Author: Selina Liu

Dear Sasquatch Connecticut Ethics Committee,

As a new member of this committee, I have written a policy proposal on the use of assisted reproductive technologies and prenatal testing for our hospital. My previous position on the Ethics Committee of the Medical Board at the Mount Sinai Hospital allowed me to gain experience in a diverse community. Being one of the few female doctors on the ethics committee at Mount Sinai, I learned that at times one must put the patient’s needs over their own personal views or the views of the majority. It is often difficult to make policy decisions that pleases everyone when it comes to controversial topics, such as assisted reproductive technology and prenatal testing. In a hospital that recently became non-denominational in a varied community that is seeing an influx of minority immigrants, its policy should reflect what patients need. The more services the hospital provides, the more patients and potential donors it will attract. A variety of services will increase patient satisfaction; however, the convictions of the healthcare provider should still be considered. Therefore, my proposal would attempt to find a middle ground where both our predominantly Irish Catholic donors and diverse community will be content. It would be insensitive for a healthcare provider that provides services to patients of different backgrounds and beliefs to have one unwavering view for hospital policies. The goal of a hospital should be to improve outcomes and create more satisfied patients.

After reviewing my initial hospital policy on abortion, I have decided to make some changes. I acknowledge that the donor base is still prominent Irish families, who will most likely have a Catholic stance on abortion: “human life must be absolutely respected and protected from the moment of conception” (Donum Vitae). However, the community is not made up of only Irish Catholics and the hospital should accommodate women in the community not of the same religion or beliefs. In hopes of reaching a middle ground, the hospital will not be providing abortion to the general public but only for extreme circumstances. These extreme circumstances that the hospital deem acceptable for abortions include pregnancies from rape and pregnancies that jeopardize the mother’s life. Although the hospital will offer prenatal testing, regardless of the results patients will have to go to another hospital if they want to abort their unborn child. “If pregnancy is highly risky, birth seems even more so”; therefore, for us as a hospital we need to do right by the patient (Ivry). If a mother’s life is in danger, the hospital can abort the unborn child out of self-defense. Rights advocates would say that one must consider the fetus’s rights as a person; however, if killing in self-defense is not punishable then aborting an unborn child that is killing the mother should not be condemned. What about the rights of the mother? This same question applies to whether or not it is okay to abort a fetus resulting from rape. The mother’s rights were violated when the rape occurred. It would be cruel to add insult to injury and make the mother keep the baby as a constant reminder of the rape. Some will argue that by aborting the fetus, there would be two instances of rights violation instead of one. For Pro-Life supporters, abortion is murder. However, if the potential mother cannot get an abortion her original life is “ending” in a way as well. Her life could potentially be ruined and forever changed, not by her own volition. For these extreme cases, the hospital will subsidize abortion services for under-insured patients.

As for In Vitro Fertilization (IVF), Sasquatch Hospital will only provide treatments for husbands and wives that are looking to start a family. According to the Catholic Church, artificial reproductive technology goes against “natural” law and Scripture. Those people that are faithful to the religion should not use artificial reproductive technologies. Since the Church associates IVF with abortion because during IVF not all embryos are implanted; therefore, an “act against the life of these human beings” (Shannon and Cahill, 154). However, it is acceptable for a husband and wife who cannot conceive to seek other options such as IVF. The prominent Irish Catholic donors should not take issue with these conservative terms and continue to donate to Sasquatch Hospital. Similar to Israel, where IVF is subject to both medical and Jewish religious oversight Sasquatch Community Hospital will offer religious counseling for patients. The interpretation that reproduction is an “imperative religious duty” prevalent in the Jewish community would encourage people to support IVF (Kahn). The option for IVF will also benefit the Lebanese Shiite and Japanese immigrants. This condition that IVF at Sasquatch hospital can only take place between a husband and wife also satisfies the religious beliefs of the Lebanese Shiite since “most Shia scholars […] argue that the act of fertilization of the woman’s egg with the sperm of a man other than her husband’s is not allowed” (Naef). The child will be considered illegitimate depending on whether or not gaze or touch occurred.

A few years ago, Athersys, a biopharmaceutical focused on stem cell research approached Sasquatch Hospital for a collaboration. The deal was that Athersys would donate funds to the hospital if doctors encouraged patients to donate their embryos to potentially life-saving research. This collaboration will be made transparent to all of the participants/patients and they can opt in to donate their embryos or pay to freeze them for later use. This potentially life-saving research can also lead to a more efficient and less invasive prenatal testing while also helping out the hospital. Since only one embryo is carried to term, the rest would either be disposed or frozen. If “extra embryos are frozen and can be kept over a period of several years for later use without significantly losing their potential develop successfully into human beings through pregnancy” then we should not let this potential go to waste (Eich). Similar to how society condemns human testing unless given informed consent one can argue that no consent was given by the donated embryo therefore a violation of rights. One opposing view is that the hospital is obligated to abide by “the inflexible principle that utter helplessness demands utter protection” (Kass). The question is at point does one considers the embryo a human being and whether or not an embryo deserves to be treated with respect.

Prenatal testing such as amniocentesis will be offered to women and families who want to reduce contingency. However, as a hospital in a predominantly Irish Catholic community we want to emphasis that these genetic tests are done not for the purpose of terminating difficult pregnancies if there is a defect but more so to allow families to make arrangements early in light of the knowledge. The hospital will not push mothers to undergo amniocentesis but they will be made aware that it is an option. If a family has a history of birth defects then and only then can the doctor suggest to the mothers to undergo prenatal testing. Since “Japanese ob-gyns are often reluctant to mention prenatal diagnosis even to older women […] some of the Israeli ob-gyns I interviewed said that they offer prenatal diagnosis to each and every patient, regardless of her age” (Ivry), the doctors at SCH will allow the patients to make the decision themselves. With this policy, I was hoping to help the Japanese immigrants feel less of a culture shock. Making prenatal testing available will also allow mothers in the Jewish community to have agency in their pregnancies.

In addition to social workers and genetic counselors, Sasquatch Hospital previously provided spiritual counseling by the Catholic clergy who often interfered with some doctors’ work. I propose that we either discontinue this in-house spiritual counseling by Catholic clergy unless we allow other religions to have counseling as well. This clash between the medical staff and the Catholic clergy does not provide a healthy environment for the patients. The fact that the Catholic clergy are interfering with patient care is unacceptable especially if the patient is not even part of the Catholic community. Bringing in other spiritual counselors of different religions such as Islam and Buddhism, Judaism will make our diverse community feel included.

The hospital’s historically Catholic nursing staff that refuse to perform these procedures can put in a request to be transferred to a different section of the hospital. Since Sasquatch Community Hospital is only offering abortions to extreme cases, switching out nurses should not be an issue. Since the budget for new hires is extremely limited, the hospital cannot replace all of the nurses and the alternative would be to transfer nurses from different wards of the hospital. I understand that it may be uncomfortable for the nurses who are devout Catholics to assist in performing these procedures but I would like them to kindly reflect upon the reasons they chose to become a nurse before asking for a transfer. If their convictions against abortion for extreme circumstances trumps helping their patients then they should request a temporary transfer. These abortions will adhere to the principle of beneficence, where medical intervention is done to make the patient better. The principle of beneficence and the principle of autonomy will hold for all procedures done at Sasquatch Community Hospital.

-Selina

 

 Works Cited (and Consulted):

Donum Vitae In Shanon, Thomas A. and Lisa Sowle Cahill, Religion and Artificial Reproduction: An Inquiry into the Vatican “Instruction on Respect for Human Life in its Origin and on the Dignity of Reproduction.” (Crossroad, 1988).

 Shirin Garamoudi Naef, “Gestational Surrogacy in Iran,” In Marcia C. Inhorn and Soraya Tremayne editors, Islam and Assisted Reproductive Technologies (Berghahn Books, 2012).

Susan Martha Kahn, Reproducing Jews: A Cultural Account of Assisted Conception in Israel (Duke University Press, 2000).

Tsipy Ivry, Embodying Culture: Pregnancy in Japan and Israel (Rutgers University Press, 2009).

Judith Jarvis Thompson, “A Defense of Abortion.” Philosophy and Public Affairs 1 (1971): 47-66.

Leon R. Kass, Human Cloning and Human Dignity (2002).

Thomas Eich, “Decision Making Processes among Contemporary ‘Ulama’: Islamic Embryology and the Discussion of Frozen Embryos.” In Jonathan E. Brockopp and Thomas Eich, Muslim Medical Ethics From Theory to Practice (University of South Carolina, 2008), 61-77.

Arthur Kleinman, “Moral Experience and Ethical Reflection: Can Ethnography reconcile them? A quandary for the new Bioethics.” Daedalus 128 (1999): 69-97.

 

 

The three readings for this unit show how Iran and Israel differ in the reception of assisted reproduction, surrogacy and the social relationships formed through the process through ethnographic methods by authors Shirin Garamoudi Naef and Elly Teman. Arthur Kleinman’s article touches upon the failure of bioethics in the lack of consideration of the poor when discussing bioethics and policies. I believe that one should read Kleinman’s article first and then reflect on how often the socioeconomic class of the people interviewed came up in the first two readings.

In Shirin Garamoudi Naef’s “Gestational Surrogacy in Iran” covers surrogacy in a Muslim society. Naef focuses on Shia thought on assisted reproduction involving a third party. Naef was able to take an ethnographical approach by interviewing people in infertility clinics undergoing ART procedures similar to Teman interviewing surrogate mothers. Naef’s in depth research and methodology gives her credibility. I appreciated how she presented the differing views of Shia religious scholars on assisted reproduction. Unlike Sunni thought, most Shia scholars do not consider surrogacy as zina (“adultery”) because it does not involve sexual intercourse. Naef argues that Shia notion of zina depends on the “illegitimate physical act that occurs through illicit sexual intercourse between a man and a woman and not on the act of conception itself” (Naef 158). The transfer of bodily substances in order for assisted reproduction to happen is not considered zina. Senior Shia clerics give their take on when it is acceptable for another man’s sperm to fertilize the woman’s egg. Permissibility of another man’s sperm fertilizing the woman’s egg mostly depended on physical contact and whether or not a gaze, a touch or illicit sexual intercourse transpired. I found it interesting that one cleric took issue with placing a stranger’s sperm directly into the woman’s uterus despite the lack of physical contact. Due to the presentation of diverse views on the subject and extensive research, I believe that Naef wrote this article for scholars who want to learn more about surrogacy in Iran. I found her chapter to be informative and the differing views she refers to does not take away from her argument.

 

Elly Teman’s “‘Knowing’ the Surrogate Body in Israel” touches upon the concept of “authoritative knowledge” and the relationship between intended mothers and surrogate mothers. She argues that the surrogates and intended mothers along with the professionals involved in the surrogacy process collectively determine what relationship the surrogate and the genetic mother would have. The concept of “authoritative knowledge” refers to the way knowledge is produced and received in interactions. Intuitive, technological and medical knowledge come together to provide “authoritative knowledge” for the intended mothers. Intuitive knowledge is when the intended mother senses or feels what the surrogate mother feels during the pregnancy: “Masha vouched that her intended mother, Tova, would call her ‘knowing’ that the baby inside her had just kicked, or that she was feeling cramps in her left side” (Teman 265). Although there is no physical evidence, these accounts given by intended mothers and their surrogates should be considered quantitative data.

Technological intervention in surrogacy further allows the intended mother to picture and conceptualize her unborn child. I find it interesting that all the surrogates interviewed acknowledged the importance of having the intended mother at every ultrasound appointment versus the film we watched in class where the surrogate and the genetic parents do not meet during the process. Where’s the concern that surrogate will grow attached to the fetus? I partly attribute this openness between the surrogate and intended mother to Israel’s cultural view of fertility and “Israel’s pronatalist impulse” (Teman 262). Technological and medical knowledge are closely linked together. The medical system structures surrogacy so that there is a hierarchy in which information is provided and to whom. This allows the intended mother to decide if she wants to “generate alterations in received scripts about the maternal nature of pregnant bodies and the non-maternal makeup of infertile bodies” and share that information with the surrogate to create a stronger relationship with the surrogate (Teman 262).

In Arthur Kleinman’s article criticizes bioethics for not considering “local cultural realities”. He believes that bioethics are removed from the socioeconomic status of the people and therefore irrelevant. “The irrelevance of ethics can be seen when considering universal ethical formulations of justice and equity that do not begin with the local moral conditions of poor people” reminds me of our discussion on natural laws in Unit 3 (Kleinman 72). It is difficult to agree on whether there is a shared human nature moreover universal ethics. I agree with Kleinman that more often than not bioethics and medical policies neglects the poor and underprivileged. They do not receive the same benefits and information as those who are able to pay for procedures and treatments. Kleinman suggests that bioethics require an ethnographic approach to connect “moral context with ethical reflection” (76). Kleinman refers to the ethnographic works of Paul Farmer and Rayna Rapp towards the end of his article as examples of ways to create an argument that fulfills his beliefs that “bioethics require both approaches: it must possess a method for accounting for local moral experience and a means of applying ethical deliberation” (73).

Dear Sasquatch Connecticut Ethics Committee,

As a new member of this committee, I have written a policy proposal on the use of assisted reproductive technologies and prenatal testing for our hospital. My previous position on the Ethics Committee of the Medical Board at the Mount Sinai Hospital allowed me to gain experience in a diverse community. Being one of the few female doctors on the ethics committee at Mount Sinai, I learned that at times one must put the patient’s needs over their own personal views or the views of the majority. It is often difficult to make policy decisions that pleases everyone when it comes to controversial topics, such as assisted reproductive technology and prenatal testing. In a hospital that recently became non-denominational in a varied community that is seeing an influx of minority immigrants, its policy should reflect what is most beneficial to those it serves. The goal of a hospital should be to improve outcomes and create more satisfied patients.

On abortion, I acknowledge that the donor base is still prominent Irish families, who will most likely have a Catholic stance on abortion: “human life must be absolutely respected and protected from the moment of conception” (Donum Vitae). However, the community is not made up of only Irish Catholics and the hospital should accommodate women in the community not of the same religion or beliefs. Personally, I believe that women should have a control in what happens to her body and have the choice whether or not to carry out a pregnancy. “If pregnancy is highly risky, birth seems even more so”; therefore, for us as a hospital we need to do right by the patient (Ivry). In hopes of reaching a middle ground, the hospital will provide and subsidize abortion services for under-insured patients with terms. One of the terms will be that abortions can only be performed within the first trimester before the fetus is able to feel any pain. There will only be a set number of abortions given per month and the process of signing up for an abortion will include a talk with the doctor performing the abortion. Extreme cases such as rape will automatically be pushed through.

As for In Vitro Fertilization (IVF), Sasquatch Hospital will only provide treatments for husbands and wives that are looking to start a family. According to the Catholic Church, artificial reproductive technology goes against “natural” law and Scripture. Those people that are faithful to the religion should not use artificial reproductive technologies. Since the Church associates IVF with abortion because during IVF not all embryos are implanted; therefore, an “act against the life of these human beings” (Shannon and Cahill, 154). However, it is acceptable for a husband and wife who cannot conceive to seek other options such as IVF. The prominent Irish Catholic donors should not take issue with these conservative terms and continue to donate to Sasquatch Hospital. In Israel, IVF is a state policy versus in America it is purely private. Different from Israel, religious experts here will not be involved in the day-to-day process at Sasquatch, but medical experts will be involved. The interpretation that reproduction is an “imperative religious duty” prevalent in the Jewish community would encourage people to support IVF (Kahn). The option for IVF will also benefit the Lebanese Shiite and Japanese immigrants. This condition that IVF at Sasquatch hospital can only take place between a husband and wife also satisfies the religious beliefs of the Lebanese Shiite since “most Shia scholars […] argue that the act of fertilization of the woman’s egg with the sperm of a man other than her husband’s is not allowed” (Naef).

A few years ago, Athersys, a biopharmaceutical focused on stem cell research approached Sasquatch Hospital for a collaboration. The deal was that Athersys would donate funds to the hospital if doctors encouraged patients to donate their embryos to potentially life-saving research. This collaboration will be made transparent to all of the participants/patients and they can opt in to donate their embryos or pay to freeze them for later use. This potentially life-saving research can also lead to a more efficient and less invasive prenatal testing while also helping out the hospital.

Prenatal testing such as amniocentesis will be offered to women and families who want to reduce contingency. However, as a hospital in a predominantly Irish Catholic community we want to emphasis that these genetic tests are done not for the purpose of terminating difficult pregnancies if there is a defect and more so to allow families to make arrangements early in light of the knowledge. The hospital will not push mothers to undergo amniocentesis but they will be made aware that it is an option. If a family has a history of birth defects then and only then can the doctor suggest to the mothers to undergo prenatal testing. Due to our influx of Japanese immigrants, we do not want them to feel pressured into prenatal testing their unborn child since “Japanese ob-gyns are often reluctant to mention prenatal diagnosis even to older women […] some of the Israeli ob-gyns I interviewed said that they offer prenatal diagnosis to each and every patient, regardless of her age” (Ivry). Making prenatal testing available will also allow mothers in the Jewish community to have agency in their pregnancies.

In addition to social workers and genetic counselors, Sasquatch Hospital previously provided spiritual counseling by the Catholic clergy who often interfered with some doctors’ work. I propose that we discontinue this in-house spiritual counseling by Catholic clergy but refer patients to certain spiritual counseling based on their religion and who they would like to confide in. This clash between the medical staff and the Catholic clergy does not provide a healthy environment for the patients. The fact that the Catholic clergy are interfering with patient care is unacceptable especially if the patient is not even part of the Catholic community. The hospital’s historically Catholic nursing staff that refuse to perform these procedures can put in a request to be transferred to a different section of the hospital. I understand that it may be uncomfortable for the nurses who are devout Catholics to assist in performing these procedures but I would like them to reflect the reasons they chose to become a nurse before asking for a transfer. Since the budget for new hires is extremely limited, the hospital cannot replace all of the nurses and the alternative would be to transfer nurses from different wards of the hospital.

 Works Cited

Donum Vitae In Shanon, Thomas A. and Lisa Sowle Cahill, Religion and Artificial Reproduction: An Inquiry into the Vatican “Instruction on Respect for Human Life in its Origin and on the Dignity of Reproduction.” (Crossroad, 1988).

 Shirin Garamoudi Naef, “Gestational Surrogacy in Iran,” In Marcia C. Inhorn and Soraya Tremayne editors, Islam and Assisted Reproductive Technologies (Berghahn Books, 2012).

Susan Martha Kahn, Reproducing Jews: A Cultural Account of Assisted Conception in Israel (Duke University Press, 2000).

Tsipy Ivry, Embodying Culture: Pregnancy in Japan and Israel (Rutgers University Press, 2009).