Pragmatism and principle regarding human gene editing

You may have seen in the general press that the gene-edited twin girls born in China last year may have had their life expectancies shortened in the bargain.  The doctor who edited the babies’ genes specifically edited one gene, that is associated with susceptibility to HIV infection.  Their father is HIV positive, but that does not put the babies at any health risk.  Further, the gene editing potentially could have increased their future risk for other infections.  Now, a group in the United Kingdom have analyzed mortality data for about 400,000 people who volunteered to have their genetic information placed in a data bank.  They reported that people who have a gene mutation similar—but apparently not identical—to the change made in the Chinese babies had a 21% lower chance of living to age 76 than people without the mutation.  Now, the average age of the people who volunteered their information for the data bank is said to be 56.5 years, so the implication is that there is a shortening of life expectancy after middle age, for people who have lived at least that long. 

One should interpret the U.K. analysis with caution, but the argument seems to be, “see, we don’t know the risks of human gene editing, so we shouldn’t be doing it.”  And indeed we do not know the risks.  But the argument in fact is, “…we shoudn’t be doing this—at least not yet.”  As Joy Riley pointed out on this blog a few days ago, the goal of a moratorium on human genome editing appears to be to allow the scientists working on the technology to take time to build public trust and consensus for it.  “We shouldn’t be doing this, ever” does not appear to be an option.  Long-term readers of this blog may recall numerous posts over the last few years describing this process of gradual acceptance in the scientific community.  The scientists draw an analogy to the 1975 Asilomar conference on recombinant DNA work, which established guard rails around that work.  But the analogy is flawed.  The risks of the work addressed at Asilomar were more readily defined, with shorter time frames to results, than can be addressed with genome editing.  400,000 middle-aged people’s mortality due to any (unspecified) cause over the ensuing quarter-century?  How many edited people, studied for how long, over how many generations, with what consent process, to determine the risks?  There can be no acceptable definition of the risks prior to actually assuming them.  “The babies are the experiment.”

The correct conceptual framework for human genome editing is not benefit-risk analysis, it is deeper reflection on where we should not let engineering encroach on the human organism.  “Keep your ambition off our bodies,” I suppose.  And when we think in those terms, we should quickly recognize territory where we fear to tread at all, not just slow down.

Oh, Those Darned Terms (Part 3)

It is hard to keep a good theme down as terminology is back in the news. It seems National Public Radio (NPR) is concerned about proper terminology as a recent “Guidance Reminder: On Abortion Procedures, Terminology & Rights” post by NPR Standards and Practices Editor Mark Memmott on NPR.com suggests. This link is one of periodic commentaries by Memmott on standards expected by journalists at NPR based upon their Ethics Handbook, which is also available on their website. The stated goal of the Ethics Handbook and the periodic commentaries is to be as accurate and unbiased as possible with reporting at NPR, which is obviously an appropriate goal in reporting the news, particularly potentially controversial topics. Read Memmott’s commentary link and see if you think NPR is meeting that goal.

I think there is room for improvement.

For one thing, while there is an appropriate “We-They” throughout the article describing NPR’s word choice versus the word choice of groups favoring “anti-abortion rights” (approved term), I failed to find a similar “We-They” within the article describing NPR’s word choice versus the word choice of groups favoring “pro-abortion rights” (not approved term). Perhaps I missed it?

Additionally, NPR favors the term “fetus” over the term “unborn”, despite the fact that fetus means “unborn offspring of an animal” per Wikipedia or “unborn or unhatched vertebrate” per Merriam-Webster. The Latin sounds more accurate but fewer people are speaking Latin these days. Nonetheless, NPR believes that “[i]ncorrectly calling a fetus a ‘baby’ or ‘the unborn’ is part of the strategy used by antiabortion groups to shift language/legality/public opinion.” I wonder if the Mayo Clinic realizes their interchangeable use of the terms “fetus” and “baby” on their fetal ultrasound web page is not only incorrect but places them squarely in the antiabortion movement trying to shift language/legality/public opinion?

Finally, NPR does not like to use the term “abortion clinics” but rather “medical or heath clinics that perform abortions”. That may indeed be more accurate but why stop there? Why not list all the procedures that a specified medical clinic performs, including the total number of each of the procedures performed, and let the reader decide how he or she wishes to categorize that particular clinic?

It is wrong to purposely select terms feigning accuracy so as to appear unbiased, particularly if the goal is to bias by use of those very same terms.

Proposed moratorium on human germline: Asilomar analogue?

The Editorial Board of The Washington Post (WaPo) recently published their opinion  on regulation of heritable genetic changes in human eggs, sperm, and embryos. The authors expressed some measure of relief that organizations such as the National Academies in the U.S., the Royal Society in Britain, and the World Health Organization are beginning to consider the daunting topic of human heritable genetic changes. The board advised, “The goal must be a framework that will enable genuine scientific advancement but avoid reckless fiddling with the source code of life.”

The WaPo editorial board further recommended “something of similar scope and power” to that of the Asilomar Conference on Recombinant DNA Molecules, held in February 1975. Asilomar, as that conference came to be called, was convened to evaluate the risks posed by the novel technology of genetically modifying organisms. The public perception of Asilomar has been primarily one of scientists shouldering the “social responsibility of science.”

Further, the WaPo article pointed out that one of the authors of the March 2019 Nature commentary calling for a “global, temporary moratorium on clinical uses of human germline editing” was Paul Berg, a Nobel laureate, and one of the organizers of the Asilomar conference. The Nature commentary, authored by Eric Lander, Françoise Baylis, Feng Zhang, Emmanuelle Charpentier, and Paul Berg, described the consensus for a moratorium thusly:

The 18 signatories of this call include scientists and ethicists who are citizens of 7 countries. Many of us have been involved in the gene-editing field by developing and applying the technology, organizing and speaking at international summits, serving on national advisory committees and studying the ethical issues raised.

This description appears to differ substantively from one Berg gave of the Asilomar analogue. In an 18 June 2011 video interview by Larry Goldstein, Berg had this to say about the success of Asilomar:

We made some decisions that were smart in retrospect. For example, one of the things we did not do – and did not include in any way in the agenda was the ethics. We didn’t talk about genetic testing… we talked about real experiments, and what the impact of those experiments would be in the field (10:40-10:58)

Of the five authors calling for a moratorium on human heritable genetic changes, only Françoise Baylis is an ethicist. A 2004 article penned by Baylis and Jason Scott Robert, “The Inevitability of Genetic Enhancement Technologies,” gives insight to her views. The paper concludes with

. . . we maintain that accepting the inevitability of genetic enhancement technologies is an important and necessary step forward in the ethical debate about the development and use of such technologies. We need to change the lens through which we perceive, and therefore approach, the prospect of enhancing humans genetically. In recognising the futility of trying to stop these technologies, we can usefully direct our energies to a systematic analysis of the appropriate scope of their use. The goal of such a project would be to influence how the technologies will be developed, and the individual, social, cultural, political, economic, ecological, and evolutionary ends the technologies should serve. It is to these tasks that bioethical attention must now fully turn.

It appears that 1) Paul Berg’s previous concerns about “ethics” being involved is not a problem to date in this enterprise; and 2) the called-for moratorium is truly only a “speed bump” on the road to converting future generations into our own laboratory experiments. The “individual” ends such experiments will serve are likely to be the individuals who are paid handsomely to do such experiments or who hold the patents to the processes utilized – not the individuals formed. Despite the extensive embrace of heritable human genome editing by the principals cited here, we need to remember that this is not a road that we must travel. Future generations are not our playground. We need to rethink this “moratorium”:  It should be an outright ban.

Emerging attempts to control gene editing

Recently, it was reported that the panel convened by the World Health Organization (WHO) to develop standards and guidelines for gene editing will ask the WHO to establish a registry for any projects on heritable human gene editing.  The idea is that, to get research funding, a project would have to be registered, and there would be a required review in order to get on the registry in the first place.  The net effect would be to control the flow of money to such projects.

Also, according to Nature, the Chinese government is looking at amending its civil code, effective March 2020, to in essence make a gene editor liable for health outcomes by declaring that “experiments on genes in adults or embryos that endanger human health or violate ethical norms can accordingly be seen as a violation of a person’s fundamental rights.”  The idea here appears to be to make gene editors think twice about whether they are sure enough of their work to accept essentially a permanent risk of being sued for all they are worth if anything goes wrong in the future.  Your correspondent knows nothing about Chinese civil procedure, but in the litigious U.S., the risk of really big, unpredictable lawsuits at some entirely unpredictable time in the future, with no limit, can make even big companies shy to pursue something. 

So maybe these approaches, by “following the money,” as it were, would at least slow down heritable genome editing, short of a ban.  Skeptics of the utility or wisdom of a ban argue that the “rogues” will just find work-arounds anyway, and that entire states can “go rogue,” limiting the effects of the ban to only the nations willing to enact and enforce it.

That’s a reasonable argument, but it still seems that, by only requiring a registry—with noncompliance always a risk—or trying to up the ante in court—a risk that some entities might take if the perceived reward is big enough to warrant it, and they can hire enough expansive lawyers to limit the risk—there is an admission that heritable genome editing is going to go forward.  And, indeed, maybe there’s no stopping it.  But it seems like promoting a stance toward human life that refuses to accept heritable gene editing is still something we should do.

When should physicians provide a good death?

A recent New England Journal of Medicine (NEJM) Perspective by Deborah Denno, Ph.D., J.D., entitled “Physician Participation in Lethal Injection” (subscription or limited free access required) discussed physician involvement in state-sanctioned capital punishment by lethal injection. Some of the arguments for physician involvement in euthanasia (“a good death”) or Physician-Assisted Suicide (PAS) would seem to apply to some degree to lethal injection and is the subject of this blog entry.

For those without access, the article explored a recent Supreme Court rejection in Bucklew v. Precythe of a Missouri death row inmate’s appeal for protection from lethal injection under the Eighth Amendment’s prohibition of “cruel and unusual punishment”. In short, Russell Bucklew has a rare vascular condition making venous access both difficult and potentially more painful to use lethal injection as the means to execute him. It was argued that his medical condition necessitated at least medical training to guide the injection process, if not actual physician/surgeon training, such as possessed by an anesthesiologist, to provide the actual vein access for the lethal injection. In rejecting his appeal, the Court responded, in part, “the Eighth Amendment does not guarantee a prisoner a painless death – something that isn’t guaranteed to many people, including most victims of capital crimes.” The Court added that methods prohibited are those that “superadd terror, pain or disgrace to their executions”, though as the article points out, the Court does not specify as to how to test those limits, and left unanswered whether physician involvement was legally required to guarantee satisfaction of the Eighth Amendment.

The article discusses the fact that national medical associations generally strongly discourage their members from providing guidance for lethal injection. The American Medical Association’s (AMA’s) own amicus brief for the case listed above states that the AMA opposes capital punishment. The American Society of Anesthesiologists (ASA) takes a similar position opposing participation of its members in lethal injection. Both the AMA and the ASA agree that capital punishment is not the practice of medicine and the ASA goes further to challenge the Court to look elsewhere for any lethal injection skills.

Interestingly, both organizations are less precise on their position regarding physician involvement in euthanasia or PAS. The AMA sees PAS as causing “more harm than good”. The ASA has no official published position on PAS that I could find on their website. Their Statement on Palliative Care does not mention euthanasia or PAS. This is important, as there is a growing demand for physician involvement in euthanasia/PAS, the implication being that there is additional benefit with physician involvement in achieving a good death.

For the record, I have always believed that physicians are uniquely the worst choice for killing people under any circumstance as our training universally focuses on honing skills that avoid causing death to our patients. We are effectively trained at not killing and would therefore provide dysthanasia – a bad death. But, perhaps, I am mistaken. There is growing demand to involve physicians in actively and purposefully killing their patients, with many holding the contrary belief that physicians uniquely have the best skill set to provide for euthanasia – a good death.

So, even though Russell Bucklew failed to make a successful legal case for physician involvement in lethal injection, did he make a sufficient moral case? If physicians and their unique skills are necessary for euthanasia/PAS, are they not equally necessary for state-sanctioned execution, particularly given that the latter involves the non-voluntary death of an individual who is guaranteed Eighth Amendment protections, and especially given our inability to provide any scientific evidence that we are satisfying those protections?

If physicians really are the best at providing euthanasia, doesn’t moral justice demand we require a physician to similarly provide a good, physician-assisted, state-sanctioned, death (PASSD) despite the stated objections of the AMA and ASA? Anything less arguably opens the door for adding “terror, pain or disgrace” to the execution.

Parental responsibility in childhood immunizations

Last week I wrote about the issue of parental responsibility and medical decision-making for children. We have good reasons for having parents be the primary decision makers for children who are not capable of making their own medical decisions. However, as I discussed in the last post, there are some situations in which parents make decisions that are not in the best interest of their child. When those decisions reach the point at which the child’s life is in danger, society clearly has a moral obligation to intervene to save the life of the child.

Parental refusal of recommended immunizations for their children raises similar issues but is more complex. We can clearly demonstrate that it is in a child’s best interest to receive at least most of the commonly recommended immunizations for children. Those immunizations help to prevent a child being affected by diseases that can be serious and have a very low risk for serious adverse effects. However, the chance of an individual child being affected by many of these diseases is relatively small and the situation is quite different from a child whose life is in immediate danger due to a parental refusal of treatment. Since the risk to an individual child is relatively small and there is some possible risk to the child from receiving the immunization, it is not clear that a parent who refuses immunizations for a child is being negligent in the same way as a parent who refuses treatment for a life-threatening illness. It can be argued that the best way to deal with this type of situation is education. Many times, parents refuse immunizations for their children because of misconceptions about the risks and a lack of understanding of the benefits of doing the immunizations. It can be difficult to counter widespread misconceptions, but physicians have the responsibility of trying to do that the best that we can. However, this is not the only issue involved in determining whether society has an obligation to intervene and mandate childhood immunizations when parents refuse.

Immunizations are unique in the way that they work. They help protect the individual who is immunized, but they also help protect the community as a whole when we can achieve sufficient levels of immunity to halt the spread of an infectious disease within the community. This is sometimes called herd immunity. We have an excellent example of how this works with the current measles outbreak in the United States. Measles happens to be one of the most easily transmittable infectious diseases that we know of. It also can be deadly in a small percentage of the people who acquire the disease. It is also primarily a disease of children and is transmitted by children. When about 97% of children have been immunized in a community the disease will not be transmitted through that community and those who have not been immunized or cannot be immunized are protected from acquiring the disease. This level of immunity was accomplished in the United States about 20 years ago and for some time the only cases of measles that were seen in the United States were cases that originated elsewhere. However, because of parents refusing to have their children immunized for measles in significant numbers in some parts of the country, herd immunity is no longer present and we are having outbreaks of measles this year that are more than we have seen in 20 years.

That raises a different question. Should we mandate immunization of children for diseases such as measles and override parental decision-making not solely for the benefit of the children whose parents refuse to have them immunized but for the common good of the community? There are some children and other individuals who cannot be immunized or for whom immunizations would not be effective who are put at increased risk when herd immunity is not achieved in the community. This makes the decision about whether to immunize a child not just a decision about what is best for that child but also a decision about what is best for the community. For Christian parent it makes the decision about whether to immunize a child a decision about love of neighbor. Immunizing one’s own child helps to protect the child, but it also helps to protect the most vulnerable in the community. If we truly love our neighbor, we should do that even if there is a small risk to our own child. The final question is whether we as a society should require children to be immunized for these diseases when a parent is not willing to authorize it out of either concern for the best interest of the child or concern for those who are vulnerable in the community.

Parental responsibility in medical decisions for children

The 2 posts on this blog this week by Neil Skjoldal and Mark McQuain raise issues related to parental decision-making for the medical treatment of their children. Neil raised this issue related to parental refusal of life-saving treatment for acute leukemia and Mark raised it related to parental decisions not to have their children immunized for measles. There are some similarities in these situations and some differences. An obvious similarity is that in both of these situations parents are making a decision to refuse treatment for their children that is the recommended standard of care. Both situations raise issues about who should make decisions about the medical care that children receive and how those decisions should be made.

One thing we should be clear about is that this is not a conflict between the principle of respect for autonomy and the principle of beneficence. Respect for autonomy says that a person should be able to make decisions about what happens to his or her own body. It says that it shows disrespect to an individual as a person to insist a person receive recommended medical care when that person has the capability of making his or her own decisions and does not consent to the recommended care. This principle does not apply to decisions about the medical care of young children. Young children are not capable of making decisions about their own care and the parents are not the ones receiving medical treatment, so respect for autonomy does not apply to these situations.

What is involved is our understanding of parental responsibility for making medical decisions for their children. Because young children do not have the ability to make their own medical decisions, someone needs to serve as a decision-maker for them. We generally understand that parents ought to be the ones making those decisions. We have good reasons for that. Decisions about the medical care of young children should be made based on what is in the best interest of those children. God has created us as human beings to be dependent during the early part of our lives. He has put us in families with parents who have the responsibility for providing for the needs of their dependent children. Parents should love their children unconditionally as a precious gift and make decisions for their children based on what is best for each child. This usually makes parents the people who care the most about doing what is best for a child and makes them the best medical decision makers for their child.

However, sometimes parents do not fulfill their parental responsibilities as well as they should. None of us are perfect, but there are times when it is clear that the decision being made by a parent is not what is best for a child. When the potential consequences for the child are serious enough it can become the responsibility of the rest of us to intervene for the benefit of the child. We should not violate parental responsibility lightly, and it needs to be done in a controlled and orderly way, but when the child’s life is in danger, we have a responsibility as a society to intervene to protect a child. We should do this in any type of severe neglect or abuse.  We should do it when parents refuse medical treatment for a child who is likely to die if without treatment and the treatment has a good chance of saving the child’s life.

That appears to be the case in the situation in Neil’s post. The concern about parents refusing immunizations for their children has some similarities, but is more complex. It will take another post to address that.

Measles: When does Screening, Quarantining and/or Vaccination become Mandatory?

As this linked PBS NewsHour interview between Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, and Judy Woodruff reports, the number of new cases of measles in the US has reached nearly 700, which is the highest number of new cases since measles was supposedly eliminated in 2000. The video is short and provides a quick review of the current causes of the outbreak and suggested steps one can take to mitigate future personal and family risks of contracting the disease. The reason for this being the subject of this bioethics blog is to touch on the ethical tensions between personal autonomy and utilitarian public health calculations regarding the recent measles outbreak.

So what is the problem with getting measles in the first place? Measles is a highly contagious viral respiratory disease. Simply being in the same room with someone with the disease can lead to becoming infected. In its milder form, the disease results in fever, runny nose, ear infection and a classic spotted red skin rash. In its more severe form, it can cause a severe pneumonia requiring hospitalization, deafness, lifelong brain damage and even death. Children under 5 years of age are at particular risk. A common two-stage vaccine called MMR is available that successfully immunizes 97% of those that receive it. It is given at age one and again around age 5.

The benefits of the immunization are two-fold. The first is direct personal protection against contracting the disease if you receive the vaccination and are one of the 97% of individuals who gain future immunity against the measles virus. The second is something called herd immunity. If enough people are immunized (experts estimate “enough” to be between 95-97% of the population), then even people who cannot be immunized, such as infants less than one year of age or individuals whose immune systems are compromised, are still somewhat protected from contracting the disease. This is because new measles cases from “outside the herd” are severely limited in their ability to spread to the small number of non-immunized people within the largely immunized herd. The immunized people effectively act as a physical barrier to protect the non-immunized people. Problem solved, right?

To quote my favorite ESPN College Gameday commentator coach Lee Corso: “Not so fast, my friend”. The measles vaccine is not completely risk-free. Minor side effects include fever, rash and local injection site infections. Much less common but more severe reactions include seizures and rare deaths from severe allergic reactions. In the late 1990s, the British medical journal Lancet published a study by Andrew Wakefield positing a link between the MMR vaccine and autism. This study was later proven to be a completely falsified claim and Wakefield was completely discredited, though some parents still use the original study to argue against vaccinating their children.

If the vaccine were completely risk-free, there would be no logical or ethical reason not to receive the vaccination. If everyone who could take the vaccine did so, herd immunity from a public health standpoint would be at its maximum, protecting the remainder of individuals unable to receive or benefit from the vaccine. The current measles outbreak argues that either we are not properly screening or quarantining new cases of measles at the point of entry to the US or our herd immunity may be breaking down (or some combination of the above).

So, at your next social function, after you have debated your usual political concerns or dismay at your favorite NFL football team’s shocking choice in the recent NFL draft, settle in to a potentially more meaningful discussion around the ethics of personal autonomy versus public health policy regarding mandatory measles screening, quarantining and vaccination. Suggested sub-topics might include:

• Is it fair for those who are able to vaccinate but choose not to vaccinate to freely rely on the herd immunity of those that do vaccinate?
• How public should one’s vaccination or immunity status be to avoid quarantine?
• What reasons are reasonable to choose not to immunize?
• Would it be fair to deny public (or private) insurance coverage for treating the measles if one chose not to take the vaccine?

Physician-assisted suicide, euthanasia, and the World Medical Association

The World Medical Association (WMA) is cogitating on physician-assisted suicide. Their current statement, adopted in 1992, “editorially revised” in 2005, and reaffirmed in 2015, is as follows:

Physician-assisted suicide, like euthanasia, is unethical and must be condemned by the medical profession. Where the assistance of the physician is intentionally and deliberately directed at enabling an individual to end his or her own life, the physician acts unethically. However the right to decline medical treatment is a basic right of the patient and the physician does not act unethically even if respecting such a wish results in the death of the patient.

WMA’s statement on euthanasia, adopted in 2002, and reaffirmed with minor revision in 2013, states

BE IT RESOLVED that:

The World Medical Association reaffirms its strong belief that euthanasia is in conflict with basic ethical principles of medical practice, and

The World Medical Association strongly encourages all National Medical Associations and physicians to refrain from participating in euthanasia, even if national law allows it or decriminalizes it under certain conditions.

Drama has been unfolding in recent months regarding these positions of the WMA. In October 2018, the Royal Dutch Medical Association (KNMG) and the Canadian Medical Association (CMA) together proposed that the WMA change its position to “neutrality.” This Proposed WMA Reconsideration of the Statement on Euthanasia and Physician Assisted Dying was retracted late in the process due to strong opposition.  The German Medical Association proposed a compromise of changes in the language. Those changes included “physician-assisted death” instead of “physician-assisted suicide,” and “physicians should not engage” in place of “unethical and should be condemned.”

The WMA decided to seek written opinions, and revisit the subject at the 2019 Council meeting. In a press release from 29 April 2019, the WMA Council announced that

It was agreed that policy work should continue on physician assisted suicide, augmented intelligence, violence against healthcare professionals and the patient-physician relationship.

With the next WMA Council and General Assembly scheduled for 23-26 October 2019 in Tbilisi, Georgia, observers should note the jockeying for position by various medical associations. It seems unlikely that those medical associations in jurisdictions where physician-assisted suicide or euthanasia are embraced would decrease pressure on the WMA. Yet we can hope that the World Medical Association will not succumb to such forces. After all, the WMA was formed in the shadow of World War II – a time when the raw wounds of incredibly inhuman acts by some humans against others had been recently seared into the minds of millions. The WMA needs to stay the course they set in 1946, for, to paraphrase George Santayana, those who do not learn from history are condemned to repeat it.

Men without chests

One thing that is essential for us to be able to think well about bioethics is an understanding of who we are as human beings. One aspect of that which has been discussed on this forum is the concept of human dignity, the idea that all human beings have inherent value which impacts how we interact with each other ethically. For Christians that is grounded in the idea that we are all created in the image of God. John Kilner has expressed so very well how our being created in the image of God is the reason why people matter.

C. S. Lewis wrote about another aspect of how we understand ourselves as human beings back in 1947 in a little book titled The Abolition of Man. The first chapter of that book is titled “Men without Chests.” As a medieval scholar he was using a medieval image to express a concern that he had about how the tendency to deny the existence of objective moral truth in his day was leading to a problem with how we function as human beings. In the image that he is using the head represents intellect or reason, the chest (or heart) represents sentiments or values, and the stomach represents the appetites or desires. He says that if we believe that statements about morality or values are simply statements about how we feel and are not statements that can be considered objectively true or false, then the chest has lost its ability to mediate between the head and the stomach. Without objective moral values humans become beings whose intellect is used to achieve their desires without any means of controlling those desires.

What Lewis predicted is where much of our society is today. We are told that our identity is based on our desires, and that if we do not fulfill our desires then we are denying who we really are. Anyone who would suggest that our desires might be wrong or that we should not fulfill those desires must hate us and is attacking us and making us unsafe. Our desires define who we are, and our intellect is given the task of fulfilling those desires.

This is in stark contrast with a Christian concept of who we are as human beings. We understand that as human beings we are created by God in his image and with a purpose. We also understand that we are fallen. This world is not how it ought to be and we are not how we ought to be. Because we are fallen, our desires are frequently wrong. Our identity is not found in our desires, but in our relationship with our creator. We understand that our creator has given us the capacity to understand which of our desires are right and which are wrong. He has enabled our intellect to comprehend objective moral values that are grounded in the goodness of God’s nature. Those moral concepts allow us to distinguish right from wrong desires. That is what ethics is about. Those moral concepts also help us understand that we fall short of what we ought to be. We need help. That is what the gospel is all about. That is why Jesus died and rose again as we just celebrated at Easter.

The idea that our desires define who we are and must be fulfilled creates men without chests who are incapable of distinguishing right from wrong and can only express how they feel about a moral issue. We must have chests which hold to objective moral truths to think ethically and be complete human beings who are not simply ruled by our appetites.