Final Assignment – Hannah Gold

My name is Hannah Gold: anthropologist, scientist, and mother. I have sent my original proposal around to the committee for review, and have carefully considered the commentary it received. Of course I did not agree with all of the feedback, nor was I willing to alter my stance on these issues if I didn’t think the counter argument was compelling enough. I have made changes where I saw fit. If I did not make a suggested alteration in my argument, I explain myself in detail. I will now present my updated opinion.

I am still speaking 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, if this is even the correct trajectory.

Now, a divorce from the Irish-Catholic denomination is a fantastic opportunity to update the ethical ground upon which this hospital operates. As committee member Keenan Davis suggested upon review of this proposal, I must explain what exactly I mean by “updating” a system of ethics:

We live in a global world, in a country where innovation is the norm. These new conditions bring with it new situations that require new moral deliberation. As Leon Kass wrote in his article Reflections on a Public Bioethics, “we are summoned to search into deep human matters in order to articulate fully just what is humanly at stake at the intersection of biology and biography, where life lived experientially encounters the results of life studied scientifically.” (Kass, 2005: 224) Living amidst constant technical novelty requires continual discussion about what the new technologies mean for our society; living in a homogenous society requires that we include belief paradigms and ethics systems of an entire community rather than just appealing to one specific (Catholic) ideology. One way we can employ an update to our hospital is by offering spiritual counseling for non-Catholics as well as Catholics. Keenan pointed out that most hospitals do offer spiritual counseling, so to discontinue that for Catholics would be more exclusive than inclusive. I propose that rather than altogether discontinuing counseling by Catholic chaplains, we widen these services to include other religions represented in this community. Again our objective is to become more inclusive; to offer services that all community members will be accepting of and have access to. As I mentioned above, globalization has resulted in increasingly homogenous communities in this country. This requires peaceful coexistence among a variety of ethnic and cultural groups. For our town, this means we now must consider the broader community of Jews, non-Irish Catholics, Japanese immigrants and Shiite Muslims when writing policy, rather than simply appealing to the majority. Let’s examine these communities now.

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 aid 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 of opinions 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 rife (thank you, Donna, I did not mean ripe like bananas) 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 in some situations. 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) However, clearly there are devout Muslims who are willing to withstand the stigma to have the treatments done. In her interviews with Lebanese Muslims, Marcia Inhorn found that many men with infertile wives were actively seeking IVF treatments for them. She writes, “In the Middle East, men in childless marriages who love their wives and ardently desire children and fatherhood must generally consider multiple options for marital preservation and family formation in light of prevailing religious moralities.” (Inhorn, 2006: 97) The same divergence in opinion we saw in Jewish and Catholic populations also exists in Muslim ones.

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 simply a lack of interest in these services.

We are now informed enough to 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. I am also not assuming that these communities will strictly adhere to stereotypes, as Keenan denounced. I simply want to highlight the discrepancies that exist within these populations to demonstrate that a decision to allow abortion, IVF or prenatal testing services may not necessarily be the most inclusive one.

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? As committee member Dr. Elmasri pointed out in his critique of my proposal, I am making an assumption here that our Irish-Catholic donors would rescind their funding if procedures such as abortion are put in place in our hospital. While I cannot be certain that a decision to refuse these services will appease all of our benefactors, I am certain of the Catholic Church’s position on them. Presumably some of our Catholic donors operate within the confines of Catholic bioethics; therefore I can predict that the opposite decision (one where we do offer these services) could result in these donors pulling their funding for our hospital.

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) 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 defect 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? This would be a tremendous loss to this hospital, and I believe 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.”

I must now be transparent with all of you. Many of you who spoke in opposition to my proposal did so because I didn’t explicitly state that women in this community should not have access to these services, even if they need or demand them. Keenan was correct in saying that I only implied this position, but here I am stating it. We shall, with no exceptions, refuse services (abortion, IVF, and prenatal testing) to all women. Those who need or demand them shall be referred to the fertility clinic we will open in lieu of offering these services at this hospital. I explain this in more detail below.

After making that clear, I can speak to the critique I received by Committee member Donna, National Organization of Women Chapter President. Listen up, Donna. I am a woman. I don’t identify as a feminist but that does not mean I don’t value and strive for equality. I am fighting against offering ART in this hospital not to promote the patriarchy, but because it is what I think will allow this hospital to smoothly transition out of its previous allegiances to Catholicism. What matters most to me about a hospital is that it can operate effectively, treat patients comfortably, and take care of its staff. This decision is in no way meant to tell you what you should or shouldn’t do with your body. This is evidenced by my proposition to open a fertility clinic in Sasquatch. I’d also like to call attention to the fact that there are feminists who stand in strict opposition to reproductive technologies. In an article in the Creighton Law Review titled Feminist Perspective, feminist Barbara Katz Rothman cites the patriarchy as the reason why women should not use reproductive technologies. She writes that under the terms of a patriarchy, “women are described as the daughters of men who bear children” (Rothman, 1991: 1600) and as such have a moral obligation to do so. One of her arguments is that women should not be expected to go to great lengths to have children simply because that is their purpose according to the male agenda. All of this is to say that being opposed to reproductive technologies cannot be equated with being anti-woman.

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 previously 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.

Keenan introduced an interesting point about different segments of the community requiring different things in order to be comfortable. In other words, how do we decide what policies will make the majority of people feel accommodated? What if those who want access to reproductive services we refuse to offer no longer feel comfortable in this space? My argument has placed more value in the opinions stated by religious bioethics than by those held by secular ethicists. More broadly, I am siding with a religious worldview over a scientific one. I can justify this in two ways, both of which speak to the main discipline I used to generate my argument: anthropology. The first justification is that we are not only considering the current perspectives of our community members, but also the history. Irish Catholics define this community more than anyone else by virtue of sheer staying power. We cannot ignore the past when shaping the future. My second justification is that in this instance, I think religious beliefs are more powerful than scientific ones. By this I mean that an Irish Catholic patient of this hospital would have a bigger problem accepting treatment here—unrelated to pregnancy—if we were to offer abortion services than a secular woman would if the situation were reversed. The only evidence I have to support this statement is my personal sentiment as a secular “techno-optimist” (Braun, 2005: 42), though I do think this holds some clout.

In his critique, Dr. Elmasri argued that too much of the support for my arguments came from opinions presented by ethnographers, not facts. He is correct that I did pull quotations from some analysis sections within the ethnographies we read, where the author is pointing out trends they noticed while conducting their research. I believe this addresses one of the limitations to my use of anthropological findings to substantiate my argument. A participant observer in a society isn’t there to collect facts, they are there to collect stories. Stories innately have bias, and the way the observer decides to tell these stories also generates bias. Perhaps had I relied more heavily on theology, I would have had a deeper understanding of where the bioethics of different religions comes from, and therefore would have more accurate things to say about the religions represented in our community.

Finally, Keenan and others pointed out that based upon my previous arguments, there may not be support for a fertility clinic in our town. In response, I say that he is misinterpreting my warning about offering these services in the framework of a historically Catholic hospital. He thinks that this means there would not be a need for nor a donor base to support a brand new clinic. I did not, however, argue that there is not a need in our community for these services. When I spoke about homogeny earlier, I did not mean our population consists exclusively of religious people. There are nonreligious, religious but not observant, and completely secular people as well—though that is not to say that everyone who identifies with these categories will be pro-biotechnology. Additionally, there are observant religious people who will go seeking these treatments despite whether their bioethics deems it permissive. Evidence for this statement can be found in Sherine Hamdy’s research on Muslims in Cairo and their interactions with new biotechnologies. She writes, “In various ways patients grappled with how to achieve the greatest benefit for themselves and their families, while at the same time trying to conform to what would please God.” (Hamdy, 2012: 156)

I am arguing that the implementation of these services in our hospital is like trying to fit a square peg into a round hole. We should allow the women in our community who demand these services to be treated, but this hospital is not a conducive environment for this to occur. We must begin with a blank slate. Rather than expecting our same hospital donor base to continue providing support after implementing a change that would go against their values, we can start anew with different donors. Rather than training an unwilling staff to perform the procedures, we hire a willing staff to do so. This is the best solution.

Leave a Reply

Your email address will not be published. Required fields are marked *