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.

The need for Christians to make distinctively biblical moral decisions

I am continuing to reflect on the recent CBHD conference. One of the paper presentations I attended was related to the role of Christian faith and the church in decisions about fertility treatments. Heather Prior and an associate are doing research on how Christian couples in their community make decisions about treatments for infertility including such things as IVF. In the preliminary results she was reporting they found that many of the churches that the couples in their study attended had statements about the use of reproductive technology, but that none of the couples dealing with infertility were aware of those statements. Few had sought any counsel on their decisions from their pastors or others in their church.

I find that concerning. In my interaction with Christian students I have become very concerned that even those with strong Christian faith tend to think about ethical issues using thought patterns they have absorbed from the surrounding culture rather than using distinctively biblical ways of thinking. I don’t think this is limited to students, and this study suggests that it is not. The culture that we live in believes that people should make their own decisions about how they live based on how they feel about any decisions they need to make. It also says that those around them should affirm whatever they decide. I fear that Christians are taking on that same attitude. If we think like the world around us, we will make decisions on things such as reproductive technology based on what we desire and how we feel and expect the church to affirm whatever decision we make. When this happens there is no distinction between the church and the rest of the world.

Those who follow Jesus need to be different from the culture around us. We have access to a solid foundation for making moral decisions and living a life that is distinctive in its goodness. That foundation for making good decisions is found in the Bible and the body of the church. If we are going to be distinctive followers of Jesus we need to recognize that what we feel and desire can easily be affected by our fallenness. We need to turn to scripture and to good counsel from those in the church who have spiritual wisdom and who have thought through ethical issues well from a biblical perspective to help us live in a way that brings glory to God.

Educating the church about how to think about bioethics

Janie Valentine’s post on Monday about a Christian health sharing ministry considering the surgical treatment of ectopic pregnancy to be the moral equivalent of abortion points out a major concern related to the church and bioethics. This is particularly a concern regarding the evangelical Protestant church and bioethics. With its hierarchical structure the Roman Catholic Church has a way of connecting the well considered thoughts about bioethical issues that are expressed by Roman Catholic ethicists with the ministries of the church. Protestant churches, and evangelical Protestant churches in particular, have a significant disconnect between those who think deeply about and write about bioethical issues and those who are doing ministry.

The issue of whether to cover the costs of surgical treatment of ectopic pregnancy illustrates the need for people within the church to learn how to think about bioethics and other ethical issues. It is not that we need to have some established evangelical set of ethical positions on issues, but rather an understanding by people in the church of how to properly analyze and think about an ethical issue. Over centuries of thought Christian scholars have recognized the principle of double effect as a good way of analyzing moral dilemmas in which doing something that is good, such as saving the life of a woman with an ectopic pregnancy results in the unwanted bad affect of the death of an embryo. It is clear that we should not focus solely on consequences and do things that are wrong even to save a person’s life, but it is reasonable at times to do good things that have unintended but foreseeable bad effects. There is a way of thinking about ethical issues that has been well established by Christian ethicists over the years which many in the church are not at all familiar with. That is a problem.

The question is how those of us who understand how to think well from a Christian perspective about moral and ethical issues can communicate that to the church in general. Over the past eight years I have been trying to do that by teaching at a Christian university. My thought has been that if we teach students who will be the future leaders of their churches how to think well about ethics they will help their churches think well about those things. However, what I have learned is that only a small minority of the students at what I consider to be an excellent Christian university actually get enough education in ethics to be able to do that. Somehow we need to convince the church that learning how to think well about moral and ethical concerns from a distinctly Christian way of thinking is important for the life and health of the church and methods to accomplish that need to be established.

Most pressing bioethics issue

In yesterday’s post Mark McQuain asked the readers of this blog what they consider to be the most pressing bioethics issue in the context of a call for our president to establish a bioethics council. He referred to my recent post on reproductive ethics and the manufacturing of children. I think that is important. I also think that abortion including the aborting of children with developmental abnormalities such as Down syndrome, euthanasia, and the treatment of children with gender dysphoria are very important. However, my most pressing concern related to bioethics in our society is freedom of conscience.

It is important that we express clearly the value of human life and how that impacts how we understand the ethics of things such as reproductive technology, abortion and euthanasia, but we are living in a time in which many do not listen to reasoned arguments about what is right. Much of our society believes that what is right is determined by how they feel and they desire to be free of any limits on what they can do. They also believe, somewhat contradictorily, that they should be affirmed in being able to do what they desire by having society help them do it; even if that means that others need to do things that they believe to be wrong. Our society is losing the concept of any objective moral values. Without objective moral values it does not make sense for someone to refuse another person’s request for help in fulfilling their desires based on conscience, particularly conscience informed by an objective understanding of right and wrong. If there is no objective standard on which to refuse such a request the refusal must involve some sort of personal rejection of the one making the request.

Thus we have ACOG saying their members must affirm patients who desire an abortion. Canadian physicians may soon be required to affirm their patients’ desire for euthanasia. There is a push for physicians, psychologists and others to be required to affirm the desire for a confused child to be identified as having a gender that is in conflict with the child’s biological sex. As Cheyn Onarecker has discussed in his posts yesterday and last week, there are some prominent ethicists who give reasoned, although faulty, arguments against rights of consciences for physicians.

The elimination of rights of conscience threatens the ability of not only Christian physicians but all people of strong moral conviction in all professions to practice their professions without violating their consciences. If allowed to go unchecked the demand to affirm every request by every person in the name of pluralism and personal liberty will leave every profession in our society without those who are most conscientious. It will also lead to the demise of ethics as a disciple. If our society really believes that there are no objective moral truths and everyone should be free to pursue his or her desires and enlist others in that pursuit, then any statement that an action is wrong will not be seen as a particular understanding of what is right and wrong which can be civilly discussed, but as an unfounded personal attack on someone who desires to do that action. Thus there will be reason to shut down all ethical discussion and the discipline of ethics will be forbidden.

In Defense of a Physician’s Right to Conscientious Objection, Part 2

Guest post by Cheyn Onarecker, MD

Today, I am continuing my comments on the recent editorial against conscientious objections from the New England Journal of Medicine (subscription required). My previous objections to the elimination of protections for conscientious objections included: 1) the importance of maintaining the traditional balance that has always existed between the needs of the patient and the physician, and 2) the fact that medical societies make decisions on the acceptability of certain procedures that are influenced by society and do not represent the views of a large percentage of its members. I will now add a couple more reasons.

Third, it is impractical and unreasonable to demand that persons considering a career in medicine should be prepared to violate their moral convictions. When the Church Amendment was passed in 1973, allowing physicians to be exempt from performing abortions, there was no outcry from the AMA or any other medical society denouncing the law or declaring that rights of conscience were unethical. Since then, the number of laws and provisions to protect conscience rights have increased, not decreased. Philosopher Mark Wicclair explains that modern medicine, in general, has accepted the right of conscientious objection, and no young person entering medicine today believes that their moral and religious convictions are incompatible with a career in medicine. In fact, the AMA issued a directive to medical schools to excuse students from performing activities that violate their ethical beliefs. Not only that, but how would physicians be able to predict that someday their chosen specialty would develop a controversial treatment? Stahl and Emanuel assume that a medical student could choose radiology, but what does the future of radiology hold? Many physicians have stated that they would rather leave practice than to be forced to do procedures or make referrals against their conscience. With widespread physician shortages already affecting the care of our citizens, what sense does it make to eliminate large numbers of talented young people from a career in medicine because they want to practice medicine conscientiously?

Fourth, by rejecting physicians who practice medicine according to their conscience, we exclude the very professionals we need to prevent medicine from drifting from its ethical moorings. The history of medicine is full of ethical catastrophes, and Stahl and Emanuel cite eugenics and the classification of homosexuality as a disease as recent examples. But, according to the authors, medicine returns to its ethical path through a self-correcting process of “reflective equilibrium,” as if by some magical force, the profession spontaneously changes course and begins to right the wrongs that had been committed. But no magical force or automatic process stopped the forced sterilization of women in the early 20th century. Men and women, guided by their conscience, fought for decades to change the hearts and minds of citizens and the medical profession. Where would we be if they had passively complied with the accepted practice of the day? If we remove such men and women from our profession, who will be the agents of reform when medicine deviates from its proper direction in the future?

A recent Annals of Internal Medicine article about teaching medical ethics under Nazism concludes that the lack of “eternal values” in medical ethics allowed them to be coopted by the politics of the day. Those who expressed any conscientious objection to the prevailing thoughts were systematically removed from medical leadership, resulting in practices that are universally condemned today. Dr. Joe Gibes critiques this study in his April 21st article for the TIU Bioethics Blog. He appropriately concludes, “It is precisely because society, government, and politics are so fickle, that it is vitally important that the practitioners of this art cling tenaciously to the universal values stated so simply and starkly in the Hippocratic Oath: I will not kill, whether in the womb or out of it.”

Finally, since they suggest that healthcare professionals should ignore their conscience and follow the dictates of their professional organizations, Stahl and Emanuel appear to be defeating their own arguments. Following their logic, because most of the professional societies oppose their views and accept physician’s conscience rights, the authors should simply keep quiet. Their article, however, implies that they believe there are times when physicians should take a stand against the status quo. Even by their own standards, conscience must have more than just a limited role in medicine. To eliminate the right of conscience would be to jeopardize the ethical foundations of the profession. Instead, we ought to look for ways that we can accommodate those rights in order to provide excellent care to our patients.

In Defense of a Physician’s Right of Conscientious Objection

Guest post by Cheyn Onarecker, MD

In their recent “Sounding Board” piece in the New England Journal of Medicine (subscription required), Ronit Stahl, PhD, and Ezekiel Emanuel, MD, PhD, denounce the rights of physicians and other health care professionals to opt out of certain procedures because of a moral or religious belief. The interests and rights of the patient, they state, should always trump those of the clinician. The only role for conscientious objection, in their view, is a limited one, when the appropriateness of a treatment or procedure is being debated.

Once a professional society determines that a treatment is acceptable, the physician must comply or get out of medicine altogether. Stahl and Ezekiel lament that the American Medical Association (AMA) and other medical societies support conscience rights, but, I believe the arguments they advance to eliminate such rights are not convincing and would jeopardize the future of medicine.

First, although the well-being of patients is one of the primary goals of medicine, there has always been a balance between the needs of patients and physicians. Otherwise, physicians would work 24 hours a day, with no time off for family, friends, or other pursuits. Physicians would be expected to respond to all patient requests, day or night. The question is not whether physicians should put patients’ needs above their own, but where the line should be drawn between the needs of the patient and the physician. In emergencies, a patient’s needs triumph, but other situations are not always so clear. When it comes to requests for treatments that violate a physician’s deepest moral convictions, no physician should be forced to cross over the line.

Second, the decisions by medical societies regarding the appropriateness of certain treatments and procedures do not occur in the idealized manner described by the authors. Anyone who has sat in a hospital department meeting knows how decisions are often made. The person, or persons, with the loudest voices and the most influence can carry the day. I have experienced the wholesale politicking that occurs at national society meetings, where resolutions that have been defeated for years are suddenly adopted as organizational policy because, finally, enough delegates were cajoled into a “yes” vote. And to say, as Stahl and Emanuel do, that medical debates are not affected by cultural and political factors is to ignore history. Physician-assisted suicide (PAS) did not become a legal medical practice in Oregon because the AMA determined that it should be so. In fact, the AMA, the largest physician organization in the country, opposed the practice. No, PAS became legal, because the state legislature passed a law. Likewise, abortion became legal due to the decisions of nine judges.

Given that professional societies can be influenced by shifting social and political trends, we should accommodate the right of a physician to rely on her conscience to decide on controversial practices. For example, the fact that abortion-on-demand is legal does not erase the truth that half of the population and a large percentage of physicians do not support the practice. Physicians who object to elective abortions are considering the well-being of the baby as well as the mother. A 51 percent vote by the members of their professional society will not change their conviction that an abortion would take the life of an innocent human being without just cause. Female genital mutilation (circumcision) is accepted in some parts of the world. If such a practice were to become legal and accepted by some professional society in this country, would those who object to the procedure remain silent and comply? In the milieu of the diversity of moral perspectives in our culture, a physician must sometimes rely on her conscience as a guide to ethical medical practice. I have several more thoughts on this topic that I will continue tomorrow in my next post.