Suicide in older adults

There is much discussion and debate within bioethics about the permissibility of physician-assisted suicide, but less discussion about suicide in general. We also spent a lot of time talking about end-of-life care and end-of-life decision-making. However, we tend to focus less on suicide in general and very little on suicide among older adults who are approaching the end of life but have no terminal disease. A recent program on NPR titled “Isolated and Struggling, Many Seniors Are Turning to Suicide” caused me to think about this.

Suicide rates in the US are generally increasing. When we think about suicide, many times we think about increases in teenage suicide rates but forget that middle-aged and older adults have higher rates of suicide than teens. Part of the reason for the higher rate of suicide in older adults is that their suicide attempts have a higher rate of resulting in death, but there are other things that put them at risk. Older adults suffer from isolation, loneliness, grief, and depression. The older we get, the more likely it is that we have lost family and friends close to us to death. That leads to the isolation, loneliness, and depression that can lead to suicide. Many older adults also live with chronic diseases which can lead to loss of ability to perform routine daily functions and cause a loss of independence. These things may also lead to isolation, loneliness, and depression. They can also result in feelings of being a burden to family members. The isolation experienced by the elderly not only leads to depression, but also makes it less likely that someone will recognize the risk of suicide and intervene.

Do our moral obligations to provide care for those at the end of life include dealing with the risk of suicide among older adults? I think they do. As physicians and other medical caregivers, it is important to recognize that suicide among older adults is a real concern and be alert to signs that a person may be at increased risk. Intervention can be lifesaving. We also have obligations as family members, neighbors, and fellow church members with those who may be at risk. Decreasing isolation can make a significant impact on the risk of suicide and all of us complaint role in that. Suicide in older adults is a real concern, and it is something we can impact.

Reclaiming the Lost Art of Dying

As I continue to reflect on the recent CBHD bioethics conference, there are several of the sessions that stand out to me. One was the presentation by John Kilner at the conclusion of the conference that I wrote about last week. Another was the very first presentation as the conference began. Lydia Dugdale spoke on the topic of “Reclaiming the Lost Art of Dying.” Many of us have recognized that there is a tendency for people in our current culture to die poorly. Dr. Dugdale suggested that our difficulty in dying well is related to our level of medical technology. Because modern medicine is able to do so much in treating and curing diseases, the allure of a cure can keep people from accepting the reality of death. She gave as an example a case of a woman with incurable cancer who never addressed the reality that she was dying because every time one treatment failed another was recommended.

She reminded us that there was a time in the middle ages when people were taught the art of dying well through a text titled “Ars Moriendi.” This booklet was published in the 1400s following the ravages of the bubonic plague in both literate and illiterate versions to help people prepare for death. It included instructions on preparing willfully for death and accepting it gladly when the time came. It spoke of avoiding temptations such as impatience, despair, pride, and doubt. It included a catechism pointing to the truths of the Christian faith and prayers for those who were dying.

She asked if something like this were possible for us today and suggested that bioethics could be a framework for learning how to die well. It can help us recognize our finitude and the limits of medicine. It can also point us toward community which can provide the support needed for those who are dying to die well. This may be as far as those in a secular setting, like the one in which Dr. Dugdale works, can go. However, those of us who share Christian faith should be able to take this farther. She challenged us with a quote from Jean-Claude Larchet’s book The Theology of Illness in which he says, “Ask God not in the first place for the return of health, but for what is spiritually most useful.” That points us back to what was understood in the days that the Ars Moriendi was written. Dying is an important part of our spiritual life, and we can grow spiritually through the experience of our own death as well as how we care for others as they die.

Ending well

By Steve Phillips

This past week I attended the CBHD summer conference. This year’s theme was “Taking Care: Perspectives for the End of Life.” As usual, the conference was filled with thought-provoking sessions and many good personal interactions. While I have much to think about from many of the sessions the one that impacted me the most was the concluding plenary session by John Kilner titled “Dignity and Life on the Line: Ending Well.” This session impacted me in a number of ways. Not the least was remembering how much Dr. Kilner has impacted my life as I listened to him talk about the end of life from the perspective of one going through his own end-of-life journey. It also came at a significant time for me as my wife and I have been grieving the recent death of her father.

However, even without those very personal things, what Dr. Kilner had to say about the end of life was significant. He reminded us that the dignity of human life that exists because every human being has been created in the image of God applies as much or more at the end of life as any other time. Since God has intended in our creation for us to be an internal reflection of him, death is truly an enemy. However, death is an enemy that has been defeated by Jesus in his resurrection. Our approach to death can be wrong if we fail to recognize either of these things. If we do not recognize death as an enemy, we may not pursue appropriate treatment, or we may pursue intentional killing as a means of avoiding suffering. Either of those is wrong. We should intend life and not death. If we fail to recognize that the enemy death has been defeated, we may try to avoid death at all costs and pursue over treatment that increases suffering because we have made life on this earth into an idol.

He also reminded us that the process of dying can include things that are positive. All human life is worth living. The life that we are living as we are in the process of dying can be of benefit to God, others, and ourselves. As we in our weakness put our lives in God’s hands and allow his body, the church, to care for us, we bring glory to God. We allow others to be blessed by serving as they care for us. In the weakness of dying we can find the hope and joy that come from God whose strength is manifested in us in our weakness. I pray that when the time comes God will help me to end my life well in this way. I also pray that I will be able to help others end their lives well.

Thank you Dr. Kilner for all that I have learned from you by your teaching, your encouragement, and the example of your life.

Parental responsibility in childhood immunizations

Last week I wrote about the issue of parental responsibility and medical decision-making for children. We have good reasons for having parents be the primary decision makers for children who are not capable of making their own medical decisions. However, as I discussed in the last post, there are some situations in which parents make decisions that are not in the best interest of their child. When those decisions reach the point at which the child’s life is in danger, society clearly has a moral obligation to intervene to save the life of the child.

Parental refusal of recommended immunizations for their children raises similar issues but is more complex. We can clearly demonstrate that it is in a child’s best interest to receive at least most of the commonly recommended immunizations for children. Those immunizations help to prevent a child being affected by diseases that can be serious and have a very low risk for serious adverse effects. However, the chance of an individual child being affected by many of these diseases is relatively small and the situation is quite different from a child whose life is in immediate danger due to a parental refusal of treatment. Since the risk to an individual child is relatively small and there is some possible risk to the child from receiving the immunization, it is not clear that a parent who refuses immunizations for a child is being negligent in the same way as a parent who refuses treatment for a life-threatening illness. It can be argued that the best way to deal with this type of situation is education. Many times, parents refuse immunizations for their children because of misconceptions about the risks and a lack of understanding of the benefits of doing the immunizations. It can be difficult to counter widespread misconceptions, but physicians have the responsibility of trying to do that the best that we can. However, this is not the only issue involved in determining whether society has an obligation to intervene and mandate childhood immunizations when parents refuse.

Immunizations are unique in the way that they work. They help protect the individual who is immunized, but they also help protect the community as a whole when we can achieve sufficient levels of immunity to halt the spread of an infectious disease within the community. This is sometimes called herd immunity. We have an excellent example of how this works with the current measles outbreak in the United States. Measles happens to be one of the most easily transmittable infectious diseases that we know of. It also can be deadly in a small percentage of the people who acquire the disease. It is also primarily a disease of children and is transmitted by children. When about 97% of children have been immunized in a community the disease will not be transmitted through that community and those who have not been immunized or cannot be immunized are protected from acquiring the disease. This level of immunity was accomplished in the United States about 20 years ago and for some time the only cases of measles that were seen in the United States were cases that originated elsewhere. However, because of parents refusing to have their children immunized for measles in significant numbers in some parts of the country, herd immunity is no longer present and we are having outbreaks of measles this year that are more than we have seen in 20 years.

That raises a different question. Should we mandate immunization of children for diseases such as measles and override parental decision-making not solely for the benefit of the children whose parents refuse to have them immunized but for the common good of the community? There are some children and other individuals who cannot be immunized or for whom immunizations would not be effective who are put at increased risk when herd immunity is not achieved in the community. This makes the decision about whether to immunize a child not just a decision about what is best for that child but also a decision about what is best for the community. For Christian parent it makes the decision about whether to immunize a child a decision about love of neighbor. Immunizing one’s own child helps to protect the child, but it also helps to protect the most vulnerable in the community. If we truly love our neighbor, we should do that even if there is a small risk to our own child. The final question is whether we as a society should require children to be immunized for these diseases when a parent is not willing to authorize it out of either concern for the best interest of the child or concern for those who are vulnerable in the community.

Parental responsibility in medical decisions for children

The 2 posts on this blog this week by Neil Skjoldal and Mark McQuain raise issues related to parental decision-making for the medical treatment of their children. Neil raised this issue related to parental refusal of life-saving treatment for acute leukemia and Mark raised it related to parental decisions not to have their children immunized for measles. There are some similarities in these situations and some differences. An obvious similarity is that in both of these situations parents are making a decision to refuse treatment for their children that is the recommended standard of care. Both situations raise issues about who should make decisions about the medical care that children receive and how those decisions should be made.

One thing we should be clear about is that this is not a conflict between the principle of respect for autonomy and the principle of beneficence. Respect for autonomy says that a person should be able to make decisions about what happens to his or her own body. It says that it shows disrespect to an individual as a person to insist a person receive recommended medical care when that person has the capability of making his or her own decisions and does not consent to the recommended care. This principle does not apply to decisions about the medical care of young children. Young children are not capable of making decisions about their own care and the parents are not the ones receiving medical treatment, so respect for autonomy does not apply to these situations.

What is involved is our understanding of parental responsibility for making medical decisions for their children. Because young children do not have the ability to make their own medical decisions, someone needs to serve as a decision-maker for them. We generally understand that parents ought to be the ones making those decisions. We have good reasons for that. Decisions about the medical care of young children should be made based on what is in the best interest of those children. God has created us as human beings to be dependent during the early part of our lives. He has put us in families with parents who have the responsibility for providing for the needs of their dependent children. Parents should love their children unconditionally as a precious gift and make decisions for their children based on what is best for each child. This usually makes parents the people who care the most about doing what is best for a child and makes them the best medical decision makers for their child.

However, sometimes parents do not fulfill their parental responsibilities as well as they should. None of us are perfect, but there are times when it is clear that the decision being made by a parent is not what is best for a child. When the potential consequences for the child are serious enough it can become the responsibility of the rest of us to intervene for the benefit of the child. We should not violate parental responsibility lightly, and it needs to be done in a controlled and orderly way, but when the child’s life is in danger, we have a responsibility as a society to intervene to protect a child. We should do this in any type of severe neglect or abuse.  We should do it when parents refuse medical treatment for a child who is likely to die if without treatment and the treatment has a good chance of saving the child’s life.

That appears to be the case in the situation in Neil’s post. The concern about parents refusing immunizations for their children has some similarities, but is more complex. It will take another post to address that.

Men without chests

One thing that is essential for us to be able to think well about bioethics is an understanding of who we are as human beings. One aspect of that which has been discussed on this forum is the concept of human dignity, the idea that all human beings have inherent value which impacts how we interact with each other ethically. For Christians that is grounded in the idea that we are all created in the image of God. John Kilner has expressed so very well how our being created in the image of God is the reason why people matter.

C. S. Lewis wrote about another aspect of how we understand ourselves as human beings back in 1947 in a little book titled The Abolition of Man. The first chapter of that book is titled “Men without Chests.” As a medieval scholar he was using a medieval image to express a concern that he had about how the tendency to deny the existence of objective moral truth in his day was leading to a problem with how we function as human beings. In the image that he is using the head represents intellect or reason, the chest (or heart) represents sentiments or values, and the stomach represents the appetites or desires. He says that if we believe that statements about morality or values are simply statements about how we feel and are not statements that can be considered objectively true or false, then the chest has lost its ability to mediate between the head and the stomach. Without objective moral values humans become beings whose intellect is used to achieve their desires without any means of controlling those desires.

What Lewis predicted is where much of our society is today. We are told that our identity is based on our desires, and that if we do not fulfill our desires then we are denying who we really are. Anyone who would suggest that our desires might be wrong or that we should not fulfill those desires must hate us and is attacking us and making us unsafe. Our desires define who we are, and our intellect is given the task of fulfilling those desires.

This is in stark contrast with a Christian concept of who we are as human beings. We understand that as human beings we are created by God in his image and with a purpose. We also understand that we are fallen. This world is not how it ought to be and we are not how we ought to be. Because we are fallen, our desires are frequently wrong. Our identity is not found in our desires, but in our relationship with our creator. We understand that our creator has given us the capacity to understand which of our desires are right and which are wrong. He has enabled our intellect to comprehend objective moral values that are grounded in the goodness of God’s nature. Those moral concepts allow us to distinguish right from wrong desires. That is what ethics is about. Those moral concepts also help us understand that we fall short of what we ought to be. We need help. That is what the gospel is all about. That is why Jesus died and rose again as we just celebrated at Easter.

The idea that our desires define who we are and must be fulfilled creates men without chests who are incapable of distinguishing right from wrong and can only express how they feel about a moral issue. We must have chests which hold to objective moral truths to think ethically and be complete human beings who are not simply ruled by our appetites.

Are pharmaceutical companies responsible for the opioid crisis?

Recently a major pharmaceutical company settled a lawsuit with the state of Oklahoma for $270 million. The state had alleged that the company’s marketing of OxyContin had helped to fuel the opioid epidemic in the state. Pharmaceutical companies in general do some things that are very good and have many times had some questionable practices. Some of their pricing and marketing practices are morally questionable, but it seems to me that it is the role of the FDA to evaluate those marketing practices and discipline pharmaceutical companies when they market inappropriately.

It does not seem to me that states suing pharmaceutical companies is an appropriate way to deal with the opioid crisis. The problem of what we used to call narcotic addiction has been around for centuries. It has been a problem long before any modern pharmaceutical companies existed. Whether the narcotic being abused was opium, morphine, heroin, or prescription pain pills the primary driver of narcotic addiction has always been hopelessness and despair. This is true whether it involved the opium dens in China or the slums of London, heroin addiction in the inner cities of the US or opioid abuse by the rural poor of states like Oklahoma or Indiana (where I practice). Supply plays a role in which narcotics are abused, but the underlying problem is a social and spiritual one.

There are many factors that go into the hopelessness and desire to escape that underlies narcotic addiction. One factor is economic. People who are unable to find work to support themselves and have no hope of being able to do so may turn to narcotics to escape. Those who are wounded by broken families and have no hope of being able to find the wholesome family relationships they desire frequently turn to alcohol and drug abuse. It would make as much sense to sue those who have contributed to these economic and social conditions as it would to sue pharmaceutical companies. Should states sue manufacturers who have yielded to economic pressures and have left empty factories scattered around our country while they profit from manufacturing goods overseas? Should they sue musicians who glorified drug abuse in their songs and modeled that in their behavior? Should they sue the entertainment industry that has promoted sexual immorality and the breakdown of families? Should they sue both state and federal legislators who have created a welfare system that promotes dependence and generational poverty?

I do not think that this is the answer. There are many things in our society that have helped to promote the increase in drug abuse that we are dealing with today. It will take all of us working together voluntarily to impact this crisis. Churches, businesses, physicians, hospitals, pharmaceutical companies, and government at the local, state, and federal level will all need to work together to help reduce the hopelessness and despair that underlies the current opioid epidemic. Research and treatment like what will be funded by the settlement of the Oklahoma lawsuit is needed, but working on the underlying problem of hopelessness and despair is essential. Local churches have the potential to impact that most effectively without needing to sue anyone.

Human germline gene editing is not a solution for genetic diseases

By Steve Phillips

I have said this before (see post on 12/5/18), but since otherwise intelligent people continue to say that we should pursue human germline gene editing because it can be used as a means of eliminating the transmission of genetic diseases to future generations, I need to say it one more time. There is no reason to expect that editing the genes of human embryos will ever be a practical and effective way to eliminate the transmission of genetic diseases to future generations.

There are several reasons for this. One is that the elimination of genetic diseases in future generations would require the widespread screening of all potential parents to identify everyone who would need to use this technique for it to actually eliminate a genetic disease. There is no reason to think that that will ever be practically possible and if it were possible it would require an extreme limitation on personal liberty (think Brave New World). If genetic diseases cannot be eliminated using this technique, then what those who take this position must be advocating using it as a means for a particular couple to avoid passing on a genetic disease when they know that they are carriers of that disease. There are additional reasons why gene editing will not be practical and effective for that.

If the couple’s sole priority is to eliminate the possibility of passing on the genetic disorder that they carry to a child, the simplest and most effective way to accomplish that is to choose not to conceive children. That means that their desire to have and raise children would need to be fulfilled through adoption, but it is the most effective way of achieving the goal of not passing on the genetic disorder that they carry. If this method is not chosen, the couple must recognize that they are trying to accomplish two goals, both having their own biological child and not transmitting the inherited disease.

For the large majority of couples trying to accomplish both of those goals the method with the least risk and highest likelihood of success would be creating a child through IVF and using preimplantation genetic diagnosis (PGD) to choose an unaffected embryo to be implanted in born. However, this method carries significant moral concerns related to the creation and elimination of embryos who have the genetic disorder. Some might think that this moral concern would be a reason to choose gene editing instead, but it is not that simple. The development of the technique of human embryonic gene editing will require using human embryos as research subjects who will be destroyed as an essential step in the research to establish the effectiveness of this technique. This means that it is not a morally superior technique for those who are concerned about the value of the life of a human embryo.

If a couple would choose to pursue embryonic gene editing for the purpose of having a biological child who did not suffer from a genetic disorder that the couple carries, there are still other problems. If gene editing is being used to transform an embryo with a genetic disorder to an embryo without that genetic disorder, it would be necessary to be able to determine that the embryo actually has the disorder before doing the gene editing. Except for the case of two potential parents homozygous for a recessive disorder, some diagnostic test would be needed. We can currently diagnose many genetic disorders in a multi-cell embryo produced by IVF by using PGD. However, for embryonic gene editing to be effective in completely removing the genes for a genetic disorder and replacing them with normal genes the best time to do the gene editing is at the single cell stage. Even if it is established that gene editing can be done effectively and safely, it is hard to see how we would be able to establish that a single cell human zygote has the genetic disorder prior to treating that single cell.

For all of these reasons, the situations in which human embryonic gene editing would possibly be the preferred means of creating a child without a genetic disorder would be quite rare. It is much more likely that the technique would be used for enhancement.

Abortion and viability

By Steve Phillips

There has been considerable reaction to the recent passage of a New York State law a regarding abortion. It has been celebrated by those who support a woman’s choice to have an abortion at any time and for any reason and strongly opposed by those who believe that a human fetus has a life that should be greatly valued because he or she has been created in the image of God. The new law basically changes two things in the previous New York State abortion law which led the way in the legalization of abortion prior to Roe v. Wade. One is that it expanded those who can legally perform and abortion in the state to include nurse practitioners, physician assistants, and midwives in addition to physicians. I will not be discussing that here. The other changes have to do with the circumstances under which an abortion may legally be done after 24 weeks gestation.

The 1970 law stated that an abortion could be done legally for any reason prior to 24 weeks, but only to protect the life of the mother after 24 weeks. Why 24 weeks? 24 weeks gestation was considered to be the limit of viability for a fetus in 1970. Today it would probably be more like 22 weeks, but they didn’t change that. What has changed in the new law is that abortion is considered legal after 24 weeks if there is an absence of fetal viability after 24 weeks or to protect the life or health of the mother. This significantly expands the cases in which abortion after 24 weeks can be considered legal. Roe v. Wade already expanded it in the second way. In that decision the Supreme Court ruled that the state could have an interest in the life of the fetus later in the pregnancy that it did not have early in the pregnancy but limited that interest by saying that a state could not say that an abortion was legal if it was done to protect the life or health of the mother. A companion decision made at the same time stated that the health of the mother should be interpreted very broadly to include the emotional well-being of the mother. That left us with the current situation in which the United States has the broadest definition of a legal abortion in the world.

The thing that I find most interesting about the new law is that it keeps the distinction between abortions done before and after 24 weeks and that it adds the condition that an abortion after 24 weeks can be legal in the absence of fetal viability. If the law is going to say that an abortion can be legal at any time during the pregnancy based on the mother suffering emotional distress, why would those making the law be concerned about fetal viability? I think that what is being said by those who have written and passed this law is that until a fetus is capable of living independently of his or her mother the life of that fetus has absolutely no value other than the value conferred by his or her mother. They want that to be contained in the law even if it actually makes no practical difference regarding the legality of abortion. Why is that so important?

I think it is important because the fundamental underlying issue regarding the permissibility of abortion has to do with how we determine who is a person who we are obligated to treat as we would want to be treated ourselves. It is essential for those who support the moral permissibility of abortion and therefore its legality to say that a fetus is not such a person. The best way to do that is to say that an individual is only a person with full moral status when that individual has certain capabilities that are like ours. One of those capabilities which can be fairly clearly defined is viability. If people can be convinced that they should look at capabilities such as viability to determine who we are obligated to treat like ourselves it will distract them from the alternative way of determining that. The alternative is to say that every human being, or every member of the human family, no matter what their level of development or capabilities is a person that we should treat as we would want to be treated ourselves. That means that every human being who is weak, helpless, and marginalized has equal value with the strongest and most privileged of human beings. That is the position of those of us who believe that every human being is important because we have been made in the image of God. That includes everyone who is dependent including those who are dependent to the point of being unable to survive outside their mother’s womb.

The hope of Christmas

By Steve Phillips

Every year at this time I try to spend some time reflecting on the meaning of Christmas and for this blog I try to reflect on how the meaning of Christmas interacts with bioethics. This year the Christmas musical program presented by the choir that I sing in at our church was focused on the themes of hope, love, joy, and peace represented by the outer candles of the Advent wreath that we light each of the four Sundays of Advent. As I have been thinking about the meaning of Christmas I have been focusing on the hope of Christmas.

One of the reasons that I have been thinking about hope is that I see so much hopelessness in the small rural community where I live and practice. Many of the patients that I care for feel hopeless. It can be seen in how the community is impacted by substance abuse and suicide as I wrote about last year. Many would relate the hopelessness to the poor economic climate of the community, and that does have a significant impact on people’s lives. But being poor does not necessarily entail hopelessness. There are many examples of those who are economically poor but rich in hope and joy. Hopelessness comes from a poverty of the soul that is more than just economic. It comes from a lack of positive relationships and positive social interaction. It comes from a lack of anyone or anything in which people can put their trust. Hopelessness comes from seeing that this world is far from what it ought to be and having no reason to think that will ever change.

The message of Christmas is that, even though we live in a broken world that is not what it ought to be, there is a remedy for the brokenness of this world. The way by which our brokenness can be healed came to earth as a baby born in Bethlehem. Jesus became one of us to be God’s clearest revelation of himself to us. His death provided the answer to our brokenness. His resurrection provided assurance of the hope that we can have in him. That is the hope of Christmas. Jesus is the answer to our own hopelessness, the hopelessness of those in our communities, and the hopelessness of the world.