Liberal Limitations of Autonomy

I’ve recently spent many hours pouring over publications of the American College of Obstetrician/Gynecologists (ACOG)–something I rarely do–in preparation for my board recertification exams next week. In all fairness, and despite my negative attitude toward this newly instituted requirement, I confess that I have learned, or relearned, a few facts of practical clinical importance. However, I have also discovered many glaring inconsistencies in ACOG’s recommendations for patient care based on their desire to present “evidence-based” data—evidence that varies from study to study. In addition, one seemingly inconsistent ethical position also surprised me: ACOG’s opposition to sex selection techniques, whether pre- or post-conceptual (Committee Opinion 360).

Concerning the issue of sex selection, the American Society for Reproductive Medicine (ASRM) opposes post-fertilization/pre-implantation sex selection for non-medical indications because it “necessarily involves the destruction and discarding of embryos.” While ACOG does not oppose post-fertilization or post-implantation sex selection techniques for medical indications such as X-linked genetic disorders, it too opposes sex selection for personal, social, economic, or cultural reasons. But ACOG’s opposition is not based on the destruction of human embryos: ACOG opposes such desires because of the risk that they are motivated by “sexist” attitudes that reinforce the devaluation of women. They state, “individual parents may consistently judge sex selection to be an important personal or family goal and, at the same time, reject the idea that children of one sex are inherently more valuable than children of another sex. Although this stance is, in principle, consistent with the principle of equality between the sexes, it nonetheless raises ethical concerns…it often is impossible to ascertain patients’ true motives for requesting sex selection procedures (italics mine)…even when sex selection is requested for nonsexist reasons, the very idea of preferring a child of a particular sex may be interpreted as condoning sexist values and, hence, create a climate in which sex discrimination can more easily flourish” (note the “slippery slope” argument).

Wait a minute…what happened to autonomy? What about a woman’s right to choose? ACOG has always supported abortion on demand—a woman’s right to terminate the life of her unborn baby at any stage for any reason–no questions asked. Why can she then not choose to carry a baby of a particular sex? Why and how do motivations—which even they admit no one can truly know–limit a woman’s right to choose? It seems that there is a “higher principle” at work here that can limit a woman’s autonomy: the principle of equality of the sexes.

It is difficult to see how such a nebulous principle as “equality of the sexes” can serve as a limiting principle to autonomy. Are they referring to qualitative or quantitative aspects of equality? Perhaps they perceive it to be an issue of justice, for justice does indeed at times serve as a check and balance on personal autonomy. But it is unclear why it is acceptable to destroy the unborn because they are perceived to be a personal inconvenience, but impermissible to do so for other reasons of personal preference? They seem to be saying that a woman’s autonomous choices can be trumped by societal justice but not by the individual justice due the unborn. Terminating the life of the unborn is acceptable as long as it doesn’t violate societal values.

But even more sinister is the fact that not only does the life of the unborn have no intrinsic value, its moral significance is contingent upon whether its “beingness” promotes values and agendas of others, whether those of the mother or–if the mother’s values are not properly aligned–of society. That makes the moral status of the unborn merely a “means” to the ends of others, ends which change as frequently as the tides.

Perhaps we should rejoice that at least in this one area of women’s reproductive health, the position of ACOG is, in part, consistent with those who value life from conception. But motivations and foundational values are indeed important. We should not be quick to join forces with those whose convoluted ethical position is nothing more than a house of cards built on the sinking sand of social values.

Why we don’t know if abstinence education works

The Illinois House and Senate recently passed bills mandating that Illinois schools that offer sex education provide information on contraception and sexually-transmitted infections (STIs). State Senator Linda Holmes said, “In fantasy land, we teach our kids abstinence — and they listen.” The accepted wisdom is that “Abstinence-only education doesn’t work.”

Which is, of course, a ridiculous statement, since abstinence-only education has not even been tried in this country in at least the last 50 years.

Oh, certainly, there have been attempts to teach school curricula that emphasize abstinence. Those classes might last an hour a day, for a limited period of time during a few school years. But consider the results of a 2010 study of 8- to 18-year-olds conducted by the Kaiser Family Foundation, which found that today’s teens spend more than 7½ hours a day consuming media — watching TV, listening to music, surfing the Web, social networking, and playing video games. I don’t know how much of that media carries either explicit or implicit messages about sex that decidedly do not promote abstinence, but from my sampling of the airwaves, 20% seems like a low estimate. That’s 90 minutes a day, day in and day out, year after year, of receiving messages and images that go contrary to anything taught in a short, limited “abstinence-only” class. Not to mention all the billboards, magazines, grocery store aisle publications, etc. that sell consequence-free sex.

When I say abstinence-only education has not been tried for at least 50 years, it’s because education is a lot more than what is taught in school. Previously, the undergirding societal sexual mores reinforced the abstinence-only message that was taught in schools — even if everybody didn’t adhere to those mores — and what was taught in schools echoed what was taught implicitly and explicitly throughout society. This is clearly no longer the case.  It should come as no surprise when we spend an hour a day for a few months teaching “Abstinence” in the face of a culture and media screaming 24 hours a day “Have sex!” and find out that 70% of teens are having sex.

So I hope that we never get to the point of believing those studies that say, “Abstinence education doesn’t work,” and end up removing abstinence from the curriculum. I am not here advocating for a return to the “Good old days,” or saying that we shouldn’t teach about contraception or STIs in sex education classes, especially given the current sex-obsessed media and culture. I am advocating for teaching abstinence as a principle most in line with human dignity, for teaching people that they are inherently different from creatures like cats and cattle who are at the mercy of their sexual drives, that self-control is not only good but possible. Pragmatically, teaching about protection from STIs and such should be provided for those who make different choices; but if we are going to provide sex education at all, we should not do so in a way that appeals to the lowest common denominator of our hormonal drives.



Deep conscience and accountability to God

In his last post Jon Holmlund referred to the concept of deep conscience as defined by J. Budziszewski. I think it is worthwhile to spend a little time on the implications of deep conscience. When Budziszewski writes about deep conscience he is distinguishing it from surface conscience. Surface conscience consists of our conscious moral beliefs which may vary from person to person and has similarities to the concept of convictions. Surface conscience applies to our day to day decisions and consists of derived beliefs that may have been derived in error. Deep conscience refers to a foundational first knowledge of morality that is what we derive our moral convictions from. As Budziszewski says in his book, What We Can’t Not Know, it consists of concepts such as friendship is good, gratuitous harm is wrong, and we ought to be fair.

Even though it may be called other things, the existence of deep conscience is widely accepted. Moral philosophers call it common sense morality when they use the moral convictions we all share as a test of moral theories. Beauchamp and Childress built their widely used principles of biomedical ethics on common morality, recognizing that people could agree on basic moral principles even though they cannot agree on moral theory. Mary C. Gentile uses common morality as the justification for teaching business managers to give voice to their values without specifying what those values are.

However, the existence of deep conscience or the fundamental principles of common morality presents a problem for those who do not recognize the existence of God as creator. As C. S. Lewis noted in Mere Christianity we not only recognize that there are moral values that all people share across time and across cultures, but we also recognize that we do not live up to those moral standards. If common morality was just the values that were found to be necessary for the existence of human society, then we would expect that those standards would be readily achievable. What we find is that we all know what is right, but we all fail to live up to those standards. That implies that there is a source of those standards beyond us. The existence of deep conscience does not fit with a godless world that has come about through chance and time. It says that there is a moral order to the world that is beyond us as humans. Just as the order and complexity of the physical and biological world leads to the idea that there must be a designer or creator, the existence of deep conscience implies that there is a source for our moral concepts who has made us with a purpose.

As Jon said in his post, deep conscience tells us that we are accountable to God. That is the uncomfortable thing about conscience in our society. We live in a society that worships autonomy. The idea that we are accountable to the one who is the source of conscience leads either to acceptance of that accountability, and can be the first step toward the answer to the problem of our not living up to what we know to be right that we find in Jesus, or leads to the suppression of our knowledge of right and wrong to try to remain autonomous.

Irreligious Bioethics

There’s a fascinating article in the December issue of the American Journal of Bioethics entitled, “In Defense of Irreligious Bioethics,” available free here. In the article, philosopher Timothy Murphy argues that the stance of bioethics towards religion should be not just neutral, but actively skeptical, even adversarial. The gold standard for bioethics should be secular moral reasoning, by which he means reasoning “based solely on regard to the well-being of mankind in the present life, to the exclusion of all considerations drawn from the belief in God or in a future state.” (footnote 2, p. 4) Such an approach, he avers, will “have a particular benefit in tamping down ideological effects.” (p. 6) He also asserts that irreligious bioethics can expose “indefensible approaches and standards” in bioethics, and provides as an example the “conceptually confused and epistemologically uncertain” notion of intercessory prayer. He concludes that “the most valuable approach to religion is to repudiate in all its manifestations the idea that there is a transcendent reality to which the immanent world is beholden.” (p. 8)

A few points: Murphy appears not to understand the nature and purpose of intercessory prayer, making the portion of his article dealing with prayer quite muddled. And secularity is certainly no defense against the excesses of ideology, as the history of the twentieth century with its almost countless victims of secular ideologies shows us. But more fundamentally, Murphy appears to believe that the secular approach to bioethics will somehow be more objective and normative, less tainted by subjective presuppositions, than bioethics practiced from a religious worldview. However, a secular or skeptical methodology is as fraught with unproven premises as any other, religious or otherwise. Even Murphy’s definition of secularity relies upon unproven assumptions and judgments of value to make any sense: for instance, in his phrase, “the well-being of mankind,” how do we define what well-being is? That definition will ultimately rest on a basic assumption that must be accepted without proof (see C. S. Lewis’s The Abolition of Man for an explanation of why this is true). Or, Who does “mankind” include? Are embryos included? One’s answer to that question will be based at least in part on preconceptions that will likely be assumed, not proven.

Murphy writes, “for bioethics the limiting factor is that religions ultimately rely on assumptions and claims that evade secular evaluation because they are typically unfalsifiable, infinitely mutable in the face of objections, rooted in personal experiences that defy independent analysis, or rooted in the murk of human history.” (p. 8)  I do not agree that this statement is entirely true; but to the extent that it is, this same description could be used for the assumptions and claims supporting any underlying worldview, even the secular and skeptical one that Murphy advocates.

(Along with the article is free access to several open peer commentaries from the same journal. I have not had the chance to read through all of them yet, so I apologize if what I wrote her inadvertently echoed some of their points.)

Professionalism vs. commercialism in medicine (or, Yet another Black Friday special!!!)

Some thoughts on medicine and commercialism on this, the high holy day of the gods of commercialism:

The understanding of medicine as the satisfaction of consumer wants is corrosive to the practice of medicine as a profession.

“The practice of medicine is not a business and can never be one . . . Our fellow creatures cannot be dealt with as a man deals in corn and coal; the human heart by which we live must control our professional relations.” (Sir William Osler, 1903)

A profession involves the freedom if its practitioners from the simple market reduction of the work to that of the tradesman. It is fundamentally an ethical and moral endeavor. It entails independence of judgment, a degree of self-regulation, a covenantal commitment to patients, the bearing of a characteristic set of responsibilities, and adherence to a distinctive ethical code.

*  *  *

From a hypothetical ad in today’s paper:

“Yes, you heard right, it’s our Black Friday special!! Have we in medical practice got a deal for you! Come over to St. Exorbitant’s where today, we’re offering one MRI for the price of two! (Actually, we’ll charge as high a rate as we can and take whatever your insurance company will allow!) Plus, we’ve got all the most-requested procedures of dubious benefit and unnecessary tests for your enjoyment!! (Unnecessary for your care, that is, but they might help finance that new atrium we’re building on to the hospital, which has really helped us attract patients away from our competition!)

“And if you don’t like our Hippocratic™ – brand selection, come on over to our other showroom, where you can peruse some of our less-traditional items! So, you’re not interested in our time-honored offerings of compassion, presence, and comfort? Well, we have a special discount today on Physican-Assisted Suicide (at such a bargain, too — at least, for our medical system which can finally stop paying for all those pharmaceuticals you’re taking!)! Looking for the perfect child? Sorry, we don’t have that yet, but we can test the one you’re carrying to see if she meets your specifications and tolerances! Now how much would you pay? But wait, there’s more! Our technicians can abort, ah, that is, terminate the child you’re carrying if we find something wrong, or for any other reason, or for no reason at all! We’re eager to serve — YOU! Here, the patient is King and Queen! We will do anything — anything — within our power (and your ability to pay) that you want, and if it isn’t within our power yet, don’t worry, we’re experimenting on your embryos to find ways to serve you better!  (We accept many insurances, cash, and all major credit cards!)”


Oh, wait — you say you can’t pay? No insurance? Well, well, funny how those market forces work, isn’t it? I’m sorry, we won’t be able to help you today. Why don’t you try the internet? I hear there’s very good care to be had there!


Science, politics, ethics, and emergency contraception

Last December 7th, Health and Human Services Secretary Kathleen Sebelius instructed the FDA not to give over-the-counter (OTC) status to the emergency contraceptive drug Plan B One-Step for girls under age 17 (It is currently OTC for all women 17 years of age and older). Sebelius gave as her reason her “conclusion that the data … are not sufficient to support making Plan B One-Step available to all girls 16 and younger, without talking to a health care professional.”

Commentators immediately went ballistic, bemoaning the “fact” that the science shows that this product should be approved OTC for all ages, but that politics overruled the science. Last week a Perspective piece in the New England Journal of Medicine (NEJM) made the same assertion, as did an earlier Viewpoint in JAMA.

However, there is more to these claims of scientific-objectivity-being-overruled-by-politics than meets the eye. Science can only tell us what is or what can be, never what should be. You cannot from the premise, “We can do such-and-such,” derive the conclusion, “Therefore, we should do such-and-such,” without the intervening value statement that “Such-and-such is good, or desirable, or right.”

In his inaugural address, President Obama promised to “restore science to its rightful place” in government, to “base our public policies on the soundest science.” But public policy decisions are inevitably decisions about what should be done; every regulation in the law is an acknowledgement that those governing believe that one particular way of doing or taxing or regulating something is better than the alternatives. In other words, every policy decision is based in some part on ethics and morals — things which objective science cannot reveal to us. To “restore science to its rightful place” means “let’s get our facts straight.” This is important: good ethics (and good policy) must start with good facts. But science’s rightful place is not, and cannot be, to make the ethical decision for us.

Science can tell us the chances of Plan B One-Step preventing pregnancy after unprotected intercourse. It can give us statistics about how women use it and what the potential side effects are. It can not tell us whether or not it is a good thing that a 12-year-old who just had unprotected intercourse should be able to get the medicine without talking to an adult such as a medical provider.

Sebelius appealed to a lack of scientific data in making her decision; I do not know if she also had an unspoken political agenda. It seems at least mildly improbable that someone so staunchly pro-choice, who is part of the administration of a President and a political party that do not oppose Plan B on political or ideological grounds, would herself do so to gain political points or power. But I do know that, contrary to all the pundits, this decision, like all policy decisions, cannot be made by empirical science alone. The accusation of “Politics trumps science” is just a front for those whose own politics, morals, and ethics lead them to a different conclusion.

Inappropriate clinicians

An article in the December 28th 2011 JAMA reports a study of doctors and nurses in 82 ICUs across Europe and Israel. These clinicians were asked whether they had provided inappropriate care, defined as “care that clashes with your personal beliefs and/or professional knowledge,” on a particular day. More than one-fourth believed the care they provided on that day was inappropriate.

An accompanying editorial asks the million-dollar question, “If so many clinicians are providing care that is not motivated by its appropriateness, what then are they trying to accomplish?”

What, indeed? Isn’t providing care that contradicts one’s beliefs and knowledge tantamount to providing unethical care?

From my own experience, I will hazard a guess that if the clinicians had been questioned about a longer time period than just one day, way more than one-fourth of them would have reported providing inappropriate care; and that the problem of providing inappropriate care extends well beyond the ICU to clinicians everywhere. I will also hazard a few guesses at just some of the motivations behind providing inappropriate care:

-The clinicians want to please patients or families, and/or are experiencing pressure from the families to provide inappropriate care;

-The clinicians are required to follow guidelines that are based on the statistical analysis of large populations, but happen not to apply to the individual patient being treated;

-The clinicians are attempting to prevent a malpractice lawsuit by doing more tests and procedures than are appropriate;

-The clinicians are following inappropriate laws, such as the one  drafted by the NRA and the Florida legislature restricting physicians’ ability to properly counsel patients.

Most reasons underlying inappropriate care stem not from the deliberately unethical practice of the clinician (although I do not deny that such things occur), but from characteristics of the system which induce them to act in ways that they feel are inappropriate.

The idealist in me believes that most people who go into medicine and nursing do so because they want to help people. Virtually all of the nurses and physicians I know (and I know quite a few) want to do the best thing for their patients. But all of these idealistic people are taken and thrown into a system that influences them to act in ways that they believe are inappropriate. The clinicians find themselves, for reasons beyond their control, giving inappropriate care.

Is inappropriate care always unethical care? How can one be an ethical clinician in a system that prevents one from acting appropriately?

Ethics and Worship

Sometimes I think evangelical Christians get confused about where ethics fits in the Christian life.  Why is it so important?  We understand that we are fallen and that there is nothing that we can do to merit God’s favor.  Salvation is a gift of God’s grace accomplished fully by Jesus’ sacrificial death.  Ethics can be seen as a set of moral laws that we are obligated to live by, but which we all fail to keep.  Why focus on the law when we have God’s grace?  Doesn’t God accept us just as we are?

The answer is worship.  While none of us can merit a relationship with a holy God through living morally perfect lives, those who have been redeemed by God’s mercy and grace desire to worship Him.  Romans 12: 1-2 tells us that we should respond to God’s mercy by presenting our lives to Him in worship.  We should desire to be transformed so that the lives we present to Him in worship are lives being lived in conformity to his good and perfect will.  Ethics is about how we should live to conform to what is good and right.  It involves living lives conformed to God’s good and perfect will.  We can’t do it on our own, but we can allow Him to transform us so that we do not conform to the immoral patterns of this world, but have our minds renewed with an understanding of what is good and right.

Ethics and Atheists

Jim Spiegel, a colleague of mine at Taylor University, published a book last year titled The Making of an Atheist. In the book he contends that the rejection of God is a matter of will, not of intellect.  He suggests that immoral behavior leads to an inability to see the clear evidence for the existence of God.  Atheists choose to reject God for psychological reasons such as the lack of a loving human father and because they do not want a God to exist to whom they would be accountable for their immorality.

Not surprisingly, his book did not go over very well with the atheist community, but there is the seed of an idea there that suggests a way ethics can be used to draw those who reject God toward truth about God.  Many who reject God still believe that there are things that are intrinsically right and wrong.  While a desire not to be subject to ethical standards leads a person to atheism, the understanding that there are ethical standards is the first step toward God.

So the next time someone who does not believe in God disagrees with you on an ethical issue commend them for their belief that morality is something to be concerned about.  Taking morality seriously can be the first step toward the one who is the source of all that is good.