Medical errors and more medical errors

Last week the BMJ reported that annually, there are 251,000 hospital deaths due to preventable medical errors in the US. There’s some debate about the calculations that they used to arrive at that number, and about what exactly constitutes a medical error. However, rather than quibble over the fine points, let’s acknowledge that medical errors are an ethical problem that must be addressed. In this post I would like to widen the conversation beyond the hospital walls. Below is a sample of some deaths due to preventable medical errors that weren’t included in the BMJ calculations (most of these ones happen outside of hospitals); nevertheless, they too affect thousands of people annually. I will also attempt to provide a taxonomy of the relevant errors.

Deaths due to the inability of the patient to obtain medical care because they couldn’t afford the care or the insurance — unknown number. The medical error here is a systemic one, the rationing of health care on the basis of who can pay for it.

Deaths of patients due to their being the subjects of human research — unknown number. This is peculiarly prevalent among embryonic patients (as Jon Holmlund wrote about last week). The medical errors include the failure to extend to embryonic research subjects the protections enumerated in the Declaration of Helsinki. There is also a category error: classifying embryonic patients as something other than human beings.

Deaths of embryonic or fetal patients through elective induced abortion — 977,000 (2014 data). The same category error as previous comes into play here: the failure to recognize the humanity of the unborn human.

Deaths of patients from drugs prescribed by their physician for the purpose of suicide — the numbers data is incomplete. The number is relatively low but projected to grow as more jurisdictions legalize physician-assisted suicide. The errors here include a professionalism lapse (forgetting that the professional status of medicine was established, among other things, on the dictum that doctors do not give deadly drugs, even if asked to do so). There is also the error of hubris: the belief that doctors can decide that someone should be allowed to kill themselves.

Preventable medical errors, all.

Seeing the Horror

A video released by The Center for Medical Progress (CMP)  about Planned Parenthood included these words: “Some viewers may find this content disturbing.” It was to warn the viewer about the images of piled fetal body parts dumped from a bag by an abortion clinic worker.

What might be most disturbing…and chilling…is not the body parts, but the casual and glib attitudes of the Planned Parenthood staff toward them.

A subsequent post  in the Bioethics Forum of The Hastings Center attempted to explain away this indifference:

…most of us also don’t want to see graphic photos of any other type of surgery either. But our desire to look away isn’t inconsistent with thankfulness for the life-saving and health-preserving results of any type of medical procedure. It just means we don’t want to watch their gory accomplishment. But physicians don’t have the privilege we have of enjoying medical results without seeing the unpleasant in-between.

I suspect that the author hasn’t watched all the videos. And I’m not sure what purpose bioethics institutes will serve for our society if they harbor notions that fetal vivisection is comparable to “enjoyable” medical results that are “life-saving and health preserving.”

Yes, as a physician, I can see body parts…and worse…without passing out. But every physician must recognize the moral significance of the connection to the human, or else the profession of medicine is not a moral endeavor. In contrast to attitudes of the abortion clinic workers, in the CMP’s videos, the former StemExpress employee Holly O’Donnell expresses a depth of moral insight to recognize that each of these aborted fetuses was more than just a “tissue opportunity.”

It had a face…I remember picking him up…he was big…I remember holding that fetus in my hands when everyone else was busy…It’s really hard knowing that you’re the only person who is ever going to hold that baby…I would think about things like that…I wonder at age 3 if she would like a color…or I wonder what it would look like, her mom or her dad…

Planned Parenthood’s brutality is the logical consequence of Dr. Alan Guttmacher’s (former president of Planned Parenthood) belief, subsequently effectively written into law by the Supreme Court, that “…no baby receives its full birthright unless it is born gleefully wanted by its parents.” Yes, Planned Parenthood and its supporters are being purely logical. But pure rationality in the face of human dismemberment is no virtue. Watching Planned Parenthood staff speak of selling fetal body parts, I am reminded of G. K. Chesterton’s words in Orthodoxy: “The madman is not the man who has lost his reason. The madman is the man who has lost everything except his reason.

A biblical view of animals

Sarah Sawicki ended her post on 8/1/15 with the questions “How can I address injustices toward animals without promoting logic that excludes some people from personhood? Is it possible to balance these two causes, or must one fall in favor of the other?” I think she is correct in her concern about the use of a capacity definition of personhood to establish the personhood of chimpanzees in order to protect them from what is seen to be abuse. I think that a biblical view of animals gives us a foundation for protecting animals while still maintaining a distinction between human beings who have personhood and animals that are not persons, but still have value and who we should care for responsibly.

Biblical Christianity has a long history of supporting the responsible care and treatment of animals while still maintaining the distinction between human beings and animals. One of the things that William Wilberforce and his friends fought for in England in addition to the end of the slave trade was an end to the cruel treatment of animals.

The Bible clearly states that animals are a part of what was good about creation. They are distinct from human beings who have been created in the image of God, but they are still a valuable part of creation. There is a difference between the value of human life and the value of animal life, but both have value. Human beings were created to have a role of being stewards of God’s creation which includes responsible care of animals. Due to our fallen sinful nature we have not done that very well and animals have suffered from the result of our sin. That is something that Christians need to address.

The Humane Society of the US has been working with some evangelical Christian leaders to produce an Evangelical Statement on Responsible Care for Animals which is scheduled to be released in late September. The statement will address in more detail the biblical foundation for how we should view animal life and care for animals responsibly. The Center for Ethics at Taylor University will be hosting a discussion of that statement on October 6 to talk about the responsibility that Christians have to care for animals.

The Physician’s Imprimatur

In a previous blog response about physician-assisted suicide (PAS), Mark McQuain asked, “Why involve physicians at all?” That question gets too little attention.

There are some easily discernible (and perhaps expressed) reasons why physicians are chosen to be the agents of assisting suicide. First, they have access to pain- or consciousness-relieving pharmacologic measures that also have the (in this case) desirable effect of stopping breathing when given in high enough doses. Second, by their professional ethic, physicians should approach patients with compassion, which, as mentioned previously, is the catchword that is quite deliberately attached to the act of assisting suicide by those who promote it.

But as Dr. McQuain suggests, access to painless methods for killing need not be restricted by to physicians, just as compassion is not; there is no law of physics that prevents others from assuming this role. To limit the methods and the responsibility to physicians is a willful act by society.

This leaves one main reason for committing the responsibility of assisting suicide to physicians: involvement of physicians gives it a much-desired moral certification, or imprimatur. Here is the logic, unspoken as it is:

  • Physicians have moral standing;
  • If physicians are involved,
  • Then the act has moral basis

But this gets it backwards. Physicians have moral standing based on what they do and what they refrain from doing. Edmund Pellegrino wrote often of the “intrinsic morality” of medicine which depended on the nature of the physician-patient relationship. Such morality stems as much from what is not done as from what is done.

We need not agree upon any particular bioethical issue to realize the significance of the tactic, in how it can could be used by proponents of various acts to enlist, and yes, even pressure or legally mandate, the involvement of physicians. Or, for that matter, the involvement other people whose life work is viewed by society as having moral standing.

If PAS were to be legal across the US, would physicians buy into the idea that it is consistent with the underlying ethic, or intrinsic morality, or their practice? I predict that most would not. Recall the vision of abortion (when first made legal by judicial decree) being done by the patient’s family physician, which presumed a longstanding benevolent and wise relationship. This of course failed to happen, and abortions have since become centered in facilities where patient and doctor remain, by no accident, strangers. Most physicians do not want to be associated with abortions ( and none of the many family physicians I’ve met) because they know that there is a quality to the act that impacts them; it would not be benign simply because they did it. And it is not consistent with the underlying moral and ethical basis for their medical practice.

So it will be with physician-assisted suicide. The strategic involvement of physicians will most certainly mean that some will be involved. But most who could be involved will decline, knowing, or at least sensing, the inverted logic behind how physicians got pulled into the affair to begin with.

“Grace” as a principle for the medical profession

The other day I was speaking to another physician about grace. This was at church, not surprisingly, but later I wondered why such discussions don’t occur in the hospital. When I recall the more remarkable physician-patient encounters I have seen, the word that comes to mind as the common theme is grace.

We can see it in the physician calmly and pleasantly treating the irascible and demanding patient in the darkest, bone-wearying moments of a long shift. We can see it in the compassionate but direct explanation of the direst of news to a frightened patient. We can see it in the happy celebration of a beautiful newborn to a relieved and exhausted mother. And we can see it in the bedside comfort given to a dying patient in those quiet moments when time slows down.

If one agrees that grace exists, then he ought to ponder from where we get it. For me it is clear: grace is God’s gift of Himself to us. We can speak theologically about godliness, but grace is a more specific and tangible manifestation of what that is. In medical ethics we have the well-known and practical principles of beneficence, non-maleficence, justice, and autonomy. But these describe the nature of what we should do. It is time, I propose, to speak of what we should be.

If we don’t speak of such things, then we ought to hope that they are at least manifest in our comportment, words, and deeds. Yet in our postmodern age, when society has abandoned such discussions, the mere mention of grace, something deeply profound, might strike that raw nerve in every man that fires the memory of something far greater than we’ve actually become. Or for many, want to become. And if the field of medical ethics is to move beyond an artful sophistry that produces philosophical justifications for our basest needs; if the profession of medicine is going to regain the moral standing in society for which it was created, then our medical schools must teach the highest principles. Like the magnificent blessing of grace we have received, that speaks to more than the nature of our acts, but to the nature of our being.

Abortion and the personhood of the fetus

In my post last week I addressed the idea that uncertainty about the personhood of a human embryo or fetus should lead us to think that we should refrain from causing harm to any entity that might be a person. Therefore, if we are uncertain about whether a human embryo or fetus is a person we should protect that embryo or fetus in case it is a person.

One of my students, Mark Taylor, wrote a paper this spring in the Medical Ethics class I teach that took a different approach to the disagreement in our society about the personhood of the human fetus in relation to the issue of abortion. In contrast to Judith Jarvis Thomson who took the position that abortion should be permissible even if the fetus is a person, he suggested that there are reasons to consider abortion impermissible even if the fetus is not a person.

His arguments are based on the idea that the impermissibility of an action is based more on the moral obligations of the person performing the action than on the rights of the object being acted upon. He presented an argument from aesthetics and virtue and an argument from justice that supported the position that abortion is impermissible even if the fetus is not a person. The first argument says that a fetus is a complex human organism which is a thing of beauty which has been created in most cases by an action chosen by the mother which was known to lead to the creation of such a beautiful being. To choose an abortion would be an irrational act that would be wrong in the same way that it would be wrong to create a great work of art only to destroy it. It would also violate the virtue of responsibility by engaging in an action know to add beauty to the world only to destroy that which is beautiful rather that caring for it. This argument only applies to the abortion of pregnancies that result from consensual sex, but those make up the vast majority of abortions. He argues that failure of contraception does not negate this argument since it is know that contraception is not foolproof.

The argument from justice is based on Rawls’ concept of justice as fairness and the use of the veil of ignorance. Central to Rawls’ system is the idea that a just society is one in which a person who does not know what role he or she will play in that society would judge the society to be fair. Taylor argues that one of those roles that the one judging the fairness of the society might assume behind the veil is the role of the fetus. Even if the fetus is not a person, we all go through the stage of being a fetus so just as the person behind the veil might take on the role of a child the role of the fetus should also be considered in whether the society is just. If the role of fetus is one that the one judging the fairness of the society may assume then it would not be concluded that if would be just to allow a fetus to be aborted.

These arguments suggest the possibility of being able to argue for the impermissibility of abortion no matter what position is taken on the personhood of the fetus. If the fetus is a person then the traditional arguments against of killing an innocent person apply. If we do not know whether a fetus is a person then we should refrain from killing an entity that could be a person. If the fetus is not a person there are still reasons why a person would have a duty not to destroy the fetus based on obligations of virtue and justice that are not dependent on fetal rights or personhood.

The implications of uncertainty about personhood

Many times the different parts of my life conflict with each other, but sometimes they come together in interesting ways. Susan Haack’s recent post on the article “The Fetus, the “Potential Child,” and the Ethical Obligations of Obstetricians” from the journal Obstetrics and Gynecology contained a quote that connected with a reference to an article by Christopher Tollefson by one of my students in a recent paper. The authors of the Obstetrics and Gynecology article stated that the issue of whether a fetus has full moral status is “irresolvably disputable” and from that drew the conclusion that the fetus has no independent moral status and subsequently reached the conclusion that abortion is permissible. Tollefson, however, has argued that an inability to decide whether a human being at a certain point in development has full moral status should actually lead to the opposite conclusion.

In his article “Embryos, Individuals, and Persons: An Argument Against Embryo Creation and Research” in the Journal of Applied Philosophy in 2001, Tollefson argued that in order to conclude that destructive research on human embryos is permissible it would be necessary to establish conclusively that the human embryo is not a person. His argument is that if it is uncertain whether an entity is a person or not it would be wrong to intentionally kill it. Therefore, it is wrong to conclude that it is permissible to do destructive research on early human embryos because we don’t know or can’t know whether those embryos have full moral status. The uncertainty about their moral status means that we should avoid the possibility of killing a person if those embryos would happen to be persons. That same idea can be applied to the “irresolvably disputable” issue of whether a fetus has full moral status. If the issue is unresolved then there exists the possibility that a fetus is a person with full moral status and we should not kill a fetus if that possibility exists.

An example that would be readily understandable to many of my rural Midwestern patients and neighbors can illustrate this point. Assume you are a deer hunter in the woods of rural Indiana and you see something move in the underbrush. You are not sure whether it is a person or a deer. It would be morally wrong to shoot at whatever was moving without determining with certainty that it was not a person. In the same way doing embryo destructive research or an abortion is wrong unless you are able to determine with certainty that what is being killed is not a person. Uncertainty about the personhood of the embryo or fetus means that it would be morally irresponsible to kill it.

It would be sad to think that the typical deer hunter has more moral responsibility than a medical researcher or physician.

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.

German debate about PGD

A recent article from Spiegel Online which is on the ABC News website discusses the debate about pre-implantation genetic diagnosis in Germany. Pre-implantation genetic diagnosis (commonly abbreviated PGD, but abbreviated PID in the article) is a technique in which one or a few cells are removed from a developing embryo produced by IVF and tested for genetic abnormalities. In the context of the discussion in Germany it is being used to allow parents who are known to be carriers of a serious genetic disorder to choose to give birth to a child without that disorder by choosing an embryo to implant who does not have the disorder from among the ones produced. Unlike the US, Germany carefully regulates reproductive technology and until 2010 PGD was illegal. A court ruling in 2010 led to a parliamentary amendment to Germany’s Embryo Protection Act to allow PGD to be used legally in exceptional cases in which parents are at high risk to have a child with a serious genetic disorder that can be detected by PGD.

Not everyone in Germany thinks this is a good idea. The arguments against PGD reported in the article come from medical ethicist Axel Bauer who wrote that he fears “that the possibilities PID offers will significantly reduce the range of ‘normality’ that will still be tolerated in our society in the future.” Hubert Hüppe, the German government’s commissioner for the disabled, says critically: “In the future, human life will only exist after quality control.”

Elke Holinski-Feder founder of the Medical Genetics Center in Munich that provides the genetic services for PGD says “I have a feeling that many of those who pass judgment on PID don’t know what we are doing here.” She says that those who oppose PGD are concerned about what it might lead to in the future, but she is concerned about parents who want to have a child but know through the experience of having a child who has died from or is living a very difficult life with a serious genetic disorder. She wants to be able to offer them the ability to have another child who is free of that disorder. Her argument is essentially that as long as PGD is limited to allowing those parents who are at high risk to have a child with a serious disorder to have a child without that disorder it should be allowed. That limitation removes the fear of reducing the range of acceptable normality in society since those detectable genetic disorders are only a small fraction of congenital abnormalities and would not allow the use of PGD as quality control. She says that going beyond that limited use, as is done in the US, would be wrong, saying “making a little sibling to be a donor for a child with leukemia, that’s not okay.” She adds that there are other ways to help those children.

What seems to be missing in this discussion is concern about the value of the life of the embryos that are discarded in the process of PGD when they are found to have a genetic abnormality. In her comments in the article Holinski-Feder does express concern about using prenatal diagnosis and abortion as a method for screening for the same genetic disorders. She says “Do you know what advice these families are usually given? Try it, and if it goes wrong, terminate the pregnancy!” She explains that is not the advice she wants to give her patients and sees PGD as a better solution. The only reference to the value of human embryos in the article is when Holinski-Feder says that when her students ask her: “When does human life begin?” she responds with a series of questions: “Imagine you were asked to place a picture of yourself as a child on the shelf. Which picture would you use? The zygote? The embryo? The baby?”

While concerns about the morally problematic things to which PGD opens the door are legitimate concerns, the most significant ethical concern about the use of PGD is the embryos that are discarded. For those who believe that human embryos have full moral status, destroying them for any reason is wrong. Even for those who do not think that human embryos have full moral status, a human embryo is a living human organism whose unique identity is continuous with the human person that the embryo will be after gestation and birth. To discard an embryo is to say that the life of that unique human being has no value or that his or her life is not worth living. That is something that the German people should be especially sensitive to avoiding since it was the concept of a life not worth living as expressed by German philosophers in the early 20th century that was the foundation for the elimination of mentally disabled children early in the Nazi regime and the springboard for more extensive atrocities.

Additional Thoughts on Sentience

Last week, I offered my opinion—a less-than-complementary one—on the decision of the American Animal Hospital Association (AAHA) to make a position statement that includes “the concept of animals as sentient beings.” My critique was based on the difficulty of assessing degrees of sentience in a very wide range of animals, making the broadness of the statement look like shabby ethical work, and its implicit agenda, avoiding direct mention of animal rights while using a term that is loaded with portent for the issuance of rights, perhaps indecipherable from the rights of human beings (a committed “anti-speciesist” like Peter Singer could be practically giddy!). Now to unpack that a bit…

There is no doubt that non-human animals display varying levels of sentience (just as human beings can, incidentally—try offering a no-anesthesia circumcision to anyone but a newborn baby boy). They have varying capacities for emotions and pain perception, based on varying levels of mental sophistication. One comment on my earlier post correctly stated that sentience is a capacity, and while capacity is a very poor way to measure the moral worth of humans, it may be one of many very fine ways to assess the moral status of non-human animals. But the “bright line” of separation must remain.

Even in the absence of a theological doctrine of humanity, the idea that human beings are moral agents and that a non-human animal, even if appropriately granted a substantial degree of moral status, is incapable of being a moral agent is significant. This is where a designation of “sentience” suffers from being both too broad and too narrow at the same time. In the first sense, it offers some implausibility. What about the practical implications of AAHA’s statement? Is animal slaughter humane enough, or should animals that we use for food be anesthetized beforehand? If I meet a grizzly on the path, should I have every expectation that his sentience means that we can work out a mutually-beneficial arrangement for our flourishing as we go our separate ways? In the second sense, that of narrowness, the intrinsic value of my humanity may, ironically, be diminished. Is my compassion for animals more a reflection of their power, their rights if you will, or a mark of my humanity? The California Veterinary Medical Association welfare guidelines issued in 2004 identified animals as “sentient beings with wants and needs.” Okay, fine. So how do we avoid a stalemate with humans who seem to have “wants and needs,” too, and often can make more articulate cases for them that even a well-socialized terrier? We are focusing on moral objects and not moral agents here, and not much can get done that way.

I would have been far more supportive of a position statement that was anthropological in nature, even as it included language that addressed the varying levels of sentience that animals may have. It is a practical reality that humane treatment for animals will arise from moral agents, humans alone, who realize that their Creator has made them to be wise stewards over creation, especially the vulnerable of their own species and the animals who share the Earth and much of the architecture of nervous systems with them.

Here’s what AAHA should have written, in my (clearly) less-than-humble-opinion:

“Because human beings have the unique role of moral agency and the awesome responsibility to ensure the welfare and flourishing of their own species, as well as the entirety of nature and the animals that we keep as companions and livestock and that inhabit the Earth we must wisely steward, we should take seriously the ability of animals to experience pain and other criteria associated with sentience in its various degrees among the wide range of neurological and mental sophistication that animals represent. It is this unique role that necessitates that humans should provide for physical and behavioral welfare to animals to the greatest degree possible, while minimizing pain and distress.”