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05/02/2018

The Ethics of the President’s Physician

We all may remember that Donald Trump’s personal physician, Dr. Harold Borenstein, released a glowing hyperbolic endorsement of then candidate Donald Trump’s health. He stated that "If elected, Mr. Trump, I can state unequivocally, will be the healthiest individual ever elected to the presidency." He further stated that "His physical strength and stamina are extraordinary," The apparent problem with this letter, as Dr. Borenstein now states, is that he did not actually compose the letter. In an article published recently on the CNN website Dr. Borenstein indicates that he did not write that letter, that it was, in fact, dictated by Donald Trump. Let me make it clear that I am not writing about Donald Trump’s ethics and honesty. This has been the subject of thousands of commentaries which can be found almost anywhere. My intention is to address Dr. Borenstein’s ethics and honesty. Because Dr. Borenstein is a physician and was acting in his capacity as a physician in writing and releasing that letter it is fully appropriate to evaluate the moral underpinning of that action by the standards of medical ethics. These principles constitute the basis of moral conduct by all physicians and medical care providers.

While statements of core medical ethical principle vary it is commonly accepted that the principles include respect for persons, beneficence, non-maleficence, and justice. The first, respect for persons, focuses on the manner in which the medical practitioner acts towards the patient. However, this statement was a communication to the general public and needs to be respectful towards them. Dr. Borenstein’s statement is only respectful if it is true and verifiable otherwise it is misleading. There is no way Dr. Borenstein can know that Trump is “unequivocally, will be the healthiest individual ever elected to the presidency." Thus, he is being dishonest and possibly provides misinformation with which citizens will determine who to vote for as President.

Beneficence essentially means doing good.  It is unclear to me that a hyperbolic statement such as this could be viewed as beneficent. How can it be beneficent to mislead? Analogously non-maleficence means do no harm. If this statement is untrue and leads to people making choices about their vote based upon untrue information it does in fact do harm. Finally, it cannot possibly be just to assist in misleading people in making important decisions. It is unjust to the voters and unjust to the other candidate.

Thus, I feel quite confident that it is apparent that in providing a physician’s imprimatur to a hyperbolic statement that was in fact written Donald Trump himself and allowing that statement to influence individual’s decisions on an important matter was a failure to act as an ethical physician. These are the standards that Dr. Borenstein is accountable to uphold. He did not.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and a Graduate Certificate in Clinical Ethics. For more information on AMBI's online graduate programs, please visit our website.



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04/23/2018

Has the U.S Department of Health and Human Services Gone too Far?

The First Amendment of the United States Constitution states that Congress shall make no law respecting an establishment of religion or prohibiting the free exercise thereof (O’Brien 2005). In recent news, the U.S. Department of Health and Human Services created a new division called the Conscience and Religious Freedom Division. This change grants healthcare workers the option to be involved or not be involved in care for patients that contradicts with their personal religious or moral beliefs (Pear 2018). The policy change creates a legal and ethical dilemma with at least two sides. 

Arguably, prior to this newly outlined protection, healthcare workers were not able to freely exercise their religious beliefs and therefore challenges their First Amendment right. President Trump states that “religious people would no longer be bullied by the federal government because of their religious beliefs” (Pear 2018).  

On the other hand, it may be debated that this new provision challenges the First Amendment from another angle because it’s respecting an establishment of religion, which as a result, may discriminate against anyone that does not share a religious belief with the medical professionals they interact with. At the top of the list may be women and the LGBTQ community, which is a recognizable violation of the Fourteenth Amendment and Equal Protection clause (Menikoff 2001, 25). 

In the days following this news a major question was: what does this mean for women’s rights? Roe v. Wade established that based on the right to privacy it is a woman’s legal right to have an abortion (Menikoff 2001, 53). Similarly, obstetricians/ gynecologists may choose to no longer prescribe contraceptives and if they do, the pharmacist may not have to fill the prescription if it contradicts their beliefs. There is the right to privacy and barriers already in place for women to have access to an abortion or contraceptives such as Plan-B. One roadblock mentioned was resources being unavailable to women within a reasonable radius. Additionally, under the Religious Freedoms Restoration Act, an employer does not need to provide coverage for contraceptives. Since companies are tried as a “person” as seen in Burwell v Hobby Lobby this may allow employers to run wild and could even lead to insurance companies picking and choosing what procedures they cover (Liptak 2014). Or, in an extreme example what if there are not any “in-network” physicians that are aligned with the patient’s beliefs?

A physician has duties that arise from the patient-physician relationship, particularly surrounding patient abandonment.  The relationship may be terminated by either the patient or the physician at any time. However, if the physician ends the relationship then tort law would require the physician to not terminate the relationship at an unreasonable time. An example of this under the new policy could be if a doctor is treating a gay male or female suddenly decides that since they now have government backing, they no longer must treat this patient. It may be argued that physicians are already refusing to treat certain patients. Prior to now it was a best practice for physicians to refer a patient to another medical professional in order to continue care and if not there may be legal ramifications for patient abandonment. If the physician chooses to terminate the relationship based on conflicting religious or moral beliefs it is unlikely they will feel required to provide a referral. 

Patients also have the right to be treated in an emergency situation and this right is protected by the Emergency Medical Treatment and Labor Act (EMATLA) which shields against discrimination of any kind (Menikoff 2001, 368). Meaning, even if there is not a prior patient-relationship the patient must be treated based on the physician’s contractual agreements. Violating this contract may result in patient abandonment or malpractice. What will happen if a pregnant woman is having complications that require an abortion and the on-call physician or the emergency room physician doesn’t share the same religious beliefs? Will the new policy impact EMATLA?

The creation of the Conscience and Religious Freedom Division is in the infant stages. It is not evident how a policy of this nature will be rolled out if medical professionals begin to utilize their freedom to exercise religious rights. It’s doubtful that this will be carried out in a non-discriminatory manner; and unfortunately, under the new provision it may be irrelevant since medical professionals will be protected. In conclusion, this exemplifies how the bioethics field continues to navigate gray areas. These areas become more undefined as laws and policies that contradict one another are introduced.   

Works Cited
Liptak, Adam. “Supreme Court Rejects Contraceptives Mandate for Some Corporations.” The New York Times, 30 June 2014, www.nytimes.com/2014/07/01/us/hobby-lobby-case-supreme-court-contraception.html.

Works Cited
Menikoff, Jerry. Law and Bioethics. Georgetown University Press, 2001.
O'Brien, David M. Constitutional Law and Politics. 6th ed., vol. 2, W.W. Norton & Company, 2005.
Pear, Robert, and Jeremy W. Peters. “Trump Gives Health Workers New Religious Liberty Protections.” The New York Times, 18 Jan. 2018, www.nytimes.com/2018/01/18/us/health-care-office-abortion-contraception.html.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and a Graduate Certificate in Clinical Ethics. For more information on AMBI's online graduate programs, please visit our website.

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03/28/2018

The Biology Behind the Fertility Clinic Meltdown

*This blog was first published at DNA Science Blog at Public Library of Science*

The spindle apparatus is among the most elegant structures in a cell, quickly self-assembling from microtubules and grabbing and aligning chromosomes so that equal sets separate into the two daughter cells that result from a division. But can spindles in cells held at the brink of division in the suspended animation of the deep freeze at a fertility clinic survive being ripped from their slumber off-protocol, as happened the weekend of March 4 at the Pacific Fertility Clinic in San Francisco and University Hospitals Fertility Center in Cleveland?

The tragic events sent me back to developmental biology courses in grad school, and I read a bunch of technical papers and polled a few nerd friends. The experiments from the 1950s onward were controlled, and so my thoughts on the damage done in early March are hypothetical. I can’t help but wonder what, exactly, happened to those eggs and embryos?It was a stunning coincidence impacting the eggs or embryos of 500 couples on the west coast and 700 using the Ohio clinic. Liquid nitrogen ran low in a cryogenic device in San Francisco, and temperature fluctuations reportedly plagued the Cleveland facility.

The Media and the Damage Done

A news conference from one legal firm filing a class action lawsuit against the clinics was long on emotion and short on details. Here’s a lawsuit from a different firm that provides a timeline of what the donors went through.

Media coverage lacked biological details too. WaPo mentions “damage to tissue” with a video proclaiming “the only way to tell the viability of the egg is to thaw and implant it.” Really? Law firm websites parroted WaPo, not scientists (many experts in reproductive biology are PhDs, not MDs).

The New York Post and other outlets shared the sad story of Amber and Elliott Ash, who froze two embryos in 2003 after his cancer diagnosis. “The medical community calls it tissue. I like to think of it as my children,” Amber said.

Carl Herbert, MD, head of the San Francisco clinic, was curiously optimistic on NPR. “The good news is, we have viable embryos — we’ve proven that from that tank.” Viable enough to transfer?

Of Oocytes and Embryos

Technically speaking, there’s no such thing as an egg or ovum. Feminism aside, our gametes are oocytes until a sperm enters one and it magically then becomes a fertilized ovum. That’s why scientific reports and reproductive health guidelines use “oocyte.” Lawyers stick to the familiar. “Has a freezer failure compromised your frozen eggs or embryos?”


When a cell isn’t dividing, spindles break down. But as one cell splits to become 2, and then 2 become 4, and 4 become 8 as the cleavage divisions of the early embryo ensue, spindles form and vanish and reform to properly distribute the chromosomes. This time, in non-sex (somatic) cells, it’s mitosis, not meiosis.An oocyte packs in maximal nutrients through two divisions of meiosis. Before birth, a female has about a million oocytes stalled in the first meiotic division. Then, starting at puberty, a few oocytes awaken each month and continue meiosis, halting just before completion until a sperm comes along. If no sperm enters, the oocyte never finishes meiosis and leaves in the menstrual flow. If the oocyte is fertilized, its spindle apparatus ensures that the resulting fertilized egg has the right number of chromosomes from the female; similar division happened as the sperm formed.

Because spindles are sensitive to temperature, the unexpected fertility clinic meltdowns are worrisome.

A Brief History of Cryopreservation

Efforts to freeze – or cryopreserve – eggs, sperm, and embryos have been ongoing for decades. The main challenge is to avoid formation of ice crystals, which can slice up cellular interiors.

Sperm freeze easiest because they have little fluid – they’re not much more than a bulbous DNA-stuffed head with a tail and a ring of empowering mitochondria. Sperm were first frozen in 1938, with the first human birth resulting in 1954.

Experiments unfurled on eggs a little later, using glycerol in the 1950s and the solvent DMSO (dimethyl sulfoxide) in the 1970s, in sea urchins, mice, hamsters, rabbits, sheep, and monkeys. Early efforts at gradual cooling wrecked the spindles of mouse, hamster, and rabbit eggs, leading to the wrong number of chromosomes (aneuploidy). The nuclei of some eggs even glommed together, ending up as “polyploidy digynics,” a form of parthenogenesis that doubles the female genome in a gamete. Might such developmental disasters appear “viable” if simply eyeballed, the chromosomes uncharted? Embryo pickers have told me, though, that they can tell a good embryo from an ill-fated one just by looking.

Various sugars, solvents, and antifreezes (glycerol, propylene glycol and ethylene glycol) have been used in egg and embryo preservation as “cryoprotectants.” They displace water while countering ice crystal formation and strengthening membranes, preserving fragile cellular insides and keeping the outsides intact as a freezing agent, like liquid nitrogen, is applied.

These chemicals have different roles. Sugars stay outside cells, drawing the water out of them by osmosis, while glycerol and ethylene glycol enter and prevent the cell from shriveling. In this way cells can dehydrate but maintain their three-dimensional shapes. It works because eggs and embryos are small; it wouldn’t work so well on a spleen, for example.

Slow cryopreservation, over two to three hours, with the cryoprotectants added one at a time as the cells gradually cooled, gave way to the much faster vitrifaction, which uses higher concentrations of cryoprotectants. It’s so fast that a glass-like consistency forms, not ice. Vitrification uses liquid nitrogen, plunging the temperature to -320.8 degrees Fahrenheit (-196 degrees Celsius).

(Theatrical asides: Han Solo in The Empire Strikes Backwas flash-frozen in carbonite, which my husband Larry the chemist says does not exist. Larry brought liquid nitrogen home for our kids’ parties – when poured on the floor it evaporates into an entertaining eerie steam. And famed baseball player Ted Williams’ head is reportedly frozen at a cryogenics lab in Scottsdale, Arizona.)

Warming is precise and delicate. “It’s basically the reverse process. The key factors that must be achieved on thawing are rehydration of the cell without blowing it up,” embryo expert Barry Behr, PhD, told Scientific American in 2005. The cryoprotectants are gradually diluted out as the temperature slowly rises, and after a few hours at body temp, embryos can be implanted if they look okay – they’ve refilled the fluid-filled space at their centers and the cells are clear and not dark.

The first baby to develop from a frozen embryo was born in 1984. Births from vitrified human eggs that were then fertilized came in 1999. (A great review is here.) Usually 20 to 30 eggs are frozen, with 6 to 8 thawed for each IVF attempt.

From Medical Need to Lifestyle Choice

As with other assisted reproductive technologies, like IVF and preimplantation genetic diagnosis (PGD), the reasons for freezing eggs have evolved from medical need to lifestyle choice.


In 2014 the American College of Obstetricians and Gynecologists (ACOG) published support of the 2013 statement.In 2013, the American Society for Reproductive Medicine and the Society for Assisted Reproductive Technology published Mature Oocyte Cryopreservation: A Guideline,which stated “there are not yet sufficient data to recommend oocyte cryopreservation for the sole purpose of circumventing reproductive aging in healthy women because there are no data to support the safety, efficacy, ethics, emotional risks, and cost-effectiveness of oocyte cryopreservation for this indication.”

At that time, egg freezing was being considered for women undergoing damaging treatments like chemo; had conditions like fragile X or XO (Turner’s) syndrome that can include ovarian insufficiency; or who had their ovaries removed to prevent BRCA-related cancers. But by 2016, when ACOG declared egg cryopreservation “no longer considered experimental,” the candidate pool expanded. And a vast economic opportunity presented itself to the egg and embryo freezers.

I perused a few relevant websites.

UCLA’s Egg Freezing website first lists medical reasons and then “fertility preservation for social or personal reasons to delay childbearing.”

The language at the Mayo Clinic website is uncharacteristically condescending: “Your doctor can help you understand how egg freezing works,” and then helpfully points out that freezing eggs doesn’t require sperm. But the first entry in the list of reasons is: “Egg freezing might be an option if you’re not ready to become pregnant now but want to try to ensure your ability to get pregnant or have a biological child in the future.”

It isn’t cheap. Egg freezing at Pacific Fertility costs $8,345 for the first retrieval and a year of storage; a second cycle is $6,995. And that’s not counting charges for drugs, new patient consultations, lab tests, and continuing storage fees.Prelude Fertility, which runs the facility in San Francisco, makes matters clear under a photo of a smiling, multiracial woman: “Find that right person. Focus on your career. Finish your education. The age of your eggs (not you) is the number one cause of infertility. Freeze your eggs to preserve your option to build a family when you’re ready.”

Back to the Spindle

A paper from 2005 in Human Reproduction raises hope – after freezing and thawing, a spindle can reform. It’s possible, because the tubulin protein pairs that build the microtubules that build the spindle naturally self-assemble.

For the study, conducted at the University of Bologna, 18 patients donated 110 oocytes. The cells were slowly cryopreserved using propylene glycol and sucrose, then thawed, as the researchers watched, capturing images with polarized light microscopy. Over the course of five hours, spindles reappeared in about three-quarters of the oocytes.

But tracking the return of the spindle, however elegantly, didn’t go far enough. Does the spindle apportion a complete set of 23 chromosomes into the maturing egg? If not, a miscarriage or birth of a child with an extra or missing chromosome could result.

Emotions and lawsuits are running high right now, but I hope an opportunity to learn something about early development from the dual disasters isn’t lost. Here’s how.

Collect data!

Pacific Fertility’s website claims “the egg recovery rate after vitrification and later thawing is 83 percent, and fertilization rate is 84 percent.” Is that so for the damaged material? How about constructing karyotypes (chromosome charts, which destroy the cell) for some of the retrieved eggs and embryos from patients who’ve stored several, leaving some aside in case things look good. If more eggs have other than 23 chromosomes, and more embryo cells have other than 46, compared to the numbers predicted based on the age of the mother when the cells were collected, then damage has indeed been done.

Perhaps what’s learned can be used to improve the process of preserving eggs and embryos.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and a Graduate Certificate in Clinical Ethics. For more information on AMBI's online graduate programs, please visit our website.

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03/12/2018

The Color of Bioethics

I would like to take you through a thought exercise. More often than not, we are reflecting on more sober, serious topics but I would like to invite you think about a different question today: what is the color of bioethics? To some this may seem like a silly question and maybe it is. However, as we move towards an increased professional presence we need to reflect on our image, including color. We reflect on how we present ourselves in body language, communication, and writing but why not color as well?

In the professional marketing world, a lot of thought is given to color.  As professionals, we are sometimes trained to wear certain colors during interviews, presentations, or even a meeting.  Wear bright bold colors like red when trying to make a bold assertive statement. Wear lighter colors such as blue when you have to say bad news.  We worry about the color of power point slides.  Organizations spend hours analyzing the color of their logo and even time deciding what color to paint their office walls. Advertisers carefully construct commercials based on color appeal and businesses market products through color.

Color is a consideration and creates meaning.  It can represent organizations or even disease awareness. Red is the color of organizations like the American Red Cross and diseases like HIV/AIDs or heart cancer. Purple is for domestic violence.  Pink represents breast cancer.  We attempt to make waiting rooms comforting by having warm colors such as pale yellow and pink.  White represents physicians and hospital walls.  Each color has a meaning and evokes an emotion. We associate colors with emotions.  Red with blood, love, and anger and blue with sadness and tears.  Color has different meanings in different cultures.  For example, in the United States white is a traditional bride color while in India it is red. Black is the color of mourning in the United States while it is white in India.

So, what is the color of bioethics? A diverse profession that strives to appreciate culture as part of its discipline. Is there a color that adequately captures all that we do? We can look to professional logos for guidance but that may not be as helpful in an individual setting. In order to truly answer this question, we must first answer: what is at the heart of bioethics? What do we want the world to perceive about our profession? This is a message we can send through a color but what should that color be? Many people talk about ethics as dealing in shades of gray. Okay which gray? A cloudy storm sky gray or a soft gray kitten?

I myself do not know if there is a real answer. And some of you may still be convinced that this is not a serious question to be contemplating. In either event, take a second to think about this question, take a breather, even if it just for the fun of it.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and a Graduate Certificate in Clinical Ethics. For more information on AMBI's online graduate programs, please visit our website.

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01/26/2018

A Reflection on Two-Physician Consent

In a recent series of clinical ethics consultations, some physicians expressed concerns over the possible unilateral nation of using two-physician consent for medical decisions for patients without capacity. This concern comes many physicians for a wide range of treatment decisions, a concern of acting without express consent.

Like many states, New York State Family Health Care Decisions Act authorizes two physicians to make medical decisions in the event that no one can be identified to act on behalf of a patient without capacity. It is a safety mechanism to ensure that even those who do not have anyone in their lives will have someone to make medical decisions on their behalf. Some states may use a different mechanism, such as an ethics committee or a surrogate decision-making committee, but the underlying goal is the same. The “unbefriend” patients are arguably one of the most vulnerable population of patients. They lack an advocate, someone to voice their preferences or to consider their best interests. At least in New York, it then becomes the moral responsibility of physicians to decide what is in the best interest of the patient.

For those who distrust the medical profession in general, mechanisms like two-physician consent may seem like a scary option, but then who else should be making these decisions? It is scary to think that maybe one day we will be alone with no family and friends but it is an unfortunate reality. Physicians have years of medical training that can guide a determination in the patient’s best interest. In addition, physicians have taken an oath to uphold a patient’s best interest and practice the standard of care. Physicians are ethically obligated to provide care that benefits and prevents harm to the patient. People who chose to practice medicine tend to have an inherent goodness as they are joining a profession that helps people. These individuals are committed to ensuring a patient’s best interest.

Yes, depending on the gravity of the medical decision and the potential impact it may have on the patient’s quality of life, making medical decisions is a burden. What is also important to note about the New York’s mechanism is it always two physician consent, one physician does not make the decision in isolation. Though there are concerns that the concurring physician will not disagree with his/her colleague.

I empathize with the physicians who express concern in making these decisions but I also think some of these physicians are too focused on the hypothetical legal consequences. This authority to make such decisions is codified in a law and is ethically supported by ancient notions of beneficence.  Maybe we have become too comfortable with the notion of autonomy and without an expression of autonomy, we become uncomfortable. We are forgetting the rest of medical ethics. This is why we have a best interest’s standard in healthcare decision-making and established standards of care.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and a Graduate Certificate in Clinical Ethics. For more information on AMBI's online graduate programs, please visit our website.

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11/16/2017

Enhancing Pediatric Decision-Making: Australian Law Allows Children to Complete Advanced Directives

It always interesting to see how different countries handle pediatric decision-making in health care. For example, Australia now has shifted more towards respecting minors’ autonomy with its recent legislation. I first heard about this law during the Legal Update at the American Society of Bioethics and Humanities Annual Meeting this past October. The new law in Victoria, Australia coming into effect in March 2018 will require physicians to honor advanced directives written by children. Any child with capacity will be allowed to write their own advanced directives. There is no age limit as for who can write an advanced directive. The advanced directives must still be signed and witnessed, like adult advanced directives, and one of the witnesses must be a medical practitioner who must certify the person appears to have decision-making capacity and understands the effect of statements made.

This law will in essence create a situation where substituted judgment standard of decision making may become applicable. Traditionally, we use best interests’ standard for decision making in children because they are presumed to lack capacity and therefore can not make valid past preferences. However, if an advanced directive written by a child is valid, then we would have valid preferences and some evidence in order to navigate substituted judgment on behalf on the child patient. This will expand decision-making standards for children as well as avoid concerns of parents not having best interests of the child in mind.

This law will also call into question the practice of using assent verse consent for minors. The law is giving weight and value to a written stated preference but yet, we may not be honoring the verbal preferences of those same individuals. For example, a 15-year-old could write an advanced directive that would be valid but verbal consent for that same 15-year-old may not be valid if we are operating under the same traditional parental authority/ child assent model. It reinforces the age-old presumption that a written preference is more valid than a verbal preference, simply because it can last the trial of time and is an easier form of evidence to prove. Granted, the design of advanced directives is to govern in the future when the individual loses capacity. However, advanced directives also operate under the premise that the individual completing them have capacity to do so, implicitly also the capacity to consent to treatment. This new law gives children some authority for their future selves but no authority around their current selves.

For those in favor of including children in the health care decision making process, this seems like a great idea. This may also seem like a great idea for proponents of increasing advanced health care planning. However, it some ways this exacerbates the issues raised both in considering pediatric decision-making and honoring advanced directives. For example, should an adolescent patient make decisions for their future adult self (the unresolvable question of how much control the present self should have over the future self)? This seems more applicable to the pediatric population as developmentally adolescents are changing so much over a short period of time (in comparison to a lifespan). Having such a law makes sense for terminally-ill mature minors with capacity who may not live for a full lifespan, assuming of course they have contemplated, understand, and appreciate their medical circumstances. What a child may want one day may dramatically change the next. It is a step forward to properly enhancing children in health care decision making but it should be a cautionary step forward. Overall, this raises the question of how much autonomy is truly necessary for healthcare decision making. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and a Graduate Certificate in Clinical Ethics. For more information on AMBI's online graduate programs, please visit our website.

 

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11/10/2017

Can we talk about gun violence in America?

A report in the New York Times shows the connection between the prevalence of guns in the United States and mass shootings. No country in the world can match the United States in the total number of guns owned by citizens. To put this in context, “Americans make up about 4.4 percent of the global population but own 42 percent of the world’s guns.” There are about 270 million guns in circulation in the United States and between 1966 to 2012 there were 90 mass shooters, no other country in the world has more than 48, million guns in circulation or 18 mass shooters. In short, the problem of mass shootings is basically an American problem because we have so many guns available for some people to use in very harmful ways.

Critics may cite other variables that could explain the inordinately high rate of mass shootings in the United States. Trump recently said of the recent mass shooting in Sutherland Springs, Texas:

“Mental health is your problem here. This was a very, based on preliminary reports, this was a very deranged individual, a lot of problems over a long period of time. We have a lot of mental health problems in our country, as do other countries."

As is often the case with his statements, the facts do not support it. About 18% of the population have mental health problems and the vast majority are not violent and are not involved in mass shoots, though a few are. Other possible variables, such as time spent playing video games, the level of racial diversity, immigration, and even crime rate, also can be ruled out statistically as being a significant factor in mass shootings—there is no statistical evidence that any of these variables account for the high prevalence of mass shootings, as well as homicides, in the United States. For example, we learn that a New Yorker is as likely as a Londoner to be robbed, but a New Yorker is over 50 times likely to be killed in the process.

There simply are no other variables other than the number of guns in circulation that would account for the uniquely high frequency of these horrific mass shootings, with which we have become all too familiar. As the report from the New York Times states:

“More gun ownership corresponds with more gun murders across virtually every axis: among developed countries, among American states, among American towns and cities and when controlling for crime rates.”

If it is the case that is there is a correlation between the number of guns available to citizens in a society and the number of mass shootings that injure and kill innocent people every year, as a matter of common sense, it seems to follow that the solution would be to reduce the number of guns in circulation. In fact this common sense perspective has been borne out by empirical research as stated in the New York Times report:

…(G)un control legislation tends to reduce gun murders, according to a recent analysis of 130 studies from 10 countries.

 The facts seem relatively clear both about the root cause of the problem and how to ameliorate it. So why aren’t people—including citizen voters and politicians—paying attention and responding? This question gets us into a whole other topic, which I don’t want to explore in any depth now. But I will say it seems clear that since the 1980s a powerful gun culture in America cultivated primarily by the zealotry, funds, and organization, of the National Rifle Association (NRA). This culture has been successful in inspiring its followers to take an expansive view of the 2nd Amendment, to see the government as a potential threat to its fundamental right of gun ownership, and live in perpetual fear that politicians will take away their guns and their right to own them. Because of the intense advocacy that puts critical pressure on key politicians, in America the NRA gun culture representing a minority view can bully its way to keeping in place laws that ensure easy access to guns, including deadly assault weapons and large clip magazines.

The fact that most Americans, including many members of the NRA, are thwarted in their desire to see sensible solutions to gun regulation is what is most concerning. According to a Pew Research report, 89% of both gun and non-gun owners favor the mentally ill from purchasing guns—which makes Trump’s repeal of a rule that blocks gun sales to certain mentally ill people, especially in light of his recent statements, all the more troublesome. Moreover, even on issues like barring gun purchases for people on no-fly or watch lists, creating a federal data base to track gun sales, banning assault-style weapons and high capacity magazines, receive two-thirds support from the public. Sadly, in America currently majority views about this and other vitally important public policy issues don’t translate into change in policy.

What is the solution? It seems evident that the majority of people in America with sensible views that are not being heard must take to necessary measures to make themselves heard. Given the trajectory of violence from mass shootings and the urgency of protecting innocent lives, it’s time for new culture of resistance to the NRA and the politicians that support them to find reasonable ways to regulate guns in America.

 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and a Graduate Certificate in Clinical Ethics. For more information on AMBI's online graduate programs, please visit our website.  

 

 

 

 

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11/10/2017

Can we talk about gun violence in America?

A report in the New York Times shows the connection between the prevalence of guns in the United States and mass shootings. No country in the world can match the United States in the total number of guns owned by citizens. To put this in context, “Americans make up about 4.4 percent of the global population but own 42 percent of the world’s guns.” There are about 270 million guns in circulation in the United States and between 1966 to 2012 there were 90 mass shooters, no other country in the world has more than 48, million guns in circulation or 18 mass shooters. In short, the problem of mass shootings is basically an American problem because we have so many guns available for some people to use in very harmful ways.

Critics may cite other variables that could explain the inordinately high rate of mass shootings in the United States. Trump recently said of the recent mass shooting in Sutherland Springs, Texas:

“Mental health is your problem here. This was a very, based on preliminary reports, this was a very deranged individual, a lot of problems over a long period of time. We have a lot of mental health problems in our country, as do other countries."

As is often the case with his statements, the facts do not support it. About 18% of the population have mental health problems and the vast majority are not violent and are not involved in mass shoots, though a few are. Other possible variables, such as time spent playing video games, the level of racial diversity, immigration, and even crime rate, also can be ruled out statistically as being a significant factor in mass shootings—there is no statistical evidence that any of these variables account for the high prevalence of mass shootings, as well as homicides, in the United States. For example, we learn that a New Yorker is as likely as a Londoner to be robbed, but a New Yorker is over 50 times likely to be killed in the process.

There simply are no other variables other than the number of guns in circulation that would account for the uniquely high frequency of these horrific mass shootings, with which we have become all too familiar. As the report from the New York Times states:

“More gun ownership corresponds with more gun murders across virtually every axis: among developed countries, among American states, among American towns and cities and when controlling for crime rates.”

If it is the case that is there is a correlation between the number of guns available to citizens in a society and the number of mass shootings that injure and kill innocent people every year, as a matter of common sense, it seems to follow that the solution would be to reduce the number of guns in circulation. In fact this common sense perspective has been borne out by empirical research as stated in the New York Times report:

…(G)un control legislation tends to reduce gun murders, according to a recent analysis of 130 studies from 10 countries.

 The facts seem relatively clear both about the root cause of the problem and how to ameliorate it. So why aren’t people—including citizen voters and politicians—paying attention and responding? This question gets us into a whole other topic, which I don’t want to explore in any depth now. But I will say it seems clear that since the 1980s a powerful gun culture in America cultivated primarily by the zealotry, funds, and organization, of the National Rifle Association (NRA). This culture has been successful in inspiring its followers to take an expansive view of the 2nd Amendment, to see the government as a potential threat to its fundamental right of gun ownership, and live in perpetual fear that politicians will take away their guns and their right to own them. Because of the intense advocacy that puts critical pressure on key politicians, in America the NRA gun culture representing a minority view can bully its way to keeping in place laws that ensure easy access to guns, including deadly assault weapons and large clip magazines.

The fact that most Americans, including many members of the NRA, are thwarted in their desire to see sensible solutions to gun regulation is what is most concerning. According to a Pew Research report, 89% of both gun and non-gun owners favor the mentally ill from purchasing guns—which makes Trump’s repeal of a rule that blocks gun sales to certain mentally ill people, especially in light of his recent statements, all the more troublesome. Moreover, even on issues like barring gun purchases for people on no-fly or watch lists, creating a federal data base to track gun sales, banning assault-style weapons and high capacity magazines, receive two-thirds support from the public. Sadly, in America currently majority views about this and other vitally important public policy issues don’t translate into change in policy.

What is the solution? It seems evident that the majority of people in America with sensible views that are not being heard must take to necessary measures to make themselves heard. Given the trajectory of violence from mass shootings and the urgency of protecting innocent lives, it’s time for new culture of resistance to the NRA and the politicians that support them to find reasonable ways to regulate guns in America.

 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and a Graduate Certificate in Clinical Ethics. For more information on AMBI's online graduate programs, please visit our website.  

 

 

 

 

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09/22/2017

Ethics As An Evolving Activity: The Need To Remain Vigilant

Working as an ethicist in a professional work environment, you quickly realize that any ethical advice worth giving to practitioners must always be relevant to real problematic, human situations. Ethics must make a difference. Elucidating one’s obligations in particular problematic situations enhances insight and confidence in working through troubling value-laden dilemmas both in individual circumstances, as in clinical ethics, and also with regard to larger social problems at the macro policy level. Most ethical solutions are provisional recommendations, i.e. always amenable to revision based on new data, based on ethical reasoning in light of the particularities of each case that may ameliorate an impasse and often helps decrease suffering: Ethics helps make the little corner of the world with which it deals a little better off.

Though I am laying out a pragmatic ethical framework, I want to be clear that ethical principles are essential to ethical problem solving. Following Kant but with a pragmatic twist, the foundation of ethics is the duty to treat each individual human being with respect and, as much as possible, to be fair to everyone. This duty reflects the two fundamental moral principles of respect for autonomy and justice. In the application of the principle of individual autonomy, respect is expressed toward human individuals in concrete situations. For the principle of justice, respect is expressed toward a community or society or connected individuals. Elucidating the pragmatic approach further, ethical principles are not viewed as absolute, quasi-religious truths that exist independent of human experience but rather grounded in human experience.

Ethical principles from this perspective are repositories of wisdom gained through reforms primarily in the democratic process of extending the moral community by recognizing more individuals as full moral agents and guaranteeing them the rights of full citizenship. Thus, the way one thinks about ethics today in contemporary America is deeply connected to, and in a real sense grows out of, the historical process of democratic politics. Just think of the bedrock principle of medical ethics, respect for autonomy and how this notion evolved historically within the legal process and the key court cases on informed consent for the past 100 years or more. Think of the political reform movements in civil, feminist, and consumer rights, etc. movements during the 1960’s. Think of the lessons learned from the abuses of human subjects research that came to light after WWII the Nuremberg Trials. Finally, think of the violations of human research described by Henry Beecher in 1966 in an article from the New England Journal of Medicine, which led to the creation of greater protection of human subjects in research. All of these and other historical events helped to give rise to a full-blown concept of individual autonomy as well as the rights of all patients and subjects to voluntary informed consent. To reiterate, ethical principles emerge historically from real human experience, not from out of the blue sky above, based on meaningful progress in the respectful and fair treatment of all human beings as full moral agents.

The larger point I am getting to is that the ethical and moral life of humans as individuals cannot be separated from the life of humans as they struggle together in community, in groups, pursuing their own interests within the political process over and against the interests of others within a legal and political process. The moral options available for individuals are always framed within the confines of a certain collective or institutional order. From this pragmatic perspective, it follows that the very integrity of ethics as an essential dimension of human life that is dependent on the integrity of the political order. Does it treat all people fairly or does it attempt to exclude and deny certain individuals their basic rights to participate in the democratic process? Think of the current commission on voter fraud investigating non-existent problems in the election process, which may result in tighter voting restrictions that will greatly impact populations not likely to vote for the current administration. Is there a commitment to truth (with a little “t”), as in empirical truth, the institution of scientific research as the principal arbiter of scientific claims, and in general to relate facts of ordinary experience? Think about the denial of the claims from climate science research or the claim made by a presidential candidate that he saw Muslims cheering at the dreadful site of 9/11. Is there commitment to treat each other with a basic respect in our interactions and dealings on the public stage? Think of all the name-calling, derogatory comments, and incitements to violence during the last presidential campaign, which has continued up to the present in the current administration. I could go on, but you hopefully get the point.

Those of us who work in areas of applied ethics must be deeply concerned about state and direction of our political process and collective life as a society. This way of thinking about ethics should cause us considerable pause as we witness the current pattern of political events in our country. Up to the present we should be grateful for the ethical framework that has emerged in the tradition that we have inherited. But there is no guarantee that we will remain so lucky. We cannot allow ourselves to reach the point, as past philosophical ethics has done, to think of ethics as an isolated, academic enterprise. It is not. It is a practical, living, and evolving, historically contingent institution of which we must be responsible stewards. That means it is important that ethicists and all concerned citizens vigilant of what is happening in politics and the larger society. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and a Graduate Certificate in Clinical Ethics. For more information on AMBI's online graduate programs, please visit our website.  

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09/14/2017

Perceived Ethical Dilemmas from Labels

Ever hear the expression it’s all in your head? In witnessing a pattern of ethics consults, I have been wondering lately how much of ethical dilemmas are truly perceived dilemmas and not really dilemmas at all. We are our own worst enemies in many ways and health care providers are no exceptions to the flaws of humanity. We perceive a conflict and therefore a conflict arises. Then comes the need for an ethics consultant. Perceptions drive much of society, including ethical dilemmas. 

A physician will hear a label, whether it is ‘drug-addict,’ ‘Christian,’ ‘illiterate,’ ‘difficult,’ ‘noncompliant,’ and he/she will assume all the characteristics that go with that label. This will then create a perceived conflict between the provider and patient based on the presumed characteristics. These labels could have attached to the patient years prior to the current admission but yet, they remain in a patient’s record as past medical history. The classic example is ‘wanting everything done’ when it comes to end-of-life care. Many jump to the conclusion based on particular faiths (or even just hearing that the patient is religious) that patients and families want everything done and will not be open to a conversation about comfort care and hospice. They assume based on a label, that may not be true. A perceived conflict has emerged. These assumptions change how the conversation will go, whether the physician realizes it or not, because the physician is preparing for a challenge. A simple question or inquiry by a family or friend about the medical information may then seem like push-back, since that is what the physician is expecting, when in reality it is just a question. 

I joke that it’s part of the ethics magic of just appearing in a room and problems are solved, but yet, there is more to it. Many would argue that it is the comforting and supporting presence just in case something goes wrong in conversations with patients and families. The presence being the ethics consultant. Much of it is facing the perceived dilemma only to realize there is no conflict at all. This is also the role of the ethics consultant, to face the conflict with the provider and to show that nothing’s wrong. There has many family meetings where providers have asked for an ethics consultant for a variety of reasons and it turns out that the providers could handle the conversation without any assistance. Some may say this is a good provider because the physician is recognizing his/her own limits and asking for help. And maybe it is but maybe labeling it as a conflict is not the best approach either. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and a Graduate Certificate in Clinical Ethics. For more information on AMBI's online graduate programs, please visit our website.  

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