Is Condom Use Morally Justified for Serodiscordant HIV Couples?

HIV/AIDS has continued to ravage developing countries of the world especially Sub-Saharan Africa. Sub-Saharan Africa generates no more than 1 percent of the total wealth produced in the world. Yet it is the home of 10% of the world’s population, lives on 1% of the global economy, and carries 68% of the world’s HIV/AIDS burden. WHO estimates that in 2014 only about 41% of people living with HIV were able to access life-saving medications. Given the epidemic nature of this disease and the lack of cure, is condom use morally justified to prevent the spread of the disease in serodiscordant couples? The Church teaches that condoms and all other related methods of birth control sever the unitive and procreative significance inherent in the marital act. Humanae Vitae prohibits “any action which either before, at the moment of, or after sexual intercourse, is specifically intended to prevent procreation” (no. 14). In addition, the U.S Catholic Bishops assert that “The use of prophylactics to prevent the spread of HIV is technically unreliable. Moreover, advocating this approach means in effect, promoting behavior which is morally unacceptable. Campaigns advocating ‘safe/safer’ sex rest on false assumptions about sexuality and intercourse.”

However, Pope Benedict XVI, in his 2010 book-length interview, “Light of the World,” hypothesized that use of a condom to prevent infection could be a first step toward moral responsibility. He used the example of a male prostitute. The Pope’s remarks have been criticized by some as a deviation from the Church’s position on contraception and supported by numerous moral theologians and ethicists. On Dec 21, 2010 Congregation for the Doctrine of Faith (CDF) expounded on the Pope’s remarks and stated that “those who know themselves to be infected with HIV and who therefore run the risk of infecting others, apart from committing a sin against the sixth commandment are also committing a sin against the fifth commandment – because they are consciously putting the lives of others at risk through behavior which has repercussions on public health.” The Note concludes that “those involved in prostitution who are HIV positive and who seek to diminish the risk of contagion by the use of a condom may be taking the first step in respecting the life of another – even if the evil of prostitution remains in all its gravity.” Similarly, the Southern African Catholic Bishops Conference (who carry the greatest burden of HIV/AIDS) asserted in the 2001 pastoral letter that in a case of a married serodiscordant couple, the use of condom to prevent the spread of the disease to the spouse was acceptable. This position was based on the principle that everyone has the right to defend one’s life against mortal danger. Furthermore, moral theologians and ethicists argue that “a married man who is HIV-infected and uses the condom to protect his wife from infection is not acting to render procreation impossible, but to prevent infection. If conception is prevented, this will be an –unintentional – side-effect and will not therefore shape the moral meaning of the act as a contraceptive act” (Rhonheimer, 2004). These views are anchored on two moral principles: Lesser of Two Evils and Double Effect. Finally, the Church has always taught that individuals can follow their well-formed consciences in difficult situation:  “Catholics with a well-formed conscience can decide to use contraceptives ‘in cases of particular emergency.'” This decision must follow only after a “serious discernment of conscience” (National Catholic Reporter, Feb, 2016).

“Can a pregnant woman infected with the Zika virus abort the fetus?”

Answer: The question can be answered from legal and ethical standpoints. To begin with the legal, in the United States, since the 1973 Roe v. Wade decision that legalized abortion at the federal level, each state has responded with its own legislation regulating abortion. In general, most current U.S. states allow abortion before the fetus gets 20 to 24 weeks old (around the end of the second trimester). Thus, the pregnant woman diagnosed with the Zika infection can get an abortion within the state’s jurisprudence. On the other hand, abortion is legally permitted in the period later than the legal period, typically when the mother is in a dire medical condition. Thus, it is unlikely that this legal exception applies to the pregnant woman with the Zika infection because it is not the woman’s health that is in peril. Some states allow the late-term abortion in the case of an extreme fetal deformity; it is up to the state’s decision whether or not the Zika-infected, microcephalic fetus belongs to that category though we do not believe it is the case.

To discuss the case from the ethical perspective, we need to frame the question within the reasoning of a particular ethical tradition. As our society is getting more religiously and culturally diversified, many different ethical traditions co-exist in the U.S. However, let us confine our response to the ethical framework of one particular tradition, which is the Roman Catholic tradition. The Church understands a “human person” to begin at conception and thus even a zygote is called a “mono-celled person” who holds the same dignity and sanctity as adult human beings. Accordingly, abortion in any embryonic or fetal developmental stage is morally prohibited. However, as in the case of law, this general moral principle is overridden when the mother’s life is in danger. The Church sees it as morally justifiable to save the mother with the death of the fetus/embryo as the unintended consequence. However, the Church nuances the verdict that, while a direct killing of the fetus is never permitted, the death of the fetus occurs in the way of saving the mother’s life as an act “not intended but merely foreseen.” Also, the Church emphasizes that the justifiable act of killing should be evidenced by a proper technical medical procedure that fits in with the category. However, one seeming controversy is that a further rule or principle is not shown why the justifiable act of killing is made in favor of saving the mother, not the fetus. It is neither that the fetus is less human person than the mother, nor that the fetus’s personhood is “potential” while the mother is “actual.” Both persons are actual human beings with the same degrees of dignity and sanctity. Then, why save the mother, not the fetus? The Church calls for “conscience” as the moral judge that determines in this type of case.

Critics argue that, since one’s conscience can voice a different opinion from that of another’s conscience, the Church has practically opened the possibility that two opposing moral solutions are possible for the same case. Thus, one can decide to save the mother or the fetus based on one’s own conscience. To say further, the Church condones the faithful to do whatever they want based on their arbitrary feelings. Then, in our case, the Zika-infected pregnant woman’s abortion in any stage is ethically permissible.

However, this is a misleading understanding of the nature of conscience. While it is admitted that a theological discussion on conscience must be furthered, the Church’s use of conscience is not to endorse or secretly allow the arbitrariness, but to explain the nature of its theological moral reasoning. In all ethical cases, relevant general moral principles should be upheld. However, there are moral dilemmas, that is, the cases where two or more moral principles or rules are in conflict. And in the cases of moral dilemmas, conscience decides which principle should be prioritized over the other. Since conscience is largely of human reason, it has a direction. Thus, it does not provide arbitrary verdicts. On the other hand, conscience as a pathway to God’s will implies the element of divinity, so it demands one’s obedience. In sum, conscience is “rational-divine moral intuition” bound to generate similar solutions for similar cases. For example, when the pregnant mother’s life is in danger, the moral intuition dictates that “Save the life of a dying adult person” should be balanced over against “Do not kill the life of an unborn person.” And all similar cases like this should be treated in this manner.

In the case of the pregnant woman with the Zika infection, at least three moral rules are relevant: “Do not kill the life of an unborn person,” “Do not put a financial burden on a society to care for mentally retarded babies,” and “Do not put a financial as well as emotional burden on an adult person to care for mentally retarded babies.” According to the Church, it seems unlikely that conscience, our moral intuition, decides in the way that the first rule trumps the other two in cases like this; nor is found a theological precedent that endorses moral prioritization in favor of the first rule against the two. Therefore, Pope Francis emphasizes that abortion is absolutely not permitted when fight the Zika virus.

Is it ethical to perform therapeutic procedures on human embryos?

As with all medical interventions on patients, one must uphold as licit procedures carried out on the human embryo which respect the life and integrity of the embryo and do not involve disproportionate risks for it but are directed towards its healing, the improvement of its condition of health, or its individual survival. Whatever the type of medical, surgical or other therapy, the free and informed consent of the parents is required, according to the deontological rules followed in the case of children. The application of this moral principle may call for delicate and particular precautions in the case of embryonic or fetal life. The legitimacy and criteria of such procedures have been clearly stated by Pope John Paul II: “A strictly therapeutic intervention whose explicit objective is the healing of various maladies such as those stemming from chromosomal defects will, in principle, be considered desirable, provided it is directed to the true promotion of the personal well-being of the individual without doing harm to his integrity or worsening his conditions of life. Such an intervention would indeed fall within the logic of the Christian moral tradition” (28)

Medical research must refrain from operations on live embryos, unless there is a moral certainty of not causing harm to the life or integrity of the unborn child and the mother, and on condition that the parents have givers their free and informed consent to the procedure. It follows that all research, even when limited to the simple observation of the embryo, would become illicit were it to involve risk to the embryo’s physical integrity or life by reason of the methods used or the effects induced. As regards experimentation, and presupposing the general distinction between experimentation for purposes which are not directly therapeutic and experimentation which is clearly therapeutic for the subject himself, in the case in point one must also distinguish between experimentation carried out on embryos which are still alive and experimentation carried out on embryos which are dead. If the embryos are living, whether viable or not, they must be respected just like any other human person; experimentation on embryos which is not directly therapeutic is illicit.(29) No objective, even though noble in itself, such as a foreseeable advantage to science, to other human beings or to society, can in any way justify experimentation on living human embryos or fetuses, whether viable or not, either inside or outside the mother’s womb. The informed consent ordinarily required for clinical experimentation on adults cannot be granted by the parents, who may not freely dispose of the physical integrity or life of the unborn child. Moreover, experimentation on embryos and fetuses always involves risk, and indeed in most cases it involves the certain expectation of harm to their physical integrity or even their death. 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.

The Charter of the Rights of the Family published by the Holy See affirms: “Respect for the dignity of the human being excludes all experimental manipulation or exploitation of the human embryo”.(30) The practice of keeping alive human embryos in vivo or in vitro for experimental or commercial purposes is totally opposed to human dignity. In the case of experimentation that is clearly therapeutic, namely, when it is a matter of experimental forms of therapy used for the benefit of the embryo itself in a final attempt to save its life, and in the absence of other reliable forms of therapy, recourse to drugs or procedures not yet fully tested can be licit (31)

What is the Catholic Church’s position on the use of medical remedies at the end of life?

 

According to the Congregation for the Doctrine of the Faith, Declaration on Euthanasia, 1980:

  1. DUE PROPORTION IN THE USE OF REMEDIES

Today it is very important to protect, at the moment of death, both the dignity of the human person and the Christian concept of life, against a technological attitude that threatens to become an abuse. Thus some people speak of a “right to die,” which is an expression that does not mean the right to procure death either by one’s own hand or by means of someone else, as one pleases, but rather the right to die peacefully with human and Christian dignity. From this point of view, the use of therapeutic means can sometimes pose problems.

In numerous cases, the complexity of the situation can be such as to cause doubts about the way ethical principles should be applied. In the final analysis, it pertains to the conscience either of the sick person, or of those qualified to speak in the sick person’s name, or of the doctors, to decide, in the light of moral obligations and of the various aspects of the case.

Everyone has the duty to care for his or her own health or to seek such care from others. Those whose task it is to care for the sick must do so conscientiously and administer the remedies that seem necessary or useful.

However, is it necessary in all circumstances to have recourse to all possible remedies?

In the past, moralists replied that one is never obliged to use “extraordinary” means. This reply, which as a principle still holds good, is perhaps less clear today, by reason of the imprecision of the term and the rapid progress made in the treatment of sickness. Thus some people prefer to speak of “proportionate” and “disproportionate” means. In any case, it will be possible to make a correct judgment as to the means by studying the type of treatment to be used, its degree of complexity or risk, its cost and the possibilities of using it, and comparing these elements with the result that can be expected, taking into account the state of the sick person and his or her physical and moral resources.

In order to facilitate the application of these general principles, the following clarifications can be added:

–If there are no other sufficient remedies, it is permitted, with the patient’s consent, to have recourse to the means provided by the most advanced medical techniques, even if these means are still at the experimental stage and are not without a certain risk. By accepting them, the patient can even show generosity in the service of humanity.

–It is also permitted, with the patient’s consent, to interrupt these means, where the results fall short of expectations. But for such a decision to be made, account will have to be taken of the reasonable wishes of the patient and the patient’s family, as also of the advice of the doctors who are specially competent in the matter. The latter may in particular judge that the investment in instruments and personnel is disproportionate to the results foreseen; they may also judge that the techniques applied impose on the patient strain or suffering out of proportion with the benefits which he or she may gain from such techniques.

–It is also permissible to make do with the normal means that medicine can offer. Therefore one cannot impose on anyone the obligation to have recourse to a technique which is already in use but which carries a risk or is burdensome. Such a refusal is not the equivalent of suicide; on the contrary, it should be considered as an acceptance of the human condition, or a wish to avoid the application of a medical procedure disproportionate to the results that can be expected, or a desire not to impose excessive expense on the family or the community.

–When inevitable death is imminent in spite of the means used, it is permitted in conscience to take the decision to refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to the sick person in similar cases is not interrupted. In such circumstances the doctor has no reason to reproach himself with failing to help the person in danger.

 

Hospital Ethics Committees – Consultation Is Primary Function

Perhaps the most important function of Hospital Ethics Committees is to provide ethics consultation to the hospital community. When physician and patient/family cannot come to agreement about an important treatment decision, the Hospital Ethics Committee is consulted. One or more of its members, with formal training in bioethics, will make a thorough evaluation and then present her findings to the committee at large. The entire Committee will then meet to discuss the case and make a recommendation, which the physician and patient/family will then discuss. If disagreement still remains, referral is made to the Courts for final adjudication

WHO CAN BE AN ETHICS CONSULTANT?

An ethics consultant should be a professional (preferably MD, MSN, MSW or PhD, or JD) with clinical experience. Also the consultant should possess advanced understanding of Clinical Ethics (preferably: MA in Health Care Ethics or Ethics Fellowship Program).

 

WHAT ARE THE CORE COMPETENCIES FOR A CONSULTANT?[i]

  • Moral reasoning and ethical theory
  • Common bioethical issues and concepts
  • Health care systems
  • Clinical contact
  • The local health care institution
  • The local health care institution’s policies
  • Beliefs and perspectives of local patient and staff population
  • Relevant codes of ethics and professional conduct
  • Relevant health law

 

EXAMPLE SCRIPT FOR CONSULTANT’S FIRST ENCOUNTER WITH SURROGATE[ii]

“Hello, my name is ________. I am an ethics consultant and have been asked by your attending physician to come and talk with you. I routinely get involved in cases where difficult ethical decisions must be made about the best course of action to take. I want to assure you that I do not have an agenda of my own with preconceived answers about what’s right or wrong. My role is to talk with you and support you in considering the options that are available, and hopefully reach an outcome with which you are comfortable and that is in the best interests of your loved one. Is it ok if we talk?”

The primary characteristic of the facilitation approach is the open-ended way the ethics consultant approaches an ethics case with the attitude of assisting those involved in the conflict to arrive at an agreed-upon consensus.

 

GUIDELINES FOR EFFECTIVE BIOETHICS CONSULTATION[iii]

It is important that the Consultant understand the stated and latent interests of the participants. It is essential that the s(he) level the playing field to minimize disparities in power, knowledge, skill, and experience that separate the parties to the dispute. The Consultant should help the parties define their interests, search for common ground and maximize the options for conflict resolution. And the Consultant should ensure that the consensus can be justified as a “principled resolution”, compatible with the principles of bioethics and legal rights of patients and families.

 

ORR/SHELTON FORMAT FOR CONSULTATION REPORT[iv]

  • Demographic Data
  • Reason for Consultation Request
  • Informants
  • Systematic Description of Case
    • Medical Indications
    • Patient Preferences
    • Quality of Life
    • Contextual Features
  • Assessment
  • Discussion and Analysis
  • Recommendation

[i] American Society of Bioethics and Humanities (2011)

[ii] D. Micah Hester (2008), Ethics by Committee

[iii] Dubler N & Liebman C (2004), Bioethics Mediation: A Guide to Shaping Shared Solutions

[iv] Jonsen A et al (2010), Clinical Ethics: A Practical Approach

Hospital Ethics Committees – Preliminary Comments

Rapid advances in medical technologies in the 1960s presented society with ethical questions it was ill prepared to answer. For example, at the dawn of kidney dialysis technology, there were many more patients with end stage kidney disease than there were dialysis machines to treat them. What is the most ethical way to resolve this rationing dilemma? In the early 1960s, kidney dialysis selection committees were established to introduce community representatives into the process of deciding which patients would receive kidney dialysis. Thus the notion of ethics committees dawned in the field of bioethics. Once Medicare was expanded in 1965 to include coverage for kidney dialysis, this particular rationing problem was resolved.

In the late 1960s, some states called for abortion review committees to determine which requests for therapeutic abortions were legitimate. The US Supreme Court Decision Roe v. Wade settled the issue in 1983 with the legalization of abortion. In the early 1980s, infant care review committees were established in some states to satisfy the federal mandate that intensive care nurseries be prevented from engaging in discriminatory practices against critically ill newborns. The Baby Doe Law in 1984 made such discrimination illegal. Drawing on these experiences, the 1976 New Jersey Supreme Court decision in the Karen Quinlin case was interpreted by many as giving credence to the importance of ethics committees for end-of-life cases.

The 1991 Patient Self-Determination Act required that every health care organization in the United States receiving Medicare or Medicaid payments convene meetings of a committee to assure compliance with the requirements of the Act regarding “advance health care directives”. And in 1992, the Joint Commission on the Accreditation of Healthcare Organizations passed a mandate that all JCAHO approved hospitals must put in place a means for discerning ethical concerns. Numerous examples were tried but most settled upon the health care ethics committee model. The 1991 Law and 1992 JCAHO regulation spawned a rapid increase in number of Ethics Committees in hospitals of all sizes.

The Hospital Ethics Committee promotes shared decision-making between patient/surrogate and the clinician. It enhances the ethical tenor of health care professionals and health care institutions. And it promotes fair policies and procedures that maximize the likelihood of achieving good, patient-centered outcomes.

WHAT DO HOSPITAL ETHICS COMMITTEES DO?

  1. CONSULTATION

Perhaps the most important function of Hospital Ethics Committees is to provide ethics consultation to the hospital community. When physician and patient/family cannot come to agreement about an important treatment decision, the Hospital Ethics Committee is consulted. One or more of its members, with formal training in bioethics, will make a thorough evaluation and then present her findings to the committee at large. The entire Committee will then meet to discuss the case and make a recommendation, which the physician and patient/family will then discuss. If disagreement still remains, referral is made to the Courts for final adjudication.

  1. EDUCATION

Another important function is ongoing ethical formation of committee members through self-study, lectures, and conferences. They will become grounded in ethical theory and learn how to apply theory to clinical decision making. As the committee grows in competency, it will develop an ethics education program for the entire hospital community. Questions to be addressed are:

  • What ethical issues are currently relevant at your institution?
  • What individuals in the institution or in the area possess ethics expertise and the ability to put theory and language of ethics into practice?
  • What is the most appropriate teaching forum?
  1. POLICY

The third function is to develop and/or revise select policies pertaining to clinical ethics, e.g. advance directives, DNR and Comfort Care Policies, withholding and withdrawing life-sustaining treatments, informed consent, organ procurement, etc. Hospital Administration may request ethical review of new or updated hospital policies. And new issues requiring policy review may surface during ethical consultations

COMMITTEE MEMBERSHIP

Typically the Hospital Ethics Committee has representation from the following areas:

  • Physician Medical Staff
  • Hospital Administrator
  • Bioethicist
  • Nurses
  • Other Clinical Specialists
  • Social Services
  • Community Representative
  • Pastoral Care
  • Legal Counsel
  • Quality Improvement

RESPONSIBILITIES OF MEMBERS

  • Commit to the Mission and Values of the Institution.
  • Understand role and function of Ethics Committee
    • Orientation Program for new members
  • Competent in their own areas of expertise and generally knowledgeable about issues in health care ethics
  • Familiar with institutional policies related to clinical and organizational ethics.

TYPICAL AGENDA FOR MEETING

  • An established leader who structures the meeting dates and topics, and leads the session
  • Presentation of the particular issue or topic by Consultation Sub-Committee.
  • A brief didactic overview of literature, ethical principles, or pertinent factors
  • Review of facility policy or previous management
  • Group discussion related to the issue
  • Summary via policy or facility understanding
  • Consensus Recommendation for Clinical Team

WHO MAY REQUEST ETHICS CONSULTATION?

At most hospitals, anyone may request an ethics consultation including the patient or family. Need to check the hospital’s policies to learn how to request an ethics consultation

WHEN TO ASK FOR AN ETHICS CONSULT

Consider asking for a consult when two conditions are met:

  • You perceive that there is an ethical problem in the care of patients.
  • Resolution does not occur after bringing this to the attention of the attending physician.

Most “ethical problems” are caused by lack of communication. However, sometimes a true ethical dilemma occurs, frequently because there is a conflict between principles (autonomy, beneficence, and justice) or between principles and outcomes.

The Catholic Church’s position on GIFT seems unclear. Can a Catholic couple having problems getting pregnant start the GIFT procedure?

Gamete Intrafallopian Transfer (GIFT) is a technique of intracorporeal artificial fertilization that involves the simultaneous but separate transfer of the male and female gametes into the fallopian tube. This technique is the recommended treatment for some forms of female infertility or male infertility, provided that the woman has at least one pervious tube. Following induction of ovulation and egg cell procurement by means of laparoscopy and procurement of sperm from within the vagina or by means of a perforated condom, the gametes, separated by an air bubble, are transferred into the fallopian tube by means of a small catheter. In this case fertilization occurs only when the egg cells and spermatozoa come in contact with each other inside the fallopian tube. Unfortunately, only 20 to 27% of the total number of gamete transfers result in completed pregnancies, due to a high incidence of miscarriage.

The instruction Donum Vitae makes no pronouncement with regard to GIFT, either implicitly or explicitly. However, the instruction does not proscribe “those cases in which the technical means is not a substitute for the conjugal act but serves to facilitate and to help so that the act attains its natural purpose”. Therefore, the CDF instruction confirms a traditional position of the Catholic Magisterium that acknowledges the physical and spiritual unity of the conjugal act as the indispensable moral requisite for generating to a new individual. In light of this tradition the intention of treating infertility does not justify any method and any process whatsoever in order to achieve conception.

From the Catholic moral standpoint the ethical dilemma associated with GIFT revolves around the question whether the intervention of the physician or the technician should be considered an assisting act of or a substantive one for the natural marital act. The facts that few oocytes are needed, that they are introduced into the fallopian tube after a short interval of time together with the spermatozoa obtained during or immediately after a conjugal act and that fertilization is inter-corporeal without any embryo manipulation reasonably classify that technique as a form of assistance and not a substitute for the conjugal act. In that case, the GIFT technique is morally acceptable.

However, not all Catholic ethicists agree with this interpretation: some consider that reproductive technology as a substitute for the conjugal act that, like the homologous and heterologous in vitro fertilization, is morally unacceptable.
———————————————————————————————————————–
1 Congregation for the Doctrine of Faith (CDF), Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation (Donum Vitae). February 22, 1987. Accessed on December 1, 2013 http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19870222_respect-for-human-life_en.html

2 Catechism of the Catholic Church, nn 2270-1.

3 United States Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services, 2009: n 49.

4 Nelson KE, Hexem KR, Fudtner C. Inpatient Hospital Care of Children with Trisomy 13 and Trisomy 18 in the United States, Pediatrics, 2012:129(5):869-76. doi: 10.1542/peds.2011-    2139. Epub 2012 Apr 9. http://www.ncbi.nlm.nih.gov/pubmed/22492767 (Accessed on August 9, 2013).

5 Janvier A, Farlow B., Wilfond B, The Experience of Families with Children
with Trisomy 13 and 18 in Social Networks Pediatrics 2012 Aug;130(2):293-8. doi: 10.1542/peds.2012-0151. Epub 2012 Jul 23.
http://www.ncbi.nlm.nih.gov/pubmed/22826570 (Accessed on August 12, 2013).

6 Koogler TK, Wilfond BS, Friedman Ross L. Lethal Language, Lethal Decisions Hasting Center Report. 2003:33, 37-41.

7 CDF, Donum Vitae, 1987: II, n.6.

8 May W.E, Catholic Bioethics and the Gift of Human Life, Our Sunday Visitor Publishing Division: Huntinghton, IN: 2008, 93-94.

My wife was told that her fetus in the 16th week of pregnancy has Trisomy 18. The Ob/Gyn is recommending an elective abortion because the condition of Trisomy 18 is not compatible with life. What is your opinion?

Trisomy 18, also known as Edwards’ syndrome, is a chromosomal abnormality associated with severe developmental abnormalities affecting multiple organs. Because of those anomalies the majority of the fetuses do not survive to term or die within their first months of life. However, 5% to 10% of infants with trisomy 18, most of whom possess an extra copy of chromosome 18 only in few cells of the body, live longer than one year and survive to the teenage years in spite of serious medical and development problems.

Elective abortion or early induction of labor constitutes the currently most common medical recommendation provided to a pregnant woman carrying a fetus with trisomy 18, on the ground that this chromosomal abnormality is a lethal and incompatible with life. According to the Catechism of the Catholic Church it is gravely immoral to support a couple’s decision to end the pregnancy through an early induction of labor when the developmental stage of the fetus is incompatible with life outside the uterus and when neither the mother’s health nor the fetal life are in danger [1]. In those circumstances, the early induction of labor configures an act of elective abortion that is morally unacceptable. That moral stance has been confirmed by the US Conference of Bishops in the Ethics and Directive for Catholic Health Care Services. In particular, paragraph 49 of that document states “For a proportionate reason, labor may be induced after the fetus is viable”.[2] Since the threshold for fetal survival in the US has been set up at 24 weeks of gestation, the early delivery of a 16 week fetus is an act of elective abortion that is utterly immoral. Furthermore, the scenario depicted in the question reveals the incorrectness of the provided medical counseling that failed to take into consideration both the improvement of survival of those infants with trisomy 13 and 18 submitted to multiple surgeries [3] as well the reports of the rewarding experience of families living with a child with trisomy 18.[4] It is highly advisable that obstetricians, genetic counselors and ethicist abandon the ‘lethal language’ leading to ‘lethal decisions’ and be more respectful of the parents’ decisions and preferences of not terminating the life of a baby with trisomy 18.[5]


[1] Catechism of the Catholic Church, nn 2270-1.

[2] United States Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services, 2009: n 49.

[3] Nelson KE, Hexem KR, Fudtner C. Inpatient Hospital Care of Children with Trisomy 13 and Trisomy 18 in the United States, Pediatrics, 2012:129(5):869-76. doi: 10.1542/peds.2011-2139. Epub 2012 Apr 9. http://www.ncbi.nlm.nih.gov/pubmed/22492767 (Accessed on August 9, 2013).

[4] Janvier A, Farlow B., Wilfond B, The Experience of Families with Children
with Trisomy 13 and 18 in Social Networks Pediatrics 2012 Aug;130(2):293-8. doi: 10.1542/peds.2012-0151. Epub 2012 Jul 23.

http://www.ncbi.nlm.nih.gov/pubmed/22826570 (Accessed on August 12, 2013).

[5] Koogler TK, Wilfond BS, Friedman Ross L. Lethal Language, Lethal Decisions Hasting Center Report. 2003:33, 37-41.

Is pre-implantation genetic diagnosis (PGD) acceptable for Catholics?

The official position of the Catholic Magisterium on prenatal diagnosis has been articulated in the instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation (Donum Vitae) issued by the Congregation for the Doctrine of the Faith (CDF). In that document it has been stated that prenatal diagnosis is “ permissible if the methods used, with the consent of the parents who have been adequately instructed, safeguard the life and integrity of the embryo and its mother and does not subject them to disproportionate risks. But this diagnosis is gravely opposed to the moral law when it is done with the thought of possibly inducing an abortion depending upon the result…”.

Although the document does not address explicitly the moral acceptability of pre-implantation genetic diagnosis (PDG) it is reasonable to infer that genetic testing performed on early, pre-implantation embryos obtained by uterine lavage with the aim to identify a suspect genetic abnormality and eventually to correct it through somatic gene therapy is morally licit. PGD can be performed either through noninvasive blastocyst culture or by splitting the 4 to 8 cell embryo in two. By virtue of the totipotency of the embryonic cells even the implantation of a ‘half’ of the embryo can develop into a whole individual. Unfortunately, this diagnostic technique has been increasingly used as a means of selecting those embryos carrying genetic abnormalities and eliminating them.  In that case PDG is manifestly contrary to the respect of every human life from the very moment of conception defended by the Catholic Magisterium and, thus, morally unacceptable.

Nostalgia for “Old Fashioned” Medicine

Throughout the current contentious national debate over Obama Care, it is clear that people do not want to lose their primary care physician. Those who are happy with the physicians (primary care and specialists) in their current health insurance plan do not want to be forced to change to another plan with a different panel of doctors. Despite the complexity of modern health care delivery and the many insurance plan options, people want to see “their” doctor when they are sick.
Why do patients get so attached to “their” doctor? A founder of modern bioethics, Edmund Pellegrino, wrote extensively on the doctor-patient relationship and described the dynamics of the encounter.  A patient who is ill goes to the doctor’s office. In her vulnerability, she describes her symptoms and often reveals some very personal information about herself. Without fear or shame she exposes her very body in its nakedness to the physician, confident in the doctor’s professional glance.

For his part, the doctor promises to help and to use his expertise to treat the patient to the best of his ability. At this point in the relationship there is a great dichotomy between patient and doctor. The patient is vulnerable and has diminished control over her body. She trusts her physician and places her health in his hands. The physician has the expertise and skills of his profession to examine, diagnose and treat the patient. He accepts responsibility for the patient’s medical care and tries his very best to help his patient. The healing process may take any of three routes. The patient may be returned to complete health, or if not cured, the medical problem may improve; or if neither is possible, at the very least the patient will be relieved of pain and made to feel comfortable. In all three cases, the physician fulfills his promise to help. Even in hospice care, with the help of family, nurse and physician, the patient regains her dignity and self-respect.

Many contend that Pellegrino is “old fashioned” and places too much emphasis on the phenomenology of the physician-patient encounter. Perhaps he fails to recognize the larger context in which medicine is practiced today. The success of modern medicine has been due to the increasing scientific basis of medical knowledge and technology. At the same time, the traditional understanding of professionalism has eroded in contemporary society. Perhaps older professional models of the physician, and the physician-patient relationship, are no longer operative in contemporary medicine.

Pellegrinos’ critics argue that medicine is a social practice and not simply a one-on-one encounter. In an age of high-tech medicine, physicians and patients are not alone when they encounter one another in the clinic. Their encounter involves many other health care professionals, insurers, clinical and hospital administrators, legislatures and regulators. Medicine is a social practice and not simply a one-on-one encounter.

Health insurers have assumed an ever increasing presence in the clinic, specifying what tests can be done, what medicines can be prescribed, and where the patient can be hospitalized. Indeed, some health insurance policies remove the personal physician from the examining room entirely and replace him with another on their approved panel of physicians. It is unclear how Obama Care will impact the physician-patient relationship. Although it’s the insurance plan, and not Obama Care per se, that determines the network of doctors and hospitals to which a patient would have access, Obama Care exerts a powerful influence on the type of insurance plans that are available. Thus there is no guarantee that a patient will be able to keep his personal physician under Obama Care.

America cannot afford the ever increasing costs of health care. American’s hunger and blind acceptance of ever new and expensive medical technology, along with the realities of scarcity and the need to allocate resources, raise fundamental questions about how medicine is understood and practiced today. Inevitably costs are affecting the physician-patient encounter. Although doctors are reluctant to place limits on the care of the individual patient before him, they realize that the die is cast and the purity of the physician-patient encounter is forever threatened.

The challenge is to maintain the “art of medicine” despite drastic changes in the social context of medicine. In so far as this is possible, “old fashioned” medicine will not die.