Care Dis-integration

The May 3rd edition of the New England Journal of Medicine brings us a powerful story. It is a tale of a patient, named Kenneth, written by his physician brother.

Central to the story is a delay in diagnosis, brought on by unfamiliarity with the patient as a whole person, biases against those with mental illness, presumptions and other errors familiar to those of us with an inside view of what can go wrong. The healthcare system allows these to occur through its “dis-integration.” From the story:

Rosenbaum highlights the larger problem: “Care integration is an attitude.” But this “attitude problem” affects countless U.S. patients, not just those with mental illness (or severe physical disabilities, like quadriplegia).Whose attitude, then, needs adjustment? Many doctors and nurses seethe about the profit-driven dis-integration of our health care “market” yet insist they can’t fix this mess themselves. Kenneth, no stranger to cognitive dissonance, said, Well, if they can’t fix it, who the hell can? This question becomes more urgent as our health care system’s balkanization becomes increasingly “normalized.”

I have just seen this up close. A friend of mine has a terminal illness. While he has long been well-served by his family physician, the onset of the illness brought specialty care, extensive and repeated imaging, hospitalizations, a rehabilitation facility, and no more contact with his physician. It also brought delayed diagnoses which seemed avoidable had he been seen regularly by someone who knew his story and his usual condition.

Wasn’t such familiarity what we always had hoped would come from the “specialty” of family medicine? And that years of familiarity would lead to an understanding no stranger could have? Such an understanding would give us what we longed for in medicine, such as more efficiency, avoidance of excessive and intrusive testing, smoother transitions of care, more acute perception of changes (and quicker diagnoses), and better advice.

Increasingly, however, the family physician of today can no longer fulfill the promise of the profession from decades past. Financial constraints keep him in the clinic exam room, efficiently churning through patients within a narrowing scope of practice— no longer on the wards, or in the nursing home, or performing obstetrics, or even seeing children under two. Unable to venture out because time (equals money) would be lost, he is no longer involved in the care of his patients when they need something beyond his clinic. And it is in those intense moments that he is needed the most.

I would like to have a simple answer. Kenneth’s question stings: “Well, if they can’t fix it, who the hell can?” The financial pressures are enormous, however. Costs are up for countless reasons, and to keep the money flowing, a physician becomes the engine that must keep running… inside the engine room that is the modern day clinic.

Perhaps nothing short of a major disassembling of our medical system will change that. Such change may only come from catastrophe; even then any rebuilding would take a level of insight and courage…and preparation…that are unlikely to appear in future leadership under modern pressures. If we’re ever to move toward a dream of “care integration,” however, we’ll have to start somewhere– with understanding where we are, how we got here, and where we ought to go.

What are the Ethics of Avoidance?

Mark McQuain, in his February 21st blog post, discussed an interesting article which proposed that ethical decisions be made by robots. Although the author’s specific arguments invite numerous responses, underneath these arguments lies the question: why does modern man spend such effort to use technology to rid himself of yet another intrinsic function of his existence?

It seems to me that this wish to pass off ethical decision making is a prime example our drive to divest ourselves of difficult, painful, messy, and often guilt-inducing work in our moral and spiritual lives.

J. Budziszewski described this problem in his book What We Can’t Not Know when he wrote, “…two universals are in conflict: universal moral knowledge, and the universal desire to evade it.”

If we look closely, behind the artfully constructed arguments heavily refined in postmodern academia, is an unspoken motive of moral avoidance–the desire to distance oneself from the emotionally painful or otherwise costly consequences of man’s existence. Technology has already been used quite well to help us avoid other discomforts— why not to help us avoid emotional discomfort as well?

For example, how many instances of discussion of physician-assisted suicide are really driven by the physician’s, family’s, and government’s sense that their lives would be so much easier if this person would just die before things got messy? How neatly this prevents emotional strain on the part of everyone besides the patient. The all-too-well-developed arguments invoking “compassion” and “dignity” are in fact contrived as a veneer to cover this motive.

And here abortion is the close cousin of assisted suicide– far better to promote “choice” than to deal with the unpleasant social consequences of unwanted pregnancies. Think of all the tough decisions we can avoid!

Of course, if there are ways to reduce or mitigate ethical dilemmas, it is reasonable to pursue those. But the article does not describe avoidable dilemmas, only a desire to avoid poor decision-making. The author states, “I don’t want it to be human. I want it to be true to its code.” But this is really avoidance of the difficult task of developing one’s own code. It is avoidance of moral decision-making, and of the hard consequences across one’s entire life once one does adopt a code. Such as if one decides to become a Christian–quite a few lifestyle decisions to make, if one truly means it. How easily we might avoid such personal decisions if we rely on a computer code instead of a personal code. But the problem is not lessened, it is just passed to others. In this article’s case, it’s passed into the hands of programmers. Or, unless computer programmers have taken a larger interest in ethics that has been heretofore apparent, into the hands of their ethics consultants.

What drives man to such avoidance? We could find any number of man’s base drives among the reasons–selfishness, greed, sloth…but among these must be fear. Fear of emotional inadequacy, fear of being wrong, fear of one’s own mortality, fear of the tough personal consequences if one were to admit what is in fact is the right thing to do. Too little in our society, or in man’s existence itself, do we admit that we are just plain afraid.

For Want of a Letter…

If one were seeking to transform our culture, he would aim for approving proclamations from officials to codify his desired belief system. The example that comes easily to mind is the President, which would then mean, of course, the Executive Branch of the federal government. Next, perhaps, would be the judicial system. Even more demonstrative of transformation would be the official policy of the US military, which lives or dies on whether it has a clear-eyed view of the world. Add to that the medical profession, which acts as a “Bureau of Standards” for the physical and psychological states of man. If the topic at hand is the redefining of gender identity, then today we have a fait accompli.

Recently, however, I witnessed a more striking albeit less public marker. At a recent conference I heard someone give a brief testimony of her daughter’s transition from female to male, and in describing her daughter, the speaker used the word, “he.”

What on earth, I thought, could make a mother speak so, a mother who carried the kicking fetus, sonographically identified as female, then birthed the child among witnesses who declared her identity, then nursed, clothed, fed, taught, loved, all with a knowledge of her identity so certain that to question it would have been too ludicrous to even come to mind?

The answer came shortly, as the speaker told of her daughter’s subsequent suicide attempt. The mother’s loss of her child–a story told countless times in print, on stage, and in film, is the greatest of tragedies. So tragic that a mother would give anything to prevent it–her own life, or her own concept of her child’s gender.

The suicidality itself is revealing, in that the rejection of self that finds its ultimate expression in suicide is preceded by the attempt to destroy one’s identity. But don’t wait for the medical profession to explain it. Gender reassignment is made increasingly with little more than a request, as a result of prompt referrals to those quite willing to facilitate the changes. It is a tragedy in itself that the profession abandons difficult inquiry in favor of declaring that the fault lies in organs that can simply be removed.

One writer who grasped the enormity of modern cultural transformation was Whittaker Chambers (1901-1961). Although the enemy he faced was Communism, make no mistake about it–Communism and this transformation of the meaning of gender are but two branches of the same philosophical vine. Chambers’ unique experience and talent made him powerfully insightful and articulate about the state of modern Western civilization. He quoted the German psychiatrist Karl Jaspers (1883-1969): “Quietly, something enormous has happened in the reality of Western man: a destruction of all authority, a radical disillusionment in an over-confident reason, and a dissolution of bonds that makes anything, absolutely anything, seem possible . . . ”

A mother drops a single letter in describing her child. It might as well have been an earthquake. Yet the significance will slip past us, we who are too busy trying to keep our frenzied lives together to recognize the fragmentation of the very cultural foundation upon which we stand. As Chambers said, “I am constantly baffled because so few seem to grasp the enormity of our situation, which is defined by the certainty that there is no way out of it that can possibly be simple, easy, familiar, usual, in terms of anything we have known before. ” Chambers saw us as, “a civilization foredoomed first of all by its reluctance to face the fact that the crisis exists or to face it with the force and clarity necessary to overcome it.” (Witness, p. 155. Regnery Publishing)

And why?

“It is the first century since life began when a decisive part of the most articulate section of mankind has not merely ceased to believe in God, but has deliberately rejected God. And it is the century in which this religious rejection has taken a specifically political form, so that the characteristic experience of the mind in this age is a political experience. At every point, religion and politics interlace, and must do so more acutely as the conflict between the two great camps of men— those who reject and those who worship God— becomes irrepressible. Those camps are not only outside, but also within nations.” (Witness, p. 386)

Man declares himself the Creator. Or perhaps the “Re-creator.” He exercises all political authority to achieve social conquest. But as this case reveals, the transformation of gender identity is far more than the simple exercise of personal liberty. It is the destruction of human identity itself. Small wonder that gender identity transformation too often precedes suicidality. Unless we make a stand, our civilization may be close behind.

From a Nighttime Ride

Not long ago, on a nighttime ride through the Nicaraguan countryside, the members of our small medical team could not help but notice the sky. Away from the dense electrical grid of the US, we could see the stars as our ancestors did. Imagine, for example, the Jews in the Sinai– ascending the mountains under the clear desert sky of old…what an amazing sight they must have seen. How could they not be in constant wonder, thinking about all of creation and the awesome power of the God who made it?

That’s not how we of modernity view the world, of course. We created our own lights on earth that blot out the ones in the sky…and now even create our own universe which we carry in our pockets or on our hips. We even create our own creatures, if you know anything about Pokemon Go. We manipulate our own bodies, and dream of changing even our DNA, all to make ourselves masters of our fate, our own saviors, the creators of our own existence.

This is nothing but blind self-pride, by which man lays his hopes on the altar of science and our own creations.

But I think that while many study science, few truly learn its lessons. Few contemplate that science has revealed the number of stars in the universe is far beyond the thousands our ancestors saw, and may number 100 octillion. The discoveries of science should make us humble, not self-proud, and even more amazed at the power of God.

I remember in medical school, as we learned embryology, the formation of a person in just a matter of weeks, we commented to each other that it was remarkable that it ever turned out right—that there is too much required, too much precision needed in time and space.

Such knowledge should lead to greater faith, not less.

Even something in the practice of medicine such as giving a pill should be understood as an article of great faith—that this chemical could permeate the complexity of the human body and achieve our intended good.

So this is perhaps the unspoken lesson of science: to understand that the only reason we are more than the dust on this earth, from our original creation as mankind to our own ultimate end, is because of a Creator of incomprehensible power and goodness.

This then becomes our commission in modern society—and the necessary foundation of the field of bioethics: to tell and show others, through our words and deeds, that to be created in God’s image is a reflection of his glory, not ours.

The Lost Narrative

In their article “Autonomy vs. Selflessness at the End of Life” published in the Summer 2015 edition of Ethics & Medicine, Hannah Martin and Daryl Sas provide a useful foray into the battle over the meaning of human dignity.

The authors describe an alternative to the “flat” version of human dignity espoused by proponents of physician-assisted suicide (PAS)—a version based solely on self-determination. In other words, a human dignity reliant only on autonomy (or, control) in decision-making lacks the depth and breadth inherent in the actual human experience. Our own individual creation ought to be sufficient to convince anyone of our lack of control over the nature of life, and brief reflection on the sheer improbability that there is any life at all should be enough to cause one to ask if there is some other force behind it.

I would add that the concept is not just flat but paper-thin, and bases its appeal on what could be called “the lost narrative.” Martin and Sas refer to the “poignant narratives of dying” that drive state laws legalizing physician-assisted suicide. These narratives succeed when we fail to articulate an alternate, and in fact, accurate view of the human experience of dying.

The authors help greatly to provide the alternative, a view in which dignity is based on virtues such as love (and its selflessness), courage, humility, and blessings such as God’s grace. Without these, autonomy will push us towards the extremes of “absolutizing life’s sanctity by claiming autonomy in life and…absolutizing life’s dignity by grasping at autonomy in death.” In fact, without God, mankind could never find balance, but instead be driven (as we seem to be) toward the extremes.

And without proper balance, where would someone establish the threshold of sufficient suffering to warrant early death? And if selflessness is removed as motive, what horrors might the medical profession produce? The “suffering” of family members and medical staff would enter into the equation (unchecked by selfless love) and push the patient toward an earlier and earlier death.

For the proponents of PAS, suffering is only bad. Human dignity becomes simply avoidance of what we can’t control. Such a view robs mankind of any hope that anyone can be anything more than the person who flips his own switch. But for those of us who have been in the presence of dying, we have had the opportunity to see for ourselves what is and is not dignified. We see it in the selfless love of caregivers, of family, and of the dying, all cherishing those final moments, wishing there were more to spend together, and never ready to end it all too soon.

Oh, Those Darned Terms!

In a recent post Jon Holmlund cited Thomas B. Edsall’s op-ed in the New York Times, “The Republican Conception of Conception.” Edsall was referring to the concept that life begins at conception. It is his hope that Republicans either stake a consistent position regarding the morality of post-conception “contraception” and incur the disfavor of the electorate, or abandon their “moral purity” in favor of “pragmatism” and agree that post-conceptional interventions are acceptable.

Edsall’s states it thus:

By this logic, a presidential candidate seeking to live up to the standards set by Sedlak and others in the anti-abortion community must then agree that the IUD and morning after pill cause abortions.

The problem is that Edsall challenges GOP candidates to take an informed and consistent position, while depending on the electorate not to. His strategy relies on manipulative use of terms to produce the opposite of clarity in moral reasoning. First, he speaks of medical interventions described as “contraceptives” that act in ways beyond merely preventing conception. But he does not give them the label “abortifacient” (the proper term for an IUD should be “contraceptive-abortifacient”); the term is simply omitted. That is the best way, of course, to ensure that users of devices such as the IUD are unaware that it may act after creation of an embryonic being.

Such a position is facilitated by ACOG’s definition of pregnancy as beginning at implantation, which Edsall also hangs his hat on. This is a willful dodge. “Pregnancy” refers to the state of the woman. To claim that pregnancy doesn’t begin until implantation fails to refute the notion that an embryonic human being is in existence before then. So the woman isn’t “pregnant”….the human being is still alive, moving toward implantation. And, if the woman isn’t “pregnant” during the time after the embryo is fertilized and before it is implanted, what is her state? Is it not different than before she conceived? Does that not deserve a name? The absence of a name for such a condition is no accident, because the unnamed state is far more difficult to assign a moral status to.

This same “reasoning” behind the proposed bill in the California State Legislature  also recently mentioned in this blog by Jon Holmlund:

“The bill would provide that nothing in its provisions is to be construed to authorize ending a patient’s life by lethal injection, mercy killing, or active euthanasia, and would provide that action taken in accordance with the act shall not constitute, among other things, suicide or homicide.”

So, according to this draft bill, one can take one’s own life and not commit suicide. The attempt to separate the actions that this bill would legalize from the term “suicide” is to attempt to prevent citizens from properly interpreting those actions using the moral values they have already acquired.

Are moral discussions about conception, contraception, abortion, and assisted suicide too painful for our electorate, having what Edsall describes as “its complex views and…pragmatism”? For many, yes, as proven by our unwillingness to clarify the terms needed to elucidate the moral issues regarding medical interventions blocking implantation. However, such discussions are not unwanted by all, but simply unknown to them. Remaining uninformed by the medical profession of the mechanisms of action of “contraceptives,” they are never given a chance to make an informed moral decision. Edsall (to achieve his desired virtue of consistency) would more properly make his challenge to all of us, to demand that each voter take a stance on the morality of embryocidal interventions. It is only then that they could properly interpret the candidates’ responses that Edsall so fervently desires.

Seeing the Horror

A video released by The Center for Medical Progress (CMP)  about Planned Parenthood included these words: “Some viewers may find this content disturbing.” It was to warn the viewer about the images of piled fetal body parts dumped from a bag by an abortion clinic worker.

What might be most disturbing…and chilling…is not the body parts, but the casual and glib attitudes of the Planned Parenthood staff toward them.

A subsequent post  in the Bioethics Forum of The Hastings Center attempted to explain away this indifference:

…most of us also don’t want to see graphic photos of any other type of surgery either. But our desire to look away isn’t inconsistent with thankfulness for the life-saving and health-preserving results of any type of medical procedure. It just means we don’t want to watch their gory accomplishment. But physicians don’t have the privilege we have of enjoying medical results without seeing the unpleasant in-between.

I suspect that the author hasn’t watched all the videos. And I’m not sure what purpose bioethics institutes will serve for our society if they harbor notions that fetal vivisection is comparable to “enjoyable” medical results that are “life-saving and health preserving.”

Yes, as a physician, I can see body parts…and worse…without passing out. But every physician must recognize the moral significance of the connection to the human, or else the profession of medicine is not a moral endeavor. In contrast to attitudes of the abortion clinic workers, in the CMP’s videos, the former StemExpress employee Holly O’Donnell expresses a depth of moral insight to recognize that each of these aborted fetuses was more than just a “tissue opportunity.”

It had a face…I remember picking him up…he was big…I remember holding that fetus in my hands when everyone else was busy…It’s really hard knowing that you’re the only person who is ever going to hold that baby…I would think about things like that…I wonder at age 3 if she would like a color…or I wonder what it would look like, her mom or her dad…

Planned Parenthood’s brutality is the logical consequence of Dr. Alan Guttmacher’s (former president of Planned Parenthood) belief, subsequently effectively written into law by the Supreme Court, that “…no baby receives its full birthright unless it is born gleefully wanted by its parents.” Yes, Planned Parenthood and its supporters are being purely logical. But pure rationality in the face of human dismemberment is no virtue. Watching Planned Parenthood staff speak of selling fetal body parts, I am reminded of G. K. Chesterton’s words in Orthodoxy: “The madman is not the man who has lost his reason. The madman is the man who has lost everything except his reason.

From Binary to Countless Fragments

In the Republican presidential debate on August 7th, former governor Mike Huckabee was asked about the federal government’s plans for inclusion of transgender people into the military. In a less-than-articulate objection, Huckabee stated, “The purpose of the military is to kill people and break things.” He did in fact then add, “The purpose of it is that we protect every American.”

Indeed, the purpose of the military is to defend the citizens and nation of America by using all necessary force; but the expectation of the American citizen is that its military conduct itself in a manner consistent with the values of the nation. While what those values are precisely could be long debated, it is evident that the notion of character distinguishes Americans who engage in war from those of other groups or nations, such as ISIS, or the Japanese military during World War 2.

This is a difficult standard to keep. To maintain integrity and courage in the most extreme situations requires a level of character beyond what America expects of its average citizen. This is because consequences of failure to do so become intolerable, as we’ve seen in My Lai and Abu Ghraib.

The question then becomes whether the federal government should endorse transgender behavior as neither obtrusive nor burdensome to military functions and operations, including relationships and therefore unit morale and cohesion. This includes all potential intense military situations and relationships of any contingency to which servicemembers may be called. It is a question of whether transgender behavior is perfectly normal.

That the transgender community has achieved a standing in enough minds so as to gain the ultimate political advocate—the President of the United States—is a remarkable success for it. Yet this modern re-definition of what men and women are has been allowed to proceed with a lack of scrutiny that in itself is remarkable…and tragic.

It is tragic because the failure to scrutinize in fact abandonment. First, it is an abandonment of the intellect. The profession of medicine is failing to critically address the phenomenon of gender redefinition, apparently unable to see that its recent explosion indicates it is a sociologic phenomenon, not a biologic one. There is a lack of intellectual scrutiny within the medical community of the psychology, philosophy, and cultural dynamics fueling this trend. Part of the phenomenon is the deliberate alteration of definitions of deviance within modern psychology by those who know that our postmodern society has abandoned other sources of inspiration for proper human conduct. The subsequent conclusion of the secular mind is that if something isn’t defined as a mental illness it is therefore normal and appropriate.

Also unscrutinized is the intentional media and social influence on the pliable mind of America’s youth, who are clearly targeted by proponents of modern transgender theories. This means that we have also abandoned our youth, who are lured by this zeitgeist into decisions that can’t be unmade. Far from being liberating for them, gender mis-identification is terribly restricting, in that it limits one to the confined, pre-occupied, and unstable world of gender re-identification. It increases social isolation by eliminating predictability and increasing uncertainty in interpersonal relationships, causing others to keep a greater distance.

Finally, it’s an abandonment of society itself of its own means for survival. No society can turn a blind eye to the importance of natural gender to its peaceful and capable functioning and yet survive. In fact, I’m hard-pressed to find another issue more important to a society than its interpretation of what a man and woman are. But that is what we’ve thrown to the winds.

Now that we’ve de-normalized heterosexuality and binary gender identity, have we completed our deconstruction of man? I fear not, but lack the imagination to foresee what could possibly be next. Or perhaps the social consequences of abandoning natural gender will become painfully apparent. Perhaps we will see that gender reassignment surgery is the frontal lobotomy of the 21st Century—a procedure hyped with great promise but destined ultimately to fail. However, the rapidity and lack of adequate scrutiny of this latest postmodern cultural phenomenon indicates that, unfortunately, many will pay a heavy price to learn its lessons.

The Physician’s Imprimatur

In a previous blog response about physician-assisted suicide (PAS), Mark McQuain asked, “Why involve physicians at all?” That question gets too little attention.

There are some easily discernible (and perhaps expressed) reasons why physicians are chosen to be the agents of assisting suicide. First, they have access to pain- or consciousness-relieving pharmacologic measures that also have the (in this case) desirable effect of stopping breathing when given in high enough doses. Second, by their professional ethic, physicians should approach patients with compassion, which, as mentioned previously, is the catchword that is quite deliberately attached to the act of assisting suicide by those who promote it.

But as Dr. McQuain suggests, access to painless methods for killing need not be restricted by to physicians, just as compassion is not; there is no law of physics that prevents others from assuming this role. To limit the methods and the responsibility to physicians is a willful act by society.

This leaves one main reason for committing the responsibility of assisting suicide to physicians: involvement of physicians gives it a much-desired moral certification, or imprimatur. Here is the logic, unspoken as it is:

  • Physicians have moral standing;
  • If physicians are involved,
  • Then the act has moral basis

But this gets it backwards. Physicians have moral standing based on what they do and what they refrain from doing. Edmund Pellegrino wrote often of the “intrinsic morality” of medicine which depended on the nature of the physician-patient relationship. Such morality stems as much from what is not done as from what is done.

We need not agree upon any particular bioethical issue to realize the significance of the tactic, in how it can could be used by proponents of various acts to enlist, and yes, even pressure or legally mandate, the involvement of physicians. Or, for that matter, the involvement other people whose life work is viewed by society as having moral standing.

If PAS were to be legal across the US, would physicians buy into the idea that it is consistent with the underlying ethic, or intrinsic morality, or their practice? I predict that most would not. Recall the vision of abortion (when first made legal by judicial decree) being done by the patient’s family physician, which presumed a longstanding benevolent and wise relationship. This of course failed to happen, and abortions have since become centered in facilities where patient and doctor remain, by no accident, strangers. Most physicians do not want to be associated with abortions ( and none of the many family physicians I’ve met) because they know that there is a quality to the act that impacts them; it would not be benign simply because they did it. And it is not consistent with the underlying moral and ethical basis for their medical practice.

So it will be with physician-assisted suicide. The strategic involvement of physicians will most certainly mean that some will be involved. But most who could be involved will decline, knowing, or at least sensing, the inverted logic behind how physicians got pulled into the affair to begin with.

The Issue of Physician Motive in Physician-Assisted Suicide

Two responses to my June 8th post provide useful points of departure for further discussion about physician-assisted suicide (PAS). The first respondent argued that the Hippocratic Oath states that physicians should not give a “poison,” as opposed to stating that they should not give a “deadly drug.” The respondent’s claim was that inherent in the term “poison” was malintent, which would make the causation of death an act murder and not PAS, which could be an act of compassion.

I believe that in fact “deadly drug” is the more accurate translation of the original Greek. Regardless, I would ask how the definition of the word “poison” differs substantively, in either a linguistic or ethical perspective, from the term “deadly drug.” Even if the respondent’s claim were correct, it would be interesting to see how one would argue that Hippocrates would disapprove of a physician giving a “poison” while not disapproving of giving a “drug that causes death.”

It is useful to cast light on the attempt to use terminology to give a deed a hue of credibility by taking advantage of connotations. What seems to be happening in the debate over PAS is that the deed is cast as morally permissible if the motive of the physician is one of compassion. Therefore, the language supporting PAS is molded to convey that sense.

In fact, the Oath does not take physician motive into account. This is an important distinction, and I believe that this omission by Hippocrates was deliberate. He would have known that regardless of claims of PAS proponents, there is no possible way to ascertain or guarantee physician motive. Physicians performing PAS might sincerely believe they are performing a compassionate act, or they could have a grotesque fascination with death, as did the infamous Dr. Kevorkian. Given the intense interpersonal dynamics present in medical care, to permit PAS is to permit undesirable motives that then in subtle or flagrant ways will influence patients (as all of us are influenced by the beliefs of those around us).

Finally, I would argue that it is not clear that physician motive is all that relevant to those desiring PAS. We can draw from the example of pro-abortion advocates, who have moved to the claim that abortion should be available on demand, and that the moral position of physicians is irrelevant. So would it be with PAS: should the movement follow this predictable course, the physician would be relegated to a position of a mere provider of a service demanded by a customer.

If legalization of PAS continues, I predict that as with abortion, physicians will likely divide into three groups: those that are vehemently opposed, those that embrace it as part of their medical practice (out of compassion, we’d hope, but could never be certain), and those who do not express vehement objections but sense that it is contrary to the logic and coherence of their view of their participation in the profession.

This brings us to the question raised by the second respondent to my post, who asked why it was necessary to involve physicians at all, as suicides don’t usually seem to require them. I will discuss this in my next blog post.