Stop those prying doctors!

 

Florida residents have their saviors in the Florida legislature to thank for shielding them from the insidious “prying into personal lives” that doctors have shamelessly been inflicting upon patients.

Apparently, doctors have been asking their patients questions about whether they own guns, and – prepare yourself for a shock – if the patient answers in the affirmative, some doctors have actually been counseling patients on how to store the guns safely and protect any other people in the home, particularly children, from accidental harm.

Fortunately, some attentive citizens were alerted to this disgusting practice and enlisted the NRA in helping them to get the Florida legislature to pass, and the Florida governor to sign on June 2nd, HB 155, which prohibits physicians from making written or oral inquiries regarding firearms ownership or recording such information in a patient’s chart (unless the doc believes “that this information is relevant to the patient’s medical care or safety, or the safety of others”).

It is a great relief to see that the physician-patient relationship — too long the purview of a suspiciously-dressed clique of highly-trained, dedicated professionals and their trusting patients, too long full of “prying into personal lives” as exemplified by questions like, “How do you feel?” “Does that hurt?”  “What do you use for contraception?” and “Did anybody in your family ever have cancer?” — is at last being exposed and regulated by those people we all trust way more than we do our doctors, the elected representatives in our legislatures.  My only regret is that some of the original provisions of the bill, such as the stipulation that a violation would amount to a third-degree felony punishable by up to five years in prison and a fine as high as $5 million, did not make it into the final legislation.

Encouraged by the NRA’s success, other bodies are stepping up to protect the unsuspecting public from some of the horrifying practices that routinely take place behind the closed doors of the consulting room.  The Tobacco Growers Coalition is promoting legislation to ban doctors from making inquiries about smoking, the GFFFA (Greasy Fried Fast Food Alliance) is working to make it illegal for doctors to counsel their patients about healthy diets, the NARL is drafting laws to ensure that doctors don’t counsel pregnant patients against abortion, and the Colombian drug cartels are looking for ways to prevent doctors from advising patients against using their special brand of products.

Sound too ridiculous to be true?  OK, I made that last paragraph up.  But read this.

Lest anyone misunderstand, this post is not about gun ownership, nor do I have anything against the NRA.  This post is about unwarranted encroachment upon the sanctity of the central economy of the medical profession, the physician-patient relationship;  and about what sort of Rubicon has been crossed when the paranoid intrusion and constraint represented by this bill is placed upon the good will and judgment of a doctor — and enshrined in the law of the land.

The Elusive Higgs Boson

Ahh, the infamous “God Particle.” Come on think about it for a second; you remember your physics teacher saying something about it between naps…

Just in case you forgot and this brief non-physicist explanation is not enough, Click Here.

The “God Particle” is an unproven hypothesis (until now maybe), which physicists hope will elucidate why certain particles have mass and even less weighty questions like: how did we come to be?

Researchers of Geneva (and Illinois)  have been diligently working with the Big Bang Machine, the multi-billion dollar 17 mile long Large Hadron Collider, that excellerates protons to nearly the speed of light in order to smash them together to reveal exotic particles. Their work has recently brought a glimpse of what may be the “God Particle,” evidence of such is still pending.

If this last remaining particle predicted by the standard model of physics is “proven,” some believe it may reveal something about “how God thought about putting the universe together.”

As exciting as the possibility of this new discovery may be to some, I think we would be remiss not to take  a moment to reflect upon the discoveries of the 20th century. After all, we know and have seen that every new technology, discovery, or scientific advancement comes with its own bundle of ethical problems. This can be seen in IVF just as clearly as the unveiling of subatomic particles.

So, what are some ethical concerns this new discovery could bring?

What great hope could it promise for our future? or, What great sorrow could it bring us?

 

Don’t get me wrong; I am not cynical about science, medicine, or technology. I, not unlike you, am just aware of the apparent problems that these discoveries or inventions bring.

You might be thinking: so what would you have then, luddite, no scientific improvement?

Probably not.

But, would I suggest that we consider each step a little more cautiously?

Absolutely! Every discovery has consequences: good and bad.

 

Thin language and the Scandal of Bioethics

As I continue to reflect on the recent CBHD conference one of the things that strikes me is the tension that was going on regarding the use of what Dennis Hollinger called thick and thin language in the communication of ethics by Christians.  As Christians we have a rich store of moral values that God has revealed to us in scripture and in the person of Jesus Christ.  We have access to that moral truth through the Holy Spirit who enables fallen but redeemed people to begin to comprehend these things from the mind of God.  Those who are not in Christ cannot begin to understand this foundation of our ethics.

That leaves us with a dilemma.  What should we do when we seek to communicate with those who do not have access to God’s resources?

We could strive to always communicate using the fullness of the scriptural and theological language that makes Christian ethics a rich source of moral truth.  That is faithful to what we believe and could be a witness of a different way in our largely secular world.  It would also be likely not to be understood by those outside of Christ and rejected without an attempt to comprehend it by many whose worldview has no place for the supernatural.

We could use the thin language of philosophical ethics and common morality to try to communicate what we believe about the moral issues of contemporary bioethics.  That would stand a chance of being understood by those with a different worldview and could have an impact on issues that we care about.  It can also be seen as an abandonment of the fullness of what we believe and have the potential of causing us to lose what is distinctive about Christian ethics in an attempt to be accepted at the table.

I would suggest that we could also use the thin language of common morality to try to bring those who do not accept Christ closer to him while we engage in the public dialog on bioethics.  When we enter the public discourse on bioethics all the participants are acknowledging that they consider moral values to be important.  They open themselves to the existence of those moral values that God has written on their hearts.  If we can help them see the existence of those moral values that have been intuitively understood across cultures and across time, they may then be able to make the step to understanding that we all fall short of those standards and are accountable to the one who made them.  That sets up the problem we all have that Jesus came to solve and the gospel can begin to make sense.  That was the process used by C. S. Lewis in explaining Christianity in Mere Christianity. I think we can use it today.

Going where no man should go

In a recent article titled “Extreme Science” (August, 2011), Wired magazine broaches a topic that few mainstream publications would be willing to touch.  What could be accomplished if scientists were prepared to set aside the “moral compass” that guides them (assuming there is one)?  Imagine the advances waiting to be made.  As Wired observes, in the real world (as opposed to the sci-fi world), “Most scientists will assure you that ethical rules never hinder good research – that there’s always a virtuous path to testing any important hypothesis.  But ask them in private… and they’ll confess that the dark side does have its appeal.”  http://www.wired.com/magazine/2011/07/ff_swr/

For example, scientists could separate sets of twins at birth in order to control and monitor their individual environments right from the start.  The gain from such an experiment is a possible solution to the nature vs. nurture dilemma.  Think about a twin study in which both individuals are eventually identified as gay, regardless of their distinct upbringing.  This could offer proof that homosexuality is all nature and not nurture.  In another example, Wired considers the possibility of “womb swapping,” i.e., switching “the embryos of obese women with those of thin women.”  Again, the experiment would determine whether environment or genetic factors determine an individual’s weight.  Then there is an experiment right out of a science fiction movie, one that cross-breeds a human with a chimpanzee.  Wired reports that the technique would be “frighteningly easy” and it would teach us much about human development.

But what actually prevents unethical research from happening?  It could be argued that these experiments are blatant violations of individual autonomy.  But the fact of the matter is that human autonomy is already disregarded with other procedures (e.g., human embryonic stem cell research, abortion, etc.).  In other words, what is the essential moral difference between destroying an early embryo in lieu of subjecting it to controlled research?  One may even maintain that the twins, separated at birth, are at least alive as opposed to embryos that are destroyed.

Then again, one could argue that the main difference is that twins will eventually come to understand their situation and realize that their autonomy has been violated.  On the other hand, destroyed embryos will never know their fate.  Fair enough.  But if morality is governed by utilitarian concerns, as it already is, it would seem that the value gained by subjecting embryos to questionable research outweighs their future concern for autonomy.  And if “awareness of one’s autonomy” is the key moral criterion, then research could be extended to any human lacking awareness (e.g., newborns, coma patients, etc.).

In short, humans have the rational capacity to consider all options to achieve an objective.  Humans have also demonstrated a natural tendency to push the moral envelope, to give priority to what can be done over what should be done.  Time will tell whether experiments which are now considered unethical will one day be the norm.

Final Reflections on “The Scandal”

 

This past week, Fox News reported on the circumstance of Yousef Nadarkhani, an Iranian pastor and leader in Iran’s growing evangelical movement whom Iran’s Supreme Court has determined may be executed  if he persists in refusing to renounce his Christian faith.

The news of Nadarkhani’s predicament served as a reminder to this reader of the serious stakes involved in identifying with Jesus Christ. Not all Christians are called to martyrdom – and my prayer is that Yousef would be released without further harm – but we are all called to assume the risk, and this because loyalty to God comes first and that loyalty entails fidelity to the gospel of Jesus Christ, which is  offensive to the unbelieving soul. Even as we endeavor to live our lives in a winsome way (1 Cor 10:32-33) – we ought not be surprised if ridicule, scorn, or even violence come our way as we proclaim the gospel message in both word and deed.

As I continue to reflect upon “The Scandal,” (see prior posts)  I think often about the question of content for a Christian bioethic. Some professing Christians argue largely on pragmatic grounds for the public casting of Christian bioethics in a “publicly accessible” language (i.e. purely philosophical argument). A more robust bioethic – one replete with theological warrant – has its place, the thought goes,  in discussions among those operating within a Christian worldview,  but not in the broader debate where Christians encounter nonbelievers who are skeptical, if not overtly hostile, to the Faith.

So, a number of questions arise: Can we truly be faithful to the Christian mission when confining theological argumentation to intramural bioethical discourse?  Can the “doing” of bioethics be rightly compartmentalized from the task of evangelization or the bearing of prophetic witness in a decadent culture?  Is it truly unethical, as some maintain, for physicians to evangelize their patients?

And finally, as I think about our brother Yousef Nadarkhani, I find myself asking, “What cost am I willing to endure in my identification with Christ in the public square?” Christian martyrdom, or the prospect thereof, forces a confrontation with truth both for the believer and the unbeliever. It demands from all a consideration of ultimate value  – specifically, is Jesus really worth dying for? To think in these terms may help us navigate the question of how best to formulate our “public” bioethics.

Your thoughts?

Black Americans and Healthcare

The USA Today recently reported on the difficulties faced by African-Americans seeking healthcare in Alabama.  Death rates are higher for most categories of illness in black communities.  Oftentimes, physicians are unfamiliar with the obstacles encountered by residents in a particular neighborhood, such as the lack of fresh, healthy food in the grocery stores.  USA Today touts a new federal Health and Human Services program as a first step in identifying health disparities.  Churches provide support groups that assist in educating people about their health.  However, there is little time or money being spent by the Christian community to build clinics in communities such as this one in Alabama.  An overall infrastructure for providing charitable ministries is missing.

In Texas, it is common for people to say that if a person wants to have good healthcare they need to pull themselves up by their bootstraps.  An African-American friend of mine at Trinity once told me in response, “The problem is, some people don’t have any straps.”

Fertility and Cancer

Bioethics is about dealing with the difficult topics, so here is one that I find particularly difficult. The more I learn about the infertility industry, the more opposed I am to IVF and many of the variants of in vitro procedures. The United States has very few regulations on this billion dollar industry, and the risks to mother and child seem to be underreported (See the web site for the documentary, Eggsploitation). Furthermore, I am skeptical of companies that make a substantial profit off of something that is so emotionally laden. Oftentimes, these companies are not up-front with the success rates of IVF, so an emotionally distraught couple is willing to pay thousands of a dollars for a procedure that has a success rate of 30-40% . One couple that I talked to told me that there are bioethical decisions at every step of the process and couples walk in ill-prepared to make these decisions. Many couples are so upset that they may not be in a position to think through these decisions. Personally, I am particularly wary of cryogenic freezing of embryos. There are a number of ethical issues related to this one particular procedure, such as what to do with left over embryos, or how does freezing affect the health of the embryos, considering how very delicate they are.

In general, however, I am also against dismissing certain medical procedures just because they may be used for unethical purposes. For example, I cannot categorically dismiss a DNC procedure even though this is used for aborting a pregnancy. DNC is also used when a miscarriage occurs, and in that sense, it is a much more humane procedure for the death of a baby in utero than the alternative. I also cannot categorically dismiss cosmetic procedures even though some people undergo them for trivial purposes because there are many cases where cosmetic procedures have helped restore a patient’s physical features and facial mobility after accidents or burns.

So, when I came across this article from ABC news about a young woman in her twenties who wanted to freeze her eggs (not embryos) because chemotherapy can cause early menopause in women, I am not sure if this situation can be evaluated from the same ethical categories as a typical IVF case. The young woman wanted to preserve her fertility so she had several of her eggs frozen. She had to take drugs that cause hyper-ovulation, a risky procedure in and of itself, and will likely have to conceive through IVF, although there may be other options available, such as inserting the unfertilized egg into her fallopian tubes.

A news story is one thing. About a year ago I had given a talk on faith and science. After the talk, I met a young woman who was in the audience. She had just recently completed chemo therapy for breast cancer, and was finally trying to put her life back together. She was young, probably not yet thirty and her mom was with her. She told me that she and her husband decided to have some embryos frozen until she was cancer free and was ready to have children. They had to quickly make this decision because, in her case, it was likely that the chemo would affect her fertility. To make the already cloudy ethical waters even murkier, she refers to the embryos as her children. They had apparently only fertilized (or only saved, I am not sure) 2 or 3 embryos, as many as she and her husband planned on having. She referred to them has her children and sees them as such; not something to be discarded or stored indefinitely.

Both of these young women give me pause. Ethical problems abound in reproductive technology. But these women, particularly the second girl that I talked to, do not view these children as commodities. And the technology may very well help them to be able to have children even if cancer treatment might take that opportunity away. Usually I hold a firm stance against IVF, but is this a case where reproductive technologies are less morally tenuous?

On a final note, the ABC article mentions an experimental drug called triptorelin that women can take concurrently with chemo that decreases the chances of infertility (or early onset of menopause) in women. Hormonal drugs always come with risks, however this seems like an ethically robust alternative to an in vitro procedure. Furthermore, this drug is cheaper than freezing eggs or embryos, and thus far seems to be safer than the hyper-ovulation drugs. Also, because tripotorelin can be taken during chemo, chemotherapy does not need to be delayed as it would with freezing procedures.

The Tragedy of Bioethics

At last week’s CBHD conference, a few of us were treated to a unique “Drinking-from-a-firehose” experience.  Jerome Wernow gave a talk with the eyesplitting title, “Bioethics:  Facing a Philosophical Theology of Tragedy and Mystery.”  Intrigued at the title in the conference brochure, but having no idea at all what it might refer to, I slid into a seat in the classroom where Dr. Wernow was to speak, prepared to be befuddled.  Instead, in the space of about about twenty minutes, those of us in the room were given an alluring glimpse into a poignantly beautiful picture for doing bioethics that alters what I see when I look at a patient.

I will attempt to present gleanings from the rich feast that was Dr. Wernow’s talk.  The early 20th Century Russian philosopher Nicloas Berdyaev wrote,  “There can be no moral life without freedom in evil, and this renders moral life a tragedy and makes ethics a philosophy of tragedy.”  As anybody who has witnessed the anguish of those who seek an ethics consult can attest, as anybody haunted by the dark questions our modern technology raises would agree, in bioethics all decisions are fraught with tragedy;  ethics consultants are actors in one-act medical dramas that are tragedies.  And tragedy is neither lessened nor assuaged when good and evil alone are used in bioethics’ calculus.  Our knowledge of good and evil is damaged, the product of a lie (“your eyes shall be opened, and ye shall be as gods, knowing good and evil“); it was in the very act of grasping for the tree of that knowledge that we were banished from the tree of life.  When we approach people whose stories have taken a catastrophic turn and we wield only the calculus of good and evil, our bioethics is left lifeless, empty, and tragic.  According to Wernow, to address tragedy we must turn to mystery, to “Mystery-revealed:” Christ, in whom is Life.  The question we ask as Christians doing bioethics is not just, “What is good?” but “How do I bring eternal life into this tragedy?  How do I bring the mystery of Life into the abyss?”

There was an amazed silence in the little classroom when Dr. Wernow finished.  Unfortunately, that is all I can leave the reader with.  I am not even sure that in my pathetic summary I presented Dr. Wernow’s vision remotely accurately;  his ideas poured out quickly and passionately, I could take only skeleton notes, and he has not as yet published an article or book that sets out the implications of the “Philosophical Theology of Tragedy and Mystery.”  But I sure love his vision of bioethics-as-drama instead of as sterile philosophical specimen;  and I can embrace the quest to bring the Mystery of Life into tragedy as a robustly and profoundly Christian way to engage and immerse myself in the tragedies of a fallen world.

 

Faithful presence

The CBHD conference last week was one of the best since I began attending in 2007.  One of the things that has stuck with me and that I am continuing to think about is Dennis Hollinger’s thoughts about living in the world in faithful presence, an idea he attributed to James Davison Hunter and his recent book, To Change the World. Hollinger said that the foundation of Christian bioethics is our Christian worldview which many in our society do not share and will not accept.  When we look at how we can try to translate the bioethical good that we are able to understand from our Christian worldview into a world that does not accept that starting point he suggested living in the world in faithful presence.

He indicated that there would be several characteristics of that approach.  We would focus on honoring God and loving our neighbor.  We would have modest expectations of our impact on our culture consistent with the Biblical metaphors of salt, light and leaven.  We would need to be bilingual, speaking in a thick fuller language to those who will accept God’s truth and a thin less complete language to those who will not.

I have been thinking about what it means to live in faithful presence in relation to bioethics in our society.  For me it includes caring for my patients compassionately and trying to be better at preparing them for the difficult places in life.  It includes helping my online bioethics students understand what a Christian worldview is and how it applies to the issues they will face in life.  It includes helping students on the Taylor campus see how their faith and how they live fit together.

What does it mean for you?

To know one’s fate or not to know?

In the Greek tragedy Prometheus Bound (attributed to Aeschylus), the priestess “Io” pleads to Prometheus, “Oh hide not from me what I have to suffer!”  Prometheus responds, “it is better for thee not to know…seek not thou to know thine own fate.”  A few hundred years later Cicero opined, “Moreover, often it’s not even advantageous to know what’s going to happen; for it’s wretched for a man to be tortured when he’s powerless to do anything about it, and to lack even the last consolation of hope, which is available to all.”

These ancient words of wisdom should be heeded by neuroscientists who venture to diagnose Alzheimer’s disease years before more severe symptoms of the disease begin to appear.  They refer to this newly discovered stage of Alzheimer’s as “preclinical Alzheimer’s disease.”  Indeed, it seems reasonable to think that Alzheimer’s is not something that occurs suddenly in old age, but over an extended period of time before the advent of critical memory loss.  And if this is the case, then it stands to reason that scientists may acquire the ability to detect it in its preclinical stage.

I have two concerns:

1)  How accurate is the diagnosis?  According to Kenneth Covinsky (who holds the Edmund G. Brown Sr. Professorship in Geriatrics in the University of California, San Francisco, Department of Medicine), “The guideline for preclinical Alzheimer’s disease is emphatic that the state of the science is not good enough to diagnose this stage in clinical practice.”  In other words, scientists currently do not have the capacity to truly diagnose Alzheimer’s at a preclinical stage.  But Covinsky warns that the essential problem with early diagnosis is that it “labels people who have completely normal cognitive function as having an illness. A key question is whether using this label will make patients better off.”  Some additional problems include evidence that individuals with “preclinical Alzheimer’s disease” may not actually contract the disease.  According to Covinsky, “many, if not most, people with these biomarkers will never get Alzheimer’s disease. For example, autopsy finding suggestive of Alzheimer’s disease are commonly found in people who never had symptoms.”  Furthermore, because “the link between the biological markers of the disease process and the clinical expression of the disease is highly variable,” Covinsky believes that “it is unlikely that we will ever be able to tell the vast majority of cognitively normal patients for sure whether they will develop Alzheimer’s disease.”  (The Hastings Center Report, Bioethics Forum, July 15, 2011).

2)  My second concern is with the potential moral dilemmas that emerge from the diagnosis of a pre-symptomatic illness.  Suppose you are told at a very early age that you are at a high risk for Alzheimer’s disease?  The question is, do you keep that information to yourself, or do you divulge it to others?  Are you morally obligated to inform a future spouse or employer of your “preclinical disease?”  So, even if it becomes possible to determine that an individual has “preclinical Alzheimer’s disease,” is it really a good idea to know this information?  Perhaps it is, if treatment is available.  Until then, we should follow the advice of Prometheus and Cicero and choose not to know.
Read more: http://www.thehastingscenter.org/Bioethicsforum/Post.aspx?id=5454&blogid=140&utm_source=constantcontact&utm_medium=email&utm_campaign=bioethicsforum20110718#ixzz1SYxUAK7p