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My “Top Ten Stories of the Decade” in Bioethics
Friday, January 8, 2010, 11:56 AM
Wesley J. Smith

The first ten years of the 2000s (please, no arguments over whether the first decade really ends this year) brought bioethics front and center into national and international prominence as never before.  Since this is the time for creating “top ten lists,” I pondered the matter over my eggnog over the holidays and compiled for NRO, the ten most important stories in bioethics of the last decade (in descending order), with commentary.  From my piece, “Technological Morality:”

10: The ascendance of an anti-human environmentalism...Radical environmentalism appears to have morphed into anti-humanism, the result of which could be a new impetus for eugenics and radical population control.

9. The growth of biological colonialism. Desperate and destitute people are increasingly being exploited for their body parts and functions…

8. The increase in American pro-life attitudes. In the last decade, polling showed a dramatic increase in the number of people who identify themselves as pro-life…If this trend continues, it could eventually shake the Roe regimen off its foundation.

7. The struggle over Obamacare. The political brouhaha over Obamacare was the bioethics story of 2009, not only in the U.S. but throughout much of the developed world…The debate will not end with the passage or failure of a bill, and health-care reform will likely be one of the most important stories of the coming decade.

6. Legalization of assisted suicide in Washington...[T]he Washington victory boosted the morale of assisted-suicide activists, who promise to wage an energetic legalization campaign in the coming decade.

5: The success of adult-stem-cell research...For example, in early human trials, adult stem cells have helped diabetics get off insulin, restored sensation to paralyzed people with spinal-cord injuries, helped heal unhealthy hearts, and provided hope to patients with autoimmune diseases such as multiple sclerosis. These and other amazing advances in adult-stem-cell research provided one of the few pieces of truly good news in a sour decade.

4. “Suicide tourism” in Switzerland. Over the last decade, Switzerland became Jack Kevorkian as a country, its suicide clinics catering to an increasingly international clientele…Alas, as was the case with Kevorkian in the 1990s, audacity was rewarded. In the face of a wave of high-profile suicide-tourism stories, England’s head prosecutor published guidelines that, in essence, decriminalized family and friends’ assisting the suicides of the dying, disabled, and infirm…

3. IVF anarchy... IVF has led to childbirth as manufacture, with our progeny chosen for their genetic makeup. It is likely that babies will soon be created with three parents. What comes next is anybody’s guess.

2. The Bush embryonic-stem-cell funding policy. When Pres. George W. Bush signed an executive order restricting federal funding of embryonic-stem-cell research to lines already in existence on Aug. 9, 2001, he set off a nearly decade-long firestorm…But the real poke in the eye for the Science Establishment and liberal media was that Bush’s policy sent a clarion message that embryos — which are, after all, nascent human life — matter, thrusting his policy into a buzz saw involving our most touchy cultural issues, particularly abortion.

1. The dehydration of Terri Schiavo. The emotionally wrenching tug of war over the life of Terri Schiavo, covered sensationally by the international media and culminating in her slow death, was — hands down — the decade’s most important story in bioethics (as well of one of the most important stories of the early 2000s). Who hasn’t heard her name? Who doesn’t have an opinion about what happened?

There is much more to say about all of these stories than I could in the abridged version presented here or in the entire article.  But I think it is very clear now: bioethics is important.  Soon, I’ll write up what I consider to be the ten biggest stories in bioethics of the coming decade.


Obamacare: Why Bioethics Matters
Wednesday, January 6, 2010, 2:19 PM
Wesley J. Smith

Yesterday, I posted about a bioethics article that advocated dropping human intrinsic dignity as a fundamental premise to be applied in bioethical analyses.  This meme is profoundly dangerous to the medically vulnerable.  Moreover and alas, human unexceptionalism is the mainstream view in the field, in the field, evidenced by the popularity of personhood theory within the movement and the “human undignified” article being published in Bioethics, a notable professional journal. (I have often said, if you want to see what is going to go wrong in the coming years, read the professional journals.)

This matters because of the wide influence wielded by bioethics in medical ethics, law, media reporting and analysis, public policy, and indeed, through those vehicles, upon the views of general society.  Here’s how I put it in Culture of Death (citations omitted):

It is important to note that bioethics is not a synonym for medical ethics and does not restrict its scope to the behavior of doctors in their professional lives vis-à-vis their patients.  Rather, bioethics concerns itself with the relationship between medicine, health, and society, a far broader and more consequential matter.  Moreover, many bioethicists presume an overarching moral expertise that is breathtaking in its ambition and hubris.  Many view themselves, quite literally, as the forgers of “the framework for moral judgment and decision making” who will create “the moral principles” that determine how “we are to live and act,” a “wisdom” they perceive as “specially appropriate to the medical sciences and medical arts.” Indeed, some claim that “bioethics goes beyond the codes of ethics of the various professional practices concerned.  It implies new thinking on changes in society, or even global equilibria.” (My emphasis.)  Not bad for a school of thought that has only existed for about 30 years…

Once bioethics moved away from ivory tower rumination and to actively influence public policy and medical protocols, by definition the field became goal oriented.  Indeed, University of Southern California Professor of Law and Medicine, Alexander M. Capron, notes that from its inception, “bioethical analysis has been linked to action.” If dialogue is linked to action, at the very least, that implies an intended direction if not a desired destination.  Even bioethics historian Albert R. Jonsen, a bioethicist himself, calls bioethics a “social movement.”  Has there been any social movement that was not predicated, at least to some degree, in ideology?  Moreover, the bioethics pioneer, Daniel Callahan, co-founder of the bioethics think tank, The Hastings Center, has admitted that “the final factor of great importance” in bioethics gaining societal respect, was the “emergence ideologically of a form of bioethics that dovetailed nicely with the reigning political liberalism of the educated classes in America.” Thus, mainstream bioethics is explicitly ideological, reflecting the values and beliefs of the cultural elite.

If Obamacare passes, the field will grow, if anything, even more powerful.  The proposed law will establish scores of bureaucracies and advisory boards.  The people who will serve on these boards, testify in front of them, and otherwise exert powerful sway over our centralized medical delivery system will be bioethicists.  That is too much–and too dangerous– power to be wielded by denizens in a field that generally rejects human exceptionalism and its corollary, the sanctity/equality of human life.


Pushing a Dangerous Anti-Human Exceptionalism “Undignified Bioethics”
Tuesday, January 5, 2010, 1:22 PM
Wesley J. Smith

A bioethicist named Alasdair Cochrane, who is, ironically, a deep thinker at the Centre for the Study of Human Rights in the UK, argues against intrinsic human dignity as a basis for establishing bioethical policies.  He attacks various theories that promote human dignity, e.g., “as virtuous behavior,” Kantian dignity, and as species integrity.  But my concern is his denial  of human exceptionalism and denigration of the concept of “inherent moral worth.”  From his article “Undignified Bioethics” published in the journal Bioethics (link to abstract):

The second important conception of dignity that we need to consider does not see dignity as a form of behaviour, but as a property. Under this conception, the possession of dignity by humans signifies that they have an inherent moral worth. In other words, because human beings possess dignity we cannot do what we like to them, but instead have direct moral obligations towards them. Indeed, this understanding of dignity is also usually considered to serve as the grounding for human rights. As Article 1 of the Universal Declaration of Human Rights states: ‘All human beings are born free and equal in dignity and rights.’

Do you now see the stakes in the debate over human exceptionalism? Cochrane hits the nail: If humans do not have intrinsic equal moral value, the philosophical bases of the U.S. Declaration of Independence (“We hold these truths to be self evident, that all men are created equal…”) and the UN Declaration of Human Rights, are rendered impotent, and universal human rights becomes impossible to sustain. Moreover, if we deny intrinsic human dignity, we open the door to using human beings as objects and mere natural resources.  Cochrane see this:

This conception of dignity as inherent moral worth certainly seems coherent enough as an idea. Indeed, we can also see why this conception of dignity is employed in certain debates around bioethics. For if all individual human beings possess dignity, then they should not be viewed simply as resources that we can treat however we please. To take an example then, it may be that we could achieve rapid and significant progress in medical science if we were to conduct wide-ranging medical experiments on groups of human beings. However, because human beings have dignity, so it is argued, this means that they possess a particular quality that grounds certain moral obligations and rights.

Alas, that crucial matter doesn’t matter to him, because he would rather judge each individual’s characteristics rather than the inherent attributes of our species:

If all human beings possess dignity–this extraordinary moral worth–we need some explanation of what it is about the species Homo sapiens that makes them so deserving. When we start looking at particular characteristics that might ground dignity – language-use, moral action, sociality, sentience, self-consciousness, and so on – we soon see that none of these qualities are in fact possessed by each and every human. We are therefore left wondering why all human beings actually do possess dignity.

Those individuals who happen to lack those attributes have either not developed them yet (embryos, fetuses, infants), or have illnesses or disabilities that impede their expression.  But those attributes are unique to the human species, they are uniquely part of our natures. That some have not developed, or have lost, them, is irrelevant–particularly given the stakes.  Indeed, judging the moral worth of individuals returns us to the pernicious thinking of eugenics and social Darwinism.

He claims, wrongly, that only Christian religion and its concept of the soul could justify human exceptionalism, which he denies as arbitrary and “controversial.” In place of human dignity, he argues a concept of “moral status:”

Obviously, given controversies over abortion, stem cell research, genetic interventions, animal experimentation, euthanasia and so on, bioethics does need to engage in debates over which entities possess moral worth and why. But these are best conducted by using the notion of ‘moral status’ and arguing over the characteristics that warrant possession of it. Simply stipulating that all and only human beings possess this inherent moral worth because they have dignity is arbitrary and unhelpful.

Hardly arbitrary, given the consequences of rejecting it and the uniqueness of human beings as the known universe’s only moral species.  Unhelpful, perhaps–in that it would prevent fetal farming, killing for organs, using human being as lab rats, and other utilitarian horrors.  But if we want universal human rights as a primary goal of society, intrinsic dignity is absolutely essential. He concludes his essay:

I urge for an undignified bioethics.

If we have an undignified bioethics, that is precisely the way we will treat the most vulnerable and defenseless among us.  In this sense, we can see how radically bioethics is straying from true liberalism based on the ideal of universal human equality.

This is why bioethics matters.  As proposed by Cochrane, bioethicists could become court apologists for tyranny. As we have seen in history, such advocacy by the intelligentsia opens the door to the most vile evil of which  man is capable.


Extended Discussion of Palliative Sedation in the New York Times
Sunday, December 27, 2009, 5:22 PM
Wesley J. Smith

Palliative sedation, that is putting an imminently dying patient into an artificial coma and allowing the disease to take its course, is a legitimate palliative technique–when the symptoms warrant it.  Thus, in the rare case where pain can’t be controlled or a patient panics due to severe agitation or inability to catch a breath, a legitimate answer is sedation.

This should give us all the great comfort of knowing we need not die in agony–no matter what our condition.  And today, the New York Times has a pretty good in-depth discussion of the issue.  It is too long to detail fully in a blog, but there are some points worth highlighting.  From the story:

Among those choices is terminal sedation, a treatment that is already widely used, even as it vexes families and a profession whose paramount rule is to do no harm. Doctors who perform it say it is based on carefully thought-out ethical principles in which the goal is never to end someone’s life, but only to make the patient more comfortable. But the possibility that the process might speed death has some experts contending that the practice is, in the words of one much-debated paper, a form of “slow euthanasia,” and that doctors who say otherwise are fooling themselves and their patients.

First, it shouldn’t be called terminal sedation because death isn’t the intent.  The words we use matter in this debate. Second, I don’t know of any palliative expert that opposes sedation as a last resort legitimate medical tool.  Indeed, if properly applied based on otherwise uncontrollable symptoms, palliative sedation isn’t slow motion euthanasia because the issue isn’t whether life is “shortened.” The issue is whether the physical suffering of the patient could not otherwise be alleviated. If not, and sedation is applied, then if death comes sooner–and as the article points out, there is usually little way to tell–it is a side effect of a legitimate treatment.

In this regard, it is important to remember that any medical treatment can have a lethal side effect. That isn’t the same thing as mercy killing. Consider: Sometimes patients die earlier than they would otherwise have during surgery intended to save life.  That is no more euthanasia than dying from legitimately applied pain control

Criticisms of legitimately applied palliative sedation, as mentioned above,  may be based on a vitalistic notion that anything that results in an earlier death is killing. But as noted above, that clearly isn’t true. Perhaps, more often, it is intended to blur the lines between euthanasia and palliation, to make the former easier to justify politically.

Among the intentional line blurrers is the assisted suicide advocacy organization Compassion and Choices–formerly the Hemlock Society–that clearly has ambitions to become the Planned Parenthood of death. C & C was the moving force behind pernicious legislation in California two years ago–AB 2747–that as originally written would have given a legal right to patients with one year or less to live to demand sedation and withdrawal of food and fluids–without regard to whether their symptoms warranted such radical action–so that death would be caused by dehydration.  (That part of the bill was defeated.) I wrote at length about AB 2747 here, for those who want more details.

That problem of blurred lines is addressed in the article:

There is one ethical guidepost for all the protocols: Terminal sedation should not become so routine that the end of life is scheduled like elective surgery, for the convenience of the doctor or the family, or because the patient’s care is no longer economically viable. Physicians occasionally feel pressure to turn up the medication, said Dr. Pauline Lesage, Beth Israel’s hospice medical director. The pressure may come from weary relatives, who say, in effect, “Now it’s enough; I just want him to disappear.” Sometimes the pressure is institutional. “You may be tempted to jump over because, oh well, ‘I need the bed,’ or ‘That’s enough, I don’t see what we are doing here,’ ” she explained. The doctors resist pressure to deliberately hasten death, she said. “Otherwise you see that you are jumping into a different field.”

Exactly.

Relevant to Obamacare and its intent to centralize the standards of medical treatment under federal control, we have also seen some apparent abuses of palliative sedation in the UK under the Liverpool Care Pathway–pushed by the country’s rationing board NICE–which seems to have been misapplied to treat dying patients as members of categories rather than individuals, meaning some received sedation whose symptoms did not warrant it.  Indeed, as I reported over at NRO, that seems to have led to the death by dehydration of at least one patient whose autopsy showed he had a treatable condition.

I am glad the NYT published the article.  And as I said, it is too long to really discuss in detail here.  I think certain distinctions could have been clearer.  But this is an issue worth knowing about.  Indeed, knowledge is the best way to keep it from being abused–both at the clinical setting and in the public square.


Obamacare: The Danger of “Evidence” Based Medicine
Wednesday, December 23, 2009, 12:49 PM
Wesley J. Smith

Don’t let the headline fool you: I am not against evidence based medicine when it is used as a guide for doctors to provide optimal individualized care.  But I am against using EBM as a method of establishing categories for health care rationing–whether of “what” or “who”–as I believe we are destined for under Obamacare.  One reason is that–like global warming computer models–it all depends on what evidence is included or excluded in creating the studies. That means the evidence could well be cooked.

This point was acknowledge in the New York Times, of all places, in a recent article on end of life care.  From the story:

The Ronald Reagan U.C.L.A. Medical Center, one of the nation’s most highly regarded academic hospitals, has earned a reputation as a place where doctors will go to virtually any length and expense to try to save a patient’s life. “If you come into this hospital, we’re not going to let you die,” said Dr. David T. Feinberg, the hospital system’s chief executive. Yet that ethos has made the medical center a prime target for critics in the Obama administration and elsewhere who talk about how much money the nation wastes on needless tests and futile procedures. They like to note that U.C.L.A. is perennially near the top of widely cited data, compiled by researchers at Dartmouth, ranking medical centers that spend the most on end-of-life care but seem to have no better results than hospitals spending much less.

Listening to the critics, Dr. J. Thomas Rosenthal, the chief medical officer of the U.C.L.A. Health System, says his hospital has started re-examining its high-intensity approach to medicine. But the more U.C.L.A.’s doctors study the issue, the more they recognize a difficult truth: It can be hard, sometimes impossible, to know which critically ill patients will benefit and which will not. That distinction tends to get lost in the Dartmouth end-of-life analysis, which considers only the costs of treating patients who have died. Remarkably, it pays no attention to the ones who survive.

Perhaps not so remarkable. I don’t know if it is true in this case, but the scientific study has become a method of ideological advocacy, and in such reports, the deck gets stacked.  In other words, sometimes the authors of such studies know what they don’t want to know because they have a result in mind rather than dispassionate analysis.

The Times gives an example:

Take the case of Salah Putrus, who at age 71 had a long history of heart failure. After repeated visits to his local hospital near Burbank, Calif., Mr. Putrus was referred to U.C.L.A. this year to be evaluated for a heart transplant. Some other medical centers might have considered Mr. Putrus too old for the surgery. But U.C.L.A.’s attitude was “let’s see what we can do for him,” said his physician there, Dr. Tamara Horwich. Indeed, Mr. Putrus recalled, Dr. Horwich and her colleagues “did every test.” They changed his medicines to reduce the amount of water he was retaining. They even removed some teeth that could be a potential source of infection. His condition improved so much that more than six months later, Mr. Putrus has remained out of the hospital and is no longer considered in active need of a transplant. Because Dartmouth’s analysis focuses solely on patients who have died, a case like Mr. Putrus’s would not show up in its data. That is why critics say Dartmouth’s approach takes an overly pessimistic view of medicine: if you consider only the patients who die, there is really no way to know whether it makes sense to spend more on one case than another.

And here’s where Obamacare comes in:

Under the House health care legislation pending in Congress, the Institute of Medicine would conduct a study of the regional variations in Medicare spending to try to determine how to reward hospitals like Mayo for providing more cost-effective care. Hospitals identified as high-cost centers might even be penalized, perhaps receiving lower payments from the government…That prospect worries Dr. Rosenthal and his U.C.L.A. colleagues, who say that unless the distinction can be clearly drawn between excellence and excess in medical care, efforts to cut wasteful spending could be little more than blunt rationing. “There’s a real risk of doing harm here — real harm,” he said.

This is a very good article, illustrating that the outcome of “studies” depends on its design, and indeed, they may mislead more than they edify.  That point aside, this is a prime example of why it would be wrong to begin treating patients as members of a category instead of as an individual.  Statistics provide general guidance. But they are no substitute for personalized care.


Flash Forward: The Year in Bioethics 2010
Wednesday, December 9, 2009, 3:26 PM
Wesley J. Smith

Each year, the CBC asks me to predict what will happen in the coming year in bioethics.  I have done so.  From my piece:

“Flash Forward” is a new and interesting television drama presented on the ABC Television Network. The premise is brilliant – due to reasons still unknown, everyone in the world (except the bad guys) blackout for two minutes seventeen seconds. Planes crash, people collapse on the streets, swimmers drown, it is an utter catastrophe that results in the deaths of 20 million people. Being unconscious, blackout victims experience a “flash forward” – a vision of precisely what they would be doing for two minutes and seventeen seconds at the same specific time in April 2010. Some have happy futuristic visions of new loves, some unhappy of broken marriages and deaths, some terrifying such as being murdered, one hilarious – an FBI supervisor is chagrined to admit he spent his entire flash forward on the toilet. Still others have nothing but blackness, indicating that they may be dead next April. The show raises several fascinating questions; whether free will exists, can “the future” be changed , indeed, can it really be predicted.

My main focus is Obamacare.  Here is how I see it coming to pass:

I predict a health care reform bill will be signed into law in 2010. That’s the easy part. The question becomes, what will it look like? That is hard to say since many of the important details will be determined by the tens of thousands of regulations promulgated to carry out the law in over the next few years. Still, the outlines are growing clear in my crystal ball. Here is my personal Obamacare flash forward:

The Public Option. One of the biggest controversies surrounding Obamacare is whether there will be a government health care plan to compete with private insurance companies. I predict that the pure PO will not become law in 2010. Instead, there will be a hybrid alternative enacted permitting non-profit companies – and only non profit companies – to join a government authorized purchasing collective. Whether they will actually threaten the private insurance sector – which I believe is the intent – will not become clear until after the law goes into effect in 2013.

Heath Care Rationing. Obamacare doesn’t call explicitly for health care rationing, but creates its foundation with the establishment of cost/benefit/best practices boards that will be given tremendous sway over the standards of medical care and extent of coverage for both private and public plans. There is almost zero chance these boards will not be part of any law that passes. That means health care rationing will remain a looming specter and a cause for continuing societal debate for years to come.

Abortion. Companies participating in the public exchanges will be required to provide some abortion coverage, but there will not be direct public funding of most abortions. However, the law will permit regulators to require indirect public funding, for example, allowing abortion coverage to be purchased with government vouchers or tax credits.

End of Life Counseling. The provision allowing doctors to be compensated for providing end of life counseling will pass. But the law will require that it be voluntary and not directed to any particular decisions or outcomes.

Illegal Aliens. The law will not explicitly provide for coverage for people who are not legally in the country. But it will not require purchasers of government underwritten health insurance to provide proof of legal status, meaning that undocumented aliens will find ways to purchase health insurance under Obamacare.

I also discuss what I think will happen with assisted suicide, health care rationing/futile care theory, and embryonic stem cell research.  Tune in to see the future.  Or, I could be wrong.  I have been both in years past. I am also interested in your predictions.  Let’s have a little fun with this.


Utilitarian Bioethics: We’re All Just Natural Resources Now
Wednesday, December 9, 2009, 12:27 PM
Wesley J. Smith

I have detected a new bioethical thrust being trotted out among the would-be medical ruling class–that each of us have a duty to be experimented upon.  First it was President Obama’s bioethicist-in-chief Ezekien Emanuel.  Now a medical professor named Anthony Mathur in the UK tells the BBC that willingness to be experimented upon should be a condition precedent to receiving medical treatment.  From the column:

Without doubt the future of medicine is dependent on clinical research that, in turn, relies on the willingness of patients to be exposed to new therapies. There exists an unwritten contract between society and medicine which acknowledges the interdependence of the two – the only way that important advances in medicine can be made is with the help of patients volunteering to participate in clinical trials. However, our experience at a major teaching hospital in London is that as the nature of new treatments becomes more complex, the willingness of our patients to participate in these trials has decreased…

But we’re supposed to believe in patient autonomy–certainly where experimental procedures are concerned!  Right?  Not necessarily:

Maybe a new contract is needed between medicine and society that assumes a default position that says that everyone attending hospital should be involved in medical research, unless they specifically opt out of the process at the time of consent? This approach has already been used in some European countries for organ donation and has led to a quadrupling in consent rates. Whatever the solution, the clinical trials await patiently those willing to put their faith in the system and hope for medical breakthroughs, if not for them, then for the benefit of others.

Forget the “maybe” hedge, typical of bioethical opinion thrusts of this genre.  This writer wants the power to deny treatment to people who do not agree to be researched upon.  Goodbye patient autonomy and informed consent, hello medical utilitarianism.

What’s the bigger picture here?  This kind of coercive thinking is a consequence of deciding that ending suffering as the overriding purpose of society, an issue we have addressed here before. Eventually, accepting this view leads to a loss of individual freedom–as in non or involuntary euthanasia–and apparently, also forced “altruism,” which is just another way of saying that we are all natural resources now.


Ron Houben/Terri Schiavo: Art Caplan Misses My Point
Saturday, December 5, 2009, 11:57 PM
Wesley J. Smith

Bioethicist Art Caplan has weighed in against my Weekly Standard column.  But he misses, or at least, fails to address, the primary point of the column.  From his blog:

Wesley Smith has a new column out, in which he inappropriately uses the case in Belgium of Rom Houben to argue that somehow Terri Schiavo should not have been permitted to have her feeding tube removed. Smith argues that a case of locked-in syndrome is somehow analogous to the chance of recovery for someone in a PVS state post anoxia. I would like to have him find three neurologists who agree with that claim.

I certainly do think Terri should not have had her feeding tube removed, but not because of the Houben case.  (I have a whole series of columns I wrote about the many reasons for this view, and why I think it was a profound injustice. They are available at my articles archive for those interested.) Rather, I am of this opinion because she was a living human being who died only because she was deprived of all nourishment, based primarily on what I consider to have been an invidious judgmentalism, pushed by a husband, who by the time he decided he wanted her to die, was living with another woman (now his wife), who he then called his fiance, with whom he was already having children.  And that wasn’t the only apparent conflict of interest. Indeed, the guardian ad litem in the case recommended against dehydration due, in part, to a large financial conflict of interest, after which he was booted off the case based on a supposed bias against Michael Schiavo’s attorney. No other ad  litem was ever appointed for her in the case in chief–and that was far from the only irregularity in the case.

Nor did I analogize Houben’s locked in state to Schiavo’s either PVS or minimally conscious state.  They are not the same neurologically. But the point wasn’t neurological. Both people were fully equal to each other, Art, me, and indeed, each of us.

But now that Art brings it up, consider: Terri was dehydrated to death nearly 5 years ago.  Five years ago, everyone except his family, thought Houben was PVS.  Thus, at the time, he would have been considered just like Terri. Even if one thinks that PVS patients should be dehydrated–and I certainly don’t–about 40% of these patients aren’t really PVS.  When we countenance dehydrating them, we are almost surely ending the lives of some people who are actually conscious, perhaps even a few like Houben, who are fully awake but locked in. This almost happened, for example, to Kate Adamson, who went without most fluids for days after an intestinal blockage, and called it more agonizing than when she had surgery with inadequate anesthesia because the doctors thought she was unconscious.

Art knows that conscious people are withdrawn from sustenance, but it doesn’t matter:

As a final point, it is important to point out that not only was Terri Schiavo in a PVS state with 100% certainty, but her husband could have directed her care to be stopped in the State of Florida even if she had been in a minimally conscious state or, for that matter, a 23 year locked-in state. No one is bound to accept medical care if it violates their religious or personal views about what they want from medical interventions. The fact that Wesley is arguing that Houben proves there was hope for Terri Schiavo neglects the core issue of the case–can a spouse direct care be stopped on the grounds that it’s provision violates the wishes and values of the patient.

Actually, I think in Florida (at least at that time), the patient had to be PVS to have food and fluids removed when there was no advanced directive.  But even so, what Art states is correct generally. That is why I have argued food and fluids should be considered in a medical category all its own. Remove antibiotics, even kidney dialysis, and the results are not 100% certain. Remove food and water from anyone, and they will die in about two weeks.

But again, even that wasn’t the point of the column.  I wrote the column in the way I did because I noticed so many in the media made a beeline to the Schiavo case as soon as the Houben news broke. There’s a reason for that.  What we did to her still cuts deep.


What Kind of Prophet Am I?
Thursday, November 19, 2009, 12:28 AM
Wesley J. Smith

Each fall the CBC asks me to predict what will happen in the coming year in bioethics/biotechnology. To say the least, I have a mixed record.  I was more worried about 2009 than turned out to be warranted by events especially about assisted suicide which moved the ball not at all in the USA.  (The UK was a different story altogether.).  The stem cell predicting the demise of the Bush ESCR funding policy was a gimme, but Obama stepped over the line of expectation–and destroyed a good and uncontroversial policy–by revoking Bush’s 2007 order requiring non embryonic pluripotent stem cell research to be federally funded. That’s when I really knew–I already had suspected–that Obama was not a great compromiser, much less a committed uniter–he is an ideologue.

In any event, here are a few more matters I got right, wrong, and missed altogether.  From my column, “2009–A Not so Dark Year After All:”

Miscellaneous

I made several predictions in other bioethical fields, and proved pretty prescient, but not infallible.

Abortion. I predicted that the Freedom of Choice Act (FOCA) – which would erase all state laws limiting abortion – would not pass. Not only did the bill not pass, no efforts were made to move the bill. However, I was wrong that federal funding for abortion would be permitted by the end of the year. That remains a goal of the Administration and the leaders of Congress, but as of now, it remains an unrealized goal.

Conscience Clauses. A great bioethical battle is coming over whether medical professionals who do not wish to be complicit in life-ending activities – such as abortion or assisted suicide – will be driven out of health care. I predicted that the “Bush Conscience Clause” protecting such dissenting health care workers would be overturned by the Obama Administration. I was certainly right that the effort would be made. Indeed, the effort was one of Obama’s first official acts. But bureaucracy being what it is, as of this writing, the revocation has not been published in the Federal Register. Meanwhile, a Ninth Circuit Court of Appeals ruled in a contraception case that a Washington regulation requiring all legal prescriptions to be filled did not violate the right to freedom of religion. If this case sticks, not only would Washington pharmacists with a religious objection to contraception be required to dispense birth control, but also to provide lethal prescriptions for use in assisted suicide…

Futile Care. Alas, I was right that Texas would not rescind its law legalizing medical futility in 2009. I was wrong that a major lawsuit in the field would make big news. Other than a temporarily stalled attempt to legalize futile care in Idaho, the field was generally quiet in 2009.

Biological Colonialism. I worried that despite legal attempts to restrict the exploitation of the world’s destitute for their body parts, biological colonialism (such as buying organs), would increase in 2009. While there were no reliable studies published about this, it is clear that at the very least, the problem remained undiminished.

Missing the Story of the Year

My greatest failure – and it’s a whopper – was missing the entire brouhaha over Obamacare. I expected health care reform to be introduced. But I never anticipated it would bloat to a 2000-page bill or that Congressional leaders would try and push the behemoth through with such scant opportunity for democratic debate. And because I missed the ruthlessness of Obamacare’s pushers, I also failed to predict the commitment and resiliency of the resistance. In other words, I wrote not a word about what turned out to be the biggest story in bioethics of the year. Why I still have this predictor gig is beyond me.

I am a bit chagrined about not seeing the approach of the big debate over Obamacare. Perhaps I thought he would learn from Hillarycare and not try to do a complete makeover.  No such wisdom.

Jennifer Lahl tells me I am still the in-house prophet, so next month, I’ll sacrifice a bull and examine its intestines to tell you what 2010 will look like.  Hey, if it was good enough for the Romans…


Final Reflection on Baby RB Case
Wednesday, November 11, 2009, 5:39 AM
Wesley J. Smith

The UK is the land of good newspapers, and salacious ones, but lets leave that part alone.  And each of the majors has a vivid voice: The Telegraph, more conservative; the Guardian, definitely liberal; The Independent, very liberal, while the Times has imploded; whatever it once was, it generally is no longer.

I bring this up because there was a good and thoughtful editorial in the Independent today about the Baby RB case, that has now ended with the father’s surrender to the doctors’ and his wife’s desire that life support be ceased.  From “Hard Cases Make Good Law:”

Technology is enabling doctors to prolong lives that would until very recently not have been viable. Baby RB, the court heard, had a severe muscular malfunction and could not breathe unaided; doctors caring for him essentially agreed that his affliction made any future life he might have not worth living. Against that had to be set the potential fallibility of doctors, the possibly conflicting interests of the parents and the child, the principle of the sanctity of life, and the less edifying matter of the cost to the public purse.

Many of these same issues came into play in the long-fought case of Charlotte Wyatt, where the parents eventually won the right not to have treatment withdrawn without their say-so. Charlotte survived against the odds; now five years old, she is reported to be thriving in foster care.

In their separate ways, the cases of Charlotte Wyatt and Baby RB reached conclusions that were acceptable, if deeply painful, to all concerned. And the way things turned out the court’s intervention in both might now seem peripheral. Yet it is surely right that the arguments should be aired in this way. At a time of rapid medical advances and shifting public mores, the judgement of professionals needs to be tested – and the court is the place to do it.

I agree.  That is why futile care cases have no place being decided in closed door star chamber settings of anonymous bioethics committees, where there is no public record, right to confront witnesses, or appeal.

But more needs to be said than in the editorial.  What are the standards that should be applied when judging these difficult cases?  I think the Independent, as liberal as it is, hinted at it–the sanctity of human life must count more than the public purse.  That should mean no one is rationed out of life and no one pushed out based on quality of life judgmentalism.  Rather, when in doubt or when there is a dispute, the default choice should be life.

Such a legal presumption would not institute rigid vitalism, but it would require those who want to force treatment to cease to prove clearly why a different decision should be made.  Such a hurdle wouldn’t stop parents from deciding on what is best for their children, whether to cease or continue treatment–or children, similarly, what is best for their parents–but it would prevent bioethicists and other assorted would-be rationers from forcing patients and their families down a one-way street that they would not otherwise choose for themselves.

These are difficult times to be expensive for which to care.  That is why we must walk the extra mile to validate the moral worth and equal humanity of such people before society and in law.

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