FAQs from the 2012 CMA Annual Conference

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FAQ #2: How does a faithful Catholic physician approach alternate lifestyle choices of patients when they are counter to Catholic teaching? Robert Motley* Lehigh Valley Health Network, Allentown, PA, USA May the Church be the place of God’s mercy and love, where everyone can feel themselves welcomed, loved, forgiven, and encouraged to live according to the good life of the Gospel. And in order to make others feel welcomed, loved, forgiven, and encouraged, the Church must have open doors so that all might enter. And we must go out of those doors and proclaim the Gospel.Pope Francis (2013, emphasis added) For the Catholic physician, developing an approach toward patients whose values and behaviors are at odds with Catholic teaching requires virtue, prayer, knowledge, Christian attitudes, and skills oriented toward respectful dialogue and the invitation to change. A difficult conversation frequently occurs when a doctor must invoke his conscience and not acquiesce to a patient’s request. The circumstances can vary from requests to cooperate with evil—perhaps enabling an immoral lifestyle by prescribing contraceptives or referring for a vasectomy—to issues of honesty, such as prescription fraud or a request to “get out of jury duty” without just cause. In the context of a healthy doctor-patient relationship, the doctor has an opportunity to witness to his faith and to explain why the request “is not good for you.” However, in other situations, there is a real risk of losing the patient. Dr. Edmund Pellegrino stated in his essay “The Catholic Physician in an Era of Secular Bioethics”: “Clearly, both the physician and the patient are responsible moral agents entitled to respect. Neither can impose his or her moral values upon the other” (Pellegrino 2011, 16). Catholic health professionals have the right to follow their consciences, while maintaining respect for the patient’s autonomy. Humans have been given the freedom to make their own decisions. Men and women were created by God with intellect and free will. The human person participates in the light and power of the divine Spirit. By his reason, he is capable of understanding the order of things established by the Creator. By free will, he is capable of directing himself toward his true good…. By virtue of his soul and his spiritual powers of intellect and will, man is endowed with freedom, an “outstanding manifestation of the divine image.” (CCC 1997, nos. 1704–1705) The gift of autonomy is to be complemented by the obligation to make informed choices, according to one’s properly formed conscience. By his reason, man recognizes the voice of God which urges him “to do what is good and avoid what is evil.” Everyone is obliged to follow this law, which makes itself heard in conscience and is fulfilled in the love of God and of neighbor. Living a moral life bears witness to the dignity of the person.” (CCC 1997, no. 1706) Ignorance, pride, and an inclination to sin are common barriers for making wise choices (CCC 1997, no. 418). The Scriptures are filled with God’s invitation to follow Him. Time and again He offers a covenantal relationship with man. When man chooses his own path, it frequently leads to additional suffering, “wandering in the desert” (Ex 16:35), or other negative consequences (see Cain and Abel – Gn 4, Sodom and Gomorrah – Gn 19, David and Bathsheba — 2 Sam). Rarely though does the Lord act without compassion. In the Gospel narratives, Jesus deals compassionately with the woman at the well and with the woman caught in adultery, saying to the latter, “Neither do I condemn you. Go your way, and from now on do not sin again” (Jn 8:11). In the story of the Prodigal Son, the father leaves the door open, hoping that his son will come to his senses—that he is capable of change (Lk 15:11–32). Jesus tells us that “the Son of Man came to seek out and to save the lost” (Lk19:10). Catholic physicians are called to witness to the truth and to share that truth with love and compassion—to hate the sin and to love the sinner. “Those who are well have no need of a physician, but those who are sick; I have come to call not the righteous but sinners” (Eph 4:2). Interactions with patients must go beyond the transactional to the relational. Doctors are called to invite their patients into a trusting relationship rooted in “beneficence”—doing what is in the best interests of the patient. From a practical standpoint, establishing an empathetic connection with a patient can take less than a minute and is possible in almost all clinical settings. Caring doctors do not judge their patients; rather, they engage them. This is frequently sacrificial work—to enter into the wounded life of another—to bring light and healing into a broken existence. “Instructing, advising, consoling, comforting are spiritual works of mercy, as are forgiving and bearing wrongs patiently” (CCC 1997, no. 2447). Disordered lifestyle behaviors frequently stem from thoughts and/or feelings learned earlier in life. The compassionate physician must enter this “feel—think—do” cycle (Glasser 1998) and use his or her skills to process feelings, foster honest rational assessments of behavior, and encourage positive change. Several effective tools have emerged from the fields of psychology and the social sciences. Techniques such as “BATHE” help patients to explore strong emotions that can potentially influence their decisions (Lieberman and Stuart 1999). The Transtheoretical Model of Health Behavior Change (Prochaska and Velicer 1997) outlines processes to assess readiness for change and describes motivational interviewing skills that can guide patients toward the Truth (CCC 1997, no. 2500) and support their commitment to living a better life. Escaping patterns of sin takes time and courage, and patients sometimes falter. It is in this space that patients can be invited to acknowledge their need for Someone greater than themselves. For many, this can be a re-introduction to a spiritual life that has been squeezed out by modern culture. To facilitate this sometimes difficult work, we Catholic physicians must be committed to daily prayer (CCC 1997, nos. 2659–2660) and the practice of virtue (CCC 1997, nos. 1803–1804). Through prayer, Eucharistic adoration, and humble reception of the sacraments, we deepen their own relationship with Jesus, the Suffering Servant (Is 52:13–15). When our patients make wayward decisions, we suffer along with our Savior, as we can sometimes anticipate the negative consequences that will follow. Our Lady of Fatima has asked us to offer prayers of reparation for the sins that offend her Son (Maria Lucia 2006). St. Paul tells us that “suffering produces endurance, and endurance produces character, and character produces hope, and hope does not disappoint us, because God’s love has been poured into our hearts through the Holy Spirit that has been given to us. (Rom 5:3–5). The cardinal virtues of prudence, temperance, fortitude (perseverance), and justice (CCC 1997, nos. 1806–1809) must be practiced, while the gifts of the Holy Spirit (CCC 1997, no. 1831) inspire us and guide us through the difficult conversations we need to have. In some cases, this consistent approach will win over the minds and hearts of our patients. At other times there will be no common ground, and we may need to withdraw from the patient’s care, or the patient may decide to vacate the relationship. Our Lord also had people walk away from Him: “Because of this many of his disciples turned back and no longer went about with Him” (Jn 6:66). Like Peter, we are prompted to affirm, “Lord, to whom can we go? You have the words of eternal life” (Jn 6:68). Catholic physicians have a special calling to minister to the broken members of the Body of Christ. As St. Paul instructs us, “I am now rejoicing in my sufferings for your sake, and in my flesh I am completing what is lacking in Christ’s afflictions for the sake of his body, that is, the Church” (Col 1:23–25). Ours is not a vocation of passivity or avoidance. Entering the suffering and engaging in the battles of patients—spiritual and otherwise—are purifying acts of charity that can help human persons rediscover their dignity, and lead their bodies to better health and their souls to Christ.

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FAQ #3: Is it ethical to perform gastric bypass in an otherwise healthy person who does not want to gain weight and does not want to eat less? Is this comparable to contraception in that it is trying to circumvent nature? Kyle M. Alpha SUNY Upstate Medical University, Syracuse, NY, USA With a prevalence of approximately 35 percent in Americans aged 20 years and older, obesity remains a pressing issue at the forefront of medicine (Ogden et al. 2014, 806). Accordingly, bariatric surgery is increasingly relevant and popular. A recently updated Cochrane review describes bariatric surgery for obesity as “a major surgical intervention” which “aims to reduce weight and maintain any loss through restriction of intake or malabsorption of food, or a combination of these” (Colquitt et al. 2014, 6). The most common bariatric procedures include gastric bypass, sleeve gastrectomy, and adjustable gastric banding, all of which are generally performed laparoscopically. The Roux-en-Y procedure, a common gastric bypass technique, involves isolating a portion of the upper stomach with staples to create a small pouch, which is then anastomosed with the small intestine. Sleeve gastrectomies entail removal of approximately 75% of the stomach volume from along the greater curvature by vertically dividing the stomach. Finally, adjustable gastric bands can be placed around the fundus of the stomach to limit its volume. This procedure is the least invasive of restrictive bariatric procedures and allows for adjustment of the band by addition or removal of saline solution via a small subcutaneous access port. Less common procedures include biliopancreatic diversion, duodenojejunal bypass, and gastric imbrication, among others. Before any ethical evaluation can begin, it seems important to consider the benefits and risks of bariatric surgeries. Since obesity is associated with numerous comorbidities, including hypertension, hyperlipidemia, type 2 diabetes, numerous cancers, and obstructive sleep apnea, its treatment could conceivably benefit patients by reducing the risks of these conditions. Recent medical literature has supported this idea and suggests that bariatric surgery is often an effective treatment for obesity and its comorbidities. For example, a review of seven randomized controlled trials reported that all studies found statistically significant weight change with surgical intervention (Colquitt et al. 2014, 17–21). All studies with type 2 diabetes patients found significantly higher disease remission with surgical intervention when compared to standard therapy or diet alone, and studies examining metabolic syndrome found that surgery significantly decreased its incidence. Effects of surgery on hypertension and lipid levels were less clear, which should be considered when formulating criteria and guidelines for surgical intervention. Risks of bariatric surgery depend on several factors including the type of procedure performed and characteristics of the patient. Generally, adverse events include gastrointestinal reflux, vomiting, nutritional and electrolyte abnormalities, wound infections and other surgical complications, anastomotic leaks or stenosis, bleeding, and a need for reoperation (Maggard et al. 2014, 554–555). A 2009 longitudinal assessment of bariatric surgery patients showed that “incidence of death and adverse events within thirty days after bariatric surgery is low but is varied among different risk groups” and should be considered alongside the competing risk of death from obesity and coexisting health conditions (LABS Consortium 2009, 452). From a purely medical standpoint, bariatric surgery raises a number of important ethical issues, many of which are relevant to any surgery. The principles of beneficence and non-maleficence lead us to question whether the potential benefits for the patient outweigh the accompanying risks. The principle of justice asks us to consider whether the economic cost of these surgeries impairs access for those of lower socioeconomic status, and whether, long-term, they alleviate or further aggravate overutilization of the healthcare system. Finally, the principle of autonomy leads us to ask whether psychological comorbidities, negative societal stereotypes and prejudices, the surgeon’s relationship with industry, or any other factors impair the ability of the patient to give free and informed consent to the surgery. These bioethical questions, as well as several sociological concerns, clearly require consideration and may often depend on the unique circumstances of individual patients (Hofmann 2010, 3–5). Several other ethical questions also arise in cases of childhood bariatric surgery, which will not be examined in this article. From a Catholic perspective, the most pertinent bioethical principle is that of respect for bodily totality and integrity. This principle was alluded to by Aristotle and Thomas Aquinas (Kanniyakonil 2006), and was succinctly stated by Pope Pius XI in Casti Connubii: private individuals have no other power over the members of their bodies than that which pertains to their natural ends; and they are not free to destroy or mutilate their members, or in any other way render themselves unfit for their natural functions, except when no other provision can be made for the good of the whole body. (Pius XI 1930, no. 71) The Ethical and Religious Directives for Catholic Health Care Services provides a practical interpretation of this principle in directive 29: All persons served by Catholic health care have the right and duty to protect and preserve their bodily and functional integrity. The functional integrity of the person may be sacrificed to maintain the health or life of the person when no other morally permissible means is available. (USCCB 2009) Applying this principle to bariatric surgery, one might say that the integrity of a patient’s stomach and gastrointestinal tract may be sacrificed in order to maintain their health “when no other morally permissible means is available.” This would suggest that lifestyle modification (changes in diet and exercise) should be attempted before resorting to surgery. Furthermore, it implies that the surgery must somehow serve to maintain the patient’s health or life. As shown in the previous discussion of common obesity-associated comorbidities, it is often true that surgery will help to maintain health and prolong life in patients with obesity. Based on the potentially life-threatening complications of obesity and the evidence supporting the efficacy of bariatric surgery in the treatment of these conditions, it would seem that bariatric surgery may be permissible in certain circumstances which serve to preserve a patient’s health. It is certainly not intrinsically immoral and, if a physician believes that bariatric surgery is the only remaining option with a chance of preventing or alleviating disease, surgery would be a morally licit option if the other ethically relevant questions mentioned earlier are addressed.

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Alpha is an M.D.-Ph.D. student at SUNY Upstate Medical University in Syracuse, New York. He is currently in the research phase of his program in the department of Cell & Developmental Biology. FAQ #4: Under what circumstances, if any, is the use of oral contraceptive pills as hormonal agents, morally justifiable for indications other than contraception? Patrick Yeung, Jr* Center for Endometriosis, Restorative Fertility Clinic, Minimally Invasive Gynecologic Surgery, Saint Louis University, St. Louis, MO, USA Short Answer The short answer to the question is that, under certain conditions, hormonal agents can be used to treat medical conditions under the principle of double effect. Here, we quote Pope Paul VI in Humanae vitae, number 15: The Church, moreover, does allow the use of medical treatment necessary for curing diseases of the body although this treatment may thwart one’s ability to procreate. Such treatment is permissible even if the reduction of fertility is foreseen, as long as the infertility is not directly intended for any reason whatsoever. (Paul VI 1968) An example of the aforementioned might be the short-term use of hormonal agents to control life-threatening hemorrhage caused by a hormonal imbalance. This quote, however, raises several issues for consideration and discussion that must inform the decision on whether to use hormonal agents for medical reasons, and we will discuss them in three areas here. Are the hormonal agents that I am using only anovulants that reduce fertility, or are other mechanisms of action at play? Hormonal agents are not just anovulants (block ovulation), but can have a significant rate of postfertilization or abortifacient effects. To be clear, if the patient is not sexually active, avoids the fertile time, or is known to be sterile, then there is no moral issue with using hormonal agents, since there is no chance of human embryos being created. However, if a patient is sexually active during the fertile time and has normal fertility potential, then there can be postfertilization or abortifacient (induced loss of a human embryo) effects. Since there is a known failure rate (that is, a known rate of pregnancy) for all hormonal agents, there must be some rate of breakthrough ovulation that raises the possibility of fertilization. Studies have shown that the breakthrough ovulation rate or the suspected rate of postfertilization effects can be significant. The rate of fertilization of intrauterine devices (IUDs) per cycle is estimated to be between 4.1–8.1% for the copper IUD, though the pregnancy rate is 0.1–0.5%. With the levonorgestrel (Mirena) IUD, the fertilization rate is up to 14% per cycle; and with a clinical pregnancy rate of 0.1 per 100 women years, the levonorgestrel IUD is estimated to lead to a 99.9% loss rate of fertilized ova (Stanford and Mikolajczyk 2002). As a result, there is a significant rate of postfertilization or abortifacient effects with IUDs. The rate of breakthrough ovulation with oral contraceptives is between 2 and 40% (2% for high dose combination OCPs and over 40% for traditional progestin-only pills; Milsom and Korver 2008); therefore, again, the rate of postfertilization effects can be significant, especially over time. Is my intention enough to justify the use of hormonal agents, since I do not desire the effect of causing sterility or postfertilization effect? A good intention is necessary but not sufficient to justify any chosen moral object and does not absolve one of the need for a full analysis of the double effect. Put another way, the ends do not (necessarily) justify the means. The pope’s aforementioned statement referring to a permissible, foreseen effect indicates that the principle of double effect is being used to justify the use of hormonal agents for medical indications (Connell 1967). The desired intention is not the only criterion that must be met for to satisfy the principle of double effect. One criterion is that the moral object chosen must be neutral or good (for example, one cannot murder an innocent human life in any situation even to save the life of another). In the case of hormonal agents that mimic a chemical pregnancy for symptomatic relief, the moral object chosen might be considered neutral. Another criterion is that of proportionality, such that the desired effect must be proportional to the undesired effect. Given that hormonal agents can have postfertilization or abortifacient effects at a significant rate (especially over time), the desired effect must be proportional to the likely loss of human embryos from hormonal agents. As in our aforementioned example, using hormonal agents (in the short term) for life-threatening hemorrhage might be justified, but the (long term) use of hormonal agents for a less serious condition such as acne would not be justified. Is there some other treatment that can be used, especially one that is treating underlying diseases of the body? Often, the use of hormonal agents for medical indications—such as pain or abnormal bleeding—are symptomatic treatments at best, and should not be considered first-line treatment. There may be other treatments that make unnecessary the use of hormonal agents, which often only treat the symptoms and not the underlying cause. One example is polycystic ovarian syndrome or PCOS. Hormonal agents may produce “regular cycles,” but they are actually inducing regular withdrawal bleeds and not regular cycles with ovulation. Also, often the most common side effect of hormonal contraceptives is abnormal bleeding (so that hormonal suppression for abnormal bleeding actually may cause what it is trying to treat or make the situation worse), which has led to many different regimens. Finally, patients may feel better with hormonal agents, but this treatment does not remove the disease, and of course does not treat infertility. Hormonal agents are often used without an adequate evaluation of the underlying causes.1 The routine use of hormonal agents for abnormal bleeding and pelvic pain are good examples. Regarding abnormal bleeding, a study showed that antibiotics reduced the rate of abnormal bleeding in those at risk for endometritis (60% vs. 29%) (Eckert et al. 1004). Regarding using hormonal contraceptives to treat pelvic pain, endometriosis is a prime example. Hormonal suppression (in the form of birth control pills or gonadotropin-releasing hormone agonist injections) are symptomatic relief as best, and usually only for the time that they are used. There is a well-documented delay in the diagnosis of endometriosis of up to 12 years, especially for younger women and adolescents (Nnoaham et al. 2012; Hadfield et al. 1996; Arruda et al. 2003). This is partly due to the use of hormonal suppression as both a diagnostic tool and as a form of treatment. However, recently, several investigators have pointed out that the status quo is not adequate for women and have advocated for earlier intervention (Brosens, Gordts, and Benagiano 2013). Regarding diagnosis, a positive response to hormonal agents is not diagnostic (Jenkins, Lui, and White 2008). Traditionally, it was presumed that women who felt relief from pelvic pain while on hormonal suppression had endometriosis. However, we now know that the lack of response to hormonal suppression when taken for pain almost guarantees having endometriosis, especially among adolescents (McNamara 2012). The American College of Obstetrics and Gynecology (ACOG) states clearly: “It is important to explain to patients that response to empiric therapy does not confirm the diagnosis of endometriosis” (ACOG 2010; italics added). Regarding treatment, the use of hormonal suppression does not remove the disease, does not prevent progression or recurrence, and does not improve fertility. One of the presumptive uses of hormonal suppression is to prevent progression of disease, with or without surgery. However, studies have indicated that the rate of recurrence after ablation of endometriosis is about the same whether or not postoperative hormones are used (Doyle, Missmer, and Laufer 2009). Furthermore, the need for birth control pills (earlier and for a longer time period) in the adolescent years, can be a marker for more advanced disease when diagnosed later in life (Chapron, Lafay-Pillet, et al. 2011; Chapron, Souza, et al. 2011), which implies that birth control pills are not very good at preventing progression. Finally, temporary hormonal suppression has been tried as an attempt to improve future fertility. It was thought that suppressing endometriosis now could be helpful in improving fertility potential later. However, this has not been shown to be true, and temporary hormonal suppression of endometriosis is not recommended to improve fertility (Falcone and Lebovic 2011). Clearly, the status quo of hormonal suppression—which is the standard way to treat adolescents and women with pelvic pain—is suboptimal medicine. We can and need to do better for women with endometriosis. Early diagnosis and optimal laparoscopic excision have the potential to eradicate disease (Yeung et al. 2011a; Yeung et al. 2011b), or at least to minimize the recurrence rate. Still, further research and better therapies are needed (Rogers et al. 2009). In Summary Medical treatment with hormonal contraceptives that cures diseases (and for significant indications), even with an undesired but foreseen effect of causing sterility, can be used under the principle of double effect. Hormonal agents, however, which can have significant postfertilization or abortifacient effects, often do not meet this criterion. They are often used for relatively minor indications, as long-term treatment, and in situations where other treatments should be considered first. Germain Grisez offers this rule of thumb: Might it be considered malpractice to not prescribe the hormonal agent, meaning could someone argue that you could have saved a life or avoided a life-threatening situation by using the hormonal agent? If so, then the use of the hormonal agent might be considered justifiable (Grisez 1997, 310–311). Overall, perhaps there is a need to reframe the dialogue. We should neither focus on the prohibition against contraception nor presume that hormonal agents are the best for women, but rather focus on what is best way to evaluate and treat the underlying disease. Catholic teaching as it pertains to medicine should not be seen as limiting but as a real application of Truth and Beauty as designed by the Creator. A fundamental paradigm shift is needed where Catholic teaching in medicine focuses away from what cannot be done, to what can be done in a cooperative and restorative fashion. Note 1. Philosophically, good ethics should make for good medicine. It does not make sense that a treatment that is abortifacient, or that goes against God’s design for us, should be the best way to care for women.

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