Corey’s Apology

My July 25 post included a reference to the controversy over a Biola University student’s attempt to display graphic images of abortion on campus, the university’s rather aggressive response to stop her from doing that, and the reaction of the Center for Bio-Ethical Reform (CBR).

About a month later (August 20), Biola’s president, Dr. Barry Corey, published an open letter addressing the matter.  In it, he apologized to the student and to “anyone of interest” in the public for actions that “were perceived to be heavy-handed and retaliatory.”  Strongly affirming Biola’s pro-life commitments, Dr. Corey outlined five types of steps the university is taking:

  • Communication—restatement by the University, starting with its president, of Biola’s “current and historic position on the sanctity of life” in various venues.
  • Instruction—through sponsoring a pro-life chapel service with invited presenters who will “demonstrate the use of images compassionately, ethically and effectively.”
  • Policy—This term, the University is developing “a clear policy supporting the ethical and compassionate use of graphic images in places trafficked by students.”
  • Leadership—in the “academic team” (the dean’s office, I presume) to ensure that pro-life commitments are reflected in the curriculum, learning objectives, and outcomes measures.
  • Continuing [Biola’s] Commitment—advocating for life in the universities activities “and through our legal action.”

I think that this letter is a model for how to address a sensitive controversy.  My understanding is that it has generally been warmly received in the pro-life community, but that the Center for Bio-Ethical Reform may not be entirely satisfied.  But I think we should be.

Potpourri about recent stories about abortion

It will hardly be news to readers of this blog that many states are enacting laws to restrict later-term abortions.  Formally, states cannot restrict access to abortion before a fetus is “viable.”  Practically, abortion proceeds largely unrestricted, at the sole decision of the woman requesting the abortion, in consultation with her physician.  (I will try not to revisit well-plowed territory here.)  The Gosnell case, having grabbed the attention of anyone willing to pay attention, seems to be a reminder that it is reasonable to take the step of protecting, in law, the lives of unborn children as they approach the point at which our best current medical efforts are capable of giving them a chance at life.   I am a bit reluctant to try to adjudicate too precisely the 20-week cutoff point in the recent Texas bill and others—legislating medical details is unavoidably problematic—but the impulse to establish a zone beyond which we agree we will not venture is appropriate, I think.

Such a step is a small one.  If I have the statistics straight, a distinct minority of abortions—about 1.5% out of a total of about 1.2 million annually in the U.S.—currently occurs after 20 weeks.  So it seems to me that in practice the “restriction” on abortion that we are talking about here would be limited indeed.

A new Wall Street Journal/NBC News poll indicates that a plurality (44% vs 37%, with 19% undecided) favor this small step.  Interesting.

Perhaps more problematic is the move to require that all abortions be done in facilities that meet more stringent regulatory requirements, such as those for outpatient surgery facilities.  I’ve been emailing with Susan Haack about this, and she points out that one might encounter a type of “slippery slope” in which other standard medical office procedures—that are similar in methods but do NOT involve terminating a nascent human life—become over-regulated.   So the counter argument, to the effect that these new regulations by some states constitute, in a sense, an over-reaction to the Gosnells of the world, is not entirely unreasonable.  (Again, however, the fundamental motive and stance behind abortion by choice must be unequivocally challenged.)  The regulatory provisions looked appropriate to me at first blush, but maybe that’s because I spend my efforts in the highly regulated arena of pharmaceutical clinical research.

Finally, perhaps you have read of the recent dust-up (to put it mildly) between the Center for Bio-ethical Reform (CBR) and Biola University, over a student’s insistence to pursue the former’s agenda of aggressively displaying graphic images of abortion, and the University’s response.   Again, I will not attempt to weigh in on the details of that confrontation, but just offer my 2 cents:

  • Visit the CBR website and you are immediately confronted a graphic abortion video that turned my stomach—and I’m an M.D. who generally can stand the sight of blood.  I think it is good that I had that reaction.
  • I think that anyone in the medical field, especially someone contemplating performing abortions in any way, must confront images like this.
  • I am ready to grant that there is a place, from time to time, for insisting that people deal with revoltingly immoral practices on a sensory level.  (Consider William Wilberforce’s “dinner cruise” scene, past the slave ships, in the movie Amazing Grace.)
  • Still, there is a time and a place and a way.  Parading or posting revolting images in public, in general, can backfire, raising resistance in some who are otherwise sympathetic to the message, or communicating condemnation to individuals who, at that point in time, are better addressed more gently.
  • Yes, images of abortion are revolting.  So is watching an amputation.  So is draining a liter of pus from an infected chest.  So are a lot of things in medicine that must be done for the good of the patient.   At issue is not the picture, but the underlying moral judgment.

Paying for oocyte donation—update from California

A number of concerned groups in California are encouraging citizens to urge Governor Jerry Brown to veto AB 926, which has passed both houses of the state legislature.   AB 926 would repeal a provision in the California Health and Safety Code that prohibits compensating women who donate their oocytes (eggs) for research purposes.   Wesley Smith has blogged against it, arguing that it would “permit Big Biotech to buy eggs from poor women to conduct human cloning and other experiments.”  One Leah Campbell, a past egg donor and author of a book entitled Single Infertile Female and an eponymous blog and website, writes in the San Diego Union-Tribune that AB926 “aims to turn women’s bodies and ovaries into an assembly line.”

What is going on?  It merits some unwinding.

In 2004, California passed Proposition 71, which established and provided $3 billion in bond funding for the California Institute for Regenerative Medicine (CIRM), to support basic and translational stem cell research.  The proposition explicitly cited human embryonic stem cell research as a major priority.  (In fairness, CIRM funds all things stem-cell, including somatic, or “adult,” stem cell research, and research with induced pluripotential cells [iPSC’s].)

As the California Senate’s analysis of the bill (available here) points out, at the request of the CIRM the Institute of Medicine (IOM) issued a 2007 report assessing the medical risks of oocyte donation for research.  Those risks included ovarian hyperstimulation syndrome (OHSS) which can have serious medical consequences in 1-2 of every 1000 stimulation cycles; risks of the procedures involved; psychological risks; and unknown but potential increased risk of some cancers.  The IOM pointed out that the stimulatory treatments needed for oocyte donation, when used in fertility treatments, are largely self-regulated by the medical specialty society involved, the American Society of Reproductive Medicine (ASRM), and the associated Society for Assisted Reproductive Technology.  Further, there is no ongoing registry of oocyte donors in place to observe women systematically, over time, for medical outcomes.  (This in the age of “evidence-based medicine.”)

Accordingly, in California law: “No human oocyte or embryo shall be acquired, sold, offered for sale, received, or otherwise transferred for valuable consideration for the purposes of medical research or development of medical therapies. For purposes of this section, ‘valuable consideration’ does not include reasonable payment for the removal, processing, disposal, preservation, quality control, and storage of oocytes or embryos” (Section 125350 of the California Health and Safety Code).  AB 926 would not change that part of the law.

However, in accordance with the sorts of concerns identified by the IOM, California law has prohibited paying egg donors more than the actual direct costs of the procedures (the “removal, processing, etc.”).  That is, women should not be charged for the medical and research procedures involved, but they shouldn’t be paid extra for their time and trouble, out of concern that such extra payment would constitute an unacceptable inducement to donate, and amount to impermissible exploitation.  This is what Ms. Campbell (and Mr. Smith, and to be candid, I) am concerned about.

Now, AB would repeal this specific prohibition, and allow this extra compensation of women who donate their eggs for research.  There are a couple of wrinkles:

First, as noted, the language prohibiting payment for the oocytes per se (or for an embryo) would not change, and new wording is provided to put a fine point on that.

Second, the bill tries to distinguish between donation specifically for research and donation for infertility treatment.  How?  To begin with, the rationale for the bill is that we already accept compensation for subjects of medical research, particularly for early clinical trials of experimental drugs given to healthy volunteers.  Such compensation can reach well into four figures per study, leading the phenomenon of the “professional research subject” who serially volunteers for these studies and tries to make a living off the compensation for participating.  Such compensation is for the subject’s time and inconvenience, and the consent form usually says so in so many words.  This is standard practice in research ethics, and there is a substantial body of literature (and ongoing debate) around the merits or harms associated with this practice.  The argument for AB 926 is that it would just treat women who donate their eggs for research like other research volunteers.  Further, without the compensation, people won’t volunteer.  (That is a safe assumption, based on the experience with drug studies in healthy volunteers.)  And, since much of the research is sponsored by industry, Wesley Smith is, in a sense, correct:  industry is not paying for the eggs proper, but they are paying for enhanced research participation.  I leave it to you to judge whether this is a distinction without a difference.

How much compensation is too much?  That is for Independent Review Boards (IRBs) to decide.  AB 926 affirms that the IRB must make this judgment in the case of compensation for women who donate their eggs for research.

But what about women who donate eggs for infertility treatment?  AB 926 tries not to be about them.  But if there are “extra” eggs—eggs that an infertile woman deems, with her doctor, she doesn’t need for her attempts to have a baby—then, if the clinic harvesting the eggs belongs to the Society for Assisted Reproductive Technology, then the IRB “shall disregard” the matter of compensation.

Got that?  The further wrinkle is that, according the California Senate’s analysis and the IOM report, while ASRM endorsed this sort of compensation for women who donate eggs for infertility treatment, it said that “total payments to donors in excess of $5000 require justification, and sums above $10,000 are not appropriate.”  Yet it is common knowledge that these payments can be much greater than that.  But in that case, AB 926 tells IRBs, “never you mind.”

Ms. Campbell (see the Union-Tribune link above) wrote that the aftermath of her egg donation included severe pain from endometriosis related to the ovarian stimulation, and, in a cruel irony, now she is herself infertile.  Her story reminds one of “Eggsploitation.”

So what to say of all this?

  • A decade after Prop 71, the commodification of the egg donation process, in the name of supporting research with created embryos, is a reality.
  • If I were on an IRB evaluating a proposal, it would be a lively meeting:
    • The egg donation is likely primae facie unethical because it supports the fundamentally unethical act to create or destroy human embryos solely for research purposes;
    • Compensation to the donor would have to at least fall within the ASRM dollar limits as described above; higher amounts should be viewed as an unacceptable inducement;
    • The required description of risks to the donor in the consent form must make the risks of severe complications of OHSS, and the lack of data on long-term risks, starkly evident;
    • I would argue strenuously that two basic requirements of IRB approval of the research—that risks are minimized and that they are commensurate with the benefits of the research—could never be met.

This one had flown under my radar, and I now need to send a letter to the governor.

Clashing worldviews in same-sex marriage and bioethics

The recent Supreme Court decisions regarding same-sex marriage have made me think about the fundamental worldview differences that underly the different positions on that very controversial issue and the similarity to the worldview differences involved in many of the issues that we deal with in bioethics. Although there are biological issues involved in the ethical positions that people take regarding homosexuality and same-sex marriage these are usually considered to be issues of social ethics and not specifically a part of bioethics. However, there are marked similarities in some of the basic worldview differences involved.

Primary in many of these issues, whether it is same-sex marriage, euthanasia, embryo destructive research, abortion, or human enhancement, is the place of personal liberty and autonomy in the worldview of the person taking a position on these issues. Much of our society holds to a worldview that says that personal liberty is one of the highest if not the highest value. Arguments for same-sex marriage rely heavily on the idea that society should not interfere with the ability of a person to pursue personal relationships and sexual fulfillment in whatever way that the person chooses. That is very similar to the argument for euthanasia based on a person’s ability to choose how he is going to die, a couple’s ability to choose what will happen to their unused embryos, a woman’s right to choose what to do with her body and a fetus living within her body, and and our ability to choose to enhance our own or our children’s abilities. These arguments are strong because all of us in our society, including Christians, believe that personal liberty and autonomy are important and should be respected. The difference is that in a Christian worldview there is a stronger understanding that personal liberty needs to be limited by objective moral values for it to remain ethically valid. Human sexuality needs to stay within the bounds of traditional marriage. Caring for those who are suffering and dying needs to respect the value of every human life and not cross the boundary of killing innocent human beings. The choices we make about the treatment of human embryos and fetuses need to be limited by that same respect for the value of human life and the proscription of killing innocents. Choices about enhancing human abilities need to be limited by a respect for the givenness of our human nature. Underlying all of these moral boundaries is the idea that there are objective moral values that are grounded in the nature of the God who has created us who is good.

Another key worldview difference involves our understanding of who we are as human beings and what it means for us to flourish as human beings. Many in our society see human beings as animals who have some advanced capabilities that give us advantages over and more moral responsibilities than other animals, but no categorical difference from other animals. This is in contrast with a Christian view of human beings that sees us as being made in the image of God which gives both an inherent value to every human life and an understanding that there is a higher purpose to our lives than fulfilling our basic desires. This difference impacts how we see such things as the fulfillment of our sexual desires, dealing with suffering, the value of the lives of human embryos and fetuses, the relative importance of our own desires and those of ones dependent on us, and whether we should strive to change our nature.

These fundamental worldview differences help to explain why there are such deep divisions on social issues such as same-sex marriage and many issues in bioethics. We need to continue to point out the importance of such basic issues as the existence of objective moral values and the nature of human beings as we discuss these issues that are of great importance in our society.

Michael Tooley’s “package deal”

Further to the May 2013 JME discussion of infanticide was a fairly gymnastic article by Michael Tooley that was in essence given central prominence in the issue.  I say “gymnastic” because, partly by his own admission, Tooley tried to cover, albeit superficially, a lot of ground in a brief essay.  But given that there is so much written, and so much information out there, that one cannot review it all in detail—Tooley himself admits as much vis-à-vis his position—one is often forced to perform similar gymnastics to form a provisional judgment of a series of claims.  And thus do I take to the trapeze for a brief discussion of Tooley’s essay.

Tooley writes that he wants to replace emotional claims with critical thinking, and yet I could not help be irritated by his tone: “pedantic” seems too strong a word, but “tendentious” and “condescending” might fit.  After lecturing non-philosophers on how they ignore critical thinking and eschew calm, dispassionate argument, and in essence telling doctors that they should defer to the wise judgment of professional philosophers (who really are the only ones who have thought long and hard about things) on ethical matters, he urges the reader to accept the “Socratic challenge” that all held beliefs are potentially suspect, and that resistance to some ideas betrays commitment to a “package deal” that includes some basic belief that one is determined to hold despite the evidence.  Of course, opposition to abortion is one such package deal because Tooley apparently has found that all abortion opponents cling to the notion that there is a God.  (He does, in passing, also say that some feminists include abortion support in their own package deal but he does not say anything further about them.)

More substantively, Tooley briefly addresses two strategies supporting “the extreme antiabortion view according to which abortion is always, at the very least, prima facie seriously wrong,” as he puts it:

  • Membership in the biologically defined species Homo sapiens is a suspect ground of moral status because, were we confronted with a lovable extraterrestrial creature that is rational, we would ascribe similar privileged moral status to that being.  We wouldn’t approve of serving him up a la Kentucky Fried Chicken, for example.  (Or, if you prefer, think of the horror of the Narnian visitors eating talking animals in Lewis’s The Silver Chair.)  So, the ground of moral status would be something like possession of “an immaterial, rational soul,” and membership in the species would not be a basic ground for a life to right (the rational soul would be a more basic ground).   But it seems to me that Tooley misses the point here. Humans are the sort of beings which have the ultimate capacity for not just thought but moral judgment, self-awareness, awareness of self-awareness, and so on.  And they are unique within the creation, or the biosphere if you will, as we encounter it.  Were Tooley’s ET to visit us, perhaps we would have another example of the sort of being with ultimate capacities such that it ought to be accorded privileged moral status simply by virtue of being one of that sort of being—a member of that “kind,” or species.  Christopher Kaczor, for one, has defended this position rather more substantially than Tooley seems to be willing to allow.
  • Possession of an immaterial, rational mind or soul is not just suspect, but patently false, for Tooley, because he thinks science has established that the mind and the brain are one and the same.  He calls out Moreland, Beckwith, and Scott Rae (among others) by name—Thomistic substance dualists all.   He may correctly identify their view but he makes it too Cartesian by identifying soul with mind, and he fails to engage the dualist argument with more than a list of science-writer level examples.  Also, in my (limited, to be sure) reading of philosophy of mind, I don’t see people considering Tooley a significant contributor.  So I take his claims against substance dualism as little more than rhetoric.  And substance dualism appears to me to be rather robust in philosophy than Tooley will allow.

Instead, Tooley asserts that “[o]nly neo-Lockean persons have a right to continued existence.”  The “neo-Lockean” person is “an entity that has conscious states at different times, and that are psychologically connected by such things as memories, desires or intentions.”  These are the states that “make for personal identity.”  They persist through temporary losses of consciousness, and so get around one objection (which Tooley considers a “straw man”) about approaches to personhood as consciousness.  And, for him, a right to life is grounded not in an essential characteristic of a being, but in something that is acquired at some point in development.

But it’s not clear why actual rather than anticipatable acquisition of capacities should ground moral status.  If we take care of a baby properly, he or she will quite predictably become Tooley’s neo-Lockean person.  In cases when that is not going to happen, we can still argue, at a minimum, that respect for the sort of beings humans are ought to stay our hand against active killing.  Yet that is not where Tooley is headed.  Because we are talking not just about abortion here, we are talking about infanticide.  And returning to the latter point, Tooley closes by mentioning that, while he thinks human fetuses and neonates “probably” have the same moral status, he seems to be questioning his earlier position that humans acquire capacity for thought episodes only some time after birth.  He says that he doubts that most philosophers are conversant in the relevant science, and that he has not been able to catch up with it.  And so the “crucial underlying scientific premise” that would support killing healthy newborn humans on purpose—viz., that neonates lack the capacity for thought—“has not yet been scientifically, firmly established.”

Well.  And if it is “scientifically, firmly established” that neonates DO have the capacity for thought—as I bet most new mothers would claim, and as I think we ought to assume for the purposes of our moral reasoning—then how established is it that there is NO capacity for thought late term in utero?  And how do we distinguish the unborn healthy 30-weeker from the post-natal 30-week preemie?  And if there is anything whatsoever to the notion that our thoughts have a private character, accessible only to us, how confident ought we to be of our ability to measure the onset of that actualized capacity in tiny humans?  The potential for pseudoscience seems substantial.

And this, finally, underscores Tooley’s own “package deal”—skepticism about the moral status of newborns comes with a firm commitment to naturalism and a physicalist approach to the philosophy of mind, at all costs.  We all start with basic beliefs that we change very slowly, if at all.  And so, rather than think that every belief ought to be held with radical skepticism, we ought to beware lines of reasoning that wind up contradicting the deepest human intuitions and experience—kind of like questioning our work when the answer to a math problem doesn’t make sense.  (I should add that Tooley’s arguments reinforce my conviction—or, in our pluralistic, secular society, should I say “despair”—that naturalism can ground any stable sense of moral obligation.)

In the meantime, while you are catching up with all that Tooley and others have written, I recommend that, rather than abandoning your most basic beliefs, you resist his reading of the Socratic challenge.  Tooley’s approach sounds less like a search for truth than a demolition job.

I wonder whether Socrates would approve.

Gosnell, the Journal of Medical Ethics, and Infanticide

On May 13, Kermit Gosnell was convicted of three counts of first-degree murder—for infanticide.  Some news reports said that the convicted man looked stunned, as if he couldn’t understand why anyone would think he did anything wrong.

The May 2013 issue of the Journal of Medical Ethics was devoted to a serious discussion of the notion that infanticide—as in, the intentional killing not only of handicapped but also healthy infants—is morally acceptable, for the same reasons that abortion, including late-term abortion, is accepted in the West.  That issue of the JME expanded on the prior online publication, in January of 2012, of an article by Giubilini and Minerva.  I found the contents of this issue available online for free (for which I was thankful, because nobody should have to pay for this tripe).  Read it, and it will be clear that the authors, and the editors of the journal, don’t understand why anyone could have been upset that it was published in the first place.

In an editorial, Julian Savulescu states that the Giubilini-Minerva article was published because of “the quality of [the] argument, the contribution to the existing literature, and the relevance to current medicine.”  But the article failed the first two criteria, and ought to fail—at least, in a decent and human society, ought to fail—the third criterion as well.

Giubilini and Minerva argue poorly in their piece.  Two key sentences:  “both a fetus and a newborn certainly are human beings and potential persons, but neither is a ‘person’ in the sense of ‘subject of a moral right to life.’  We take ‘person’ to mean an individual who is capable of attributing to her own existence some (at least) basic value such that being deprived of this existence means a loss to her.”  In a reply, Francis Beckwith points out that this position has been carefully refuted on numerous occasions in recent years, and criticizes the notion of a “potential person” as misguided.  An unborn or newborn baby is not a “potential” person in the way that, for example, a piece of wood is a potential desk or Michael Tooley’s cat is potentially smart if only it is injected with the right potion.  Rather, the fetal or newborn human is a being so ordered that it essentially has the capacity to express, when fully developed, the range of higher capabilities that Giubilini, Minerva, and other like-minded people say confers moral status only when realized—either fully, or fully enough.  What would constitute “fully enough” they are unwilling to venture.  They also claim that refusing the burden of caring for a baby is reason enough to warrant infancitide (as it is, de facto, sufficient justification for abortion under our current legal regime).  But Beckwith demonstrates that, for them, infanticide is morally permissible even in the absence of any burdens—so an appeal to “burden” is irrelevant.

At bottom, Giubilini and Minerva’s paper is nothing more than a rehash of old arguments for abortion and infanticide, without proper regard for substantial criticisms that have been previously and extensively published and discussed.  Accordingly, their article adds nothing whatsoever to the current literature save provocation.  It does have one merit: it serves as a reminder that if abortion is morally permissible, it is difficult if not impossible to declare, on the merits, that infanticide—or, for that matter, the elective murder of children of some indeterminate older age—is not morally permissible.  Several contributors to the May 2013 JME point this out in one way or another.

Finally, the relevance to modern medicine:  In his contribution, Robert George states that “killing an infant because he or she is unwanted is evil” and that advocating it, or its moral permissibility, is “madness.”  And so it is.  To ask seriously, “is it permissible to kill an infant because he or she is unwanted?” or “under what circumstances is it permissible to kill an infant because he or she is unwanted?” is to speak from a heart desperately twisted by evil.  We must forcefully reject the premises of such questions.  They can never be relevant to modern medicine.  They are considered relevant only because we live in the days of the Groningen protocol for neonatal euthanasia—which, we are told, is decreasing euthanasia (or so it is believed) in favor or more abortions, for things like spina bifida.  (An “updated report” is due later this year.)

Apparently, after the online publication of their article, Giubilini and Minerva received death threats.  Such a response is also evil.  That is it was affirmed explicitly by several contributors—both pro- and anti-infanticide, or pro- or anti-abortion—to the May 2013 JME.  But again, the authors and editors don’t appear to understand why there should be such outrage, and some of them seem (rather sanctimoniously, to my ear) to cloak themselves in a sense of martyrdom.   Outrage must be controlled, and supported by proper warranted belief and sound argument.  But correctly-directed outrage cannot be replaced by a cool rationalism.

And so, indeed, in responding to what George has properly called this “madness,” we must be civil but we must not be gentle.  Academic freedom and the First Amendment demand that we abide such talk, at least to a point.  However, serious advocacy of killing healthy infants or children by choice ought not to be acceptable in decent, humane conversation, and we should aggressively press the point that this one has been “asked and answered.”  Daniel Dennett has said that people who believe in God should be dismissed with derision from intelligent conversation.  We must be more patient, but I am tempted to ask whether sauce for the goose is sauce for the gander here.

It is said that Hippocratism arose as a counter-cultural protest movement, and that early Christians bore reproach for their opposition to infanticide.  Those of us who consider ourselves “neo-Hippocratists,” if you will, may be facing such a time again.  I wonder: just how many of our fellow citizens think that Gosnell did something wrong?  Or that he didn’t?  And would not most frankly reject infanticide?  I suspect that most people in the general public don’t realize this discussion of infanticide is going on.  We must educate them.  And we must be polite—but not too nice—in opposing the “experts” pushing infanticide.

The Irony of “Rational” Secularism

This past week I attended the meeting of the Council on Health Care Ethics for our state medical society. In the packet of information for the meeting was a resolution on “right of conscience” along with 2 “supporting” documents, one by Julian Savulescu and the other by Alta Charo, both addressing the issue of abortion and both filled with “entitlement” rhetoric (the article by Salvulescu even stated that those who are unwilling to provide services to which people were “entitled” should not be physicians, as if abortion is the vital core of healthcare). Based on the “supporting” documents, the tenor of the meeting seemed less than balanced.

To my great surprise, the author of the resolution was a first-year medical student. The resolution had been brought to the state convention, where it encountered considerable opposition and was sent to our committee for further discussion (presumably out of deference to her status as a young student). The resolution in its current state was greatly truncated, seeking merely to  preserve “collegiality” among physicians  through support of the right of conscience of all physicians by the state medical society.

When the resolution was read by the author to our committee, there was silence in the room. To break the uncomfortable tension I applauded the resolution and spoke of the importance in a pluralistic society of protecting the right of conscience of all practitioners, noting that much of our disagreement centers on differing definitions of conscience (self-chosen values vs. moral obligation to a Higher authority).  Taking advantage of the opportunity, I then addressed the fallacies of the “supporting” articles by Savulescu and Charo, pointing out that both ignored (or implicitly denied) a crucial fact: that abortion is a negative right which entails no corresponding obligation–a fact ignored by most supporters of abortion “rights.”

There. It was out in the open: that “a” word. I watched with curious amusement as the other members danced around that word for the remainder of the brief discussion. Brief? Yes, brief, because one member quickly responded by slinging out the term “moral fascists.” Moral fascists? Really? (I seem to say that a great deal lately.) Really? The comment was profoundly ironic: those trying to establish protection from the moral encroachments of others are labeled “moral fascists”; and secularists who label religious sensibilities “irrational”–who claim no higher power than reason–are unable to mount a rational argument in defense of their position.

The discussion detoured briefly before dead-ending in the issue of “referral for abortion” which has curiously become the central contention in the debate–another curiosity. For 25 years I have practiced obstetrics and gynecology–now just gynecology–in rural communities with no abortion services, located in both eastern and mid-western states. In those 25 years I have never had a patient come to me 1) seeking an abortion,  2) asking where to go to obtain an abortion, or 3) requesting a referral for abortion. Two patients (two!) have made appointments with me to discuss their decision and/or to receive assurance that they could return to me for care after the procedure. In both cases those women already had appointments scheduled for the procedure. Patients “know” where to go, whether through family or friends or general “street knowledge”–not to mention that it is first listing in the yellow pages after “abortion alternative.”  Nor are referrals required by the provider or insurer. In cases involving congenital fetal anomalies or life-threatening maternal health conditions, the patient is sent to a tertiary center for evaluation, counselling, and treatment–not specifically for abortion. Quite frankly, the issue seems like a red herring…

Right of conscience extends far beyond the issue of abortion into many other aspects of care, a horizon that will no doubt expand even farther in the coming years as our technological innovations continue to outstrip our moral sensibilities, yet the same principles apply. A decade ago, Nigel Cameron suggested that given our ideological disparities, medicine might best be served by the establishment of two separate factions of  healthcare providers: Hippocratic and non-Hippocratic. Perhaps it is an idea whose time has come. Just as all businesses have “mission statements” today (another irony–or oxymoron…), hospitals, clinics, and individual providers could have their mission or value statements posted on-line or at the facilities, allowing individuals to choose  primary providers and facilities whose values were most consistent with their own. It would also fulfill the idea of informed consent, enabling individuals to make informed choices about the providers of their care. It is an option that would eliminate “moral fascism” and promote freedom in a pluralistic society–the essence of “liberty and justice for all” in healthcare.



Emergent Dualism and the Sanctity of Human Life

My wife and I spent May 10-11 at the annual conference of Biola’s Center for Christian Thought (CCT), where the theme for 2012-2013 has been “Neuroscience and the Soul.”  The plenary talks are not all on the web, yet, although some are on Facebook, but a number of discussions on the general topic may be accessed here.  I encourage readers of this blog to spend some time knocking around the CCT website.

The weekend (though perhaps not the year, more broadly) didn’t have much neuroscience in it.  Most of the time was spent talking about philosophical and theological anthropology—in particular, what is the soul?  As I have previously written on this blog, I am most attracted to a “Thomistic substance dualism” (after Thomas Aquinas) of the sort advocated by J.P. Moreland of Biola, who argues that the “soul” is a simple (it doesn’t have parts) nonmaterial substantial entity that contains all the ultimate capacities of an organism and which is intimately involved in directing that organism’s development and expression of those capacities.  The word “ultimate” is critical here, because, as we all know, not all members of the human race realize all capacities at all times.  Moreland’s development shores up some shortcomings of Aquinas’s dualism (e.g., the notion that human embryos acquire souls at either 40 [males] or 80 [females] days of prenatal development), while attempting to retain its merits.  It, and other approaches that reject equating mind with brain function, appeal to certain Cartesian intuitions, like those of self-awareness, the sense of “what it is like” to have an inward experience, and others.  The philosophers call these “qualia” of mental events, which make them non-identical with physical/biologic events.  At the same time, Moreland and those of like mind reject the radical Cartesian distinction between mind and body in favor of a more wholistic, as it were, view of what the soul is and does.

Now, this fits nicely with the biblical notion of the image of God, even if one rejects Moreland’s view that the image is what man is, not just what man does (tend the earth), or the relationship between man and God, or the “status and standard” of man relative to God, creation, and the ultimate perfection man.  But I would argue that Moreland’s Thomistic substance dualism is not just faith-based, but also supported by formidable philosophic arguments and accessible on the terms of general revelation.   As such, I think it provides the strongest support available for the sanctity of individual and collective human life.  One sees this in arguments most commonly employed (perhaps not surprisingly) by Roman Catholic thinkers like Robert George; to wit, “humans are the kind or sort of being that….”

Two criticisms of Moreland’s view are:

  1. It amounts to vitalism, an otiose idea long-ago relegated to the biology’s scrap heap of history.   Moreland’s rejoinder to this is to claim that bad, old-fashioned vitalism was too crude, and that a more modern view, “organicism,” is more promising.  (I can’t carry on about that, yet.)
  2. Evolution is irreconcilable with the Thomist view of the soul, because the latter requires that genus and species not be degreed properties, but be in a real sense, immutable.  I agree that the Thomist view pushes one there, and I think that (along with Moreland, I believe), as these critics claim, the Thomist view requires one to accept that God is progressively active in creation.  But these points are said to be unacceptable because of the science of human evolution.

So, as an alternative, some philosophers who remain sympathetic to the idea that mental phenomena are not reducible to physical processes, and in fact are different in ways that cannot be fully explained by appealing to physical processes, nonetheless inescapably depend on those processes and “emerge” from them.  However, they would hold, what is emergent is not just mental properties but an actual, and in a meaningful sense, substantial self.  So they are dualists about human nature—even, in a sense, “substance dualists,” but they are less ready to allow that the human soul might exist independently of bodily life and processes—particularly those of the brain.

Now, there is more to be said about this than I can say, here or elsewhere, but it seems to me that the appeal to a “degreed” nature of life or consciousness disallows categorical distinctions of moral status between individual people, or people in general, and other beings.  (It seems to me that the emergent dualist also conceives “soul” as too readily identified with higher mental properties than the Thomist view would insist on.)  It risks making “personhood,” or “dignity” or moral status a degreed property.  Should we be more concerned about an anencephalic baby, or a fetus with Down syndrome, than a fully-endowed and functioning gorilla, and if so, why?  Should we be troubled about creating a human/non-human hybrid, and if so, why?  Would a super-intelligent robot, if there could be such a thing, potentially be a rival of “natural” humans in competing claims for concern?

I tried this out on a prominent Christian emergent dualist at the conference, and he quickly dismissed my objections.  To be fair, I hit him with a “drive by” on the coffee break, but as it happened, when I pushed, he responded, in effect, we can’t base all our moral appeals on rational argument.  Sometimes we have to just demonstrate the truth of the gospel, and show people the choice between worldviews and their consequences, and ask them what do they really prefer?  And, as unfairly as this brief post may be posing the issues, that kind of rejoinder worries me.

Ultimately, some appeal to a “givenness” of human nature is necessary to defend boundaries in bioethics.  We might indeed appeal to the naturalist by counseling caution—evolution has, over millions of years, presented us with ourselves, including our common intuitions—and we ought to have a “default” position of “no-go” on the most “out there” ideas.  We might indeed present a “two views” picture, and ask people to choose what kind of world they really want and what sort of people they ought to be.  We might argue, as I take the German philosopher Jürgen Habermas to argue, that the interplay of human autonomy, human language, and human social relationships lead us to conclude that some technological interventions would tend fundamentally to destroy who we are in community, and so ought to be avoided.  But I think it’s harder to identify, on emergent dualist grounds, what if any specific maneuvers ought to be proscribed with “thou shalt not,” or words to that effect.

The emergent dualists might be right.  (I tend to agree with Moreland that the position is unstable, tending toward either his dualism on the one hand or functionalism on the other.)  If so, we should, as the philosopher I challenged told me, follow the inquiry where it leads.  (One approach that could be called into question is Francis Schaeffer’s approach of asking whether one can live with the consequences of one’s philosophy.)  But my efforts, at least, are still awfully preliminary.

Conscience, Data, and the Burden of Proof

Dr. Susan Haack’s recent posts on conscience, and the ongoing struggle over the HHS regulations on mandatory insurance coverage for contraception under the Affordable Care Act, demand more careful further reflections than will fit in a blog post, but I will dare to stick a toe in nonetheless.

In The Line Through the Heart: Natural Law as Fact, Theory, and Sign of Contradiction, J. Budziszewski argues (see pp 8-15, for example) that “deep conscience,” which is “rooted in the constitution” of all humans, is a cardinal indicator of the existence of a natural moral law.  Deep conscience “remembers” general moral norms (including, he argues, the Decalogue).  I’d take this to be Dr. Haack’s “antecedent” function of conscience.  Budziszewski then distinguishes three “modes” of conscience:  cautionary, accusatory, and (for lack of a single term) confession/reconciliation-seeking—the “consequent” functions Dr. Haack mentions.  He would certainly agree with Dr. Haack (as do I) that conscience points to a transcendent authority.

Presumably (me talking now, not Budziszewski), we form correct moral convictions by agreeing with deep conscience about moral truth.  However we arrive at those convictions, we can argue that they too have “antecedent” functions in that they are, if properly understood, sufficient to motivate ethical behavior.  (I just glossed over a major discussion in ethical philosophy that I ask the reader to accept for the sake of argument here.)  Convictions do not, however, produce a sense of guilt, accountability, or of a need for reconciliation.   Conscience does that.   Whether we recognize it or not, conscience is witnessing to our accountability before God.  People who deny God’s existence, however—and who may well also interpret “guilt” to mean a response to bad-faith intimidation by the organized church—can still coherently claim, it seems to me, to act out of conviction with accountability to the community, as long as the standard is some sort of community-recognized norm.  In a pluralistic society, one can appeal to positive law or what we can agree on; or, alternatively, one can appeal to the shared understanding of what it is to be an autonomous moral agent (as I take the German philosopher Jürgen Habermas to do).  Just don’t plead metaphysics.  But the appeal to convictions is not ripped from its community connections—it depends on them, just in a different, but critically different, way.

And that, of course, is the problem.  People like me are making a metaphysical argument (actually, I want to argue for a form of natural law) in a positive law world.  Some of the “positive lawyers” claim that their convictions are objective, not relativistic, because they are available to observation, as in the natural sciences, so we can agree on them, revising our understanding as we get new information.  We are left with a sort of “naturalist’s natural law.” I think that is irredeemably relativistic, in the end—if God is dead, nothing is out of the question.   I understand Budziszewski to agree.  He criticizes the “positive/natural lawyers,” if you will, of pursuing a “second-tablet project”—that is, isolating the “second [stone] tablet” of the Decalogue (Commandments 5-10) from the more explicitly God-directed first 4 commandments of the “first tablet.”

So what?  First, I would submit that the “conscience/convictions” argument doesn’t help all that much in cases like the HHS mandate.  The issue is how much room to give to particular metaphysical stances—the public/private square problem.  Pluralistic norms vs religious freedom is still the battle.  And it will not do to say that profit-seeking makes the moral application of metaphysical commitments illegitimate.  To put the fine point on it, Hobby Lobby’s owners ought to be accorded the same freedom of conscience as are the Catholic Church, or a church-run hospital, or Wheaton College (for example).  I worry, perhaps too much, that bioethicists in particular worship at the altar of non-profit status in ways that risk serious mistakes.

Second (and cf. the recent post by Dr. Joe Gibes), statements like “[The] lack of any substantial evidence for post-fertilization effects [of emergency contraceptives] may significantly weaken conscience claims, and may militate against refusals to dispense or to refer,” [Lewis and Sullivan, Ethics & Medicine 28:113-120, 2012] will not do.  Failure to prove is not disproof.  Absent definitive data, prohibition of emergency contraceptives may be weakened.  But without definitive data—which may not be accessible by ethical experiments—sufficient to free the conscience of concerns, conscience claims of someone with a reasonable doubt about what the data mean ought to be vigorously defended, even against a strong majority consensus.   We should not let a prevailing tide of naturalistic, “data-driven” ethics confuse our use of the data in service of true moral precepts.

Is emergency contraception abortion?

Emergency contraception (EC) — the “morning-after pill” — is taken by a woman after an episode of unprotected intercourse in order to try to prevent pregnancy.  It contains a hormone that acts to prevent pregnancy by preventing ovulation (the release of an egg from the ovary). However, theoretically, if ovulation has already occurred, EC might prevent pregnancy by preventing implantation, the attaching of an already-fertilized egg to the lining of the uterus. This second, conjectural mechanism raises ethical problems for those of us who consider that life begins at the moment of conception, since preventing the implantation of a fertilized egg could be viewed as inducing an abortion. Should we oppose EC because it might in theory cause an abortion?

The authors of a review article in the Fall 2012 issue of Ethics & Medicine address just this question. They review the best available scientific evidence and conclude that  there is “sufficient motivation” to believe that EC does not prevent implantation, and therefore does not cause abortion. (p. 116)

Good ethics begins with good facts. But our understanding of scientific facts is constantly changing; so even though we use the same moral reasoning (“It is wrong to deliberately take a human life, so one should not use a medication to cause an abortion”), our ethical conclusions may change as our understanding of the facts progresses  (i.e., if the facts indicate that EC causes abortion, we should not advocate its use; on the other hand, if the best data indicates that EC does not cause abortion, it may be ethically justifiable to use in certain circumstances ).

In a fallen world, our knowledge of the truth will always be imperfect; but it is the best we have to work with. Given the current state of knowledge, it appears that EC is not tantamount to abortion, and that I should not use “It might cause an abortion” as a reason not to prescribe it in certain circumstances (such as rape). I am open to changing this stance as knowledge grows and changes; what I am not willing to change is my commitment to not deliberately take a human life.

(See my post here for more on this topic.)