Sai Greeshma Magam – Religion and Healing 2017

Sai Greeshma Magam – Final Assignment (Part 1)

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

Sai Greeshma Magam – Midterm Assignment (Part 1)

Sasquatch Community Hospital

Sasquatch, Connecticut

March 21, 2017

Dear Ethics Committee,

It is my understanding that your hospital currently subsidizes medical care for under-insured patients, a practice that must be very beneficial to the low-income members of your community. However, with the rise of artificial reproductive technologies and the expensive cost of these amenities, I understand where your dilemma comes from.

Although abortion services are still a highly debated topic in the healthcare industry, there are certain circumstances in which I believe that offering these services are necessary. Due to the expensive nature of these services and the size of your hospital, it would be impossible to subsidize abortion services to every under-insured patient considering the procedure. However, I do believe that the subsidization of abortions at your hospital should be offered to under-insured women on a case-by-case basis. In order to form a guideline for what circumstances permit the subsidization of abortion services, I looked to the stance that the US government currently takes with federal funding. The Hyde Amendment prohibits the use of taxpayer funding to cover the costs of abortion services in Medicaid patients (ACLJ). However, a provision during the Obama Administration made it flexible, so that abortion services be provided to Medicaid patients in the case of rape, incest, or threat of life to the woman (ACLJ). While this amendment is also under debate, I believe this is a good guideline to follow for the subsidization of abortion services at your rural, privately-owned hospital.

As a member of the healthcare industry with research background, I do believe that there should be a provision where the hospital should encourage families to allow unused embryos to be donated for potentially life-saving research for families undergoing the IVF treatments. While this decision is entirely up to the parents, I believe that educating them about the progress being done in this field, and the benefits of this research, is essential for parents to make an informed decision regarding their unused embryos. In my opinion, donating unused embryos to science is a great idea, especially since those embryos will die on their own given time. Recent research has shown that there is a potential in embryonic stem cells that isn’t available in adult stem cells and using this method to further research can help in “gene therapy for genetic disorders, and the generation of replacement tissues and organs for transplant” (APH). While encouragement from the hospital is acceptable, under no circumstance should the hospital try to pressure parents to change their decision regarding donating their unused embryos for research purposes.

Prenatal testing and amniocentesis are rights that I believe should be offered to all expecting parents, regardless of their ability to afford the costs. It should be a parent’s decision whether or not they would like to use prenatal testing or amniocentesis during their pregnancy, but I believe that they should be available to everyone across the board. Prenatal testing, or blood serum testing, is not a diagnostic tool; however, is necessary for “prevention, protection, and reassurance” for family members and can detect for neural tube defects, such as spina bifida, down’s syndrome, and anencephaly (The Burden of Knowledge, 1994). Unlike the blood serum test that is common in prenatal testing, there is more concern with amniocentesis, as there is a 0.05% chance of miscarriage after undergoing the procedure (The Burden of Knowledge, 1994). Whether or not to use the amenities provided by the hospital is a decision left to the parents, but in the end, I still think that access to these types of tests is necessary, for those who choose to use them. Even if the subsequent procedures are not available, it is my belief that the knowledge is always beneficial in preparing the parents about what to expect in raising a child with disabilities. In addition, there is a significant Jewish population within the community your hospital serves. As Tsipy Ivry describes in her ethnography, Embodying Culture, there is an authoritative knowledge of pregnancy in Israel called “geneticism,” in which the mother is responsible for undergo diagnostic testing in order to ensure the health of her child. In order to be inclusive of the views of your patient population, there should be access to testing within your hospital, and the decision to use these services should be left up to the parents and family members involved.

Thank you for taking the time to consider my position regarding these topics. I hope that I was able to provide an alternate perspective to your discussion of artificial reproductive technology.

Sincerely,

Greeshma Magam, M.D.

Sources

https://aclj.org/pro-life/four-things-you-need-to-know-about-the-hyde-amendment-federally-funded-abortion

http://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/Publications_Archive/CIB/cib0203/03cib05#Evaluating

Unit 7 – Inventing Bioethics – Greeshma Magam

This week, we read the book Magical Progeny, Modern Technology by Swasti Bhattacharyya and the article Impossible Gifts: Bodies, Buddhism, and Bioethics in Contemporary Sri Lanka by Bob Simpson. Both readings utilized religious texts to explain the relevancy of ARTs as they were first written and how they can be interpreted in the modern culture.

Bhattacharyya’s book was written for the purpose of “enriching the ongoing bioethical dialogue concerning artificial reproductive technology” and to “increase the religious awareness of the sensitivity of the healthcare delivery team” (Page 2). In order to achieve this goal, Bhattacharyya used an “interdisciplinary and organic” methodology – Interdisciplinary by incorporating South Asian studies, literature, religion, bioethics and nursing and organic by constructing these disciplines around the ethics preserved in the Hindu epic, the Mahabharata (Page 2-3).

Bhattacharyya begins her book by discussing the function of religion in medicine and bioethics. She explains that, across many cultures, there is (or used to be) an overlap between religious leaders and healers (Page 8). She uses the example of a mother, pregnant via gamete intra-fallopian transfer (GIFT) to explain that individuals can use reproductive technologies, but still attribute the resulting pregnancy to God’s graces (Page 15). Using additional patient examples, Bhattacharyya discusses the importance of “cultural competency” and its significance in bettering patient-provider communication and increasing the compliance amongst patients (Page 23). Cultural competency, from the perspective of a healthcare provider, is “the ability to provide care that is compatible with the values, traditions, and faiths of the patient” (Page 21). Similar to Bhattacharyya’s stance on the topic, I believe that cultural competency is an integral component of a successful healthcare provider.

Although the rest of this book focuses primarily on the Hindu faith, it is clear that cultural competency is not limited to a specific cultural or religious identity.

The next portion of Magical Progeny, Modern Technology focuses on the Hindu epic, the Mahabharata, and three examples of infertility presented within. To begin, Bhattacharyya gives her readers a background of Hinduism and the fluidity that this religion has compared to other world religions, emphasizing that there is no “universal Hindu view” (Page 26). Being an active follower of Hinduism myself, I appreciated her stressing the concept of pluralism in the Hindu faith. Bhattacharyya begins to explain the complicated family of King Samtanu and the dilemma he faces when the succession of his kingdom must run through his second wife, Satyavati. Throughout the stories of Gandhari, Kunti, and Madri, many methods of artificial reproductive technologies arise, including paternal surrogacy, abortion, sperm donation, adoption, and gene selection (Pages 39-47). One theme that is relevant throughout many generations of the Mahabharata is the idea of Niyoga, or levirate marriage, where a woman can have sexual relations with men other than her husband, in order to produce a child or an heir (Page 34). This idea of Niyoga was very interesting to me, as compared to Marcia Inhorn’s “He Won’t Be My Son,” there is a completely different view of the legitimacy of children. As we discussed earlier this semester, Sunni Muslims rely on the paternity of the child in order to denote kinship, while in Hinduism, there are multiple acceptable ways to produce an heir without the involvement of paternal genetics (Page 39).

Throughout the rest of the book, Bhattacharyya continues to use the stories of Gandhari, Kunti, and Madri to analyze the key elements of Hinduism, primarily focusing on karma, dharma, and ahimsa. She concludes by discussing the case of Jaycee Buzzanca, a child born via surrogacy to parents who had separated after her conception and before her birth (Page 78). Using the Hindu ideologies discussed throughout the book, she analyzes the Buzzanca case.

Discussion Questions

Do you think cultural competency is as essential to the positive outcome of a patient as Bhattacharyya implies with her examples in Chapter 1?
There is confusion whether Gandhari’s actions were indicative of an abortion or actions of a concerned mother during pregnancy. After reading her story, what do you believe is more supported by Bhattacharyya?
Bhattacharyya analyzes the Buzzanca case in extreme detail – which of her examples do you feel best supports the actions of John and Luanne Buzzanca?

Our second reading for this week, Impossible Gifts: Bodies, Buddhism, and Bioethics in Contemporary Sri Lanka by Bob Simpson, focused on the concept of donation in Buddhism. While eye donations and blood donations are common in Sri Lanka, Simpson focuses on how this can lead to the use of ovum/sperm donation in facilitating reproduction amongst this population (Page 840). Simpson first discusses the general idea of dana (donation) in Buddhism, as it is the first of the ten perfections (dasa paramita) needed to attain nibbana, the ultimate goal for a Buddhist (Page 842). There are three factors in which one’s dana is judged, including the motive of the donor, the purity of the recipient, and the item which is being donated (Page 842). There are also three ways in which dana can occur: donating one’s possessions, donating one’s body parts, and sacrificing one’s life for another (Page 843).

As Simpson states, this idea of sacrificing one’s life is also present in other world religions, such as Christianity and Islam. There are many overlapping ideas in both Bhattacharyya and Simpson’s works, indicating a close similarity between Hinduism and Buddhism. As Simpson explains the idea of nibbana as “the realization,” I am reminded of the concept of moksha in Hinduism, which is the ultimate goal involving the release of the soul (Page 843).

Through the story of the Sivi King, Simpson explains the significance of eye donation and organ donation in the Theravada Buddhist population. The increase in eye banks and donations came with problems as well, especially when pertaining to recruitment and exploitation of donors (Pages 846 – 847).

Organ and blood donations are common in Buddhism due to the justification of the practice (Page 852). However, new technology has raised questions involving the donation of ovum, sperm, or embryos in producing life, as opposed to prolonging life. Contrary to all of the justifications behind organ and blood donation, there seems to be an opposition to sperm donation. As Simpson explains, there is a presence of shame, not pride, when a man has given a sperm sample for donation (Page 854). Interestingly, however, this opposition isn’t generalized to all reproductive organs – egg donation is less opposed because there is a pain in the retrieval process, indicating it’s similarity to the dana of donating one’s body parts (Page 854).

Discussion Questions

How do you feel about the early practice of the Eye Donation Society, in which members sought out potential donors from the family members of the deceased? Do you believe family members have the authority to provide consent on behalf of a deceased person?
Do you believe that there is a cultural stigma to infertility in Buddhism since it is assumed that the woman is the source?

Unit Five – Cultures of Testing – Sai Greeshma Magam

This week’s readings differ from the topics we have covered thus far in class. While we’ve discussed the aspects of artificial reproductive technologies (ARTs) as they affect people of different faiths, this week’s readings branch off and detail a mostly female approach to options considered during an ongoing pregnancy.

Testing Women, Testing the Fetus is a full-length ethnography by Dr. Rayna Rapp. Her ethnography covered a spectrum of topics relating to the healthcare system, discussing the history of genetic testing, the current prenatal testing (amniocentesis), healthcare reform in the United States, and ethnic disparities in the healthcare industry. Her methodology involved qualitative interviews of patients receiving prenatal testing and genetic counselors, which provided her with a comprehensive evaluation of prenatal testing from both perspectives. Her background also provides a unique perspective to this ethnography, as she had gone through the procedure of prenatal testing, received a positive diagnosis of Down Syndrome for her fetus, and decided to terminate her pregnancy (pg. 3).

Throughout the discussion of ethnic differences in the female perspective to prenatal testing and pregnancy, Dr. Rapp talks about the cultural ideological differences that arose with genetic testing. One part of the ethnography that stood out to me was the disparity in understanding familial history. As Dr. Rapp points out, some research participants were adamant that the environment surrounding them was more likely to influence their child, as opposed to the family history of the parents (pg. 163). Similarly, I was intrigued to learn that parents who already had children found themselves more confident that their body would produce healthy babies, especially when compared to first-time parents of a higher socioeconomic status (pg. 69). This disparity was evident through prenatal testing, as the statistics showing a Down Syndrome occurrence of 3 in 1000 births were perceived differently in those two populations of parents. Another ethnic difference she discusses surrounds populations in which a male child is preferred to a female child, resulting in fetal femicide, a practice more common in Asian populations (pg. 94).

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The other reading from this week was an article from Medicine Anthropology Theory, titled “Blessing Unintended Pregnancy,” written by Dr. Seeman and his colleagues. This article displayed results from their ethnographic research conducted at Naomi’s House, a homeless women’s shelter with a predominantly African American population. Many of the research subjects were women who decided to raise their children independently, with the exception of one woman who was living with her partner (pg. 39). Like the title suggests, this article examines the beliefs of women who were faced with an unplanned pregnancy, yet many of whom still deemed the pregnancy as a blessing. Many of the women interviewed indicated that their child was a strong reason to pursue a “better life,” and in cases of teenage pregnancies, continue their education or leave destructive familial situations.

In addition to questions regarding their pregnancy, these women were also approached with questions about their faith and spirituality. Although the shelter itself was non-denominational, there is a religious history to the center, even though a majority of its residents identified as “spiritual but not religious” (pg.41). A majority of the interview participants responded that their pregnancy was intended by “an agency that trumps human planning,” even if it was not intended by themselves (pg. 42).

While Dr. Rapp’s ethnography details the genetics of prenatal testing and the decisions parents have to make to choose the procedure, Dr. Seeman’s research discusses the choices left in the hands of (mostly) single, pregnant women. Despite the differences in ethnographies, both discuss the need to understand each other’s perspective of reproduction.

Discussion Questions

Dr. Rapp describes a divide/miscommunication between the patient and healthcare provider – do you believe this is accurate? Do you think this is limited to prenatal testing or do you think this is prevalent in other areas of the healthcare field?

How would you distinguish the differences between being religious and being spiritual and how do you think this affects women during pregnancy?

Dr. Rapp examines the implications of prenatal testing toeing the line between reproductive rights and disability rights. Based on what we’ve read this week, what are your opinions of this debate?

In Testing Women, Testing the Fetus, Dr. Rapp discusses the limitations to prenatal testing. She talks about how certain members may have access to the testing, but not have access to the subsequent procedures, such as selective termination – if this is the case, do you believe prenatal testing is still important?