27 Jan Interview with Dr. Joy Riley
Bioethics – making right decisions regarding life issues – is colliding with our culture today. From the making of life (in vitro fertilization) to the taking of life – how do we even start thinking about some of these issues? It takes a Medical Ethicist to help us wade through. No matter what your educational background or what you do, you will have bioethics decisions to make in your life. Welcome Dr. Joy Riley on the show today.
D. Joy Riley, M.D., M.A. (Bioethics), is Executive Director of The Tennessee Center for Bioethics & Culture in Brentwood, Tennessee, and also serves as ethics consultant for a Nashville, Tennessee, area hospital. Board certified in internal medicine, her writing and lecture topics include medical ethics, organ transplantation ethics, stem cell research, genetics, and assisted reproductive technologies.
Christian Bioethics: A Guide for Pastors, Health Care Professionals, and Families by C. Ben Mitchell, PhD and D. Joy Riley, MD
Living in an era of highly technical medicine is comforting and sometimes confusing. How should Christians make life and death decisions? How do we move from an ancient text like the Bible to twenty-first-century questions about organ transplantation, stem-cell research, and human cloning? What kind of care do we owe one another at the end of life? Is euthanasia a Christian option?
Using a dialogue format, an ethicist and physician talk about how to think about thorny ethical issues. Combining their backgrounds in medicine and theology, they deal with real-life moral questions in an accessible way. C. Ben Mitchell and D. Joy Riley let readers eavesdrop on their conversation about the training of doctors, the interpretation of the Bible, and controversial issues like abortion, assisted-suicide, genetic engineering, and in vitro fertilization.
The book examines these topics under three general headings: the taking of life, the making of life, and the faking of life. Christian Bioethics is a guidebook for pastors, health care professionals and families—anyone facing difficult decisions about health care.
Click to read Transcript
EASLEY: Welcome today to the broadcast. We’re in studio with Dr. Joy Riley. Dr. Riley is the Executive Director of the Tennessee Center for Bioethics and Culture. She’s also board certified in Internal Medicine. She has done research in a field of biochemistry in many areas including stem cell research, the Cloning Debate, genetic issues, Transhumanist Movement. On and on it goes. Thank you for coming to the studio today.
RILEY: Thank you for having me, Michael.
E: Now, these are big issues, Joy. You hear some of the bioethics and stem cell research and we kind of glaze over, so Doctor give us the primer. We’re twelfth grade educated people so how do we start thinking about some of these issues from a high level before we start talking about them specifically?
R: That’s a great question. Bioethics-just the term tends to make those eyes glaze over and so it’s helpful to remember that it’s a made up word. So there are two components: bio meaning life and ethics meaning doing right. So it’s about making right decisions regarding life issues and no matter what your educational background and no matter what you do, you will have bioethics decisions to make in your life.
E: Right, right. When you started out in medicine, were you interested in this from the beginning, or was this something that sort of came up when you were training?
R: Actually in college, I had a medical ethics class under Richard Barber at the University of Louisville. Then in Medical school I took what was an elective in medical ethics and then basically medical ethics wasn’t so much a separate discipline at that time at least in our institution. The primary ethical teachers we had were our attendings, so the Attending Physicians, the professors were the ones that taught you not just about medicine, but about the art and science of medicine and that included ethics as well.
E: So give me a couple of scenarios: A person who’s not been to the hospital before, they’ve not faced some dilemma and now they’re facing an ethical issue. What does that look like for a patient?
R: Ok, well actually there are several things. In fact everyone who’s admitted to a hospital will be asked if they have advanced directives. A hospital is required to ask that. You’re not required to have them, but they are required to ask so that will be your first time, and that’s at intro, ok, so that’s when you’re checked in or registered. I remember when my son who was eighteen was admitted for an interior, an ACL tear, and he was going to have that repaired. The admitting officer asked, “Do you have advanced directives?” He of course had no idea what that was. I was his mother and very in touch and said, “I am his guardian and he is a full code.” So, that obviated further discussion, but at any rate who gets involved with ethics discussions in the hospital? Usually ethics problems in the hospital tend to rise primarily from communication problems. So it can be a patient who can be not pleased with his or her care or their family, or it could be they have not communicated their desires effectively to the staff. There could be a question about code status so…
E: When you say code you mean?
R: Oh, ok sorry. When someone stops breathing, their heart stops beating, do they desire to be resuscitated? And that’s not a no brainer question, because not everyone who has CPR or attempted resuscitation actually is resuscitated. There are other issues that come to the fore regarding that so if someone has rib fractures already, from like metastatic cancer you probably wouldn’t want to have that person resuscitated because it would just be more fractures of ribs.
E: Let’s think of it from birth to death. So we’re coming into a hospital and a woman is having a child and now the child’s got an issue, maybe it’s a Trisomy 18 birth, maybe it’s some medical…they’ve never heard these words before and all of a sudden you’ve been through the joy of birth and now the disappointment of this news and now they ask the questions, “What do you want us to do?” This child will have no quality of life based on this condition. Let’s start with the birth.
R: Well, you’re right that bioethics issues stem from actually, originate from, either pre birth issues to birth, to natural death, or prolonged death, but if a family comes, or a couple comes to birth, in a hospital and the child is born with difficulties that were unanticipated, then they will wonder when was this known, so they’ll have lots of questions about that. But beyond that, to answer the question, “What do you want us to do?” That really, you need to have a good conversation about that. You need to have the parents available and talking about that.
E: But I’m thinking, I’m a twenty something young mom and husband and I’ve never heard these words. Now all these doctors in white coats are telling me things and I guess I’m supposed to do what they say.
R: Well, it doesn’t pay to “check your brain at the door” as they say. When you go into a hospital you need to take your reasoning ability with you. You need to in as much as possible be informed and when you’re not, you need to ask questions, so that’s probably the first thing. Nurses are more likely to be interested in education at the bedside than physicians, not so much their lack of interest, but lack of time. So the nursing staff has often taken the role of educator for the patient and family and that’s important, but the underlying desire really for the patient should be that they get their information and how you do that is to keep asking questions and if it’s not explained in terms that you understand then you need to ask more questions, ask them to explain again. Typically, whatever you say as a physician to a patient they cannot repeat that to you later, because there’s a lot of information that comes with that, it’s the setting and the attention isn’t alway to the facts, if you will.
E: Let’s talk a little bit about more common things like infertility. We’ve got lots of options today we didn’t have fifteen, twenty years ago.
R: Aw, true. Infertility is a problem for a good number of couples. It’s unclear how many people are afflicted, although I think the latest CDC information I saw on that was about fifteen percent of reproductive age females will have used infertility services. That doesn’t translate clearly or cleanly over. Infertility can be a problem from a variety of issues: anatomy, physiology. It can be either a problem with the male or female in the relationship. Often there is no discernable problem. So everything works, everything seems to work, but there’s still no baby. July 25th, the anniversary, the world’s first test tube baby was Louise Joy Brown. She was born on July 25 in 1978. That really did open a wide variety of infertility practices or possibilities for couples and it’s hard to proceed through all of those, if you will, alphabet soup concoctions, and so it’s important to know for the would be patients as well as their pastors and those who consult with them, their friends, to understand where life begins, because if you don’t understand that then it’s a little difficult when you get further down the road. For instance, after Louise Joy Brown was born in Britain, Parliament was worried. They said, “We don’t have rules about this sort of thing, that we don’t have laws.” They put together a committee, headed by Mary Warnock and she was an ethicist; she’s now Baroness Warnock. The Warnock Committee basically advised the Parliament regarding infertility and in vitro fertilization and they said in a nutshell, “We can’t tell you what the embryo is.” They knew it was human and they knew it was alive. “We will not tell you what it is, but we can tell you what to do with it.” I would pause at that: One cannot know what to do with something unless you know what it is.
R: So it’s important to know what you’re dealing with is human life especially in terms of embryo’s.
E: Well, prior to what, about 1970 something in the states, Roe vs Wade, certainly before then, life was the moment of conception.
R: Yes and OBGYN Techs would say that as well. Now people are kind of side stepping that a bit because when you have an egg and sperm put together in a petri dish, and it is not. That’s fertilization. When the egg and sperm come together and the sperm fertilizes the egg it is then called a Zygote. It can be developed in the lab for several, well multiple days, five to seven days it’s called a blastocyst. That’s also an embryo. So an embryo goes up to eight weeks gestation, after that it’s a fetus, and after that, hopefully it’s a newborn and you can always say, “I’m having a baby.”
E: But when do we start changing the definition of life?
R: Exactly! It’s hard to say that this person is pregnant if the embryos in a dish, so lots of people have moved that goal post if you will, to say that pregnancy is when the baby implants, when the embryo implants in the uterus.
E: So when we have so called in vitro fertilization and we’ve taken sperm and egg into a petri dish and we have several real viable embryos at that point. Now we’re going to freeze those because we don’t want to implant four.
R: Well see there you go. That’s part of the problem, because if you understand that the embryos are human and alive and they are children, or grandchildren is it in their best interest to be frozen? Because embryos that are frozen, when they are thawed, a good number of them die. So those are some questions and a RAND study back in the early 2000s found in the US, we had more than four thousand embryos on ice.
E: Snowflake babies? That’s the term they use.
R: Snowflake babies. So part of that stems from what we understand our responsibility is, and what we understand about life itself.
E: You and Ben Mitchell have written a book Christian Bioethics, a guide for pastors, health care professionals, and families and it’s great format the way you’ve laid it out because you don’t have to have a masters, or an MD or a PHD to navigate through, which is what we need as consumers we need the help. I love the way you break it out under three headings: The Taking of Life, The Making of Life and the Remaking /Faking of Life. Let’s take those each one at a time.
When we talk about Taking a Life and euthanasia we know the name Jack Kevorkian perhaps, assisted suicide. Is there a place medically that you as a doctor would say, “Yes, we should take the life of a patient?”
R: I cannot. I could not say that.
E: We have this wonderful problem. We’re living longer but the downside is that we got all kind of complex issues in our eighties and nineties. Most of us.
R: That is true. However, it has rarely in the history of mankind been the answer to difficulty to get rid of the person with the difficulty. That’s not the same thing, so if you are suffering, I can express sorrow, I can suffer with you, which is the real definition of compassion, but to kill you to get you out of your misery or mine, is a step that we’re not allowed to take.
E: But if I’ve got cancer and I’m in intractable pain, there’s no cure, and it’s just slowly eating me away and I’ve done chemo and radiation and all these drugs that don’t even have names yet, and I’m in misery, why would you prevent me from taking my own life?
R: I would do my best to encourage you that in the midst of this suffering that there is perhaps some time for you to deal with situations near family, that need to be dealt with before you die. I would do my absolute best to treat your pain. Dr. Pellegrino, who died last year was a strong proponent for pain relief and felt that by and large most pain can be relieved or at least diminished, such that there should be no call for either physician assisted suicide or euthanasia. Physician assisted suicide is basically requiring people who have been trained as healers to become killers. While they may not wield the needle, the syringe, but by writing a prescription for a drug that is life ending and explaining to the patient how to do that, they become culpable in this death. I liken it to a thought experiment. So say the chefs in a particular city were given the privilege or the responsibility of not only providing food, but providing poison on request. So you have a family member who just graduated from college, say you go out to dinner in the city and you’re having a lovely time. As you’re seated, you see that there is a couple seated near you, an older couple, and their food comes before yours and you’re about to receive your salad. They’ve got their main course. And you notice that the older gentleman is slumping in his chair. How comfortable are you going to be, picking up your fork to dive into your salad? So when you give people a dual responsibility, the blurring of the lines is not the only things that’s blurred. So I find it inappropriate that because you want to kill yourself then you make me want to be responsible for your death. I think that’s unfair, and not only that, it goes against Millennia of Hippocratic Medicine. So…
E: For those who don’t know the Hippocratic Oath, the first thing…
R: You’re probably referring to the basic concept of do no harm. The Hippocratic Oath actually comprises three parts. The first part is swearing to the gods and goddesses. The second part is the responsibility of the Hippocratic Physician to his teachers and they were all male at that time, so that’s not a misnomer. The Hippocratic Physician swore that he would teach only his children or the children of his teacher’s medicine.He would protect that art. Finally the third part of the oath is a delineation of his responsibilities to his patients. A couple of things; they are noteworthy. One was that: the Hippocratic Physician swore he would not provide a pessary to cause an abortion for a woman; another is that he would not prescribe a poison even if asked; a third is that anything he heard would be held confidential; and fourth that he would not sexually assault the patients or their servants. So now what do we have as Dr. Pellegrino pointed out, we have twenty five hundred years or so of Hippocratic Medicine and only a few decades of medical ethics. But we have gotten to the points where the provision, at least in certain states, namely Oregon, Washington, Montana, and now Vermont, the provision for not killing your patient no longer applies necessarily if you prescribe the medication. No longer is the promise necessarily made regarding abortion. No longer is the promise made of us, sadly sexual assault, and the final one is about confidentiality. So we have HIPAA.
E: But it’s all electronic and available.
R: Sadly, yes.
E: A brave new world. Let’s move from the taking of life to the making of life. We’ve touched on that a little bit with in vitro. What are some other issues? They sound great medically if they come along for this young couple that’s trying to have a baby and yet there are some boundaries there.
R: There are boundaries, and yet I think it behooves the young couple to avail themselves of input from people like yourself, from pastors, as well as read themselves. They need to educate themselves in this arena. The Making of Life would include more recently, something that has come on the horizon and it’s closer than the horizon actually, it’s through parent embryos. In 2008 there were at that time over forty countries that banned germ line modification and I’ll explain this. In the egg and sperm you have your chromosomes. Your chromosomes will compliment of who you are and in all of your cells have nuclei except egg and sperm you have forty six chromosomes, the normal human person. The egg and sperm, each of those have twenty three chromosomes so when the egg is fertilized by the sperm the twenty three and twenty three come together for forty six chromosomes in a normal child. There is DNA outside the nucleus. Those chromosomes are inside the nucleus of the cell, the central portion of the cell. The outside of the nucleus is called the cytoplasm and in the cytoplasm are the little powerhouses called the mitochondria. Mitochondria have DNA of their own and if you’re looking at your mitochondria, you would see only your mother’s mitochondria and so the maternal mitochondria line is passed down, not from the father. So some women have mitochondrial disease and the mitochondria have about thirty seven genes or so and primarily about thirteen of those are of interest, so if a person has a, a woman has mitochondrial disease, she doesn’t want to pass that along to her child. These are varied in their expression as well as kind of problem. So the work around has been that you take a normal egg from a donor, lop out that nucleus, take the nucleus from the would be mother, lop that out of her egg, put that in the donor egg, fertilize that with the father’s sperm. But as I said, your mitochondrial DNA come from your mother. In this case, it would come from the egg donor. So for the first time, we’re contemplating having DNA from the father and the mother in the nuclear DNA, but then having DNA from a third party.
E: Another mother.
R: So you’ve got “a three parent embryo.” That is one form of germ line engineering in that those genes will be passed down.
E: So this is taking the concept of designer baby to a whole new level.
R: It is. It is. Britain has run a consultation on it. They have the body that authorizes, that monitors and licenses all labs that deal with eggs, sperm or embryos. They have given it the go ahead, but Parliament will have to change laws if they’re going to do this.
E: Now let’s go back. A percentage of women with that mitochondrial problem?
R: Oh! Great question. Well in Britain, about one hundred babies are born with mitochondrial disease. And again it’s variable. It’s variable in expression, how severe is it…
R: …And the kind of disease that it is.
E: The science for the three parent is working.
R: Well we don’t know that. It’s done in animals. Thank you for pointing that out.
R: Mitalipov at the Oregon Health Science & University has succeeded, I believe it’s chimpanzees, but at any rate an animal model.
E: Well then of course it’ll work in humans. (Laughter)
R: Exactly, we don’t know if it’s going to work in humans. So you’re basically doing research on all succeeding generations whereas never before have we contemplated.
E: Again, so science and technology and medicine are wonderful things all. At what point do we stop, Joy? If we stop researching ALS or we stop researching Alzheimer’s or Arthritis; my mother has Type 2 Diabetes and all that goes along with that and how, oh how I wish there was some procedures for her Retina issues, on and on. We all have a parent or a loved one, I mean goodness gracious, where do we evaluate philosophically how far we should go with these things?
R: That’s a great question. Well you can take penicillin as an example. If your child were very ill from some bacterial process and penicillin will be the right drug for him or her, why would you not give it? The considerations there would apply to these issues as well. Did you kill the druggist in order to get it? Did you get the prescription validly? Did you pay a fair price for it? Was anyone harmed in the middle of that? Did you drive too fast and run over a pedestrian or something? So all of these issues come to the fore as “Have I harmed someone in the process of attaining my goal?” And does my goal, is it consonant with the fact that I am to be a good steward of what I’ve been given? Is it consonant with the fact that I have a beginning into my life? Is it consonant with the fact that God is in charge of our days? So those are some of the issues.
We are talking with Dr. Joy Riley, co-author with Ben Mitchell, Christian Bioethics, a guide for pastors, health care professionals, and families, covers a wide array of issues from the Taking of Life, Making of Life, Remaking/ Faking of life. Joy also deals with organ transplantation, stem cell research, genetic engineering, in vitro fertilization, abortion, euthanasia, on and on it goes. Big issues. We’ve just scratched the surface again, Christian Bioethics, a guide for pastors, health care professionals, and families, Ben Mitchell and Dr. Joy Riley. Thanks, Joy, for coming to the studio today.
R: Thank you, Michael, for having me.
E: This is Michael Easley inContext.
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