On Slippery Slopes

In a recent commentary ethicist Arthur Caplan discusses the difference between physician-assisted dying (which he finds morally permissible) and physician-assisted suicide (which he finds troubling). He notes that “there are some very disturbing developments” in Belgium and Holland. Instead of having a terminal illness as a trigger, these countries have a different standard: “Are you suffering and is it irremediable?”

Caplan notes, “During the past year, people in Belgium and Holland have been given access to lethal doses of medication by doctors for things like a bitter divorce, losing their job, going blind, and very severe depression. People who are not dying and healthy persons are requesting help in dying from a doctor—and getting it—on the grounds that their life has lost meaning or that they do not want to go on because of their suffering.”

Caplan correctly finds this troubling. I wholeheartedly agree with his warning about the potential slippery slope that America is facing. If the past is any indication of the future, it will not be long before a seriously depressed person files suit challenging a state’s assisted-suicide law, arguing that they too have the “right to die.” Interestingly, however, he offers no solutions to prevent this from happening. Perhaps that is because slippery slopes seldom have off-ramps.

Indeed, those who have argued against all physician-assisted suicide (whether for terminal diseases or deep depression) have often utilized the ‘slippery slope’ argument that Caplan now employs. Opponents of PAD have consistently argued that once physicians move away from their role as healers to the role of assisting in suicide, slippery slopes are bound to follow.  Is there any way to reverse a slippery slope?

On Cuba’s Birth Rate

Last month The Washington Post reported that “Cuba is giving parental leave to the grandparents of newborns, the country’s latest attempt to reverse its sagging birthrate and defuse a demographic time bomb.” Upon closer look, the low Cuban birth rate has been a cause of concern for years. Of course, fewer babies spell demographic trouble. The population on the island country is aging and if things continue, there will not be enough people to replace them when they die. The problem becomes even worse when one considers that there are many who flee the country every year. It makes better sense for those people to have children after they leave the country, not before.

Explaining this potential crisis, one website notes that “Cuba’s low birth rate is largely attributable to three factors: the sluggish economy, emigration of women of child-bearing age, and the fact that over 70% of the labor force is professional women (who tend to delay childbirth while they pursue careers).” On a personal note, someone I know was visiting the country recently and was told by a young couple, “Why would we want to bring children into this situation?”

Additionally, when The New York Times reported on the Cuban birth rate issues two years ago, it noted the island’s high abortion rate:

“There is another factor that alters the equation in Cuba: Abortion is legal, free and commonly practiced. There is no stigma attached to the procedure, helping to make Cuba’s reported abortion rates among the highest in the world. In many respects, abortion is viewed as another manner of birth control.

“By the numbers, the country exhibits a rate of nearly 30 abortions for every 1,000 women of childbearing age, according to 2010 data compiled by the United Nations United Nations. Among countries that permit abortion, only Russia had a higher rate. In the United States, 2011 figures show a rate of about 17.”

While The Times article thinks the Cuban abortion rate is more a result of the bad economy than the cause of the low birth rate, it is difficult to ignore such a high rate.

One further factor comes to mind. In his 2013 Erasmus Lecture to the Institute on Religion and Public Life, Rabbi Jonathan Sacks addresses the possibility of believers establishing “creative minorities” in cultures that are not necessarily friendly toward religion. As he outlines his proposal, he interacts with a 2004 lecture from then Cardinal Ratzinger in which he discusses the population decline in Europe. Sacks remarks, “Though he [Ratzinger] did not use these words, he implied that when a civilization loses faith in God, it ultimately loses faith in itself.” These words might also be applied to Cuba’s population growth problem. Stated another way, faith in God ought to lead to greater faith in humanity, because faith is able to see that humans are created in the image of God. It ought to inspire a culture of life, where hope and love are in abundance.

Bioethics & SCOTUS Appointment

Some of us had hoped that bioethics would have been an issue in the presidential election of 2016, but that was not to be. Now, less than three weeks into the Trump presidency, bioethics appears to have resurfaced in the nomination of Judge Neil Gorsuch to be an associate justice on the Supreme Court.

Amidst all the media coverage of his appointment, The Washington Post, among others, made note of the fact that Judge Gorsuch has published a book arguing against euthanasia and physician assisted suicide. The Future of Assisted Suicide and Euthanasia is temporarily out of stock on Amazon , but the Post writer offers a summary of the 2006 publication, calling it “exhaustive, but evenhanded, treating respectfully the positions of those who disagree with him.” The premise of Gorusch’s argument is that “. . . [A]ll human beings are intrinsically valuable and the intentional taking of human life by private persons is always wrong.”

During the nomination process, Judge Gorsuch will be asked all kinds of questions on any number of important legal issues. In light of the recent activity in the United States on physician-assisted suicide laws, I am hoping that at least one senator will ask him how his views on PAS and euthanasia may have changed in the past decade.

Happy New Year!

As I sit to write this blog, 2016 is nearing its end. It seems like many people are quite happy about this prospect. I must admit, the year became rather wearying at points with all of its ups and downs.

I took a few moments to reflect upon my blogs from the past year. Zika, physician-assisted death, and pharmaceutical prices were some of things I blogged about in 2016. Undoubtedly, each of those, along with many others, will continue to be issues in 2017.

At the beginning of 2017, with all of the things that are rapidly changing around us, there is one thing that remains constant: the intrinsic value of a human life. As we approach 2017, let us remember that this value is not an economic number, based on an individual’s contribution to the national GDP. Neither is the value of a human life based on intellectual ability, tied to a person’s IQ. Too often, humanity’s measurements of a person’s value—physical strength, intelligence, or buying power—all miss the point. Those from a Judeo-Christian perspective understand that each and every human is made in the image of God; therefore, each deserves to be treated with honor and dignity. Bioethics is at its best when it recognizes this unchangeable reality.

Have a great 2017!

Race & Physician Assisted Suicide

Is physician-assisted suicide only for white people? That is a question that came to mind when reading a recent Washington Post article by Fenit Nirappil that reports on the proposed “Right to Die” law in Washington, D.C.  The law is drawing opposition from members of the African American community.

The Post article quotes a Georgetown Law School professor, Patricia King, who states, “Historically, African Americans have not had a lot of control over their bodies, and I don’t think offering them assisted suicide is going to make them feel more autonomous.” In other words, the law would have no benefit for those who already feel a high level of skepticism about the current medical system. Interestingly, the article also reports that only “one African American has chosen to exercise the provisions of the law in Oregon, which became the first state in the country with such a law in 1997.”

The concerns reported in the article are worth consideration. For some members of the African American community, the law brings back painful reminders of the Tuskegee experiments. For others, it is a reminder that many in their community lack resources to receive the best treatment available. A recent article in the Daily Caller  quotes D.C. Council member Brianne Nadeau: “Those with least access to quality health care are most likely to get a late-stage terminal diagnosis . . . They’re least likely to have coverage for expensive interventions. I believe they’ll also be most likely to consider this option as their best option, even if it’s not.”

It’s not clear whether or not the issue will become law in D.C. However, it is wise for the council members to listen to the concerns of their community.

Christianity and Physician-Assisted Suicide (2)

October 10, 2016

A few blogs ago, I discussed a Time op-ed that spoke of a Christian perspective to physician assisted suicide. Understanding that Christian is a hopelessly ambiguous term, I wanted to see if there was anything noticeably Christian about the op-ed.

My reflection at the time was that any advocate of PAS – Christian, religious, spiritual, or secular—could have written the piece. The only spiritual elements were prayer and having peace with the decision.

Last week Archbishop Emeritus and Nobel Peace Prize laureate Desmond Tutu wrote an op-ed in the Washington Post stating that as he grows older, he wants to lend his voice to the cause of “death with dignity.” What makes Tutu’s op-ed interesting to me is that he couches his conclusion in the language of Christianity: “In refusing dying people the right to die with dignity, we fail to demonstrate the compassion that lies at the heart of Christian values.”

The question, of course, is whether or not PAS is an adequate expression of Christian compassion to the dying? Tutu places the choice starkly: if you don’t allow PAS, people will suffer horribly. It is almost as if to him palliative care is a non-entity. He overlooks the historic Christian example of providing comfort and support to the dying, be it the believers of the early church or the contemporary hospice movement.

I have long agreed with those who think that love should be at the center of Christian ethics, because of its central place in the teaching of Jesus (see the “Two Commandments” of Matt 12:37-38). Tutu’s invoking of compassion as the Christian basis of PAS makes me think that further clarification of what it means to love is very much needed.

Zika and Genetically Modified Mosquitoes

Just last week, I received a call from a pollster.  It’s election season and I live in a hotly contested ‘swing state,’ so I wasn’t surprised.   What surprised me were the questions I was asked, mostly about the Zika virus—its spread and possible prevention.  One question especially caught my attention:  Are you in favor of genetically modified (GM) mosquitos?   Bioethics in a poll question!  I could hardly contain my excitement.

Floridians have grown accustomed to mosquito treatments.  (See a recent report from the CDC, here.) The government begins by spraying pesticide and encourages residents to get rid of any standing water.  Screens and insect repellent also are part of the strategy.

There have been some accounts that the pesticide has had undesirable consequences, including the death of bees.  It also produces a concern that pesticide cannot possibly be beneficial to the environment.  If traditional methods used to control mosquito populations have not been successful, GM mosquitoes offer a measure of hope.  Neuhaus and Caplan note, “The mosquitoes are genetically engineered to express a ‘self-limiting’ gene that kills offspring before they reach adulthood.”

The possibility of GM mosquitoes is not new.  According to Ernst, et al., the “Florida Keys Mosquito Control District proposed the first release of a GM mosquito” to help combat an outbreak of dengue fever in Key West, Florida.   Now, with concern growing over the Zika virus, GM mosquitoes have become an issue once again. There will be a non-binding referendum in November for the Keys to express their view as to whether or not the GM mosquitoes should be released.

Neuhaus and Caplan speak out for implementation of this proposal.  They believe it to be in the best interest of the public and the environment.  They base their conclusion in part on the FDA’s conclusion that saw no long-term problems with the release of GM mosquitoes. Others, especially those who live in Key Haven (the site of the release) are voicing their concerns.

Public health officials must always consider the public good.  They wrestle with possible unintended consequences and must think beyond solving the problem of the moment, by consider the long-term effects of their decisions.  I agree with Ersnt, et al, who observe, “Novel public health strategies require community engagement.”  If the Mosquito Control Board finally decides to proceed with GM mosquitoes, many will be watching to see what, if any, long-term implications will follow.  Perhaps you might have a genetically modified species in your neighborhood in the not-too-distant future.

On Genetic Data

In case you’ve run out of things to worry about, Kayte Spector-Bagdady gives us another in a recent post entitled “Why you should worry about the privatization of genetic data.”

Spector-Bagdady compares President Obama’s Precision Medicine Initiative with the work of the direct-to-consumer testing company, 23andMe.  Her concern is that “private companies don’t necessarily have to follow the same regulations regarding access to their data that federally funded researchers do.  And a recent proposal to change consent regulations for human research may make it cheaper for private companies to collect and use this data than public ones.”

A major concern is the possible creation of private monopolies of genetic data, making the data collected by 23andMe and others a ‘business asset’ that can be sold privately and cannot be readily accessed by public researchers. (According to Spector-Bagdady, Genetec offered to pay up to $60 million for data.)  She concludes, “our medical information is more than a business asset for private leverage. We need to make sure that public genetics researchers are private industry’s partners, not dependents, and that we enable public banks so private ones do not become monopolies.”

Though 23andMe provides the public with some clever advertising and the hope of having a handle on possible future medical risks, consumers would be wise to be aware of what happens to their data.  This, of course, raises another important question–to whom does our data belong?

Bioethics & Pharmaceutical Prices

Just last week a man walked into my office holding a vile of insulin.  He told me its cost and how much it has increased over time.  He expressed genuine fear that people would not be able to afford it much longer and that they would eventually die because of it.

Later that day, I noticed that the Washington Post and other media outlets were running stories on the dramatic rise of cost of EpiPens—up 450% since 2004.  Given that this product saves lives, the spike in cost is quite concerning.  When it came to light that the CEO of Mylan, producer of EpiPens, is the daughter of a United States Senator, the indignation increased.  Just today, in an apparent attempt to save face, it is reported that Mylan will produce a generic version of the EpiPen that will cost half of the brand name.  (Please also see the blog of Mark McQuain on the EpiPen.)

Last week JAMA published an article entitled, “The High Cost of Prescription Drugs in the United States.”  It notes, “The most important factor that allows manufacturers to set high drug prices for brand-name drugs is market exclusivity…” If the playing field is cleared of all competition, there are few, if any, market forces that might cause prices to stabilize.  Especially disturbing was the discussion of “pay to delay”– when drug manufacturers pay the makers of potential generics to delay their production.

I have met those who argue strongly that the free market must be respected, even in the face of skyrocketing prices.  They say that pharmaceutical companies have the right to charge whatever the market will bear because they’ve done the hard work of research and development.  Undoubtedly, they argue, the companies will use the profits to develop other life-saving drugs.  Put simply, they conclude that it is the result of the law of supply and demand.  But if the pharmaceutical company has a monopoly endorsed by the federal government, is it really a free market?

It seems that by applying the principle of justice, bioethics may have much to say about the rising cost of prescription drugs.  In an age where incredible things are happening with the creation of life-saving drugs, it is important they reach as many people as humanly possible.

Christians and Physician Assisted Suicide

In my experience working with terminally ill patients over the past seven years, I have often seen people of the Christian faith go all out in the ICU, wanting “everything done” for a terminally ill loved one. In these circumstances, when I speak with family members of the patient, they tell me they will continue to pray for a miracle to happen. As a person of faith, I respect their faith and their right to exercise it. When appropriate, I gently remind them that ultimately we all die and that, in the case the miracle does not happen, it is good to have an end-of-life plan in place.

This experience came to mind when I read a recent article in www.time.com by Corinne Johns-Treat, a cancer patient who has decided that she wants “death with dignity.” The article stands out because she explains how she came to that decision in the context of her faith: “…[T]he more I learned about the safeguards and autonomy in the law, and the more I prayed about it, having seen people suffer so much at the very end of their lives, I came to believe in that it fit into my faith. I found comfort in this law” (California’s ‘End of Life Option Act’).

As I read her thoughtful article, several familiar themes arose: autonomy, personal suffering, and the painful experiences of others. These, of course, are used by others defending PAS who do not necessarily have a particular faith commitment. To place her decision within the framework of her Christian faith, Johns-Treat adds this thought: “If God grants us the intelligence to enable doctors to offer treatments that prolong life—that have prolonged my life—wouldn’t that same logic apply to those of us nearing the end of our life? When science can’t offer life-sustaining treatments anymore, then the role of medicine should be to relieve suffering.”

I don’t know anyone in the medical field who would disagree with the goal of “relieving suffering.” The question is how to define it. Cannot palliative care offer more to the dying patient than PAS? My work in hospice showed me that death does not need to be anguish for patient and family alike during the final hours of life. Palliative care physicians and their teams do tremendous work every day to relieve the terminally ill of their suffering. As the field of palliative care continues to deepen and grow, and as people become more aware of their mortality, I hope that PAS does not become the default method of “relieving suffering.”

Christians – and members of other faith groups – will undoubtedly continue to wrestle with these issues in the coming days. This is important because they are indeed matters of life and death.