The Old Guard

In an effort to disconnect from the craziness of life, I recently watched “The Old Guard,” a popular 2020 Netflix movie.  [Note:  spoiler alerts ahead.]  It tells the story of four “immortals,” led by Andromache of Scythia (also known as “Andy,” portrayed by Charlize Theron), and the ups and downs of their existence.  

As we are introduced to each of the immortals, we find that they were born in different centuries and have been alive for a very long time.  The bulk of their time seems to be participating in battles that have taken place throughout history  (e.g., The Crusades, the Napoleonic era, etc.).  It’s not clear from the movie that they were always immortal, but each one finds out quickly after sustaining a deadly wound and suddenly come back to life.  A fifth immortal, Marine officer Nile Freeman (portrayed by KiKi Layne) is introduced in a graphic scene where her neck is violently slashed and she is basically dead, but remarkably, she heals without explanation and without scars.  Within a few scenes, Andy takes Nile taken from her military camp and has introduced her to the team of immortals.

Obviously, there are some big questions here that we hear the immortals ask throughout the movie:  “Why me, why am I immortal and others are not?”  Or, “What are we supposed to be doing with this ‘immortality’?”   “Are we making any difference in a world that seems like it is getting worse instead of better?”  By the end of the story, the viewer gets an idea about the difference that the immortals have made throughout the years, but the “why” question remains unanswered.  Andy is a confirmed atheist and views Nile’s faith in God as illogical.  

More ethical issues arise when Big Pharma gets involved.   The villain of the movie, Steven Merrick (portrayed by Harry Melling) is the young Zuckerberg-esque head of his own pharmaceutical company.  He enlists help from a former CIA agent, James Copley (portrayed by Chiwetel Ejiofor) to capture the immortals and to run a series of endless tests on them.  As you might expect, the immortals are eventually captured and meet Merrick face to face.  He informs them that it is their duty to submit to his torturous experimentation because in the long run, they will help humanity.  He goes so far as to tell the heroes that it is ethical duty to do this because they could help so many people.

Copley’s ruthlessness clearly tells the viewer that his ethics are problematic.  He is not simply an altruistic scientist, he is an entrepreneur who wants to ensure that the immortals do not fall into the hands of his Big Pharma competitors.  His words about helping humanity ring hollow because of his overall devotion to the bottom line.  Or as he was told at the end of the movie, “It was not your choice to make.”

“The Old Guard” is a cautionary tale cloaked in the garb of a twenty-first century Netflix feature with all the special effects one might hope for.  Humanity never seems to learn their lesson; technology always seems to have a leg up on ethics.  In our fast-paced world, a cautionary tale may be just the thing we need.

Covid-19, Economics and Bioethics

Bioethics, in its essence, is multi-disciplinary. It involves medicine, philosophy, theology, political science, and supernumerary other scholarly fields. And, of course and, perhaps, unfortunately, economics. Bioethics is blessed, and plagued, by its confluence of academic influences, and operates within their inevitable, intersecting, conflicting, uncomfortable gray areas. The Covid-19 pandemic speaks to the bioethical implications that go beyond who gets ventilators and when do we get a vaccine to even more elemental questions. Can we survive the economic paralysis that comes from a quarantine designed to arrest or slow the spread of the novel coronavirus in the United States? Was it “worth it” to force a government shutdown of many industries in an effort to keep our population as safe as possible….and, perhaps, forestall further economic devastation…and, even if so, what is our endgame?

I write this as a veterinarian, a bioethicist, a small business owner, a father of three high schoolers suddenly thrust into “e-learning,” and the son and son-in-law of octogenarians. If those seem conflicting interests, then they are indeed representative of just what a mess this pandemic finds our society. We aren’t unique but, in so many ways American, have managed to find ourselves the world leaders in Covid-19 deaths, infections, tests and are the economic “canary-in-the coal-mine” for the industrial world.

The Atlantic, hardly a shill for the Trump administration or its apologists, has a sober assessment, two months into the general national “quarantine” zeitgeist that has been our reality in most of America. The complex effects of the coronavirus on our economics are described in this piece, one that also looks at what those economic effects have on other nations and, yes, the mental and physical health of our own citizens. It isn’t pretty. Macroeconomics is a bioethics issue.

Americans have now been forced to face, and decide between, our competing ethics of safety (a biggie in contemporary society), personal liberty (autonomy, in ethical lingo, another biggie) and self-sacrifice for a greater civic good (mostly read about in vintage World War II texts, but bringing on a new significance). And it seems we can’t begin to reconcile them, so we just retreat into support of one of the first two, claiming the third as its moral anchor. As we are seeing, this is no way to orchestrate a response to a pandemic that has left (as of this writing) over 80,000 Americans dead and an economy that currently can only be measured by the Great Depression levels of unemployed, but really should only begin to be assessed the way we do tornado damage…when the sun comes up and the clouds lift.

There are no numbers to encourage us. Yet, reports tell us that there are available hospital beds and ventilators, and that the navy ships brought in to our urban “hot spots” to offer more space were (thankfully) never needed. We succeeded in “flattening the curve,” that goal that was always our fundamental one when we paralyzed our economy and society many weeks ago. So what is the goal now? Is it avoiding a new wave that will create a curve that needs flattening again? Is it a quick or gradual reversal of the paralysis of the economy that lets us eat out, shop in malls, have gatherings with friends, play sports and see marching bands perform, and worship in community again? Governors have played a primary role here, perhaps an illustration of the wisdom of federalism to some, the limitations of the same when dealing with a pandemic across fifty free borders to others. It is inescapably political in an election year…do you want to see people die or go bankrupt? That is our apparent binary choice, and our political polarization has already entrenched the position of each side.

I reinforce to my clients who are making decisions for my patients, their pets, as well as to my own children, should they be listening, that every decision we make has consequences, and virtually none makes everyone a winner. The Atlantic article mentions the profound economic devastation that comes to our health if we enter an economic abyss. Some of that is already realized. That bioethical decisions are inextricably economic should be painfully obvious to all. It has always been the “elephant in the room,” sometimes at a micro- and others at a macro-level. We have viewed economics as, at best, a stern taskmaster who wants to ruin a good thing and, at worst, the archenemy of bioethics. In the West at least, we have been blessed by wealth to make high-level bioethical decisions. The challenge of who gets dialysis was answered by “everyone,” because we found a way to pay for it without creating economic devastation. When that wealth erodes, we are on a different playing field. Covid-19 shows us what happens when a bioethical decision runs headlong into economics. Again, it isn’t pretty.

Fundamentally, we need to decide what human dignity and human flourishing look like in a modern society. Justice for all, and with particular attention paid to those at the margins, always dictate this. The margins we face in Covid-19 are, of course, the elderly, the immune-compromised, the chronically ill. But they are also those who struggle in good times to make financial ends meet and who are suddenly out of work weeks after the highest level of employment in recent history. Some are facing mental health and addiction crises. Global poverty, and its accompanying hunger and death, will rise. Whether one out of five or one out of ten, whether in North America or sub-Saharan Africa, we have a group of people at the margins. The number will inevitably widen as the storm damage is fully assessed. To fail to account for them in our public health decisions is inept and insensitive. To ignore the power of a disease caused by a novel virus for which no nation in the world has yet achieved “herd immunity” is no better.

Be careful how strongly you support either position. Those who lead, ultimately, are successful when they disappoint those who follow them equally. This is not a Solomonic baby-splitting, but the hard work of public policy and personal behavior. We will give up (and already have given up, to a great extent) some things that are excruciatingly painful losses. Our Western obsession with safety, with the quest for immortality that cannot be realized, for choosing death on our own terms and in our own time, has come under attack. Now we can be safer, but lose our prosperity, or remain wealthy but sacrifice many more thousands of our own. We can’t have both. Our public health decisions must recognize that national and global economics are bioethical, human flourishing, epidemiological decisions that cannot be ignored. A cavalier approach to loss of human life is ghastly, and an economy that fails means a health care system that fails.

Project Nightingale

Technology always seems to outrun ethics.  But just because something can be done does not mean that it should be done.  Usually this discussion is focused on the latest life-sustaining medical device, but with emergence of electronic medical records, a whole new set of problems have appeared

Last month, Rob Copeland of The Wall Street Journal (behind pay wall) published a report focusing on the partnership between Google and Ascension health subtitled:  “Search giant is amassing health records from Ascension facilities in 21 states; patients not yet informed.”  Google has named their efforts “Project Nightingale.”

The idea behind medical records being available on the cloud (or somewhere electronically) sounds very appealing at first.  However, it is not difficult to imagine “Project Nightingale” turning into “Project Nightmare” when it comes to patient’s privacy.  This was what drove a Google whistleblower to come forward: “why was the information being handed over in a form that had not been ‘de-identified’ – the term the industry uses for removing all personal details so that a patient’s medical record could not be directly linked back to them?  And why had no patients and doctors been told what was happening?”

Dr. David Feinberg, the head of Google Health, addresses the concerns that have been raised: “Google has spent two decades on similar problems for consumers, building products such as Search, Translate and Gmail, and we believe we can adapt our technology to help. That’s why we’re building an intelligent suite of tools to help doctors, nurses, and other providers take better care of patients, leveraging our expertise in organizing information.”  (I’m not sure using Google Translate as a positive example will bring comfort to many readers.) Feinberg also discusses the precautions that Google has put into place.

Since the original WSJ broke last month, Congress has gotten involved.  Consumer Affairs reports “that the U.S. Department of Health and Human Services has opened an inquiry into the project to determine whether it violates the Health Insurance Portability and Accountability Act of 1996 (known as HIPAA).”

Maintaining patients’ privacy is an important issue and must not be glibly overlooked.  It will no longer suffice simply to say that we trust Google (or Facebook, etc.) to do the right thing.

Racial Bias in Algorithms?

Can algorithms show racial bias?   That is the conclusion of a recent article published in Science by Obermeyer, et al., entitled, “Dissecting racial bias in an algorithm used to manage the health of populations.”  

According to Science, the algorithm’s goal is “to predict complex health needs for the purpose of targeting an intervention that manages those needs.”  Fair enough.  That certainly sounds like a worthy goal, especially in these days of complex medical conditions, with equally complex treatments.  However, the problem raised by the research done by Obermeyer, et al., is that “the algorithm predicts health care costs rather than illness, but unequal access to care means that we spend less money caring for Black patients than for White patients.  Thus, despite health care cost appearing to be an effective proxy for health by some measures of predictive accuracy, large racial biases arise.”   The study concluded that with a reduction of bias in the algorithm, a much larger percentage of Black patients would receive the advanced interventions that the health care system offers.

In addition, the Minneapolis Star-Tribune reports that “New York regulators are calling on Minnetonka-based UnitedHealth Group to either stop using or show there’s no problem with a company-made algorithm that researchers say exhibited significant racial bias in a study.”

In its note on the research, Nature  states that Optum (the algorithm’s developer) raised questions about the study’s conclusions:  “The cost model is just one of many data elements intended to be used to select patients for clinical engagement programs, including, most importantly, the doctor’s expertise.”  Nature also reports that “Obermeyer is working with the firm without salary to improve the algorithm.”

The results of this study deserve to be examined closely.  If we truly want to affirm the dignity of each individual, bioethics must address these areas of disparity whenever possible.  It’s not likely that we will ever achieve a bias-free world, but it is surely helpful to be made aware of our biases so that we can better serve those in need.

Jeffrey Epstein & Transhumanism

In November 2018, journalist Julie Brown of the Miami Herald published an important three-part report called “Perversion of Justice,” describing the case of billionaire Jeffrey Epstein.  Brown’s reporting strongly indicates that Epstein’s punishment appeared relatively small when compared to the crimes that were actually committed.  The report, in part, led to further examination of the case and a recent indictment by the Southern District of New York.  Eventually the Secretary of Labor, Alex Acosta, resigned his cabinet position over questions about his role as a prosecutor in the case a decade earlier.

If the account of the crimes isn’t horrific enough, the New York Times reported last week that Epstein used his wealth to speak to prominent scientists about his goal to spread his DNA world-wide through impregnating groups of women at his New Mexico ranch.  In what reads like a creepy sci-fi novel, the articlereports: “Mr. Epstein’s vision reflected his longstanding fascination with what has become known as transhumanism: the science of improving the human population through technologies like genetic engineering and artificial intelligence.  Critics have likened transhumanism to a modern-day version of eugenics, the discredited field of improving the human race through controlled breeding.”

Epstein used his wealth and influence to ingratiate himself to the scientific community, according to the Times.  Prominent attorney Alan Dershowitz is quoted in the article: “Everyone speculated about whether these scientists were more interested in his views or more interested in his money.” Not surprisingly, several of the scientists contacted by the Times had a less than positive view of Epstein’s scientific musings.

One of the appeals of transhumanism is its goal to make humanity better through technology.  Living easily past 100 without all of the ailments of old age seems like a worthy goal. However, as is often the case, technology runs ahead of morality.  In Jeffrey Epstein’s case, it contradicts our understanding of basic human rights to think that the future belongs solely to amoral billionaires and the scientists they enlist in their causes.

Fertility Fraud

By Neil Skjoldal

Last week, Canadian fertility specialist Dr. Norman Barwin lost his medical license after complaints that he had used his own sperm to artificially inseminate his patients without permission. Bionews.org reports that there were understandably strong reactions from the families affected by his horrific actions.  And now it has come to light that he had done this at least 11 other times.

This case brought to mind a case that came to prominence last year.  Dr. Donald Cline, an Indiana fertility specialist, used his sperm to artificially inseminate his patients and is said now to have more than 50 biological children.  Apparently, up until recently, there were no laws stating that it was illegal for a physician to do so. In light of the Cline scandal, Indiana passed a fertility fraud law which singles out fertility doctors who use their own sperm.  Theindychannel reports:  “The law, which takes effect July 1, makes it a level 6 felony if someone makes a misrepresentation involving a medical procedure, medical device or drug and human reproductive material.”  

It is truly sad that it takes a law to ensure that doctors will not artificially inseminate patients without their consent.  However, I am glad that Indiana did so.  (California has a more general law). If individuals are unable to regulate their behavior based on their own personal morality and ethics, it becomes incumbent upon society to investigate the matter to determine whether a law is needed or not.  This is what happened in this case.

Bonnie Steinbock takes an interesting perspective on the Cline case.  While acknowledging that the doctor was unethical, Steinbock questions whether or not the children born from this unethical behavior were actually harmed by him:  “What makes the lawsuits of the children Cline sired problematic is the fact that, but for Cline’s use of his own sperm, none of these children would have existed.”  She concludes, “If there are to be any medical malpractice suits against Cline, these should be limited to the parents, not the children.”

These unethical acts demand our attention. What can be done to stop them? And what of those who were victimized by this behavior? At the very least, they deserve answers. I hope that Indiana’s law might make a difference. Hopefully other states are taking notice.

Bad News

Many of us have witnessed the giving of bad news to a patient.  It is never a pleasant experience.  Unfortunately, some medical professionals are simply not skilled enough to share bad news in a way that is both compassionate and comprehensible.  And even if they are, it is still bad news after all. 

Recently, the media reported the story of a patient and family in California who received bad news via “a robot.”  On its face, that doesn’t sound like a very good idea.  If you take a minute to watch the clip from CNN’s website, you can see a doctor speaking to a patient through a video device, so it wasn’t exactly a robot delivering the news.  It’s a short clip, so it is difficult to reach a conclusion on the nature of the encounter, but it is clearly bad news for the patient.  The media reported that the family was upset, the HLN news anchor called it “callous,” and those of us who work with patients on a daily basis see another setback in patient relations.

In an important reaction to this story, ICU physician Dr Joel Zivot notes several salient points:

“This is not a failure of technology, it seems. More likely, it was a failure to communicate via anymethod. Medical schools are bad at teaching how to deliver bad news. Patients often don’t know how to receive it, either. A doctor-patient relationship of trust can successfully occur over the phone and be bungled completely in a fac-to-face encounter. We do not know the mind of the doctor, of what came before, or the mental state of the patient or his granddaughter. Absent that, this story tells us nothing about whether remote technology should be used to deliver this sort of news.”

More training is needed for these important conversations.  There are multiple resources available for those willing to learn, including the SPIKES framework, noted by Craig Klugmanin a recent blog.  Above all, we must continue to respect the humanity of each patient.  As Zivot concludes, “Technology is the helper to the physician but not presently the replacement. If we allow the technology to strip away our common humanity, we will all be diminished as a consequence.”

Eugenic immigration policies revisited

Many people, when they think of the history of eugenics, think of Nazi Germany. However, eugenics was widely accepted and implemented as policy in America long before the Nazis rose to power.

At the beginning of the 20th century, the numbers of immigrants to the United States were increasing rapidly. This greatly alarmed those who were aligned with the eugenics movement, the quasi-scientific movement to preserve “racial purity.” In 1920, Harry Laughlin, superintendent of the Eugenics Record Office, testified before the House of Representatives Committee on Immigration and Naturalization that the “American” gene pool was being polluted by certain immigrants who were portrayed as social inadequates, intellectually and morally deficient — understood as those from southern and Eastern Europe. Laughlin was subsequently appointed the committee’s “Expert Eugenics Agent.” The committee crafted the Immigration Act of 1924, which was designed to limit the immigration of “dysgenic” peoples: Italians, Slavs, Eastern European Jews, and Africans; Arabs and Asians were banned outright. The quotas were set to favor those from the racially superior Northern European countries. According to the State Department Office of the Historian, “In all of its parts, the most basic purpose of the 1924 Immigration Act was to preserve the ideal of U.S. homogeneity.” The House of Representatives History, Art, and Archives website describes the act as “a legislative expression of … xenophobia.” President Coolidge commented as he signed the act, “America must remain American.”

With the specter of a new, Gattaca-like eugenics staring us in the face, it had seemed like the worst abuses of the old eugenics — forced sterilization and the like — were history. It is painful — but plain — to see, if recent reports prove true, that the elitist, racist mentality behind the eugenics movement still holds sway at the highest levels of our government.

From Coercion to Christmas

The recent wave of stories of sexual abuse and harassment led my residents (I teach family medicine residents) and me to a discussion of sexual ethical violations in medicine. The annals of disciplinary actions by state medical boards are filled with penalties inflicted upon physicians who have entered into sexual relationships with patients.

Why is it that in the patient-physician relationship, sexual intimacy between two (often) consenting adults is proscribed, and has been since Hippocrates prohibited it in his oath? Why, even in our sexually permissive age in which anything goes, is this still taboo?

The issue with physicians and patients — as with most of the accusations making headlines recently — is power. The patient-physician relationship is radically asymmetric with regards to power. The patient is vulnerable; the physician is not. The patient reveals dark secrets, and uncovers his or her body for examination; the physician does not. One person in the room is exposed, figuratively, and literally, and it ain’t the doctor.

It is this asymmetry, this difference in power, that makes it so difficult for an intimate relationship to be truly consenting; there is a very real danger that the less-powerful party will act from some sense of coercion, even if the coercion is unrecognized and unacknowledged. When a relationship as intimate and personal as a sexual relationship is coerced, even subtly, the potential for harm to the weaker partner is so great that the ancients, in their wisdom, forbade it, and we moderns have seen fit to respect that prohibition.

Of course it is not just patient-physician relationships that are asymmetric and thus liable to abuse. Whenever one person exploits their position of superior power over another the potential for abuse exists, such as when a person with great political power personally attacks those in positions of less power on social media. We call such abuse of power “bullying.” We rightly condemn such abuses.

This got me to thinking about the most asymmetric relationship possible: the relationship between God and people, the Creator and the created. While there is no sense in which God could be said to abuse his power, he seems remarkably restrained in his exercise thereof. We read of times when he shows up in dazzling displays — think of the children of Israel leaving Egypt, or God speaking to Job out of the whirlwind — but more often than not he is veiled: a still small voice, a dream, a soft but persistent voice in the night that keeps calling our name.

And when God gives us the clearest revelation of who he is, he eschews any semblance of powerful exhibition, and comes as a baby. When he grow up and displays his power, it is veiled in love: he heals, he saves a wedding celebration from disgrace, but often with admonition, “Don’t tell anyone.” Even his greatest display of power — his Resurrection — was carried out in such a way that many of those nearest to him had a hard time understanding or believing it.

God is powerful, no doubt. But he rarely uses his power to overwhelm or coerce us. He seems to prefer self-giving love as his means of persuasion. We are told that someday he will come in a full demonstration of his power and glory. But for now, as we celebrate at Christmas, he comes to us as a baby. He comes to be with us, as one of us, so that he can lead us from where we are to God. Or, as an old Christian named Athanasius said, “He became as we are, that he might make us what he is.”

I’m on call for our obstetrical service this holiday. I’m going to try to let each baby I see be a reminder of how God deals with us: power that clothes itself in self-giving love.

Racial inequalities in cancer survival

Three studies published in a supplemental issue of the journal Cancer this month come to disturbing conclusions: in the United States, the survival rates for colon, breast, and ovarian cancer are lower for black people than for white people.

The news isn’t all bad: overall cancer survival rates are going up. The three studies mentioned here draw from two larger studies of worldwide cancer survival, the CONCORD study, published in 2008, and the CONCORD-2 study, published in 2015. Between CONCORD and CONCORD-2, cancer survival increased across all groups. But in both studies, the survival of black people in the United States lagged behind that for white people by about 10%.

Now there are certainly many reasons for the difference. Black people may be getting diagnosed with cancer at later stages, when survival is lower. There may be differences between the two groups, like genetic factors or the presence of other illnesses, that cause the cancers to be more aggressive in blacks. Mistrust of the health care system is more common among black patients, so they may be less likely to access care or access it early enough.

But other reasons include socio-economic status and access to health care; those who can’t access medical care because they can’t afford it or because it is not available nearby are less likely to receive necessary screening and treatment. And most troubling is the “consistent finding that black women do not receive guidelines-based treatment compared with white women, even when treated within the same hospital.”

The situation is too complex for simplistic answers; one can’t say from these studies that doctors are individually practicing blatant racism, and there is after all such a thing as systemic racism. But the medical profession should take such findings seriously, and seek every available avenue of education and self-monitoring to ensure that of all the places people encounter racism, the health care system is not one of them. And Christians especially, who believe that God created all people with equal dignity because all of us are created in His image, should work towards a health care system where the value — or length — of one’s life does not vary based solely on the color of one’s skin.