DNA Research and (Non)Anonymity

Last week, the Wall Street Journal reported on a paper in the journal Science (article free with registration), regarding the ability to identify supposedly anonymous donors to genetic research.  Science carried an accompanying perspectives article and news summary.

The upshot:  Imagine a fictitious Mr. Hogswobble (we’ll call him “H” in view of my limited typing skills), who donates a blood sample so his DNA can be sequenced as part of a study of genetics of a larger number of people, with the goal of learning something that can eventually help diagnose or treat human disease.  H does this because he wants to support good science and medicine, but he’d rather not have his identity known, on the off chance that it could make it harder for him or his family to get insurance, for example, at some unknown time in the future.  So the researchers tell H that they will do everything they can to keep his personal identity anonymous.  He will not be identified in any scientific publication.  The sample and the data gained from it will be “deidentified;” i.e., no personally identifying information, like his name, initials, Social Security Number, etc will be kept in the same place with it.  Maybe there is such a linking record somewhere, maybe not, but if there is, it is under lock and key and held securely.  His sample is given a unique identifier—maybe a number, like “43” (was that the number in The Hitchhiker’s Guide to the Galaxy?).

But the de-identified specimen and data are made publicly available, in the interest of open access for other scientists to work on it.  This kind of sharing is critical to the free operation of good science.  Critically, to make scientific sense of it, it likely includes certain “metadata,” such as H’s name, his country or state of residence, how old he was when the sample was obtained, maybe even some level of medical information relevant to the scientific research.  But most people looking at the data could tell only that it comes from some guy, not from H personally.  Now, to be sure, this information could be used to narrow down the field substantially—there are only so many 55 year-old men in California, for example—but other information on how many of those had, I don’t know, hypertension, let’s say, would NOT be readily had because of privacy laws governing medical records.

The problem is that we as a population freely make lots of other information about ourselves public.  (No, I’m not including whether we own a gun, I don’t want to go there.)  That’s where the researchers on the Science paper worked.  The “metadata” were huge in their work, but the treasure trove was a public genealogy service.  Send us a sample for your DNA, and some personal information (like your name), and we will make all of that public to help you and similarly-interested people find your long-lost relatives, for whatever reason you or they have for being interested.

So there are two public databases—the one more limited one with the DNA data and some metadata, and the broader one with DNA data and names—including, quite possibly, one or more men named Hogswabble.  From the first database, the scientific research one, a list of genetic markers can be obtained—in this case, ones called “SNPs,” but we will call them, collectively, “Steve”—and that list can be compiled, then compared with the genealogy database to see how many H’s have DNA with “Steve” in them.  That gives one a guess of whether any of the donors for the first study—the supposedly anonymous donors—are named Hogswabble.  Surf the ‘Net for other publicly available information and these researchers could finger the identities of 50 donors to an actual scientific study intended to study a total of 1,000 people.  So that’s 5%–50/1000.

A fundamental ethical tenet of human subject research is that measures must be in place to protect the privacy and confidentiality of research subjects.  But in the age of big data and research on genomics and other large-population based biologic matters, assurance of confidentiality can seem like it’s founded on quicksand.  What to do about it?  Take whatever measures reasonably can be taken.  In the informed consent process, tell a research subject that it is simply not possible to provide an absolute guarantee of confidentiality.  Train researchers on ethical behavior—“do not hack Steve,” for example—but realize that in an open-source environment, the sort of steps described here could be done by just about any smart wise guy with Internet access.  Limit the amount of metadata available; NIH is doing just that, although some tough judgment calls may be involved.  Limit the availability of data?  Now things are getting touchyBetter not to over-react, the scientists reasonably counsel.

Laws are in place, such as “GINA,” the Genetic Information Nondiscrimination Act of 2008, to prevent at least some types of discrimination (e.g., health insurance, employment) based on genetic information.  These issues are with us to stay.  In medical research, protecting our privacy and confidentiality has limits.

More on “Shared Decision Making”

Back on November 27, I posted on shared decision making, or SDM for short, and opined that in broad brush, this seems like a mom-and-apple pie initiative, with the goal of encouraging better communication, informed by better data more clearly communicated, about an individual’s medical decisions.  Central to that effort is the desirability for tools—written, audiovisual, and the like—that support the decision by making complex medical matters accessible to the average person, who is likely not to be sophisticated about medical or scientific matters.

Now, in a recent “Perspectives” article in the New England Journal of Medicine, Emily Oshima Lee and Ezekiel Emanuel urge more formal efforts to develop, certify in some meaningful sense, and use these decision-support tools.  The discussion strikes me as similar to a long-standing parallel concern about how to develop better consent forms for human subject research.

The kicker is that the authors urge a strong active stance by government to mandate the use of such tools.  This would serve three goals:  “promote an ideal approach to physician-patient decision making, improve the quality of medical decisions, and reduce costs.”

Although the authors of the article seem clearly to endorse a strong physician-patient relationship, with clear communication and decisions aligned with the patient’s values, the assumption is that in the preponderance of cases involving aggressive or costly care, or difficult decisions, the cheaper course of action will also be the medically appropriate course and the one that patients will prefer.  That may often be the case (and they cite reports from groups like the Kaiser Foundation to that effect), but when the patient prefers the more costly approach, there could be a conflict, to say the least.

The government would approve the tools, and, in order to ensure not only their use but the chance to collect data about the effect of using them, would demand they be used in Medicare, on pain of reduced reimbursement along the scale currently imposed on hospitals if they have to re-admit too many patients too soon after discharging them.  The CMS, the agency that administers Medicare, has the legal authority to proceed, that authority having been granted in the Affordable Care Act.  All they have to do is write the regulations, and put them into effect after the legally required advance notice (with open comment period) to the public.  CMS would mandate the use of the tools, not specific decisions about care—at least, they would not necessarily mandate specific decisions, not initially in any event.

Over at his “Human Exceptionalism” blog, Wesley J. Smith worries that this constitutes “the bureaucrat looking over your doctor’s shoulder.”  On one level, I’m not so worried—in my experience, the government is generally an accurate source of summary medical information, as on the NIH websites, for example.  Further, I bet the authors would insist that they do not mean to override individual decisions by a patient and his or her doctor.  It’s an open question how much the decision-support tools that eventually are derived will be written to push decisions one way or another.  In its human subject protection rules, the government is quite concerned, from at least the Belmont Report since, to guard individual safety and choice, so I am loathe to jump to conclusions here.

 

On another level, the goals do not exactly align with what I understood SDM to entail when I wrote about it before.  I thought that we were talking about helping a patient understand choices and clarify his or her values in conversation with the doctor, to support as informed a choice as possible—realizing that fully informed consent remains an elusive goal.  I didn’t think cost control was part of the deal.  While it is important to control costs, and it’s important that doctors not practice ineffective medicine, especially when to do so is expensive, cost control per se seems to me outside the boundaries of what I’d consider SDM to entail.

Further, I think we encounter again the tacit assumption that “data” will usually underwrite unambiguous, general rules that apply to all, or nearly all, medical decisions of a given kind and that are unencumbered by scientific controversy.  Regular readers of my posts will recall that I am suspicious of that assumption.  Add to that an assumption that government officials are especially if not uniquely equipped to create the decision-support tools, analogous to the HHS’s recent suggestion that it develop a single, national informed consent form for use in all U.S. clinical trials, a suggestion that I understand is being questioned by significant parts of the clinical research community.

Were this approach to SDM being taken by the medical insurance industry, we’d rightly be concerned that profit maximization was the goal.  But if the government—which pays roughly half of all health care costs in the country, and whose lead on payments is often followed by the private sector—is driving the process, should we be more confident that it has the patient’s interests at heart?  When does the government move from being a facilitator to a driver of care?  And should we really care?

These questions may be moot.  This interpretation of SDM is empowered in law and is probably coming.  Perhaps it would be a development of a more privately-driven approach, as well.  It seems like large organizations and rule-making regimes (I choose this language rather than the ill-suited term “system”) are engulfing more physicians’ regulated participation through mechanisms like direct employment, large contracts, etc, so this all may be the tide of history at work.  But we—patients and physicians—may need to read the print—which hopefully will not be too fine—carefully.

Sentience, the Image of God, and Human and Animal Souls

Not to steal Jerry Risser’s topic, but I think a further response to his last two posts on sentience warrant a separate post, not just a comment…

To start:  I heartily endorse Jerry’s analysis, and I agree with him that human moral agency seems to be a fruitful approach to addressing the moral status of animals.  As Dr. John Kilner suggested in his comment last week, one may be concerned that the AAHA’s statement cloaks an agenda, in which the uniqueness of human status in creation is obscured by a sort of mirage in which the raising of animals’ status serves, in part, to pull human status down, creating, as it were, a blurred “horizon line” between man and beast.  But the issue is one of metaphysics, if you will, not just ends and means.

Jerry’s key point is that anthropology is the correct starting point.    This means asking what is the essential nature of humans, not “just” what is their standing in creation.   Here, I believe that reflection on the soul, such has been done by J.P. Moreland, may help.  Recall that Moreland takes a “Thomist” view of the soul, understanding it to be the “substantial, unified reality” that informs an individual’s entire being, grounds all of that individual’s ultimate capacities, is capable of existing in different states, and possesses different faculties.  Also, if I understand Moreland (and Scott Rae) correctly, we should distinguish between a being’s ultimate capacities—what it is capable of when fully developed and functioning—and its “capabilities,” which are “realized” or actualized capacities that can be actualized to greater or lesser degrees at different points in an individual’s existence.  It seems to me that this distinction between capacities and capabilities is real.  We are on shaky ground indeed when we attempt to ground moral status on capabilities (realized capacities), which are degreed properties.

Now, Moreland—and, if I am correct, Aristotle and Thomas before him, and, in contemporary days, Leon Kass—holds that animals do indeed have souls.  Indeed, Moreland says, so teaches the Bible.  But Moreland identifies several human capacities that do not characterize animals’ souls (for what follows, see Moreland’s booklet “What is the Soul?”, especially chapter 4):

  • Libertarian freedom of the will—and therefore, moral agency (as Jerry pointed out)
  • Ability to distinguish between desire and duty
  • Ability to entertain abstract thoughts
  • Ability to distinguish true universal judgments from mere generalizations
  • Awareness of themselves as selves, which envelopes [animals’ lack of] “desires to have desires, beliefs about their beliefs, choices to work on their choices, thinking about their thinking, and awareness of their awareness”
  • Finally, Moreland does not accept that animals possess language, which he argues requires symbols and not just signs.

Note that none of these bullet points is necessarily theistic in origin and none comes from a straightforward exegesis of Scripture.  But the implication, Moreland says, is that animals have souls and value before God, but not the intrinsic human dignity people, who are made in God’s image, have.  Humans “do not have duties to animals, [but] duties with respect to animals.”

This is all a longer way of endorsing Jerry’s “moral agency” approach.  But I must also add this: to get there, whatever one concludes about a narrow exegesis of the term “image of God” in scripture, one must allow that being in the image of God means something about the essence of man and woman—about what kind of beings we are.  I think that point is an indispensable starting point of a biblical approach to bioethics, and I find what I understand to be a more minimalist reading that the image of God is “a status and a standard” to be deeply, deeply unsatisfying.  I also think—forgive me, Dr. Kilner, for casting all humility aside here—that “the conclusion that animals matter much less than people because they are not God’s image” is NOT fallacious.  If you really believe that position is fallacious, then I submit you need to be prepared to negotiate with Jerry’s grizzly bear.

PS: Jerry’s emphasis on “responsible stewardship” echoes the current Presidential Commission on the Study of Bioethical Issues, which proposed “responsible stewardship” as a guiding principle in its statement on synthetic biology a couple of years ago.

An Early Nominee for a Top Bioethics Story of 2013

We’ve just come through the 2012 retrospectives season.  Rather than try to recount the top bioethics stories of 2012—a worthy task, to be sure—allow me to nominate one prospectively for 2013: the Supreme Court decision on the Myriad Genetics case.  Reports in the general press say that the Court will hear the case this coming spring (with a decision sometime after that).  I am not a patent attorney, so any discussion I can offer here will be ignorant about the legal nuances, and I must therefore be reserved.  But  as I understand the case, at issue is whether a gene sequence that is found in nature—in this case, the BRCA1/BRCA2 genes—can be patented.  Now, methods to target those genes, or their products, can be patented in the course of, for example, drug discovery and development.  And a specific method of assaying the gene can be patented.  But can the sequence itself be patented, and what does that say for any intellectual property rights around the interpretation of the results?

I am in the camp that is suspicious of patenting actual gene sequences—normal or mutant—as opposed to methods to assess them or to interdict the consequences of their biologic activity.  Of course, a decision in that direction would invalidate the Myriad Genetics patent, breaking their monopoly on the BRCA1/BRCA2 test—and lowering the price of testing in the process.  Some entrepreneurial opportunities would be hindered as a result, but my overall impression is that not only academic research, but the possibility for competing tests and for lower costs for personalized medicine in the process, would be enhanced.

Either way, it will be of keen interest to see the breadth of whatever decision the Court reaches, and its implications for other patents in biotech.  Rather than speculate here, I will wait for the decision.

A Couple of Other Bioethics Blogs Worth Checking Out

“Merry Christmas to all, and to all a good night….”

I am mailing it in on the holiday.  To do so, I thought I’d encourage readers of this blog to check out at least two other bioethics blogs that may not always be linked in the usual places.

One is Wesley Smith’s “Human Exceptionalism” blog at National Review Online.  Posts are reasonably frequent (although none in December 2012), with an emphasis on human dignity concerns (end-of-life, distinguishing human and animal moral status), biotechnology and risks of commoditizing human life, and the implications of the Patient Protection and Affordable Care Act (aka “Obamacare”).  Conservative, both socially and politically, as I take conservatism generally to be understood in today’s America.

The other is the “Over 65 Blog” at the Hastings Center website.  Organized by Daniel Callahan and colleagues, this blog focuses on reflections by senior citizens on health care, health policy, and generational issues raised by those and by the aging of our population generally.  The five stated goals are “a stronger role for seniors, self-determination, more care/less technology, confronting the cost problem, and the economic and family needs of the over-65 generation.”  The general perspective is more progressive or at least center-left.  Last week brought a really interesting post from Alicia Munnell, a management professor at Boston College, refuting the idea that older people working longer will mean taking jobs from the young.

I think both are thoughtful and authoritative, and welcome respites from the talking-point fiascos of broadcast journalism.

Don’t Forget the Soul

I believe that if we are properly to defend human dignity and limits on what we will be willing to attempt with biotechnology, we must do our best to define and defend an essential human nature, which ought not be tinkered with.  I further believe that effort means that we affirm that each human being has a real, immaterial soul that survives the body at death and that is not just “the software” or “the output” of the brain or DNA or our bodies in general.  I find it astounding that some Christians now deny that the Scripture requires this position, an argument made admirably by John Cooper in his book Body, Soul, and Life Everlasting.

In addition, I think that a philosophical defense of the soul is also critical, and in this I am attempting to digest and follow the arguments of Professor J.P. Moreland of Biola University.  He has developed those at book length in Body and Soul (co-authored with Scott Rae), in a related pamphlet What is the Soul?  Recovering Personhood in a Scientific Age, and, in shorter form, in a recent lecture for Biola’s Center for Christian Thought (click here for audio and for a subsequent lecture by John Cooper).

Why should we think the soul is a substantial, real entity, not just an epiphenomenon of brain function?  Space and my meager philosophical skills limit what I can say here, but I understand Prof. Moreland’s key points to be, at least in part:

1)      Mental events are not identical to physical events, even if the latter are intimately linked with the former.  For example, our experience of pain is different from the nerve firings that are the physiologic events that accompany a pain.

2)      Our basic self-awareness—in particular, our awareness that each of us owns our individual experiences, and each of us is an enduring self—cannot be adequately accounted for if we aren’t each individually a soulish, or spiritual/mental substance.

3)      A unified, first-person perspective can only be explained by the presence of a soul.  If we are primarily physical beings, then first-person statements can all be just as well described in the third person.

4)      If we can choose to act at all—that is, if we have free will to any meaningful extent—then there must be an agent acting.  This requires that there be an immaterial soul that is essentially who we are.  Otherwise, we have to hold that our actions are events determined entirely by physical causes, including other events, or that our actions are only seemingly “our” actions, since “we” can’t really cause anything other than what is caused by the biologic operations of our bodies (plus the movements of objects around us, at least in some cases).

5)      By an argument appealing to modal logic, if we can reasonably, or “strongly,” conceive of a state of affairs in which we exist disembodied, then we have good grounds for thinking we are not identical to our bodies, which cannot exist disembodied.  (This one for me is the most challenging of the five points listed here.)

The above are just bullet points indicating the sort of arguments Moreland advances in support of substance dualism, the view that the body (with the brain) and the mind/soul are two distinct things or substances.  Moreland identifies three forms of substance dualism: a Thomist form, to which he subscribes, that holds the human soul to contain all the ultimate capacities of a human being; a Cartesian form (advanced by Richard Swinburne, for example) that holds the soul to be more closely identified with mind in particular, and an “emergent” form (advanced by William Hasker) that holds the soul initially to emerge from brain and nervous system functioning but then to “exercise its own causal powers and be sustained by God after death” (Moreland, What is the Soul?, p. 29).

None of this considers the body, much less the deeds done in the body, to be diminished in its importance.  To be sure, the Scripture affirms bodily resurrection.  But I think that Christians in bioethics ought to be substance dualists and spend some time delving into the issues around it.  In an age when people seek to explain complex human decisions (like whom to mate with or whether to take a gun to a roomful of children) by appealing to DNA sequences or DNA expression or brain chemistry, we should remind ourselves and others that we are, most fundamentally, our souls—which need to be, and can be, fitted for heaven only by God Himself.

On the Boundaries of Moral Complicity

Last week’s lively exchange about the moral legacy of “the father of space medicine” invokes the broader issue of how to decide when one is being complicit in an immoral act.  (Please note that I am NOT attempting to weigh in further on the individual discussed last week—whose name I will not write here, in hopes that I can protect this post from further exchange about him personally.)

We all agree that what the Nazis did in the name of “human subject research” was evil.  At least, I think we all agree.  But would it be evil to use an anatomy text whose illustrations had been derived from the Nazis’ efforts?  Or, to be more contemporary about it, would it be unethical to take a new drug whose development included laboratory tests using stem cells from embryos specifically created or destroyed for use in those tests?   The Nazis are easy targets, but not a shield from more thorny issues that might strike closer to home.

Dr. Robert Orr addressed the issue of moral complicity at length in an article posted in 2003 on the website of the Center for Bioethics and Human Dignity.  In it, he posed several scenarios of moral complicity, and argued that they are not ethically equivalent.  To distinguish among them, he proposed five criteria:

1)      Timing—Association with a future immoral act is worse than association with one that is past.

2)      Proximity or remoteness—The more closely one is involved, the worse it is.

3)      Degree of certitude—how surely are the facts of the case known?  If not known, does one need to steer clear to avoid the possibility of appearing complicit?

4)      Degree of knowledge of the facts—Knowing them makes one more responsible than not knowing them (although I suppose we should be concerned about hiding behind a sort of “ignorance is bliss” argument).

5)      Intent—or, to be more exact, whether the intent of the person performing the immoral act and of a potentially complicit person are the same or different.

Dr. Orr explicitly rejected the possibility of “hand washing” in an attempt to absolve oneself from complicity (see: Pilate), and he counseled humility in judging the complicity of others.  Finally, he pointed out that hard and fast rules will be elusive, and that sensitivity to issues of the heart is paramount.

Read the whole thing.

On the Value and Importance of “Shared Decision Making”

A physician should make difficult medical decisions in close consultation with his or her patient.

Duh, right?

In America, where we place high value on personal autonomy and open communication, and tend to look askance at paternalism in medicine, “duh” would seem to be the correct response. (Perhaps this is not so much so in cultures where the patient is not even told of certain diagnoses.) But insuring the effective involvement of patients in their own medical decision making is not a simple matter. The information is complex, the situation may be distressing, the messages (from numerous health professionals, the Internet, family members, etc.) may be mixed, and what the patient really wants or values may not be clear—even to the patient.

In medical ethics/bioethics at large, a lot of work has been done on defining a practical, relatively simple, formal framework, with practical tools, to assist the process of “shared decision making” between patient and physician. In part because these kind of communications are hard, and in part, I suppose, because we need to make everything “scientific” or rule-driven, shared decision making, or SDM (everything needs an acronym, too) seems to have become—quite reasonably—a subspecialty within medical ethics.

I am not versed in the SDM literature at all, but I recently saw an article on the subject in the journal The Oncologist. (This journal’s content is generally available for free on the web, and should be easily found with a Google search.)
The relevance of SDM is easily grasped in oncology, but it of course encompasses all of medicine. A more detailed, formal process is recommended if:

1) There is substantial uncertainty about the best medical decision in a given situation, in which case–
2) The decision and its pros, cons, and alternatives are described to the patient (similar to the formal process of informed consent);
3) The patient’s preferences are elicited; and
4) A plan for next steps is agreed upon.

This all seems to make great good sense. The second and third steps seem to me the most challenging. Few people in America are sufficiently “medically literate” to follow instructions for taking their medicines. (I can’t seem to locate the reference right now, but it is true.) Also, medical information tends to be communicated in complex, scientific language that goes over most folks’ heads. Add the constant controversy over medical close calls, and explaining options in terms a person can understand is a substantial challenge for any clinician, especially one who is harried and unlikely to be paid for the time and effort to have the conversation at all.

Further, eliciting patient preferences is NOT seen as a matter of setting up a “what if” game of tradeoffs. Rather, it involves a more personal, complex process of understanding, over time, what really matters to a person and how that will effect medical decisions. End of life care is the most obvious example but the principle applies more broadly. It requires an ongoing relationship that is closer than the episodic encounters most of us have with the modern medicine. It takes a spouse, a pastor, a family, a group of friends who are aware of the importance of such values clarification. It seems necessarily hard—think of how hard it can be just to decide what to have or where to go out for dinner sometimes.

I think that sometimes our attention—or at least, my attention—in bioethics can be preoccupied with extreme cases or prospects. We do well to remain aware that important work on SDM is being done. It seems to me that this work is not particularly worldview-dependent. And given the structural and economic pressures affecting contemporary medicine, we should guard against trends that make it harder for people to engage, with their doctors, in the hard calls about their care.

On the Aging and Passing of the “Francis Schaeffer Generation”

In his fine post yesterday, Jerry Risser wrote that he is “certainly not a proponent of fighting the culture wars of the 1980s and 90s.” He then went on to say that on critical moral issues, we must stand firm. It seems that a loud and growing majority agrees, in a sense, with the first statement, by saying “you social and religious conservatives just go away.” One writer on National Review Online suggested religious conservatives on “on the verge of a new Babylonian Captivity.” These sentiments clearly complicate attempts to stand firm as Jerry exhorts.

My wife and I, who were in our 20s when President Reagan was elected, tended to interpret “faith in action” as activism in support of the “life issues,” notably abortion, to which American Evangelical Protestants had been awakened, albeit belatedly, by the work of Francis Schaeffer, in particular. We are in the “Francis Schaeffer Generation” as much as the “Reagan Generation.” In his book (with Dr. C. Everett Koop) Whatever Happened to the Human Race? (and working against a background of 20th century totalitarianism), Schaeffer urged us to be appropriately alarmed and outraged, and to act constructively. And he warned us against taking lazy solace in “personal peace and affluence.”

Now, the Francis Schaeffer Generation is getting old. Some of its mightiest warriors are dying off (Schaeffer and Chuck Colson, for two, are with the Lord). It’s being told it’s out of touch.

But far be it from me, a nameless foot soldier in the “culture war,” to suggest or admit defeat. To be sure, an angry, clenched-fist, condemnatory stance does not honor Christ or communicate love and respect. But in a world where an unpopular stance on moral issues is considered hatred on its face, no one should bear any illusion that the culture war is over. The secularists will press their advantage. Consider, for example, on abortion: why is it treated not just as a matter of choice but as a public good? Why is any attempt to discourage it labeled as a “war against women?”

What should we foot soldiers do? How about:
1) Double down on Schaeffer’s principles. He was right.
2) Support the leaders and people and organizations on the “front lines.”
3) Recruit, support, and gently persuade emerging leaders of the new generation, who, unlike fossils like me, are “in touch.” This includes future political candidates.
4) Realize that there is still a place for good-old-fashioned litigating and legislating. For example, I read remarks by Richard Doerflinger to the effect that legislative protection of certain conscience rights may be feasible, such as with riders to larger bills that would not be likely to be vetoed.
5) Support “emotional,” “narrative-based” approaches as Jerry suggested. There is an army of emerging, imaginative workers, particularly in the performing arts, who should be encouraged to craft high-quality cinema and other works that engage audiences more thoroughly and gently than “Christian” films that amount to cinematic Evangelical sermons, as nice as these may be.
6) Realize, as Jerry pointed out, that thoughtful, rational arguments can still carry the day. Did we all notice that Massachusetts rejected physician-assisted suicide—by a narrow margin, to be sure—last week, and that some of the most eloquent positions to that end were articulated by people like Dr. Ezekiel Emanuel who cannot be mistaken for religious conservatives?
7) “Change the water.” Recall the old joke about the two young fish who swim past an older one, who asks them, “How’s the water?” They respond, “fine,” then swim on a bit before one asks the other, “What’s water?” We must be aware of the “water we swim in,” and question and seek to change cultural assumptions, where necessary. It seems to me this goes on in our extended families and on our streets, in conversation with people closest to us.
8) Learn about, and teach our kids about science and proper scientific reasoning. Jerry pointed out that “good science” should be embraced. But by that we must mean not only science pursued ethically (e.g., iPSCs vs embryo creation and destruction to get ESCs), but also science done well and honestly, and appropriately interpreted. Anecdotes—even a lot of them—added up and posted on a “scoreboard” do not substitute for properly controlled clinical trials, and we must remember that there is profiteering going on with some uses of adult stem cells, and there have been some cases scientific fraud committed in iPSC research. Examples not to be overemphasized, but they are out there.
9) Above all, pray for God’s guidance and for his truth to prevail, trust His sovereignty, and obey Him as fully as possible, with His help.

“3-4-50,” Bioethics, and the Church

In bioethics, we focus—necessarily, I suppose—on rules and principles to address concerns at the boundaries of human life. Compelling as this may be (How shall we limit the mischief committed in the name of progress? How shall we forge a “grand solution,” if one is even accessible, to ensure that everyone gets the medical care he needs?), I sometimes wonder whether we are barking up the right trees—or, maybe I should say, barking at branches while the trunk rots.

In partial response, I give you Dr. Nick Yphantides: disciple of the Lord Jesus Christ, Chief Medical Officer for San Diego County, and brother of one of the elders of my congregation. He describes how our “health care” is really “sick care” for preventable, lifestyle-related conditions. While many have commented on this, Dr. Nick’s formula is simple—3-4-50:

o Three behaviors—poor diet, lack of exercise, and tobacco use—lead to
o Four diseases—cancer, heart disease, Type 2 diabetes, and lung cancer—which cause
o Fifty percent of deaths—in San Diego and the U.S., and the world (at least, the industrialized world).

Whatever other arguments we have about medicine, ethics, economics, and politics, if we would attend to the “three,” we would do ourselves a lot of good, make ourselves healthier in the balance, and probably dramatically lower the costs of our “sick care.” We can debate that last point, and expensive medicine will not go away overnight, but changing the three harmful behaviors seems common sense about which there is broad agreement.

Oh, by the way, Dr. Nick used to weigh 467 pounds. Now he weighs 194. It’s all described on his website, HealthSteward.com, and his book, My Big Fat Greek Diet. (Note that if you Google on “healthy stewards” you can also pull up websites addressing fitness.)

All well and good—but is there a specifically Christian take on this? I worry about “Christian” approaches that seem more faddish than theologically grounded. My grandparents’ Christian bookstore used to carry a title, The Fat is in Your Head (I think Revell was the publisher), and who can forget the exercise video “Firm Believer” (get it?) from the 80’s?

Well, Dr. Nick’s testimony is that the Christian approach is both simple and foundational—be a steward of the health of the gifts our God-created bodies are. He starts with Jesus’ admonition to the Pharisees to “clean the inside” first, and the outside WILL follow. From there, Dr. Nick proceeds to ground seven “pillars” of health stewardship in love and gratitude. Read more about this on his website and in his book. HealthStewards is a specific ministry for Dr. Nick—“Building the kingdom through shrinking the body,” as he tells me in an e-mail.

It seems to me there is a legitimate Christian stance by which we, in recognition of who we are as God’s creatures, joyfully encourage each other and those outside our community to live more healthily—starting from youth. I think such a stance is gentle and grace-based, not legalistic; that it steadfastly AVOIDS stigmatizing anyone; that it encourages moderation while avoiding some sort of asceticism while also reminding ourselves that gluttony and sloth are two of the Seven Deadly Sins; that it fosters a culture of “personal best” rather than pursuit of some ideal, especially of fitness or beauty; and that it admits of some freedom on the margins (I’m in the Presbyterian Church in America, or “PCA,” which, as the joke goes, stands for “pipes, cigars, and alcohol [or ammo].”)

Two final points, for now: First, I’m terribly ambivalent about the proper scope of government paternalism over all this. I am sympathetic to restrictions on smoking but find Mr. Bloomberg’s limits on soda sizes misguided, for example. Second, while it is tempting to start discussions of “3-4-50” with the costs of “sick care,” I think the usefulness of that approach is limited. Less Type 2 diabetes means less expense to control blood sugar or treat the complications of diabetes, for sure. But coronary bypass and colonoscopy and the latest drug for breast cancer may still be relatively expensive in the U.S., for one, and for another, I read that knee replacements for active seniors are becoming a cost-driver for Medicare.

What do you, readers of this blog, think about all this? For the moment, it’s off to the gym for me. I’m 6’3” and 220, making me 20 pounds overweight by BMI. And I wish, at age 55, that I was built like an NFL safety. Sooooo not gonna happen….