Tuesday, September 1, 2015

Legalizing Medical Marijuana

TUESDAYS WITH ROSEMARY AND MYRA
Virtually everyone is familiar with Mitch Albom’s book, Tuesdays With Morrie. Myra Christopher (Foley Chair at the Center and former Center CEO) and Rosemary Flanigan (Retired Center Program Staff) have decided to regularly contribute to the Center for Practical Bioethics’ blog and call it “Tuesdays with Rosemary and Myra” (even though it won’t necessarily be published on a Tuesday). Read more about Rosemary and Myra at the bottom of this post. 


Note:  Today, Myra and Rosemary are discussing an article about the legalization of marijuana that appeared in National Geographic.


M:  Rosemary, I’m sorry, but I did not get my homework done. So, you are going to have to tell me about the National Geographic article that we agreed to read. Good ethics start with good facts; so, give me the facts, Mam.

R: Okay, basically the article says that marijuana has been found to be helpful in cases of childhood epilepsy and other seizure disorders, and its use in relieving or ameliorating these tremors or whatever the child goes through has led many people to project its use for other medical purposes.  

As you know, across the nation, states are legalizing marijuana for medicinal purposes. However, I believe that the argument for it has got to include further research about its use and side effects. My argument is that we need the research for the justification of its use for purposes other than those for which we have evidence that it works. 

M:  That’s a good argument, but we actually have very little evidence for most of what is done in medicine, and let’s talk about the fact that some states are also legalizing the use of marijuana for “recreational purposes”; so, what’s the distinction? It’s okay to smoke it for fun but not if it helps your back pain? Many people with other illnesses such a migraine claim to benefit from its use.  

Rosemary, a dear friend of yours and mine who died of cancer a few years ago called me shortly before her death and said that her doctor had encouraged her to use marijuana to stimulate her appetite. She asked me if I thought that was ethically OK. I said for, “God’s sake, you are dying of cancer. If it helps you to eat a bite or two, what harm will be done?” And she said, “But it’s illegal!” I think that sometimes we confuse what is legal with what is ethical.

R: So, her doctor wanted her to eat it.

M:  I don’t know if he wanted her to eat it or smoke it. Probably smoke it because I know that when people smoke marijuana they get “the munchies”, and I don’t know what difference it would make if someone smoked it or ate it. Do you think there is a difference?

R:  No, no! I was just asking out of curiosity.

M:  I assume that, like other drugs, marijuana affects different people in different ways. Rosemary, I am assuming that you have NOT smoked or eaten marijuana, but I have. When I was in my late 30s or early 40s, I smoked a marijuana cigarette. 

I had not been part of the “drug culture” in my youth, and I wanted to know what it would be like. Actually, my experience was awful. I felt completely out of control, and anyone who knows me knows how important control is to me. I did not get hungry – just paranoid.

R:   So like Bill Clinton, you didn’t inhale.

M:  Oh no, I inhaled! I can’t imagine why people want to do it, but clearly many, many people like it, and many, many people think it helps them with health problems.
 
I struggle with why we are so twisted up about the use and abuse of marijuana, when our society literally runs on alcohol. I want you to tell me what the difference is in smoking marijuana and having a Manhattan.

R: Society has made alcohol acceptable. It is interesting how often a societal response to something can move the consideration of something from “right” to “wrong.”

M.  Society may think alcohol consumption is morally acceptable, but there are more than 80,000 alcohol related deaths in the United States each year. I don’t want to sound like Carrie Nation, but given what you just said, is the issue about the legalization of marijuana really a moral issue rather than an ethical issue? And if so, why and what is the distinction?

R.   Let me try an analogy. I have always justified the states’ use of capital punishment, but from a global view, capital punishment has come to seen as immoral and, therefore, ethically unjustifiable. Couldn’t the same be said of the use of marijuana, which has been seen as illegal because it is immoral, but with its legalization, has come a shift in the perception of its moral evaluation?

M.  That could be true, but I’m not sure I accept that argument. In bioethics we often use the terms moral and ethical as though they are synonyms, but I want to be able to make a distinction between them because it is important to me that what is “ethical” is not determined by a public opinion poll. Nor do I want something to ethical because it is legal or illegal (slavery was legal). I want that determination made through an analysis of facts, values, motivations, consequences, etc.

R.  True, true, true!  But there are practices in our society that we allow when we do not know whether the effect of something will benefit or harm human nature -- such as the use of marijuana.  hat’s why I’m arguing for further research within a society where it has been made legal. 

M.  So, are you saying that its use is ethical “for now” -- until proven to be harmful?

R. Yes, until we have more evidence.

M.  I sort of hate to agree with you because this has been fun, but I do agree. The value we place on autonomy and personal freedom has to trump (I’ve come not to like using that word in the last few week but…) ambiguity about whether something is right or wrong. I wonder what our readers think. 


About Rosemary and Myra

For several years before her retirement, Rosemary facilitated an online discussion group, primarily for ethics committee members, which had a faithful following. We hope some who participated and others will read our blog posts and respond with their thoughts on whatever subject we are writing about. We would also be grateful if you would provide suggestions for future blog topics. With your help, the two of us are moving into the 21st century, but for Pete’s sake, don’t expect us to tweet!


We have decided to write a regular blog for several reasons. First, there has never been a greater need for ethical reflection than there is today. We both agree about that, but we are very different people, and often disagree on issues. We hope it will be helpful for us to model respectful disagreement. In addition, we just finished writing a history of the Center which took us three years, and we enjoyed doing that so much that we need an excuse to continue writing together on a weekly basis. So, we don’t mind bothering you with our ideas.


I call myself a “philosophical Christian agnostic” and Rosemary is a member of the Sisters of St. Joseph of Carondolet. Rosemary taught high school English and philosophy at Rockhurst University. She is a stickler for the “King’s English” and proper grammar. I grew up in Texas and just like to talk. We are both old; I turned 68 in July; Rosemary is older. We both have had training and education in ethics, but Rosemary has a PhD. We have both worked in bioethics for many years, and we both LOVE to argue. As Rosemary says, “Doing ethics is all about argument.” But ethics is not about mean-spirited disrespectful exchanges that are so prevalent today in a “red-state/blue-state culture.” Through blogging, we hope that our agreements and disagreements will demonstrate that we can argue respectfully and still love and care about one another.

Labels: ,

Laughing When It’s No Laughing Matter

Tarris Rosell, PhD, DMin, and David Casarett, MD
At our 2015 annual Flanigan Lecture events, I had expected more controversy and less humor. The topics were CPR and medical marijuana, and ethics issues pertaining to both.

Off the lecture circuit and in clinical or personal situations, Flanigan lecturer Dr. David Casarett encounters plenty of controversy, and not much to joke about. He is a palliative care and hospice physician. His patients are either suffering or dying, or both. Families are traumatized or grieving. Serious business. In healthcare facilities, controversy erupts daily around treatment decisions and transitions of care, and about what should be done when a patient stops breathing.

Serious Cases, Controversial Outcomes


Some seriously controversial occurrences were impetus for both of Dr. Casarett’s recent book projects.

• A 2 year old, Michelle Funk, drowns in a cold creek, and after 3 hours of protracted CPR attempts, she (miraculously?) comes back to life—with brain cells intact and working.

Does this mean that we should default to CPR for everyone who stops breathing or loses a heartbeat, and that rescuers should almost never stop, on the chance that the victim could be another Michelle Funk?

• A 42 year old with end-stage cancer and associated pain gets some relief from getting stoned, and moves to Colorado hoping for ready access to “medical marijuana.”

Does this mean that permissive marijuana laws such as those in Colorado, and increasingly elsewhere, are right and good, to be emulated everywhere?

Controversy.


Humorous Paths to Thoughtful Conversation


Casarett finds humor in the midst of ongoing debates regarding what ought to be done with “the recently dead” or those who find pain relief from a reefer. Book titles—Shocked and Stoned—reflect  a not entirely serious treatment of controversial topics. His next book is on assisted suicide. We brainstormed one-word titles to fit a trilogy. Nothing very funny, or appropriate, came to mind. And that is a challenge one faces when addressing serious topics with humor. Joking around with the suffering of others could be experienced as insensitive and inappropriate.

In person, David Casarett is just the opposite. He comes across as witty but thoughtful, even shy. I expect his patients and colleagues love him, and he them. He also has a penchant for finding issues in palliative and hospice care that pique our curiosity—and tickle the funny bone.

It is hard not to smile at some early attempts to resuscitate newly dead bodies. Casarett writes and speaks about a method once used that involved blowing tobacco smoke up the rectum. Really.

Although medical marijuana is supposedly about getting relief from symptoms and not about getting high, just mention Colorado these days and “stoned” jokes start to fly. Casarett provokes this response, or perhaps anticipates it, by the title of his book on the subject.

Suffering and dying are no laughing matters, and we surely do not all agree on what ought to be done about default CPR standards or legalizing marijuana for medicinal use. Behind each controversy are the incredibly sad stories of persons who died and others who suffer the pain and discomfort of incurable diseases. Our wish to avoid these experiences, or conflict, may lead to avoidance altogether. Scholar-practitioners like David Casarett enable us to engage the serious and controversial with tasteful good humor. Everyone likes a good joke. When the laughter dies, thoughtful conversation might begin—as it did for Flanigan Lecture participants on August 12th.



By Tarris Rosell, PhD, DMin
Rosemary Flanigan Chair at the Center for Practical Bioethics

Labels: ,

Wednesday, August 26, 2015

The Sale of Fetal Tissue

TUESDAYS WITH ROSEMARY AND MYRA

Virtually everyone is familiar with Mitch Albom’s book, Tuesdays With Morrie. Myra Christopher (Foley Chair at the Center and former Center CEO) and Rosemary Flanigan (Retired Center Program Staff) have decided to regularly contribute to the Center for Practical Bioethics’ blog and call it “Tuesdays with Rosemary and Myra” (even though it won’t necessarily be published on a Tuesday). Read more about Rosemary and Myra at the bottom of this post.

The Sale of Fetal Tissue


M:  Rosemary, you know all the hub-bub about the video of the executive from Planned Parenthood being caught on tape talking about the sale of fetal tissue to two people posing as employees of a company looking to procure fetal tissue for research purposes. It’s been all over the Internet…

R:  I do know about it. It’s gone viral!

M:  It certainly has, and it has provided fodder for those hoping to be nominated by one of the parties for the 2016 presidential election. The video has been proven to be an example of “hit and run” journalism, but that doesn’t negate the ethical question that underpins it, i.e., “Is it acceptable to sell fetal tissue?” And that’s what I want to talk about.

R:  And I want to ask is there any difference in fetal tissue and other human tissue, all of which gets “sold.”

M:  THAT’S THE QUESTION!

R:  Of course, there is something special about fetal tissue, but does that mean that it can’t be used for research. It’s not the same kind of tissue that comes off your elbow…

M:  Why not? What makes it different?

R:  It is because of the potentiality involved in what it can or could become, but let’s don’t have an argument about that right now. Even though it will certainly come up in our argument later, I’m still going to say that fetal tissue can be used for research purposes.

M:  Okay, but your first claim reminds me of one that Don Marquis, a philosopher at Kansas University, made in an argument against abortion years ago in an article he wrote for the Center. He said the difference between tissue from your elbow and a fetus is that the elbow has a past, i.e., we know something about the arm it hinged, but has no future, whereas a fetus has a future but no past that could reveal anything about its history or values. Is that your argument?

R:  No! It’s not just about tissue’s history; I am trying to skirt intrinsic worth. So, don’t you push me into talking about that, Myra Christopher. I hate objective whatevers!

M:  Whatevers? Sorry, Rosemary, but I want to push you just a little. Most all of us will say that human life is sacred/special, and what I want to talk about may align with your “potentiality” comment, but it may not; I don’t know. But I want to talk to you about the difference between human tissue and a human “being.”

R: I would find it morally reprehensible to use fetal tissue for insignificant research purposes.

M: You‘re still avoiding my issue, but OK….  Insignificant research like what?

R:  I’m trying to get circumstances involved here so that they cast a moral evaluation on their use in one instance and their not being used in another. For example, I would not object to fetal stem cells being used to find cures for cystic fibrosis or sickle cell disease, but I would find it morally reprehensible to use fetal tissue to find a better face cream and make old women look younger.

M:  I agree. I think it is repulsive. It reminds me of the former chair of the President’s Bioethics Commission Leon Kass’s determination based on what he called the “yuck factor”, i.e., if it is just plain old gross, it may be just plain old wrong.

R:  I’ve thought this for a long time, and there is something to be said that should lead us to reflect on why we feel the “yuck”, and maybe in some instances it should cause something to be tagged “unethical”, but in other instances it may simply be a societal “no-no”.

M: I think the point you are getting to is important – not just in this discussion, but in many arguments claimed to be “ethical arguments”. There are important distinctions that should be made between ethics, social norms, etiquette, and the aesthetic.

Last night, I was thinking about us possibly blogging about this topic today, and I remembered being at a women’s rights rally once and a person claiming to be absolutely opposed to abortion was walking around trying to force people to look at an aborted fetus she had in a box. It struck me as the epitomy of irony that a person crusading for the sanctity of life would objectify a fetus for political purposes. 

R:  Poor soul! She was very confused. 

M:  Rosemary, when I was thinking about this last night, I thought about the many, many times I have heard you ask (when teaching ethics committee members), “Is it wrong to torture little children?”

R:  “Needlessly, needlessly torturing little children!” Is what I asked? The point behind that was that, most often, general rules need to have adverbs to make them valid and true.

M:  I agree and add that speaking in “absolute” terms almost always forces you into a corner. But I want to go back to the distinction I need to make between human “tissue” and human “beings” Because it is critical to my position.

For me, “being” implies “personhood” and by that I mean an independent individual whether 1 day old or 100 years old. I would argue that it applies only to fetuses that are sustainable independent of the mother.

R:  You’re not placing the same meaning on potentiality that I am. So, you and I will have a different argument because we differ in the meaning of the potentiality involved in the fetus. That is so simple to me. You want to say that the point of differentiation is when it (the fetus) can live on its own. I say that is not the point; we have to respect it until it gets there; so I am going to call for more heavy arguments for the use of fetal tissue than you would before it is sustainable.

What I'm saying is that justification for use of fetal tissue ought to be weightier the closer the fetus comes to live birth before being aborted. I'm trying to show that potentiality develops and thus the arguments must take that development into account.

M:  I think that’s true. However, I think at a certain point in the development of the fetus our lines cross, and we find ourselves at the same place. However, I want to say that I agree wholeheartedly that fetal tissue, no matter the gestational age of the fetus from which it comes, should always be treated with respect. 

I am reminded of a situation years ago, probably 20 years ago, when a faith-based hospital reached out to the Center for help in deciding what to do with fetal tissue that was not suitable for research. Fertility specialists in their institution were burning such tissue in trash cans in their clinic. That is one extreme. Another was a time when the Center was contacted by a hospital because a group was demanding that the hospital “bury” fetuses with a proper ceremony – no matter its gestational stage.

R:  Why do you call burning tissue in a trash can an extreme?

M:  Good question, because I wouldn’t find it objectionable to burn it in the hospital’s incinerator.  I think the “aesthetics” of the situation were objectionable to me. The whole idea that it was “trash” bothered me and others in the hospital. 

R:  I see it’s not the “burning”; it’s the “trash” that bothers you. So much of these arguments depend on the way we use language and define specific terms.

M: Back to the Planned Parenthood fiasco; I think we agree and disagree about components of this situation. Although we get there along different paths, we agree that when used for significant research that could potentially help people living with disease and injury AND when conducted in done in a way that is respectful of the “donation”, the use of fetal tissue in research can be justified.

However, there are other important factors as well, including “tone”, context, and intent when in discussion about ethically sensitive issues.

About Rosemary and Myra


For several years before her retirement, Rosemary facilitated an online discussion group, primarily for ethics committee members, which had a faithful following. We hope some who participated and others will read our blog posts and respond with their thoughts on whatever subject we are writing about. We would also be grateful if you would provide suggestions for future blog topics. With your help, the two of us are moving into the 21st century, but for Pete’s sake, don’t expect us to tweet!

We have decided to write a regular blog for several reasons. First, there has never been a greater need for ethical reflection than there is today. We both agree about that, but we are very different people, and often disagree on issues. We hope it will be helpful for us to model respectful disagreement. In addition, we just finished writing a history of the Center which took us three years, and we enjoyed doing that so much that we need an excuse to continue writing together on a weekly basis. So, we don’t mind bothering you with our ideas.


I call myself a “philosophical Christian agnostic” and Rosemary is a member of the Sisters of St. Joseph of Carondolet. Rosemary taught high school English and philosophy at Rockhurst University. She is a stickler for the “King’s English” and proper grammar. I grew up in Texas and just like to talk. We are both old; I turned 68 in July; Rosemary is older. We both have had training and education in ethics, but Rosemary has a PhD. We have both worked in bioethics for many years, and we both LOVE to argue. As Rosemary says, “Doing ethics is all about argument.” But ethics is not about mean-spirited disrespectful exchanges that are so prevalent today in a “red-state/blue-state culture.” Through blogging, we hope that our agreements and disagreements will demonstrate that we can argue respectfully and still love and care about one another.

Labels: ,

Monday, August 17, 2015

Rapping about Dying

ZDoggMD is something of a celebrity among physicians and medical students. He is the “Weird Al” Yankovic of the medical world – parody songwriter extraordinaire, satirist of medical culture and, at his best, a seriously funny human being. Whether lampooning hospital readmissions or mocking anti-vaxxers, his music videos bring humor to physicians’ challenges as well as their follies.

But listen closely and you will find that, beneath the humor, there often lies a serious message in ZDoggMD’s lyrics. The parodies aim to entertain healthcare workers, of course. But they also seek to educate. “Let’s just prevent readmissions/manage those chronic conditions/need time preparing the handoffs/move along to other clinicians,” he raps in “Readmission,” a parody of the R&B hit “Ignition (remix).” In the music video, ZDoggMD utters these lines in a hospital ward, wearing a lavish fur coat and sunglasses in the fashion of a rap musician. The routine is absurd – and funny – but the goal is more than mere entertainment. ZDoggMD’s light touch of humor warms us up for a serious conversation on a topic that is no laughing matter.

Ain’t the Way to Die

For his latest video, “Ain’t the Way to Die” (a parody of Eminem’s “Love the Way You Lie”), ZDoggMD forgoes humor altogether – a first, according to his blog. Stripping away humor, the song takes a more direct approach to talking seriously about a topic that many of us prefer to avoid – death and dying. As ZDoggMD writes, “…we too often fail to have those difficult but crucial discussions about dying, and this failure leads to untold human suffering and billions in squandered resources. We are failing as caregivers, we are failing as family members, and we are failing as individuals – failing to simply have a conversation that ensures that we direct our own destiny. Plainly put, we need to talk about dying.”

Talking about dying is hard. It’s uncomfortable. As a medical student, I’ve become acutely aware of the discomfort. I feel it too, even as an observer. For all of us, the challenge is to communicate effectively about death and dying in spite of the discomfort, and in that regard ZDoggMD’s sentiment too often rings true: We are failing as caregivers, family members, and individuals to have these crucial conversation about the end of life.

Conversation Starter

Thankfully, there are people working to make these conversations a little easier. Caring Conversations, a resource developed by the Center for Practical Bioethics, for years has guided patients and their families through the process of advanced care planning. In its own way, ZDoggMD’s “Ain’t the Way to Die” can also facilitate these conversations, by melodically breaking the ice on death and dying: “Just gonna stand there and watch me burn/end of life and all my wishes go unheard/they just prolong me and don’t ask why/it’s not right because this ain’t the way to die, ain’t the way to die.” 

The musical stylings may be off-putting to some, but for those who enjoy rap music – and those who can tolerate it – the lyrics of “Ain’t the Way to Die” succeed in broaching a wide range of end-of-life issues, from family discord to resuscitation. And this brings us to what is perhaps the greatest virtue of “Ain’t the Way to Die” – that the breadth of issues addressed in the short video makes the parody a conversation-starter for healthcare workers and patients alike.  

All of us must find a way to communicate clearly in conversations about the end of life. “Ain’t the Way to Die” may help some of us find the words to do so. With that in mind, I encourage you to watch the video and share it with others.  No matter one’s background or profession, each of us will one day face the end of life. Starting a conversation about how you want to face it gives you the best shot at doing it on your own terms. 


Written By Joel Burnett. Joel Burnett is an MD candidate at the University of Kansas School of Medicine.

Labels: , ,