Author: Molly Nestor

In a rapidly developing world centered around technology, I think it is time we, as a hospital, introduce the use of reproductive technology and prenatal testing to our hospital. These technologies not only reflect the incredible strides made in the medical world, but also provide pregnant women and their families with the ability to prepare for their future. As a physician at the Sasquatch Hospital, I believe these technologies are necessary to our hospital, for they will greatly improve the treatment we are able to provide to our patients. Having provided the ethics committee as well as other doctors and hospital administrators with my initial proposal, I have considered all counter arguments and suggestions presented, and applied a few changes to my proposal where I saw fit. That being said, I think it is important to remember that when considering changes in medicine and healthcare as a result of technology, the question of bioethics if confronted with a very difficult dilemma. As mentioned by Dr. Arthur Kleinman, bioethics is faced with the challenge of “how to reconcile the clearly immense differences in the social and personal realities of moral life with the need to apply a universal standard to those fragments,” (Kleinman 1999: 70). With that in mind, I present to you the revised and final outline of my proposal.

With a growing and varied local population, the ultimate goal of our hospital should be to provide the best medical care our diverse population needs. While I understand the importance of our Catholic origins and what they mean to our donor base, I think it is more important to acknowledge the changing culture in our area. I recognize that some of the policies I am going to propose will not be conducive to Catholicism as well as other religions. However, I feel as though we should not limit the medical care and services our hospital can offer due to differing religious and cultural beliefs among our population. As doctors and providers of care, we made a decision to help the lives of others above all else, regardless of whether or not we personally agree with such services.

One of the major policy changes I wish to make would be to provide reproductive technologies, such as in-vitro fertilization, and prenatal testing, such as amniocentesis. Over the past decade, these technologies have grown in popularity and acceptance, but still face some resistance regarding the ethics surrounding the decisions and outcomes of such technologies. Personally, I do not believe in-vitro fertilization nor prenatal testing are unethical. Both technologies exist to facilitate and better comprehend pregnancy and its outcomes. While some may argue that IVF violates the natural laws regarding the appropriate way to conceive a child, I believe “natural laws” are more so a social construct and differ based on the individual and their beliefs. For example, the French bioethics laws initially, “restricted access to artificial reproductive technologies (ART) to sterile, heterosexual couples of childbearing age,” (Ball 2000: 545-546). The French put these restrictions in place out of fear the technological advances would alter cultural norms and defy what they considered “natural.” Although nature served as the source of truth for many Enlightenment philosophers, Rousseau stated, “philosophers of natural law who hold too strictly to the dictates of nature are ‘in habit of abstracting the content of natural law from the behavior of men in civil society. . .’” (Ball 2000: 579). I agree with Rousseau’s statement and believe that what most consider to be natural is subjective and developed from observations of society.

Along with providing IVF treatments, I would suggest implementing a provision to encourage families to allow unused embryos to be donated for life saving research. From a medical standpoint, research done on embryos is somewhat rare and the findings from such research could turn out to be crucial in the future. I understand some families will be unwilling to donate their unused embryos due to personal beliefs, but I think the provision should be included regardless. Our community has changed and progressed dramatically over the years and I think more individuals would be willing to donate unused embryos for research purposes. In order for a patient to make what they believe to be the right decision, it is important for doctors and medical professionals to explain in detail what donating an unused embryo to research entails, conveying both the benefits and consequences of donations. I want to stress that it is unacceptable to make families feel as though they are forced to donate. Pressuring a patient into making a decision that goes against what they believe in is unethical and violates our role as doctors to provide the best possible care and treatment. If the patient chooses not to donate their unused embryo, then we must honor their decision.

            It was brought to my attention by a few of my colleagues that my above provision would potentially be met with opposition from those of the Catholic faith. As stated in Donum Vitae, in the eyes of Catholicism, from the first moment of existence, a human demands the “unconditional respect that is morally due. . .in his bodily and spiritual totality,” (Donum Vitae 1988: 149). In this instance, the first moment of existence is considered to be the moment the zygote is formed. While I personally do not agree that the formation of a zygote is equivalent to a human life, I understand the ethical and moral issues at hand and would like to elaborate on my reasoning for the use of unused embryos in a research setting. In 2001, the Bioethics Advisory Committee in Israel release a report on ethical implications of stem cell research (Prainsack 2006: 180). This report states the status of embryos within Jewish law, which believes that embryos outside of the uterus are not to be regarded as human life, which I personally agree with (Prainsack 2006: 181). Because an embryo outside of a uterus is not regarded as a human being, the use of unused embryos from IVF for research purposes is considered ethically permissible. However, if the IVF embryo is suitable for implantation, then it is considered unethical to use the embryo for research. I concur that if an embryo is suitable for implantation, then it should not be used for research purposes. Therefore, I believe it is not unethical to perform research on unused embryos located outside of a uterus, but only if the embryo is unsuited for implantation for IVF. The ongoing debate of when a human life truly begins presents a difficult issue within bioethics, one that may never be agreed upon. I comprehend the reasoning behind the opposition that has arisen due to my suggestion to use unused embryos for research purposes, but I personally do not hold the same beliefs. Because I do not consider an embryo outside of a uterus to be comparable to a human life, I believe that the use of existing, unused embryos for research purposes is not unethical and will therefore maintain my initial proposal.

Prenatal testing is another service I suggest we provide at our hospital. Prenatal testing, such as amniocentesis, allows pregnant women to test for abnormalities, disorders, and defects of the fetus that previously could have only been realized once the child was born. From a medical standpoint, this technology is revolutionary, providing women with a wealth of knowledge while also giving them time to consider their situation and prepare for the outcome. As stated by someone who has undergone prenatal testing, “what harm can a test do if its going to provide you with important information?” (The Burden of Knowledge: Moral Dilemmas in Prenatal Testing, 1994). Some claim that by offering the tests we would be creating anxiety; however, I find that to be completely false. Just because the tests exist, it does not mean one must undergo them. Israeli pregnancy theory conveys the relationship between pregnancy and biomedicine as pregnancy being “a chaotic process in which nature is liable to make mistakes, and it is this process that biomedicine must handle,” (Ivry 2009: 74). While I don’t believe biomedicine must handle the chaotic process of nature, I do believe that biomedicine provides a way in which one can prepare for the anxieties and uncertainty that may arise from the chaotic process of pregnancy.

Along with providing the option to receive prenatal testing, it is important that we as medical professionals educate women on both the medical and psychological aspects of testing. Although I don’t necessarily agree that the mere offering of prenatal testing would create more anxiety than women experience during pregnancy in general, I understand that the choice to undergo testing could be met with anxiety and psychological turmoil. I want to again stress that just because we offer the prenatal testing, it does not mean that a woman should feel pressure to undergo testing. I do understand that each individual is different and will react to situations differently, but this is something that is out of our control. I suggest fully educating women on both medical and psychological aspects of testing in the hopes that this might help women deal with or avoid having to deal with some of the psychological stresses of prenatal testing. Perhaps if women were told about the entirety of the prenatal testing process, some might opt to not have the testing because they realize it might cause them greater anxiety to undergo testing. I recognize that this is not a sure-fire solution to the issue of addressing anxieties of prenatal testing, but I am not sure there is a guaranteed solution to this matter. Personally, I think these tests provide a way to minimize anxieties of pregnancy by eliminating the unknown and providing answers to women, allowing them to prepare for what is to come. But, I do understand that my beliefs and understanding of prenatal testing are heavily influenced by my medical profession and may prevent me from completely understanding the anxieties people undergo due to prenatal testing and its possibilities.

In regard to the efficacy of prenatal testing, I believe offering and deciding to receive prenatal testing are both ethical decisions. In a study about women and the option to undergo prenatal testing, Reyna Rapp, a feminist anthropologist, described women who received prenatal testing as “moral pioneers.” She viewed these women as individuals who, “submitted to the discipline of a new reproductive technology in order to reap its biomedical benefits,” (Rapp 2004: 307). The decision to use prenatal testing has been given a negative stigma due to the fact that the test results may cause one to be more likely to get an abortion. However, that is not always the case and it should be noted that prenatal tests have the ability to provide women immense medical benefits, without resulting in a negative outcome. The tests allow women to become aware of the situation they are going to face and provide them with more knowledge and time to prepare for the arrival of their child. Although prenatal tests are considered unethical by certain religions, I believe, as a non-denominational hospital, it is important to look at access to prenatal testing on a more individual, secular basis.

To minimize the potential negative outcomes due to such testing, I would recommend implementing steps to prevent women from using the test results to get an abortion. One step could be to provide or recommend counseling services where women could learn about the alternative options they have to abortion, such as adoption. Another step could be to educate women about the conditions or disabilities their child might potentially face, either through genetic counseling or other means. A lot of women choose abortion after receiving their tests results because they are scared and feel as though they unable to take care of a child with disabilities. I think that if we were able to better provide women with more information regarding the disabilities of their future child, it might allow them to feel more prepared for what is to come and lead them to reconsider abortion. I understand this is not a foolproof solution to the negative outcomes that can potentially arise from prenatal testing, but I think these are two ways in which we could help the women facing a difficult decision in a difficult situation, and have an impact on those women who would have previously chosen abortion as a solution.

While I personally support the use of prenatal testing, I do understand the issues some individuals still have with such tests, one of them being abortion. A few years ago, the majority of our community felt that it was unacceptable, on an ethical and moral account, for our hospital to provide abortion services. I understand the reasoning and ethical beliefs of those who are against abortion and would never force them to alter their beliefs. I also acknowledge that people are going to have uncompromising views on this subject rooted in both religious and non-religious beliefs and sentiments, making compromise or a unanimous decision on this subject almost impossible. However, I would still advise that our hospital provide abortion services to both insured and uninsured patients. I also maintain my suggestion that subsidies for abortions be provided and should be determined on a case by case analysis of the patient and their financial situation.

One of the main oppositions to abortion comes from the concept that abortion is a form of murder. This notion is based on the view that human life begins at the moment of conception. I understand that under this view, a zygote is equivalent to human life, making the act of getting an abortion equivalent to killing a fully grown human being. However, it must be acknowledged that not everyone regards a zygote or embryo as being equivalent to a human being. Here, the question of where a human life begins ultimately determines whether there is an act of murder occurring or not. Personally, I do not believe human life begins at the moment of conception, therefore, I do not regard having an abortion as equivalent to murdering a human being. I also think it is important to acknowledge the potentially negative aspects of preventing or outlawing abortion. For example, consider the life of a child born to a woman who did not want to have a child or was incapable of caring for a child. Let’s assume the woman did not want to have a child because of this didn’t take the necessary precautions one would normally take during pregnancy. This women could drink and take drugs throughout her pregnancy, resulting in the child having multiple birth defects and disabilities. Assuming this woman did not want to have a baby in the first place and still does not want one now, the baby would be neglected by the mother, ultimately leading to the mistreatment of this child. Wouldn’t an instance like this, where a baby is brought into the world only to live a terrible life of abandonment and mistreatment, be worse than allowing the mother to have an abortion? I understand that those opposed to abortion because it is considered murder would argue that this instance is not worse because the baby is allowed to live their life instead of being murdered in the womb but, I think it is an important instance to consider. Again, abortion is an instance in which it is near impossible to achieve a compromise because individuals hold different views on the subject, views rooted in a multitude of facets. I understand the opposition but because of my belief that a human life does not begin upon conception, I do not regard abortion to be equivalent to murder and believe that, in some instances, it could lead to a better outcome for the unborn child.

The notion of cultural competency has become extremely important in aiding the communication and understanding between patients and their medical team. Defined as, “the need [for healthcare providers] to be understanding as well as sensitive to the different cultures, socioeconomic backgrounds, and belief systems of their patients,” cultural competency allows doctors to adequately and effectively provide care based on their patient and the patient’s needs (Bhattacharya 2006: 5). Regarding the improvement of cultural competency, I think it would be beneficial to continue counseling from Catholic clergy and expand counseling services to clergy of all religions. I believe the expansion of religious counseling services is integral to providing the best care to our growing and diversified community. Throughout my experience, I have come to find that religion helps some patients better understand the rather secular nature of the medical language.

In implementing this provision, it has come to my understanding that some doctors have complained about how the opposition to reproductive technology by clergy interferes with their work as medical professionals. As a doctor myself, I understand the frustration that stems from patients choosing to listen to religious guidance over medical expertise, but the implementation of religious counseling could greatly improve the patient/provider relationship. An example of how religious beliefs come to effect medical decisions can be found in a study done by Sherine F. Hamdy in which she examines why Muslim men come to refuse life-saving treatments. One Muslim dialysis patient in Egypt refused to get a kidney transplant because he believed his body “belong[ed] to God,” and God had already decided when he would die before he was even born, so accepting a transplant would be altering God’s decided path for him (Hamdy 2013). As a doctor, it’s hard to see a patient refuse a treatment that would save their life, but it is important to respect their decision and understand the beliefs behind the decision.

With these new provisions in place, I believe this hospital will be better suited to serve the needs of our local population. By acknowledging both our individual differences and the ever-changing nature of society, we will be able to provide more advanced medical service and improve the lives of those in our community. Although these proposed policy changes may come as a shock to some, we must remember that changes in societal norms and technological advances have altered what is considered to be the norm. Decisions made today will shape the social domain of the future, as previous decisions have shaped the society we occupy today. Through some revisions, I hope I was able to clearly address all counter arguments by elaborating on why I held the positions I did. Thank you all for your time.

Sincerely,

Dr. Nestor, M.D.

This week’s readings included two pieces about the public debate and interpretations surrounding bioethics, while the other looked at a “new” movement in bioethics. The first reading, Reflections on Public Bioethics: A View from the Trenches by Leon Kass, is a review of the major work done by the President’s Council on Bioethics. The President’s council on Bioethics is “a public body, devoted to public questions, whose activities are fully open to public scrutiny” (222). Kass asserts the point that this council has “a duty to promote a greater understanding of these issues for a wider national public,” repeatedly mentioning the importance of discussing bioethics in terms of “ordinary public discourse” (223, 228). I think this is an important point because, before having read any of the articles presented in class, I personally didn’t know very much about human cloning and found it hard to interpret all the issues surrounding it due to the use of bioethics jargon.

The majority of Kass’s essays reviews the five major works of the council, which attempt to address the previously mentioned goals of the council. The first of these works, Human Cloning and Human Dignity: An Ethical Inquiry, was one of our readings from last week and discusses the case for and against cloning-for-biomedical-research and cloning-to-produce-children. As mentioned by Paula in her blog post last week, the majority of the council recommended no human cloning to be allowed.

Monitoring Stem Cell Research is an update that summarizes the significant developments in stem cell research, with the overarching goal “to convey the moral and social importance,” surrounding stem cell research (232). Because stem cell research was a relatively young and constantly developing field at the time, the council intended for this section to improve understanding in order to achieve better public discussion and decision making with regards to stem cell research.

Beyond Therapy: Biotechnology and the Pursuit of Happiness examines the use of biotechnology to serve “human goals beyond healing disease and relieving suffering,” (234). This section deals with questions of human character and humanity, looking into human desires for ageless bodies, happy souls, and “better children.” I found this section to be very interesting. On the one hand, I think the use of technology to potentially treat or prevent mental illness could be beneficial. However, I don’t think we should use these technologies to attempt to create “better children” by selecting for specific genetic traits. In the future, I think this can lead to a blurred line between what is humanity and what is not, while also making regulation of bioethics very difficult to put in place or enforce. As mentioned by Kass, the issues presented in this section force one to look beyond issues of fairness, autonomy, and equality and to consider issues of identity, hubris, and humility to name a few (237).

Being Human: Readings from the President’s Council on Bioethics focuses on aspects of “being human” and how bioethics issues touch on matters “close to the core of humanity,” (238). To address these questions in greater depth, the council published an anthology of readings surrounding the questions of what it means to be human. The final section of the council’s works, “Reproduction and Responsibility: The Regulation of New Biotechnologies,” discusses regulation of biotechnologies, finding that present regulatory institutions are unable to remain up to date with the fast pace of technological advance (242). Instead of recommending a proposal for new regulatory institutions, the council provided a proposal that targets what they believe to be unethical practices in human reproduction, one of which being the prohibited “use of human embryos in research beyond a designated stage in development,” (244).

While this report had the goal of improving public understanding surrounding the debate on bioethics, Kass notes that it is hard to educate people without telling them a direct answer on what they should do. Kass cites “the life question” as one of the “most frustrating aspects of public bioethics,” because it leads most to forget about other important aspects of public bioethics, such as human dignity and human freedom. The life question is “the principle that calls for protecting, preserving, and saving human life,” which as Kass states, although an important consideration, “cannot continue to be the sole consideration in public bioethical discourse,” (249).

Questions:

• In his essay Kass asks, “When and to what extent should we strive to change and alter nature and especially our own given nature, in an effort to improve or save it?” When do you think the altering of human nature should be stopped or regulated?

Our next reading, Not Just for Experts: The Public Debate about Reprogenetics in Germany by Kathrin Braun examines how policy debates in Germany regarding reproductive and genetic technologies stemmed debates on the definition of ethics and the role ethicists play in public policy. As Braun states, ethics in this context is about “how a nation-state should handle developments in science and technology, specifically in biology and medicine,” (42).

The two sides of the bioethics debate in Germany consist of techno-skeptics and techno-optimists, but the two sides are not strictly split based on ideologies. Techno-optimists “emphasize technologies potential benefits, welcome enhancement of choice, and believe that society is able. . .to calculate and to control potential risks,” (43). For them, ethics is a matter of choice with the task of rationalizing different conflicting values. Understood as a “specific type of professional academic expertise,” techno-optimists think the task of ethics is best performed by professionals.

Techno-skeptics on the other hand, “underscore the limits of technological solutions and the price that individuals and society might have to pay for them,” (43). An important ethos for techno-skeptics incorporates the will to not distinguish between a life worth living and a life not worth living. They conceive ethics as “a matter of paying respect to a set of common legal and moral principles,” fundamentally meant to convey the nature of a good society (43-44). For them, ethics should not be left to the experts, rather ethics requires participation of citizens in a public debate.

Braun conveys the different ways to link politics to ethics through two different discourses: managerial and republican. Managerial discourse is characterized by the belief that problems surrounding genetic and reproductive technologies can be handled through a risk-benefit analysis. Ethics, in this case, is “a set of tools and techniques to solve problems and make decisions,” and emphasizes the competence of experts to handle questions of ethics (44). Republican discourse assumes that problems of technology are a social problem, with genetic and reproductive technologies seen as “affecting fundamental moral principles, questions of identity, and the meaning of life,” (44). Emphasizing citizen engagement and the notion of a good society, problems of ethics cannot be solved, according to republican discourse, without the engagement between citizens and policymakers in a public debate setting (44).

In the rest of Braun’s paper, she applies these differing sides and discourses to portray the development of the bioethics debates in Germany. While the German Embryo Protection Act was highly restrictive, the German abortion law considers abortion to be “illegal but not subject to prosecution,” meaning that abortion is only necessarily considered morally and legally wrong in principle. Something I found interesting about the German abortion laws is that it is based on the idea of “support instead of punishment,” assuming social support is more effective in encouraging women to continue their pregnancy instead of banning abortion entirely, which I tend to agree with. Surrounding the debate on the status of embryos, in 2002 it was decided that the importation and use of embryonic stem cells be prohibited in principle, with the passing of the Stem Cell Act that same year.

Questions:

• Do you relate more to a managerial or republican discourse surround the meaning of ethics and its place in policy?
• Do you think it’s entirely possible to distinguish between a life worth living and a life not worth living? How would the distinction translate into ethical policy?

Our last reading, The New Conservatives in Bioethics: Who are they and what do they seek? by Ruth Macklin, analyzes the new label of a “conservative” movement in bioethics which they believe challenges ideas and topics in liberal, mainstream bioethics. Throughout the reading, Macklin asserts how these new labels have led to misunderstandings and misinterpretations within bioethics. For example, what used to be deemed conservative bioethics is generally considered to be liberal bioethics now. Macklin cites conservative bioethicists as opponents of biotechnology and its use in “interventions they term ‘artificial’”, new reproductive technologies, stem cell research involving the destruction of embryos, and biomedical efforts to enhance physical or mental capabilities (35).

The mission of conservative bioethics is “to prevent our transformation into a culture without awe filled with people without souls” (37). Conservatives find that mainstream bioethics often disregards the “deeper questions of human dignity and human nature,” (37). Macklin takes issue with the mission of conservative bioethics and find that it leads to confusion about the bioethics field. Through the use of poetic and metaphoric language, appeals to emotion, sentiment, and intuition, mean spirited rhetoric, and discussion of “projects,” Macklin conveys how conservative bioethics has come to misconstrue many concepts and ideals within bioethics. This made me think about our two previous readings for this week, and how both conveyed how important it is to discuss the debate in bioethics in terms the public can understand. Personally, I found many of the examples cited by Macklin to be troubling, especially the opposition to all things “artificial.” The label of being artificial can come with a negative connotation and I think the way the conservatives use this term is inaccurate. As mentioned by Macklin, there is no “artificial sex” that brings “artificial babies.” The babies conceived in this way are quite real, with nothing artificial about them, and they are not conceived through sex because, usually, the female is unable to conceive a child the “natural” way.

Questions

• Do you think labels like liberal and conservative can be applied to bioethics? Or do you agree with Macklin that such labels render confusion within the field?
• In her discussion of making children “more biologically equal,” by researching stem cells that could help address child diseases, Macklin asks the question, “Why is it acceptable (or is it?) to alter the physical environment to benefit individuals with disabilities (i.e. accommodations for wheelchairs) but not their biological attributes?” What do you think about this question? Do you think physical environment and biological attributes are comparable in this instance?

This week we read ‘Knowing’ the Surrogate Body in Israel by Elly Teman and Gestational Surrogacy in Iran: Uterine Kinship in Shia Thought and Practice by Shirin Garmaroudi Naef. Through interviews and participant observation field work, both ethnographic works take a look at surrogacy and its place in Israeli and Shia cultures, respectively.

The goal of Elly Teman’s work is to analyze surrogacy as a “cultural anomaly” in Israel and how it has made its own place in Israel’s pronatalist society.  She uses the concept of ‘authoritative knowledge’ to convey how “surrogates, intended mothers, and health professionals attempt to solve the anomaly of surrogacy in practice” (263). Through intuitive, medical, and technological knowledge, Teman provides insight on the surrogacy process women experience in Israel. Intuitive knowledge refers to the situation in which the intended mother ‘knows’ the pregnant body of the surrogate, providing a way for the intended mother to claim maternity. Statements from both surrogates and intended mothers mention how each woman knew she had chosen the ‘right woman’ to go through this process with her as soon as the women had met. This intuitive knowledge also served to minimize the connection between the surrogate and baby while emphasizing the intended mother’s ‘meant to be’ relationship with the unborn child through an equal partnership in the pregnancy.

Teman uses ultrasound experiences to convey another way in which surrogates extract themselves from the pregnancy and allow the intended mothers to go through the pregnancy experience as if they were pregnant. During ultrasound screenings, the surrogate “symbolically becomes a silent participant, a transparent medium,” allowing intended mothers to view the fetus as an “individual entity, alone on the screen, as if removed from the surrogate’s body” (268). Doctors and ultrasound technicians would address the intended mother and father during the screenings, reemphasizing the removal of the surrogate from the situation, both emotionally and physically, while simultaneously allowing the intended parents to feel more connected to the pregnancy process.

Doctors and other medical practioners play an important role in the surrogacy process through their “effort to designate the intended mother’s status” by addressing her as “the mother” and directing all medical knowledge to her instead of the surrogate patient (271). Along with the equal partnership between the two women, medical practioners work to create a unitary patient construction, treating the intended mother the same way they would the surrogate, providing her with all the same care. The concept of a ‘hybrid patient’ address the abnormalities that surrogacy presents (i.e. having two separate patients) and allows for normal practices to ensue after birth.

The 3 different forms of knowledge confirm the intended mother’s maternal identity and serve to “confirm, rather than challenge, the Jewish-Israeli cultural belief system” (276). I found the emphasis of an equal partnership between the surrogate and intended mother to be a very interesting experience. Also, the emphasis from the doctors and medical staff of the intended mother’s maternal identity played a very important role throughout the process, a role that I  was previously unaware of.

Questions:

• Do you think Teman’s analysis effectively addresses the “anomaly” of surrogacy in a pronatalist society such as Israel?
• Do you think all societies should promote an equal partnership approach between the intended mother and surrogate? Does this help surrogacy fit a more culturally norm framework of pregnancy?
• What type of relationship should exist between a surrogate woman and the child that is born? Should such a relationship exist at all?

In our second reading, Shirin Garmaroudi Naef explored surrogacy in Shia thought and practice and the relationships established through surrogacy and uterine kinship. Through analysis of Islamic legal texts, consultations with Shia scholars, and ethnographic field research, Naef attempts to “show how juridical meaning ascribed to physiological facts and bodily substances. . . leaves room for the legal permissibility of gestational surrogacy” (160).

In the first part of her chapter, Naef mentions that the “notions of contact and transfer of bodily substances has become an approach for studying kinship and assisted reproduction in Muslim societies” (161). Naef argues that the definition of incest in Shia thought does not depend on the transfer or contact of bodily substances, but rather on, “the illegitimate physical act of illicit sexual intercourse, and not on the act of conception itself” (163). With this notion of kinship relation, she conveys why and how Shia thought and practice define surrogacy and assisted reproduction as acceptable.

Naef emphasizes the distinction between directly inserting sperm into a female surrogate’s uterus and implanting an embryo into the surrogate’s uterus, citing it as a reason as to why sperm donation is not entirely forbidden. While it is forbidden in Sunni Islam, Shia scholars argue that, although it is not allowed, fertilization of a women’s egg with donor sperm from a man other than her husband is not analogous to zina (Islamic law concerning unlawful sexual intercourse). Shia authorities authorize such insemination in a lab dish which may then be implanted into the wife’s uterus because, since the sperm is not inserted directly into the wife’s uterus, no forbidden act has taken place. From this, traditional surrogacy is not religiously permissible according to most scholars, but gestational surrogacy is viewed as an acceptable form of assisted reproduction because fertilization takes place outside of the woman’s uterus. Also, this translates into the donation of gametes and embryos. Since the fertilization takes place outside of the woman’s uterus, it is not considered zina and the resulting child is considered legitimate. Thus, embryo transfer and gestational surrogacy are not forbidden according to Shia Islam.

Another distinction made between Sunni and Shia thought is maternal relatedness. Shia jurisprudence “recognizes a bilateral filiation in which maternal filiation acquires the same importance as paternal” (166). Because of this, females play an important role in producing and contributing to the line of descent of a child through ties of uterine kinship. Shia scholars argue maternity is established at conception and, in the case of egg donation or gestational surrogacy, regard the mother as the producer of the ovum. Because of this, a child conceived through gestational surrogacy is not considered to be related to the gestational mother or her family in any way. Likewise, the father is considered to be the man who produces and provides the sperm.

Naef also looks at the issue of breastfeeding and the important position it holds in Islamic legal tradition. According to Islamic customs, the milk bond, “establishes [a] permanent legal realtion[ship] between the child and the milk mother” as well as all members of the milk mother’s kin (173-174). The Shia position on milk kinship states that “kinship relations created by the ‘act’ (and not ‘milk’ as substance, my emphasis) of suckling is equivalent to kinship relations created by nasab” (174). However, according to the viewpoint of Ayatollah Mo’men, a prominent Shia scholar, gestational surrogacy should not be analogous to milk kinship because gestational surrogacy, “does not establish any filiation (nasab) and marriage prohibition (mahramiyat) between the children conceived in this way and the surrogate” (174-175).

The final parts of Naef’s chapter look at the experience of Iranian gestational surrogates and what they think of their experience. While many of the women she interviewed had financial incentives to partake in surrogacy, many of the women also expressed emotional reasons for surrogacy, in order to help friends or family. In both instances, “both groups emphasized the altruistic aspect of the process, helping a woman to become a mother as well as preventing a marriage from falling apart because of infertility” (176). In the end, all women believe that the resulting child does not belong to them, the gestational surrogate, but the contributors of the embryo, the “true parents.” As previously mentioned, no women considered this to be adultery because, according to the Shia notion of adultery, it is only established by the social and physical act of illicit sexual intercourse,” not the biological act, which was an important distinction to be made for many of the women. Also, many women acted as surrogates for siblings who were unable to conceive on their own because they believed it to be better than involving a complete stranger. This wasn’t considered incest because it violated no social or physical illicit act.

One of Naef’s main findings was how surrogates used the language of kinship to “disconnect themselves from the experience of surrogate pregnancy,” while also maintaining “the social order in dealing with infertility” (181-182). She also found throughout her fieldwork that, even in the presence of assisted reproductive technologies, God was still considered to be the divine creator of human life. An important conclusion made by Naef was the importance of women in the establishment of nasab as well as the important place they held in the establishment of kinship ties. Naef showed how Shia scholars applied ancient religious and legal texts to challenge the bioethical dilemmas presented by surrogacy in Iran (183).

Questions:

• As mentioned in the chapter, is motherhood a biological or legal determination? Does giving birth to a child entitle the person to motherhood?
• Do you think having your sibling as a surrogate is considered incest? Or do you agree with the Shia definition of incest, in which having your sibling as a surrogate does not violate the realm of incest?
• Can surrogacy be a truly altruistic act?

In a rapidly developing world centered around technology, I think it is time we, as a hospital, introduce the use of reproductive technology and prenatal testing to our hospital. These technologies not only reflect the incredible strides made in the medical world, but also provide pregnant women and their families with the ability to prepare for their future. As a physician at the Sasquatch Hospital, I believe these technologies are necessary to our hospital, for they will greatly improve the treatment we are able to provide to our patients.

With a growing and varied local population, the ultimate goal of our hospital should be to provide the best medical care our diverse population needs. While I understand the importance of our Catholic origins and what they mean to our donor base, I think it is more important to acknowledge the changing culture in our area. I recognize that some of the policies I am going to propose will not be conducive to the Catholic religion. However, I feel as though we should not limit the medical care and services our hospital can offer due to differing religious beliefs among our population.

One of the major policy changes I wish to make would be to provide reproductive technologies, such as in-vitro fertilization, and prenatal testing, such as amniocentesis. Over the past decade, these technologies have grown in popularity and acceptance, but still face some resistance regarding the ethics surrounding the decisions and outcomes of such technologies. Personally, I do not believe in-vitro fertilization nor prenatal testing are unethical. They are both harmless procedures and exist to facilitate and better comprehend pregnancy and its outcomes. While some may argue that IVF violates the natural laws regarding the appropriate way to conceive a child, I believe “natural laws” are more so a social construct and differ based on the individual and their beliefs. For example, the French bioethics laws initially, “restricted access to artificial reproductive technologies (ART) to sterile, heterosexual couples of childbearing age,” (Ball 2000: 545-546). The French put these restrictions in place out of fear the technological advances would alter cultural norms and defy what they considered “natural.” Although nature served as the source of truth for many Enlightenment philosophers, Rousseau stated, “philosophers of natural law who hold too strictly to the dictates of nature are ‘in habit of abstracting the content of natural law from the behavior of men in civil society. . .’” (Ball 2000: 579). I agree with Rousseau’s statement and believe that what most consider to be natural is subjective and developed from observations of society.

Along with providing IVF treatments, I would suggest implementing a provision to encourage families to allow unused embryos to be donated for life saving research. From a medical standpoint, research done on embryos is somewhat rare and the findings from such research could turn out to be crucial in the future. I understand some families will be unwilling to donate their unused embryos due to personal beliefs, but I think the provision should be included regardless. The demographic in our community has changed dramatically over the years and I think more individuals would be willing to donate unused embryos for research purposes. In order for a patient to make what they believe to be the right decision, it is important for doctors and medical professionals to explain in detail what donating an unused embryo to research entails, conveying both the benefits and consequences of donations. I want to stress that it is unacceptable to make families feel as though they are forced to donate. Pressuring a patient into making a decision that goes against what they believe in is unethical and violates our role as doctors to provide the best possible care and treatment. If the patient chooses not to donate their unused embryo, then we must honor their decision.

Prenatal testing is another service I suggest we provide at our hospital. Prenatal testing, such as amniocentesis, allows pregnant women to test for abnormalities, disorders, and defects of the fetus that previously could have only been realized once the child was born. From a medical standpoint, this technology is revolutionary, providing women with a wealth of knowledge while also giving them time to consider their situation and prepare for the outcome. As stated by someone who has undergone prenatal testing, “what harm can a test do if its going to provide you with important information?” (The Burden of Knowledge: Moral Dilemmas in Prenatal Testing, 1994). Some claim that by offering the tests we would be creating anxiety; however, I find that to be completely false. Just because the tests exist, it does not mean one must undergo them. If anything the existence of the tests can serve to shorten the period of anxiety and relieve women of the unknown.

In regards to the efficacy of prenatal testing, I believe offering and deciding to receive prenatal testing are both ethical decisions. In a study about women and the option to undergo prenatal testing, Reyna Rapp, a feminist anthropologist, described women who received prenatal testing as “moral pioneers.” She viewed these women as individuals who, “submitted to the discipline of a new reproductive technology in order to reap its biomedical benefits,” (Rapp 2004: 307). The decision to use prenatal testing has been given a negative stigma due to the fact that the test results may cause one to be more likely to get an abortion. However, that is not always the case and it should be noted that prenatal tests have the ability to provide women immense medical benefits, without a resulting in a negative outcome. The tests allow women to become aware of the situation they are going to face and provide them with more knowledge and time to prepare for the arrival of their child. Although prenatal tests are considered unethical by certain religions, I believe, as a non-denominational hospital, it is important to look at access to prenatal testing on a more individual, secular basis.

While I personally support the use of prenatal testing, I do understand the issues some individuals still have with such tests, one of them being abortion. A few years ago, the majority of our community was Catholic and many members of the community felt that it was unethical for our hospital to provide abortion services. In recent years, the demographic of our community has sufficiently changed, bringing new cultures and beliefs to our population. After surveying the population, I found close to half of the community identified as pro-choice, reflecting a shift in our cultural norm. Because of this, I advise that the hospital provide abortion services to both insured and uninsured patients. Subsidies for abortions should also be provided and should be determined on a case by case analysis of the patient and their financial situation. I realize that most of the donors still identify with the Catholic religion and the church’s viewpoint on abortion, but we must realize that we are now a non-denominational hospital, and we should respect and cater to the changing ideals reflected in our society. As doctors and providers of care, we made a decision to help the lives of others above all else, regardless of whether or not we personally agree with such services.

The notion of cultural competency has become extremely important in aiding the communication and understanding between patients and their medical team. Defined as, “the need [for healthcare providers] to be understanding as well as sensitive to the different cultures, socioeconomic backgrounds, and belief systems of their patients,” cultural competency allows doctors to adequately and effectively provide care based on their patient and the patient’s needs (Bhattacharya 2006: 5). Regarding the improvement of cultural competency, I think it would be beneficial to continue counseling from Catholic clergy and expand counseling services to clergy of all religions. Being as we are no longer a predominately Catholic community, I believe the expansion of religious counseling services is integral to providing the best care our diversified community. Throughout my experience, I have come to find that religion helps some patients better understand the rather secular nature of the medical language.

In implementing this provision, it has come to my understanding that some doctors have complained about how the opposition to reproductive technology by clergy interferes with their work as a medical professional. As a doctor, I understand the frustration that stems from patients choosing to listen to religious guidance over medical expertise, but the implementation of religious counseling could greatly improve the patient/provider relationship. An example of how religious beliefs come to effect medical decisions can be found in a study done by Sherine F. Hamdy in which she examines why Muslim men come to refuse life-saving treatments. One Muslim dialysis patient in Egypt refused to get a kidney transplant because he believed his body “belong[ed] to God,” and God had already decided when he would die before he was even born, so accepting a transplant would be altering God’s decided path for him (Hamdy 2013). As a doctor, it’s hard to see a patient refuse a treatment that would save their life, but it is important to respect their decision and understand the beliefs behind the decision.

With these new provisions in place, I believe this hospital will be better suited to serve the needs of our local population. By acknowledging both our individual differences and the ever-changing nature of society, we will be able to provide more advanced medical service and improve the lives of those in our community.