From IVF to human trafficking, and how liberal bioethics led the way (actually, it followed)

 

Ross Douthat of The New York Times wrote recently of The Failure of Liberal Bioethics to provide any ethical guidance in the area of reproductive technologies. He recounts how liberal bioethicists, for all their eloquence about monitoring and controlling new reproductive technologies, really just act as a rubber stamp for whatever anybody wants to do, finding reasons “to embrace each new technological leap while promising to resist the next one . . . You can always count on them to worry, often perceptively, about hypothetical evils, potential slips down the bioethical slope.  But they’re either ineffectual or accommodating once an evil actually arrives. Tomorrow, they always say — tomorrow, we’ll draw the line. But tomorrow never comes.”

This marked failure in line-drawing in years past is bearing grim fruit today. In the August 4th New England Journal of Medicine, George Annas wrote of Canadian legal efforts to regulate the international trade in reproductive medicine. In order to bypass local regulations and expenses, people buy sperm from one country, ova harvested from women in another country, and rent a woman to act as a gestational surrogate from a third country, to try to have a child. These are just the sort of practices against which “conservative” bioethicists, those concerned with human dignity, the meaning of procreation, and the commodification of children, have warned; and about which “liberal” bioethicists have opined, “Well, there’s a theoretical risk here, we’ll have to watch that —” and then watched as theory became practice and practice became madness. Annas writes of the fear of many that reproductive medicine is “becoming a branch of international trafficking in women and children.”

This fear is reality. Last winter the Wall Street Journal ran an article featuring PlanetHospital.com LLC, a California company that scours the globe to find the “components” for its “business line” of internationally trafficked reproductive materiel and technology. ”PlanetHospital’s most affordable package, the ‘India bundle,’ buys an egg donor, four embryo transfers into four separate surrogate mothers, room and board for the surrogate, and a car and driver for the parents-to-be when they travel to India to pick up the baby.” The international nature of this enterprise places it under the radar of any governmental regulation that might interfere with the “business line,” and there does not appear to be much internal ethical regulation on the part of the company itself; anything goes, even when an apparent pedophile wants to have a child. As chief executive of PlanetHospital Mr. Rupak says, “Our ethics are agnostic. How do you prevent a pedophile from having a baby? If they’re a pedophile then I will leave that to the U.S. government to decide, not me.”

If liberal bioethicists continue to have their way, the unthinkable practices of today will become the commonplaces of next week. Annas bears disquieting witness to this when he writes of ”acts that were once thought to be so universally condemned that prohibitions against them could be incorporated in an international treaty.  These prohibitions include the knowing creation of a human clone, the creation of an embryo from the cell of a human fetus or from another embryo, the maintenance of an embryo ex utero for more than 14 days after fertilization, the use of sex-selection techniques for a reason other than the diagnosis of a sex-linked disorder, the performance of germline genetic engineering, the use of nonhuman life forms with human gametes, the creation of chimeras for any purpose, and the creation of hybrids for reproduction.”

How many of these “acts that were once thought to be so universally condemned” are already standard procedure today? If liberal bioethics continues to have its way, which of today’s unthinkables will be the next California company’s “business line?”

 

(If you have time, read all three articles.  They are very disturbing. If you think that the work of CBHD is unimportant, you may just change your mind.)

The Patient-Consumer and His New Role

As some of you may know, I am not a caregiver. Due to this fact I try not to be too critical of the way caregivers act and perform their duties. This is not to say that at times I do not offer some suggestions based upon the historical practice of medicine and some theological-ethical considerations.

However, there is a somewhat recent truth about medicine that allows for harsher criticism. For, as much as it dismays me to say so, medical practice has become a consumer-driven vocation.

That’s right, I said it. I will give you a moment to take it in…

I know, I know, you are probably the exception to the rule.

I know it hurts.

I do not make this observation with malignant intent, but instead with the desire to be realistic about the profession as it is today.

Take a long hard look at what is going on in the medical profession…

From the last couple of weeks of my fellow bloggers’ blogs: making humans better/improving the human condition outside of need, fascinating new pharmaceuticals and medical procedures, and how medical technology has replaced the patient as the focus of medical practice. (I understand these are not proofs per se)

What we can see in this smattering of ideas is by and large what we are forced to confront as “bioethicists” of the day. Sure medicine is (was) about curing, but we are humans; so our (perhaps, darkest) desires have shaped the broadening applications of ‘helpful’ technologies. This, in part, has exploded the marketability of medical services and products.

The reality is we are no longer fighting to keep medicine from becoming consumer-driven—it is. And, it is most likely going to stay that way. However, this also means that consumers can redirect the marketplace of medicine.

Doctors do have a voice and power to fight it. But just like any product/service provider in the marketplace, they are, to a point, going to oblige the demands of the consumer. This is not necessarily seen in every transaction between doctor and patient (i.e. a bunion removal). It is seen, however, in the overall trends of the market itself.

And frankly, for too long we have solely concentrated on how doctors can try to take back the Hippocratic tradition. As consumers in the marketplace of medicine we have been given a powerful voice.

We ought to be informed about procedures, professionals and pharmaceuticals. We should feel free to call into question the guiding values of the professionals from whom we receive services.

I know it may seem paradoxical, but we as patient-consumers should try to preserve the founding principles of medicine by not reaching beyond the precipice of curing. We can choose with scrutiny according to the values of the Hippocratic tradition that once so proudly guided medicine.

 

 

To Tell the Truth

One of the foundations of medical ethics is the importance of truth-telling by physicians.  The relationship between a patient and physician depends on the patient being able to trust the physician which depends on truth-telling.  When I discuss this with students their expectations are for physicians to be fully and completely honest with their patients.

But what about patients being truthful with their doctors?  Recently Time online referred to an article in The Arizona Republic about patients lying to their doctors.  It talks about the ways that patients tend to be less than fully honest when they talk to their doctors, and how that can interfere with getting proper care.

It seems obvious that physicians should be truthful with their patients and patients should be truthful with their physicians, but we don’t always do that because it is hard.   It is hard to tell a patient something the he or she does not want to hear.  It is hard to tell your physician that you are not really exercising three times a week (or your dentist that you don’t floss every day).  We want to please other people and have them approve of us, and we don’t want to make them feel bad.

Sometimes, though, we need to do what is hard to do what is right.  1 Cor 13:6 reminds us that love “rejoices with the truth.”

What’s so bad about making humans better (Part 2)

In my previous blog, I raised the question of why it should be considered wrong to improve the human condition.  After all, we turn to technology to improve our health.  Why not expand technology to make humans better?  In my first response, I argued that by eliminating all human defects, we run the risk of dehumanization.  That is, we remove the characteristics that define us as humans i.e., our relational, volitional, spiritual, rational, moral, and creative capacities.  Transhumanism does not actually enhance, but rather cheapens the significance of humans by reducing human nature to mere information.

In addition, the rise of transhumans will inevitably leave some humans behind.  Political writer Francis Fukuyama believes that the separation between “Naturals” and the “Enhanced” will be so deep that it will make all other divisions based on religion or race seem insignificant in comparison.  Indeed, he thinks that it would result in a “full-scale class war” (Radical Evolution).  One could question whether there is any track record of long term civility in the history of humankind to indicate that we will avoid life-threatening conflict between radically divergent species.  As Bertrand Russell once observed, “Science has not given men more self-control, more kindliness, or more power of discounting their passions…Men’s collective passions are mainly for evil; far the strongest of them are hatred and rivalry directed toward other groups.”

My conclusion then is that, transhumanism is fueled by technological hubris.  It is a story with striking similarities to the account of the tower of Babel.

Then they said, “Come, let us build ourselves a city, with a tower that reaches to the heavens, so that we may make a name for ourselves and not be scattered over the face of the whole earth.” But the LORD came down to see the city and the tower that the men were building.  The LORD said, “If as one people speaking the same language they have begun to do this, then nothing they plan to do will be impossible for them.  Come, let us go down and confuse their language so they will not understand each other.”  So the LORD scattered them from there over all the earth, and they stopped building the city. That is why it was called Babel—because there the LORD confused the language of the whole world. From there the LORD scattered them over the face of the whole earth (Genesis 11: 3ff, NIV).

In both cases, we find 1) humans driven by a desire to accomplish a feat that would otherwise seem impossible i.e., build a tower that could reach heaven, build a machine into which a human could be downloaded to achieve immortality, and 2) make a name for themselves, to be able to say that human effort can realize a god-like task.  Brent Waters observes that, “The history of the world [is] not an account of creation being drawn mysteriously to a destiny assigned by its creator, but an unfolding tale of human potential and capability” (From Human to Posthuman).  But what precautions are taken into consideration with advancing technologies?  As scientist Martin Rees warns, “Humans should not create something new unless they are reasonably certain something awful will not result” (Radical Evolution).  Indeed, humans do not have a very good track record of taking care of themselves.  I am inclined to agree with Bill Joy that we are more likely to instigate the “Hell Scenario” where unimaginably horrific events begin to unfold.  Thankfully, the Christian worldview affirms the sovereign God who is not threatened by human technology, and who promises believers that there will come a day when a true and everlasting transformation will occur.

Going Viral on Anti-virus Treatment

A research group at MIT reported in PLoS One (see here for the MIT article) initial proof-of-concept experiments for an antiviral drug treatment that can combat viral infections as a robust, generally applicable fashion, much like antibiotics for bacterial infections. As of now, the current treatments for viral infections include:

1) Drugs designed to inhibit particular viral attachment to a specific target

2) Vaccines that are designed to combat a specific virus

3) “Interferons and other pro- or anti-inflammatories” – drugs that activate the cell’s system to respond to pathogens

All three of the current treatments have two major issues 1) they require a specific design for the particular virus and 2) they have unknown or adverse side effects.  First, the problem with requiring a specific design for every virus is that “specific design” means hours of research on pharmaceuticals that target whatever cell type or viral genome a particular virus attacks. The process is time-consuming and expensive and the end product is only good for one type of virus. As the MIT article points out:

“There are a handful of drugs that combat specific viruses, such as the protease inhibitors used to control HIV infection, but these are relatively few in number and susceptible to viral resistance. “ (MIT report).

Viruses undergo rapid mutation, so even after a treatment is developed, viruses may eventually develop resistance to it. While for some viruses (such as HIV) scientists have developed “cocktails” of 3 or more drugs that attack different factors of the virus to prevent resistance, this requires time and is still only efficacious against a particular virus, not viruses in general.

In order to target a large range of viruses with one drug or technique, one must target whatever viruses have in common. This particular group at MIT, developed a technique that targets cells with double-strand RNA (dsRNA), something only viruses produce. They based their model on the body’s own defense system. By targeting this type of RNA, their technique was able to kill infected cells, while leaving healthy cells alone, and important factor in decreasing the deleterious side effects often caused by antiviral drugs. This detection method is not sequence or virus specific, but looks for one of the fundamental products of any type of viral infection. Furthermore, not only is this detection system modeled after the body’s natural defenses against viral attack, but the research team made sure that once the cells were detected, they would then undergo apoptosis (cell death) another naturally occurring process in the body.

Preliminary tests show that this technique has been able to target and kill cells infected with various types of viruses including cold viruses and H1N1. The authors report that they still need to refine and improve their technique, but are ready to begin trials in mice.

As always, I think pharmaceuticals are an important aspect of medical ethics. Several reports have already come out touting this technique as being as revolutionary as penicillin was. While their initial reports do show promise, I am always wary about claims that [technique of the time] will be the next panacea. Adult stem cells, for example, have shown great promise for healing a number of cellular conditions, however, they are not the cure-all that some would claim. They can’t cure viral infections, for example. The research paper reports some interesting finding, but the researchers themselves report needing to refine their technique. Also, the paper seems to indicate that there is a window of time when this antiviral treatment can be done. This will need to be explored since viruses are known to spread rapidly.

Machines on the Maternity Ward

I’m going to dovetail on Joe’s post once again.  Today, my girlfriend and I visited the hospital to see her friend’s new baby boy.  The floor was quiet as we got off the elevator.  We must have looked confused because the custodian set his mop down for a second and said, “You have to use the phone.”  Sure enough, next to a set of large double-doors was a red phone.  We picked up the phone.  “Yes, we’d like to see so-and-so.  She is here with her new baby.”  The unseen operator responded with a buzz, and magically the big doors swung open.  The big doors were there for security reasons, and I suppose they work for less than the watchman or the receptionist.  After we surrendered our IDs in exchange for “Visitor” stickers, we found the hum that was the room of the mom and her new son.  Friends and family stirred around taking turns holding the bundle of joy.  There was mom watching on, sitting up in her hospital bed.  And there was the machine–tall, flickering, and looming over the bed.  You see, she was not just the mother here; she was the patient.  I was thankful for the armoire of dark wood in the corner that lent a little softness to the room with its tiny, soft inhabitant.  After a while, the nurse entered and began to rummage around the hospital bed.  Yes!  Hurrah!  She began to untether mom from the IV bag.  Mom said, “Sure is good to get all that stuff off of me.”  Yes, I thought, maybe now she can hold her baby.

 

Of Machines and Men (Part II)

 

I observed last week that machines are increasingly shaping the nature of medicine; rather than medicine using its machines, its machines are starting to “use” medicine, to shape and direct the nature of medicine and adapt medical practice to the nature and methods of the machine. In this process, human activity absorbs the ethos and rhythms of the machine. Machines are all about efficiency, standardization, precision, data, and automation. Is this not becoming characteristic of the practice of medicine?

In medicine, “Efficiency” appears to be the watchword and underlying criterion for more and more decisions. The term “industry,” which previously one never would have used in the same sentence as the word “medical,” has become an accurate representation. Interactions between “medical consumers” and “providers” are increasingly mediated through machines. Leaders in medicine strive for standardization, automation, the effacement of individual practice variations, and centralization. Specialization is ever-increasing, and specialists with more techniques and machines to offer are valued more highly (and reimbursed more handsomely) than generalists who are the masters of less technology. Health care workers have reached the point where they can not practice without their gadgets. Practice quality is measured only by what is quantifiable; data, information, seems to have become the primary distinguishing characteristic of medicine, over and above relationship. Medical ethics is being reduced to machine-like process; content has become almost irrelevant. Technology is used more and more in an attempt to eradicate all ambiguity, imprecision, and uncertainty. Technology is used more and more simply because the technology exists. Both physicians and patients feel the increasingly machine-like nature of medical practice, even if they can not express it as such: patients complain of the impersonalization, sterilization, and dehumanization of medicine, while doctors feel more and more like cogs in a machine.

Efficiency is the end-all and be-all of machine medicine;  eliminating inefficient means becomes part of the grand project. And who in our time quibbles with eliminating inefficiency? The problem is compounded when the efficiency value system is applied not just to medicine, but to the humans it was meant to serve, when those patients who are considered “less efficient” are eliminated as blithely as last year’s smartphone. It happens now in the unborn, with prenatal genetic diagnosis identifying those “less efficient” humans who are then prevented from being born; it happens in the older and disabled, with euthanasia and physician-assisted suicide removing those who are too sick or old to be of use to themselves or others. Where will it be applied next?

To remain a human profession, medicine must regain and retain its human ethos . . . which, is why ethics is so central to its practice. In a future post I will consider some ways to resist the usurping of the essence of medicine by the efficient principle of the machine.

 

Doing Drugs for Science

 

There is a place in Chicago where you can be paid to take mind-altering drugs.

In the Human Behavioral Pharmacology Laboratory at the University of Chicago, psychiatry professor Harriet de Wit studies various licit and illicit mind-altering drugs, from caffeine to Ecstasy, by testing their effects on human volunteers. The purpose of the research is to find out how different people react to different drugs, in order to answer the central question of drug abuse research: Why do some people become addicted to drugs when most people who try them do not?

Study subjects must be between the ages of 18 and 35 and have no history of drug abuse, except those volunteers participating in the studies of Ecstasy, who must already have tried the drug.  After the studies are completed, there is no long-term follow-up of volunteers.

The story in which I first read of these studies was on the front page of the August 7th Sunday Chicago Tribune. The studies are approved by two review boards and the national advisory council of the National Institute on Drug Abuse; yet, reading about the research, I felt a bit uneasy. I believe that research done on human subjects is supposed to have at least a potential benefit to the subjects under study. Will the knowledge gained in these studies really have enough of a potential benefit to the subjects to outweigh the risk? According to the story, “studies have shown that experiments like these do not make subjects more likely to use illicit drugs.” But that does not rule out the possibility that someone who takes part in these studies could thus become exposed and addicted to an illegal drug they might otherwise never have encountered. I vividly recall patients describing to me the stories of how they became addicts the first time they took a drug (cocaine and meth are the two I remember in particular), and I can easily imagine that happening in a study such as those described; in fact the story tells of one subject who was given methamphetamine and liked the feeling of the drug: “I felt extra happy . . . I was cheerful and peppy.”

Am I overly cautious?  Am I too obstructionist?  Is the knowledge gained from these studies worth the chance that even one person might, through participation in the study, become addicted to an illegal drug?  In other words, is this ethical human-subject research?

 

Euthanasia, mercy, and the Good Samaritan

Lately I’ve been discussing infant euthanasia with some of my online students.  They are impacted very strongly by the argument from mercy.  When they consider an infant who appears to have “hopeless and unbearable suffering” as referred to in the Groningen protocol used in the Netherlands they are convinced that nonvoluntary euthanasia should be allowed if not required.  Mercy includes a desire to relieve suffering and the argument for euthanasia says that suffering should be relieved even if that means killing the sufferer.

One of the clearest expressions of mercy in the Bible is Jesus’ parable of the Good Samaritan.  In answering a question about how to love your neighbor Jesus tells a story about a man who would be rejected by those who were listening.  He finds a man who is beaten and half dead and who has been abandoned by his countrymen.  If he were a dog or a horse it would have been appropriate to put him out of his misery, but instead the man cares for his wounds and takes him to where he can receive further care.  The man who cared for the other’s wounds is identified as one who showed mercy.

The mercy that Jesus described in the story and provided for others involved hands on care for the needs of those who were injured or ill.  It sometimes involved bringing people back to life, but it never involved ending those lives.  Paul Ramsey captured Jesus’ attitude well in his ethic of “(only) caring for the dying,” and those who followed in his footsteps expressed it as “always to care, never to kill” (see First Things, Feb 1992

When we can see the importance of affirming the inherent value of every human life and search for the way to care for those who are suffering including optimal palliative care without violating the inherent dignity of that person we can be like the Samaritan that Jesus identified as a loving neighbor.

What’s so bad about making humans better? (Part 1)

In the previous two blogs, I’ve made transhumanism my focal point.  I concluded that transhumanism correctly highlights human imperfections, but incorrectly assumes that the essence of human nature is information.

Still, it may be fitting to question why it should be considered necessarily wrong to improve the human condition.  It is a fair question to raise; after all, Christians should not naïvely presume that all human enhancements are inherently evil.  Moreover, Christians must admit that Scripture does not specifically address the issues of human enhancement or transhumanism.   Thus, even if altering human nature is against God’s intentions for humans, it may not be possible to make a conclusive case from Scripture against it.  Furthermore, even if one could present a biblical case against transhumanism, transhumanists generally do not accept Scripture as an authority.

I continue my critical response with what I believe to be some of the negative consequences of transhumanism. Transhumanism, the philosophy that drives it, and its actual fulfillment, will negatively impact humanity in at least two areas:  1) the dehumanization of humans, and 2) the unavoidable but dangerous distinction between the “Naturals” and the “Enhanced.

First, a strong case can be made that, by forfeiting the negative traits that make us human (in our current form), we lose the potential positive qualities that result from difficult life experiences.  In the book Radical Evolution by Joel Garreau, one chapter underscores the negative impact of transhumanistic assumptions.  Political writer Francis Fukuyama observes that, “Human nature exists, is a meaningful concept, and has provided a stable continuity to our experience as species.”  It is, “with religion, what defines our most basic values.”  But in the transhumanist world, we “no longer struggle, aspire, love, feel pain, make difficult moral choices, have families, or do any of the things that we traditionally associate with being human.”  Consequently, we “no longer have the characteristics that give us human dignity.”  He continues:

“Even something like the elimination of pain and suffering… There’s something about the experience of pain and longing and anxiety and all of these things that our therapeutic society is trying to get rid of.  It is somehow necessary to our self-understanding of what we are as human beings.  I mean, you can’t have courage without risk.  You can’t have real compassion or sympathy with the personal experience of pain.

Human nature provides us with a sense of morality as well as the ability to make moral, social and creative choices.  It allows humans to dialog with each other about issues pertaining to justice, autonomy, human rights, politics and, ironically, whether transhumanism is a good idea.  Brent Waters continues this sentiment by summarizing Leon Kass’ perspective, “It is in coming to terms with their finite limits, and the inherent pain and suffering entailed in those limits, that humans embody the nobility of spirit that is supremely expressed in procreation.”

British neuroscientist Susan Greenfield adds that, in the end, humans will lose their individuality and personal identity.  They will lose the will to achieve because achievement will be built into the technology.  Perhaps the worst facet of the transhumanist scenario is that, if the successful transfer to machines occurs, then humans won’t know that they are dehumanized, nor with they care to know it.

In next week’s blog, I will discuss a second potential downside to transhumanism – a new form of class war!