Case Study in Catholic Bioethics

1. Case Study in Catholic Bioethics Some Guiding General Principles

2. Case “A” 12 year old girl, globally delayed, non-verbal from a mitochondrial disorder. Has a gastrostomy tube, a seizure disorder, and vesicostomy. She can take a few steps at a time but is typically wheelchair bound. Catholic mother vs. Catholic pediatrician Requesting hysterectomy for reasons of hygiene and because “she will never reproduce.” Pediatrician disagrees with the intervention but refers to the gynecologist who does the hysterectomy with pediatric urologist assisting.

3. Case “B” 12 y/o girl with severe Down Syndrome, intellectual disability, aggression, and fecal smearing. Catholic mother vs. Lutheran pediatrician Mother requests hysterectomy secondary to concerns about hygiene and fears that she might be taken advantage of Pediatrician says, “She’s a minor and this violates her human rights” …

4. Suggests taking to the Ethics Committee. Mom becomes indignant. Goes to the patient’s endocrinologist who proclaims the pediatrician “ridiculous”. Recommends circumventing the system by going to Mpls. Children’s and having it done. Situation is unresolved at this time.

5. Questions • Is it ever ethical to perform hysterectomy on a severely medically complicated or developmentally delayed minor? • Does “double effect” principle apply here? • If it is unethical, is it “aiding and abetting” the process to refer the patient’s family to GYN? • Why did the endocrinologist tell the mother that his colleague was “ridiculous”?

6. You’re Ridiculous!! Catholic Approach to Bioethics is thought to be: Unscientific Unreasonable Legalistic Arbitrary

7. True Source of Morality The dignity of human life flows from creation in the image of God, from redemption by Jesus Christ, and from our common destiny to share a life with God beyond all corruption. Catholic health care has the responsibility to treat those in need in a way that respects the human dignity and eternal destiny of all Part II “Introduction” to the ERDs

8. Pillow Angel Ethics • This case can be found at … • http://content.time.com/time/nation/article/0,8599,1574851,00.html • And … • http://content.time.com/time/nation/article/0,8599,1575325,00.html

10. Ashley “Treatment” • Hysterectomy • Mastectomy • High Dose Estrogen Administration

11. Principle of Integrity • Refers to each individual’s duty to preserve a view of the human person in which the order/function of the body and its systems are respected and not unduly compromised by medical interventions • Anatomical - material or physical integrity of body • Functional - systematic efficiency or functionality of the body

12. Principle of Totality • An individual organ or a part of the human body may be sacrificed if that sacrifice means continued survival of the whole person or is for the good of the whole

13. Integrity/Totality in the ERDs All persons served by Catholic health care have the right and duty to protect and preserve their bodily and functionalintegrity. The functionalintegrity of the person may be sacrificed to maintain the health or life of the person when no other morally permissible means is available. ERD #29 The well-being of the whole person must be taken into account in deciding about any therapeutic intervention or use of technology. Therapeutic procedures that are likely to cause harm or undesirable side-effects can be justified only by a proportionate benefit to the patient.ERD #33

14. Ashley “Treatment” • Principle of Integrity? • Exposes her to procedures without proportionate benefit and compromises the function of her body • Principle of Totality? • The mutilations of this treatment are not for the survival or the good of the whole

15. Proposed Proportionate Benefits? • Hysterectomy —> menstrual cramps/rape pregnancy • Mastectomy —> breast CA/fibrocystic dz/discomfort • Estrogen —> prevent growth • Social —> home placement

16. The Risk - Dr. Gunther “… is thrombosis or blood clot, which is a risk in anybody taking estrogen. It’s hard to assess in a young child because noonethisyounghasbeentreated with estrogen”

17. Proxy Consent in Experimentation • Therapeutic Experimentation = Designed to secure some benefit for the patient • Non-therapeutic Experimentation = Not designed to benefit the subject but at securing knowledge for the benefits of others

18. Non-therapeutic Proxy Consent Non-therapeutic experiments on a living embryo or fetus are not permitted, even with the consent of the parents. ERD #51 Since the human individual, in the prenatal stage, must be given the dignity of a human person, research and experimentation on human embryos and fetuses is subject to the ethical norms valid for the child already born and for every human subject Charter for Health Care Workers #82

19. Back to the Questions • Is it ever ethical to perform hysterectomy on a severely medically complicated or developmentally delayed minor?

20. Here’s Case “A” Again 12 year old girl, globally delayed, non-verbal from a mitochondrial disorder. Has a gastrostomy tube, a seizure disorder, and vesicostomy. She can take a few steps at a time but is typically wheelchair bound. Catholic mother vs. Catholic pediatrician Requesting hysterectomy for reasons of hygiene and because “she will never reproduce.” Pediatrician says “not on my watch” and refers to the gynecologist who does the hysterectomy with pediatric urologist assisting.

21. Here’s the Principle of Integrity Again • Refers to each individual’s duty to preserve a view of the human person in which the order/function of the body and its systems are respected and not unduly compromised by medical interventions • Anatomical - material or physical integrity of body • Functional - systematic efficiency or functionality of the body

22. Here’s the Principle of Totality Again • An individual organ or a part of the human body may be sacrificed if that sacrifice means continued survival of the whole person or is for the good of the whole

23. Here’s Case “B” Again 12 y/o girl with severe Down Syndrome, intellectual disability, aggression, and fecal smearing. Catholic mother vs. Lutheran pediatrician Mother requests hysterectomy secondary to concerns about hygiene and fears that she might be taken advantage of “She’s a minor and this violates her human rights”

24. Here’s the Principle of Integrity Again to Apply to Case “B” • Refers to each individual’s duty to preserve a view of the human person in which the order/function of the body and its systems are respected and not unduly compromised by medical interventions • Anatomical - material or physical integrity of body • Functional - systematic efficiency or functionality of the body

25. Principle of Totality • An individual organ or a part of the human body may be sacrificed if that sacrifice means continued survival of the whole person or is for the good of the whole

26. Back to the Questions • Does “double effect” principle apply here?

27. Synderesis • A habit “bestowed on us by nature” • “Is said to incite to good and murmur at evil” • With regard to first principles/speculative intellect • Employed by the intellect in practical matters of moral decision-making through the virtue of prudence

28. “Do Good” vs. “Avoid Evil” • The action in itself must be morally good or indifferent • The good effect cannot be obtained through the bad effect • There must be a proportion between the good and bad effects brought about • The intention of the subject must be directed toward the good effect, the bad being merely tolerated

29. Double-Effect Applied A dying woman is in severe pain due to a terminal illness. The normal dose of analgesia is ineffective. To control the pain, the minimum effective dose might also hasten her already impending death. However, her pain is so severe that her physician gives her the drug in an amount just sufficient to bring her comfort. Her breathing is affected by the pain reliever, and she dies sooner than might otherwise have been the case

30. Action itself, administration of analgesic, is good • The physician intended only to relieve pain, not kill her • The relief of her pain was brought about by the medication, not by means of an early death • The pain itself is so severe that if left uncontrolled, it might be reasonably expected to shorten her life, so that there is a proportionality between the good and bad effects

31. Questions • Does “double effect” principle apply in the two pediatric cases?

32. Questions • If it is unethical, is it “aiding and abetting” the process to refer the patient’s family to GYN?

33. Principle of Cooperation in Evil • Guides limiting acting to avoid contributing to evil • A distinction between the actions of a cooperator and of the principal committing the wrongdoing • Not dependent on the agent knowing the act is evil • Moral object … Intention of actor … Circumstances

34. Types of Cooperation - Formal and Material • Formal - In which the cooperator intends the evil • Explicit - Cooperator directly approves • Implicit - Cooperator intends the evil of the agent not for its own sake but as a means to some other end

35. Types of Cooperation - Formal and Material • Free and knowing assistance to another’s evil act • Absence of intending the principal agent’s evil act • Immediate - cooperator does not share intent but participates in circumstance essential to the act • Mediate - cooperator participates in circumstances that are not essential to the commission of an act such that the action could occur even without the cooperation

36. ERD #70 • Catholic health care organizations are not permitted to engage in immediate material cooperation in actions that are intrinsically immoral, such as abortion, euthanasia, assisted suicide, and direct sterilization

37. Scandal An attitude or behavior which leads another to do evil … anyone who uses the power at his disposal in such a way that it leads others to do wrong becomes guilty of scandal and responsible for the evil he has directly or indirectly encouragedCCC 2284, 2287

38. Questions • If it is unethical, is it “aiding and abetting” the process to refer the patient’s family to GYN? • Am I cooperating in evil if I make a referral for the patient’s family to GYN in these two cases? And, if so, what type of cooperation is it?

39. Licit Mediate Material Cooperation • If some great good were gained or evil avoided? • Is the mediate material cooperation proximate or remote? • The danger of scandal must be avoided.

40. Suggests taking to the Ethics Committee. Mom becomes indignant. Goes to the patient’s endocrinologist who proclaims the pediatrician “ridiculous”. Recommends circumventing the system by going to Mpls. Children’s and having it done. Situation is unresolved at this time.

41. Why is Mom B Indignant?

42. Principle of Stewardship Over the Gift of Life • Requires us to appreciate God’s gifts of Creation and our human nature • Principle is grounded in our creation in God’s image and likeness … and … • In God’s absolute dominion over creation which is the basis for our limited dominion and stewardship over them

43. Genesis 1:26-30 Then God said: Let us makehuman beings in our image, after our likeness. Let them have dominion over the fish of the sea, the birds of the air, the tame animals, all the wild animals, and all the creatures that crawl on the earth. God created mankind in his image; in the image of God he created them; male and female he created them. God blessed them and God said to them: Be fertile and multiply; fill the earth and subdue it. Have dominion over the fish of the sea, the birds of the air, and all the living things that crawl on the earth. God also said: See, I give you every seed-bearing plant on all the earth and every tree that has seed-bearing fruit on it to be your food; and to all the wild animals, all the birds of the air, and all the living creatures that crawl on the earth, I give all the green plants for food. And so it happened.

44. Genesis 2:19-20 So the LORD God formed out of the ground all the wild animals and all the birds of the air, and he brought them to the man to see what he would call them; whatever the man called each living creature was then its name. The man gave names to all the tame animals, all the birds of the air, and all the wild animals; but none proved to be a helper suited to the man.

45. Genesis 2:15-17 • The LORD God then took the man and settled him in the garden of Eden, to cultivate and care for it. The LORD God gave the man this order: You are free to eat from any of the trees of the garden except the tree of knowledge of good and evil. From that tree you shall not eat; when you eat from it you shall die.

46. When I see the heavens, the work of your hands, the moon and the stars which you arranged, what is man that you should keep him in mind, mortal man that you care for him? Yet you have made him little less than a god; with glory and honor you crowned him, gave him power over the works of your hand, put all things under his feet. All of them, sheep and cattle, yes, even the savage beasts, birds of the air, and fish that make their way through the watersPsalm 8

47. Why is Mom B Indignant?

48. Principle of Respect for Autonomy • Autonomy is the capacity for self-determination • Being autonomous is not the same as being respected as an autonomous agent • One should be free from coercion in deciding to act which is exercised in process of informed consent • Does not imply that one must cooperate with another’s actions