Author: Jonah M. 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.

Hospital Regulations of ARTs in Sasquatch, Connecticut

Background information:

I am a cardiothoracic surgeon that has worked in the Sasquatch Hospital for 20 years. I was born and raised in a religious Catholic home and married a Catholic girl, but throughout our marriage, we have become a little 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 talks.

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 IVF treatments and prenatal testing, including amniocentesis. My initial thought reflects 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. 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? I believe she should have the right to an abortion.

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 actually 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. “Each and every marriage act must remain open to the transmission of life” (Humanae Vitae, 11). Additionally, IVF is forbidden by the Catholic church because the leftover embryos after treatment have the potential to develop into children. “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 this multitude of reasons, I believe that the hospital in Sasquatch should not provide IVF treatments for any patients.

When considering whether to offer prenatal testing 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. The first reason 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 is to be able to prepare in advance if you know there is something wrong with your fetus. 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 is question 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). Additionally, amniocentesis unacceptably increases the chances of a miscarriage. 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). 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, 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 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 whatever services they wish. Because I have been born and raised in a Catholic home and lived a Catholic life, I believe that these procedures are ethically questionable, but that does not mean that hospitals should not provide these procedures as treatment options.

I have become slightly more secular as my career has progressed, and although I do not think that I would condone abortion and reproductive services in my family or my community, I believe they should be provided at the hospital. As previously discussed in section 1, there are extenuating circumstances in which I believe abortion to be acceptable (rape cases, etc.). Additionally, just because something goes against a religion does not mean that people do not want it. A very small percentage of individuals that practice religion are devout in their observance.

Now to answer the question of how to deal with nursing staff who refuse to perform abortions and reproductive services. Nurses have certain responsibilities that come along with their job, and regardless of how they personally feel about tasks they are asked to perform, they are expected to complete the assignment. If a nurse is not willing to conduct abortions and reproductive services required by their job description, I believe the hospital should initially provide notice that if the required services are not provided to patients, the nurse will be fired. There are no other hospitals within a 45-minute drive, leaving nurses with few alternative job options nearby. The hospital may not have a large budget to hire additional staff, but I suspect that most of the nursing staff will not risk their jobs over this issue. In the event that a few nurses leave, the hospital can utilize the small budget for replacements.

Inventing Bioethics

This week, we read two pieces of literature: Magical Progeny, Modern Technology by Swasti Bhattacharyya and Impossible Gifts: Bodies, Buddhism, and Bioethics In Contemporary Sri Lanka by Bob Simpson. Both of these works focus on relating the use of artificial reproductive technologies to ancient texts. Swasti Bhattacharyya focuses on Hinduism and the ancient writing of Mahabharata narratives, and Bob Simpson focuses on Buddhism and how ancient Buddhist thought relates to modern technological advances in the reproductive field.

The goal of Bhattacharyya’s book is to “increase the cultural/religious awareness and sensitivity of the healthcare delivery system” (Page 2). By utilizing the interdisciplinary nature of bioethics, Bhattacharyya analyzes the role of “Hindu philosophy, religion, culture, history, and experience” presented in ancient Hindu stories in order to derive what is referred to as Hindu ethic (Page 3). The first chapter of Magical Progeny, Modern Technology is dedicated to discussing the principle of cultural competency, which is defined as “the need [for healthcare providers] to be understanding as well as sensitive to the different cultures, socioeconomic backgrounds, and belief systems of their patients” (Page 5). I believe that cultural competency is integral for healthcare providers in order to adequately treat patients. Bhattacharyya provides multiple examples of doctors misdiagnosing patients on account of cultural or translational misunderstandings (Page 22, 24). Aside from having a complete understanding of medicine, doctors must also possess an understanding of their patient’s cultural backgrounds.

Another argument presented here is that Bhattacharyya claims that religion has played a crucial role in the development of medicine, especially in regards to Judaism and Christianity. I think Bhattacharyya possesses a unique cosmology on this topic as a result of her upbringing. “Born and raised in the United States of America, my family combined South Asian and Japanese ancestry with Hindu, Buddhist, and Christian religious traditions…[this background] allowed me the freedom to question and probe the presuppositions that underlie our philosophical paradigms” (Page 4). This diverse perspective is utilized to argue against the secular bioethics movement. Bhattacharyya asserts that secularism set up a dichotomy between reason and faith, and by doing so, attempted to separate bioethics from religion. Personally, I believe this to be impossible on all levels. Bhattacharyya argues that separation of bioethics and religion is possible on an academic level, but not in a clinical setting (Page 14).

In reality—in a clinical setting—patients are commonly experiencing extreme emotions of joy or sadness, fear or relief. “Religion is the space in which these individuals can both express their joys and struggle with realities of suffering and death” (Page 16). Religion can provide hope in dire circumstances. Bhattacharyya continues to state that “eliminating religion often leads to an unwarranted dependence upon law as a source of morality” (Page 17). My opinion is that law does not always reflect morality. For these reasons, current bioethical books are mainly written with a focus on religion.

Do you think that bioethics and religion can be treated as independent entities in both academic and clinical settings?

The intention of law is to provide justice (hopefully), but does justice imply morality?

Do you think it is ethical for a doctor a doctor to alter patient care based on the religion that patient practices? What if the change in care puts the patients at greater risk?

Another interesting part of Magical Progeny, Modern Technology is the discussion of Hindu beliefs and practices. “A defining characteristic of traditions within Hinduism is their multivalent natures” (Page 26). Hindus practice in many different ways depending on their beliefs and traditions. This reminded me of our study on Judaism. We learned that in Judaism, depending on which Rabbinical opinion is followed, observance can vary tremendously.

In Judaism and Christianity, both religions use scripture in order to deduce reasoning for observances and traditions. These books are considered sacred.  Both Judaism and Christianity interpret stories presented in sacred texts to answer ethical questions. Contrarily, the Mahabharata is considered “of secondary authority” (P.30), but it can help us answer questions because it “preserves the moral philosophical thinking of the Indian traditions” (Page 50). There are numerous references to sperm donors and other forms of alternative reproductive options in the Mahabharata, which can guide us in our ethical decision on contemporary issues. For example, there is a story in the Mahabharata that deals with the use of postmortem sperm. This story directly relates to a previous discussion of ours regarding Israeli soldiers donating to sperm banks, so if they perish in action, their legacy and genetic line can live on. The Mahabharata can help us answer these questions from a Hindu perspective. After analyzing the stories presented, we can conclude that “the Mahabharata would not only permit the use of surrogacy, sperm donation, participation in gene selection, and embryonic manipulation, it would condone such practices” (Page 52). Also, Bhattacharyya makes a big distinction between Judaism and Christianity and Hinduism. In the Old and New Testaments, there is an overarching belief of divine control over pregnancy. This belief is not present in the Mahabharata.

Even though the Mahabharata is not considered primary authority, do you think that looking at the stories presented here is a reasonable/logical place to find answers to our ethical questions on ARTs from a Hindu perspective?

Do you think that a certain level of “holiness” associated with a text is required in order to use it to guide our ethical principles?

Today, and even in the ancient writing of the Mahabharata, character traits of sperm donors were chosen. Do you think this type of eugenics is ethical?

In order to evaluate ethical dilemmas, Bhattacharyya analyzes the six key elements of Hindu thought. Three core concepts here are dharma, karma, and ahimsa. Dharma is described as an “ethical category” (page 68). Karma literally means “action”, and is the concept that all action has consequence, positive and negative. Ahimsa “suggests the principles of nonmaleficence and beneficence” (Page 73). With an understanding of these principles, we can analyze an ethical dilemma from a Hindu perspective. In the final chapter of Magical Progeny, Modern Technology, the ethical case of the Buzzanca family is presented.

What do you think is the ideal course of action in the Buzzanca case?

Our second reading this week, Impossible Gifts: Bodies, Buddhism, and Bioethics in Contemporary Sri Lanka, takes a similar approach to Bhattacharyya’s work in that it uses ancient texts to try and justify the use of ARTs in contemporary times. Bob Simpson delves into Buddhist text and tradition about charity that has led to the widespread donation of human tissue, specifically eye donation and blood donation. Simpson analyzes the permissibility of these two types of donations according to Buddhist tradition and discusses the viability of sperm and egg donation at the end of his article.

In order to gather information about Sri Lankan Buddhist culture, Simpson conducted research about “the reception of new reproductive and genetic technologies among doctors, clinicians, and others involved in regulation and policy-making in Sri Lanka” (Page 840). In Theravada Buddhism, the ultimate goal of nibbana is achieved through numerous actions, including the act of donation, called dana. In “Buddhist practice, the intention-action nexus is crucial when it comes to evaluating the consequences and worth of an action” (Page 843). To me, this sounds very similar to the Hindu principle of karma.

In this article, Simpson references the term “ethical publicity” multiple times. Ethical publicity is defined as “draw[jng] on the core values of society, culture, and religion to shape the motivation to give in each particular context” (Page 840). This principle is used to try and describe the transition to normalcy that both eye and blood donation have undergone to become common in Sri Lankan society. Ethical publicity does not include sperm donation because sperm is considered the “highest of substances” in Ayurvedic Medicine (Page 853).

In this article, there is a proposed system of blood donation where if you need a blood transfusion, it is expected that a family member donate an equal amount to replenish the used blood. Do you think this is ethical with blood? With eyes? What about other body tissues/substances?

In Sri Lankan society, it has become relatively normalized to donate eyes and blood. Do you think that with ethical publicity it is possible for kidney donation to become common in this society?

Making Comparisons in Technology and Culture

              In Tsipy Ivry’s ethnographic work entitled Embodying Culture, Ivry provides insight on the pregnancy experience of heterosexual women from Israel and Japan who were impregnated in their twenties or thirties without the use of medical intervention (Page 5). She draws on both her participant observational research conducted in both countries and her time spent living in the countries of Israel and Japan. In the introduction to her ethnography, Ivry begins with a short story from her personal life that occurred back in 1996. Ivry was studying at Tokyo University when she became pregnant with her first child. Ivry describes her first experience with pregnancy as “overwhelming and an all-encompassing sense of becoming ‘different’” (Page 1). During her pregnancy, she travelled from Japan to Israel. While there, Ivry scheduled an appointment with her local ob-gyn. At that appointment, the Israeli doctor was reviewing the prenatal tests that had been conducted back in Japan, and he demanded that Ivry return to the clinic the following day to receive a vital test: the triple marker. The triple marker is “a screening test that uses a biochemical analysis of maternal blood to estimate the probabilities of chromosomal abnormalities in the fetus” (Page 3). The results of the triple test indicated unclear results regarding the health of the fetus and further testing was urged, including amniocentesis. Ivry chose not to undergo the amniocentesis, but rather opted to receive an ultrasound. The ultrasound showed optimistic results for the fetus’s health, but the doctors could not be certain of the condition of the fetus without amniocentesis. The tremendous anxiety that Ivry endured worrying about the health of her baby was taxing throughout the rest of her pregnancy. In the end, Ivry gave birth to a healthy baby girl.

Now the mother of four daughters, Tsipy Ivry has not only experienced pregnancy first-hand in Israel and Japan, but has also conducted vast anthropological research on how each of these cultures view pregnancy. Ivry is interested in studying “pregnancy as a cultural and social phenomenon” (Page 1). Through her experiences, she realized that the notion of pregnancy and how society treats pregnant women can vary tremendously depending on culture. One major example that Ivry provides is when she is comparing and analyzing authoritative knowledge about pregnancy in Japan and Israel. Ivry labels both Japanese and Israeli approaches towards pregnancy. Japan’s authoritative knowledge on pregnancy is called “environmentalism”, and Israel’s is called “geneticism”.

Environmentalism and geneticism are two major factors included in the analysis of this ethnography. Environmentalism refers to the Japanese belief that the overall health of the fetus is the direct responsibility of the mother’s body (the uterus being the environment of the fetus) (Page 11). Thus, upkeep of the body by avoiding massive weight gain and strictly monitoring diet during pregnancy is crucial to maintaining a healthy environment for the fetus.

Geneticism refers to the Israeli approach to pregnancy in which genetic material—genes and chromosomes—are responsible for the health of the fetus. In this case, the responsibility to maintain the health of the fetus still falls on the mother, but in a different way than with environmentalism. In geneticism, the mother is responsible to undergo genetic diagnostic testing with modern technologies in order to help ensure a healthy fetus. If the diagnostic testing yields questionable results, the woman can be put in a tough spot in deciding whether to get an abortion.

In this ethnography, Ivry also points out that large-scale issues can directly play a role in pregnancy laws of a country. On a national scale, population sizes, birth rates, economic performance, and many other factors can play a role in both abortion laws and also when setting quotas on how many children a family can raise. Additionally, both Japanese and Israeli governments highly regulate the public image and stigma of prenatal diagnosis, amniocentesis, and even abortion. Ivry goes into depth describing how the Japanese government monitored the state of national affairs and altered their reproduction laws accordingly throughout the past one-hundred years.

On page 74 of the ethnography, Ivry provides a succinct description of Israeli pregnancy theory. “Pregnancy is basically a chaotic process in which nature is liable to make mistakes, and it is this dangerous process that biomedicine must handle.” In Israel, the use of prenatal diagnosis (PND) is widespread and rarely refused. PNDs do not receive harsh criticism in Israeli society. In fact, at public Israeli educational pregnancy events, “horror picture shows” are presented. These displays instill fear into women and encourage them to seek out PNDs. Pregnant Israeli women are described as “hysterical” and have a need to know for sure that their fetus is healthy. There is no negative stigma associated with PND use in Israel. In Israel, PNDs are recommended to all women above the age of 35, but most pregnant women are encouraged to seek out PND testing, regardless of age. Additionally, amniocentesis is commonly conducted in Israel. Even though there is risk involved with the procedure, the popular opinion is that the benefits outweigh the risk. This public attitude towards PND testing and amniocentesis directly reflects the Israeli geneticism perspective on pregnancy.

In Japanese cultures, on the other hand, prenatal diagnostic testing is not mainstream, as in Israel. Pregnant Japanese women do undergo pregnancy testing, but not nearly to the same extent as Israeli women. Furthermore, Japanese women rarely will utilize amniocentesis. Ivry even displays that in Japan, “women who dread fetal abnormality face tremendous difficulties in managing their anxieties, and their anxieties might not necessarily lead them to undergo diagnostic tests such as amniocentesis” (Page 181). This approach exemplifies the environmentalist approach that the environment of the uterus will provide health to the fetus. The belief in Japan both by doctors and the general society is that health is provided to the fetus by not gaining large amounts of weight and also by eating a healthy diet during pregnancy. This is such a paramount concern for Japanese doctors that they almost obsess over a woman’s weight while pregnant. Contrarily, Israeli doctors do not pay much attention to weight gain during pregnancy. Ivry even provides accounts of Israeli doctors not even weighing women once throughout the duration of their pregnancy.

As we can see from both Israeli and Japanese pregnancy cultures, the norms of pregnancy from a medical perspective, personal perspective, and anthropological perspective vary greatly depending on the culture we are analyzing.

One topic that I found particularly interesting from Tsipy Ivry’s ethnographic work was her discussion on “common knowledge” (P. 130-131). Common knowledge is described as essentially facts that are nearly universally held in a society. One example is presented when discussing precautions of riding on trains when pregnant in Japan. The thought is that the jerking of the train can possibly cause a miscarriage during the first trimester. Obviously, this is not a commonly held precaution worldwide, but in Japan it is widely believed. I found this observation intriguing because there is no evidence linking train-riding to miscarriages, but the entire Japanese society appears to take caution with pregnant women riding trains. My point is that common sense/knowledge is possibly only common to a specific culture, but may not be so commonly known or believed in other cultures. Common knowledge is dependent on many factors and can vary culture to culture.

Questions:

During the discussion of amniocentesis practices, Ivry points out that—in general—Israeli doctors may leave out details of possible negative outcomes of the amniocentesis procedure. Even if the society that you live in supports the use of amniocentesis (Israel, for example), is it ethical for doctors to leave out these details in order to ensure that the practice of amniocentesis continues?

Is it ethical for doctors to perform amniocentesis to prevent unhealthy births (effectively protecting the life of the child) when there is risk of death, although small, for the mother?

Assuming that you believe that everything is “created in G-d’s image”, do you think PND/amniocentesis use is ethical? If yes, how can you justify “proofreading” G-d’s work (fetus)?

From a doctor’s perspective, are there times that patients should be required to undergo amniocentesis? What if a woman is at high-risk and is petrified of fetal abnormality?

How can you justify changing national laws that were instituted based on moral principles, as happened in Japan? This question is in reference to the altering of abortion laws depending on the economic state of the country.

Do you think there should be limits on when amniocentesis results should be used when deciding when to have an abortion? This question is in reference to Ivry’s mentioning of some types of fetal abnormalities in which individuals can develop to live productive and independent lives. For example, with Down’s syndrome, individuals can develop into functioning individuals who live independently and support themselves with a career.

In class last week, we discussed the concept that knowledge has the potential to be more harmful than helpful. Do you think that technology also has the capacity to be more harmful than helpful? If so, how?