DNR Ebola: Is there a professional obligation to provide treatment?

By Avigile Baehr

Overhead pages are a staple of a busy ER. They give doctors and nurses a couple extra minutes to prepare for the quick action needed to save patients’ lives after strokes, heart attacks, or trauma. Now, imagine a case today:

Attention, ER staff. A 32 year old female at high risk for Ebola is coming in via ambulance with fever, vomiting, and unstable vital signs. If you are willing to accept the personal risk inherent in providing medical care to this patient, please report to room 3. Otherwise, please disregard this announcement.

A conditional appeal, not an imperative. A qualification that seems to run counter to the oaths that medical professionals take. And yet, a stipulation that hospitals and healthcare providers have considered as they decide how and whether to engage with this deadly infection. Ebola poses a very real threat to providers: two nurses contracted the virus while caring for a patient in Dallas, and California nurses have gone on strike in response to lack of preparedness for safely dealing with the infection. Given the disease’s documented transmission to healthcare providers, its high fatality rate, and the lack of an FDA-approved treatment or vaccine, what are our professional obligations in caring for these patients?

The classic principles of medical ethics are autonomy, beneficence, justice, and nonmaleficence. For the purposes of the ‘obligation to treat’ dilemma, I will assume that Ebola patients want to receive treatment, and I will not consider the ethics of experimental treatments as they might relate to the ‘do no harm’ principle. The principles of beneficence and justice, however, are particularly salient to this question. Healthcare providers are not merely obligated to do no harm, but we must also do good by our patients. Despite the uncertainty regarding some experimental treatments for Ebola, timely supportive care is unquestionably beneficial for these patients. Intravenous fluids help prevent shock and organ failure. Breathing tubes can keep patients alive until the virus runs its course. In certain cases, CPR can restart a heart and give someone a chance to survive. Fair and equitable treatment of Ebola patients requires that they be treated by the same clinical standards that apply to any other critically ill patient. By these core principles, the ethical imperative to provide medical treatment to Ebola patients is clear.

What argument can be made, then, for refusing to provide comprehensive medical treatment to a patient with Ebola?

Perhaps providers are only obligated by these principles once they accept someone as a patient. Can a doctor or nurse then ethically refuse to engage in a provider-patient relationship with someone suffering from Ebola, thus freeing him or her of any obligation to treat?

In routine medical care, maybe or maybe not. Most states have specific clauses that allow providers to refuse to provide certain treatment, such as abortion care, on the basis of moral objections. But, both the law and medical professional societies uniquely distinguish emergency situations as obligating medical treatment without qualification. The Emergency Medical Treatment and Active Labor Act requires that all hospitals who offer emergency care services and who receive any Medicare funding (read: the vast majority of US hospitals) evaluate and stabilize any patient who seeks medical care. This law was designed to prevent hospitals from refusing to treat uninsured or underinsured patients, but it also serves to promote fairness and ameliorate other treatment disparities. Similarly, the American Medical Association Principles of Medical Ethics dictates that physicians should be free to choose the terms in which they agree to provide medical care, except in emergencies. By virtue of their agreement to serve as medical professionals, providers implicitly engage in a patient-provider relationship with anyone who seeks urgent care at their facility.

But, perhaps there should be an exception for personal risk. A similar dilemma with concern for provider safety arose in the early days of the HIV/AIDS epidemic, but both the American Medical Association and the American Dental Association explicitly reaffirmed the duty to treat. Both professional societies appealed to fairness, stating that a patient should not be subjected to discrimination based on any characteristic, including disease status. There is a utilitarian argument to be made in support of this personal risk exception: if a provider treats and subsequently contracts Ebola from one patient, then that provider’s other patients might suffer. However, in the United States, healthcare associated transmission of Ebola remains an incredibly rare event, and a utilitarian analysis does not fall in favor of refusing to treat Ebola patients. Two of the 170+ people who had direct or possible contact with the three Ebola patients from Dallas contracted the virus, and no healthcare provider has died from Ebola transmission in the United States. To put this number in context, an estimated one in ten healthcare workers experiences a needle stick each year, placing them at risk for blood borne pathogens such as HIV and Hepatitis C. Providing care for sick patients inherently carries a certain degree of risk, but so long as providers are able to mitigate that risk through personal protective equipment and standard precautions, this does not excuse them from their professional responsibilities.

In conclusion, the basic principles of medical ethics unequivocally support treatment of Ebola patients. Ebola patients can present in critical condition and require timely medical care, thus placing them in the category of a medical emergency and further obligating providers and hospitals to accept these patients for treatment. Personal risk might be an important consideration, but the risk of transmission can be appropriately mitigated through proper protective equipment in the United States. Ebola patient in room 3? That announcement will never sound routine, but we must treat even these patients fairly and by the highest standards of medical care. 

Avi is currently an MD/MBE candidate at the University of Pennsylvania. She graduated from Vanderbuilt University in 2011 with a degree in biology and philosophy. This post was chosen as a finalist for the 2014-2015 Daniel Callahan Young Writer’s Prize. 

A Misguided Race to Solve the African American Kidney Access Problem

By Pooja Patel

“A renewed trust in inherent racial differences provides a convenient but false explanation for persistent inequities despite the end of de jure discrimination.”           - Dorothy Roberts

African Americans comprise 34% of the kidney transplant waiting list yet they are recipients of only 25% of cadaveric renal transplants and experience a wait time double that of their white counterparts (1;2).  The most popular explanation for this problem is a race-based human leukocyte antigen (HLA) differential.  HLA match is among the criteria used by the United Network for Organ Sharing to assign priority to kidney waiting list members (2).  Race-based HLA studies suggest that African American patients have distinct HLA patterns and are therefore best matched with African American donors (1).  Clinicians thereby mistakenly conclude that the issue of African American access to cadaveric kidneys is intimately tied up with their reluctance to become organ donors.

Using race-based HLA studies to explain the issue of African American access to cadaveric kidneys is problematic.  Race, a social construct, cannot be used to explain biological phenomenon like immunological difference (1).  The use of race in medicine stems from the common understanding that race accurately categorizes people who share distinct physical features.  The idea is that since physical features are genetically inherited, racial categories represent genetically distinct groups of people, thereby giving race a natural place in medicine.  In reality, however, racial boundaries are drawn along historical and sociopolitical lines.  In fact, studies have shown that the genetic difference between members of the same racial groups is comparable to the genetic difference between members of different racial groups (3). This alone disqualifies linkage between race and genetics. 

Race-based HLA studies operate under the same problematic assumptions of race-based medicine in general.  The fact that the researchers determine the race of the participants based on phenotype introduces social and cultural biases into the studies.  There is no scientific mechanism for determining whether an individual is black, white, or a member of any other racial group.  Therefore, clinicians rely only on socially prescribed ideas of what it means to be a member of a particular race phenotypically (1).  For example, conventionally, individuals who are identified as black typically have darker skin than individuals who are identified as white.  A clinician conducting a race-based HLA study must rely on this loose distinction alone when categorizing individuals in a study.  A lack of stringent criteria for differentiating between racial groups invites great potential for error. Further, the use of researchers’ beliefs to assign patient categories is a far cry from the principles of evidence-based medicine in which the scientific community takes immense pride. 

The results of these flawed studies incorrectly demonstrate that the HLA patterns found on the kidneys of white and black patients are significantly different (4).  This implies that a kidney coming from a white donor is unlikely to be a match for a black patient in need of a renal transplant.  Reliance on these studies provides a false but convenient explanation for the high wait times experienced by African American patients on transplant wait lists: because most donors in the registry are white, black ESRD patients are at a disadvantage in terms of organ access because there are not enough donors that are a good immunological match for them (1).    The solution that follows from this logic, then, is to put time and energy into convincing African Americans, who typically have a low organ donation rate, to become organ donors (5). 

However, the fact that African Americans are less likely to donate their organs has little to do with the kidney access problem in the community, demonstrated by long wait times.  This solution will not adequately address the kidney access problem, which likely has roots in social issues. It potentially exacerbates mistrust in the healthcare system based on a history of misinformation, which makes African Americans reluctant to donate in the first place.  It is an attempt to solve a problem deeply rooted in social issues without engaging social problems and relies instead on flawed data to effectively mislead African Americans into serving the needs of organ procurement agencies in the name of directly improving problems in their own communities.  This solution is problematic not because more African American organ donors would be a bad thing, but because it is being touted as a solution for a problem that it may not fix. 

Using race-based HLA studies as evidence for the assertion that increased African American organ donation rates will shorten wait times for African Americans will slow the process of achieving transplant equity.  The appeal to race-based HLA differences also places the burden on African American communities, instead of a potentially unjust healthcare system, for solving the problem of equity in transplant access.  Because race-based HLA studies are flawed, they cannot be used to explain the delays that African Americans experience in receiving cadaveric kidneys once on the wait list.  Thus, it is not certain that increased African American donors will decrease wait list times for African Americans, and it will take time before African American donor levels increase to appreciable levels that demonstrate whether they help with wait times or not.   

Organ procurement agencies use what is essentially propaganda to encourage minority organ donation, asserting that “all individuals waiting for an organ transplant will have a better chance of receiving one if there are large numbers of donors from their racial/ethnic background (6).” It is unfair and ineffective to attempt to change the attitudes of a community that has strong reservations about donating due to a historical mistrust in the healthcare system by ignoring this mistrust and using convenient but misinformed explanations instead.   Today, about thirty-eight percent of African Americans refuse to donate their organs (7).  The most alarming reason for this lack of enthusiasm that regularly appears in the literature is a mistrust of the medical community. 

The results of HLA studies are being used to make it seem as though increasing African American organ donation rates is the key to solving the kidney access problem.  However, like the reluctance of African Americans to become organ donors, the kidney access problem likely has deep social roots and is more complex than a simple case of supply and demand.  Although their intentions may be noble, organ procurement agencies are exploiting African American communities by using the results of race-based HLA studies in this way.  Efforts should be made, instead, to use well designed studies that investigate and address the social issues at the heart of both the kidney access problem and reluctance to donate in the African American community.  

Pooja is a recent graduate of Northwestern University, where she received a B.A. in English Literature.  Her research interests include the causes of health disparities among ethnic and racial groups and health issues pertaining to medically underserved populations. 

References

1. Gordon, EJ. (2002). What “race” cannot tell us about access to kidney transplantation. Cambridge Quarterly of Healthcare Ethics, 11.02, 134-41. 

2. Organ Procurement and Transplantation Network. (2014). OPTN Policies. Retrieved from http://optn.transplant.hrsa.gov/ContentDocuments/OPTN_Policies.pdf#nameddest=Policy_08.

3. Krieger, N., Basset, M. (1986). The health of black folk: disease, class, ideology, in science. Monthly Review, 38.3, 74-85.

4. Mori, M., Beatty, PG., Graves, M., Boucher, KM., Milford, EL. (1997). Hla gene and haplotype frequencies in the North American population: the national marrow donor program donor registry. Transplantation, 64.7, 1017-027.

5. Kasiske, BL., Neylan, JF., Riggio, RR., Danovitch, GM., Kahana, L., et al. (1991). The effect of race on access and outcome in transplantation. New England Journal of Medicine, 324.5, 302-07.

6. U.S Department of Health and Human Services. (2014). Why Minority Donors are Needed. Retrieved from http://www.organdonor.gov/whydonate/minorities.html

7. Minniefield, WJ., Yang, J., Muti, P. (2001). Differences in attitudes toward organ donation among African Americans and whites in the United Sates. Journal of the National Medical Association. 93.10. 372-79. 

Daniel Callahan Young Writer's Prize Winner

Congratulations to Michelle Bayefsky on winning the first Daniel Callahan Young Writer's Prize! Michelle will be receiving the prize award of $500 and a copy of Daniel Callahan's autobiography, In Search of the Good: A Life in Bioethics. Thank you to the finalist judges, Daniel Callahan, Michael Gusmano, and Laura Haupt (their bios can be found here). 

Uterine Transplant: Where, If Anywhere, Should We Draw the Line?
By Michelle Bayefsky

In October 2014, researchers from the University of Gothenburg in Sweden reported the first case of a live birth following a uterine transplant. The uterus was transplanted from a postmenopausal woman into a 36 year-old woman born without a uterus. At nearly 32 weeks of pregnancy, she gave birth to a male child with normal birth weight for gestational age and excellent APGAR scores.[1]

The birth of this child represents a tremendous breakthrough in the treatment of infertility. There are many causes of female infertility, including damaged fallopian tubes, premature menopause and endometrial (uterine tissue) abnormalities. Corresponding treatments include in vitro fertilization, use of donor eggs, and use of a gestational surrogate. Uterine transplantation could obviate the need for gestational surrogates for patients with uterine infertility, allowing these mothers-to-be to carry their own pregnancies and potentially precipitating a decline of the controversial practice of surrogacy.

But why stop there? If uterine transplantation is a treatment for absolute uterine infertility, trans-women also have this condition, and so do all men. In this essay, I will explore whether and where to draw the line for those who should be eligible for a uterine transplant.

It is not yet possible for individuals with XY sex chromosomes to gestate a child. However, the desire for transgender women to carry a pregnancy is present,[2] and at least one bioethicist, Timothy Murphy, has begun to think about the prospect of uterine transplants into trans-women.[3] Murphy correctly focuses on state funding, since the hands-off regulatory attitude towards reproductive medicine in the United States[4] makes it unlikely that transgender uterine transplants would be banned outright. The debate about the appropriateness of transgender uterine transplants will therefore center on the need to prioritize limited healthcare resources.[5]

There are two central questions at stake. First, is there such a thing as a right to a uterine transplant? Second, is there a reason to distinguish between cis-women, trans-women, and men with regards to their claims to a uterine transplant, whether or not rights are at stake? If so, the state could be justified in prioritizing the needs of cis-women over trans-women over men who desire to gestate a child.

Uteruses are a scarce resource, and the state cannot ensure uteruses to all those who might lack and strongly desire them. It is therefore difficult to claim that people have a right to a uterine transplant, though they may have a right to fair access to an established supply of uteruses, should one come to exist. The scarcity issue is compounded by the fact that uteruses, like other organs, exist within other people’s bodies. Unless a sufficient number of uteruses are supplied via donation, claiming a right to a uterine transplant would be claiming a right to someone else’s body part. One could conceive of body parts as public goods, but such a view would violate our closely held beliefs about bodily autonomy. Since the state cannot forcibly redistribute organs, the right to a uterus can only be a right in an abstract sense. Nevertheless, the relative strength of claims to this abstract right can be used to determine what constitutes fair access to the limited supply of uteruses. Who, if anyone, should be prioritized?

Answering this question requires that we carefully examine our notions of infertility and instincts about childbearing. Intuitively, we might think there are reasons to differentiate among cis-women, trans-women, and men based on physical features and what it means to be “infertile.” For instance, it may be tempting to argue that cis-women without uteruses are infertile because they lack the typical reproductive organs of an XX-woman, while trans-women and men are fertile because they can still use sperm to ‘father’ children in the classic XY manner. However, all three categories are fertile in terms of their gametic capacity to reproduce but infertile with regards to the capacity to gestate.

One might also attempt to argue that women, whether cis or trans, have a stronger claim to the experience of carrying a child because it is typically a woman’s experience and part of being female. However, many women choose not to have children and are not lesser women because of it. Furthermore, arguments about childbearing based on assumptions about what it means to be a woman risk unjustly imposing societal norms and expectations on women, both cis and trans.

It may seem that distinctions among the three groups most plausibly rely on assertions relating to the prospective happiness of the transplant recipient. It is possible that cis-women have greater childbearing expectations, and would be most anguished by the inability to carry a pregnancy and should thus be given highest priority. Similarly, trans-women, who identify as the sex that typically bears children, may be more anguished than a self-identifying man. It is easy to imagine, though, a trans-woman who has always longed to gestate a child, or even a man with a very strong desire to carry a child, who would suffer deeply if they could not obtain a uterine transplant – even more than some cis-women without functional uteruses. Thus psychological impact could not reliably be used to distinguish among the three groups.

Ultimately, a priori distinctions could most reasonably be made on the basis of differential resource expenditure. If uterine transplantation is significantly easier, more successful or less expensive in a cis-woman, or a trans-woman who has undergone hormone therapy, this justifies prioritizing these groups the same way recipients are prioritized in the donation of other organs.[6]

Realistically, given the general lack of coverage for fertility services in the United States,[7] it is unlikely that either cis or trans-gender uterine transplants will be funded in the near future.

However, if uterine transplants do receive public funding and transplants into XY women and men are equally successful and no more economically burdensome than transplants into XX women, trans-women, as well as men with a profound desire to gestate, should be equally eligible to receive a uterine transplant.

Michelle Bayefsky is a first-year pre-doctoral fellow in the Department of Bioethics for the National Institutes of Health. She graduated from Yale University in 2014 with a B.A. in Ethics, Politics and Economics. She worked as a research assistant for two consecutive directors of the Yale Interdisciplinary Center for Bioethics. She also founded and served as Editor-in-Chief of the Yale Bioethics Journal. Michelle currently investigates ethical challenges posed by innovations in genetic technology, issues related to the regulation of genetic testing, and questions that arise at the intersection of genetics and reproductive medicine.
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[1] Brännström, M., L. Johannesson, et al. (2014). "Livebirth after uterus transplantation." The Lancet.

[2] Mott, Stephanie. "Trans-Uterus." The Huffington Post. TheHuffingtonPost.com, 21 Jan. 2014. Web. 14 Nov. 2014.

[3] Murphy, Timothy. "The Ethics of Helping Transgender Men and Women Have Children." Perspectives in Biology and Medicine 53.1 (2010): 46-60.

[4] Leigh, Suzanne. "Reproductive 'tourism'" USA Today - Health and Behavior. USATODAY.com, 02 May 2005. Web. 19 Sept. 2014; Williams, Benjamin. "Screening for Children: Choice and Chance in the “Wild West” of Reproductive Medicine." George Washington Law Review 79.4 (2011): 1305-342.

[5] Murphy, Timothy. "Uterus Transplants for Transgender Women?" Weblog post. Ethics and Choices about Children. Timothyfmurphy.blogspot.com, 27 Apr. 2014. Web. 14 Nov. 2014.

[6] The use of cost-effectiveness arguments in prioritizing organ transplantation is itself controversial (see, for example, Dan Brock, “Ethical Issues in the Use of Cost Effectiveness Analysis for the Prioritisation of Health Care Resources”), but I cannot explore this issue here.

[7] "State Laws Related To Insurance Coverage for Infertility Treatment." Insurance Coverage for Infertility Laws. National Conference of State Legislatures, Jun. 2014. Web. 12 Nov. 2014.

Congratulations Finalists

Thank you to every person who submitted to the Daniel Callahan Young Writers Prize! There were nearly thirty excellent submissions and the five finalists have been chosen. 

Their essays will be read by the following panel of judges:

Daniel Callahan, PhD-- As President Emeritus and co-founder of The Hastings Center, Callahan helped shape the bioethics field. He has written over 47 books and has had hundreds of peer-reviewed publications and op-eds. 

Michael K. Gusmano, PhD-- Gusmano is a a political scientist who holds adjunct appointments at Columbia University and Yale University and is a Research Scholar at The Hastings Center. He has published widely in the areas of health policy, aging, and comparative welfare state analysis.

Laura Haupt, M.A.-- Haupt is the Managing Editor for two peer-reviewed bioethics journals, the Hastings Center Report and IRB: Ethics and Human Research. Her background is in English literature and she has helped edit a number of special reports for the Hastings Center Report, including LGBT Bioethic: Visibility, Disparities, and Dialogue. 

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Daniel Callahan Young Writer's Prize Finalists

Avigile Baehr, MD/MBE Candidate, University of Pennsylvania

"DNR Ebola: Is There a Professional Obligation to Provide Treatment?"

Michelle Bayefsky, Pre-Doctoral Fellow, NIH Department of Bioethics

"Uterine Transplant: Where, If Anywhere, Should We Draw the Line?"

Rachel Conrad, MD Candidate, Baylor College of Medicine

"The Ethical Crisis in Medical Training"

Michael DiStefano, Research Assistant, University of Pennsylvania

"Religious Values and Refusal of Highly Effective Life-Saving Treatment by Minors"

Tim Rubbelke, PhD Candidate, St. Louis University Center for Healthcare Ethics

"The Paradox of Government Vaccine Mandates" 

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

We anticipate an announcement of the winner in mid-January. Thank you again to all the participants, we look forward to posting some of the other compelling submissions to this blog in the coming months. There were far more fantastic entries than could be chosen. 

Deadline Approaching

The deadline to submit for the Daniel Callahan Young Writer's Prize is this Saturday, November 15th. Below is a summary of the contest and the guidelines for submission. Don't forget to submit!

Prize Summary 
This post is pleased to announce a new award, The Daniel Callahan Young Writer's Prize, sponsored by Daniel Callahan. Submissions will take the form of essays on a bioethics topic that are written as blog posts, designed for this blog, Bioethx Under 25. From all submissions, a group of finalists will be chosen and then an expert panel of bioethicists, including Daniel Callahan, will read the finalists' essays and award one prize amounting to $500. 

All submissions will be considered for publication on the blog and eligibility to be a finalist or receive the prize is dependent on willingness to edit and revise the essay for publication. Submissions will be judged anonymously. Please see guidelines below for further information. 

Prize Submission Guidelines

- Essays must be 500-1000 words and original submissions to Bioethx Under 25 i.e. never posted before on the blog. 

- Essays must conform to all other submission guidelines for the Bioethx Under 25 blog and thus, be clearly related to bioethics and be written in an accessible manner. Please refer to the blog's About Page for more information. 

- Essays will be accepted from September 10th, 2014 to November 15th, 2014. 

- Any writer who is also a student in high school, college, or a graduate program is eligible to submit. Any writer who is not a student is eligible so long as he/she has not completed a PhD and/or worked more than 5 years in the bioethics field with a terminal degree (e.g. JD or MD). So long as the other guidelines have been met there is no age limitation or requirement for submission. 

- Writers are not eligible if they currently or have previously worked full time for The Hastings Center or Daniel Callahan. Anyone affiliated with Bioethx Under 25 in an editing capacity is also ineligible. 

- To submit, please email bioethicsunder25@gmail.com with your essay attached in word format. In the body of the email please indicate that you are submitting for The Daniel Callahan Young Writers Prize and include your name, phone number, email address, current occupation and place of occupation (if a student, then your school, potential degree, and expected graduation year), and your highest degree attained with the school and year. 

- For any questions please email bioethicsunder25@gmail.com or comment below. 

Paws and Talk About Cost

By Chelsea A. Jack

“The capacity for suffering and enjoying things is a prerequisite for having interests at all, a condition that must be satisfied before we can speak of interests in any meaningful way,” –Peter Singer

Singer has argued for the equitable and fair treatment of animals based on their ability to suffer in ways similar to humans. I wonder if, in some circumstances, ill pets are treated more humanely in times of crisis than their human counterparts.

Daniel Callahan, co-founder of The Hastings Center, has thoughtfully written on how Americans view cost as a morally acceptable factor in decision-making when it comes to the death of a pet, but not always the death of a human loved one.  Veterinary doctors are not only willing to explain a patient’s prognosis, but also the financial costs for a family choosing among various treatment options for their pet. The reason for this seems to be that conversations about end-of-life decision-making come more easily in the context of veterinary care than when the patient in question is a human loved one. Because medical doctors are often reluctant to talk about end-of-life care with their patients, conversations about the financial costs of such care do not occur either. This is not necessarily the case with veterinary care, where, if anything, vets go out of the way to prepare families for the likelihood of death – and its costs. With both human and non-human patients facing illness, the financial costs of care can be startling and deeply upsetting. Callahan has asked how medical doctors might deliver care options to patients in the way his family’s vet did: “beautifully integrat[ing] money, medical candor, and compassion.”

I found myself considering Callahan’s reflection on the death of his own Cavalier King Charles as I sat in the waiting room of the VCA Animal Specialty & Emergency Center in Wappingers Falls, New York a few weeks ago. In no more than three minutes, my beloved 8-month-old Boxer-Pit mix named Trapper – after MASH 4077’s Trapper John, MD – ventured away from me with another canine companion during a cookout with my neighbors. He played leap frog in-between cars speeding down a nearby highway. When I realized he was gone, I ran down to the road with an ominous feeling in my gut. After calling his name for a minute, an adrenaline-charged Trapper came bolting up from the highway and collapsed at my feet completely out of breath. He had deep abrasions along his front-left paw, which was visibly knotted, and, as the adrenaline wore off, he could barely stand, even though he remained stoically silent with his ears back and eyes locked to my face.

I broke every speed limit on the way to the emergency care center where Trapper went into shock and began convulsing. Exchanging worried glances, the nurses quickly carried him away from me into another room where they attempted to stabilize him.

Immediately, but kindly, a nurse presented me with a series of consent forms and unsettling numbers: Was I okay with paying $400-600 to stabilize Trapper? Did I want them to try and resuscitate Trapper if his heart stopped, even if it meant spending $500 on a procedure with a success rate around 17 percent? Did I consent to the three recommended x-rays of his front-left leg, chest, and hips, which would approach $400 – without factoring in the possibility of further x-rays later over the next 24 hours? There was a possibility that Trapper would pass away due to contusions in his lungs – did I want to keep him overnight for monitoring even if that was another $200? Did I want to see the credit plan offered for 12 months without interest for patients who cannot afford expensive high-quality care?

Throughout the whole nightmare, the doctors and nurses presented each decision-making scenario with at least two options: cost projections for the “ideal” treatment plan versus the “less-ideal” treatment plan. As I weighed these projections, I thought how the word “ideal” places a nontrivial degree of guilt onto the decision-maker who opts for the less-ideal options. It problematically values the more costly decision as morally preferable, even when this might not accurately reflect the moral landscape – marked by competing financial obligations – in which real-time decisions are made.

Individuals and families (more often than not) cannot isolate an immediate, short-term moral decision from the other long-term ones lingering in the background. For example, as I weighed the two treatment plans presented to me, I thought, “I have signed a lease committing me to pay $X/month. I love my apartment and cannot legally break this lease agreement, and I cannot emotionally or financially afford to forfeit my living situation even if it means that Trapper has to receive the 'less-ideal' treatment plan". As a recent post-grad, I weighed the costs of fulfilling one long-term goal (i.e. living happily in my new home) against the costs of fulfilling my obligations to care for Trapper as my pet who was facing a health crisis. Committed and interdependent moral agents are forced to make these kinds of decisions every day. In my case, it was productive to not only have Trapper’s physician initiate a conversation about our end-of-life preferences, but also address possible treatment options and possible costs. 

Miraculously, Trapper is expected to make a full recovery and came  home from the emergency care center after 24 hours of observation. I’ll borrow Callahan’s language to describe my own personal take-away from this ordeal: Trapper’s care team embodied those qualities that “we might hope for from a doctor for our care, but by no means yet reliably available” in the human medical context.

Chelsea is a Research Assistant at The Hastings Center. She graduated with highest distinction from the University of Virginia, where she received a B.A. in political and social thought and anthropology with a minor in bioethics. Her research interests include medical and legal anthropology, political and social theory, bioethics, and contemporary feminist thought. 

A Minor Case for Existentialism in Biosemiotics

By Matthew Cuffaro

“Existentialism protests the rationalism and idealism who would see man creatures only as a subject—that is, as having reality as a thinking being.” p. 12 Angel, Ellenberger, May, Existence: A New Dimension in Psychiatry in Psychology.

The following argument advocates existentialism in biosemiotics to the reader of this blog—presumably up-and-coming bioethicists—to mull over how an existentialist understanding of biosemiotics is relevant to considering the ethics of medicine and health, environment, etc.

What biosemiotics is, how it can integrate existential thought, and how it relates to the bioethicist is a major concern: the predisposition to think of animal cognition and decision-making as purely genetic impedes our attempts, as organisms “creative past our genes”, to identify with animals, if not the biological world. In fact, you can derive the entire motivation and most of the points from the first page of the preface in J. Hoffmeyer’s Biosemiotics. Hoffmeyer’s writing is beautifully lucid and recommended to the readers, but it will be kept short so the existential argument may be covered.

To begin, the crux of contemporary biosemiotics can be understood as the disbelief that organic communication is merely “mechanical.”

What J. Hoffmeyer, Biosemiotician, offers:

With the current outlook, other organisms remain empathetically inaccessible—they are separated by a gulch of misunderstanding or anthropocentrism. We are still surprised when new research reveals “human” emotions (grieving) in animals. Perhaps the difficulty of stationing “complex” emotions in cultural terms—terms not patently equivalent to a notion of a general animal culture—perpetuates this idea.

Partially the mechanical explanation is to blame from theoretical biology’s honest expedition to resolve the problem.[1] The complete genome is an enticing structure; it is not hard to imagine that a reductive appetency towards a promise of rich structural coding creates a tendency to “delegate to [the animal’s] genetic apparatus” the complete spectrum of their ethology as well. This continually denies the creature the evolutionary merit of having an intellectual middle-man. Hoffmeyer uses this example to describe the creative semiotic faculty of the animal:

“When a brown hare spots a fox approaching in the open landscape, the hare stands bolt upright and signals its presence instead of fleeing…ethologist A. Holley [claims that the] hare can easily scape a fox simply by running – a fact that the fox seems to ‘know.’”.

The hare signals the fox that it has been spotted, and so subverting the actual use of its physiological advantages. The quick legs of the hare begin to have a more symbolic importance to the hare that tries to remove the need of their use.

Perhaps we can assume that a being capable of understanding not just their asset’s advantage, but what the asset means for it, is to imply that the genetic body of the hare is interpreted and communicated to other animals by a being that can experience itself.

The hare capable of interpreting and communicating itself must recognize the significance of itself in sustaining its life. We suppose that the hare has not just experienced life but is capable of commuting its interpretations into actions fundamentally significant to its survival, e.g. signaling the fox. The hare is striving to exist, and so it is exercising a creative faculty to mediate itself with the environment.

To account for the experiential and concomitant existential[2] questions that would crop up if Hoffmeyer and Co.[3] had their way, I sketch in the sand existential biosemiotics (EBS) to take up the burden.

           

What Existential Biosemiotics offers:

The overt task for existential biosemiotics is to extend semiotic theory, or the study of signs—“things that refer to something else”—into the domain of experience. We may formulate this project to coincide Merleau-Ponty’s phenomenology with scientific knowledge under a common metalanguage. Hoffmeyer lobs us a notion of biological referentiality to organize the analyses of the organism’s relation to itself. In the case of the hare above, the hare’s reference to itself is tickled by a suppression of its internal or bodily ability to run (which it is genetically equipped to do well) in light of an external threat.

If we take seriously a creative faculty in the animal, then there is, in the fabric of experience, certain semiotic weights that give it shape. The EBStian would deal with identifying the significant[4] structure underlying shaped experience. In other words, how a bundle of signs (e.g. a predator, a potential mate, a hare’s leg, the arrangement of a room) designs the world of the experiencing organism, or á la Hoffmeyer, how the “ubiquitous intentionality of communicative behavior” is articulated, and how these decisions that govern the total and embodied experience of the creature (e.g. run very fast, a sense of peace in a clean room) have a conjugate physical response (e.g. mad adrenaline rushes through the prairie, muscular relaxation etc.) and vice versa (how does a particular space become associated with my impressions of it, my gut feeling, etc.?).

The biosemiotician in this scope hopes to demonstrate that communicative and behavioral similarities between organisms enriches approaches to interact, understand, and imagine the biological sciences.

Matthew Cuffaro is a philosophy student at the University of South Florida with a concentration in the philosophies of mathematics and religious studies. 

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[1] Conway’s Game of Life, for instance, illustrates evolutionary “life” as a series of small-order recursive processes that, with special initial states and a sufficient run-time, can construct superstructures that remind us of genetic transcriptions. Check it out here.

[2] Mind you, “existential” here brackets the organism’s self-consciousness of mortality; “There, organisms never ‘try to survive’–for the simple reason that they cannot know they are going to die.” Instead, viz. generalize “existential” to the organism by its own presumed agency making decisions not to avoid death but to continue life.

[3] Biosemioticians such as Emmeche, Merrill, Rigby, Seboek, Uexkill, &c.

[4] Pertaining to signs. Semiotics may be argued as a science that identifies the significant aspects in a scene caveat emptor, tread lightly.