Professional Ethics?

I am watching this judicial showdown with great interest.

First of all, by one reading, I, too, belong to a professional organization (i.e., The United Methodist Church) that has its own professional licensing procedures (The Board of Ordained Ministry). Although my organization's professional licensing procedures are not in any sense overseen, supervised by, or practiced at the mandate of any federal or state legislation, there is at least one major circumstance in which my authorization as a pastor is linked to my authorization to provide a legal service: that is, marriage.

What if my professional organization's licensing procedures were in conflict with the state's guidelines concerning the practice of performing marriages? This could potentially come up, given that my professional organization currently forbids its members to officiate at weddings that are considered legal in some states. I am not aware of any cases where my professional organization has exercised its authority in this matter (the UMC is not exactly known for its episcopal backbone), but what if it did? Would the state recognize the right of a professional organization to set its own ethics, even to the inconvenience of the state or its citizens?

This problem is much more acute in the case of medical practitioners whose ethics conflict with the state's interest in carrying out its business. And the scalpel cuts both ways, politically speaking: at present, doctors are permitted to refuse to perform or refer for procedures or treatments to which they have a moral objection, even where state law has recognized access to those procedures and treatments as a civil right. Generally speaking, those who would be in support of the Medical Board's attempt to do an end run around the law with regard to the death penalty tend to be highly critical of practitioners' attempts to do an end run around the law with regard to abortion and certain forms of birth control.

I'm very, very curious to see how it will play out.

Christian Bioethics?

This past week, I began a four-week lecture series in a local church's Sunday School class. The parish, a significant portion of which is comprised of doctors and lawyers, had requested a class in Christian bioethics.

Believing they were expecting a four-week class in "which side to come down on" ethics, and hoping to problematize their approach somewhat, I decided to focus on biblical portrayals of health and sickness for the first three weeks of the class. We won't get to "Issues in contemporary medicine" until the last week.

The first class focused on Old Testament depictions of health. I depended heavily on observations by Norman Wirzba and Ellen Davis on the holistic nature of the Hebrew concept of Shalom--a concept that included human health, of course, but also the health of the land, of the people's relationship to its God, of the politics of the people, and of interpersonal relationships among the people. Not just health, but justice, mercy, forgiveness, love, economic responsibility, and environmental stewardship are encompassed in the biblical concept of health and wholeness.

We looked at texts like Isaiah 65 and Leviticus 26 to ground our understanding of God's desire for all of creation to share in God's Shalom. I'm hoping that they begin to see that "health," as we moderns understand it (i.e., the absence of pathology in an individual body), is a paltry substitute for Shalom.

Better to live on the corner of the roof . . .

Marital Strife Makes You Sick.

Duh.

Conflicting Goods?

I've often been suspicious of the starring role played by the principle of autonomy in most medical ethics treatises.

So it's interesting--to say the least--to hear a presidential candidate propose a solution to our country's health care dilemmas that proposes limiting patient autonomy in a substantial way--or at least penalizing the irresponsible exercise thereof.

John Edwards (Does anybody else keep accidentally calling him Jonathan Edwards?) recently proposed health care policy that would mandate certain preventative measures, including annual checkups and mammogram screens.

Now, this is a very interesting proposal. In many ways, it naturally follows from the combination of the logic of the market and the logic of liberalism, both of which also depend on autonomy as their chief good. Medicine has been almost completely subsumed into both--it has become an enterprise almost completely dominated by its economic side, and government intervention into and regulation of the practice of medicine is taken as normative. (Ask even the most ardent libertarian whether he'd like his son to be operated on by a doctor who was not board-certified.)

So, assuming medicine to be a predominantly economic enterprise, and assuming government responsibility to make this economic enterprise run well, it makes sense for the government to exercise its authority by incentivising and disincentivising behaviors that have economic consequences within the system.

This means you have three disciplines or systems which derive their internal logic from a primary commitment to autonomy, combining in such a way that virtually demands a limitation of individual autonomy. Fascinating.

In all honesty, though, as much as I loathe Edwards' proposal, I think he is the first candidate whose proposals show that he understands the complexities of the health care problem. Few of the other proposals I've seen seem to take seriously the complex interplay of economics, psychology, law, and biology that comprises health care. I'm not sure he adequately addresses the dynamics of the patent system or litigiousness, but he has covered more bases than most people.

The only bit of utter cluelessness came when he said, in response to the question of whether people would find this too invasive, "We mandate public education—public or private—and no one minds that."

Now, I know he's only homeschooling his kids this year so that they can spend time together as a family while he's campaigning. So he's not a hard-core homeschooler. But still, you'd think he'd have heard of a movement of a couple million people who decidedly "mind that." Or maybe have read of the violent resistance that attended the introduction of compulsory schooling?

Books in Review

Hector Avalos, in Health Care and the Rise of Christianity, makes the case that a study of the health care milieu in which Christianity arose is necessary for understanding the attraction that Christianity might have had for, particularly, the chronically ill in the Greco-Roman world.

Avalos helpfully surveys Jewish and pagan sources for indications of the values and practices surrounding sick members of those societies, particularly with respect to chronic illness. The survey of pagan culture is particularly helpful (at least for this non-Classicist) in that it enumerates the different health care options available to inhabitants of the Roman world, as well as the likely cross-pollination between Jewish monotheism and Roman paganism.

I am not conversant enough with Classical sources to know whether his presentation of health and sickness in the Roman world is accurate, but I was disappointed with his survey of Judaism. He dealt almost exclusively with the canonical texts, and seemed to weigh the New Testament critiques of Pharisaism rather more heavily than may be warranted. He did not seem to make use of more modern (and more charitable) studies of Jewish culture in the Second Temple period.

Additionally, his reading of the canonical texts was deeply problematic. He seems to have found in the texts a deep concern for protecting the state (meaning, especially, the levitical priestly hierarchy) from the burden of the chronically ill and underproductive. He takes the strict regulations concerning purity and contamination to be less interested in regulating the spread of contagious illnesses than in isolating and stigmatizing those with chronic illnesses which left them unable to be economically productive. His evidence for this interest is scant--he makes the point that the gradated requirements for thanksgiving offerings after healing (as in Leviticus 14) acknowledge the possibility that chronic illness may render a person economically unproductive, but he implies that levitical regulations are intended to marginalize those persons who have become poor.

He seems to have missed the deep concern for the poor and economically unproductive evident throughout, especially, the priestly code. The passage in question, for example, could be read as a particular effort to include those who have become poor through chronic illness and to mitigate the effects of their disadvantaged position. Economic disadvantage and unproductivity, in other words, is not an impediment to participation in the liturgical life of the community. Chronic illness is, to be sure, but there is little to no evidence that the Jewish community isolated and stigmatized the economically unproductive on a regular basis. Contagion and purity concerns are a much more convincing read of the levitical regulations regarding blood and bodily fluids.

That said, his more basic point is quite sound: whether or not such was the intention of the levitical code, and whether or not the Second Temple Jewish community practiced the levitical code exactly as written, the effect of the canonical regulations concerning chronic illnesses was to create a sub-group of people who would be particularly interested in the healing ministries of Christian missionaries, as well as the theological commitment to non-isolation of "sinners" and lepers.

Both Judaism and paganism, by Avalos's read, created a demographic group of disaffected members of society that would be attracted to Christianity precisely because it rejected (at least in its canonical texts) the very practices that had isolated them from their own societies. This partly explains, Avalos contends, the tremendous growth in the first decades after the death of Christ.

Psychologists Scrap Interrogation Ban

Well, I really like how the APA was thinking here, in the proposed ban. Even though it was ultimately not carried, I liked what they were trying to do.

I'm not sure that they've read their history, though. The Methodist Episcopal church of the nineteenth century passed a ban on ordained pastors owning slaves. The first person to challenge that ban--a Bishop Andrew--was remonstrated and threated with expulsion. All this did was lead to the formation of the Methodist Episcopal Church, South.

I fear that if any such professional organization were to try to enforce such a ban (like the AMA's ban on doctors' participation in executions), we would simply find ourselves with two national professional organizations where once there was one.

Terminal Does Not Equal Disposable

A federal appeals court decided yesterday that terminally ill patients do not have a constitutional right to access highly experimental treatments for their (terminal) conditions, following a longstanding tradition among bioethicists that refuses to see terminally ill patients as disposable.

(Yahoo article here)

While a dissenting judge was appalled at the court's apparent willingness to interfere in what she considered a private choice to pursue life at all costs, I think the writer of the majority opinion and the FDA spokesperson who commented on the decision had the better view of the status, if you will, of terminally ill patients.

The FDA spokesperson was quoted as saying that the decision appropriately balanced the needs for public safety and access to as yet unproven treatments. In her view, then, the terminally ill patient is still a member of the public whose safety the FDA was founded to protect. Like all other patients, the terminally ill patient can be taken advantage of by researchers (whether unscrupulous or merely overoptimistic) and can be harmed by lack of proper scientific knowledge. Their desperate circumstances must not be seen as an excuse to forgo the normal protections and safeguards which are given to the general public (even if the same circumstances lead them to wish to forgo those protections themselves).

The writer of the majority opinion implied the same valuation of the terminally ill patient--their deaths could be hastened by an unapproved treatment, and that premature death would be as much a tragedy as if it were a non-terminal patient.

While the desire to extend every possible opportunity for a terminally ill person to be healed is laudable, it often goes along with a more sinister (and usually unarticulated) re-valuation of the place of the terminally ill person in society. Virtually every time it is proposed that rules, procedures, standards, and policies be different for the terminally ill patient, the difference is intended to mark a separation of the dying patient from the general public, even when the differences are intended to benefit the dying patient. These special policies and procedures proclaim, "The dying person is a different kind of person. The normal rules don't apply."

If this breaking of the "normal rules" meant an increased participation in the life of the community (as in some monastic orders, where the community rushes to the bedside of the dying brother or sister to be with him or her in death, even if it means that the liturgical practices of the community are interrupted), I would be for it.

But it never does, does it?

A Philosophical Disease: Bioethics, Culture, and Identity

A Philosophical Disease is a Wittgensteinian critique of Western biomedical culture. Carl Elliott engages the intersection of language and our construction of reality, morality, and relationality.

For an example of how this sort of critique works, Elliott's discussion of the construction of gender is paradigmatic. There are a number of medical conditions--including birth defects, genetic abnormalities, and medical mishaps--which render a person's sexual identity . . . well, complicated.

In one part of the Dominican Republic, one such condition is sufficiently prevalent that there is a name for it: guevedoche. (Penis-at-twelve.) Individuals with this genetic condition are genotypically male, but appear female from birth through puberty. Most guevedoches, although they had been raised as females, make the transition to male societal roles after puberty--including marrying women and taking jobs usually given to men. It is not so much that this culture is blase about gender roles (quite the opposite); it is rather that their experience with a particular condition allows them to code for a third gender, as it were. They have the experience of it, they have a name for it, and they have cultural practices which surround it.

By contrast, the US has retained a more strict understanding of the world as divided into male and female. Thus, their cultural practices surrounding the same genetic condition--or conditions in which gender identity is similarly ambiguous--are different. They have a medical name for the condition (5-alpha-reductase deficiency), but not for persons afflicted with the condition. Indeed, the cultural experience of such conditions is so rare that medical practices surrounding these conditions tend to involve surgery to make the genitalia match the individual's perceived sexual identity. (That is, if the individual feels more "female," the genitalia are surgically altered to match that feeling.) American language and experience is almost exclusively bound by the male/female dyad, such that surgical intervention is required to make one's biology match the linguistic and philosophical convention.

Elliott similarly investigates the way language about identity intersects with psychiatry. These chapters were some of the most interesting, as that intersection has received far less attention than it should in the bioethics literature. How does severe depression affect competence to consent? Do emotional ties reduce or enhance rational decision-making? Why do we have an intuitive sense that a willingness to sacrifice oneself is morally praiseworthy, while a willingness to profit from someone's sacrifice is morally reprehensible?

This is, in addition, an eminently readable book. The motivated amateur could certainly tackle this book, although it is geared toward an academic audience. If your interest is in the culture of medicine--not just the hot topics in bioethics, but the culture in which these topics get discussed--this is a book worth reading.

Something the Lord Made

Even though this movie was recommended by a normally reliable source, I can't say that I had terribly high expectations of it--at least not after looking at the back matter. An HBO film? With, well, Mos Def?

I mean, I thought it would be "loosely based" and formulaic (like Remember the Titans or some such), with stupid dialogue and trite sermonizing. But, I thought, at least it would deal with "important issues" or something, so it would be worth watching.

It was none of the things I had thought.

Well, yes, it dealt with "important issues" (see here for the historical background), but so gently and subtly that it didn't feel like an "important issues" movie.

It was not at all formulaic, either. And the dialogue was restrained, well-written, appropriate.

And Mos Def did an outstanding job. His Vivien Thomas was gentle, subtle, restrained, yet completely compelling.

I keep using those words--gentle, subtle, restrained. That's how I would characterize the whole movie, actually. With the exception of Alan Rickman's southern accent (which is about as successful as Kevin Costner's British accent in Robin Hood), nothing was larger-than-life or overdone. It felt real--no small feat for a movie portraying incidents of another era, one with high probability for emotionalism and sermonizing.

If I had one negative thought about the movie, though, it was that Vivien Thomas was a rather "safe" black hero. He was a man who suffered quietly the insults he was offered more often than not, who accepted with gratitude the recognition he was finally given (decades late and still fairly inadequate), and who cared more about the life-saving work he was doing than what he had to endure to do it--or how his using his gifts benefitted and enriched everyone but himself.

Yes, his character is a shining example of Christ-like virtue (patient suffering and self-giving in the face of others' vainglorious pursuit of "success"), but he may have been rather too easy on Blalock and Johns Hopkins--and, by extension, us. It was too easy for Blalock to enjoy the material and societal benefits of his association with Thomas (who enjoyed only the moral satisfaction of his work), and to atone for it at the end of his life with the recognition that "I have some regrets."

And too easy for us. As James Cone supposedly said at a recent AAR conference (I'm getting this third-hand, so my apologies if I'm getting the story wrong), "You white theologians always wanna talk about Martin. When are you gonna talk about Malcolm?" If our pantheon of civil rights saints is limited to figures like Vivien Thomas and, yes, even MLK, we (white America) are letting ourselves off rather too easily.

What Mike Pressler Should Have Done

Or, Why I'm Not Rallying Around the "Innocent" Lacrosse Players

Don't get me wrong. I'm happy that three men are no longer under an undeserved indictment, that what appears to have been a cruelly false accusation has been set right, and that the legal system has proved itself able to negotiate a complex case with relative justice.

But I don't particularly care for the triumphalist tone being bandied about: "Innocent Lacrosse Players Vindicated!!" "Finally, Justice for the Dear Sweet Boys Who Never Did Anything Wrong!" "Mounting Pressure for Duke To Apologize to the Clearly Wronged Former Lacrosse Coach!"

Uh, no. Especially not to that last one.

Mike Pressler tolerated an atmosphere among his players that should never have been tolerated. This permissive attitude is what led to the night which remains an embarrassment to the University, irrespective of whether a felony was committed.

Had Pressler done, say, something like this a long, long time ago, this painful night might never occurred. And, more importantly, those boys might have had a chance to grow into real men. I fear that now, they never will.