David Wainwright Evans, MD, FRCP: Rest in Peace

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David Wainwright Evans was a good man, a good scholar, and a good friend. His vita would be impressive by any standard: service in the Royal Air Force in World War II, both as a bomber pilot and a fighter pilot, Fellow of the Royal Society of Physicians, Consulting Cardiologist, Papworth Hospital, UK, and Fellow Commoner, Cambridge University, UK. I first met Dr. Evans via e-mail in 1996. I was planning to edit a book of scholarly articles in opposition to brain death criteria for declaring a person dead. Dr. Evans immediately agreed to contribute to the volume, and he wrote a fine chapter, “The Demise of ‘Brain Death’ in Britain.” He worked with a number of scholars and physicians on article on brain death and on ethical issues that arise if brain death is not death. This has obvious implications for the ethics of organ donation. Dr. Evans believed, as I do, that removal of unpaired vital organs from the “brain dead” individual is the taking of innocent human life and is therefore morally wrong. Dr. Evans remained true to his values even when pressured to change, and he retired early from cardiology in order to express openly his beliefs. That takes a great deal of moral courage, and I admire Dr. Evans for that. He was also an opponent of war, having seen its destructiveness as an RAF pilot. Dr. Evans was a fine Christian gentleman, a member of the Church of England who was faithful in his duty to God.

I had the privilege of seeing Dr. Evans twice in person while visiting England, first to attend a conference, and next on vacation (or “holiday” as the British call it). He and his wife, Rosemary, were gracious hosts and both visits were pleasant for me and (in the second visit) for my wife as well. Dr. Evans and I exchanged hundreds, perhaps thousands, of e-mails, in an excellent personal and professional friendship. The suddenness of his passing was a shock, but he was well into his eighties and died peacefully in his sleep. He is in the hands of God now, and I hope to see him again one day in a far better world than this one. Rest eternal grant unto him, O Lord, and may light perpetual shine upon him. May his soul, and the souls of all the faithfully departed in Christ, rest in peace. A-men.

Jahi McMath, Brain Death, and the Lies of the Medical Establishment

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After post-tonsillectomy bleeding, Jahi McMath suffered a cardiac arrest that damaged her brain. She was declared brain dead. The hospital wants to remove her ventilator, but the family is opposed. While there have been extensions granted by judges, the hospital, the medical establishment, the State of California, and the bioethics establishment have ganged up to force Ms. McMath’s ventilator to be removed. The hospital refuses to do a needed tracheotomy since “we can’t operate on a dead person” (this in spite of the fact that the hospital would support removing the organs of a person declared “brain dead” even though that is surgery as well). The hospital refuses to authorize transport, and under California law, the coroner “has to release the body.” This is an example of declaring a person dead by fiat and is a logical consequence of the acceptance of “brain death” criteria beginning in 1968.

Henry K. Beecher was the chairman of the Harvard committee on brain death. In an article in the 1968 JAMA, he argued that brain death should be considered death in part because organs could then be harvested from the patient while they are still perfused with oxygenated blood. In later articles he was more explicit in saying that death was redefined in the interests of organ transplantation. The 1981 Uniform Determination of Death Act (UDDA) or a compatible law has been passed in all fifty states. The law says death can either be declared after cardiopulmonary arrest or when the “whole brain” is dead. The President’s Commission report claimed that once the brain is dead, the body’s organic unity is gone.

Brain death criteria are not well-supported by evidence. Cicero Coimbra, a neurologist in Brazil, has noted that one of the tests to determine brain death, the apnea test, which involves removing the ventilator from a patient suspected of being brain dead for three minutes to check for spontaneous respiration. Dr. Coimbra points out that this test can itself cause brain death in patients who are not initially brain dead. He also argues that there is hope for some of these patients–hypothermia and other treatments to preserve brain cells may have good results. There have been cases in which a person was about to have organs removed for transplantation–and the person fully recovered. It is possible that removing a ventilator from Ms. McMath might take the life of a person who might not otherwise die from her head injury.

The entire brain is not dead in most cases of brain death–studies have found EEG activity in the majority of so-called “brain-dead” patients tested. For organs to be removed, body temperature has to be close to normal, and body temperature is mediated by the hypothalamus, which is part of the brain (along with the pituitary gland, part of the endocrine system). Supporters of brain death claim that these parts of the brain do not count–one wonders what else they would say would not count if further evidence of continuing brain activity is found.

As the recent President’s Council report points out, brain dead people are organic unities. Their blood circulates, and oxygen/carbon dioxide exchange continue. While the ventilator provides oxygenated air, machine dependence is not equivalent to death. Some conscious people are ventilator-dependent, and no sane person would consider them dead. The President’s Council identified death with loss of respiratory function combined with permanent loss of consciousness. Why, then, does ventilation count for life and not the heartbeat? Also, given that our knowledge is limited concerning the generation of consciousness in the brain, claims of permanent unconsciousness are arrogant at best.

I respect Arthur Caplan as a significant scholar in bioethics. What I cannot respect is his ignoring opponents of brain death in his public statements as if there is no current debate on the topic in academia. It reveals a lack of respect for opponents of brain death criteria, some of whom are physicians (Dr. Coimbra and Dr. Alan Shewmon as well as the late Richard Nilges practice or practiced neurology). Professor Caplan is surely aware that just because a law says death occurs at a certain point does not imply that the law is correct. Many bad laws have been passed–the UDDA may be another example of bad law.

Current bioethicists tend to think that patient autonomy is fine when the patient (or the patient’s family in the case of an incompetent patient) refuses care. But if a patient or patient’s family wants continued care, then there are appeals to “futility,” as if “futility” is not a value-laden term. “Death” is also a value-laden term and can be used for utilitarian ends such as justifying organ harvesting from heart-beating donors or to save money by removing a ventilator from a little girl. The hypocrisy of many doctors, hospital administrators, and “bioethicists” is sickening. The trashing of the value of Ms. McMath’s life is ethically monstrous. Given the history of movements such as the eugenics movement and experiments such as the Tuskegee Syphilis Experiment, I wonder what motivations are really in the minds of some of those most eager to remove Ms. McMath’s ventilator. Utilitarianism now trumps the value of human life, and medicine is corrupted to the point that I wonder whether some doctors are really practicing medicine any more.

If it were determined that Ms. McMath could not recover, the family’s wishes should be honored, even if the care Ms. McMath receives is “extraordinary care.” The family would also have the moral right to ask that the ventilator be turned off — but autonomy goes both ways and not only in the direction that cynical “bioethicists” desire.

Belgium: The Return of “Useless Eaters”

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English: Skull and crossbones

English: Skull and crossbones (Photo credit: Wikipedia)

At http://www.france24.com/en/20121218-belgium-looks-euthanasia-minors-alzheimers-sufferers is an article on a proposal that will most likely pass Belgium’s legislature that allows euthanasia for minors and for Alzheimer’s patients. Increasingly secular, godless Europe is finally passing laws that reflect the decline of the remnants of Christian ethics that held on for a while after the decline of religious belief. The phrase “useless eaters” was coined by a Nazi doctor who was discussing Nazi Germany’s euthanasia program. It had no problem killing minors and people with senility of whatever cause. With no clear cut behavioral diagnostic difference between Alzheimer’s Disease and senile dementia in general, the new law, when passed, could de facto be applied to some non-Alzheimer’s senile patients.

What are the limits on the age of minors? Apparently none–any minor deemed “too sick to live” by a doctor and by parents or guardians could be killed. The slippery slope that supporters of euthanasia claimed would not happen is already fact. Next door in The Netherlands, voluntary euthanasia quickly led to involuntary euthanasia, and there was, for a time, a proposal on the table to have a “quality of life threshold” below which a person would no longer have the right to live. It may just be a matter of time before the severely mentally retarded will join the list of “useless eaters” and euthanized. A godless society only gives life a utilitarian value. Although Kant tried to set up a secular system that allowed for intrinsic human dignity, his dream died, at least in some European countries, and the remnants of the Christianity that still influenced Kant died away. Now there is no bar to making decisions regarding euthanasia not based on alleged “mercy,” but on a person’s ability to “contribute” to society. The fittest survive; those considered unfit will be eliminated. The most frightening instances of murder are those murders that use mercy to justify them. The only “mercy” involved may be for the family to get a burden off their back and the state to save on medical bills due to fewer patients requiring long-term care.

The United States, for now, has enough residual Christian belief to avoid Europe’s direction for now. However, given the responses of most of my medical ethics students to questions regarding the moral rightness or wrongness of physician assisted suicide, it seems that those supporting PAS will win in the long run. If they do, it will be no surprise if PAS leads the way into voluntary active euthanasia and eventually to involuntary active euthanasia. Society will be at last be in part of a eugenics movement that will make the earlier movement in the first decades of the twentieth century seem like child’s play. God help us all if that happens–and it will happen in Western Europe (and probably in Canada) before it happens in the United States. But with 30% of young people in the U.S. classifying themselves as “irreligious,” the road toward Europe may be wider than one might think.

Atheists forget, when they catalog the crimes of religion, that the mass murderous regimes of the twentieth century were atheistic: Nazi Germany, the Stalinist Soviet Union, Maoist Communist China, North Korea, and Cambodia when it was under the rule of Pol Pot. The sanctity of human life does not make sense in an atheistic framework; the value of human life must be instrumental and not intrinsic in a consistent atheistic system. It is no surprise, then, that Belgium and the Netherlands are going the route toward allowing more and more classes of people to potentially be subject to euthanasia. The Nazi world of alleged “useless eaters,” a world Europe once claimed to eschew for good, is coming back to haunt a godless society. The price paid for such folly will be very high.

Anti-Religious Bias in Medical Ethics

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English: Medicine

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A few of my medical ethics students (not by any means the majority) object to my including such a large component of religious ethics in my teaching. Such an attitude is not surprising–it is another instance of religion’s increasing exclusion from public life and debate (Fr. Richard John Neuhaus‘ “naked public square,” but it is nevertheless disturbing. The founders of the great Hippocratic tradition of medicine (and ethics) were Pythagoreans, and their thought cannot be understood apart from Pythagorean mysticism. Roman Catholic scholars were producing texts in medical ethics as early as the seventeenth century, and taught medical ethics as a university course long before the contemporary bioethics revolution began in 1966. Roman Catholic concepts such as the principle of double effect and the ordinary-extraordinary care distinction have become a part of the ethical vocabulary in medicine.

In addition, Protestant scholars, such as Paul Ramsey and James Gustafson, have made important contributions to medical ethics. Jewish scholars, such as Hans Jonas and Leon Kass, have also contributed to the field, with Professor Kass serving as the chairman of the President’s Council on Bioethics during the Bush administration. Muslim scholars are beginning to be published in both mainstream medical and in medical ethics journals. At a practical level, understanding diverse religions is important for any health care provider.

The terms of the debates over key bioethical issues such as abortion and euthanasia cannot be adequately understood without understanding the religious arguments involved in these debates. I am not denying the possibility of a consistent secular ethics; I am saying that, as a matter of fact, de-emphasizing the religious aspect of medical ethics is irresponsible, period, and would be more irresponsible for me from a scholarly/teaching point of view.

What is more disturbing than students’ attitudes, which may be as much due to lack of exposure to alternative views (especially for those students who are “rabidly secular”), is the increasing exclusion of religious points of view from medical ethical debates. This exclusion is not absolute; journals such as the Hastings Center Report occasionally publish articles from a religious perspective, as do some other journals in medical ethics, but this is becoming increasingly rare. The false Enlightenment assumption that religion is only a private, subjective matter is part of the problem. Such a view reveals utter ignorance of the function of religion in personal behavior and in society. As one of my teachers at UGA once said, “I would never be such a damned fool as to claim that religion is only a private matter.” He was a liberal Protestant and not a raging Fundamentalist, but he understood the function of religion to be inherently social. He also understood that religions make claims about reality, and such claims can be broadly tested against human experience in general, although there will always be an element of faith and of mystery in religion.

Increasingly, I find a small group of students who could be called “misotheists”–they hate God or at least the notion that any Creator exists. Since these are mostly science students, I would guess they were encouraged to believe such things by some of their science teachers, as well as by the strict methodological atheism of modern and contemporary science. Far too many science teachers make sweeping metaphysical claims regarding religion being a superstition and claim that such a view is “scientific.” Of course this is really the philosophy of “scientism,” the view that science can explain all reality and that any reality claims that go beyond a mythical “scientific method” are, by their very nature, not part of reality. Such a view needs to be justified by argumentation, but neither the scientists who accept scientism nor students are willing to present arguments–their hostility to religion is palpable. Other students (and atheists and agnostics in general) are angry ex-religious people who have rebelled against, perhaps, a harsh religious background (or maybe they just want to get laid and don’t want any religion to get in their way). Since misotheism is, like scientism, an emotionally-based position, there is no rational way to get most people who hold such views to think them through.

I admit I’m frustrated. It is becoming increasingly difficult to be a religious believer who teaches in a college or university. They follow the logic of the eighteenth century Enlightenment, adopting not only its positive side (toleration for different points of view) but also its negative side (the total secularization of the academy). Even in religious schools, the logic of the Enlightenment leads many faculty be be atheists or agnostics and to minimize the role of religion in public life. It is sad that this attitude has spread to future health care providers.

Newspapers and Stillborns

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Memorial Service

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Before I read Robert Kastenbaum’s textbook on death and dying, I was not aware that some U. S. newspapers refuse to print the obituaries of stillborn infants. I had to read the statement twice to believe it was there–to be fair to Kastembaum, he does not like that fact any more than I. Although my fraternal twin brother, Jeffrey, was not stillborn, he died two hours after birth of severe bilateral pulmonary hemorrhage. The tendency in society is to downplay the import of such losses and downplay the parents’ grief. “The child really didn’t get a chance to live.” Granted, the child’s life was short, but what follows from that? Is a mother or father’s love somehow missing because a baby was stillborn or died shortly after birth? What gives a newspaper a moral right to deny the existence of such infants to the point of refusing to print their obituaries? I wonder if a society that allows abortion through the ninth month of pregnancy (provided, during that last trimester, that a woman has a doctor certify that the fetus is a threat to her physical and/or “mental” health) can properly value stillbirths or infants dying shortly after birth. Those newspapers that forbid such obituaries are reflecting the values of moral liberals in the wider society, liberals who do not admit the intrinsic value of human life from conception onward. Such an attitude is reflected in bioethicist Peter Singer’s statement that “An adult chimpanzee is of more moral worth than a newborn human infant.” He would go as far as to deny personhood to a newborn until the baby is a week old, and even then Singer does not believe that true moral personhood is present until the child is several years old. American society may not be quite that radical, but when children are considered to be burdens rather than gifts, a stillborn infant can be relegated to secondary status–or perhaps to tertiary status, lower on the scale of value than nonhuman animals.

Recent research on grief suggests that parents, especially mothers, mourn deeply over stillbirths and over infants who die shortly after birth. The least a newspaper can do is to acknowledge their loss by printing their child’s obituary. To do otherwise is to exhibit a fundamental lack of respect for the dignity of the stillborn infant or of the infant who dies shortly after birth. To do otherwise says that the severe grief felt by parents over the infant’s death is misguided. I suggest that it is not the parents who are misguided; it is newspaper editors who refuse to respect the dignity of all human persons, born, stillborn, or unborn.

The Fundamental Goal of Medicine

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A medicine icon.

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The fundamental goal of medicine is the patient‘s good. Edmund Pellegrino and David Thomasma both focus on that point in their 1981 book, A Philosophical Basis of Medical Practice, the book that has most influenced my approach to medical ethics. All other goals–having an up-to-date facility, having the best equipment at a clinic or hospital, turning a profit, and efficiency in finances, must be subsumed under that primary goal. The good of the patient may involve curative care, or it may involve palliative care in the case of a dying patient. The human person is a whole, body and soul, so medical practice must focus on the good of the whole person and not just on body parts and diseases. The good of the patient may include physical good, but it may also include psychological and spiritual good. Recognizing the complex dimensions of personhood and treating a patient as a person, not as a thing, will do more for the good of the patient than merely diagnosing and treating a physical disease. Even a “physical disease” contains a psychological component, since the patient’s mood can influence the course of the disease for good or ill. Sometimes a physical disease can be triggered by psychological stress. Extreme emotional stress can activate the HIV virus so that a person gets full-blown AIDS. Other diseases may be activated by stress: cardiovascular disease, cancer, rheumatoid arthritis, lupus, infectious diseases. Part of a medical practitioner’s job is to recognize when a patient is having a great deal of emotional stress and encourage the patient to deal with that stress.

Treating the patient as a person implies that assembly line medicine is not ideal. Despite massive debt that young physicians often try to pay off with a high volume of appointments, at some point a provider is spending too little time with patients and comes across an uncaring. Constantly looking at one’s watch does not help. Talking to a patient in a real conversation does. Of course any doctor, PA, or nurse practitioner must have some limitations on patient appointments in order to receive all those in need. Finding the correct balance is not subject to exact rules and is a matter of prudence. Prudence is the ability to make a good decision in both routine and in more troublesome and complex situations. It is an essential virtue, necessary for both everyday medical, as well as for moral, decision making. A list of absolute rules to follow will not help in ethical dilemmas in which rules conflict and are only prima facie, which higher-level rules may supercede.

The fundamental end of medicine implies the principles of benevolence, nonmaleficence, and justice. Autonomy is trickier, since it is an enlightenment concept that may be conditioned by contemporary Western Culture. Kant himself thought we would autonomously give ourselves the moral law, but the term is used today for “the right of every adult to make choices based on their own value systems.” In practice, there is limited autonomy in medicine; not everyone can practice medicine, and drugs must pass FDA approval before being placed on the market. These limitations are so patients will not be misled by quacks or those pushing an untested, ineffective, and perhaps dangerous, drug. Autonomy in patient decision making recognizes that it is the patient’s body who is being affected by medical treatment, and that the patient’s values are not necessarily the physician’s values. I think of respecting autonomy in terms of respecting the free will of patients to make their own decisions regarding health care.  This helps preserve the dignity of the patient in a setting in which the sick patient, feeling powerless, tends to lose a sense of dignity.

There are a number of controversial issues in medical ethics that focus on the nature of the patient’s good, or even if there is a patient present to whom the health care provider does good or harm. The abortion issue is one of these–if the fetus is a patient, then abortion amounts to murdering a living human person. If the fetus is not a patient because he is not a person, then the opposite conclusion seems stronger. My own view is that personhood begins at conception, so that any doctor or health care worker helping with an abortion is violating the fundamental end of medicine. The same would follow for euthanasia and for physician-assisted suicide. Many people will disagree with these positions, and I welcome rational argument on any position I set forth in this blog.

Most issues regarding the fundamental good of medicine are more mundane that the large scale bioethical issues often discussed in undergraduate medical ethics courses. Usually the practical everyday issues involve the amount of time spent with patients, dealing with difficult patients, keeping information confidential, keeping medical records accurate instead of falsifying “the little stuff,” and so forth. All these issues involve remembering that the patient is a human person with feelings, with a life, with loved ones, just like the health care provider–and that providers can help a person leave better than when he arrived.

Academics and Closed-Mindedness

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Acadèmia (iii)

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There is a thin line between open-mindedness and giving up reason, but closed-mindedness is always a threat to reason. College and university education should be the ideal place where open-minded but rational professors help students to think. This implies that professors love truth above professional success, fame, and other temptations. There are many professors who do place truth above finite goods–thank God for their presence in the academy. From my experience, other professors are locked into their world views and refuse to think outside the box, placing acceptance by their colleagues above seeking the truth.

One area in which such narrowness is found is politics. The vast majority of humanities professors are liberal Democrats; some are Marxists. Although some of these professors are “true liberals,” allowing students to express contrary opinions, others are intolerant of difference. Those who oppose liberals position on entitlement programs, for example, are labeled as “racist” by these professors, who obviously have no idea what the term “racist” really means. The situation is worse concerning moral issues: opposition to abortion can get a student labeled as a “pro-life nutcase.” Opposing practicing homosexuality automatically gets a student labeled as a bigot, and the student may be punished. Some faculty members have been fired for even bringing up arguments opposing homosexuality, although one such case was overturned by a court and the professor was rehired. Professors who count themselves as “trendy” are really the most conformist people of all. They are more predictable than religious Fundamentalists, and emotionally they have the same mindset.

Speaking of religion, there is a bias among many academics against traditional religious beliefs. Academics may have no problem with a watered-down liberal Protestantism or liberal Roman Catholicism, but may detest traditional Christian beliefs and morality. And even though Muslims hold traditional moral values, the academic left is not as critical of them because they are non-Christians. Religion is considered to be a crutch, an opiate (to use Karl Marx’s term), an excuse for persecuting the poor,  a denial of reality, and an enemy to society in general. What religious expression there is is relegated to the private realm–woe be to the faculty member who mentions his Christianity in class, and the same often applies to students, especially to traditional Evangelicals and to traditional Roman Catholics.

Some professors are guilty of other kinds of prejudice. Psi phenomena, such as telepathy, clairvoyance, and psychokinesis are well-documented to the point that parapsychologists mainly do process studies to show how psi works rather than proving that psi exists. Yet many professors dismiss a student or colleague who accepts the reality of psi as a “new-aged nut.” “I don’t know what happened to him, but somewhere along the line he went nuts.” Such conclusions are reached without an open and honest examination of the evidence for and against psi phenomena. The sciences have been the most closed-minded disciplines concerning psi. And although there was a period in the 1970s in which the humanities were more open to psi, today the situation has reverted to the same kinds of prejudice found in the sciences. Papers that accept the existence of psi  are usually only accepted by psi journals and at psi conferences, although recently there have been a few exceptions among psychology journals. Opinions contrary to the establishment are silenced by lack of publication, a death-knell to any instructor seeking tenure.

A third area in which there is closed-mindedness in academia is medical ethics. It is more and more difficult to find an article in a mainstream bioethics journal from a traditional moral perspective. One major exception is the UK-based Journal of Medical Ethics which has published articles from many different points of view, including morally conservative ones. Looking over issues of the Hastings Center Report, the premier bioethics journal in the United States, the articles in the 1070s reflected far more balance between traditionalists and nontraditionalists in ethics than the articles today. There was a greater role for theological ethicists, such as the late Paul Ramsey, to have their say. On the issue of health care allocation, The New England Journal of Medicine has served more as an apologetics journal for Mr. Obama’s health care program rather than a journal that presents a balanced point of view. From the point of view of the university professor, it is easier to get articles published in mainstream journals if one is in favor of abortion rights, embryonic stem cell research, physician assisted suicide, and even, as Jonathan Hardwig, in favor of a “duty to die,” including a duty to commit suicide if one’s illness is financially and emotionally harming one’s family. Would a pro-life professor have any chance to become department head at a major state university? I doubt it. Traditionalists are forced to take jobs at the few Roman Catholic institutions that affirm traditional morality or at an Evangelical Protestant school, and even the latter are moving to the left on moral issues. I am not opposed to a moral liberal, a religious liberal, and/or a political liberal being in academia. But there are other positions out there that need to be heard so that students have a more balanced perspective. Maybe one day the legacy of the 1960s closed-minded radicals who ruined much of academia may change–the sooner the better.

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