Will Ariadne Lead Us Through the Maze of End-of-Life Healthcare?

Note: The Bioethics Program blog will be moving to its new home on April 1, 2015. Be sure to change your bookmarks to http://bioethics.uniongraduatecollege.edu/blog/

 

by Richard Koo, Bioethics Program Alum (MSBioethics 2011) and Adjunct Faculty

About four years ago, Susan D. Block, M.D. posted a blog on Harvard Business Review’s website as part of a series of writings focusing on innovation in health care. In her blog, she bemoaned the “lousy job” doctors do in communicating with patients when it becomes apparent that additional treatment and technology will fail to stave off death. Among several other proposals, she suggested that standards for appropriate documentation of end of life discussions should be developed, promulgated, and used as reportable indicators of quality care. To carry out that innovation, she proposed that “all electronic medical record systems would be expected to support documentation of the patient’s health care proxy, values and goals” and “a broadly-agreed-upon definition of populations for whom these discussions and documentation are appropriate would be developed.”

Dr. Block is no stranger to the subject of end of life communications between doctors and patients. She participated in a number of panels and has authored articles on the subject since the 1990s. She also did not wait for the medical profession to follow through on her proposals. As Director of the Serious Illness Program at Ariadne Labs, Dr. Block spearheaded the development of a system (the “System”) to assure that doctors caring for seriously ill patients can develop competency in communicating with their patients so that the patients “can live with their serious illness and into the last stage of life with dignity, control and a sense of peace.” The System aims to train physicians in identifying appropriate patients for such communication, determining the right time to initiate the serious illness conversation, engaging in serious illness planning, helping patients discuss their end-of life preferences with their families, and documenting those plans and preferences in the patient’s electronic health record.

Presently, Ariadne Labs is evaluating the outcomes of the System through a series of clinical and implementation trials measuring outcomes in oncology, primary care, nephrology, chronic illness, surgical and emergency settings and adapting it to culturally diverse populations. The plan is to launch the System nationally in the fall of 2015 through a collaborative of approximately 20 health care networks to test it in different populations across the country.

Even before System launch, I’ve heard some potential concerns about the System from health care professionals who work with seriously ill patients day to day:

Pushback 1: “Discussions with patients with serious illness near the end of life are intensely personal and depend on an individual’s health care trajectory, views on life, death, and religion, financial situation as well as family dynamics. No standardized set of conversation guides, scripts, checklists and reminders can be practically useful.”

Counterpoint: “Standardized” doesn’t necessarily mean one size fits all. Though the System hasn’t yet been publicly released, based on Dr. Block’s body of work, my bet is that the System will direct physicians to take into account individualized variations in patient background, prognoses, situations and preferences. It should also help the physicians structure their communications according to those variations.

Pushback 2: “The reason why the medical profession does a “lousy job” in end of life communications is because many doctors have little motivation or interest to get good at it. Changes to the U.S. health care delivery system of a more fundamental nature have to be made before the medical profession current approach to communications with seriously ill patients will change.”

Counterpoint: So what are health care professionals supposed to do: sit on their hands until fundamental changes happen?   Communicating with patients is an integral part of the provision of health care. Health care professionals have an ethical imperative not to do a “lousy job” in that regard, whether or not these improvements are financially rewarded.

Pushback 3: “The medical profession would be better off leaving the task of difficult discussions near the end of life to those who presently deal with it best, namely palliative care physicians, nurses and nurse practitioners, hospice care specialists, social workers and patient advocates.

Counterpoint: One of the driving forces behind the development of the System is to raise the recognized standard of care of all physicians who treat seriously ill patients. Leaving the task of having appropriate end of life planning and communications in the hands of a cadre of specialists does nothing to address the “lousy job” physicians do that Dr. Block bemoaned. Any improvement in serious illness communications and the heightened sensitivities that the System might help bring about would also enhance the prospects that physicians will work collaboratively with the rest of the health care team to improve patient care near the end of life.

From a broader view, these potential concerns about the System seem symptomatic of the threat that innovative ideas present to the status quo. Personally, I’m excited about the possibilities of the System, in part because of my great respect for Ariadne Labs and its leaders, including Executive Director Atul Gawande, M.D.

[The contents of this post are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]

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The Man Who Mistook His Life For A Hat

by Jacob Dahlke, Bioethics Program Alum (MSBioethics 2012)

Our society tends to put on pedestals the celebrities among us, particular upon their deaths. For author Oliver Sacks, it is no different except that he is not yet dead. He did, however, recently announce in the New York Times that metastasized tumors were found in his body. His diagnosis is terminal in the near future. There is an ease and confidence with which he declares, “It is up to me now to choose how to live out the months that remain to me”. These are not the words of a man who plans to rage against the dying of the light, he simply plans to confront (as Hume did) the difficulty “to be more detached from life than I am at present.”

We could certainly expect – from his own energetic accounts – Dr. Sacks to plunge aggressively into treatment. He describes himself in the NY Times piece with powerful, vivid words, a “man of vehement disposition, with violent enthusiasms, and extreme immoderation in all (his) passions.” One might presume that such a person, when faced with the prospect of a terminal illness such as Dr. Sacks’, he would opt for Thomas’ strategy. And yet, when given the opportunity to consider his path, he has chosen differently. Dr. Sacks decided to forgo aggressive treatments – choosing the quality of his life over its quantity. His path is not the one less traveled, but rather one recently reflected in the perspectives of healthcare providers and patient alike.

What is so striking about Dr. Sacks’ writing, then, is how he elucidates the transition from a life with one set of goals and purposes to another set, with goals and purposes all their own. People outside the shadow of a terminal illness may see this transition as a loss of will to live out their remaining days – hence the outcry over such stories as Brittany Maynard, or of the recent news in Canada about assisted suicide. But Dr. Sacks cut through such presumptions with surgical precision: “This is not indifference but detachment.” It is not a loss of the will to live, but instead a loss of the will to live as before. It’s not that issues like global warming are no longer important; they’re just not important to him individually anymore.

It is as though Dr. Sacks’ life as a public figure is a sort of hat. Something worn, but not entirely revealing. And now that he is nearing home, his hat has become less useful. It is, perhaps, time to take his hat off.

I am not sure we will hear much more, if anything, from Dr. Sacks from now until his death in the coming months. He decided to focus on those close in his life, and that is certainly to be respected and praised. But Oliver Sacks’ potential withdrawal from the public sphere is a loss for our society as a whole. It remains difficult to translate the thinking about end of life decisions well, and his experience and skill, his work does that with such clarity.

His accomplishments are many, but for health care professionals whose patients approach death’s door, this short piece will be perhaps the most useful. These health care professionals themselves wear many hats, and, increasingly, one of these pushes patients, families, and the public to confront what it means for their light to fade. Of course, they may choose to fight to the very end. But the brutal honesty of Olivers Sacks’ reflections opens a space for these patients to say (and for their families to hear) that they, like Dr. Sacks, have decided not to rage. Instead, they have chosen to look back and say: “Above all, I have been a sentient being, a thinking animal, on this beautiful planet, and that in itself has been an enormous privilege and adventure.”

[The contents of this post are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]

How to Die in Canada

by Sean Philpott-Jones, Director of the Center for Bioethics and Clinical Leadership

Last week, our neighbors to the north took a huge step towards legalizing physician aid-in-dying. On Friday, the Supreme Court of Canada unanimously struck down that country’s ban on the practice, suspending two sections of the Criminal Code that outlawed assisted suicide and euthanasia, and ordering the Canadian Parliament and the various provincial legislatures to draft new legislation that would allow physician aid-in-dying.

This is not the first time that Canada has dipped it toe into these treacherous waters. Earlier this year, the Canadian province of Quebec passed Bill 52, also known as ‘An Act Respecting End-of-Life Care’. That Act, which would have taken effect in December, would grant terminally ill Quebecers the right to request a physician’s aid in dying.

In order to qualify for medical assistance in ending their lives, however, these patients must have “an incurable illness that is causing unbearable suffering”. They would have to be in constant and unbearable pain that doctors couldn’t relieve with treatment. The request for aid-in-dying would also have to be made in writing, witnessed by the attending physician, and approved though consultation with a medical team after two doctors determine that the patient is competent to make this request.

The Supreme Court ruling went much further than what Quebec’s law would allow. The nine Canadian justices ruled that physician-assisted suicide should be made available to any competent adult who “clearly consents to the termination of life and has a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition.”

By including references to disability and psychological suffering, the Court potentially opened the doors not only to those with terminal illnesses, but also those with chronic but not life threatening illness or disabilities, as well as those suffering from mental illness.

It is unclear how Canadian legislators and medical professionals will respond to this ruling, but they will face a number of challenges in devising an aid-in-dying process that will allow seriously ill patients to end their lives peacefully while still protecting their rights and safety.

But this is a Canadian problem, right?. Why should we care what is happening in the Great White North? Rulings by that country’s Supreme Court have no bearing on US law. Moreover, any aid-in-dying process that our neighbors create is likely to be limited to the citizens and residents of Canada, preventing so-called ‘euthanasia tourism’.

But we should care about what’s happening in Canada because the aid-in-dying movement is also becoming an increasingly powerful voice in US medical practice (particularly following the death of Brittany Maynard, the terminally ill 29-year-old who spoke publicly about moving from California to Oregon in order to legally end her life). American policymakers and physicians can learn a lot from watching the Canadian experiment.

Currently, only five states allow physician aid-in-dying: Montana, New Mexico, Oregon, Vermont, and Washington. In three of those states, laws allowing terminally ill patients to request a doctor’s assistance in ending their own lives were passed by popular referendum or legislative votes. Similar legislative bills or public referendums have been proposed in other states, and popular support for physician aid-in-dying is increasing.

Just last November, for instance, Massachusetts’ voters narrowly defeated a referendum called Question 2 that would have legalized physician aid-in-dying in that state. That narrow 51-49 loss occurred only after well funded and politically savvy opponents were able to reframe discussion about the referendum. The public debate about Question 2 became less about the rights of the terminally ill and more about potential abuses of the disabled and the elderly. But recent polls suggest that nearly two-thirds of voters in the Bay State now support physician aid-in-dying, and a new bill to legalize the practice is currently winding its way through the Massachusetts legislature.

Those of us who live in the Empire State may never get a chance to vote on physician aid-in-dying as New York does not have a popular initiative and referendum process. Efforts have been made to introduce aid-in-dying bills in the state legislature, but these bills face an uphill battle due to strong opposition by religious groups, disability advocates and conservative lawmakers. But this doesn’t mean that physician-assisted suicide won’t soon be legal in New York.

As with Montana and New Mexico, physician aid-in-dying may become legal in New York via court ruling. Just last week, a group of terminally ill patients and clinicians filed a lawsuit asking the New York Supreme Court to invalidate the state’s current prohibition on assisted-suicide.

Currently, a doctor who prescribes a fatal dose of medication to a terminally ill patient can be prosecuted for manslaughter under New York’s Assisted Suicide Statute, which makes it a crime to “intentionally cause or aid another person to commit suicide.” To date, no doctor has ever been prosecuted under this statute. Despite this, the plaintiffs argue that current assisted suicide laws violate the equal protection clause of the State Constitution. For example, physicians are already help some terminally ill patients die (by removing life support) but they cannot help patients who do not rely on continuous medical intervention to live.

Whether or not the New York Supreme Court will rule for the plaintiffs in this case remains to be seen, but the tide of public opinion is clearly shifting in favor of physician aid-in-dying. Physician aid-in-dying may not become the law of the land in New York anytime soon (be it by legislative action or judicial fiat), we need to start talking about it.

No matter which side of the debate you are on — either for or against physician aid-in-dying — we need to have a thoughtful and respectful discussion about dying, about the rights of the terminally ill, and about the role that physicians should play in helping patients attain a peaceful death. And we should watch the Canadian experiment carefully (and the experience of Montana, New Mexico, Oregon, Vermont, and Washington), and learn from their success and mistakes.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on February 12, 2015, and is available on the WAMC website. The contents of this post are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]

Can Safety, Freedom And Rationing Co-Exist For The Elderly?

by Susan Mathews, Bioethics Program Alumna (2014)

In a recent op-ed article, Dr. Ezekiel Emanuel, former Special Advisor for Health Policy to the Obama Administration, stated that he did not want to live beyond the age of 75. At that point, his productive life would be over and he become a burden rather than a benefit to his family, his friends and his country.

Whether or not you agree with Dr. Emanuel’s provocative statement, he raised an important point in his article: in order to contain health care costs, Americans will have to make difficult decisions about rationing of medical care. This is particularly true of end-of-life care for the elderly, which is a significant contributor to medical spending in the United States.

The problem will only become more acute in the coming years. The 65 and over population is projected to grow from 13 percent of the population today to 20 percent by the year 2030. In that same period, the population of the “old-old” (85+) will quadruple as the large baby boomer cohort reaches these advanced ages.

So as explicit rationing of medical care becomes a reality, how can costs be managed while still respecting the rights and safety of the elderly?

To read more, click here.

[This post is a summary of an article published on Life Matters Media on January 16, 2015. The contents of this blog are solely the responsibility of the author and do not represent the views of the Bioethics Program or Union Graduate College.]

 

Taking the Icy Plunge (Or Not)

by Sean Philpott-Jones, Director of the Center for Bioethics and Clinical Leadership

There’s an epidemic that is sweeping this country. It’s not Ebola, despite all of the hype and misinformation about that disease that has dominated the news in the past two weeks. Rather, I’m talking about the ice bucket challenge.

Anyone who has watched television in the last couple of weeks has seen this: newscasters, celebrities and athletes like Matt Lauer, Martha Stewart and Nick Swisher being doused with a bucket of ice water in the name of charity. The goal of the ice bucket challenge is to raise money and awareness about amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig’s disease).

ALS is a neurodegenerative disease that affects nearly 30,000 Americans. It primarily affects people in their mid-40s to mid-60s, and is characterized by an increasing loss of motor function. Initial symptoms include muscle weakness or slurred speech. As the disease progresses these symptoms become increasingly pronounced. Patients with ALS gradually lose the ability to walk, speak, eat and (eventually) breathe. They slowly become prisoners in their own bodies, fully aware but trapped in an increasingly uncooperative shell.

The root cause of the disease is still unknown, and there is no known cure. Treatments can slow the onset of symptoms, but most patients succumb to the disease rather quickly. The majority of people living with ALS die within 3-5 years of their initial diagnosis, although there are notable exceptions like famed physicist Stephen Hawking, who has lived with the disease for over 50 years

The federal government spends about $60 million on ALS research. Private organizations like the ALS Association also spend money, both to develop new treatments and to provide care for those affected by the disease. As a non-profit organization, however, the ALS Association depends on contributions from people like you and me, and that’s where the ice bucket challenge comes in.

The challenge is simple. A person either donates $100 to the ALS Association or agrees to post a video of them getting doused with ice water on a social media site like Facebook (usually with a hash tag like #IceBucketChallenge or #StrikeOutALS). That person then challenges three of their friends to do the same: donate or get doused.

The campaign has been remarkably successful. In the past month, the ALS Association has raised over $1.5 million. Donations are up nearly a hundredfold since the campaign began. That’s a good thing, so what I’m about to say is likely to be surprising and even a little upsetting to some.

I think the ice bucket challenge is a crock, and I want no part of it. To all my friends who have called me out on Facebook to participate, my answer is ‘no’.

This isn’t to say that I don’t believe that ALS is a terrible disease. It is. I have seen the effects first hand, when the brother of a close friend contracted the disease. I have also donated to the ALS Association in memory of a former student’s father, who died from complications related to ALS last year

I am opposed to the ice bucket challenge for a number of reasons. First, I don’t believe that it does anything to raise awareness of ALS in the long term. Most of the videos that I have seen posted on Facebook, Vine and other social media sites say little to nothing about the disease and its impact on the families affected by ALS. They also don’t discuss why monetary donations are desperately needed, where to donate to, or how the money will be used.

Second, I have a real problem with a fundraising campaign in which public humiliation or exhibitionism seems to be the primary goal, with donations to a charitable cause an afterthought. Consider the rules of the ice bucket challenge: you either film yourself getting doused with ice water or you donate $100 to a charity. Charitable donations are the consolation prize in this extortive game.

In fact, what most people don’t realize is that the ice bucket challenge predates the ALS Association campaign. It was actually started as a game among pro athletes like golfer Greg Norman, with those who refused asked to donate to a charity of the challenger’s choice. The original challenge was never about raising money or awareness of a charitable cause, and now we have thousands or millions of Americans who feel like they’ve contributed to ALS research without actually doing anything.

If you want to help those living with ALS, dunking a bucket of cold water over your head is not the way to do it. Rather, you should visit the websites of organizations like the ALS Association and learn more about the disease. You should donate money to the cause and encourage your friends and family to do the same (without subjecting them to hypothermia). You should write your Congressional representatives and encourage them to increase funding for ALS research. Finally, you should consider donating your time to help those with the disease and their families.

Save the ice for your drinks.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on August 14, 2014, and is available on the WAMC website. The contents of this post are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]

Your Doctor Has a DNR Order, But Not for the Reasons You’d Think

by Jacob Dahlke, Bioethics Program Alum (MSBioethics 2012)

How many doctors would choose to have a “Do-Not Resuscitate” (DNR) order over a full code option? 88.3%, at least according to a new study. For those counting at home, that’s greater than percentage of Americans who currently disapprove of the job that Congress is doing.

This means that nearly 9 out of every ten physicians would not personally choose the treatment that they routinely perform on their elderly, frail, critically ill, or emergent patients. (There is some concern that these patients are not routinely provided an effective mechansim for making this decision, meaning the default treatment in most cases is to provide CPR regardless of underlying conditions; perhaps that’s a topic for another post.)

This is an intriguing figure, one that on its face seems to imply that physicians may be providing treatments that they know they ought not; after all, if they don’t choose it for themselves, then certainly it is not an effective treatment. Perhaps there is an alternative view, however. Before I discuss this modified perspective, let’s first get into CPR a bit more.

First, CPR refers to cardiopulmonary resuscitation, or an attempt to restart a person’s heart that has stopped beating. This loss of function means that there is no blood (and thus no oxygen) pumping through the body, meaning that a person will not have a pulse if checked. The subsequent lack of oxygen to the brain leads to death. Second, where you receive the CPR attempt can determine it success. Only 1 out of 8 persons who suffer cardiac arrest outside of a hospital survive. It initially appears that survival is higher in a hospital setting: 38% of patients over the age of 70 who received CPR had a return of blood circulation.

This statistic alone can be misleading, however, since over half of those patients (the ones who received CPR) don’t survive until being discharged from the hospital. If we reorganize the definition of success based around patient goals – surviving until getting out of a hospital, or not dying in a hospital – then that number drops to 12%-18% (based on age). CPR may provide an additional 24 hours, albeit in a hospital. So this is, in a conservative estimate, a potential reason that physicians decide against this treatment for themselves.

But the tone in such news articles seems to suggest that physicians have some sort of secret that they are holding against their patients. Instead, it could be a lack of access to relevant information, and a lack of education on the part of the patient to make informed decisions at this juncture of their lives. A physician who becomes a patient is simply in a better position to be informed about the risks, benefits, and alternatives to any proposed treatment, including CPR. To expect that a ‘typical’ (non-medically trained) patient would have the same level of knowledge is inaccurate.

Instead, by presuming that a patient does not know what they don’t know, then there becomes a responsibility to ensure that a patient understands their clinical situation. So the physician, at age 72, would opt out of attempts at CPR because s/he knows that there is only an 18% chance of survival and recovery. For the other patient, s/he may choose to remain full code, believing that nearly 1 in 5 is a good enough chance to ‘go for it’. Or not. But the medical community must do a better job of communicating relevant information about end-of-life treatments and options.

To advocate for more, and better, discussions about CPR, DNR, and code status is not to advocate for wresting control away from patients and limiting their lives. It is instead empowering them to make better, more informed decisions about treatments that align with their personal values.

[This blog entry was originally posted in a slightly different form on Mr. Dahlke’s blog on May 30, 2014. Its contents are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]

Alzheimer’s Disease: The Forgotten Epidemic

by Sean Philpott-Jones, Director of the Center for Bioethics and Clinical Leadership

We hosted a conference on Alzheimer’s disease at the College last week, inviting a distinguished group of physicians, researchers, caregivers, advocates and policymakers to discuss the ethical and legal challenges of diagnosing and treating those with the disease.

These issues are particularly important to me. I have immediate family members who have been affected by Alzheimer’s disease, as patients and as long-term caregivers. I also carry a genetic trait known as APOE-e4 that makes me far more likely to develop the disease, and to do so at a younger age.

As someone whose career and self-worth are tied to my ability to think and write creatively, the very thought that I could slowly lose everything that makes me who I am terrifies me. I also worry about the huge personal and financial impact that a diagnosis of Alzheimer’s could have on my family.

Those living with Alzheimer’s, their families, and their friends also struggle with a myriad of practical issues as the disease slowly robs them of their memory, their thoughts, their speech, and their motor functions. They face difficult choices about treatment, independence, safety, long-term care, and end-of-life decisions.

There is also emotional toll. It is never easy to lose a parent, a sibling, a partner or a friend. But unlike patients suffering from other terminal illnesses, those with Alzheimer’s and similar neurodegenerative disorders die twice. They die mentally when their dementia reaches the point that they no longer recognize or remember family and friends. They are still alive physically, and may continue to live for many more years, but the person they were is gone. Family members are left to grieve the loss of their loved one while still caring for the stranger that they have become.

This is the cruel reality of Alzheimer’s. It is also a reality that most of us will have to deal with in the years that come.

The US Centers for Disease Control and Prevention (CDC) ranks Alzheimer’s as the sixth leading cause of death in the United States. An estimated 84,000 Americans died of the disease in 2010.

But that is likely to be a gross underestimate of Alzheimer’s physical toll. According to a recent study conducted at Rush Alzheimer’s Disease Center in Chicago, the number of deaths that are actually attributable to the disease may be 5 to 6 times higher. That would mean that nearly half-a-million Americans died of Alzheimer’s in 2010, making it the third leading cause of death in the US. Only heart disease and cancer took more lives.

Currently, 1 in 9 Americans aged 65 or older has Alzheimer’s. That proportion rises to nearly 1 in 3 for those aged 85 and older. That translates to 5 million people in the United States who have the disease, a number that is expected to triple over the next few decades with the demographic changes associated with the aging of the baby boom generation.

Alzheimer’s is already the most expensive disease in the US. We now spend over $200 billion dollars a year caring for those with Alzheimer’s including $150 billion in Medicare and Medicaid. About half of all nursing home residents are people with Alzheimer’s disease or other neurodegenerative diseases, most of who rely upon Medicaid to pay for their long-term care.

But that too is likely a gross underestimate of the financial toll of this disease, as it fails to take into account all of the unpaid care provided by family and friends. Nearly 18 billion hours (or $200 billion) of free care was provided in 2013. Most often than not, this care was provided by women who left the workforce in order to care for an ailing spouse, parent, or sibling.

Unless we do something to reverse this tide, Alzheimer’s is going to bankrupt us financial and emotionally. We can’t reduce the economic cost of caring for those with the disease, so the only solution is to find new ways of slowing or preventing the onset of dementia. We need more research that is aimed at developing new cures and treatments.

Despite this, funding for Alzheimer’s research lags considerably when compared with other diseases like breast cancer, stroke, heart disease and HIV/AIDS. Although Alzheimer’s now kills nearly as many people as cancer, for example, the federal government spends twelve times as much on cancer research as it does on Alzheimer’s.

This has got to change. We need more bills like the Alzheimer’s Accountability Act, introduced in 2014 by Representatives Paul Tonko (D-NY-20) and Brett Guthrie (R-KY-2). We need to provide more funding for Alzheimer’s research, but we need to do so in a way that doesn’t rob other research initiatives (including efforts to find a cure for cancer) of desperately needed resources.

Unfortunately, this is unlikely to happen. Our Congressional leaders are too focused on cutting costs, including slashing the federal budget that supports biomedical research, to recognize the looming crisis. Alzheimer’s will, I fear, remain an overlooked and forgotten epidemic until it is to late intervene.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on May 22, 2014, and is available on the WAMC website. The contents of this post are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]