Human limitation and ethics

By Steve Phillips

I recently read Cody Chambers’ article “The Concept of Limitation in Emil Brunner’s Ethics” in Ethics in Conversation from the Kirby Laing Institute for Christian Ethics. The article is well done and you need to read it to get the full impact of what he has said. What resonated with me was the idea that being limited is a part of what it means to be human and that our limitations are essential for our relationship with God and each other. It is our limitedness that helps us see that we need both God and other people and that we were made for those relationships. This is central to ethics because it is in our relationships with God and other people that we find our understanding of what ethics is.

This understanding that we are in our nature limited beings created by an unlimited God could not be more different from the conception of human beings held by many in the culture around us. They desire to see human beings and particularly themselves as having unlimited potential and freedom with no creator at all. That desire for personal freedom dominates contemporary ethics and shows itself in all areas of bioethics.

Chambers looks at how this impacts thinking about gene editing. Those who advocate doing human germline genetic modification see it as the freedom to create a child who is made to be what the parents creating the child desire the child to be. This is usually expressed in terms of creating a child free from genetic disease, but there are simpler ways to have a child without a disease carried by the parents (including adoption). It is ultimately the desire to be free of natural human reproductive limitations and create a child we have designed and chosen. Being limited helps us to see that we need each other and must respect others, including our children, as they have been made by God. Our natural lack of control over the characteristics of our children leads to an understanding that those children are a gift from God that we should accept unconditionally. Using technology to try to take control of the creation of our children leads to creating children that will fulfill our desires and a loss of the unconditional acceptance that is the foundation of a positive parent-child relationship.

Freedom in the proper context is good. The desire for unlimited freedom leads to putting ourselves above others and ultimately controlling and subjugating others, including our children, to our desires. Proper ethics requires an understanding that our freedom is limited.

The essence of humanity

BY STEVE PHILLIPS

Over the past few days I have been reflecting on this year’s CBHD conference which was titled Bioethics and Being Human. In reviewing all the thought-provoking presentations and discussions, I think the opening address by Dennis Hollinger impacted me the most. His talk was entitled Why Humanness Is the Key to Bioethics. He began by saying that in the culture around us the focus has shifted from concept of human dignity to the concept of humanness or what it means to be human. He suggested the technology which is developing artificial intelligence that may be able to reason and robots that take on roles that we have traditionally considered to be human raises questions about what counts as a human being.

The core of what he said related to the idea that there has been a shift in how the culture around us thinks about these things. Our surrounding culture now questions whether there can be an essence of realities. If the existentialist assertion that existence precedes essence is true and there is nothing outside the self to define the self, all our concepts, including our understanding of humanness, become subjective.

Those of us who see the world from a biblical Christian viewpoint understand that there are objective realities in the world. We see that human beings do have a nature, a humanness, that is not subjectively defined, but it is an objective reality that exists due to how we have been created by God. We find that objective understanding of what it means to be human represented in the ultimate human being, Jesus.

But how do we express this understanding of an objective reality of humanness to people in a culture that believes that everything is subjective? I think Hollinger suggested a strategy when he identified the ironies of our surrounding culture’s thinking. He said that the surrounding culture rejects humanness, but longs for relationship; rejects intrinsic moral norms, but longs to be treated justly and honestly; and rejects human meaning, but longs for something beyond. We live within a culture that leaves people without a solid foundation for meaning, relationship, and values. That foundation is available in the God who created us and in his Son, who became one of us, died for us, and rose again to redeem us. He is the essence of humanity and we can share Him with those around us who are deeply in need of the hope that He can provide.

A Supreme Court of One

BY MARK MCQUAIN

Like Neil Skjoldal in yesterday’s blog entry, I, too, am a Supreme Court watcher and enjoy reading their decisions as some might enjoy watching a good sports match or listening to a beautiful symphony. Nerd that I am, I find a well-articulated argument a beautiful thing to behold, even when it runs counter to my bioethics, as it can be a learning experience to help me sharpen my counter argument. My counter argument becomes moot if five or more Justices concur with that original argument, as it is rare, though not impossible, for the Court to completely reverse itself.

Last week, the legal landscape suffered the equivalent of a San Andreas-like major tremor along its political fault-line with the announced retirement of Associate Supreme Court Justice Anthony Kennedy. Justice Kennedy has generally been considered the political center of the Court, the all-important tiebreaker, if you will, on controversial bioethical issues related to abortion, gay marriage and the death penalty. Presently, we give 9 Justices the authority to be the final interpreters of our laws, including those that determine our collective bioethics. Amazingly, we will accept a majority rule 5-4 split decision as being just as acceptable as a 9-0 unanimous decision when validating or invalidating our laws. Being the tiebreaker on previous controversial issues effectively made Justice Kennedy what I call “a Supreme Court of One”. And that is exactly how both political parties are treating the selection of Justice Kennedy’s replacement.

And they should.

In a past blog entry, I tried to make the case that it vitally matters who is interpreting our Constitution, as those individuals are grounding our secular bioethics. Allowing one tie-breaker to decide these important issues is too much power and responsibility in one individual but that has been the reality in our presently divided Court.

My favorite legal philosopher is the late Yale Law School professor Arthur Leff. He gave a lecture at the Duke University Law School in the late 1970s called “Unspeakable Ethics, Unnatural Law”. He made the case that if our source of right and wrong is anything other than a transcendental (unnatural) source, then the resulting ethics/law is always open to challenge. The U.S. Constitution is an example of a natural source of law, perhaps the best that mankind can create for itself, but, since it was created by us, it is therefore always open to challenge by us. Given its internal checks and balances, as long as “We the People” continue to agree to be governed by the Constitution (and this is by no means a permanent agreement), rulings by the Supreme Court essentially function as our collective approval of laws that determine our national bioethics.

I have shared the following quote from Leff’s lecture before but it again seems appropriate:

As long as the Constitution is accepted, or at least not overthrown, it successfully functions as a God would in a valid ethical system: its restrictions and accommodations govern. They could be other than they are, but they are what they are, and that is that. There will be, as with all divine pronouncements, a continuous controversy over what God says, but whatever the practical importance of the power to determine those questions, they are theoretically unthreatening. It is only when the Constitution ceases to be seen as fulfilling God’s normative role, ceases, that is, to be outside the normative system it totally constitutes, or when, as is impossible with a real God, it is seen to have “gaps,” that a crisis comes to exist. What “wins” when the Constitution will not say, or says two things at the same time?

Presently, the Supreme Court interprets those gaps and decides what wins and what loses in our national bioethics debates. Given our present evenly split Court, picking the next Supreme Court of One can literally make all the bioethical difference in the world.

The death and resurrection of Jesus and how we view death

This is the week when we who are Christians particularly focus on the death and resurrection of Jesus. As I have been reflecting on this I have been thinking about how Jesus’ death and resurrection impact how I think about bioethics. I think that the largest impact is on how I think about death.

Whether we realize it or not, much of bioethics is impacted by how we view death. This is most clear when we are thinking about end-of-life issues. Some of the most difficult medical decisions that people must make are related to how aggressively we should try to prevent death and when we should accept the inevitability of death and focus on palliative care. However, it also impacts beginning of life and reproductive issues, because many times those issues are significantly impacted by our understanding of who has the type of moral status that says we should not cause the death of that person. It is also the foundation of transhumanist desires to go beyond the limitations of human mortality.

How does Jesus’ death impact how I think about death? It reminds me that death is the result of evil and may involve deep suffering. It was not a part of God’s original good creation but is a part of the brokenness of that creation caused by human sin. It reminds me that we have a God who understands what it means to suffer and die and can truly love us with a compassionate love. Jesus’ resurrection reminds me that he not on the understands death but has defeated it. We who follow him can know that death is not the end. We have a hope that goes beyond death that changes how we think about it.

Understanding God’s compassionate love for us can help us live with a deeper compassion for those around us. Having a hope that goes beyond death and an understanding that there can be meaning in suffering allows us to face the reality of our own deaths without fear. When we are at peace with our own death we can better help others, who are dying. We can understand that death itself is evil and that it is good for us to develop medical treatments and administer them to people in order to prevent death, but also understand that preventing death is not our ultimate goal because we can have a relationship with God that is eternal.

Reviewing the ethics of paying human research subjects

Sometimes it is both necessary and proper to pay a person to participate in a clinical trial, of a drug or some other medical intervention, or a data-collection study, or something else that involves people.  An article in this week’s New England Journal of Medicine reviews many of the relevant ethical issues.

A link to the article is here.  Correction to initial post:  subscription or purchase does appear required.

Why pay somebody to be in a trial?  The main reasons are to reimburse them for unavoidable expenses, to compensate them for time that would not otherwise be required in the course of standard medical care or normal life, and, indeed, to get them to participate in the first place.  In cancer medicine, where I’ve worked, the subjects are cancer patients who are generally not paid to participate; they usually are willing to do so in the hope of possible benefit, plus, often, a sense of altruism.  But most drugs have their first human testing in healthy volunteers, to begin to identify potential safety concerns and understand how, and how rapidly, the drug is eliminated from the body.  In those cases, the research subjects are almost always paid, sometimes substantially.

Such payments are not necessarily unethical, as long as they are not too big.  If they are, then they could create an undue influence to participate.  That would upset the balance of benefits and risks and compromise true informed consent.  By well-accepted ethical standards for research on human subjects—many of which are codified in regulation—the risks to human subjects must not be excessive, must be avoided or mitigated to the extent reasonably possible and commensurate with the goals of the research, and must not exceed the foreseeable benefits of the research, either to the individual subject or to society overall (e.g., in the form of important medical knowledge), or both.

Payment to a subject is not considered a benefit in and of itself, but should be “neutral” to the benefit/risk assessment.

There’s no hard and fast rule about paying subjects—no single standard “fee schedule,” so to speak.  Rather, each ethics board reviewing a study must also review and approve the amount and timing of payments to subjects.  Again, such payments should be high enough to respect the subject’s contribution to the research, but not too high so as to give them incentive to participate when maybe they should not.  Also, it’s a general principle that payment should be in installments; generally, no more than 10-15% of the total should be held back to the very end of the study.  Why this last point?  Because it’s also a principle that subjects can opt out of a study at any time, but if they think “I have to stay in to the bitter end to get paid,” that could pressure them too much.

Note, BTW, that such pressure is not the same as coercion, which by definition involves a threat, and does not apply to this payment question.

Also, payments must be appropriate so that subjects don’t get a wrong idea about the potential value or efficacy of an experimental drug, or that they might be induced to try to be in more than one study at once.  You might be surprised how significant that last risk is.  In my past IRB work, we just to worry about “professional subjects” who make some level of living by going from one research study to another.  More than one at once means getting two or more drugs at once that probably ought not to be combined, willy-nilly.

And of course, the potential for economic exploitation of low-income individuals must also be considered and respected.

The NEJM article really doesn’t break new ground but is a helpful review for those interested in essential research ethics.  The FDA has also provided guidance, which can be reviewed here.

The self-evident superiority of objective moral truth

We live in a culture in which moral relativism, or what some would call moral individualism, seems very inviting to many. This is not a new thing. Twice in the book of Judges the writer says about the people of Israel that “everyone did what was right in his own eyes.” (Judges 17:6 and 21:25) This happened to Israel because they, like us, were fallen human beings more interested in themselves than anyone else and because of their tendency to absorb things from the cultures of the nations around them. However, they had been given something better than this.

Before his death and in preparation for the nation of Israel crossing the Jordan river to take possession of the land that God had promised to them, Moses reminded God’s people that God had given them something even more important than the promised land. He had given them his law. He let them know that when they lived out the commands that God had given them the nations around them would take notice and say about Israel “Surely this great nation is a wise and understanding people.” (Deuteronomy 4:6)

Think a little about what Moses was saying. The nations around Israel were living by the relativistic principle of everyone doing what was right in his own eyes, but they would recognize that living according to God’s objective moral commands made Israel a wise and understanding people. Even though many today live according to moral relativism, those who look at ethics more closely realize that ethics is meaningless without some type of objective standards. Few still follow the course of the skeptics. Even the utilitarians who dominate modern secular ethics hold to objective principles that allow them to say that it is better to do what is best for everyone than to simply do what is best for oneself.

It is also interesting, however, that it was not Israel’s eloquent proclamation and rational defense of God’s commands that would impress the surrounding nations. It was what the nations would see when they observed Israel living in obedience to God’s commands that would convince them of the wisdom of those commands.

We who understand God’s objective moral truth need to be ready to express those truths clearly, but it is living by those truths that will impact the world around us.

Is Medical Artificial Intelligence Ethically Neutral?

Will Knight has written several articles over this past year in MIT’s flagship journal Technology Review that have discussed growing concerns in the field of Artificial Intelligence (AI) that may be of concern for bioethicists. The first concern is in the area of bias. In an article entitled “Forget Killer Robots – Bias is the Real AI Danger”, Knight provides real world examples of this hidden bias affecting people negatively. One example is an AI system called COMPASS, which is used by judges to determine the likelihood of reoffending by inmates who are up for parole. An independent review claims that algorithm may be biased against minorities. In a separate article, Knight identified additional examples in other AI algorithms that introduced gender or minority bias in software used to rank teachers, approve bank loans and interpret natural language processing. None of these examples argued that this bias was introduced intentionally or maliciously (though that certainly could happen).

This is where Knight’s the second concern becomes apparent. The problem may be that the algorithms are too complex for even their programmers to retroactively examine for bias. To understand the complexity issue, one must have an introductory idea of how the current AI programs work. Previously, computer programs had their algorithms “hard-wired” so to speak. The programs were essentially complex “if this, then do this” sequences. A programmer could look at the code and generally understand how the program would react to a given input. Beginning in the 1980’s, programmers started experimenting with code written to behave like a brain neuron might behave. The goal of the program was to model a human neuron, including the ability of the neuron to change its output behavior in real time. A neurobiologist would recognize the programming pattern as modeling the many layers of neurons in the human brain. A biofeedback expert would recognize the programming pattern as including feedback to change the input sensitivities based upon certain output goals – “teaching” the program to recognize a face or image in a larger picture is one such example. If you want to dive deep here, begin with this link.

This type of programming had limited use in the 1980s because the computers were too simple and could only model simple neurons and only a limited number at one time. Fast forward to the 21st century and 30 years of Moore’s Law of exponential growth in computing power and complexity, and suddenly, these neural networks are modeling multiple layers with millions of neurons. The programs are starting to be useful in analyzing complex big data and finding patterns (literally, a needle in a haystack) and this is becoming useful in many fields, including medical diagnosis and patient management. The problem is that even the programmers cannot simply look at these programs and explain how the programs came to their conclusions.

Why is this important to consider from a bioethics standpoint? Historically, arguments in bioethics could generally be categorized as consequentialist, deontological, virtue, hedonistic, divine command, etc… One’s stated position was open to debate and analysis, and the ethical worldview was apparent. A proprietary, cloud-based, black-box, big data neural network system making a medical decision obscures, perhaps unintentionally, the ethics behind the decision. The “WHY” of a medical decision is as important as the “HOW”. What goes in to a medical decision often includes ethical weighting that ought to be as transparent as possible. These issues are presently not easily examined in AI decisions. The bioethics community therefore needs to be vigilant as more medical decisions begin to rely on AI. We should welcome AI as another tool in helping us provide good healthcare. Given the above concerns regarding AI bias and complexity, we should not however simply accept AI decisions as ethically neutral.

The reformation, sexuality, and the body

In honor of the 500th anniversary of the beginning of the reformation I have been reading the new biography of Martin Luther by Eric Metaxas. One of the things that caught my interest was the role the theology of the human body played in the reformation. That is something that significantly impacts Christian bioethics.

The 95 theses that Luther posted for academic debate 500 years ago related to the issue of the church selling indulgences, but there are many deeper underlying issues that Luther and the reformers were addressing. Primary were issues about the authority of scripture and believers receiving salvation directly from God by grace. However, there were also issues about the unity of Christian believers that were very significant. The church of Luther’s day had drifted into many thoughts and practices that conflicted with the clear teachings of scripture. One of those was the establishment of two separate classes of Christian believers. One consisted of priests, monks, and nuns who were considered to be spiritually superior and the common people who were far below them. This was manifested ritually in priests taking both the bread in the wine in the Eucharist, while the people only received the bread. It was also represented by the priests, monks, and nuns being expected to be celibate, while the common people married and had children. There is certainly a scriptural place for singleness and celibacy in serving God, but Luther understood that this elevation of celibacy as being spiritually superior was a result of ideas about the human body and sexuality that had found their way into the church from Greek philosophy rather than biblical teaching.

Greek thought saw the spiritual and immaterial as good and saw the physical as evil. This concept which did not have a biblical foundation led to the church seeing the human body and particularly human sexuality as evil, which made celibacy spiritually superior. As Luther began to recognize that all Christian believers were on equal standing before God because our relationship with him was based on God’s grace alone, he understood that the incarnation of Jesus meant that the physical nature of human believers had been redeemed and restored to its original state at creation which was good. That meant human sexuality, marriage, and bearing children were also good as a part of redeemed creation.

Understanding that God created human beings as an integrated whole composed of both physical and spiritual parts, and that human sexuality, marriage, and childbearing were designed by God as good parts of his creation are very important parts of the Christian world view that impacts how we think about what is right and wrong. We do wrong when we misuse the physical part of ourselves and do things that are outside of how God designed us to live. We do what is right when we follow his plan for marriage and family.

Common ground in ethical debates

On 7/10/17, Janie Valentine posted a review of the new book, Why People Matter, edited by John Kilner. Recently while I was on vacation I had the chance to read it and found the basic concept of the book very interesting. It begins with the idea that people on opposite sides of many of the ethical debates in our society actually have common ground that they agree on which can be used to engage each other in a constructive way. I heartily agree with that idea and would suggest that one area of common ground is that those interested in moral and ethical issues agree that morality is important and that there are ethical standards that should influence how we live. That is good place to start. Dr. Kilner and his co-authors are more specific in suggesting that the concept that people matter, that they have moral significance and should be treated with respect, is an underlying concept that people on both side of many currently debated issues use to support their positions. That is also a very good place to start.

From that starting place the authors look at five common ways of looking at the world and moral issues and show that there are some problems with supporting the common idea that people matter within those ways of seeing the world. They contrast that with the robust support for the significance of people with in a Christian view. I was particularly impressed by the reviews of utilitarianism, individualism, and naturalism by Gilbert Meilaender, Russell DiSilvestro and Scott Rae. Those are the most common views from the surrounding culture that I see influencing the students I interact with. In each case they show why those views actually undermine the common understanding that human beings have significance – that they matter, and how a Christian biblical view provides much better support for the significance of human beings.

I think that their analyses also address the common ground that morality is important. As Dr. Meilaender points out utilitarianism is unworkable unless we are omniscient and omnipotent, which we are not. That leaves us without a way to determine what we should do. As Dr. DiSilvestro shows, individualism makes moral concepts subjective and gives no objective standards by which we can guide our moral choices. It makes ethical discussion meaningless. With Dr. Rae we can see that naturalism provides no foundation for the validity of rational thought that represents the reality of the world, let alone moral concepts to guide us. In contrast, a biblical view gives us a solid foundation for morality and ethics that is grounded in the nature of God who is good and who created a world and human beings who reflect the goodness of his nature.

No matter which of these areas of common ground we choose, we can engage those who see moral issues differently than we do by recognizing the areas on which we agree and then exploring how those areas of commonality fit with how we view the world. If we do this well with a genuine desire to understand how others think we can encourage civil discussion that will help all of us to grow and come closer to what is true.

Charlie Gard, the New England Journal of Medicine, and the Limits of “Conscience”

I would venture that most bioethicists would agree it would be ethically permissible to remove life support and active care from little Charlie Gard, and let him die.   The hospital in Britain where he has been receiving his care wants to do that, and the courts agree.  But why do they insist on this action when his parents want to transfer him for another try at experimental treatment, have raised the money, and reportedly have a center in the US willing to accept him for such an attempt?

I can think of two reasons.  One is a frank utilitarian insistence on limiting costs.  It has been publicly charged that is precisely the motive for this and similar recent cases in the U.S.

Or it could be that those caregivers who argue against the futility of such care do so on conscience grounds.  This is at least a more charitable reading.

But if that is the case, then might we not ask:  on what grounds do such conscience concerns mandate blocking the wishes of the baby’s parents—setting aside just how quickly the futility of further care would be evident?  It is commonly argued that practitioners who wish not to provide abortions or participate in assisted suicide retain a professional obligation to refer to someone who will perform the procedure in question.

So why don’t we demand that the British hospital actively refer Charlie’s parents to another facility?  Just wondering…

Maybe the parents in this case are the ones appealing to conscience, but, in the view of the medicolegal authorities, wrongly so.  In postings dated June 2 and June 6 of this year, this blog carried a 2-part rejoinder to an April 6 article in the New England Journal of Medicine that took the position that conscientious objection by medical practitioners should be considered unethical.

The NEJM has now published correspondence in response to that “Sounding Board” article.  Unlike the initial article, a subscription is not needed to read these letters and the responses of the authors.  Three letters were published.  One argues that the initial article relied on “reflective equilibrium” as the critical process by which medical practice standards are established, but to do so and reject conscientious objectors is wrongly to restrict that process, which in any case does not indubitably lead toward moral truth.  The second wondered aloud about whether construing the doctor-patient relationship as covenantal matters, whether doctors also have some degree of autonomy that commands respect, and whether the consensus of the medical profession is always ethical.  In the third, a clearly irritated correspondent complains that it is rich to offer, as the authors of the initial article stated, that potential practitioners just avoid moral issues by voluntarily excluding themselves from specialties in question; i.e., would-be OB-GYNs who consider it immoral to perform an abortion need not apply.  In response, the authors say that objectors need not be silenced but must comply, and that society expects physicians to act against their personal beliefs if necessary.

Most tellingly, the authors in question, Stahl and Emanuel, claim that the doctor-patient relationship is NOT a covenant precisely because it is not a relationship of equals; doctors hold immense power of different sorts.  Physicians must respect this inequality by avoiding specialties that pose moral conflicts to them.

I thought that the patient’s special need was precisely why a covenantal relationship is the only framework sufficient to guarantee that the patient as person is appropriately cared for.  Stahl and Emanuel are quite explicit; doctors may not stand in the way of societal calculations, on their patients’ behalf.  They have to get out of the way.

Can there be a new society of physicians dedicates to the categorical rejection of this thinking?  Could such a group possibly practice in today’s legal environment, and in the political-economic spirit that has turned medicine into a centrally-managed public utility?

Dr. Cheyn Onarecker, in the two posts in early June, addressed these points, in opposition to Stahl and Emanuel and, in fact, anticipating their responses in the new correspondence.  Read those again.

But we need to go further, and attempt to restore the covenantal view of medicine.  I’d like to hear more from Dr. Onarecker and other real doctors on this blog about that.