Sasquatch Community Hospital
Sasquatch, Connecticut
March 21, 2017
Dear Ethics Committee,
My name is Greeshma Magam and I am a female Indian-American physician who is an active follower of the Hindu faith. Due to my diverse background, I was asked by the hospital administrators to provide a complementary perspective to the pressing questions addressing alternate reproductive technologies that your committee is discussing at this time.
It is my understanding that your hospital currently subsidizes medical care for under-insured patients, a practice that must be very beneficial to the low-income members of your community. However, with the rise of artificial reproductive technologies and the expensive cost of these amenities, I understand where your dilemma comes from.
Although abortion services are still a highly debated topic in the healthcare industry, there are certain circumstances in which I believe that offering these services are necessary. Due to the expensive nature of these services and the size of your hospital, it would be impossible to subsidize abortion services to every under-insured patient considering the procedure. However, I do believe that the subsidization of abortions at your hospital should be offered to under-insured women on a case-by-case basis. In order to form a guideline for what circumstances permit the subsidization of abortion services, I looked to the stance that the US government currently takes with federal funding. The Hyde Amendment prohibits the use of taxpayer funding to cover the costs of abortion services in Medicaid patients (ACLJ). However, a provision during the Obama Administration made it flexible, so that abortion services be provided to Medicaid patients in the case of rape, incest, or threat of life to the woman (ACLJ). While this amendment is also under debate, I believe this is a good guideline to follow for the subsidization of abortion services at your rural, privately-owned hospital.
In-vitro fertilization (IVF) is an expensive procedure for families who are unable to conceive naturally. While I believe that IVF is an important medical service that should be offered, I understand due to its’ expenses why your hospital would be unable to subsidize these services for under-insured patients. Unless your hospital can receive funding for these services, I do not believe that IVF should be subsidized. However, I do believe that these services should be in-place in this hospital in the event that patients who can afford its’ services want to undergo this procedure.
As a member of the healthcare industry with research background, I do believe that there should be a provision where the hospital should encourage families to allow unused embryos to be donated for potentially life-saving research for families undergoing the IVF treatments. While this decision is entirely up to the parents, I believe that educating them about the progress being done in this field, and the benefits of this research, is essential for parents to make an informed decision regarding their unused embryos. In my opinion, donating unused embryos to science is a great idea, especially since those embryos will die on their own given time. Recent research has shown that there is a potential in embryonic stem cells that isn’t available in adult stem cells and using this method to further research can help in “gene therapy for genetic disorders, and the generation of replacement tissues and organs for transplant” (APH). While encouragement from the hospital is acceptable, under no circumstance should the hospital try to pressure parents to change their decision regarding donating their unused embryos for research purposes.
Prenatal testing and amniocentesis are rights that I believe should be offered to all expecting parents, regardless of their ability to afford the costs. It should be a parent’s decision whether or not they would like to use prenatal testing or amniocentesis during their pregnancy, but I believe that they should be available to everyone across the board. Prenatal testing, or blood serum testing, is not a diagnostic tool; however, is necessary for “prevention, protection, and reassurance” for family members and can detect for neural tube defects, such as spina bifida, down’s syndrome, and anencephaly (The Burden of Knowledge, 1994). Unlike the blood serum test that is common in prenatal testing, there is more concern with amniocentesis, as there is a 0.05% chance of miscarriage after undergoing the procedure (The Burden of Knowledge, 1994). Whether or not to use the amenities provided by the hospital is a decision left to the parents, but in the end, I still think that access to these types of tests is necessary, for those who choose to use them. Even if the subsequent procedures are not available, it is my belief that the knowledge is always beneficial in preparing the parents about what to expect in raising a child with disabilities. In addition, there is a significant Jewish population within the community your hospital serves. As Tsipy Ivry describes in her ethnography, Embodying Culture, there is an authoritative knowledge of pregnancy in Israel called “geneticism,” in which the mother is responsible for undergo diagnostic testing in order to ensure the health of her child. In order to be inclusive of the views of your patient population, there should be access to testing within your hospital, and the decision to use these services should be left up to the parents and family members involved.
Your committee is also debating the inclusion of spiritual counseling by Catholic clergy. While historically Catholic, your hospital is currently non-denominational. Due to this, I believe that if Catholic clergy is present for counseling, your patients should have access to clergy members of other faiths as well, especially since the population you treat includes people of many faiths and cultural backgrounds. Regardless of the testing and technology that the medical staff favors, the eventual decision for or against the use of assisted reproductive technologies should encompass the views of the patients. As a member of the science community, it can be hard to sometimes differentiate your views from others, but in the end, this decision will impact the lives of the parents more than it will impact the lives of the healthcare providers. Catering to the values, traditions, and faiths of individual patients is equitable to the conversation that Swasti Bhattacharyya describes as “cultural competency” in her book Magical Progeny, Modern Technology (Page 23).
I understand that some of your nursing staff is concerned regarding the potential reproductive technologies your hospital may offer, especially since they hold conservative Catholic views. In order to provide these services and still keep the staff of your hospital satisfied, I believe the hospital administrators should send out a questionnaire to understand exactly how many members of the staff will not provide the procedures, how many are comfortable with assisting in the procedures, and how many will provide the procedures. Using this data, hospital administrators can devise teams of members who can perform the procedures. In this case, the hospital will be developing teams who are comfortable in performing prenatal testing, IVF, amniocentesis, and abortion, while also respecting the views of the primarily Catholic staff who do not want to perform the procedures.
Thank you for taking the time to consider my position regarding these topics. I hope that I was able to provide an alternate perspective to your discussion of artificial reproductive technology.
Sincerely,
Greeshma Magam, M.D.
Sources
https://aclj.org/pro-life/four-things-you-need-to-know-about-the-hyde-amendment-federally-funded-abortion
http://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/Publications_Archive/CIB/cib0203/03cib05#Evaluating
Dear Dr. Magam,
You have provided the hospital with an insightful proposal regarding our dilemmas on the offering of reproductive technologies and prenatal testing. It was refreshing to read the opinion of another female physician, and I found you and I shared similar beliefs on what the hospital should decide to do.
Regarding IVF services, I also agree that the hospital should definitely offer these services to couples that are unable to have a child on their own. I feel as though as a non-denominational institution, it is important to not operate on guidelines based on a certain religion. I also strongly agree that it should be entirely up to the patient as to whether or not their leftover embryos should be donated to research. As you mentioned, I believe it is essential to educate the patient and their family on what it means to donate their embryos and the benefits and consequences of such a decision.
I also agree with you in that I believe all patients should have a right to prenatal testing. These tests provide patients with important knowledge that would allow them to prepare for the arrival of a potentially disabled child. I appreciate that you stress the importance of the decision to undergo such testing to be entirely up to the patient. Its important for a patient to understand that just because the hospital offers prenatal testing, it is not necessary nor required for a patient to have the tests.
On the topic of abortion services, I also agree that as a hospital we should offer such services to our community. Like you said, there are certain circumstances where such services are necessary (i.e. rape), and I think it would be a disservice to deny our community access to such treatments. I also believe we should continue to subsidize uninsured patients when it comes to abortions, and I think the guidelines you propose provide a good solution on how to decide who receives subsidies.
Although I do agree with most of your proposal, there is one area in which I take issue. While I understand some of our staff are unwilling to perform abortion services, I do not think we should send out a questionnaire in order to figure out who would be willing and unwilling to do so. As providers of care, I believe we have a responsibility to provide the best medical care possible to our patients, regardless of whether or not the treatments or services align with our personal beliefs. Since I am not an extremely religious person, I understand that some might take issue with my stance. However, I strongly believe that one should be able to separate one’s professional life from their personal life. If our staff is unwilling to perform such services due to their own personal beliefs, I feel as though we would be able to replace them with another medical professional who is willing to do so.
In all, I think it is important to remember the notion of cultural competency, as you mentioned. With that in mind, I feel as though your proposal provides a step in the right direction for our hospital. I believe that by providing these reproductive technologies and services, we will be better equipped to serve our diverse population. Thank you for your insight and I look forward to working with you and hopefully implementing some of your suggestions!
Sincerely,
Molly Nestor, M.D.
Dear Dr. Magam,
Thank you for taking the time to provide your advice on the dilemmas our hospital is facing as we undergo the transition to becoming non-denominational. As a fellow physician, I agree with many of your medical opinions on the procedures to be performed at the hospital. However, I would like to challenge you on two points presented in your policy proposal.
You have provided a detailed outline on whether or not to subsidize abortion services and IVF treatments, but you have not addressed the issue of actually providing these services at the hospital. I assume from your funding comments that you are in support of these services. I agree that IVF treatments should be offered at our hospital, but as a devout Muslim male I am against abortion services being offered. Many members of the Catholic and Lebanese communities agree with me on this point. You mention that subsidization of abortion services should be given to those cases that are outlined in the Hyde amendment. As I mentioned in my proposal, the same amendment states that these patients can get federal funding for it and hence they can go elsewhere to get these services.
Secondly, I would like to further develop your proposal to continue the use of clergy at our hospital. I agree that it is important to have religious counseling when making difficult decisions on medical procedures as my own beliefs also strongly enforce individual religious reasoning for all situations. However, throughout my time at the hospital my fellow medical staff and I have noticed how the clergy have been interfering with our professional opinions. We have been extremely frustrated in our endeavors to treat our patients in the best way possible. I am a proponent of an inter-religious clergy, but there needs to be some restrictions and rules on the manner in which they can interfere with the medical staff.
Overall, I am in agreement with your proposal and there are the two things I believe we should focus on moving forward. I hope we can work together to find a middle ground between our proposals. Once again, I appreciate your advice as a devout Hindu as it is important to take in all perspectives with how quickly the community in Sasquatch is changing.
Sincerely,
Dr. Tangutoori
Dear Dr. Magam,
Thanks for your thoughtful comments. You seem to be fairly well-versed in both medical and comparative bioethical literature, but I would like to hear more. I have always thought, following your own Mahatma Gandhi, that all religions are different paths to the same goal, but you are suggesting there that on matters as weighty as life and death, the murder of unborn children, that your religious tradition and that of others do not share our deeply held convictions. How can this be? I am especially perturbed by you assertions about the Jewish people who after all share our Scripture and our sacred commandment, “Thou Shalt not Kill.” So how can they–and frankly how can you, as someone who has taken the Hippocratic oath–maintain that the murder of many children by design, as in abortion, or as a side-affect, as in IVF treatments, are a matter of so little ethical import? I must say, I was happy to see, over the past several years, the growth in diversity in our little town, reflected both in the kinds of patients and medical professionals involved at our hospital. But I am finding this all quite challenging if we cannot agree on the most basic of moral commitments. If you had said you were an atheist, rather than a practicing Hindu, I would have been perhaps less surprised. I realize of course that you are a physician and not an ethics expert or a clergyman–priest?– of your faith, but since you have brought religion into it yourself, I would like to ask for your help in understanding. I am beginning to have second thoughts about the whole decision to become an independent hospital, especially as some of your colleagues (below) have gone so far as to begin questioning the freedom of expression of chaplains at this hospital!
best wishes,
Father Donnigan, Director of chaplains