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New Book

Since its inception in 1968, the brain-death criterion for human death has enjoyed the status of one of the few relatively well-settled issues in bioethics. However, over the last fifteen years or so, a growing number of experts in medicine, philosophy, and religion have come to regard brain death as an untenable criterion for the determination of death. Given that the debate about brain death has occupied a relatively small group of professionals, few are aware that brain death fails to correspond to any coherent biological or philosophical conception of death. This is significant, for if the brain-dead are not dead, then the removal of their vital organs for transplantation is the direct cause of their deaths, and a violation of the Dead Donor Rule.

This unique monograph synthesizes the social, legal, medical, religious, and philosophical problems inherent in current social policy allowing for organ donation under the brain-death criterion. In so doing, this bioethical appraisal offers a provocative investigation of the ethical quandaries inherent in the way transplantable organs are currently procured. Drawing together these multidisciplinary threads, this book advocates the abandonment of the brain-death criterion in light of its adverse failures, and concludes by laying the groundwork for a new policy of death in an effort to further the good of organ donation and transplantation.

Can be purchased here.

Ethics Dilemma

Here is my response to another question on an interesting ethical dilemma regarding human embryos. Originally posted here: http://blog.soundrezn.com/2010/01/26/bioethics-2/

Question: In a room there is a 4 month old human baby girl. Also in the room is a container of 30 human frozen embryos. You are there in the room also. The room, and its contents, will briefly be totally destroyed. You can escape taking either the baby girl, or take with you the 30 embryos and leave the baby girl to be destroyed with the room. Which do you leave with, and why? Is crushing an acorn the same as cutting down a full grown tree with a chain saw?
Define the term \"person\".
Is an embryo a person?
Thanks and Good Luck,
Bill

Response: The questioner begins with a dilemma posed in the form of an unlikely scenario. Before we attempt an answer, there are several other important questions that must be addressed. First, how should we define a person? For clarity's sake, I will prefer to pose the question in this form: “what is a human person?” There are two general answers among bioethicists to that question. Some define a human person in functionalist terms. Until and unless a human organism functions in a certain way, that is, until the organism has certain person-making capacities, we are in no way justified in granting moral standing to the organism in question. What those capacities are differ depending on who one asks. For most functionalists, persons are human beings who have the capacity for consciousness (or some key mental capacity), a necessary condition of which is an intact cerebral cortex. This view depends on a body-self (or body-person) dualism that supposes that the person comes to be (and may cease to be) at one time and the human organism associated with that person at another. Depending on which form of functionalism one embraces, functionalists generally disqualify human embryos, fetuses, newborns (in some cases), as well as adult humans in certain diminished neurological states (PVS, brain death, and some cases of dementia and amnesia) as persons. But designating these humans as non-persons has numerous counter-intuitive problems. (Two excellent critiques are: Lee, Patrick, and Robert P. George. Body-Self Dualism in Contemporary Ethics and Politics. New York: Cambridge University Press, 2007. Francis Beckwith. Defending Life: A Moral and Legal Case Against Abortive Choice. Cambridge, 2007.)
The traditional substance view defines a human person in terms of its substantial identity (or nature). A thing is what it is according to its nature. According to the substance view, a human person throughout its development and decline does not undergo any substantial changes that alter its identity until it dies. Indeed, it remains numerically identical to itself as long as it exists even when it is unable to exhibit all the functions normally associated with healthy adult human persons. Hence, mere membership in the species homo sapiens is sufficient reason to attribute intrinsic value and rights to any human individual in recognition that it is “one of us.” There are several important factors to note about human embryos that render them human persons. First, an embryo is from the start distinct from any cell of the father and mother. This is due to its internal, directed, and distinct growth toward maturation. Second, the embryo is human with a genetic make-up characteristic of humans. Third, the embryo, though immature, is a complete or whole organism that will, barring disease, violence, or variation in environment, direct itself toward full expression of its nature or essence. All of these features are present in the embryo and none of the changes it undergoes during its development generates a new direction of growth. In short, the thing that you and I are now is identical to the organism that came to be at conception. Therefore, we as persons are human organisms of a substantial kind and what would make it wrong to kill you and me now would have been present at every stage of our development. In short, a human person is an organism belonging to the species homo sapiens.
The questioner asks whether crushing an acorn is the same as cutting down a full-grown tree with a chain saw. It appears that the questioner is attempting to make the analogy that an acorn is not a tree in the same way that an embryo is not a person, and as such, killing an embryo is not the same thing as killing a person. The analogy, however, is a false one. An acorn is certainly not a tree. A tree is a fully developed plant and an acorn is an underdeveloped plant. However, both the acorn and the tree are by nature plants of a particular kind. If the acorn came from an oak tree, then it shares the same nature as the oak tree from which it came. Therefore, the difference is not an essential one, but merely accidental—a difference in development. In the same way, although an embryo is not a toddler, adolescent, or adult, it is by nature a human person. Additionally, I would add that an acorn has not yet germinated. This further shows the weakness of the analogy. There is no human equivalent to pollination and germination. I don't rake oak trees out of my yard when I collect acorns, but I would argue that I certainly pull up oak trees when I pull up the sprouts.
Now to the dilemma. Here we are confronted with having to make a choice between saving a four-month-old baby girl, and saving multiple embryos. If we accept the reasoning above, the 30 embryos are human persons. So, how do we resolve this dilemma? I think the best way to approach this scenario is to treat it as we do in circumstances that call for Triage. Triage is a process of sorting or selecting who can benefit most in a crisis situation . It is often used in emergency rooms, on battlefields, or at disaster sites when there is a real need to allocate resources and time. The process does not adjudicate based on status, age or gender but rather on the likelihood of benefit from immediate attention. The 30 embryos are most likely discarded or left over embryos from the reproductive process known as in vitro-fertilization (IVF). [IVF poses multiple ethical problems, at least as it is currently practiced.] They will probably never be implanted and allowed to develop further. In short, they are doomed whether or not they are saved from the impending disaster presented in the scenario. However, the four-month-old baby girl will clearly benefit from my saving her. Therefore, I would choose to save the baby girl.

End-of-Life Ethics Question

This was originally posted in response to a question raised by a listener on a radio broadcast of the show Sound Rezn. Follow this link to the show's blog where my original response was posted: http://blog.soundrezn.com/2010/01/21/bioethics-qa-1/

QUESTION: Just started listening to today’s program. I always appreciate the Biblical teaching you bring when I am able to listen. On today’s topic, I need more information, Biblical council concerning caring for elderly parents. I wonder how much medical assistance, prescription drugs, etc.,we should pursue when trying to provide care. My father is in a nursing home. He is unable to do anything without assistance. He has a feeding tube because he lost the ability to swallow last spring and he made the decision to have the tube put in. Today he is barely able to talk or carry on a conversation. His sight is almost gone. He yells “help” day and night. Sometimes he needs help. Usually, he simply wants someone by his side so that he is not confused about the activity around him or in the hallway. Sometimes he really needs help. It has been suggested to increase a drug that he is currently using which would probably cause him not to yell so much, but probably sleep more. I do not know how to make these decisions. Watching both my parents suffer with Alzheimer’s disease, I wonder what we are doing by adding another drug to keep them going. My heart aches with this ethical question wanting to be obedient to God and to honor my father and mother as we are commanded to do. This is only a small portion of the situation. I know my family is not the only one struggling with elderly parents. I would appreciate any council you may offer. Most of all, I am asking for prayer. Our Father in heaven is not a god of confusion. But, at times, I ache with confusion.

REPLY: It is no easy thing to watch a loved one deteriorate when there is no perceivable hope of recovery. That’s why cases like these can be so hard to decide. This case also exemplifies how technological advances in medicine, while many in their benefits, also bring with them burdens. Fortunately, traditional medical ethics, informed by the Hippocratic and Christian traditions, provides us with important distinctions that are helpful in guiding our way through the maze of these kinds of hard cases.

The oldest of these is the Hippocratic tradition. This tradition maintains that the primary duty of the physician is to do no harm. This precludes the administration of poisons in order to prematurely end the lives of patients. The Hippocratic ethos conceives the primary practice of medicine as the relief of suffering wrought by disease. When medicine can no longer accomplish this end, the physician and patient ought to recognize the futility of medicine and withdraw or withhold its use. Thus, this tradition asserts that the purpose of medicine is to relieve suffering associated with sickness and disease and that when medicine can no longer achieve this goal, the physician should no longer employ medicine. (The exception here is comfort care. This should always be prescribed.) The implication is that the extension of medicine beyond its purpose could potentially cause greater harm to patients in hopeless medical conditions.

In conjunction with the Hippocratic tradition, traditional Christian medical ethics draws out two important distinctions that remain well embedded in American law and ethics. While recognizing an obligation to heal, there exists no moral obligation to extend life at all costs. The traditional means for determining whether care is beneficial is found in the distinction between ordinary and extraordinary care. Ordinary care refers to any treatment modality that has reasonable benefit for the patient, as determined by the patient. According to the Christian moral tradition, foregoing these sorts of treatments is morally prohibited. Extraordinary care refers to any treatment modality that does not provide reasonable benefit to the patient, as determined by the patient. In other words, the treatment is overly burdensome and benefits the patient little, if at all. These sorts of treatments may be foregone.

There is also the distinction between killing and allowing to die. While the Christian tradition prohibits the direct killing of an innocent human person, allowing someone to die is sometimes morally permissible. For instance, a patient may decide not to employ certain medical treatments to prolong his or her life. Withholding such treatment, if the treatment is deemed extraordinary by the patient, is morally acceptable even though it will result in the death of the patient. In another case a patient may decide to stop a medical treatment or procedure that has already begun. In cases of this sort, withdrawing treatment is considered morally permissible if such treatment is considered extraordinary by the patient. Finally, when the administration of pain medication contributes to a patient’s death, the general consensus is that in such cases the intention to relieve pain qualifies the act as an indirect cause or a hastening of death (by use of the principle of double effect).. In these cases it is the underlying condition that is considered the direct cause of death. When the wishes of a patient are unknown, then a surrogate should decide based on either the substituted judgment standard (in which case the surrogate decides by virtue of his or her personal knowledge of the patient) or the best-interest standard (what is in this patient’s best interest).

The application of these distinctions to this case indicates that the best course of action is to accept the increase of the drug as an effort to make your father more comfortable. Clearly his diminished condition is causing him distress, which is only going to get worse as time goes on. When it is clear that a patient is dying, is unaware, and cannot improve, it is appropriate to consider limiting life-extending treatment. But that is different than extending care to ease suffering. It’s not clear that the administration of the drug will needlessly prolong his suffering. Rather, it sounds like a comfort care measure that ought to be given.

Another related issue concerns the continued administration of the feeding tube that your father initiated. It is possible that in the course of discussing options with his health care providers, the suggestion of withdrawing the feeding tube may come up as his condition deteriorates.. This could potentially complicate matters. There is considerable debate among Christian ethicists concerning the appropriateness of withdrawing nutrition and hydration. Some argue that it should be considered ordinary care under all circumstances, while others might consider it extraordinary under certain conditions, such as when a patient enters a state of severe diminished conscious capacity (e.g., patients in a permanent vegetative state). These are hard cases, especially when a patient has failed to make his or her wishes known ahead of time. My recommendation is that you should seek means to ensure that your father is as comfortable as possible in his final days, and since his condition does not fall into a category in which the tube might be considered overly burdensome (extraordinary), the feeding tube should not be removed.

New Breakthrough May End Donor Shortage and Relieve Ethical Concerns

Another “proof of concept” success involving adult stem cells is showing once again that the proposals of many in the bioethics community to increase the pool of organ donors through an expansion of death criteria are both shortsighted and ethically wrongheaded. A recent press release reports, “US scientists have coaxed recycled hearts taken from animal cadavers into beating in the laboratory after reseeding them with live cells.” If this procedure is extended to humans, the potential “for almost limitless supply of hearts, and possibly other organs” could diminish the need for heart-beating cadaver organ donors. The theory behind the procedure involves developing “transplantable blood vessels or whole organs that are made from your own cells” thus eliminating the need for immunosuppressive drugs.

The well-publicized acute shortage of donor organs is highlighted by the fact that approximately 50,000 patients die every year waiting for a heart transplant. Many leading bioethicists have proposed expanding death criteria to include higher-brain death as a means for increasing organ supply. This would mean that patients in a permanent vegetative state (PVS) could be declared dead and their organs removed for transplantation, provided that either prior consent from the patient or consent by proxy is obtained. Given the tenuous nature of a PVS diagnosis, such proposals are certain to raise more controversy and greater suspicion regarding the means of procurement for the good of life-giving organ transplants.

Furthermore, these proposals fail to take into account that, under the current system, many recipients of donor hearts don’t survive any longer than those left on waiting lists. (See: Deng, Mario C., Effect of receiving a heart transplant: analysis of a national cohort entered on to a waiting list, stratified by heart failure severity BMJ 2000;321:540-545.) This is due primarily to the fact that the pre-existing weakened condition of heart patients is further compromised by the surgical procedure and the ensuing immune-suppressant diseases characteristic of organ recipients. The prospects of transplantable organs derived from recipients’ own cells are clearly preferable to the proposals of many in the bioethics community. Not only will it eliminate much of the controversy currently surrounding the procurement of organs for transplantation, but also promise greater survival rates for recipients.



Press Release: http://afp.google.com/article/ALeqM5jrDcLbJiEj8KXtPaMo_sPrzoUsKQ
Telegraph Report: http://www.telegraph.co.uk/earth/main.jhtml?view=DETAILS&grid=&xml=/earth/2008/01/13/sciheart113.xml

The Depersonalization of Genetic Selection

In the futuristic movie Gattaca, parents are encouraged to “design” their babies through the technology known as embryo screening. The process is portrayed as practically guaranteeing a baby devoid of genetic defects and undesirable characteristics. In concert with Gattaca’s portrayal, most people today envision embryo screening as a means to “weed out” genetic defects and select those embryos with the potential to develop into persons who possess valuable traits.

But to the surprise of many, recent discoveries of couples utilizing the technique to choose offspring with genetic defects is causing quite a stir. A recent survey of U.S. clinics that offer embryo screening suggests that some dwarf and deaf couples may be intentionally choosing to implant embryos that carry the genetic markers for dwarfism and deafness. http://www.msnbc.msn.com/id/16299656/

Moved by the desire to “reproduce children in their own image,” these couples are fighting for their “right” to have the kind of children capable of sharing in the dwarf and deaf cultures where these sorts of defects are considered “normal.” Critics of the practice say that this “deliberate crippling of children” has taken the “concept of designer babies too far.” While there’s much that can be discussed here, such as whether embryo screening is ethical to begin with, and whether this practice serves the goals of medicine, I am going to focus briefly on an underlying philosophical point that’s often overlooked.

Debates of this kind are indicative of the failure to rightly situate the philosophical source of personal value. Notions of personal value based on a repeatable trait or cluster of attributes fall short in providing stability for grounding human dignity and worth. Rather than relying on replicable traits, personalist philosophers focus on that which is irreducible and unrepeatable in persons—something that can only be grasped from an inward turn.

From an interior perspective, one is able to lay hold upon the personal subjectivity and the incommunicable being with which each person can claim as uniquely his own and not another’s. Introspection of this metaphysical standpoint opens up a depth of being far more capable of establishing the uniqueness of each human person. Notions of personal identity and value based on a shared trait or culture fail to adequately capture what is irreplaceable in the person. Thus, efforts to encourage and support the flourishing of individuals with disabilities can only properly flow from a perspective that values persons as persons, not just for the traits they possess or the cultures of which they are a part. (For further exploration, I recommend John Crosby’s The Selfhood of the Human Person.)

The Future of Organ Transplantation

Two recent breakthroughs in human cell research suggest that a revolution in transplantation may be on the horizon.

In August of 2005, a study funded by the UK Government, and led by researchers from Kingston University’s School of Life Sciences, disclosed that the research team had grown an artificial liver from umbilical cord stem cells. Hailed as the first step in creating a fully artificial liver for transplantation, researcher Dr. Colin McGuckin said, “the transplant of a section of liver grown from cord blood could be possible within the next 10 to 15 years.”
http://www.kingston.ac.uk/%7Ekx25594/news/news-archive/2005/august/Stem_Cell.htm

More recently, (April 2006), news reporting agencies documented a breakthrough in the growth of transplantable human bladders from tissue taken from recipients’ own defective bladders. The bladder cells were cultured in a nutrient bath in a laboratory, and after two months, the bladders were fully grown. Not only were the transplants successful, but the recipients were free of side effects, including tissue rejection. The Wake Forest University team of scientists are currently working on ways to grow 20 different tissues and organs. http://news.bbc.co.uk/1/hi/health/4875244.stm

This is surely welcomed news. For not only will these advances potentially relieve the problems of organ rejection and the immense shortage of suitable donors, but also the ethical problems surrounding the use of brain dead donors.

Those familiar with the history of brain death and organ transplantation know they share a common, and perhaps, dubious past. In 1968, when a Harvard ad hoc committee first suggested neurological tests for the condition known today as brain death, they failed to say why (biologically or philosophically) brain death should be equated with human death. Instead the committee justified brain death on pragmatic grounds, one of which was to remove the ethical problems surrounding organ donation. But if brain dead patients are not really dead, then the removal of their organs for transplantation is the direct cause of their deaths.

Despite latter attempts to construct a conceptual basis for brain death, many bioethicists continue to recognize that brain death fails to correspond to any coherent biological or philosophical conception of death. In fact, over the last 20 years or so, advances in critical care medicine continue to challenge the conceptual assumptions put forth by brain death proponents. But instead of abandoning brain death, some bioethicists are suggesting that certain neurologically diminished patients (such as PVS patients) are not really being harmed if their organs are removed for life-giving transplants, given their severe, neurologically impaired state. Such utilitarian thinking, however, would only further the problems surrounding organ donation. Instead, prudence suggests that we ought to focus our energies on more promising technologies that remove the problems of organ rejection and donor shortage, while at the same time allay much of the ethical controversy surrounding current practice.