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As a Catholic nun, who was raised in a non-Catholic family and converted as a young adult, I do not believe that we should begin providing and subsidizing abortion services for under-insured patients. Every life, which is started at conception, is a gift from God—no ifs, ands, or buts—and thus should be protected. By providing and helping to pay for these services, it shows that we are in support of humans having the right to place or take away value on an innocent life (Donum Vitae 1988: 147). Furthermore, I do not think we should support IVF treatments and prenatal testing including amniocentesis. These services “expose [man] ‘to the temptation to go beyond the limits of a reasonable dominion over nature’” (Donum Vitae 1988: 141). A life is not ours to say whether or not it should be worth living, even if it may be in a woman’s womb.

Prenatal testing and amniocentesis gives patients the knowledge and the chance to “play God”, to be able to choose whether the life of a fetus is worth living or if the patient is able to care for the fetus when born. Prenatal testing does not tell a patient if his or her baby has a genetic disease. It only tells patients if the baby is at risk. In order to ensure a baby has a certain genetic disease, then amniocentesis should be carried out. Amniocentesis is an invasive process, and when getting this procedure, the patient has a 1:200 chance of getting a miscarriage, which is the same ratio of chance of a patient’s baby having Down’s syndrome if the patient is older. Additionally, being a parent includes the commitment to unconditionally love one’s baby, and choosing to get an abortion because of a genetic disease interferes with that commitment. Also, if given the option, “an infant wouldn’t choose to die like an adult would choose to die at the end of his [or her] life” (“The Burden of Knowledge: Moral Dilemmas in Prenatal Testing” 1994).

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

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

In addition to social workers and genetic counselor, the hospital use to provide spiritual counseling by Catholic clergy. This counseling should be continued and not open to clergy of other religions. These Catholic values are not just Catholic. They are humane values of humans valuing other human’s lives. They are values any human could have if they have respect for human life. Though I understand that the medical staff believes that the Catholic clergy are interfering with their work by opposing assisted reproductive technology and late term genetic testing, the medical staff can sometimes be close-minded to not the argument that the Catholic clergy are making. The medical staff can make decisions that they think are the best for the patients but fails to think about its consequences on the fetus. The decision to end a life of a fetus is not favored by us Catholics who also believe that our beliefs align with natural law.

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

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

I will also try to remind the nurses that ultimately, although I am also against these services, if the hospital starts to provide these services, that we are all children of God. The first commandment that God gives us is to love one another. We are not all perfect and strong enough to decide to have reject these abortion and reproductive services. Shower patients with love and patience while they are going through a difficult moment in their life. Unless they would like to resign from their position or continue to express their discontent to the administrators of the hospital, I would leave the work  with those are willing to do the services. In the case of having no nurses to provide the nurses, then the hospital should reconsider providing abortion and reproductive services especially if some funds will be lost and nurses refuse perform procedures. The hospital has to decide which is more important: serving the patient population or continue operating and functioning as a hospital.

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

God bless,

Sister Nguyen

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.

 

Sasquatch Community Hospital

Sasquatch, Connecticut

 

March 21, 2017

 

Dear Ethics Committee,

My name is Greeshma Magam and I am a female Indian-American physician who is an active follower of the Hindu faith. Due to my diverse background, I was asked by the hospital administrators to provide a complementary perspective to the pressing questions addressing alternate reproductive technologies that your committee is discussing at this time.

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

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

In-vitro fertilization (IVF) is an expensive procedure for families who are unable to conceive naturally. While I believe that IVF is an important medical service that should be offered, I understand due to its’ expenses why your hospital would be unable to subsidize these services for under-insured patients. Unless your hospital can receive funding for these services, I do not believe that IVF should be subsidized. However, I do believe that these services should be in-place in this hospital in the event that patients who can afford its’ services want to undergo this procedure.

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

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

Your committee is also debating the inclusion of spiritual counseling by Catholic clergy. While historically Catholic, your hospital is currently non-denominational. Due to this, I believe that if Catholic clergy is present for counseling, your patients should have access to clergy members of other faiths as well, especially since the population you treat includes people of many faiths and cultural backgrounds. Regardless of the testing and technology that the medical staff favors, the eventual decision for or against the use of assisted reproductive technologies should encompass the views of the patients. As a member of the science community, it can be hard to sometimes differentiate your views from others, but in the end, this decision will impact the lives of the parents more than it will impact the lives of the healthcare providers. Catering to the values, traditions, and faiths of individual patients is equitable to the conversation that Swasti Bhattacharyya describes as “cultural competency” in her book Magical Progeny, Modern Technology (Page 23).

I understand that some of your nursing staff is concerned regarding the potential reproductive technologies your hospital may offer, especially since they hold conservative Catholic views. In order to provide these services and still keep the staff of your hospital satisfied, I believe the hospital administrators should send out a questionnaire to understand exactly how many members of the staff will not provide the procedures, how many are comfortable with assisting in the procedures, and how many will provide the procedures. Using this data, hospital administrators can devise teams of members who can perform the procedures. In this case, the hospital will be developing teams who are comfortable in performing prenatal testing, IVF, amniocentesis, and abortion, while also respecting the views of the primarily Catholic staff who do not want to perform the procedures.

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

Sincerely,

Greeshma Magam, M.D.

 

Sources

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

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

 

My name is Hannah Gold: anthropologist, scientist, and mother. I am here to speak in opposition to this policy proposal. I am from a nearby city outside of Sasquatch therefore I can provide an unbiased, reason-based outsider perspective on this ethical dilemma. I want to begin by outlining the Catholic Church’s position on the topic of Assisted Reproductive Technologies (ART). We must first understand where this hospital stood on this issue prior to its separation from the church in order to judge just how big of a value shift this hospital would have to make if we were to begin to subsidize abortion services, IVF treatments, and prenatal testing. Donum Vitae, the statement by the Congregation of the Doctrine of the Faith on bioethical issues, takes a clear stance against ART if it in any way endangers a fetus. The church states, “Since the embryo must be treated as a person, it must also be defended in its integrity, tended and cared for, to the extent possible, in the same way as any other human being as far as medical assistance is concerned.” (CDF, 1987: 149) This translates to a complete opposition to abortion and IVF (due to the fact that it is not morally permissible to destroy an embryo at any stage), and acceptance of but strict limitations to prenatal testing. Hypothetically this hospital could offer non-invasive prenatal testing and have it align with its previous values. However, what happens if the tests uncover something horribly wrong with the fetus? There are no options here, as abortion is absolutely not permitted. This begs the question, what is the use of offering amniocentesis procedures if nothing can be done about positive results?

Beyond the official documentation of the Catholic Church’s position, these values permeate into the everyday lives of practicing Catholics. A look into the history of this town and its inhabitants is proof of this; it took until 2017 for this hospital to even consider offering assisted reproductive services. In her ethnography Testing Women, Testing the Fetus, anthropologist Rayna Rapp interviewed American women of many denominations to understand the role that spirituality plays in decision-making during pregnancy. One woman said, “Basically, I grew up Catholic, I think it’s tragic to end a pregnancy, to end a life.” (Rapp, 2004: 155) Rapp writes, “several catholic women…told me they were afraid to go to confession in their neighborhood parish churches after having amniocenteses.” (Rapp, 2004: 159) It should be clear by now that, based on the value system outlined above and the fact that this town has operated under Catholic auspices for over one hundred years now, this hospital has a long way to go on the road to accepting and offering reproductive technologies.

Now, a divorce from the Irish-Catholic denomination is a fantastic opportunity to update the ethical ground upon which this hospital operates; an opportunity to include belief paradigms and ethics systems of this entire community rather than just appealing to the catholic ideology. One way we should do so is by discontinuing spiritual counseling for Catholics. This type of counseling serves a very narrow audience. Our objective here is to become more inclusive; to offer services that all community members will be accepting of and have access to. Spiritual counseling through medical decisions can very well continue within specific religious circles, however it is not a necessary component of this hospital. A separation from the Catholic Church requires a clean slate and a redesign of the foundational values this community is built upon. We now must consider the broader community of Jews, non-Irish Catholics, Japanese immigrants and Shiite Muslims, and the values systems represented by individuals within these groups.

In her ethnography Reproducing Jews, Susan Kahn evaluates the Jewish-Israeli position on assisted conception, which is arguably the most liberal out of our four representative populations. She writes, “at the time of my research in the mid-1990s, there were more fertility clinics per capita in Israel than any other country in the world.” (Kahn, 2000: 2) Kahn ultimately argues that these technologies are supported by, not counter to, Jewish religious law. She writes, “from the perspective of Jewish law, infertile couples seeking to solve their childlessness with the air of new reproductive technologies does not evolve out of a consumerist impulse but out of a compulsion to fulfill a divine commandment.” (Kahn, 2000: 170) However, despite a general acceptance of ART in the Jewish community, that is not to say that all Jews are equally tolerant. In his chapter in the book Kin, Gene, Community, Dr. Don Seeman mentions Rabbi Eliezer Waldenman, an “important posek (decisor) identified with the Haredi or ultra-Orthodox community of Jerusalem, which opposed IVF as ‘unnatural.’” (Seeman, 2009: 349) A similar dichotomy is observed in the Shi’ite Muslim population. In her article titled Kinship, Propriety, and Assisted Reproduction in the Middle East, Morgan Clarke writes, “Almost all authorities, Sunni and Shi’a, are in agreement that artificial interventions in human reproduction are welcome, as a scientific advance and medical boon, insofar as they involve only a husband and wife couple.” (Clarke, 2007: 74) While this guideline seems simple, it is actually ripe with complexity in practice. IVF, donor insemination, and surrogacy arrangements are considered forms of adultery, therefore are forbidden by Islamic law. (Clarke, 2007: 75) Even when the procedures are performed, there is extreme judgment surrounding them. Through interviews with medical contacts in Lebanon, Clarke found that “infertility is stigmatized, and any suspicion of abnormality, especially in the field of sexuality and reproduction, is to be avoided.” (Clarke, 2007: 74) Lastly, we shall examine Japanese populations. In her studies on reproductive technologies in Japanese medical practice, anthropologist Tsipy Ivry found that technologies such as prenatal diagnosis “currently [are] located backstage of prenatal care.” (Ivry, 2010: 77) She cites the reason for this opposition to be the fact that Japanese people regard a mother and fetus as one single entity. She writes,

“The gravity of the conceptual tension that PND tests—a set of technologies in which ‘the embryo and fetus come to be visualized as patient-like entities entirely or largely independent of the woman’s body’ (Locke 1998, 206)—introduce into a medical system that tends to emphasize the embodied mode of maternal responsibilities for fetal health.” (Ivry, 2010: 105)

Here there isn’t so much a conflict of beliefs and values like we have seen in Catholic, Jewish, and Muslim populations, there is just a general lack of interest in these services.

We can now consider a scenario in which this hospital provides abortion services and subsidizes them for under-insured patients, and how this would affect our patients, staff, and finances. As detailed above, the values held by the ethnic and religious groups in this community have extremely mixed opinions about ART. Even in the Jewish population, seemingly the most liberal when it comes to reproductive technologies, there exists fierce opposition to many of the practices. Of course the positions I outlined above are not by any means wholly representative, rather they likely inform the individual experience of decision-making during pregnancy. We therefore should not offer these services because evidence suggests there would not be a large enough consumer/user population.

Next, we must consider the staff of this hospital and the administrators who run it. A useful analogy here is that of traffic waves. When a traffic incident occurs such as an accident or construction, traffic on a highway will continue in a specific location long after the cause of the back-up has cleared. This physical phenomenon is analogous in many ways to the introduction of new technologies into a hospital. Say we make a decision to offer ARTs in our hospital. We have resolved our ethical traffic jam; however there would be persistent consequences of the implementation of these technologies for the staff who must use them. We are, essentially, forcing a value system upon a population of healthcare professionals and requiring that they perform procedures they do not agree with. Even if the doctors are willing to do the procedures, consider the stigma they hold. In her interviews with medical professionals in Lebanon, Morgan Clarke found that clinicians had to be extremely careful to tiptoe around the stigma. She wrote, “medical contact in Lebanon initially insisted on my signing a confidentiality clause, warning me, with perhaps exaggerated concern, that a breach of privacy could result in ‘honour killings’.”(Clarke, 2007: 77) In Rayna Rapp’s work, she found that many Catholic women feared going to their neighborhood churches after having amniocentesis. (Rapp, 2004: 159). I will now outline potential consequences of requiring hospital personnel to do these procedures.

As I mentioned above, the values held by our predominantly Irish-Catholic staff would interfere with them performing procedures such as abortions, IVF, and amniocentesis. This is a large reason why our hospital should not offer them. Though we are working with trained healthcare professionals, it is not a good idea to allow a community of healthcare workers to perform procedures they fundamentally do not agree with. This would be irresponsible for a hospital to do, as the quality of care would go down.

Finally, we all know how important a donor base is to a hospital, especially one in rural Connecticut. Who is to say that we could even afford the technology, never mind pay new specialists to perform the procedures and counsel our patients? Without a donor base, how conceivable is it that we could acquire the technology, hire people to train our staff, and hire more staff to perform the procedures? It has come to my attention that doctors have complained about Catholic clergy interfere with their work. Susan Kahn describes a similar scenario in Reproducing Jews, where rabbinic concerns for ART provide a major obstacle to Orthodox Jews seeking these medical procedures. In fact there is an entire organization (titled PUAH) is dedicated to mediating the relationship between religious and medical authorities in Orthodox Jewish communities in Israel (Kahn, 2000: 89). My answer to this dilemma is, what about the business we lose when patients deflect to other hospitals? What about the money we lose on equipment and professionals to perform procedures, with no one willing to have them? Perhaps most significant, what about the money we lose when we lose our donor base? To a certain point it is very important to appeal to the values of those who give us money. As Adam Smith said, “all money is a matter of belief.”

On the one hand, a hospital has a duty to reflect the beliefs of its population, or else a foundation of trust and mutual understanding cannot exist. Anthropologist Sherine Hamdy writes,

“the perceived efficacy of a treatment plays an important role in shaping one’s ethical stance toward it. To understand how patients arrive at complex ethical decisions, we must be attentive and vigilant to their own experiences and understandings of their disease processes and etiology and their own cost-benefit analyses, which may be articulated in religious terms.” (Hamdy, 2012: 156)

If we begin to offer and subsidize abortion services, individual with strict catholic beliefs on abortion will feel less comfortable seeking treatment at this hospital. Being the main resource for healthcare in this community, that cannot and should not be the case. In Testing Women, Testing the Fetus, Rayna Rapp discusses the importance of environment to women and families seeking care at hospitals. The more successful patient care settings Rapp observed are those in which patients feel the most comfortable. She writes, “entering into the ecology of prenatal clinics are the stability of residential neighbourhoods: city, state, and federal health care funding and politics, hospital labor contract negotiations and issues of community control.” (Rapp, 2004: 169) Additionally, in her book Magical Progeny, Modern Technology, Swasti Bhattacharyya highlights the importance of what she calls “cultural competency.” This 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.” (Bhattacharyya, 2006: 5) By offering treatments that fundamentally clash with the beliefs of most of our patient demographic, we are putting our cultural competency in jeopardy. This hospital thus should not offer or subsidize abortion services, IVF treatments or prenatal testing.

On the other hand, as a modern-day hospital it would be irresponsible to not offer the most advanced and up to date treatments to our community. Additionally, not offering these services does not mean members of our community will not seek them out, it just means they have more hoops to jump through to receive adequate care. I propose we open a separate fertility clinic in our community, not affiliated with the hospital. This will provide an opportunity to offer abortion, IVF services, and prenatal testing, as well as hire a new staff with no conflicts of interest. Through a detailed analysis of many religious/cultural standpoints on issues of bioethics, it becomes extremely clear that patients seeking reproductive therapies should be considered in a case-by-case basis so as to respect the complex nature of decision-making in pregnancy. In their ethnographic work titled Blessing Unintended Pregnancy, Don Seeman et al write, “as many studies show, women make decisions about mothering and reproduction amid a complex layering of structures, beliefs, and values…” (Seeman et al, 2016: 44) Rayna Rapp argues that women are “at once held accountable at the individual level for a cascade of broadly social factors which shape the health outcome of each pregnancy, and individually empowered to decide whether and when there are limits on voluntary parenthood.” (Rapp, 2004: 319) A hospital previous rooted to such a specific set of values is not equipped to honor this complexity. However, a separate clinic in our community would. Let’s stop trying to squeeze the practice of ART into our institution, a place that comes with heavy baggage that would be tough to divorce from. Rather, let’s focus our efforts on building a safe space–unaffiliated with any one belief system–and hiring trained and willing staff so families can make their own decisions about fertility therapies.

 

 

 

 

 

Assisted Reproductive Technologies and Prenatal Testing Policy Proposal

 

Dear Ethics Committee of Sasquatch Medical Center,

My name is Petar Zotovic and I am a fertility physician here at Sasquatch Medical Center (SMC). Recently, the Catholic Church has allowed our hospital to become non-denominational, one of the reasons being due to the diverse and growing population of Sasquatch, Connecticut. As you all know, Sasquatch has deep Irish Catholic roots and this was an important factor to consider while constructing the policy proposal. To members of the committee who do not fully understand the beliefs of each group in Sasquatch, I will state them briefly to you.

Irish Catholics are vastly against the use of Assisted Reproductive Technologies (ARTs) and prenatal testing (in cases of abortion), such as amniocentesis (Cahill et al. 1988: 143). In recent years, the city has seen a rise in population of minority groups which hold differing beliefs regarding ARTs and prenatal testing. The Jewish community favors the idea of ARTs, noting God’s first commandment, “Be fruitful and multiply, and fill the Earth, and subdue it…” (Bible Hub, Genesis. 1.28). With regards to prenatal testing, the Jewish population supports and even encourages procedures which may benefit a mother and fetus (NISHMAT 2000: 2). The Caucasian and African American population also support the use of ARTs and prenatal screenings if prices are affordable. The majority of African Americans in Sasquatch who live in poverty has increased by four percent in the past decade, and most are under-insured (Armstrong, Plowden 2012: 652). I am mentioning this because these individuals will qualify as patients for which the hospital will subsidize their medical care. In addition, Lebanese Shiites are proponents of ARTs as long as they are able to preserve their faith in Allah during the procedures. Similarly, they support prenatal screenings (Inhorn 2006: 96-97). The increasing Japanese population advocate the use of ARTs, especially in vitro fertilization (IVF), but opt out on prenatal testing. They prefer to abide by an “environmentalist” approach, which states that the mother is directly responsible for her fetus and is to make sure she does not gain excessive weight or engage in any unhealthy activities (Ivry 2009: 11). After taking into consideration the various beliefs of the people in Sasquatch, I am proposing a policy which allows the use of all ARTs available to the hospital; in addition, prenatal screenings are only allowed if the intention is to not abort a fetus if an abnormality is found to exist. My policy proposal attempts to satisfy the diverse population in Sasquatch, while still attempting to adhere to its Catholic roots regarding prenatal testing.

In attempts to abide by the still prevalent and dominant Catholic faith in Sasquatch, all attempts at abortion will not be executed. In the past, Sasquatch was a safe haven for Irish Catholics and was once ruled by Catholic auspices, so retaining some of their beliefs is still important. In addition, I agree with Cahill et al. in Donum Vitae when they state that “The human being must be respected- as a person- from the very first instant of his existence” (1988: 147). As a result, subsidies will not be granted in abortion cases. In alliance with my stance on abortion, prenatal screenings may only be conducted to examine a fetus for abnormalities. No attempts at termination may be done once tests have been performed. If the results of a prenatal test, such as amniocentesis, return with negative results, then the patient will have the opportunity to discuss their feelings and find ways to cope with a hospital counselor. All ARTs, including IVF, will be subsidized by the hospital for under-insured patients. IVF protocol will have a provision which will respect Islamic law; the provision will state that Shiite Muslims are eligible to participate in IVF if it involves a husband and wife couple. I am stating this because of Morgan Clarke’s ethnographic study in Lebanon; she concluded that Islamic law plays a crucial role in determining rules by which females must abide by if they want to undergo IVF treatment (Clarke 2007: 72). In her study, she comments “The prime principle at stake here is whether such scenarios are analogous to, if not identical with, the heinous crime of zina, that is sexual relations between parties not bound by a contract of marriage…” (Clarke 2007: 74-75). The preceding quote demonstrates the necessity of a husband and wife couple when performing IVF on Muslims. Of course, IVF treatment not between a husband and wife couple will be allowed if the patient and donor both agree and/or if no religious beliefs are interfered with. The following protocol on IVF will show the emerging minority population their beliefs are heard of and will be respected at SMC.

With regards to unused embryos being used for life-saving research, SMC must abide by two provisions. The first provision states that SMC will not be allowed to abort any embryos, keeping in line with Catholic roots in Sasquatch. The second provision states that frozen embryos may be used for life-saving research if they have not been placed inside the mother’s uterus and if the patients’ give consent. With regards to the second provision, I align with the Islamic belief that an embryo is not considered human if it is not inside the mother’s uterus; the embryo outside the uterus will not survive if it is unfrozen and is therefore not considered human (Eich 2008: 63). In “Decision Making Processes Among Contemporary ‘Ulma’: Islamic Embryology and the Discussion of Frozen Embryos”, Thomas Eich describes ‘Abd al-Salam al-Ibadi’s view on the topic by mentioning “Concerning the question of frozen embryos, he argued that the majority of classical fuqaha would have opposed abortion. Therefore, the use of frozen embryos for research could not be allowed, and the embryos should be implanted in the mother’s uterus” (2008: 68). I disagree with Ibadi’s statement because a large number of Muslims have differing views from the classical fuqaha he describes. Instead, expected costs and benefits, such as the opportunity to save a life, should be analyzed when deciding to donate frozen embryos for research.  Above all listed priorities, patient consent is paramount. Only once patients have been fully informed about the research process, they will be able to donate their frozen embryos for research. This will eliminate any confusion on behalf of the patient and enable them to have more confidence in their decision.

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

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

 

Thank You,

Petar Zotovic, M.D.

 

 

 

Works Cited

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

vol. 9, no. 6, 2012, 651-658.

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

“Prenatal Testing.” NISHMAT, 2000, 2.

All other sources are from class readings.

 

 

 

 

 

 

 

 

 

 

I am on the hospital ethics committee as the head of the nursing staff and as a nurse practitioner. I am from an Irish catholic background as are the majority of the other nurses. I have worked at this hospital for 30 years and was reluctant to see it go through the transition of becoming non-denominational. I speak for the majority of the nurses at the hospital who have expressed to me similar complaints as myself.

1.

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

Similarly to the reasoning behind refusing abortion services, I believe that the hospital should not allow for IVF treatments when such treatments result in the discarding of “extra” embryos. It is important to reflect on this position from a rational lens, examining the fundamental values of life and whether or not it is permissible for technological interventions to replace human procreation and to affect a human in the first stages of development (Donum Vitae 1987: 146). In fact this teaching has been backed by science in the sense that “modern genetic science brings valuable confirmation. It has demonstrated that, from the first instant, the program is fixed as to what this living being will be: a man, this individual man with his characteristic aspects already well determined. Right from fertilization is begun the adventure of a human life” (Donum Vitae 1987:148). Therefore IVF treatment disrupts the development of a new life, and therefore changes the natural course of events in human’s biology. Technology is so advanced that now individuals can choose embryos based on lack of disability, or even gender. This type of selectivity puts the physician and the parents as usurpers of the place of God, as they will be “the master of the destiny of others inasmuch as [they] arbitrarily chooses whom [they] will allow to live and whom [they] will send to death and kills defenseless human beings” (Donum Vitae 1987:154). To prevent IVF is to safeguard against what could approach becoming a new type of eugenics, pitting parents against children of disability or children of a certain sex. We as a hospital ethics board must continue to prevent these future immoral acts.

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

2.

The community based around this hospital is increasingly diverse, and I believe that we as a hospital system should grow in our spiritual counseling to reflect that diversity. The Church holds the utmost respect for other religions and I believe that we should diversify our counseling group to reflect this. In less centralized religions such as Islam or Judaism, the advice of different counselors is especially important to families as there is less of a centralized mandate compared to that of the Church. The values placed on new families may also be different, for instance instead of focusing on natural law and the human person, Islam bases much of its reproductive ethics on the legitimacy of kinship relation (Clarke 2007: 82). These different methods of guidance should be available to our patients.

While many of these religions are more permissible and flexible with regards to ARTs, abortion and prenatal testing, it does not require us as a hospital to provide these different services. On one hand, belief systems of patients may play a large role in why patients choose to undertake procedures that are considered morally impermissible and against natural law (Rapp 2000: 53). At the same time, healthcare delivery in the United States is centered on choice and free will and these patients may go elsewhere to take part in these services. It would be more morally impermissible for us as a hospital to create exceptions, allowing for certain religious groups to obtain these procedures and going against our traditional hospital mandate, than for us to make a blanket statement that provides equivalent and morally justified services to all of our patients.

With regard to the claim that Catholic clergy are interfering with the doctors’ work, it is important to understand that families absolutely always have the right to refuse testing or ARTs, or any treatment in general. The doctors in this hospital should not be recommending that women undergo treatment that puts the fetus at unnecessary risk and should not allow for IVF treatment due to the destruction of fertilized embryos. If doctors are unable to recommend against these procedures for the reasons stated earlier they should at the minimum remain value neutral and refer the patient elsewhere if it is their expressed desire to undertake these morally illicit procedures.

3.

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

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

The inevitable solution to a situation in which different groups of people have different objectives is to provide most services but restrict their usage. We should provide In Vitro Fertilization (IVF) treatments for our patients. Studies have shown that a small but significant portion of the Jewish and Lebanese Shi’ite communities use IVF as a way to overcome infertility. Though these studies were not conducted in the United States, the anthropologists at Sasquatch hospital have made similar conclusions among the Jewish American and American Lebanese Shi’ite communities. The statement made in Genesis that we should “be fruitful and multiply” has been interpreted by the Jewish community to be a commandment. The Jewish community places an emphasis on reproduction. Additionally, most religious leaders agree that life does not begin at conception. These reasons among others lead to the general acceptance of IVF among Jews (Kahn 2000:3). Shi’ite Islam promotes decision-making through the use of individual thought processes, also known as ijtihad, but practicing Shi’ites also hold the guidance of local religious leaders in high esteem. Most of these leaders have approved of IVF technology provided that certain precautions are taken. Shaikh Fadlallah, one of such religious leaders, and a Sunni religious leader both agreed that IVF is permissible when the gametes are provided by the couple that wishes to conceive through this process (Inhorn, 2006: 111). IVF is valued by important segments of our population, so we need to provide these services to them.

It is important to appeal to our largely Irish Catholic donor base as well because without them, we cannot run this hospital. We should take their perspective into account when making policy influencing pregnancy. We should not subsidize abortion services because doing so would contribute money from donors towards initiatives they do not approve of. Additionally, the Department of Social Services (DSS) in Connecticut funds all abortions that are medically necessary as per Doe v. Maher in 1986. Medical necessity is decided by the physician of a patient. It includes “health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition; or to prevent a medical condition from occurring. (Cohen, 2010: 1). We should fully cooperate with the DSS of Connecticut to allow under-insured patients to receive abortions under conditions where they are medically required.  To reduce instances of abortion and unnecessary killing of what many Catholics deem as life, we should only allow it to be performed in situations when the mother’s or fetus’ life is at risk during the pregnancy (Cardinal Joseph Ratzinger and Archbishop Alberto Bovone, 1987: 149). In addition to abortions, prenatal testing and amniocentesis are necessary provisions to allow people to exercise precautions in their pregnancy. In particular, members of the Jewish community utilize these resources (Ivry, 2010: 11). Individuals using this service at our hospital would not be able to terminate a pregnancy based on any genetic conditions they discover, however, because under my policy proposal the hospital wouldn’t allow voluntary abortions. Instead, they could use this information to prepare for the consequences of the genetic disease once the child is born. These services would also allow healthcare providers to ensure the health of the fetus and mother during the progression of the pregnancy. The restrictions placed on abortions, prenatal testing, and amniocentesis would appeal to our Irish Catholic donor base, so our hospital can continue to run under their generous financial contributions.

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

In regards to spiritual counseling, it is necessary to make a change in policy. We cannot provide all these assisted reproductive technology services and continue to have a solely Catholic spiritual counseling service. This would send out a conflicted message to our community that we provide these resources, but our staff vehemently discourages patients from using them. Additionally, we need a more diverse group of counselors to allow patients to make informed decisions. Patients should be allowed spiritual and cultural support of their choosing before they make decisions about whether they should use assisted reproductive technology or not. I propose that we incorporate counselors from different disciplines. This should include support that ranges from African American Catholic priests to Japanese cultural advisors. The diversity of opinions should alleviate concerns by doctors that the Catholic spiritual counseling is directly conflicting with their work. While I don’t expect secular doctors to fully support any spiritual counseling, I believe it is important for patients to be able to reach out for religious support when they see fit.

Some staff members may oppose many of the new initiatives I propose to incorporate into our care of patients. If the hospital is going to move in this new direction, we need the full cooperation of all our healthcare staff. Therefore, we should not only provide training programs to teach our current staff how to perform these new procedures, but we should also hold educational sessions to remind the staff that what we are doing is ethical and is best for the community as a whole. If many staff members continue to resist performing these procedures, we should train a group of current staff dedicated solely to performing these procedures and ensuring that patients feel as comfortable as possible during the process.

As the CEO of Sasquatch Hospital, I have proposed a plan here that requires concessions from all members of the community but addresses everyone’s concerns. A situation as dynamic and complex as this one requires oversight and openness to change. It is necessary to assess the satisfaction of the variety of groups affected by our decisions. Therefore, we should reevaluate after a year to see how doctors feel about the change in protocol and if patients are using the services we provide. We should also see if patients are using the spiritual counseling resources in their decision making process. Though we always need to reevaluate, I am confident that the plan proposed here would allow the hospital to address the concerns of the diverse population of Sasquatch, Connecticut.

 

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

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.

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

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

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

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

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

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

Discussion Questions

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

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

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

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

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

Discussion Questions

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

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?