AMA: "People aren't going to waste time on Embryonic Stem Cells, anymore"

A member of the "lobby group Comment on Reproductive Ethics" maintains that there are "some scientists who like to hold on to what they've got, but" she doesn't "think people are going to waste time on embryonic stem cells any more."

(Josephine Quintanelle, quoted in the Guardian, 3/1/09)

The American Medical Association sends its members a "Morning Rounds" email with the latest headlines on science and medicine. The articles have more links than my posts and the editors seem to choose that days' big story.

Today's big story is that the Washington Post (free registration required) reports on a from a Letter to the journal, Nature. Two groups of scientists, one from Toronto (Andras Nagy, from the University of Toronto) and another from Edinburgh (Dr Keisuke Kaji, at the Medical Research Council Centre for Regenerative Medicine at the University of Edinburgh) have found a way to make skin cells transform into embryonic-like stem cells without using viruses.

This should lead to a cheaper way for people to have their own cells transformed into therapies. Farther down the line, it could help us treat disease and injury -and aging - in place, by inducing repair where it's needed and without transplants. On the other hand, if we use embryonic stem cells, it would be necessary to make a clone of each person or find some sort of universal donor cell that would not be rejected. The previous way of reprogramming cells to an embryonic stage used viruses that could not be removed and which have the potential to cause cancer if left in the DNA of the cells.

The scientists used human fibroblasts - a type of skin cell - which were treated with a "jumping gene" from a cabbage looper moth, that inserts itself into chromosomes along with the genes that "reprogram" the fibroblast -- then, the extra gene can be removed.

From the Post, a very clear description.

The alternative cells, known as induced pluripotent stem cells, or iPS cells, appear to have many of the same characteristics as embryonic stem cells but are produced by activating genes in adult cells to "reprogram" them into a more primitive state, bypassing the moral, political and ethical issues surrounding embryonic cells. Until now, however, their use has been limited because the genetic manipulation required the use of viruses, raising concerns the cells could cause cancer if placed in a patient. That has triggered a race to develop alternative approaches.

"These viral insertions are quite dangerous," Nagy said.

In the new work, Nagy and his colleagues in Toronto and at the University of Edinburgh in Scotland instead used a sequence of DNA known as a transposon, which can insert itself into the genetic machinery of a cell. In this case, the researchers used a transposon called "piggyBac" to carry four genes that can transform mouse and human embryonic skin cells into iPS cells. After the conversion took place, the moth gene, called "piggybac" lost its ability to insert itself into the chromosomes of the cells and "disappear" or can be removed.

"PiggyBac carries the four genes into the cells and reprograms the cells into stem cells. After they have reprogrammed the cells, they are no longer required, and in fact they are dangerous," Nagy said. "After they do their job they can be removed seamlessly, with no trace left behind. The ability for seamless removal opens up a huge possibility."

Unfortunately, for some reason the scientists used (non-stem) fibroblast cells from embyros as the cells that are reprogrammed, so the research is being repeated in cells from non-embryonic sources.

Other news articles on the breakthrough are at BBC News, Nature News,
AFP, Financial Times, the Candian Press, the Guardian and the Globe and Mail.

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.

UK Teens, Abortion Rights?

The Family Planning Association in the United Kingdom is pushing a video called "Why Abortion" for use in schools teens, according to the Telegraph.co.uk website.

The laws in the United Kingdom differ in different regions. Abortion is still illegal in Northern Ireland, for instance. England and Wales, where abortion is legal and, like contraception and the morning after pill, paid for by the National Health System, has the second highest abortion rate is the second highest in Europe.

Nevertheless,

the Government announced that sex and relationships education will become compulsory in primary schools as part of a drive to cut teenage pregnancy rates. The National Children's Bureau also wants all secondary schools to have on-site sexual health clinics, while girls as young as 13 will be urged to have contraceptive injections and implants.

The FPA is offering schools the chance to buy a copy of the DVD for £25 together with a booklet that claims to explode the "myths" that having a surgical abortion can harm a woman's ability to conceive in the future, and that terminating a baby is always upsetting.

No mention that parents might not wish their daughters and sons to have sex at 13 -- and that the great majority do not. Or the risk that the 13 year old might be a victim of sexual abuse.

On Conscience: Philosophical, not Scientific or Medical Debate

Some of you may have already seen this transcript from the September '08 President's Bioethics Council meeting. Three physicians gave testimony on September 12th, including Dr. Farr Curlin, Dr. Howard Brody, and (from the American College of Obstetrics and Gynecology, although she says she's not there as an ACOG representative) Dr. Anne Drapkin Lyerly.

Council member Robert P. George has this to say about the debate (speaking specifically on conscience and the American College of Obstetrics and Gynecology's Ethics Statement on conscience and physicians, "The Limits of Conscientious Refusal in Reproductive Medicine," )

The first thing to notice about the ACOG Committee report is that it is an exercise in moral philosophy. It proposes a definition of conscience, something that cannot be supplied by science or medicine. It then proposes to instruct its readers on, "...the limits of conscientious refusals describing how claims of conscience should be weighed in the context of other values critical to the ethical provision of health care."

Again, knowledge of these limits and values, as well as knowledge of what should count as the ethical provision of health care, are not and cannot possibly be the product of scientific inquiry for medicine as such. The proposed instruction offered here by those responsible for the ACOG Committee report represents a philosophical and ethical opinion — their philosophical and ethical opinion.

The report goes on to, "outline options for public policy," and propose, "recommendations that maximize accommodation of the individual's religious and moral beliefs while avoiding imposition of these beliefs on others or interfering with the safe, timely, and financially feasible access to reproductive health care that all women deserve."

Yet again notice that every concept in play here — the punitive balancing, the judgment as to what constitutes an imposition of personal beliefs on others, the view of what constitutes health care or reproductive health care, the judgment about what is deserved is philosophical, not scientific or, strictly speaking, medical.

To the extent that they are medical judgments even loosely speaking they reflect a concept of medicine informed and structured, shaped by philosophical and ethical judgments. Those responsible for the report purport to be speaking as physicians and medical professionals.

The special authority the report is supposed to have derives from their standing and expertise as physicians and medical professionals, yet at every point that matters, the judgments offered reflect their philosophical, ethical, and political judgments, not any expertise they have by virtue of their training and experience in science and medicine.

At every key point in the report their judgments are contestable and contested. Indeed they are contested by the very people on who consciences they seek to impose, the people whom they would, if their report were adopted and made binding, force into line with their philosophical and ethical judgments or drive out of their fields of medical practice. And they are contested, of course, by many others. And in each of these contests a resolution one way or the other cannot be determined by scientific methods, rather the debate is philosophical, ethical, or political.

Lay aside for the moment the question of whose philosophical judgments are right and whose are wrong. My point so far has only been that the report is laced and dependent upon at every turn philosophical judgments. I've not offered a critique of those judgments, although anyone who cares to can find plenty of criticisms in my work of those judgments. But lay that aside for now.

The key thing to see is that the issues in dispute are philosophical and can only be resolved by philosophical reflection and debate. They cannot be resolved by science or methods of scientific inquiry. The committee report reflects and promotes a particular moral view and vision and understandings of health and medicine shaped in every contested dimension and in every dimension relevant to the report's subject matter, namely the limits of conscientious refusal, by that moral view and vision.

The report, in other words, in its driving assumptions, reasoning, and conclusions is not morally neutral. Its analysis and recommendations for action do not proceed from a basis of moral neutrality. It represents a partisan position among the family of possible positions debated or adopted by people of reason and goodwill in the medical profession and beyond. Indeed, for me, the partisanship of the report is its most striking feature.

Its greatest irony is the report's concern for physicians' allegedly imposing their beliefs on patients by, for example, declining to perform or refer for abortions — or at least declining to perform abortions or provide other services in emergency situations and certainly to refer for these procedures. The assumption here, of course, is the philosophical one that deliberate feticide is morally acceptable and even a woman's right.

But lay that aside for now. Of course, the physician or the pharmacist who declines to dispense coerces no one, though I think that Prof. Brody and I would have a debate about that.

Interesting that both Dr. Lyerly and Dr. Brody refuse to discuss the ACOG statement.

A compelling look at the problem of contrasting world views is posed by Dr. Gilbert Meilander:

. . . the fascinating question you raised under your slide on professional integrity about a professional elevating the — in this case the patient's needs above his own interests, and then you said does one's own interest include one's personal integrity. But then you confused — and I think that's — it's like, you know, "Should I be prepared to go to hell in order to help somebody," a question which theologians have actually discussed.

But you gave the, to me, puzzling example of physicians who should be willing to risk their own lives in an epidemic, for instance, to do it, and then you said, you know, if you'd risk your life, why wouldn't you risk your integrity.

But I thought the 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.

How can anyone live well without integrity? Or, from the Christian philosopher, Paul, "What shall it profit a man if he gains the whole world, but loses his soul?"

(Edited to add italics on that long quote.)

30 years: In Vitro Fertilization,Bioethics and Public Health

My own first child is a little older than Louise Brown, the first child born from in vitro fertilization (IVF). This incidental pioneer celebrates her 30th birthday this month, calling for reviews and editorials on what her birth has meant to culture and to individuals, such as this one from the UK's Telegraph.

It's good to hear that Ms. Brown has a child of her own, "naturally conceived" with her husband. Full circle.

Gynecology and Obstetrics Policy makers respond to doctors on conscience

It appears that the American College of Obstetricians and Gynecologists and ABOG (the American Board of Obstetricians and Gynecologistsmay be about to abort their efforts to change laws concerning conscientious refusal in Washington. It remains to be seen whether they will deliver on their promise to support -- without limits - the Conscientious Refusal to perform or refer for certain procedures. (I'm sorry, I can't resist obvious puns, even on such a serious subject.)

LifeEthics has been covering the controversy over the American College of Obstetrics and Gynecology's "Opinion #385, Limits of Conscientious Refusal in Reproductive Medicine," which states that,

Providers with moral or religious objection should either practice in proximity to individuals who do not share their view or ensure that referral processes are in place. In an emergency in which referral is not possible or might negatively have an impact on a patient's physical or mental health, providers have an obligation to provide medically indicated and requested care."

First, "medically indicated" should be up to the physician and not dependent on autonomy - the patient's wants and wishes. Remember that Joseph Kennedy, the father of John and Robert, had his daughter lobotomized because she was too wild. At that time, according to Joe, the lobotomy was medically indicated.)

Obviously, this is not a moral obligation - but one that can be enforced by the use of the words "standard practice" and "standard reproductive services." In other words, abort, refer, or face lawsuits and risk your board certification. And the definition of "emergency" varies.

We also reported that the Secretary of Health, Michael O. Leavitt, had written to the Presidents of the American College of Obstetrics and Gynecology, the professional organization that supposedly sets the standard for these professionals, and the American Board of Obstetrics and Gynecology which certifies and tests OB/Gyns Presidents of ACOG and ABOG. He informed them that they were in danger of risking their own funding for training programs and status by any attempt to override the protections for Conscience in Federal funding regulations.


Even NPR noticed and covered the controversy.

The leaders at the Christian Medical and Dental Association have let CMDA members know that the President of ACOG, Kenneth L. Noller, MD, responded to the Fellows (certified OB/Gyns) last week and Norman F. Gant, MD, the President of ABOG, responded to Secretary Leavitt by letter on March 19, 2008.

Dr. Gant doesn't have a clue what the Secretary is talking about:

I am responding to your letter addressed to me asking about the American Board of Obstetrics and Gynecology’s stand with respect or to a physician’s choice to violate their conscience by referring patients for abortions or taking other objectionable action, or risk losing their board certification.” I can only say that I do not know where you came up with any suggestion, much less documentation, that the American Board of Obstetrics and Gynecology has ever asked anyone to violate their own ethical or moral standards.

And Dr. Noller reassures the Fellows that in this case, an Opinion is just an Opinion (and we're supposed to forget the attempts to change the laws):

We want to be clear the Opinion does not compel any Fellow to perform any procedure he or she finds to be in conflict with his or her conscience and affirms the importance of conscience n shaping ethical professional conduct. For example, while this is not a document focused on abortion, ACOG recognizes that support of or opposition to abortion is a matter of profound moral conviction and ACOG respects the need and responsibility of its members to determine their individual position on this issue based on their personal values and beliefs. We want to assure members with a diversity of views on this issue that they have a place in our organization.
Ethics Committee Opinions provide guidance regarding ethical issues. This Committee Opinion is not part of the “Code of Professional Ethics of the American College of Obstetricians and Gynecologists.” This Committee Opinion was not intended to be used as a rule of ethical conduct which could be used to affect an individuals initial or continuing Fellowship in ACOG. Similarly, it is not cited in the American Board of Obstetrics and Gynecology’s “Bulletin for 2008,” and “Bulletin for 2008 Maintanence of Certification” and an obstetrician-gynecologist’s board certification is not determined or jeopardized by his or her adherence to this Opinion.
Conscience has an important role in the ethical practice of medicine. While this Opinion attempted to provide guidance for balancing the critical role of conscience with a woman’s right to access reproductive medicine, the Executive Committee has noted the uncertain and mixed interpretation of this Opinion. Thus, the Executive Committee has instructed the Committee on Ethics to hold a special meeting as soon as possible to reevaluate ACOG Committee Opinion #385.

Doctors, Abortion and Conscience

The debate on medical ethics has definitely moved from "Our Bodies, Our Choice," to "My Choice, You Don’t Have a Choice." Autonomy, the "I want" ethics, trumps the right to life, the right to liberty and the physician's duty to do no harm. Where once laws were written to punish doctors who harmed patients, doctors are now threatened with lawsuits and the loss of our licenses for refusing medications or procedures demanded by patients and their surrogates.

The American College of Obstetricians and Gynecologists ethics statement, "The Limits of Conscientious Refusal in Reproductive Medicine" is a case in point. Abortion is so important to the ACOG Ethics Committee that they deny the right not to be killed and threaten the right not to be enslaved by calling abortion the “standard reproductive care that patients request” and demands that doctors who “deviate from standard practices” (object to abortion) “practice in proximity to individuals who do not share their views or ensure that referral processes are in place” (with a willing abortionist). The President of ACOG then wrote letters asking Congress for laws to force these limits on our consciences: doctors who object to abortion should either change their practice so that they don't take care of women and girls or move close to a willing abortionist.

The Christian Medical Association and 28 other pro-life, pro-family organizations have written a letter criticizing ACOG’s Statement as “a profound misunderstanding of the nature and exercise of conscience, an underlying bias against persons of faith and an apparent attempt to disenfranchise physicians who oppose ACOG's political activism on abortion.”

GrannyGrump posted several reasons conscientious doctors should consider elective intentional abortion bad for the mother. I agree with her that abortion is wrong because it is bad for women. I also believe that she begins from the same viewpoint that I do: Even if abortion weren't bad for women, it would still be wrong.

Elective intentional abortion is immoral because it takes the life of a human being. If the mother's life is in danger, she has the right to self preservation and it is moral to help her save her life. Even then, the child's life should also be protected if at all possible. The intent can never be to produce a dead child.

State officials have mandated that all medical students learn to perform abortions in New York and that all pharmacies stock and dispense contraceptives in Illinois and Washington. ER doctors are forced to dispense Emergency Contraception in Connecticut, California, Massachusetts, New Jersey, New Mexico, New York, Ohio and Washington. How long before autonomy supersedes the physician's right to conscience at the end of life since the American Medical Association has condoned the use of Oregon's "Physician Assisted Suicide" law (now renamed and redefined as "Aid in Dying")?

Laws against the conscience are a poor substitute for medical ethics and will result in the death of those same ethics. The end result of limiting the physician’s conscience is cook book health care written in court rooms by lawyers and judges. The practice of medicine will no longer be a profession, much less a calling, practiced by men and women of conscience. It will become a job done by people capable of following orders, doing what they believe is wrong.

Wesley Smith on Toronto Conference on End of Life

Wesley's report is at his blog, Secondhand Smoke.

The medical interventional suicide or "Physician Assisted Suicide" (PAS) offers a false sense of control to people who are actually the healthiest of the patients who know that they are nearing the end of life.

It's false because before legal medical regulations can be used to "help" terminal patients to control the "time and manner of their death," the laws are actually being sold to voters who aren't sick, who are encouraged to think "there but for the grace of God, go I." Instead of giving dignity to patients in pain, talking about the indignity of having others care for our bodies and the horrors of uncontrollable pain increases the revulsion toward physical weakness and dependency.

Mr. Smith says that in Toronto ( as at the Houston Holocaust Museum last month), he focused the bulk of his talk on "Futile Care Theory."

Calling all cases of withdrawal of care "Futile Care Theory" and eugenics is also false. It denies any acknowledgment that doctors act on their conscience. By denying that doctors and medical ethics committees -a group of peers and lay people, clergy, and ethicists - can be acting in good conscience, even when it goes against the wishes of surrogates and families condemns us all. If we can't trust these people, how can we trust a judge or a jury to act in good conscience?

I hope everyone reads what Wesley says about another speaker, Ms. Frazee:

She told the audience that there are two general veins of opposition to assisted suicide; political and spiritual, with people in each camp disagreeing with each other on other issues. She suggested that the best way to work together would be to develop a philosophical approach that would include all and permit people to also pursue other agendas when not working against assisted suicide.

Too often, the only common ground is the hatred of the control that doctors seem to have. Suicide proponents and "futile care" activists declare doctors the bad guys who diagnose and couldn't cure, who bring the bad news of unavoidable death and who won't "do everything."

As I reported after Wesley spoke at the Houston Holocaust Museum, the risk is to squeeze doctors between two extremes.

I suggest that the doctrine of double effect can help us make the distinction. Doctors may not act with the intended result of death, but we know that some of our actions may cause death, unintentionally. In all cases, the intention and the act must be ethical, but sometimes - as when we poison the body with chemotherapy or radiation to fight cancers - only medical knowledge and experience can inform our conscience.

Laws and the legal process are a poor substitute for medical ethics and will result in the death of those same ethics.

The logical result is an end to all laws protecting the conscience of doctors, pharmacists, and nurses, in favor of laws leading to court and cookbook algorithms. The practice of medicine won't be a profession - much less a calling - with peer review, judgment and conscientious men and women. It will be a job done by people capable of following orders, even when it goes against their best medical and moral judgment.

Who will you trust? Lawyers and judges like Blackmun and Greer? Juries who live in a society that forces medical professionals to act in a way they believe is wrong? Legislatures and referendums that give us Oregon's assisted suicide? Or doctors and pharmacists who are prescribing and dispensing the potassium, heart stimulants or blood pressure control in the IV, adjusting the ventilator, dialysis machine and the dosage of pain meds under the watchful eye of nurses and the rest of their community?

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.

CNN objects to conscience

This subject again.

CNN, that bastion of upstanding plants ethics, objects to doctors with morals - or at least the ones who act on them.

The CNN video (not a "news piece") shows interviews with a woman who was refused contraception by one doctor and a second interview with another doctor who is Catholic and who does not believe that contraception is moral and so he does not prescribe it.

The reporter is shocked that 60% of doctors feel that it's okay to tell patients our moral views.

The reporter asked the patient whether she felt "rejected." The woman said that she did and that she felt that the doctor was judging her and imposing his morals on her. She said that any doctor who would not do what his patients wanted should not be in practice.

The woman isn't judging or imposing her morals on every doctor, is it?

Doctors make "judgments" all the time. We are not simply dispensers of products that people want. We must "impose" our judgment on patients who smoke (a perfectly legal drug) and drink (ditto) or who have become overweight from eating legal food and choosing not to exercise enough to burn off calories faster than they take them in. We are responsible for determining whether a patient is becoming addicted to pain medications, asking for a note for missing work when they were never sick, or a handicapped parking sticker when they're not disabled.

Much more often, we make judgments about the cause of a patient's symptoms or disease and how best to treat it. Our job is not to make the patient feel good about themselves, although most doctors I've met prefer to do so. What we do is diagnose and treat in order to help the patient be as healthy as we are able.

While I don't object to non-abortifacient contraception, it is an elective service in most cases. It is very rarely necessary to maintain the health of the body of patients. It is truly a "choice."

As I've said before, it would be simpler for people who feel that contraception is important to arrange to pay doctors who will write and dispense those medications and devices to go around to the areas where they are needed.

The alternative is to find a way to trust a doctor who will act against his conscience - to do what he considers the wrong thing for your pet issue - to do the right thing every other time.


Hat Tip: Blog.bioethics.net

Christian Medical Association on Right to Conscience

If the scientist or doctor is driven by curiosity (and a desire for her own set of money making patents?) or because "it's legal" and patients want it, where do we draw the line between preference, opinion and conscience?

We've been discussing the significance of ethics and conscience at here at LifeEthics.org, the Women's Bioethics Blog and Bioethics.net (The latter two "bioethics" sites, emphasize laws and science at all cost, almost to the point of dismissing ethics and, especially conscience, at all. The subject is also the theme of posts at Bioethics.com, the blog of the Center for Bioethics and Human Dignity.

Now, the weekly email newsletter of the Christian Medical and Dental Association has dedicated an issue to the subject, in light of the statement (opinion?) on conscience from the The American College of Obstetricians and Gynecologists. There are links to the statement, itself, and rebuttals by Dr. Robert Orr, and Dr. Edmund Pellegrino.

Laws, conscience, medicine and bloggers

In contrast to the hype that you might read on blogs and in the press, the Federal District Court judge in Washington has upheld the law of that State. The basic right to not be forced into action that one considers unethical or immoral - the right to liberty - was upheld first, by the Washington State Legislature and affirmed by the Court.

According to the Seattle Times article, there will be a trial next year and the "rules were meant as a compromise after long, contentious hearings and intervention by Gov. Christine Gregoire, who threatened to replace members of the Board of Pharmacy who didn't vote to protect women's rights." (Emphasis mine, BBN.)

The judge ruled in favor of State Law and overturned regulations passed by the Washington State Board of Pharmacy which were changed in July of this year to require that "pharmacies must maintain at all times a representative assortment of drugs in order to meet the pharmaceutical needs of its patients." The plaintiffs, two individual pharmacists and a corporate pharmacy were asking to be allowed to follow their previous practices "refuse and refer."

The Court's ruling is posted here at the Seattle Times website, which also has a fairly good review of the case to this point, here. (I've saved copies of each, so let me know if they disappear).

Judge Ronald B. Leighton issued an injunction that delays the force of the regulation, since it appears that the regulation violates laws passed by the Washington State legislature to protect the rights of individuals:

"As a part of the Health Care Access Act, the legislature expressed the recognition “that every individual possesses a fundamental right to exercise their religious beliefs and conscience.” RCW 70.47.160(1). The Legislature further acknowledged that “in developing public policy, conflicting religious and moral beliefs must be respected.” RCW 70.47.160(1). Accordingly, the Legislature provided that “no individual health care provider, religiously sponsored health carrier, or health care facility may be required by law or contract in any circumstances to participate in the provision of or payment for a specific service if they object to so doing for reason of conscience or religion.” RCW 70.47.160(2)(a). No person may be discriminated against in employment or professional privileges because of such objections. RCW 70.47.160(2)(a). The right of conscience, however, is not intended to result in a patient being denied timely access to any service included in the basic health plan. RCW 70.47.160(2)(b).

"An identical right of conscience was included within the Insurance Reform Act adopted by the Legislature in 1995. RCW 48.43.065."

(emphasis in italics are mine, BBN)


The regulation itself was poorly written.

The phrase "at all times" is a big problem. Would that mean that all pharmacies must change their hours so that they are open or on call 24/7? As to the phrase, "representative assortment," that might mean different things to different people. The wording open to the widest interpretation, however, is the phrase, "pharmaceutical needs of its patients." (Let's forget that pharmacies don't have patients, pharmacists do.)

The "pharmaceutical needs" of patients is wide open to interpretation, especially in the case of Plan B. I've covered the evidence (here) that indicates that Plan B only works to prevent ovulation and fertilization the 5 days or so of the month before and the day of ovulation and the lack of evidence that it acts in any way as an abortifacient. Unfortunately, this isn't acknowledged in the court's ruling or by any of the other parties in the case.

I depend on pharmacists to evaluate the prescriptions I write for my patients. They have often helped me by catching and refusing to fill scripts because they knew about drug interactions, allergies, and fraudulent prescriptions when I didn't. I would like for them to notify me if they refuse to fill my scripts, but their professional judgment is the very thing we physicians and patients are depending on, isn't it? If we force them to do what they believe to be wrong, the only pharmacists we'll be left with will be people who will do wrong because they were "only doing their job." (Where have we heard that before?)


There's an especially over-wrought emotional discussion over at the Women's Bioethics Project blog. No posts are published without the permission of the author, who evidently has some pretty strong feelings involved. I added to the intensity of the silliness and self-righteousness with my comments, I'm afraid. (So far, they haven't posted my remarks from 12 hours ago about cigarettes as a legitimate treatment for priapism [an old remedy - no longer advised - that was actually used as late as the '80's], prescribing of wine as a relaxant, and the fact that I make it a policy not to prescribe medications until they are on the market long enough to be proven by lots of other doctors' patients.)


As Mick Jagger sang, "You can't always get what you want. . . but you can try sometimes to get what you need."

(edit - typos fixed at 5:30 PM CST 11/14/07)

Watson un - reasonable

Dr. James Watson, the man who is credited with discovering the structure of DNA, along with Francis Crick and Rosalin Franklin, has lost his laboratory and much of his status as a respected science icon after allegedly making racist remarks.

From the Times Online (London, UK):

In his interview Watson had said that he was “gloomy about the prospects for Africa” because “all our social policies are based on the fact that their intelligence is the same as ours — whereas all the testing says not really”.

He also said he opposed discrimination and that he hoped all races could be equal, but added: “People who have to deal with black employees find this not true.”

Last month, Dr. Watson spoke at the opening to the "Medical Ethics and the Holocaust: How Healing Becomes Killing: Eugenics, Euthanasia and Extermination" series of lectures co-sponsored by the University of Houston and the Houston Holocaust Museum. (Earlier posts on the series here

At that event, Dr. Watson was one of three Nobel laureates (along with Eric Kandel, MD and Feric Murad, MD, PhD) who spoke on the history and - at least in my opinion - of eugenics, including the sad history of eugenics studies in the early part of the 20th century at Cold Spring Harbor Laboratory.

Dr. Watson opened by telling us that he does not believe that the traits and abilities of people are completely genetic. He believes that his values for life were taught to him by his parents, who taught him to make his decisions based on reason, with "nothing from revelation. They also taught him the value of honesty, kindness, and involvement.

The doctor appeared to fall asleep a couple of times during the Houston presentation. He went out of his way to note that he came before us with "No religious feeling whatsoever." (I believe that he had an assumption that the people in the audience were interested in religion.) He also said that if you are better than than others, you'd better be perceived as helping others, and implied that the Jews killed by the Nazi's in Germany were marked and hated because they were more intelligent and successful than other Germans.

We learned that he had declined information about his genome that would tell us whether or not he carried the genes for a familial type of dementia. He stated that he believed that the study of the genome would improve psychiatry, which he said is still at the level that it was in Nazi Germany.

One of the most truthful statements he made is that "Since I won the Nobel Peace Prize I am heard."

AMA editorial on Partial Birth Abortion Ban

I would like to respond to the Commentary by Lawrence O. Gostin, JD, “Abortion Politics: Clinical Freedom, Trust in the Judiciary, and the Autonomy of Women.” in the Journal of the American Medical Association, October 3, 2007.(behind a pay wall)

Declaring that the Supreme Court's consideration of the “respect for the dignity of human life” in their ruling on the Partial Birth Abortion Ban Act (Gonzales vs. Carhart, 2007) is “Congress’ overtly political discourse,” he neatly sums up his position in this sentence from his last paragraph:

“Morality alone is an insufficient justification for the government to intrude on the private lives of women and the clinical freedom of physicians.”

On the contrary: morality, especially the laws concerning the killing of one human being by another is the basis for all law:

“What makes killing morally wrong, then, when it is wrong, is that a human life, the one killed, is treated as a life that has little or no worth rather than as a life of incalculable worth and as one having a right to be treated accordingly. If laws were permitted to embody the idea that in some circumstances life loses its worth, or that some people lack sufficient worth to have their lives protected, individuals would no longer enjoy equal protection of the law so far as their lives are concerned. Furthermore, some principled basis for protecting human life other than its sanctity would have to be provided to justify what would constitute violations of the unquestioned worth of every individual human life.” Arthur J. Dyck When Killing is Wrong (Cleveland, Ohio: Pilgrim Press, 2001), p. 77. Emphasis mine)

However, the Court did not review the "right to abortion" in Gonzales vs. Carhart. It only ruled on the Constitutionality of the regulation of medical practice in one narrow procedure, which Gostin admits "does not save a single fetus because physicians could instead use a standard D&E method."

Gostin objects to the Supreme Court of the United States over-ruling lower Federal courts and to State governments who dare to regulate medical practice as though he Founding Fathers wrote the Constitution so that only the Federal Judiciary decides the really, really important issues and the representatives of the People are only allowed to decide the inconsequential. He forgets or ignores that Blackburn’s 1973 Court intervened between State legislators and their rightful power to regulate the practice of medicine in Roe vs. Wade, and invented State’s rights that gradually phase in based on trimesters.

Moreover, he seems unaware of the precedent set and precedents reviewed in Washington vs Glucksberg (1997), or Vacco vs. Quill, (1997) when that Court ruled in favor of laws from Washington and New York that served to criminalize “physician assisted suicide.”

Concerning the 1993 Planned Parenthood vs. Casey ruling to which Mr. Gostin frequently refers,

"At the heart of liberty is the right to define one's own concept of existence, of meaning, of the universe, and of the mystery of human life. Beliefs about these matters could not define the attributes of personhood were they formed under compulsion of the State." (Casey, 505 U. S., at 851.)

the Court has stated,

“[A]lthough Casey recognized that many of the rights and liberties protected by the Due Process Clause sound in personal autonomy, 505 U. S., at 852, it does not follow that any and all important, intimate, and personal decisions are so protected” (Washington vs. Glucksberg, 1997)

I suggest that it’s important to share at least some perceptions about reality within the Universe. Otherwise we would not be able to discern the difference between sanity and insanity, much less between ethical and unethical medical practice.

Saletan stirs up bioethics, blog

Wesley Smith's "Secondhand Smoke" and Science Blog's "Denialism Blog" both comment on William Saletan's latest Slate column, "Rights and Wrongs: Liberals, progressives, and biotechnology."

I have to admit, that while I find Saletan slightly disorganized at times, he manages to make quite a few people disagree with him, and does it so well.

You need to read the actual Saletan piece, as well as the comments on the two blogs.

For what it's worth, here's part of my contribution to the conversation at the "Denialism Blog," where Mark Hoofnagle, an MD/Ph.D student, proves that we shouldn't "mistake denialism for debate:"

You obviously feel very strongly that there's some quality in humanity that can be diminished, but you continue to mix "defining life" with a request to define the characteristics that you personally believe constitute "humanity" or a "person."

Let's begin from the assumption that whatever it is that you feel can be diminished in humanity or that can cause you moral repugnance doesn't come from a religious belief. Perhaps it's empathy, imagination or simple learning from the history of humanity.

There's a distinction between the cell produced by fertilization (a more accurate term than "conception"), parthenogenesis, or the various ways to reprogram somatic cells and other cells or groups of cells. It's the same organization and integrated functioning that is lost at whole brain death with current technology. That's why you work with embryos rather than gametes, and why Lee Silver's comment about teratomas is incorrect.

History tells us - this thread reinforces - that when we begin with one point of discrimination allowing intentional acts that disrupt the life span of an individual or groups of individuals, the lines of demarcation are "fuzzy."

By the way, is that "William" who posted a comment, the William, Saletan himself?

Ethics statments from the AMA and CMDA

Last month, I wrote about the Christian Medical and Dental Association's ethics statements. There's a comment about them in last weeks' CMDA "News and Views." See Dr. Robert Scheidt's comments, with the links to the three ethics statements that were approved at this year's CMDA House of Directors. This week, we have the NEJM article on "Futile care."


elow is what I believe are the pertinent section from the AMA Ethics "Policy Finder." (See E-10.05, 3c)

E-10.05 Potential Patients

(1) Physicians must keep their professional obligations to provide care to patients in accord with their prerogative to choose whether to enter into a patient-physician relationship.
(2) The following instances identify the limits on physicians’ prerogative: (a) Physicians should respond to the best of their ability in cases of medical emergency (Opinion 8.11, "Neglect of Patient"). (b) Physicians cannot refuse to care for patients based on race, gender, sexual orientation, or any other criteria that would constitute invidious discrimination (Opinion 9.12, "Patient-Physician Relationship: Respect for Law and Human Rights"), nor can they discriminate against patients with infectious diseases (Opinion 2.23, "HIV Testing"). (c) Physicians may not refuse to care for patients when operating under a contractual arrangement that requires them to treat (Opinion 10.015, "The Patient-Physician Relationship"). Exceptions to this requirement may exist when patient care is ultimately compromised by the contractual arrangement.
(3) In situations not covered above, it may be ethically permissible for physicians to decline a potential patient when: (a) The treatment request is beyond the physician’s current competence. (b) The treatment request is known to be scientifically invalid, has no medical indication, and offers no possible benefit to the patient (Opinion 8.20, "Invalid Medical Treatment"). (c) A specific treatment sought by an individual is incompatible with the physician’s personal, religious, or moral beliefs.
(4) Physicians, as professionals and members of society, should work to assure access to adequate health care (Opinion 10.01, "Fundamental Elements of the Patient-Physician Relationship").* Accordingly, physicians have an obligation to share in providing charity care (Opinion 9.065, "Caring for the Poor") but not to the degree that would seriously compromise the care provided to existing patients. When deciding whether to take on a new patient, physicians should consider the individual’s need for medical service along with the needs of their current patients. Greater medical necessity of a service engenders a stronger obligation to treat. (I, VI, VIII, IX) Issued December 2000 based on the report "Potential Patients, Ethical Considerations," adopted June 2000. Updated December 2003. * Considerations in determining an adequate level of health care are outlined in Opinion 2.095, “The Provision of Adequate Health Care.”



E-10.015 The Patient-Physician Relationship

The practice of medicine, and its embodiment in the clinical encounter between a patient and a physician, is fundamentally a moral activity that arises from the imperative to care for patients and to alleviate suffering.

A patient-physician relationship exists when a physician serves a patient’s medical needs, generally by mutual consent between physician and patient (or surrogate). In some instances the agreement is implied, such as in emergency care or when physicians provide services at the request of the treating physician. In rare instances, treatment without consent may be provided under court order (see Opinion 2.065, "Court-Initiated Medical Treatments in Criminal Cases"). Nevertheless, the physician’s obligations to the patient remain intact.

The relationship between patient and physician is based on trust and gives rise to physicians’ ethical obligations to place patients’ welfare above their own self-interest and above obligations to other groups, and to advocate for their patients’ welfare.

Within the patient-physician relationship, a physician is ethically required to use sound medical judgment, holding the best interests of the patient as paramount. (I, II, VI, VIII) Issued December 2001 based on the report "The Patient-Physician Relationship," adopted June 2001.

E-9.12 Patient-Physician Relationship: Respect for Law and Human Rights

The creation of the patient-physician relationship is contractual in nature. Generally, both the physician and the patient are free to enter into or decline the relationship. A physician may decline to undertake the care of a patient whose medical condition is not within the physician’s current competence. However, physicians who offer their services to the public may not decline to accept patients because of race, color, religion, national origin, sexual orientation, or any other basis that would constitute invidious discrimination. Furthermore, physicians who are obligated under pre-existing contractual arrangements may not decline to accept patients as provided by those arrangements. (I, III, V, VI) Issued July 1986; Updated June 1994.

Christian Docs' Ethics on The Moral Worth of Human Life

Yesterday, at the annual meeting of the House of Representatives of the Christian Medical and Dental Association, three statements on ethics were approved. I don't have all of the text or the final versions of any of them at this time and will report on them in more detail later, but I would like to brag on the our Ethics Commission and the work of the House. (I'm the Chair of the Family Medicine Section.) Watch for more here and - hopefully - in the Press. I'll post links as soon as they're published on line.

The Chair, Dr. Robert Scheidt also gave one of the workshops on Conscience issues, which I'll discuss after I get home. At the meeting, he introduced statements on "Abuse of Human Life," "Human Stem Cell Research and Use" and "Human Life: Its Moral Worth."

These are statements from an unabashedly Christian world view - with strong logic and historic background. And some of the most elegant language on "person," the image of God, and the moral worth of human life. Here's a bit of the wording - draft version:

Every being of human origin is a person. A person is not a Homo sapiens with the superadded quality of "personhood." Some, however would attempt to withhold moral worth from human beings unless they "qualify" as persons. The status of "personhood" cannot be conferred by society.

The beginning and continuity of the moral worth of human life are concurrent with human life itself. Human worth begins with the one-cell human embryo and lasts lifelong. A living human being is an integrated organism with the genetic endowment of the species Homo sapiens. . . . Thus a human being, despite the expression of different and more mature secondary characteristics, has genetic and ontological identity and continuity throughout all stages of development from formation of the human being until death.

There is beautiful language on the image of God, the sacred nature of human life, and the love of God. I will post these more fully as soon as I get home. Now, I have to go catch a 7 AM plane.

What kind of world do we want to live in?

A most appropriate question on this day, when the Supreme Court ruled that Oregon's laws allowing physicians to write prescriptions intended to cause the death of patients.

This time, the question is asked by Kathryn Hinsch,the founder of the Womens Bioethics Project, in her "guest column" in the Seattle Post Intelligencer. The subject of the column is the fraud of Korean veterinarian, Hwang Suk Wu, who falsely claimed to have cloned human embryos in order to harvest stem cells. She notes the temptation to "play G_d" with biotechnology and concludes that the decisions are "too important to leave to the bioethicists, the scientists or the politicians."


It may seem that each day brings a new crisis for those of us who view human life as something to be valued and protected, whether the human is very young and may not even be born yet, whether conceived naturally or by the use of complicated technology and in a lab, or very sick or very old, and dependent on even more medicine and technology.

There's only one subject, not many. Cloning, harvesting of embryos for their stem cells, abortion, euthanasia and so-called "physician-assisted suicide" are all basically the same thing: the division of humans into those who will be protected by society and those who will not. Once we agree that our fundamental principle is that human life is to be protected from deliberate killing by others and that humans should not be used for the benefit of others without consent and benefit to the one being used, we can see that all the crises are actually only one crisis.

I agree with Ms. Hinsch that it is time for each of us to have a voice.

It is time to call, write or email your Federal and State legislators, demanding protection of human life, at all stages of life.

Edited January 27, 2010

Mandatory Abortion Referral Bill

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.

This would be the first time that doctors have ever been required to refer for an elective procedure. Physicians are not required to refer for plastic surgery, for instance.

Referral would include, at the least, giving patients the name of "providers." That would make it the doctor's legal and moral responsibility to be familiar with the skills of the other doctor. It would also make the doctor responsible for follow up and, possibly/probably, legally liable for bad outcomes. I have always preferred to have my office staff assist the patient in making an appointment in referrals.


No one would disagree with a referral for care in the case of a tubal pregnancy or some other life threatening event. Caring for a woman whose child has already died or who has a severe infection in her uterus - or even a need for life-saving cancer treatment could justify a referral. In the latter cases, I'd actually refer to a doctor that believed in the sanctity of life. Both for the mother's sake as well as her child's.

But an elective, intentional abortion doesn't even rise to the level of a tummy tuck in urgency or medical necessity. A tummy tuck or eyelid lift can at least make the patient's life better. And there is no third life (the unborn child) involved.


Some of us believe that putting a patient in contact with an abortionist is too close to aiding in the unethical procedure intended to kill a member of our species. How can anyone be required to act to aid the killing of our children?



Everyone should write their Senators and let them know that we object to any requirement to refer for an elective medical procedure. Is it right for physicians to be required to provide any service for their patients when we are certain that the service is not in the interest of our patients?

labels added 12/20/08