Burwell v. Hobby Lobby: A thin margin indeed

The recent Supreme Court decision, Burwell v. Hobby Lobby, has been hailed as a victory for religious rights, but in the Supreme Court’s majority opinion there are ominous signs for bioethics.

First, no commentator so far has mentioned that the Supreme Court decision implies that the only legally viable objection to underwriting abortifacient interventions must be religious in nature. The thin margin of decision by a majority that repeatedly referred to the Religious Freedom Restoration Act indicates that anything less compelling than a “sincere Christian belief” would be insufficiently persuasive. The belief at issue was that life begins at conception.

Thus there seems to be no legal room for a secular argument against funding abortifacients in Hobby Lobby’s situation. But what if someone held a purely scientific belief that life begins at conception? Would we not hope that such a person, who came to such a conclusion based on scientific evidence, would then have deeply held moral views about abortifacients? And if so, shouldn’t there be any an equal legal respect for such views?

In fact, what is specifically “Christian” is not the belief that life begins at conception. That is a scientific fact; what the Christian then does is conclude that there is moral consequence to the fact. He then has conviction to act based on this belief.

There are serious concerns here—one is that these events indicate that in our society those without religious beliefs are failing to demonstrate the moral conviction to act on the scientific fact that life begins at conception. The second is that should such secular moral conviction occur, the legal system would fail to grant legal standing to it. The Supreme Court majority made no attempt to accommodate a nonreligious belief; certainly the minority would not do so either.

A third concern is that there is ample evidence that many who support abortifacients deny the scientific facts altogether. They create arguments that what is being destroyed by abortion and abortifacients is not yet actually human life. In these instances they reveal that while they retain a moral sense that ending human life is wrong, they decide to override it with fanciful and convoluted cogitations in order to justify other desires. They simply lack sufficient moral conviction that respecting human life is paramount; both truth and the embryonic human become expendable.

The outcome of Burwell v. Hobby Lobby certainly could have been worse. But as it is it bodes poorly for the state of modern bioethics, for it is shows that there is no active nor legally viable line of defense against assaults on nascent human life than a Christian community increasingly marginalized by its own government.

Musing About the Hobby Lobby Decision

I am in the camp that applauds this week’s Supreme Court decision in the Hobby Lobby case.  But of course others disagree, and I was not surprised to see that there is alarm on the pages of the New England Journal of Medicine.   A “Perspectives” article written by two attorneys (one with a bioethics degree) and one M.D. includes two graphs, in particular, that I think are key.

The first:

[I]n the wake of Hobby Lobby, we may anticipate challenges to other medical services that some religions find objectionable, such as vaccinations, infertility treatments, blood transfusions, certain psychiatric treatments, and even hospice care. Hobby Lobby‘s implications may also extend into civil rights law, with employers asking to “opt out” of laws intended to protect people from employment and housing discrimination based on religion, race, sex, national origin, or pregnancy status. Although the majority deemed these slippery-slope concerns unrealistic, the dissent expressed serious concerns.

So the slippery slope is a fallacy, except when it isn’t.  This paragraph sounds like Justice Ginsberg’s dissent, which commentators much more qualified than I have found over the top.  But grant that this decision may not—and I guess I should say, probably will not—stop with this case.  How plausible is the list above?

  • Vaccinations?  I think that a challenge would fail because the government’s interest is too compelling—although as I understand it the Court majority did not invoke this line of reasoning in Hobby Lobby. Parents already “opt out” of vaccinations for their kids—a poor decision, in my view.  And maybe a separate government initiative to insure that vaccinations are paid for would be a good idea.  I don’t think this one is a likely problem.
  • Infertility treatments?  Legitimate point.  I might see religious objections to providing insurance that pays for IVF—and I believe such an objection should be honored.
  • Blood transfusions?  I wouldn’t rule out a challenge, but I doubt it would succeed.  Too interwoven in too much of medicine and surgery, and too compelling an interest to allow an opt out under the Religious Freedom Restoration Act (RFRA).  (I suppose if we had single payer, that would be an alternative for the government…)
  • “Certain” psychiatric treatments?  I guess I’m not sure what is meant here.  Perhaps some reader can fill in the blanks.  On the other hand, the government might try to block insurers from providing access to “certain” counseling treatments deemed illegitimate by them but allowed by some religious groups.  I suppose.
  • Hospice care?  No way.  Unless a secular business owner wanted to prefer coverage of physician-assisted suicide/physician-aid-in-dying.  I’d expect religiously devout people to want to protect hospice care out of concern for human dignity.  Perhaps a Christian Scientist would object under the umbrella of not wanting to provide access to medical care—but couldn’t such a person decline to insure employees at all and choose to deal with the consequences under the provisions of the ACA?  Or wouldn’t we expect a broad challenge on religious grounds to fail, again because the government’s interest is too compelling?
  • “Opt outs” that are really forms of civil discrimination?  I thought that was specifically excluded under RFRA.

The second key graph:

Though the decision applies only to closely held, for-profit corporations, it sets a precedent for religious exemptions that could have sweeping implications — and reflects the Supreme Court’s great potential impact on U.S. health care. Yet the Court was applying Congress’s statute, and Congress could, if it chose, scale back the protection offered to religious objectors — a good reason to share public reactions to the decision with our elected representatives.

This sounds like a fair point and fair warning.  The struggle for religious freedom continues.

I can’t resist adding that, if people could freely buy their own individual insurance, and not have to depend on employers providing it, maybe the range of choice could be more easily accommodated.  Our employers don’t tell us what our auto insurance options are.  They may offer life and disability insurance, but we can buy more, or different, coverage.

As a long-winded pastor used to say, “This and I’m through”—Justice Alito’s discussion of what it means to incorporate pointed out, if I am getting it right, that forming a corporation is one way for human beings to associate to achieve ends that are not limited to profit.  That, of course, is the hard thing for medical-related enterprises to keep in focus and put into practice.  But it is clearly true.  As organizations get bigger and more far-flung, however, the interests of the human beings become less commensurate, and we slip into money being the sole reason for existence.  But it is not.  Most of the people who work for a drug company, for example, may not be bound to the Hippocratic Oath, but the company works, as it were, under a “Hippocratic umbrella” where the needs of the patient, or patients—and I would distinguish this from the population—dictate the rewards for all other actors in the system.

“The Power of Three”

That is the title of a news piece accessible at Nature’s website this week.  It refers to something that Steve Phillips and I posted on back in February; to wit, the potential for “three parent babies” resulting from the transfer of a nucleus (and its genetic material) from a diseased mother’s egg cell into the enucleated egg from a healthy donor.  (I am skipping important technical nuances with that description; see the Nature article for at least a partial description.) The disease(s) in view are mitochondrial diseases, rare but devastating disorders resulting from abnormal mitochondrial genes, of which there are all of 37, compared with on the order of about 20,500 human genes overall.   Human sperm transmit no mitochondria to offspring, so mitochondrial diseases are inherited from the mother.

The Nature piece, while far from complete, is a pretty good introductory discussion of the work for the general reader.  It briefly addresses some, but not all, of the implications.  The subtitle says that this work is “on the verge of clinical use” in the hope that women with mitochondrial diseases might be able to bear unaffected offspring.

I count at least 10 ethical issues raised by this work.  There may be more.  Steve and I touched on several in February, but the Nature article offers the occasion to try to list them briefly.  I don’t pretend the following list is complete, and space prevents me from trying to address them.   Also, there was an excellent piece last year in CBHD’s Dignitas, which I cannot lay hands on, and could not do justice to, here, in any event.

First is the question of risks to any immediate offspring.   It is not clear that the egg modification process will eliminate diseased mitochondria, or avoid further complications, including, conceivably (apparently based on work in mice and fruit flies) other genetic or general disorders not directly related to the mitochondrial defects.  As Steve and I commented in February, these risks are far from fully understood.

Second is the question of informed consent.  The unborn, much less the yet-to-be-conceived or yet-to-be-implanted, obviously can’t provide informed consent.  The intended mother would have to do that.  That’s not necessarily outside the pale.  Presumably a child otherwise destined to be afflicted with these disorders would be willing to take considerable risks to try to avoid them, and in any event existing regulations allow more-than-minimal risk research in pediatric populations if there is a sufficient prospect of direct benefit to the subjects.

Third is the question of whether there would be any risk of inherited disorders to the second generation—the offspring of the “treated” child.  Researchers in the US have followed two generations of monkeys after the sort of nuclear DNA transfer envisioned, and report they appear normal.  Some scientists would want to see many more generations.

Fourth is the possible strategy of sex-selective abortion to try to prevent the concern raised by the third issue.  One presumably would want to have only boys born of these procedures, to try to interdict any subsequent maternal transmission.  This assumes that the boys’ genomes are not adversely affected in the process.

Fifth is the practical fact that, to perfect the nuclear transfer technique, it would be considered advisable to do substantial practice with human eggs and sperm—i.e., create human embryos solely for research purposes, and of necessity subsequently destroy them.

Sixth is the commodification issue.  The eggs developed would be considered a form of cellular therapy, and be subject to strict manufacturing controls.  Presumably each case would be unique, so that buying and selling would be limited to compensation of the healthy egg donor.

Seventh is a form of the “slippery slope” worry—that the technique is broadened to become a treatment for infertility (already actively contemplated).  This is a concern in that it further commodifies reproductive medicine, and that it portends other ambitious extensions of the genetic modification of  humans.

Eighth, and related, are the broader twin concerns of confusions about parentage, and the wisdom of opening the door to introducing heritable changes on purpose into humans.  There is both the more consequentialist perspective on this—do we know what we are doing?—and also the concern that choices about introducing the technician so much more intimately into the outcomes of reproductive choices.

Ninth is the fact that all this is coming with relatively little discussion in the general public.

Tenth is a type of justice issue—this won’t be cheap.  Why this and not some other use of our resources?

Now, a difference of 37 mitochondrial genes is not going to make someone wonder who his mother really is.  Perhaps this would be one thing if we could be assured that we can establish a narrow scope and firm boundaries around this work, in the name of observing the “therapeutic boundary.”  But experience shows that such boundaries do not hold.

Abortion and the personhood of the fetus

In my post last week I addressed the idea that uncertainty about the personhood of a human embryo or fetus should lead us to think that we should refrain from causing harm to any entity that might be a person. Therefore, if we are uncertain about whether a human embryo or fetus is a person we should protect that embryo or fetus in case it is a person.

One of my students, Mark Taylor, wrote a paper this spring in the Medical Ethics class I teach that took a different approach to the disagreement in our society about the personhood of the human fetus in relation to the issue of abortion. In contrast to Judith Jarvis Thomson who took the position that abortion should be permissible even if the fetus is a person, he suggested that there are reasons to consider abortion impermissible even if the fetus is not a person.

His arguments are based on the idea that the impermissibility of an action is based more on the moral obligations of the person performing the action than on the rights of the object being acted upon. He presented an argument from aesthetics and virtue and an argument from justice that supported the position that abortion is impermissible even if the fetus is not a person. The first argument says that a fetus is a complex human organism which is a thing of beauty which has been created in most cases by an action chosen by the mother which was known to lead to the creation of such a beautiful being. To choose an abortion would be an irrational act that would be wrong in the same way that it would be wrong to create a great work of art only to destroy it. It would also violate the virtue of responsibility by engaging in an action know to add beauty to the world only to destroy that which is beautiful rather that caring for it. This argument only applies to the abortion of pregnancies that result from consensual sex, but those make up the vast majority of abortions. He argues that failure of contraception does not negate this argument since it is know that contraception is not foolproof.

The argument from justice is based on Rawls’ concept of justice as fairness and the use of the veil of ignorance. Central to Rawls’ system is the idea that a just society is one in which a person who does not know what role he or she will play in that society would judge the society to be fair. Taylor argues that one of those roles that the one judging the fairness of the society might assume behind the veil is the role of the fetus. Even if the fetus is not a person, we all go through the stage of being a fetus so just as the person behind the veil might take on the role of a child the role of the fetus should also be considered in whether the society is just. If the role of fetus is one that the one judging the fairness of the society may assume then it would not be concluded that if would be just to allow a fetus to be aborted.

These arguments suggest the possibility of being able to argue for the impermissibility of abortion no matter what position is taken on the personhood of the fetus. If the fetus is a person then the traditional arguments against of killing an innocent person apply. If we do not know whether a fetus is a person then we should refrain from killing an entity that could be a person. If the fetus is not a person there are still reasons why a person would have a duty not to destroy the fetus based on obligations of virtue and justice that are not dependent on fetal rights or personhood.

The implications of uncertainty about personhood

Many times the different parts of my life conflict with each other, but sometimes they come together in interesting ways. Susan Haack’s recent post on the article “The Fetus, the “Potential Child,” and the Ethical Obligations of Obstetricians” from the journal Obstetrics and Gynecology contained a quote that connected with a reference to an article by Christopher Tollefson by one of my students in a recent paper. The authors of the Obstetrics and Gynecology article stated that the issue of whether a fetus has full moral status is “irresolvably disputable” and from that drew the conclusion that the fetus has no independent moral status and subsequently reached the conclusion that abortion is permissible. Tollefson, however, has argued that an inability to decide whether a human being at a certain point in development has full moral status should actually lead to the opposite conclusion.

In his article “Embryos, Individuals, and Persons: An Argument Against Embryo Creation and Research” in the Journal of Applied Philosophy in 2001, Tollefson argued that in order to conclude that destructive research on human embryos is permissible it would be necessary to establish conclusively that the human embryo is not a person. His argument is that if it is uncertain whether an entity is a person or not it would be wrong to intentionally kill it. Therefore, it is wrong to conclude that it is permissible to do destructive research on early human embryos because we don’t know or can’t know whether those embryos have full moral status. The uncertainty about their moral status means that we should avoid the possibility of killing a person if those embryos would happen to be persons. That same idea can be applied to the “irresolvably disputable” issue of whether a fetus has full moral status. If the issue is unresolved then there exists the possibility that a fetus is a person with full moral status and we should not kill a fetus if that possibility exists.

An example that would be readily understandable to many of my rural Midwestern patients and neighbors can illustrate this point. Assume you are a deer hunter in the woods of rural Indiana and you see something move in the underbrush. You are not sure whether it is a person or a deer. It would be morally wrong to shoot at whatever was moving without determining with certainty that it was not a person. In the same way doing embryo destructive research or an abortion is wrong unless you are able to determine with certainty that what is being killed is not a person. Uncertainty about the personhood of the embryo or fetus means that it would be morally irresponsible to kill it.

It would be sad to think that the typical deer hunter has more moral responsibility than a medical researcher or physician.

Autonomy, Moral Status, and Consequential Conundrums

At times our unreflective declarations, pronouncements, and moral positions made without adequate forethought consequentially lead to moral conundrums, with which we are then left to wrestle. A recent article entitled “The Fetus, the “Potential Child,” and the Ethical Obligations of Obstetricians,” in Obstetrics and Gynecology exemplifies an effort to reframe just such a conundrum. In this article, the authors attempt to justify a physician’s obligation to deny maternal requests that jeopardize her unborn child without rationally jeopardizing her right to abort the unborn child if she so chooses. Secondarily it addresses the issue of how an obstetrician is to define his or her moral responsibility to a being in utero.

Quickly setting aside the issue of abortion, which is stated to be grounded on the essentially unassailable right to bodily integrity (“negative” autonomy) and supported by “mainstream” ethical opinion, the issue of “positive” autonomy is addressed: are there limits on the right of a woman to demand treatment that negatively impacts her child? Acknowledging that physicians also possess negative autonomy rights and consciences (defined as “professional integrity”), on what basis can a physician refuse a maternal demand for treatment or care that is not in the unborn child’s best interests? The answer: distinguish “fetus” (having “value” but no interests) from “potential child” (having anticipatory interests that will “evolve and ultimately attain at delivery”). According to the authors, the fetus has no independent moral status because the issue is “irresolvably disputable,” confirming the arbitrary nature of that determination. So what is it that determines this distinction in moral status? Maternal choice. By the decision to eschew abortion and continue the pregnancy a woman grants moral standing to the child within while simultaneously constraining and limiting her own affirmative autonomy. This decision also enables the physician to resume the fiduciary role to the unborn that has traditionally been entailed in the care of pregnant women.

And so in an attempt to keep previous moral proclamations from overflowing their banks and being carried to their logical conclusions—conclusions which would invalidate our standing as providers of obstetrical care–they are shored up by creating new categorical boxes. But as I am so fond of saying these days, flesh and bones do not fit into boxes without remainder; embodied life is not that simple. Having created the box labeled “potential child” it is then poked full of “subjunctive” holes that make room for contingencies: “the interests of the potential child might infringe on a pregnant woman’s right…”; and “as those interests (of the fetus) rise to a level at which they can be considered…” Oh, what tangled webs we weave!

Life is fragile; and from this particular perspective, so is our moral standing as human beings, contingent as it is upon the good graces of those upon whom we are relationally dependent. Our moral agency becomes not something inherent in our nature as beings created in the image of God, but a goal to be attained–not by any act of our own but by the circumstantial whims of another.

Treating the concept of moral standing with irreverence has greater implications for other vulnerable humans as well, dependent as they often are on the grace of others for their care. Their moral standing is also now jeopardized, hanging in the balance.

And so we must return to the basic questions, as difficult and painful as they might be: What is the source and meaning of our moral standing? Who has the authority and right to determine the moral standing of another human being—and on what moral ground?

In playing with the concept of moral agency, we play with our human nature and identity; and we do so to our own detriment. In our efforts to distinguish grounds for granting degrees of moral status to the unborn in order to support our own changing personal and political agendas, we dehumanize ourselves. Moral agency has become so capricious, arbitrary, and contingent as to be meaningless.

Ultrasound before Abortion: Consideration of Recent Research–Closing Comments

In my previous two posts (April 22 and April 29) I discussed an article in the January edition of Obstetrics & Gynecology entitled, “Relationship Between Ultrasound Viewing and Proceeding to Abortion.” The authors found that in Planned Parenthood clinics in LA, the voluntary viewing of ultrasounds by patients seeking abortions appeared to dissuade a very small percentage from continuing on to abortion. From their data the authors concluded that women should not be required to view ultrasounds prior to elective abortions. They state that, “…because fewer than half of women select this option, mandatory viewing “may have negative psychological and physical effects even on women who wish to view.”

Three points regarding the authors’ ethical calculus: First, their equation is incomplete; second, to weigh “effects” we must be more precise in what they are; third, they fail to describe the one group of people who ought to be doing this ethical calculation, but are not.

First, this article certainly does not weigh all the adverse psychological and physical consequences involved in the act of abortion, or even all the consequences—good or bad—of mandated ultrasounds. It is premature, therefore, on the basis of this study to argue that they are either harmful or beneficial psychologically or physically. The authors make no mention of the possibility that harm or benefit of one’s actions may proceed well into the future, or of the possibility that simply because there is “certainty” regarding abortion that the decisions are informed, or not coerced.

Second, the authors cite “negative psychological and physical effects,” but this is a most imprecise description—by design, I believe. What are these untold effects but modern society’s taboos of guilt and regret? These words must not be spoken of by those in favor of abortion because they would remind of us of right and wrong existing beyond personal choice. Guilt and regret, after all, do not spring de novo. They are born of some sense of wrongness, and point to values beyond simple autonomy. To hold to the thin reed of “choice”, however, one must disallow discussion beyond “psychological and physical effects.” But this blinds us to the existence of a greater morality than individual choice, and therefore to the reality of the human condition.

Finally, in this research the focus on whether or not women changed their mind after viewing their ultrasound or even desired to view it at all fails to acknowledge that there is one group of moral agents whose decision-making is central to the issue of abortion, including to the decisions of the women themselves: physicians. As Justice Blackmun stated in Roe v. Wade’s majority opinion, “the abortion decision in all its aspects is inherently, and primarily, a medical decision, and basic responsibility for it must rest with the physician.” A reading of the subsequent opinion will show that this medical decision-making is ultimately a moral endeavor. But where is the physician in this article’s abortion process? Where is the seeking of each patient’s story, fears, concerns, goals, needs, and so on, that are all necessary for rendering a proper “medical” (but truly moral) decision? In pro-abortion arguments, no allowances whatsoever of physician judgment are allowed to eke into the discussion, yet the Supreme Court justified the legality of abortion on its active (and determinative) role in each decision to abort.

This “medical” decision is supposed to have a certain inherent moral authority, or imprimatur, born of the professional judgment and obligations of physicians. If such individualized contemplation regarding each procedure of abortion is not modeled by those medical professionals whose careers ostensibly carry the moral credentials stemming from caring for others, then there is no surprise when a woman in crisis does not reach a moral epiphany that directs her to the exit. It is sad that our society, which once had a physician profession that was firmly and universally dedicated to the well-being of the unborn, now senses some need to get moral awareness awakened by some other means. The problem, then, wasn’t that the women viewing the ultrasounds failed to change their minds, it’s that the physicians performing them didn’t.

 

Ultrasound before Abortion: Consideration of Recent Research, part 2

Last week I began a discussion about an article in the January edition of Obstetrics & Gynecology entitled, “Relationship Between Ultrasound Viewing and Proceeding to Abortion.” The authors found that in Planned Parenthood clinics in LA, the voluntary viewing of ultrasounds by patients seeking abortions appeared to dissuade a very small percentage from continuing on to abortion. Overall there appeared to be 0.6% absolute risk reduction (99.0% of those who did not view the ultrasound, and 98.4% of those who did, proceeded to abortion).

This is a small reduction indeed. If we calculate the “number needed to treat,” or NNT (we might use the term “number needed to scan” in this setting), we find that it took 151 ultrasounds to cause one woman to change her mind. But how should we interpret these results? That is, how should we assign a value to raw numbers?

If one considers that an ultrasound could be a “screening” test to find that cohort of patients who would change their minds about abortion, and that the outcome is a saved human life, then the numbers become quite appealing. In other words, if the number needed to treat (or scan) to save one life is 151, then scanning is an outstanding intervention. In contrast, nine times as many women aged 50 to 59 years must be screened for breast cancer with mammograms to achieve the same number of lives saved.  One could try to calculate in the relative risks to women’s lives from abortion vs. term pregnancy, but these numbers are quite small compared to the relative risk to the fetus’s life from abortion vs. term pregnancy.

Is not one human life gained worth the time, effort, and cost of 151 ultrasounds? As a physician I perform or order countless tests, including many as part of standard prenatal screening, with much slimmer hopes of benefit. And, with succeeding generations of lives produced from each fetus saved, the NNT drops dramatically. For those opposed to abortion, the statistics seem to provide little hope for a significant change of minds that they would hope for. But whenever I observe the dramatic miracle of a single birth I see an outcome grand enough to justify the effort.

It is a fundamental flaw of the research to impose a moral equivalency on all outcomes. It is not simply a matter of weighing 150 choices in one direction for every one choice in another—it is the weighing one human life gained vs. all other outcomes. Isn’t the saving of lives what we’re here for? Or do physicians direct their lives’ work toward simply accumulating “choices” satisfied?

Next post will discuss the ethical conclusions made by the authors, who raised concerns about risks of viewing the ultrasound itself.

Ultrasound before Abortion: Consideration of Recent Research

In the January edition of Obstetrics & Gynecology was an article entitled, “Relationship Between Ultrasound Viewing and Proceeding to Abortion” by Gatter et al that has already received publicity. There is no doubt that this article will be oft-cited for many years, so it merits discussion.

The authors performed a retrospective review of one year’s worth of records at Planned Parenthood clinics in Los Angeles, finding that in that particular practice setting the voluntary viewing of ultrasound (after being asked, “Do you want to see your ultrasound picture on the screen as the clinician performs the examination?” or a similar question) did very little to dissuade women who were seeking an abortion from going through with it. They found that, “Most women presenting for abortion care in our sample had high decision certainty, and ultrasound viewing had no effect on their abortion decision.” Even among those who had “medium or low decision certainty” about having an abortion, 95.2% of those who viewed the ultrasound proceeded to abortion, compared to 98.7% who had not. Overall the difference was even smaller: 98.4% compared to 99.0%.

We can all probably agree on one conclusion— that this particular article certainly does not provide data to support the notion that viewing ultrasounds of pregnancies causes women seeking abortions to change their minds in significant numbers. But it is, unlike what the authors might nudge us toward believing, too early to write off the merits of offering and performing ultrasounds for these patients.

But what critiques can we make? I can think of a few, which I will enter over the coming weeks.

First, the reader must note that the ultrasounds were done in Planned Parenthood clinics in Los Angeles. The article did not attend to any details of what the “viewing” of the ultrasound entailed; the authors did not indicate that there was any attempt to “script” that process. I would propose that in the setting of a clinic dedicated to providing abortions, the discussion surrounding the ultrasound may bear little resemblance to the detailed explanation of fetal anatomy that a happily expectant couple may get from her obstetrician. Features like the brain, spine, heartbeat, limbs, fingers and toes, spontaneous movements as well as reactions to the pressure of the ultrasound are all part of what I discuss with my patients. For the woman seeking abortion, the physician performing it seems unlikely to attend to these details. I propose that not all ultrasound experiences are alike.

The article later raises concerns about mandated ultrasound viewing (arguing against it). It is a contentious notion already; to suggest that the viewing of an ultrasound ought to contain specific content and discussion would make it only more so. But would not true informed consent require it? And for the purposes of research, would not a dismissal of the impact of ultrasound’s effects on a woman’s decision require a more descriptive effort of what happens inside the exam room?

This is a reflection on the method of the intervention; in coming blogs I will add more thoughts about interpretation of results, and the ethical conclusions made by the authors.

Euthanasia, pediatric and adult, and the underlying concept of a life not worth living

Jon Holmlund’s recent post about pediatric euthanasia in Belgium made me think about what I had posted a couple of weeks ago about PGD and lives not worth living. There is a way in which the concept of a life not worth living underlies a whole spectrum of ethical issues from PGD and selective abortion to pediatric and adult euthanasia. There is a basic conflict between those who take different ethical positions on these issues over whether there are certain quality of life issues that can allow one person to decide that another person’s life not worth living.

For those who take the position that it is permissible for couples who are at risk to have a child with a serious genetic disorder to use PGD or prenatal diagnosis with selective abortion to try to insure that any child that is born is free from the genetic disorder, a part of the argument for their position is that it is permissible to discard the embryos found to have the disorder or abort the fetuses found to have the disorder due to the poor quality of life that would be experienced by those children if they were born. That is saying that the lives of those children would not be worth living. That decision is being made by the parents for their children and being confirmed by the physicians and others who participate in the process.

Those who support the permissibility of active infant euthanasia as practiced in the Netherlands under the Groningen protocol are also saying that the infants whose lives are being ended have lives that are not worth living. Again this decision is being made by the parents and confirmed by the physicians involved that the infant’s life is not worth living.

The situation with voluntary euthanasia of children as it has recently been allowed in Belgium is more complex. If the child does not actually have full decision making capacity or is being overtly or covertly coerced, it is again someone other than the child who is making the decision that the child’s life is not worth living and the situation is similar to infant euthanasia. If the child has full decision making capacity then it could be reasonable to consider the situation to be the same as adult voluntary euthanasia.

With adult voluntary euthanasia some would argue that the concern about one person deciding that another person’s life is not worth living is not an issue because it is the one whose life is being ended who is making that decision. However, whether what is being done is voluntary active euthanasia in which a physician is administering a lethal drug or physician assisted suicide in which the physician prescribes the drug with the intent that the patient will self-administer it, the physician who is involved must make the decision that the act of ending that patient’s life is warranted. Few would be willing to take respect for autonomy so far as to say that anyone who requested assistance to end his or her life should be provided the means to do so without a judgment by the physician that the decision to do so was an appropriate one. Assisting someone to commit suicide who is despondent over a break-up of a relationship is irresponsible. Thus physician participation in voluntary active euthanasia or assisted suicide requires an independent decision by the physician that the decision to request assistance in ending life is reasonable. The only way a physician can make the decision to participate is to decide independently that the patient’s life is not worth living.

The only situation in which ending a life to avoid a poor quality of life could be done without one person deciding that another person’s life is not worth living would be unassisted suicide. There are Christian and Kantian arguments for why that is not morally permissible, but that lies outside the realm of these thoughts.

Since all of these actions, from PGD to adult voluntary assisted suicide involve one person making a decision that another person’s life is not worth living, a crucial issue is whether it is morally permissible for us to make such a decision about another person’s life. For those of us who have an understanding that every human life has value simply because of being human, we must answer that it is not permissible to make that decision. We understand that no matter how difficult a life may be that person still has value and our response to those whose quality of life is poor and who are having to endure more suffering than it would seem that they ought to is to affirm the value of that person’s life by caring for the person’s needs. We cannot say that another’s life is not worth living.