In a rapidly developing world centered around technology, I think it is time we, as a hospital, introduce the use of reproductive technology and prenatal testing to our hospital. These technologies not only reflect the incredible strides made in the medical world, but also provide pregnant women and their families with the ability to prepare for their future. As a physician at the Sasquatch Hospital, I believe these technologies are necessary to our hospital, for they will greatly improve the treatment we are able to provide to our patients. Having provided the ethics committee as well as other doctors and hospital administrators with my initial proposal, I have considered all counter arguments and suggestions presented, and applied a few changes to my proposal where I saw fit. That being said, I think it is important to remember that when considering changes in medicine and healthcare as a result of technology, the question of bioethics if confronted with a very difficult dilemma. As mentioned by Dr. Arthur Kleinman, bioethics is faced with the challenge of “how to reconcile the clearly immense differences in the social and personal realities of moral life with the need to apply a universal standard to those fragments,” (Kleinman 1999: 70). With that in mind, I present to you the revised and final outline of my proposal.
With a growing and varied local population, the ultimate goal of our hospital should be to provide the best medical care our diverse population needs. While I understand the importance of our Catholic origins and what they mean to our donor base, I think it is more important to acknowledge the changing culture in our area. I recognize that some of the policies I am going to propose will not be conducive to Catholicism as well as other religions. However, I feel as though we should not limit the medical care and services our hospital can offer due to differing religious and cultural beliefs among our population. As doctors and providers of care, we made a decision to help the lives of others above all else, regardless of whether or not we personally agree with such services.
One of the major policy changes I wish to make would be to provide reproductive technologies, such as in-vitro fertilization, and prenatal testing, such as amniocentesis. Over the past decade, these technologies have grown in popularity and acceptance, but still face some resistance regarding the ethics surrounding the decisions and outcomes of such technologies. Personally, I do not believe in-vitro fertilization nor prenatal testing are unethical. Both technologies exist to facilitate and better comprehend pregnancy and its outcomes. While some may argue that IVF violates the natural laws regarding the appropriate way to conceive a child, I believe “natural laws” are more so a social construct and differ based on the individual and their beliefs. For example, the French bioethics laws initially, “restricted access to artificial reproductive technologies (ART) to sterile, heterosexual couples of childbearing age,” (Ball 2000: 545-546). The French put these restrictions in place out of fear the technological advances would alter cultural norms and defy what they considered “natural.” Although nature served as the source of truth for many Enlightenment philosophers, Rousseau stated, “philosophers of natural law who hold too strictly to the dictates of nature are ‘in habit of abstracting the content of natural law from the behavior of men in civil society. . .’” (Ball 2000: 579). I agree with Rousseau’s statement and believe that what most consider to be natural is subjective and developed from observations of society.
Along with providing IVF treatments, I would suggest implementing a provision to encourage families to allow unused embryos to be donated for life saving research. From a medical standpoint, research done on embryos is somewhat rare and the findings from such research could turn out to be crucial in the future. I understand some families will be unwilling to donate their unused embryos due to personal beliefs, but I think the provision should be included regardless. Our community has changed and progressed dramatically over the years and I think more individuals would be willing to donate unused embryos for research purposes. In order for a patient to make what they believe to be the right decision, it is important for doctors and medical professionals to explain in detail what donating an unused embryo to research entails, conveying both the benefits and consequences of donations. I want to stress that it is unacceptable to make families feel as though they are forced to donate. Pressuring a patient into making a decision that goes against what they believe in is unethical and violates our role as doctors to provide the best possible care and treatment. If the patient chooses not to donate their unused embryo, then we must honor their decision.
It was brought to my attention by a few of my colleagues that my above provision would potentially be met with opposition from those of the Catholic faith. As stated in Donum Vitae, in the eyes of Catholicism, from the first moment of existence, a human demands the “unconditional respect that is morally due. . .in his bodily and spiritual totality,” (Donum Vitae 1988: 149). In this instance, the first moment of existence is considered to be the moment the zygote is formed. While I personally do not agree that the formation of a zygote is equivalent to a human life, I understand the ethical and moral issues at hand and would like to elaborate on my reasoning for the use of unused embryos in a research setting. In 2001, the Bioethics Advisory Committee in Israel release a report on ethical implications of stem cell research (Prainsack 2006: 180). This report states the status of embryos within Jewish law, which believes that embryos outside of the uterus are not to be regarded as human life, which I personally agree with (Prainsack 2006: 181). Because an embryo outside of a uterus is not regarded as a human being, the use of unused embryos from IVF for research purposes is considered ethically permissible. However, if the IVF embryo is suitable for implantation, then it is considered unethical to use the embryo for research. I concur that if an embryo is suitable for implantation, then it should not be used for research purposes. Therefore, I believe it is not unethical to perform research on unused embryos located outside of a uterus, but only if the embryo is unsuited for implantation for IVF. The ongoing debate of when a human life truly begins presents a difficult issue within bioethics, one that may never be agreed upon. I comprehend the reasoning behind the opposition that has arisen due to my suggestion to use unused embryos for research purposes, but I personally do not hold the same beliefs. Because I do not consider an embryo outside of a uterus to be comparable to a human life, I believe that the use of existing, unused embryos for research purposes is not unethical and will therefore maintain my initial proposal.
Prenatal testing is another service I suggest we provide at our hospital. Prenatal testing, such as amniocentesis, allows pregnant women to test for abnormalities, disorders, and defects of the fetus that previously could have only been realized once the child was born. From a medical standpoint, this technology is revolutionary, providing women with a wealth of knowledge while also giving them time to consider their situation and prepare for the outcome. As stated by someone who has undergone prenatal testing, “what harm can a test do if its going to provide you with important information?” (The Burden of Knowledge: Moral Dilemmas in Prenatal Testing, 1994). Some claim that by offering the tests we would be creating anxiety; however, I find that to be completely false. Just because the tests exist, it does not mean one must undergo them. Israeli pregnancy theory conveys the relationship between pregnancy and biomedicine as pregnancy being “a chaotic process in which nature is liable to make mistakes, and it is this process that biomedicine must handle,” (Ivry 2009: 74). While I don’t believe biomedicine must handle the chaotic process of nature, I do believe that biomedicine provides a way in which one can prepare for the anxieties and uncertainty that may arise from the chaotic process of pregnancy.
Along with providing the option to receive prenatal testing, it is important that we as medical professionals educate women on both the medical and psychological aspects of testing. Although I don’t necessarily agree that the mere offering of prenatal testing would create more anxiety than women experience during pregnancy in general, I understand that the choice to undergo testing could be met with anxiety and psychological turmoil. I want to again stress that just because we offer the prenatal testing, it does not mean that a woman should feel pressure to undergo testing. I do understand that each individual is different and will react to situations differently, but this is something that is out of our control. I suggest fully educating women on both medical and psychological aspects of testing in the hopes that this might help women deal with or avoid having to deal with some of the psychological stresses of prenatal testing. Perhaps if women were told about the entirety of the prenatal testing process, some might opt to not have the testing because they realize it might cause them greater anxiety to undergo testing. I recognize that this is not a sure-fire solution to the issue of addressing anxieties of prenatal testing, but I am not sure there is a guaranteed solution to this matter. Personally, I think these tests provide a way to minimize anxieties of pregnancy by eliminating the unknown and providing answers to women, allowing them to prepare for what is to come. But, I do understand that my beliefs and understanding of prenatal testing are heavily influenced by my medical profession and may prevent me from completely understanding the anxieties people undergo due to prenatal testing and its possibilities.
In regard to the efficacy of prenatal testing, I believe offering and deciding to receive prenatal testing are both ethical decisions. In a study about women and the option to undergo prenatal testing, Reyna Rapp, a feminist anthropologist, described women who received prenatal testing as “moral pioneers.” She viewed these women as individuals who, “submitted to the discipline of a new reproductive technology in order to reap its biomedical benefits,” (Rapp 2004: 307). The decision to use prenatal testing has been given a negative stigma due to the fact that the test results may cause one to be more likely to get an abortion. However, that is not always the case and it should be noted that prenatal tests have the ability to provide women immense medical benefits, without resulting in a negative outcome. The tests allow women to become aware of the situation they are going to face and provide them with more knowledge and time to prepare for the arrival of their child. Although prenatal tests are considered unethical by certain religions, I believe, as a non-denominational hospital, it is important to look at access to prenatal testing on a more individual, secular basis.
To minimize the potential negative outcomes due to such testing, I would recommend implementing steps to prevent women from using the test results to get an abortion. One step could be to provide or recommend counseling services where women could learn about the alternative options they have to abortion, such as adoption. Another step could be to educate women about the conditions or disabilities their child might potentially face, either through genetic counseling or other means. A lot of women choose abortion after receiving their tests results because they are scared and feel as though they unable to take care of a child with disabilities. I think that if we were able to better provide women with more information regarding the disabilities of their future child, it might allow them to feel more prepared for what is to come and lead them to reconsider abortion. I understand this is not a foolproof solution to the negative outcomes that can potentially arise from prenatal testing, but I think these are two ways in which we could help the women facing a difficult decision in a difficult situation, and have an impact on those women who would have previously chosen abortion as a solution.
While I personally support the use of prenatal testing, I do understand the issues some individuals still have with such tests, one of them being abortion. A few years ago, the majority of our community felt that it was unacceptable, on an ethical and moral account, for our hospital to provide abortion services. I understand the reasoning and ethical beliefs of those who are against abortion and would never force them to alter their beliefs. I also acknowledge that people are going to have uncompromising views on this subject rooted in both religious and non-religious beliefs and sentiments, making compromise or a unanimous decision on this subject almost impossible. However, I would still advise that our hospital provide abortion services to both insured and uninsured patients. I also maintain my suggestion that subsidies for abortions be provided and should be determined on a case by case analysis of the patient and their financial situation.
One of the main oppositions to abortion comes from the concept that abortion is a form of murder. This notion is based on the view that human life begins at the moment of conception. I understand that under this view, a zygote is equivalent to human life, making the act of getting an abortion equivalent to killing a fully grown human being. However, it must be acknowledged that not everyone regards a zygote or embryo as being equivalent to a human being. Here, the question of where a human life begins ultimately determines whether there is an act of murder occurring or not. Personally, I do not believe human life begins at the moment of conception, therefore, I do not regard having an abortion as equivalent to murdering a human being. I also think it is important to acknowledge the potentially negative aspects of preventing or outlawing abortion. For example, consider the life of a child born to a woman who did not want to have a child or was incapable of caring for a child. Let’s assume the woman did not want to have a child because of this didn’t take the necessary precautions one would normally take during pregnancy. This women could drink and take drugs throughout her pregnancy, resulting in the child having multiple birth defects and disabilities. Assuming this woman did not want to have a baby in the first place and still does not want one now, the baby would be neglected by the mother, ultimately leading to the mistreatment of this child. Wouldn’t an instance like this, where a baby is brought into the world only to live a terrible life of abandonment and mistreatment, be worse than allowing the mother to have an abortion? I understand that those opposed to abortion because it is considered murder would argue that this instance is not worse because the baby is allowed to live their life instead of being murdered in the womb but, I think it is an important instance to consider. Again, abortion is an instance in which it is near impossible to achieve a compromise because individuals hold different views on the subject, views rooted in a multitude of facets. I understand the opposition but because of my belief that a human life does not begin upon conception, I do not regard abortion to be equivalent to murder and believe that, in some instances, it could lead to a better outcome for the unborn child.
The notion of cultural competency has become extremely important in aiding the communication and understanding between patients and their medical team. Defined as, “the need [for healthcare providers] to be understanding as well as sensitive to the different cultures, socioeconomic backgrounds, and belief systems of their patients,” cultural competency allows doctors to adequately and effectively provide care based on their patient and the patient’s needs (Bhattacharya 2006: 5). Regarding the improvement of cultural competency, I think it would be beneficial to continue counseling from Catholic clergy and expand counseling services to clergy of all religions. I believe the expansion of religious counseling services is integral to providing the best care to our growing and diversified community. Throughout my experience, I have come to find that religion helps some patients better understand the rather secular nature of the medical language.
In implementing this provision, it has come to my understanding that some doctors have complained about how the opposition to reproductive technology by clergy interferes with their work as medical professionals. As a doctor myself, I understand the frustration that stems from patients choosing to listen to religious guidance over medical expertise, but the implementation of religious counseling could greatly improve the patient/provider relationship. An example of how religious beliefs come to effect medical decisions can be found in a study done by Sherine F. Hamdy in which she examines why Muslim men come to refuse life-saving treatments. One Muslim dialysis patient in Egypt refused to get a kidney transplant because he believed his body “belong[ed] to God,” and God had already decided when he would die before he was even born, so accepting a transplant would be altering God’s decided path for him (Hamdy 2013). As a doctor, it’s hard to see a patient refuse a treatment that would save their life, but it is important to respect their decision and understand the beliefs behind the decision.
With these new provisions in place, I believe this hospital will be better suited to serve the needs of our local population. By acknowledging both our individual differences and the ever-changing nature of society, we will be able to provide more advanced medical service and improve the lives of those in our community. Although these proposed policy changes may come as a shock to some, we must remember that changes in societal norms and technological advances have altered what is considered to be the norm. Decisions made today will shape the social domain of the future, as previous decisions have shaped the society we occupy today. Through some revisions, I hope I was able to clearly address all counter arguments by elaborating on why I held the positions I did. Thank you all for your time.
Dr. Nestor, M.D.