Issues at the end of life. The revised Ethical and Religious Directives discuss suicide, euthanasia, and end-of-life procedures

Part 5 of the Ethical and Religious Directives for Catholic Health Care Services reminds us that death is necessary for the transition to eternal life. Thus, although Christians have a duty to preserve worldly life, a gift from God, that duty is not absolute. Suicide and euthanasia are never morally acceptable. On the other hand, life-prolonging therapy need not be used if it provides insufficient benefit or imposes an excessive burden. Directive 55 describes the comfort and care that should be given to dying patients. Directives 56 through 59 discuss the ethical norms for either using or forgoing procedures designed to prolong life. Directive 60 repeats the Church's teaching in regard to euthanasia and physician-assisted suicide (PAS)--that is, whatever the intentions of those who employ them, euthanasia and PAS remain forms of murder. Directive 62 considers the methods used to determine that death has occurred. Directive 66 encourages patients to donate their organs and bodily tissue after death. However, the directive says, Catholic healthcare facilities should not make use of tissue obtained by direct abortions.     

Safeguarding patients' dignity. The revised directives discuss spiritual and professional considerations

The Catholic health ministry recognizes that caring for the spiritual nature of a person is a high priority. The rights of patients and residents in their relationship with care givers are also important. These topics are treated in Parts 2 and 3, respectively, of the Ethical and Religious Directives for Catholic Health Services. This article focuses on those directives. Directive 10 says pastoral care should be available to all persons in a Catholic healthcare facility, no matter their religious affiliation. Directives 12 to 20 are concerned with the reception of the sacraments of baptism, penance, anointing, and communion by Catholics. Directive 21 discusses the appointment of priests and deacons to the pastoral care staff. Directive 23 reminds care givers that respect for human dignity must inform all Catholic healthcare. Directives 24 and 25 discuss norms for responding to advance directives and the responsibilities of surrogates. Directives 26 to 28 are concerned with free and informed consent on the part of patients and surrogates. Directives 29 to 30 say care givers have a moral obligation to preserve a patient's anatomical and functional integrity. Directive 31 discusses the ethical limits on medical research, and Directive 33 discusses therapeutic procedures likely to harm the patient. Directive 34 says care givers must protect patients' privacy. Directive 36 discusses the care of women who have been raped, including treatment that would prevent ovulation as a result of the rape. Directive 37 says ethical consultation should be available to all Catholic facilities, usually through an ethics committee.     

Attitudes of adolescent males toward abortion, contraception, and sexuality

Younger males appear to be reassessing their roles in preventing unwanted conception. This article reports the findings of a study of the attitudes of 1,017 younger men toward pregnancy, family planning, and sexuality. A questionnaire was used over a 2-year period, administered before educational sessions conducted by the Planned Parenthood Association of the Chicago Area.     

The morality of assisted reproduction and genetic manipulation

The author analyzes the pros and cons of various forms of assisted reproduction, including the use of so-called 'genetic manipulation'. He shows how in ethics the only arguments with any chance of reaching a consensus (or at least an agreement) are those of the rational type, based on universally acceptable ethical principles or corroborated by empirical facts and real life experience (as the starting point for identifying problems requiring analysis). After an analysis in which he identifies the incoherence and inconsistency of arguments against assisted reproduction, the author defends the right of human beings to decide autonomously about the most healthy forms of procreation, including those involving genetic manipulation. His starting point is the moral principle by which it is morally preferable to intervene in natural processes (as opposed to not intervening) whenever this implies preventing and reducing disease and suffering.     

Interpreting Advance Directives: Ethical Considerations of the Interplay Between Personal and Cultural Identity

In many industrialized countries ethicists and lawyers favour advance directives as a tool to guarantee patient autonomy in end-of-life-decisions. However, most citizens seem reluctant to adopt the practice; the number of patients who have an advance directive is low across most countries. The article discusses the key argument for seeing such documents as an instrument of self-interpretation and life-planning, which ultimately have to be interpreted by third parties as well. Interpretation by third parties and the process of self-reflection are conceptually linked by a qualitative concept of identity. Identity is conceived here as constructed in a processual dialogue between a personal and a cultural perspective. How the cultural dimension comes into play in understanding the motivation, rejection or content of wished for end-of-life-decisions, is shown by a brief review of empirical and cultural studies. Understanding advance directives as a culturally embedded tool of self-interpretation should help to overcome urgent moral problems in clinical settings: how to interpret such documents, how to deliberate on the content and on the best form.

If,when, and how to discuss available abortion services in the primary care setting

Many women prefer to receive abortion care with their primary care provider; yet, prior studies have suggested that women do not know or assume that their provider does not offer abortion care. Our objective was to explore if, when, and how women wish to be informed of available abortion services at their primary care clinics. We conducted interviews with 21 women at their primary care site during June–July 2014. Vignettes were used to identify clinic visit types in which information regarding abortion services would be welcome and appropriate and inappropriate ways for providers to inform patients of these services. All participants were open to provider-initiated discussion of available abortion services, particularly during women’s wellness exams or contraception visits. Themes associated with appropriate communication of abortion services included: 1) using sensitive language, 2) respect for and assessment of patient beliefs, and 3) contextualizing abortion services within reproductive health. Advantages to discussing available abortion services included strengthening the patient-provider relationship and improved awareness of the spectrum of services offered. Routine inclusion of abortion services counseling may help educate patients about available services, strengthen the patient-provider relationship, and reduce the stigma surrounding abortion care.     

Creating children: The medical and social dilemmas of assisted reproduction

This paper addresses two main issues: first, the separation of sexual fulfillment from the procreation of children; second, of those who achieve parenthood through assisted conception programmes, how have they experienced the process of infertility through to pregnancy and parenthood. The data reported raise questions about legislation and provide insights of use in infertility counselling.     

Choice of the levonorgestrel intrauterine device,etonogestrel implant or depot medroxyprogesterone acetate for contraception after aspiration abortion

ObjectiveWomen who have abortions are at high risk of contraception discontinuation and subsequent unintended pregnancy. The objective of this analysis was to identify factors associated with choice of highly effective, long-acting, progestin-only contraceptive methods after abortion.Study designWomen presenting for surgical abortion who selected the levonorgestrel intrauterine device (IUD), the progestin implant or the progestin injection (depot medroxyprogesterone acetate or DMPA) as their postabortion contraceptives were recruited to participate in a 1-year prospective cohort study. We used multivariable multinomial logistic regression to identify factors associated with choosing long-acting reversible contraceptives (IUD or implant) compared to DMPA.ResultsA total of 260 women, aged 18–45 years, enrolled in the study, 100 of whom chose the IUD, 63 the implant and 97 the DMPA. The women were 24.9 years old on average; 36% were black, and 29% were Latina. Fifty-nine percent had had a previous abortion, 66% a prior birth, and 55% were undergoing a second-trimester abortion. In multivariable analyses, compared with DMPA users, women who chose the IUD or the implant were less likely to be currently experiencing intimate partner violence (IPV); reported higher stress levels; weighed more; and were more likely to have finished high school, to have used the pill before and to report that counselors or doctors were helpful in making the decision (all significant at p<.05, see text for relative risk ratios and confidence intervals.) In addition, women who chose the IUD were less likely to be black (p<.01), and women who chose the implant were more likely to report that they would be unhappy to become pregnant within 6 months (p<.05) than DMPA users.ConclusionA variety of factors including race/ethnicity, past contraceptive use, feelings towards pregnancy, stress and weight were different between LARC and DMPA users. Notably, current IPV was associated with choice of DMPA over the IUD or implant, implying that a desire to choose a hidden method may be important to some women and should be included in counseling.ImplicationsIn contraceptive counseling, after screening for IPV, assessing patient’s stress and taking a history about past contraceptive use, clinicians should discuss whether these factors might affect a patient’s choice of method.     

Technology assessment and knowledge brokering: the case of assisted reproduction in The Netherlands

OBJECTIVES: Even when policy makers show interest and evidence-informed and convincing HTA studies are available, use of assessment products is not guaranteed. In this article, we report our experience with knowledge brokering to foster evidence-informed policy making on cost-effective treatment and reimbursement of assisted reproduction in The Netherlands. METHODS: From earlier work in the field of knowledge brokering, we foresaw the need for a deliberative strategy to manage the inherent tension between scientific rigor demanded by researchers and responsiveness to real-time needs demanded by policy makers. Therefore, we structured the process in three distinct steps: (i) agreement about the main messages from the research, (ii) analysis of the policy context and of the meaning of the main messages for the actors involved, and (iii) an invitational meeting to make recommendations for action. RESULTS: One of the recommendations that would require changes in ministerial policy was followed up instantly, whereas the other recommendation is still under debate. The Dutch Society of Obstetrics and Gynecology activated the revision of two guidelines. The patient organization uses the new scientific insights in informing members and the public. Closing the loop, The Netherlands Organisation for Health Research and Development (ZonMw) funded research to close knowledge gaps that became apparent in the process. CONCLUSIONS: Knowledge brokering is a promising approach to bring HTA into practice. We conclude that the methodologies to feed research results into the policy process are still in an incipient stage and need further development.     

Adolescence and contraception: 1. A study knowledge and use among women hospitalized for childbirth or abortion

A study of the knowledge and utilization of contraceptive methods by adolescent is presented. An analysis was carried out based on data collected from interviews with and recorded case histories of 78 puerperal adolescents (childbirth or abortion), assisted by an obstetric service in the county of Cotia, SP, Brazil, between May 1 and July 31, 1986. Of all the adolescents studied, 61.5% had some knowledge of contraceptive methods; the findings showed that such knowledge was influenced by factors such as: age, school background, parity and marital status. The main sources of information on contraception were: friends, relatives and partners, in this order; those least sought for in this regard were health professionals. Only one in each ten adolescents made use of some contraceptive measure, the most prevalent methods being the contraceptive pill, the Ogino-Knauss method, condoms and coitus interruptus. In all of the cases of the utilization of these methods the same had been "recommended" by persons belonging to the adolescents' social group, and had been acquired in shops, without any health control.     

The Supreme Court, abortion, and the jurisprudence of class.

The US Supreme Court's decision in Planned Parenthood of Southeastern Pennsylvania v Casey both protects a woman's liberty to choose to terminate her pregnancy and permits the state to make it more difficult for her to exercise her choice. In their opinion on the case, Justices O'Connor, Kennedy, and Souter eloquently defend constitutional protection of the right to make intimate decisions like continuing or ending a pregnancy. At the same time, they permit the state to try to persuade pregnant women not to have abortions and to make abortion harder to obtain and more costly, as long as the state's methods do not create an "undue burden" on the decision. Any restriction on abortion is a burden; whether it is "undue" (and therefore unconstitutional) depends on one's circumstances. The Court appears to view the difference between an undue burden and mere inconvenience from the perspective of privilege. The restrictions that were upheld may not significantly affect middle-class access to abortion, but they could prove insurmountable for many less privileged women.     

Dutch Institute for Health Care Improvement revised guideline, 'Sexually transmitted diseases and neonatal herpes'

The Dutch Institute for Health Care Improvement revised guideline, 'Sexually transmitted diseases and neonatal herpes' summarises the current scientific position on the diagnosis and treatment of a great number of sexually transmitted diseases (STD) and neonatal herpes. Symptomatic treatment of suspected Chlamydia trachomatis infection and gonorrhoea without previous diagnosis is not recommended. Treatment can be started immediately, once samples have been taken. Risk groups eligible for screening or proactive testing on C. trachomatis infection include: partners of C. trachomatis-positive persons, visitors of STD clinics, women who will undergo an abortion, mothers of newborns with conjunctivitis or pneumonitis, young persons of Surinam or Antillean descent, young women with new relationships and individuals whose history indicates risky sexual behaviour. A period of 3 months can be adopted between a risky contact and the HIV test (this used to be 6 months), unless post-exposure prophylaxis was used. For the treatment of early syphilis no distinction is drawn between HIV-infected and non-HIV-infected persons. It is no longer recommended that women in labour with a history of genital herpes are tested for the herpes simplex virus. Virological testing of the neonate is only advised if the mother shows signs of genital herpes during delivery.     

Ethical, religious and factual beliefs about the supply of emergency hormonal contraception by UK community pharmacists

BACKGROUND AND METHODOLOGY: Community pharmacists' role in the sale and supply of emergency hormonal contraception (EHC) represents an opportunity to increase EHC availability and utilise pharmacists' expertise but little is known about pharmacists' attendant ethical concerns. Semi-structured qualitative interviews were undertaken with 23 UK pharmacists to explore their views and ethical concerns about EHC. RESULTS: Dispensing EHC was ethically acceptable for almost all pharmacists but beliefs about selling EHC revealed three categories: pharmacists who sold EHC, respected women's autonomy and peers' conscientious objection but feared the consequences of limited EHC availability; contingently selling pharmacists who believed doctors should be first choice for EHC supply but who occasionally supplied and were influenced by women's ages, affluence and genuineness; non-selling pharmacists who believed EHC was abortion and who found selling EHC distressing and ethically problematic. Terminological/factual misunderstandings about EHC were common and discussing ethical issues was difficult for most pharmacists. Religion informed non-selling pharmacists' ethical decisions but other pharmacists prioritised professional responsibilities over their religion. DISCUSSION AND CONCLUSIONS: Pharmacists' ethical views on EHC and the influence of religion varied and, together with some pharmacists' reliance upon non-clinical factors, led to a potentially variable supply, which may threaten the prompt availability of EHC. Misunderstandings about EHC perpetuated lay beliefs and potentially threatened correct advice. The influence of subordination and non-selling pharmacists' dispensing EHC may also lead to variable supply and confusion amongst women. Training is needed to address both factual/terminological misunderstandings about EHC and to develop pharmacists' ethical understanding and responsibility.