Conscience: more than abortion

Last month, a judge in Montana ruled that patients have the right to a doctor's assistance in their intentional death by suicide. Baroness Warnock argues that doctors who will not kill their patients on demand are "wicked." The States of Washington and Oregon already have legalized "Aide in Dying." Is it now my duty to inform my patients on Hospice that they have a "right" to "safe(?) and legal" death by prescription?

Here is part of a poignant Letter to the Editor from an Internal Medicine doc in Oregon:

I was caring for a 76-year-old man who came in with a sore on his arm.

The sore was ultimately diagnosed as a malignant melanoma, and I referred him to two cancer specialists for evaluation and therapy.

I had known this patient and his wife for more than a decade. He was an avid hiker, a popular hobby here in Oregon. As he went through his therapy, he became less able to do this activity, becoming depressed, which was documented in his chart.

During this time, my patient expressed a wish for doctor-assisted suicide to one of the cancer specialists.

Rather than taking the time and effort to address the question of depression, or ask me to talk with him as his primary care physician and as someone who knew him, the specialist called me and asked me to be the "second opinion" for his suicide.

She told me that barbiturate overdoses "work very well" for patients like this, and that she had done this many times before.

I told her that assisted suicide was not appropriate for this patient and that I did NOT concur.

I was very concerned about my patient's mental state, and I told her that addressing his underlying issues would be better than simply giving him a lethal prescription.

Unfortunately, my concerns were ignored, and approximately two weeks later my patient was dead from an overdose prescribed by this doctor.

His death certificate, filled out by this doctor, listed the cause of death as melanoma.

The public record is not accurate.

My patient did not die from his cancer, but at the hands of a once-trusted colleague.

This experience has affected me, my practice, and my understanding of what it means to be a physician.

Abstinence vs "plus"

The Texas Legislature is about to reconvene and the sex ed debate in our State is already in the news. (Free subscription required.)

Unfortunately, the news article blurs the line between sex ed for all children in our schools and the problem that some of our girls have multiple pregnancies as teenagers. What little evidence we have about "abstinence-plus" vs "abstinence-only" sex ed (some of which is reviewed here and here) is never mentioned, while the fact that our State teen pregnancy rate has dropped is seen as a failure or completely ignored.

Along with many of our local physicians, I teach the doctor's portion of "Worth the Wait." The program is taught in all our county's schools. The classes begin in the 6th grader (the students are 11 and 12 years old) and continue into High School health classes (through grade 12, or 17 to 18 years old). The course consists of 16 or 17 classes, including one on STD's that is taught by local doctors and one on the legal consequences, taught by local lawyers.

The main contrast between "Worth the Wait" and "Big Decisions," the program mentioned in the article ( available for download, free, here), is that in each of the 10 to 12 lessons, the latter emphasizes condom use for those who do choose to have sex. There's even a supplemental lesson that teaches how to correctly use a male condom.

Many point out that since some teens will have sex before marriage, and that many will do so much earlier than expected, the earlier these lessons are taught, the better. However, in my experience, the kids who are having sex before 17 or 18 are the ones who are also engaged in other risky behavior, including drinking alcohol and smoking, or who are being abused. (See the story about the 18 year old young man, here.)

I'm uncomfortable with early discussions about "taking action" to buy condoms and how to use them because it seems to actually endorse the idea that there is a healthy way to have sex outside of a committed, monogamous relationship - one that 14, 15 and most 16 and 17 year-olds are not able to establish.

I believe that the best decision is the one that parents, teachers and our schools should teach. We do not talk about the safest way to drive a car before they are 16 and have passed several tests or that seat belts will protect them if they drive recklessly, we don't teach them which alcohol to drink when they are under the legal age limit, and we never tell them that if they are going to smoke, here's the way to do it.

In my "How to live a healthy life" talk that I give adolescents and teens (and sometimes adults) I talk about the physiological and medical reasons we encourage helmets for skaters, seat belts in cars, and why we discourage certain other behavior. I mention the job of the liver, the differences in the body as it matures, the risk of addiction, injury, and infections. Then, I talk about the psychological and social risks and consequences.

For instance, can you really trust someone selling an illegal drug to be honest about what he's selling you? If someone pressures you to have sex without a condom, knowing the risk of even deadly infections (yes, I talk about condoms in my office) does he even love himself, much less you?

It astonishes me how varied the apparent ages of these children are - even through the High School classes (up to age 18). Some still appear to be prepubescent and some look to be fully developed physical adults. While discussing sexual abuse, I remind the 11, 12, and 13 year-olds that in the State of Texas, that it is absolutely illegal to have sex under the age of 14.

And in every class of 6th graders, there's at least one girl who raises her hand and asks if she could go to jail.

Why we need legal protection for the conscience

The pro-abortion forces are objecting to the regulations that Secretary Leavitt has been working on, claiming that the Bush Administration is trying some "last minute" manipulations.

However, LifeEthics reported way back in September 2005 about a move to make referral for abortion mandatory for doctors -- in a sneaky way, too:

The American College of Obstetricians and Gynecologists (ACOG) is sponsoring a bill that would require that all doctors refer patients to abortionists. ACOG is asking that Senators tuck this provision into the the FY06 Labor, Health and Human Services, and Education Appropriations bill. According to an internet alert from the American Association of Pro-Life Obstetricians and Gynecologists, if the provision is not voted down by our Senators, every doctor would be required to help arrange abortions at the patient's request.

The American Journal of Bioethics devoted one of its debates to conscience in 2007. LifeEthics reviewed the subject, here.

ACOG stirred the pot again, about a year ago, as reported in these posts:

Governments threaten physicians for anti-abortion policy

Tuesday, December 11, 2007: CMDA to ACOG: Stop Attack on Conscience

Tuesday, December 11, 2007: Text of Letter from CMA to ACOG on Conscience

Wednesday, December 12, 2007: Doctors, Abortion and Conscience

In response, the conversation about these specific clarifications of the regulations has been covered on LifeEthics and at the Christian Medical and Dental Association since March, 2008:

Saturday, March 15, 2008: Secretary of Health Supports Conscience

Thursday, April 03, 2008: Gynecology and Obstetrics Policy makers respond to doctors on conscience

Saturday, August 02, 2008: Forcing Pro-life Doctors Out of Baby Business?

George on "Obama and Infanticide"

"Obama chose to defend the widest possible scope for legal abortion by building a fence around it, even if that meant permitting a child who survives an abortion to be left to die without even being afforded basic comfort care."

Two of the greatest ethics minds today explain the controversy surrounding Senator Barack Obama's blatant misrepresentation of his pro-abortion and pro-infanticide legislative and public policy. Professor Robert B. George is joined by Yuval Levin at the Witherspoon Institute as he follows up on his earlier discussion about the por-abortion views of Democratic Presidential candidate, Barack Obama.

During the last Presidential Candidate debate, Obama stated,

''There was a bill that was put forward before the Illinois Senate that said you have to provide lifesaving treatment and that would have helped to undermine Roe v. Wade. The fact is that there was already a law on the books in Illinois that required providing lifesaving treatment, which is why not only myself but pro-choice Republicans and Democrats voted against it.''

George and Levin respond:

A few years ago, after it became clear that some infants who were born alive in the course of an attempted induced abortion at Christ Hospital in Chicago and elsewhere were being left to die without even comfort care, Republicans and Democrats around the country united in an effort to make the practice illegal and declare that any child outside the womb, even if she was an abortion survivor whose prospects for long-term survival might be in doubt, was entitled to basic medical care. Even the most ardent advocates of the pro-choice position agreed that a child born alive, even after an attempted abortion, deserves humane treatment.

The tragic stories of infants being left to die moved legislators to act at both the state and federal levels. In Washington, D.C., consensus can be a rare commodity, and never more so than on the issue of abortion. But the Born-Alive Infant Protection Act of 2002 was just such a rarity. The bill passed both houses of Congress without a single dissenting vote-it was 98-0 in the Senate-and numerous states then proceeded to enact similar measures. In Illinois, however, a series of efforts to pass ''Born-Alive'' legislation from 2001 to 2003 met with stiff resistance from legislators concerned the measure would constrain the right to abortion in the state. Prominent among these opponents, and the only one to actually speak in opposition to the bill when it was debated in 2002, was state Senator Barack Obama.

Obama's case against the bill did not revolve around existing state law, as he seemed to suggest last night. The law Obama referred to in the debate was the Illinois abortion statute enacted in 1975. But at the time of the debate about the Born Alive Act, the Illinois Attorney General had publicly stated that he could not prosecute incidents such as those reported by nurses at Christ Hospital in Chicago and elsewhere (including a baby left to die in a soiled linen closet) because the 1975 law was inadequate.

"Expelled, The Movie" Conversation Continues

The many Anonymice are still discussing world views on a post from last October.

(In case you wondered where I've been:

We've had our primary, with one hotly contested local Republican race ending in a cliff-hanger. The same seat was decided by 54 votes out of about 20,000 in 2006. This time, it looks like the winner may be decided by about 38 votes out of 30,000, before the mail in ballots are counted. We're expecting a recount.

It turns out that the consequences of politics and policy became personal this last 2 months. We've spent the last year - over 14 months, now - working out a plan to remodel our 65 year old house only to find out that the city adopted the new provisional FEMA flood plain map, and we can't remodel - we have to fill in the basement, tear down the old house, and build 2-3 feet higher. I'll admit that I haven't reacted very well. But, still, the City's bureaucrat literally lost the plan for 6 weeks before telling us that the concrete-poured-in-place house and basement that's still plumb, smooth and level after more than 60 years might float up and turn on its side.)

Brain Death

Wesley Smith is blogging around the Web on the sad death of a 50 year old Atlanta man whose family took the doctors and hospital to court. Wesley rightly notes the poor communication.

The reporter is indeed a very bad communicator. I wonder about the reliability of the whole story because of the reporter's description of the patient: "he was brain dead and being kept alive by life support." While I can believe that the docs used "life support," the reporter goes on to say that the patient "passed away" when the ventilator was stopped and used the phrase, "pull the plug."

"Brain dead" patients are not alive and they're not on "life support." The doctors are using "artificial support." for the organs on a dead patient. (See this British Journal of Medicine article and comments, below.) Just as we support the body while waiting for the arrangements for organ donation (or for the birth of a child of a brain dead mother), it is customary to notify the family and give them a chance to "say goodbye" before discontinuing the ventilator and medications supporting the

Way down at the bottom, the article actually says,

"doctors told the family the stroke caused massive bleeding in Donald's brain. Four different physicians examined Fennell and his brain scans and determined his brain, including the brain stem which controls basic bodily functions like breathing, had ceased to function, according to court and patient records."

However, the problem started with the nurse who called security to have the family removed from the hospital because Mr. Fennell's 3 sons,

21, 20 and 18-year-old college football players— cried loudly and shouted "No!" when told their father was brain dead. After that, she said, security guards were posted at the door whenever they visited."

It's hard to talk to people who are shouting, but it's harder to talk to them when they've been kicked out of the building.

I'm trying to get my head around the medico-legal problem of delaying the declaration of death by the docs, scheduling a time to turn off the ventilator, and the comment about the machines being broken.

However, people don't live by laws alone. We often act from our hearts.

The New England Journal of Medicine published a review article describing the determination of death by neurological criteria in 2001. And here's an excellent (free) article from 2002, from the British Journal of Medicine that actually calls the ventilator and cardiac support "artificial support" and includes the ethical caveat that ""No physician engaged in euthanasia or medically assisted suicide should be responsible for diagnosing brain death.

Not coincidentally, the subject of yesterday's Secondhand Smoke was the case of an Orthodox Jewish man in Canada. The gentleman is on a ventilator and suffering from the effects of heart failure, pulmonary hypertension and renal failure. Three doctors, including one selected by the family have determined that he is dying and, even without the consent of the patient or the family, decided to remove the ventilator. The family has taken the doctors to court to prevent the removal of the ventilator on religious grounds.

One of the family's lawyers actually said that removing the ventilator is the same thing as smothering the patient with a pillow, and that (of the docs and nurses who must maintain the ventilator and adjust its settings):

"To do what they are suggesting would involve a physical act," he said. "You have to touch him, you have to remove the tubes. My reading of the law is that without consent ... they can't do it. I submit that is assault and battery."

(According to newspaper reports, the docs plan to remove the feeding tube, also. But that's not relevant, here, since Mr. Golubchuk will die within minutes if he is unable to breathe on his own off the ventilator. If any of the docs are making a fuss about the feeding tube, they are not very wise, since doctors and nurses aren't needed to maintain or monitor the feedings.)

An article from the Winnipeg newspaper on December 11 says that

"An orthodox rabbi consulted by the family quotes from guidelines on Jewish medical care that say it is imperative for doctors to prolong life, even if the patient is "suffering greatly" and asks for care to stop."

It's my understanding that Orthodox law forbids disconnecting the machine until the heart stops, even though there has been talk of a machine in use in Israel to randomly turn off ventilators so that the people won't have to. But I've never read that the Orthodox go so far as to demand that suffering be ignored.

In fact, withholding care under Orthodox Jewish law is acceptable. See the discussion about flickering candles, here. Here's a very well written review of Orthodox Jewish law on end of life, from the Virtual Mentor, the AMA ethics journal.

Do you suppose the family really believes that they should force other people to cause suffering? The family lawyer does point us to the ethics of intent and consequence of "a physical act." While the family may have the right to continue their father's suffering and to prevent the removal of the ventilator they don't have the right to force any particular doctor, nurse, or tech to act to violate their own conscience by adjusting, cleaning, and monitoring the ventilator.

Surely there's an Orthodox doc in the area who is willing to care for Mr Goubchuk and his family.

Ethics, Conscience and Cheating

Is there a difference between matters of conscience and things you shouldn't do? If there is something that would just get you in trouble but you don't believe it's wrong, how do you decide what to do?

The blog, Adventures in Science and Ethics, is one of the ScienceBlogs that I follow. (I love her "Friday Sprog Blogging" about her kids and the discussions about being a woman and having a family in Academia.)

There's a conversation on morality and cheating:

A reasonable ethical decision is one that you can defend -- to others, not just to yourself. You can give reasons why, of the choices available, this was the right way to go.

A course of action that you are taking pains to hide -- one which you would not want to have to defend to others -- is a red flag, ethically speaking.

Being able to justify a course of action to others is a more stringent requirement than being able to justify it to yourself. Folks who see themselves as living up to a high moral standard ought to keep that in mind and make sure their deeds can meet this requirement.

I was raised on the Bible, being taught to respect the authorities and to understand that a sin is a sin is a sin. However, I have a sense of "that's not fair" when I think of putting highway speed limits on the same plane as hurting someone else or even cheating on a test.

Court upholds Texas Prenatal Protection Act

In 2003, the Texas Legislature passed a Prenatal Protection Act, which named the unborn children of Texas individuals from fertilization to natural death. Texas law also calls the "individual" a "person." With the world the way it is after Roe versus Wade, and because most of us have compassion for a woman who believes she doesn't have a real choice, we had to make exceptions for the decisions of the mother, including abortion and - even when the child is not in her womb - for those she empowers, such as doctors and techs at in vitro fertilization clinics.

However, the law in Texas protects a woman and her child against some one else taking the life of her child against her wishes. We will also punish the murderer when we can't protect them.

Today, the Sixth Texas Court of Appeals upheld the conviction of a man for killing his pregnant girlfriend under our Prenatal Protection Act.

The man was dating two women when one became pregnant. He told the other woman that he would "take care of it," and then shot the mother of his child 3 times with a shotgun, once in the face.The jury determined that he knew the woman was pregnant and that he intended to kill them both. He was convicted of capital murder and sentenced to life imprisonment.

The Court decision plainly states:
"By expressly defining capital murder such that one of the victims may be any unborn child from fertilization throughout all stages of gestation, the statute leaves no ambiguity as to what conduct is proscribed. In particular, the plain language of the statute prohibits the intentional or knowing killing of any unborn human, regardless of age. No ordinary person reading the statute would have any doubt as to whether it encompasses victims at all stages of gestation."

We know that violence often begins when a woman is pregnant and that 25% to 30% of deaths during pregnancy are due to homicide, usually at the hands of the father of the child.

I hope that this Court opinion and the original law will save lives. I wish for a day when no one is in danger of being intentionally killed by someone else, much less a loved one. And I hope that the publicity about this law will cause everyone - the person about to get behind the wheel after drinking as well as the abusive husband or boyfriend, to consider the risk of harming a mother too dangerous to even think about.

I believe we are much more likely to overturn Roe now than we have been at any time since 1973, while still ending up with restrictions in at least as many States as we had then. And I believe that the reason why this is so is because more than half of our citizens are unhappy with elective intentional abortion on demand as it is practiced in too many States today.

I also believe that a pro-life Congress could restrict the Courts from interfering with the States' legislative actions on abortion tomorrow, on the grounds that it's obvious that the unborn are persons.

For one thing, we have 4-D ultrasounds now and babies born as young as 20 weeks go home healthy.
In addition, many minds were changed - are still being changed - by the debate over partial birth abortion.


However, the reality is that there is zero chance of getting a Human Life Amendment through the Senate, much less getting 2/3 of the States to ratify it if the States themselves are not already doing it. (Please read up on how the 13th and 14th were ratified: the Legislators from the Southern States were not allowed to participate.)

Far too many men and women think of abortion as insurance against their bad decisions, rather than one more (awful) bad decision.

There are still too many people who think rape and incest are appropriate reasons in themselves for an abortion. They haven't heard how many women decide to carry their children to term after rape or considered the very real humanity of the unborn child, who shouldn't be punished for his father's crime.

But we do have a chance at returning the choice to the States where the majority would restrict abortion except to save the life of the mother. And each person that we teach to think of the unborn child as a person, the closer we get to ending elective intentional abortion.