The 83rd Legislature of the State of Texas still has a couple of weeks to go, and it ain’t over ’till both the House and Senate are sine die, but it appears that SB 303 did die over the weekend.
Representative Susan King, who broke her leg last Sunday, just the day before the marathon meeting of the House Public Health Committee, has done an incredible job of working with Senator (Dr.) Bob Duell in their attempt to reform our State’s Advance Directive Act through SB 303.
The Committee Substitute which Representative King presented in the Committee had all of the benefits I wrote about last week, as well as a revision to prohibit a doctor from writing a DNR order against the wishes off a competent patient.
(Talk about unintended consequences: current law is silent on “DNRs,” so it’s apparently legal for a doctor to order that resuscitation not be performed on a competent patient without any discussion with the patient, much less obtain consent! I have sincere doubts that any doctor would do so, but there have been allegations. Even though the ones who claim to have knowledge – and who have not produced one iota of proof – are the same disingenuous cynical scaremongers (I’ll call them “CS2″) I’ve mentioned before, this reform would be a good. And should be accepted on its face.)
Because of the egregious misrepresentations of the CS2, Committee Chair Lois Kolkhorst declined to allow SB303 out of the Committee as it was written. Rep. King tried one more time, with a bare bones CS1 containing the protection against DNRs for competent patients and the prohibition against withdrawal of Artificial Hydration and Nutrition, except when it would harm the patient or hasten his death.
So, for the next two years, when you hear the CS2 complain about Texas “death panels” or read a plea for funds to fight “secret DNRs” and withdrawal of food and water in Texas hospitals, remember the CS2 who killed pro-life reform in the 83rd Legislature.
If we can still believe scientific journals, Cell reports in the June 6, 2013 issue indicate that scientists have succeeded in cloning human embryos.
The term used for cloning by the group is “reprogramming” fibroblasts using somatic cell nuclear transplantation. However, there’s no longer an attempt by the authors or members of the scientific press to create a new “unfertilized blastocyst” or pre-embryo: the embryos are called embryos, morula, and blastocysts.In recognition that these are not quite the same as embryonic stem cells derived from embryos produced by direct fertilization, the stem cells derived from the cloned blastocysts are designated as “Nuclear Transfer Embryonic Stem Cells” or NT-ESC.
Tachibana’s group obtained well over a 100 oocytes from women who underwent ovarian stimulation and transvaginal retrieval.
The growth of four embryos to the blastocyst stage resulted in NT-ESC, after differentiation into a blastocyst with a trophoblast (precursor of the placenta) and the inner cell mass (the part that will develops into the actual body of the human). These embryos were destroyed to harvest the ICM.
The report details years of research to find the optimum technique for cloning human embryos. It was found that the mitotic stage of the oocytes, MII, is critical. The researchers further developed a protocol utilizing caffeine and electrical stimulation to induce activation of the fused nucleus from the skin cell and donor oocyte. In addition, the authors found that “higher quality oocytes,” those more likely to form viable embryos, resulted when the ovarian stimulation yielded fewer than ten oocytes. If larger numbers of oocytes were produced due to the ovarian stimulation, somatic cell nuclear transfer was less likely. In fact, the first four clones that developed far enough to produce NT-ESC came from one woman who donated eight oocytes in one cycle, resulting in the production of five cloned embryos.
There are several ethical problems which surround this research.
First, as strongly noted by the Center for Bioethics and Culture, the ovarian stimulation risks abuse of women who might be placed at risk due to the hormones administered to induce ovulation. As noted in the paper,
“In the context of generating patient-specific pluripotent stem cells, reproducible results with various patient-derived somatic cells and with different egg donors are a necessity.”
Although the donation is called voluntary and anonymous, the women were compensated for their “time, effort, discomfort, and inconvenience associated with the donation process.” I can’t help but wonder about how long the anonymity will last for the one woman whose oocytes yielded those first four successful clones and NT-ESCs or for the two women whose oocytes yielded the clones confirming the reproducibility of their method, in the second stage of the research. Or how much pressure they will face to continue to donate “voluntarily.”
The lack of concern for the women involved is revealed in this interview with the authors at The Scientist,
““I was worried that we might need a couple of thousand eggs to make all these optimizations, to find that winning combination. But it actually took just 128 [eggs], which is a surprisingly low number to make 6 [hESC] lines.””
6 NT-ESC lines were derived from 128 harvested oocytes, for a yield of 4.6% In later stages, the success rate was still 2 NT-ESC lines from 7 embryos and 15 oocytes, or 13% of oocytes.
The primary objection is that 100% of the human embryos were created in harm’s way and must be destroyed to harvest the NT-ESCs.
These embryos are delayed human twins, artificially induced. Although the first cell of these embryos began in the lab, as the result of highly technical and involved procedures, they are human embryos and near-identical twins of the somatic cell nucleus. There is indirect acknowledgement that the embryos are twins of the donor of the fibroblasts by the reporting that tests of the chromosomes of the cloned embryos show that the DNA matches that of the donor of the fibroblasts, a patient with Leigh’s syndrome.
The sources of fibroblast nuclei raise other ethical dilemmas. The first research was carried out using female fetal fibroblasts. Later research involved creating human embryos with Leigh’s syndrome. Leigh’s syndrome results from a genetic defect of the mitochondria, the cell “power plant,” which is inherited from the mother and only found in the cell cytoplasm, not the nucleus. Reports are already ignoring the fact that the donor’s twins were produced with the express intention of destroying them for their inner cell mass. At least one is predicting that this is a technique which can be used to create future children for mothers who have the abnormal mitochondria.
The report, Tachibana et al., “Human Embryonic Stem Cells Derived by Somatic Cell Nuclear Transfer,” Cell (2013),http://dx.doi.org/10.1016/j.cell.2013.05.006, is available on-line and in PDF (as of today).
Note: I’ve heard that there’s a new Committee Substitute that will soon be introduced that is more explicit on DNR’s, especially on informed consent and on competent patients.
If laws demand that physicians perform acts against our consciences, you will end up with only doctors without consciences willing to perform the acts in question.
After a few more words about the meeting of the 83rd Texas Legislature Public Health Committee, I’ll post my written testimony that I turned in to the Committee. You can watch the video of the meeting, here. My testimony begins about 4:59/8:20.
I spoke just before midnight, after many others had covered the good (or bad, depending on their opinions) reforms in SB 303, so I didn’t really go in to those when I talked. Instead, I explained how I handled the few times I’ve had to write DNR’s without consent from the patient or a surrogate.
I also talked about the medical judgement of physicians, about the definition of the “right to life”as a negative right. This means that I can be prohibited from killing, but not that I can be forced to indefinitely act against my conscience and medical judgment. It’s a tough concept, meaning no one can claim that their right to life means that they can take my food and shelter, my labors or my liberty to keep them alive.
Then, I explained that yes, doctors have a special relationship, a covenant or, at least, a professional relationship due to our privilege of practicing medicine. But the duties aren’t unlimited and they are not all one way. The 10 days plus 21 days in the version of SB303 that we were discussing that night should be a sufficient time trial or test of time for the patient and the doctor’s decisions about the medical treatment, including DNR’s, that the family demands.
The explanation about the nature of medical judgment that I gave is in the written testimony:
May 13, 2013
Chair Kolkhorst and members,
The Texas Advance Directive Act of 1999, created a procedure for resolving disagreements between doctors and their patients or surrogates about which interventions are medically appropriate. The experiences of patients and doctors during the few times that procedure has been invoked over the years, revealed some problems.
The reforms in SB 303 improve the Advance Directive Act by
· Giving patients and their surrogates much more time and assistance than current law provides in order to prepare for the ethics committee meeting and, if necessary, to find a new doctor willing to accept responsibility for the care of the patient,
· Clarifying the succession of surrogates under state law,
· Protecting the patient’s access to artificially administered hydration and nutrition,
· Restating Texan’s belief that patients should be treated equally regardless of age, disability or ability to pay,
· Adding a whole new section regulating the implementation of Do Not Attempt Resuscitation orders, which our State law hasn’t addressed at all in the past, and
· By protecting the conscience rights of doctors from undue threat of civil, criminal and regulatory liability.
After all, while the hospital provides structure in the form of policies and the medical committee provides oversight about ethics and standard of care, it’s doctors like me, not hospitals or committees, who practice medicine using our medical education and experience guided by conscience, or medical judgment. Medical judgment, not lawyers and paperwork at the bedside, is what enables me to predict the effectiveness of interventions before I order them.
Like all but a handful of Texas doctors, I’ve never had to ask for a medical ethics committee review, but I have had to ask another doctor to co-sign a DNR when I couldn’t find a legal surrogate. As a family doctor, I’ve found that algorithms and “cookbook medicine” or lines of succession for absent family members sometimes aren’t enough when a patient’s physical condition is deteriorating quickly or even when disease runs its expected course, causing organ system after organ system to fail.
Ethics and laws generally lag behind medical advances. Once upon a time, people who couldn’t breathe for themselves were considered to have died a “natural death,” but we keep changing the rules about what we expect human bodies and the “art” of medicine to do. Please support the necessary and important reforms in SB 303.
Thank you for your time and attention,
Beverly B. Nuckols, MD, FAAFP, MA (Bioethics)
Last night, an emergency meeting ot the 83rd Texas Legislature’s Public Health Committee addressed Senate Bill 303, by Senator Duell in a 12 hour long meeting. Representative Susan King, who authored the Companion Bill in the House and sponsored SB303 in this meeting, appeared only one day after a fracture of her tibia. This woman is a hero!
I also want to thank Chair Lois Kolkhorst for ensuring that the meeting was held so that SB303 – and all the people who are so passionate about patients rights and good medicine in Texas could be heard.
It was wonderful to see all the people who volunteer so much of their time to influence Texas law – even when they disagreed with me. What a pleasure to meet new friends, including a gentleman whose name I can’t recall (will fix this later) and Jacqueline Harvey, Ph.D.
Here’s an excerpt from Dr. Harvey’s testimony,
While opponents say that S.B.303 grants power to providers to remove care patients in irreversible conditions, I’d remind them again that one cannot extend to providers power which they already legally possess. Opponents claim that S.B. 303 adds this broad definition, when in fact; this broad definition was established in TADA and is current Texas Law. What S.B. 303 does is add protections to prohibit discrimination against persons with disabilities by ensuring that care may be removed only when harmful (i.e. treatment would fail, hasten patient death, exacerbate another medical condition or cause unnecessary pain). These conditions are standard medical ethics a la “do no harm.”
I’ll write more after I get a chance to review the video of the hearing. There’s some sort of glitch at the Legislature Audio and Video page. (Might have something to do with 12 hours of recordings, ending after 2 AM)
Life After Life: A Novel, by Kate Atkinson is based on the premise that the protagonist, Ursula Todd, lives her life over and over and over and over. The suggests that the reason might be so that she can do it until she gets it right. Ursula never seems to get it right.
The book illustrates the main reason I don’t believe in multiple universes or reincarnation. The Creator seems to have set up an orderly universe, with predictable consequences – you know, those laws of physics like, an object in motion tends to stay in motion, conservation of mass and energy in a closed system, and that for action there’s and equal and opposite reaction. He has also instilled unconditional love as our highest value. None of which is consistent with forcing us to go through life – or death – over and over until we get it right.
The best part of the book is that most of the story takes place in London during World War II. Ursula was born, each time she was born, in 1910, so she was a teen during the War to End All Wars and a young woman working for the British Government during the Battle of Britain and the Blitz. We Americans are blissfully ignorant of the nightly (“save one”) bombing of London for 10 weeks in September and October, 1940, followed by bombing of that city and others by the Germans the attempt to instill terror in the British and to literally destroy Britain. I am in awe of the people who lived through those nights and of the Air Raid Wardens who served them.
The author pretty much lost my respect for her insight because of a scene in which Ursula is raped. I’m not sure the act could physically be completed the way it’s described, but there’s no way that rape is that nonchalant, non-violent and silent. Perhaps it would have been more plausible if she had induced a fugue state in Ursula. Ms. Atkinson does a much better job with the miserable timeline during which Ursula marries an abusive husband.
There is an interesting detour as Ursula sort of falls into the outer ring of Adolph Hitler’s inner circle.
I only finished the book because of the Battle of Britain stories and a hope of making some sense out of the author’s concept. Or maybe I just wanted a happy ending?
Gov. Rick Perry today issued the following statement on the Kermit Gosnell verdict:
This trial and verdict shed light on a detestable and gruesome industry that takes the lives of hundreds of thousands of babies every year in communities across our nation. Those of us who believe in the sanctity of life will continue to fight for the day when abortion is nothing more than a sad footnote in American history.
“Father Tad” is the Director of Education at the National Catholic Bioethics Center. The Texas Catholic Conference published his commentary on “DNR’s” on May 10, 2013.
These judgments are tricky to make, because the specifics of each case differ, and those specifics change with time and disease progression. DNR’s should be put in place only when the circumstances warrant it, that is to say, on a case-by-case, patient-specific basis. In other words, when CPR/resuscitation can reasonably be determined to no longer offer a hope of benefit to the patient or if it entails an excessive burden to him, at that time a DNR can be put into place.
Some of the possible burdens that may need to be considered in deciding whether to pursue resuscitative interventions for a patient would include some of the following: the risk of rib or other bone fractures, puncture of the lungs by a broken bone (or from the trauma of lung compression and decompression), bleeding in the center of the chest, cerebral dysfunction or permanent brain damage, the small risk (about 3 or 4 percent) that the patient might end up entering a vegetative state, and subsequent complications if the patient ends up staying on a ventilator for an extended period following the resuscitation.
During resuscitative efforts, elderly patients are more likely to experience complications or to have ribs break during CPR. Younger patients, on the other hand, tend to show a greater resilience and are often better able to tolerate CPR. Patients suffering from advanced cancer are also known to fare poorly following resuscitative efforts.
In terms of overall statistics, when a patient codes in the hospital and all resuscitative measures are taken, patients frequently do not end up leaving the hospital, especially when they are elderly or have other co-accompanying conditions. Based on data from the National Registry of Cardiopulmonary Resuscitation (NRCPR), studies have determined that patients who undergo cardiac arrest in the hospital have an overall survival to discharge rate of about 17 percent. The rate drops even lower (to around 13 percent) for cancer patients. In other words, the benefits are oftentimes few and short-lived, while the burdens tend to be high. There are, of course, exceptions — while many patients do not experience significant benefits from resuscitative measures, a small percentage do.
So when death is imminent, and disease states are very advanced (perhaps with multiple organ failure), and assuming other spiritual matters, such as last sacraments, have been addressed, a DNR order may not raise any moral problems. The key consideration in making the judgment will be to determine whether the benefits of resuscitation outweigh the burdens. So when death is imminent, and disease states are very advanced (perhaps with multiple organ failure), and assuming other spiritual matters, such as last sacraments, have been addressed, a DNR order may not raise any moral problems. The key consideration in making the judgment will be to determine whether the benefits of resuscitation outweigh the burdens.
DNR orders can be misused, of course, if they are broadly construed as calling on medical professionals to abandon or otherwise discontinue all care of a patient. Even as patients may be declining and dying of serious underlying illnesses, we must continue to care for them, support and comfort them, and use the various ordinary means that they may have been relying on, such as heart and blood pressure medications, diuretics, insulin, etc.
We should always seek to do what is ethically “ordinary” or “proportionate” in providing care for our loved ones, though we are never obligated to choose anything that would be heroic, disproportionate or unduly burdensome when it comes to CPR or other resuscitative measures.
An opponent of SB 303 and I have been discussing the Bill on an earlier post. She referred to my “list of endorsements.” This is a fairly strong list of endorsements, at least for those of us who are believers, don’t you think?
The Texas Baptist Christian Life Commission is ” is pleased that SB 303 was recently voted out of the senate.”
Texas Catholic Bishops letter to members of the Texas House of Representatives urging support for SB 303
The Morality and Wisdom of Incremental Legislation: The Case for SB 303 by Rev. Tadeusz Pacholczyk, Ph.D.
Texas Catholics Bishops Conference been very active over in the many efforts over the years to reform of the Texas Advance Directive Act and all have signed the endorsement strongly urging passage of SB303 http://www.txcatholic.org/press-releases/336-texas-catholic-bishops-strongly-urge-house-vote-on-end-of-life-care.
I’ve relied on the National Catholic Bioethics Center ( Marie Hilliard and Father Tad) for their consistent and coherent efforts to preserve traditional medical ethics. NCBC has also endorsed the Bill, and written an excellent response to criticism of SB303.
Added 5/11/13 at 11:00 AM, more endorsements and information:
Here is another discussion about the end of life for my Catholic friends who are trying to decide whether to support SB 303.
Life, however, is not an absolute good.
Treatment and life support
Questions about the use of medical treatments and life-support systems are distinct from—and yet often associated with—euthanasia. The scriptural insights can be very helpful with these issues, even if they cannot give details. As good stewards, we believe that death is not the final word, that life is not an absolute good. Therefore, we do not have to keep someone alive “at all costs.”
The Catholic tradition helps with the details, providing this guidance: ordinary means must be used; extraordinary means are optional. Ordinary means are medicines or treatments that offer reasonable hope of benefit and can be used without excessive expense, pain or other inconvenience. Extraordinary means do not offer reasonable hope of benefit or include excessive expense, pain, or other inconvenience. What is important to remember is that “ordinary” and “extraordinary” refer not to the technology but to the treatment in relation to the condition of the patient, that is, to the proportion of benefit and burden the treatment provides the patient (see the Vatican’s Declaration on Euthanasia, #IV, 1980).
Many people remember when Cardinal Joseph Bernardin of Chicago decided to stop the treatment for his cancer. The treatment had become extraordinary. He did not kill himself by this choice but did stop efforts that prolonged his dying. He allowed death to occur. (This distinction between allowing to die and killing, as in euthanasia or assisted suicide, is of great significance in the Catholic tradition. The rejection of this distinction by several U.S. courts raises serious concerns.)
Within the Catholic Church, debate still surrounds the question of providing medical nourishment through a feeding tube. Let’s look at two positions.
1) “Life must almost always be sustained.” This position holds that the withdrawal of medically assisted nutrition and hydration cannot be ethically justified except in very rare situations. The fundamental idea for this position is the following: Remaining alive is never rightly regarded as a burden because human bodily life is inherently good, not merely instrumental to other goods. Therefore, it is rarely morally right not to provide adequate food and fluids.
This position acknowledges that means of preserving life may be withheld or withdrawn if the means employed is judged either useless or excessively burdensome. The “useless or excessive burden” criteria can be applied to the person who is imminently dying but not to those who are permanently unconscious or to those who require medically assisted nutrition and hydration as a result of something like Lou Gehrig’s or Alzheimer’s disease. Providing these patients with medical nourishment by means of tubes is not useless because it does bring these patients a great benefit: namely, the preservation of their lives.
2) “Life is a fundamental but not absolute good.” This approach rejects euthanasia, judging deliberate killing a violation of human dignity. On the other hand, while it values life as a great and fundamental good, life is not seen as an absolute (as we saw in the section on scriptural foundations) to be sustained in every situation. Accordingly, in some situations, medically assisted nutrition and hydration may be removed.
This position states that the focus on imminent death may be misplaced. Instead we should ask if a disease or condition that will lead to death (a fatal pathology) is present. For example, a patient in a persistent vegetative state cannot eat enough to live and thus will die of that pathology in a short time unless life-prolonging devices are used. Withholding medically assisted hydration and nutrition from a patient in such a state does not cause a new fatal disease or condition. It simply allows an already existing fatal pathology to take its natural course.
Here, then, is a fundamental idea of this position: If a fatal condition is present, the ethical question we must ask is whether there is a moral obligation to seek to remove or bypass the fatal pathology. But how do we decide either to treat a fatal pathology or to let it take its natural course? Life is a great and fundamental good, a necessary condition for pursuing life’s purposes: happiness, fulfillment, love of God and neighbor.
But does the obligation to prolong life ever cease? Yes, says this view, if prolonging life does not help the person strive for the purposes of life. Pursuing life’s purposes implies some ability to function at the level of reasoning, relating and communicating. If efforts to restore this cognitive-affective function can be judged useless or would result in profound frustration (that is, a severe burden) in pursuing the purposes of life, then the ethical obligation to prolong life is no longer present.
Disagreements in the Church
How are these significantly different positions judged by the Roman Catholic Church? There is no definitive Catholic position regarding these two approaches. Vatican commissions and Catholic bishops’ conferences have come down on both sides of the issue. Likewise, there are Catholic moral theologians on both sides.
Emphasis by underlining is mine. Edited 5/10/13 BBN
For my Catholic readers who are concerned about SB 303 and the discussion about a doctor’s decision that it’s medically appropriate to withhold artificial food and nutrition by feeding tube or IV:
Such persons, if treated with a feeding tube and intensive nursing care, can sometimes live for months or years. When they die, it is typically due to complications of feeding-tube treatment, such as pneumonia caused by food placed in the stomach going up the esophagus (foodpipe) and down into the lungs.
Thinking about using feeding tubes in a rare condition such as post-coma unresponsiveness is very different from thinking about using feeding tubes in more common diseases such as cancer, AIDS, Alzheimer’s disease, Lou Gehrig’s disease or Parkinson’s disease. Tube feeding in these types of patients will often result in great burden, no net benefit and multiple complications.
In very many such cases, tube feeding will meet the criteria by which it could be considered extraordinary or morally optional. These diseases continue to progress and get worse-no matter what treatment is offered. Complications such as pneumonia are much more common when feeding tubes are used for such patients.
Patients with dementia sometimes pull the tubes out and would need to be restrained in order to be fed. In fact, in these conditions it has even been difficult to show that the use of feeding tubes actually makes the patients live longer. Clearly, in many such cases, the burdens of treatment can be judged disproportionate with respect to the benefits, and the treatment could therefore be judged extraordinary or morally optional.
The opponents of Senate Bill 303 may not realize it, but they are promoting the very thing they claim to oppose: elevating the patient’s right to determine his own care above the doctor’s conscience will result in doctors who practice medicine without consciences.
The consequences of elevating autonomy above non-maleficence (“first do not harm”) go to the very heart of medical ethics. In fact, the promotion of patient autonomy is the common justification for euthanasia and elective abortion on demand.
The doctor is the one whose hands, conscience, and medical judgment will be writing the orders for or actually carrying out the resuscitation. Just as it’s not ethical to force doctors to cause the death of patients, it’s not ethical to demand that doctors write orders and perform interventions when their medical judgment indicates that the intervention will not be successful and will increase pain and suffering while prolonging the process of death.
As ethicist Gilbert Meilaendar noted at the President’s Bioethics Council Meeting in September 12, 2008,
[T]he reason for a physician being willing to risk his life in an epidemic was precisely that he didn’t think staying alive was the most important thing, that there was something else that was morally more compelling and obligatory even than preserving his existence. And that would have something to do with the personal integrity that you seem willing to think may be — one should be willing to set aside in embracing what one thinks is evil.
If there’s no such thing as right and wrong or good and evil, why are we arguing in the first place?
If you crack the egg of a bird on the Endangered Species List, it won’t matter that the bird was a fetus or embryo. You’ve still broken Federal law. Why is the species of an (unhatched) animal so clear cut under law, but human embryos have no protection under current law? Legal follies such as this underscore our lack of seriousness and consistency when contemplating our children of tomorrow. My concern is that we are not teaching them why they should treat us kindly, much less giving them a good example.
Bioethics dilemmas and most political disputes may seem to be new problems, but they’re not. Every “new” problem is another facet of the potential to deny the existence of right and wrong or to infringe on the inalienable rights of our fellow humans. Knowledge of the basics can guide decisions and actions.
If there’s no such thing as right and wrong or good and evil, why are we arguing in the first place? These truths transcend relative social considerations and laws, including religious beliefs, ideology, or the wants and wishes of the powerful or majority. They even transcend time and space: if you take a close look at the big debates, the speakers aren’t simply talking to each other: we’re arguing with the great thinkers of the past and trying to convince people who come along after us.
The unique nature of the species Homo sapiens sapiens is the source and the definition of “human dignity,” and the reason that all members of the species and our offspring are human beings who should be valued equally, without discrimination.
And of course, we are unique, since It looks like we’re the only species having this conversation. We’re the only species that, when an individual has safety, food and sex, doesn’t just go to sleep. Our species makes art, records history, and argues about the nature of the universe. Humans seem to naturally “know” “that’s not fair,” even at 3 or 4 years old. We seek Unconditional Justice, Truth, Love, Beauty and Knowledge. And we value Unconditional Love most of all.
The Negative rights to Life, Liberty and Property are owned and endowed upon individuals; they are not the property of or gift of societies or governments. These exist in a necessary order; a hierarchy of importance and power to call on society for protection. The right not to be killed trumps the right not to be enslaved, which precedes the right not to have your property taken from you by force or fraud. If they can kill you, there are no limits on how much they can enslave you or take from you. We must be secure that others won’t take our property against our will, because earning and owning property is how we avoid enslavement to others and how we make plans and lay by the staples of life to support the lives of ourselves and our families, both immediately while we can earn, and later when we are unable to work.
Society and government must protect these “inalienable” rights of individuals, but only as far as to ensure equality of opportunity, not the equality of outcome. These are protections against the actions of others, not against words or thoughts. It is not protection or promotion of someone’s personal tastes and not the right to not be offended. We must be very, very careful when we tax and even more careful if we presume to force the actions of others.
Good politics and science cannot exist in a moral vacuum. The powerful, the majority, the surging mob. the man with the biggest gun or governments cannot do good when their actions infringe on the life, liberty or property of the individual. To claim that people must act or give up property indefinitely for the greater good – Utilitarianism – ends in domination without measurable or objective limits.
And yet, to function in society carries responsibilities. Extraordinary privileges like those given to lawmakers, doctors, and scientists to do good, may also result in extraordinary power to do evil through abuse of unequal power of weapons, tools, numbers or even knowledge and skill. This is where conscience and the first principle of “first do no harm” come in. The right of conscience is a function of the liberty of an individual not to be forced to act against his understanding of good and evil, right and wrong.
Medicine and science have held a unique position to advocate for the protection of human rights, at least since Hippocrates, who formalized the now 2500 year old oath to “heal when possible, but First, do no harm” Non-maleficence, or not acting in order to avoid harm, must precede and be incorporated in the desire to do good or beneficence.
Once again, we come back to that first point: all of our offspring, descendants deserve the same value and protection of their rights to life, liberty and property without discrimination. It’s possible that we already have offspring among us who are not of our species. Science has created human embryos with more than two biological parents and others who have been the subject of genetic manipulation. Also out there are is the Humanity+ or Transhumanism movement in all its permutations, along with more accessible enhancement of the human mind and body through technology, medicine, machines, and manipulation at the nano-level.
We must consider how our children of tomorrow will consider us. It is true that humans aren’t perfect, we will make mistakes, and some humans will purposefully infringe on the rights of others. However, what values and principles will the pattern of our governments and individual action reflect? Will it be our respect and love for one another? Will they respect and love us or will they look back in horror or disgust?
(I want to thank Robert Spitzer, who wrote “Healing the Culture,” one of the best Ethics books in existence.)
This is a March, 2011 post from LifeEthics. org. Why Ethics? | LifeEthics. Edited 5/10/13 to move to top of the list.
Should all girls “of child bearing age” be able to walk into the corner pharmacy and buy Plan B without ID, age restrictions or parental supervision? I don’t think so!
However, my professional organization, the American Academy of Family Practice, issued a statement this week advocating for just that. Our online newsletter included my comments in an article published today:
On the other hand, family physician Beverly Nuckols, M.D., of New Braunfels, Texas, said she has issues with the Academy statement because it is inconsistent with its own Family Medicine, Scope and Philosophical Statement.
“Family physicians not only treat the patient within the context of her family, we also strive to treat the whole patient — ‘biological, behavioral (and) social,’” Nuckols said. “In this case, the ‘disease’ we are trying to prevent is the high-risk behavior of unprotected sex. Parental involvement is vital to the health of children and is the best prevention for high-risk behavior, including adolescent sexual activity.
“The AAFP normally and correctly advocates parental involvement and intervention to prevent other high-risk activity, such as driving without a license, the use of guns without adult supervision, smoking, or overeating, etc.,” she said. “What is the rationale for treating adolescent sexual activity any differently than we would treat other risky behavior or preventable risk factor?”
Nuckols, who serves as chair of the Christian Medical & Dental Association’s Family Medicine Section, said she also has concerns about OTC Plan B One-Step because there are few controlled, randomized studies that prove levonorgestrel to be medically safe and effective for adolescents at the dosage given.
“The published data on emergency contraception don’t break out the numbers of adolescent girls, but the numbers appear to be low,” she said. “The closest I’ve found are small studies for treatment of menstrual disorders and inherited bleeding disorders by chronic use of oral or intrauterine levonorgestrel, with the youngest age at 14.”
(BTW, The author quoted my written statement, exactly, so any errors are mine. I goofed in identifying myself to the author: Much to my relief, our CMDA Family Medicine Section elected a new Chair and I’m now the Past-Chair. I didn’t realize we had passed the turn-over date. Oh, and “data” really is plural, so “data … don’t” is not terrible grammar, just awkward.)
Here’s an excellent professional article about end of life care for patients that’s relevant to our discussion about SB 303.
Two Roads to Death
Two major pathways to death have been described: The easy and the difficult road Figure 1. Depending on the road a patient takes, the intensity of ED management may vary significantly. For instance, some patients are highly symptomatic at the EOL, requiring intravenous medications and even continuous drips to maintain comfort while others can be managed by relatively simple oral regimens in the home setting, with the support of hospice services.For symptoms like pain, the EM skill set proves sufficient as the management of healthy patients and those at the EOL is similar. EM treatment algorithms are less relevant, however, for symptoms like dehydration, delirium and dyspnea in the dying patient. For this reason, we will focus our attention on the unique approach to these common and often troublesome EOL issues.
A team of researchers at the University of Calgary’s Hotchkiss Brain Institute (HBI) have discovered that adult brain cell production might be determined, in part, by the early parental environment. The study suggests that dual parenting may be more beneficial than single parenting.
Scientists studied mouse pups that were raised by either dual or single parents and found that adult cell production in the brain might be triggered by early life experiences. The scientists also found that the increased adult brain cell production varied based on gender. Specifically, female pups raised by two parents had enhanced white matter production as adults, increasing motor coordination and sociability. Male pups raised by dual parents displayed more grey matter production as an adult, which improves learning and memory.
“Our new work adds to a growing body of knowledge, which indicates that early, supportive experiences have long lasting, positive impact on adult brain function,” says Samuel Weiss, PhD, senior author of the study and director of the HBI.
Surprisingly, the advantages of dual parenting were also passed along when these two groups reproduced, even if their offspring were raised by one female. The advantages of dual parenting were thus passed along to the next generation.
To conduct the study, scientists divided mice into three groups i) pups raised to adulthood by one female ii) pups raised to adulthood by one female and one male and iii) pups raised to adulthood by two females. Researchers then waited for the offspring to reach adulthood to find out if there was any impact on brain cell production.
Scientists say that this research provides evidence that, in the mouse model, parenting and the environment directly impact adult brain cell production. While it’s not known at this point, it is possible that similar effects could be seen in other mammals, such as humans. The study is published in the May 1 edition of PLOS ONE. It was funded by the Canadian Institutes of Health Research (CIHR).
The research paper can be read online: http://dx.plos.org/10.1371/journal.pone.0062701.
Government could decree that “East” is now “North.” After all, they’re just arbitrary names for concepts, right? However, until all the old signs and maps (and compasses!) are replaced and gone forever, a lot of people will be lost and possibly hurt in transportation accidents.
Changing the family structure by government laws and regulations on marriage is reckless social experimentation, more like changing “up” to “down,” than “East” to “North.”
Rand Paul, (small-l)ibertarian Republican junior Senator from Kentucky and the son of perennial Presidential candidate Ron Paul, told the National Review that the Republican Party’s “problem” with gay marriage could be solved by changes eliminating references (and benefits) to marriage in the tax codes.
However, as an editorial in The Hill commentary noted,
Paul did not address in the interview how he might deal with other advantage and privileges extended to legally wed heterosexual couples, like federal spousal benefits, pension plans, health care, and Social Security survivors benefits.
And Paul ignores the societal consequences on our children of tomorrow.
Research confirms that the best environment for children is to live in a home with their married biological parents. When the ideal is not possible, statistics still favor stable, traditional marriage and the 2 parent home for the successful adult child of blended families and adoption. Please take a look at peer-reviewed studies published on the effects of stable families on children, here and here.
Want proof that government interference can change society for the worse? Look at the harm government has done to lower income families all those years when benefits were denied to families when the father was in the home. Or the negative influence of housing subsidies on marriage. (I can email the full article.)
Society and government ignore facts at the risk of harming the life, liberty, and pursuit of happiness of future generations. Don’t expect me to vote for or pay for dangerous societal experimentation – or even to sit quietly while someone outlines his intention to play social engineer.
Update: see this post from May 5, 2013, showing more evidence for the benefit to children of being reared in the home with their biological parents.
The House rejected an amendment to allow the people of Vermont to vote on a referendum. The Vermont Senate has not passed the Bill.
MONTPELIER, Vt. (AP) — After a second long day of debate, the Vermont House gave final approval Wednesday to a bill that would allow terminally ill patients to ask their doctors for a lethal dose of medication.
Doctors don’t swear oaths as part of our training anymore; and certainly not the Hippocratic Oath. After all, the Hippocratic doctor swears to follow his conscience, even when the patient disagrees. He must refuse to give women medicine or devices to cause abortion or to give poisons to kill patients, no matter who asks for it.
Neither doctors nor hospitals killed Terri Schiavo. Terri Schiavo was killed by her husband’s lawyers and the probate judge who forbade food and water by mouth and by IV or feeding tube.
Just after I hit “publish” on yesterday’s effort to explain the mechanism of Plan B and why we still shouldn’t allow minor girls to buy it over the counter, I found the news that the Obama Administration has decided that the FDA will appeal the ruling by a New York Federal Judge Edward Korman that gave the FDA 30 days to remove all age restrictions on Plan B, the “morning after pill.” This will not change this week’s decision to move the age requirement down to 15 years of age, it is a good, if minor, move.
USA Today has an article that’s typical for those who object to the appeal, written by Cecile Richards, the former National president of Planned Parenthood (and the daughter of the late Texas Governor Ann Richards).
The comments on CBS News’ coverage of the appeal point out one big problem that teens who have unplanned sex may also have: the “emergency” aspect of “emergency contraception.” One person suggests that Plan B should be available in vending machines and restrooms, as condoms often are. Several readers are concerned that teens who have unprotected sex plan won’t ahead or be able to find a pharmacy open when they need it..
Obviously, the writer of that comment doesn’t understand that the pill can be useful up to 5 days — and is still very effective (if it’s going to be) for at least a day or two. As I responded, there is a difference between a condom and Plan B: the latter is ingested and will have an effect, however small, on the hormonal balance of whoever takes it. Condoms don’t make people nauseous or throw up!
I didn’t expect this!
President Barack Obama’s administration on Wednesday angered allies in women’s groups by appealing a judge’s ruling that the morning-after pill must be available over the counter to girls of all ages.
The administration has argued that the pill should not be readily available to young teens, so the appeal is consistent with that position.
Update 5/02/13: The Obama Administration has decided to appeal the judge’s ruling that the age restrictions must be removed completely from Plan B sales.
Because of a ruling by a Court in New York on April 5, 2013 and the April 30, 2013 announcement that the Obama Administration has published its intent to allow 15 year olds to buy Plan B over the counter without a prescription or adult supervision, the news is full of the controversy about whether or not Plan B is an abortifacient because it kills the embryo or blocks implantation.
(How about that: she’s old enough to buy over the counter emergency contraception, but she’s still young enough for her parents to buy her insurance until she’s 26!)
There is quite a lot of evidence that Plan B does not interfere with the embryo if fertilization occurs and none that it does. If, as the evidence supports, it doesn’t cause the death of the human embryo, before or after implantation, Plan B is not an “abortion pill.”
But it still shouldn’t be sold over the counter to minors.
I don’t know anyone who thinks it’s healthy for 12, 14 or 15 years olds to have sex – whether boys or girls. While Texas does have the “Romeo and Juliet” defense ( when there’s no force, both are over 14 years old, opposite sex and within 3 years of the same age), 15 year olds can’t legally consent to sex. Texas law deems it a “crime of indecency” to have sex with a minor under 17. Our State has also decided that 15 year olds can’t drink alcohol, can’t buy tobacco or Sudafed, and they usually can’t get a driver’s license.
We do this to protect them, because we know that they are not prepared to make good decisions. Their brains are not mature enough and they don’t have the experience and knowledge to adequately judge the difference between immediate gratification and future benefit. The fact is that most parents are their children’s best protectors and advocates. We are legally responsible for our children, but we are also morally responsible for them. We love them and don’t want them to hurt!
Parents need – and have the right – to know what our dependent children are doing and what medicines they are taking. By changing these regulations, the Federal government is moving between the parent and child — a much more sacred relationship than “a woman and her doctor.”
There is very strong evidence from good scientific experiments published in the last 10 years that Plan B does not interfere with the implantation or development of an embryo.
Plan B only works, when it works, by preventing fertilization for 4-5 days in the middle of the month – before ovulation – it delays ovulation so there is no egg to fertilize and by preventing the sperm from getting to the egg.
Plan B is a high dose of progesterone, the main hormone produced by the ovaries during the second half of a woman’s monthly cycle. Before ovulation, Progesterone or Plan B delays ovulation (the release of the egg from the ovary) and makes it difficult for the sperm to get to the egg. At or after ovulation, progesterone appears to slow the sperm’s travel to the egg (prevents fertilization) In nature, this prevents fertilization of an old egg – and its effect is one of the signs used by women who use “Natural Family Planning.” Progesterone normally encourages the development of the lining of the womb after ovulation. In fact, doctors sometimes give Progesterone to women who have repeated miscarriages.
It wouldn’t be ethical to conduct experiments on women who are ovulating and having sex, because those women might be carrying a human embryo that hasn’t implanted or who could be harmed. While it is true that there have been no experiments on women who might be pregnant, there are good studies which were done on ovulating women who have their tubes tied or who agree to abstain from sex during the experiment. Then, they were studied by checking repeat exams, blood work, ultrasounds and biopsies of the womb. No evidence that Plan B interferes with implantation or damages the embryo has been found.
Current evidence is that Plan B decreases the risk of pregnancy for those women who take it properly, Plan B cuts the risk of pregnancy by 50- 70%. At the population level, it does not decrease either the pregnancy rate or the abortion rate. In fact, even women who have the pills in their medicine cabinet – who don’t have to pay $45 when they have unprotected sex – don’t use the pills consistently. This is true in countries like Scotland, the UK and Jamaica where teen girls can obtain the medication without a prescription or are provided the medication in advance of need.
I am a pro-life doctor who, like Texas law, believes that the individual begins at fertilization. I spend much of my time advocating for laws that protect the human right not to be killed and for traditional medical ethics. Yes, I am a Christian , but I prefer to make my arguments from the science side because I’m convinced that science will prove me right in the long run. After all, the “Nature’s Creator “ cited in the Declaration of Independence created science!
For the science, see these articles:
Added 8:00 PM 5/2/13 One of the best and oldest. I can email a copy of the entire article to anyone who needs it http://www.contraceptionjournal.org/article/S0010-7824%2805%2900045-4/abstract
The Texas Advance Directive Act of 1999 (TADA) describes “Advance Directives to Physicians” (what most people would call a “Living Will”) and contains Section 166.046, an attempt to outline the procedure for resolving a disagreement between a doctor and patients or their surrogates about what is medically appropriate treatment.
The law currently in effect requires the doctor to notify the patient or the surrogate when he or she believes that their request is medically appropriate. If there is still a disagreement, the doctor asks the hospital to convene a meeting of their ethics committee. If the committee agree agrees with the doctor, and no other doctor is willing to take over the care of the patient, the treatment in question can be withheld or withdrawn. TADA doesn’t allow “Physician Assisted Suicide” and certainly doesn’t allow euthanasia, where the patient might be killed on purpose.
The Texas Senate passed Senator Bob Duell’s Senate Bill 303, which significantly improves current law. SB 303
Because SB 303 still needs to pass in the House, Texas Alliance for Life asked me to help them make a video explaining how it reforms current law.
If you agree that SB 303 is a pro-life reform Bill please call your State Representative at 512-463-4630 and ask him or her to support SB 303.
My “Ethics 101″ on the law: “Back to Basics on Texas Advance Directive Act”
Texas Senate Passes Pro-Life SB 303 to Help FamiliesProtect Loved Ones Near the End of LifeLt. Governor David Dewhurst and Sen. Donna Campbell M.D. Deserve Thanks!April 24, 2013Dear Larry and Beverly:Very good news! Last week the Texas Senate passed SB 303, a strong pro-life bill that will change current law to help families protect their loved ones near the end of life. Supported by pro-life Lt. Governor David Dewhurst and authored by Sen. Bob Deuell (R-Greenville), the full Senate passed SB 303 on a decisive 24-6 vote.Your Texas state senator, Sen. Donna Campbell M.D., voted to support SB 303, a pro-life vote. Please thank Lt. Governor Dewhurst and Sen. Campbell for their support. See sample messages below.SB 303 is strongly supported by broad coalition of pro-life and provider organizations including Texas Alliance for Life, the Texas Catholic Conference of Bishops, and the Texas Baptist Christian Life Commission.Voting for SB 303 were: Campbell, Carona, Davis, Deuell, Duncan, Ellis, Eltife, Estes, Fraser, Garcia, Hinojosa, Huffman, Lucio, Nelson, Nichols, Rodriguez, Schwertner, Seliger, Uresti, Van de Putte, Watson, West, Whitmire, and Zaffirini.Voting against SB 303 were: Hancock, Hegar, Patrick, Paxton, Taylor, and Williams. Senator Brian Birdwell was absent.
Prevents secret DNAR orders (“Do Not Attempt Resuscitation”). Current law allows doctors to order DNARs without even notifying the patient or family.
Prevents the involuntary denial of food and water, except in extreme circumstances when the treatment would harm the patient or hasten his or her death.
Increases the time of the dispute resolution process from 12 to 28 days when a family and patient disagree about appropriate end of life care.
Significantly limits the class of patients to whom the dispute resolution process can be applied.
Requires doctors and hospitals to treat all patients “equally without regard to permanent physical or mental disabilities, age, gender, religion, ethnic background, or financial or insurance status.”
Preserves conscience protections so physicians are not required to provide futile or harmful procedures indefinitely.
A great deal of false and misleading information about SB 303 has been spread by several groups, especially by one group in particular that is based in Houston. In response, the Texas Catholic Conference of Bishops issued a strongly-worded letter to set the record straight. Please see this: http://txcatholic.org/news/327-misstatements-against-end-of-life-care-reform-corrected-in-letter-to-lawmakers
See my earlier post about the rebuke TRTL received from the Texas Catholic Bishops Conference. – http://wp.me/p1FiCk-XW – and an even earlier explanation (long winded, I’m afraid) – http://wp.me/p1FiCk-Wb
Edited 4/27/13 to add that last paragraph – BBN
Using words such as “egregious,” “cynical,” “outrageous,” and “deceive,” the Texas Catholic Bishops Conference have published the letter that they sent to Texas Legislators concerning the actions of Texas Right to Life concerning Senate Bill 303 and its companion, House Bill 1444 on April 15, 2013.
Since employees and representatives of TRL continue to “stoke fear through ridiculous claims,” (and to harass those who support the Bills) here’s the letter (I’ve reproduced the emphasis is in the original):
The Texas Catholic Conference is compelled to publicly correct the misstatements and fabrications that continue to be perpetuated by the Texas Right to Life organization against legislation to improve end-of-life care by reforming the Texas Advance Directives Act.
It has been said that all is fair in love, war and Texas politics. However, the actions of Texas Right to Life have been so egregious and cynical, especially when comes to misrepresenting the moral and theological doctrine of the Catholic Church, that the TCC cannot stay silent.
Texas’ Advance Directives Act needs reform. Current law lacks clarity given the complexity of end-of-life care, contains definitions that could permit the withdrawal of care for patients – including food and water – and permits unilateral Do Not Resuscitate Orders without the permission of, or even consultation with, the family.
Senate Bill 303 and House Bill 1444 are based on Catholic moral principles and reasonable medical standards for defending human life and protecting the conscience of both families and physicians. Both billsprevent unilateral DNRs, improve communication between medical providers and families, ensure a clear and balanced process for resolving differences, and give families the right to challenge Do Not Resuscitate Orders before a medical ethics committee.
In both its materials and communications with legislative offices and staff, Texas Right to Life has tried to stoke fear through ridiculous claims of nonexistent “death panels” and assertions that doctors are “secretly trying to kill patients.” Both claims are absurd. The truth is, many factors are involved in the sausage-grinding process of public policymaking. Some have less to do with making good laws and more about individual personalities and fundraising opportunities of organizations.
It is outrageous that an organization purportedly committed to the rights and dignity of life would resort to such disingenuous tactics that deceive honest and caring people. What is worse is doing so in a way that perpetuates current law and may cause unnecessary patient suffering.
Texas Right to Life has no authority to articulate Catholic moral teaching, and certainly does not have permission to represent the views of the Roman Catholic Bishops of Texas. If you have any questions, please feel free to contact us at the Texas Catholic Conference. We are more than happy to answer any questions or provide the Texas Catholic Bishops’ position on any issue before the Legislature.
(Edited for spelling and grammar, 4/25/13 BBN)
How reliable is a US government funded study that uses the term, “astroturf?”
Research using your tax dollars is under scrutiny – once again – and the subject of recent hearings in Congress. The National Cancer Institute, a wing of the National Institutes of Health, paid for this “study.” It was published in a “peer reviewed” journal, Tobacco Control, one of the “BMJ Group” (British Medical Journal) publications.
The tobacco companies have refined their astroturf tactics since at least the 1980s and leveraged their resources to support and sustain a network of organisations that have developed into some of the Tea Party organisations of 2012.
What this paper adds
Rather than being a grassroots movement that spontaneously developed in 2009, the Tea Party organisations have had connections to the tobacco companies since the 1980s. The cigarette companies funded and worked through Citizens for a Sound Economy (CSE), the predecessor of Tea Party organisations, Americans for Prosperity and FreedomWorks, to accomplish their economic and political agenda. There has been continuity of some key players, strategies and messages from these groups to Americans for Prosperity, FreedomWorks and other Tea Party-related organisations.
Funding This research was funded by National Cancer Institute grants CA-113710 and CA-087472. The funding agency played no role in the selection of the research topic, conduct of the research or preparation of the manuscript. SAG is American Legacy Foundation Distinguished Professor in Tobacco Control.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
Note the estimated 85,000 who escaped the Border Patrol in 2011. Secure the border, first, then we can talk about how to get a Green Card. (Hint: it begins by getting in line legally and in their own country.)
A recent Government Accountability Office report cites Border Patrol data from fiscal 2011, the latest available, that 61 percent of estimated illegal crossings on the southern border resulted in capture, 23 percent turn back to Mexico and 16 percent got away.
Of the 85,467 who got away, 70,980 (83 percent) were counted by sign-cutting, with nearly all the rest from cameras and plain sightings.
Despite such precise tallies, Border Patrol Chief Mike
We’ve all been hearing about the supposed “War on Women” by Conservative law makers – and, by extension, voters – in Texas. Well, President Obama and Secretary of Health Kathleen Sebellius just fired another shot in the war against Texas and State’s rights.
UPDATE: In an emailed statement, Texas Department of State Health Services spokeswoman Carrie Williams says that the agency just received notice that it will lose the Title X grant and is “reviewing the information to get a sense of the full impact.” The agency hopes the transition is smooth and the provider base remains strong, she wrote.
EARLIER: The federal government has pulled from the state of Texas millions in family planning funding, granting the money instead to a coalition led by the Women’s Health and Family Planning Association of Texas, which says it can serve a greater number of women with the available funds.
For more than four decades, federal Title X funding has been dedicated to funding family planning services and covering clinics’ infrastructure costs. The funds are generally granted to providers (like Planned Parenthood) and/or to state health agencies. In Texas since 1980, the majority of the funding has been administered by the Department of State Health Services — roughly $18 million in 2012, for example; since 2009, DSHS has been the sole grantor of Title X funds.
(Edit, maybe it’s only half of that.)
Before this year, Federal tax dollars came back to Texas in two major funds: the Women’s Health Program and Family Planning, or Title X funds. Texas “matched” a certain amount and the Texas Department of Health and Human Services administered the dispersion of the money. Because the money paid for or freed up other funds for staff, marketing, and “infrastructure” or office overhead, PP was helped to keep their abortion clinics running. The overall effect was that State matching tax dollars helped PP to funnel patients, if not dollars, to their abortion clinics.
Texas was forced to make severe Budget cuts across the board in 2011, including Family Planning funds. This led to prioritizing what little money we had:
“State lawmakers cut funding for family planning services by two-thirds in the last legislative session, dropping the two-year family planning budget from $111 million to $37.9 million for the 2012-13 biennium. They also approved a tiered budget system for family planning funds, which gives funding priority to public health clinics, such as federally qualified health centers and comprehensive clinics that provide primary and preventative care over clinics that only provide family planning services.”