Doctor-Assisted Suicide in Canada: the Next Step

The general press is reporting that the Liberal majority in Canada has drafted proposed legislation to establish the conditions under which physician-assisted suicide (PAS) would be legal.  Per the Canadian Supreme Court’s order last year that PAS is allowed in Canada, the Parliament has until June 6 to pass it, or the Court’s prior order would come into force.  This would effectively leave judgments of when or how to carry out PAS in Canada to individual doctors or regional governments.  The province of Quebec had already acted separately in support of PAS.

It is reported that the proposed law:

  • ·       Would apply to people age 18 or older with “grievous and irremediable” medical conditions;
  • ·       May not be clear about whether people with dementia or degenerative diseases would be eligible;
  • ·       Would require a 15-day waiting period after review of the patient’s written request by two physicians or nurses;
  • ·       Would apply only to Canadians (those eligible for services in the Canadian health care system—no “suicide tourism” allowed;
  • ·       May not be clear about whether conscientious-objecting doctors will be allowed to opt out of participation (the Health Minister says yes, but some health-care workers worry that the law is too vague on this point, or that complicity will be unavoidable);
  • ·       Could not be used in advance to create a directive to carry out PAS at some future date.

I and other contributors to this blog have written extensively against PAS.  I will not rehearse those arguments again here.  My guess is that this provision in Canada will become law. 

Wesley Smith adds the criticism that the Canadian law, by protecting suicide-assisters from legal liability if they act in good faith, eliminates any guarantee that the process will be limited to those who freely and voluntarily request death.  There is too much wiggle room.  

I would add this worry:  active euthanasia by physicians or nurses appears to be included.  From the bill (text can be found here):  

“medical assistance in dying means

(a) the administering by a medical practitioner or nurse practitioner of a substance to a person, at their request, that causes their death; or

(b) the prescribing or providing by a medical practitioner or nurse practitioner of a substance to a person, at their request, so that they may self-administer the substance and in doing so cause their own death. (aide médicale à mourir)” [emphasis mine].

“People get ready, there’s a train a’comin…”

Experimentation on nonviable human embryos

Nature News recently reported that a second Chinese research team has done research on non-viable triploid human embryos in which they used CRISPR-Cas9 genome editing to introduce a mutation that cripples the immune cell gene CCR5 and would make individuals with the mutation resistant to HIV. This research raises a multitude of ethical concerns. Should we be pursuing such research when we have not decided whether using these techniques to create individuals who would be brought to birth would be permissible? Does the fact that only 4 of 26 human embryos targeted were modified and that those were not modified on all of their chromosomes and there were a large number of unintended mutations indicate we are nowhere near ready to try this technique on human embryos? If this could be done effectively would we want to make children with an impaired immune system, but who are resistant to HIV?

I would like to focus on a more basic ethical concern. The researchers in this and the prior Chines study reported in April 2105 justified experimenting on human embryos by using embryos that were non-viable. They obtained from a fertility clinic early human embryos that were triploid, meaning they came from eggs that were fertilized by two sperm and contain 69 chromosomes rather than the normal 46. This is a fatal condition. Most naturally occurring triploid fetuses miscarry in the first trimester and the very few who survive until birth seldom live more than a few days after birth. Embryos created during IVF that are identified as being triploid are not implanted since those doing IVF desire a healthy child, not a disabled one. The researchers contend that the fact that these embryos will not survive makes it permissible to use them for genetic research because it removes the concern that a genetically modified human being could be born.

However, does the fact that a human embryo is destined (almost always) to die prior to birth mean that it is permissible to use that embryo as a research subject? If a human embryo is a human being who has been made in the image of God, then the life that the embryo is living has value and should be respected even if that individual will never be born. When we do research on children who are not able to voluntarily consent to being research subjects we restrict that to research that either has minimal risk to the subject or is being done to try to benefit a child for whom no other treatment is available. Embryos are not able to consent to be research subjects, yet this research is being done on them with great risk to the life that they do have and with no intent to benefit them. If these two sets of researchers do not believe that human embryos deserve this type of respect, then why not use normal embryos instead of triploid ones? In both cases they would be experimenting on living human beings who are incapable of consent and are being killed and the end of the research. Why would it be more acceptable to do that with human beings who are more disabled and have a shorter life expectancy?

We have made significant ethical advances over the past century in our understanding of how we should conduct human subject research. We need to remember that human embryos are human subjects when they are used in research.

“Imago Dei” by any other name…

William Shakespeare reminded us that an object’s essence is not determined by the label we assign to it. No one has since proven Shakespeare wrong. Despite this fact, nowhere have labels been more strongly asserted than in the bioethical debate of abortion. Exactly what or who exists in the uterus of a pregnant human female? The list of labels is long and includes: “baby”, “the pregnancy”, “embryo”, “fetus”, “the products of conception”, “the unborn” and “potential future person”. These labels may honestly reflect an individual’s sincere belief or understanding of the essence of the object in question. But the labels can impede an honest discussion of and agreement upon the essence of that very object. Termination of a baby carries more moral alarm than termination of a pregnancy even though both refer to the same event. We even have different labels to identify the opposing groups on the abortion issue that avoid naming the procedure; Pro-Life and Pro-Choice.

With abortion being the third rail of social politics, it should surprise no one when we see our politicians on both sides of the aisle politically injured when mishandling the subject. When asked if a pregnant woman should be held liable for seeking an abortion in some hypothetical future where abortion is illegal, Mr. Trump eventually suggested she might be subject to “some form of punishment”(1), though later walked back the statement after realizing his assertion upset both Pro-Choice and Pro-Life groups. Since this was a legal rather than ethical question, a non-lawyer could similarly struggle to rationalize how one presently can be held criminally liable for the unintentional death of the fetus of a pregnant woman via a motor vehicle collision(2) but not held criminally liable for the intentional death of the same fetus under current (read: legal) abortion laws(3). No discussion was undertaken from an ethical standpoint to explain why punishment might be deserved in the first place.

Within a week of Mr. Trump, Ms. Clinton caused a different abortion controversy by “referring to the unborn as a person”, drawing the ire of her Pro-Choice supporters(4). The label “person” usually carries moral protection prohibiting, for instance, potentially fatal surgical procedures without informed consent, and abortion is certainly fatal, at least from the standpoint of the unborn, particularly when promoted to a person. Similar to a previous statement above, aborting a person carries more moral alarm than aborting the unborn.

For the Christian, the essence of the pregnancy, products of conception, embryo, fetus, unborn or potential future person must include the Image of God, the Imago Dei. It is this essence that provides moral boundary and ethical guidance regardless of other human attributes, whether potential or realized. See this recent blog entry for further detail.

As per Shakespeare, we cannot ignore the smell of the rose, regardless of how we choose to label it. Would that we could not ignore the essence of the Imago Dei, regardless of our ethical, social or political beliefs.

 

The pertinent portion of note 3: “If the mother can intentionally terminate the pregnancy at three months, without regard to the rights of the fetus, it becomes increasingly difficult to justify holding a third person liable to the fetus for unknowingly and unintentionally, but negligently, causing the pregnancy to end at that same stage. There would be an inherent conflict in giving the mother the right to terminate the pregnancy yet holding that an action may be brought on behalf of the same fetus under the wrongful death act.”

A Brief Comment About Our Political Moment

Some comments are prescient, but some are more prescient than others.

This is a bioethics blog, not a political opinion blog, but the general tenor of the current campaign and the headlines about the role of legal demands or prohibitions to address ethical matters seems to merit a brief general comment.  A political conservative writing some 50 years ago commented that political liberty demands an acknowledgment of a transcendent ground of morality, and I am inclined to wonder about the future of liberty itself.

To expand on it, my wife reminded me of a certain passage.  I imagine many if not most of the readers of this blog are thoughtful evangelicals.  If that describes you, see if you recognize the following:

[T]he central message of biblical Christianity…has secondary results, among them the unusual and wide freedoms which biblical Christianity gave to countries where it supplied the consensus.  When these freedoms are separated from the Christian base, however, they become a force of destruction leading to chaos.  When this happens…then, to quote Eric Hoffer (1902—), “When freedom destroys order, the yearning for order will destroy freedom.”

At this point the words left or right will make no difference. They are only two roads to the same end.  There is no difference between an authoritarian government from the right or the left: the results are the same.  [Emphasis in the original.]  An elite, an authoritarianism as such, will gradually force form on society so that it will not go on to chaos. 

Recognize this yet?  Maybe a bit more of a hint?  The author continued:

And most people will accept it—from the desire for personal peace and affluence, from apathy, and for the yearning for order to assure the functioning of some political system, business, and the affairs of daily life.  That is just what Rome did with Caesar Augustus. 

Francis Schaeffer, How Should We Then Live?, 1976, page 245.

Four things Christians need to know about ethics #3

Knowing who is a person with full moral status

In Luke 10 Luke tells the story of an expert in the law who had a conversation with Jesus. After Jesus had confirmed that he was correct that the essence of the law was to love God and to love our neighbor, the man asked Jesus another question. His motive was wrong, but the question was a good one. He asked “Who is my neighbor?” Jesus answered him with the story that we know as the parable of the Good Samaritan. Jesus’ answer was a very inclusive one, but the culture around us would suggest we should be more restrictive.

We live in a culture that gives an answer to the question that is much closer to what the man talking with Jesus was looking for. I suspect that he was wanting to narrow down the list of people who qualified as a neighbor since he was desiring to justify himself. Many in our culture would say that our neighbor is someone like us and say that we can come up with a list of characteristics or capacities that an individual needs to have to be one whom we have an obligation to treat like ourselves. Ethicists would call this defining personhood or determining who has full moral status. Western philosophical ethicists commonly have devised lists of capacities required to be a person. Mary Ann Warren’s list includes consciousness and ability to feel pain (sentience), reasoning, self-motivated activity (will), capacity to communicate, and presence of self-concepts and self-awareness.

This is not a new idea and just like the man talking with Jesus cultures have sought to justify what they wanted to do by choosing characteristics of who was a person or neighbor so that those whom they chose to mistreat would be left out. In past cultures a person has been defined as needing to have such characteristics as being white, male, or a member of a particular nation or tribe. That left out those who were black, female, Jewish, or a slave. Today the dominant culture would choose to leave out those who are not fully developed such as embryos and fetuses, those with mental disabilities such as Down syndrome or dementia, and others who are weak or frail or dying.

The Bible tells us that all human beings have dignity and value because we have been made by God in his image. That means that every member of the human family, no matter what that individual’s level of development or capacities may be, should be seen as a person with full moral status who is our neighbor. Even the weakest and most vulnerable should be included.

Recently I asked a group of senior science majors if they thought they would agree to participate in a research project that would involve the destruction of human embryos and a large majority of them said they would participate. For many of them it was because they did not see a human embryo as a person that they had an obligation not to kill. For others it was because the possible benefits of finding a treatment for a serious genetic disorder in the scenario I had given them outweighed their concern about destroying the embryos. That relates to the consequential moral reasoning I discussed in issue #2 of this series.

Those of us who claim to follow Jesus need to be careful to be as inclusive as he was regarding who is our neighbor.

I am – is it?

This past summer, researchers at RPI’s Cognitive Science Department programmed three Nao robots to see if they could pass a test of self-awareness. Modeled after the classic “Wisemen Puzzle”, the robots were asked whether or not they had been given a “dumbing pill” (in this case, a tap on their head, which muted their verbal output) or a placebo. The test not only required the robots to respond to a verbal question (“Which pill did you receive?”) but also recognize its own voice as distinct from the others and correctly respond (“I was able to prove that I was not given the dumbing pill”). For a $9500 retail robot, this is an impressive artificial intelligence (AI) test and worth watching HERE.

Dr. Selmer Bringsjord, lead investigator and chair of the Cognitive Science Department at RPI is careful to point out that these robots have been programmed to be self-conscious in a specific situation and describes his work as making progress in logical and mathematical correlates to self-consciousness. His biography page on the RPI faculty website provides a rather tongue-in-cheek assessment of the results of his research: “I figure the ultimate growth industry will be building smarter and smarter such machines on the one hand, and philosophizing about whether they are truly conscious and free on the other. Nice job security.”

I believe philosophizing about whether the robots are truly self-conscious to be the more interesting topic. In their current form, while the robot appears to a human observer to be self-aware, it is really the algorithm or program that correctly indicates (realizes?) that the robot did not receive the dumbing pill. But the algorithm itself is not aware that it correctly determined which pill the robot received. One could make the algorithm more complex, such that the algorithm tests whether the algorithm correctly determined which pill the robot received. But would that algorithm really be aware that the algorithm was aware which pill the robot received? One can see the infinite regression building. (Google: “It’s turtles all the way down”)

Perhaps the more interesting question is how we humans will react as the robot AI algorithms appear more self-aware, whether or not they actually are. Taking Dr. Bringsjord’s lead, should I invest in the domain name “spcr.org”* now or give it some more time?

 

* Society for the Prevention of Cruelty to Robots

A(nother?) tangled surrogacy story

I must be candid.  I am grateful that my two sons, who please me immensely, cannot be called products of an “industry.”

That is, my wife and I never faced the pressure that some must feel, for a variety of reasons, to become ensnared in that tangled-web-we-have-woven called gestational surrogacy.

A writer named Michelle Goldberg has written a thoughtful article for the online magazine Slate describing the mess that one surrogacy case has become.  A woman chose to become a commercial surrogate to augment her income.  She has four kids of her own—including triplets—and had carried one prior surrogate pregnancy.  She agreed to carry a pregnancy for a deaf, single postal worker “who lives with his parents.”  There was a separate egg donor.  They signed a contract.  Three embryos were transferred, and all implanted.  Gender selection was done at the man’s request.  (Ms. Goldberg says the doctor who did the implantation has marketed embryo selection for desired characteristics—hair and eye color, and the like.)  Because of complications, there is pressure on the woman to abort (at least?) one.  There are disputes about who—or whose insurance—pays for the woman’s care.  The intended “father” (forgive me, I feel compelled to use the quotation marks) is running out of money, wants to limit her prenatal care, and worries he can’t afford three babies.   Jennifer Lahl, of the Center for Bioethics and Culture, has gotten involved.  (Follow this link to a page for her video Breeders: A Subclass of Women?)  The story has been reported in the New York Post.  (It’s a couple months old.  I’m just learning about it now.)

This is all going on in California, where the law requires that both parties to these arrangements have their own attorneys, and that, in the presence of a contract, the gestational surrogate surrenders all parental rights.  (Courts cannot consider the best interests of the children in deciding legal challenges to this, Ms. Goldberg writes.)  There is no screening of intended parents.  Adoption it ain’t.  The law is described as friendly to the fertility “industry.”  There is baby selling.  There is corruption.  Surrogates get shafted, financially, when the counterparties to the contract (that phrase sounds so much more apt) can’t afford to pay them.

And this is only one example.  “There are 8 million stories in the naked city,” as the line went.

In her article, Ms. Goldberg argues for greater care in establishing surrogacy arrangements, and greater regulation over the whole practice.  Read the whole thing.

Again, I found this article thoughtful.  And I am sure that most people who enter into gestational surrogacy arrangements do so with good motives.  Why would you do it otherwise?  And I understand that some of these stories end at least apparently happily.

And yet, I cannot resist saying “Hello!  McFly!”  When we rend family and kinship and the begetting of children so radically, dare we be surprised when things go awry?  Dare we pretend we weren’t asking for it?  Dare we be so proud as to believe we can create a happy new human framework in common law, in a thicket of regulations, out of whole cloth?

I am in IMHO territory here.  Yes, I know about Abram and Sarai and Hagar.  I don’t read Genesis, or any other part of the Bible, as condoning such a thing.  Yes, I know that the Christian Medical and Dental Associations countenances gestational surrogacy in limited circumstances.  But I believe I must respectfully dissent.  Yes, I know that childlessness is an affliction, that the desire for children is so strong (I really know that), and that people have a right to their own choices.  But there are limits.

I do not seek to condemn anyone.  But IMHO, gestational surrogacy is wrong.  Period.

UK approves gene editing

This week, UK regulators gave approval to a group of scientists in London to genetically modify human embryos. Dr. Kathy Niakan, the researcher who will be performing the experiments, said, “We would really like to understand the genes needed for a human embryo to develop successfully into a healthy baby. The reason why it is so important is because miscarriages and infertility are extremely common, but they’re not very well understood.” Researchers will alter the genes in donated embryos, then destroy them at age seven days.

The story was reported, among other places, on the BBC news website. Reading the story there, I was arrested by the author’s description, in which he writes, “The experiments will take place in the first seven days after fertilisation. During this time we go from a fertilised egg to a structure called a blastocyst, containing 200-300 cells.”

The word in the description that captured my attention is “We.” We go. The author writes “We” — he, me, you — go from a fertilised egg to a blastocyst. I don’t know if the author had this implication in mind when he wrote “We,” but he is right: that little, profoundly inclusive word means that the human embryo, even at the blastocyst change, is one of us. One of our tribe, our group, our species. Human, like we are. All of us were at one time blastocysts; blastocysts, given the right conditions, will grow to be like we are. These are our own young.

Lest there be any confusion: the UK fertility regulator has approved experimentation on some of “us” — our fellow human beings. The experiments will involve genetic editing, following which researchers will “destroy” some of us. (Why does “destroy” sound less reprehensible than “kill” in this case?) The main difference between those of us performing the experiments and those of us being experimented upon is that the latter are smaller, younger, weaker — and have no voice.

 

Can there be a “Right to Die?”

I generally give 5 reasons for opposing physician-assisted suicide (PAS), which is commonly recommended by its advocates by invoking the notion of a “right to die”:  it destroys the soul of medicine as the profession dedicated to healing; it deflects attention from palliative care; it rests on a very slippery slope; a right to die implies a reciprocal duty to kill; and the notion of a right to die itself is problematic if not incoherent.

I want to focus a bit on this last argument here.  I am most familiar with it from the work of Leon Kass, who expanded the argument in chapter 7 of his 2002 book Life, Liberty, and the Defense of Dignity.  Kass holds that a “right to die” is groundless, philosophically and legally.  I turn to his philosophic argument in this post.  I’ll address the legal argument next week.

In rejecting a right to die, Kass is not referring to the right to refuse treatment, which he regards indisputable, or a right to commit suicide “all by oneself,” which he regards debatable at best.  Rather, he construes a right to die “in its most radical intention as a right to become dead, by active means and if necessary with the assistance of others.”  He writes that a claim to a right to die is best understood as asserted not as a “liberty right” against those who would deny it, nor as a “welfare right” against people unwilling to provide the means, but as a demand against the ill fate of suffering or a debilitating condition—a sort of “tort claim against nature,” as it were.

A right to die cannot be a natural right, of the sort that Hobbes and Locke wrote about, because such rights are given by nature, and the most fundamental natural right is the right to life, presupposing a “self-interested attachment to our own lives.”  All other natural rights rest on the right to life, and a “right to become dead” cannot be an exercise of a faculty, necessity, or aspiration of life.

A right to die cannot be of the sort that Kant envisioned, grounded not in nature but in reason, because Kant held a willful act of self-destruction to be self-contradictory.  “Autonomy” for Kant meant something like “self-legislation,” requiring “acting in accordance with…one’s rational will determined by a universalizable, that is, rational maxim…not being a slave to instinct, impulse, or whim, but rather doing as one ought, as a rational being.”  And as Kant himself wrote (quoted by Kass), “To destroy the subject of morality in his own person is tantamount to obliterating from the world, as far as he can, the very existence of morality itself; but morality is, nevertheless, an end in itself.  Accordingly, to dispose of oneself as a mere means to an end of one’s own liking is to degrade the humanity in one’s person (homo noumenon), which, after all, was entrusted to man (homo phaenomenon) to preserve.”  That is: humans have a rational duty to preserve humanity, which entails living in accordance with rational moral precepts enacted by autonomous rational beings.  Kill the autonomous rational being and poof: you vaporize the foundation of ethics itself.

Not that this isn’t where contemporary humanity is headed anyway, and on purpose at that.  To claim a right to die, Kass argues, requires that it be understood in the “willful modern meaning” in which the autonomous, Nietzschean self finds true meaning in “unconditioned acts of pure creative will.”  But this approach also fails, because at most it can be an expression, a cry, of wanting to be done with this life—a legitimate emotion in some cases, it must be admitted.  The “willful modern” approach cannot support a right to have someone else’s assistance in dying (implying a limit on the other person’s autonomy), and my autonomy cannot support another person’s right to kill me or help me die.  Here, Kass’s argument seems to revert to the concern that a right entails someone else’s duty.

The “willful modern” approach requires one to be mentally competent (as, to be sure, PAS laws attempt to ensure), but cannot support proxies or “advance directives” of the sort that Courtney Thiele cautioned about this week.  And should that proxy not be chosen by the person, it is self-contradictory to think that proxy could exercise the patient’s right of autonomy.  And, finally, it is “at least paradoxical to say that our autonomy licenses an act that puts our autonomy completely out of business.”

If a “right” is just the unbridled will of the creative self, then Kass, quoting Harvey Mansfield, says that self is “open-ended…[and} cannot have interests; for who can say what is in the interest of a being that is becoming something unknown?   [The result is a society] characterized by a loss of predictability and normality; no one knows what to expect, even from his closest companions.”

In a word:  chaos.

A Book for Anyone Interested in Bioethics

Being Human: Core Readings in the Humanities, edited by Leon Kass, is one book worth a spot on the shelf of anyone interested in bioethics or concerns about human dignity.  A series of excerpts from things that we read—or should have read—in high school or college, it was selected by the members of President George W. Bush’s President’s Council on Bioethics in 2003.  The readings are sorted into ten chapters, organized into three major sections:  “natural imperfection and human longing,” “the human being and the life cycle,” and “living well.”  Each chapter’s group of readings is preceded by a brief introduction that appears intended to guide your typical undergraduate seminar discussion—or your neighborhood book club.  The short bite-sized selections can easily be used for discussion groups, without burdening group members with too heavy a reading assignment.  Or they can be read and meditated on, individually, at leisure.  Or they can be goads to go back and read more fully that novel that you never got to in college.  This is a collection of and from literature, a needed respite from the all-too-often robotic thinking of daily business or the relatively sterile exercise of analytic argument, not to mention the mindless rhetoric of television, the internet, and social media that militates against reflection and discourse.  Don’t hesitate to get it.