Ethics at the Beginning of Life and the ERDs: Complex Cases, Difficult Decisions

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

2. Disclaimers • Not a physician (or clinician of any kind) • Not a woman (but have a wife and son) • Not a Pope (despite my name) or priest even

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: • Explaining underlying concepts and principles • Reviewing Relevant Directives • Identifying points of question • So that you may be better able to form your conscience regarding these complex cases

4. Outline • Cases for Context • Principles and Concepts • Relevant ERDs • Case Analyses • Conclusion: A Final Thought • Questions and Discussion

5. Cases for Context 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

6. Cases for Context 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

7. Cases for Context 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

8. Concepts & Principles Human Dignity • Inherent worth and value of every human life • Right to life is the fundamental right • Positive obligation to preserve life that takes account of concrete circumstances of the patient, holistically considered • Absolute negative obligation never to directly intend to kill human life

9. Concepts & Principles Double Effect An action that has both a good and a bad effect is justified, if: • Action itself is not intrinsically immoral • Direct intention is for the good effect • Good effect is proportionate to bad effect • Bad effect does not cause the good effect • Bad effect does not precede good effect

10. Concepts & Principles Double Effect (Medical Context) A treatment that offers a benefit but also has a foreseen harmful effect is justified if: • The treatment is immediately therapeutic • The harm is only a foreseen “side-effect” • Benefit is equal to or greater than harm • A less harmful treatment is not available • The harmful effect is not the means used to achieve the intended benefit

11. Concepts & Principles Objectively Immoral (intrinsic evil) An act that in Catholic moral teaching is considered unjustifiable, regardless of how good the (secondary) intentions of the agent or the consequences of the act Direct Intention An effect that is willed as an end for its own sake or as a means to some other end Indirect Intention An effect that is foreseen but merely tolerated

12. Concepts & Principles Subjective Culpability The moral responsibility or blameworthiness that an individual bears (or doesn’t bear) forthe commission of a morally wrong act Duress Limitations on individual choice arising from threatening circumstances such that one’s moral culpability for wrongdoing is diminished or, in some circumstances, even eliminated

13. Concepts & Principles “Decisions that go against life sometimes arise from difficult or even tragic situations of profound suffering . . . . Such circumstances can mitigate even to a notable degree subjective responsibility and the consequent culpability of those who make these choices.” ~JP II, Evangelium Vitae, no. 18

14. Concepts & Principles Respect for Patient Autonomy • The ability to advance one’s spiritual and physical welfare through participating in decision-making • Autonomy and its corresponding rights are not absolute • Human Dignity, Common Good & Stewardship • No right to demand treatment • Basis for informed consent and legal right to refuse treatment

15. Relevant ERDs Part IV, Introduction “Catholic health care ministry witnesses to the sanctity of life ‘from the moment of conception until death.’ The Church’s defense of life encompasses the unborn and care of women and their children during and after pregnancy. The Church’s commitment to life is seen in its willingness to collaborate with others to alleviate the causes of the high infant mortality rate and to provide adequate health care to mothers and their children before and after birth.”

16. Relevant ERDs 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. Catholic health care institutions are not to provide abortion services, even based upon the principle of material cooperation. In this context, Catholic health care institutions need to be concerned about the danger of scandal in any association with abortion providers.”

17. Relevant ERDs 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.”

18. Relevant ERDs Ethical and Religious Directive no. 53 “Direct sterilization of either men or women, whether permanent or temporary, is not permitted in a Catholic health care institution. Procedures that induce sterility are permitted when their direct effect is the cure or alleviation of a present and serious pathology and a simpler treatment is not available.”

19. Case Analyses Case Analysis #1: PPROM with Chorioamnionitis • Object of act is induction of L & D, which is itself morally neutral • Direct intention is to evacuate infection • Infection could threaten the life of the mother; thus, good effect is proportionate to bad • IV antibiotics tried but unsuccessful; thus, no simpler treatment available • Baby dies as a result of early delivery

20. Case Analyses Case #2: Fetal Anomaly Incompatible with Life • Mother and fetus have equal right to life • Anencephaly is a pathology of the fetus, not the mother • There is no threat to the mother’s life (in this case) • The death of the fetus is not a “side-effect” • The object of the act is to end life of the fetus as a means to relieving psychological distress • The relief of psychological suffering is not proportionate to the loss of life • Not justified under Double Effect/ERD 47

21. Case Analyses Case #3: Endometrial Ablation w/TL • Ablation intended to cure a present pathology • No simpler treatment available (hormone therapy contraindicated; IUD unacceptable) • “Hostile uterine environment” is a side-affect • Ablation is justified by double effect • Direct intention of TL is to prevent conception • Thus tubal ligation not justified under ERD 53

22. Conclusion “The distinction between objective morality (i.e., what is helpful or harmful to the human person by reason of the moral object) and subjective culpability (i.e., a person’s own understanding and responsibility for good or ill) is fundamental to the activity of Ethics, which is directed toward helping people overcome the gap that often exists between moral truth and moral sensitivity . . . .

23. Discussion & Questionswww.ascensionhealth.org