Death and Dying in the Land of Paradise (part 2)

Two weeks ago I wrote about the case of Robert and Jeri Orfali.  While they were living in Hawaii, Jeri developed ovarian cancer and died an excruciating death.  After the experience, Robert Orfali became a staunch advocate of physician-assisted suicide.  Needless to say, it’s difficult to imagine the emotional anguish that Robert must have felt and, to an extent, one can empathize with his desire to see his wife experience death with dignity.  In my blog, I shared that I can understand why a person who does not acknowledge God’s sovereignty over life and death would think that PAS should be permitted.

This week (and 2 subsequent weeks) I would like to share a few thoughts about health, disease, “playing God” and death.  As a disclaimer, I should mention that I seek to understand these matters from a Christian worldview. Thus, I am compelled to respond from that perspective.

First, what can we determine from Scripture about the avoidance of disease and the pursuit of health?  In the Old and New Testaments, Scripture clearly teaches that disease is a common but undesirable feature of humanity.  In addition, even a cursory reading of Scripture will reveal that the pursuit of good health is a desirable and worthy objective.  We see, for example, that the Lord commanded Moses to bring those with infectious diseases to the priests for care until declared clean.[1]  Then again, disease was sometimes a punishment for wrongdoing.  For instance, Elijah warned Jehoram that, because of his sin, God would punish him with, “a lingering disease of the bowels, until the disease causes your bowels to come out.’[2]

In the New Testament, we read that Jesus “went throughout Galilee…healing every disease and sickness among the people.”[3] And in Acts, Peter preached that “Jesus of Nazareth… went around doing good and healing all who were under the power of the devil, because God was with him.”[4]  The healing ministry continued in the early church where Luke reports that “people brought the sick into the streets and laid them on beds and mats so that at least Peter’s shadow might fall on some of them as he passed by.  Crowds gathered also from the towns around Jerusalem, bringing their sick and those tormented by evil spirits, and all of them were healed.”[5]  Paul also healed Publius’ father who was sick in bed, suffering from fever and dysentery.”  Paul “went in to see him and, after prayer, placed his hands on him and healed him.  When this had happened, the rest of the sick on the island came and were cured.”[6]  Earlier in Paul’s ministry he argues that some of the believers in Corinth were sick and some died because of sin and God’s discipline.  “That is why many among you are weak and sick, and a number of you have fallen asleep… when we are judged by the Lord, we are being disciplined so that we will not be condemned with the world.”[7]

These passages do not in any way suggest that believers are entitled to health.  As a matter of fact, other passages indicate that healing did not always occur; individuals did become sick and eventually die, after all.  And Christians believe that death is the eventual consequence of sin.   As Nigel Cameron so deftly describes it:

“The sin/death causality runs through the biblical-theological understanding of the nature of reality, and offers one of the foundation-stones of the Judeo-Christian worldview… [it] lies at the heart of Christian understanding of what it means to be human… Sickness, the shadow of death and its foretaste – indeed every sickness – brings with it evidence of our final mortality.”[8]

On the other hand, Cameron continues:

“as we seek to understand the predicament of our mortality, we find that our ground for hope lies in the radically unnatural character of death.  If the cause of death is not natural, if it is both moral and supernatural, if it is sin and the divine judgment upon the sin, then we also believe in a final great reversal in which, after weeping has lasted for a night, joy comes in the morning.”[9]

In any case, even if it is true that disease and death are part of fallen humanity, Scripture concurs that death is an enemy and good health is a noble goal.  Does this give humans the right to play God in these matters?  I will attempt to answer this question in next week’s blog.


[1] Leviticus 13.

[2] 2 Chronicles 21:12-15.  See also Psalm 106: 13-15.

[3] Matthew 4:23.

[4] Acts 10:38.

[5] Acts 5:15-16.

[6] Acts 28: 8-9.

[7] 1 Cor. 11: 30-32.

[8] John Kilner, Robert Orr, and Judith Shelly, The Changing Face of Healthcare, (Grand Rapids, Michigan, William B. Eerdmans Publishing Company, 1998)  41.

[9] Ibid,  41.

Technology, Life and Death

Why do we push for technological progress?  Whether it is stem cell research or genetic engineering or nanotechnology or enhancement drugs, people seem to be looking for the same general things:

  • Extending life
  • Finding cures for diseases (or eradicating disease all together)
  • Decrease suffering
  • Maintaining cognitive abilities through old age (or enhancing cognitive abilities)
  • Maintaining good health through old age (or enhancing physical abilities)
  • Overcoming some biological needs or limits

Consider the transhumanists. Transhumanists are often viewed as being on the fringes of science with a religious take on science and technology. However, I find their work interesting to read because I believe they are much more honest about their views of technology and medicine than many of us are. The transhumanist vision, as articulated by Nick Bostrom (See here for a 2003 article by Nick Bostrom on transhumanism)”

This vision, in broad strokes, is to create the opportunity to live much longer and healthier lives, to enhance our memory and other intellectual faculties, to refine our emotional experiences and increase our subjective sense of well-being, and generally to achieve a greater degree of control over our own lives.

In reality, most of us would sympathize with the desires of the transhumanists. Who wouldn’t want to end disease and suffering? Who wouldn’t want to enjoy a healthy body into old age? Who wouldn’t want to undo the effects of the fall? Not everyone would want everything that the transhumanists desire (e.g. cryogenic freezing), but we can certainly sympathize with those desires.

 

We live in a time that enjoys the fruits of the Scientific Revolution. We have seen remarkable advancements in medicine, pharmaceuticals, genetics, and technology over a very short period of time. The structure of DNA was only discovered in 1953. Now there are entire disciplines devoted to genetics or biochemistry. Medicine and technology provides hope for the weak, the infirmed and for those of us who will be weak or infirmed one day. But does it provide ultimate hope?

 

Despite all of the advances in science and medicine, we still do not have a hold on cancer. Many cancers are curable that were once not. We know how to screen for many cancers, but the mechanisms and causes of cancer in many cases remains elusive. We still do not have a cure for degenerative diseases, such as Alzheimer’s or Parkinson’s. We have drugs that can slow the progress, but nothing that will cure it. We also don’t have a cure for the oldest disease, death. Medicine and technology may hold off death for a while, but we have yet to conquer it.

 

And then again, maybe death has been conquered after all. Much of our life is spent concentrating on the physical, but it is at death that we must come face-to-face with the immaterial as well. The Bible provides a link with the physical and immaterial. Consider the promises of the resurrected body. All of the desires listed above are promised in the resurrection. At the resurrection our body will be transformed to be a body like Christ’s (Phil 3:20, 21). The body will not be riddled with disease, and it will not die. The resurrected body will not succumb to aging and it will not be limited by biological needs. It will be strong and healthy (1 Corinthians 15:35-58). The resurrection promises the very things that many people desire in medicine and technology.

 

In many ways, I sympathize and agree with desires of the transhumanists, but I do not agree with where they place their hope. I enjoy many of the benefits of medicine and technology, but I do not believe that they will ultimately save me.

 

Death is swallowed up in victory. O death, where is your victory? O death, where is your sting?

The Ideas of the 1%

The Occupy Wall Street protests in New York, Oakland, Atlanta, Chicago, and elsewhere have made headlines the last several weeks.  I don’t really know if only 1% of the populace controls the majority of wealth in America.  But the “1% Hypothesis” makes you think about the influencers in the field of bioethics.  The number of Christian bioethicists influencing American bioethics probably is greater than 1% but it is still small.  When considering bioethical views in the general populace on subjects like abortion, euthanasia, and stem cell research, one might make the case that secular bioethics leadership as exemplified by the ASBH, Penn, Stanford, Case Western and others may be a minority view in the U.S. as a whole.   However, whether a minority view or not, these positions drive the practices of American medicine.  For instance, there is no doubt that euthanasia is gaining momentum in the U.S.  This is reflected in the assisted-suicide practices in places like Oregon, Washington, and Montana and the fact that the idea has become commonplace on medical school campuses.  But what are the actual numbers, do you think?  Is 1% calling the shots?

A small plea for more humanities in medical education

In 1910 a professional educator named Abraham Flexner published Carnegie Foundation Bulletin Number Four, also called the Flexner Report. Flexner visited all 155 medical schools in the United States and wrote a scathing report on the general condition of medical education in this country. Based on his findings, he made several recommendations for medical education reform, which for the most part were adopted by the medical schools (at least the ones that were not closed as a result of the report!). Part of the effect of the report was to ground and immerse medical training in basic sciences and scientific research.

A perhaps unintended consequence of the reforms the report sparked is that some medical personnel and researchers are well-versed in science, with data and empirical observation and precise methods, but lack acquaintance with the humanities. This has great implications for ethics. Data is important; all good ethics begins with good data. But scientific inquiry can only tell us what is, what can be done. It can say nothing directly about what ought to be done; that is, at least partly, the job of ethics. To get any deeper than very superficial ethical skimming requires engagement with the humanities, with the best thought and writing and wisdom and beauty of centuries of philosophy, theology, literature, social studies, and the arts.

The overweening optimism, bordering on hubris, exemplified in some research agendas such as genetic manipulation, cloning, or transhumanism might be tempered by conversation with the great thoughts and acts and perspectives of the past. The infatuation, bordering on worship, of the new and technological that imbues medicine and medical research today might be softened by realizing that it is not only the new and shiny that has value, but the old and well-worn also.

Would embedding scientific medical education in the humanities make the difference I hope it would? It is hard to say, but as long ago as 1926 Hugh Cabot, dean of the University of Michigan Medical School, wrote that “I am not prepared to admit at the present time that in the equipment of the practitioner a knowledge of science is of more real value than a knowledge of the way in which mankind has behaved in the past and how he is on the whole behaving at the present time. The problems of medicine, on the whole, are quite as likely to require sound judgment based upon a knowledge of history, sociology, philosophy and psychology as on the facts of science.”

The Price of Knowledge

Is it ever good to not know? Is all information good information? These questions, I would contend, are at the heart of some of the testing options during pregnancy. Now before I stick my foot in my mouth, I am not referring to any medically necessary tests or procedures for pregnancies. These offer options for therapeutic solutions.

What I am referring to are tests that are in an effort to uncover “birth defects”, such as Down syndrome and Cystic Fibrosis. These two happen to be the most contentious of diagnoses because knowing your developing child has either of them offers no therapeutic solution(s). (I say “therapeutic solutions” because abortions are rarely that and are definitely not in the case of either of these diagnoses).

Opting to receive this particular kind of information during pregnancy does not offer much resolve. There are only two answers that it offers. One is somewhat reasonable and the other is not.

The first answer is so that parents may prepare themselves. This foreknowledge gives parents an opportunity to say: “brace yourself”, but it offers no power or control over the things to come. (I would interject that having knowledge about temporal things we cannot change is often more enfeebling than it is empowering).

The second is to take the life of the child. This “solution” is the real concern. Parents are offered information/diagnoses that leave some feeling as if their only choice is to end the life of a person of potential. This is a travesty that neglects the inherent value of this person, which is abandoned in the act of placing value upon an external instead of the value given by God.

 

Science and a Christian worldview

Christian bioethics continuously lives at the interface of biotechnology and Christian moral values. Recently some students asked me to talk with them about whether I saw any conflicts between science and a Christian worldview. Their question took me back to the first CBHD bioethics conference that I attended in 2007 and Alvin Plantinga’s talk about that issue. He expressed things that I had understood, but had never heard expressed as well as he expressed them.
Plantinga made it clear that the conflict was not a conflict between Christian thought and science, but a conflict between the philosophy of naturalism and Christianity. He pointed out that many people assume that science, which is a method of acquiring knowledge about the physical world, was identical with philosophical naturalism which says that all that exists and all that we can know is what we can know through the empirical methods of science. However, understanding that science is a proper way to learn about the physical universe does not imply that naturalism is true, and science does not depend on supposing naturalism. In fact Plantinga showed that naturalism forms a very poor foundation for science, because the unguided evolution that must be assumed by the naturalist as the process by which human cognitive processes were formed does not give us reason to believe that those cognitive processes would be reliable sources for truth. (I always knew there was some reason why I liked epistemology.)
It is actually a Christian worldview that provides the foundation that science needs to function. We believe that God has created the universe so that it is rationally understandable and has given human beings the ability to accurately perceive the universe and cognitive faculties that are designed to comprehend truth. Those are the presuppositions needed to expect science to be a valid method for discovering the nature of our universe.
The problem is not that there is a conflict between science and a Christian world view. The problem is why someone without a Christian worldview would think that science is a reliable source of truth.

Ethics in the ER

My recent experience on call in the ER the other night prompts me to offer the following scenario:

The patient is a 40-year-old, mildly mentally retarded woman accompanied by an employee from the group home where she lives.  You decide to conduct the interviews separately.

The patient claims to be pushed and choked by the group home staff.  It is somewhat difficult to understand her speech presumably due to complications of Down syndrome, but her nodding and response to your questions seem to indicate she comprehends the conversation fully.

The group home staff member claims the resident throws tantrums, yells loudly, and for the most part makes life difficult for others.  She claims she never laid a hand on anyone.

What do you do?

The ethics of PSA testing

 

The humble little PSA test has become a hot-button ethical issue.

The PSA (prostate-specific antigen) test is a blood test that can detect prostate cancer at an earlier stage than can physical exam. It is not a perfect test; it misses about 25% of cancers. But it is the best thing we have for detecting prostate cancer early.

The United States Preventive Services Task Force (USPSTF) reviews all of the available evidence regarding screening tests for various conditions, and makes recommendations based on the scientific evidence. Earlier this month, the USPSTF posted a draft of its update to its 2008 prostate cancer screening guidelines. The earlier guidelines had recommended that men over 75 not be screened with a PSA test, and said that there wasn’t enough evidence to make a recommendation one way or the other for younger men. The proposed new guidelines, based on more recent studies, go further, giving screening a “D” recommendation, which means that there is moderate or high certainty that the service has no net benefit, or that the harms outweigh the benefits, and the task force discourages use of the service.

But how can a PSA cause harm? It’s just a poke in the arm, right?

It is not the test itself that causes harm, but what we do with it. 90% of men with PSA-detected prostate cancer undergo radiation and/or surgical treatments that have considerable risks and side effects. The chair of the USPSTF said that for every 1,000 men treated for prostate cancer, five die of perioperative complications; 10-70 suffer significant complications but survive; and 200-300 suffer long-term problems, including urinary incontinence, impotence or both.

These numbers might be acceptable if there were evidence that treating early prostate cancer did some good. But, counterintuitive as it may seem, studies have shown little if any positive benefit from treating prostate cancer early. When men diagnosed and treated by PSA screening are compared with those who are not treated, there is virtually no reduction in prostate cancer mortality at 10 years.

J. A. Muir Gray wrote, “All screening programmes do harm; some do good as well.”

For a profession that takes seriously Primum non nocere, “FIrst, do no harm,” it seems, with what we know at the present time, that this particular screening test may contravene our first ethical principle.

The Help and what it means to be human

I am currently reading The Help by Kathryn Stockett. I saw the movie first and as I read the book it really is true the book is better, even though the movie is very well done. For those who haven’t done either one, the story is about a young white woman in Jackson, Mississippi who decides to write a book that tells the stories of African American maids working for white families in Jackson in the early 1960s. But the book, like her book, is mostly about those women and the truth of what their lives were like.

As I experience their lives in the midst of the novel I have been thinking about the ethical issues that were going on during the turbulent times of the civil rights movement in the sixties. The major issues revolve around what it means to be human and how one human being should treat another. That resonates with what is at the heart of many of the issues we face in bioethics today.

Aibilene is the first of the maids to agree to tell her story. Interestingly she is a woman with a strong Christian faith who writes out her prayers to God and sees him answer as she expresses her concern mostly for others and occasionally for herself. She models virtues of love and compassion while hurting from the injustice of life in a world where she is not seen as a person of full moral value. She is not perfect, but her virtues and endurance under hardship demonstrate a humanity that touches me. It is amazing that as a society we could have told her she was not fully human.

How many are being told today that they are not fully human by the things our society chooses to do?

Death and Dying in the Land of Paradise

My father just turned 85.  He resides with my mother, who is suffering from Alzheimer’s disease, in an assisted care facility.  As I witness my father’s health gradually deteriorate, I wonder what it must be like to know that death is likely close-at-hand.  He is currently unable to accomplish tasks that I take for granted, such as bending over to pull up his pants, or making it to the bathroom in time.  Yet, even in his current state, it could be much worse.

A recent (October 17) ABC news report presents the story of Jeri Orfali, a promising software executive who, at 56, developed ovarian cancer.  Jeri and her husband of 30 years were living in Hawaii at the time of her death.  The report describes her final days of bearing “excruciating pain that was not helped by palliative care.”  According to her husband, “In the end I could see tumors coming out of her legs and in her neck,” he said. “Her legs were swollen and her stomach was so bloated, the cancer almost burst out of her. She couldn’t get her next breath.”[1]

As a result of the experience, Robert Orfali (the husband) would like Hawaii to legalize physician-assisted suicide.  In fact, apparently it was “legal” in Hawaii as far back as 1909 based on the following stipulation for PAS:

[W]hen a duly licensed physician or osteopathic physician pronounces a person affected with any disease hopeless and beyond recovery and gives a written certificate to that effect to the person affected or the person’s attendant, nothing herein shall forbid any person from giving or furnishing any remedial agent or measure when so requested by or on behalf of the affected person.”

As a result, advocates for PAS believe that it is now time to establish a legalized ‘death with dignity.’  Of course, the movement to support PAS has its critics.  The Catholic Church and other right-to-life groups fear the potential consequences of PAS and call for Hawaiians to resist PAS’s legalization.  Indeed, previous attempts to legalize PAS in Hawaii were overturned (by a narrow margin) through opposition groups.  Thus, there is a significant divide that pits those who fear the negative results of PAS against those who view end-of-life care as insufficient.

Frankly, I struggle with this.  As a Christian, I have strong convictions against taking matters into our own hands; PAS, I believe, is wrong from a biblical/theological standpoint.  Yet we live in a secular society, one that does not necessarily share my beliefs.  I would oppose the legalization of PAS in America, but I base my opposition on the view that God is sovereign over life and death.  Honestly, I can understand why a person without theistic principles would think that PAS should be permitted.

In next week’s blog, I will present some of my theological conclusions about death and dying.  In the meantime, what do you think are some of the strongest arguments against PAS outside of Scripture?


[1] Susan Donaldson James, October 17, 2011.  http://abcnews.go.com/Health/retired-hawaiian-doctors-test-102-year-physicians-assisted/story?id=14739855&singlePage=true