Ethics at the Beginning of Life and the ERDs: Controversial Cases

1. Ethics at the Beginning of Life and the ERDs: Controversial Cases John Paul Slosar, PhD Vice President Ethics Integration & Education

2. Disclaimer I must be insane!

3. Objectives • Given my disclaimers, my objective is not to say what I think is right or wrong, but to help you understand and apply the Ethical and Religious Directives for Catholic Healthcare Services by: • Distinguishing the clear cases from the more complex • Identifying the questions we need to wrestle with in these more complex guidance • Identify the concepts that can provide some guidance • So that you may be better able to form your conscience regarding these complex cases

4. Outline • Review of Concepts and Principles • Review of ERDs • Review of Cases • Complex Cases Contrasted • Conclusion: A Final Thought • Questions and Discussion

5. Review: Concepts & Principles Human Dignity • Inherent worth and value of every human life • Right to life is the fundamental right Double Effect • Direct – Indirect Intention • Means must not itself be intrinsically immoral Intrinsically Immoral • Subjective Culpability • Mitigating Effect of Duress

6. Review: Concepts & Principles Respect for Autonomy • Not absolute, right to participate and refuse • Limited by human dignity, common good and stewardship Ethical and Religious Directive no. 45 “Abortion (that is, the directly intended termination of pregnancy before viability or the directly intended destruction of a viable fetus) is never permitted. Every procedure whose sole immediate effect is the termination of pregnancy before viability is an abortion, which, in its moral context, includes the interval between conception and implantation of the embryo.

7. Review: Concepts & Principles Ethical and Religious Directive no. 47 “Operations, treatments and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child.”

8. Review: Cases Case #1: PPROM with Chorioamnionitis • 32 y/o female, primi-gravida, 20 wks g/a • Presents with Pre-term Premature Rupture of Membranes, fever elevated WBC count • Given intravenous antibiotics for 24h • Dx of Chorioamnionitis, fetal heart tones • OB and mother (along with father) want to induce

9. Review: Cases Case #2: A Fetal Anomaly Incompatible with Life • 42 y/o, female, 15 wks g/a • Tri-panel screen and ultrasound reveal anencephaly • OB recommends D&E to end “futile pregnancy,” avoid psychological distress • Gives woman “a couple days to think about it,” while Dr. makes arrangements

10. Review: Cases Case #3: Endometrial Ablation w/TL • 48 y/o female, 3 grown kids • Severe menorrhagia • Hormone therapy contraindicated • IUD “unacceptable” to patient • Physician recommends ablation with subsequent tubal ligation, due to post-ablation risk of tubalpregnancy and associated maternal and fetal mortality

11. Complex Cases Case #1: PPROM without Chorioamnionitis • 32 y/o female, gravida IV, 18 wks g/a • Three previous miscarriages • Presents with PPROM • No signs of infection, oligohydramnios,fetal heart tones, inevitable miscarriage • Admitted and put on IV Antibiotics • Mother and father want to induce to “end the ordeal”

12. Complex Cases Case #1: PPROM without Chorioamnionitis • No signs of infection… • Can we say a “pathological condition of the mother is present”? • Mother’s life is not immediately threatened… • How certain do we need to be that a life threatening pathological condition will arise? • Moral Certitude and PPROM as Pathology? • Induction vs Augmentation?

13. Complex Cases Case #2: Pregnant with Spinal Cancer • 32 y/o, uninsured female, 15-3/7 wks g/a • 4 kids, 2, 4, 5 & 8 y/o • Persistent fever, severe back pain • DX: spinal cancer, Chemo & radiation • Oncologist willing to take case, won’t proceed without D&E because of risk of hemorrhaging • Baby will die either way

14. Complex Cases Case #2: Pregnant with Spinal Cancer • Mother has life threatening pathology • Baby would die as indirect effect of chemo and radiation therapy • Chemo and radiation contraindicated during pregnancy due to risk of bleeding out • D&E is not a therapy directly intended to curecancer • Death of the fetus is the means by which safe condition for therapy is achieved • Transfer? Sole Provider? Duress?

15. Complex Cases Case #3: Perinatal Peripartum Cardiomyopathy plus Pregnancy (PPCM+P) • 25 year old female, Gravida 2, with peripartum cardiomyopathy • Rx Lasix, Lisinopril and Coreg • Stopped taking meds., became pregnant and presented around 6 weeks g/a • At 7 weeks g/a, underwent dobutamine stress test • Resulted in V-Tachand cardiac ischemia = 90% mortality • Phys. recommending induction with Cytotec

16. Complex Cases Case #3: Perinatal Peripartum Cardiomyopathy plus Pregnancy (PPCM+P) • Cardiomyopathy is independent of pregnancy • Induction does not cure underlying cardiomyopathy…. • Therefore, traditional analysis would conclude direct • However, removing the normally functioning placental does directly lead to reducing blood volume; eliminating primary threat to the woman’s life • Pius XII argued could remove healthy organ when exacerbates pre-existing condition • Question of to whom does the placenta belong?

17. Conclusion "We cannot insist only on issues related to abortion, gay marriage and the use of contraceptive methods. This is not possible. I have not spoken much about these things, and I was reprimanded for that. But when we speak about these issues, we have to talk about them in a context...We have to find a new balance; otherwise even the moral edifice of the church is likely to fall like a house of cards, losing the freshness and fragrance of the Gospel." ~Pope Francis

18. Discussion & Questionswww.ascensionhealth.org