Midterm Assignment (Hannah Gold)

My name is Hannah Gold: anthropologist, scientist, and mother. I am here to speak in opposition to this policy proposal. I am from a nearby city outside of Sasquatch therefore I can provide an unbiased, reason-based outsider perspective on this ethical dilemma. I want to begin by outlining the Catholic Church’s position on the topic of Assisted Reproductive Technologies (ART). We must first understand where this hospital stood on this issue prior to its separation from the church in order to judge just how big of a value shift this hospital would have to make if we were to begin to subsidize abortion services, IVF treatments, and prenatal testing. Donum Vitae, the statement by the Congregation of the Doctrine of the Faith on bioethical issues, takes a clear stance against ART if it in any way endangers a fetus. The church states, “Since the embryo must be treated as a person, it must also be defended in its integrity, tended and cared for, to the extent possible, in the same way as any other human being as far as medical assistance is concerned.” (CDF, 1987: 149) This translates to a complete opposition to abortion and IVF (due to the fact that it is not morally permissible to destroy an embryo at any stage), and acceptance of but strict limitations to prenatal testing. Hypothetically this hospital could offer non-invasive prenatal testing and have it align with its previous values. However, what happens if the tests uncover something horribly wrong with the fetus? There are no options here, as abortion is absolutely not permitted. This begs the question, what is the use of offering amniocentesis procedures if nothing can be done about positive results?

Beyond the official documentation of the Catholic Church’s position, these values permeate into the everyday lives of practicing Catholics. A look into the history of this town and its inhabitants is proof of this; it took until 2017 for this hospital to even consider offering assisted reproductive services. In her ethnography Testing Women, Testing the Fetus, anthropologist Rayna Rapp interviewed American women of many denominations to understand the role that spirituality plays in decision-making during pregnancy. One woman said, “Basically, I grew up Catholic, I think it’s tragic to end a pregnancy, to end a life.” (Rapp, 2004: 155) Rapp writes, “several catholic women…told me they were afraid to go to confession in their neighborhood parish churches after having amniocenteses.” (Rapp, 2004: 159) It should be clear by now that, based on the value system outlined above and the fact that this town has operated under Catholic auspices for over one hundred years now, this hospital has a long way to go on the road to accepting and offering reproductive technologies.

Now, a divorce from the Irish-Catholic denomination is a fantastic opportunity to update the ethical ground upon which this hospital operates; an opportunity to include belief paradigms and ethics systems of this entire community rather than just appealing to the catholic ideology. One way we should do so is by discontinuing spiritual counseling for Catholics. This type of counseling serves a very narrow audience. Our objective here is to become more inclusive; to offer services that all community members will be accepting of and have access to. Spiritual counseling through medical decisions can very well continue within specific religious circles, however it is not a necessary component of this hospital. A separation from the Catholic Church requires a clean slate and a redesign of the foundational values this community is built upon. We now must consider the broader community of Jews, non-Irish Catholics, Japanese immigrants and Shiite Muslims, and the values systems represented by individuals within these groups.

In her ethnography Reproducing Jews, Susan Kahn evaluates the Jewish-Israeli position on assisted conception, which is arguably the most liberal out of our four representative populations. She writes, “at the time of my research in the mid-1990s, there were more fertility clinics per capita in Israel than any other country in the world.” (Kahn, 2000: 2) Kahn ultimately argues that these technologies are supported by, not counter to, Jewish religious law. She writes, “from the perspective of Jewish law, infertile couples seeking to solve their childlessness with the air of new reproductive technologies does not evolve out of a consumerist impulse but out of a compulsion to fulfill a divine commandment.” (Kahn, 2000: 170) However, despite a general acceptance of ART in the Jewish community, that is not to say that all Jews are equally tolerant. In his chapter in the book Kin, Gene, Community, Dr. Don Seeman mentions Rabbi Eliezer Waldenman, an “important posek (decisor) identified with the Haredi or ultra-Orthodox community of Jerusalem, which opposed IVF as ‘unnatural.’” (Seeman, 2009: 349) A similar dichotomy is observed in the Shi’ite Muslim population. In her article titled Kinship, Propriety, and Assisted Reproduction in the Middle East, Morgan Clarke writes, “Almost all authorities, Sunni and Shi’a, are in agreement that artificial interventions in human reproduction are welcome, as a scientific advance and medical boon, insofar as they involve only a husband and wife couple.” (Clarke, 2007: 74) While this guideline seems simple, it is actually ripe with complexity in practice. IVF, donor insemination, and surrogacy arrangements are considered forms of adultery, therefore are forbidden by Islamic law. (Clarke, 2007: 75) Even when the procedures are performed, there is extreme judgment surrounding them. Through interviews with medical contacts in Lebanon, Clarke found that “infertility is stigmatized, and any suspicion of abnormality, especially in the field of sexuality and reproduction, is to be avoided.” (Clarke, 2007: 74) Lastly, we shall examine Japanese populations. In her studies on reproductive technologies in Japanese medical practice, anthropologist Tsipy Ivry found that technologies such as prenatal diagnosis “currently [are] located backstage of prenatal care.” (Ivry, 2010: 77) She cites the reason for this opposition to be the fact that Japanese people regard a mother and fetus as one single entity. She writes,

“The gravity of the conceptual tension that PND tests—a set of technologies in which ‘the embryo and fetus come to be visualized as patient-like entities entirely or largely independent of the woman’s body’ (Locke 1998, 206)—introduce into a medical system that tends to emphasize the embodied mode of maternal responsibilities for fetal health.” (Ivry, 2010: 105)

Here there isn’t so much a conflict of beliefs and values like we have seen in Catholic, Jewish, and Muslim populations, there is just a general lack of interest in these services.

We can now consider a scenario in which this hospital provides abortion services and subsidizes them for under-insured patients, and how this would affect our patients, staff, and finances. As detailed above, the values held by the ethnic and religious groups in this community have extremely mixed opinions about ART. Even in the Jewish population, seemingly the most liberal when it comes to reproductive technologies, there exists fierce opposition to many of the practices. Of course the positions I outlined above are not by any means wholly representative, rather they likely inform the individual experience of decision-making during pregnancy. We therefore should not offer these services because evidence suggests there would not be a large enough consumer/user population.

Next, we must consider the staff of this hospital and the administrators who run it. A useful analogy here is that of traffic waves. When a traffic incident occurs such as an accident or construction, traffic on a highway will continue in a specific location long after the cause of the back-up has cleared. This physical phenomenon is analogous in many ways to the introduction of new technologies into a hospital. Say we make a decision to offer ARTs in our hospital. We have resolved our ethical traffic jam; however there would be persistent consequences of the implementation of these technologies for the staff who must use them. We are, essentially, forcing a value system upon a population of healthcare professionals and requiring that they perform procedures they do not agree with. Even if the doctors are willing to do the procedures, consider the stigma they hold. In her interviews with medical professionals in Lebanon, Morgan Clarke found that clinicians had to be extremely careful to tiptoe around the stigma. She wrote, “medical contact in Lebanon initially insisted on my signing a confidentiality clause, warning me, with perhaps exaggerated concern, that a breach of privacy could result in ‘honour killings’.”(Clarke, 2007: 77) In Rayna Rapp’s work, she found that many Catholic women feared going to their neighborhood churches after having amniocentesis. (Rapp, 2004: 159). I will now outline potential consequences of requiring hospital personnel to do these procedures.

As I mentioned above, the values held by our predominantly Irish-Catholic staff would interfere with them performing procedures such as abortions, IVF, and amniocentesis. This is a large reason why our hospital should not offer them. Though we are working with trained healthcare professionals, it is not a good idea to allow a community of healthcare workers to perform procedures they fundamentally do not agree with. This would be irresponsible for a hospital to do, as the quality of care would go down.

Finally, we all know how important a donor base is to a hospital, especially one in rural Connecticut. Who is to say that we could even afford the technology, never mind pay new specialists to perform the procedures and counsel our patients? Without a donor base, how conceivable is it that we could acquire the technology, hire people to train our staff, and hire more staff to perform the procedures? It has come to my attention that doctors have complained about Catholic clergy interfere with their work. Susan Kahn describes a similar scenario in Reproducing Jews, where rabbinic concerns for ART provide a major obstacle to Orthodox Jews seeking these medical procedures. In fact there is an entire organization (titled PUAH) is dedicated to mediating the relationship between religious and medical authorities in Orthodox Jewish communities in Israel (Kahn, 2000: 89). My answer to this dilemma is, what about the business we lose when patients deflect to other hospitals? What about the money we lose on equipment and professionals to perform procedures, with no one willing to have them? Perhaps most significant, what about the money we lose when we lose our donor base? To a certain point it is very important to appeal to the values of those who give us money. As Adam Smith said, “all money is a matter of belief.”

On the one hand, a hospital has a duty to reflect the beliefs of its population, or else a foundation of trust and mutual understanding cannot exist. Anthropologist Sherine Hamdy writes,

“the perceived efficacy of a treatment plays an important role in shaping one’s ethical stance toward it. To understand how patients arrive at complex ethical decisions, we must be attentive and vigilant to their own experiences and understandings of their disease processes and etiology and their own cost-benefit analyses, which may be articulated in religious terms.” (Hamdy, 2012: 156)

If we begin to offer and subsidize abortion services, individual with strict catholic beliefs on abortion will feel less comfortable seeking treatment at this hospital. Being the main resource for healthcare in this community, that cannot and should not be the case. In Testing Women, Testing the Fetus, Rayna Rapp discusses the importance of environment to women and families seeking care at hospitals. The more successful patient care settings Rapp observed are those in which patients feel the most comfortable. She writes, “entering into the ecology of prenatal clinics are the stability of residential neighbourhoods: city, state, and federal health care funding and politics, hospital labor contract negotiations and issues of community control.” (Rapp, 2004: 169) Additionally, in her book Magical Progeny, Modern Technology, Swasti Bhattacharyya highlights the importance of what she calls “cultural competency.” This is 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.” (Bhattacharyya, 2006: 5) By offering treatments that fundamentally clash with the beliefs of most of our patient demographic, we are putting our cultural competency in jeopardy. This hospital thus should not offer or subsidize abortion services, IVF treatments or prenatal testing.

On the other hand, as a modern-day hospital it would be irresponsible to not offer the most advanced and up to date treatments to our community. Additionally, not offering these services does not mean members of our community will not seek them out, it just means they have more hoops to jump through to receive adequate care. I propose we open a separate fertility clinic in our community, not affiliated with the hospital. This will provide an opportunity to offer abortion, IVF services, and prenatal testing, as well as hire a new staff with no conflicts of interest. Through a detailed analysis of many religious/cultural standpoints on issues of bioethics, it becomes extremely clear that patients seeking reproductive therapies should be considered in a case-by-case basis so as to respect the complex nature of decision-making in pregnancy. In their ethnographic work titled Blessing Unintended Pregnancy, Don Seeman et al write, “as many studies show, women make decisions about mothering and reproduction amid a complex layering of structures, beliefs, and values…” (Seeman et al, 2016: 44) Rayna Rapp argues that women are “at once held accountable at the individual level for a cascade of broadly social factors which shape the health outcome of each pregnancy, and individually empowered to decide whether and when there are limits on voluntary parenthood.” (Rapp, 2004: 319) A hospital previous rooted to such a specific set of values is not equipped to honor this complexity. However, a separate clinic in our community would. Let’s stop trying to squeeze the practice of ART into our institution, a place that comes with heavy baggage that would be tough to divorce from. Rather, let’s focus our efforts on building a safe space–unaffiliated with any one belief system–and hiring trained and willing staff so families can make their own decisions about fertility therapies.