Tag Archives: philosophy

When Activism Becomes Your Identity Recovery Suffers

Eating disorder (ED) treatment sits at an uneasy intersection: medicine and meaning, physiology and identity, personal suffering and social narrative. In that terrain, clinician activism can be a force for good, reducing stigma, broadening access, and challenging harmful norms.

But there is a predictable failure mode when activism frameworks become not just a tool, but a clinician’s very identity. In the eating disorder community, particularly where more militant clinician activists strongly endorse the Health at Every Size (HAES) principles which have been long abandoned by the ASDAH and “White Supremacy Culture” frameworks, identity fusion can undermine clinical objectivity and, in turn, inhibit recovery.

The Core Dynamic: Identity Fusion in Clinician-Activism

Identity fusion (also described as role engulfment, overidentification, or enmeshment) occurs when “the cause” becomes inseparable from “the self.” The clinician activist no longer merely uses a framework; they become and are the framework. They view disagreement or complexity as an existential threat not to an idea, but to their very own identity. In doing so, professional, objective debate becomes impossible since the disagreement is no longer about an eating disorder issue. It is perceived to be about the person.

In that state, clinical questions are vulnerable to moralization:

  • A clinical disagreement becomes “harm.”
  • A treatment trade off becomes “violence.”
  • A patient’s ambivalence becomes “internalized oppression.”
  • A colleague’s caution becomes “complicity.”

None of this requires malice although identity fusion is inevitably morphing into a malice-based reality. It arises from the same impulse that draws many clinicians into ED work: a commitment to relieve suffering and protect vulnerable people. The problem is that fused identity tends to produce epistemic lock-in, a narrowing of what counts as legitimate evidence, clinically relevant language, and/or acceptable outcomes.

And this results in harming patients.

7 Ways Militant Identity-fusion Harms Patients

1) Disagreement is improperly perceived as harm

When a professional fellow clinician asks about vitals, level of care, growth curves, or weight trajectory and your first move is moral accusation (“harmful,” “violent,” “unsafe”), you’ve replaced clinical reasoning with social control.

Impact: Teams stop speaking plainly. Errors persist longer. Patients inevitably deteriorate.

2) “Weight-neutral” becomes “weight-blind”

Stigma reduction is not the same as refusing clinically relevant data.

If your practice has blanket taboos, “never weigh,” “never discuss weight adjacent information,” “never document it,” “never acknowledge weight change even when medically relevant” … you are letting ideology override physiology.

Impact: Delayed recognition of instability, delayed escalation, preventable crises.

3) The framework becomes the differential diagnosis

If every case collapses into one explanation (diet culture, oppression, stigma) and alternative hypotheses are treated as betrayal, you’re no longer practicing medicine or psychotherapy … you’re practicing narrative enforcement.

Impact: Missed complexity of the intersection of ARFID, OCD, Autism, Trauma, substance use, GI-endocrine resulting in impaired and slower recovery.  

4) “Internalized ____” is used as a trump card

If a patient’s goals or fears are explained away as “internalized fatphobia,” “internalized white supremacy,” etc., without genuine exploration, you’re doing something coercive: you’re disqualifying the patient’s agency by definition.

Impact: Performance over honesty; more secrecy, more dropout, less change.

5) Outcomes are replaced with virtue

If you spend more time policing language, “calling in/out,” and attempting to establish moral positioning rather than tracking response to treatment, you’re drifting from care to identity maintenance.

Impact: Plans don’t update when they aren’t working. Patients stay stuck longer.

6) You punish measurement instead of fixing measurement

Measurement can be stigmatizing. The solution is not to ban it; it’s to do it professionally and competently:

  • blinded weights when indicated
  • trauma-informed procedures
  • clear consent scripts
  • a focus on vitals, labs, function, behaviors, impairment
  • explicit thresholds for escalation

Impact when you ban instead: You lose safety signals and invite late-stage emergencies.

7) Institutions are treated like enemies, not systems to improve

If “White Supremacy Culture” language becomes a cudgel (to win arguments) rather than a tool (to identify disparities), it stops improving care and starts producing fear and paralysis.

Impact: Staff self-censor, teams fracture, equity work becomes theater rather than outcome based.

Why ED Recovery Is Especially Vulnerable to Identity Fusion

ED recovery is rarely linear and almost never purely ideological. It typically requires:

  • honest assessment of risk (medical, behavioral, psychiatric)
  • tolerating discomfort and ambiguity
  • confronting avoidance and cognitive rigidity
  • willingness to test beliefs against real-world outcomes

Identity-fused activism can unintentionally reinforce the very rigidity that EDs thrive on—only now it’s dressed up as ethics.

This type of identity activism generally manifests in at least five (5) different mechanisms.

Mechanism 1: Skewed Assessment—When “Weight-Neutral” Becomes “Weight-Blind”

When HAES was relevant, a HAES approach could help reduce shame and prevent naïve weight moralizing. But when weight neutrality becomes identity instead of strategy, it drifts into weight blindness. This is a refusal to engage with weight-adjacent data even when medically and diagnostically relevant.

That matters because ED medical risk is often not negotiable and manifests in:

  • bradycardia, hypotension, syncope
  • electrolyte abnormalities
  • refeeding risk
  • growth suppression in adolescents
  • medication dosing and side effect profiles tied to physiological status

A blanket avoidance of weight trajectories, growth curves, or energy deficit indicators can lead to:

  • under recognition of medical instability
  • delayed escalation to higher levels of care
  • misinterpretation of deterioration as “diet culture panic” rather than clinical decline

Paradoxically, this can increase the likelihood of crisis, i.e., forcing coercive interventions later that could have been avoided with earlier, calmer medical clarity.

Mechanism 2: Ideology First Treatment Planning—One Lens for Every Patient

Recovery requires individualized formulation: what maintains the disorder for this person, with this body, history, and risk profile?

When activism is fused with identity, the framework can become pre-emptive and totalizing:

  • the formulation is decided in advance (oppression, diet culture, stigma)
  • the clinical plan becomes a demonstration of ideological consistency
  • alternative hypotheses are filtered out

In practice, this can look like:

  • prioritizing worldview alignment over stabilization sequencing
  • treating weight change (in either direction) as inherently suspect or unspeakable
  • minimizing patient-specific drivers (trauma, OCD, autism/ARFID presentations, bipolarity, GI/endocrine issues, substance use, family dynamics)

The result is not “anti-oppressive care.” It is reduced differential diagnosis and reduced responsiveness to real-time clinical feedback—two reliable ways to prolong illness.

Mechanism 3: Speaking Taboos and Team Brittleness—When Consultation Becomes Risky

High quality ED treatment depends on teams: medical providers, therapists, dietitians, psychiatrists, higher levels of care and the family. Teams improve outcomes when they can speak plainly about risk, behaviors, and response to treatment.

Identity-fused activism can create taboo trade-offs: certain words and outcomes become morally contaminated. For example:

  • “weight loss” and “weight gain” become unsayable even when clinically relevant
  • “Obesity” cannot ever be said
  • “medical necessity” is treated as a pretext for bias rather than sometimes a reality
  • case presentations omit key data to avoid value conflict

Teams then develop avoidance patterns:

  • clinicians don’t raise concerns that might trigger ideological conflict
  • supervision becomes performative
  • “safe/unsafe person” sorting replaces “strong/weak hypothesis”

When honest consultation becomes socially risky, subtle deterioration is easier to miss and recovery slows.

Mechanism 4: Therapy Turns into Recruitment—Undermining Autonomy and Informed Consent

A less recognized harm of identity-fused clinician activism is coercivealignment. Patients pick up on what a clinician needs them to believe to be considered “good,” “safe,” or “not harmful.”

This can inhibit recovery by:

  • replacing curiosity with compliance
  • encouraging patients to outsource thinking to ideology
  • shaming patients for goals they genuinely hold (including weight-related goals, either direction)
  • pathologizing disagreement as “internalized” something, rather than treating it as an authentic value conflict

In ED recovery, where identity and control are already central themes, this dynamic can be particularly damaging. The patient’s job becomes to perform correctness rather than do the hard work of change.

Mechanism 5: “White Supremacy Culture” as a Total Explanation … From Equity Tool to Clinical Shortcut

Equity frameworks can illuminate real disparities: who gets believed, who is labeled “noncompliant,” whose pain is minimized, whose ED is recognized early, and who can access care. Used well, these frameworks can sharpen clinical accountability.

Used as identity, they can become a clinical shortcut:

  • a slogan substitutes for specific behavioral analysis
  • staff anxiety about “getting it wrong” reduces honest assessment
  • outcome metrics get replaced by moral language

In the worst case, the framework becomes an interpretive monopoly: if a patient isn’t improving, the explanation is always the system or diet culture, never the possibility that the chosen intervention isn’t working for this person.

Recovery requires feedback loops. Any framework that discourages revising the plan when the data demand it will predictably inhibit recovery.

What This Looks Like to Patients

Patients tend to experience the downstream effects in concrete ways:

  • Confusion: “We’re not tracking the things that make me feel unsafe—why?”
  • Silence: “Certain topics make my clinician tense, so I avoid them.”
  • Pressure: “If I don’t adopt the right worldview, I’m seen as the problem.”
  • Delay: “We stayed in the wrong level of care too long because talking about risk felt taboo.”
  • Discouragement: “Treatment became about theory, not about me.”

And for many patients, the ED seizes on the contradiction: if the clinician won’t name physiological reality, the disorder will.

Guardrails: Keeping Advocacy Without Losing Objectivity

The remedy is not “less compassion.” It’s more structure; clinical, ethical, and team based.

1) Separate roles explicitly

Use an internal “two hats” model:

  • Advocate hat: values, access, dignity, stigma reduction
  • Clinician hat: differential diagnosis, risk, measurement, falsifiable hypotheses

2) Require a “facts-only” case summary

Before any formulation, write a short paragraph of observable data:

  • vitals, labs, behaviors, impairment, psychiatric risk, trajectory
    Then add the narrative and equity lens.

3) Pre-commit to falsifiers

Ask: “What would make us change the plan within 2–4 weeks?”
Define escalation criteria clearly, including medical thresholds.

4) Build structured dissent into the team

Rotate a designated “alternative hypothesis” role in case conference. Formulate on alternative platform. This has the effect of reducing groupthink without moral conflict.

5) Make informed consent real

If a clinic centers a framework, say plainly what it means in practice:

  • how monitoring is handled (e.g., blinded weights when needed)
  • what outcomes are targeted
  • what happens if the patient’s goals differ
  • what alternatives exist

6) Translate equity frameworks into measurable clinic behaviors. In emphasizing this aspect, this keeps antiracism clinical rather than rhetorical.

Focus on:

  • access inequities
  • bias in diagnosis rates
  • differential treatment dropout
  • pain and symptom dismissal patterns
  • culturally competent engagement.

Conclusion: Recovery Needs Reality, Not Ritual

Activism in the ED field has certainly helped some patients feel less shame and more seen. But when clinician activism becomes identity fusion—particularly around HAES and “White Supremacy Culture” frameworks, the risk is that treatment becomes less falsifiable, less individualized, and morally brittle.

ED recovery thrives on flexible thinking, accurate assessment, and iterative change. Any approach that turns clinical conversation into taboo, ideology into identity, or disagreement into harm will predictably inhibit recovery by narrowing what can be said, measured, reconsidered, and healed.

The goal is not to remove values from care. It is to keep values in their proper place and perspective: guiding dignity and equity, while preserving the clinician’s first obligation in ED treatment … to see clearly, respond to data, and help the patient recover in their own life, not inside someone else’s ideology.

ADDRESSING DIFFICULT TOPICS THROUGH SHARED WISDOM AND COLLABORATION

We exist in a perpetual moving cycle of life, death and rebirth. In that cycle, we may be given the opportunity to discover and if we have the wisdom, to embrace a greater understanding of ourselves. And maybe as well, we will receive a brief glimpse of our soul’s purpose on this plain of existence.

Life. Death. Rebirth.

Questioning what awaits us. Exploring the unanswerable questions of … do we have a soul? And, what awaits us after we leave this existence?

Life. Death. Rebirth.

Fewer things frighten people as much as the belief that death is the end. It is eternal. It is darkness. It is final and everlasting. For so many of us, we fear the great unknown. We do not understand it. For many of us, we do all we can to delay the inevitable. If we are bestowed with the gifts of logic, reason and wisdom, we understand that each day of life brings us closer to our last day of life.

And so, we are afraid.

Three years ago, when Dr. Jennifer Gaudiani and her colleagues wrote a paper on “Terminal Anorexia,” she brought to the forefront of our consciousness the great unknown.  Our greatest fear. Our mortal existence. When confronted with a difficult topic which is controversial or which stirs deep emotions, more often than not, people react with fear. With anger. With what they believe is righteous indignation.

I was certainly the Grand Master of that parade of indignation.  Filing complaints with medical boards. Writing scathing articles. Calling her “Dr. Death.” Certainly, the death of my beloved daughter clouded my vision on this issue. In addition, death visited me far too often in a very short time frame.  Within thirteen (13) months, my father, my mother and my older brother were all taken.

And so, my logical, reasoning brain took a holiday. This was a crusade. A righteous mission. And then, life happened.

I was afforded the opportunity to meet with Dr. Gaudiani and look her in the eyes. To ask questions. To challenge her. It was an opportunity to spew forth my views on death, and the soul, and our existence. By God my righteous indignation was going to be heard!

But inexplicably, I experienced a soul. A person in pain. A person in fear. A person who desired to be heard on this most difficult issue. And so, I listened. And learned.

And, I found a person of compassion. I also discovered that perhaps Dr. Gaudiani reasoned that what awaits us after this existence is not something to be feared but instead, is a release from pain. A new beginning. A transition to a higher level of consciousness. Bringing us one step closer to a greater understanding of our soul. A step closer to the Divine.

In the past few months I also discovered at the time the paper on “Terminal Anorexia” was being written, one of her co-authors, Dr. Joel Yager, was battling for his own life. Cancer had sunk its insidious claws into Dr. Yager. It finally claimed his life at 83 years old on December 22, 2024. Imagine if you can, that as you are fighting for your own life, as you are facing the greatest fear of all, you are contributing to this controversial issue. What incredible courage and strength that must have taken. And another life lesson was learned.

One of the more admirable qualities a person can have is the ability to look at themselves, acknowledge past mistakes, own those mistakes and then, take steps to rectify those mistakes.

That journey is so incredibly difficult. It requires a person to be vulnerable. To be open to the gift of being able to listen to learn. To her immense credit, Dr. Gaudiani did exactly that.

She reached out to people who not just strongly disagreed with her, but who sought to end her career. She hosted a summit in Denver in which persons who both agreed and disagreed with her views were granted the opportunity to state their opinions and points of view. To talk. To start a journey of greater understanding and cooperation.

Dr. Gaudiani admitted her mistakes. And desired to listen to those who disagreed with her. Those who sought collaboration.  That journey was not always smooth and trouble free. But most persons persevered. She actively sought professionals who disagreed with her views. And from those discussions and meetings, an evolution began to happen.

An evolution of not just the thinking about end of life, but an evolution of the heart. An evolution of the soul. An evolution of substance.

This past week, the Journal of Eating Disorders published an article written by Dr. Gaudiani. That article is embedded here:

https://jeatdisord.biomedcentral.com/articles/10.1186/s40337-025-01279-x

I strongly believe that had this article been written first, Dr. Gaudiani would be looked upon as a pioneer in how we care for the sickest of the sick. There is intelligence, compassion, testing boundaries, a firm, resolved commitment to her patients expressed in the article.  And it would set the foundational standard upon which intelligent discourse and future collaborative conduct could have been built.  And hopefully … that is what happens now.

There will always be those who oppose and seek to denigrate Dr. Gaudiani. Not just her viewpoints and medical opinions. But her as a person. These people tend to personalize an issue. More often than not, because their identities become the very topic at issue. The world to them is black and white. They cannot separate the professional from the opinion. And they languish in their own fear.

I still strongly oppose medical aid in dying for anorexic patients. A society struggling with how we keep alive our loved ones afflicted with this illness is light years away from being able to intelligently and compassionately implement a protocol which assists our loved ones into their next plain of existence. We know so very little about this illness. What we do know, our knowledge, wisdom and understanding have been clouded by tribal idiocy.

Dr. Gaudiani and I have communicated on a frequent basis. Our communications have gone from initially hesitant, respectful, and perhaps a bit distrustful to … sending each other family photos on holidays. Dr. Gaudiani was gracious enough to take a call from my sister who was struggling with a severe gastrointestinal issue.

Whereas I strongly believe that medical aid in dying should not be utilized for anorexia nervosa, I just as strongly believe that this topic, no matter how uncomfortable it may be, should and must be discussed among professionals. Opinions, research and experience must be shared.  We cannot possibly make progress if we are unwilling or unable to meet with fellow professionals, set aside our personal animus, and explore all options.

Finally, I believe that Dr. Gaudiani has a right to be very proud of this article. Mostly because of the substance behind the words. She has found a way to “humanize” very deep emotions and given grace and a platform to allow intelligent discussion on one of the most complex riddles which faces humankind today … our very existence.

I hope and pray that as a community, we can utilize a hopeful message as a rallying cry for unity. Society and our culture will not allow us to reach an accord on all points of disagreements.  Our fear will not allow us.

That is not important. But, collaboration, respect and giving grace. Aren’t those the qualities which bring us wisdom and insight? Aren’t those the very qualities which bring us closer to the Divine?

Kintsugi

The tragic reality regarding eating disorders is that every objective, fact-based study and research paper indicates the number of persons afflicted with eating disorders, the severity of those eating disorders, and the mortality rate for persons afflicted with eating disorders are at the highest level we have ever known. In short, more people are suffering and more people are dying. And yet, no accountability is being taken. No consequences are being enforced. Honest answers to difficult and pointed questions are avoided or are non-existent.

There are undoubtedly many causes for that grim reality. Unfortunately, part of that reality must be laid at the feet of the eating disorder therapist mind set — group think currently infesting and harming the community.

In general, when many therapists are asked about the cause of the alarming reality, they point fingers at Covid, and “diet culture,” and fat phobia and white supremacy and weight discrimination and the patriarchy and ableism and healthism and every “ism” know to humankind.

However, where do most therapists refuse to point any fingers?  What will not be investigated? The answer quite simply is … themselves. There is no push back let alone accountability. Conflicts of interest ignored. Patients also being utilized as employees. Narcissism. In the name of social justice, reduced priority given to those who suffer and their families. And that is the “most unkindest cut of all.”

Make no mistake … there are some incredibly erudite, insightful, wise, compassionate and inspirational therapists. They are more than deserving of our gratitude, admiration and respect. But they are far too few and far too unknown. And that leads to tribal mentality and questionable mind sets and programs.

For example, a new proposed, certification program for eating disorders, not even in its infancy and not accredited by anyone, starts to roll out its program not by discussing eating disorders, nor their serious nature, nor the many complex factors and issues involved nor the incomprehensibly horrific mortality rate.  No. This program starts out by addressing “Indigenous Peoples’ Land Use Acknowledgement” and how you can reach out to groups supporting that “very important aspect of eating disorders.”

Because nothing says “this certification program is a very serious, hard-hitting, science based, evidence rich program designed to effectively address eating disorders in the 21st Century” than leading right out of the gate addressing Indigenous Peoples’ Land Use Acknowledgement! And the people who thought that would be an incredibly good idea are … therapists?

My initial response was going to expose the absurd nature of that messaging and its irrelevancy to eating disorders. In a very direct and blunt manner. But then sometimes, a different message comes to us in the most unexpected way.  And in being open to that messaging and the wonders of the multiverse, we perhaps start to see and realize alternate ways of thinking, feeling and believing.

For there can be beauty in the broken.

Kintsugi is a Japanese art form that repairs broken pottery with gold, rendering a new piece more exquisite than it was before the break. It literally means “to join with gold.”

Katherine and Jay Wolf, in their book, Suffer Strong, state:

“The story of kintsugi—this style of pottery—may be the most perfect embodiment of all our trauma-shattered lives… Instead of throwing away the broken beloved pottery, we’ll fix it in a way that doesn’t pretend it hasn’t been broken but honors the breaking—and more so, the surviving—by highlighting those repaired seams with gold lacquer. Now the object is functional once again and dignified, not discarded. It’s stronger and even more valuable because of its reinforced, golden scars.”

An article written by Vaneetha Risner beautifully states, “Rather than trying to hide the damage, kintsugi highlights the repair. The imperfections are what make it beautiful and valuable. A broken piece that is put back together has more of a story, seems more authentic and real, is stronger and more resilient than something that has stayed pristine.”

“God is the restorer, the kintsugi Master who skillfully and tenderly puts the broken pieces of our lives back together.”

Kintsugi. Kintsugi.

And so, regarding that attempted new, broken certification program, roll it back, revise it, edit it.  Consult with intelligent people who disagree with you. Collaborate with professionals from throughout the community not just those in your tribe. There is gold for you to use in addressing the flaws in the program. Find the gold and utilize it. Mold it and make something better. And most importantly, always remember…  IT IS NOT ABOUT YOU!

Therapists … You are merely the messengers. It is about the families who are suffering from eating disorders.  And when your child is suffering, you simply want them to heal, to embrace the richness of life.

Now, I don’t like to think of our suffering children as being “broken.” Perhaps, bent a bit. Fractured perhaps. But from those hardships, those obstacles, from deprivation, from fear and hurt and anger can come … healing. Enlightenment. Beauty. Resiliency and strength. Kintsugi.

Our therapists, those whom we entrust to help save the lives of our children, must embrace the concept of kintsugi. You must be wiser, more insightful, get past your preconceptions, your own fears, your own inner turmoil. Instead of believing you have all the answers, know that you absolutely do not. But you can get closer to a place of healing by opening your hearts, your minds, your souls to the wisdom of others.

Take the broken. And make it more beautiful than it ever was before.

Kintsugi.

Obstacles, Self-Awareness and our Humanity

When people, organizations, and yes, even nations have strong disagreements, it seems to be human nature to focus on the need to be right. We look at existing problems myopically. It has become ingrained that we must be correct. We listen to reply … not to learn. And somewhere along the way, we lose our humanity.

Our humanity.

The essence of who we are, who we complex, yet fragile people are, becomes secondary if not lost altogether.

Our humanity.

This reality was recently brought home in an unexpected way. While on vacation, I was bobbing around in the Atlantic Ocean on the eastern most island in the Caribbean. I got this feeling of being a speck really, at the mercy of a force far greater than me. The ocean, its deep mysteries, its majestic nature, its unique characteristics, was made manifest as wave after wave pressed its might against me. Unstoppable. Unrelenting. I was in the presence of an overwhelming force, filled with its own living organisms and truth be told, I was helpless and at its mercy.

One individual. One human. Overwhelmed by the reality that the forces around me could take a life, any life, my life, without hesitation or delay. There was no humanity that I could see.

And yet, it is humanity about which we must be keenly aware. Especially in times of conflict, strife and crisis.

By now, most people know or have heard about the lawsuit involving Bonnie Harken, iaedp and the three (3) directors overseeing all of the corporate chapters. People may know the lawsuit alleges and illegal tying agreement involving certification and iaedp membership and mandatory attendance at iaedp’s symposium. This by itself would be a large obstacle.

But that is not the only huge obstacle being faced.  Complaints have also been directed against iaedp regarding BIPOC membership and lack of BIPOC leadership. The petition involving those topics (and certification) and calling for Ms. Harken’s resignation, is now up to 208 signatures. This number is incredibly significant when considering the size of the eating disorder community.

Then there is the issue pertaining to the demands for dissolution from iaedp corporate chapters. Baltimore. New Haven. St. Louis. Denver. Central Coast. Baltimore. Phoenix. All wishing to disassociate from the national chapter.

Any person facing these significant obstacles alone would surely question their own motivations and conduct. Your membership and chapters demanding disassociation and your resignation. The heartache knowing that an organization for whom you toiled for 22 years no longer wants you is shattering to the ego of any person.

And now, the stakes have escalated and exposure is far greater. With this added reality, the pressure must be nearly inconceivable. These added stakes now include complaints and requests for investigation being made to:

The Internal Revenue Service

The U.S. Department of Labor

The California Franchise Tax Board

California Senator Dan Cortese

The same Senator Cortese, the Chair of California’s Senate Labor, Public Employment and Retirement Committee who stated, “An independent contractor is a specific designation for self-employed people or businesses engaged in contract work. It’s not a gimmick for organizations to avoid paying for employee healthcare and other benefits or reducing their tax liability. Any company found breaking the law will be brought to justice, and they would certainly have no business advising other companies on labor law.”

If my reading of the law and its interpretation is correct, the tax issues facing not just Bonnie Harken and iaedp, but iaedp’s national board of directors could be momentous.  And result in draconian measures against one and all.

Ms. Harken believed she could run all operations of iaedp and remain outside the purview of state and federal administrative agencies. Most tax-exempt organizations, such as iaedp, are required to withhold and pay federal income tax with respect to wages of their employees in the same manner as for-profit organizations. These organizations are also required to withhold and pay these taxes, also known as Federal Insurance Contributions Act taxes, in the same manner as for-profit organizations.

California requires employers to withhold state income tax from wages paid to employees. There are also three other state payroll taxes.

Presumably, Ms. Harken believed she could get avoid these taxes by classifying herself as an independent contractor and utilizing her dissolved corporation as a “go between” entity.  If she is wrong, the consequences for not just her but iaedp’s board of directors could be financially, mentally, and emotionally catastrophic.

With all of these issues, I cannot begin to fathom the pain, the fear, the uncertainty, the anguish experienced every day by a person facing those insurmountable objects. As the twilight of our existence on this plain overtakes us, most of us hope to be able to look back upon a life well lived and filled with happiness, purpose and love. To be thrust into numerous battles against state and federal agencies would test the resolve and strength of any person. In the twilight of our life and career though? Devastation.

We are all but specks of living tissue. Fragile bodies. Throughout our lives, we face forces so much greater than us. What we are left with as we fight our on-going and dying battles is our humanity.

Humanity.

And grace that must be extended to those in such pain. For in extending grace, we embrace our own humanity. Accountability? Yes, absolutely. But that should never color or diminish extending grace and embracing our humanity.

And the humanity of others.

DOUBLE EFFECT AND PHYSICIAN ASSISTED SUICIDE

With the approaching legalization of Physician Assisted Suicide (“PAS”) for mental disorders set to take effect in Canada on March 17, 2024, both proponents and opponents are making last ditch efforts to forestall or support implementation.

The statutory law is complex, extensive and awash in legalese.  So, I am embedding a link to this law:

https://www.parl.ca/documentviewer/en/44-1/AMAD/report-2/page-ToC

A Reader’s Digest version of this law, as it pertains to “mental disorders,” and presuming the “mental disorder” does not result in a natural death that is reasonably foreseeable is as follows:

Safeguards for persons whose natural death is not reasonably foreseeable.

The following procedural safeguards apply to persons’ whose natural death is not reasonably foreseeable (*indicates safeguards specific to those requests):

  • request for MAID must be made in writing: a written request must be signed by one independent witness, and it must be made after the person is informed that they have a “grievous and irremediable medical condition” (a paid professional personal or health care worker can be an independent witness);
  • two independent doctors or nurse practitioners must provide an assessment and confirm that all of the eligibility requirements are met;
    • *if neither of the two practitioners who assesses eligibility has expertise in the medical condition that is causing the person’s suffering, they must consult with a practitioner who has such expertise;
  • the person must be informed that they can withdraw their request at any time, in any manner;
  • *the person must be informed of available and appropriate means to relieve their suffering, including counselling services, mental health and disability support services, community services, and palliative care, and must be offered consultations with professionals who provide those services;
  • *the person and the practitioners must have discussed reasonable and available means to relieve the person’s suffering, and agree that the person has seriously considered those means;
  • *the eligibility assessments must take at least 90 days, but this period can be shortened if the person is about to lose the capacity to make health care decisions, as long as both assessments have been completed;
  • immediately before MAID is provided, the practitioner must give the person an opportunity to withdraw their request and ensure that they give express consent.

To provide greater insight, I am embedding testimony taken in May 2022 before the Special Joint Commission on Medical Assistance in Dying:

https://www.parl.ca/DocumentViewer/en/44-1/AMAD/meeting-9/evidence

This site contains much of the evidence and testimony elicited when the Canadian law was being vetted. And of course, there are a number of matters and issues of concern contained within the Report and testimony.

For example, with regard to the crucially important, “Balancing Individual Autonomy and the Protection of the Vulnerable,” the Committee’s findings constituted only four (4), short paragraphs and ended with the following conclusion: “The committee recognizes that a delicate balance must be struck between promoting individual autonomy and protecting against socio-economic vulnerabilities.”

We have an adequate grasp of the painfully obvious. Perhaps the Committee should have focused on the merely obvious conclusion.

Under the Canadian law, the Committee stated, “To be eligible for MAID, a person must have a ‘grievous and irremediable medical condition.’ As Jennifer Chandler explained, “irremediable” is not a medical or scientific term. Rather, as noted above, “grievous and irremediable” is defined in the law as incurability, being in an advanced state of irreversible decline, and “enduring physical or psychological suffering that is intolerable to [the person] and that cannot be relieved under conditions that [the person] consider[s] acceptable.”

Because of this wording, eligibility must meet ALL of these criteria. Further, if we are to use that definition, doesn’t that necessarily exclude all instances of anorexia nervosa? Incurability? Anorexia?

With regard to Minors, the Committee stated, “In Canada, a person must be at least 18 years old to access MAID. However, minors with the requisite capacity are generally entitled to make their own healthcare decisions. The exact parameters of minor consent to healthcare vary by province.” The Committee then held, “The term ‘mature minor’ refers to a common law doctrine according to which “an adolescent’s treatment wishes should be granted a degree of deference that is reflective of his or her evolving maturity.”

Minors. Our teenagers. Our children.  The Committee also found, “In the Netherlands, MAID is allowed for minors aged 12 and over, and may soon be expanded to include younger children. In Belgium, there is no minimum age, so long as the minor has the requisite capacity.”

So, are we to allow young people, our children, whose brain is not biologically developed let alone mature to make life or death decisions? Where is the morality in that?

Principle of Double Effect

Which brings us to the issue of a just society and the morality not only of medical professionals making this life or death call, but whether the very act in question is morally right. To this, we turn to the Principle of Double Effect. (Principle)

The Principle has its historical roots in the medieval natural law tradition, especially in the thought of St. Thomas Aquinas (1225-1274). It has been refined both in its general formulation and in its application by generations of Catholic moral theologians[1].

Although there has been significant disagreement about the precise formulation of this principle, it generally states that, in cases where a contemplated action has both good effects and bad effects, the action is permissible only if it is not wrong in itself and if it does not require that one directly intend the evil result.

Classical formulations of the Principle of Double Effect require that four conditions be met if the action in question is to be morally permissible:

  1. First, that the action contemplated be, in itself either morally good or morally indifferent;
  2. Second, that the bad result not be directly intended;
  3. Third, that the good result not be a direct causal result of the bad result, and;
  4. Fourth, that the good result be “proportionate to” the bad result.

Supporters of the Principle argue that, in situations of “double effect” where all these conditions are met, the action under consideration is morally permissible despite the bad result[2].

The Principle is regularly invoked in ethical discussions about palliative sedation, terminal extubation and other clinical acts that may be viewed as hastening death for imminently dying patients. Unfortunately, the literature tends to employ this useful principle in a fashion suggesting that it offers the final word on the moral acceptability of such medical procedures. In fact, the rule cannot be applied appropriately without invoking moral theories that are not explicit in the rule itself. Four tenets of the rule each require their own ethical justification. For example, the third condition must necessarily invoke the Pauline Principle which states, “One should never do evil so that good may come.” 

Some ethicists believe that if a suffering, terminally ill patient dies because of intentionally receiving pain-relieving medications, it makes a difference whether the death itself was intended or merely anticipated.  If the death was intended it is wrong but if the death was anticipated it might be morally acceptable[3]. 

Philosophers and medical ethicists have speculated that, “According to this Principle, euthanasia and physician-assisted suicide are always illicit acts, while the same is not said for other actions that bring about patient’s death as a foreseen effect, namely, palliative treatments that hasten death or failure or interruption of life support. The reason for this difference is that, in the first two cases, the patient’s death is intended as a means of pain relief; whereas, in the latter two, death is only a side effect of a medical act, an act justifiable if it is necessary to achieve a proportionate good.”

We also need to question whether the moral objection to an action is the same as the physical performance of that action. Dr. Paulina Taboada addressed this question accordingly, “But the physical performance of an action (actus hominis) does not necessarily coincide with a moral act. Only an action in which human freedom is exercised (actus humanus) can be morally qualified. A moral act is essentially an act in which human freedom is exercised. This means that the moral act itself is marked by an ‘intrinsic intentionality’; it tends towards an object (called moral object).”

Dr. Taboada then stated, “Hence, the moral act cannot be properly characterized by describing a mere physical performance. In order to find out which is the kind of moral act we are performing (i.e., the ‘moral species’ of the act), the key question is: What are you doing? And an answer like “injecting morphine to this patient” would not do it. The proper answer to this question – relieving pain – reveals the ‘intrinsic intentionality’ of the moral act. An analysis of the lived ethical experience shows that the moral character of our free acts is basically determined by this ‘intrinsic intentionality’ of the act, i.e., by the kind (‘species’) of act we perform.”

Dr. Taboada then concluded, “A careful analysis of our most basic human moral experience shows that the ethical character of human acts does not primarily depend on the motivation or intention of the agent, but on the moral species of the action to be performed. Hence, the common saying ‘the end does not justify the means’.[4]”

The Canadian law, at best, paid lip service to this incredibly complex issue. An issue which not only touches our existence, but the very heart of our humanity. Faith. The Soul. Life. Death.

Our society seems to be in such a rush to show all others that we are capable of performing a certain act better than it has ever been done … and thus, show our individual wisdom and humanity. However, in doing so, we have lost sight of the question we need to be exploring, that is, “Should we do this act?”

A question that our medical and mental health providers certainly cannot answer. Perhaps there is no answer. And yet, if we do not keep exploring the boundaries of our being, our imagination, our very lives, we will continue to fail. We will fail on a generational level.

We cannot, and do not have the luxury of taking action without seeking wisdom from all interested parties. We must work toward being open to options we never previously considered. We must strive to chart the unknown and unlimited possibilities of existence.

And we can only do that if we take all reasonable and necessary steps to preserve the sanctity of life.

[1] http://sites.saintmarys.edu/~incandel/doubleeffect.html

[2]https://pubmed.ncbi.nlm.nih.gov/3080130/#:~:text=The%20doctrine%20holds%20that%2C%20in,%2C%20and%20(d)%20there%20is

[3] https://medicine.missouri.edu/centers-institutes-labs/health-ethics/faq/euthanasia

[4] https://hospicecare.com/policy-and-ethics/ethical-issues/essays-and-articles-on-ethics-in-palliative-care/shaws-criticism-to-the-double-effect-doctrine/