Late Term Zika Abortions: Thankfully not Euthanasia

If I were the editor of a recent Newsweek article by Cornell Law Professor Sherry F. Colb, the above title would have been my choice for her article. I must encourage you to read the actual article, lest you believe that the summary that follows is somehow taken grossly out of context. Her concern is that a late term abortion to terminate the life of a Zika-infected baby might be morally problematic because it might be misconstrued as euthanasia rather than simply a late term abortion.

She begins factually with her concern for the increasing prevalence of Zika, a virus causing severe microcephaly of babies born to parents with the infection. Further complicating the matter is that the birth defects are not apparent until well into the third trimester. Thus, per Professor Colb, Zika pregnancies require us to answer two moral questions. The first question is whether it is “…right to end a pregnancy because the baby would be severely disabled if brought to term?” The second wonders whether it is “right to take the life of a fetus late in pregnancy, regardless of the reason?” (I was encouraged at this point that she conceded both that the fetus was alive and that a baby was a direct result – my optimism did not last long.)

She was quick to point out that she considers “…the reasons for a woman’s choice to terminate her pregnancy to be irrelevant to the question of whether she should be legally permitted to do so…” as she is “…entitled to be free of the bodily intrusion that is pregnancy, even if her reason for wanting to assert her bodily integrity is an offensive one.” Her reason for even bothering to discuss the moral issues is because she anticipates that large numbers of women may be wanting to terminate their pregnancies so the discussion is worth having, “…even if our answer will not affect the legal conclusion that the woman should be free to terminate.”

In answering her first question in the affirmative, she effectively equates routine abortion to contraception and considers the fetus to be a “potential” life, arguing that even in Down Syndrome, parents choose abortion, and since Zika is a worse condition (her stipulation), “…it may be that an abortion will spare not only the parents but their child a life that is, in some sense, not worth living.” (I have always wondered what it is we are sparing a specific child by not having it live – a non-entity cannot be spared anything – the concept seems incoherent)

The second question is more troubling for her. Her “no-go” line for abortion and moral significance is sentience but she admits that others have different criteria. However she further concedes that the later one goes in the third trimester, “…the more likely that people will have the moral intuition that we are no longer talking about a ‘potential’ child but are instead talking about either an existing child or at least someone worthy of nearly as much moral consideration as a newborn baby.” For her, the moral calculus has changed. Bodily image abortion arguments fail (simply birth the child alive, “…thereby ending the internal occupation…”). Terminating the pregnancy at this point does not need to terminate the life of the fetus or baby, and “…the choice to have an abortion (one that kills the fetus or baby) is really a choice to take the life of the fetus or baby because it is not considered a life worth living.” She is equating late term abortion to euthanasia. (Correctly in my mind, and, since I have different criteria for abortion, specifically, nothing post conception, therefore, all abortion is euthanasia)

She solves her moral dilemma by hiding inside a legal loophole. “If one nonetheless concludes that because of the potentially catastrophic nature of the birth defects, children with Zika are better off not existing than living severely compromised lives that they would otherwise live, the fact that they live inside a pregnant woman may give people a legal –if not a moral—loophole through which they can achieve their desired end, though it is really euthanasia.” The pregnant woman can do all this “…without beginning the slide down the euthanasia slippery slope, because we can fit what she has done under the heading of “abortion” instead of “euthanasia.”

Let that last bit of mental gymnastics sink in.

From what vantage point does one judge the slippery slope of one moral issue whilst sliding down the slope of another?

Observations from a recent discussion of doctor-assisted suicide

Early this past June, the Annual Meeting of the American Society of Clinical Oncology (ASCO) included an ethics session featuring a point-counterpoint discussion, with audience Q+A, of “physician aid in dying,” or, as I think more accurate, “physician-assisted suicide (PAS).”  Discussants were Dr. Timothy Quill, a palliative care specialist who is a past plaintiff in court cases seeking legal approval of PAS, and Dr. Daniel Sulmasy, an oncologist who is an outspoken opponent of PAS.   Both have written extensively on the subject.

I missed the session but only now was able to review it on ASCO’s “Virtual Meeting,” available only to subscribers.  I cannot summarize it fully but will just relay some observations from my listening.  I will say that the session lived up to its billing as a “thoughtful discussion,” one that demonstrates just how far our thinking has come (wandered?) on this matter.

I think it important to say that, although I consider Dr. Quill an adversary, his presentation clearly demonstrated concern for his patients.  Some of his noteworthy points:

  • ·       Although he calls PAS a “last resort,” he includes it in the umbrella of palliative care measures, and claims that the same issues of potential harms arise with all of them.  I’m not so sure; one can heavily sedate someone, not intending to kill him but accepting that risk (by the rule of “double effect”), and that is different from purposely helping that person kill himself.
  • ·       He emphasized that more patients ask about PAS than actually go through with it.  But he showed data from Washington state in which the numbers of the two were nearly identical.
  • ·       Because of that, he is concerned that a refusal to discuss PAS with a patient could compromise the care of the patient by turning a deaf ear to the patient’s concerns—which, as well recognized, are typically around loss of control, not pain, at the end of life.
  • ·       He voiced support for a conscience-based “opt out” by doctors opposed to PAS but said “that doesn’t take [the doctor] off the hook,” meaning not that the doctor must refer to a “PAS doctor,” if you will, but that the challenging task of caring for the patient remains.
  • ·       Similarly, he commented that in about half of PAS cases in the US, the lethal prescription is written by a doctor with less than 6 months’ acquaintance with the patient.  I understood Dr. Quill to say this is not a good thing, suggesting breakdown of longer-term physician-patient relationships precisely when those relationships are most critical.
  • ·       He said that the legally-approved method of taking the prescription in Washington State is not easy.  Recall the patient, not someone else, administered the prescribed drug, which is 100 capsules of secobarbital, opened by the patient one by one and dumped into applesause (or something similar), making a distasteful concoction.  I couldn’t help being saddened just imagining someone following through on the grim task.
  • ·       He said that, although we might want to get clean resolutions in all cases, the fact is that care of some patients is genuinely so hard that true relief of symptoms is not possible.

Dr. Sulmasy countered with a strong and classic argument against PAS as bad medicine and bad policy, following reasoning like what has been written previously on this blog by me and others, so I will not try to rehearse it fully here.   He drew the distinction between providing medical care and actively helping someone kill herself.  Further:

  • ·       People looking at the Oregon or Washington experience to argue that the “slippery slope” is not real are ignoring the contrary data from the Netherlands and Belgium, where the practice has been in place longer, and where people are offered PAS for depression.
  • ·       To those who object that “depression” does not apply to terminally ill patients who request PAS, Dr. Sulmasy countered that all too often treatable depression is not even sought by the physician, much less treated.
  • ·       The logic and experience with PAS will eventually demand that it be offered to people who are not terminally ill.
  • ·       Similarly, arguments based on autonomous choice will unavoidably be used to argue for actively killing people who can’t take a lethal prescription themselves, such as people with dementia or neurodegenerative disease, or children.
  • ·       “Opt outs” are being forcefully opposed in Belgium and Canada.
  • ·       He argued that symptoms are treatable in nearly all cases.
  • ·       Perhaps most notably, to the point that “existential suffering” about loss of dignity or loss of control is paramount, Dr. Sulmasy argued for caring for the patient in the face of this, and not succumbing to PAS.  In so saying, he commented that it is not part of the doctor’s calling to “relieve the human condition.”

Three questioners stood out:

One said that his main local hospice has announced it will NOT participate in PAS.  He supported this, but worried it will “affect his ability to refer” patients who may want to explore PAS to that hospice.  (Dr. Sulmasy commented that institutions as well as individuals should be free to opt out of PAS based on conscience.)

A second questioner, who said he consults and accepts PAS referrals in Oregon—aessentially arguing “somebody’s got to do it”—said that in his experience, many, many times the physician (oncologist) has not only failed to discuss end of life care at all with the patient, but has not even told the patient that the diagnosis is terminal.  This was part of a longer comment saying that we should not condemn the short-term relationships between patients and doctors who write lethal prescriptions.  This made Dr. Quill uneasy.  He objected that “specializing” in PAS was deeply suspect ethically because “it would make [PAS] too easy, and this [palliative care] is not easy”

A third questioner suggested revising the Hippocratic Oath to remove any indication that doctors should not participate in PAS.   After all, we don’t appeal to Apollo anymore, do we?  (And, unspoken at the session, many medical schools have dropped the Hippocratic proscription of abortion.) But no, we should not!  That’s the point!  The Hippocratic tradition confirms the essential role of the physician as healer, not killer, and doctors in the 21st century should likewise affirm that principle robustly.

Evil on its Face

In June of this year, a group of ethicists—should I say that I use that term loosely?—issued a “consensus statement” to guide legislation and institutional policy regarding conscientious objection in medicine.  Conscientious objection, they explained, “is the refusal to provide a certain medical service, for example an abortion or medical assistance in dying, because it conflicts with the practitioner’s moral views.”  Their words, not mine.

They went on to aver that the general medical principle that the care of the patient is paramount, taking priority over the practitioner’s “moral or religious views.”  Not that the practitioner must efface his or her self-interest for the sake of the patient’s best interest, pace Dr. Pellegrino, but that moral arguments must take a back seat to “a patient’s desire for a legal, professionally sanctioned medical service.”  So, in other words, if the law and the powers that be determine that something is permitted within the bounds of medical practice, all practitioners must submit to that.  If they object to, for example, participating in euthanasia when the legislature has deemed this permissible, they must state their reasons—including going before a “tribunal,” if necessary—and refer for the service or perform it themselves if no referral is available.  Punishments are in order: “Healthcare practitioners who are exempted from performing certain medical procedures on conscientious grounds should be required to compensate society and the health system for their failure to fulfill their professional obligations by providing public-benefitting services.”  I’m not sure whether “by providing public-benefitting services” is intended to modify “compensate” here—that is, the punishment should be community service of some unspecified sort—or to modify “obligations”—that is, construing doctor-assisted suicide and abortion as primary public goods and medical duties.

Further, medical students “should not be exempted” from learning how to perform these acts, because they might need to do so “in an emergency situation.”  Well—emergency doctor-assisted suicide?  Emergency abortion?  In the latter case, certainly procedures to protect a woman’s life in situations that do arise, such as heavy bleeding or the presence of an already-dead fetus should be included, but performance of elective abortions, or of late-term abortions?  Rare cases in this last instance may arise, but not to warrant “practice” in elective cases.  And, as anyone who went to medical school knows, “see one, do one, teach one.”  Learning means doing.

Finally, the tenth and last “principle” is “Healthcare practitioners should also be educated to reflect on the influence of cognitive bias in their objections.”  Really, now.  Follow the link above and read not just the statement but the often-salty comments that follow, and ask just whose “consensus” this is, and note one commenter’s point about the last principle, related to “cognitive bias,” that “mutatis mutandis, the same principle might be enforced on philosophers.”

Sometimes, civility is the enemy of truth, so I must say here that this is calling evil good, a naked attempt to ram abortion, doctor-assisted suicide, and, by extension, numerous other objectionable practices down the throats of Hippocratic-thinking physicians.  There is nothing good to say about this “consensus statement.”  It represents no “consensus” at all and should be condemned in the strongest possible terms and resisted steadfastly.

“Hat tip” to Wesley Smith, who flagged it in a blog post, calling it an example of “medical martyrdom,” an attempt to drive people who revere human life and dignity out of the medical professions.  See here and here.  (Note: National Review Online has folded Smith’s blogging into its “Corner” blog, closing down the separate “Human Exceptionalism” blog, which I, for one, will miss.)

Public discussions on human gene editing

On August 3, the National Academies of Science, Engineering, and Medicine posted online the slides and talks from its July 12 meeting to discuss public implications of the Human Gene-Editing Initiative.  A total of four meetings plus a related workshop were held: an introductory discussion in December 2015, followed by three more substantial meetings plus the related workshop in February, April, and now July of 2016. 

I’m still working through the materials, notably Francis Collins’ slide set from the July 12, 2016 meeting, addressing regulatory processes, in utero gene editing, and other topics.  But what first caught my eye was a brief written statement from the same meeting, from Ron Cole-Turner of Pittsburgh Theological Seminary.  In it, he states that Christian opinions on human gene editing are not monolithic; that, far from being reflexively in opposition, those opinions are quite open to editing even of the human germline as long as safety concerns are addressed, embryos are not sacrificed in the process of research, and therapy rather than enhancement are in view.

I must say the statement disappointed me.  The “safety argument” is the most prominent ethical concern raised in discussions of whether editing human genes in heritable ways is ethically permissible.  We certainly want assurances that we would not put the “edited” individuals at risk, and we really would want some level of certainty that the downstream effects would not be disastrous.  But of course, the latter may be impossible to assess, since adverse consequences could be subtle and might become apparent over many generations.

Beyond that, I thought Cole-Turner’s statement was too limited, with no mention of questions of informed consent, and with no deeper reflection on how human germline editing might (I would say, would) alter the way we look at ourselves, each other, our children, and the human race in general.  The push would be further toward seeing humans as plastic, alterable entities without limit, and, beyond questions of “simple” justice (how would we keep from making benefits available only to the rich?), would create a class of, as C.S. Lewis suggested, “conditioners,” or as contemporary European thinkers have put it, a class of engineering humans who work on other, engineered humans.  Finally, Cole-Turner did not really engage the concern that there is a constant eugenic temptation in humanity that would likely re-assert itself with force.

Cole-Turner’s statement was not proud; he opened by admitting that no one person could speak for all Christians.  And maybe brevity was necessary on the occasion of the committee meeting.  But I still would hope for more robust “religious” inputs at sessions like this.  Otherwise, one gets the feeling that all that is sought is a token religious imprimatur on the most cutting-edge biotechnologies of the “brave new world.”

Follow the link in the first sentence of this post, and the statement by Cole-Turner, as well as other materials from all the meetings, may be reviewed in detail.  It is good that these are posted, because, although it’s easy to say that a thorough public discussion of transformative biotechnology should be held with all stakeholder groups, only so much is generally done to achieve that.  Even interested parties, like your humble correspondent, have limited time to devote to the details.  But more of us in the general public should labor to make time to dig in deeper.

ADDENDUM: After posting the above I went back to the link (top of this post) and read through the slides from Dr. Collins.  Readers of this blog should by all means do so as well.  At the end, he muses about the level of acceptability of 28 current or possibly future interventions, placing them on a grid of when they will be in practice vs. level of ethical concern they prompt.  The slides are self explanatory and worth musing over.–JTH

How can we make the “brave new world” a campaign issue?

Wesley Smith, who, based on his writing, I consider a kindred soul in bioethics, has published an essay in First Things dated August 5, 2016, and entitled, “Brave New World Should be an Election Issue.”  In it, he quickly runs down the revolutionary changes in the very nature of humanity that appear in the offing based on biotechnological developments since the publication of Aldous Huxley’s novel.   Noting that Huxley initially thought the “horrors” described in Brave New World would take 600 years to materialize, only to revise that estimate to a century or less, Smith concludes, “It doesn’t have to be that way. We need not helplessly, passively, watch biotechnology’s power and influence surge. We can shape biotechnological advances to achieve moral ends. But that will require far more consideration of these issues than we have yet given them.”

Hear, hear.  But how to get people to listen?

Now, when it comes to politics, I’m an opinionated blowhard but no pundit.  (I know, I know, a distinction without a difference?)  Yet from what I read and see it looks like people vote based on their near-term concerns, not longer-term issues or matters that appear more abstract or are hard to understand (these days, > 140 characters).  Hence, the economy, jobs, trade, immigration, terrorism, how we view and empower and deal with the police, and the like are what come to the forefront in political campaigns.  These issues make for more striking video and/or louder shouting matches on TV, and most folks feel close enough to them to form opinions.

Less so with the technically complex issues of the new biotechnology, which we almost by necessity leave to “experts,” expecting that “they” (or maybe I should use Thomas Pynchon’s “They”) will steer these to places that we will find convenient and congenial.  And often times, that boils down to “what will they think of next?” rather than, “do we really think this should be done at all?”

And so, the challenges are to get people’s attention, communicate complex matters in ways they understand, and convince them not to support questionable actions even if they make life more comfortable.  And so, how to get people to understand what’s potentially at stake with human gene editing?  How to get them to stop what they are doing long enough to try to think through how much we should use genetic diagnosis to control the phenotypes of our offspring?  And how to get them to at least question something that could be awfully convenient and career-friendly, like artificial gestation, admittedly still rather further off than the other two examples here—or, than, IVF and gestational surrogacy?

Essays, blogs, the occasional Congressional testimony, and 2-minute spots on cable news may be necessary but hardly seem sufficient.  Expert conferences, open to the public though they may be, are practically limited to the experts who live the issues being discussed, and who have the time, energy, and experience to be able to address the concerns, give them priority, and then, in turn, be listened to coming out of the conference. 

(It’s as if we need a “Reformation-style,” if you will, public availability of the “Bible of science,” with common folk encouraged and empowered to read it on their own and draw their own common-sense conclusions, rather than rely on a learned “clergy” for their hermeneutics.  But that surely is also fraught—common sense can surely go awry, and a certain amount of learning is needed to read at all.)

What to do?  Well, I suppose: focus on education, from a very young age, in normative anthropology—what it is to be human—and on normative views of the family and procreation; keep theology central, as much as the secular world resists that; take individual techniques and issues and try to demonstrate, in simple terms, where they not so much might lead but are likely to lead; create creative works—movies short and long, public service announcements, ad campaigns—trying to illustrate concerns (think about the campaign against texting while driving); talk matters up in normal conversation.

Social media?  You tell me.  I never touch the stuff.

That in turn requires, I think, a group of people with the persistence, wherewithal, and creativity to press the different cutting-edge bioethical concerns in new ways, on an ongoing basis.  It requires a different approach than the advocacy of the last 40 years that attempts to “influence policy,” in an age where the opportunities, much less the efficacy, of that kind of advocacy appear constricted.

I’m not exactly sure how one would do it, or who.  Pray God will raise up a new generation.

And suggestions are welcome.

The need for believers to base moral decision on biblical concepts

The article “I’m a Christian with Stage IV Cancer. I Want Death with Dignity.” by Corinne Johns-Treat on that Neil Skjoldal discussed in his post on Monday illustrates a problem within the church that I have become very concerned about. I have written about this concern before in the context of what I hear from students at the Christian university where I teach, but I think it is a problem within the church as a whole. I am concerned that people who sincerely believe they are followers of Jesus and a part of his church make important decisions about how to live their lives based on underlying concepts that come from the secular culture around us and not based on biblical concepts.

In the article Johns-Treat says, “the more I learned about the safeguards and autonomy in the law, and the more I prayed about it, having seen people suffer so much at the very end of their lives, I came to believe in that it fit into my faith,” and “I think when you look at a personal experience, governing doctrines from a church don’t seem to matter nearly as much.” These two statements provide insight into the thought processes that have led the author to her conclusions. The problem is that these thought processes are grounded in the thinking of the secular culture that surrounds us and not in biblical concepts.

In the first statement she refers to the principle of autonomy which is the primary moral principle used to defend the moral permissibility of assisted suicide or medical aid in dying. From a biblical perspective we have reason to respect the autonomy of others because God does that in allowing us to make our own choice whether we follow him or not. However, if we do choose to be disciples of Jesus, we have chosen to submit ourselves to him and our decisions should be made based on submission to God’s revealed truth in scripture and not based on our own autonomy.

Implied in the first statement and stated more clearly in the second statement is the author’s underlying concept that moral decisions are based on our personal feelings and experience rather than on biblical truths. As long as a person feels that assisted suicide or aid in dying is not wrong then it is permissible and it is not necessary to base that decision on biblical concepts. When I think about why I would think it would be wrong for me to turn to assisted suicide if I had terminal cancer it is because of the concept of the sanctity of human life due to being made in the image of God and the idea that my life belongs to God and not to myself. We live in a society that says that our moral choices are based on how we feel, but by choosing to follow Jesus I have chosen to live based on God’s understanding of what is right and wrong rather than based on how I feel.

In his post Neil expresses a desire that people would see good palliative care as the better way to relieve suffering at the end of life rather than turning to assisted suicide. For those who are followers of Jesus there are biblical reasons based on the sanctity of human life and our submission to God as the Lord to whom we belong to choose palliative care over assisted suicide.

Toward human-animal hybrids

To be published tomorrow in the Federal Register, the massive, Byzantine thousands-upon-thousands of pages repository for all of the rules and regulations that constitute so much of de facto law in the contemporary United States: a Request for Public Comment on the Proposed Changes to the NIH Guidelines for Human Stem Cell Research and the Proposed Scope of an NIH Steering Committee’s Consideration of Certain Human-Animal Chimera Research.  

As always, the technical issues are complex.  But, briefly, some scientists are working on putting human “pluripotent” stem cells—like embryonic stem cells, the kind that can produce many different organs or tissues or even a full human being—into early embryos of other mammals, such as mice or pigs.  Why?  To try to understand a disease better, or, in the case of some of the pig work, event to “grow” a human organ in an animal for future transplantation.

The National Institutes of Health (NIH) limits the scope of what it will pay for, because, frankly, we don’t know what we will get.  Concerns include having an animal with a more “human-like” brain, or one that can make human sperm and egg cells, or one that could breed to “spawn,” if you will, a part-animal, part human or even a human baby in a female animal.  More generally, what percentage of human cells does it take for a living being to be considered human, and how far might we experiment with adding human cells to animal embryos and animal cells to humans?

Farfetched?  Some scientists have reportedly looked at human stem cells in mice to see if brain function is affected in a way that can help understand psychiatric conditions.  See this discussion from the New York Times.

The proposed revisions to the NIH rules purport to make restrictions tighter by prohibiting government funding of experiments in which any pluripotent cells, not just the specific ones in the current guidelines, are inserted into early embryos from non-human primates (monkeys, apes) or breeding animals when the work may have contributed to human sperm or egg cells having been produced. 

But they would open introduction of human cells into other mammals’ embryos, or in non-breeding situations, as long as a committee determines that there could not be “a substantial contribution or a substantial functional modification to the animal brain by the human cells.”  Even here, they exclude rodents, presumably to permit such work in mice or rats to proceed.

The NIH wants to claim that this work can be carefully monitored and regulated to keep it from getting out of hand.  But non-government funded research would not be affected, and intrepid actors will invariably try to stretch the boundaries.  And some are concerned that even in the specific case, much less the “field” as a whole, we can’t predict where it will all lead.

If the society could, it should slow much more of this work down, if not call a halt entirely.  But legal bans are likely to be circumvented, and appeals to potential benefits generate continual pressure to move ethical boundaries further.   I think that ultimately it will not do to argue that eventual risks outweigh benefits.  Rather, we would have to convince our fellow humans that ethics require that we just forego some opportunities.  And that’s a hard sell.

Some California Physicians are trying to fight back against Doctor-Assisted Suicide

The Wall Street Journal op-ed page this week carried an offering (subscription required) from one Dr. Philip Driesbach, a cancer doctor in California who is one of six plaintiffs on a lawsuit attempting to block California’s new “End of Life Options Act,” which went into effect July 9.  Dr. Driesbach’s article covers several key points:

  • ·       By allowing such individuals as potential heirs and the owners of caregiving facilities to be formal witnesses to a request for aid in dying—something the law prohibits them from doing if the document in question is a will—the law removes protections from vulnerable people.
  • ·       The law does not require psychological referral—and hence screening for coercion or easily treatable conditions—unless there are clear signs of mental illness. 
  • ·       “Killing is never medical care,” and doctor-assisted suicide is “fundamentally incompatible with the physician’s role as healer,” a position still affirmed by the American Medical Association.
  • ·       There is no compelling reason to compel doctors, as opposed to others, to take on the role of “agent of death.”
  • ·       There is something contradictory about asking the medical community, which has objected to participating in capital punishment, to become the agents of hastening peoples’ deaths.  (Dr. Driesbach actually said, “killing the innocent” here—I’m sanitizing, perhaps unnecessarily.)
  • ·       He cited the 2015 testimony of Dr. William Toffler of Oregon, who stated that doctor-assisted suicide in Oregon operates under “a shroud of secrecy” under which getting accurate data about the practice is “impossible” unless one works for the Oregon Health Division.

Rather, Dr. Driesbach charges that the push for doctor-assisted suicide is part of a social campaign, a “necro-political” movement, funded by rich donors who are quick to invoke equal protection under the law in other contexts but ignore it here.  I think he’s right.

A similar lawsuit has been filed in Vermont against that state’s law. Not everyone in the medical profession is supine before the doctor-assisted suicide juggernaut.

The Strange (Future) Case of Doctors & Mr. Hyde

On 28 June 2016, the Supreme Court declined to hear an appeal of a Ninth Circuit decision that forced a small pharmacy in Washington to dispense Plan B (a “morning after pill” that terminates a pregnancy via abortion) despite the religious objections of the pharmacist owners. In other words, the lower court ruled that the pharmacists must violate their conscience by prescribing Plan B or terminate their pharmacy business. Only three Supreme Court Justices agreed to hear the case; four are required. It can be argued that if Justice Scalia were still on the Court, The Court would have heard the case. As such, the Ninth Circuit’s ruling stands but is limited to the Ninth Circuit. Justice Alito’s dissent is worth the 15 page read. Doctors of Pharmacy no longer have religious/conscience protections in the United States within the Ninth Circuit.

Read that last sentence again.

Conscience protection for other health care providers may be more tenuous than is generally granted. Previously, multiple federal amendments provided health care workers conscience protections (Church Amendment, Public Health Service Act 245 & Weldon Amendment) A separate rider to annual omnibus bills called the Hyde Amendment actually prohibited federal Medicare and Medicaid funding of abortion specifically. The PPACA (Obamacare) changed the funding rules and arguably some of the previous conscience protections to the point where President Obama had to issue Executive Order 13535 specifically guaranteeing continuation of those protections in order to secure passage of the PPACA. The alleged tenuousness of current conscience protections mentioned above is the fact that an Executive Order can be easily be rescinded by this or any future president while overturning, even in part, the PPACA is no easy task. Additionally, efforts by those pro-abortion to eliminate amendments like the Hyde Amendment in its current form are vigorous and ongoing. (The link is presented as evidence not endorsement)

Regarding the title, the late Congressman Mr. Henry Hyde, author of the Hyde Amendment, is the antithetical homonym of the fictional Mr. Edward Hyde, the evil sociopathic alter ego of the philanthropic Dr. Henry Jekyll. Ironically, the present day Hyde (along with the other amendments listed) may be one of health care’s last protections against future violations of moral integrity by continuing to allow the unobstructed practice of medicine with one’s conscience intact.

On the “Moral Era” of Medicine

A colleague shared a recent JAMA article titled “Era 3 for Medicine and Health Care.” The author, Dr. Don Berwick, quickly surveys Era 1 — the “era of professional dominance”– and Era 2 — the “era of accountability and market theory”– before introducing what he hopes to see in “Era 3,” the “moral era.”

Berwick identifies nine changes that need to take place in order to accommodate this new era which has seen the implementation of ACA, the extensive use of electronic medical records, and the consolidation of hospitals and health plans. Several of the suggested changes are already taking place in health care systems across the country. Others are a bit more idealistic. I would like to use this space to mention two of the more idealistic changes.

Change number 8 is “hear the voices of the people served,” a noble goal indeed. While many health care organizations have moved in the direction of ‘patient-centered care,’ fewer embrace “paying special attention to the needs of the poor, the disadvantaged, and the marginalized, and firmly defending healthcare as a universal human right.” Seeing each patient as a human being, possessing great worth and dignity, is fundamental to all areas of bioethics, from the research lab to the bed of the dying patient. Humans need to be treated with humanity.

Change number 9 is even more idealistic: “Reject greed.” Berwick writes:

“Health care has slipped into tolerance of greed and it has to stop, through volunteerism when possible, through strong regulation when not. Rapacious pharmaceutical pricing, hospitals’ exploiting market leverage to increase prices, profiteering physicians, and billing processes that deteriorate into games with consultants coaching on how to squeeze out more profit all hurt patients and impair trust.”

Idealistic, right? But we know that one devastating medical emergency can bankrupt an insured middle class family and that many others are finding it impossible to make ends meet while undergoing expensive medical treatment. Bioethics should continue to address the staggering financial impact that medicine has on our society. As Berwick suggests, blindly ignoring these factors will lead to even greater regulation.

Bioethics has much to say if “Era 3” is truly to be the “moral era.”