Final Assignment (Part 1) By Jonah Adler

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.