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Chaos, Mob, not filibuster, subverted Texas Senate #SB5 #TxLege

In the Texas Senate, the filibuster is a method of allowing a minority viewpoint known. The minority Legislator is allowed to speak without time limits and without unwanted interruptions, as long as he or she follows the rules laid out beforehand.

Yes, Senator Windy Wendy Davis began a filibuster. She knew the rules, and she broke them. Her fellow Democrat Senators engaged in stalling tactics, but it was the noise and chaos in the gallery that made the three minutes of difference that killed the Bill.

You can watch the Senate video at this page.The

Senators West, Whitmire,Watson, Ellis, Van de Putte, Zaffirini, and (of course) Senator Davis proved to all of us that they value the elective abortion of human beings above orderly government and Legislators.

I was, unfortunately, not shocked that Senator Leticia Van de Putte encouraged the gallery to disrupt the Senate. It also appears that she lied about the timing of her motion to adjourn. See the roll call vote beginning about 12:19/15:50. Note that she spoke and that the temporary President, Senator Duncan, responded after the roll call began. 12:31

I was surprised that the gallery wasn’t cleared much earlier, even though it might have meant that I would have had to leave. However, until the last hour, the outbreaks were intermittent and quickly calmed down.

My friends and I were very concerned about the reaction of those who so clearly showed no respect for the rest of us and who greatly outnumbered the State Troopers.  Every seat was full, the pro-life crowd was greatly outnumbered and the halls were crammed with more people in orange.  When the standing and shouting became constant, the Lt Governor signaled to the Troopers who began to remove people in an orderly manner.

More Troopers arrived, but they were constantly at risk of physical confrontation, with some of the Orange shirts resisting the request for them to file out. At one point, the Troopers were forced to lock the West doors of the Gallery and the Mob continued to push from the hall and fill the Rotunda.

I certainly didn’t want to be in the middle of a fight with these people and am grateful that the Troopers kept some semblance of order. I don’t believe that there was a way to clear the gallery earlier or with less disruption than we had and am proud of the State Troopers.

 

BMJ on RCOG Fetal Awareness White Paper #SB5 #TxProlife

The Royal College of Obstetricians and Gynecologists published their white paper on “fetal awareness” in 2011. (Royal College of Obstetricians and Gynaecologists. Fetal Awareness – Review of Research and Recommendations for Practice. London: RCOG Press 2010 http://www.rcog.org.uk/files/rcog-corp/RCOGFetalAwarenessWPR0610.pdf  Accessed June 24, 2013).

 
Here is a peer-reviewed, “editor’s choice” editorial outlining the flaws in that paper. “Fetal awareness and fetal pain: the Emperor’s new clothes” by Dr Martin Ward Platt, Newcastle Neonatal Service, of the Royal Victoria Infirmary http://fn.bmj.com/content/96/4/F236.long#ref-1 (Accessed June24, 2013).

 
The author, Dr. Platt, points out that the evidence for no fetal awareness until birth has no evidence in humans, only in animals. He further points out that it goes against our experience with sleep/wake cycles and what we know about the ability of the fetus to learn his mother’s voice and other learning, including long-term effects on brain anatomy and response to pain:

 

“So, what is the evidence that the human fetus lacks ‘awareness’? In a word, there is none. The only evidence, including the bit about the chemical environment, is in sheep and one or two other experimental animals. I have looked at the references in the report, and the references in the references, and when I finally got back to the primary literature I found no evidence for the contention that human fetuses lack awareness, or exist in some different conscious state, beyond the unwarranted extrapolation from sheep.

“In contradiction to the notion of the ‘unaware’ fetus, the everyday experience of pregnancy – the felt behaviours and responses of the unborn baby, especially to sound – as well as much primary research literature on the human fetus, contains strong evidence for an opposite view. There is an extensive literature, in humans, on fetal sleep and wakefulness, fetal motility, fetal memory, fetal hearing, fetal breathing and its control and fetal behaviour – and these are just examples that scratch the surface. None of this work is easily reconciled with the notion of a permanently unconscious human fetus. The third point in box 1 is simply not true.”

and

“. . . the precautionary principle of prevention and treatment of pain in case it is being experienced, which is an ethical rather than a scientific argument, nor does it affect the evidence in relation to the long term neurobiological effects of pain experiences in preterm babies.”

and

 

 

. . . “One notices statements in the report such as: “Interpretation of existing data indicates that cortical processing of pain perception, and therefore the ability of the fetus to feel pain, cannot occur before 24 weeks of gestation”. We could rewrite this as ‘in theory they can’t feel pain, therefore they don’t’. It is the substitution of wishful thinking for empirical enquiry. It reminds me of my days as a medical student when I was taught that once the periosteum was anaesthetised, bone marrow aspiration was painless because there were no nerve endings in the bone. As soon as I came to perform bone marrow aspiration I realised that, whether there were supposed to be nerve endings or not, the procedure caused deep bone pain. So: should we deny patients’ real experiences on entirely theoretical grounds, or accept them and look harder for the underlying cause? We now know that bone is richly innervated, but older techniques of bone histology were unable to demonstrate the fibres.”

BTW, Here’s the part of that (debunked by Dr Platt) 2011 RCOG paper that I found most interesting:
“One possible solution is to recognise that the newborn infant might be said to feel pain, whereas only the older infant can experience that they are in pain and explicitly share their condition with others as an acknowledged fact of being.”

Chub, Scrub, Stuff and Stall #SB5 #TxLege

Orange t-shirts admittedly outnumbered those of us in blue at the Texas State Capitol on Sunday, June 23. However, in the long run, what mattered in the passage of the House version of Senator Hegar’s Senate Bill 5, sponsored in the House by State Representative Jodi Laubenberg, is that Texas voters had sent a clear majority of pro-life Republicans to the House of Representatives.

If you’ve always wondered about the meaning of “chubbing,” look at the 6/23/13 record of the House video, available at the House website. Pro-abortion Democrat after Dem took the microphone to bring an amendment, with fellow pro-abortion Dems standing to ask questions and run out the clock.

You can also watch the effects of “POO,” or calling for “points of order” around 4:30 PM. House Democrats called for a review of the Rules, resulting in adjournment and restart after a delay of 2 hours.

As to those t-shirts, someone showed up with 1000 t-shirts to give away. Where did that money come from?  Interestingly, the women who gave out the shirts also wore Planned Parenthood buttons and successfully instructed those in the shirts how to act in the Gallery. And the orange shirts obeyed immediately.

One theme the Dems repeat is that SB 5 is not the protection for women that the Republicans say it is. They claim that pro-life laws are not about human life and ethics, but rather, simply about winning Republican primaries. This is a great example of “projection” of one’s own motives and wishes onto another. While I believe that Jessica Farrar would abort everyone with spina bifida and that Thompson is convinced that the embarrassment of the trauma of rape and incest is cured by abortion, the ultimate reason for the long night of interruptions and delays is that the clock is running out on the Special Session. If the Dems manage to delay long enough, SB 5 will not pass in the House. Even when it passes, the time used up in the House decreases the time that will have to be wasted in blocking it by filibuster in the Senate.

In the long run, the Democrat members in the Texas Legislature have repeatedly called for unfettered and unregulated elective abortion on demand.They claim that abortion is better for women and families than spending money on babies and children, that allowing babies to be born will ruin women’s lives, that it’s better to abort children with “fetal anomalies” and “birth defects” even when the “defective” human could live and make his or her own way through life. Senfronia Thompson even brought out a coat hanger to shake at the House and claimed that the cure for the “embarrassment” of the trauma of rape and incest is abortion, even after 20 weeks. Every one of the Dems seemed to have no understanding that the facility improvements will not be required for 15 months.

SB5 was passed finally in the House this morning. It will now have to go back to the Senate. There may not be time enough for reconciliation with the Senate version because of delays caused by both the House Republicans and House Dems. I hope that the protections in the Bill become law to protect the women who make the choice to abort their children and to protect the lives of fetuses at 20 weeks and greater.

Edited 7/11/13 for grammar and spelling errors – BBN

Stand for Life Sunday 6/23/13 1PM @ Texas Capitol #SB5 #HB60

#TxProlife and all Texas voters who would stop (or at least limit) the abortions of our little brothers and sisters are asked to join us in a prayerful, peaceful stand in favor of no abortions after 20 weeks, higher standards for abortion facilities and a requirement that the doctors who perform abortions maintain hospital privileges within 30 miles of the facility.

(seriously: doctors should have local hospital privileges, don’t you think?)

Please consider joining us at the Capitol when the House debates these Bills on Sunday. Wear blue, so we can show our numbers.

If you can’t attend, please pray for us and call your Representative’s office to ask for a “yes” vote on SB5 and HB60. Our best chance is to pass the Senate Bill, so the law will go through faster and with less chance of stalling. If the Senate has to agree with a different Bill, there may not be time.

Pray for a peaceful stand for life and courageous Legislators who will defend the Texans of tomorrow!

I won’t be able to follow this page very well during the meeting at the House, but should be able to keep up with those of you who contact me on Twitter, at bnuckols.

House State Affairs disruption #TxLege #HB60 #SB5

“There are many ways to kill a child, and abortion may be the kindest way to do it.”

That first line was not only a statement made by one woman who testified tonight (watch the meeting at the House website, here), it was a recurring theme at the House State Affairs Committee meeting on June 20,2013, even though there is no evidence that increased elective intentional abortion has ever decreased child abuse.

But, the suggestion that it is acceptable to kill children was not what disrupted the meeting of these Texans.  After many, many times of reminding them not to film the proceedings, not to engage in outbursts that broke up the meeting, Chair Byron Cook announced that he would limit the testimony in order to bring up the second Bill on the Agenda. At that point, the crowd began shouting and some tried to speak without being called to their turn. The Chair called a brief recess and testimony resumed. (Personally, I agree with the Chair that the crowd should be better behaved and with the citizens who had signed in that they should be allowed to speak.)

Earlier this week, Representative Jessica Farrar (D- 148, Houston) sent out this email:

Friend,Governor Perry has declared war on women.  Last week he vetoed the Texas Lilly Ledbetter Act because he thinks women should be paid less than men for doing the same work.  Now, he has added bad women’s health bills restricting safe access to abortion to the Special Legislative Session. This week is your only opportunity to speak out against these bills.Come to the State Capitol this Thursday afternoon and evening, June 20th, when the House State Affairs Committee will hold a hearing on these bad bills.  The hearing will begin at 1:00 p.m. or upon adjournment of the House in Room JHR 140.Please prepare a three minute testimony on the subject, and speak from your heart. What you say can make a difference.  Be ready for a long night, as the hearing will go on as long as it takes.You can also fight back against Rick Perry’s war on women by helping to elect Democrats who will stand up for equal pay and women’s health issues. Please consider donating $5, $10, or $25 to the Texas House Democratic Campaign Committee to ensure that our key Democratic legislators return, and that we are able to gain seats in the House.  Your support now will build the foundation we need to ensure this war on women will go no further.Sincerely,Jessica

Pol. Adv. paid for by the Texas House Democratic Campaign Committee, Lon Burnam, Treasurer.
P. O. Box 1925, Austin, TX 78767

Although Rep. Farrar admitted early on Thursday night, that “there are two lives involved” in abortion,   she is the one who suggested that we should abort every child with spina bifida in Committee, back in the regular Session. Below are some of the other continuing themes we’ve heard during testimony in favor of the status quo and against any new restrictions on abortion providers.

Texas has a culture of hate for women, so we should abort children (male and female) in order to prevent a “brain drain.”

A married Social Worker told us that she was “elated” after her abortion to be relieved of a responsibility she never wanted. Another woman said that her friends had abortions between 18 to 24 years old, claiming that it was before they were able to choose their majors in college or decide on an outfit! Many men said that they were “relieved” not to be burdened with unwanted children. One that really stuck out was 24 years old when he enabled the abortion of his own child.

One man, an angry 30 year old unemployed lawyer, echoed the wish of many of those who came at the call of the Texas Democrats. He and the others believe that the Texas Legislature should work on laws that will give him a job, healthcare benefits. (And child day care, Medicaid for all, maybe even an allowance for stay at home women.)

There were the usual complaints that men in the Legislature were trying to control the women of Texas (ignoring that the author of the Bill, many of the co-authors and a great many of the voters who put them in office are women) and the repetitive accusations that only religious bigots are “anti-choice.”

“There are many ways to kill a child, and abortion may be the kindest way to do it.” Maybe, because then the child will never know. But there are no GOOD ways to do it.

Addendum (or a couple of other recurrent themes):

1. The claim that abortion will prevent the consequences of post partum depression. Abortion is never treatment for what is properly called “perinatal” depression. In fact, perinatal depression can be triggered by miscarriage or spontaneous abortion and by elective interventional abortion.

2. Don’t forget that women and children will be harmed most by the limits on abortion and that Texas’ legislature should let President Obama give us free expanded Medicaid and Obamacare!

Update: the video can be viewed, here, at the Texas Legislature Online website.

Edited 6/21/13 at 9:00 AM to add the link to the video and add the ‘tag” HB60 – BBN

Edited 6/21/2013 for typos and to fix the penultimate (how often do I get to use that word?) paragraph “post partum depression,” not “post partum abortion.” (The latter is not possible, yet.) BBN

RX: Sack cloth and ashes for #SB303 opponents

Searching the news for stories on #SB303, led me to accusations that supporters of the Bill gossiped with Capitol staff and “maligned Texas Right to Life, stooping so low as to criticize our sartorial manners, footwear selections . . . “

When you stop laughing enough to read further, notice that the premise of the article, after turning private gossip into public gossip, is that elaborate conspiracies hidden within the minds of doctors, nurses, and entire staffs of “hospitals” and “facilities” judge the “futility of the patient’s life.”

“We agree that some treatments do stop achieving the intended goal of that specific treatment, such as dialysis no longer filtering uric acid from the blood.  When a treatment or therapy is in fact medically futile, no physician would ever continue that, and a properly informed patient or his surrogate would not want to continue futile or harmful treatment, and nothing in current law or in any of Texas Right to Life’s past or present proposals would require the continuation of such medically futile treatment.  Physicians would not continue medically futile treatment anyway.”

“Conflicts arise when the futility judgments are transferred from the efficacy of a medical treatment to a value judgment on the futility of the patient’s life.”

Isn’t the entire conversation about whether the doctor determines the “efficacy of a medical treatment?” No,thanks to articles like this one, the debate on medical conscience is all about pretending to read minds and gossip about the motives of doctors, hospitals, bald-faced claims that the Texas Conference of Catholic Bishops is only interested in the “$$$” from Catholic hospital systems. Every discussion I’ve attempted with the opponents of reform devolves into accusations that I “want to kill” patients.

In the grim tale told by TRTL,the physician’s conscience and medical judgment isn’t denied or even trivialized as equal to a lobbyist’s choice of suits or shoes. We, the doctors who are currently the only ones licensed by the State of Texas to write orders and administer treatments, are either ignored altogether or treated as a tool for some mythological eugenic “hospital committees that have decided by their own subjective standards that the lives of these patients have little or no value and should therefore be denied medical treatment.” They object that the physician’s finding that, in his or her  “reasonable medical judgment, resuscitation would be medically ineffective” is not defined in the law and accuse us of deciding “that imminent death is better than resuscitative efforts.”

Frankly, I have no idea what that last means, since resuscitation is only needed in the event of imminent or actual natural death, when the heart or breathing stop functioning.  Based on this statement and the note about failure of dialysis, I’m certain that no doctors were consulted by or gave feedback to the authors. Again, the lack of physicians who oppose SB 303 is not an indication that we are all involved in a conspiracy. Instead, it is proof of our medical judgment – and consciences.

The end sought by the opponents of SB303 is “treatment-pending-transfer,” including “resuscitative efforts” prescribed by law, not doctors, on every patient who has not specifically refused in advance. When the doctor’s medical judgement and conscience lead him to determine that such would be medically futile, they demand that the doctor set aside conscience and medical judgment and do exactly what they say no doctor would do.

Complete autonomy on the part of patients and their families awarded by legislation the ability to demand what they want, when they want, as long as they want and with as much legal liability as possible cannot turn around the failure of organ system after organ system, and physiological cascade after cascade. All of which we doctors can measure and predict with good certainty.

The authors of this article are proud of their “successful” campaign to ensure for at least two more years, that patients and their surrogates

  • don’t have the right to be notified of DNR’s placed on their charts,
  • have no protection against the removal of artificial nutrition and hydration,
  • don’t have the right to medical records before the medical ethics committee meets,
  • don’t have the right to be accompanied in the medical committee meeting, and
  • don’t have an additional 7 days to prepare for the medical ethics committee and an additional 14 days to find another doctor willing to accept responsibility for the medical treatment of the patient.

If there is any clothing I’d suggest that the authors wear, it’s the sackcloth and ashes of the repentant sinner.

Denouement: The Death of #SB303

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.

Cloned human embryos announced

Cell SCNT diagramTachibana May June2013If 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).

My Testimony on #SB303 (Conscience, Rights, Medical Judgment and Law)

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)

Public Health Hearing on #SB303

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)

Office of the Governor Rick Perry – [Press Release] Statement by Gov. Rick Perry on the Kermit Gosnell Verdict

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.

via Office of the Governor Rick Perry – [Press Release] Statement by Gov. Rick Perry on the Kermit Gosnell Verdict.

Going Too Far with DNR? | Texas Catholic Conference

“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.

via Going Too Far with DNR? | Texas Catholic Conference.

More than “a list of endorsements” (with Addendum)

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.

Point by Point Refutations of Criticisms to SB 303

Texas Catholic Conference Handout comparing SB 303 with current law

Texas Catholic Conference’s response to NRLC’s analysis of SB 303

National Catholic Bioethics Center letter supporting SB 303

National Catholic Partnership on Disability letter supporting SB 303

Texas Catholic Conference Policy Backgrounder on Advance Directives Reform

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:

 

 

End-of-Life Ethics: Preparing Now for the Hour of Death – Catholic Update August©2006

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.

via End-of-Life Ethics: Preparing Now for the Hour of Death – Catholic Update August©2006.

Emphasis by underlining is mine. Edited 5/10/13 BBN

Are Feeding Tubes Morally Obligatory? – January 2006 Issue of St. Anthony Messenger Magazine Online

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.

via Are Feeding Tubes Morally Obligatory? – January 2006 Issue of St. Anthony Messenger Magazine Online.

Opponents of SB303 Promote Doctors Without Conscience

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.

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