Printers Aren't Just For Homework Anymore: The Science and Ethics of Bioprinting - by Christian Brugger

In Culture of Life Foundation

What do you get when you combine the technology of inkjet printers, digital modeling, and 3-D manufacturing?  Right.  3-D printers. 

Okay, that was easy.  Now add living tissues to the mix. 

Very funny.  But no… not an Obama bobble head with human hair.

The real answer?  Three-dimensional cellular construction, also known as 3-D bioprinting.

Standard 3-D printers have been around since the 1980s.  Guided by a three-dimensional computer image, the printer-head lays down successive layers of a material such as plastic in the form of an image, say, the Eifel Tower.  The outcome is a precisely-fashioned plastic model of the thing imaged. 

In the last ten years, the technology has become quite common in fields such as dental, automotive and aerospace engineering, architecture, as well as in the design of footwear, jewelry, eyewear, etc.

Printing Human Tissues

Scientists in the field of regenerative medicine conceived the idea of using 3-D printing technology to produce—to print—human tissues and organs.  Rather than layers of plastic, bioprinters set down layer upon layer of biomaterials such as living cells, which are built up into three-dimensional structures.  The technology is at various stages of development, most still at the research phase.

What’s “the ink”?  Most techniques use induced Pluripotent Stem (iPS) cells, the revolutionary technology that we’ve covered in these pages several times over the last few years.  The iPS cells are usually derived from healthy tissue samples taken from would-be transplant recipients.

One example of the new technique is skin printing, which researchers hope will improve graft treatments for burn victims.  It involves printing sheets of iPS cells derived from healthy skin samples from burn victims.  The cells grow and differentiate into the different layers of skin and then can be transplanted.  In some cases, the skin cells are printed directly onto a victim’s wound.

At Cornell University, experimental heart valves and knee cartilage have been printed; at Wake Forest, functional kidney cells; and at the University of Missouri-Columbia, sheets of beating heart muscle.

Bio-scaffolding

Even more innovative is the technique of bio-scaffolding to create larger organs, for example, new bones for bone replacement surgery.  A digital image of a segment of bone is developed from a bone injury patient.  From that image, a three-dimensional bone scaffold identical to the segment is “printed out” using artificial materials.  The scaffold is then coated with stem cells derived from the patient’s own body.  The printed bone structure is then transferred into the patient, where, over time, the artificial scaffold harmlessly degrades, leaving behind new bone grown from the patient’s own stem cells.

Scaffolding technology has already been used to create replacement tracheas, blood vessels and bladders for use in surgical transplants (watch this interesting video). Researchers at the University of Louisville predict that within ten years, bioprinting will be used to create fully-functioning “bioficial” human hearts.

Ethical Considerations

What ethical questions are raised by the new technology?  The first concerns the sources of stem cells used in a given technique.  Although most bioprinting protocols use iPS cells, not all do.  Some use adult stem cells, which are morally legitimate.  But others use stem cells derived from destroying human embryos.  This is the case, for example, with research at Heriot-Watt University in Edinburgh, Scotland, where researchers have developed a bioprinter that uses human embryonic stem cells as its “ink.” 

Safety concerns are also important to consider.  The urgent need for transplantable organs mustn’t move us to cut corners in clinical safety trials with this new generation of “bioficial” products.

We also have reasons to be concerned about researchers stretching towards unethical boundaries; for example, if they were to begin coveting the forbidden fruit of producing whole brains for purposes of transplanting them into humans. 

I do not mean to stigmatize research into the repair and regeneration of damaged neurological tissue.  I have family members with Alzheimer’s disease and would welcome (they would welcome!) therapeutic treatment options for overcoming the crippling condition. 

But whole brain transplants?  Even if they were ever possible utilizing brain matter derived from one’s own stem cells, which is doubtful, they would so impact a person’s personality and conscious identity (loss of memory, character, psychological development, brain-body history) that in all but the most narrow of circumstances I don’t see how they could be ethically licit.  (Perhaps in fetuses with severe traumatic brain injury; but only perhaps.)

Not all agree.  Just last week, the Promethian juices of scientists were stimulated when the journal Nature announced that “mini-brains” had been produced in vitro for the first time. 

Austrian researchers grew stem cells upon a gel that resembled some of the brain’s natural connective tissues.  The cells developed into neural tissue clumps that when infused with nutrients and oxygen began to interact in ways characteristic of fetal brains in the early weeks of human development. 

One enthusiastic scientist interviewed for the article (and not involved in the study) proclaimed: “It’s a seminal study to making a brain in a dish!”  But, he continued, a “fully formed artificial brain might still be years away.”  Phew!  I guess we don’t need to worry.

Defend Our Ethical Boundaries

This new technology, especially the scaffolding method, puts us in reach within a decade of the elusive goal of achieving a surplus of transplantable organs for those who need them.  And it seems that the goal can be achieved through morally licit forms of research. 

This is unbelievable.

Ten years ago scientists were arguing that this was only possible if we “relaxed” our morality: “give us embryos,” they cried, “otherwise people will die;” or if not embryos, then at least suspend the “dead-donor rule” for vital organ donation. 

The amoralists were proven wrong; iPS cell research and adult stem cell research now dominate the field of regenerative medicine.

But the amoralists haven’t gone away.  Even in the face of the staggering failure of embryonic stem cell research, they’re still clamoring for human embryos, though not as loudly.  And more and more are advocating for the abandonment of the dead-donor rule in transplant medicine.

We mustn’t lose hope that reason will prevail over lust in the field of regenerative medicine.  Where scientific genius is guided by good morals, remarkably good things can happen.  Shinya Yamanaka’s breakthrough with iPS cells in 2007 is merely the most recent example.

 

Yamanaka and iPSCs: A reply to some skeptical friends in the pro-life community - by Christian Brugger

In Culture of Life Foundation

In 2006/7 Japanese cell biologist Shinya Yamanaka published important research showing that specialized adult cells such as skin cells could be “reprogrammed” to become pluripotent stem cells.  Yamanaka called the reprogrammed cells “induced pluripotent stem cells” (or iPSCs) and the type of research “cell reprogramming”.

He neither created nor experimented upon human embryos in his research.  But to make reagents for reprogramming the somatic cells, he apparently did use cells from a cultured cell line created in 1977 and originally derived from the tissue of a child who was aborted earlier in the 1970s (called “HEK cells,” Human Embryonic Kidney cells).  If I understand the process correctly, the genes used to reprogram the somatic cells were delivered into the cells using viruses (called lentiviral vectors).  These viral delivery systems were created using HEK cells.

Pro-life groups such as Children of God (COG) for Life have drawn attention to this little known fact and in doing so have provided the pro-life community an important service.  

Unfortunately, some of these groups are claiming that because Yamanaka used ‘tainted’ cells in his research, the production of iPSCs by cell reprogramming is intrinsically evil. 

They are incorrect.  The production of iPSCs does not require the use of HEK cells, and can be—and is being—done successfully without them.  If the research is carried out without using ‘tainted’ cells, then the procedure itself need pose no moral problems.  

They also argue that because Yamanaka used tainted cells, his research, for which he received the 2012 Nobel Prize, deserves a blanket condemnation.  For two reasons, I disagree.  

First, a blanket condemnation fails to make distinctions between what is praiseworthy and what might deserve criticism.  With respect to the latter, if Yamanaka knew the immoral origin of the HEK cells, had reasonable alternatives available to him, and yet still used the tainted cells, then (to that extent) I think he did wrong.  

His wrongdoing certainly would not be the wrong of killing; nor would it be wrongful cooperation in killing, since using cells from the cultured line 30 years later did not facilitate the original evildoing in any way.  Moreover, using HEK cells in research is unlikely to cause scandal in the formal sense (i.e., be a cause of leading others into grave sin), since HEK is so widely used in the scientific community that it barely raises an eyebrow.  

Its wrongness would lie in the failure of the duty we all share to testify to the value of human life, in this case by refusing to use products created by exploiting life: a failure of duty to bear witness to the truth.  To constitute a moral failure, however, Yamanaka would have had to know the origins of the cells, have reasonable alternatives available, and not select them.  I don’t know if these conditions prevailed.

Because of Jesus’ perspicuous self-sacrificing witness to truth, Christians, called to be Christ in the world, have an especially strong duty to bear witness.  I don’t know if Yamanaka is a Christian.  If he is, then he shares that stronger duty.  If not, he still has a duty to the truth.  But we know that even Christians, including Christian leaders, sometimes fail to bear rightful witness.  Blanket condemnations of their lives or apostolates would be simplistic and could be wrongful.  Why?  Because one’s life is a complex matrix of actions, some of which may, and others of which may not, bear perspicuous witness.

If in one respect his research fails to measure up to ethical standards, in another, the Japanese researcher has been an extraordinary witness to the truth of the sanctity of human life.  As one of the leading adult stem cell researchers in the world, he dedicated years of his life to finding a way of deriving pluripotent stem cells without killing embryos.  His research has transformed a field, which once was almost monolithically committed to embryo destructive research.  At a time when Obama was about occupy the Oval Office and running on a platform of overturning the Bush stem cell policy, just twelve months earlier (Nov. 2007) Yamanaka published this almost incredible news: “a new way to make pluripotent—embryonic like—stem cells without exploiting embryos.”  I don’t think there’s any doubt that because of his accomplishments, many, many less embryonic people are being killed today in research than otherwise would be.  And this was precisely part of Yamanaka’s motives, to stop embryo destructive research.  Whatever in his research deserves criticism, this deserves praise.  

Second, modern secular science is a morally mixed bag.  The wheat and weeds are mixed together in a giant field we call the scientific endeavor.  One of the points of genius of the empirical method is its limitless and unfolding capacity for generating new and deeper knowledge by building on the systematic accomplishments of earlier research.  If earlier research, however, entails immoral activity, the products and knowledge gained by it will in some way be tainted by the immorality.  

In the field of stem cell research, including morally licit adult stem cell research, no one can claim that the knowledge they rely upon or the products they use are “pure” and unrelated to prior research that has been illicitly obtained.

So how should we assess scientific accomplishments, such as those of Yamanaka, that include morally questionable elements?  We condemn gross immorality when we find it; and so we condemn the original killing of the baby in the 1970s, which Yamanaka had nothing to do with.  We criticize the scientific exploitation of the baby’s mortal remains.  We deplore the indifference of some scientists to the original killing.  And we admonish researchers in the present to bear witness to the truth by refusing to use products derived from the baby’s tissues.  

If they use them out of non-culpable ignorance, then they do no more wrong than did children who innocently drank Pepsi products that utilized flavor chemicals developed in research using HEK cells.  

If they use them with full knowledge, but don’t have reasonable alternatives, then we assess two things: 1) whether the use is likely to cause scandal, and 2) if the research is serious enough to warrant tolerating (but not intending) other harms that might arise from the use (e.g., legitimizing in people’s minds the original illicit act).  If there is proportionately grave reason and if using the products is unlikely to cause scandal, then we may conclude the researchers are justified in using them.  

If reasonable alternatives are readily available, and informed researchers don’t use them, then we are warranted in concluding that they fail in their duty to witness to the truth by refusing to use the alternatives. 

But we also praise the good they do, in Yamanaka’s case, in effectively—and by intent— dealing a lethal blow to one of the most immoral forms of scientific research in modern history.

Carrying Out End-of-Life Refusal Orders in a 'Culture of Refusal' - by by E. Christian Brugger, D.Phil., Senior Fellow and Director, Fellows Program

In Culture of Life Foundation 

2 Criteria to Determine Licitness of Rejecting Life Sustaining Treatment

WASHINGTON, D.C., JULY 4, 2012 (Zenit.org ).- Here is a response to a question on bioethics, answered by the fellows of the Culture of Life Foundation.

Q: I am a nurse in a surgical intensive care unit. It is not uncommon for family members to announce that their incapacitated loved one would not want all of the invasive equipment such as ventilators, feeding tubes, vasopressive medications, etc.  We are not infrequently directed to remove tubes and medications and to start a morphine infusion and to titrate it upward to make the patient comfortable.  Is it licit for me to carry out these orders?  

E. Christian Brugger responds:

The answer to this question depends on at least two things: first, whether or not the directive is expressive of the wishes (i.e, the will) of the patient; and second, whether the directive is morally legitimate. Permit me to consider both.

 

The decision whether or not to accept or continue some treatment is first and foremost the patient's. The wishes of family members can play an important role in assisting patients to make good decisions. But these wishes are secondary. This is consistent with the "principle of autonomy." Autonomy is simply a technical term (derived from the Greek words for "self," autos, and "law," nomos) for the truth that God entrusts to each person the moral responsibility for self-direction. Autonomy designates both the right and the duty of each person to seek out and find the truth and when it's found to adhere to it. The medical ethical principle of "free and informed consent" derives from autonomy.

If a patient has an Advance Directive (AD), health care workers should appeal to it for information about patient wishes. Unless there is good reason to believe that the information on the AD is false or fraudulent (i.e., not expressive of the rightful will of the patient), or directs some kind of immoral behavior (e.g., suicide), medical personnel can carry out the directives in good faith, including orders for the removal of life-sustaining treatments (cf. USCCB, Ethical and Religious Directives for Catholic Health Care Services (ERD), 5th ed., no. 59).

If the patient has designated a proxy decision-maker through the execution of a Health Care Power of Attorney (HCPoA), then the proxy is legally authorized to act as the patient's health care agent to make any necessary care decisions on the patient's behalf. The proxy has a grave moral responsibility to make decisions according to the will of the patient, and if the patient's will is unknown, to make decisions that are in the best interests of the patient.

If the patient has neither an AD nor a HCPoA, next of kin are often consulted in order to clarify the mind of the patient for end-of-life care. Because family members sometimes have mixed interests in these end-of-life decisions, health care workers should always perform due diligence to ensure that the oral directives of family members are consistent with the wishes of the patient. If, for example, an elderly widow or widower has three children, the doctor or nurse if possible should consult with all three before any consequential decisions are executed. Because of the irreversible character of decisions to remove life-sustaining treatments, an even greater measure of due diligence is required before executing them than before executing decisions to continue treatments that are medically indicated to preserve life.

If a health care worker has doubts as to whether some serious directive stems from the legitimate will of a patient, he or she should resolve the doubts before proceeding with any activity, especially activity that will result in the patient's death.

"Culture of removal"

I said above that rightfully executing medical directives also depends on whether the order is morally legitimate. Several factors bear upon the question of legitimacy. I will speak about one in particular.

The last 25 years in end-of-life care in the US has witnessed the rise of an increasingly rigid "refusal mentality" toward the use of life-sustaining procedures, especially for the elderly. It characterizes not only the culture of health care institutions and elder-care facilities, but also of elderly persons themselves and their families. "I don't want to be a burden." "Being hooked up to tubes is dehumanizing." "I would never want to live like that!", (meaning on life-support). "I'd rather die than sacrifice my independence." In our attempt to prize independence and high-functioning, we are unwittingly becoming a culture that's intolerant of that stage of radical dependency that inevitably accompanies old age.

Catholic teaching holds that a life-sustaining treatment is rightly refused -- and only rightly refused -- if it's futile (i.e., it does not promise a reasonable hope of benefit) or it's excessively burdensome (cf. ERD 57). Otherwise, it should be accepted. Why? For the simple reason that life is always good, even when incapacitated. Because of its intrinsic goodness, the effort to preserve it ordinarily holds a presumption over letting die. This is simply another way of saying that sustaining life, though not always required, is never pointless. The proposition that asserts: "this or that life is not worth living" is literally never true. No human life, no matter how diminished in its capacities, is without intrinsic worth. So strictly speaking, every life at every stage under every condition is worth living.

But morality does not require us in every instance to do everything possible to sustain life. The presumption to act on behalf of its preservation (but never to act against it) can be overridden when very serious burdens promise to accompany its preservation. No one who knows Catholic teaching on end-of-life care in the last 60 years can rightly accuse the Church of imposing, advancing, or even implicitly holding an unreasonable "preservationist" mentality.

Whereas the pendulum in the 1950s-1970s may have tilted excessively in the direction of adopting life-preserving measures, no such excess exists today. The "duty to refuse" has become the mantra of the 21stcentury. And health care workers must do what they can to resist it.

Given the widespread refusal mentality today and the pressure it places especially on elderly persons, there is an increasing probability that refusal directives, whether given orally or codified onto forms such as Living Wills (or the dangerous new document known as the POLST form), will be wrongly decided. Patients who have a duty to accept antibiotic infusions, or intubation for assisted feeding or respiration, or CPR, or dialysis, precisely because those treatments would not be futile and do not pose an excessive burden, may be wrongly motivated to direct that they be removed or withheld.

Having said this, I do not think that health care workers are morally bound to scrutinize the motives of every patient who directs the refusal of life-sustaining treatments. This would unnecessarily burden the delivery of health care by imposing on physicians, nurses and physician assistants a task that at least in some instances could not be carried through to completion (an unconscious patient with a refusal order can no longer express his or her intentions).

But those who advise and assist patients in completing ADs have the duty to facilitate good moral decision making. Patients inclined to refuse life-support should only do so for upright reasons (e.g., when proposed treatments are disproportionate to the benefits promised). Likewise they should be encouraged (without coercion) not to act on disordered motives (e.g., because they feel their life has lost its value, because others want them to refuse, because they are afraid of being a burden on their caregivers, etc.). Advisers should, I believe, inform patients completing AD's of the work of the Patients Rights Council .

Finally, immoral orders should not be carried out. In some instances, assessing the wrongness of an order is straightforward, for example, the order to remove nutrition and hydration from a patient for whom they are necessary to sustain life (cf. ERD 58). But some refusal orders are more difficult to assess.

In principle, any order that directs the withholding or removal of life-sustaining procedures judged to be ordinary and proportionate is unethical and contrary to Catholic teaching (cf. ERDs 56-57). Making this judgment is not always so simple. And so, following ERD 59 , health care workers may presume that refusal orders are rightly decided unless there are good reasons for concluding otherwise. If there are good reasons, then health care workers should undertake due diligence in order to resolve their doubts before carrying out the order.

Round and Round She Goes: More on Abortion and Mental Health - by E. Christian Brugger, D.Phil.

In Culture of Life Foundation

In the September 2011 issue of the British Journal of Psychiatry, Priscilla K. Coleman, of Bowling Green State University in Ohio, published an influential statistical analysis of the existing research on the question of abortion and mental health (reported to be the “largest quantitative estimate of mental health risks associated with abortion available in the world literature”; see my Sept. 14 Zenit article ). Her study concludes that women who have induced abortions because of unwanted pregnancies suffer an incredible 81% increased risk of mental health problems across a variety of categories.

Now, a new and improved “world’s largest” study concludes precisely the opposite. On December 9, the London-based Royal College of Psychiatrists (RCP) published a report entitled “Induced Abortion and Mental Health: A Systematic Review of the Mental Health Outcomes of Induced Abortion, Including their Prevalence and Associated Factors.” The 248 page review, purporting to be the “the world’s largest, most comprehensive and systematic review into the mental health outcomes of induced abortion,” concludes that procuring an abortion for an unwanted baby poses no more danger to a woman’s mental health than bringing an unwanted child to birth. The real danger to women’s mental health lies not in having an abortion, but in carrying an “unwanted pregnancy.”

How can two empirically based comprehensive reviews of the literature on the same subject render such contradictory conclusions?

Earlier this week, Dr. Coleman released a short critique (copied below) of the RCP report, which she called “hauntingly similar” to other influential literature reviews on the subject, specifically a widely quoted report in 2008 by the American Psychological Association. She concludes that the RCP report was “not undertaken in a scientifically responsible manner” and sets forth several reasons why scientists and clinicians should reject its conclusions.

Perhaps the most significant reason is that the RCP study, she says, ignores “large segments” of the scientific literature on abortion and mental health. Coleman mentions 74 studies in particular: 19 literature reviews published between 1990-2011; 35 empirical studies examining the prevalence of post-abortion mental health problems and comparing the mental health of women who abort with those who carry unplanned pregnancies to term; and 20 more empirical studies “published in highly respected peer-reviewed journals” identifying risk factors for post-abortion mental health problems.

Three dozen of these studies, she notes, were excluded simply because they did not follow their subjects for more than 90 days. The RCP report says the studies were likely to be measuring merely “transient reactions to a stressful event” (namely, having an abortion) and not real mental health problems caused by the event. Coleman believes this exclusion criterion is superficial. Women who suffer reactions in the first 90 days may very well continue suffering long after the study in which they participate concludes. Moreover, to exclude their mental health complications as “transient reactions” is completely unwarranted. Their reactions may very well constitute “serious and more acute episodes” that are amenable to treatment soon after exposure. She notes that the RCP report itself even states: “ Women who show a negative emotional reaction immediately following an abortion are likely to have a poorer mental health outcome.” Coleman asks: “How can this ‘conclusion’ be derived if studies that only examined women in the first 3 months following abortion were eliminated? Moreover, if this is true, why would these studies have been eliminated in the first place? Shouldn’t the researchers be most concerned with those most likely to be adversely impacted?”

Dr. Coleman concludes her critique with the following strong words:

“This report constitutes no less than a crafty abuse of science and if the merits of this report are not seriously challenged, we will shamefully grow more distant from our ability to meet the needs of countless women. Until there is acknowledgement than scores of women suffer from their decision to undergo an abortion, we will remain in the dark ages relative to the development of treatment protocols, training of professionals, and our ability to compassionately assist women to achieve the understanding and closure they need to resume healthy lives.”

Her entire letter is copied (with permission) here .

Mississippi Personhood Amendment Should be Supported

by E. Christian Brugger, D.Phil., Senior Fellow and Director, Fellows Program

In Culture of Life Foundation

If Mississippi’s Initiative 26 (the “personhood initiative” or “PI”) passes next Tuesday, its state constitution will be amended to read : “Person defined. “The term ‘person’ or ‘persons’ shall include every human being from the moment of fertilization, cloning or the functional equivalent thereof.”

The New York Times has found this so threatening that it’s dedicated three pieces (1 , 2 , 3 ) in the last 8 days to persuading people against it. The Washington Post’s eager atheist Susan Jacoby tells us that the “pernicious” initiative is based on “religious extremism and ignorance of human anatomy and biology”. The LA Times quotes a Mississippi law professor—with entirely too much time on his hands—as saying that if the initiative passes, unsuspecting women who consume alcohol or engage in “a strenuous physical competition” may be exposed to criminal prosecution. Other nervous journalists tell us that the law would force doctors to let women die on their floors, prohibit the use of the morning after pill “in all instances”, outlaw IUDs, shut down IVF clinics, permit religious interference with the female reproductive system, and require the prosecution of women who miscarry. Pro-aborts haven’t gotten his worked up since Pennsylvania Governor Robert Casey urged the High Court in 1992 to overturn Roe v. Wade as having been wrongly decided.

The favorite talking point of pro-choicers is that, because the initiative is so extreme, it has even “split the anti-abortion movement .” There’s a modicum of truth to this. But the “split” has nothing to do with the intent of the initiative to secure legal protections for all human beings from fertilization. The split is over strategy. Although Mississippi’s largest Christian denomination, the Mississippi Baptist Convention backs the PI, as well as the American Family Association, the Family Research Council, and influential Republican pundits such as former Arkansas governor, Mike Huckabee, the initiative is not supported by two of the most influential pro-life voices in the U.S., the United States Conference of Catholic Bishops (USCCB) and National Right to Life (NRL).

Neither group is a newcomer to the concept of a personhood amendment. And both have long supported federal initiatives to amend the U.S. Constitution to define nascent human life as constitutionally protected persons. But over the past five years, Catholic bishops and the NRL have consistently discouraged similar state initiatives. In 2007 Georgia Right to Life introduced in the state legislature a Human Life Amendment (HR 536), which the Georgia Catholic Conference and National Right to Life refused to support.

They likewise refused to support two ballot initiatives in Colorado aimed at constitutionally defining preborn human beings as persons. Both measures failed miserably (in 2008, by an enormous percentage margin of 73-27, and in 2010, by a 70-30 margin). But when it comes to social issues, Mississippi and Colorado may as well be separate countries. (Remember, Colorado was the first state to legalize abortion in 1967 under limited circumstances.) Both supporters and opponents of Mississippi’s PI believe that the proposal is likely to pass.

The opposition of U.S. bishops stems almost exclusively from the judgment that if states such as Colorado or Mississippi approve a personhood amendment, the success will be a Pyrrhic victory (winning a battle at the state level at the cost of losing the war at the federal). The U.S. Constitution guarantees access to abortion via the so-called right to privacy. If preborn human beings are guaranteed constitutional protection in Mississippi, most abortions there will be prohibited, setting up a challenge between the state and federal constitutions. The amendment immediately will be challenged in the state or federal courts and will be ruled unconstitutional. Pro-lifers backers will then petition the U.S. Supreme Court for a “writ of certiorari” (will ask the high court to review the lower court’s decision) and either “cert will be denied” (the Supreme Court will refuse to review the case), or if it agrees to hear the case, given its ideological make-up, will most likely rule against it. By reaffirming Roe, the last state of affairs will be worse than the first.

The reasoning is plausible but not iron tight. An appeal could take several years. Can we be sure today what the Supreme Court will look like in several years? Do we know that juridically answering Roe’s unsettled but all-important question of the status of the preborn will not pass constitutional muster? Why? Because of the indirect implications of such an answer for abortion ‘rights’? Yes, maybe. But the state also has an interest in settling the question of the status of the preborn; and Roe doesn’t answer the question, so Mississippi’s PI does not directly challenge Roe. And gobs of facts in developmental biology are accessible today that weren’t when Blackmun wrote his infamously evasive words on personhood.

For five years Catholic bishops have gone public in opposition to these initiatives. How many more years will they continue? If Obama gets re-elected and appoints even one more pro-Roe justice, will they become permanent opponents of state initiatives to extend constitutional protection to the unborn? Hard-headed pragmatism is sometimes a justifiable way for Christian shepherds to proceed, but sometimes it’s not, especially if doing so offers a confusing witness to values that stand at the core of the Gospel. At very least, testifying to a maligned truth always has some value, such as the truth of the personhood of human beings from fertilization.

But I believe the possibility of scandal needs to be seriously considered here. Scandal is defined as leading another to commit serious sin. This, of course, can be done intentionally. But it also can be done unintentionally, as when one adopts a course of action that gives an ambiguous message on some gravely important matter. For example, a priest frequents a pub with his sister (who happens to be a beautiful blond); somebody contemplating becoming a Catholic is having a beer on his way home from work and sees Father and his sister chatting cozily in the neighboring booth, doesn't know they're siblings, wrongly interprets the ambiguous message, and decides "ah, the Catholic Church is full of hypocrites", and stops his pursuit of full communion. The priest would be culpable for wrongdoing for not foreseeing that his confusing example (although arising from an act that was in itself innocent) might wrongly but understandably be interpreted to the spiritual harm of others.

Catholics and non-Catholic alike in Georgia, Colorado, and Mississippi have expressed serious misgivings about the Catholic bishops’ approach to the question of personhood amendments in their states. I know anecdotally from my own experience in Colorado that at least some good Catholics have lost trust in their bishops over the issue. Some Protestant pro-life brothers and sisters have felt alienated. And enemies of the Church, both within and without, have exploited the confusing example in criticisms against the Church.

Since the pragmatic argument is far from certain, and since opposing PIs risks scandal, I recommend that our bishops and other pro-life leaders, even those with misgivings, offer at least qualified support for Mississippi’s initiative and others like it; and urge Catholics and all citizens, after serious consideration of the issues at stake, to vote in the way they judge to be most effective in protecting the lives of human persons from fertilization to natural death.

Legalizing Euthanasia by Omission - And Making It a Doctor's Order

by E. Christian Brugger, D.Phil., Senior Fellow and Director, Fellows Program

In Culture of Life Foundation

DENVER, Colorado, AUG. 24, 2011 (Zenit.org ).- A problematic new end-of-life medical form is rapidly gaining ascendency in U.S. healthcare. It is called the "POLST" document. (In my own state of Colorado, it's called a MOST document.) The acronym stands for Physician Orders for Life-Sustaining Treatment. (MOST = "Medical Orders for Scope of Treatment;" its provisions are almost identical across states.) Click here to see an example of a standard POLST document.

The document consolidates on a single form provisions formerly dispersed over several documents: it acts as a living will specifying the scope of medical interventions a patient wishes in case of incapacitation; it makes specific provision for a do-not-resuscitate order (DNR); it has a box to check in the event a patient wishes to refuse treatment with antibiotics; and it allows a patient to designate a proxy decision maker.

Similar to other advanced directives, patients complete the POLST form when their capacities are in tact and the document becomes effective when consciousness is compromised.

But different from older-type directives, the POLST document has provision for the signature of a physician (or physician assistant). This gives the designations on the document the force of an actionable medical order.

The national trend, supported by Compassion & Choices (formerly the Hemlock Society), is to structure state laws on medical directives in accord with the POLST paradigm (as illustrated by its recent adoption by states such as California, Colorado, Hawaii, Idaho, New York, Pennsylvania, Oregon, Tennessee, Utah, Washington, West Virginia and Wisconsin).

Why is the document problematic? I will speak from first-hand knowledge of the legislation that normalized the document in Colorado. I believe my criticisms are relevant to all POLST-type laws in the U.S.

The Colorado law (signed in summer 2010) abrogated an extremely important condition on living wills going back two decades. The former law authorized adults to direct medical professionals to withhold or withdraw life-support only on the condition that they were terminally ill (or in a so-called persistent vegetative state [PVS]). So for purposes of the law the refusal was conditioned by the fact that a patient was already dying. (The PVS provision was accepted under the false assumption that it was a terminal condition.) Forty-five percent of the states in the U.S. presently impose similar statutory limitations on the removal of life-support.

The POLST-type legislation removes the condition that a patient is terminally ill or diagnosed in a PVS before a refusal order is actionable. In other words, the new law permits any adult patient to refuse any treatment at any time for any reason in the event they lack decisional capacity; and health care professionals, directed by a doctor's medical order, ordinarily would be (and are) required to carry out the order. Although the law for strategic purposes is rhetorically formulated as bearing upon end-of-lifemedical decisions, it sets forth no requirement that a patient's refusal of life-support must be limited to end-of-life conditions.

If someone refuses life-support with the specific aim (or intention) of causing his or her own death, the person is choosing suicide. Morally speaking this is no different from ingesting a lethal dose of medication, or sitting in a running car with the windows closed and a hose stretching from the tail pipe to the cabin. "Why are you doing X?" If the answer is: "To die," then the person is intending self-killing, suicide, and that's always wrong.

But isn't it the case that terminally ill patients also can direct the refusal of life-support for purposes of bringing about their deaths? It is true, the condition of terminality does rule out the possibility that patients will be motivated by suicidal intentions when taking advantage of the liberties permitted by the older-type law. But in establishing the refusal of life-support in the context of medical conditions diagnosed as "terminal," the older-type law privileged as the normative context for refusing life-support the motive "to-be-free-from-burdens-in-my-remaining-days-of-life." Suffering from a condition from which one was dying, the law granted a person the civil right to refuse procedures that prolonged the dying process.

This is not the place to rehearse the ethical argument for the legitimate removal of life-support. Suffice it to say that until recently, common ethical opinion accepted the judgment that if some treatment was futile or excessively burdensome, then a person legitimately could refuse the treatment, even if its refusal promised the hastening of death. [Note: the procedure, not the life, is judged burdensome.] One intends to be free of the burden of painful, risky, or futile treatments during one's final days of life, and one accepts that one's death may be hastened as an unintended consequence.

The POLST-type law grants adults the civil right to direct healthcare professionals to remove life-sustaining procedures when those procedures are not futile and when the burden imposed by them would be offset by a reasonable hope of recovery. It juridically extends the ordinary context for the refusal of life-support to include the motive of bringing about death. Without using the term, the new law authorizes euthanasia.

This is not the only problem with the POLST model, but it's the most serious problem that the model introduces. Other problems, such as the document's provision for the removal of food and water from patients for whom they reasonably would be judged to be ordinary/proportionate care, or the simplistic designation, "No Antibiotics," whether or not such drugs are medically indicated, already infect older type documents.

When the Colorado Catholic Conference, which I assisted, was fighting (ultimately unsuccessfully) at the state capital in Denver to amend the POLST-type legislation before passage to reintroduce the condition of terminality, we argued that the legislation as written was effectively legalizing euthanasia by omission. Some legislators believed that we were being alarmist. They thought that because physician-assisted suicide was not legal in Colorado, nor explicitly legalized by the proposed legislation, we had nothing to fear. We said we thought this was short-sighted, that groups like Compassion & Choices would find fertile soil in the law for advancing its aims. Most were unconvinced.

On August 17, 2011, Compassion & Choices (CC) launched a nation-wide public education campaign entitled "Peace at Life's End – Anywhere." The euphemism means "legal self-killing anywhere in the U.S." (The press conference was held in Denver, Colorado!) The central purpose, indeed the sole purpose of the campaign is to tell people everywhere that they can kill themselves legally anywhere in the U.S.; all they've got to do is to refuse life-support, in particular food and water. The Web site reads:

One method of peaceful dying…universally available, legal, safe, painless and suitable for a gentle parting in one's own home…is the purposeful refusal of food and fluids, in medical jargon known as voluntarily stopping eating and drinking (VSED).

"VSED," its press release stated, "is a legally recognized option for mentally competent adults who wish to end their suffering." And best of all, "it requires no special laws or regulations. VSED is legal -- for patients and their caregivers -- today, in every state."

The POLST document is not a precondition for the success of CC's campaign. Any living will that permits the removal of food and water would be adequate. But the new document sure helps.

If the POLST model is not already legally recognized in your state, five to one chance that legislation is being drafted at your state house as we speak. You might call your legislator and find out.

Is Proportionalism Reasonable? Problem Lies in Idea of Maximizing Good -

by E. Christian Brugger, D.Phil., Senior Fellow and Director, Fellows Program

In Culture of Life Foundation

WASHINGTON, D.C., JULY 27, 2011 (Zenit.org (http://www.zenit.org /)).- Here is a question on bioethics asked by a ZENIT reader and answered by the fellows of the Culture of Life Foundation (http://www.culture-of-life.org /).

Q: Prior to "Humanae Vitae," was the idea of "proportional morality" ever discussed (e.g., in the work of the papal birth control commission)? By proportional morality, I mean the ranking of moral issues such that one issue trumps another. For example, if overpopulation threatens to destroy everything, wouldn't this trump the prohibition against birth control and
abortion? -- Rob. Sedona, Arizona.

E. Christian Brugger offers the following response:

A: The question concerns a moral theory known as Proportionalism, widely held by Catholic academic theologians in the U.S. and Europe. It is a form of ethical reasoning known as Consequentialism.

A moral theory is Proportionalist (or Consequentialist) to the extent that it appeals to a comparative evaluation of benefits and harms to determine the morality of acts. An act's morality is assessed by weighing the relative benefits ("goods" or "values") to be gained by a contemplated course of action against the corresponding harms ("evils") being threatened. If good outweighs evil, the act is judged morally right despite the fact that evil may have been done.

In Catholic thinking, the turn toward Proportionalist reasoning post-dates the work of the Papal Birth Control Commission, but not by much. The commission finished its work in the summer of 1966. European theologians were flirting with Proportionalist reasoning at the time, but the idea had not yet come to prominence.

As late as 1971, U.S. theologians were still wary of Consequentialist morality. The late Rev. Richard A. McCormick S.J., father of U.S. Proportionalism and celebrated theologian at Notre Dame, seems to have assented to the Proportionalist premise around 1972. Before that time, he
expressed concern that if the moral theory was applied right down the line, it would destroy the concept of intrinsece malum, that is, that some acts are "intrinsically evil" ex objecto (i.e., by virtue of the kind of acts they are, notwithstanding the benefits to be gained from performing them). (See his "Notes on Moral Theology" in Theological Studies from 1971.)

McCormick was prescient. The method did dispense with intrinsically evil acts and so with the Catholic tradition that defended their existence. He believed that the so-called preference principle was central to moral reasoning; it was self-evident, for it holds that one ought always to prefer the alternative of choice that promises the greater good or the lesser evil, and it would be absurd to choose an alternative promising lesser good or greater evil. This method leads to the denial that there are any actions, described in non-morally evaluative terms, that are intrinsically evil and can never be rightly chosen. He admitted that some norms are "practical absolutes" insofar as it is unlikely that violating them would yield the "greater good" or "lesser evil" (e.g. rape). But the principle still holds and there might be very unusual situations when doing a deed of this kind might be the lesser evil.

Why isn't McCormick's "preference principle" sound? Why can't a calculus of "greater good" and "lesser evil" be an adequate way to proceed? The problem lies in the idea that we can maximize good, that human good can be quantified in any rationally meaningful way. This is both erroneous and presupposes a superficial view of human good and the moral life.

The human goods at stake in moral choosing are simply not commensurable. How can one measure the value of human life compared to friendship or knowledge of the truth, or how can one measure the value of my life compared to yours? Human good is not simply "out there" waiting to be maximized. It resides in the heart of a person who has committed himself to authentic human goods prior to their external manifestation, and it endures even if one's commitment to them fails to produce good results. For example, the commitment of a mother to the well-being of her child has a reality in her heart quite apart from the success of her endeavors to promote her child's welfare. Her commitment to the good of her daughter does not merely hinge on the possibility of "well-being" which may be realized if all goes according to plan. Or the commitment of a husband to his irreversibly comatose wife. Leaving her for another might very well promise greater benefit. What then justifies remaining faithful to her,
perhaps for many years? Certainly no quantitative measure of greater good and lesser evil. Rather, the reverence he has for their marital covenant -- his love for his wife and for the reality of their enduring one-flesh relationship; and for the goodness of her life right now, disabled, unresponsive, supine, and yet really and objectively good.

A Proportionalist ethic is also superficial. Morality is not simply concerned with "doing good," in the sense of maximizing beneficial states of affairs in the world, but about being good. And being good requires committing oneself to reverencing human good as it exists in the integral and full being of individuals and communities (instantiated in bodily life, friendship, marriage, harmony with God, knowledge of truth, etc.).

Thus the basic requirement of morality is that all elements of human good be respected in all our choices, even if acting contrary promises some measurable benefit. If we act in this way, we shape our wills and ourselves in a way that reverences the good. John Paul II writes: "human acts are moral acts because they express and determine the goodness or evil of the individual who performs them. They do not produce a change merely in the state of affairs outside of man but, to the extent that they are deliberate choices, they give moral definition to the very person who performs them, determining his profound spiritual traits" ("Veritatis Splendor," no. 71).

A final fatal flaw of Proportionalism is its claim that we can make in advance a comparative evaluation of net good and bad promised by a particular course of action. But to do this one would need to be able to see into the future, to have access to the providential realm. Such an
aspiration is no less illusory than the search for the fountain of youth. The apparently objective moral analysis of Proportionalism will necessarily favor certain projected consequences over others, especially those pressing most acutely on the emotions of the chooser, effectively reducing the outcome to subjective preference. Ironically, Father McCormick made this argument very early on, better than I can make it: "But who can confidently make such a judgment? An individual? Hardly. It seems to demand a clairvoyance not granted to many mortals and would paralyze decision in most cases. For example, what individual can say whether this present abortion will, in the long haul, undermine or promote the value of maternal and fetal life? This is especially true if the individual in question has a great stake in the abortion and presumably, therefore is more focused on the immediate impasse than on the long-term stakes" (Notes On Moral Theology 1965 Through 1980, Washington, D.C.: University Press of America, 1981, p. 319; see also John Paul II in Veritatis Splendor, no. 77).

If a type of action always destroys, damages or impedes some basic element of human good, then no ranking of proportional outcomes can make that action consistent with integral human flourishing. To deliberately choose that action makes us bad. This is why John Paul II taught in "Veritatis Splendor" that Proportionalism is both unsound and unfit for use in Catholic moral reasoning (nos. 76, 79).

Fighting to Live Versus Dying to Die: U.S. Bishops Challenge the Right-to-Die Movement

by E. Christian Brugger, D.Phil., Senior Fellow and Director, Fellows Program

In Culture of Life Foundation

WASHINGTON, D.C., JULY 6, 2011 (Zenit.org).- Political advocacy for assisted suicide in the United States dates back to the eugenics movement of the early 20th century and the failed Ohio euthanasia bill of 1906.

Activists organized themselves in the 1930s around the former Protestant minister Charles Potter (who first abandoned the Baptist and then the Unitarian church because both were too conservative), and formed the Euthanasia Society of America. The movement remained on the social fringe until the 1970s, when the case of Karen Ann Quinlan mobilized its energies.

The 21-year-old Quinlan was diagnosed in a persistent vegetative state (PVS) after suffering severe brain injury from oxygen deprivation. After several months of ventilator support without improvement, her parents requested that the hospital remove the ventilator and leave her to die.

The battle was fought in the courts and on the front pages of newspapers throughout the country. Although the central ethical question concerned the removal of life support and not intentional euthanasia, the case became a cause célèbre for the still fringe right-to-die movement, which found its social voice arguing for the inhumanity of forcing disabled patients to linger in their disabilities.

The New Jersey Supreme Court ruled in favor of her parent's petition, and the ventilator was removed in 1976. But because Karen's family continued to feed her, she lived for another nine years. The courts and the country were not yet ready for the "merciful starvation" requests that were bound to follow in the 1990s. And follow they did.

In 1990, the euthanasia movement mobilized around the family of Nancy Cruzan, a 33-year-old woman diagnosed in a PVS after suffering a brain injury in a terrible car accident. The family petitioned to remove her feeding tube and the U.S. Supreme Court, after some hesitation, ruled in favor of the request. Her starvation lasted for 12 days.

The liberty to refuse life support was only an interim step for euthanasia activists. All along the goal was full-fledged intentional self-killing legally facilitated by the medical community, or physician assisted suicide (PAS).

In 1970, British-born euthanasia activist Derek Humphry, who founded the Hemlock Society USA in 1980, facilitated the suicide of his own wife, Jean. Derek mixed a lethal cocktail of drugs and dispensed it into Jean's morning cup of coffee. She thanked him, said good-bye and drank the coffee.

He memorialized her suicide in a book called "Jean's Way: A Love Story." Humphry's Hemlock Society, now using the euphemistic moniker Compassion & Choices , has sponsored most all right-to-die initiatives of the past 20 years.

In 1997, Oregon became the first state to legalize PAS with its Death with Dignity Act . Activists in Washington State tried unsuccessfully the same year to pass a similar law; and finally 10 years later achieved their goal in shepherding the passage of Washington's Death with Dignity Act (2008).

In state judiciaries, the Florida and Alaska Supreme Courts both refused to find constitutional rights to suicidal assistance in 1997 and 2001 , respectively. Unfortunately, Montana's Supreme Court in Baxter v. Montana (2009) granted protection to patients seeking death through lethal prescription and to the doctors who accommodate their requests.

Euthanasia and PAS have gone from fringe issues nurtured by voices on the cultural margins to centerpieces on the table of the Western culture wars. Nobody interested in preserving the norm against intentional killing and defending against the deputizing of physicians as killers of their patients can remain indifferent to the cancer being vigorously advanced by right-to-die (and-kill) activists.

The USCCB responds

A recent reply to the movement came from the American bishops. At its June General Assembly in Seattle, the United States Conference of Catholic Bishops (USCCB) approved a policy statement on the issue of PAS, "To Live Each Day with Dignity: A Statement on Assisted Suicide."

The text is a successor document to the Conference's 1991 Statement on Euthanasia , the Vatican's important Declaration on Euthanasia (1980), and the many conference "fact sheets" over the years on end-of-life issues. The USCCB press release says the text "marks the first time the full body of bishops has issued a statement devoted to this issue."

Following the rhetorical approach used in their 2009 document on assisted reproduction, "Live-giving Love in an Age of Technology," the statement is written in a non-technical, even folksy style, with concise sentences, no complicated footnotes and a tone of urgency throughout. It is relatively brief, with only six pages of text followed by a seventh listing helpful references to Vatican and USCCB documents on related issues. It is written to be read by non-experts, which is both a strength and a weakness of the document.

The document is divided into six sections: an introduction; a summary of the threat posed by the campaign to legalize PAS; a section debunking the illusion that self-killing is an expression of authentic freedom; a refutation of the euphemism that assisting in another's suicide is truly compassionate; the proposing of a "better way"; and a conclusion.

The document sets forth 10 salient points worth mentioning:

1. People who request death are vulnerable. They commonly suffer from clinical depression. They should be treated for depression, not aided in killing themselves.

2. Chronically and terminally ill patients are liable to suffer undue influence from the biases and wishes of others, often from those who are physically strong and impatient with weakness and disability.

3. Proposals to legalize PAS define a small class of people -- those with "terminal illness" -- as legally exempt from laws against assisting in the suicide of another. But clinical definitions of "terminal illness" are notoriously unreliable and ambiguous and risk sweeping up into themselves chronically ill patients who could live a long time if given proper care.

4. "The assisted suicide agenda promotes a narrow and distorted notion of freedom, by creating an expectation that certain people, unlike others, will be served by being helped to choose death" (p. 3).

5. But human life is always good and always sacred. It may be accompanied by serious privations, but of itself, life is always a basic human good. "By rescinding legal protection for the lives of one group of people, the government implicitly communicates the message … that they may be better off dead" (p. 3).

6. But we cannot both defend and promote human dignity and at the same time devalue some lives by saying through law that they are better off dead.

7. In countries where assisted suicide is legal, a dangerous lack of scrutiny and oversight exists. Physicians have moved from assisting in the suicides of patients who request it, to taking the lives "of adults who never asked to die, and newborn children who have no choice in the matter" (p. 4).

8. It is never compassionate to kill another or to assist another to kill himself. Such so-called mercy killing "invites a slippery slope toward ending the lives of people with non-terminal conditions. Dutch doctors, who once limited euthanasia to terminally ill patients, now provide lethal drugs to people with chronic illnesses and disabilities, mental illness, and even melancholy" (p. 4).

9. Thus the bitter truth of the right-to-die movement is this: It ends up posing grave risks to those whom it claims to serve, namely, people with serious illness.

10. Rather than investing in more efficient ways of killing infirmed patients, our society should invest in improving palliative care.

The document ends with a call to Catholics and all Americans to reject the lure of the "quick fix" of assisted suicide for those who are suffering. Christ-like love is a better way.

We can learn a lot about ourselves from our enemies. Thus when the bullies at Compassion & Choices announced in response to the USCCB statement that the conference has "launched a new attack on terminal patients' end–of-life choice," and that it aims "to impose its religious orthodoxy on all Americans," and that the bishops have "prompted calls for doctrinal purity," you may suspect that our shepherds have done something right.