Month: May 2017

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.

Sincerely,

Dr. Nestor, M.D.

To Whom It May Concern,

Background Information

            My name is Zoraiz Ahmed. I am a general surgeon currently working at the private hospital in Sasquatch, Connecticut. I identify as a Lebanese Shi’ite Muslim male. My family and I moved to Sasquatch 10 years ago, at which point we were the only Lebanese family in the community. However, there has been an influx of Lebanese immigrants and I am proud to say that I was recently elected as the president of the new Lebanese Cultural Association. With the growing immigrant populations in our community and my medical expertise, I am humbled to serve on this ethics committee as we transition to becoming a non-denominational hospital.

Amendments to Initial Proposal   

After submitting my initial proposal to the Sasquatch Hospital ethics committee, I received several comments and suggestions from my fellow peers on the ethics committee. I have thought long and hard about the critiques of my proposal and I have amended a portion of my initial pitch regarding the use of reproductive technology. My suggestions for IVF treatments, prenatal testing, and abortion have stayed the same, but I expanded on my reasoning. However, I have decided to compromise with my peers on the donation of unused embryos. I have also stood by my original recommendations for regulations of the counseling and medical staff.

Final Policy Proposal

Reproductive Technology Use

IVF Treatments and Prenatal Testing

I believe the Sasquatch Hospital should begin to provide in-vitro fertilization (IVF) treatment and prenatal testing including amniocentesis. Though, the risk of miscarriage during an amniocentesis procedure is 1 in 200 (Rapp 97), which is the equivalent to the probability of babies born with Down syndrome, patients in our community deserve to have the right to know about possible birth abnormalities. Furthermore, with the growing diversity in population and thereby increased risk of genetic diseases, the availability of this procedure is essential as genetic diversity is also increasing.

I acknowledge that the results of prenatal natal testing can cause a great amount of anxiety and psychological trauma to the patients and families involved, but I support the fact that access to knowledge outweighs this distress and the risk of miscarriage. As a physician, I believe parents in the Sasquatch community have the right to be given all relevant information to make a well-informed medical decision regarding their unborn child. However, as medical personnel looking out for the overall well-being of our patients, we can provide hospital services to alleviate distress post-test results. These are addressed in propositions for counseling staff regulations.

Abortion

            The hospital should not provide abortion services, unless extenuating circumstances persist. These circumstances fall in line with the United States federal guidelines listed under the Hyde Amendment. Abortion services should only be provided when the pregnancy is a result of rape or incest or is a medical threat to the woman’s life. Although this federal amendment was made in regards to funding of abortion services, I have chosen to use the guidelines as a line of compromise between the devout population against abortion and the new growing liberal and diverse population in the Sasquatch society.

Though the hospital has become non-denominational, we must still consider the prevalent religious practices present in our community. IVF and prenatal testing allow for the expansion of knowledge, but abortion by two out of the three dominant religions in this community (Catholicism and Shi’ite Islam) prohibit the murder of a living being and an unborn fetus can be considered living as it is in the mother’s womb. The holy Quran teaches that “God had given people their bodies as a trust (amana) and that (we are) therefore responsible to take care it (Hamdy 151).” As a devout Muslim, I do not think it is ethical to break the amana that God has bestowed upon mankind and my fellow Catholic staff feels the same.

However, I also know that I have taken the Hippocratic oath and will follow all means to help patients live healthily. Thus, I propose that this hospital only provide abortion services when it is a medical necessity as explained at the onset of this section. I define “extenuating circumstances” as rape and incest and nothing more. There will always be compelling arguments for genetic abnormalities and diseases as extenuating circumstances for abortion, but this opens up a vast spectrum of new cases. Given the general limitation of new hires and the limited time of the ethics committee to handle a case-by-case analysis these situations, I have chosen to strictly define what qualifies as extenuating in this policy proposal.

Unused Embryos

After careful consideration of my colleagues’ critiques, I retract my original suggestion that unused embryos should be donated to research. I still agree that from a medical standpoint that research from unused embryos could lead to life-saving results. However, I believe slow policy reform will bring about the most fruitful change at Sasquatch Hospital. Under the same religious reasoning as above, the Catholic community is still dominant and many believe that embryos are living and thereby destruction of living embryo is still murder. Though that is a very controversial thought, I was swayed by my colleague who pointed out that there is no way we ensure that the donated embryos will not be destroyed or just thrown out by researchers who deem them to be unfit for their purposes.

Under-insured Patients

Subsidized funding for underinsured patients should be provided only for testing purposes, not abortion services even when extenuating circumstances persist. It is a pretty common standard around the Western world for governments to provide these funds. For example, “The French government normally reimburses medical procedures up to 80%, but in the case of infertility diagnosis and treatment, the national health insurance system covers the cost of the entire process (Ball 547).” Thus, I do not believe our hospital which condones abortion overall should provide funding for abortion services of those under-insured since they can get the funding elsewhere. Indeed the United States can currently use federal funds to fund under-insured patients with extreme cases for abortion.

Counseling Staff Regulations

Spiritual counseling by clergy should be continued, but the clergy should be opened to other religions that have recently become more prevalent within the Sasquatch community. Under my own Muslim doctrine it can be stated “Shi’ites practice a form of individual religious reasoning known as ijtihad (Inhorn 18).” Medical choices of any sort are extremely personal and hence I advocate for individual religious reasoning in the decision-making process. Thus, I believe all patients to this hospital across all religions should be able to have access to religious counseling in order to determine their course of medical action. Given that the vast majority of the community served is religious in some way, the inter-religious clergy will aid in daily smooth function of our hospital.

I propose implementing a mandatory training program for all counseling staff including social workers, genetic counselors, and clergy. This training program will educate counseling staff on official hospital policy regarding assisted reproductive technology and prenatal testing. It will give guidelines as to how staff can counsel under their own religious doctrines, while still adhering to hospital policy and national law.

Additionally, there should be an increased number of trained inter-religious clergy specifically available at the prenatal testing facilities of the hospital. This aims to alleviate the arduous decision making process that some patients and families might undergo after receipt test results.

Medical Staff Regulations

            Furthermore, I propose a similar training program for all medical staff at the hospital. All staff will not be required to be in agreement with hospital policies proposed, but rather should be aware of official hospital policy. The staff should be willing to uphold the official policies at the very least.

I know there is currently significant tension among the Catholic nursing staff to perform these procedures. I do not think any of the staff should ever be required to perform procedures that are against their religious beliefs. Thus, a team of new hires and a few of the current staff who are willing will be chosen to make a team designated for all the procedures stated in this policy proposal. Nonetheless, as stated in the above training program, the staff unwilling to perform the procedures will still have to acknowledge that the procedures are being conducted at this hospital under structured circumstances.

Closing Remarks

My final proposal encompasses my best attempt to view the situation in an open-minded manner while staying true to my medical and religious values. I believe the best method to allow for a smooth transition at our hospital is slow reform. As a physician, I support the advancement of new scientific technologies, but I also acknowledge the importance culture and religion within the Sasquatch community. Though our hospital is becoming non-denominational, I stand strong under the opinion that a complete and drastic change to the current policies will not prove successful in such a short period of time. I have done my best to find a middle ground between the conservative and liberal perspectives on abortion and prenatal testing services at play in the larger Sasquatch community. Thank you for your time and consideration of my policy proposal.

Sincerely,

Dr. Zoraiz Ahmed, M.D.

 

Works Cited

Nan T Ball, “The Reemergence of Enlightenment Ideas in the 1994 French Bioethics Debates.” Duke Law Journal 50 (2000): 545-587.

Marcia Inhorn, He Won’t Be My Son: Middle Eastern Men’s Discourses of Gamete Donation.” Medical Anthropology Quarterly 20 (2006): 94-120.

Sherine F. Hamdy, “Does Submission to God’s Will Prevent Biotechnological Intervention?” In Jeremy Stolow editor, Deus In Machina: Religion, Technology and the Things In-between (Fordham University Press, 2013), 143-57.

Rayna Rapp, Testing Women, Testing the Fetus (Routledge, 2000).

To the ethics committee:

The church decided to become non-denominational. Although the hospital is no longer affiliated with the Catholic Church, I understand non-denominational to still be Christian but without an association to any specific church under Christ such as Protestantism and Catholicism. At the forefront of a non-denominational church are the messages and values of the Bible. Though the Bible has many different interpretations, the Bible sends a message of valuing human life, since it is granted by God. Still being a non-denominational (not non-religious) affiliated hospital, the hospital should still be firm in its conviction and follow God’s words.

Catholics believe that life begins at conception while others believe that life can begin after a certain amount of months, after the baby is born, or even after the baby can start to reason. Why is there an argument over when life starts? If God granted us with the blessing of life, then why are we trying to deny our blessings? A life is a life is a life. Being specific over when life start then becomes a worldly matter and provides an excuse to rationalize one’s decision to perhaps get an abortion. Thus, since conception makes a zygote, which then turns into a fetus, and eventually an embryo, life starts at conception, for those who want to be specific of when life starts. Thus, services such as prenatal testing, IVF treatment, and abortions should not provided at this hospital. I still would like the patients to be informed. I would like them to know the benefits, risks, and alternatives (all sides of the situation) before they still make a decision. Hopefully, after all the genetic counseling as well as non-religious, moral counseling, the patient will decide not to have an abortion.

Mary, the mother of God herself, was blessed with a human life, with Jesus. When angel Gabriel came to tell her that she was going to give birth to the son of God, she was really scared; she was just a teenager. She could have decided to reject Jesus’s life because as some people would say, he was not human or a person yet. Even if they did not have abortion, I believe that if Mary said no to God’s plan for her then God will not have continued to make her give birth to Jesus. However, despite the fact that Jesus was still a fetus then, Mary decided to continue to nurture him in her stomach and eventually give birth to him. Where would Jesus be if he was not born? Similarly, abortion, despite the circumstances, can neglect the future life of the fetus that you were blessed with because your mom did not reject you.

As a Catholic nun, who was raised in a non-Catholic family and converted as a young adult, I do not believe that we should begin providing and subsidizing abortion services for under-insured patients. Every life, which is started at conception, is a gift from God—no ifs, ands, or buts—and thus should be protected. By providing and helping to pay for these services, it shows that we are in support of humans having the right to place or take away value on an innocent life (Donum Vitae 1988: 147).

Moreover, I agree that everyone should have equal access to healthcare. I understand that there are Jewish people (Kahn 2000), Japanese immigrants (Ivry 2009), and Lebanese immigrants who are Shi’ite Muslims who might want abortion services as well as IVF treatments. These IVF treatments may be more attractive than other reproduction methods because for example IVF is funded in Israel to encourage woman to have babies (Kahn 2000). However, patients are coming into a hospital that is known to be Catholic but now non-denominational. It is logical that we follow values of non-denominational Christianity. If we did not follow values of our religious affiliation, then why are we even affiliated with any religion? I would suggest that we refer patients who would like abortion services or even IVF treatments and prenatal testing to another hospital or clinic However, I would only refer them after they have been informed from medical professions and received generalized non-religious counseling. Though some might see this as hypocritical of me to say this, above all the rules and regulations of Catholicism, we are taught to love our neighbors. Though they are seeking something that I would not approve of, I would still like to keep their safety in mind. They might seek unsafe ways of abortion. If even after counseling and informing patients on alternate options and patients still would like to have an abortion, I would rather that it be a safe procedure to help protect the life of the woman.

In terms of extreme cases such as rape, I still do not think abortion should be allowed. There are alternatives. Babies of rape victims can be put up for adoption. Bad things can happen to good people, but that does not mean we should then inflict those consequences on a future baby. They should still have a right to life.

Furthermore, I do not think we should support IVF treatments and prenatal testing including amniocentesis. These services “expose [man] ‘to the temptation to go beyond the limits of a reasonable dominion over nature’” (Donum Vitae 1988: 141). A life is not ours to say whether or not it should be worth living, even if it may be in a woman’s womb.

Prenatal testing and amniocentesis give patients the knowledge and the chance to “play God”, to be able to choose whether the life of a fetus is worth living or if the patient is able to care for the fetus when born. Prenatal testing gives the mother knowledge of either presence or risk of a genetic disease. This knowledge can induce fear of not being prepared or capable to care for someone who has a genetic disease. Although some people believe that they have a right to know if their fetus is going to have a genetic disease, some people believe that they have the right to not know(“The Burden of Knowledge: Moral Dilemmas in Prenatal Testing” 1994).  The latter allows them to practice the virtue of patience but encourages them to love the child as he or she is. Furthermore, amniocentesis is an invasive process, and when getting this procedure, the patient has a 1:200 chance of getting a miscarriage, which is the same ratio of chance of a patient’s baby having Down’s syndrome if the patient is older. Additionally, according to one of the parents in The Burden of Knowledge: Moral Dilemmas in Prenatal Testing, being a parent includes the commitment to unconditionally love one’s baby, and choosing to get an abortion because of a genetic disease interferes with that commitment. Also, if given the option, “an infant wouldn’t choose to die like an adult would choose to die at the end of his [or her] life” (“The Burden of Knowledge: Moral Dilemmas in Prenatal Testing” 1994).

Some would argue for abortion in that any right that she may give up still pertains to her (Thompson 1971: 51), but however, there are differences between rights innate to us as humans and rights that are given to us by God. Right to not carry a baby in her stomach and denying the right to a life that is already there. Another point made in rebuttal is that a fetus is still a part of the mother before a certain stage (Thompson 1971: 60). Because the fetus is a part of the mother, then aborting the baby will be killing a part of the mother. Thus, protecting the life of a baby is protecting the life of the mother.

Giving these services and allowing patients to choose whether or not to keep the fetus further puts a stigma on people with disability. Why is it okay to have a normal baby whose personality might drive one crazy rather than a baby with Down’s syndrome? Why is it not normal to have a baby with Down’s syndrome? This is answer is due to societal pressures and a pressure to look like everyone. Lastly, these services only test for certain genetic diseases. There are a million other things that could go wrong during a pregnancy that we do not have technology to test for. If money and fear of not being able to provide the necessary care for children with genetic diseases arise, then there are still options such as putting the baby up for adoption. For example, according to the documentary “The Burden of Knowledge: Moral Dilemmas in Prenatal Testing”, there is waiting list of people wanting to adopt kids with Down’s syndrome (1994).

Though the local area is home to those who are in favor of IVF treatments, abortion, prenatal testing and amniocentesis, the hospital was based on Catholic roots. I think the Catholic roots should be respected. The hospital was able to make it where it is today while respecting Catholic roots. Additionally, the donor base is still prominently Irish Catholics. The hospital operates mostly from funds from our donors. Since we are choosing to subsidize medical care for under-insured patients, this hospital cannot function without our donor base, and thus the hospital should look to uphold Catholic values.

Our society, which seems to be more secular than before, are still strongly tied to and influenced by religious values. Similarly, the influence of the way the hospital is run is still influenced by religious values. Catholicism, which aligns with non-denominational Christianity, speaks to something more than just a rule or a positive deed. Its values are based on natural law, rights that we believe to be innate to our own human being. The chances of a sperm and egg becoming a zygote is very slim; hence, this is the reason why during IVF treatment women have to give more than one egg to ensure that an embryo forms. It truly is a blessing if an embryo is formed.

In addition to social workers and genetic counselors, the hospital should continue to provide spiritual counseling by Catholic clergy. Because the hospital is non-denominational, I believe that we should open up counseling by clergy, in additional to Catholic clergy, to those of Protestantism and non-denominational Christianity. If people would like counseling from another religion, I would refer them to a clergy of their own practice outside of the hospital, keeping in line of the convictions of non-denominational hospital.

Though medical staff are expertise on their technical knowledge of medical treatment and procedures, I do not think they should be superior to the clergy. Medical staff have knowledge on a specific expertise in their specific field. They have knowledge on technical procedures. However, a lot of the moral decision-making come from a conceptual standpoint that society tends to fall back on religion to help answer. (Braun 2005:45) There are conceptual, moral questions that I do not think technical experts should be the only person to help decide.

On non-religious and moral standpoint, there is no rational statement that a fetus is nothing other than human (Arkes 1986: 388).

Catholic clergy are not making a rushed decision but rather carefully thinking through the decision. We Catholics make our decisions based on natural law. Natural law refers to rights that are embedded in nature and that can be reasoned out. Therefore, natural law cannot be opposite of what Scripture says. Both reason and Scripture influence each other. Natural law is also evident in the Declaration of Independence, a document that is dear to the hearts of all Americans. It states that we Americans have self-evident rights, which are then listed as life, liberty, and the pursuit of happiness. Life here is extended to the life of unborn people as well since life starts at the point of conception. Thus, the reason that the Catholic Church makes universal claims that we think others should also consider is because they are grounded in natural law.

Our historically Catholic nursing staff has been alarmed by the possibility that the hospital will now provide abortion and reproduction services. I do not think that abortion services should be provided. The nurses and medical staff should make sure that the patients do know all the current options available. Being misinformed can result in a decision that the patients are going to regret, especially while carrying fetus and while the woman’s body is going through hormonal changes. For example, if some patients knew that there was a waiting list of people wanting to adopt children with Down’s syndrome, they would not have continued with abortion. Making sure to reiterate their options to the patients will help them to make a more informed decision. I would ask the nurses to listen to the patients to see their reason for doing such procedures and see if there is anything the nurses can inform them about to help them make their decision.

There have been some interests in opening a clinic close by that provides prenatal, IVF, and abortion services that is not affiliated in any way to the hospital. I am opposed to the idea of opening a clinic close by that is not affiliated with the hospital because of my universal Catholic values. However, I still want to protect life. That being said, I cannot stop what the ethics committee ultimately decides. I will say that although technology has helped to advance medicine and treatment in our society, not every technological advancement is necessarily morally right.

Though we no longer in Biblical cosmology, Biblical cosmology can still continue to shape our society (Delaney 1995: 188). Our subconscious knows that life is precious. Killing a person can bring much guilt to a person. Conception brings about life that cannot be denied. If you had been someone with Down’s syndrome, and your parents decided to terminate you, how would you feel? Though at that point, one probably would not be able to feel, one also does not have the right to decide to terminate another person’s right. Every human, fetus, and embryo has the self-evident right to life.

I believe that my perspective and viewpoint broadens this discussion amongst the people within the ethics committee. I give my own angle to this difficult, moral problem. Without presenting many, different perspectives, the people who have a say at this ethics table will have a more narrow, less multi-faceted overview of how to proceed.

 

God bless,

Sister Nguyen

Assisted Reproductive Technologies and Prenatal Testing Policy Proposal

Dear Ethics Committee of Sasquatch Medical Center,

Upon reviewing all the comments made on my original policy proposal, I have taken into deep consideration the various beliefs and suggestions made. Even though I respect the opinions of my colleagues, I have decided to remain firm on my initial suggestions regarding in vitro fertilization (IVF) and spiritual counseling. However, I do agree with the vast majority of the committee that I fell subject to generalizing religious groups, and as a result, I have attempted to correct this mistake in the following revised proposal. My reason for not altering positions on a specific issue are explained in the respective section of the proposal.

As you all are familiar with, my name is Petar Zotovic and I am a fertility physician here at Sasquatch Medical Center (SMC). Recently, the Catholic Church has allowed our hospital to become non-denominational, one of the reasons being due to the diverse and growing population of Sasquatch, Connecticut. Sasquatch has deep Irish Catholic roots and this was an important factor to consider while constructing the policy proposal. Upon analyzing the differing religious beliefs in Sasquatch, I am proposing a policy which allows the use of all ARTs available to the hospital; in addition, prenatal screenings are only allowed if the intention is to not abort a fetus if an abnormality is found to exist. My policy proposal attempts to satisfy the diverse population in Sasquatch, while still attempting to adhere to its Catholic roots regarding prenatal testing.

In attempts to abide by the still prevalent and dominant Catholic faith in Sasquatch, all attempts at abortion will not be executed. In the past, Sasquatch was a safe haven for Irish Catholics and was once ruled by Catholic auspices, so retaining some of their beliefs is still important. In addition, I agree with Cahill et al. in Donum Vitae when they state that “The human being must be respected- as a person- from the very first instant of his existence” (1988: 147). As a result, subsidies will not be granted in abortion cases. In alliance with my stance on abortion, prenatal screenings may only be conducted in order to examine a fetus for abnormalities. No attempts at termination may be done once such tests have been performed. The main goal of performing prenatal screenings (e.g. amniocentesis) is to prepare a mother for the possibility of her fetus having a defect. In screenings that confirm fetus abnormalities, the mother will have the opportunity to cope and discuss her feelings with a hospital counselor.

All ARTs, including IVF, will be subsidized by the hospital for under-insured patients. Through this advancement, both Caucasians and African-Americans living in poverty will have the ability to become pregnant without major financial setbacks; in recent years, the poverty rate in Connecticut among these groups has increased by four percent, with most of the individuals being under-insured (Armstrong, Plowden 2012: 652). In addition to assisting the poor, the subsidization of ARTs will benefit both the thriving Jewish and Japanese community; with regards to IVF and other reproductive procedures, Jewish ethicists commonly cite God’s first commandment: “Be fruitful and multiply, and fill the Earth, and subdue it…” (Bible Hub, Genesis. 1.28). The IVF protocol will contain a provision which will respect Islamic law; the provision will state that Shiite Muslims are eligible to participate in IVF if it involves a husband and wife couple. I am stating this because of Morgan Clarke’s ethnographic study in Lebanon in which she concluded that Islamic law plays a crucial role in determining rules by which females must abide by if they want to undergo IVF treatment (Clarke 2007: 72). In her study, she comments “The prime principle at stake here is whether such scenarios are analogous to, if not identical with, the heinous crime of zina, that is sexual relations between parties not bound by a contract of marriage…” (Clarke 2007: 74-75). The preceding quote demonstrates the necessity of a husband and wife couple when performing IVF on Muslims. Of course, IVF treatment not between a husband and wife couple will be allowed if the patient and donor both agree and/or if no religious beliefs are interfered with. The following protocol on IVF will show the emerging minority population that their beliefs are heard of and will be respected at SMC.

A common criticism of my initial proposal was that allowing IVF treatment indirectly leads to more abortions, thus contradicting my stance on a zero-tolerance abortion policy. The accusation was formed on the basis that IVF leads to the creation of unnecessary embryos which ultimately end up being destroyed. Patients often decide to undergo IVF treatment because of their inability to have a child due to infertility reasons. If IVF treatment is successful, the likelihood that the mother will deliver the baby to term is ninety-three percent. Out of all abortion cases, only seven percent are a result of fetal/mother health complications and sixty-nine percent are due to the mother not being emotionally and socially fit to care for a child (“U.S. Abortion Statistics” 3). If a mother has decided to proceed with IVF, it is reasonable to conclude that she sees herself fit to raise a baby. In addition, the course of action regarding unused embryos at SMC will obey the following provision. Frozen embryos may be used for life-saving research if they have not been placed inside the mother’s uterus and if the mother provides consent. With regards to the provision, I respect the Islamic belief that an embryo is not considered human if it is not inside the mother’s uterus; the embryo outside the uterus will not survive if it is unfrozen and is therefore not considered human (Eich 2008: 63). In “Decision Making Processes Among Contemporary ‘Ulma’: Islamic Embryology and the Discussion of Frozen Embryos”, Thomas Eich describes ‘Abd al-Salam al-Ibadi’s view on the topic by mentioning “Concerning the question of frozen embryos, he argued that the majority of classical fuqaha would have opposed abortion. Therefore, the use of frozen embryos for research could not be allowed, and the embryos should be implanted in the mother’s uterus” (2008: 68). I disagree with Ibadi’s statement because a large number of Muslims have differing views from the classical fuqaha he describes. Instead, expected costs and benefits, such as the opportunity to save a life, should be analyzed when deciding to donate frozen embryos for research. Due to the provisions and reasons listed above, the use of embryos for life-saving research is not considered abortion in my opinion and is why I have decided to remain firm on the issue.

A second criticism I received involving IVF treatment was the impact it might have on a person’s dignity. As Leon Kass states in her ethical inquiry to President Bush, there “…are deeper concerns about where biotechnology may be taking us and what it might mean for human freedom, equality, and dignity” (16). Even though I agree with Kass’s statement that ARTs can result in psychological damage to a child, I feel that the statement should be approached on a case-by-case basis. The sole goal of IVF treatment is to place a fertilized egg inside a mother’s uterus; the remaining pregnancy process continues as if IVF treatment did not occur. The resultant child has genetic material of both mother and father and is not at risk of future heath complications due to the treatment. The only difference I see between a normal pregnancy and one due to IVF is the process by which an egg becomes fertilized. As a result, I do not find much justification in the argument that IVF treatment may affect one’s dignity later in life. In other forms of assisted reproduction, such as cloning, the argument changes entirely. In cloning, the process of birth is altered entirely and the clone remains at heightened risk of future health complications (Kass 17). In extreme forms of reproduction (e.g. cloning), the idea of loss in human dignity needs to be weighted differently, thus making its emotional impact distinct from that of IVF treatment.

Throughout patients’ time at SMC, they will have access to genetic and social counselors. Spiritual counseling by Catholic clergy and access to spiritual counseling of other religions will not be utilized. Genetic counselors will be tasked with informing patients of risks they might face through ARTs/prenatal screenings and social counselors will help patients cope with any negative news that result from such screenings (as mentioned earlier in proposal). Spiritual counseling of any religion will not employed because physicians and nurses (mostly Catholic) at SMC will be required to enroll in a “cultural competency” course which will enable them to better understand the beliefs of all patients. Because the hospital budget for hiring new personnel is limited, this provision will not only save the hospital money, but will also improve physician/nurse-patient communication. Swasti Bhattacharyya mentions in Magical Progeny, Modern Technology: A Hindu Bioethics of Reproductive Technology that cultural competency is “the ability to provide care that is compatible with the values, traditions, and faiths of the patient” (2006: 21). This will be a new task physicians and nurses encounter, but will ultimately prove beneficial for the functioning of the hospital.

A third criticism of my original proposal was that the lack of spiritual counseling would prove disadvantageous when attempting to understand a patient’s beliefs. I disagree with this idea because I feel there is a different goal in mind among spiritual counselors and those who engage in cultural competency. My critics of the issue argue that spiritual counselors are necessary in order to corroborate a patient’s beliefs about a situation. Through this mindset, the goal of the counseling is not find a compromise between physician and patient, but to strengthen “own personal beliefs” (“Spiritual Counselor Careers” 1). As a result, the ability to progress in treatment options becomes stifled and leaves physicians in an uncomfortable position. On the contrast, cultural competency educates physicians and nurses on the beliefs of other religions and allows them to understand the thought process of a patient (Bhattacharyya 2006: 21). As compared with spiritual counselors, physicians and nurses educated on cultural competency can find appropriate methods to continue the healing process of a patient without being too intrusive on the patient’s religious beliefs.

My job in this hospital is to be a fertility physician, which means doing anything in my power to ensure the healthy status of a fetus or baby. At the same time, I realize that the population of Sasquatch is changing rapidly and new hospital accommodations are necessary. The policy proposal I am presenting to this committee attempts to reflect the hospital’s Catholic origins, while at the same time portraying a sense of humility to the increasing minority group in Sasquatch. I urge the entire ethics committee to consider this policy proposal with open minds and to vote for the passing of the proposal only if they believe it serves a humbling and beneficial purpose to the hospital staff and patients.

 

Thank You,

Petar Zotovic, M.D.

 

 

 

 

Works Cited

Armstrong, Plowden. “Ethnicity and Assisted Reproductive Technologies.” NCBI,

vol. 9, no. 6, 2012, 651-658.

 The Bible. Bible Hub, Columbia International University, 1993.

“Prenatal Testing.” NISHMAT, 2000, 2.

“Spiritual Counselor Careers.” Careers Psychology, 1.

“U.S. Abortion Statistics.” Loxafamosity Ministries, Inc., 2005, 3.

All other sources are from class readings.

 

 

 

 

As the CEO of Sasquatch Hospital, I have been asked to craft a new policy proposal regarding assisted reproductive technologies and prenatal testing. I accepted this job just as the hospital was shifting away from its official association with the Catholic religion a few years ago. Over the past few years, I have gotten to know the many different populations that make up Sasquatch, Connecticut. I have also been in communication with anthropologists who, over the past year, have been talking in depth with our patients about their feelings on these assisted reproductive technologies. Although these conversations are limited in their confinement to the hospital setting, interview format, and absence of long-term relationships, they offer the best perspective we have on the population we are trying to serve. With such a diverse array of individuals in our lively community, we must take every voice into consideration. Nonetheless, it is impossible to please everyone in our quest to set regulations on healthcare. This new policy proposal certainly does not set a unified front for all the voices in our community; But I have worked diligently to address everyone’s concerns in a way that fosters cooperation between different religions and cultures.

The inevitable solution to a situation in which different groups of people have different objectives is to provide most services but restrict their usage. It is also important to appeal to our largely Irish Catholic donor base because without them, we cannot run this hospital. We should take their perspective into account when making policy influencing pregnancy. We should not subsidize abortion or IVF services because doing so would contribute money from donors towards initiatives they do not approve of. Additionally, the Department of Social Services (DSS) in Connecticut funds all abortions that are medically necessary as per Doe v. Maher in 1986. Medical necessity is decided by the physician of a patient. It includes “health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition; or to prevent a medical condition from occurring. (Cohen, 2010: 1). We should fully cooperate with the DSS of Connecticut to allow under-insured patients to receive abortions under conditions where they are medically required. To reduce instances of abortion and unnecessary killing of what many Catholics deem as life, we should only allow it to be performed in situations when the mother’s or fetus’ life is at risk during the pregnancy or in instances of rape (Cardinal Joseph Ratzinger and Archbishop Alberto Bovone, 1987: 149). We should justify this position to non-Catholics who might seek abortions in other instances by claiming the need to reflect our Catholic roots to some degree. These patients would have to seek treatment elsewhere if they want abortions in other instances.

In addition to abortions, prenatal testing and amniocentesis are necessary provisions to allow people to exercise precautions in their pregnancy. In particular, members of the Jewish community utilize these resources (Ivry, 2010: 11). Individuals using this service at our hospital would not be able to terminate a pregnancy based on any genetic conditions they discover, however, because under my policy proposal the hospital wouldn’t allow voluntary abortions. Instead, they could use this information to prepare for the consequences of the genetic disease once the child is born. These services would also allow healthcare providers to ensure the health of the fetus and mother during the progression of the pregnancy. The restrictions placed on abortions, prenatal testing, and amniocentesis would appeal to our Irish Catholic donor base, so our hospital can continue to run under their generous financial contributions.

We should also provide In Vitro Fertilization (IVF) treatments for our patients. Studies have shown that a small but significant portion of the Jewish and Lebanese Shi’ite communities use IVF as a way to overcome infertility. Though these studies were not conducted in the United States, the anthropologists at Sasquatch hospital have made similar conclusions among the Jewish American and American Lebanese Shi’ite communities. The statement made in Genesis that we should “be fruitful and multiply” has been interpreted by the Jewish community to be a commandment. The Jewish community places an emphasis on reproduction. Additionally, most religious leaders agree that life does not begin at conception. These reasons among others lead to the general acceptance of IVF among Jews (Kahn 2000:3). Shi’ite Islam promotes decision-making through the use of individual thought processes, also known as ijtihad, but practicing Shi’ites also hold the guidance of local religious leaders in high esteem. Most of these leaders have approved of IVF technology provided that certain precautions are taken. Shaikh Fadlallah, one of such religious leaders, and a Sunni religious leader both agreed that IVF is permissible when the gametes are provided by the couple that wishes to conceive through this process (Inhorn, 2006: 111). IVF is valued by important segments of our population, so we need to provide these services to them. It has been argued that the policies outlined above may offend the hospital’s Catholic donors. We may risk losing our funding from Catholic donors, but we hope the policy initiatives will attract new donors from different religions. If we attract enough new donors, we can reconsider subsidizing abortions and IVF.  Some Catholics will object to the use of IVF on the grounds that it gives scientists god-like power to make decisions on life and death.  They see life as beginning from conception. (Cardinal Joseph Ratzinger and Archbishop Alberto Bovone, 1987:156). They may point to the fact that some embryos are inevitably not transferred to a woman’s uterus, so they are left to expire.  The expiring of embryos is seen as equivalent to abortion. I would not try to convince these people to change their views, but I would remind them that the beginning of life is a subjective matter. As a non-denominational hospital, we cannot simply align our views with that of the Church’s. For example, many Jews believe life doesn’t begin until many days after conception Jews (Kahn 2000:3). But we should not also simply align our views with that of other religions like Judaism. Thus, we should only allow IVF in instances of sterility; so, for instance, a woman would not be allowed to utilize IVF if she wants a child but lacks a partner. This would limit IVF to cases where it is absolutely necessary.

The procedures ascribed to dealing with unused embryos from IVF create another challenge for Sasquatch hospital. Despite the fact that we would be allowing IVF, we need to be respectful of the official Catholic position that life begins at conception. In addition to not subsidizing abortion funds, we should strongly reject any research initiative where embryos are harmed no matter what future result the research could bring. However, we should financially support any study where the embryos are completely unharmed and the research has a clear positive outlook for future patient health. Since we would be performing IVF, we would have to allow unused embryos to expire. But we should encourage the donation of extra gametes to other couples to avoid this. Some Jewish and Islamic individuals have been accepting of gamete donation, so we have people that will benefit from this provision (Ivry, 2010: 209-211; Inhorn, 2006: 111). Although I propose to not act in accordance with the official Catholic belief that every child has the right to be raised by his or her parents, donation of gametes should reduce the wasting of unused embryos (Cardinal Joseph Ratzinger and Archbishop Alberto Bovone, 1987: 158).

In regards to spiritual counseling, it is necessary to make a change in policy. We cannot provide all these assisted reproductive technology services and continue to have a solely Catholic spiritual counseling service. This would send out a conflicted message to our community that we provide these resources, but our staff vehemently discourages patients from using them. I propose that we hire non-denominational counselors for our hospital. It has been brought to my attention that it will be costly and difficult to find counselors from various disciplines. In light of this argument, I think we should hire counselors that are skilled in a variety of religions. It will certainly be less difficult to find non-denominational spiritual counselors than spiritual counselors for each religion. Additionally, we can hire fewer counselors than we would have to if we needed to find counselors from several religions. But we should set standards to ensure that these counselors have experience in the variety of religions reflected in our populace. If we have a patient that desires support that cannot be given by our non-denominational counselors, we should hire a spiritual counselor from their religion on a case by case basis. This spiritual counselor would be hired to come to the hospital to speak to that one patient. The diversity of opinions reflected by my proposal should alleviate concerns by doctors that the Catholic spiritual counseling is directly conflicting with their work. While I don’t expect secular doctors to fully support any spiritual counseling, I believe it is important for patients to be able to reach out for religious support when they see fit. Doctors are not trained to deal with the ethical issues that arise from the technologies they utilize. They should be involved in the conversation, but there should also be other voices present. Spiritual counselors have the training to contribute to discussions about when life begins and what practices are morally right.

Some staff members may oppose many of the new initiatives I propose to incorporate into our care of patients. If the hospital is going to move in this new direction, we need the full cooperation of all our healthcare staff. Therefore, we should not only provide training programs to teach our current staff how to perform these new procedures, but we should also hold informational sessions to show the staff that regardless of individual beliefs, what we are doing is the best way to satisfy the most people. If many staff members continue to resist performing these procedures, we should train a group of current staff dedicated solely to performing these procedures and ensuring that patients feel as comfortable as possible during the process. If we end up not having enough nurses to meet the demand for ARTs, we will have to limit some of our practices even further. For example, we can make a regulation to offer IVF for only one child per family. Since IVF is not a medical emergency like the abortions we perform are, that should be the first thing we restrict. Abortions in medical emergencies should be the very last thing we limit because of its threat to the life of the mother.

As the CEO of Sasquatch Hospital, I have proposed a plan here that requires concessions from all members of the community but addresses everyone’s concerns. Rather than substituting financial stability for a coherent moral and medical vision, my proposal crafts a moral vision informed by several different perspectives. In doing this, I acknowledge the subjectivity of morality and the need to present an ideology that doesn’t enforce its own moral agenda on the population. Instead, it reflects the moral perspectives exhibited by the community. A situation as dynamic and complex as this one requires oversight and openness to change. It is necessary to assess the satisfaction of the variety of groups affected by our decisions. Therefore, we should reevaluate after a year to see how doctors feel about the change in protocol and if patients are using the services we provide. We should also see if patients are using the spiritual counseling resources in their decision making process. Though we always need to reevaluate, I am confident that the plan proposed here would allow the hospital to address the concerns of the diverse population of Sasquatch, Connecticut.

Analyst, Robin K. Cohen Principal. “STATE PAYMENT FOR ABORTIONS.” STATE PAYMENT FOR ABORTIONS. N.p., 17 Mar. 2010. Web. 21 Mar. 2017

The community of Sasquatch, Connecticut, is an increasingly diverse population, and as such, has a diverse set of needs. Though the town has a predominantly Irish population, Sasquatch has notable Jewish communities, mixed white and black communities, as well as influxes of Lebanese Shia and Japanese immigrants. Due to large distance between the town and a major hospital, major decisions must be made on a number of controversial topics. I am an outsider to the community of Sasquatch, and study in Atlanta. My experiences are not those of these community members’, and I have used a central doctrine of mutual respect, respect for the established law, and maximal freedoms for the most people. My ethical judgements will largely be made on the legal and normative lines, with an attempt to respect and please people from various backgrounds, to provide a set of ethics suggestions.
Before we begin, one must ask the question: what is the nature of the Catholic-affiliated hospital’s shift to become non-denominational? The background information of whether this move was motivated by diversity or as a nominal tactic is imperative to understand what effects this report’s suggestions may have. I will, however, proceed under the assumption that the shift was more than a titular change.
 The American hospital system exists largely in the private sector with various government regulatory agencies and legislatures who oversee the creation and maintenance of rules and protocols. It is under that umbrella that many of the implicit suggestions made in the prompt of this paper raise legal eyebrows—is it within the law for hospitals to refuse to provide particular treatments or procedures? Due to conscience clauses in Connecticut, only individuals would be able refuse particular care, but it institutionally cannot refuse emergency situations in cases of uninsured people (“Refusing to Provide Health Services” 2017). Therefore, life-threatening abortions that are provided to insured patients ought to be granted to uninsured ones as well.
A second presumption that must be made is that both scenarios of each question are legal. I believe that once the argument becomes pointedly about the law, this becomes a conversation for lawyers and jurists, not for bioethicists. The nearby hospital subsidizes care for under-insured patients, an assistance that can be seen in many hospitals across the United States. There is a growing issue of growing medical costs that result from the assistance of the under-insured—a burden that falls to a great extent on the deductibles of the lower middle class. The assistance given by the hospital close to Sasquatch has also been implicitly called into question.
 A third presumption is that these fragmented populations will behave or believe similarly to those we have read about in our course. It is entirely conjectural and reductionist to pigeonhole a group of people as similar to their macrocosmic religion, an identity which they may or may not hold as very salient.
 With these initial conditions, the principal debate is that of assisted reproductive technologies (ARTs) and prenatal testing, a controversial topic that varies by culture, which must be taken into account given the heterogeneous population of Sasquatch. First, let’s take into account the faith and tradition of the Irish Catholic population. According to the Congregation for the Doctrine of Faith’s Donum Vitae and Dignitas Personae, we know that in vitro fertilization (IVF) and prenatal testing which would lead to termination of the fetus are not permissible. We must also recognize that this is the religious view of the Catholic Church, the majority religion of the Sasquatchian community and the religion of the hospital’s donors. Therefore, the power of this situation likely falls into the hands of the Catholics, akin to the axiom “money talks.”
It would be important to know how fundamentalist this Irish population is—the advocacy and maintenance of their religion may be an importantly held value to them, which would highly influence their interactions with the rest of the town. In the United States, the availability of choice is very important. Few things are mandatory and few things are banned, many fall in between and are available if one would like, which can be seen in the American controversy of autism-causing immunizations whereby parents sometimes forego vaccines only later to be hit by a crippling (and preventable) disease. What keeps this process continuing is the American adherence to ‘choice’ and ‘rights.’
I would like to define a tenet of American culture that I have observed, ‘refusable availability.’ One often retains the right of choice and is infrequently obligated to anything. For example, a parent can choose not to vaccinate their child. Conversely, the thought of a political obligation for a woman to carry a child to term is being met with mainstream animosity (Rothman 1991). In-line with this thinking, medical services in general ought to be available but refusable.
To support this claim, I’d like to provide a few more analogies to substantiate the notion of ‘refusable availability,’ but first I’d like to highlight its weakness. It is not absolute, and both federal and state governments occasionally extend their reach past the bounds of ‘refusable availability.’ This is a natural process, as any governing body alters its own capacity of control and is met with either complicity or opposition. During a tuberculosis outbreak, denizens are mandated to be tested and re-tested through state laws, whether or not one wants to. Additionally, the US military conscription has proven not to comply as readily with religious exemptions as most other parts of the American government. Many Black Muslims of The Nation of Islam were jailed for objecting to the draft of World War II, as well as 6,000 other conscientious objectors being imprisoned (Chambers 1987). These exceptions seem to occur only when there is a tremendous desideratum, such as public health or war.
Two US Supreme Court cases that strongly elucidate the theory of American ‘refusable availability’ are Burwell v. Hobby Lobby and Gonzales v. O Centro Espirita Beneficente Uniao do Vegetal. In Burwell v. Hobby Lobby, Hobby Lobby escaped an Obamacare-era mandate to provide connectives to employees because of a religious exemption. In perhaps a converse situation, a New Mexican branch of the Brazilian church União de Vegetal was allowed to import and consume a Schedule I drug as a part of a sacramental ritual, since some Native Americans were already authorized to use peyote, another Schedule I drug, under the doctrine of religious equality. This latter case highlights evidence for the presence of ‘refusable availability’ in a negative sense. 
 A fourth and final presumption is that people who shy away from a particular technology will not be bothered by another group taking advantage of that technological service, unless the group in question is paying for it. This is a large condition, and assumes that there is no in-fighting between minority groups because of what is available, but leaves room for donors of a particular religion (in this case, Irish Catholics) to be choosy when providing certain services that do not adhere to their own religious beliefs. This is perhaps the weakest of my presumptions, and assumes that a Catholic would be content in his complicity to abortion and would continue to donate to the hospital. It assumes a particular American-ness and respect for one’s neighbor that is likely too naïve (Ball 2000).
I would now like to address the likely wants and needs of the minority populations. In some Jewish cultures, ART’s and prenatal testing are largely accepted, with little issue in early fetus termination (Kahn 2000). In terms of the Shia populations, there are religious ways to circumvent the religious red tape associated with reproductive technologies (whose legality in the United States I am not sure of), so the presence of further testing or assistance probably would not bother a Shia in the next room (Clarke 2007). 
 Because the hospital has chosen to become non-denominational, it should no longer refuse services on the basis of religion or to appease religious donors. Based on the tenet that I have alluded to of ‘refusable availability’, hospital ought to provide uniform assistance to the under-insured. It could incorporate religious restriction if it were explicitly a religious institution, but by becoming non-denominational, it has foregone that privilege. If pre-natal exams, IVF, and ART, are being provided at the hospital, it should follow the guidelines for the under-insured that other medical services observe. As the only hospital that services a large area, it carries an analogously large responsibility to serve a diverse community that has no alternative options. The Emergency Medical and Treatment Labor Act (EMTLA) of 1986 guarantees uninsured patients care in both private and public hospitals. However, private hospitals may turn away patients in a non-emergency situation. This means that in the case of a pregnancy that threatens the life of the mother, the hospital should provide an abortion, even in the case of being uninsured.
It is also the hospital’s choice to provide particular services, which then affect different classes or ratings of the hospital (such as being a Level 1, 2, or 3 trauma center depending on trauma-related resources). It is not the place of the ethics committee to tell the hospital which services to provide, but it is my belief that the assistance that the under-insured enjoy should be matched in religiously controversial medical policies. If the line between offering a service is between agreed and disagreed upon practices based on religion, the dispute is protected by the first amendment to the US Constitution. If the line between offering a service is based on ability to pay, both the hospital and the doctor in question could be liable under EMTLA. It is for this reason that I believe the question of being insured should not carry much weight in this conversation. 
 As for hospital employees encouraging families to allow unused embryos to be donated for research, I do not believe there is as much ground to defend such a request. Additionally, the same reasoning can be applied to limiting counseling by the Catholic clergy. There is little precedent to claim clergies from any particular religion should be throttled, as I would not support the same of any other religion. This interpretation upholds the federal First Amendment, which has recently been used to overturn Trump’s travel ban. This recent judicial precedent suggests that the First Amendment not only protects expression of religion, but denies legal judgement or restriction on the basis of religion.
 Concerning the finances of the hospital and the potential unwillingness of historically Catholic nursing staff to perform abortions, there is no way I can support forcing nurses into performing abortions, but this can perhaps be ameliorated with a combination of switching nurses around departments to maximize abortion-capable nurses in the obstetric department, as well as financially incentivizing performing abortions. Additionally, whether or not any of the prior suggestions are taken up by the hospital’s board, serious investments into cultural competency should be made. In order to meet needs of a mixed community, staff ought to take a cultural competency course so that they can understand “the values, traditions, and faiths of the patient” (Bhattacharyya 2006).
As Dr. Zotovic commented in a prior iteration of this report, a limitation here is that it had no mention of counseling services. Naturally, counseling services should be provided if any sort of abortion is available at the hospital. The stance of abortion for an individual is not likely to change; however, the stance of whether others could is the contentious dialogue we experience today. Therefore, I do not feel its the place of the ethics reviewer to take stance, but rather to determine derivative and parallel issues.
The church has taken a shift to being non-denominational within Christianity. Non-denominational does not suggest ‘secular,’ but it is likely to have similar attention to diverse needs than with which a purely sectarian branch may be concerned. Rather, it means that it is not under the institutional sway and consideration from one body of Christianity, and instead appeals to a more diverse set of backgrounds. In line with this, the hospital has a responsibility to the community as one of the only sources of healthcare in 90 minute radius, assuming use of personal transportation (Bhattacharyya 2006). It does not have an obligation to provide any service on-demand, but ought to consider the needs of the community. At the very least the hospital should provide uninsured patients identical emergency care to insured ones, on a purely legal basis. Since there is not alternative, its morality should not stand in the way of someone getting the treatment they would in any area. These are not mandates, but rather issues and responsibility to a low-access healthcare community to consider when negotiating the future of the institution.

Outside Bibliography
-Chambers, J.. To Raise an Army: The Draft Comes to Modern America. New York: Free Press, 1987.
-“Refusing to Provide Health Services.” Guttmacher Institute. Guttmacher Center for Population Research Innovation and Dissemination, 01 April 2017. Web.

Hospital Regulations of ARTs in Sasquatch, Connecticut

Background information:

I am a cardiothoracic surgeon that has worked in the Sasquatch Medical Center for 20 years. I was born and raised in a religious Catholic home and married a Catholic woman, but throughout our marriage we have become slightly more secular. I believe in Catholicism, but I am not sure how I feel about the rigidity of Catholic doctrine. Since the hospital administration knows that I am Catholic and are looking to retain their Catholic-based medical practice, they have decided to place me on the ethics committee that considers issues involving assisted reproductive technologies and prenatal testing. I am conflicted whether to provide my true opinion or my expected, devoutly Catholic opinion in these ethical discussions.

1. The first question our ethical committee is tasked to answer is whether or not the hospital should begin providing and subsidizing abortion services for patients. This question also extends to the use of in vitro fertilization (IVF) treatments and prenatal testing, including amniocentesis. My initial thoughts reflect the Catholic perspective, which is firm and precise. According to The Congregation for the Doctrine of Faith, it is explicitly clear that abortion is forbidden in all “No one can in any circumstance claim for himself the right to destroy directly an innocent human being” (Donum Vitae 147). This statement suggests that abortion is forbidden for everyone, Catholics and non-Catholics alike. Hadley Arkes furthers this argument from a non-religious standpoint. “Arguments which have been regarded as quite plausible by large sections of our public may be exposed as either vacuous or embarrassing one they are framed explicitly as justifications for the taking of human life” (Arkes, 1986: 363). Arkes believes that from a fundamental standpoint of humanity, nobody has the right to deprive others of life without justification. The definition of “justification” is discussed at length and, in the end, Arkes arrives at the conclusion that in order to constitute justification, we must appeal to the law of society. In Catholicism, at the moment of conception, the mass of cells is considered a human being with the right to live. According to Arkes, we have no justification for “killing” the embryo via abortion.

Although I have been an active member with the local Catholic church for my entire life, after serving as a healthcare provider for 20 years, I have seen numerous cases in which I question this law. I do not by any means believe that abortion is acceptable in all cases. I believe abortion to be an atrocity in many situations, but in some cases, it may be an acceptable course of action. For example, many years ago when I was in residency, I saw a patient who had been impregnated after being the victim of rape. Should this woman now be forced to have the child? After carefully balancing my roles of living a Catholic life and serving my community as a medical doctor, I decided she should have the right to an abortion.

Rape victims and women in similar unfortunate circumstances should have the right to an abortion because they had no say in whether or not they get pregnant. A baby that is the product of rape may not be loved or cared for. This could mean sentencing an innocent baby to a life of misery and depression. Having a child is a very large commitment and an endeavor with everlasting responsibility. A woman who is raped never asked for this responsibility and cannot be expected to take on this burden if she does not wish to. As a righteous Catholic, I have had to swallow my qualms in this situation because I believe the medical and social factors for aborting the pregnancy outweigh the religious factors. As a physician, it is my ethical duty to provide the best treatment options to patients in order to help them live the healthiest, most fulfilling lives possible. In Faye Ginsburg’s work, Contested Lives, Ginsburg presents an applicable argument from a pro-life advocate, “I really believe that you evolve from a point of trying to control someone else’s life into a point that you realize circumstances are so different for everyone that you can’t possibly say there’s no divorce, there’s no abortion. I mean nothing is absolute” (Ginsburg, 1989: 163). Ginsburg seems to hint that we must appraise each situation independently and consider factors involved on a case-by-case basis.

In terms of using IVF treatments in this hospital, I am firmly against the idea. Conventionally, when using in-vitro fertilization, many embryos are created and only a few are selected to be implanted into the mother’s uterus. The leftover embryos are “disposed of”. From a Catholic perspective, this treatment is extremely problematic. “According to the Church, ‘each and every marriage act must remain open to the transmission of life.’ It is inappropriate, even a sin, to separate intercourse and conception” (Bhattacharyya, 2006: 61). The Church objects to the use of IVF for multiple reasons. One reason is because IVF separates the act of intercourse from conception, which violates the overarching purpose of marriage. Additionally, IVF is forbidden by the Catholic church because the leftover embryos after treatment are living beings. “The human being is to be respected and treated as a person from the moment of conception and therefore from that same moment his rights as a person must be recognized, among which in the first place is the inviolable right of every innocent human being to life” (Donum Vitae, 149). Moreover, the means used to acquire the materials necessary for IVF are scrutinized by the Catholic church. “Sperm donation is prohibited because sperm is usually obtained through masturbation and thus apart from the sexual intercourse of the married couple. IVF also separates the act of sexual intercourse from fertilization; consequently, it too is prohibited” (Bhattacharyya, 2006: 61). Furthermore, if IVF were to be offered at the hospital, using the leftover embryos for research is strictly forbidden. “To use human embryos or fetuses as the object or instrument of experimentation constitutes a crime against their dignity as human beings having a right to the same respect that is due to the child already born and to every human person” (Donum Vitae, 153). My opinion on IVF is in accordance with the Catholic Church’s assertions. While I sympathize with those of other faiths, for these multitude of reasons, I believe that the hospital in Sasquatch should not provide IVF treatments for any patients.

When considering whether to offer prenatal diagnoses (PNDs) that includes amniocentesis, there are various factors to consider. The places in which PNDs and amniocentesis become unethical are in their underlying purpose of the tests, in the additional risk of miscarriage, and in the risk of negative symptoms affecting the mother following the procedure/testing. A patient would only undergo PNDs and amniocentesis for three reasons: prevention, preparation, and reassurance. Prevention is to acquire information about the fetus’s health, and if there is something wrong with the fetus, have the opportunity to abort the pregnancy. The second reason, preparation, is to have the opportunity to prepare in advance if you know there is something wrong with your fetus. This provides the opportunity for parents to prepare themselves for possible supplemental needs that their child may require. The third reason is to ease the parent’s anxiety by knowing that there is nothing wrong with your fetus (Movie: The Burden of Knowledge). There are questions about whether the outcome of the test could influence mothers to abort their pregnancy. Test results allow us to make judgements based on probabilities, not certainties, and may encourage mothers to abort. “Man is wrestling for control with G-d…morally and spiritually…That is G-d’s territory” (Movie: The Burden of Knowledge). Ethically, as a Catholic, I cannot endorse PNDs or amniocentesis because of the risk that mothers may end up aborting their pregnancy upon hearing of bad test results.

[Prenatal Diagnosis] is gravely opposed to the moral law when it is done with the thought of possibly inducing an abortion depending upon the results…eliminating fetuses which are affected by malformations or which are carriers of hereditary illness, is to be condemned as a violation of the unborn child’s right to life and as an abuse of the prior rights and duties of the spouses. (Donum Vitae, 150-151)

Accordingly, PNDs should be administered only after the parents have signed an agreement that they will not seek an abortion upon negative results of the testing. In Tsipy Ivry’s book entitled Embodying Culture, Ivry discusses the risks associated with amniocentesis: “Should suspicion arise about fetal health [in Israel], women will…undergo amniocentesis, with its 1/200 risk of miscarriage” (Ivry, 2010: 39). Even if both parents agree not to seek an abortion upon negative amniocentesis results, amniocentesis is not an ethically acceptable option because incurring any additional risk of miscarriage is wholly unacceptable. After considering the purpose of prenatal testing, given that abortion is not an option, there is nothing tested for that we can do anything about; in this case, abortion is certainly out of the question. The only potential benefit of prenatal testing/amniocentesis is preparation.

2. As previously stated in Part 1, the Catholic Doctrine of Faith applies to everyone, not just Catholics. Since I am a Catholic, I believe that the hospital should retain its counseling by Catholic clergy even though the hospital is now technically non-denominational. I have become slightly more moderate in terms of my religious observances throughout my years of practice, and I entertain the idea of having clergy of other religions in the hospital to guide patients of alternate faiths. Just a few decades ago in Sasquatch, Connecticut, this would not have been considered because such a large majority of the population were Irish Catholics. Today, since a diverse array of religious communities have moved into the area, including communities of Jews, a mix of white and African-American non-Irish Catholics, Lebanese Shiite Muslims, and a Japanese community, we must consider their perspectives and be tolerant of their beliefs as well. I believe that the hospital should only provide medical services that are acceptable according to Catholic law (except in aborting pregnancies resulting from cases of rape and incest), while also allowing clergy of other faiths to advise patients who desire counsel. This gives clergy the opportunity to provide counsel to patients of all faiths, but treatment options should consist strictly of Catholic-approved treatments. This principle of cultural competency—defined as, “the need to be understanding as well as sensitive to the different cultures, socioeconomic backgrounds, and belief systems of their patients” (Bhattacharyya, 2006: 5)—allows patients to receive optimal care because clergy of various faiths will have the opportunity to consult with doctors about “various cultural and religious influences, [so that] a healthcare provider can be sensitive to the particular needs of a patient” (Bhattacharyya, 2006: 22). This is crucial because the purpose of a hospital is to take the best possible care of their patients, and this would increase the quality of care.
3. As discussed in Part 1, abortion and reproductive services are not acceptable according to Catholicism. The hospital is a private institution and can provide whichever services they wish. Because I was born and raised in a Catholic home and live a Catholic life, I believe these procedures to be ethically questionable.

I have become slightly more secular as my career has progressed, and although I do not condone abortion and reproductive services under conventional circumstances, I believe they should be provided at the hospital exclusively under extenuating circumstances. As previously discussed in Part 1, there are justifying circumstances in which I believe abortion to be an acceptable course of action (rape cases, etc.).

Hypothetically if the hospital were to offer abortion and reproductive services, what is the best way to deal with nursing staff who refuse to perform these controversial procedures? Since the population in Sasquatch is no longer predominantly Irish-Catholic, the hospital should hire nurses whose religious and ethical beliefs allow them to perform these procedures. Nurses who feel uncomfortable performing abortion and reproductive services should not be forced to do so. Seeing as many of the Irish-Catholic nurses on staff would view these procedures as murder, the hospital cannot force them commit “murder.” The hospital should offer to transfer any nurse who feels uncomfortable with performing abortion and other reproductive services to a new department.  There will certainly be some nurses who refuse to work for an institution that performs abortion and reproductive services. The hospital should replace the nurses who quit with non-Irish Catholic nurses and assign the new hires to the reproductive-services and infertility department. The hospital may not have a large budget to hire additional staff, but I suspect that by simply replacing the nurses that quit, the hospital will be able to stay within their budget. If a few nurses leave, the hospital can utilize the small budget for replacements.

After thorough review of my original proposal by the ethics committee, I have received some feedback from fellow committee members. Dr. Nestor responded with criticism regarding my policy of having clergy of various faiths consult with patients. Dr. Nestor suggested that if Sasquatch Medical Center allowed clergy of multiple faiths to consult with patients, the clergy would advise their patients to request procedures not permitted by Catholicism, and thus not provided by the hospital. My solution is to require every clergy member that consults patients in our hospital to undergo a thorough training course in basic Catholic doctrine to learn why certain procedures are or are not offered in our hospital. Thus, every clergy member will be aware of patients’ available treatment options when advising patients. Dr. Nestor also discussed her views on the use of IVF. My belief, as previously stated, is that IVF should not be permitted in Sasquatch Medical Center because embryos will be created, but not used. Catholicism views the destruction of these embryos as equivalent to murder. As a practicing Catholic, I believe that we cannot allow IVF procedures to be provided in our hospital.

I would also like to address Dr. Gabanic’s response to my initial proposal. Dr. Gabanic takes a unique position, arguing that the hospital should provide abortions on the rationale that if our hospital does not provide women seeking abortions the desired service, they will search elsewhere for a place that will provide the service. I find this argument very intriguing, but I fundamentally disagree with Dr. Gabanic based on principle. I believe that as a long-standing Irish-Catholic hospital, Sasquatch Medical Center has a duty to represent a set of morals in-line with the Catholic doctrine. After all, both Dr. Gabanic and I are Catholic, and the Catholic doctrine applies to all individuals. If women choose to travel to a different medical center when seeking an abortion, that is their prerogative. We at Sasquatch cannot tell others what to do, but as a private institution, we have the right to decide which procedures we will perform.

Dr. Gabanic goes on to discuss the possibility of performing IVF in Sasquatch Medical Center, arguing that,

IVF is licit if and only if the treatments do not take away from the conjugal act and no embryos are harmed. This can be achieved by using a perforated condom, so that the act of marriage is still open to life, while still being able to collect sperm. Singular embryos can be made as to not harm any embryos, therefore creating a licit way to IVF treatment.

I have a few issues with Dr. Gabanic’s stance on this topic. While technically this does not directly violate Huminae Vitae, which discusses how acts of marriage must include the possibility of creating life, I would argue that this method of sperm collection is not in the spirit of the law. The law indicates that conception should not be separated from intercourse. In this scenario, the intended purpose of the law is to create children only directly through a martial act. Wearing a perforated condom during intercourse to collect a semen sample not only indicates a clear intention outside of the marital act, but also certainly reduces the chances of conception from the marital act. Furthermore, technology is not perfect. By creating one embryo at a time through IVF, we introduce a chance that more than one embryo is created, which places us in a tough spot when deciding what to do with the extra embryo. With the use of IVF, we are relying on a medical technician to initiate the process of conception and then implant the embryo into the mother’s uterus. This introduces more room for error to occur that could waste reproductive materials. Additionally, the practice of creating one embryo at a time with IVF is extremely expensive and not a practical financial expense.

 

I want to thank the entire ethics committee at Sasquatch Medical Center for reviewing my proposal, and I hope that we can act on this issue in the near future.

 

Sincerely,

Jonah Adler, M.D.

I am on the hospital ethics committee as the head of the nursing staff and as a nurse practitioner. I am from an Irish catholic background as are the majority of the other nurses. I have worked at this hospital for 30 years and was reluctant to see it go through the transition of becoming non-denominational. I speak for the majority of the nurses at the hospital who have expressed to me similar complaints as myself. We are aware of the controversies that have surrounded Catholic hospitals and their refusal to provide abortions. Legal challenges brought against some hospitals have not necessarily brought clarity on this extremely complex and delicate legal issue. We have followed these cases very closely (see: http://www.washingtontimes.com/news/2016/apr/11/court-nixes-suit-force-catholic-hospitals-abortion/ and https://www.aclu.org/cases/tamesha-means-v-united-states-conference-catholic-bishops). While we are no longer a Catholic hospital, the Catholic values that have been serving our community for all these years should be respected as these values are set apart to assist and preserve human dignity and human life. It is important that the standard of charity and of respect for all persons be maintained for our patients, regardless of their age, racial, religious, socioeconomic status or background.

1.

Our private hospital should continue in its longstanding tradition of not providing abortion services to our patients. Not only do our donors come from Catholic backgrounds and we would risk our funding in order to provide these services, but most importantly abortion services are immoral and do not respect the dignity of the individual. Medicine works to protect the good of human life, and healthcare staff work to assist a patient struck with illness, regardless of their insurance status (Donum Vitae 1987:145). It is important that we continue to exercise the Christian will of charity to address the needs of our poorest and most vulnerable patients by continuing to subsidize other forms of medical care. However, the most vulnerable in our society include the defenseless and those with no voice. It is therefore that as members of this community we must protect the unborn who only have us to speak up for them. It is important to note that these Catholic teachings are not only based in scriptures shared with our fellow Abrahamic religions but are also based in secular reasoning. For instance, while it is written in the book of Genesis that man was made in the image of God, rational arguments based in nature are also used by the Church to defend its positions, and those arguments can be used in any secular setting. Donum Vitae, the church’s doctrine on the respect for human life with regard to new technologies, states, “No biologist or doctor can reasonably claim, by virtue of his scientific competence, to be able to decide on people’s origin and destiny” (Donum Vitae 1987:145). It is outside of the moral bounds of any healthcare professional to be able to defend or justify their own ability to possess this deterministic value with regards to who will survive. It is our job and the job of this hospital to alleviate suffering of its patients and not to provide abortion services. While our hospital is somewhat remote from others, abortion services are not sought in emergency settings and therefore individuals who choose not to follow this mandate are able to find these services in other clinics in the state of Connecticut. The state of Connecticut follows the national precedent of Roe v. Wade and recognizes a human person after the beginning of the third trimester (although scientific advances are proving that premature babies are beginning to survive at even earlier gestation weeks than set out by the law). We argue that while the beginning of physical life at conception does not by any means “contain the whole of a person’s value nor does it represent the supreme good of man”, it does “constitute in a certain way the ‘fundamental’ value of life precisely because upon this physical life all the other values of the person are based and developed” (Donum Vitae 1987:146).

However, we are suggesting that our hospital will make exceptions in the cases where the mother’s life is at immediate risk and there is no other option but to proceed with the abortion as an indirect consequence of saving the mother’s life. Under such circumstances this action would be permissible as the life of the mother is equally as important as that of the fetus. Note that here I am suggesting an important change to the original position of our hospital as we are no longer nondenominational. Several lawsuits have been filed against Catholic hospitals due to the physicians and staff not treating women who were having dangerous miscarriages and needed to abort the child. The doctors in these cases interpreted the lesson in Donum Vitae to not treat any woman for any abortion, even when the woman was in extreme danger. However, the more recent (2009) Ethical and Religious Directives for Catholic Health Care services state: “Operations, treatments, and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child” (Ethical and Religious Directives for Catholic Health Care Services). This claim should be upheld as we are a remote hospital and it is our duty to treat women who are in extreme peril. Furthermore, as we shift to no longer being a non-denominational hospital it is important to support all of our patients who request other kinds of medical services, even those we could not ourselves support for the aforementioned reasons. This would permit our physicians and nurses to comply with the professional ethics guidelines from the American College of Obstetricians and Gynecologists which state “Providers with moral or religious objections should either practice in proximity to individuals who do not share their views or ensure that referral processes are in place” (ACOG). It is in this way that we can continue to serve and support all women who come to our hospital.

Similarly to the reasoning behind refusing abortion services, I continue to believe that the hospital should not allow for IVF treatments when such treatments result in the discarding of “extra” embryos. It is important to reflect on this position from both a rational and moral lens, examining the fundamental values of life and whether or not it is permissible for technological interventions to replace human procreation and to affect a human in the first stages of development (Donum Vitae 1987: 146). In fact this teaching has been backed by science in the sense that “modern genetic science brings valuable confirmation. It has demonstrated that, from the first instant, the program is fixed as to what this living being will be: a man, this individual man with his characteristic aspects already well determined. Right from fertilization is begun the adventure of a human life” (Donum Vitae 1987:148). IVF treatment disrupts the development of a new life, and therefore changes the natural course of events in human’s biology. The human life is an incredible gift, and with the arrival of technologies the importance of this can be diminished. In order to protect human life and uphold it’s dignity, the disruption of biological processes for the gain of others should not be permissible.

Technology is so advanced that today individuals can choose embryos based on lack of disability, or even gender. This type of selectivity puts the physician and the parents as usurpers of the place of God, as they will be “the master of the destiny of others inasmuch as [they] arbitrarily chooses whom [they] will allow to live and whom [they] will send to death and kills defenseless human beings” (Donum Vitae 1987:154). To prevent IVF is to safeguard against what could approach becoming a new type of eugenics, pitting parents against children of disability or children of a certain sex. We as a hospital ethics board must continue to prevent these future immoral acts. We acknowledge that such position may conflict with the goal of serving a broader population. It may even have negative financial consequences for our hospital as some patients or insurance companies may decide not to make use of our services. However, this is an area where we believe we are not in conflict with the goal of providing necessary care to the ill and the vulnerable. Our Catholic tradition can still guide us in making what we believe are fundamental, life-respecting choices. The fact that IVF is not morally permissible still rests on the fact that “extra”, disposable embryos are being created and are therefore destroyed or used for testing, and are not being treated with the dignity of human life. This rests as the greatest moral harm done by IVF treatment. Secondly, IVF does not maintain the naturalness of human life and of human reproduction. Thirdly, IVF technologies have advanced so far in that parents and doctors are able to “choose” their child based on characteristics they personally prefer, which can be seen as allowing for a type of eugenics.

Furthermore, I maintain that IVF testing is a procedure that should not be allowed in our hospital because of additional ethical considerations based more on social justice than on religious beliefs. In one sense, allowing for any form of IVF will have socioeconomic limitations over which sort of patients may benefit from these procedures. As couples throughout the world and across all socioeconomic statuses can – or cannot — be blessed with the gift of a child, it is unfair for us to provide a treatment that, because of its costs and potential lack of insurance coverage, will allow only wealthy couples to benefit from the gift of a new life via artificial technologies. Additionally, allowing for IVF invites an incredible amount of complications for our ethics committee to handle. Would only heterologous, same-sex, married couples be allowed to have this procedure? Would we allow for donations or surrogates to be impregnated in our hospital? These issues are handled in a wide, complex array of levels from different religions and cultures. And while we may upset some people in our community by not being “convenient” for them to be able to receive IVF, we would be treating each individual in the same manner regardless of their background.

Finally, prenatal diagnosis is acceptable under the moral lens of the church, and I believe that we should continue to assist expecting mothers in all ways possible including prenatal testing. Prenatal testing can assure mothers that they are expecting a healthy baby, or it can make it possible for mothers to plan for accommodating disability or future medical procedures to be carried out on the child (Donum Vitae 1987:150). However, amniocentesis may only be performed if it is believed to “safeguard the life and integrity of the embryo and the mother, without subjecting them to disproportionate risks” (Donum Vitae 1987:150). Amniocentesis is becoming an increasingly safe practice with a trained professional so we believe the evaluation of the risks should be performed and explained to the mother on a case-by-case basis. While I believe that on a hospital-level prenatal diagnosis must continue to be performed, it is important to note that we as medical professionals should not “induce expectant mothers to submit to prenatal diagnosis planned for the purpose of eliminating fetuses which are affected by malformations or which are carriers of hereditary illness, is to be condemned as a violation of the unborn child’s right to life” (Donum Vitae 1987:150). The purpose behind prenatal diagnosis should not be to result in abortion but rather to provide reassurance or assistance to expecting mothers. It is important that as medical professionals we inform mothers of the nature of the testing or at the minimum remain value neutral in order not act in favor of terminating life based on whatever characteristics are considered “better”.

2.

The community based around this hospital is increasingly diverse, and I believe that we as a hospital system should grow in our spiritual counseling to reflect that diversity. The Church holds the utmost respect for other religions and I believe that we should diversify our counseling group to reflect this. In less centralized religions such as Islam or Judaism, the advice of different counselors is especially important to families, as there is less of a unified mandate compared to that of the Catholic Church. The values placed on new families may also be different. For instance, instead of focusing on natural law and the human person, Islam bases much of its reproductive ethics on the legitimacy of kinship relation (Clarke 2007: 82). These different methods of guidance should be available to our patients, and all our patients should be informed of resources that are currently not provided by our hospital on a case-by-case basis.

While many of these religions are more permissive and flexible with regards to ARTs, abortion and prenatal testing, this does not require us as a hospital to provide these different services. Respecting diversity does not imply that we should provide different services to hospital patients based on their religious tradition. On one hand, belief systems of patients may play a large role in why patients choose to undertake procedures that are considered morally impermissible and against natural law (Rapp 2000: 53). However, it is not the role of the hospital to interpret the moral dilemmas posed by each religion or to assess the sincerity of each person’s professed faith. At the same time, healthcare delivery in the United States is centered on choice and free will and these patients may go elsewhere to take part in these services (of course, emergency procedures are an exception to this ruling). It would be more morally impermissible for us as a hospital to create exceptions, allowing for certain religious groups to obtain these procedures and going against our traditional hospital mandate, than for us to make a blanket statement that provides equivalent and morally justified services to all of our patients. It is in this way that we are able to treat our patients equally, regardless of their background.

With regard to the claim that Catholic priests are interfering with the doctors’ work, it is important to understand that families absolutely always have the right to accept or refuse testing or ARTs, or any treatment in general. The doctors in this hospital should not be recommending that women undergo treatment that puts the fetus at unnecessary risk and should not allow for IVF treatment due to the destruction of fertilized embryos. If doctors are unwilling to subscribe this recommendation of the Catholic Church, they should at the minimum remain value neutral and refer the patient elsewhere if it is their expressed desire to undertake these morally illicit procedures. While the hospital is no longer Catholic in its administration, it is important that values that were protected by the Catholic Church such as respect for human life be maintained.

3.

Clearly as the head of the nursing staff and a nurse practitioner I believe that new nurses should absolutely not be screened and hired based on their willingness or unwillingness to assist in abortion and IVF procedures. It is in the right of a nurse or doctor to refuse partaking in these services as they do not want to be a part of a morally illicit activity that results in the death of human persons. It is morally impermissible for a hospital institution to force an individual to act against their religious beliefs with the threat of being fired. This would violate hospital policy as well as state and federal law (Title VII if the Civil Rights Act of 1964). If these services are not provided to our patients, this would no longer be an issue for the nurses at this hospital. Refusing to allow for abortion services is also important to our donor base that allows for us to run a hospital that saves the lives of individuals in this relatively remote area, an objective we as a board should prioritize above all else.

Citations:

Committee on Ethics. “The Limits of Conscientious Refusal in Reproductive Medicine.” The American Congress of Obstetricians and Gynecologists. N.p., 2016. Web. <http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Ethics/The-Limits-of-Conscientious-Refusal-in-Reproductive-Medicine>.

“Ethical and Religious Directives for Catholic Health Care Services Ethical and Religious Directives for Catholic Health Care Services.” United States Conference of Catholic Bishops. N.p., 2009. Web. <http://www.usccb.org/issues-and-action/human-life-and-dignity/health-care/upload/Ethical-Religious-Directives-Catholic-Health-Care-Services-fifth-edition-2009.pdf>.

“Religious Discrimination.” U.S. Equal Employment Opportunity Commission. N.p., n.d. Web. <https://www.eeoc.gov/laws/types/religion.cfm>.

 

Sasquatch Community Hospital

Sasquatch, Connecticut

 

May 2, 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 has been discussing throughout the past few months.

I understand 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.

After the submission of my initial policy proposal, I received multiple questions and comments regarding the stance that I took on some of the ART’s in question. While I appreciated all of the feedback I received, there were some comments that I agreed with and some that I did not agree with. With the advice that I received, I have altered my initial policy proposal with a clarification of my stance, which overall stayed the same.

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. I say this from both a medical professional and a follower of the Hindu faith. As Swasti Bhattacharrya details in her book, Magical Progeny, Modern Technology, there is a story within the Mahabharata, one of the Hindu epics, that can be interpreted to question whether abortion is a viable option. Gandhari’s actions during her prolonged pregnancy was to remove “the iron ball of clotted blood” (Page 46). While Bhattacharyya is explicit in stating that Gandhari’s actions were to result in the birth of her child, this story can be interpreted that there are certain circumstances where abortion may be an option, for example when the mother’s life is in danger. Father Donnigan questioned how I, as a Hindu, could accept the possibility of offering abortion services when Mahatma Gandhi fought with a nonviolent perspective. While Gandhi was, and still is, a figure of strength in India and Hinduism, I don’t believe that my policy should change due to the nonviolence that he preached. Additionally, I wholeheartedly believe that offering these services is nonviolent, in that it will result in a greater good for the patient. This is similar to how I do not think that my stance goes against the Hippocratic Oath that I took when I completed my education to become a doctor. The procedures that are in question are not illegal in the United States of America, and thus allows physicians and medical professionals to perform these procedures while still keeping to the Hippocratic Oath.

Due to the expensive nature of these services and the size of your hospital, I understand that it would be impossible to subsidize abortion services for every under-insured patient wanting 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 referenced 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. Dr. Tangutoori questioned that since the Hyde Amendment would allow these patients to receive the procedure elsewhere, why should SCH need to provide the services? To respond, I would like to remind the hospital board that your hospital is the only one within a 45-minute drive in all directions. In extreme, life-threatening situations, this is too much time to take a patient to another hospital that provides the procedure. Because the provision is allowing the federal government to subsidize abortion services under the same conditions that I am proposing to you, I believe that little funding from your hospital will be necessary to provide the procedure. More important than funding the procedure, in my opinion, is the need for there to be a medical staff within your hospital able to perform the procedure when necessary. I will discuss the staffing dilemma you face after clarifying my stance on the other ART’s in question.

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 outside funding for these services, I do not believe that IVF should be subsidized, as it does not seem like an economically stable decision for the hospital to take. 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. Concerns for my stance on IVF is the community that this hospital serves. I understand that the Catholic hospital background and the conservative population in Sasquatch, CT may not be as understanding to my views of accepting the ART’s that are now available. However, like I stress throughout my proposal, I am not stating that these procedures should be offered freely to everyone or should be forced onto someone due to their situation, but rather that they should be available in the event that someone within your community finds the need to use them.

As a member of the healthcare industry with a 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. While my medical and research background would suggest that the donation of unused embryos is more beneficial than not, it is not my decision, or any other individual’s, to persuade someone to do what they do not personally believe in. To my peers who, once again, questioned the acceptance of the community for my stance, I would continue to say that my medical background is what guides me to make this policy recommendation. While any stance will have an opposition, I believe that the stance that I have chosen to take allows the community to choose whether or not to use the services that are available. In no way am I suggesting that the community should be forced to use an ART if they do not wish to use it. Similar to how my views are not above those of the community or other hospital members, their views are not above mine, and I believe that my stance allows the community the freedom to choose for themselves without imposing their beliefs on others.

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 the “prevention, protection, and reassurance” of 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 a prevalent knowledge of pregnancy in Israel called “geneticism,” in which the mother is responsible for undergoing 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. Similar to my earlier statements, this should be a procedure offered by your hospital, but not one imposed on members of your community.

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 the Catholic clergy are 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 patients more than it will impact the lives of the healthcare providers. I do, however, agree with Dr. Tangutoori that this may create a barrier between medical professionals and religious clergy and that there should be a certain limit to which the clergy can impose their views on the patients. As a medical professional myself, I believe the overall health of my patients is the most important factor to consider, and with that guaranteed, discussions regarding values and religion can take place. Catering to the values, traditions, and faiths of individual patients are equitable to the conversation that Swasti Bhattacharyya describes as “cultural competency” in her book Magical Progeny, Modern Technology and with what I have seen practicing medicine, this is an extremely necessary pillar of support for patients undergoing a medical decision (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. If there are not enough members to assemble a team, I recommend using the funding you have to hire other professionals who are able to perform the services you are offering. Dr. Nestor has questioned this method of developing medical teams to perform ART’s and I understand where she is coming from in saying that, as a medical professional, staff should not bring their personal views into their professional duties. In an ideal world, I would agree that regardless of their personal views, a medical professional should perform the procedures that fall under their area of specialty. With such a strong Catholic staff, I don’t believe that the hospital would benefit from forcing the staff to perform procedures that they are completely against. I fear that this force would result in resignations of staff who cannot fathom the procedures that SCH offers, leaving the hospital unable to perform other medical treatment to benefit your community. With your limited funding in mind, I would recommend against this.

Thank you for taking the time to reevaluate my policies regarding the artificial reproductive technologies you are discussing. I hope that my alternative viewpoint is helpful in finding a balance between the medical professionals at your hospital and the community you serve. If you have any additional questions or comments, please let me know and I will clarify my stance further.

 

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