (perhaps not surprisingly) by Roman Catholic thinkers like Robert George; to wit, “humans are the kind or sort of being that….”

Two criticisms of Moreland’s view are:

  1. It amounts to vitalism, an otiose idea long-ago relegated to the biology’s scrap heap of history.   Moreland’s rejoinder to this is to claim that bad, old-fashioned vitalism was too crude, and that a more modern view, “organicism,” is more promising.  (I can’t carry on about that, yet.)
  2. Evolution is irreconcilable with the Thomist view of the soul, because the latter requires that genus and species not be degreed properties, but be in a real sense, immutable.  I agree that the Thomist view pushes one there, and I think that (along with Moreland, I believe), as these critics claim, the Thomist view requires one to accept that God is progressively active in creation.  But these points are said to be unacceptable because of the science of human evolution.

So, as an alternative, some philosophers who remain sympathetic to the idea that mental phenomena are not reducible to physical processes, and in fact are different in ways that cannot be fully explained by appealing to physical processes, nonetheless inescapably depend on those processes and “emerge” from them.  However, they would hold, what is emergent is not just mental properties but an actual, and in a meaningful sense, substantial self.  So they are dualists about human nature—even, in a sense, “substance dualists,” but they are less ready to allow that the human soul might exist independently of bodily life and processes—particularly those of the brain.

Now, there is more to be said about this than I can say, here or elsewhere, but it seems to me that the appeal to a “degreed” nature of life or consciousness disallows categorical distinctions of moral status between individual people, or people in general, and other beings.  (It seems to me that the emergent dualist also conceives “soul” as too readily identified with higher mental properties than the Thomist view would insist on.)  It risks making “personhood,” or “dignity” or moral status a degreed property.  Should we be more concerned about an anencephalic baby, or a fetus with Down syndrome, than a fully-endowed and functioning gorilla, and if so, why?  Should we be troubled about creating a human/non-human hybrid, and if so, why?  Would a super-intelligent robot, if there could be such a thing, potentially be a rival of “natural” humans in competing claims for concern?

I tried this out on a prominent Christian emergent dualist at the conference, and he quickly dismissed my objections.  To be fair, I hit him with a “drive by” on the coffee break, but as it happened, when I pushed, he responded, in effect, we can’t base all our moral appeals on rational argument.  Sometimes we have to just demonstrate the truth of the gospel, and show people the choice between worldviews and their consequences, and ask them what do they really prefer?  And, as unfairly as this brief post may be posing the issues, that kind of rejoinder worries me.

Ultimately, some appeal to a “givenness” of human nature is necessary to defend boundaries in bioethics.  We might indeed appeal to the naturalist by counseling caution—evolution has, over millions of years, presented us with ourselves, including our common intuitions—and we ought to have a “default” position of “no-go” on the most “out there” ideas.  We might indeed present a “two views” picture, and ask people to choose what kind of world they really want and what sort of people they ought to be.  We might argue, as I take the German philosopher Jürgen Habermas to argue, that the interplay of human autonomy, human language, and human social relationships lead us to conclude that some technological interventions would tend fundamentally to destroy who we are in community, and so ought to be avoided.  But I think it’s harder to identify, on emergent dualist grounds, what if any specific maneuvers ought to be proscribed with “thou shalt not,” or words to that effect.

The emergent dualists might be right.  (I tend to agree with Moreland that the position is unstable, tending toward either his dualism on the one hand or functionalism on the other.)  If so, we should, as the philosopher I challenged told me, follow the inquiry where it leads.  (One approach that could be called into question is Francis Schaeffer’s approach of asking whether one can live with the consequences of one’s philosophy.)  But my efforts, at least, are still awfully preliminary.

The Egg-Freezing Express

Oh, my.

The “Review” section of last Saturday’s Wall Street Journal (my paper of record) carried a piece by one Sarah Elizabeth Richards, entitled, “Why I Froze My Eggs (And You Should, Too).”  (Of course, she’s written a whole book about it.)

Egg cryopreservation has progressed to the point where human eggs do well enough in a freeze-thaw that subsequent success rates with IVF are, apparently, at least competitive with IVF using freshly-harvested eggs.  So a woman who doesn’t want to risk compromising her career, or who is having trouble finding a mate, can alleviate at least some of the pressure of the “biological clock” for procreation, and have her own eggs frozen and saved for future IVF when said mate has been found.  Ms. Richards reports that freezing her eggs helped her relax, seek a man interested in marriage, and look forward to raising a family within the bounds of what sounds like her hoped-for traditional marriage.  Apparently she has friends with similar experiences and intentions.  And she rejects the tyranny of the biological clock, while acknowledging that nothing is foolproof and motherhood can’t be postponed indefinitely in a woman’s life.

So, insofar as preserving fertility of, say, a young female cancer patient receiving chemotherapy, or—assuming you agree that IVF within the bounds of marriage is ethically acceptable—helping infertile couples, one might argue that egg freezing is a welcome development, a relatively small step that will enhance reasonable family planning and might actually discourage some couples from seeking eggs from a third-party donor.  So far, so good—or, maybe, “so far, so OK.”  (Oh, there was nothing much in the article about the process of inducing ovulation or hyperovulation with drugs, which is tacitly assumed to be risk-free.)

But of course there is no reason in principle for it to stop there.  Ms. Richards acknowledges that egg freezing can help single-mothers-by-choice, and, if a woman’s own eggs don’t survive the process, then “instead of paying tens of thousands of dollars [to an egg donor], [a woman] can buy her eggs piecemeal for a couple of thousand dollars each,” online, from one of several clinics selling eggs provided by some 300 donors.  Gee, I wonder how long before one can get a really great deal at Costco.

It all gives women power over the last area of their lives that limits their opportunity.  What’s not to like?

In an accompanying article, “The Ethics of Egg Freezing,” Christine Rosen of the New America Foundation raises concerns about complications of workplace accommodations for women and families, and she points out that the likely accompanying increase in the use of preimplantation genetic diagnosis will have people seeking “just the child [they] want by choosing its sex” or some other genetic traits.   The greater sense of control brings with it different expectations; viz., people will want the resulting child to match their expectations.  Ms. Rosen would not ban egg freezing, but she worries that if young women routinely freeze their eggs then our society “could develop very different attitudes about children and the arc of a human life.  The danger lies not in a particular technology but how it might allow us to indulge our hubris and pretend that we and our families are not subject to the relentless march of time.”

Check, check, check, check, and check.  Ms. Rosen is correct on all points.   Most people don’t believe in the providence of God anymore, but they do believe in the providence of man (and woman).  (Oh, BTW, over at his “Human Exceptionalism” blog, Wesley Smith recently took to task a recent New England Journal of Medicine piece promoting the sale of made to order embryos.  And Ms. Rosen didn’t comment—as well she might have—that such control, such ‘autonomy,’ could readily come under control of the state someday.  “Ms. Smith, do you have your government-approved pregnancy permit?”)

I don’t pretend that this freight train will stop.  And I would not try to ban egg freezing—for eventual use in, say, gamete intrafallopian transfer.  Old fashioned and inefficient, I know.  But I am convinced that human IVF was a line we ought never to have crossed.  Having crossed it, I agree with the Roman Catholic commentators who argue it is a practice of which followers of Christ ought to repent.  (I know I am at odds with received evangelical opinion here.)   And we must promote an attitude that children are a gift, not a product.  And we must raise our kids and encourage people in general that procreation is properly limited to true marriage—as describe by Robert George’s group, a complete union of husband and wife, body and soul, uniquely ordered for procreation and the raising of children, necessarily exclusive and permanent.

Let’s lean into that.

What Should We Want?

At a biotech industry conference last week, I sat in on a panel discussion entitled “The Affordable Care Act is Here to Stay.”  The upshot:  black crepe all around—biotech-driven research and development of new drugs is going to get squeezed.  And so, it seems, it clearly will be.  And a panelist representing patient advocacy organizations said, “What do patients want?  We want access to all new drugs, we want the drugs to be ever better, and we don’t want to pay for them.”

Okay.

I’ll limit my comments here to oncology, because it’s the area I know best.  There appears to be an emerging sentiment among cancer clinical researchers that a tactical reassessment of the 40+-year-old “War on Cancer” is in order.  To wit:  the story thus far has been to throw money at the problem, rush every possible development forward, and try to piece together every incremental development, no matter how small, to make gradual progress.  (And to hold no end of events “for the cure” in the process.)  And, indeed, this is how progress in cancer treatment has been made; some thunderbolts of discovery have struck, but progress just as often has been slow, and truly apparent only over a number of years, even decades.

Now, however, because the new consensus is that doctors should be paid by the patient instead of by the test, procedure, or encounter; because it’s clear that payment arrangements that reward more and more treatment create incentives for physicians that are questionable at best and frankly unethical at worst; and because the public, through government or through private insurance (and what can be gargantuan out-of-pocket payments), is increasingly unwilling or unable to pay for certain expensive new drugs—for all those reasons, cancer doctors are thinking that good medicine, human decency, and common sense demand more effectiveness from every new drug, and they’re trying to define what they mean by that.  “How high should we set the bar?”

To that end, the American Society of Clinical Oncology (ASCO) has put out for public comment a draft proposal defining “clinically meaningful outcomes.”  I wish I would have been watching this more closely; the deadline for public comment is tomorrow, May 1.  But that notwithstanding, and even if you are not a doctor, I encourage you to look at and see what you think.  Note that however the recommendations come out, what is “clinically meaningful” will be defined by “evidence;” i.e., data from controlled clinical trials, not what worked for Aunt Agnes.  And the recommendations will be an example of doctors raising an authoritative voice on behalf of their patients—what they think they ought to insist a drug do to warrant putting their patients through the risk and trouble of getting them.  As a matter of process, both points are as they should be, I think.

And what should we, the public, consider “clinically meaningful?”  Well, that’s what ASCO is inviting comment on.  The doctors’ voice is authoritative but not dictatorial.   And how should we comment?  From a perspective that realizes that this life is not all that there is, that realizes that death is a conquered enemy, and that understands that human dignity may be challenged by, but is not obliterated by, terminal illness.  And, above all, we in the church should remember that bringing the gospel of eternal life to all is our most urgent task.