ABORTION

Ethical Principles:
The principle of double effect
The lesser of two evils principle
The principle of cooperation

Double Effect:
•also known as the rule of double effect; the doctrine of double effect,
•is a set of ethical criteria for evaluating the permissibility of acting when one's otherwise legitimate act will also cause an effect one would normally be
obliged to avoid.
•Double-effect originates in the thought of Thomas Aquinas
•This set of criteria states that an action having foreseen harmful effects practically inseparable from the good effect is justifiable if upon satisfaction of the
following:
–the nature of the act is itself good, or at least morally neutral;
–the agent intends the good effect and not the bad either as a means to the good or as an end itself;
–the good effect outweighs the bad effect in circumstances sufficiently grave to justify causing the bad effect and the agent exercises due diligence to minimize
the harm.

Lesser of 2 Evils Principle:

•also known simply as the lesser evil,
•is the idea that of two bad choices, one isn't as bad as the other, and should be chosen over the one that is a greater threat.
•Eg. Indirect abortion

Principle of Cooperation:
•Formal cooperation
•Implicit formal cooperation
•Immediate material cooperation
•Mediate material cooperation
•Formal cooperation occurs when a person or organization freely participates in the action of a principal agent, or shares in the agent’s intention, either for its
own sake or as a means to some other goal.

•Implicit formal cooperation occurs when, even though the cooperator denies intending the object of the principal agent, the cooperating person or organization
participates in the action directly and in such a way that the it could not be done without this participation. Formal cooperation in intrinsically evil actions,
either explicitly or implicitly, is morally illicit.
•Immediate material cooperation occurs when the cooperator participates in circumstances that are essential to the commission of an act, such that the act could
not occur without this participation.
•Immediate material cooperation in intrinsically evil actions is morally illicit.

•Mediate material cooperation occurs when the cooperator participates in circumstances that are not essential to the commission of an action, such that the
action could occur even without this cooperation.

Direct Abortion:
•A direct abortion is the one that is induced with the immediate purpose of destroying the human fetus at any stage after conception

Medical Abortions:
•
Non-surgical, uses pharmaceutical drugs and are only effective in the first trimester of pregnancy.
•Combined regimens include METHOTREXATE or MIFEPRISTONE, followed by prostaglandin (either MISOPROSTOL or GEMEPROST)
•When used within 49 days gestation, approximately 92% of women undergoing medical abortion with a combined regimen completed it without surgical
intervention.
•Misoprostol can be used alone, but has a lower efficacy rate than combined regimens.

Surgical Abortion:
•A vacuum aspiration abortion at 8 weeks gestational age (6 weeks after fertilization).
1: Amniotic sac
2: Embryo
3: Uterine lining
4: Speculum
5: Vacurette
6: Attached to a suction pump

Suction-Aspiration-Vacuum Abortion:
•Common method.
–Manual Vacuum Aspiration (MVA) abortion consists of removing the fetus or embryo, placenta and membranes by suction using a manual syringe
–Electric vacuum aspiration (EVA) abortion uses an electric pump.
–MVA, also known as "mini-suction" and "menstrual extraction", can be used in very early pregnancy, and does not require cervical dilation. Surgical
techniques are sometimes referred to as 'Suction (or surgical) Termination Of Pregnancy' (STOP).
–15th wk -26th, dilation and evacuation is used consists of opening the cervix of the uterus and emptying it using surgical instruments and suction.

Dilatation & Curettage:

•Gynecological procedure performed for a variety of reasons, including examination of the uterine lining for possible malignancy, investigation of abnormal
bleeding, and abortion.
•Curettage refers to cleaning the walls of the uterus with a curette.] The term D and C, or sometimes suction curette, is used as a euphemism for the first
trimester abortion procedure, whichever the method used.

Other Methods:
2nd week of gestation
•Premature delivery can be induced with prostaglandin; this can be coupled with injecting the amniotic fluid with hypertonic solutions containing saline or
urea.
After the 16th week of gestation
•Intact dilation and extraction (IDX)- requires surgical decompression of the fetus' head before evacuation.
• Hysterotomy abortion - similar to a caesarean section and is performed under general anesthesia. It requires a smaller incision than a caesarean section and is
used during later stages of pregnancy
20th to 23rd week of gestation
•Injection to stop the fetal heart can be used as the first phase of the surgical abortion procedure to ensure that the fetus is not born alive.
•Abortion is sometimes attempted by causing trauma to the abdomen. The degree of force, if severe, can cause serious internal injuries without necessarily
succeeding in inducing miscarriage
•insertion of non-surgical implements such as knitting needles and clothes hangers into the uterus. These methods are rarely seen in developed countries where
surgical abortion is legal and available.[28]

Indirect Abortion & Double Effect:

Indirect Abortion:
•Is one in which the direct, moral object of the action (immediate intrinsic purpose of the procedure) is therapy for the mother, but in which the death of the
fetus is the side effect that cannot be avoided. (O’Rourke, K., Ethics of Health Care, 3rd ed., 2002)
•Example
–Removal of a pathological tube containing a fertilized ovum in an ectopic pregnancy
–Removal of a cancerous gravid uterus
–Are justified by the principle of DOUBLE EFFECT
Double Effect:
•Saint Thomas: “Nothing hinders one act from having two effects, only one is intended, while the other is beside the intention. Now moral acts take their
species according to what is intended, and not according to what is beside the intention, since this is accidental.”
•(Summa Theol., II-II, q.64, a.7)
•Helps us determine whether or not it is morally correct to perform one act, which will bring about a good as well as an evil effect.
•(L. Ciabal, Ethics for Health Professionals, 1st ed., 2003)

Situation
–Pregnant woman was found to have a cancerous uterus, a surgeon could remove the cancerous uterus in order to save a woman’s life, a good moral object.
–The surgeon would realize that removing the gravid uterus will result in the death of the fetus, but this effect is beyond the intention of the woman and the
surgeon
–If they could, they would both counteract the cancer and save the child, but the evil effect is inextricably connected with the good effect.
•1st of the FOUR conditions
–The directly intended object (finis operis) of the act must not be to instrinsically contradict one’s own fundamental commitment to God and to neighbor, or to
oneself.
–It must be an action judged to be good by reason of its moral object.
•2nd of the FOUR conditions
–The intentions of the agent must be to achieve a good effect and to avoid the harmful effects in so far as possible.
–The evil effect is only indirectly intended.
•2nd of the FOUR conditions
–The intentions of the agent must be to achieve a good effect and to avoid the harmful effects in so far as possible.
–The evil effect is only indirectly intended.
•3rd of the FOUR conditions
–The foreseen beneficial effects must not be achieved by means of the evil effect.
–In the example, it would be unethical to kill the fetus directly (as the moral object) to make it easier to remove the uterus.
•4th of the FOUR conditions
–The benefits of the action must be equal or greater than the foreseen harmful effects
•Now, let’s analyze the situation in accordance to the principle of double effect by:
–The act itself is directly aimed at treating the pathology: ethical
–The mother & physician would save the child if it was possible; (LAST RESORT)
–The death of the child is not a means to treat the mother but only a side effect of the procedure
–The proportionate reason for the procedure is to save the mother’s life

Virtues of a Catholic Health Care Giver:

Virtue: moral excellence; trait of character or habit of disposition to think and act in ways that are good

Importance of Virtue: what one is, determines what one does; fosters trust

Fidelity:
Definition: Faithfulness to trust and promise
Basis of the Covenant of Trust:
•Good greater than harm
•Best interest
•Informed consent
•Advocate
Healthcare Delivery: competent care; respect for colleague

Honesty:
Definition: Truthfulness and integrity (For respect, freedom of conscience, & justice)
Truthfulness - convey correct information, avoid deception, protect privacy
Integrity - true to oneself; be what you preach
Healthcare Delivery: truthful about patient’s illness & options

Humility:
Definition: Honesty with oneself & acknowledging it; simplicity; accepting the limitations of nature & science
Healthcare Delivery: updating competence, letting patient make decisions, referrals

Compassion:
Definition: Feel suffering of another & attempt to help without seeking reward
Healthcare Delivery: Listen to a patient’s life story then adjust accordingly; humane care

Justice:
Definition: Constant will to give another his/her due; adjusting what is owed to the specific needs of the person (charity)
Healthcare Delivery: Basic medical care for all; caring for those at fault

Courage:
Definition: Decide & then do what is right without undue fear
Healthcare Delivery: Decision-making; advocacy

Prayerfulness:
Definition: Communicating with & seeking God in everything one does
•Express anxiety
•Self-understanding (meaning & purpose)
•Capacity to forgive
Healthcare Delivery: Strength, faith, hope

Prudence:
Definition: foresight; caution & circumspection
Healthcare Delivery: particularize patient recommendations; use good evidence

Counseling on Abortion:
•Increasing knowledge about Natural Family Planning including health & societal benefits
•Providing complete & accurate information on the risks of having an abortion
•Discussing the different alternatives to abortion
•Spiritual guidance & support from the Church, family, friends, etc.

Alternatives to Abortion:
Advocacy campaign groups (Grace to Be Born) help pregnant women in crisis
•Shelter for unwed mothers
•Orphanage & care for abandoned babies
•Maternity expenses shouldered
Supported by citizens, NGOs, church, & civic groups
Adoption (Christian Adoption Services)
Abortion Case:
•Having given accurate information & guidance, the physician must respect the right of the patient to make her own decision
•The physician has the right to withdraw from the case if what is decided by the patient is contrary to his/her own personal or institution’s values
•Referring the patient to another physician involves formal cooperation & is unethical (agree w/ the purpose of the other knowingly & willingly)

Post-Abortion Complications & Care:

•A health care provider who cares for the patient after an abortion cooperates only materially & remotely
–assists, but disagrees w/ immorality of the action

•Ethical when only in this way, can greater harm be prevented, provided:
–Cooperation is not immediate (take part in act itself)
–Degree of cooperation & degree of scandal are taken into account

House Bill No. 5043:

AN ACT PROVIDING FOR A NATIONAL POLICY ON REPRODUCTIVE HEALTH, RESPONSIBLE PARENTHOOD AND POPULATION
DEVELOPMENT AND FOR OTHER PURPOSES

•Reproductive Health and Population Development Act of 2008

Declaration of Policy:
•The State upholds and promotes responsible parenthood, informed choice, birth spacing, and respect for life.
•The State shall uphold the right of the people to effective and reasonable participation in the formulation and implementation of the declared policy.
•This policy is anchored on the rationale that sustainable human dev’t is better assured with a manageable population of health, educated, and productive
citizens
•The State likewise guarantees universal access to medically-safe, legal, affordable and quality reproductive health care services, methods, devices, supplies,
and relevant information

Guiding Principles:
•There should be NO bias for either modern or natural methods of family planning
•RH goes beyond a demographic target because it is principally about health and rights
•Gender equality and women empowerment are central elements of RH and population dev’t
•Freedom of informed choice, which is central to the exercise of any right, must be fully guaranteed by the State like the right itself.
•Since manpower is the principal asset of every country, effective RH care services must be given primacy to ensure the birth and care of healthy children and
to promote responsible parenting
•Protection and promotion of fender equality, women empowerment and human rights are imperative
•While nothing in this Act changes the law on abortion, as abortion remains a crime and is punishable, the government shall ensure that women seeking care
for post-abortion complications shall be treated and counseled in humane, non-judgmental, and compassionate manner.

HB 5043 Section 9:
•Hospital-based Family Planning
–Tubal Ligation
–Vasectomy
–Intrauterine Device Insertion
•Available in ALL national and local government hospitals

Section 10:
•Contraceptives as Essential Medicines
–Hormonal contraceptives, IUDs, injectibles and others
–Under the category of ESSENTIAL medicines and supplies in the PNDF.

Section 21:
•Prohibited Acts:
–Knowingly withholding information or impede dissemination or provide incorrect information about the RH programs and services
–Refusal to perform voluntary ligation and vasectomy and other medically- safe and legal RH care services
–Refusal to provide RH care services to abused minor
–Falsification of certificate of compliance
–Any person who maliciously disengages in disinformation about the intent and provisions of this act
ABNORMAL PREGNANCIES

Maternal-fetal conflicts:
Include medical or surgical complications neccessitating invasive diagnostic/therapeutic procedures during pregnancy that may adversely affect either
the mother or the fetus
Directed toward saving both lives
If not possible, treatments directly intended to cure mother & not directly intended to terminate pregnancy are permitted for curing a serious pathological
condition of the mother which cannot be safely postponed, even though it may result to fetal death

Ethical Principles:
Double Effect
Serves as guiding principle in maternal-fetal conflict.

5 Conditions…
1. The action itself must be morally good or at least indifferent.
Action itself independent of its effect.
Action should be fair.

2. The intention of the agent should be directed towards the good effect.
Direct voluntary

3.The evil effect must never be directly intended.

Indirect voluntary.

4.There should be no relationship of causality.

Evil effect must not cause the good effect.

5. Proportionality.
The good must compensate for the evil.

Autonomy
Pregnant women have a right to make decisions concerning their medical care
Proposals to control the woman’s behavior for the fetus’s sake are problematic, in part, because her autonomy would be violated.

Beneficence
Doctor has an obligation to the pregnant woman and, when conferred moral standing is justifiable, to the fetus.

Avoid Killing
When conferred moral standing is ethically justifiable, there is a strong presumption against killing the fetus.
It is not clear that killing always harm the one killed, since there might be genuine cases of mercy killing.
Also, harm to the one killed does not exhaust the moral significance of killing, as there might also be adverse social consequences.
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Moral Standing of the Fetus
Two main approaches:
1.The fetus becomes a person when it acquires some special characteristic during gestation.

2. The fetus becomes a person when it has a moral standing based on considerations in addition to its own characteristics.
[The second approach recognizes that no characteristics acquired during pregnancy give rise to personhood but asks whether the fetus has a moral
standing based on considerations in addition to its own characteristics]

Pope Pius XII has said, “Life, from the moment of its inception is sacred.”
Life is God’s gift and to be valued as such, a gift to be protected, cherished and upheld; so that as far as the moral status of the embryo is
concerned, its status, rights and dignity are equal to that of the mother’s.

1. The fetus becomes a person when it acquires some special characteristic during gestation.
-“indicators of personhood”
-Viability
-Potential to become a rational self-conscious individual
-Membership in an intelligent species (which begins at conception)
-Having basic anatomical structure of human beings
-Sentience
-Self-consciousness

[None of the arguments that personhood begins during gestation have been successful. Moreover, there is a widely held view implying that any attempt
to locate the beginning of personhood during gestation is mistaken.
--
On this view, self-consciousness is a necessary and sufficient condition for personhood. This is a characteristic lacking in fetuses and newborns
acquired by human beings at a later stage in development.]

2. The fetus becomes a person when it has a moral standing based on considerations in addition to its own characteristics.
Conferring moral standing on fetuses might be justified by the consequences of doing so.
Self-consciousness is necessary to be a ‘person in the strict sense’.
We might confer upon infants and others who are not persons in the strict sense the status ‘person for social considerations’

[Conferring moral standing on fetuses might be justified by the consequences of doing so. Example: Benn suggests that one reason for treating infants
with tenderness and consideration is the good consequences this might have for the persons they grow up to become. Failure to provide tender care to
some might also lead to callous concern for others.

If a case like this can be made for infants, it may apply equally to fetuses; or at least, to fetuses at a stage of maturity at which we can reasonably
associate the way we treat them with the way we treat babies’.]

The closer an individual is to the paradigm of a human being who is a person in the strict sense, the more likely it is that consequences of the sort
identified will occur, and thus the stronger the argument for conferred moral standing.
Embryos and fetuses in early gestation
Argument is considerably weaker
Lack:
Basic anatomical structure of human beings
Sentience
Viability
Significant social role
Less similar to the paradigm
Fetuses during the third trimester
Members of an intelligent species
Potential to become persons in the strict sense
Have the basic anatomical structure of human beings
Reached viability
Are Sentient
Occupy a social role
[Viability – normally occurs during later second trimester; Indications that they occupy a social role to some degree:
-Pregnant women can purposefully act in ways that benefit her fetus (eating nutritious meals)
-Obstetricians can monitor the health status of the third-trimester fetus and offer interventions when needed
-Parents often have a deep psychological attachment to the fetus by this time]
Third-trimester fetuses are nearly as ‘person’ as infants. The difference lies in the fact that infants typically are more involved in a social role.
The strength of the moral standing of fetuses in the third trimester should be regarded as very close to, although perhaps not quite as strong as that of
infants.
Serious moral standing cannot be conferred upon fetuses near term without at the same time denying the personhood of women.
It does not necessarily follow that fetuses near term should have legal rights equal to those of women
Even if fetuses and women had equal legal rights, it would not necessarily follow that forced treatment or other control of pregnant women would be
ethically or legally justifiable.
Role of the health provider
It is the moral responsibility of the health professional to provide his patient with an accurate “risk assessment.”
Support a patient’s informed and free decision regarding a treatment process, as far as the physician’s personal values would allow.
Role of the health provider
The health provider should not feel obliged to provide a service which conflicts with his values and he should openly communicate this information to
his patient at the onset of the patient-physician relationship.
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Maternal Behavior Harmful to the Fetus
Woman’s rights should never be overridden.
Forced treatment would disrupt the woman’s relationship with her doctor, possibly interfering with her receiving needed care, thus resulting harm for
mother and fetus.
Maternal Behavior Harmful to the Fetus
Pregnant women are persons in the strict sense, while third-trimester fetuses have a conferred moral standing that is less strong.
These arguments support a presumption in favor of the woman’s autonomy and well-being that is very strong but not absolute.
It might be legally and ethically justifiable to override the woman’s autonomy in rare extraordinary situations provided that two conditions are met
The treatment poses insignificant or no health risks to the woman or would promote her interest in life or death.
There must be compelling reasons to override the mother’s autonomy.

Maternal Behavior Harmful to the Fetus

Compelling reasons may vary depending on the case, and usually would consist of a combination of factors:
Protecting fetal life
Preventing serious harm to the infant-to-be
Preventing abandonment of other children due to maternal death
Preventing harm to the mother’s health
Protecting the mother’s life
Preserving the ethical integrity of the doctor
Promoting the well-being of the community
[Some of this alone might never justify court-ordered treatment, but several in combination might do so in exceptional cases]

Pregnant addicts
State custody in detoxification centers
Drive drug-using women away from prenatal care
Highly invade the liberty of women
Coerced treatment of drug addiction sometimes does not receive the cooperation of the patient
Detention is not an appropriate approach.
Early delivery
Significant risks of neonatal complications:
Brain hemorrhage
Lung disease
Death
Early delivery is not the best approach
Persuade the woman to return to the hospital
[BECAUSE THERE IS SIGNIFICANT CHANCE THAT THE PRINCIPLE “DO NO HARM” WOULD BE VIOLATED, early delivery is not the best
approach.]
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Management of Fetal Anomalies

The autonomy of the pregnant woman gives rise to the doctor’s obligation to help her make informed decisions when fetal anomalies are detected
[This obligation requires the doctor to explain the possible management options to the woman.]

Four main approaches

Abortion
Aggressive approach
Non-aggressive approach
Balancing approach

Abortion
In the United States, is not legally available after viability
Aggressive approach
Continuing the pregnancy in a manner that attempts to optimize the well-being of the fetus.
[Aggressive approach:
It utilizes procedures involving increased maternal risks when needed for the fetus including tocolysis = use of labor-arresting drugs, and Cesarean
delivery]

Non-aggressive approach
Resolves conflicts between maternal and fetal well-being in favor of the woman
Balancing approach
Intermediate approach to weighing the interests of mother and fetus
Individual decisions would be based on factors such as the degree of risk to the woman posed by a particular procedure, as well as the degree and
likelihood of potential benefits for the fetus.
[Non-aggressive approach:
Avoids interventions that pose increased risks for the mother
Balancing approach:
This approach would permit the woman to be exposed to increased risks in some, but not all, situations]

Appropriate recommendations will depend on:

Strength of the argument for conferred moral standing in a given case
Fetal prognosis with and without proposed interventions
Reliability of the fetal diagnosis
Maternal risks posed by interventions
Likelihood that such risks would materialize
Whether the procedures used would constitute killing
Fetal anencephaly
Diagnosed in utero with a high degree of certainty
Lack of cerebral cortex
No pain or other sensations
Lacks sentience
No interests
Lacks the capacity to be benefited or harmed
The mother’s interests clearly should be the primary consideration

Fetal anencephaly
Aggressive and balancing approaches would not be appropriate
Abortion
Short non-sentient existence so prompt death would not deprive it of any benefit
Not cause pain – absence of awareness
Ethically justifiable if it promoted the autonomy or well-being of the woman
[Because there is no chance of benefiting the fetus, aggressive and balancing approaches would not be appropriate

Reduces the degree of similarity with the paradigm and weakens the argument for conferred moral standing

The court has stated that before viability, the woman has a constitutionally protected right to abortion. The assessment of viability is left to the
judgement of the doctor]

Occipital encephalocele and microcephaly

Fetus lacks potential for cognitive development necessary for personhood
Non-aggressive management
Potential fetal benefit from aggressive interventions is small and significant maternal risks would be avoided
Fetus is viable and presumably it is sentient
[Occipital encephalocele – herniation of brain and meninges through a defect in the skull resulting in a sac-like structure
Microcephaly – abnormally small head]

Occipital encephalocele and microcephaly

Principle of avoiding killing is weightier
False-positive diagnosis is possible
Abortion would not be ethically justifiable unless necessary to prevent serious harm to the mother.
Hydrocephalus and lumbar meningomyelocele
Non-aggressive approach
Cephalocentesis
Inserting a needle into the cranium so cerebrospinal fluid can be extracted to reduce head size
Almost always result in stillbirth or neonatal death within several days
Would likely violate the principle of avoiding killing
Potential harm to the fetus is great

Hydrocephalus and lumbar meningomyelocele

Aggressive approach
Delivery as soon as fetal lungs are mature
Cesarean delivery to avoid fetal head trauma
A choice by the woman for cesarean delivery should be fully supported by the doctor.
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Early Induction of Labor:
A caesarian section to remove a viable fetus is permitted, even with the risk of the life of the mother, if needed for a successful delivery, or with the risk
of the fetus, if needed for the safety of the mother

Anencephaly:
Brain is partially or almost totally absent
Death is a virtual certainty

Renal Agenesis:
Kidneys and lungs are underdeveloped
Death is also a certainty

Dilemma:
Some mothers are willing to allow pregnancies to go to term, others find it distressing once they know that their babies will inevitably die of their lethal
abnormality soon after birth
Let pregnancy go to term? Or induce early delivery once the diagnosis is made?

Case in favor of premature delivery:

Fetuses are incapable of long-term survival
To relieve her distress, mother would be justified to withdraw her life-support of pregnancy by early induction thereby allowing defective fetus to die of
its inherent fatal condition soon after delivery
Whether delivered at 16, 24 or 40 weeks, death follows after birth
Extra weeks of uterine life would not be of any benefit to the fetus & would cause additional distress to the mother

Providence Alaska Medical Center:

"Early induction is a medical procedure available to women who are experiencing life-threatening complications to themselves or their fetus during
pregnancy. This is a procedure performed in many Catholic hospitals. These are tragic, grief-filled and difficult decisions that are made between a
physician and a family based on medical necessity does have an ethics review team that evaluates each early induction case on its merits and whether
the procedure remains within Catholic ethical and religious directives. It is important to note that this is a procedure that is performed infrequently, at
most, five times a year . . . .
“The increased availability of genetic services and the wider use of obstetric ultrasound have revealed a large number of fetuses with anomalies that
previously were not detected prenatally.”

Case against premature delivery:

Pregnancy is the natural supportive environment for the fetus & cannot be compared to an extraordinary artificial life-support system
A lethally deformed fetus is still a living human individual to whom a duty of reasonable care is owed
Enable fetus to develop & grow to the stage of maturity required for survival without the life-support provided by the uterus
Deliberate non-therapeutic early induction of a fetus with anencephaly or even a healthy fetus before maturity for survival in extra-uterine conditions is
ethically indistinguishable from direct abortion
Fetus would die of prematurity as a result of early induction, not anencephaly

Regard for Fetuses:

Fetus should be accorded the status of a person from conception (has heart beat & can breathe spontaneously)
Labor & delivery of fetuses are difficult at term
Anencephaly
Shoulder dystocia can cause baby to become stuck in the birth canal, resulting in extreme trauma & high risk of maternal hemorrhage (Caesarian
section is needed)
Absence of cranial vault = birth at term painful for the baby

Health of the Mother:

Neither condition presents an immediate danger to the mother. Anencephaly causes no complications to the mother. Renal agenesis may lead to
complications if the child dies in the uterus, but close monitoring greatly reduces this risk.
Early induction can be done in situations such as when the mother's physical health is imminently endangered. Yet early induction also presents
potential problems for the mother increased risk for an incompetent cervix in a later pregnancy, for breast cancer and for impaired mental health so
these physicians say this procedure should be avoided at all costs.
Medically speaking, according to physicians who deal with difficult pregnancies on a regular basis, there is no more valid reason to perform an early
induction for a baby with fatal anomalies than there is for a healthy unborn child.

Prenatal Diagnosis:
"Prenatal diagnosis is morally licit - if it respects the life and integrity of the embryo and the human fetus and is directed toward its safeguarding or
healing as an individual." Catechism of the Catholic Church (no. 2274).
Mistakes can be made the diagnosis of a fatal abnormality in the unborn child & a healthy child could be forcibly born prematurely

National Conference of Catholic Bishops:

Moral Principles Concerning Infants with Anencephaly (1998
Hence, it is clear that before "viability," it is never permitted to terminate the gestation of an anencephalic child as the means of avoiding psychological
or physical risks to the mother. Nor is such termination permitted after "viability" if early delivery endangers the child's life due to complications of
prematurity. In such cases, it cannot reasonably be maintained that such a termination is simply a side effect of the treatment of a pathology of the
mother. Anencephaly is not a pathology
of the mother, but of the child, and terminating her pregnancy cannot be a treatment of a pathology she does not have. Only if the complications of the
pregnancy result in a life-threatening pathology of the mother may the treatment of this pathology be permitted, even at a risk to the child, and then, only
if the child's death is not a means to treating the mother. The fact that the life of a child suffering from anencephaly will probably be brief cannot excuse
directly causing death before "viability" or gravely endangering the child's life after "viability" as a result of complications of prematurity.

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Why do some women consider the early induction procedure after a diagnosis of fetal abnormalities incompatible with life?
They are overwhelmed by emotional and mental stress.
They are convinced that going to full term will not improve the child's chances of survival.
In cases of renal agenesis, fetal death in utero could result in release of toxins dangerous to the mother.
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What are the major ethical and medical objections to this procedure?
Early induction is only permissible when the physical life of the mother is gravely endangered a very rare situation.
Prenatal diagnosis can be wrong, and a healthy child could die as a result.
The procedure presents increased risk to the mother of conditions including incompetent cervix, impaired mental health and breast cancer.
Prematurity reduces the chances of survival for a child already diagnosed as unable to survive.

Ectopic Pregnancy:
Pregnancy that occurs outside the uterine cavity usually at an adjacent site, generally, the fallopian tube.
This may happen if the fertilized egg cell remains in the ovary or in the fallopian tube or if it lodges on the free abdominal cavity.

In more than 98% of ectopic pregnancies, the primary site is the fallopian tube. The rest occur in the abdominal cavity, on the ovary or in the cervix.

Risks:
Blood loss (fallopian tube rupture, significant intraperitoneal bleeding) and its consequences
Implications for future reproductive performance. After one previous ectopic pregnancy, the chance of another is 7 to 15 percent (Ankum and
colleagues, 1996; Coste and associates, 1991).
Psychological effects of the loss of the pregnancy

Ectopic Pregnancy
If left untreated, an ectopic pregnancy can tear or rupture the fallopian tube which can lead to severe internal bleeding, which is life-threatening
most ectopic pregnancies occur in women between the ages of 35 to 44
Ectopic pregnancy is also more prevalent in women whose fallopian tubes have been blocked or damaged due to endometriosis, scarring after tubal
surgery, pelvic inflammatory disease (PID), or a previous ectopic pregnancy

The “dangerously affected” part of the mother may be removed even though fetal death is foreseen, provided that the operation is not just a separation
of the embryo or fetus from its site or a direct abortion

 “No intervention is morally licit which constitutes a direct abortion.” (directive 48)
Physicians & moral theologians: do not agree upon which procedures would be direct or indirect abortions.

Ectopic pregnancies are the leading cause of maternal deaths in the first trimester
By ten weeks (in the case of a tubal pregnancy), the fallopian tube will likely rupture, causing severe hemorrhaging that can result in death. Such
cases most often occur when the ectopic pregnancy is not diagnosed
most deaths caused by ectopic pregnancies each year are among minority groups and the poor whose access to prenatal care is limited
Moral Principles
lives of both the mother and child are placed at risk
Respect the lives of both

“In the case of extrauterine pregnancy, no intervention is morally licit which constitutes a direct abortion”-U.S. Conference of Catholic Bishops

 “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” - U.S.
Conference of Catholic Bishops

a moral distinction must be made between directly and intentionally treating a pathology and indirectly and unintentionally causing the death of the
baby in the process
Treatment
laparoscopy
salpingostomy- removal of embryo
salpingectomy- removal of part of the FT or the whole FT

[-A partial salpingectomy is performed by cutting out the compromised area of the tube. The tube is then closed in the hope that it will function properly
again
-Full salpingectomy is performed when implantation and growth has damaged the tube too greatly or if the tube has ruptured ]

Treatment
Methotrexate - medical alternative to surgery; injection of the medication terminates the pregnancy by halting cell growth

Majority of Catholic moralists reject salpingostomy and MTX on the basis that these two amount to no less than a direct abortion
In both cases, the embryo is directly attacked, so the death of the embryo is not the unintended evil effect, but rather the very means used to bring
about the intended good effect
Both do not follow the principle of double effect
Salpingectomy –morally licit
Partial salpingectomy is performed by cutting out the compromised area of the tube. The tube is then closed in the hope that it will function properly
again
Full salpingectomy is performed when implantation and growth has damaged the tube too greatly or if the tube has ruptured
Treatment
unlike the first two treatments, when a salpingectomy is performed, the embryo is not directly attacked
The infected tube is the object of the treatment and the death of the child is indirect
Since the child’s death is not intended, but an unavoidable secondary effect of a necessary procedure, the principle of double effect applies
Treatment
2 circumstances that make the use of MTX and salpingostomy morally acceptable:
1. when an ectopic pregnancy has been diagnosed, but no signs of life exist
2. when the fallopian tube ruptures, whether or not the embryo is alive
-an immediate threat to both mother and child. If nothing is done, both will die. The doctor is morally obligated to act, even though only one life
can be saved
BIRTH REGULATION & FERTILITY CONTROL

oEthical Principles
o Different Methods of Fertility Control
o Responsibilities of a Catholic health care giver
o Pregnancy prevention after sexual assault
oA couple with five children finally decided to stop making a baby due their financial situation.
oUnable to resist temptation, they thought of resorting into using artificial methods.
oThey look back into the ethical principles which were taught to them way back in med school.

Birth Control & Fertility Control:

The many principles used in discussing these issues are as follows:
Well formed Conscience
Human Dignity
Totality and Integrity
Stewardship and Creativity
Inner Freedom
Personalized Sexuality

Well-formed Conscious:
“Conscience is a judgment of
reason whereby the human person
recognizes the moral quality of a
concrete act. . . . [Every person] is obliged to follow faithfully what he [or she] knows to be just and right” (Catechism of the Catholic Church, no. 1778).
As Catholics, there is a lifelong obligation to form our consciences in accord with human reason, enlightened by the teaching of Christ as it comes to us through the
Church.

Human Dignity:
Maximal integrated satisfaction of the innate and cultural needs- biological, psychological, ethical, and spiritual- of all human persons, as individuals and as members
of both their national communities and the world community. (Ashley and O'Rourke, 2002)
Principle of Totality & Integrity:
That the lower functions of human person may be sacrificed for the better functioning of the whole person, but basic capacities that define human personhood are
never sacrificed unless this is necessary to preserve life itself (Ashley and O'Rourke, 2002)
Stewardship & Creativity:
It requires us to appreciate the two great gifts that a wise and loving God has given: the earth with all its natural resources, and our own human nature (embodied
intelligent freedom) with its biological, psychological, social and spiritual capacities
We must take the utmost care to conserve our ecological system unpolluted and unravished and to recycle raw materials and energy supplies. Similarly, our own
bodies and minds are wonderfully constructed.
“If it can be done, It should be done” is a misuse of our creative intelligence. Our creativity should be a co creativity with the creator and not a reckless wasting of his
gifts (Ashley and O'Rourke, 2002)

Inner Freedom:
To be free to follow our conscience, we must avoid actions that may cause addiction to our immoderate physical pleasures or obsessive fears that could result in a loss
of rational control of our behavior.
If such a loss occurs, one must seek therapy and help from others who have an obligation to intervene and support recovery (Ashley and O'Rourke, 2002)

What Is Sexuality:
Sexuality can be defined in two different ways:
Function of the human person by which we form friendships, create community and ensure through the marital act the continuation of human race
Bond of unity between husband and wife

Principle of Personalized Sexuality:

The gift of human sexuality must be used in marriage in keeping its intrinsic, indivisible, specifically human teleology (The study of design or purpose in natural
phenomena)
It should be a loving, bodily, pleasurable expression of the complimentary, permanent self giving of a man and woman to each other which is open to fruition and
expansion of this personal communion through the family they beget and educate (Ashley and O'Rourke, 2002)

Values of Marital Sexual Activity:

It is a search for sensual pleasure and satisfaction, releasing physical and psychic tensions
Search for the completion of the human person through the intimate and personal union of love
It is a social necessity for PROCREATION of children so as to expand the human community (Ashley and O'Rourke, 2002)
Sexual activity is a Sacramental mystery revealing the cosmic order and our human destiny because it stands for the creative love of God for his creatures and their
loving response to him

On the Human Life Encyclical:

Pope Paul VI stated that:
“The Church’s teaching on contraception, often set forth by the Magisterium, is founded upon the inseparable connection, willed by God and unable to be broken by
human beings on their own initiative, between the two meanings of the conjugal act; the unitive meaning and the procreative meaning (Paul VI 1968, n.12)”
Pope John Paul II added in Reflections on the Encyclical “On Human Life or Humanae Vitae 1968”
“The pertinent principle of conjugal morality is therefore, fidelity to the divine plan manifested in the “intimare structure” of the conjugal act and the inseparable
connection of the two aspects cannot be deprived of their full and adequate significance by ARTIFICIAL means”
In addition, when couples by means of contraception separate these two meanings – love and potential fecundity- that God the creator inscribed in beings of man and
woman… they act as arbiters of the divine plan and they manipulate and degrade sexuality and themselves by manipulating the value of total self giving (John Paul II
1984,23)

God’s Loving Design:

Married love particularly reveals its true nature and nobility when we realize that it takes its origin from God, who "is love," the Father "from whom every family in
heaven and on earth is named."
Marriage’s purpose in reality was to effect in man His loving design
that union of two persons in which they perfect one another, cooperating with God in the generation and rearing of new lives.

Married Love:
It is not merely a question of natural instinct or emotional drive but also an act of the free will
to survive the joys and sorrows of daily life, but also to grow, so that husband and wife become in a way one heart and one soul, and together attain their human
fulfillment.
It is Total
in which husband and wife generously share everything, allowing no unreasonable exceptions and not thinking solely of their own convenience.
Faithful and exclusive of all other, and this until death
fidelity is in accord with the nature of marriage; it is the source of profound and enduring happiness.
Fecund
"Marriage and conjugal love are by their nature ordained toward the procreation and education of children. Children are really the supreme gift of marriage and
contribute in the highest degree to their parents' welfare."

Responsible Parenthood:
requires that husband and wife, keeping a right order of priorities, recognize their own duties toward God, themselves, their families and human society
are not free to act as they choose in the service of transmitting life, as if it were wholly up to them to decide what is the right course to follow. They are bound to
ensure that what they do corresponds to the will of God the Creator.
knowledge of the biological processes involved in reproduction
man's reason and will must exert control over his innate drives and emotions (self-control)
With regard to physical, economic, psychological and social conditions, it is exercised by those who prudently and generously decide to have more children, and by
those who, for serious reasons and with due respect to moral precepts, decide not to have additional children for either a certain or an indefinite period of time
Observing the Natural Law:
The Church teaches that each and every marital act must of necessity retain its intrinsic relationship to the procreation of human life.
Sexual intercourse is “Noble and worthy''
New life is not the result of each and every act of sexual intercourse
God has wisely ordered laws of nature and the incidence of fertility in such a way that successive births are already naturally spaced through the inherent operation of
these laws

Union & Procreation:

The marriage act has both of unitive and procreative significance
unites husband and wife in the closest intimacy,and also renders them capable of generating new life
If preserved, the use of marriage fully retains its sense of true mutual love and its ordination to the supreme responsibility of parenthood to which man is called.

Faithfulness to God’s Design:

To experience the gift of married love while respecting the laws of conception is to acknowledge that one is not the master of the sources of life but rather the minister
of the design established by the Creator
Hence to use this divine gift while depriving it, even if only partially, of its meaning and purpose, or if imposed on one's partner without regard to his or her condition
or personal and reasonable wishes in the matter is equally repugnant to the nature of man and of woman, and is consequently in opposition to the plan of God and His
holy will

Different Methods of Fertility Control

ETHICAL UNETHICAL

Natural Family Planning Artificial Contraception

“rightly use a facility provided to them by nature.” obstructs the natural development of the generative process

both cases for acceptable reasons, have the intention of avoiding children both cases for acceptable reasons, have the intention of avoiding children

abstain from during the fertile period Performance of sexual intercourse with deliberate intention of rendering
infertile an act that could be fertile
during infertile days, “use their married intimacy to express their mutual
love and safeguard their fidelity towards one another.”

conception control based on the natural fertility cycle in women

refers to a variety of methods used to plan or prevent pregnancy, based on identifying the woman's fertile days
“fertility awareness-based methods”
Refers to the family planning methods approved by the Roman Catholic church

Based on the doctrine that God created sexual intercourse to be both unitive and procreative

Humanae Vitae cites "physical, economic, psychological and social conditions" as possibly compelling reasons to avoid pregnancy

3 Main Types of Natural Family Planning:

Observational (Billing’s Method, Basal Body Temp., Symptothermal)
Statistical (Rhythm Method, Standard Days Method)
Lactational Amenorrhea

Observational:
Primary signs (Basal body temp., cervical mucous, cervical postion)
-fertility awareness methods
-track biological signs of fertility

Billing’s Method:
Ovulation Method or Cervical Mucus Method
Interpret changing cervical secretions based on sensation of wetness, color and elasticity of the secretion. (Secretions: clear, stretchy, wet, slippery)

Basal Body Temp:

Done by observing body temperature each morning before beginning any activity
The body temperature is lower before ovulation and rises slightly to about .2 oC or .4 oF after ovulation

Symptothermal Method (Combination of Billings & BBT):

How does the symptothermal method work?
• Woman needs to take her temperature every morning and
learn about her body's natural fertility signs which include cervical mucus consistency, cervical position, mid-cycle cramping, and mood.
• Daily temperature readings are performed using a basal thermometer.
• This level of precision is necessary to detect the slight temperature increase that marks the end of the fertile period.
• The woman keeps a chart where she records her daily temperature and also other body signs that indicate when ovulation will occur.

Statistical (statistical estimates as to when a woman is fertile):

Rhythm/Calendar Method:
Woman need to keep a record of the length of each menstrual cycle.
You can use an ordinary calendar. Circle day one of each cycle, which is the first day of your period.
Count the total number of days in each cycle. Include the first day when you count. Do this for at least eight cycles (12 is better).
•To predict the first fertile day in your current cycle
Find the shortest cycle in your record.
Subtract 18 from the total number of days.
Count that number of days from day one of your current cycle, and mark that day with an X. Include day one when you count.
The day marked X is your first fertile day.
To predict the last fertile day in your current cycle
Find the longest cycle in your record.
Subtract 11 days from the total number of days.
Count that number of days from day one of your current cycle, and mark that day with an X. Include day one when you count.
The day marked X is the last fertile day.
Predicting your first fertile day.
shortest cycle = 26 days
26 – 18 = 8
Predicting your last fertile day.
longest cycle = 30 days
30 – 11 = 19
In this example, the 11th through the 22nd are unsafe days. All the others are safe days.

Standard Days Method:

New simple fertility awareness-based method
Relies on a "standard rule" or a fixed "window" of fertility that makes it easy for women to know when they are likely to become pregnant
It works for women who always have menstrual cycles between 26 and 32 days in length
Lactational Amenorrhea:
•based on the natural postpartum infertility that occurs when a woman is amenorrheic and fully breastfeeding

Artificial Family Planning:

The Pill:
•Combination of estrogen and progestin
•The hormones in the pill work by keeping a woman’s ovaries from releasing eggs — ovulation. The hormones in the pill also prevent pregnancy by thickening a
woman’s cervical mucus. The mucus blocks sperm and keeps it from joining with an egg.
•2 types of pill packets: 21 active pills containing hormones and 7 reminder pills of different colors that do not contain hormones.
•Do not protect against STD
Advantages:
•Effective when used correctly
•Regular monthly periods with fewer days of bleeding and milder menstrual cramps
•Fertility returns soon after stopping
•Can be used as emergency contraceptive after unprotected sex
•Help prevent: endometrial ca., ovarian ca., benign breast disease
Disadvantages side effects:
–Nausea
–Spotting or bleeding between menstrual periods
–Amenorrhea
–Mild headaches
–Breast tenderness
–Slight weight gain
–Depression, mood changes
–Acne
–Chloasma
More serious: Thromboembolic events

Barrier Methods of Birth Control:

Condoms:
•Rubber processed collagenous tissue (lamb caecum) sheaths, or from latex or non-latex material, that fits over the erect penis and act as a barrier to the transmission of
sperm into the vagina
•By covering the penis and keeping semen out of the vagina, anus, or mouth, condoms also reduce the risk of sexually transmitted infections.
ADVANTAGES
let men help prevent pregnancy and sexually transmitted infections
are inexpensive and easy to get
are lightweight and disposable
do not require a prescription
can help relieve premature ejaculation
may help a man stay erect longer
can be put on as part of sex play
can be used with all other birth control methods except the female condom to provide very effective pregnancy prevention and to reduce risk of sexually transmitted
diseases
DISADVANTAGES
Latex condom may cause itching
May decrease sensation
Possibility that it will slip off or break during sex
May weaken if stored too long or in too much heat

Female Condoms:
•Soft ring at the closed end of the tube covers the cervix during intercourse and holds it inside the vagina.
• Another ring at the open end of the tube stays outside the vagina and partly covers the lip area.
• It collect pre-cum and semen when a man ejaculates
• Prevent STDs, no hormonal effects
ADVANTAGES
allow women to share responsibility for preventing infection
are easy to get — can be purchased in drugstores and some supermarkets
can be inserted by a partner as part of sex play
can be used by people who are allergic to latex
can be used with oil-based as well as water-based lubricants
do not have an effect on a woman's natural hormones
do not require a prescription
may enhance sex play — the external ring may stimulate the clitoris during vaginal intercourse
stay in place whether or not a man maintains his erection
DISADVANTAGES
cause irritation of the vagina, vulva, penis, or anus
slip into the vagina during vaginal intercourse, or into the anus during anal intercourse
reduce feeling during intercourse
be noisy — adding extra lubricant can help if the female condom is noisy

Sponge:
•A contraceptive sponge contains a spermicide, nonoxynol-9, that is released over the 24 hours that the sponge may be left in the vagina.
•The sponge covers the cervix and blocks sperm from entering the uterus.
•The sponge also continuously releases a spermicide that keeps sperm from moving.
ADVANTAGES
It can be carried in pocket or purse.
It generally cannot be felt by you or your partner.
It has no effect on a woman's natural hormones.
It does not interrupt sex play — the sponge can be inserted hours ahead of time and can be worn for up to 30 hours after you put it in. During that time, you can have
intercourse as many times as you like during the first 24 hours without removing or reinserting the sponge.
It can be used during breastfeeding.
DISADVANTAGES
It may be difficult for some women to insert or remove the sponge. If you cannot remove a sponge, or if one breaks into pieces and you cannot remove all of the
pieces, see your health care provider immediately to have the sponge removed.
It may cause vaginal irritation.
It may make sex too messy or too dry. Some women complain that the sponge is messy because it requires too much liquid. Others have complained the sponge makes
sex too dry. Using a water-based lubricant may help dryness.

Cervical Cap:
•A cervical cap is made of rubber and shaped like a large thimble.
•It fits tightly over the cervix and is used with a spermicide.
•Does not protect against STD
ADVANTAGES
It can be carried in your pocket or purse.
It generally cannot be felt by you or your partner.
It is immediately effective and reversible.
It has no effect on a woman's natural hormones.
There is no interruption of sex play — it can be inserted up to six hours ahead of time.
It can be used during breastfeeding.
DISADVANTAGES
cannot be used during menstruation
may be difficult for some women to insert
may be pushed out of place by some penis sizes, heavy thrusting, and certain sexual positions
must be in place every time a woman has vaginal intercourse
may need to be replaced with a slightly larger cap after pregnancy

Diaphragm:
•A diaphragm is a round, dome-shaped device made of rubber with a firm, flexible rim.
•It fits inside the vagina and covers the cervix, the opening of the uterus.
•It should always be used with a sperm-killing cream or jelly (spermicide).
•Does not protect against STD
ADVANTAGES
It can be used during breastfeeding.
It can be carried in your pocket or purse.
It generally cannot be felt by you or your partner.
It is immediately effective and reversible.
It has no effect on a woman's natural hormones.
There is no interruption of sex play — it can be inserted hours ahead of time.
DISADVANTAGES
cannot be used during your period
may be difficult for some women to insert
may be pushed out of place by some penis sizes, heavy thrusting, and certain sexual positions
must be in place every time a woman has vaginal intercourse
may need to be refitted

Other Birth Control Methods:

Depo-Provera:
•Depot medroxyprogesterone acetate (DMPA) is a progestin-only hormonal contraceptive birth control drug which is injected every 3 months.
•Inhibit follicular development and prevent ovulation as their primary mechanism of action
•A secondary mechanism of action of all progestin-containing contraceptives is inhibition of sperm penetration by changes in the cervical mucus.
•No estrogen side effects
•Delayed return of fertility, does not protect against STDs
Advantages:
Using the birth control shot is safe, simple, and convenient.
The shot provides very effective, long-lasting pregnancy protection.
There is no daily pill to remember.
There is nothing to do right before having sex.
Some women say it improves their sex lives because it helps them feel more spontaneous.
It is also a very private method of birth control — there is no packaging or other evidence that might be embarrassing for some people.
The birth control shot does not contain estrogen, another type of hormone that is in many types of birth control, including the pill, patch, and ring. This means the shot
can be a good choice for women who cannot take estrogen and for women who are breastfeeding.
The shot can help prevent cancer of the lining of the uterus.
Disadvantages:
For most women, periods become fewer and lighter. After one year, half of the women who use the birth control shot will stop having periods completely.
Some women have longer, heavier periods.
Some women have increased spotting and light bleeding between periods.
change in sex drive
change in appetite or weight gain
depression
hair loss or increased hair on the face or body
headache
nausea
nervousness, dizziness
a rash or darkening of the skin
sore breasts
weight gain

Norplant:
•6 small capsules are placed in the woman’s upper arm
•Contains progestin which is released very slowly from all 6 capsules.
•No estrogen
•Prevents pregnancy for at least 5 years
•Minor surgical procedures required
•Don’t protect against STDs
ADVANTAGES
The ability to become pregnant returns quickly when you stop using Implanon.
It can be used while breastfeeding.
It can be used by women who cannot take estrogen.
It gives continuous long-lasting birth control without sterilization.
There is no medicine to take every day.
Nothing needs to be put in place before vaginal intercourse.
DISADVANTAGES
For most women, periods become fewer and lighter. After one year, 1 out of 3 women who use Implanon will stop having periods completely.
Some women have longer, heavier periods.
Some women have increased spotting and light bleeding between periods.

IUD:
•A small flexible, plastic frame, often has a copper wire or copper sleeves.
•Inserted to the woman’s uterus through the vagina
•With strings tied to it that hang through the opening of the cervix in the vagina.
•The strings can be used to check if the IUD is still in place, and to remove the IUD
•Types: Copper bearing, Hormone releasing (progestin), Inert (plastic or stainless steel)
ADVANTAGES
IUDs may improve your sex life. There is nothing to put in place before intercourse to prevent pregnancy. Some women say that they feel free to be more spontaneous
because they do not have to worry about becoming pregnant.
The ParaGard IUD does not change a woman's hormone levels.
The Mirena IUD may reduce period cramps and make your period lighter. On average, menstrual flow is reduced by 90 percent! For some women, periods stop
altogether.
IUDs can be used during breastfeeding.
The ability to become pregnant returns quickly once the IUD is removed.
DISADVANTAGES
Spotting between periods is common.
ParaGard may cause a 50–75 percent increase in menstrual flow. In some cases, this can lead to a low red blood cell count.
You may experience menstrual cramps or backaches.

Permanent Family Planning:

Tubal Ligation:
•The fallopian tubes are severed and sealed or "pinched shut", in order to prevent fertilization.
•Approximately 99% effective in the first year following the procedure.
•In the following years the effectiveness may be reduced slightly as the fallopian tubes can, in some cases, reform or reconnect which can cause unwanted pregnancy.
•Tubal ligation is a more major surgery than vasectomy, and carries greater risks
•Reversal surgery is difficult and very expensive
ADVANTAGES
You don't want to have a child biologically in the future.
You have concerns about the side effects of other methods.
Other methods are unacceptable.
Your health would be threatened by a future pregnancy.
You don't want to pass on a hereditary illness or disability.
You and your partner agree that your family is complete, and no more children are wanted.
You and your partner have decided that sterilization is better for you than vasectomy is for him.
DISADVANTAGES
may want to have a child biologically in the future
are being pressured by a partner, friends, or family
are using it to solve problems that may be temporary — such as marriage or sexual problems, short-term mental or physical illnesses, financial worries, or being out of
work

Vasectomy:
•Surgical procedure in which the vas deferens of a man are cut for the purpose of sterilization
•Local anesthesia to the scrotum and vas deferens
•A "normal" vasectomy typically seals both ends of the vas deferens with stitches, heat, metal clamps or a combination, after cutting.
•The open-ended vasectomy obstructs only the top end of the vas deferens.
•Reversibility is often possible
•Less expensive and less risky than female sterilization
Advantages:
You want to enjoy having sex without causing pregnancy.
You don't want to have a child biologically in the future.
Other methods are unacceptable.
You don't want to pass on a hereditary illness or disability.
Your partner's health would be threatened by a future pregnancy.
You and your partner have concerns about the side effects of other methods.
You and your partner agree that your family is complete, and no more children are wanted.
You want to spare your partner the surgery and expense of tubal sterilization — sterilization for women is more complicated and costly.
Disadvantages:
may want to have a child biologically in the future
are being pressured by a partner, friends, or family
want to use it to solve problems that may be temporary — such as marriage or sexual problems, short-term mental or physical illnesses, financial worries, or being out
of work

Ethical Principles Violated:

1. Inviolability of Life - drugs and devices that inhibit fertilized ovum transport to and implantation in the uterus or its development; they kill the fetus
2. Stewardship - promotes a hedonistic mentality with refusal to accept the reproductive responsibility of sexuality or to recognize God as the final Creator of a new
human being.
3. Nonmaleficence - all forms of contraception promote premarital and extramarital sex and acts of homosexuality. ex: IUDs promote infection, castration removes a
healthy organ
4. Respect for Person & Justice - to have one spouse use the other spouse as a means to one’s satisfaction or pleasure is a sign of disrespect. Man may forget the
reverence due to a woman, and reduce her as a mere instrument for the satisfaction of his own desires.
5. Personalized Sexuality - deliberate choice to subvert the life-giving order and meaning of the conjugal act aside from violating personalized sexuality, leads to an
increase in collapse in the family.
Advocating contraception would separate the two aspects of conjugal act into two different realities, not connected with each other: offspring and sex.
Sex  intangible and unlimited right
Children impose them as burdens
Separation of 2 aspects of conjugal act: act as arbiters of the divine plan; manipulate & degrade sexuality & themselves by manipulating the value of total self-giving
Inseparability of the 2 aspects: act as ministers of God’s plan; benefiting from their sexuality
6. Totality - suppression of the reproductive function
Examples: tubal ligation, vasectomy, castration
Church does not object on the use of contraceptives in curing organic diseases provided that contraception is not directly intended. Sterility effect is a secondary effect.
7. Beneficence - do not promote responsible parenthood nor facilitate pregnancy
-------
Humanae Vitae:
“Let them (doctors and members of the nursing profession ) therefore continue constant in their resolution always to support those lines of action which accord with
faith and with right reason. Moreover, they should regard it as an essential part of their skill to make themselves fully proficient in this difficult field of medical
knowledge”
Hippocratic Oath (Modern):
“I will neither prescribe nor administer a lethal dose of medicine to any patient even if asked nor counsel any such thing nor perform the utmost respect for every human
life from fertilization to natural death and reject abortion that deliberately takes a unique human life”
Promote the Church’s teaching
It is always intrinsically wrong to use contraception to prevent new human beings from coming into existence.
To defend & explain the church’s teachings, using the science and language of contemporary society
Catholic healthcare is dedicated to promoting human dignity and the sacredness of life; it has an "option for the poor"; …it prohibits abortion, in vitro fertilization,
contraceptive sterilization, and assisted suicide procedures in free-standing Catholic healthcare institutions.
Physician has right to withdraw from the case if what is decided upon by the patient, or the family, is contrary to his or her own personal or the institution’s values
No person may be obliged to take part in a medical or surgical procedure which he judges in conscience to be immoral nor may a health facility or any of its staff be
obliged to provide a medical or surgical procedure which violates their conscience.
"Any cooperation institutionally approved or tolerated in actions which are in themselves, that is, by their nature and condition, directed to a contraceptive end . . . is
absolutely forbidden. For the official approbation of direct sterilization and, a fortiori, its management and execution in accord with hospital regulations, is a matter
which, in the objective order, is by its very nature (or intrinsically) evil."
Catholic health institutions may not promote or condone contraceptive practices but should provide instruction about the Church's teaching on responsible parenthood
and in methods of natural family planning.
Direct sterilization, permanent or temporary, is not permitted.
Only permitted when their direct effect is the cure or alleviation of a present and serious pathology and a simpler treatment is not available.
A Catholic health care institution that provides treatment for infertility should offer not only technical assistance to infertile couples but also should help couples
pursue other solutions (e.g., counseling, adoption).
-----
Pregnancy prevention after sexual assault:
Sexual assault - any sexual act performed by one (or more) person/s on another without consent; it is usually accompanied by the use of threat or force
ROLE:
1.Counseling (to overcome trauma)
2.Provide medical care to abrasions and injuries that might have occurred
3.Preventive Treatment:
Antibiotics (possible STDs)
Antidepressants or antianxiety drugs (victims who have psychological problems – nightmares, flashbacks, easily startled)

Pregnancy prevention:
contraceptives may be taken to prevent ovulation or to render the sperm inoperative (only if ovulation has not yet occurred)
contraceptives to destroy or prevent implantation of an already fertilized ovum (abortion)

RAPE CASE:
A 20-yr old college student was raped by her uncle. She is a graduating student and is in fear of conception since she will be missing out on a lot of things
during her pregnancy. Is it ethical to push through with contraceptives?

Although a woman who has been raped has the right to protect herself from conception, she does not have the right to do so at the expense of another human
being.
i
EUTHANASIA

“I will give no deadly medicine to any one if asked, nor suggest any such counsel.” - the Hippocratic Oath
•1606, from Gk. euthanasia "an easy or happy death," from eu- "good" + thanatos "death."
•Is any action committed or omitted for the purpose of causing or hastening the death of a human being after birth, allegedly for the purpose of ending the
person's suffering.
-Human Life International, Facts of Life: Chapter 23: Euthanasia
•"By euthanasia is understood an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated.“
–Vatican’s Declaration on Euthanasia

Direct Euthanasia:
• Direct/Active/Positive
•is action taken for the purpose of causing or hastening death.
–Human Life International, Facts of Life: Chapter 23: Euthanasia

Indirect Euthanasia:
•Indirect/Passive/Negative
•is action withheld for the purpose of causing or hastening death.

Similarities:
•(1) Both have the same telos (Greek for purpose or end), which is death
•(2) Both are done out of compassion
•(3) Both are unlawful using Thomistic standards

Differentiation made by the Catechism of the Catholic Church:

DIRECT EUTHANASIA - Actions taken by which one ends the life of someone else
INDIRECT EUTHANASIA - Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome

Differentiation by Approach:
DIRECT EUTHANASIA
•Positive action; puts life and death in the hands of man

INDIRECT EUTHANASIA
•Negative action; allowing someone to die by not taking extraordinary measures
respects the nature God has made and recognizes his authority regarding life and death

Differentiation by Example:
DIRECT EUTHANASIA
(1)Lethal Injection
(2)Overdose committed by a physician
INDIRECT EUTHANASIA
(1)Withholding or withdrawal of life sustaining measures, including food, hydration (water), and oxygenation
(2)Infanticides

Physician Assisted Suicide:

occurs when a physician facilitates a patient’s death by providing necessary means and/or information to enable the patient to perform the life-ending act
fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks
eg, the physician provides sleeping pills and information about the lethal dose, while aware that the patient may commit suicide

Ethical:
•May be a rational choice for a person who is choosing to die to escape unbearable suffering
•The physician’s duty to alleviate suffering may, at times, justify the act of providing assistance with suicide.
Unethical:
•Directly counters the traditional duty of the physician to preserve life.
•May be abused, if it becomes legal.
•Patients may become pressured and left with no option but to choose PAS to escape expensive and more complex care options.

Autonomy:
•intentional taking of innocent human life (one’s own or that of another) is never medical treatment, and is never ethical. There is no such thing as physician-
assisted suicide. There is merely suicide, at times assisted.
•The profession of the accomplice is accidental to the act.
•Suicide isn’t a medical act, and assisted suicide has nothing to do with autonomy as understood in medical ethics. Autonomy is the right to refuse medical
treatment, not the right to a non-medical act performed by a physician.

Positive Autonomy:
•right to obtain a specific medical treatment
•is profoundly constrained(limited) and is limited by the judgment of the medical profession as to what treatments are effective and appropriate

•EXAMPLE CASE:
A patient with a brain tumor has a right to a very limited range of treatments. The options only include treatments accepted by the medical profession as
appropriate to brain tumors. Patient has a right to brain surgery, or to radiation therapy, or to chemotherapy. He does not have a right to countless other medical
treatments, such as amputation, antibiotic therapy, liposuction, a heart transplant, etc.
Negative Autonomy:
•The radical right of a competent adult to be left alone to decide and accept/refuse medical treatment/care appropriate to their illness
•Patients have a right only to negative autonomy. The medical profession decides what acts constitute appropriate medical treatment.
•Thus the assertion that physician-assisted suicide is a matter of patient autonomy is mistaken and even misleading. The issue of physician-assisted suicide has
nothing to do with issues of autonomy; all patients have a right to choose among appropriate medical treatments.

Recommendations:
Instead of participating in assisted suicide, physicians must aggressively respond to the needs of patients at the end of life.
Patients should not be abandoned once it is determined that cure is impossible.
Multidisciplinary interventions should be sought including specialty consultation, hospice care, pastoral support, family counseling, and other modalities.
Patients near the end of life must continue to receive emotional support, comfort care, adequate pain control, respect for patient autonomy, and good
communication.

Hospice Care:
Hospice care demonstrates that terminally ill patients need not be left to die alone or in unfamiliar, sterile environments, and that pain and other symptoms can
be prevented or adequately treated.

Three Crucial Fears of the Terminally Ill

a.Fear of unbearable pain
b.Fear of excessively burdensome, futile treatments
c.Fear of loss of autonomy and personal dignity

Services provided:
a.Psychological
b.Pain and symptom management
c.Short term inpatient services
d.Training
e.Medical equipment, drugs, and supplies
f.Bereavement care and counseling
g.Comfort

•Respect for Person and Autonomy

 have inherent dignity which must be respected
 can and should decide what is best for them without constraints from others

Indeed, when a person with a fatal, terminal and irreversible condition refuses to undergo treatment, this must be respected.

Hollistic Approach to Palliative Care:

Seek the patient’s best interest holistically
Uses common sense in prioritizing the medical and the moral support given

GOALS OF CARE
- curing the disease
- prolonging the patient's life while managing symptoms
- major goal might be to restore or maintain function
- comfort for the patient and family.

MEDICAL TREATMENT
- making the patient as comfortable as possible
- monitor the patient's treatment plan closely
- patient should be monitored by a nurse who can help to make him/her more comfortable
-when symptoms are unbearable and cannot be relieved, sedation may be offered to ease patient suffering

PRACTICAL CONSIDERATIONS
-patients should be assured that their physical symptoms can be addressed through a therapeutic treatment plan
- decide where patients will live out their remaining days.
- choices for dying patients include being cared for at home, in the hospital, or in an inpatient hospice care facility

PSYCHOLOGICAL & SPIRITUAL TREATMENT

- anxiety, depression, hopelessness, and remorse
- restore a level of psychological and spiritual well-being.
- for psychiatric conditions, treatment includes supportive psychotherapy and the use of antidepressant or anti-anxiety drugs
- spiritual distress may be confronted with curative approaches that address feelings of disappointment, remorse, and loss of personal identity

"You matter because of who you are. You matter to the last moment of your life, and we will do all we can , not only to help you die peacefully, but also to live
until you die".
--Dame Cicely Saunders

Case on Hospice Care:

Mang Jo is already 8O years old, has Alzheimer’s disease and lives with his only daughter who is married and has three children. Since Mang Jo’s disease
is progressing, he needs more care and attention which his daughter cannot give him. His daughter decided to put him under hospice care and visits him twice
a month.

Virtue:
•From the latin word “virtus” signifies courage
•From St. Thomas’s entire Question on the essence of virtue: “habitus operativus bonus”, an operative habit that is essentially good.

Divisions of Virtue:
I.Intellectual
–Prudence
–Understanding
–Wisdom
II.Moral
–Justice
–Temperance
–Fortitude
III.Theological
–Faith
–Hope
–charity

Intellectual Virtue:
•Necessary for right action and correct thinking.
•Habit of perfecting the intellect to elicit with readiness acts that are good in reference to their proper object, namely, truth.

Prudence:
•Directs on in the choice of means most apt, under existing circumstances, for the attainment of due end.
•Ability to judge between virtuous and vicious actions, with regard to appropriate actions at a given time and place.
•As defined by St. Thomas, is the right method of conduct.

Understanding:
•apprehending Christ’s public revelation easily and profoundly
•gives great confidence in the revealed word of God and leads those who have it to reach true conclusions from revealed principles
•one of the seven gifts of the Holy Spirit

Wisdom:
•exceeds the gift of understanding in that it shows us God’s perspective
•fullness of knowledge through affinity for the divine
•supplements the virtue of faith

Moral Virtues:
•From the word mos, which signifies a certain natural or quasi-natural inclination to do a thing.
Justice:
•an essentially moral virtue
• regulates man in relations with his fellow-men
•disposes us to respect the rights of the patients, to give each man his due
• A sin against justice requires reparation.
• A person is to compensate for the harm he has inflicted.

Temperance:
•Restrains the undue impulse of concupiscence (from latin word concupiscentia meaning a desire for worldly things) for sensible pleasure
•Practice of moderation
•It is the first virtue that perfects man’s ability to act well with one’s self from within one’s self.
•regulates every form of enjoyment that comes from the exercise of human volition, and includes all those virtues, especially humility, that restrains the
inordinate movements of one’s desires or appetites

Fortitude:
•steadiness of will in doing good despite obstacles in the performance of one’s daily duty
•A certain moral strength and courage, is the virtue by which one meets and sustains danger and difficulties, even death itself
•firmness of spirit

Theological Virtues:
•All virtues dispose man to act conducive to his true happiness
–Faith
–Hope
–Charity

Faith:
•Hebrews 11:1 “Now faith is the substance of things hoped for, the evidence of things not seen.”
•Faith is the “evidence” of what Christians “know” to be true within their own hearts that has revelead to them by God.
Hope:
•Divinely infused virtue, by which we trust, with an unshaken confidence grounded on the Divine assistance, to attain life everlasting.
•From St. Paul (Romans 8:24): “For we are saved by hope. But hope that is seen is not hope. For what a man seeth, why doth he hope for?”

Charity:
•Theological virtue, by which God is loved by reason of His own intrinsic goodness or amiability, and our neighbour loved on account of God.
•Greatest of the three virtues
•Caritas: selfless love
•While charity excludes all mortal sin, faith and hope are compatible with grievous sin; but as such they are only imperfect virtues; it is only when informed
and clarified by charity that their acts are meritorious of eternal life.

i
Transcribed by Aubrey Del Rosario B2012
CARE FOR THE ELDERLY/CHRONICALLY ILL

The 2000 census enumerated about 4.6 million persons aged 60 years and over, comprising
2.1 million males and 2.5 million females. This number
represents 6 percent of the total population in 2000 (76.5 million).

The world’s population is graying fast and it is occurring three times as fast as in Asian countries.

The average longevity span of the

Filipino female – 72.8 years
Filipino male – 67.5 years

To be able to deliver quality health care to older people, we must be sensitive to and be aware of the special needs and problems of the elderly
1.Longer life expectancy
2.Diminished reserve
3.Easily disrupted homeostasis
4.Depression is common
5.Multiple chronic diseases
6.Multiple cause for malnutrition
7.Multiple cause for functional disability
8.Multiple causes for pain and discomfort
9.Polypharmacy

Illness tends to affect older people in the following atypical ways:

1.Functional decline
2.Decrease or cessation of eating/drinking
3.Falling or gait disorder
4.Urinary incontinence
5.Dizziness
6.Mental confusion
7.Weight loss
8.Depression and withdrawal

Barriers to Communication:

1.Memory or cognitive loss

2.Vision loss
3.Hearing loss
4.Educational level
5.Ageism
6.Motivation
7.Conflicts between patient and care giver
AGEISM
• the attitude that disease and disability are inevitable part of aging and can lead to delayed diagnosis and treatment and misses opportunities to develop full life
potentials
POLYPHARMACY
• is very prevalent in the elderly as the number of diseases esp. chronic ones increases as age increases
DEPRESSION
• Is common and frequently under diagnosed
Hearing loss and Vision loss can lead to withdrawal, increased morbidity and mortality

Comprehensive Geriatric Assessment (GSA):

Should include functional tests:
Physical exam
Mini-Mental State exam
Status exam
Depression scale
Psycho-social exam
Economic and Environmental Domains
Common syndromes of elderly persons:
- acute delirium
- dementia
- falls / gait problem
- urinary incontinence
- constipation
- malnutrition
- depression
- polypharmacy
- frailty
- sensory loss
Common Diseases/Disorders in the Elderly:
- coronary heart diseases
 - hypertension
- osteoporosis, fractures
- diabetes mellitus
- Alzheimer’s disease
- Parkinson’s disease
- infection
- pressure sores
- osteoarthritis
- sleep problems
- cancer
- loss of vision, hearing
PRINCIPLES OF CARE FOR GERIATRICSi
GOAL: Care not cure, comfort, function and independence
- comprehensive multidisciplinary assessment is essential
- look for undiagnosed diseases, it is almost always present
- beware of non-specific presentation of illness
- depression is the great masquerader in geriatrics
- do not underestimate the morbid contributions of hearing and vision loss
- the older person is teachable and treatable
- when giving drugs, start slow and go slow
- the family is crucial to good geriatric care
- aim for rehabilitation: seek increments in function, however small
- health promotion and preventive care should be early goals
- ethical issues are central to geriatric care practice

Mission of Geriatric Medicine:

Identify, stabilize and delay the progression of chronic medical conditions and prevent acute and iatrogenic conditions

*** Physicians caring for the frail elderly should recognize the importance of focusing on the following as goals of geriatric care:
Functional abilities/Quality of life/Comfort/Safety/Happiness
Human Rights and the Elderly
The elderly do not forfeit their claim to basic human rights because they are old…
“Every man has the right to life, to bodily integrity, and to the means which are suitable for the proper development for life; these are primarily food, clothing,
shelter, rest, medical care, and finally the necessary social services. Therefore, a human being also has the right to security in cases of sickness, inability to
work, widowhood, old age, unemployment, or in any other case in which he is deprived of the means of subsistence through no fault of his own” (Pope John
XXIII, Peace on Earth)

The Right to Life - On one level, the elderly, along with the sick and the handicapped are the targets of a “mercy killing” mentality which would dispose of
the unwanted. Even well-meaning legislative efforts to cope with complex questions about when and when not to use extraordinary technological and
therapeutic means to preserve life pose genuine dangers, particularly since some would place fateful decisions solely in the hands of physicians or the state.
“The elderly have the right to “new life”: not just to material survival, but to education, recreation, companionship, honest human emotions, and spiritual
care and comfort.”

The Right to Health Care - Health care is a basic right, but it is often regarded as an expensive luxury. Despite passage a decade ago of Medicare, millions of
elderly people still lack adequate medical care.
The Right to Eat - Elderly are the most severely malnourished group in society. Poor nutrition is a major factor in the incidence of poor health among them.
Universal declaration of human rights (1948), which states that, “All human beings are born free and equal in dignity and rights”

Chronic Dysfunction:
Disabled versus Chronically ill
Both are persistent dysfunction that can not be cured
May be stable, intermittent, vulnerable to exacerbation, or inexorably progressive
Maintaining stability requires long term care
People whose biological condition departs dysfunctionally from the species- typical state are to be found everywhere. When an individual’s dysfunction is
persistent, and cannot now be cured, the person usually is thought of as being chronically ill or disabled. Such a chronic condition may be stable, or
intermittent, or vulnerable to exacerbation, or inexorably progressive. Maintaining the individual’s stability, or mitigating or delaying symptoms, often calls for
regular medical interventions and/or long- term care.

Disability:
person’s ability to execute major life activities is compromised by the consequences of past infection, injury, or other mishap, but the cause of the
impairment is not expected to recur.
Eg: inborn disabilities

Chronic Illness:
Some people with chronic health problems are not disabled
Continuing medical treatment can mitigate dysfunction so the person encounters no extraordinary difficulties in executing major life activities
Eg: multiple sclerosis, diabetes, glaucoma, HIV infection, and sickle cell disease
In most chronic illnesses and long term care situations, the health of the whole family is intrinsically connected to the patient’s well-being that every
ethical considerations must consider the long term course of decisions and how it will affect the family.

Autonomy:
Any notion of moral decision making assumes that rational agents are involved in making informed and voluntary decisions. In health care decisions, our
respect for the autonomy of the patient would mean that the patient has the capacity to act intentionally, with understanding, and without controlling influences
that would mitigate against a free and voluntary act. This principle is the basis for the practice of "informed consent" in the physician/patient transaction
regarding health care

Informed Consent:
Informed consent is the process by which a fully informed patient can participate in choices about her health care. It originates from the legal and ethical right
the patient has to direct what happens to her body and from the ethical duty of the physician to involve the patient in her health care.

Justice:
Justice in health care is usually defined as a form of fairness. It is generally held that persons who are equals should qualify for equal treatment. Our society
uses a variety of factors as a criteria for distributive justice, including the following:
• To each person an equal share
• To each person according to need
• To each person according to effort
• To each person according to contribution
• To each person according to merit
• To each person according to free-market exchanges
Non-maleficence:
The principle of non-maleficence requires of us that we not intentionally create a needless harm or injury to the patient, either through acts of commission or
omission. We consider it negligence if one imposes a careless or unreasonable risk of harm upon another. Providing a proper standard of care that avoids or
minimizes the risk of harm is supported not only by our commonly held moral convictions, but by the laws of society as well.

In a professional model of care one may be morally and legally blameworthy if one fails to meet the standards of due care. The legal criteria for determining
negligence are as follows:
•The professional must have a duty to the affected party
•The professional must breach that duty
•The affected party must experience a harm; and
•The harm must be caused by the breach of duty.

This principle affirms the need for medical competence. It is clear that medical mistakes occur, however, this principle articulates a fundamental commitment
on the part of health care professionals to protect their patients from harm.

Beneficence:
The ordinary meaning of this principle is the duty of health care providers to be of a benefit to the patient, as well as to take positive steps to prevent and to
remove harm from the patient. These duties are viewed as self-evident and are widely accepted as the proper goals of medicine. These goals are applied both to
individual patients, and to the good of society as a whole.

Competency/Capacity Issues:
-Is the legal designation that recognizes that person’s beyond a certain age generally have the cognitive ability to negotiate certain tasks
- the capacity to make one’s own health care decisions
- it is a matter of whether the patient has a minimal degree of functional ability regardless of the clinical diagnosis or whether the physician personally agrees
with the patient’s decision
determined on a decision-specific basis
-Decisional capacity is variable, rather than steady state, in many older patients
-Physicians should try to communicate with the patients about their care as much as possible during the patient’s window of lucidity
-Additionally, many older person’s may be capable of assisted consent with extra time and effort on the physician’s part, especially if a person has a supportive
family or friends available

Decline In Intelligence w/ Age:

There are certain aspects of intelligence that declines with age
However, those aspects which decline, principally, short term memory and ability to think quickly, are not those aspects which allow one to make competent
decisions
Questions that should be included in the physician’s inquiry about a patient’s capacity:
Can the patient make and communicate any choices regarding medical interventions?
Can the person express any reasons for the choices made (to indicate that some reasoning process is taking place)?
Are the stated reasons underlying the person’s choices rational in the sense that the person starts with a factually accurate understanding of the medical
situation and can reason logically to a conclusion?
Does the person understand or appreciate the implications, including the likely personal risks and benefits, of the alternatives presented and choices made?

Justice:

Utilitarian Approach Egalitarian Approach

Based on Cost and Benefit to Society Equal distribution of sources

Justice to those who produces more benefit to the society (eg. The Each and every person has the right, regardless of age, to medical care
young)
Increase economic productivity due to reallocation of resources By rationing health care based on age we would fail to respect the fundamental
dignity of the elderly.

Needs of the elderly put a drain on resources Considers the need for health care, likelihood of recovery as well as the improvement
of the quality of life

Care of the elderly:

Should consider relief of suffering and improvement of the quality of life rather than expensive or extraordinary life prolonging treatments that have little
benefit to the patients condition
Aging and death is part of the human condition and is a natural process.
Goal of a Caring Response:
1. Prevention of new symptoms
Decrease the severity (if present)
2. Rehabilitation and health maintenance
3. Vigilance not to assume every new symptoms is part of the original chronic condition

Informed Consent:
•Under the Principle of Autonomy and Self-Determination
•Every adult patient has the right to make personal decisions regarding medical care, including decisions about which diagnostic and treatment interventions to
undergo
•Although every person has the right to decline a particular intervention, the principle of autonomy does not establish a right to demand test or treatments that
the physician believes would be worthless or even harmful to the patient
•Physicians are under no ethical or legal obligation to provide, and indeed should not provide, futile or non-beneficial treatment to a patient.
Infomed Consent – competence, info, comprehension, voluntariness

There are 4 elements needed to consider a patient’s choice as ethically and legally valid exercise of informed consent:
1. A capable decision maker
- patient must be cognitively and emotionally able to weigh alternatives rationally
- when a patient lacks adequate capacity, someone else must act as decision maker on the patient’s behalf
2. The patient’s choice must be adequately knowing or informed.
- physician must communicate in understandable lay terms material information about the patient’s situation
Diagnosis
Nature and purpose of proposed intervention
Reasonably foreseeable risks
Probability of success
Viable alternatives and anticipated benefits and risks
Result expected without the intervention
Advice (i.e. Physician’s recommendation)

3. The patient should be able to fully comprehend the implications of such decisions.
- physician must make sure that the patient fully grasp or understand the situations and conditions of making decisions.
- advantages and disadvantages
- risks involved
4. The patient’s participation in the decision-making process and the ultimate decision must be voluntary.
- free of: force/fraud/duress/intimidation/undue constraint or coercion

Guardianship:
•chief means of transferring decision making to a surrogate without the patient’s permission
• appointment of a surrogate to make certain decisions on behalf of an incompetent person
• the guardian is required to make the same decisions that the patient would make, according to the patient’s own preferences and values to the extent that they
can be ascertained
•highly consistent with respect for patient’s autonomy
• when patient’s own preference cannot reasonably be ascertained, the guardian is expected to rely on the “traditional best interests” standards
• decisions be made in a manner that, from the guardian’s perspective, confers the most benefits and least burden to the patient

Durable Power of Attorney:

•a legal document, authorized by the state
• voluntarily delegating or directing future medical decision-making power
• a competent individual (principal) directs, through the appointment of an agent (attorney in fact, need not be an attorney at law), the making of medical
decisions in the event of future incapacity
• the principal may give the agent general or specific instructions to direct future decision making or may make the grant of authority unrestricted

1. Immediate DPOAs
-Comes into effect immediately on the naming of an agent.

2. Springing DPOAs
-The legal authority is transferred from the patient to the agent only when some specified future event has occurred (i.e. confirmation of the principal’s
incapacity by an examining physician)

Advance Directives:
Are documents that instructs what kind of health care the person will want, in case he/she is unable to speak or think clearly at some future time
Assures patient’s that their end-of-life wishes are honored
Restores the responsibility of deciding to the one who is most affected – the patient
Creates a mechanism for capable adults to anticipate future scenarios and instruct their physicians prospectively regarding the use of LSMTs.
Oral statements to relatives, friends and health care providers constitute the most common form of advance directives.
Properly verified oral statements carry the same ethical and legal weight as formal written directives.

Living Will:
• Based theoretically in the right that all competent person have the right to refuse treatment or extra-ordinary measures;
• try to provide a mechanism for determining the wishes of an incompetent patients and carrying them out
• try to put the responsibility where it is perceived to belong – on the patient – by ensuring that the person’s wishes will be respected even when he/she cannot
speak directly to this particular situation

3 Types of Living Will:

Legalizing Active Euthanasia
•Voluntary request
•Person over 21
•Victim of painful, terminal illness
•Euthanasia administered under supervision of court or hospital panel
•Agent not subject to prosecution for homicide
Clarifying Competent Patient’s Right
•Right to refuse treatment
•Status of prior request by now incompetent patient
•Question of penalty for not ff instructions
•Deciding on evidence of incompetence with regards to refusal or treatment
Decision-Making for Incompetent Patients
•Consider the cases of those who have never been competent or those who had not expressed their wishes for treatment preferences
•Rely on authority of M.D.
•Rely on authority of next of kin
•Rely on authority of guardian
•Rely on authority of court
Arguments for the necessity of such bills center around the tendency of physicians to treat even when treatment is futile. This tendency has several sources:
Medicine’s purpose is to conquer disease
There is a vitalism that implies that a physician should always do everything to ensure the patient’s survival
Because today’s laws are unclear, many doctors feel that they have a legal obligation always to treat the patient
When incompetent patients suffering from a terminal illness are having the dying process prolonged through life-support measures, many people simply do not
know what to do

PATIENT’S SELF-DETERMINATION
-Individual’s exercise of the capacity to form, revise and pursue personal plans for life
- It manifests the wish to be an instrument of one’s own and “not of other men’s acts of will”

Informal Family Decision-Making:

Physicians turn to family members as surrogate decision makers for incapacitated patients.
Based on the assumption that the family members generally know best the basic values and preference of their relatives and would act as a trustworthy
advocates for their relatives best interest
Should always be alert to possible serious conflicts of interest that can render a relative inappropriate to act as a surrogate decision maker for the patient
Physicians and other health professionals should encourage persons who presently have the capacity to document their preference regarding future medical
treatment in the form of a written instruction directive or DPOA

“DO NOT” Orders:

-A capable adult has the same right to agree to a “do not” order as to make any decisions about the use of LSMT
- for an incapacitated person, prospective clarification may be made based on the patient’s previously executed living will or the current instructions of a
surrogate
- may reduce the potential legal risks and should curtail physicians’ legal anxieties

Euthanasia:
Knowingly and intentionally performing an act that is clearly intended to end another person’s life and that includes the following elements: the
subject is a competent, informed person with an incurable illness who has voluntarily asked for his or her life to be ended; the agent knows about the person’s
condition and desire to die , and commits the act with primary intention of ending the life of that person; and the act is undertaken with compassion and
without personal gain.
Assisted Suicide:
Assistance in suicide means knowingly and intentionally providing a person with the knowledge or means or both required to commit suicide, including
counseling about lethal doses of drugs, prescribing such lethal doses or supplying the drugs.

…Suicide is always a morally objectionable as murder. The Church’s tradition has always rejected it as a gravely evil choice. Even though a
certain psychological, cultural, and social conditioning may induce a person to carry out an action which so radically contradicts the innate inclination to life,
thus lessening or removing subjective responsibility, suicide, when viewed objectively, is a gravely immoral act. In fact, it involves the rejection of love of self
and the renunciation of the obligation of justice and charity toward one’s neighbor, toward the communities to which one belongs, and toward society as a
whole. In its deepest reality, suicide represents a rejection of God’s absolute sovereignty over life and death as proclaimed in the prayer of the ancient sage of
Israel: “You have power over life and death; you lead men down to the gates of Hades and back again”
No human being has absolute control over his or her own life; God alone has dominion over all creation.
Institutional Ethics Committee:
-An internal, disciplinary structure set up to help a facility or agency and its professional staff to deal with difficult treatment decisions in an ethically
acceptable way
- its involvement in a particular case has positive legal benefits for the organization and its staff in terms of reducing unnecessary guardianship petitions,
deterring possible lawsuits and evidencing good faith to bolster the defense against any malpractice cases

Virtues:
Essence of human spirit and content of our character
Character trait or quality valued as being GOOD
RESPECT
A feeling of deep admiration, or sense of worth or excellence, for someone by personal quality or ability
Show respect by:
Speak and act with courtesy
Treat others with dignity and honor the rules of our family, school and nation
“Respect yourself, and others will respect you”
PATIENCE
State of endurance under difficult circumstances, which can mean persevering in the face of delay or provocation without becoming annoyed or upset
Exhibiting forbearance when under strain, especially when faced with longer-term difficulties
COMPASSION
Human emotion prompted by the pain of others
More vigorous than empathy:
Feeling commonly gives rise to an active desire to alleviate another's suffering
INTEGRITY
Quality of having strong moral principles
consistency of actions, values, methods, measures, principles, expectations and outcome
As a holistic concept, it judges the quality of a system in terms of its ability to achieve its own goals
COMMITMENT
act or quality of voluntarily taking on or fulfilling obligations
Caring deeply about something or someone
Deciding carefully what you want to do, then giving it 100%, holding nothing back
JUSTICE
Concept of moral rightness based on ethics, rationality, law, natural law, fairness, religion and/or equity
Practicing justice is being fair
PRUDENCE
Exercise of sound judgment in practical affairs
Often associated with wisdom, insight, and knowledge
Ability to judge between virtuous and vicious actions but with regard to appropriate actions at a given time and place
HONESTY
Speaking truth and creating trust in minds of others
Includes all varieties of communication (verbal and non-verbal)
Honesty implies a lack of deceit
A statement can be strictly true and still be dishonest if the intention of the statement is to deceive its audience
A falsehood can be spoken honestly if the speaker actually believes it to be true
HUMILITY
Intrinsic self-worth
A quality by which a person considering his own defects has a humble opinion of himself and willingly submits himself to God and to others for God's sake
St. Bernard defines it as,
"A virtue by which a man knowing himself as he truly is, abases himself. Jesus Christ is the ultimate definition of Humility."

i
Transcribed by Aubrey Del Rosario B2012
GENETIC ENGINEERING

To repair genetic defects at their genotypic source in the genes and chromosomes rather than in their phenotypic effects; To control and produce at will new
combinations of genetic traits in offspring; To determine at will the sex of the fetus

Is it right for persons to become their own creators?

Do parents have the right to order the sort of child that they want?
Can genetic engineering hasten the processes of evolution by eliminating troublesome wisdom teeth or appendixes or at least by some type of surgery
at a very early age, before trouble arises?
“ A strictly therapeutic intervention whose explicit objective is the healing of various maladies such as those stemming from deficiencies of chromosomes will,
in principle, be considered desirable, provided it is directed to the true promotion of the personal well-being of man and does not infringe on his integrity or
worsen his conditions of life.”
Can genetic engineering hasten the processes of evolution by eliminating troublesome wisdom teeth or appendixes or at least by some type of surgery
at a very early age, before trouble arises? – Pope John Paul II
Stewardship:
“The Lord God took the man and settled him into the Garden of Eden to cultivate and care for it.” (Gn 2:15)

God has called human beings to use their own initiative and originality in completing His work but people have to respect their own limits and the limits of
materials with which they must work.
Theological Points:
God is a generous Creator, who in creating human beings also called them by the gift of intelligence to share in his creative power.

Creating improvement is possible because theology can accept the idea that God has made an evolutionary process that is not yet complete.
Human creativity depends on a human brain, thus any alteration that would injure the brain would be a mutilation.

Principle of Human Dignity:

All of us are created in the Image and Likeness of God.

Human beings should not be violated psychologically and physically (genetically altered)
May be harmed in the advent of genetic engineering
Confidentiality and privacy of gene mapping
Alteration of the human gene pool

Genetic interventions in humans should be limited to treatment of individuals with genetic disorders (somatic cell therapies) and should not include attempts
to change human reproductive cells (germ cell alterations) that could affect the image of God in future generations. All interventions in human beings for
genetic reasons should be taken with great moral caution and with appropriate protection of human life at all stages of its development.
Inviolability of Life:
Proposed as the sanctity, dignity or respect for human life

Human life has dignity because life is God’s gift. Man comes directly from God, is created according to God’s plan and destiny. It is God who is the source,
who sustains and perfects man’s life.
Respect: This is the recognition of the equality possessed by every human being as a unique, worthy, rational, self-determining creature, having the capacity
and right to decide what is best for himself.

Not undermined by states of suffering, disability or disease

Respecting the life and integrity of the embryo and the human fetus and directed toward its safeguarding or healing as an individual.

Prenatal Diagnosis:
Informed consent from parents
Safe methods
Minimize disproportionate risks
Violated when prenatal diagnosis is done with the thought of possibly inducing an abortion depending upon the results
Totality:
Refers to the whole

Every person must develop, use, care for and preserve all his parts and functions for themselves as well as for the good of the whole.

Ethical only if…

If they did not suppress any of the fundamental human functions that integrate the human personality
Sense the external world (use the five senses)
Experience human emotions
Be capable of parenthood (experience human sexuality)
“Genetic manipulation becomes arbitrary and unjust when it reduces life to an object, when it forgets that it is dealing with a human subject, capable of
intelligence and freedom, worthy of respect whatever may be their limitations…” -Pope John Paul II
Beneficence & Non-maleficence:
To do good; to provide benefit
To prevent, remove or not to risk harm

In some cases, benefit is towards the parents and harm for the child

Norms for Genetic Manipulation of Human Beings:

1. Genetic engineering and less radical transformations of the present normal human body would be permissible if they improve rather than
mutilate the basic human functions, especially as they relate to supporting human intelligence and creativity. Transformation is forbidden,
however, if human intelligence and creativity are endangered and if the fundamental functions that constitute human integrity are
suppressed.
2. Experimental efforts of this radical type must be undertaken with great caution and only on the basis of existing knowledge, not with high
risks to the subjects or to the gene pool.

Medical Genetics:
Is known to be a field of medicine which deals on hereditary disorders.
Different from human genetics since this field deals on the diagnosis,
management and counseling on individuals having genetic or
hereditary disorder.
It has several subspecialties:
Clinical Genetics
Genetic Counseling
Metabolic / Biochemical Genetics
Cytogenetics
Molecular Genetics
Mitochondrial Genetics
Victor McKusick (1921-2008) – considered to be the father of Genetic Medicine
Goals of Medical Genetics:
To help people with a genetic disadvantage and their families to live and
to reproduce as normally as possible.
To make informed choices in reproductive and health matters.
To assist people in obtaining access to relevant medical services
(diagnostic, therapeutic, rehabilitative or preventive) or social
support systems
To help individuals to adapt to their unique situation
And to become informed on new relevant developments.

Justice
Treating persons with fairness and equity and distributing benefits and burdens of health care as fairly as possible in society.
Fair allocation of public resources to those who most need them.
Respect for the autonomy of persons
Respecting decision making of all individuals.
Freedom of choice in all matters relevant to genetics. The woman should be the final decision maker in reproductive choices.
Voluntary approach necessary in services, including approaches to testing and treatment; avoid coercion by government, society, or health professionals.
Respect for people's basic intelligence, regardless of their knowledge.
Non-maleficence
Avoiding and preventing harm to persons or, at least, minimizing harm.
Prevention of unfair discrimination or favouritism in employment, insurance, or schooling based on genetic information.
Timely provision of indicated services or follow-up treatment.
Refraining from providing tests or procedures not medically indicated.
Providing ongoing quality control of services, including laboratory procedures.
Beneficence
Giving highest priority to the welfare of persons and maximizing benefits to their health.
Education about genetics for the public, medical and other health professionals, teachers, clergy, and other persons who are sources of religious information.

Human Genome Project:

HGP is known to have started at from October, 1990 and
was completed at the year 2003.
It was started by the US Department of Energy and the
National Institute of Health. Several countries have
followed and helped in the completion of the project including UK, Japan, France, Germany, China
and several other countries.
DNA sequence is being read contained on each cell.
By reading this sequence of the human genome, scientists hope to gain an understanding of the underlying code that determines how a complex biological
system acts and reacts.
It is also used in understanding human health and to develop better treatments for different diseases (such as SARS).
“Its main goal is to discover the estimated 20,000 – 25,000 human genome and the DNA base pair of 3 billion subunits.”
1984 - Alta, Utah, conference highlighting the growing role of recombinant DNA technologies. OTA incorporates Alta proceedings into report
acknowledging value of human genome reference sequence.
1987 - Congressionally chartered DOE advisory committee, HERAC, recommends a 15-year, multidisciplinary, scientific, and technological undertaking to
map and sequence the human genome. DOE designates multidisciplinary human genome centers.
1990 - The 15-year project formally begins. Research and development begun for efficient production of more stable, large-insert BACs.
1992 - Low-resolution genetic linkage map of entire human genome published.
1993 - International IMAGE Consortium established to coordinate efficient mapping and sequencing of gene-representing cDNAs. GRAIL sequence-
 interpretation service provides Internet access at ORNL (major source of presentation).
1995 - Sequence of smallest bacterium, Mycoplasma genitalium, completed; provides a model of the minimum number of genes needed for independent
existence.
1996 - Methanococcus jannaschii genome sequenced; confirms existence of third major branch of life on earth.
1997 - Escherichia coli genome sequence completed.
1998 - Human Genome Project passes midpoint.
1999 - First Human Chromosome Completely Sequenced! On December 1, researchers in the Human Genome Project announced the complete
sequencing of the DNA making up human chromosome 22.
2000 - HGP leaders and President Clinton announce the completion of a "working draft" DNA sequence of the human genome.
2001 - Human Chromosome 20 Finished - Chromosome 20 is the third chromosome completely sequenced to the high quality specified by the Human
Genome Project.
2003 – Completion of the Human Genome Project by April of the said year.
Genome – collection of an organism’s genetic material.
A single human chromosome may contain more than 250 million DNA base pairs.
DNA Analyzation:
Taken from small samples of blood or tissue obtained from many different people.
Although the genes in each person’s genome are made up of unique DNA sequences, the average variation in the genomes of two different people is
estimated to be 0.05 to 0.1 percent.
Approximately 1 in 1,000 to 1 in 2,000 nucleotides will be different from one individual to another. Thus the differences between human DNA samples from
various sources are small in comparison to their similarities.
There are two methods of Gene mapping and Sequencing:
Linkage or Genetic Mapping
- Method that only identifies the relative order of the genes in a chromosome.
- Created mainly by following inheritance patterns in large families over many generations.
Physical Mapping
- More precise method that places genes in a more specific distances from another.
Done with the help of several advance technologies (robotics, lasers & computers) to measure distances of each genes.
During the progress of this project, already, there were advancement of better techniques which have provided doctors better genetic diagnosis and
predictive testing.
The extensive genetic maps have increased the pace by which different disease genes that are possible for every human person.
Enabled doctors to determine susceptible area of the genome that is responsible for some disorders (diabetes, hypertension, certain forms of cancer).
Provides a certain amount of understanding of the fundamental organization of human genes and chromosomes.

1.Fairness in the use of genetic information by insurers, employers, courts, schools, adoption agencies, and the military, among others.
Who should have access to personal genetic information, and how will it be used?
2.Privacy and confidentiality of genetic information
Who owns and controls genetic information?
3.Psychological impact and stigmatization due to an individual’s genetic differences.
How does personal genetic information affect an individual and society’s perceptions of that individual?
4.Conceptual and philosophical implications regarding human genome responsibility, free will vs. genetic determinism, and concepts of health and disease.
- Do people’s genes make them behave in a particular way?
- What is considered acceptable diversity?
- What is the line between medical treatment and enhancement?

Pro HGP:
Stopping research might be opting for comfortable ignorance of illusion rather than uncomfotable truth.
It is unlikely that existing world views, beliefs, and attitudes can be protected by shutting down basic research.
As a practical matter, it maybe that government cannot stop basic research.
Stopping research blocks both possible benefits and risks. All research carries with it the likelihood of changing one’s conception of the world and so of
changing one’s attitudes.i
Cloning:
From Greek word klon meaning twig

Production of genetic copy of another human being either “splitting” of embryo’s cell or through somatic cell transfer
Therapeutic Cloning
Goal: NOT to create human beings
To harvest stem cells
study or potential treatment of a disease
Tissue and organ replacement

Reproductive Cloning

Goal: to produce a child

Embryo cloned, implanted in uterus, allowed to develop/mature

Inviolability of Life
Stewardship
The availability of cloning technology does not mean ipso facto that the application of this technology to human beings is morally
 acceptable. -Fr Albert
Respect for persons
Personalized sexuality

Prenatal Testing:
Comprises a set of techniques for sample collection and analysis

Aims to detect fetal anomalies

Advances in genetic research promise great strides in the diagnosis and treatment of many childhood diseases

Testing and screening before the development of definitive treatment or preventive measures

Careful consideration must be given

It is the best interest of the child

Risk factors

> 35 years old

Previously premature babies or babies with defect

Women with high BP, diabetes, epilepsy

Family histories or ethnic backgrounds prone to genetic disorders

Pregnant with multiples (twins / more)

Previous miscarriages
Non-invasive methods and Less Invasive Methods
Maternal serum β-hCG (total or free)
Pregnancy-associated plasma protein A (PAPP-A)
Fetal nuchal translucency (by ultrasonography)
Maternal levels of serum α-fetoprotein (MSAFP)
Ultrasonography
Invasive
Chorionic Villus Sampling
determine chromosomal or genetic disorders in the fetus.
Sample of the chorionic villus to test
Risks: Apart from a risk of miscarriage, there is a risk of infection and amniotic fluid leakage (àunderdeveloped lungs)
Amniocentesis
Amniotic fluid is extracted from the amnion or amniotic sac surrounding a developing fetus
Fetal DNA is examined for genetic abnormalities
Risks: Injury, infection, miscarriage

Need for Prenatal Testing:

Enable timely medical or surgical treatment of a condition before or after birth

Give the parents the chance to abort a fetus with the diagnosed condition

Give parents the chance to "prepare" psychologically, socially, financially, and medically for a baby with a health problem or disability, or for the likelihood of
a stillbirth

Ethical Issues:
Temptation to make decisions not in accord with sound mortality

Eugenic intentions

Presumes to measure the value of human life only within the parameters of “normality” and physical well-being

Opens the way to legitimizing infanticide and euthanasia

Option to continue or to abort
Risks of prenatal diagnosis (amniocentesis) worth the potential benefit?
Ability to pick and choose what children parents would like to have
Questions the value of mentally or physically disabled people in society
Genetic Counseling:
Help families make informed decisions

Evaluates family history and medical records

Ordering genetic testing

Evaluating the results

Help parents understand and reach decisions about what to do

Strive to provide information, support, and counseling in a context that is unique for each family

Demonstrate empathy, respect, and unconditional positive regard for their patients

Guide patients and families in understanding their own values, in making decisions that are appropriate

Elicit beliefs, values, and feelings from patients

Dilemma: a conflict of bioethical principles of respect for autonomy and beneficence

Is Prenatal Diagnosis Morally Licit?
Respects the life and integrity of the embryo and the human fetus

Directed toward safeguarding or healing as an individual

Do not involve disproportionate risks of the child and the mother

Early therapy

Informed acceptance of the unborn child

AFFIRMATIVE

Stem Cells:
Cells that are capable of totipotent and pluripotent operations
In many tissues, they serve as internal repair system
unspecialized cells capable of renewing themselves through cell division, sometimes after long periods of inactivity.

under certain physiologic or experimental conditions, they can be induced to become tissue- or organ-specific cells with special functions
Research:
Scientific and biological study of a stem cell that can become any kind of cell and develop into different types of cell

generate tissues that can be used to repair damaged tissues

Understand earliest stages of human development

Embryonic Stem (ES) Cell Research

Human fetal tissue following elective abortion
Human embryos created by IVF no longer needed by couples
Human embryos created by IVF with gametes donated for the sole purpose of providing research material
Human embryos generated asexually
Adult Stem Cell Research
Umbilical cord, placenta, amniotic fluid
Adult tissues (like in bone marrow, liver, epidermis, retina, and others)

Embryonic SC Ethical Issues:

1.Retrieval of embryonic stem cells

Spare embryos

One wrong choice does not justify an additional wrong choice to kill them for research
2.Respect for Human Embryos

The human being must be respected and protected from the very first instant of his existence

His rights as a person be recognized, among which is the right to life

In extracting stem cells, the embryo gets destroyed and killed

“No circumstances whatsoever, even in an intention to study about embryonic stem cells for possible cure of diseases, can justify the destruction of
the embryo itself”
Fifth commandment violated
The end does not justify the means

“The deliberate decision to deprive an innocent human being of his life is always morally evil and can never be licit either as an end in itself or as a
means to a good end… disobedience to the moral law… it contradicts the fundamental virtues of justice and charity”- Evangelium Vitae, On the Value
and Inviolability of Human Life, 1995

3.Against human dignity

Keeping human embryos in vivo or in vitro is opposed to human dignity (spare embryos)

Human life is reduced to a mere biological species or object which can easily be discarded as desired
4.Researcher takes the place of God (even though he may be unaware of this)
“There are no lives that are not worth living; there is no suffering, no matter how grave, that can justify killing a life; there are no reasons, no matter
how noble, even if carried out to help others, that make plausible the creation of human beings, destined to be used and destroyed” - Pope John Paul II,
“The Gospel of Life” 1995. Origins 24:42

Adult SC Research:
Moral as long as it does not put the life of the person at risk

Informed consent secured

Adult stem cells are increasingly being shown to have same potential as embryo stem cells

56 diseases in which adult stem cell research has been successfully used in humans
The Catechism of the Catholic Church recognizes that:

…scientific research is a significant expression of man’s dominion over creation. Science and technology are precious resources when placed at the service of
man and promote his integral development for the benefit of all…
Neverthelels, it reminds that:

…By themselves however, they cannot disclose the meaning of existence and of human progress. Science and technology are ordered to man; hence they find
in the person and in his moral values both evidence of their purpose and awareness of their limits… in conformity with the plan and will of God
Respect for persons
They are human beings, made in the image of God
Humility
Knows the limits of the medical profession, recognizing one’s capabilities and limitations
Never plays God
Prudence
Foresight: a habitual deliberateness, caution and circumspection in action
Consider how different options may affect others before making a decision

Honesty
Truthfulness
convey the truth (about an illness, its nature, prognosis, effectivity of care, and research findings) to others as best one knows
Integrity
Uprightness
Wholeness of character; acting in the same way one says he should act and believes he should act
Sincerity
Authenticity (when they do what they are supposed to do)
Courage
Doing what one sees as right without undue fear, or standing up against what one sees as wrong even if it means standing up alone
Faith
Establishing trust in both emotional and rational level
Involves faith in God as Author of Life and considers himself only a steward of human life
Love
Caring and compassionate
Treating patients as persons and not as objects of research, experiments, and future medical findings and discoveries

i
Transcribed by Aubrey Del Rosario B2012
ORGAN TRANSPLANT
•It is a surgical operation where a failing or damaged organ in the human body is removed and replaced with a new one.
Organ donation - giving of tissue/organ by a person to another person or to an institution

Donor
•The giver who may be a cadaver or a living person
•A donor who exchanges the organ for money is a vendor.

Recipient
•The receiver who may receive directly from the donor or from an institution.
A recipient who pays for the organ is a buyer.
1. Autotransplantation – the donor and the recipient of are one and the same individual
2. Heterologous transplantation – the donor and the recipient of transplantation are 2 different individuals.
•Animal to human transplantation
Human to human transplantation (cadaver-donor; living-donor)
Transplanting organs from one living person to another is also ethically acceptable provided that the following criteria are met:
1.There is a serious need on the part of the recipient that cannot be fulfilled in any other way.
2.The functional integrity of the donor as a human person will not be impaired, even though anatomical integrity may suffer.
ANATOMICAL INTEGRITY
-refers to the material or physical integrity of the human body.
-when all the parts of the human body that are supposed to be there are all accounted for.
FUNCTIONAL INTEGRITY
- refers to systematic efficiency of the human body.
- When all the anatomical parts are normally functioning for the good of the whole bodily system.
Example:
•If one kidney were missing from a person’s body, there would be lack of anatomical integrity, but if one healthy kidney were present and working, there would
be functional integrity because one healhty kidney is more than able to provide systemic efficiency.
3. The risk taken by the donor as an act of charity is proportionate to the good resulting for the recipient.
-It is a manifestation of generosity and love
-It should be done first and foremost , to save and improve the quality of life of another
•Principle of common good
-Both donor and recipient should benefit from the process
-A donor shall be reimbursed for the expenses related to the donation and transplantation (medical, loss of income, inconvenience), but not for the organ itself.
4. The donor’s consent is free and informed
-No deception in the information given, no coercion in obtaining of consent, and volunteerism on the part of the donor and recipient
5. The recipients for the scarce organs are selected justly.i
•Principle of Justice and Equity
-Benefits and burdens must be equally distributed
-A gratuity should be given to the donor
-There shall be transparency in the whole process
-Non-directed donated organs shall be allocated equitably among patients with priority based on the objective criteria for medical need and probability of
success as specified by the Donation Allocation Guidelines

Live vs. Cadaveric

Organ transplant
•is the moving of an organ from one body to another (or from a donor site on the patient's own body)
•purpose of replacing the recipient's damaged or failing organ with a working one from the donor site.
•Living or deceased

Transplantable from living donor:

Lung/Kidney/Liver/Intestine/Bone/Bone Marrow
Deceased Donor:
Lung/Kidney/Liver/Intestine/Bone/Heart/Pancreas/Cornea

Living Transplant
involves an organ taken from one living person and given to another living person
Deceased/Cadaveric Transplant
involves an organ or tissue taken from a dead person and given to a living person

Living Organ Donation:

1.Related
–Donation between genetically related persons
–They can be:
•Parents
•brothers and sisters (over 18 years of age)
•other blood relatives (aunts, uncles, cousins, half brothers and sisters, nieces and nephews)
2. Non-related
•Unrelated living donors are healthy individuals emotionally close to, but not related by blood
•They can be:
–spouses
–in-law relatives
–close friends
–co-workers, neighbors or other acquaintances
3. Non-directed
•living donors who are not related to or known by the recipient, but make their donation purely out of selfless motives.
•This type of donation is also referred to as anonymous, altruistic, altruistic stranger, and stranger-to-stranger living donation.

4. Paired Donation
–consists of two donor/recipient pairs whose blood types are not compatible
–The two recipients trade donors so that each recipient can receive a kidney with a compatible blood type.
–Once the evaluations of all donors and recipients are completed, the two kidney transplant operations are scheduled to occur simultaneously.

5. Kidney Donor Waiting List Exchange

–donor who is not compatible with their intended recipient offers to donate to a stranger on the waiting list
–the intended recipient advances on the waiting list for a deceased donor kidney
–This type of living donation is also referred to as list-paired exchange and living donor/deceased exchange.

6. Blood Type Incompatible

- allows candidates to receive a kidney from a living donor who has an incompatible blood type.
- to prevent immediate rejection of the kidney, recipients undergo plasmapheresis treatments before and after the transplant to remove
harmful antibodies from the blood, as well as the removal of the spleen at the time of transplant.

Acceptable Living Donors:

•Physically fit and in good general health
•18-60 years old
•Compatible blood type with intended recipient
•Written living donor informed consent form
Benefits of Living Donation:
•Superior results for the recipients
•Eliminate the long wait for a deceased-donor organ
•Allow transplant surgery to be scheduled when both the organ donor and recipient are in top physical and mental health
•The sooner a failing organ is replaced, the quicker and easier it is to recover. The longer a person must wait, the more likely further health complications are
to happen.

Informed Consent:
•All aspects of the donation process, the potential risks and benefits of it, as well as center-specific factors must all be understood by the potential donor.
•Only a competent adult can agree or disagree to be a living donor through free and informed consent.
•In an incompetent person (severely mentally disabled adult or a minor living donor), it is unethical for the guardian to consent for an organ donation.
•Most living donors are family members which provide a better donor-recipient tissue match, thus there will be reduced risk of rejection.

Cadaveric Transpant:
•is when a person declared brain dead and their immediate family has given consent for their organs to be donated for transplantation
• transplanting an organ or tissue from a dead person to a living person presents no ethical problem

1.Heart – Beating Cadaver Donors/ Neomorts (HBCD’s)

•Patients who have been declared dead on neurological grounds or “brain dead”
- irreversibly lost all brain function
- also called as a Neomort
•Organs removed while the donors are still on respirator and their hearts are still beating
•Ideal – no delay between cessation of heartbeat and removal of organs

2. Non – Heart – Beating Cadaver Donors (NHBCD’s)

•Patients who have been declared dead on the grounds of cardiopulmonary criteria.
•Their hearts are no longer beating at time of organ procurement.
•Not Ideal – there is a delay between the death of the donor/patient and the harvesting of the organs

Consent of Deceased Donor:

•"organs and tissues may be removed from a deceased person who has bequeathed them verbally or in writing or, in the absence such clear expression of the
deceased person's will, with permission of the family.“
•the wishes of those grieving for the person's death should be taken into account

Ethical Considerations:
•harm and risk of human must be minimal or proportionate to the benefits to be derived
–the dying cannot be killed
–organ must not be necessary for life (brain),
–organ must not be for personal or procreational identity (penis)
•the donor must be cared for before, during, and after the donation.
–proper screening
–standard healthcare (insurance)
–reimbursement for medical expenses
–disability and livelihood lost
–prevention of discrimination
–community acceptance
•the intrinsic worth and dignity of the donor must be respected
–free and informed consent
–information about
•the process of matching,
•the chance of success, and
•permission to refuse must be provided
•in case of cadaver donors, consideration must be given to the family
–family’s consent must be obtained
–if “organ donation card” was signed by the patient, consent of the family is not needed
–when a dead body is unclaimed within 48 hours, the state now owns the body and allows the organ to be harvested
Medical Decisions:
especially that of the donor should be:
•free (voluntary)
•not coerced
•based on a sound understanding of what is at stake

Donating Within Families:

Unavoidable Pressures
•intended recipient will die without the transplantation, which of course makes any decision highly charged
•only one person in the family is a suitable donor and so the spot-light falls on him or her alone
Avoidable Pressures
•pressure put on a family member to donate in exchange for certain favors - whether specified or left more vagus
•there may be threats of disapproval, perhaps implied or unspoken, if a person refuses to donate
•lasting harm to relationships in the family

Sources of Donor Organs:

•Living Donor/Cadaveric Donor/Anencephalic Infants/Human Fetuses/Stem Cells/Animal Organs

Living Organ Donor:

•when a living person donates an organ or part of an organ to someone in need of a transplant
•functional integrity of the donor as a human person will not be impaired, even though anatomical integrity may suffer
•risk taken by the donor as an act of charity is proportionate to the good resulting in the recipient

Transplanting organs from one living person to another is also ethically acceptable provided that the following criteria are met:
Act of Charity
It is a manifestation of generosity and love
It should be done first and foremost, to save and improve the quality of life of another

whatever justification a person accepts, there is one consideration which should inform all decisions about living donation - Informed Consent

Cadaveric Organ Donor:

•harvesting from a dead person will do no harm
•once a person dies, his or her organs may be donated if the person consented to do so before they passed away
•a person’s consent to donate their organs is made while still living, appears on a driver’s license or in an advance directive
•if the deceased person’s organ donation wishes are unknown, the hospital, physician, or organ procurement organization will approach a family member to
obtain consent to remove the organs

•the family members with the authority to do so is generally determined by this hierarchy:
–spouse
–adult child
–parent
–adult sibling
–legal guardian
Anencephalic Infants:
•infants born with a major portion of their brain absent and without cognitive function
•organ donation may only be considered if the anencephalic infant has satisfied the criteria for brain death or somatic death as applied to other human beings.
•studies showed that use of anencephalic child’s organs leads to unsuccessful transplants because of the ff reasons:

▫AI will not usually satisfy the standard brain death criteria because of adequate brainstem function that maintains spontaneous respiration and heart rate after
birth.
▫by the time brain death or somatic death has been declared, the organs will have undergone ischemic damage, making them unsuitable for transplantation
▫use of life support does not improve the chance of successful organ donation from anencephalic infants

Human Fetus:
•if the fetus has died of natural causes, the ethical issues would be similar to other transplants from the deceased
•but if the fetus died from abortion, the organ should not be used for donation because it will justify the use of abortion

Stem Cells:
•unspecialized cells that can self-renew indefinitely and differentiate into more mature cells with specialized functions
•these “super” cells have a magic clinical potential in tissue repair and they represent the future relief of a wide range of incurable diseases, or replacement of
defective organs and tissues, by restoring their normal functions

With all its controversiality, due to its origin, the question is: can these cells be isolated and used? If so, under what conditions and restrictions
In order to discuss the moral aspect of isolation and use of HuSC, it is essential that we first understand exactly what these cells are, where they come from,
their intended application, and the ethical questions regarding its different sources.

"Stem cells will cure everything"

"Stem cells kill embryos"
Where Do They Come from?
–early embryonic stages
–embryos
–fetal tissues
–umbilical cord
–bone marrow

•embryonic stem cells were the only pluripotent stem cells capable of differentiating into cells of ectodermal, mesodermal, and endodermal origin.
•embryos are destroyed in the process of extracting the stem cells
•the Vatican condemned research using human embryos as "gravely immoral," because removing cells kills an unborn child
•“the Roman Catholic church teaches that life begins at conception and must be safeguarded from that point. It encouraged the use of cells from adults instead
of embryos, which it called `the more reasonable and humane step.’”

Animal Organs:
Xenotransplantation
transplants of animal organs into humans
•experiments have been performed on transplants of bone marrow, hearts, neurons and other tissues from baboons, chimpanzees and pigs, with limited success
in terms of patient survival or organ functionality
•rejection issues and the risk of transmission of animal diseases to humans
–human immune system reacts violently to pig organs and pigs contain ubiquitous retroviruses which may adversely affect humans
Ethical issues surrounding the use of animal organs for human transplants appear to be threefold
•issue of animal rights and the breeding of animals simply for human consumption and medical benefit
•xenotransplant technology is just another way for biotech companies to make money, and they are not concerned with the welfare of the animals or truly
concerned with the welfare of mankind
•new infection be introduced for which we have no cure

Selection of Recipient Donor/Matching:

•Patients on the waiting list are in end-stage organ failure and have been evaluated by a transplant physician at hospitals
•Subjected to intense scrutiny by the government, and the medical profession.
•Organ transplantation is built upon altruism and public trust. If anything shakes that trust, then everyone loses.
•Implicit rationing
–doctors, HMO's, and the individual's ability to pay, control who gets limited resources
•Explicit rationing
–government, through public health authorities, controls the allocation of limited resources

Entry into Transplantation Programs:

First stage
- deals with the considerations w/c should be taken into account in deciding on the identity of the individual patients to whom offers of transplants
are to be made.
Entry to a program - assessment of patients
Exclusion criteria - age restrictions, abnormalities in other organ systems, previous history of malignant disease and other medical considerations.
A medical practitioner whose patients become candidates for admission would have a conflict of interest if he or she had the sole responsibility for selection.
Second stage
- It relates to whether an individual chooses to become a transplant recipient.
- It is a decision to be made by the patients in the light of advice form their medical attendants and consultation with their families.
- Patient should receive a full description of what is entailed in the program, what procedure can be expected and their possible risk and benefits.

Organ Procurement and Transplant Network (OPTN):

All patients accepted onto a transplant hospital's waiting list are registered with the UNOS Organ Center.
When donor organs are identified, the procuring organization typically accesses the UNOS computerized organ matching system, enters information about the
donor organs, and runs the match program.
For each organ that becomes available, the computer program generates a list of potential recipients ranked according to objective criteria (i.e. blood type,
tissue type, size of the organ, medical urgency of the patient, time on the waiting list, and distance between donor and recipient).
[UNOS – United Network for Organ Sharing - where a centralized computer network links all organ procurement organizations (OPOs) and transplant
centers.]

After printing the list of potential recipients, the procurement coordinator contacts the transplant surgeon caring for the top-ranked patient
Depending on various factors (e.g. donor's medical history and the current health of the potential recipient), transplant surgeon determines if the organ is
suitable for the patient. If the organ is turned down, the next listed individual's transplant center is contacted, and so on, until the organ is placed.
Once the organ is accepted for a potential recipient, transportation arrangements are made for the surgical teams to come to the donor hospital and surgery is
scheduled.

“From the moral standpoint of view, an obvious principle of justice requires that the criteria for assigning donated organs should in no way be
‘discriminatory’ (ie, based on age, sex, race, religion) or ‘utilitarian’ (ie, based on work capacity, social usefulness) Instead, in determining who should have
precedence in receiving an organ, judgment should be made on the basis of immunological and clinical factors. Any other criterion would prove wholly
arbitrary and subjective, and would fail to recognize the intrinsic value of each human person as such, a value that is independent of any external
circumstances.” – Pope John Paul II
Selection of Recipient:
“Disabled & suffering… Waiting & wondering”
Selection of the patient
Serious need on the part of the recipient that cannot be fulfilled in any other way.
Selection of the sickest patient
An offer to the patient who is most likely to die without it might appear the most reasonable basis. However, this is not necessarily the “best use” of
a limited resource.
Selection of the patient most likely to benefit based on medical or other criteria
- preference should be for the best possible tissue match in the patient with the best outlook (optimal medical condition at the time of the operation,
least risk of recurrence of the diseases occasioning transplantation, younger age, etc)
Selection of the patient on the waiting list for the longest period
Priority on the basis of length waiting period has administrative advantages of ready identifiability and defensibility
Argument: the fact that a patient has survived for a long period after meeting the requirement for entry to waiting list might indicate that he or she
was in better condition than others on that list.
The question might then be put whether for this reason, his or her NEED was less.
* All patients on the waiting list should have an equal chance of selection
* Recipient selection of patients are done justly (on the basis of their importance for the well-being of others)
* Preference in selection of patients who have previously had one or more transplants
•Principle of free and informed consent
–adequately informed regarding the expected benefits, risks, burdens and costs of the transplant and aftercare, and of other possible alternatives
•Principle of human dignity
–All are equally persons, have the same human rights, and have the same claim to justice and dignity.
–The same criteria is applied to everyone who is referred for a transplant
–Because donated organs are such a limited resource, the probability of a good outcome is emphasized (the utility principle).
–At the same time, patients have complex medical conditions so each individual patient is evaluated within these broad criteria (the beneficence principle).

•The expected length of survival and the possibilities regarding rehabilitation should be considered
•Care must be taken not only that they extend life biologically, but that they also offer the patient a real chance for a healthy life
•The new organs should add new years to life, and help to provide a new and better life

Give priority to those who have great need and who are expected to benefit greatly.

Organ selling/buying:
•Organs are precious GIFTS.
•Organs are NOT resources.

•In the face of scarcity, these gifts of life are turned into market commodities.
•1996-2006  the number of kidney transplants locally, increased
•Transplant from living and related donor flattened while the number of non-related transplant donors ballooned out from 52 in 1999 to 473 in 2006.
•The number of foreign recepients in 2004 and 2005 increased by 62%.
•In 2007, 50% of transplant operation involved foreign recipient despite of law which restrict the number of transplant to foreign to 10% of the total.
•Selling or exporting human organs carries a 20-year jail term and stiff fines—but presecutions are rare.

In Baseco, on Manila Bay, about 3000 of the slum’s 50,000 inhabitants are reported to have sold a kidney
•These donors are all male, with an ave. age of 29.
•A third of them have not even reached high school
•Most are farmers or tricycle drivers with a 4000 PhP average household monthly income
•They received just 150,000 PhP for a kidney
•3/4 did not improve their lives economically
•4/5 felt their capacity to work was reduced
•None would recommend that others sell their kindney

Elements of Tragedy:
Patient whose life hangs in the balance
Desperately poor whose organs now have monetary value, and who are vulnerable to exploitation in a growing industry known as “transplant tourism”

Church’s Stand:
•“Organ Selling is IMMORAL”
–It is contrary to the dignity of the human body.
–Those who NEED such a gift should receive it, rather than only those who can PAY.
Ethics of Health Care, 3rd edition, Ashley and O’Rourke

Issues:
•Proponents of the market
–Primary focus and purpose has been to propose financial incentives due to decreased organ donation.
There is an increasing interest in addressing the shortage of transplantable organs by using monetary payments to obtain them.
Their primary focus ad purpose has been to propose financial incentives for decreased donation.
The source of these commentaries has been from those who do not have direct care responsibility for transplant patient or organ donors.
•Practice Itself
–“use of organ sales as remedy for the poor to life themselves out of destitution.”
–There is an increase in exploitation by creating incentives, ignoring other alternatives for helping the poor.
•The Buyer
–Persons who vitally need an organ so as to live a full life are under considerable pressure.
–Buyer: “Buying an organ from a poverty-striken person enables chance for a better life for that person and his family.”
•The Seller
–Organ sales have brought little benefit to those selling them.
–Number of participants living below the poverty line has even increased.
–Reports from India reveal: kidney donors are worse off than they were before their nephrectomy.
–Deterioration in health status also occurs.
•Economic conditions
–There is exploitation of the weak countries by rich and powerful nations.
–The victims are usually the very poor.
•Professional Consequences
–A program of ORGAN SELLING creates conflict between the Physician-Patient relationship.
•Patients are not clients, nor commodities.
–This approach threatens the core values of the profession of medicine.
•Physicians become “market providers”
•Patients become “consumers / clients”
•Any attempt to assign a monetary value to the human body or its body parts diminishes human dignity and devalues human life.
•Scientific Justifications Nor Cost-Effectiveness Analyses does not overcome Ethical Concerns.
Donate with LOVE in our hearts and for the sole purpose of giving and helping those in need without monetary enrichment as the primary
motivation.

Virtues:
“It is a good operative habit.” –St. Thomas Aquinas
Traits of character or habits of disposition to think and act in ways that are morally good. - Alora, Angeles. Bioethics for students.
Fidelity
faithfulness to trust and promise
keeping patient’s best interest first in mind
Respect for Persons:
They are human beings, made in the image of God and made in the image of Christ.
They have inner worth, unique and equal dignity and rights.
They stand above all things and have rights which are universal and inviolable.
Scientific Competence:
- Diligence in research
- Updating and consultation with peers
- Patience
- Perseverance
Great Heart:
- Integrity/Public Spiritedness/Humility/Love/Faith/Hope/
Honesty - refers to both truthfulness and integrity
Truthfulness - the good faith intent to convey the truth to others as best one knows
Integrity - being true to oneself or wholeness
Justice
- constant will to give another his due
- adjusting what is owed to the specific needs of the person even if those needs do not strictly fit what is owed
Compassion
- feeling for the loss/suffering of another with an attempt beyond obligation to help or avoid that loss/suffering
- self sacrifice : for the benefit of another whose needs are greater, expecting no gain, recognition or payment in return
Humility
- recognizing one’s capabilities and limitations
- accepting deserved praise graciously and denying undeserved praise
Prayerfulness
seeking God’s help in everything one does
“The health worker “becomes a mediator of something which is particularly meaningful, the gift of self by a person – even after death – so that another might
live.”

i
Transcribed by Aubrey Del Rosario B2012
PEDIATRICS

Pediatrics is concerned with the health of infants, children and adolescents, their growth and development, and their opportunity to achieve full potential as
adults."

Around 2 million babies are born in the Philippines each year. The number of children aged 0 to four years old run up to around 10 million, and children aged
five to 10 are another 10 million.

Newborns refer to infants during the first month of life. Infants are those that are still below one year old. On the other hand, children refer to the age group
between one year old to less than 10 years old.

Neonatal Care Principlesi

FIRST PRINCIPLE: “Everything always for the best interest of the child.”

Benefit or Harm is sometimes difficult to define; in many instances, patients cannot speak for themselves and/or do not have the developmental maturity to
balance short-term discomfort against possible long-term outcomes.

FIRST PRINCIPLE “Everything always for the best interest of the child. “
The legal guardians or even the physician often times has competing interests.

In these situations, special care should be taken to keep in mind at all times what is in the best interests of the child.

Parents are best qualified decision-makers because they know the child best and the intimacy of family life makes it the greatest personal bond that tries to
protect the child from interference from others and think only the child’s best interest.

Parents have the moral and legal right to decide for their children.

Gift vs. Burden

Example: when a family is strained financially because of the costs of the child's medical care or feels that siblings have been neglected because of the time
required by the sick child.

SECOND PRINCIPLE: “Physicians: the advocates of children”

Doctors
> Mediates and identifies the parental decisions or children’s actions jeopardize children’s health and well being
> Pediatricians are given special responsibilities in these situations because if they do not intervene, children might suffer serious, long-lasting harm.
THIRD PRINCIPLE: “ Respect for future autonomy”
Their potential autonomy as future adults deserves respect

Physicians need to help ensure that parental decisions do not close off a child’s open future as a unique person
FOURTH PRINCIPLE: “Parents and family’s interests”
Physicians should respect the aptitude, resources, and cultural values of these individuals.

A balance between: Best for the family; Best for the child

FIFTH PRINCIPLE: “Emergency Cases”

bias toward preserving life and limb at all cost
To ensure that the child's best interests are served, erring on the side of treatment rather than foregoing treatment is appropriate

Example: Trauma surgery for a child injured in an automobile crash in which the parents are also injured and unable to respond. Few children have advanced
directives concerning care; if the physician later learns from the parent that the extent of treatment exceeds the parent's wishes, treatment can then be
discontinued

Emergency Baptism
Catholic Church determined in its spiritual wisdom to baptize infants as soon as they were born. This would ensure that infants would also receive their new
heart and spirit to guide them in life. This would be their guarantee of salvation as children of God should they die before reaching the age of reason.
In the case of an emergency, anyone can baptize another person as long as he has the intention of doing so and says the proper words. He is only required to
pour water over the person's head and say the words,
"I baptize you in the name of the Father, the Son and the Holy Spirit." (C.C.C. # 1284)
SIXTH PRINCIPLE: “Disclosure of information to children”
Children should be provided information that is presented in an age-appropriate manner to help them participate in decision-making.
SEVENTH PRINCIPLE: “Confidentiality”
Physicians should maintain the confidentiality of pediatric patients as they would any other patient.

Surrogate Decision maker or guardian is the person to decide with whom the info may be shared

Every child’s privacy and confidentiality must be respected at all times.

Presentation in teaching sessions may be allowed only if it is likely to benefit the child or in cases where there is no likely benefit to child, will be of benefit to
others.
In both cases, free and informed consent must be obtained and precautions must be taken to preserve the dignity of the child.
Confidentiality Exceptions
Confidentiality: Exceptions
Physicians and other health care workers must report cases of suspected child abuse or neglect to child protective services agencies.

Physicians might need to disclose health information to schools – only what is needed.
EIGHT PRINCIPLE: “Informed Consent”
Three elements
Information, Comprehension, Freedom
Right and Responsibility that each person has with regard to his or her own well-being and pursuit for happiness the right of a competent adult to decide, after
consultation with a physician

Problems in autonomy
children cannot weigh risks and benefits, compare alternatives, or appreciate the long term consequences of decision

they are incapable of making informed decisions

EIGHT PRINCIPLE: “Informed Consent”
Diagnostic and Therapeutic Procedures
Each available medical procedure of treatment should be considered from the child’s perspective in light of the overall benefit that it may offer and the burdens
it may entail.
That free and informed consent of the patient’s surrogate (parents or persons authorized by law to sign in patient’s behalf) is required for all medical
procedures and treatment except in emergency situations when the child is left alone in the hospital and consent cannot be obtained.
Diagnostic and Therapeutic Procedures
(3) The well being of the child must be taken into account in deciding about any use of technology or therapeutic intervention.
(4) The capacity for decision making is developmental.
(5) Respect for religious beliefs of patient/family should be taken into consideration in the decision making process.
Should Adolescents Make Their Own Life-and-Death Decisions?
Yes: Ethicist Robert F. Weir and pediatrician Charles Peters assert that adolescents with normal cognitive and developmental skills have the capacity to make
decisions about their own health care.
No: Pediatrician Lainie Friedman Ross counters that parents should be responsible for making their child’s health care decision. Children need to develop
virtues, such as self-control, that will enhance their long-term, not just immediate autonomy.

Informed Consent & Proxy Consent

Informed consent is the process of providing the patient or, in the case of a minor or incompetent adult, the custodialparent or legalguardian with relevant
information regarding diagnosis and treatment needs so that an educated decision regarding treatment can be made by the patient or custodial parent/legal
guardian
Proxy Consent
Children cannot provide informed consent because they lack the capacity to become fully informed
Consent is assigned to another person (proxy)
basis: supposition that the “proxy” will decide for the patient’s best interest
Two Types of Proxy Consent:
1) Power of attorney to consent to medical care
usually used by patients who want medical care but are concerned about who will consent if they are rendered temporarily incompetent by the medical care
It can delegate the right to consent to a specific person

2)Living will

Proxy Consent Form:

name and date of birth of pediatric patient;
name, relationship to patient, and legal basis for adult
to consent on behalf of minor;
treatment, alternatives, and risks;
potential adverse sequelae specific to the procedure;
an area for the patient or parent/guardian to indicate all questions have been asked;
signature lines for the dentist, parent or legal guardian, and a witness.

Parental Consent
means that you will need to get permission from a parent if you are under a certain age, usually 18

Parental Notification
means that you will have to tell a parent if you are under a certain age, usually 18, but you don't need their permission.
Goals of Parental Consent:
It includes the development of the patient's comprehensive understanding of the clinical situation, and the timely exercise, by the patient, of active choices
regarding the circumstances

The doctrine of informed consent reminds us to respect persons by fully and accurately providing information relevant to exercising their decision-making
rights.

Provision of information
Assessment of the patient's understanding of the above information.
Assessment, if only tacit, of the capacity of the patient or surrogate to make the necessary decision(s).

Assurance,that the patient has the freedom to choose among the medical alternatives without coercion or manipulation.
Parental consent may refer to:
1.MedicalTreatment
A parent's right to be informed, before their minor child undergoes medical treatment.
2.Body Modification
A parent's right to give consent before their minor child undergoes this procedure such as piercing or tattooing.
3. Marriage
A parent's right to consent to their minor child marrying before he or she reaches marriageable age.
4. Education
A parent's right to be involved in their minor child's education, including the right to approve or disapprove of certain curricula, or to consent to extracurricular
activity and field trips.
Parental Permission and Shared Responsibility:
Decision-making involving the health care should flow from responsibility shared by physicians and parents.

Doctors should seek the informed permission of parents before medical interventions (except in emergencies when parents cannot be contacted).
Usually, parental permission articulates what most agree represents the ``best interests of the child.''
Healthcare providers of children have to carefully justify the invasion of privacy and psychological disruption that come with taking legal steps to override
parental prerogatives
Assent of the Patient
Decision-making involving the health care of older children and adolescents should include, to the greatest extent feasible, the assent of the patient as well as
the participation of the parents and the physician.
Pediatricians should not necessarily treat children as rational, autonomous decision makers, but they should give serious consideration to each patient's
developing capacities for participating in decision-making

Assent should include at least the following elements:

Helping the patient achieve a developmentally appropriate awareness of the nature of his or her condition.
Telling the patient what he or she can expect with tests and treatment(s).
Making a clinical assessment of the patients understanding of the situation and the factors influencing how he or she is responding (including whether there is
inappropriate pressure to accept testing or therapy).
Soliciting an expression of the patient's willingness to accept the proposed care. In situations in which the patient will have to receive medical care despite his
or her objection, the patient should be told that fact and should not be deceived.
THE PATIENT'S REFUSAL TO ASSENT (DISSENT)
There are clinical situations in which a persistent refusal to assent (ie, dissent) may be ethically binding. This seems most obvious in the context of research
(particularly that which has no potential to directly benefit the patient).
Medical personnel should respect the wishes of patients who withhold or temporarily refuse assent in order to gain a better understanding of their situation or
to come to terms with fears or other concerns regarding proposed care.
Coercion in diagnosis or treatment is a last resort.

AAP “Informed Consent, Parental Permission, and Assent in Pediatric Practice (1995)
“Thus “proxy consent” poses serious problems for the pediatric health care provider. Such providers have ethical and legal duties to their child patients to
render competent medical care based on what the patient needs, not on what someone else expresses…The pediatrician’s responsibility to his or her patient
exist independent of parental desires or proxy consent.”
Ordinary and Extraordinary Means to Prolong Life
1. Physicians and moralists often use the terms ordinary means and extraordinary means with different connotations. Physicians use these
terms insofar as the means to prolong life is standard and accepted or experimental and unproved. Ethicists, conversely, look to the way in
which the therapy will affect the person’s ability to function at the spiritual level of human potential.
2. Although the physician has the expertise and the right to make decisions concerning the usefulness or medical effects of some particular
medical procedure, the patient has the right to determine whether a particular medical procedure is ordinary or extraordinary from an
ethical viewpoint.
3. If the means in question are determined to be ordinary from an ethical viewpoint, then they must be employed; if extraordinary, they may
or may not be employed.
Newborn Screening: The practice of testing every newborn for certain harmful or potentially fatal disorders that are not otherwise apparent at birth
Procedure:
Blood sample: at least 24 hours after delivery
Obtained by pricking the baby’s heel (Guthrie spot)
Dried on a special paper
Sent to the Newborn Screening Program for testing
Importance:
Metabolic disorders - Phenylketonuria, galactosemia
Hormonal disorders - Congenital adrenal hyperplasia, hypothyroidism
Genetic disorders - Cystic fibrosis, Duchenne muscle dystrophy
Transplacental infections - HIV, congenital toxoplasmosis
Principles:
1. Identification of the genetic condition must provide a clear benefit to the child
2. a system must be in place to confirm the diagnosis
3. treatment and follow-up must be available for newborns affected with the condition
Ethical Issues:
Voluntary
- proxy consent of parents
- authority of parents over their child
Mandatory

- explicit refusal of parents

- society’s obligation to promote child welfare
Voluntary vs. mandatory
informed consent
provide parents with adequate information on the risks and benefits of screening programs
Risk-benefit issues
- benefit of early detection & intervention

- for conditions with no known cure: risk of subjecting the child to treatment that are of no value or even harmful
Newborn Screening Act of 2004:
The state shall institutionalize a newborn screening program that is comprehensive, integrative and sustainable.
Objectives:
-health practitioners are aware of the advantages of newborn screening and of their respective responsibilities in offering newborns the opportunity to undergo
newborn screening
-To ensure that parents recognize their responsibility in promoting their child’s right to health and full development
Provisions:
Health care providers should inform the parents or guardian of the nature and benefits of newborn screening prior to delivery
Screening must be done after 24 hours but not later than 3 days after delivery

Patients that need to be placed in the ICU: before 7 years of age

DOH is responsible for continuing education and training of health personnel on the risks, benefits and procedure of newborn screening

DOH shall require healthcare institutions to provide newborn screening services as a condition for licensure and accreditation
CONGENITAL ANOMALIES
are a major cause of stillbirths and neonatal deaths, but they are perhaps even more important as causes of acute illness and long-term morbidity.

refer to structural defects, chromosomal abnormalities, metabolic errors and hereditary disease present at birth.
MONGOLISM (Down’s Syndrome)
Affected child would be severely retarded

May lead a life without pain or discomfort and without being aware that he is even handicapped à family and the community suffer more than the individual
PHENYLKETONURIA
Disorders of amino acid metabolism

An autosomal recessive genetic disorder characterized by a deficiency in the enzyme hepatic phenylalanine hydroxylase.

Cause problems with brain development, leading to progressive mental retardation, brain damage, and seizures.
CLEFT PALATE AND CLEFT LIP
congenital deformity caused by abnormal facial development during gestation.

may cause problems with feeding, ear disease, speech and socialization.
TO TREAT OR NOT TO TREAT?
“There is no ethical problem in offering, and indeed there is an obligation to provide, comprehensive treatment to handicapped infants and children, who,
without treatment, would still live and whose lives can be made better by skilled treatment.”
Christian Principles:
Inviolability of life; Stewardship; Nonmaleficence; Beneficence; Justice
Inviolability of life:
All human life from the moment of conception and through all the subsequent , is sacred.

It is a gift of GOD and the fruit of love.

The principle recognizes that death is a natural end of life and biological life is not the highest value.
Stewardship:
Man has dominion over God’s creations: himself, other creatures and environment.

Man must take care and cultivate creatures within the creature’s innate nature and teleology and within man’s knowledge and understanding
Nonmaleficence:
One should not do and risk harm

A healthcare giver should do no harm. Harm are providing incompetent care, disrespecting dignity etc.
Beneficence:
One should prevent or remove harm or risk of harm, do good, provide a benefit.

One condition that require one to perform a beneficent act is:

THE ACTION IS NEEDED AND LIKELY TO SUCCEED

Justice:
Justice is both a principle and a virtue relating to the rightness on people’s interactions and relationships.

One should give one another what is due.

i
Transcribed by Aubrey Del Rosario B2012
PEDIATRICS

Pediatrics is concerned with the health of infants, children and adolescents, their growth and development, and their opportunity to achieve full potential as
adults."

Around 2 million babies are born in the Philippines each year. The number of children aged 0 to four years old run up to around 10 million, and children aged
five to 10 are another 10 million.

Newborns refer to infants during the first month of life. Infants are those that are still below one year old. On the other hand, children refer to the age group
between one year old to less than 10 years old.

Neonatal Care Principlesi

FIRST PRINCIPLE: “Everything always for the best interest of the child.”

Benefit or Harm is sometimes difficult to define; in many instances, patients cannot speak for themselves and/or do not have the developmental maturity to
balance short-term discomfort against possible long-term outcomes.

FIRST PRINCIPLE “Everything always for the best interest of the child. “
The legal guardians or even the physician often times has competing interests.

In these situations, special care should be taken to keep in mind at all times what is in the best interests of the child.

Parents are best qualified decision-makers because they know the child best and the intimacy of family life makes it the greatest personal bond that tries to
protect the child from interference from others and think only the child’s best interest.

Parents have the moral and legal right to decide for their children.

Gift vs. Burden

Example: when a family is strained financially because of the costs of the child's medical care or feels that siblings have been neglected because of the time
required by the sick child.

SECOND PRINCIPLE: “Physicians: the advocates of children”

Doctors
> Mediates and identifies the parental decisions or children’s actions jeopardize children’s health and well being
> Pediatricians are given special responsibilities in these situations because if they do not intervene, children might suffer serious, long-lasting harm.
THIRD PRINCIPLE: “ Respect for future autonomy”
Their potential autonomy as future adults deserves respect

Physicians need to help ensure that parental decisions do not close off a child’s open future as a unique person
FOURTH PRINCIPLE: “Parents and family’s interests”
Physicians should respect the aptitude, resources, and cultural values of these individuals.

A balance between: Best for the family; Best for the child

FIFTH PRINCIPLE: “Emergency Cases”

bias toward preserving life and limb at all cost
To ensure that the child's best interests are served, erring on the side of treatment rather than foregoing treatment is appropriate

Example: Trauma surgery for a child injured in an automobile crash in which the parents are also injured and unable to respond. Few children have advanced
directives concerning care; if the physician later learns from the parent that the extent of treatment exceeds the parent's wishes, treatment can then be
discontinued

Emergency Baptism
Catholic Church determined in its spiritual wisdom to baptize infants as soon as they were born. This would ensure that infants would also receive their new
heart and spirit to guide them in life. This would be their guarantee of salvation as children of God should they die before reaching the age of reason.
In the case of an emergency, anyone can baptize another person as long as he has the intention of doing so and says the proper words. He is only required to
pour water over the person's head and say the words,
"I baptize you in the name of the Father, the Son and the Holy Spirit." (C.C.C. # 1284)
SIXTH PRINCIPLE: “Disclosure of information to children”
Children should be provided information that is presented in an age-appropriate manner to help them participate in decision-making.
SEVENTH PRINCIPLE: “Confidentiality”
Physicians should maintain the confidentiality of pediatric patients as they would any other patient.

Surrogate Decision maker or guardian is the person to decide with whom the info may be shared

Every child’s privacy and confidentiality must be respected at all times.

Presentation in teaching sessions may be allowed only if it is likely to benefit the child or in cases where there is no likely benefit to child, will be of benefit to
others.
In both cases, free and informed consent must be obtained and precautions must be taken to preserve the dignity of the child.
Confidentiality Exceptions
Confidentiality: Exceptions
Physicians and other health care workers must report cases of suspected child abuse or neglect to child protective services agencies.

Physicians might need to disclose health information to schools – only what is needed.
EIGHT PRINCIPLE: “Informed Consent”
Three elements
Information, Comprehension, Freedom
Right and Responsibility that each person has with regard to his or her own well-being and pursuit for happiness the right of a competent adult to decide, after
consultation with a physician

Problems in autonomy
children cannot weigh risks and benefits, compare alternatives, or appreciate the long term consequences of decision

they are incapable of making informed decisions

EIGHT PRINCIPLE: “Informed Consent”
Diagnostic and Therapeutic Procedures
Each available medical procedure of treatment should be considered from the child’s perspective in light of the overall benefit that it may offer and the burdens
it may entail.
That free and informed consent of the patient’s surrogate (parents or persons authorized by law to sign in patient’s behalf) is required for all medical
procedures and treatment except in emergency situations when the child is left alone in the hospital and consent cannot be obtained.
Diagnostic and Therapeutic Procedures
(3) The well being of the child must be taken into account in deciding about any use of technology or therapeutic intervention.
(4) The capacity for decision making is developmental.
(5) Respect for religious beliefs of patient/family should be taken into consideration in the decision making process.
Should Adolescents Make Their Own Life-and-Death Decisions?
Yes: Ethicist Robert F. Weir and pediatrician Charles Peters assert that adolescents with normal cognitive and developmental skills have the capacity to make
decisions about their own health care.
No: Pediatrician Lainie Friedman Ross counters that parents should be responsible for making their child’s health care decision. Children need to develop
virtues, such as self-control, that will enhance their long-term, not just immediate autonomy.

Informed Consent & Proxy Consent

Informed consent is the process of providing the patient or, in the case of a minor or incompetent adult, the custodialparent or legalguardian with relevant
information regarding diagnosis and treatment needs so that an educated decision regarding treatment can be made by the patient or custodial parent/legal
guardian
Proxy Consent
Children cannot provide informed consent because they lack the capacity to become fully informed
Consent is assigned to another person (proxy)
basis: supposition that the “proxy” will decide for the patient’s best interest
Two Types of Proxy Consent:
1) Power of attorney to consent to medical care
usually used by patients who want medical care but are concerned about who will consent if they are rendered temporarily incompetent by the medical care
It can delegate the right to consent to a specific person

2)Living will

Proxy Consent Form:

name and date of birth of pediatric patient;
name, relationship to patient, and legal basis for adult
to consent on behalf of minor;
treatment, alternatives, and risks;
potential adverse sequelae specific to the procedure;
an area for the patient or parent/guardian to indicate all questions have been asked;
signature lines for the dentist, parent or legal guardian, and a witness.

Parental Consent
means that you will need to get permission from a parent if you are under a certain age, usually 18

Parental Notification
means that you will have to tell a parent if you are under a certain age, usually 18, but you don't need their permission.
Goals of Parental Consent:
It includes the development of the patient's comprehensive understanding of the clinical situation, and the timely exercise, by the patient, of active choices
regarding the circumstances

The doctrine of informed consent reminds us to respect persons by fully and accurately providing information relevant to exercising their decision-making
rights.

Provision of information
Assessment of the patient's understanding of the above information.
Assessment, if only tacit, of the capacity of the patient or surrogate to make the necessary decision(s).

Assurance,that the patient has the freedom to choose among the medical alternatives without coercion or manipulation.
Parental consent may refer to:
1.MedicalTreatment
A parent's right to be informed, before their minor child undergoes medical treatment.
2.Body Modification
A parent's right to give consent before their minor child undergoes this procedure such as piercing or tattooing.
3. Marriage
A parent's right to consent to their minor child marrying before he or she reaches marriageable age.
4. Education
A parent's right to be involved in their minor child's education, including the right to approve or disapprove of certain curricula, or to consent to extracurricular
activity and field trips.
Parental Permission and Shared Responsibility:
Decision-making involving the health care should flow from responsibility shared by physicians and parents.

Doctors should seek the informed permission of parents before medical interventions (except in emergencies when parents cannot be contacted).
Usually, parental permission articulates what most agree represents the ``best interests of the child.''
Healthcare providers of children have to carefully justify the invasion of privacy and psychological disruption that come with taking legal steps to override
parental prerogatives
Assent of the Patient
Decision-making involving the health care of older children and adolescents should include, to the greatest extent feasible, the assent of the patient as well as
the participation of the parents and the physician.
Pediatricians should not necessarily treat children as rational, autonomous decision makers, but they should give serious consideration to each patient's
developing capacities for participating in decision-making

Assent should include at least the following elements:

Helping the patient achieve a developmentally appropriate awareness of the nature of his or her condition.
Telling the patient what he or she can expect with tests and treatment(s).
Making a clinical assessment of the patients understanding of the situation and the factors influencing how he or she is responding (including whether there is
inappropriate pressure to accept testing or therapy).
Soliciting an expression of the patient's willingness to accept the proposed care. In situations in which the patient will have to receive medical care despite his
or her objection, the patient should be told that fact and should not be deceived.
THE PATIENT'S REFUSAL TO ASSENT (DISSENT)
There are clinical situations in which a persistent refusal to assent (ie, dissent) may be ethically binding. This seems most obvious in the context of research
(particularly that which has no potential to directly benefit the patient).
Medical personnel should respect the wishes of patients who withhold or temporarily refuse assent in order to gain a better understanding of their situation or
to come to terms with fears or other concerns regarding proposed care.
Coercion in diagnosis or treatment is a last resort.

AAP “Informed Consent, Parental Permission, and Assent in Pediatric Practice (1995)
“Thus “proxy consent” poses serious problems for the pediatric health care provider. Such providers have ethical and legal duties to their child patients to
render competent medical care based on what the patient needs, not on what someone else expresses…The pediatrician’s responsibility to his or her patient
exist independent of parental desires or proxy consent.”
Ordinary and Extraordinary Means to Prolong Life
1. Physicians and moralists often use the terms ordinary means and extraordinary means with different connotations. Physicians use these
terms insofar as the means to prolong life is standard and accepted or experimental and unproved. Ethicists, conversely, look to the way in
which the therapy will affect the person’s ability to function at the spiritual level of human potential.
2. Although the physician has the expertise and the right to make decisions concerning the usefulness or medical effects of some particular
medical procedure, the patient has the right to determine whether a particular medical procedure is ordinary or extraordinary from an
ethical viewpoint.
3. If the means in question are determined to be ordinary from an ethical viewpoint, then they must be employed; if extraordinary, they may
or may not be employed.
Newborn Screening: The practice of testing every newborn for certain harmful or potentially fatal disorders that are not otherwise apparent at birth
Procedure:
Blood sample: at least 24 hours after delivery
Obtained by pricking the baby’s heel (Guthrie spot)
Dried on a special paper
Sent to the Newborn Screening Program for testing
Importance:
Metabolic disorders - Phenylketonuria, galactosemia
Hormonal disorders - Congenital adrenal hyperplasia, hypothyroidism
Genetic disorders - Cystic fibrosis, Duchenne muscle dystrophy
Transplacental infections - HIV, congenital toxoplasmosis
Principles:
1. Identification of the genetic condition must provide a clear benefit to the child
2. a system must be in place to confirm the diagnosis
3. treatment and follow-up must be available for newborns affected with the condition
Ethical Issues:
Voluntary
- proxy consent of parents
- authority of parents over their child
Mandatory

- explicit refusal of parents

- society’s obligation to promote child welfare
Voluntary vs. mandatory
informed consent
provide parents with adequate information on the risks and benefits of screening programs
Risk-benefit issues
- benefit of early detection & intervention

- for conditions with no known cure: risk of subjecting the child to treatment that are of no value or even harmful
Newborn Screening Act of 2004:
The state shall institutionalize a newborn screening program that is comprehensive, integrative and sustainable.
Objectives:
-health practitioners are aware of the advantages of newborn screening and of their respective responsibilities in offering newborns the opportunity to undergo
newborn screening
-To ensure that parents recognize their responsibility in promoting their child’s right to health and full development
Provisions:
Health care providers should inform the parents or guardian of the nature and benefits of newborn screening prior to delivery
Screening must be done after 24 hours but not later than 3 days after delivery

Patients that need to be placed in the ICU: before 7 years of age

DOH is responsible for continuing education and training of health personnel on the risks, benefits and procedure of newborn screening

DOH shall require healthcare institutions to provide newborn screening services as a condition for licensure and accreditation
CONGENITAL ANOMALIES
are a major cause of stillbirths and neonatal deaths, but they are perhaps even more important as causes of acute illness and long-term morbidity.

refer to structural defects, chromosomal abnormalities, metabolic errors and hereditary disease present at birth.
MONGOLISM (Down’s Syndrome)
Affected child would be severely retarded

May lead a life without pain or discomfort and without being aware that he is even handicapped à family and the community suffer more than the individual
PHENYLKETONURIA
Disorders of amino acid metabolism

An autosomal recessive genetic disorder characterized by a deficiency in the enzyme hepatic phenylalanine hydroxylase.

Cause problems with brain development, leading to progressive mental retardation, brain damage, and seizures.
CLEFT PALATE AND CLEFT LIP
congenital deformity caused by abnormal facial development during gestation.

may cause problems with feeding, ear disease, speech and socialization.
TO TREAT OR NOT TO TREAT?
“There is no ethical problem in offering, and indeed there is an obligation to provide, comprehensive treatment to handicapped infants and children, who,
without treatment, would still live and whose lives can be made better by skilled treatment.”
Christian Principles:
Inviolability of life; Stewardship; Nonmaleficence; Beneficence; Justice
Inviolability of life:
All human life from the moment of conception and through all the subsequent , is sacred.

It is a gift of GOD and the fruit of love.

The principle recognizes that death is a natural end of life and biological life is not the highest value.
Stewardship:
Man has dominion over God’s creations: himself, other creatures and environment.

Man must take care and cultivate creatures within the creature’s innate nature and teleology and within man’s knowledge and understanding
Nonmaleficence:
One should not do and risk harm

A healthcare giver should do no harm. Harm are providing incompetent care, disrespecting dignity etc.
Beneficence:
One should prevent or remove harm or risk of harm, do good, provide a benefit.

One condition that require one to perform a beneficent act is:

THE ACTION IS NEEDED AND LIKELY TO SUCCEED

Justice:
Justice is both a principle and a virtue relating to the rightness on people’s interactions and relationships.

One should give one another what is due.

i
Transcribed by Aubrey Del Rosario B2012
INFERTILITY & NEW REPRODUCTIVE TECHNOLOGIES

Respect for Life:

2258 “Human life is sacred because from its beginning it involves the creative action of God and it remains for ever in a special relationship with the Creator, who is
its sole end.”
Life begins at the moment of fertilization.

Nonmaleficence:
Do no harm
“I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them.”
– Hippocratic Oath
[It is the obligation not to harm people, intentionally, directly, physically, mentally and their own interest.]

Beneficence:
Do good
Goes beyond non-maleficence
[The obligation to help others further their interests when we can do this without risk to ourselves. It is also the obligation to regard the welfare of others as they attempt
to fulfill their plans.
Beneficence goes beyond non-maleficence that if you cannot do good, at least do no harm.]

Respect for Others:

The human person ought to be respected always
We do this through the application of bioethical principles
We are all made in the image and likeness of God.
Reverence, esteem, and recognition of the person
Sacrament of Marriage:
Unitive and Procreative aspects
“The unity of procreation is destroyed if any element of natural procreation is replace by a reproductive technique or performed by a third party.”
[A technique can be morally acceptable only if it does not replace but merely “facilitates the conjugal act or helps it reach its natural objectives.”]
----
Infertile Couple
Infertility: Biological inability of a man or a woman to contribute to conception
Age of the Female Contraceptive-free intercourse

Under 35 years old 12 months

Over 35 years old 6 months

The male is incapable of fertilizing the egg.

The female is incapable of carrying a pregnancy to term.

Therapeutic Options:
Artificial Insemination
In Vitro Fertilization
Embryo Transfer
GIFT
TOT
Surrogate Motherhood
Reminder! Marriage = Union + Procreation

Artificial Insemination
•Sperm is placed into a female’s uterus or cervix using artificial means rather than by natural sex
•Collection of specimen: MASTURBATION
•Artificial Insemination by a Donor (AID)
•Artificial Insemination by the Husband (AIH)

Artificial Insemination by a Donor (AID):

•Placement of sperm into the uterus or cervical canal that is from a man other than a woman's husband

Artificial Insemination by the Husband (AIH):

Placement of sperm from the husband into the uterus or cervical canal of his wife
From the husband to the wife

Ethical Considerations:
When the marital act of sexual intercourse is not able to attain its procreative purpose, assistance that does not separate the unitive and procreative ends of the act,
and does not substitute for the marital act itself, may be used to help married couples conceive.
Method of collection
Masturbation
“The Church, in the course of a constant tradition, and the moral sense of the faithful have been in no doubt and have firmly maintained that masturbation is an
intrinsically and gravely disordered action.”
Unity + Procreation
Marriage act is aided, not substituted
Method of collection

In Vitro Fertilization
“Test tube babies”
Union of sperm and egg outside the body (petri dish)
Complex and delicate procedure
Timing: key to a successful IVF
Mature eggs must be retrieved
Woman must be hormonally prepared to accept the embryo

Laparoscopy: most common way to retrieve eggs

Needle guided by ultrasound can also be used

Procedure:
1.Insertion of the laparoscope into the incised abdomen (needle into the vagina)
2.Through a second incision, follicles are punctured using a double aspirating needle
3.Aspiration of fluid and maturing eggs
4.Determination of presence of eggs
Sort out and discard any damaged or malformed eggs
5.Recovered eggs are placed in petri dish in a nutrient solution
6.Incubation
4 to 8 hours to begin cell division
For males
Sperm are separated from the seminal fluid, washed and concentrated by centrifugation
Incubation in a tube for 1 hour
Most active sperm are used for fertilization

7.Droplets of the incubated eggs are placed in separate petri dishes

8.Few drops of highly concentrated sperm are pipetted onto each dish
9.Mixture is replaced in the incubator
10.Resulting embryo is introduced into the uterus using a catheter

Embryo Transfer:
Transfer of a developing fertilized egg before implantation from one woman to another
A woman is artificially inseminated by the sperm of the recipient’s husband
Lavage
Technique used to remove the embryo
Flushing the uterus with a solution introduced and recovered through a catheter

Originality of Human Procreation:

The various techniques of artificial reproduction, which would seem to be at service of life and which are frequently used with this intention, actually open the door to
new threats against life. [-John Paul II]

The evaluative ethical criterion must take account of the originality of human procreation, which derives from the originality itself of the human person.
Every means and medical intervention must always be by way of assistance and never substitution of the marriage act.
...Sometimes medical intervention replaces the conjugal act.
Cong.Doct.Faith, Instruct. Donum vitae, February 22, 1987, in AAS 80 (1988) 76

Assisted Procreation Within Marriage:

Homologous In Vitro Fertilization with Embryo Transfer is illicit because conception is not a result of a conjugal act but outside it.
Fertilization takes place outside the body. Child is not born as a gift of love but as a laboratory product.

In Vitro Fertilization: Aggravating Factors

IVF is morally inadmissible because of the circumstances and consequences of its present day practice.
Procured abortions:
-Embryonal losses
-Congealment of suspension of life of the so-called “Spare Embryos”
Intro of at least 4 embryos of which only 1 implants and develops; others are discharged.

Ethical Negativity of Heterologous IVF & Embryo Transfer:

-Recourse to gametes of people other than spouses is contrary to the unity of marriage and the fidelity of the spouses
-These techniques ignore the common and unitary vocation of the partners to become father and mother only through one another

Gamete Intrafallopian Transfer (GIFT)

Eggs are mixed with concentrated sperm, and then the egg-sperm mixture is placed back into the fallopian tube
GIFT vs IVF
 sperm and egg fuse and develop in their natural environment
One- day procedure
Reduction of costs for potential parents

GIFT Procedure:
Hyperstimulation of ovarian follicles
Oocyte retrieval by transvaginal needle aspiration via an ultrasound guide
Oocyte is cultured in a special nutrient
Semen sample is obtained and washed
Sperm is loaded into a special catheter with the eggs
Gametes are injected into the fallopian tubes by laparoscopy
Fertilization
Progesterone supplementation
The patient goes home the same day
Pregnancy test is done 11-16 days later

Policy:
The use of GIFT by marital spouses is not excluded, provided that the following restrictions are observed:
1) the retrieval of ova and sperm must follow a natural act of sexual intercourse;
2) sperm must be collected from that act of intercourse by morally acceptable means;
3) the procedure must be carried out in such a way as to avoid the possibility of extracorporeal conception;
4) any ova collected but not transferred back into the woman’s body must not be fertilized in vitro, with the resulting embryos frozen for later implantation.

Theological Perspective:
Msgr. Carlo Caffarra, head of the Pope John Paul II Institute for the Family in Rome, approved the GIFT procedure in 1985
 with the restriction that sperm are collected during an act of sexual intercourse.
not accepted by all theologians
Rev. Donald McCarthy of the Pope John Center
The conjugal act in the described procedure remains the essential step in getting the ovum and sperm to meet. This step is followed by the repositioning of the ovum
and sperm in a manner which markedly increases the likelihood of fertilization. Hence, GIFT...can be seen as a medical procedure which assists, rather than replaces,
the conjugal act.
[In conclusion, while the GIFT technique uses technology to assist fertilization, it simply re- positions the sperm and ova to enhance the desired outcome of
fertilization. The link between the marital act and procreation is realized by technical assistance. William May contends that this procedure makes the conjugal act
incidental to the achievement of pregnancy in that an act of sexual intercourse is needed only to obtain sperm in a morally acceptable way
Donald DeMarco also contends that these procedures make the conjugal act...incidental to the achievement of pregnancy]

Tubal Ovum Transfer:

Performed when there is a blockage in the fallopian tube
Ova are removed from the ovaries after the use of a hyperovulatory drug, and are injected into the fallopian tube below the blockage.
Couple then engages in intercourse or artificial insemination is performed
Fertilization occur within the reproductive tract
Facilitates easier access for the sperm in the woman’s fallopian tubes
Low sperm count, sperm slow-moving
Most theologians consider the procedure known as TOT to be morally acceptable. This involves transferring the wife's egg beyond a blockage in the fallopian tube so
that marital relations can result in pregnancy
(JOHN HAAS.Faith Facts. "Reproductive Technology." Lay Witness (January/February 2001)

Some bishops and scholars, like Cincinnati’s Archbishop Daniel E. Pilarczyk and Donum Vitae committee members Bartholomew Kiely and Elio Sgreccia, come
down on the side that sees GIFT and TOT or LTOT as aids to natural intercourse and procreation. Therefore they view these methods as morally permissible uses of
reproductive technology.

Surrogate Motherhood
A woman is artificially inseminated with the sperm of a man who is not her husband, but she agrees from the outset to give up any resulting child to the man and,
typically his wife.
1.Commerical
- the surrogate is paid a fee plus any expenses incurred in her pregnancy

2.Altruistic
- the surrogate is paid only for expenses incurred or is not paid at all

Motivation of Surrogate Mothers:

1.Most do it for the money.
2.Many do it in order to deal with past emotional trauma.
3.Some just enjoy being pregnant.
4.Many women cite the altruistic motive of wanting to give a couple “the gift of life”.
 Selfish intensions

Ethical Concerns:
Treats the creation of a person as a means to the gratification of the interests of others, rather the child as an end in himself.

Treats the child as a commodity.

Represents an objective failure to meet the obligations of maternal love, of conjugal fidelity and of responsible motherhood. (Congregation for the Doctrine of the
Faith, “Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation” --Feb, 22, 1987)

Point 2376: Techniques that entail the dissociation of husband and wife, by the intrusion of a person other than the couple are gravely immoral. These techniques
infringe the child’s right to be born of father and mother known to him and bound to each other by marriage. They betray the spouses right to become a father and
mother only through each other.

Directive 42: “Because of the dignity of the child and of marriage, and because of the uniqueness of the mother-child relationship, participation in contracts or
arrangements for surrogate motherhood is not permitted. Moreover, the commercialization of such surrogacy denigrates the dignity of women, especially the poor.”

Adoption
Defined as a socio-legal process of providing a permanent family to a child whose parents have voluntarily or involuntarily relinquished parental authority over the
child.

For children who cannot be reared by their biological parents and who need and can benefit from new and permanent family ties. Adoption provides the same mutual
rights and obligations that exist between children and their biological parents.

It comprises of social work and other professional services that are required in the placement of children in adoptive families.

3 Kinds of Adoption in the Philippines:

Agency adoptions are those in which a licensed adoption agency finds and develops adoptive families for children who are voluntarily or involuntarily committed.
The adoptive families go through the process from application to finalization of the child's adoption under the auspices of the Department of Social Welfare and
Development or a licensed child-placing agency like the Kaisahang Buhay Foundation. Through this type of adoption, the legal rights of the child, the parents who gave
birth to the child and the parents who will adopt the child, are all equally protected.
Family or relative adoptions are those where the biological parents make a direct placement of the child to a relative or a member of their extended family with
whom they relinquish their child.

Private or independent adoptions could either be a direct placement to a family known by the child's biological parents or through the use of an intermediary or a
go-between. In an intermediary placement, an individual knows of parents who want to have their child adopted and arranges such placement to a family or someone
who wants to adopt.

Effects of Adoptions:
Sever all legal ties between the biological parent(s) and the adoptee, except when the biological parent is the spouse of the adopter
Deem the adoptee as a legitimate child of the adopter;
Give adopter and adoptee reciprocal rights and obligations arising from the relationship of parent and child, including but not limited to;
The right of the adopter to choose the name the child is to be known ; and
The right of the adopter and adoptee to be legal and compulsory heirs of each other.
Catholic Principles for Adoption Ethics:
Adopting children can fulfill the gospel command “to love one’s neighbor, through preferential option for the poor”
Adopting children creates families that can fulfill the needs of all members for intimacy, love, and support, thus going beyond “sacrifice” and “fulfillment”.
Adoption is part of a larger social justice picture. It challenges social structures that disrupts families, exploits women and children, and create the necessity for
families with resources to adopt children of families unable to meet basic needs.
Adoption ethics requires the participation and decision making authority of all participants, including birth families, as well as of service providers who can represent
the needs and interests of communities that send childrem to families abroad through international adoption.
Adoption as an anti-abortion Platform
“Give me your children..”- Saint Theresa of Calcutta
Advocacy against new reproductive technology.
Opposition to civil unions of gay couples

Virtues of a Catholic Health Care Giver

Fidelity:
Faithfulness to trust and promise
Fulfilling the promise of the healthcare professional to be a patient advocate
Providing competent care and avoiding conflicts of interests
Avoid using the patient as means to advance one’s power or exploiting a patient in research
Respect the dignity of man
Provide the truth
Obtaining the free and informed consent

Honesty:
Truthfulness and integrity
Telling the patient the truth about the illness, benefits and burdens of alternative actions

Humility:
Recognizing one’s capabilities and limitations
Recognizing the patient as one who knows and should decide what is best for one

Courage:
•Doing what is right without undue fear
Integrity:
•Being true to oneself or wholeness

Justice:
•Constant will to give another his due

•Adjusting what is owed to the specific needs of the person

Compassion:
Feeling for the loss/suffering of another with an attempt beyond obligation to help or avoid that loss/suffering
Being a “friend”