When does personhood begin?

There are arguments for personhood beginning at fertilisation, at implantation in the womb, at birth.

Fertilisation seems possible. It is a specific time that 2 gametes which are not persons become a single cell. This single cell has a continuity with the person born. That is, there is a discontinuity at fertilisation and no discontinuities thereafter, and there is little disagreement that the sperm and egg are not persons.

However embryos split into two sometimes and humans can also artificially split them and continue to split them. Some argue that a new soul occurs when an embryo splits into 2 (which is a somewhat reasonable argument). More problematic is the issue of multiple embryos combining to form a mosaic. Does this mosaic baby have 2 souls, or do 2 souls become 1, or does 1 die (probably not as both cell lines continue in various ways)?

Further, the embryo becomes 2 distinct structures: the baby and the placenta. The latter supports the baby through pregnancy but it is not exactly part of the baby. The embryo can develop solely into support organs (placenta) in a molar pregnancy (hydatidiform mole) and there does not appear to be a person at any stage even though fertilisation has taken place.

The problem with womb being the definition of personhood is what about ectopics that survive? Abdominal gestation occurs rarely but they are clearly babies. Ectopic pregnancies are usually tubal, but can occur elsewhere, and abdominal pregnancies may have started out tubal.

Theologically traducianism implies personhood at conception for continuity. There must always be a soul because the soul is inherited. Conversely, if the concept of the new creation of souls (creationism) is correct, this potentially allows for a gap between conception and personhood. Note that these arguments (traducianism and creationism) are a result of the theology and our theology should be scriptural. So what does the Bible argue for?

Birth seems too late. Many scriptures point to personhood starting before birth, though to argue specifically for fertilisation from the Bible is a little harder. Job talks about the night he was conceived (Job 3:3).

Although previously I thought conception equalled personhood, I am now not so certain. In Scripture life is very clearly connected to blood. Combining this with what we know about human physiology, one could argue for circulating blood: a heart and blood cells. Death should be defined by absence of a beating heart (not brain death). If this is the case then perhaps personhood starts when the heart and blood cells are made: about 2–3 weeks post conception. Note that this is 4–5 weeks after usual dating; pregnancy dates are calculated from last menstruation which is (usually) about 2 weeks prior to fertilisation.

There is also an enigmatic verse in Ecclesiastes that says

As you do not know the way the spirit [ruach] comes to the bones in the womb of a woman with child, so you do not know the work of God who makes everything. (11:5)

It is unknown whether ruach should be translated "spirit" or "wind" here, but if it is the former, it is at least possible that God sends the spirit into a fetus in a way that we do not understand.

Brain death

In an earlier post some years back Blair D raised the question of brain death. He mentioned those who are considered brain dead

I have never known of a person diagnosed as brain dead to breathe, in a manner consistent with life sustaining way, for very long. In other words the brain dead person has commenced the process of dying.

and those in a persistent vegetative state

To the clinicians and she was as good as dead in that she was deemed to have none of the higher brain functions remaining intact and therefore was described as a "living brain stem" but no more. No ability to perceive, experience (to give meaning to) and or communicate in any way.

One needs to be careful how death, including brain death, is defined, this should not be happening,

Stephen Thorpe, then 17, was placed in a medically-induced coma following a multi-car pileup....

Although a team of four physicians insisted that his son was “brain-dead” following the wreck, Thorpe’s father enlisted the help of a general practitioner and a neurologist, who demonstrated that his son still had brain wave activity.  The doctors agreed to bring him out of the coma, and five weeks later Thorpe left the hospital, having almost completely recovered.

Today, the 21-year-old with “brain damage” is studying accounting at a local university.

Now many people whose brains are non-functional following trauma never recover, they fail to wake up ever. However because some do wake up, perhaps brain death may not be the best way to define death. This position is consistent with what I understand the biblical definition of death to be. If we are going to have "brain death" then we need to have absent brain function. If there is no brain function then such a person will stop breathing because breathing is controlled by the brain. (The heart is affected by the brain but can continue to function without brain input.) Heart cessation will occur shortly following breathing cessation.

Then why not call brain death a form of death when there is no brain activity in the region that causes respiration? Perhaps medically this could be a definition. However the situation could arise where the breathing centre of the brain has some damage (temporary or permanent) but the person retains higher cognitive functions. He will then be aware that his breathing is being maintained artificially (similar to high neck injuries). So for brain death we need evidence of minimal brain activity, no awareness, and lack of respiratory effort. Even with all these we cannot be certain of irreversibility and people can be maintained in this situation for years. Contra cardiac cessation which is permanent after several minutes (somewhat depending on the temperature).

If we accept that death is cardiac (plus or minus respiratory), where does that leave us with those who are considered brain dead or others who are in a persistent vegetative state?

This is actually a different question to whether or not brain death is death. I would phrase the question: Can we withhold medical treatment from a minimally conscious person who is unlikely to recover?

Which raises another question: What is medical treatment?

The answer to the first question is a guarded yes. If a person is thought to be permanently brain damaged and is in an induced coma the least one should do is "wake" him up. Assessment of response to stimuli should involve significant stimuli in the absence of sedation. But if there is strong evidence for irreversible brain damage and no response to stimuli (without sedation) and the person is without consciousness, then I see no ethical command to maintain life using ongoing medical treatment. This is not to say that  providing such medical treatment is necessarily immoral, rather that there is not an automatic moral responsibility to maintain life artificially indefinitely.

Which leads to the second question: What is medical treatment? If a person is unable to breathe then the removal of ventilation will lead to cessation of respiration followed shortly by cardiac arrest and death. If a person is able to breathe then they may continue to live for several days but die from kidney failure without fluid. The provision of air via an artificial respirator is considered medical treatment because it is a high-tech intervention. The provision of water and food via a feeding tube is not considered high-tech and it is often assumed that this is not a medical intervention but providing the essentials of life. However the respirator is also providing an essential of life: oxygen. That a respirator happens to be more complex than a tube is morally irrelevant. What is relevant is that we are providing air or water or food for the patient. That the person cannot breathe for themselves or swallow for themselves means that we are providing not just vitals for life but the mechanism of receiving vitals.

Brain death may not be the best definition of death. There is no moral duty to maintain medical treatment for someone who is brain dead. Medical treatment is providing the mechanism of receiving the vitals of life regardless of how high-tech that mechanism is.

Does illegal abortion increase the death of mothers?

Peter Saunders, CEO of the Christian Medical Fellowship in the UK argues that improvements in maternal mortality, including deaths associated with abortion, were due to improved medical practices and not to the legalisation of abortion.

First, maternal mortality from all causes, including abortion fell dramatically long before abortion was legalised as a result of better medical care.

Second, many so called ‘back-street abortions were actually carried out ‘illegally’ by ‘skilled professional’ nurses and doctors using surgical instruments in sterile conditions.

Third, legalising abortion did not eliminate all maternal deaths, as some women now began to die of legal abortions, and in addition there was still a trickle of illegal abortions.

Pregnancy and birth is not without danger. Modern medical practices have reduced the harms to both mother and baby.

If abortion is the intentional killing of a human person, the murder of a fetus, then the unintentional death of the persons involved in the activity is not an argument for legalising abortion. However it seems that maternal deaths following abortion are not even related to the legality of abortion. Therefore are no grounds to propose legalising abortion anticipating that maternal mortality might decrease.

Defining death biblically

Modern medicine defines death in several ways. There can be cessation of heart beating, cessation of breathing, or cessation of brain activity. The latter is intended to be defined quite clearly so as to not include people in comas that may potentially wake up.

Heart death is when the heart stops pumping and electrical activity ceases (asystole, flat-lining). A heart may stop beating but the electrical activity continues. This may occur because the heart cannot pump (pulseless electrical activity) such as when there is no blood (bleeding), or nowhere for the blood to go (clot in the lungs), or no space for the heart to contract (blood around the heart). It may also occur when abnormal electrical activity does not cause heart contraction (ventricular fibrillation). Both these situations very rapidly become asystole if not treated, and frequently even if treated, especially when death is expected.

Cessation of breathing, eg. blocked airway or drowning, leads to a rise in carbon dioxide in the blood and decreasing oxygen. Increased carbon dioxide quickly leads to unconscious and acidification of the blood. The heart stops after a few minutes (unless there is severe hypothermia) for various reasons.

Brain death is defined as no electrical activity of the brain, no brain reflexes, no response to a stimulus. The person cannot breathe independently, and sometimes cannot maintain a heart beat; thus such a definition exist because of advances in medicine allowing prolonged mechanical ventilation.

These definitions of death are somewhat reasonable. Nevertheless we need to consider what Scripture may say to the issue and whether that modifies our thinking around physical death.

The Bible has several references to various organs of the body. Kidneys, intestines, eyes, liver, skin, blood, bone, heart. Several of the occurrences are literal when describing sacrifice: what to do with the kidneys or liver when offering sacrifices to God. Several are metaphorical, though different to the metaphors we use in English. Thus translators may use English metaphors, though some have become English metaphors from the Hebrew via the English Bible.

"Kidney" (kilyah) may represent emotion. Consider Jeremiah 17:10a

“I the LORD search the heart (leb)
and test the mind (kilyah), (ESV)

I, the Lord, probe into people’s minds (leb).
I examine people’s hearts (kilyah). (NET)

"Kidney" appears on the second line, translated "mind" in the ESV and "heart" in the NET. "Heart" (leb, lebab) in the Hebrew apears in the first line. The ESV retains heart whereas in the NET it is translated as "mind". The NET's translation of "heart" as "mind" is not without justification as "heart" often carries the connotation of "will" in Hebrew, whereas it tends to reflect "emotion" in English.

me`ah means intestines or other internal organs such as stomach or uterus (also beten). Literally Psalm 22:14 reads:

I am poured out like water,
and all my bones are separated;
my heart is like wax;
it is melted within my intestines (insides);

The relevance of this to our discussion relates to the word "blood". Blood represents life in Hebrew. The question is whether this is primarily metaphorical, or symbolic, or whether blood is perceived as the source of life. "Blood" (dam) occurs over 300 times in the Old Testament. It is clearly used at times when "life" (nephesh) is meant. As such it has a figurative use. Though I am inclined to think that this is because the association with life is meant to be a literal one. After the Flood God instructs Noah concerning food and death:

But you shall not eat flesh with its life (nephesh), that is, its blood (dam). And for your lifeblood (dam nephesh) I will require a reckoning: from every beast I will require it and from man. From his fellow man I will require a reckoning for the life (nephesh) of man.

“Whoever sheds the blood (dam) of man,
by man shall his blood (dam) be shed,
for God made man in his own image. (Genesis 9:4-6)

God tells Noah that meat has to be drained of blood because the blood is life. In verse 4 blood is identified with life in a definitional manner:

• Life is blood.

"Life" and "blood" are also juxtaposed in verse 5 which is translated by the English word "lifeblood", or alternatively "blood of your life".

Another consideration in understanding death is the word breath. Breath (neshama) and breathe (naphach) are used in the creation account.

then the LORD God formed the man of dust from the ground and breathed (naphach) into his nostrils the breath (neshama) of life (chay), and the man became a living (chay) creature (nephesh). (Genesis 2:7)

Though there is a connection between breath and life here, it does not seem to be as strong. The breath (spirit) of God is required and it is the breath of life, ie the breath that causes life, but it is not definitional. The breath itself is not identified as the life itself (even though it is the source or cause). An argument can be made for an association between breath and life, though I think it less convincing than blood.

The association of blood with life in Scripture provides us with material to deduce a biblical definition of death. If we accept that blood represents life, or is life, then the complete loss of blood or the cessation of blood flow is a coherent biblical definition of death. How does this correspond to current medical views? We know that cessation of blood flow is due the heart ceasing its function as a pump. Therefore a medical definition of cardiac death as asystole is equivalent the biblical definition of death. The Bible would also allow the loss of significant blood from bleeding, pulseless electrical activity, and ventricular fibrillation as definitions of death, though without medical intervention these situations very rapidly become asystole.

Biblically, death is the loss of blood flow, that is the non-perfusion of (all) organs with blood, this is usually due to the cessation of cardiac function.

If we were to argue that breath also relates to life, a secondary biblical definition of death is cessation of breathing, which incidentally leads quickly to cessation of blood flow, our primary definition.

Brain death is not primarily a biblical definition of death of itself, other than that it involves lack of ability to breath spontaneously.

This leads to some interesting conclusions. It should influence how we think about sentience and life. It may have implications concerning euthanasia, abortion, organ donation, mechanical ventilation and other supportive therapies.

Is salt good for your health?

I have long been suspicious of the claim that salt is bad for human health. I suspect that the more salt you eat, the more thirsty you become and the more water you drink. The kidneys handle this all very well.

The debate has been going on a few decades. Some studies suggest that blood pressure is lower with lower intakes, others find no difference, and a few indicate low salt is bad for your health.

This week JAMA published one of the latter. The way it is written makes me wonder if the authors are apologising for the result. The study shows more deaths from heart attacks and strokes in those who consume less salt. They also claim that increasing salt over time increases blood pressure, but by a tiny amount. More about this below.

Kaplan-Meier Survival. From JAMA.

Reuters have reported on this finding, as has the New York Times. The salt police have reacted negatively to this article. It is clearly full of holes. Salt is evil and nothing should stop our crusade to ban this dangerous chemical.

The Times article talks to Peter Briss from the Centers for Disease Control who is convinced that salt is bad for your health and to Michael Alderman who is not. Briss complains that

that the study was small; that its subjects were relatively young, with an average age of 40 at the start; and that with few cardiovascular events, it was hard to draw conclusions.

Which would be true if the event rate were statistically insignificant. But as the study did find a difference this complaint is void. You can't argue that type 2 errors (false negative) are possible after a statistically significant result is found. The concern then is, have you made a type 1 error?

And the study, Dr. Briss and others say, flies in the face of a body of evidence indicating that higher sodium consumption can increase the risk of cardiovascular disease. 

Except that the evidence is conflicting. There is much data that points to salt not being a health concern.

But among the study’s other problems, Dr. Briss said, its subjects who seemed to consume the smallest amount of sodium also provided less urine than those consuming more, an indication that they might not have collected all of their urine in an 24-hour period.

Well they did exclude implausible urine volumes. But this comment doesn't make sense. People who eat less salt are likely to produce less urine on average. The high salt consumers raise the salt levels in their blood slightly which drives thirst. Increased fluid intake will associated with increased urine output. People can drink more than thirst dictates. But the average urine volume will likely be higher in the group who eat more salt. Finding the same urine volumes across the groups would be the real concern.

Lowering salt consumption, Dr. Alderman said, has consequences beyond blood pressure. It also, for example, increases insulin resistance, which can increase the risk of heart disease.

“Diet is a complicated business,” he said. “There are going to be unintended consequences.”

One problem with the salt debates, Dr. Alderman said, is that all the studies are inadequate. Either they are short-term intervention studies in which people are given huge amounts of salt and then deprived of salt to see effects on blood pressure or they are studies, like this one, that observe populations and ask if those who happen to consume less salt are healthier.

Exactly. Even if it does affect blood pressure, which is not certain, blood pressure is a proxy for other outcomes, mainly heart attacks and strokes. Blood pressure is clearly implicated in these diseases, but if less salt increases your blood pressure slightly and at the same time causes other changes that are detrimental for your heart then, on balance, it might be a bad thing.

We may not even be able to easily decrease our salt intake. Some research suggests that we closely monitor our salt intake thru specialised cells in the brain. If we are exposed to more salt we decrease our intake, and if we lack salt we actively seek it, such that the amount consumed over time remains a constant 4 grams per day.

Dr. Briss adds that it would not be prudent to defer public health actions while researchers wait for results of a clinical trial that might not even be feasible. 

So we should make recommendations and alter society in case salt turns out to be unhealthy when all the data is in, even though there is a possibility that such action may turn out to be hazardous?

Dr. Alderman disagrees.

“The low-salt advocates suggest that all 300 million Americans be subjected to a low-salt diet. But if they can’t get people on a low-salt diet for a clinical trial, what are they talking about?”

He added: “It will cost money, but that’s why we do science. It will also cost money to change the composition of food.” 

Much more sensible. Do nothing in public policy currently. Continue to do a variety of studies and gain an understanding of how salt works. Even then, such answers are physiological, they do not tell us public policy, they can at most inform us.

I am off to have some chips, for the good of my heart of course.

Conduct disorder leads to road trauma

From the files of the completely bleeding obvious we are informed that boys behaving badly are more likely to be involved in motor vehicle accidents, 37% more likely according to an Ontario study

Teenage male drivers contribute to a large number of serious road crashes despite low rates of driving and excellent physical health. We examined the amount of road trauma involving teenage male youth that might be explained by prior disruptive behavior disorders (attention deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder).

We conducted a population-based case-control study of consecutive male youth between age 16 and 19 years hospitalized for road trauma (cases) or appendicitis (controls) in Ontario, Canada over 7 years (April 1, 2002 through March 31, 2009). Using universal health care databases, we identified prior psychiatric diagnoses for each individual during the decade before admission. Overall, a total of 3,421 patients were admitted for road trauma (cases) and 3,812 for appendicitis (controls). A history of disruptive behavior disorders was significantly more frequent among trauma patients than controls (767 of 3,421 versus 664 of 3,812), equal to a one-third increase in the relative risk of road trauma (odds ratio = 1.37, 95% confidence interval 1.22–1.54, p<0.001).

I am amused when I read terms like oppositional defiant disorder and that it is considered a psychiatric diagnosis.

Apparently naughty girls are not exempt

We... replicated our methods in girls rather than boys,... the results yielded... about the same estimated risk (odds ratio 1.31).

The editors add

The results of this study suggest that disruptive behavior disorders explain a significant amount of road traffic crashes experienced in male teenagers. Overall, attention deficit hyperactivity disorder, conduct disorder, and oppositional defiant disorder are associated with about a one-third increase in the risk of a road traffic crash.

Who would have thought?

Does brain dysfunction cause spiritual experiences?

Barbara Hagerty investigates the conjecture that spiritual experiences originate from within the brain. She interviews someone who claims to induce spiritual experiences thru magnetic fields.

The helmet is supposed to stimulate my right temporal lobe with weak magnetic fields, and create the illusion of God in my head. Well, not God exactly, but a sensed presence, a feeling that another being is in the room.

There are several problems with religion-is-a-by-product-of-brain-disorders perspective. Not the least that Christianity is based on historical fact. The philosophical arguments for God and the evidence for the resurrection of Jesus are proof of the veracity of Christianity. But here I wish to address an error in the brain causation theory.

Interference with the brain may cause thoughts and hallucinations, through magnetic fields or direct electrical stimulation during brain surgery. This fact has absolutely no bearing on the reality of what we think and sense. This should be patently obvious and is alluded to in the article.

Does the fact that we can track spiritual feelings in our temporal lobe mean that there's nothing spiritual going on? ...Think about a man and woman who are in love,

True enough. But forget love as an analogy. Love is abstract. Choose something more concrete. (I am not saying love is not real, but its abstract quality allows people to argue that the feeling of love is real even if love itself does not exist).

Consider a tree blooming, or a dog barking, or a water slide. If we can manipulate parts of the brain so a man visually hallucinates a blossom, or hears a dog, or feels the sensation of wetness and speed; does this mean that flowers and rottweilers and theme parks do not in fact exist? Eyes, and ears, and pressure sensors in the skin produce a combination of  impulses which are transmitted along nerves and modified until they reach the cortex of the brain where we become conscious of them. So, we can bypass the sensing event but stimulate the cortex to mimic random events. How is this remotely relevant to the existence of things we otherwise perceive?

Counterfeit neither disproves the original exists, nor explains the source of the original. It shows we know how to make a copy.

Optimising a health system

It could be argued that the state has no place involving itself in healthcare. And I have sympathy with that view. Government should focus first on its primary responsibilities such as justice and national defence. But many governments are involved in healthcare; and the promise to deliver health will attract votes in a democracy. So here are my thoughts of how I think government involvement could be useful and deliver good, cost contained (for the government) healthcare. This is based on my ideas in the previous post.

1. I think that people should be responsible for their own health care including funding.
2. I think the proportion of people needing reasonable funding at some stage in their life means the concept of sharing risk via insurance for most illness is meaningless.
3. I think if people do not take care of their health, they will likely still get care and others will advocate for them; but there will be costs that someone has to cover.

The second point means that individuals each need to save roughly the average amount of money spent per person in their lifetime. If most people use a moderate amount of money in health and that is say $200,000 on average, then every person should be encouraged to save, say, $400,000 over their lifetime, much of which will be used in their later years.

The third point is important because the situation occurring as the result of people making bad decisions will be used to argue for socialised government in the name of caring.

I think the Singaporean system, or a model based on it, is worth considering.

Here is some reading on the Singaporean system as it is.

• International Health Systems: Singapore
• The Singapore Model
• The Singapore health system—achieving positive health outcomes with low expenditure

My proposal is essentially: government enforced compulsory health saving. Because under this proposed system the government will remove itself from the funding, there will be a decreased requirement for tax monies; and the savings will be cost neutral for the individual. The basic rules would be:

1. All workers are to pay 5% of their income into an individual, managed, low-risk health account.
2. There is a tax cut of the same amount so individuals have the same take home pay.
3. Employers are not required to give any money toward their employees account, nor can unions force this issue. This prevents people being locked into jobs because of the health benefits.
4. The money is yours, it cannot be taken by the government, it can be passed on in a will at death to other healthcare accounts, hospitals or medical research; or possibly as cash to the beneficiaries of the will.
5. Compulsory insurance is paid from the account to cover rare, unexpected, high-cost events (eg. kidney failure requiring life long dialysis).
6. You can use your account to pay healthcare costs. The potential healthcare and the costs are determined by government; that is, both what you can get medically and the maximum amount you can pay. It would include doctor, nurse, hospital visits, etc. It would include prescription and immunisation costs. It would cover dental care.
7. You can only cover your own and your dependants healthcare costs.
   
8. You can purchase a higher level of care, or medical services outside normal practice, but this is unable to come from your healthcare account.
9. All provision is by private providers who can charge what they will, though adequate competition should keep costs down.

This solution intends to do several things. It means that people pay for their own medical care which, while being somewhat unpredictable, is able to be planned for. It intends to minimise government actually paying for individual health. It prevents people making poor decisions from becoming an unsustainable financial burden. It doesn't add to the burden of employers who do not have a responsibility to the personal health of their workers other than the provision of a safe work environment. Of course employers are free to offer benefits as they wish as part of valuing employees, but there is no financial incentive to do so, nor the need to increasingly complicate tax law. It limits other family members from pressuring individuals to pay for their care. It still allows people to purchase any extra healthcare they wish as money allows (unlike the Canadian system).

There are problems. It does not deal to those who are not employed. It does not deal well with congenital conditions. It does not cover visitors to the country such as tourists. And it does not offer a solution as to how a different system can be transitioned to this. But with medical costs increasing rapidly because of new and better diagnostic and treatment modalities, it is impossible for governments to sustain future expenditures. And when individuals see how much an intervention really does cost, then they may consider whether the benefit is worth it.

Afghans are not going to get swine 'flu

Apparently Afghanistan does not have many pigs. 1 in fact. In a zoo. And it has been locked away,

Afghanistan's only known pig has been locked in a room, away from visitors to Kabul zoo where it normally grazes beside deer and goats, because people are worried it could infect them with the virus popularly known as swine flu.

I checked the date but it wasn't April 1.

Is there any real risk?

There are no pig farms in Afghanistan and no direct civilian flights between Kabul and Mexico.

"We understand that, but most people don't have enough knowledge. When they see the pig in the cage they get worried and think that they could get ill," Saqib said.

Frankly the whole article is hilarious.

Conflict of interest

The Institute of Medicine has released a report on conflict of interest in medical practice.

Collaborations between physicians or medical researchers and pharmaceutical, medical device, and biotechnology companies can benefit society—most notably by promoting the discovery and development of new medications and medical devices that improve individual and public health. However, relationships between medicine and industry may create conflicts of interest, potentially resulting in undue influence on professional judgments.

...The committee’s report stresses the importance of preventing bias and mistrust rather than trying to remedy damage after it is discovered. It focuses specifically on financial conflicts of interest involving pharmaceutical, medical device, and biotechnology companies.

The committee recommends the implementation of policies and procedures that will reduce the risk of conflicts that can jeopardize the integrity of sci­entific investigations, the objectivity of medical education, the quality of patient care, and the public’s trust in medicine.

The New York Times notes the report has stated that doctors, medical schools and hospitals should not accept gifts from pharmaceutical companies.

doctors should stop taking much of the money, gifts and free drug samples they routinely accept from drug and device companies.

And the suggestion is to remove funding from education courses as well

Drug companies spend billions of dollars wooing doctors — more than they spend on research or consumer advertising. Much of this money is spent on giving doctors free drug samples, free food, free medical refresher courses and payments for marketing lectures. The institute’s report recommends that nearly all of these efforts end.

3 brief questions.

• If medicine was fully privatised would this be as great a concern?
• While money can be a strong conflict of interest, so is ideology. Do people note competing interests based on philosophical, theological, or political beliefs? Is this a bad thing?
• Should this be extended to democracy? Should any person receiving financial favours from the government (excluding legitimate work done at governments behest) forfeit their vote? Welfare recipients, subsidised farmers, corporations that have specific laws written for them.

Medicine and morality

The New England Journal of Medicine recently published a paper titled Religion, Conscience, and Controversial Clinical Practices. It was the results of a survey asking physicians about their views on providing treatments that they object to on moral grounds. In their introduction they state:

On the one hand, most people believe that health professionals should not have to engage in medical practices about which they have moral qualms. On the other hand, most people also believe that patients should have access to legal treatments, even in situations in which their physicians are troubled about the moral implications of those treatments. Such situations raise a number of questions about the balance of rights and obligations within the doctor–patient relationship. Is it ethical for physicians to describe their objections to patients? Should physicians have the right to refuse to discuss, provide, or refer patients for medical interventions to which they have moral objections?

The medical profession appears to be divided on this issue. Historically, doctors and nurses have not been required to participate in abortions or assist patients in suicide, even where those interventions are legally sanctioned. In recent years, several states have passed laws that shield physicians and other health care providers from adverse consequences for refusing to participate in medical services that would violate their consciences. For example, the Illinois Health Care Right of Conscience Act protects a health care provider from all liability or discrimination that might result as a consequence of "his or her refusal to perform, assist, counsel, suggest, recommend, refer or participate in any way in any particular form of health care service which is contrary to the conscience of such physician or health care personnel." In the wake of recent controversies over emergency contraception, editorials in leading clinical journals have criticized these "conscience clauses" and challenged the idea that physicians may deny legally and medically permitted medical interventions, particularly if their objections are personal and religious. Charo, for example, suggests that the conflict about conscience clauses "represents the latest struggle with regard to religion in America," and she criticizes those medical professionals who would claim "an unfettered right to personal autonomy while holding monopolistic control over a public good." Savulescu takes a stronger stance, arguing that "a doctor's conscience has little place in the delivery of modern medical care" and that "if people are not prepared to offer legally permitted, efficient, and beneficial care to a patient because it conflicts with their values, they should not be doctors.

Savulescu's article that is referenced concludes:

Values are important parts of our lives. But values and conscience have different roles in public and private life. They should influence discussion on what kind of health system to deliver. But they should not influence the care an individual doctor offers to his or her patient. The door to "value-driven medicine" is a door to a Pandora's box of idiosyncratic, bigoted, discriminatory medicine. Public servants must act in the public interest, not their own.

The New England Journal of Medicine article, while weighing in on this problem, is actually a survey of 1144 physicians and analysis of only a few of the comments. The survey, while comprehensive, is slightly simplistic in how it approaches ethical questions. They find that

• 63% of physicians believe that it is ethically permissible for doctors to explain their moral objections to patients
• 86% believe that physicians are obligated to present all options
• 71% believe physicians are to refer the patient to another clinician who does not object to the requested procedure

They also found that those that did not think they needed to disclose information about alternative procedures or needed to refer patients for medical procedures to which they objected on moral grounds were more likely to be men, those who were religious, and those who had personal objections to morally controversial clinical practices.

In their conclusion they make the astute observation:

Thus, those physicians who are most likely to be asked to act against their consciences are the ones who are most likely to say that physicians should not have to do so.

And this is the point isn't it. It is pointless to ask persons about objecting to behaviour they do not find morally repugnant. Issues discussed included contraception, abortion, assisted reproduction, euthanasia. It is not uncommon for persons to find these behaviours acceptable. It is all very fine for those that accept these activities to condemn those who don't for being unwilling to do them or even being unwilling to refer patients elsewhere. But many people find it difficult to understand others point of views. What they need to do is ask physicians about other objectionable practices; practices that pro-abortionists may not find acceptable. 2 examples would be administering a lethal injection to a criminal or handing over homosexual offenders (in a Muslim country say) to the authorities for imprisonment or execution.

The predictable response to this suggestion will be that these actions are immoral and therefore the issue is irrelevant. It however is very relevant and perfectly illustrates the point. They claim it is immoral to think abortion is wrong, it is immoral to tell a patient your anti-abortion views, it is immoral not to perform the procedure (especially if you base your opinion on "religious" reasons), if you refuse to perform the procedure it is immoral not to refer the patient. But place them in the same position with regard to something they morally object to and they will say they are not bound to behave in this way because it is wrong. But what is "wrong" in this sentence but a moral judgment?

Trevor G Stammers in the rapid responses to Savulescu's article says:

...if values have no place in determining medical care, on what basis does Savulescu attempt to impose his own moral values on conscientious objectors? The paternalism he so despises is only matched by Savulescu’s own and his ideal of “statute-driven medicine” seems to me more ‘idiosyncratic, bigoted and discriminatory’ than the moral values he is so intolerant of.

The objectors claim moral neutrality but they are far from it. If placed in a situation they find morally obscene they would think similarly, how could one not. To ask someone to restrict moral behaviour to his private life results in cognitive dissonance. To ask someone to behave contrary to his morals is morally repugnant. And to act according to one's morals is far more moral than to act against them.