Bioethics is biopolitics

Kathryn Hinsch, founder of the Women's Bioethics Project and the Women's Bioethics Blog recommended the questions and answers from an article by Joshua Perry published in the Journal of Legal Medicine. (It cost $32 to access - perhaps we ought to talk about open access in publishing.)

Perry notes that others have noted that bioethics has always been "biopolitics," it just took a while for the political angle to "arrest the attention of so many commentators."

In the introductory essay to the June 2006 issue of the Journal of Medicine and Philosophy, Jeffrey P. Bishop and Fabrice Jotterand note: “Bioethics has always been a biopolitics and the political dimension is only now coming into relief for bioethicists.” Writing in the May-June 2006 issue of the Hastings Center Report, Jeffrey Kahn echoes this sentiment when he comments: “Bioethics has always been involved in policy issues and the politics surrounding them.” So, despite a history of political intersections, why has bioethics and its entanglement with politics only recently arrested the attention of so many commentators?

The attention shouldn't surprise anyone. Multiple events have worked together to increase public attention on bioethics questions. Along with the evolution of medical technology and expectations in the treatment of patients who once would have died, the backlash against Roe v. Wade juxtaposed with assisted reproductive techniques, the "right to die" movement alongside of the advance directive, there's also the emergence of the internet and instant communication that is both personal and impersonal.

Oh, and there was the creation of Dolly the cloned sheep and Hwang Wu Suk, the "rock star" cloner turned fake.

There's also the insular nature of the community of bioethics, which I believe actually limits the debate. Don't look for a single "anti-abortion" much less "pro-life" viewpoint in the lists of contributors at the Women's Bioethics Blog site or the editors and pseudoeditors who post at the blog of the American Journal Of Bioethics. I'm not sure there's a conservative on the lists, and can identify only 2 or 3 that self-identify as believers. William Saletan's much commented about article this month pointed me to Dan Callahan and other's comments on the politicization of bioethics, including the exclusion of conservatives and religious ethicists, and the notion of "Progressive Bioethics."

CALLAHAN: Just first a comment on John’s thesis. I would say my hardest struggle at the Hastings Center – I ran the place for 27 years; my hardest struggle was getting the secular philosophers to even allow a theologian, liberal or conservative, to even come to our meetings. Again and again I would say, what about so-and-so? No, no theologians. And the thing that was very striking, how many of the secular philosophers, particularly analytically trained, were extraordinarily hostile to religion. And I just fought year after year saying, let’s get some in and they just wouldn’t – I mean, I did it because I ran the place, but they were usually unhappy. (Laughter.)
But I have a question for Eric. This is an interesting political question. As many of you know, one of the sharper criticisms of Leon Kass’s council was that it did not take up questions of health policy and the whole problem of the uninsured. Now, interestingly enough, neither did NBAC take those up, but nobody dumped on them for not taking it up. But I was told that NBAC was told – instructed not to take up those issues, which if true was a gratuitously political command.

Eric Meslin answered that he never received any commands not to take up any issues, but he did relate an incident when he and NBAC Commissioner Jim Childress were told by National Institute of Health officials that the NIH was "concerned" that the NBAC would propose regulations that would slow research.

It wasn’t a threat. It wasn’t – it was, we were invited to dinner – box lunch. (Laughter.) I wasn’t very hungry at the end of it.

Nevertheless, I don't believe that there was much room for dissenters among the members of Clinton's National Bioethics Advisory Commission. Who on the NBAC could be compared to Gazzaniga or Blackburn in the President's Bioethics Council?

And I didn't notice any objection to Alta Charo's politicization of her luncheon talk, using terms like "endarkenment" and personally attacking Wesley Smith, who was in the audience at that July 06 "Bioethics and Politics" conference in Albany.

Ethics, embryos, and e-rants

Kevin T Keith (His often profane blog, Sufficient Scruples, focusing on why it's wrong to be religious, pro-life or pro-abstinence is here) wonders (in 1700+ words) how scientists ever began to speak in terms of "ethical" and "unethical" about sources of stem cells at the Women's Bioethics Blog:

To emphasize that: the search for "ethical" stem cells has no importance whatsoever, other than the fact that it responds to objections raised by a certain segment of the religious right and grounded on their religous (sic)beliefs. There is no need for them otherwise, and they are less desirable therapeutically than the already-available alternative of actual embryonic stem cells. Such lines of research, and the diversion of time and resources they represent, have no point unless that religious objection is demonstrated to be a compelling moral claim.(Italics in the original)

Let's forget that embryos require that oocytes be harvested from women, risking their health or that embryonic stem cells from embryos created by in vitro fertilization can never be "patient-specific" until and if human cloning is perfected. Let's forget growing evidence that the differentiation of stem cells is dependent on local factors and conditions - the 'niche' in which the cells are found. And, along with Kevin, we can forget that there are in fact people who object to the destruction of human embryos without a religious objection.

Let's look at the question of applying the concept of ethics to research.

Kevin obviously has very strong feelings that there is a right side and a wrong in determining whether or not destructive embryonic research is "ethical."

Isn't the act of determining one position right and others find that position wrong making "ethical" or "moral" decisions?

Sam Harris at the Aspen Ideas Festival

Sam Harris, author of the books, The End of Faith: Religion, Terror, and the Future of Reason and Letter to a Christian Nation, was given a forum at the Aspen Ideas Festival. I'm not sure how I ended up finding the video, "Believing the Unbelievable: The Clash Between Faith and Reason in the Modern World," but I believe I was referred by one of the Science Blog forums. I can't remember which one, and, as far as I can tell, only one of these blogs is owned by a believer.

Which is probably how I got lost. There's a bit of a row, right now, concerning the derision of believers by "Pharyngula." (Which is surprising, since that seems to be his purpose in blogging.) I was once again struck by the idea that science and religion are incompatible, chased some links, and ended up watching a video from the Festival.

Mr. Harris spent his time at the Festival blurring the edges between “Christianity, Judaism, and Islam,” with a little Hinduism and Buddha thrown in to strengthen his point. There doesn’t seem to be any difference in his viewpoint, although he does grudgingly admit to a questioner that “moderate” Christians and Jews have been influenced by the belief in human rights and equality by secular, outside influences, while Muslims have remained isolated and so have not “evolved.”

Beyond the fallacy of treating all religions as one, Mr. Harris denies that atheism is a religion, using his second favorite technique, mockery and one liners designed to encourage his listeners to laugh with him. He mocks the Second Commandment: “Is this as good as it gets? . . . How about, ‘don’t deep fry all of your food?’” and mocks the idea that agnostics are a separate from believers and atheists by saying, “I haven’t met too many agnostics about Zeus.”

The biggest logical fallacy in which Harris engages is his statement that religions change from without, due to secular ideas about human rights. In fact, the Judeo-Christian tradition teaches that we are all created in the image of God.

While Christians have cited the fact that very young children naturally display concern for others and seem to understand the concepts of justice and beauty as proof of God, Mr. Harris believes that this actually disproves the “usefulness” of religion. While he admits that 70% of (I presume, U.S.) college graduates believe in the Biblical God, he strongly commends “peer review” in science.

His major point seems to be that “much of the Bible and Koran is life-destroying gibberish.” He dismisses the rest. While he insists that believers who promote their religions or teach their children to follow them are enabling religious fanatics who kill in the name of religion, shouldn’t Harris, who has been called an "Atheist Evangelist" take responsibility for enabling those who kill and enslave to suppress religion, as in China? Or the Western academic powers that be that harass, deny recommendations, employment and funding to those who fall out of favor, such as Richard Sternberg (see the review at Sternberg's site and at National Public Radio)?

Sam Harris, author of the books, The End of Faith: Religion, Terror, and the Future of Reason and Letter to a Christian Nation, was given a forum at the Aspen Ideas Festival. I'm not sure how I ended up finding the video, "Believing the Unbelievable: The Clash Between Faith and Reason in the Modern World,"but I believe I was referred by one of the Science Blog forums. I can't remember which one, and, as far as I can tell, only one is owned by a believer.

Harris spent his time at the Festival blurring the edges between “Christianity, Judaism, and Islam,” with a little Hinduism and Buddha thrown in to strengthen his point. There doesn’t seem to be any difference in his viewpoint, although he does grudgingly admit to a questioner that “moderate” Christians and Jews have been influenced by the belief in human rights and equality by secular, outside influences, while Muslims have remained isolated and so have not “evolved.”

Beyond the fallacy of treating all religions as one, Mr. Harris denies that atheism is a religion, using his second favorite technique, mockery and one liners designed to encourage his listeners to laugh with him. He mocks the Second Commandment: “Is this as good as it gets? . . . How about, ‘don’t deep fry all of your food?’” and mocks the idea that agnostics are a separate from believers and atheists by saying, “I haven’t met too many agnostics about Zeus.”

The biggest logical fallacy in which Harris engages is his statement that religions change from without, due to secular ideas about human rights. In fact, the Judeo-Christian tradition teaches that we are all created in the image of God.

While Christians have cited the fact that very young children naturally display concern for others and seem to understand the concepts of justice and beauty as proof of God, Mr. Harris believes that this actually disproves the “usefulness” of religion. While he admits that 70% of (I presume, U.S.) college graduates believe in the Biblical God, he strongly commends “peer review” in science.

His major point seems to be that “much of the Bible and Koran is life-destroying gibberish.” While he insists that believers who promote their religions or teach their children to follow them are enabling religious fanatics who kill in the name of religion, shouldn’t Harris, who has been called an "Atheist Evangelist" (and Dawkins and Hitchens, etc.) take responsibility for enabling those who kill and enslave to suppress religions, as in China? Or the Western academic powers that be that harass, deny recommendations, employment and funding to those who fall out of favor, such as Richard Sternberg (see the review at Sternberg's site and at National Public Radio)?

Saletan stirs up bioethics, blog

Wesley Smith's "Secondhand Smoke" and Science Blog's "Denialism Blog" both comment on William Saletan's latest Slate column, "Rights and Wrongs: Liberals, progressives, and biotechnology."

I have to admit, that while I find Saletan slightly disorganized at times, he manages to make quite a few people disagree with him, and does it so well.

You need to read the actual Saletan piece, as well as the comments on the two blogs.

For what it's worth, here's part of my contribution to the conversation at the "Denialism Blog," where Mark Hoofnagle, an MD/Ph.D student, proves that we shouldn't "mistake denialism for debate:"

You obviously feel very strongly that there's some quality in humanity that can be diminished, but you continue to mix "defining life" with a request to define the characteristics that you personally believe constitute "humanity" or a "person."

Let's begin from the assumption that whatever it is that you feel can be diminished in humanity or that can cause you moral repugnance doesn't come from a religious belief. Perhaps it's empathy, imagination or simple learning from the history of humanity.

There's a distinction between the cell produced by fertilization (a more accurate term than "conception"), parthenogenesis, or the various ways to reprogram somatic cells and other cells or groups of cells. It's the same organization and integrated functioning that is lost at whole brain death with current technology. That's why you work with embryos rather than gametes, and why Lee Silver's comment about teratomas is incorrect.

History tells us - this thread reinforces - that when we begin with one point of discrimination allowing intentional acts that disrupt the life span of an individual or groups of individuals, the lines of demarcation are "fuzzy."

By the way, is that "William" who posted a comment, the William, Saletan himself?

"Exaggerated resistance" (Or how not to report science)

Scientific American gives us several reasons to "resist" the information in its pages this month, the August, 2007 issue. Unfortunately, only the Table of Contents is free, but the problem is in the titles given "news" stories themselves.

Under the title, "Roots of Science Hatred," on page 29 we learn that people learn to trust their own experiences, causing us to have "exaggerated resistance" to scientific reports:

For instance, because objects fall down if not held up, kids may have trouble accepting
the world is round, reasoning that things on the other side should naturally fall off.
Intuitive notions concerning psychology also lead children to see everything as designed for some reason—for example, a cloud’s purpose might be to rain—which can lead to opposition to evolution. In reportingtheir work in the May 18 Science, the researchers also note that when both adults and kids obtain knowledge from others, they judge claims based on how much they trust the source of an assertion. It suggests that science will meet exaggerated resistance in societies where alternative views are championed by trustworthy authorities, such as political or religious figures. —Charles Q. Choi (emphasis is mine)

Yeah, and the exaggeration is all on our part, and due to "hate," "religion," and "politics," right?

Since SA can't be engaging in politics, then only someone inclined to hate science would notice the problem with the following headline on page 32: "SciAm Perspectives: Worse Than Gasoline: Liquid coal would produce roughly twice the global warming emissions of gasoline." Couldn't they have used the more correct and less political term, "green house gasses?"

Yes, I'll admit to being a human-caused-global-climate-change skeptic. I remember the '60's and early '70's, when we humans were told that we were the cause of global cooling. I believe it had something to do with clouds blocking the sun's radiation from warming the earth. I'm watching and waiting, although I've always believed in keeping my little micro-climate as clean as possible..


However, for a review of the current "consensus" on global climate change, those of you with access to SA can read "The Physical Science behind CLIMATE CHANGE" (all caps in the original), beginning on page 64.

Fashion, style, modern love and abortion

The New York Times editorial staff has once again descended to a new low. Perhaps their intent is to demean "modern love," pregnancy, and the "choice" of whether or not to abort a child. Today's "Fashion and Style - Modern Love" section presents us with "Would Our Two New Lives Include a Third?," the story about one woman's decision to forgo an abortion and have her baby. (The article is accompanied by the graphic, above, of a blind-folded woman and a pinata - in the shape of a baby.)

Thankfully, the author decided to "keep it," and convinced her husband that the child would not get in the way of their plans and life "Style."

Despite the final, mature decision by the couple, I was brought to tears by the essay that seemed to weigh the life of a child against his mother's and father's age, marital status, career plans, and politics. It struck me that, although the decision seemed to be the mother's choice, she felt pressure to defer to the decision of the father, even against what she reports as her own growing wish to protect her baby. Until I realized that the piece was published in the "Fashion and Style" section, under "modern love," I intended to write about the difficulty created by teaching that a child is a "choice" that can be weighed against careers and previous choices and that deliberations about that choice threatens marital unity much more than the actual changes a new baby brings with him.

The shallow treatment of the story by the NYT is a true reflection of the environment in which these two people were forced to make this "choice."

"Real-life male pregnancy would be revolutionary

Or, "gender in a blender."

Can someone give me a "duh"??

Jen Graves, of the (adults only) Seattle Stranger, has written a very long and informative essay on pregnancy, women, and men - especially the possibility of men becoming pregnant. Trust me, we have the technology.

As a matter of fact, Ms. Graves tells us that there have been over 200 ectopic, abdominal pregnancies in the last 20 years: where women (still) have had babies implant on their intestine or abdominal walls and both the babies and their mothers survived.

I am impressed that Ms. Graves calls her baby a baby (because he or she had a heatbeat - and I should write her and tell her that until 8 weeks, the child was an "embryo," not a "fetus" - but most of us call them "babies"), no matter how wrong it might seem to others from a political correctness factor. I can identify with her wish to make permanent and public her exclusive relation ship with her "partner," Patrick. I am so sorry that she lost her first pregnancy in the first month or so, that she mourns that baby, that people expect her (like all of us who have lost a baby before birth) to get over it and get pregnant (at least partly to replace the lost child).I hate it that her friend, Linda's baby ,Patrick, died so young of bacterial meningitis.

She shows her love and confusion and Patrick's incredible patience and insight by describing their conversations and text messaging over the possibility of his becoming pregnant with "her" child.

I'm seriously impressed with Patrick. Not because he considers or because he rejects the idea of having a child implanted within his abdominal cavity, taking female hormones and/or having a planned C-section. I'm impressed that he can bear the stress the whole conversation must place on his own gender identity that his "partner" wrote this article for publication and considers herself to more typically follow the pattern society expects of fathers than of women. (Yes, of course she implies that mothers are inferior and subservient to the role of motherhood.)
And I love "what if" stories.

However, the over all impression that I get - even though I want to give her all the credit I can for her grief - is that of a selfish, self-centered woman who should be neither mother or father with this attitude toward parenting. Being the polly-anna that I am - and with the deep seated belief that we humans are well suited - designed or evolved, if you will - to parent and love our children -- and with my very sexist idea that women are either naturally or "nurturally" susceptible to gushing over and eventually falling in love with small humans, I'm convinced that she would have more jealousy and resentment of Patrick's status as child-bearer than she could ever imagine.

Go read it - it's not much longer than my post!

Global Warming: No Debate? (Reporting bias)

Just one more example of the effects of reporting bias in the scientific literature - and another warning to be wary, even about "consensus."

The journal, Nature, now reviews its own blogs on a web page titled the "From the blogosphere,"a subheading of the "Author" web page., on the homepage of the journal's website. The "From the blogosphere" heading was on this morning's "headlines" that were chosen by my Google search page. Unfortunately, the blogs are behind a paywall.

One of the blogs, "Peer-to-peer: for peer-reviewers and about peer review" has a discussion about the controversy over a meta-analysis published in Science magazine by the science historian, Naomi Oreskes, based on this opinion piece - that is available for free - at the UK Guardian, by Jonathan Wolfe. I believe that the point of Mr. Wolfe's commentary is that non-experts should "shut" our mouths, because we flat don't know enough.

Neither Mr. Wolfe nor the Nature blogger make any mention that the report by Oreskes was severely flawed and inaccurate. However, as the one comment at "Peer to Peer" reports, "This is very odd. The main critic of Oreskes' work was Benny Peiser, who is not a blogger or a think-tanker, but a member of faculty at John Moores University and a fellow of the Royal Astronomical Society."


I hope Mr. Wolfe or the Nature bloggers will follow up on the Oreskes article and the controversy surrounding it, because there appears to be a secondary theme: bias can lead to error, even in peer reviewed, scientific journals.

Oreske's article, originally published in Science in December, 2004. This review of the scientific literature is often quoted to support the position that there is no disagreement among scientists about whether the earth is warming due to the increase of "greenhouse" gases, and that those greenhouse gases are due to the influence we humans have on our environment. However, the problem appears to be a flaw in both the professor's methodology and her reporting. She mis-reported her search terms, and those terms - the use of the three words, "global climate change," rather than "climate change" - make a huge difference.

Here is the "Erratum" published in January, 2005 by Science:

Essays: “The scientific consensus on climate change” by N. Oreskes (3 Dec.2004, p. 1686). The final sentence of the fifth paragraph should read “That hypothesis was tested by analyzing 928 abstracts, published in refereed scientific journals between 1993 and 2003, and listed in the ISI database with the keywords ‘global climate change’ (9).” The keywords used were “global climate change,” not “climate change.”

The choice of search terms seems to make a huge difference. From a web page entitled, "The Letter Science Magazine refused to publish," by professor of anthropology, Benny Peiser, we learn,

On December 3rd, only days before the start of the 10th Conference of Parties of the United Nations Framework Convention on Climate Change (COP-10), Science Magazine published the results of a study by Naomi Oreskes (1): For the first time, empirical evidence was presented that appeared to show an unanimous, scientific consensus on the anthropogenic causes of recent global warming.

Oreskes claims to have analysed 928 abstracts she found listed on the ISI database using the keywords "climate change". However, a search on the ISI database using the keywords "climate change" for the years 1993 - 2003 reveals that almost 12,000 papers were published during the decade in question (2). What happened to the countless research papers that show that global temperatures were similar or even higher during the Holocene Climate Optimum and the Medieval Warm Period when atmospheric CO2 levels were much lower than today; that solar variability is a key driver of recent climate change, and that climate modeling is highly uncertain?

These objections were put to Oreskes by science writer David Appell. On 15 December 2004, she admitted that there was indeed a serious mistake in her Science essay. According to Oreskes, her study was not based on the keywords "climate change," but on "global climate change" (3).

Her use of three keywords instead of two reduced the list of peer reviewed publications by one order of magnitude (on the UK's ISI databank the keyword search "global climate change" comes up with 1247 documents). Since the results looked questionable, I decided to replicate the Oreskes study.

***

DISCUSSION:
According to Oreskes, 75% of the 928 abstracts she analysed (i.e. 695) fell into these first three categories, "either explicitly or implicitly accepting the consensus view". This claim is incorrect on two counts: My analysis shows that only 424 abstracts (or less than a third of the full data set) fall into these three categories.

It also shows that many abstracts on "evaluation of impact" and "mitigation" do not discuss which drivers are key to global climate change, instead often focusing exclusively on the possible effects of elevated CO2 levels on plant growth and vegetation. Many do not include any implicit endorsement of the 'consensus view' but simply use certain assumptions as a basis for often hypothetical impact assessments or mitigation strategies.

Quite a number of papers emphasise that natural factors play a major if not the key role in recent climate change (4). My analysis also shows that there are almost three times as many abstracts that are sceptical of the notion of anthropogenic climate change than those that explicitly endorse it (5, 6, 7).

I guess our lesson should be to be skeptical of "consensus," just as we are becoming skeptical of "peer reviewed" journals that rush to print on "hot" stories about cloning and stem cells.

Pallimed (a blog on palliative care) on the cadaver

I stumbled on the blog, Pallimed, while chasing links last week. Today, I was able to read some of the posts. The blog is owned by a doctor and discusses the various elements of Hospice and Palliative medicine.

Read this post for a beautiful excerpt of a statement by a Mr. Thomas Lynch while testifying to the President's Bioethics Council on the way we humans regard the bodies of our loved ones after death.

Ethics statments from the AMA and CMDA

Last month, I wrote about the Christian Medical and Dental Association's ethics statements. There's a comment about them in last weeks' CMDA "News and Views." See Dr. Robert Scheidt's comments, with the links to the three ethics statements that were approved at this year's CMDA House of Directors. This week, we have the NEJM article on "Futile care."


elow is what I believe are the pertinent section from the AMA Ethics "Policy Finder." (See E-10.05, 3c)

E-10.05 Potential Patients

(1) Physicians must keep their professional obligations to provide care to patients in accord with their prerogative to choose whether to enter into a patient-physician relationship.
(2) The following instances identify the limits on physicians’ prerogative: (a) Physicians should respond to the best of their ability in cases of medical emergency (Opinion 8.11, "Neglect of Patient"). (b) Physicians cannot refuse to care for patients based on race, gender, sexual orientation, or any other criteria that would constitute invidious discrimination (Opinion 9.12, "Patient-Physician Relationship: Respect for Law and Human Rights"), nor can they discriminate against patients with infectious diseases (Opinion 2.23, "HIV Testing"). (c) Physicians may not refuse to care for patients when operating under a contractual arrangement that requires them to treat (Opinion 10.015, "The Patient-Physician Relationship"). Exceptions to this requirement may exist when patient care is ultimately compromised by the contractual arrangement.
(3) In situations not covered above, it may be ethically permissible for physicians to decline a potential patient when: (a) The treatment request is beyond the physician’s current competence. (b) The treatment request is known to be scientifically invalid, has no medical indication, and offers no possible benefit to the patient (Opinion 8.20, "Invalid Medical Treatment"). (c) A specific treatment sought by an individual is incompatible with the physician’s personal, religious, or moral beliefs.
(4) Physicians, as professionals and members of society, should work to assure access to adequate health care (Opinion 10.01, "Fundamental Elements of the Patient-Physician Relationship").* Accordingly, physicians have an obligation to share in providing charity care (Opinion 9.065, "Caring for the Poor") but not to the degree that would seriously compromise the care provided to existing patients. When deciding whether to take on a new patient, physicians should consider the individual’s need for medical service along with the needs of their current patients. Greater medical necessity of a service engenders a stronger obligation to treat. (I, VI, VIII, IX) Issued December 2000 based on the report "Potential Patients, Ethical Considerations," adopted June 2000. Updated December 2003. * Considerations in determining an adequate level of health care are outlined in Opinion 2.095, “The Provision of Adequate Health Care.”



E-10.015 The Patient-Physician Relationship

The practice of medicine, and its embodiment in the clinical encounter between a patient and a physician, is fundamentally a moral activity that arises from the imperative to care for patients and to alleviate suffering.

A patient-physician relationship exists when a physician serves a patient’s medical needs, generally by mutual consent between physician and patient (or surrogate). In some instances the agreement is implied, such as in emergency care or when physicians provide services at the request of the treating physician. In rare instances, treatment without consent may be provided under court order (see Opinion 2.065, "Court-Initiated Medical Treatments in Criminal Cases"). Nevertheless, the physician’s obligations to the patient remain intact.

The relationship between patient and physician is based on trust and gives rise to physicians’ ethical obligations to place patients’ welfare above their own self-interest and above obligations to other groups, and to advocate for their patients’ welfare.

Within the patient-physician relationship, a physician is ethically required to use sound medical judgment, holding the best interests of the patient as paramount. (I, II, VI, VIII) Issued December 2001 based on the report "The Patient-Physician Relationship," adopted June 2001.

E-9.12 Patient-Physician Relationship: Respect for Law and Human Rights

The creation of the patient-physician relationship is contractual in nature. Generally, both the physician and the patient are free to enter into or decline the relationship. A physician may decline to undertake the care of a patient whose medical condition is not within the physician’s current competence. However, physicians who offer their services to the public may not decline to accept patients because of race, color, religion, national origin, sexual orientation, or any other basis that would constitute invidious discrimination. Furthermore, physicians who are obligated under pre-existing contractual arrangements may not decline to accept patients as provided by those arrangements. (I, III, V, VI) Issued July 1986; Updated June 1994.

NEJM comments on Texas "futile care"

The New England Journal of Medicine has a "Perspective" article commenting on the Emilio Gonzales case in Austin, Texas It's available free online, and there's an audio interview with the author.

The comments are very specific on the ethics of the case, and the author does a good job of outlining the Texas Advance Directive law, the various reasons given by the doctors who refuse to carry out the surrogates' wishes in these sorts of cases, and some of the objections to the ethics committees that decide whether or not the doctor's refusal to follow the surrogate's wishes is ethically appropriate. There's also a link to another free article that details findings about the "burnout" of ICU nurses.