How Far Can We Fall If There is No Bottom?

A May 26th post in the Bioethics Forum of The Hastings Center asks “Are we reaching a tipping point in the debate over physician aid in dying?” The author cited the case of a Cornell psychologist who opted to commit suicide with physician assistance before Alzheimer’s caused her to lose “all quality of life” and “meaning.”

Cases such as these are compelling, because aging, infirmity, and dying are so. Each instance causes distress, and to remove distress seems to be the ultimate humanitarian act.

We must ask, however, why Hippocrates thought it necessary so long ago to include in the physician’s oath the injunction against assisting suicide. What was it he saw that made it necessary to draw this bright line? Certainly suffering was at least as common then, as physicians did not have nearly as many tools to alleviate it. For Hippocrates to draw this line in the face of suffering, he would have had to see how far physicians could go in willfully causing their patients’ deaths, and the consequences of such actions on the profession, the community, and the relationship between them. We don’t see such problems today, as we are still living off the fruit of that ethical standard.

In ethics we ought to consider the importance and value of clear lines such as those written into the Hippocratic Oath. They do not guarantee that nothing undesirable will happen. They do, however, serve as a floor, guaranteeing that professional conduct will only fall so far. If removed, what then becomes the insurance that we will not step lower and lower?

Many years ago I spoke with the head of a large shelter for the homeless. He had an impressive background, retiring from the Army where he had served in the Rangers. Driven by the imperative of his Christian faith to aid his fellow man in need, he had become a nurse and eventually in charge of this shelter in a Georgia city. I asked him what was it that he saw that worried him the most. He said, “Youth today have no bottom.” After I asked him to explain, he said that many youth so lacked any moral foundation that there was no depths of depravity to which they couldn’t fall. A few months later was Colombine.

We could debate in detail each of the author’s premises, such as claims as to what is “quality of life,” or “meaning,” or the role of physicians. One thing we must recognize, however, is that line drawn so long ago by Hippocrates has served as a “bottom,” preventing physicians from plumbing the depths of increasingly abhorrent acts. In discussions of PAS, proponents of it extract the positive feelings and leave the scene before the unpleasant consequences emerge. Hippocrates must have known those full well, and with that knowledge wrote his oath. I fear that we will soon regain that knowledge…the hard way.

In Memoriam

Memorial Day serves as a holiday so that, we might hope, we pause to remember those who gave the ultimate sacrifice for our freedom. We might take a holiday from thinking about things bioethical as well. But could this day hold a lesson for the field of bioethics?

To set aside a day to remember those who died in defense of freedom is not simply to make some gesture for the fallen; what we do today is of course meaningless to them. To think upon those who have passed away, especially those who died for our freedom, is to set aside time to wonder what that means for how we should live. There is no better incentive for a man to ponder what he ought to do with his life then to be reminded how easily it is lost. And if someone dies for us, then we must ask—was it worth it? What features of character and conduct must we have to merit such a sacrifice?

Perhaps the best-known modern portrayal of this idea is in the movie, “Saving Private Ryan.” As he lay dying, Tom Hanks’ character utters the words to Matt Damon’s character, Private Ryan: “Earn it.” The movie then shows the older version of Private Ryan in sorrowful remembrance, asking if he had in fact done so.

If we think about various issues in the field of bioethics, we can recognize that there are those who have made the ultimate sacrifice as well. We could consider victims of medical experimentation, perhaps. We might also consider the nearly invisible—the human embryos also sacrificed for experimentation or convenience. But there is one group whose ultimate sacrifice comes foremost to mind this Memorial Day—the aborted. These millions are far more numerous than any other group of Americans that has lost their lives for our freedom.  Of course, we could argue whether this is truly “freedom” that abortion has provided, but that is how it is justified to us.

So what features of character and conduct would render us worthy of that which has been sacrificed? It is impossible to come up with any that are consistent with nature of the act of abortion itself. For to be a people of such character to have earned the “freedom” that the aborted have given us would be to be a people who would not do the procedure at all.

Withering Man

After reading articles such as this one, one must wonder at the speed and degree of the shift in public views about the nature of man. Not only are ideas vigorously promoted that in previous years would have been dismissed as nonsensical, the language used to portray views held widely for centuries has changed to one of derision, and at best mere astonishment that such views could even be held.
Over the span of just a few years, for example, we have seen how attitudes toward abortion changed so quickly that the professional organization dedicated to the successful culmination of the existence of a fetus would now espouse the right to destroy it. How views toward something so blatantly obvious as gender changed toward the belief that it is up for grabs. And how the special status of physicians in our lives could so quickly be turned into an instrument by which to assist us to commit suicide.
Such ideas would once have been dismissed out of hand. Now, instead, we find people struggling to maintain a defense of that which was previously taken for granted. It is nothing but chronological hubris, however, for the promoters of today’s most radical (they would like to say, “progressive”) views to think that they know better. But how do we explain why what we once believed was right?
We must be able to describe how “traditional” beliefs gave the greatest opportunity for each person to thrive–how they contributed to social stability and created a foundation upon which each person could find steady footing, from which to step up into the greatest possible fulfillment. And that to abandon them is to take our foundation and turn it to sand, or even quicksand, into which we all will fall.
We might start by trying to explain how we got here—how views once so widely normative are now rejected, and those once viewed as absurd are becoming normative. If we do this, then we can at least shed light for others on what the dynamics in society are, so that they can understand that those ideas now being promoted as inerrant truth are in fact quite recent concoctions of the creative and untethered mind. Considering that in our times no man holds his audience but for a few moments, here is how I might list to others the major cultural phenomena:

1. The breakdown of family connections, so that the knowledge and acceptance of values are not passed from father and mother (and grandfather and grandmother) to son and daughter, but from media and other cultural influences directly to the child;
2. The subsequent loss of the understanding of the origins and logic behind these values; concurrent with this is the sense that if the values were not deemed critical for parents to pass on to their children, then they must not have credibility;
3. The artificialization of life, in which man is no longer intimately familiar with the physical stages of human existence, nor with the painful consequences of unwise personal choices;
4. The compartmentalization of personal lives, further distancing the person from exposure to the full range of human existence (good, bad, and evil);
5. The dominance of sensuality as the driving motive behind human endeavors;
6. The rise of the imperative of autonomy in all things, with its injunction to separate oneself from outside influences, including previously held beliefs and values.

The most critical specific phenomenon in this societal/cultural shift is both a cause and a consequence—the loss of influence of Christian views toward human existence. Into this void of belief comes a plethora of other beliefs, perhaps most importantly a Philosophy of Whatever, from which one can’t muster an argument against any belief system except that which opposes me from being right in whatever I claim.
This void is not just an accident of history, but a deliberate end state for many. For those pushing the biggest changes in society, Christianity then becomes the major obstacle, and must be silenced by any means possible. This is why state laws explicitly supporting religious freedom are so viciously attacked, regardless of what they actually say. The important thing for their opponents is to disallow the accommodation of expression in words and deeds of Christian views. These attacks are not against Hinduism and Buddhism, after all. It would be most interesting to see how the opponents of the Indiana Religious Freedom Restoration Act would answer the question, “How would you guarantee the right for someone to live out his belief that same-sex marriage is wrong?” The trend seems to be toward no accommodation of such belief whatsoever, moving us toward a tyranny never before seen in America.
For the field of bioethics, the loss of a Christian understanding of the meaning and value of life is most ominous, for human life becomes yet another malleable tool for somebody’s claim of personal self-actualization. Many assert that such freedom to redefine man itself brings opportunity for great fulfillment. But for those of us who may be still attached to their full human identity, there is a real sense that we’re losing portions intrinsic to our being. As Shuman and Volck state in their book, Reclaiming the Body (Baker Publishing Group, 2006), “…if the mind and identity itself can be altered…what part of the disembodied self is making these choices? Apparently there is nothing left to enliven this puppet self but the tiny part of the mind or soul that makes choices.”
Unless we all wish to wither away to this tiny part, we must shine a light on the breakdown in the generational chain of understanding, by showing how we got here. And from there show that preceding generations knew a lot more than the hubristic progressive would admit.

Unenhanced Thoughts about Neural Enhancement

An April 20th post in the Hastings Center’s “Bioethics Forum” brings attention the recent report by the Presidential Commission for the Study of Bioethical Issues (PCSBI) entitled, “Gray Matters: Topics at the Intersection of Neuroscience, Ethics, and Society.

Chapter 2, “Cognitive Enhancement and Beyond” is a useful summary of issues surrounding “cognitive enhancement,” and provides a brief overview of three scientific goals: maintaining or improving neural health and cognitive function, treating disease and other impairments, and expanding or augmenting function above the normal human ranges. The PCSBI uses the term “neural modifiers” to refer to the broad array of agents that act on the brain across this spectrum of interventions.

Ultimately, the PCSBI provides sensible recommendations regarding the study and use of “neural modifiers”. It rightly attends to “societal background conditions” such as diet, sleep, exercise, and an environment unburdened by toxic agents as a top priority. Other recommendations include the need to prioritize treatments, and to “study novel neural modifiers to augment or enhance neural function.” This is not a commitment to the idea that they are a good idea, only that more information is needed to guide their ethical use. While the PCSBI leaves an open door to the possibility that there may be ethical uses for cognitive enhancement and augmentation, it is protective of children, drawing an ethical line: “Clinicians should not prescribe medications that have uncertain or unproven benefits and risks to augment neural function in children and adolescents who do not have neural disorders.”

The PCSBI raises important cautions about long-term effects, over-medicalization, and exploitation by those who would stand to gain the most (in this they cite the pharmaceutical industry, but we would do well to consider that other persons or groups could also find reasons to exploit). The most important contributions of this publication, however, come in the form of questions that the PCSBI does not, and cannot, answer in its brief report. Three such comments stand out:

  • “What might happen, scholars ask, to traditional understandings of free will, moral responsibility, and virtue if science makes significant advances in the ability to technologically control the mind?”
  • “Further, when we consider altering our memories, we trigger concerns at the core of defining one’s self.”
  • “This desire for control might erode our appreciation for natural human powers and achievements.”

The PCSBI urges that more research be performed in order to provide us with more evidence for ethical decision-making, and that “professional organizations and other expert groups…create guidance about the use of neural modifiers.” They do us a service to highlight these concerns. But we must recognize that while the scientific method may produce clinical evidence to facilitate ethical decision-making, the foundational sense of what it means to be human will never come from a randomized controlled trial.

A Not-So-Open Discussion

Courtney Thiele posted on March 3oth about an article in the Washington Post describing “a new push to de-stigmatize the nation’s most controversial medical procedure by talking about it openly and unapologetically.” A clinic in Maryland called “Carafem” dispenses abortion pills, and “promises a ‘spa-like’ experience for women with an open and unabashed approach to pregnancy termination.” (quotations from the Washington Post’s article)

This clinic is no doubt trying to move the experience of abortion as far away from Gosnellian horrors as possible. But despite the claims of the owners (and the Washington Post), their own terms reveal that it is not openness they seek, but a façade to hide the truth.

Whenever we hear the term “stigma,” we know that we’re getting lectured about judgmental people who are imposing their bad thoughts, and seeking to infringe upon someone’s freedom. The term in medical use describes a “mark” due to some condition, and therefore a natural consequence and characteristic identifier. In non-medical parlance, it has come to represent an externally imposed non-physical mark, unfairly applied.

For those wishing to deflect criticism, this is a useful word. It serves to convey the impression that if we feel anything negative about an entity or act, it is the fault of external forces, usually having malevolent intent. “Stigma” becomes a surrogate—a strawman—for “guilt” and “shame.” The founders of this clinic, of course, are trying to sell abortion, and trying to blame the guilt that participants may feel on judgmental others.

Most revealing is the clinic staff’s use of a term describing the abortion itself. They dodge the truth when they state how the abortion pill will “pass the pregnancy.” Pregnancy, as we know, is a state of being, not something to pass out of one’s body. It occurs because something is in the body, namely an embryo or fetus. By misusing the term, the clinic staff belies their understanding that the issue is about the human being of the embryo. But, if they acknowledge its being then moral questions must arise, and their goal of casual and stress-free abortion fails. Better to not acknowledge it. Simply talk around it, by substituting a misleading term, and we can pretend there isn’t really a person there.

I’ve seen enough about the coarsening of our culture to have a general sense of pessimism about the ability for many to see through this verbal obfuscation. Still, the sense that a pregnancy is a human is not going to go away, and unlikely to be something the modern public is oblivious to, especially with technological advances in ultrasonography. I doubt that there will be a time when those who take part in abortion are completely free from the burden of guilt, knowing that what they have passed was not simply their condition, but someone on our common path toward birth.

Good Ethics Requires Bad News

Some bad news took me by surprise this week, taking the form of an article in the Annals of Family Medicine entitled, “Why Medical Schools Are Tolerant of Unethical Behavior.”  The authors described a medical school graduation ceremony in which the speaker thanked professors and healthcare professionals not just for competent and humane care, but for providing examples of “pure unethical behavior.”

I wondered if my surprise at these circumstances was a bit of bad news in itself. Either I was blessed to be away from such an environment, or ignorant of similar problems around me. To some relief I found (after looking quickly) that the authors were from Brazil, but a book by an American author is but the most recent reminder that the problem resides between our shores as well.

The authors themselves seemed surprised by the audience’s lack of unease or objection to the allegation, and concluded that the professional environment must be tolerant of the behaviors. They asked why, and described these possible reasons:

  1. Barriers to reporting, due to fear of retaliation, lack of anonymity, and complaining seen as a sign of weakness;
  2. Leaders turning a blind eye to problems;
  3. “Systemic disrespect,” that is, widespread problems of the healthcare system that produce long waiting times for patients, excessive staff workloads, and a culture where mistakes are not acknowledged and apologies not made;
  4. Lack of accountability by accrediting organizations for ethical behavior.

They go on to discuss conflicts between explicit and implicit values, with the implicit ones being “culturally appropriate” yet far from admitted publicly. Such conflicts produce a systemic delusion, as well as cynicism in the young and developing healthcare professional.

That such a situation exists merely highlights how critical the truth is to ethical behavior. Organizational dishonesty, in whatever form, corrodes the integrity of individuals and provides fertile ground for unethical behavior. Integrity requires a willingness both to hear bad news and to give it. Values greater than one’s personal image, comfort, or success must be paramount, or else bad news becomes a problem unto itself, as opposed to a useful and necessary tool for ferreting out problems and making organizations better.

We can’t find such integrity from purely utilitarian arguments. The authors cite, unfortunately, only utilitarian arguments for building a professional ethic (increased costs, medical errors, etc.), reminding me how the language of virtues has long ago faded from modern societies. They do note utilitarianism’s inadequacies in the problem of “administrative evil,” in which “standard operational procedures within an organization inflict harm or suffering on individuals by blindly following a cold bureaucratic rationality committed for the ends but not the means to those ends.”

It is virtue ethics that is required to fight the corrosive effect of pure utilitarian thinking, for it reminds us that one of the ends produced when disregarding means is that one becomes the sort of person who uses those means. This requires an understanding of virtues and the central nature of the character of man to any ethical system.

I am not confident that modern society is ready to recover the lost language of virtue. Virtue, it seems, must not be spoken of, lest the speaker be subject to the vitriol as experienced in the strident denunciations of Christianity we hear more and more about. To escape our mean state, however, we must venture to do so.

To discuss virtues, in turn, requires that we articulate a robust vision of the telos—the purpose and ends—of the practice of medicine. A description of a state of being greater than our common existence, greater than mathematical calculations of gains and losses, would give direction and meaning to our efforts. It would enable us to see beyond self-interest, to make the necessary sacrifices for the truth, to move ourselves and our organizations along the road to that greater goal. For such a journey, bad news becomes not an impenetrable wall or obstacle to avoid, but merely a stepping-stone.

Speaking about dignity

Several years ago, while on the verge of delivering the baby of a seventeen year old, I was taken aback by the number of friends that she had asked to accompany her at the event…an event formerly considered far more private than one in which fifteen or so friends might attend (it was a large delivery room). And speaking of private, the wording and location of her tattoo demonstrated further that private areas had lost their former distinction.

The only practical option at that time was to ignore the crowd and attend to the imminent delivery, and ensure the newborn’s and mother’s safety. I could only hope that everyone had the sense to stay out of the way if an emergency arose. There was no time for instructions, explanations, or crowd control.

All turned out well. The teenager delivered a healthy baby, and I stayed on duty on labor and delivery. Our paths never crossed again, but I have thought of that brief encounter many times over the ensuing years.

When I think of the struggle to protect human dignity from innumerable external onslaughts, I think of battles such as those over public policy, technology, and cultural trends. But what I have not seen well is how the struggle extends to the hospital bedside, when the most pressing threat is from the patient herself. How much ought we, as physicians, while comforting and testing and treating and advising, take a firm stand and square off with patients, to explain why they themselves are the biggest threat to their own dignity?

Such a stance doesn’t reconcile easily with the current notions of patient autonomy. A sense of patriarchy within the medical profession comes rushing back, and it would be foolish to claim that patriarchy was always done well.

I am hard pressed to think of examples of seeing a physician address such concerns, unless couched in biomedical terms. It is difficult to know which of the numerous behaviors a patient exhibits falls, ethically and practically, within the realm of the practice of medicine. What I can say, with the advantage of some years, is that with the transformation of medicine to an autonomy-centered realm, we have lost sight of the most important defender of each person’s human dignity: the person herself. If we are to claim our dedication to a patient’s dignity, then should we not be more willing to speak the truth about it—even if it shines a light on an area the patient would rather not be seen?

“Grace” as a principle for the medical profession

The other day I was speaking to another physician about grace. This was at church, not surprisingly, but later I wondered why such discussions don’t occur in the hospital. When I recall the more remarkable physician-patient encounters I have seen, the word that comes to mind as the common theme is grace.

We can see it in the physician calmly and pleasantly treating the irascible and demanding patient in the darkest, bone-wearying moments of a long shift. We can see it in the compassionate but direct explanation of the direst of news to a frightened patient. We can see it in the happy celebration of a beautiful newborn to a relieved and exhausted mother. And we can see it in the bedside comfort given to a dying patient in those quiet moments when time slows down.

If one agrees that grace exists, then he ought to ponder from where we get it. For me it is clear: grace is God’s gift of Himself to us. We can speak theologically about godliness, but grace is a more specific and tangible manifestation of what that is. In medical ethics we have the well-known and practical principles of beneficence, non-maleficence, justice, and autonomy. But these describe the nature of what we should do. It is time, I propose, to speak of what we should be.

If we don’t speak of such things, then we ought to hope that they are at least manifest in our comportment, words, and deeds. Yet in our postmodern age, when society has abandoned such discussions, the mere mention of grace, something deeply profound, might strike that raw nerve in every man that fires the memory of something far greater than we’ve actually become. Or for many, want to become. And if the field of medical ethics is to move beyond an artful sophistry that produces philosophical justifications for our basest needs; if the profession of medicine is going to regain the moral standing in society for which it was created, then our medical schools must teach the highest principles. Like the magnificent blessing of grace we have received, that speaks to more than the nature of our acts, but to the nature of our being.

Academic Medicine: In need of an examination?

Being a physician in an academic setting, my attention was drawn to this recent article in Academic Medicine: “Time Well Spent: The Association Between Time and Effort Allocation and Intent to Leave Among Clinical Faculty” by Pollart et al.

I had mixed gut reactions to this topic; ranging from the notion that this is an awesome topic long overdue for attention, to the questioning of why academia is spending its valuable time on such internally focused research.

But I found that there is a significant practical problem facing academic institutions that is driving this and similar research—the ongoing loss of experienced and capable faculty. What the study reports to have found is that the intent to leave an academic institution and academia in general was related mostly to the clinical staff’s impression as to whether the amount of time in a given area (clinical, research, teaching, administration) was too much or too little. The authors proposed that, “academic hospitals can work with individual faculty members to find the right mix of clinical, teaching and administrative responsibilities.” This seems simple enough, but do individual organizations have such flexibility? For example, very few said that they spent too much time in research (@ 1%); the dissatisfaction here was that too little time was spent. I suspect that the demands to produce revenue through clinical duties make it unlikely that all those desiring more time for research can be accommodated.

This first article then led me to a second in Academic Medicine, entitled “Why are a quarter of faculty considering leaving academic medicine? A study of their perceptions of institutional culture and intentions to leave at 26 representative U.S. medical schools,” by Pololi et al.

What was disturbing about the results was the authors’ “central and concerning finding…that faculty dissatisfaction was saliently associated with faculty members’ negative perceptions and distress 
about the nonrelational and ethical culture of the workplace.” The last thing the medical professional needs is such an environment in which medical students acquire their professional values. As the authors point out, “the detrimental culture for faculty members constitutes part of the hidden curriculum for medical students, who often become less altruistic and more cynical through the four years of medical school…” and that “if faculty project that the moral, ethical, professional, and humane values articulated in the formal curriculum are not reinforced in their own experience as faculty (through the medium of the hidden or informal curriculum), the goals of educating and graduating competent, professional, and humanistic physicians may be undermined.”

My academic setting is a smaller hospital and not the large university medical center and school setting, making it impossible for me to perceive the extent of the concerns; the article itself only highlights them, but does not help to clarify the scale of the problem. However, we ought to ask why there is such a questioning of the moral and ethical environment of medical schools, which are the formative environments of our medical profession. Perhaps the practical limits on advancement and the inherent competitive nature of large organizations (filled with driven professionals) prevent development of mutually supportive relationships. Perhaps it is but one manifestation of the consequences of the growth in cost of a highly complex medical system arising out of the advances in science and technology. Our capabilities exceed what we can pay for, and the institutional environment demonstrates the effects of the demands to produce something to justify the cost. Such demands can lead to ethical compromise.

I also wonder if ethical misdirections of our academic centers arise from a shrinking of the ethical foundation of medicine itself, to the narrow principle of autonomy. As the authors state, “[t]he scale of ethical/moral distress
 reflects reactions to the prevailing norms and possible erosion 
of professionalism and increased organizational self-interest.” If we have elevated autonomy to the highest principle, we should be unsurprised when self-interest begins to crowd out other professional motives.

Dying and Dignity

On November 1st, Brittany Maynard, a 29 year-old Oregonian with an incurable brain tumor, took her own life using a medication prescribed by a physician specifically for this purpose. The medication, legal under the Oregon’s Death With Dignity Act, was prescribed weeks earlier.

The case is well-known because Brittany became a spokesperson for efforts to expand “assisted suicide” laws to other states. Through her own efforts, her story appeared in numerous publications and websites, and has been held up by the organization “Compassion & Choices” as exemplifying the justification for making assisted suicide legal nationwide.

Brittany feared many things about dying with brain cancer—her own physical pain, progressive debilitation, dependency, seizures, as well as emotional pain for her family. To avoid these through her own choice, was to die with “dignity”. This term has been held tightly by assisted suicide advocates, such as by the Swiss group “Dignitas”. The organization “Compassion & Choices” holds to a few more terms it wishes to apply to assisted suicide.

When reading the stories about Brittany it is difficult to bring oneself to find fault with her decisions, knowing the heartbreak that she and her family were going through. It is as if such conversations themselves are too painful, and so, like Brittany Maynard did of her life, we terminate them before they’re complete.

But there is much to critique about “assisted suicide”. What is striking is the usurpation of terms, most notably the term “dignity”. It is a shallow interpretation indeed, for according to the website, to die with dignity is to die “in control”. The term “dignity” is reduced to describe the ultimate act of autonomy. To give it the imprimatur of compassion and approval, a physician prescribes the fatal medication; we know full well, however, that physicians are not necessary participants should one decide to end his or her life.

Real dignity is much more. I thought about the young Mrs. Maynard today after I visited a friend dying of cancer. And I thought back to my own parents’ terminal illnesses, including one with a tumor in the brain. Somehow I can’t fit the term “dignity” into any circumstance in which one of them would have willfully avoided their final moments. Those are painful days, hours, and minutes, but precious nonetheless. They bring us together, force us to cast off trivialities, and sharpen our focus on what is most important. They call out the best in us, and send us away with a sense of something greater…including perhaps a resolve to make something more of the life we are given. After all, why does God give us death but to remind us how to live?

My wife said of my mother, “She showed us how to die.” There, in a debilitated and helpless state, was true dignity. I am eternally thankful for every moment.