Re-imagining Our Mortal Stuff: Finding Dignity Amongst the Matter of You (And Me)
By Bernard Leuthart
Wise man lookin’ in a blade of grass
Young man lookin’ in the shadows that pass
Poor man lookin’ through painted glass
For dignity.
Sick man lookin’ for the doctor’s cure
Lookin’ at his hands for the lines that were,
And into every masterpiece of literature
For dignity.
~Bob Dylan
“Don’t go all timid on me, now! We’re only just getting to know where we are both going here and we ain’t there yet. Look, take my pulse. I know you are gonna work me out.” (Juanita J.)
When I met Juanita early in my medical novitiate, I was terrified. Juanita was a Texan with Texan self-assurance and a state-sized understanding of her own diagnoses and the appropriate ways to keep her well. This had me on the back foot: she would tell me so kindly what was going on and what was to be done to hand her back to herself. But the gift with which she dignified my learning, ostensibly allowing me to do the doctoring, was her coming often to consult me and her ability to invite me into the personal space of her relapsing, remitting, interminable suffering. She got me amongst her stuff. When she died, I felt broken at the loss of that element of love that revealed more in me than I could reveal or heal in her.
Generalists spend a great deal of time building their catalogue - episode after episode of care and delving into problems forming the skeleton of learning that informs the next consultation and the next. But Juanita had assisted me to something different, unfolding a map of possibility between us which pointed more to encounter than perfect solutions.
Hungarian poet Miroslav Holub writes eloquently of a detachment of personnel sent into the
Taking this illustration, religious educator Maria Harris, whose work has had a profound influence on my role in general practice, makes the point that imagination brought to bear on our engagements has a power similar to the map of the Pyrenees. It has a prospective and explorative quality which can open possibility1 and delve down into the dignity dwelling at the heart of our encounters. And at this core is mortal matter - our frail human stuff that seeks the kind of transformation that can point us, we can imagine, towards the divine.
Engagement that sets out on this footing, that cleaves to a disposition for encounter, can’t help but engender dignity. It invites quite naturally an emptying of the subjective ego and an imaginative opening of ourselves to the person present there. It recognises something between subjects (the subjects you and me and the subject matter) that perhaps approaches reverence; what Martin Buber refers to as perceiving ‘a thou’ there. It establishes, re-imagines and re-forms the covenant potentiated between each other there, through which trust comes and grace is allowed to work.
I am reminded of a recent audience with 102 year-old Ken, in the locked dementia unit, who, across a corridor, beams his appreciation to the nurse who has just kissed his head and told him he is amazing. Grinning, he draws a harmonica from his pocket and plays for her and me a jaunty hornpipe. His dignity is renewed there. And, irrefutably, ours is too.
Dignity emerges when, despite differentials of power, knowledge, mobility or well-being between us, we are both disposed to accompanying the other and making space for the other, especially when the matter is unwieldy and the outcomes elusive. The doctor and the patient, in a very real way, are tasked with making the stuff between them ‘something other’. We are, I believe, in our medical or ordinary encounters that matter, to become witnesses together to something being made holy: our frail human stuff dignified by a redemptive transaction that, as bioethicist Dr Michael McCabe has put it, “joins the dots on grace.”
Attending to engagement, grounding ourselves, as Juanita did, in a disposition for encounter and rooting out the deep dignity made mutual there, can unfold the map on us. It can bring us to the transcendent value of human heartedness that helps us into gratitude and a eucharistic kind of openness to real presence in each other. It’s the matter of you and me. Bigger than
Dr Bernard Leuthart is Clinical Director at Waiwhetu Medical Group in Lower Hutt.
Endnotes:
1. Harris. M. Teaching and Religious Imagination. 1987. Harper and Row, San Francisco.
What ‘Artificial Intelligence’ can teach us about humanity
Lynne Bowyer and Deborah Stevens
The term ‘Artificial Intelligence’ (AI) was coined by the computer scientist John McCarthy in 1956. It is an area of computer science involved with the development of computer systems capable of performing tasks normally requiring aspects of human intellect. We are currently seeing exponential growth in AI, and this is due to a number of factors: the availability of faster hardware; the ability of computers to run more complex algorithms; the development of massive data sets; and the enormous monetary incentives involved with this technology.
Our lives are already permeated by a range of what has been called ‘Narrow AI’ applications. ‘Narrow AI’ is incorporated into many of the products and procedures that impact on our daily lives: automatic heat pumps; smart-phones; web-based searches; self-driving cars; complex assembly work in industrial processes; Facebook automatically labelling your friends in photos; Amazon and Netflix making personalised product and film recommendations. Already these ‘Narrow AI’ applications do calculative tasks faster than humans can, and are altering our world in significant ways. The increase in speed and capability of ‘Narrow AI’ has enabled increased flexibility within AI systems so that in many cases those systems are able to transfer what they ‘learn’ in one domain to another. For those working in the field, this is fuelling the idea that we can create what has been termed ‘Artificial General Intelligence’(AGI).
AGI technologies have been built that incorporate algorithms that mimic aspects and degrees of human cognitive function, including visual perception, speech recognition and means-ends decision-making. This field of research draws on experiments with ‘machine learning’ that utilise neural network technology. This technology creates simplified models of brain networks that can self-organise and solve problems. With such things as voice and image recognition, and faster computational power, it is envisaged that AGI will be as capable as any human across any ‘intellectual task’. This is said to include things like complex reasoning, thinking abstractly and learning from experience.
These claims and the impetus behind these developments give us pause for thought. They give us the opportunity to ask the questions: What is human intelligence? How is human intelligence developed? Can human intellect ever be simulated by a computer programme?
We argue that human intellect cannot be simulated by a computer programme, however complex that programme may become. This is because human intelligence is more than being able to access and process information in an abstract way and calculate means-ends decisions. Genuine human intelligence is embodied and embedded in a particular shared world and is concerned with making sense of our earthly existence in a way that enables us to enact the moves that enable all to flourish. Consequently, our human life-world will be dangerously eroded if the push for AI is allowed to continue unchecked.
We begin by discussing how a dominant paradigm of thought perpetuates the idea that human intelligence is all about abstract calculation and means-ends decision making. This framing supports the notion that more complex forms of ‘super-computation’ will enable the development of AGI. We argue that such a paradigm offers an attenuated understanding of human cognition that veils genuine human intelligence. We then attend to the way in which genuine human intellect is embodied and discursively formed within a community of others who are embedded in sustainable ways of life and who are responsive to the “slings and arrows of outrageous fortune”1 that can derail us from time to time. At such times, our human intellect can hold us and others in being, in moments of existential uncertainly, enabling people to live well together.2
The dominant framing of human intellect
The philosopher Rene Descartes has exerted an enduring and pervasive influence on dominant western conceptions of human beings and their relation to the world.3 Descartes based his arguments on a metaphysical position that takes a reductive approach to seeking knowledge of things. This reductive approach isolates entities from their environmental context, strips them of all significance and pares them down into ‘component parts’. Descartes claimed that this process was thought to give us a sure and certain knowledge of things.
In relation to human beings, Descartes’ reductive approach opened up a chasm between the mind, the body and the world, and located the ‘human’ aspect of our Being in the mind. The mind, somehow associated with the brain, is said to be the locus of rational thought. On the Cartesian model, the ‘human’ is a fragmented and divided form of existence - human beings are a compound of a mind substance (res cogitans) and a body substance (res extensa), which somehow come together but need no other thing in order to exist. The mind, as the place of rational thought and language, is said to be an ontologically different substance from the body, and as the mind does not require the body, thought is essentially a disembodied process.4 To be human is to be a ‘thinking non-extended thing’ conscious of an ‘extended, non-thinking thing’, so that we are both subject and object.
The Cartesian framework sets each of us up in a private world of our own in which we establish “sure and certain knowledge” through the machinations of the rational mind. The mind, associated with the brain (and in subsequent theories that retain a Cartesian dualism, equated with the brain), is said to contain internal representations that correspond to an external reality. ‘Thinking’ is considered to be an isolated, inner process done in the mind/brain in terms of these representations and the way that they are manipulated. The ability to manipulate mental representations according to formal rules is said to be the ability to reason, and Descartes considered logic, especially mathematics, to be the quintessential form of human reasoning.5 As reasoning is considered to be a formal process, it is said to be universal: correct reasoning builds complex ideas out of simple ones in a way that anyone capable of applying the process can grasp. As rational beings – the archetypal animal rationale - Descartes’ epistemology claims that we are capable of expedient calculation through rigorous reflection on our ideas and mental operations. It is through this process that we can ‘know’ with absolute certainty that when we think, we exist…cogito sum.6
This particular approach to the framing of ‘humanity’ and ‘rationality’ forms the basis of many western practices and institutions, and it underpins the initial forays into AI and AGI.
Initial ventures into Artificial Intelligence
When human thinking is equated with the ability to calculate ‘rationally’, understood as the abstract manipulation of representations according to formal rules, one can see how those working in computer science developing ‘artificial intelligence’ envisage that we can create machines capable of surpassing humans in “all areas of reasoning”. However, when reasoning has been pared down to ‘instrumental reasoning’ or ‘calculative reasoning’, concerned with the most efficient means to a given end, meaning and significance are drained from the world.7 Friedrich Nietzsche was one of the first people to articulate this existential situation.8 He noticed that a reductive, instrumental rationality had come to dominate our approach to science, and this ‘scientific thinking’ was permeating all aspects of life. At the same time, other ways of thinking and the values and ideals they embrace, began to be seen as increasingly less ‘rational’. Over time, instrumental rationality has been increasingly adopted and normalised to the point where it has been unquestioningly and uncritically accepted. It has come to arrange and dominate all aspects of our lives, permeating our social institutions and creating bureaucratic spaces devoid of humane understanding. As a corollary, it shapes who we are and what we can do.
With ‘rationality’ unhinged from human meaning and significance, the need for ‘moral theories’ came to the fore, in order to work out the ‘right’ thing to do. Such theories, for example utilitarianism, emanate from the same impoverished mode of thinking that reduces intelligence to a calculation formula, whilst presenting it as a universal logic which it (falsely) claims is the same for everyone. In other words, instrumental reasoning has produced a way of inhabiting the world and relating to others that is hideously flawed, losing sight of the mystery and richness of what it means to be truly human.
We therefore need to pause and consider our human way of being and what has been effaced by the dominance of instrumental thinking. In so doing, we have cause to question both the approach and the outcomes of Cartesian claims, and the practices, including the development of AI and AGI, that push forward in their wake.
Our human way of being – embodied, embedded and discursively informed
When Descartes made his famous conclusion - cogito sum – he failed to ask about, or take into account, the I that thinks. For in order for any abstract, instrumental, reflective thinking to occur at all, there must be someone, somewhere, doing something that is pre-reflective; that is, there first of all has to be a self, engaged in a world of activity, who can then come to reflect upon that activity.
When we attend to the way in which human beings engage with the world, we see that human activity is first and foremost embodied activity, that is, discursively embedded in a world of human endeavours. The things we come to know are the things we come to do, and they are learnt over time through our interaction with significant others.
Our knowledge of things is through our involvement with them, and this knowledge is inscribed into our very being and it has an inexpressible aspect. For example, one can write down the rules involved with a game of football, along with explanations of player positions, the physics involved with every play of the ball, and the biomechanics of the player’s moves. But none of this grasps the way in which we learn to play football, the dispositions and qualities of character inculcated through training and participation, the reading of the nuanced bodily moves done by one’s own team and the opposition, the self-discipline required to be able to play one’s role well, and the shared aspirations and unity of purpose that makes participation meaningful.
As we learn to play the game we become attuned to the thoughts and actions of one another. We come to feel and think as others do, because “our flesh is inseparable from the flesh of the world”.9 In the immediacy of a unique situation we anticipate where other players are going to move next and what they are likely to do when they get there. Our understanding of what to do in each moment is shaped by cues that we are not explicitly aware of: the ‘thwack’ of the ball; the feel of the grass and soil under our feet; the movement of the wind around us. Informed by the dynamic existential feel of the situation, players come to move as one, in seamless and complex ways that embody the game and defy any linear or algorithmic programming, or calculating of ‘probability’.
Like any other human activity we are engaged in, be it making friendships to making a cup of tea, we become accomplished in that activity through being immersed in it, practicing our moves, making mistakes, being guided, corrected and encouraged by others who have been there before us, and who have our well-being in mind. At the same time we come to embody the language that frames aspects of our world, along with the dispositions and qualities of character needed to live in that world together. In the situation of coming to play football, we will be told “take it slowly, look up…. towards where you are going” and “steady….full strength now….pass to Stevie on the wing”. Such words are accompanied by the appropriate gestures and facial expressions of those who are nurturing us into this practice. In this way, through our engaged, practical involvement with things, we come to embody a range of dispositions towards the world, as we learn the meaning of a language. In this embodied, interactive way we come to be “in the world and the world is in us”.10
The complex, rich, dynamic and ineffable character of human life means that it is not possible to create a list of rules, or a programme, for all eventualities; we cannot learn a fixed set of structured dispositional responses to events in the world. Instead we must learn the art of responsively negotiating the contingencies of the world, flexibly drawing on past situations to inform our present moment in light of future considerations.11 Consequently, human intelligence is a temporally integrated, hermeneutic achievement of an embodied, dispositionally informed individual embedded in a lived, meaningful environment.
As we learn to navigate the world appropriately through the guidance of others, we develop a sense of who we are, as well as what we can do and how we should do it. For example, we may make a fortnightly commitment to mow the lawns and weed the garden for an elderly neighbour, as we know that he struggles to do this job and that his family do not live close enough to help out on a regular basis. We also know how much pleasure he gets from sitting in his garden and admiring it. Our action is based on the insights we have developed over time, which orient us in light of the significance of things in this particular situation, and which illuminate what is a fitting response.12 The motivations that inform our thinking are the values that circumscribe our shared understanding of the world. As well as being an expression of what is good in this particular situation, we also come to understand ourselves as someone who can be relied upon to uphold the values of our community. Others also come to see us in this light. Aristotle has argued that the human intellect is determined by upbringing, and not abstract calculative thought. The shaping of an individual’s reasons for acting and ways of acting are discursively constituted in community, so that her upbringing is responsible for instilling the excellences of character required to respond appropriately to the situations she encounters. That is, she perceives the situation in its entirety and responds with practical wisdom.13
Although we are first and foremost embodied creatures immersed in a world of pre-reflective activity, we can of course re-present and reflect on an aspect of our life and consider ways we can improve what we are doing and hence, who we become. For example, we make an inappropriate comment to a friend and see that we have upset her. We do our best to apologise, but realise that we have hurt her deeply. Reflecting on this gives us the opportunity to ask ourself such questions as: “How did I lose sight of what matters, and how can I avoid doing that again?” How can I now make amends when my verbal apology is certainly not enough? Such reflection gives us the opportunity to sharpen our insights and refine our understanding of the situation, enriching what we have to draw on as we move forward. At the same time we shape who we will become, as we consider what has happened and what we will enact next, in light of the values that we - in our community - hold to be salient and want to uphold.
What is significant to note however, is that this reflective process is a derivative mode of thinking, dependent upon having a pre-reflective understanding of things. It does not have the foundational status that the dominant Cartesian-based framework of things has given it; nor is it merely means-ends instrumental thinking, as the ends themselves are evaluated and shape our very way of being.
The move to embodied AGI
Some AI researchers have recognised the significance of our human body for thinking. Rodney Brooks is an Australian roboticist and a leading proponent of embodied cognition. Noting that experiencing the world like a human is essential to developing human-like intelligence, he argues that a machine needs to have a body — it needs to perceive, move, survive and deal with the world. Brooks also notes that abstract computation is the least important human skill, and that embodied, sensorimotor skills are essential for higher level skills like common-sense reasoning.14 Proponents of embodied cognition have also recognised the importance of engaged human interaction for enabling someone to become ‘human’. They argue that a humanoid robot makes people more comfortable in their interactions with it, and this will make it easier for the robot to learn.
However, one wonders what is fuelling the drive to create such a machine, and whether those involved with AI research fully comprehend what is entailed in our human way of being.
What narrative will an AGI machine come to inhabit, and why? Do AI researchers grasp that flesh and blood creatures such as ourselves are intimately connected to the cosmos that sustains us, and this connection must inform the narrative that we live, as our very survival depends upon it? Do they understand the way in which a unique character is informed and shaped within a discursive community, embedded within a form of life that structures a liveable narrative, framing the significance of things, and thereby the values that we enact? Do they comprehend the significance of the relationships that encourage, comfort, uphold and affirm us, so that we hold one another well?
Do they understand how our interpretation and understanding of the world, and hence, what we do, is shaped by language? For example, if we take any concept – let’s say the concept ‘bear’ - and we consider how we have come to grasp this concept through a myriad of contextual interactions which have secured its multiple roles in our conceptual system, what are we to say about this concept in a machine? Can an ‘artificial intelligence’ ever really think, as opposed to calculate? Can it know what it ‘thinks’? Do those who talk about embodied machines and push this notion of AGI really know what they are saying when they make their claims?
Conclusion
We have argued that human beings are so much more than just creatures of instrumental rationality. Although instrumental reasoning is responsible for the development of the tools, techniques and technologies that have made life easier and more comfortable for us, its dominance has come at a cost. It has arguably thinned out and devitalized the richness of our humanity, along with the world we inhabit. It has allowed the calculation of the most efficient means to a given end to replace the evaluation of those ends themselves. It has left many people bereft of understanding the significance of their life, as in a world requiring mere calculation, the self recedes; for it is when enacting practical wisdom that the self is chosen. If we continue to allow the narrow and impoverished concept of instrumental thinking and the practices that it underpins to define our world for us in an un-checked way, our humanity will suffer and our world will become less liveable.
If we uncritically allow the push for the creation of AGI to go unchallenged, we may find that the entities we meet in government departments, healthcare situations, education, lawyer’s offices etc., lack the human touch.
Dr Lynne Bowyer is an educator with a background in philosophy and mental health. Lynne has a PhD in philosophy and bioethics and has taught in primary, secondary and tertiary settings. Dr Deborah Stevens is a science communicator and educator. Her PhD in bioethics education is informed by her interdisciplinary background in science, psychology, public medicine and education.
They are founding Trustees of the Centre for Science and Citizenship (www.nzcsc.org), a charitable trust that works with students and communities throughout New Zealand promoting thoughtful engagement with the ideas and actualities that contemporary science and its accompanying technologies bring, in order to consider whether and how we can live well with them.
Endnotes
- William Shakespeare, Hamlet, Act III, Scene 1.
- The idea of ‘holding one another in being’ is developed in the philosophy of Martin Heidegger; see Being and Time, translated by John Macquarrie & Edward Robinson. Oxford: Basil Blackwell, 1962. It has been used beautifully by Hilde Lindemann Nelson in “What Child is This?” The Hasting’s Centre Report, 32: 6 (2002): 29-38.
- René Descartes, Meditations on First Philosophy, Cambridge: Cambridge University Press, 1996, I, V.
- Descartes, Meditations on First Philosophy, I, VI.
- Ibid., V
- Ibid., II
- Max Weber, The Sociology of Religion London: Methuen, 1971, 270. Heidegger, “What calls for Thinking”, Basic Writings, from Being and Time (1927) to The Task of Thinking (1964), ed. David Farrell Krell, New York: HarperCollins, 1993,, 369-391; Theodor Adorno and Max Horkheimer, Dialectic of Enlightenment, trans. John Cumming, London: Verso, 1997, 37.
- Friedrich Nietzsche, “Thus Spoke Zarathustra: A Book For All And None”, The Portable Nietzsche, ed. and trans. Walter Kaufman, New York: Penguin, 1976.
- Heidegger, Being and Time, 98-99.
- Heidegger, Being and Time, 376-377, 387-388.
- John McDowell. Mind, Value, and Reality. Cambridge Massachusetts: Harvard University Press, 2002, 30-32.
- Rodney A. Brooks & Lynn Andrea Stein. ‘Building Brains for Bodies’. Autonomous Robotics 1 (1): 7-25 (1994).
- John McDowell. Mind, Value, and Reality. Cambridge Massachusetts: Harvard University Press, 2002, 30-32.
- Rodney A. Brooks & Lynn Andrea Stein. ‘Building Brains for Bodies’. Autonomous Robotics 1 (1): 7-25 (1994).
Kidney Transplantation: A New Zealand Perspective
Tony Stephens
This article has come about in response to a request to The Nathaniel Centre for information about the processes and ethical issues surrounding kidney transplantation. When we approached the Donor Liaison Coordinator in the Renal Department at Capital and Coast DHB for updated information about kidney donation, he agreed to provide the following piece which describes the practices involved. There are currently about 700 people in New Zealand on waiting lists for a kidney transplant.
Organ transplantation is a life-saving and life-enhancing therapy for many people. In New Zealand the heart, heart valves, lungs, liver, pancreas, kidneys, corneas and skin can all be transplanted.1
While most donated organs come from deceased people, live donors can give one of their kidneys or part of their liver to someone in need.
A transplant kidney allows the recipient to lead a relatively normal life. While they must take anti-rejection medications for the rest of their life, this is easier to fit into normal life than dialysis.
In New Zealand over 91 percent of kidney transplants are working after one year with over 82 percent still working five years after surgery.2 Some transplants have lasted for over 30 years.
Deceased Organ Donation
In some countries - including New Zealand - a person or family must make a conscious decision to be an organ donor after death. This can be done by stating ‘donor’ on our driver’s license but, most importantly, by informing our families of our wishes. This approach is known as ‘opt-in’.
If you are in a non-survivable condition in an Intensive Care Unit (ICU) your family will be asked to consider giving permission for organ donation after death. If you want to be an organ donor, your family is much more likely to agree if they know in advance. Therefore, it is essential that you inform your family of your wishes to be an organ donor or not.
An ‘opt-out’ system is the opposite; a person and family must make a conscious decision not to be an organ donor. In the absence of a decision to opt-out it is assumed they have given consent to be an organ donor. In such cases, family members are also assumed to have given consent for organs to be removed from their loved one. An individual or family may not feel completely comfortable about being a donor but may feel that the pressure of society to donate compels them to be a donor.
Intensive Care
Over recent years, in an attempt to improve donation rates in New Zealand, there has been a focus on training ICU doctors and nurses to better identify potential donors and then sensitively raise the question with family members.
Unfortunately, some people mistakenly believe a patient may be treated less well in ICU because of the focus on their organs rather than their recovery. This is not true.
One of the most important issues addressed by ICU staff during family discussions is that the care of the patient will not be compromised, whether organ donation has been agreed or not.
The ICU and transplant teams are separate entities. The ICU team focuses on treating the patient, and someone who is going to donate organs after death is treated the same as anyone else with all possible steps taken to improve their condition.
While the transplant team is informed when there may be a potential donor dying in the near future, this team is not involved with the patient’s care while they are still alive. The transplant team performs its roles with deep respect, sensitivity and gratitude to the person and their family.
The doctors of potential recipients are also not involved in the care of someone dying in ICU, and are only informed of a potential organ donation late in the process. They do not go to the ICU to talk with family members or to influence the care and treatment the patient is receiving.
Sometimes families decline organ donation and often face criticism from the media. While it’s easy to criticize, we must remember that the family is in shock with their loved one dying in front of them. To then be faced with the decision to have organs removed can be overwhelming.
However, if the family knows that their loved one wishes to be a donor, it may be easier for them to agree to the organ donation. Conversely, if the family knows the person does not want to be an organ donor, they can express this clearly to the ICU staff who will respect and honour this wish.
Live Donation
A healthy person can donate a kidney to someone in need. Live donors are usually members of the recipient’s family, although friends are also often donors. Donors can also offer a kidney in an anonymous (non-directed) manner. In this case the best matching recipient from the waiting list is allocated the kidney from the non-directed donor.
Live donors go through an extremely vigorous testing process to help ensure they will be fit and healthy for the operation and for the rest of their lives. This testing process takes place over many months and involves many appointments with nurses, doctors, surgeons and psychologists. A live donor can withdraw from the process at any stage with the support of the renal team. Equally, at any stage they may be found unsuitable due to a health condition or concern about their future with one kidney.
There are risks involved in being a live kidney donor – risks associated with the surgery as well as a slightly higher chance of developing renal failure (due to having only one kidney). There is also a higher chance of developing high blood pressure later in life and the consequences this can have on the donor’s health and life expectancy. A younger donor will have a longer life ahead of them for possible complications to develop.3
In New Zealand, the minimum age to be an organ donor is 18. While all potential donors are asked why they want to donate, extra care is taken with young donors - an 18 year-old would be asked at each stage if this is what they really want to do and would undergo a psychological assessment to help determine their motivations and their mental state.
Due to the long-term risks of kidney donation, anyone with diabetes or hypertension is ruled out of being a donor. Other factors ruling out live kidney donation are obesity and major psychiatric issues.
Kidney donors are monitored by the renal service or their GP for the rest of their life to help ensure they stay healthy.
At times a live anonymous donor will specify that they would like to donate their kidney to a child, or a particular person (a celebrity for example) or to someone ‘who has looked after themselves.’ This is not an option as non-directed kidneys are allocated purely on a tissue-typing test. This test identifies the person on the waiting list who best matches the donor. This person is offered the kidney and, if they agree, a surgery date is arranged. If the recipient does not agree, the next person on the waiting list with the closest tissue match is offered the kidney.
Ranking by tissue-typing gives the donor kidney the best chance of working and of not being rejected by the recipient.
Safeguarding the Interests of live donors
The interests of the donor are safeguarded throughout the live kidney donation process. They have a different doctor to the recipient, enabling each doctor to focus on their particular patient without the possible conflict of interest, or pressure to help one over the other.
As the donor is seen by many health professionals throughout the process, there are many stages at which these professionals can determine whether organ donation is the right thing for a particular donor.. The healthcare team can also determine if the donor is being pressured, in which case a strategy can be formed to decline the donor in a way that keeps them safe from any possible family repercussions.
Coming forward as a potential live donor takes a great deal of courage. To go through surgery for no physical benefit is very brave. Potential donors do sometimes feel pressure to donate, not necessarily from their family but from within themselves. A person may feel they need to donate a kidney to their loved one, but also feel the need to look after their own family.
Overcoming these conflicting feelings is very difficult, and our advice for someone in this situation would be to not donate. Being a kidney donor requires single-minded determination and focus. If there is too much going on in the donor’s life it is likely to be too much for them to cope with.
Throughout the process, staff maintain the privacy of the donors’ information. At times a recipient will ask about how ‘their donor’ is getting on. Due to confidentiality reasons we cannot give information about the donor to the recipient. If a recipient wants information about the donor they will need to ask the donor.
Buying and Selling Organs
In some countries (such as India and Sri Lanka) some people sell their kidneys as a source of income. Invariably, these donors sell a kidney out of financial desperation and post-surgery are often treated poorly by the transplanting hospital.4 In New Zealand it is illegal to buy or sell organs for transplant. Nevertheless, this option is sometimes raised by people. In such cases, they are actively discouraged from going overseas to receive a kidney transplant. This is to try and reduce the demand in the organ market and to provide protection for donors who are driven by desperate circumstances to sell.5
Conclusion
Kidney transplantation is part of the wider treatment of kidney disease and offers a recipient the best chance of a better health outcome.
Kidney transplantation relies on brave and noble people to be donors – either after dying or as a live donor. Donors and their families are motivated by a strong desire to help someone in need.
For live donors, the desire to help someone and to improve the life of the recipient outweighs the short and long-term risks to their own health. Families of deceased donors often gain some comfort from the knowledge that the death of their loved one has given life to other people.
Tony Stephens is a Registered Nurse and works as Donor Liaison Coordinator in the Renal Department at Capital and Coast DHB.
Endnotes
- http://www.donor.co.nz/facts-and-myths/faqs/
- http://www.donor.co.nz/facts-and-myths/statistics/
- Reese, P, Boudville, N, Garg, A. (2015). Living kidney donation: outcomes, ethics and uncertainty. The Lancet. Vol 385, May 16: 2003-13
- Matas, A. (2012). Incentives for organ donation: proposed standards for an internationally acceptable system. American Journal of Transplantation. Vol 12(2): 306-12.
- http://www.declarationofistanbul.org/
Organ Donation and Catholic Teaching: A Summary
Staff of The Nathaniel Centre
Catholic teaching on organ and tissue donation and transplantation speaks of it as a form of "self-giving", a selfless act of love modelled on Jesus Christ's unselfish offering of his own life. Thus, the donation of human tissue and organs is often referred to as an "enduring gift".
No one should ever presume such a gift – the decision to donate organs or tissue must always be explicit, free and informed. Provoked by love, and freely offered, an act of tissue or organ donation can be seen as a rich gesture of generosity, an expression of human solidarity that serves the common good. It is, in other words, an intensely personal act and, as such, should only ever be done with the explicit consent of a person.
As Pope Saint John Paul II noted in Dolentium Hominum (1991): “… the human body is always a personal body, the body of a person. The body cannot be treated as a merely physical or biological entity, nor can its organs and tissues ever be used as items for sale or exchange. Such a reductive materialist conception would lead to a merely instrumental use of the body, and therefore of the person.”
We acknowledge the need for, and benefits of, increasing the relatively low rates of deceased organ donation in New Zealand. However, the view of organ donation as a ‘gift’ means that it is not something that anyone should feel obliged to do or be pressured into.
For this reason, we reject any purely ‘utilitarian’ approaches to increasing the rates of donation that focus narrowly on raising numbers and that fail, intentionally or otherwise, to acknowledge the importance of the process. The process surrounding the donation of organs should be driven by a holistic understanding that respects the dying patient as a person – a person who is at the same time part of a family with its own needs and specific cultural dynamics – while upholding the dynamic of giving.
‘Opt-out’ models of consenting to organ donation (which are based on the notion of presumed consent) fail, in our view, to uphold the dynamic of genuine, intentional and consensual giving that marks out organ donation as an intensely personal and generous act.
While acknowledging that the process of being an organ donor makes significant demands on a person’s family and friends at a time of intense grief, and while also acknowledging that the family need to remain closely involved, the principle of respect for the dignity of a person implies that their expressed wishes as to what happens with their body after death should be upheld. This principle should only be departed from in exceptional cases.
Meanwhile, application of the principle of justice requires that “the criteria for donated organs should in no way be 'discriminatory' (i.e., based on age, sex, race, religion, social standing, etc.) or 'utilitarian' (i.e. based on work capacity, social usefulness, etc.). Instead, in determining who should have precedence in receiving an organ, judgements should be made on the basis of immunological and clinical factors. Any other criterion would prove wholly arbitrary and subjective, and would fail to recognize the intrinsic value of each human person as such, a value that is independent of any external circumstances.” (Pope Saint John Paul II: Address to the 18th International Congress of the Transplantation Society).
For further reading see the following articles available at: www.nathaniel.org.nz
“Organ donation - An Enduring Gift” by Michael McCabe. Nathaniel Report, Issue 12, April 2004.
“Making a Life-Saving Difference: Organ Donation and Consent” by John Kleinsman. Nathaniel Report, Issue 13, August 2004.
Nathaniel Centre Submission on Human Tissue (Organ Donation) Amendment Bill. Nathaniel Report, Issue 19, July 2006.
“Organ and Tissue Transplantation and the Catholic Moral Tradition: A Case Study in the Evolution of Moral Teaching” by John Kleinsman. Nathaniel Report, Issue 19, August 2006.
[Synopsis only] Disability in the Catholic Intellectual Tradition since the Second Vatican Council
Zach Duke examines how disability was perceived in Catholic thinking prior to and after the Second Vatican Council. This piece highlights St Thomas Aquinas’ reflection; a creature by its very existence gives glory to God. More recent reflections on the ‘dignity’ of all human persons provide a theoretical framework for all persons, including those living with a disability, to be welcomed and respected unconditionally. Pope Francis’ openness and comfort in the presence of those with disabilities shows how the rhetoric of earlier times can be lived out in practice.
The full article is available by subscription to The Nathaniel Report
A Cannabis Referendum Starter Kit
by Deborah Stevens and Lynne Bowyer
At the same time as the 2020 General Election, a binding referendum is to be held on the legalisation of cannabis for personal use. The referendum will consider both medicinal and recreational use of cannabis. The debate between pro- and anti- cannabis law reform has already begun in the media and this will only intensify over the coming months. It is important that people are well informed, understand the terms used in the debate, and consider as thoughtfully as possible the impact of any law changes on individuals and communities.
The purpose of this commentary is to explain terms that are frequently used and provide a foundation from which to consider the various perspectives put forward during the debate. An article to unpack the social context in which the law reform is being proposed will follow in another edition of the Nathaniel Report.
Some history
Cannabis has been cultivated and used in a variety of ways throughout recorded history. The Cannabis sativa plant has been a source of fibre (hemp), oil, food and linctis. It has been used as a ‘recreational’ drug in a dried plant form (commonly called marijuana), in a resin (hash or hashish), and in an oil (hash oil) form.1
Cannabis is known by other terms including: marijuana; pot, weed; dope; grass; mull; dak; hash; smoke; buds; skunk; cabbage; ganja; reefer; and Mary-Jane. Dried cannabis rolled into a cigarette to be smoked is known as a ‘joint’.
A joint of cannabis in the 1970s contained approximately 1-2% THC. In current times, a regular joint is 20-25% THC. Put another way, the average joint of the 1970s contained roughly 5 to 10 milligrams of THC, while a single joint today can contain 100 milligrams of THC
Of the several hundred chemical compounds in the cannabis plant, two are well-known: Delta-9-tetrahydrocannabinol, known as THC; and Cannabidiol, known as CBD. THC and CBD are known as ‘cannabinoids’; chemical compounds that were first isolated from the Cannabis sativa plant. THC is a psychoactive compound in cannabis. A substance is said to be psychoactive if it affects a person in a way that changes perception, mood, consciousness, cognition or actions. CBD is non-psychoactive. The potency of cannabis and its ability to produce a ‘high’ depends on the concentration of THC.
Historically, plants grown for ‘recreational’ purposes have been selected for their higher THC content. However, the levels of THC present in cannabis have increased significantly over recent decades. A joint of cannabis in the 1970s contained approximately 1-2% THC. In current times, a regular joint is 20-25% THC. Put another way, the average joint of the 1970s contained roughly 5 to 10 milligrams of THC, while a single joint today can contain 100 milligrams of THC.2 The concentration of THC is higher in resin than in the dried plant, and higher still in hash oil.
Hemp is very low in THC, containing less than 0.3% (measured in the dried flowering tops), and is nonpsychoactive. Hemp is also a cultivar of Cannabis sativa. Hemp was known and used by people across the middle latitudes of Europe and Asia from 5,000 BC,3 and has long been used as a fibre for industrial purposes. In Egypt it was used as rope when building the pyramids, and it formed the fabric on which the Guttenberg Bible and the Magna Carta were printed. Hemp is currently grown in NZ under permit for fibre, hemp/hemp seed oil, and hemp seed food products.4 Hemp is very low in THC, containing less than 0.3% (measured in the dried flowering tops), and is nonpsychoactive.
Some science
In 1964, Israeli organic chemists Raphael Mechoulam, Yehiel Gaoni and their team, isolated the structure of THC. Identifying the CBD molecule followed shortly afterward. It was discovered that THC and CBD had the ability to bind molecularly with certain receptors distributed throughout the body. The two types of cannabinoid receptors identified to date are known as CB1 (cannabinoid 1) and CB2 (cannabinoid 2).
Scientists wondered why there were specific receptors within our bodies for this type of molecule. If our bodies have the receptors, perhaps we produce these molecules ourselves – and indeed we do. In 1992, Mechoulam and his team identified a molecule that is secreted naturally within the human body: Anandamide.
Anandamide was the first endocannabinoid identified. Endo meaning ‘within’ and cannabinoid because it was received by the same system of receptors as the cannabinoid THC from the cannabis plant. Another endogenous (naturally and spontaneously occurring) cannabinoid in our bodies, 2-arachidonylglycerol (2 AG) was identified in 1993. 2AG exerts similar effects to Cannabidiol (CBD).
The identification of cannabinoid receptors and endocannabinoid molecules triggered an exponential growth of scientific studies, which led to the identification of a wider system of intercellular communication within our bodies, known as the Endocannabinoid System (ECS). The endocannabinoid system is distributed throughout the body, including the brain, central nervous system, the immune system, the gastro-intestinal tract, bone and skin. Maintaining the complex balance – the homeostasis – between the different functions of the body, the ECS regulates our body temperature and the pH level within our body. The ECS controls motor co-ordination, is involved in pain control, sleep cycles, appetite, working memory, fertility and pregnancy.
The ECS does not develop through exposure to cannabis; it exists throughout our lives and is involved in our pre- and post- natal development. The ECS is vital in brain development including synaptogenesis – the formation of the synapses in the neurons of the brain and central nervous system. It also plays a significant part in synaptic pruning, which occurs at two foundational times in our life: early childhood and adolescence.
New Zealanders are among the highest users of illegal drugs in the world, and according to the United Nations 2012 Drug Report,7 top the list for cannabis use.
Identification of the Endocannabinoid System helps explain how cannabis affects systems in the human body, but cannabis is not why the Endocannabinoid System exists. It is now known that all vertebrates and invertebrates including the humble sea-squirt that evolved over 600 million years ago, have an endocannabinoid system.5
The word ‘cannabinoids’ now refers to every chemical substance – regardless of its origin or structure – that unites with cannabinoid receptors in the ECS, and has similar effects to those produced by the plant Cannabis Sativa L.6 Cannabinoids are differentiated by their source. Those that are plant based are termed Phytocannabinoids. Compounds developed in the laboratory are termed Synthetic cannabinoids. There is still a great deal to be learned and understood about the ECS and how it is affected by endocannabinoids, phytocannabinoids and synthetic cannabinoids.
Current legal situation of cannabis
Cannabis is the most widely used illegal drug in New Zealand and the fourth most widely used recreational drug after caffeine, alcohol and tobacco. New Zealanders are among the highest users of illegal drugs in the world, and according to the United Nations 2012 Drug Report,7 top the list for cannabis use. Statistics for Oceania (predominantly Australia and New Zealand) show cannabis use between 9.1 and 14.6 per cent of people, compared with 2.8 to 4.5 per cent globally.8 The longitudinal Christchurch Study reports that in their cohort of over 1000 people born in 1977 in Christchurch, 80% have tried cannabis at least once.9
Cannabis use in New Zealand is governed by the Misuse of Drugs Act 1975. The Misuse of Drugs Act 1975 and subsequent amendments classify a wide range of controlled and illegal drugs according to the level of risk of harm they pose to people who misuse them. Cannabis oil and hashish are classified as Class B drugs and are deemed to pose a “high risk of harm”. Cannabis seed and cannabis plant are classified as Class C drugs, deemed “moderate risk of harm”. Under this Act, unauthorised possession of any amount of cannabis for any purpose is illegal.
The Misuse of Drugs (Medicinal Cannabis) Amendment Bill10 was passed into law on December 11th 2018. With the passing of this Bill, cannabis can now be used by patients who are terminally ill or in palliation – that is, patients who are seriously ill, where the focus of treatment is on improving their quality of life. In addition, the Misuse of Drugs (Medicinal Cannabis)
Amendment Bill now makes non-psychoactive cannabis-derived products available as they are no longer classified as controlled drugs.11 The law fully decriminalises cannabidiol (CBD) products and allows medicinal cannabis products to be manufactured in New Zealand. Under this new legislation it is the Governor- General who establishes regulatory standards for cannabis products. Medicinal cannabis products are not subsidised and come at a significant cost to a patient when prescribed.12
It will take until the end of 2019 for the new regulations established by the Misuse of Drugs (Medicinal Cannabis) Amendment Bill 2018 to be rolled out. Meanwhile, a statutory defence for terminally ill and palliation patients to possess and use cannabis took effect immediately.
Half of all New Zealanders with a drug dependence issue were already dependent by the time they were 19 years old, indicating that serious drug use starts early.
It is generally accepted that the usage rate of ‘recreational’ cannabis in New Zealand is high. Accordingly, the possession of cannabis in small quantities may often not be prosecuted. Instead, in some cases, first offences may result in a formal warning and confiscation by police. Such depenalisation approximates decriminalisation. Decriminalisation would involve removing the criminal penalties for possession, whilst having a sliding scale in terms of personal limits, potential civil penalties, and health referrals.
Some effects of cannabis use
Half of all New Zealanders with a drug dependence issue were already dependent by the time they were 19 years old, indicating that serious drug use starts early.13 A recent survey shows that the most common age of first drug use in New Zealand is between 15 and 17 years of age but more startling is the fact that almost one in five drug users were 14 years or younger when they first tried drugs.14 Two longitudinal studies carried out in New Zealand, where study participants have been examined from birth onwards, have produced internationally recognised data on cannabis use.
The Dunedin Multidisciplinary Health and Development Study15 is following 1,037 Dunedin individuals since their birth in 1972/1973. Regular users of cannabis within this cohort have shown impairment of everyday cognitive function, and a greater decline in IQ and memory loss compared with other participants. Impairment is concentrated among adolescent-onset cannabis users, with more persistent use associated with greater decline. Another project in this study has shown a significant increased risk of schizophrenia in later life for teenagers who use cannabis, especially for a vulnerable minority of teenagers with a predisposition to developing schizophrenia.16 Quitting or reducing cannabis use did not fully restore brain functioning among adolescent-onset cannabis users.17 The researchers suggest that cannabis has a neurotoxic effect in the adolescent developing brain, causing damage to the central and/or peripheral nervous system.
Greater understanding of the endocannabinoid system and research on endocannabinoids and how they interact, is required. We need to know more about phytocannabinoids – the myriad of cannabinoids including THC and CBD that are plant based – including their properties, their possible therapeutic applications and their long-term safety of use.
The Christchurch Health and Development study18 is following the health, education and life progress of a group of 1,265 people born in the urban region of Christchurch during mid-1977. Eighty percent of the study cohort have tried cannabis at least once, although only a small number use regularly or heavily.19 One research paper from this study looked specifically at the young people between the ages of 15 – 25yrs.20 The study concluded that regular or heavy cannabis use was associated with harms to the user including: an increase in amotivational syndrome (educational failure, employment problems, welfare dependence); the precursor to use of other illicit drugs; and the increased risk of developing psychotic symptoms. Adolescent onset and heavier users were deemed most at risk.
Considerations
The conversation around cannabis law reform is scientifically, legally and socially complex. Scientifically, there is still a good deal to learn and understand about the potential harms and benefits of cannabis-based products. Greater understanding of the endocannabinoid system and research on endocannabinoids and how they interact, is required. We need to know more about phytocannabinoids – the myriad of cannabinoids including THC and CBD that are plant based – including their properties, their possible therapeutic applications and their long-term safety of use. Research in these areas is currently being undertaken, and academically, the field of cannabinoid research generates some 10 000 articles per annum globally.21
It is important that people thoughtfully engage with the different facets of the cannabis law reform debate in order to take an informed stance in the referendum. Our next article will raise some issues around the social complexity of cannabis law reform.
Dr Deborah Stevens and Dr Lynne Bowyer are the co-directors of the New Zealand Centre for Science and Citizenship (www. nzcsc.org), a charitable trust that promotes informed public engagement on a range of ethical issues.
Endnotes
1 https://www.drugfoundation.org.nz/info/drug-index/cannabis/ 2 Berenson, A. (2019). Tell your children the truth about marijuana, mental illness and violence. New York: Free Press, p.40-41 3 Barber, Elizabeth Wayland. (1992). Prehistoric Textiles: The Development of Cloth in the Neolithic and Bronze Ages with Special Reference to the Aegean. Princeton University Press. p. 36. 4 NZ Govt Press Release: Hemp seed can now be sold as food. Nov 6 2018. http://www.scoop.co.nz/stories/BU1811/S00149/hemp-seed-can-nowbe- sold-as-food.htm 5 https://medium.com/randy-s-club/7-things-you-probably-didnt-knowabout-the-endocannabinoid-system-35e264c802bc 6 https://www.fundacion-canna.es/en/cannabinoids 7 Kiwis World’s Top Cannabis Smokers. NZ Herald June 2012 https://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=10815874 8 United Nations Office on Drugs and Crime - World Drug Report 2012 http://www.unodc.org/unodc/en/data-and-analysis/WDR-2012.html 9 Boden J. Cannabis – what’s the harm? Christchurch Health and Development Study https://vimeo.com/272146311 10 Misuse of Drugs (Medicinal Cannabis) Amendment Bill http://www.legislation.govt.nz/bill/government/2017/0012/latest/DLM7518707.html 11 Misuse of Drugs (Medicinal Cannabis) Amendment Act, Dec 2018, NZ Ministry of Health. https://www.health.govt.nz/our-work/regulationhealth-and-disability-system/medicines-control/medicinal-cannabis/misuse-drugs-medicinal-cannabis-amendment-act 12 Personal correspondence from a South Island based General Practitioner. 13 New Zealand Drug Foundation (2017) https://www.drugfoundation.org.nz/matters-of-substance/october-2017/the-right-message/ 14 http://riskgroup.co.nz/Drug_Dogs/Schools.html 15 The Dunedin Multidisciplinary Health and Development Study. https://dunedinstudy.otago.ac.nz/ 16 Cannabis use ‘trigger for schizophrenia’. New Zealand Herald 20 Feb 2019. https://www.nzherald.co.nz/technology/news/article.cfm?c_id=5&objectid=10116853 17 Meier et al 2012, PNAS 109 (40) Persistent cannabis users show neuropsychological decline from childhood to midlife. https://www.scribd.com/document/280247224/Meier-2012-PNAS-Persistent-Cannabis-Use 18 The Christchurch Health and Development study https://www.otago.ac.nz/christchurch/research/healthdevelopment/ 19 Boden J. Cannabis: what you need to know 2018 https://www.otago.ac.nz/otagomagazine/issue47/opinion/otago696401.html 20 Fergusson, David; Joseph M. Boden; L. John Horwood (April 2006). “Cannabis use and other illicit drug use: Testing the cannabis gateway hypothesis”. Addiction. 101 (4): 556–569. doi:10.1111/j.1360-0443.2005.01322.x. PMID 16548935 21 Bab, I. (2011). British Journal of Pharmacology August 163(7), 1327-1328. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3165944/