Musings from another nursing home

Like Joe, who wrote Friday about visiting his sister in a nursing home, I was in a nursing home with a family member Saturday. I was there with my mother and father visiting my 97-year-old grandmother who was dying of end stage dementia. Grandma had a gradually progressive dementia and had been unable to communicate verbally for the past year or so.
Thursday my mother had called to let me know that Grandma had become unresponsive and unable to eat or drink. The nurses had asked if they should give her fluids and nutrition by feeding tube or IV. My mother wanted my advice as her son and the doctor and ethicist in the family.
This was an easy ethics consult. Grandma had made it clear before her dementia progressed to the point that she could not make her own decisions that she did not want anything like that done. She had let us know that when it came time for her to die she was ready to go. She had put it in writing as well, but most importantly we knew what she wanted. Even so my mother needed me to reassure her that it was OK to say no. I was able to tell her that doing those things would not change the fact that Grandma was going to die and would just cause unneeded discomfort. Her doctor agreed and she was allowed to ease peacefully out of this life.
When I visited Saturday even the limited ability to respond that she had before was gone. I sat with her for a while with my hand on hers remembering all she meant to me and telling her I loved her. Then we moved furniture. My grandmother and my mother shared being very practical women. It seemed appropriate to take care of things like finding a use for the furniture she no longer needed, so I had brought my truck to haul some things home. I understood it was my mother’s way of coping with losing her mother.
Last night my parents called to say Grandma had died quietly. Later this week we will gather to remember her life and all she meant to us. I will express my thankfulness for her and that she was able to ease gently into the arms of her Lord.

Why Bioethics Needs the Church (and vice versa)

Back in June I wrote a post to let people know about the newly published book Why the Church Needs Bioethics edited by John Kilner with contributions from many people connected to Trinity and the Center for Bioethics and Human Dignity. At the time my appreciation for what the book represented was based on the people involved and what they had set out to do. I just finished reading the book and they have accomplished their goal well.
They titled the book Why the Church Needs Bioethics, but it could easily have been titled Why Bioethics Needs the Church, because what comes through is how bioethics and the church need each other. I found the insights of biblical scholars and theologians such as Richard Averbeck, Kevin Vanhoozer and D.A. Carson particularly helpful in dealing with the issues of infertility treatment, enhancement, and the end of life that are the focus of the book. But many others from areas as diverse as business ethics, counseling, law, intercultural ministry, medicine and nursing, pastoral care, preaching and Christian education brought insights from all parts of the church to enlighten how we see the bioethical issues that people deal with in real life and how the church can play a role in helping them through difficult times. John Kilner, William Cheshire and John Dunlop brought each section of the book together to help the reader see how it all fit.
The church needs an understanding of bioethics to be able to help people as they face bioethical issues in their lives. Bioethics needs the church to enrich its understanding of how biblical truth impacts bioethical issues and how the body of Christ can prepare people for and help people through the bioethical challenges they face in their lives. Those of us involved in both bioethics and the church are challenged to bring those two together for the good of all.

Voting on personhood

The issue of how we define personhood or how we define who has full moral status is one of the most fundamental issues in bioethics. It determines who is included in our considerations of ethical issues. The worldview of Christians who understand the Bible to be the foundation of our understanding of God’s moral truth and who hold to the traditional creeds of the church points to a biological definition of personhood. This biological definition would include every living human being from the time he or she became a separate biologic entity as a zygote following fertilization or its equivalent. This is in contrast to those who would define personhood functionally by the presence of what are considered human attributes.
Next week the people of Louisiana will vote on an amendment to the state constitution that would add the following statement, “Person defined. As used in this Article III of the state constitution, “The term ‘person’ or ‘persons’ shall include every human being from the moment of fertilization, cloning or the functional equivalent thereof.”
For those of us with a Christian worldview the proposed amendment raises two questions. 1) Is this definition correct? We would answer that with an unequivocal yes. 2) Is it prudent to add this definition to a state constitution? The answer to that is less clear. If by adding this definition the lives of defenseless unborn human beings are spared then it is clearly a good thing. If this amendment leads to a reaction at a national level which more deeply establishes personal autonomy as the legal priority over the value of the lives of those who are unable to speak for themselves then more unborn lives may be lost than if it were not passed.
We must always be clear in expressing what we understand to be God’s moral truth. When we venture into public policy we need to understand that we are working in a fallen world where that truth may not be understood and a focus on the self may distort it. We need wisdom to decide how to proceed because what is most prudent may not be clear.

Science and a Christian worldview

Christian bioethics continuously lives at the interface of biotechnology and Christian moral values. Recently some students asked me to talk with them about whether I saw any conflicts between science and a Christian worldview. Their question took me back to the first CBHD bioethics conference that I attended in 2007 and Alvin Plantinga’s talk about that issue. He expressed things that I had understood, but had never heard expressed as well as he expressed them.
Plantinga made it clear that the conflict was not a conflict between Christian thought and science, but a conflict between the philosophy of naturalism and Christianity. He pointed out that many people assume that science, which is a method of acquiring knowledge about the physical world, was identical with philosophical naturalism which says that all that exists and all that we can know is what we can know through the empirical methods of science. However, understanding that science is a proper way to learn about the physical universe does not imply that naturalism is true, and science does not depend on supposing naturalism. In fact Plantinga showed that naturalism forms a very poor foundation for science, because the unguided evolution that must be assumed by the naturalist as the process by which human cognitive processes were formed does not give us reason to believe that those cognitive processes would be reliable sources for truth. (I always knew there was some reason why I liked epistemology.)
It is actually a Christian worldview that provides the foundation that science needs to function. We believe that God has created the universe so that it is rationally understandable and has given human beings the ability to accurately perceive the universe and cognitive faculties that are designed to comprehend truth. Those are the presuppositions needed to expect science to be a valid method for discovering the nature of our universe.
The problem is not that there is a conflict between science and a Christian world view. The problem is why someone without a Christian worldview would think that science is a reliable source of truth.

The Help and what it means to be human

I am currently reading The Help by Kathryn Stockett. I saw the movie first and as I read the book it really is true the book is better, even though the movie is very well done. For those who haven’t done either one, the story is about a young white woman in Jackson, Mississippi who decides to write a book that tells the stories of African American maids working for white families in Jackson in the early 1960s. But the book, like her book, is mostly about those women and the truth of what their lives were like.

As I experience their lives in the midst of the novel I have been thinking about the ethical issues that were going on during the turbulent times of the civil rights movement in the sixties. The major issues revolve around what it means to be human and how one human being should treat another. That resonates with what is at the heart of many of the issues we face in bioethics today.

Aibilene is the first of the maids to agree to tell her story. Interestingly she is a woman with a strong Christian faith who writes out her prayers to God and sees him answer as she expresses her concern mostly for others and occasionally for herself. She models virtues of love and compassion while hurting from the injustice of life in a world where she is not seen as a person of full moral value. She is not perfect, but her virtues and endurance under hardship demonstrate a humanity that touches me. It is amazing that as a society we could have told her she was not fully human.

How many are being told today that they are not fully human by the things our society chooses to do?

Privacy and the risks of IVF

A recent article in Toronto’s National Post tells of the experience of Dr. Rosanna Weksberg, a University of Toronto geneticist, when she presented a talk on the need to study risks associated with IVF (in vitro fertilization) to the Canadian Fertility and Andrology Society. Her talk related her experience in seeing an increased number of children with rare genetic disorders among children conceived by IVF. Some of those disorders are seen as much as 10 times more often in children born by IVF.

She expressed her concern that follow-up studies of children born by IVF are needed. The reception from the meeting of fertility specialists was polite, but no interest in her proposal for study was expressed. She said she has been trying to find fertility clinics willing to partner in studies of children born with the help of reproductive technology, but has not found any willing to work with her. A spokesman for the fertility society said they were interested, but that clinics could not afford to fund research.

In the United States assisted reproduction is a 3 billion dollar a year industry, but like in Canada there is no accurate information on the risk of genetic disorders, birth defects, or other increased health risks of the children produced by these procedures. Our culture has set apart everything having to do with sexuality and reproduction in a domain protected by privacy. That protection is so complete that it causes assisted reproductive technology to be entirely unregulated and makes any attempt to study the outcomes of the children produced exceedingly difficult. We need to recognize that, even though privacy in reproductive decisions is important, people cannot make responsible decisions without good information. Those contemplating the use of assisted reproductive technology need to know what the risks are for the children they bring into the world. They owe it to their children.

Ethical Blind Spots

Recently I have been impressed with how much there is for those of us who are involved in bioethics to learn from those who study other areas of ethics. Business ethics in particular has a lot to offer. A recent article in The Age discusses a book titled Blind Spots written by Max Bazerman, a professor of business administration at Harvard Business School, and Ann Tenbrunsel, a professor of business ethics at the University of Notre Dame, that discusses the concept of unintentional ethical misbehavior.  They talk about how we can behave unethically without being aware of it by excluding important and relevant information from our decisions.
One of the examples in the article is medical.  It involves a person with cancer who goes to a surgeon who recommends surgery and then to a radiation oncologist who recommends radiation therapy.  It could appear that each specialist is being intentionally self-serving, but they suggest that it is possible for both specialists to genuinely believe that their treatment is superior.  They can fail to realize that their opinions are biased by their training, incentives, and preferences.
It made me think about how I may do the same thing.  As a family physician I have a bias toward treating things I can diagnose as medical diseases with medicines.  I try to incorporate other things such as counseling and physical treatments such as exercises and physical therapy, but since those are not the things I was trained to do, I may not use them as much or as well as I could.  It is easier and more comfortable to prescribe a medicine.  To make ethically sound recommendations about what is in a patient’s best interest we need to be aware of our own biases and be sure to encourage input from others who can see the patient’s needs from a different point of view.

Why do people buy snake oil?

There a lot of ethical concerns about stem cell research.  Many have to do with the destruction of embryos for embryonic stem cell research.  Those of us who oppose embryo destructive research frequently promote the potential for adult stem cell research as a better and less ethically problematic alternative.  But adult stem cell therapy has a different problem. It is becoming the most recent version of snake oil.

While legitimate research involving adult stem cells should be supported, everyone from Texas Governor Perry to Indianapolis Colts quarterback Peyton Manning have been getting unproven adult stem cell treatments outside of valid research protocols.  Why would otherwise intelligent people subject themselves to unproven and potentially risky treatments?

Part of it may have to do with our human tendency to believe that something is true when we strongly desire for it to be true.  Our desires can be so strong they cloud our ability to reason and there are plenty of people who understand they can take advantage of that for their own profit.  They sell everything from snake oil to mangosteen juice to stem cells to people whose desire for a cure makes them vulnerable.

Another part may be our society’s unrealistic belief that scientific medicine should be able to cure everything.  Researchers’ hopeful expression of what may be possible with treatments such as stem cell therapy can make people with medical problems for which there are not effective treatments susceptible to trying an unproven treatment because of that potential.

Then again there is always the possibility that an unproven treatment may work.  Snake oil was actually a traditional Chinese remedy that used the fat of the Chinese water snake that was high in a prostaglandin precursor to help relieve inflamed joints.  When used correctly it may work.  Adult stem cell therapy may turn out to be effective for some of the things it is being used for by those selling unproven treatments.  But we won’t know unless those treatments are done in properly controlled trials.

Ethics and Worship

Sometimes I think evangelical Christians get confused about where ethics fits in the Christian life.  Why is it so important?  We understand that we are fallen and that there is nothing that we can do to merit God’s favor.  Salvation is a gift of God’s grace accomplished fully by Jesus’ sacrificial death.  Ethics can be seen as a set of moral laws that we are obligated to live by, but which we all fail to keep.  Why focus on the law when we have God’s grace?  Doesn’t God accept us just as we are?

The answer is worship.  While none of us can merit a relationship with a holy God through living morally perfect lives, those who have been redeemed by God’s mercy and grace desire to worship Him.  Romans 12: 1-2 tells us that we should respond to God’s mercy by presenting our lives to Him in worship.  We should desire to be transformed so that the lives we present to Him in worship are lives being lived in conformity to his good and perfect will.  Ethics is about how we should live to conform to what is good and right.  It involves living lives conformed to God’s good and perfect will.  We can’t do it on our own, but we can allow Him to transform us so that we do not conform to the immoral patterns of this world, but have our minds renewed with an understanding of what is good and right.

A Lesson from the “Ethically Impossible” Guatemalan STD studies

Yesterday the Presidential Commission for the Study of Bioethical Issues announced the release of its report titled “Ethically Impossible” detailing its investigation into the U.S. Public Health Service studies conducted in Guatemala in the 1940s that involved intentionally exposing vulnerable populations to sexually transmitted diseases without the subjects’ consent. They concluded that “the Guatemala experiments involved unconscionable basic violations of ethics, even as judged against the researchers’ own recognition of the requirements of the medical ethics of the day.”  Commission Chair Amy Gutmann said, “A civilization can be judged by the way that it treats it most vulnerable individuals…in this dark chapter of our medical history we grievously failed to keep that covenant.”

It seems to me that people are likely to respond to this report by saying, “Of course that was wrong.  No one would do that today.” But I think the most important lesson to learn from the report is why those who approved these obviously unethical studies did so.  The report shows that they justified what they did by citing the urgent need for proven methods to treat and prevent STDs in the military forces fighting World War II.  They were being good utilitarians.  When there is much good that can be done for many people by doing something it is easy to overlook those who are being hurt and whose inherent value as human beings is being ignored.

It happens when the need for organs to be transplanted causes people to suggest paying donors for their organs without considering the value of those who will be exploited.  Or when the desire to provide cures for spinal cord injuries or Parkinson’s disease leads people to destroy embryos to use their stem cells for research.  If we focus solely on what we can accomplish without being concerned about protecting those who are unable to protect themselves we fall too easily into immoral behavior.