Under the ethical principles of respect for persons, beneficence and nonmaleficence this procedure is ethical and can be performed in Catholic hospitals.

Respect for persons refers to the right of a person to exercise self-determination and to be treated with dignity and respect. One of the fundamental elements of a physician-patient relationship is the right of a patient to receive information from physicians and to discuss the benefits, risks, and costs of appropriate treatment alternatives. This obligation by physicians includes within the obligation to inform patients of all current medical options available to them for a particular condition. The NovaSure Ablation System is one of various options open to women who are experiencing menorrhagia. Because of the risks and benefits associated with  the other options, the first option should always be the drug therapy option of using estrogen-progestogen combinations or progestogens alone. This therapy is the safest and allows the woman to maintain her fertility. However, if this is unsuccessful then the D & C would be the next step to control the excessive bleeding. This does not provide the patient with long-term definitive results but in combination with the drug therapy it allows women to maintain their fertility. Of the ablation methods, it appears that the NovaSure System is the safest and most effective. It is also a less risky method and a less invasive alternative than a hysterectomy which should be the last option. While the NovaSure System has its risks, they are far less than a hysterectomy which is a major surgical procedure with its accompanying surgical and anesthesia risks and has a lengthy recovery period.  

Birth control is an issue with this procedure. The Ethical and Religious Directive for Catholic Health Care Services state clearly that “Catholic health institutions may not promote or condone contraceptive practices but should provide, for married couples and the medical staff who counsel them, instruction both about the Church’s teaching on responsible parenthood and in methods of natural family planning.”[1] The NovaSure Ablation procedure is for women who have excessive uterine bleeding that can cause serious health problems. Many of the women this effects are celibate women and birth control would not be an issue for them. Married women should be instructed about the dangers of becoming pregnant after the NovaSure Ablation procedure and should be instructed on the proper use of Natural Family Planning (NFP). In good conscience, however, the physician should explain to the women that there are other methods of birth control available to them that may also reduce their chances of becoming pregnant. Patients have a right to be informed about the advantages and disadvantages of any treatment as well as about all viable alternatives. Unless patients are told about the other birth control options available to them, they cannot give informed consent. Giving each person this information does not violate Directive 52 because the physician can clearly state that the Catholic Church only approves of NFP and that if used correctly and consistently it can help the woman avoid possible pregnancies in the future. Failure to give all the options available to protect the health of the woman and her fetus, if the woman should become pregnant, would violate the basic dignity and respect that all persons deserve.

Beneficence involves the obligation to prevent and remove harm to and to promote the good of the person by minimizing possible harms and maximizing possible benefits. Beneficence includes nonmaleficence, which prohibits the infliction of harm, injury, or death upon others. In medical ethics this principle has been closely associated with the maxim Primum non nocere: “Above all do no harm.” After examining the possible options for a woman with excessive uterine bleeding, it appears that the NovaSure Ablation System is both the most effective and the safest of the new generation of endometrial ablation devices. As stated above, drug therapy should be the first treatment option but it is only effective about 50% of the time and usually must be continued in order to remain effective. The D & C procedure can be a second tier option used if drug therapy is ineffective but it is only a temporary solution that reduces bleeding for a few cycles. Conventional endometrial ablation removes the lining of the uterus with an electrosurgical tool or laser and effectively reduces the bleeding in approximately 85% of patients. The risks however include perforation of the uterus, bleeding, infection and even heart failure due to fluids used to open or distend the uterus.[2] The new generation of endometrial ablation devices destroy the endometrium by using either heated fluid or freezing temperatures to destroy the tissue.  These options are intended for women who no longer desire to maintain their fertility.[3] The benefits of the NovaSure Ablation System clearly outweigh these alternative options because it is safer, more effective, less invasive, and does not destroy the endometrium and cause the woman to become sterilized. In addition, prior to other endometrial ablation procedures, patients often need to take a pretreatment drug such as Lupron for 1 to 2 months to thin the lining of the uterus. No pre-treatment drugs are needed with the NovaSure Ablation System.[4]

The only other treatment alternative is a hysterectomy. As stated above, a hysterectomy is a major surgical procedure performed in the hospital under general anesthesia and is associated with the risks and complications of major surgery. Some complications include blood clots, infection, excessive bleeding or an adverse reaction to the anesthesia. Other risks are:

1. Damage to the urinary tract, bladder or rectum during surgery, which may require further surgical repair.
2. Loss of ovarian function.
3. Early onset of menopause[5]

In addition to the hospitalization, depending on the technique used, a recovery period of up to six weeks is not uncommon. By contrast, the pre-clinical, clinical and post-approval data on the NovaSure Ablation System shows this procedure to be more beneficial to women than a hysterectomy. One major advantage over a hysterectomy is that this procedure is a minimally invasive outpatient alternative.  General anesthesia and its possible complications are avoided because the NovaSure procedure is usually done with local anesthesia with or without IV sedation. The NovaSure Ablation System has also been shown to improve the quality of life of those women who have undergone this procedure. In randomized, controlled clinical studies on this procedure a majority of patients had their bleeding reduced to light or moderate periods, and many reported that their bleeding had stopped completely. In addition, many women have experienced significant reduction in painful menstruation as well as meaningful reduction in PMS symptoms.[6] There are certain post-procedure complications that can be associated with this procedure. These include the fact that one can develop a fever, nausea, vomiting, shortness of breath, dizziness, bowl or bladder problems, and/or a greenish vaginal discharge. However, clinical studies have shown these complications to be minimal. Most women can return to normal activities within a day or two of their treatment. Sexual activity can be resumed after the patient’s first check-up, usually 7 to 10 days after the procedure. Surgical risks can be perforation of the uterus, bleeding, infection, injury to organs within the abdomen and pelvis and the accumulation of blood within the uterus due to scarring. Another important risk is that it may decrease the doctor’s ability to diagnose cancer of the endometrium.[7] Despite these possible complication and risks, the clinical data collected to date confirms that the benefits and advantages of the NovaSure Ablation procedure clearly outweigh its risks. By comparison to the other endometrial ablation procedures and a hysterectomy, the NovaSure Ablation procedure is safer, less invasive and more cost effective.  Ethically, the NovaSure Ablation procedure respects the autonomy of the patient by giving the woman a procedure that is safer and more effective and it clearly passes the test of beneficence and nonmaleficence.

Conclusion: The NovaSure Ablation procedure is not only an effective and safe modality in the treatment of patients suffering from excessive menstrual bleeding; it also has a very low complication rate and avoids all endometrial pretreatments. This procedure is accomplished within 90 seconds and can easily be performed under IV sedation and paracervical block anesthesia in an office setting. The medical benefits and the cost effectiveness of this procedure make it a very viable option to a hysterectomy, which under most circumstances is the last option for a woman with menorrhagia. There is the issue that women who undergo this procedure should avoid future pregnancies for their own health and the health of the fetus. However, in many circumstances, particularly with celibate women, this is not an issue. For those who are married, the physician should explain the option of NFP, along with other options to satisfy the ethical principle of informed consent. This should satisfy the birth control issue that concerns some about allowing this procedure in a Catholic health care facility.  Under these circumstances, it appears that the NovaSure Ablation System is not only ethical but should be utilized in Catholic facilities for the good of women suffering from menorrhagia.

[2] Education Department-Novacept, Inc, p. 4.

[3] Education Department-Novacept, Inc, p. 4.

[4] Education Department-Novacept, Inc, p. 2.

[5] Mayo Clinic Staff, “Hysterectomy: Benefits and Alternatives,” Mayo Clinic Health Information, March 15, 2004, pp. 1-5. http://www.mayoclinic.com/invoke.cfm?id=HQ00905

[6] Education Department-Novacept, Inc., p. 4. See also, FDA, “Summary of Safety and Effectiveness Data,” p. 19.

[7] Education Department Novacept, Inc., p. 5.

During the past 20 years, advances in molecular biology and the Human Genome Project have had a tremendous influence on the field of genetics. After centuries of description, we are now on the eve of truly understanding the cellular processes of the human body. Up until the late 1980s, tracing the causes of genetic disease involved time-consuming linkage analysis of families by limited sets of genetic markers. A new age has dawned in the Human Genome Project – the mapping of all our 80,000-100,000 genes and the decoding of our entire DNA sequence of 3 billion base pairs. The Project has tremendously stimulated the development and dissemination of advanced DNA technology, and the first and substantial result has been a spectacular acceleration in finding out the causes of genetic disease. Nearly all common genetic diseases (150-200) and a large number of rarer ones (600-800) have been traced back to one or more defective genes (1500-2000). In most cases, causal mutations have been found, which has delivered a substantial improvement in diagnostic power.

Genetic testing can be done at many different times in one’s life. If parents are concerned they may be at risk to have a child with a genetic disorder, such as Tay Sachs Disease, they may undergo carrier identification testing. Women may undergo prenatal testing to determine whether their fetus has a genetic disorder, such as Downs Syndrome or Cystic Fibrosis. Newborn infants get genetic screening checks for various metabolic diseases, such as phenylketonuria (PKU).  Late-onset disease testing determines if one has a genetic change that increases the risk for developing a disease, such as breast cancer or Huntington’s Disease. Genetic testing can determine whether a person will have a particular reaction towards a drug or medication, thus fostering patient-specific medical treatment.  And forensics uses genetic identification (DNA fingerprinting) to solve crimes or identify a body.

Ethicists are struggling to keep pace with rapid advances in genetic research and technology. Reaching ethical conclusions about the new genetics is challenging for two reasons. First, it is inherently difficult to understand the subtleties of genetics and the wealth of data tumbling out the Human Genome Project. Second, it is almost impossible to foresee accurately the implications and consequences, short-term and long-term, intended and unintended of genetic research and technology.

On the issue of genetic testing for an individual, three ethical principles are relevant:

1. Consent … Genetic information should only be obtained from persons when they have given genuine consent. Consent is genuine when the information has been communicated appropriately and agreement is given freely.
2. Privacy … Every person is entitled to privacy. Privacy in the context of genetic testing can be understood as a person’s right not to be obliged to disclose information about his or her genetic characteristics.
3. Confidentiality … Where an individual has chosen freely to disclose private genetic information, the disclosure should be treated as confidential. This means that genetic information should not be communicated to others or used for new purposes without the consent of the person disclosing the information.

At the level of public policy, the primary focus of debate on genetic testing concerns the use and storage of genetic information. Once genetic information has entered databases, it may be difficult to prevent disclosure or effect its removal. One area of concern is the use of genetic information by insurers. There is the risk of basing decisions on unreliable tests and the possibility of excluding vulnerable groups from obtaining insurance.  Another area of concern is the use of genetic information in the workplace. The availability of such information may subject employees to unfair discrimination. On May 21 2008 Congress passed and the President signed the Genetic Information Non-discrimination Act which provides substantial protection for Americans against discrimination based on their genetic information when it comes to health insurance and employment.

Genetic Research and Testing – Religious Perspectives

A literature search of “religion”, “spirituality” and “genetic counseling” reveals remarkably little information as to how religious values contribute to genetic decisions or the attitudes and behaviors of healthcare providers. Questions of faith and spirituality generally arise in two ways in the genetics arena. The first has to do with the ethical concern that in our use of genetic technologies we are somehow “playing God”; the second encompasses the pastoral issues that accompany genetic testing and decision making, which include grief, suffering and loss.

The charge of “playing God” is often used to suggest that humans, through our genetic technologies, are exceeding the bounds of what we ought to be doing. As medical technology advances, much of what was once attributed to God, such as control over death and life, has been challenged by medical technology. We can now manipulate and sustain life to a considerable degree; as a result, we sometimes find ourselves confused about where our human capabilities and responsibilities end. At its root, the issue of how much one should control human life, disease, death and the genome is a moral question about how we perceive ourselves in the world and in relationship to God. The Judeo-Christian tradition offers a variety of perspectives. In one view, humans are perceived as God’s creation, part of the natural world, and thus subject to the same natural laws as other living things. In another, we stand apart from nature, as “co-creators” with God and made “in the image of God”, and by virtue of our reflective capacities and intelligence, empowered to manipulate nature. These two images often come into play in decisions at the beginning and end of life and are likely to surface in genetic decisions, depending on the decision maker’s personal attitudes, values, goals and beliefs.

Questions of faith and spirituality also arise in the context of genetic testing and decision making. Once the decision is made to go forward with genetic testing, there is always the risk that testing will bring unfavorable results. As in much of medicine, after receiving unexpected and disappointing news, first reactions may include shock, grief, guilt and confusion. Many will attempt to answer the universal questions: “Why me?” “Why now?” “What did I do wrong?” They may turn to their faith to ask, “Why is God doing this to me?” “What should I do now?” “What does God want me to do?” It is not uncommon for people to blame themselves when facing bad news, to assume the diagnosis is a consequence or punishment for some act of stupidity or moral flaw. They may blame God, angry that a supposedly powerful God has let this misfortune occur. Or they may simply be morally and theologically confused, wondering if and how their faith can help them. At such times of spiritual crisis, people often seek the advice and counsel of friends and spiritual advisers. Over time, in the context of their ongoing personal relationship with God, most people of faith ultimately arrive at acceptance and peace. Others struggle with this spiritual conflict all their lives.

RGT (reproductive genetic technology) presents ethical and religious challenges for Judaism, Christianity and Islam because prenatal genetic testing can lead to a decision to abort the fetus. The three monotheistic religions have different views on the beginning of human life and thus their teaching on abortion. For Judaism the fetus gains human status at forty days of gestation, once it is implanted and growing in the mother’s womb. For Islam the fetus gains human status by one hundred twenty days. For Roman Catholicism and Evangelical Christian denominations, human status begins at the moment of conception.

For Judaism and Islam, PGD (preimplantation genetic diagnosis) is an option which avoids fetal termination. This procedure involves screening the fertilized egg in vitro at the very early four-to-eight-cell stage. Many Jewish and Islamic theologians would say that the embryo at this early stage has elements of humanness but has not yet attained human identity. For many couples of these two faiths, PGD is a way to avoid giving birth to a child affected with a genetic condition that is not viewed as an abortion. In contrast, Roman Catholicism and Evangelical Christian denominations are opposed to PGD. From their religious point of view, also shared by Jewish Orthodoxy, avoiding having children with severe genetic conditions must be accomplished through some other means. That means is preconception genetic testing to check whether both members of an at-risk couple carry a single gene copy for the same genetic condition. If they do, adoption is one option.

Despite the official positions of the three monotheistic religions, there are differences of opinion in their members. Most liberal and mainline Protestant as well as liberal Jewish groups are not opposed to abortion and do not hold embryonic life to be sacred. They tend not to be advocates of reproductive genetic technologies, but neither are they opposed.

Despite differences of opinion among religious groups on RGT, religion has served as a prime contributor to discussion of whether and in what context a given application of genetic technology should occur. It serves as a qualitative check on the contention that just because a technology is possible it should be launched into use. The qualitative role implies that religious principles and beliefs are capable of imposing more than just an absolutist stamp on action. They can suggest alternatives based on the type of application envisioned and the circumstances involved. Judaism, Christianity and Islam have all welcome the therapeutic potential of genetic research in the prevention and cure of diseases as long as it does not bring harm to the individual or human society. All three religions look favorably on somatic cell gene therapy, aimed at restoring bodily cells, because it so directly carries forward the ethos of healing. All agree that germ-line gene therapy targeting adult reproductive cells, gametes, and/or early embryos poses overwhelming risks. Errors unintentionally introduced into the genome would be perpetuated into future generations. Beyond safety issues, all share a concern for fairness and equitable distribution of benefits and burdens, particularly for the less well-off. Ongoing dialogue among religious groups will help individuals and human society to face the many challenges presented by genetic research and technology.

References cited:

Evans, J.H., “Religious Belief, Perceptions of Human Suffering, and Support for Reproductive Genetic Technology”, Journal of Health, Politics, Policy and Law, 31: 6, December 2006, 1047-1074

“Evans, J.H. & Hudson K., “Religion and Reproductive Genetics: Beyond Views of Embryonic Life”, Journal of the Scientific Study of Religion, 2007, 46:4, 565-581

Modell, S., “Genetic Reproductive Technologies in the Light of Religious Dialogue”, Zygon, 42:1, 163-181

Parker, M. & Hope, T, “Problem Cases in Medical Ethics”, The Medicine Publishing Company, 2005, 33:2, 22-24

Rosner, F., “Judaism, Genetic Screening & Genetic Therapy”, The Institute for Jewish Medical Ethics, 2008, http://jewishvisuallibrary.org/jsource/Judaism/genetic.html

White, M.T., “Religious and Spiritual Concerns in Genetic Testing & Decision Making”, The Journal of Clinical Ethics, Summer 2006, 158-167

To bridge the transition between the time medical treatment ceases and palliative care begins, I am proposing a Christian ritual that can be used by clergy, pastoral care workers, parish ministers of care, etc., in order to ensure that the fear of abandonment is transformed into the hope of acceptance through the commitment of family and friends. This is a period of time when many in the healing ministry feel helpless in the presence of the suffering patient.  What does one say to a patient when he or she has been told that further medical treatment is useless? Any words that might be spoken at this moment would seem almost hollow. Instead, a sense of aloneness seems to pervade the situation. Many within the healing ministry recognize an emptiness here that needs to be filled. But how can this emptiness be filled and who can fill it? To address this need, I am proposing a “Rite Of Christian Commitment To The Terminally Ill,” which can be administered by anyone in the healing ministry in conjunction with family members and friends of the terminally ill patient.  Ritualizing our Christian commitment to one another enables the bond that holds us faithful to one another, which can be expressed by our willingness to be present to one another, to be revitalized and strengthened.  I believe this ritualization is not only needed but is imperative, especially now when many in our society are advocating physician-assisted suicide as the most humane viable option for the terminally ill.  Unless terminally ill patients know that family and friends are committed to be present to them during the dying process, the option of physician-assisted suicide becomes more of a reality.   

Rite of Christian Commitment To The Terminally Ill

I.  Introductory Rites:

            A. Greeting

                        1. The peace of the Lord be with you always.

                                    R. And also with you.

            B. Instruction:

My dear brothers and sisters, the Lord Jesus, who went about doing good works and healing sickness and infirmity of every kind, commanded his disciples to lovingly care for the sick and dying, to pray for them, and to lay hands on them. In this celebration we shall entrust our sick brothers and sisters to the care of the Lord, asking that he will enable them to bear their pain and suffering in the knowledge that, if they accept their share in the pain of his passion, they will also share in its power to give comfort and strength. We ask this through Christ our Lord. Amen^[i]

II. Liturgy Of The Word

            A. Suggested Readings:

                        Hebrew Scripture                                                      New Testament

                        1. Psalm 23                                                                  1. 2 Corinthians 1: 3-7

                        2. Psalm 71                                                                  2. Romans 8: 31b-35, 37-39

                        3. Job 7: 1-4, 6-11                                                       3. Romans 8: 18-27

                        4. Job 7: 12-21                                                            4. Colossians 1:22-29

                        5. Job 19: 23-27                                                          5. Matthew 5: 1-12 

                        6. Isaiah 35: 1-10                                                        6. Matthew 11: 28-30

                        7. Isaiah 52: 13-53:12                                               7. Luke 12: 22-32       

                        8. Isaiah 61: 1-3                                                            8. John 6: 35-40         

                        9. John 6: 53-58                                                           9. Wisdom 9: 1, 9-18                                                                                                                                         

III. Prayers Of Christian Commitment

 The Pastoral Care member will begin by introducing the individual prayers of Christian commitment with a short prayer calling upon God to give comfort and care to the person who is ill. Then each person present will extemporaneously present a prayer for the person who is ill stating his/her intention to be present to the person who is ill throughout the remainder of their illness. The patient, if possible, will then state his/her intention to allow family and friends to be present to him/her.

 Introduction:

 Jesus came as healer of body and of spirit in order to cure all our ills. He chose to be like us in all things, in order to assure us of his compassion. He bore our weakness and carried our sorrows. He felt compassion for the crowd, and went about doing good and healing the sick.  With trust let us pray to Jesus that he will comfort (N.) with his grace and that he will fill (N.) with new hope and strength.

 Family & Friends:

I pray that Christ will comfort you as you follow him on the path he has set before you. As your (family member/ friend)I promise to walk with you on your journey and that I will be present to you in both word and action. Just as Jesus felt compassion for the crowd, and went about doing good by caring for them, I promise that I will watch over you, that I will be there when you need me, and that I will show you the love of Christ by my very presence. (N.), in the presence of God and your family, I commit myself to you with the love of Jesus Christ.

  Patient:

The patient, in his/her own words, accepts the care and love offered and agrees to allow family and friends and health care professionals to be present to him/her.

 IV. Prayer of Blessing

 All present will extend their hands over the person who is ill and pray the following prayer.  At the conclusion of the prayer each person will trace the sign of the cross on the forehead of the person who is ill.

 Lord, our God, you sent your only begotten Son into the world to bear our infirmities and to endure our sufferings. Look with compassion upon your servant (N.). Give (him/her) strength in body, courage in spirit, and patience in pain.  Support (N.) with your grace, comfort (him/her) with your protection, and give (him/her) the strength to fight against all evil. Since you have given (N.) a share in your own passion, help (him/her) to find hope and consolation in suffering, for you are Lord for ever and ever. Amen

 All: Our Father

 V. Concluding Rite:

 God of mercy, look kindly on your servant (N.) who has grown weak under the burden of illness. Strengthen (him/her) by your grace and help (him/her) to remain close to you in prayer. Fill (him/her) with the strength of your Holy Spirit. Keep (him/her) strong in faith and serene in hope, so that (he/she) may give us all an example of patience, and joyfully witness to the power of your love.

Lord, we ask you to soothe the hearts of the family members and friends of (N.) gathered here today. In your loving kindness enlighten their faith, give hope to their hearts, and peace to their lives.  We ask this through Christ our Lord. Amen.

 Dismissal:

Go in the peace of Christ to serve him in the sick and in all who need your love.

^[1]The Joint Commission of Catholic Bishops’ Conferences, “Order For The Blessing Of Adults,” Book Of Blessings, (New York, Catholic Book Publishing Co., 1989), No.383, p. 165.

The principle of nonmalficence – the duty to do no harm – and the principle of beneficience – the duty to act for the benefit of others – have ancient roots in the code of medical ethics. But truthfulness does not. The Hippocratic Oath does not mention an obligation of truth-telling or disclosure, and until 1980 even the professional code of the American Medical Association did not say anything about dealing honestly with patients. Over the years physicians viewed the truth as something to conceal or reveal in so far as it impacts the therapeutic welfare of the patient. For example, a physician might be reluctant to disclose the diagnosis of cancer to a vulnerable patient if he judges that the truth would be harmful, unsettling and depressing. This paternalistic approach – doctor knows best – is less common today. Now there is more of an emphasis on the principle of autonomy and informed consent.

Contrary to what many physicians have thought in the past, a number of studies have demonstrated that patients do want their physicians to tell them the truth about diagnosis, prognosis, and therapy. For instance, 90% of patients surveyed said they would want to be told of a diagnosis of cancer or Alzheimer’s disease. Similarly, a number of studies of physician attitudes reveal support for truthful disclosure. For example, whereas in 1961 only 10% of physicians surveyed believed it was correct to tell a patient of a fatal cancer diagnosis, by 1979 97% felt that such disclosure was correct.

When physicians communicate with patients, being honest is an important way to foster trust and show respect for the patient. Patients place a great deal of trust in their physician, and may feel that trust is misplaced if they discover or perceive lack of honesty and candor by the physician.

In addition to fostering trust and demonstrating respect, giving patients truthful information helps them to become informed participants in important health care decision. Thus, patients should be told all relevant aspects of their illness, including the nature of the illness itself, expected outcomes with a reasonable range of treatment alternatives, risks and benefits of treatment, and other information deemed relevant to that patient’s personal values and needs. Treatment alternatives that are not medically indicated or appropriate need not be revealed. Facts that are not important to the patients ability to be an informed participant in decision making, such as results of specific lab tests, need not be told to the patient. Also, complete and truthful disclosure need not be brutal; appropriate sensitivity to the patient’s ability to digest complicated or bad news is important.

There are two main situations in which it is justified to withhold the truth from a patient. As noted above, if the physicians has compelling evidence that disclosure will cause real and predictable harm, truthful disclosure may be withheld. Examples might include disclosure that would make a depressed patient actively suicidal. This judgment, often referred to as the therapeutic privilege, is important but also subject to abuse. Hence it is important to invoke this only in those instances when the harm seems very likely, not merely hypothetical.

The second circumstance is if the patient states an informed preference not to be told the truth. For instance, some patients might ask that the physician instead consult family members. In these cases, it is critical that the patient give thought to the implications of abdicating their role in decision making. If they chose to make an informed decision not to be informed, however, this preference should be respected.

Specifically, an out-of-hospital DNR order is a written order that is issued by a person’s attending physician that directs EMS providers to withhold CPR from the person in the event of that person’s cardiac or respiratory arrest. Thus, if an ambulance is called to attend to a person for whom an out-of-hospital DNR order has been issued and the ambulance crew observes the out-of-hospital DNR order with original signatures with the person, or observes that the person is wearing an out-of-hospital DNR bracelet or necklace, the ambulance crew will not attempt CPR unless it is appropriately communicated to a member of the crew that the out-of-hospital DNR order has been revoked.

Definitions:
1. Cardio-Pulmonary Resuscitation (CPR): refers to the medical procedures used to restart a person’s heart and breathing when the person suffers cardiac or respiratory arrest. CPR may involve simple efforts such as mouth-to-mouth resuscitation and external chest compression. Advanced CPR may involve insertion of a tube to open the person’s airway or to assist breathing, injection of medications, or providing an electrical shock (defibrillation) to resuscitate the heart.
2. End-Stage Medical Condition: An “end-stage medical condition” is an incurable and irreversible medical condition in an advanced state caused by injury, disease, or physical illness that will, in the opinion of the attending physician, to a reasonable degree of medical certainty, result in death, despite the introduction or continuation of medical treatment. If a patient having an end-stage medical condition serves as the reason for which an out-of-hospital DNR order is sought for that patient, the attending physician must make the determination that the patient has an end-stage medical condition before the physician may issue an out-of-hospital DNR order for the patient. All persons who are in a terminal condition have an end-stage medical condition.
3. Permanently Unconscious: “Permanently unconscious” is a medical condition that has been diagnosed in accordance with currently accepted medical standards and with reasonable medical certainty as total and irreversible loss of consciousness and capacity for interaction with the environment. The term includes, without limitation, a persistent vegetative state or irreversible coma. If a patient being permanently unconscious serves as the reason for which an out-of-hospital DNR order is sought for the patient, the attending physician must make the determination that the patient is permanently unconscious and the patient must have previously executed a living will which provides that no CPR be administered in the event of the person’s cardiac or respiratory arrest if the person becomes permanently unconscious, or authorizes a surrogate or other authorized representative of the person to make that decision under those circumstances.
4. Emergency Medical Services (EMS) Provider: EMS providers are individuals licensed, certified, recognized, or otherwise authorized under the Emergency Medical Services Act (35 P.S. §§ 6921-6934) to provide medical care on an emergency, out-of-hospital basis. They are most frequently associated with ambulance services. EMS personnel who administer emergency treatment include EMTs (emergency medical technicians), EMT-paramedics (paramedics), prehospital registered nurses, ambulance attendants, first responders and health professional physicians. EMS providers also include individuals given good Samaritan civil immunity protection under Pennsylvania law (42 Pa.C.S. § 8331.2) when using an automated external defibrillator. Physicians who provide medical command to EMS personnel must also honor an out-of-hospital DNR order when appraised of it by EMS personnel.
5. Attending Physician: An attending physician is a physician who has primary responsibility for the treatment and care of the person. More than one physician may have primary responsibility for the medical care and treatment of a person. A physician who is requested to issue an out-of-hospital DNR order for a person needs to make a good faith judgment as to whether the physician is an attending physician of the person based upon the medical care the physician provides to the person. If the physician determines that the circumstances of the physician-patient relationship do not enable the physician to determine whether he or she qualifies as the patient’s attending physician, the physician will attempt to supplement that knowledge with information the physician secures after making reasonable inquiries of the person or the person’s surrogate or other authorized representative regarding the medical care the person is receiving from other physicians.
6. Surrogate: For purposes of the repealed DNR Act and the regulations that were adopted pursuant to that act, a surrogate is an individual who has, or individuals who collectively have, legal authority to request an out-of-hospital DNR order for another person or to revoke that order. Under the Act the term “surrogate” is limited to a health care agent or health care representative as those terms are defined in the Health Care Agents and Representatives Act (20 Pa.C.S. §§ 5451-5465). This does not include all persons who fall under the former definition of “surrogate.” However, the Act permits persons other than surrogates, by virtue of their special relationship to the person for whom an out-of hospital DNR order is sought, to also make a request for an out-of-hospital DNR order for that person. An example of such a person is a parent of a child who has an end-stage medical condition who is under 18 years of age and who is not emancipated, who has not graduated high school or been married, and who does not have a court-appointed guardian. Yet another example is a court-appointed guardian for an adult who has an end-stage medical condition and who the court concludes is unable to meet essential requirements for his or her physical health or safety because the person does not have the ability to receive and evaluate relevant information effectively or communicate relevant decisions. However, other than when a person is relying upon the definition of “surrogate” in the Act to qualify to ask for an out-of-hospital DNR order for another person, the focus should be on whether that person, by virtue of a special relationship to the person for whom the out-of-hospital DNR order is sought, has legal authority to request an out-of-hospital DNR order for that person. We encourage you to seek the advice of an attorney if you have a question regarding who can serve as a surrogate or other authorized representative for another person to request an out-of-hospital DNR order for that person.

Pennsylvania recognizes two types of advance directives, durable power of attorney for health care decisions and living wills. A Values History is another form of advance directive (which may or may not include a living will and durable power of attorney for health care decisions). Here is a link to a sample Values History form. The AbioCor Implantable Heart Trial required all research participants to fill out a Values History Form.

Here is a link to the AMA’s public web-site for advance directives. It includes samples of a living will and DPA form. Pennsylvania does not require these forms to be notarized. But since some states do, the forms include a line for notarization as well. http://www.ama-assn.org/public/booklets/livgwill.htm

Durable Power of Attorney for Health Care Decisions (DPA) – This is a document indicating the patient’s choice of surrogate in the event that the patient loses decisional capacity. It must be filled out by the patient while he/she has intact decisional capacity. In many states, including Pennsylvania, it must also be signed by the designated surrogate. This is also referred to as “health care proxy” or “designated surrogate.” Designating a DPA helps moderate disagreements among family members and clarify who makes the decisions for the patient. Without such a document, there can be confusion over who should make decisions for the patient. In the absence of a DPA, many institutions will choose the next of kin to be the surrogate decision-maker for a patient who lacks the capacity to make his/her own decisions. DPA is essential if the person you wish to make decisions for you is not your next of kin or if you do not have any close relatives (for example, a parent might be chosen over a live-in partner, or an individual’s spouse might be chosen even though the couple had been separated).

Living Will – This is “a document executed by an adult which indicates his or her preferences regarding the initiation, continuation, withholding, or withdrawing of medical treatment in the event that he or she loses decision-making capacity.” (Ibid.) This helps the surrogate make decisions for the patient. It also promotes the patient’s actual wishes instead of someone else’s. Few people write living wills. It is difficult to anticipate future medical situations and what you might want at that time. However, these decisions are always difficult. Living wills provide support to loved ones by guiding them in your wishes and relieving some of their burden.

Under the federal Patient Self Determination Act, all health care institutions receiving Medicare or Medicaid funding:

1. must provide written information regarding his or her rights under state law to make decisions concerning medical care, including advance directives, to each adult receiving medical care through the provider or organization.

2. cannot condition the provision of care or discriminate against an individual based on whether or not the individual has executed an advance directive.

3. must comply with patients’ advance directives in a way that is consistent with state law.

4. must note patients’ records whether or not they have advance directives.

5. provide education about advance directives. (PSDA Interim Final Rule, 57 Federal Register 8194-8204 [3/06/96]).

Pennsylvania’s Advance Directive for Health Care Act, allows an individual of sound mind who is 18 years or older (or has graduated from high school or is married) to execute an advance directive. It also includes the following:

1. There is civil and criminal immunity for health care providers who follow the procedures set forth in the act.

2. There is no specific format for the advance directive.

3. The advance directive does not need to be notarized, but must be signed by the declarant or another on behalf of the declarant and witnessed by two adults.

4. The advance directive becomes operative when “a copy is provided to the attending physician and the declarant is determined by the attending physician to be incompetent and in a terminal condition or in a state of permanent unconsciousness.” These prognoses must be confirmed by a second physician.

5. An advance directive can be revoked at any time and in any manner by the declarant regardless of his/her mental or physical condition. The revocation is effective upon communication to any health care provider by the declarant or a witness to the revocation.

6. Artificial nutrition and hydration are identified as forms of life-sustaining treatment and thus, may be withdrawn if requested by the patient in the advance directive.

7. Health care providers who feel morally unwilling to comply with the patient’s advance directive can transfer care to another qualified health care provider who will comply if possible. But, if this is not feasible the health care provider must comply with the patient’s advance directive.

8. Any pregnant woman who is incompetent and either terminally ill or permanently unconscious must be maintained on life support until the fetus can be safely delivered. However, there is no requirement to perform a pregnancy test.

There are three exceptions to this requirement. They hold if the attending physician and an obstetrician after an examination believe that…

1. life-sustaining treatment, nutrition, and hydration would not result in the development and live birth of the fetus;

2. such treatment would be harmful to the woman;

or

3. the treatment would cause her pain that medication could not alleviate.

Under such circumstances, the living will can be followed.

9. The medical command physician may authorize emergency medical personnel to honor an advance directive. The medical command physician may base this decision on prior notification that a valid and operative advance directive exists or the notification by emergency medical services personnel that they have been presented with a signed, advance directive. Emergency medical services personnel must immediately notify the medical command physician when presented with a living will, signed by the patient, or other authorized person.

10. “Emergency medical services personnel confronted with any conflicting information regarding the patient’s wishes for life-sustaining treatment shall act according to the accepted treatment protocols and standards appropriate to their level of certification.( 5413)”

(Advance Directive for Health Care Act, 1992, April 16, P.L. 108, No. 24, 5402-5501)

Particular Questions about Advance Directives:

1. When will my living will take effect?

Your living will takes effect when the following three conditions are met:

(a) Your physician or health care provider has a copy of your living will;

(b) Your physician has determined that you are incompetent; and

(c) Your physician has determined that you are permanently unconscious or suffer from an end-stage medical condition.

2. What does it mean to be incompetent?

To be incompetent means that you are unable to understand the risks and benefits of a medical decision, you cannot make a medical decision on your behalf, or you cannot communicate a medical decision to your health care provider. For example, if you are unconscious or you suffer from dementia, your health care provider likely will determine that you are incompetent. A formal adjudication of incompetency by a court is not required for your living will to take effect. Back to top

3. What is an end-stage medical condition?

An end-stage medical condition is an incurable or irreversible medical condition in an advanced state that even with the introduction of medical treatment will result in death. For example, advanced Alzheimer’s disease or terminal cancers are considered end-stage medical conditions.

4. Does my health care provider have to follow the instructions in my living will?

Generally, yes. Pennsylvania law requires health care providers to follow the instructions in your living will. However, there are special rules about pregnant women who have living wills. Also, a living will cannot instruct your health care provider to act contrary to Pennsylvania law. If your health care provider cannot follow your instructions because of moral beliefs, your health care provider must transfer your care to another health care provider who can follow your instructions.

5. What is a health care power of attorney?

A health care power of attorney allows you to appoint someone to make medical decisions for you should you be unable to make medical decisions for yourself. You can also provide instructions to help your appointed decision maker make medical decisions. Back to top

6. When does a health care power of attorney take effect?

A health care power attorney takes effect when the following two conditions are met:

(a) Your health care provider has a copy of your health care power of attorney; and

(b) Your health care provider determines that you are incompetent.

7. What is a health care representative?

A health care representative is a person authorized by Act 169 of 2006 to make medical decisions for you if you do not have an advance directive and your physician determines that you are incompetent.

8. What medical decisions can my health care representative make?

Generally, the medical decisions your health care representative can make are the same as the decisions an appointed decision maker can make under a health care power of attorney. That means your health care representative can consent to surgery, authorize your admission to a nursing home, access your medical records, and consent to donation of your organs.

9. Who can be my health care representative?

Act 169 of 2006 provides a list of persons who can serve as your health care representative. The following persons, in the order listed, can be your health care representative:

(a) Spouse and, if applicable, your adult children from a prior relationship;

(b) Adult children;

(c) Parents;

(d) Adult siblings;

(e) Adult grandchildren; and

(f) Any adult who has knowledge of your values and beliefs (e.g. close friend, cousin, roommate)

10. Can I have more than one health care representative?

Yes. All members of the same class can act as your health care representative. For example, if you do not have a current spouse, but you have three adult children, all three adult children can act as your health care representative.

11. What if my health care representatives cannot agree to a decision regarding my care?

Act 169 of 2006 allows health care providers to follow the instructions of the majority of your health care representatives. For example, if you have three adult children who are acting as your health care representative and they cannot agree on a medical decision, the health care provider will follow the majority decision.

12. What are the main differences between a living will and a health care power of attorney?

A living will and health care power of attorney serve different functions. First, a living will is more limited in scope than a health care power of attorney. A living will only applies to medical care and decisions regarding end-of-life care. A health care power of attorney is broader in scope as it applies to all medical care and treatment. Second, a health care power of attorney allows you to appoint a decision maker to make medical decisions on your behalf. A living will generally does not appoint anyone to make medical decisions for you. Rather, you provide instructions to your health care provider regarding end-of-life care. Third, a health care power of attorney takes effect when you are incompetent while a living will does not take effect until you are both incompetent and permanently unconscious or suffer from an end-stage medical condition.

13. Does Pennsylvania recognize advance directives from other states?

Generally, yes. As long as the instructions in your advance directive are not contrary to Pennsylvania law, your advance directive from another state is valid in Pennsylvania.

14. Do other states recognize advance directives from Pennsylvania?

Likely, yes. However, you should check the law of the other state to be sure that the state recognizes out of state advance directives.

15. Is a health care power of attorney the same as a financial power of attorney?

No. A health care power of attorney is specifically limited to medical care and treatment. Typically, a financial power of attorney does not authorize the appointed individual to make medical decisions.

16. Where can I get more information regarding advance directives?

If you are admitted to Lancaster General Hospital, LGH staff can provide you with more information. Also, to following organizations are available for you to contact:

Pennsylvania Department of Aging

555 Walnut Street, 5^th Floor

Harrisburg, PA 17101-1919

(717) 783-6842

http://www.aging.state.pa.us/

Pennsylvania Medical Society

777 East Park Drive

P.O. Box 8820

Harrisburg, PA 17105-8820

1-800-228-7823

http://www.pamedsoc.org/

Aging with Dignity

P.O. Box 1661

Tallahassee, FL 32302-1661

(888) 594-7437

http://www.agingwithdignity.org/

GUIDELINES FOR EVALUATING REIKI AS AN ALTERNATIVE THERAPY

Committee on Doctrine

United States Conference of Catholic Bishops

25 March 2009

1. From time to time questions have been raised about various alternative therapies that areoften available in the United States. Bishops are sometimes asked, “What is the Church’s

position on such therapies?” The USCCB Committee on Doctrine has prepared this resource inorder to assist bishops in their responses.

I.                   HEALING BY DIVINE GRACE AND HEALING BY NATURAL POWERS

2. The Church recognizes two kinds of healing: healing by divine grace and healing thatutilizes the powers of nature. As for the first, we can point to the ministry of Christ, who

performed many physical healings and who commissioned his disciples to carry on that work. In fidelity to this commission, from the time of the Apostles the Church has interceded on behalf of

the sick through the invocation of the name of the Lord Jesus, asking for healing through the power of the Holy Spirit, whether in the form of the sacramental laying on of hands and

anointing with oil or of simple prayers for healing, which often include an appeal to the saints for their aid. As for the second, the Church has never considered a plea for divine healing, which

comes as a gift from God, to exclude recourse to natural means of healing through the practice of medicine.[i] Alongside her sacrament of healing and various prayers for healing, the Church has a

long history of caring for the sick through the use of natural means. The most obvious sign of this is the great number of Catholic hospitals that are found throughout our country.

3. The two kinds of healing are not mutually exclusive. Because it is possible to be healed by divine power does not mean that we should not use natural means at our disposal. It is not

our decision whether or not God will heal someone by supernatural means. As the Catechism of the Catholic Church points out, the Holy Spirit sometimes gives to certain human beings “a

special charism of healing so as to make manifest the power of the grace of the risen Lord.”[ii]This power of healing is not at human disposal, however, for “even the most intense prayers do

not always obtain the healing of all illnesses.”[iii] Recourse to natural means of healing therefore remains entirely appropriate, as these are at human disposal. In fact, Christian charity demands

that we not neglect natural means of healing people who are ill.

II.                REIKI AND HEALING

A)    The Origins and Basic Characteristics of Reiki

4. Reiki is a technique of healing that was invented in Japan in the late 1800s by MikaoUsui, who was studying Buddhist texts.[iv] According to Reiki teaching, illness is caused by some

Reiki, the “universal life energy,” from the Reiki practitioner to the patient. There are numerous designated hand positions for addressing different problems. Reiki proponents assert that the

practitioner is not the source of the healing energy, but merely a channel for it.[v] To become a Reiki practitioner, one must receive an “initiation” or “attunement” from a Reiki Master. This

ceremony makes one “attuned” to the “universal life energy” and enables one to serve as a conduit for it. There are said to be three different levels of attunement (some teach that there are

four). At the higher levels, one can allegedly channel Reiki energy and effect healings at a distance, without physical contact.

B)    Reiki as a Natural Means of Healing

5. Although Reiki proponents seem to agree that Reiki does not represent a religion of its own, but a technique that may be utilized by people from many religious traditions, it does have

several aspects of a religion. Reiki is frequently described as a “spiritual” kind of healing a opposed to the common medical procedures of healing using physical means. Much of the

literature on Reiki is filled with references to God, the Goddess, the “divine healing power,” and the “divine mind.” The life force energy is described as being directed by God, the “Higher

Intelligence,” or the “divine consciousness.” Likewise, the various “attunements” which the Reiki practitioner receives from a Reiki Master are accomplished through “sacred ceremonies”

that involve the manifestation and contemplation of certain “sacred symbols” (which have traditionally been kept secret by Reiki Masters). Furthermore, Reiki is frequently described as a

“way of living,” with a list of five “Reiki Precepts” stipulating proper ethical conduct.

6. Nevertheless, there are some Reiki practitioners, primarily nurses, who attempt to approach Reiki simply as a natural means of healing. Viewed as natural means of healing,

however, Reiki becomes subject to the standards of natural science. It is true that there may be means of natural healing that have not yet been understood or recognized by science. The basic

criteria for judging whether or not one should entrust oneself to any particular natural means of healing, however, remain those of science.

7. Judged according to these standards, Reiki lacks scientific credibility. It has not been accepted by the scientific and medical communities as an effective therapy. Reputable scientific

studies attesting to the efficacy of Reiki are lacking, as is a plausible scientific explanation as to how it could possibly be efficacious. The explanation of the efficacy of Reiki depends entirely

on a particular view of the world as permeated by this “universal life energy” (Reiki) that is subject to manipulation by human thought and will. Reiki practitioners claim that their training

allows one to channel the “universal life energy” that is present in all things. This “universal life energy,” however, is unknown to natural science. As the presence of such energy has not been

observed by means of natural science, the justification for these therapies necessarily must comefrom something other than science.

C)    Reiki and the Healing Power of Christ

8. Some people have attempted to identify Reiki with the divine healing known to Christians.[vi] They are mistaken. The radical difference can be immediately seen in the fact that

for the Reiki practitioner the healing power is at human disposal. Some teachers want to avoid this implication and argue that it is not the Reiki practitioner personally who effects the healing,

but the Reiki energy directed by the divine consciousness. Nevertheless, the fact remains that for Christians the access to divine healing is by prayer to Christ as Lord and Savior, while the

essence of Reiki is not a prayer but a technique that is passed down from the “Reiki Master” to the pupil, a technique that once mastered will reliably produce the anticipated results.[vii] Some

practitioners attempt to Christianize Reiki by adding a prayer to Christ, but this does not affectthe essential nature of Reiki. For these reasons, Reiki and other similar therapeutic techniquescannot be identified

with what Christians call healing by divine grace.

9. The difference between what Christians recognize as healing by divine grace and Reiki therapy is also evident in the basic terms used by Reiki proponents to describe what happens in

Reiki therapy, particularly that of “universal life energy.” Neither the Scriptures nor the Christian tradition as a whole speak of the natural world as based on “universal life energy” that is subject to manipulation

by the natural human power of thought and will. In fact, this worldview has its origins in eastern religions and has a certain monist and pantheistic character, in that distinctions among self, world, and God tend

to fall away.[viii]We have already seen that Reiki practitioners are unable to differentiate clearly between divine healing power and power that is at human disposal.

III.             CONCLUSION

10. Reiki therapy finds no support either in the findings of natural science or in Christian belief. For a Catholic to believe in Reiki therapy presents insoluble problems. In terms of caring

for one’s physical health or the physical health of others, to employ a technique that has no scientific support (or even plausibility) is generally not prudent.

11. In terms of caring for one’s spiritual health, there are important dangers. To use Reiki one would have to accept at least in an implicit way central elements of the worldview that

undergirds Reiki theory, elements that belong neither to Christian faith nor to natural science. Without justification either from Christian faith or natural science, however, a Catholic who puts

his or her trust in Reiki would be operating in the realm of superstition, the no-man’s-land that is neither faith nor science.[ix] Superstition corrupts one’s worship of God by turning one’s religious

feeling and practice in a false direction.[x] While sometimes people fall into superstition through ignorance, it is the responsibility of all who teach in the name of the Church to eliminate such

ignorance as much as possible.

12. Since Reiki therapy is not compatible with either Christian teaching or scientific evidence, it would be inappropriate for Catholic institutions, such as Catholic health care

facilities and retreat centers, or persons representing the Church, such as Catholic chaplains, to promote or to provide support for Reiki therapy.

Most Rev. William E. Lori (Chairman) Most Rev. John C. Nienstedt

Bishop of Bridgeport Archbishop of St. Paul and Minneapolis

Most Rev. Leonard P. Blair Most Rev. Arthur J. Serratelli

Bishop of Toledo Bishop of Paterson

Most Rev. José H. Gomez Most Rev. Allen H. Vigneron

Archbishop of San Antonio Bishop of Oakland

Most Rev. Robert J. McManus Most Rev. Donald W. Wuerl

Bishop of Worcester Archbishop of Washington

The simplest definition of competence is “the ability to perform a task.”[1] From this definition it is important to note that an individual’s competence is directly correlated with the specific task at hand. And in the medical setting this usually pertains to a patient’s competence to make decisions regarding his or her treatment. It is necessary to point out that strictly speaking, it is the court system that evaluates competence/incompetence while the health care professionals determine capacity/incapacity for decision-making. However, these two terms end up being used interchangeably since “this distinction breaks down in practice.”[2]

The determination of an adult patient’s competence is essential in the process of obtaining an informed consent because decisions made by patients who have been declared incompetent are considered invalid while those made by competent individuals would be acceptable. The concept of informed consent relates to two important aspects. The first is that it meets the requirement of getting consent from patients prior to any medical procedure be it diagnostic, therapeutic, or research. And secondly and more relevant to this discussion is that an informed consent represents a person’s “autonomous authorization of a medical intervention or of participation in research.”[3] Clearly competence and the bioethical principle of autonomy are linked inseparably. Competence is a necessary requirement for a person to exercise his or her autonomy.

What then are the criteria that need to be met in order for an adult patient to be declared competent?

(1) The patient should be oriented to time, place, and person. It is possible that a patient could be oriented at certain times and disoriented at other times. Thus it is necessary to continuously track the waxing and waning of the patient on the chart since this could be a crucial element if ever something wrong happens and the case ends up in court.

(2) The patient should understand relevant information. Does the patient understand the basics of the procedure that is being suggested? We have to acknowledge the fact that an average patient would be hard pressed to grasp the medical and technical details of the procedure especially when the medical staff tends to use highly scientific terms when talking with the patient. But a general understanding of the procedure should be acceptable.

(3) The risks and benefits of the various options should be clear to the patient.

(4) The consequences of all options – including the refusal of any treatment – should be clearly understood by the patient as well.

(5) The patient should be able to clearly and voluntarily express (verbally or otherwise) his or her preference. Any sign of coercion or involuntariness would be a red flag.

An adult patient’s competence then enables him or her to give a valid informed consent. As an autonomous individual and having been presented with the various options and their respective risks and benefits, the competent patient is then requested to make a choice. It is the obligation of the medical staff to respect the patient’s autonomy by respecting whatever decision he or she makes.

Now we are back to the question: Could a competent, adult patient make a wrong decision? It is a fact that sometimes medical personnel get so frustrated when a patient makes a choice that is not to their liking. Some have resorted to requesting a psychiatric consult. If they truly have some sound basis for doubting the competence of the patient and just want a confirmation from a psychiatrist, then this seems to be acceptable. They should be reminded that they could also ask their colleagues for a second opinion on this matter. However, if the motive behind the psychiatric consult is to find a way to declare the patient incompetent so they could then convince the relatives, or whoever the surrogate decision-maker would be, to choose their preferred option then this action is not only unacceptable but smacks of paternalism. And in so doing, the patient’s autonomy is not being upheld. If the medical personnel could not in good conscience carry out the choice of the patient, they still have another option – that of passing on the care of the patient to another health care professional. A physician can never abandon the patient so he or she is still responsible for the patient’s care until another physician has accepted this transfer or the patient has decided to leave AMA or against medical advice.

Being human means being imperfect. We make mistakes every now and then. So long as an adult patient has been declared competent then she is merely exercising her autonomy every time she makes an informed decision.

[1] Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, Sixth edition (New York: Oxford University Press, 2009) 112.

[2] Beauchamp and Childress 111.

[3] Beauchamp and Childress 119.

The 2500-year-old Hippocratic Oath has stood the test of time. It is still the most popular pledge made by medical students at the time of their graduation. In part, it states, “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”. The oath obliges the physician, based on his ability and judgment, to benefit the patient. This is the principle of beneficence. The Oath also places on the physician the obligation not to harm the patient (“primum no nocere”). This is the principle of non-maleficence. In this case, the physician exercises the principle of beneficence by refusing to order a test, which, in his judgment, is not needed. In addition, he exercises the principle of non-malfeasance because, in his judgment, the test may be harmful to the patient. It would expose him to unnecessary radiation.

Notice that the Hippocratic Oath is subjective. It is based strictly on the physician’s judgment even if his colleagues do not agree. Also, notice that it is based on the physician’s judgment, not the patient’s. The Oath implies that the physician has the experience and expertise to make decisions on behalf of the patient even if his judgment is in conflict with the patient’s wishes, as it is in this case. Thus, the Hippocratic Oath does not support John’s argument that the physician has a moral obligation to order a CT angiogram.

Serious challenges to the Hippocratic Oath began in the 1970s. First, one may challenge the way benefits to the patient are assessed. If CT angiograms were considered the standard of care for all patients regardless of symptoms or risk factors, the physician would be hard pressed to refuse the patient’s request for the test. The objective judgment of the profession would trump the subjective judgment of one physician. However, that is not the case here. At this time (July 2008) there is no objective evidence to support the benefit of this test in John’s case.

Another challenge to the Hippocratic Oath came for the American Medical Association. Although its previous codes were essentially Hippocratic, the AMA changed its code in a dramatic and significant way in 1980. The new version is the first to speak of patient rights. “The physician shall respect the rights of patients, of colleagues and of other health professionals, and shall safeguard patients’ confidences within the constraints of the law”. The 1980 AMA code breaks with the Hippocratic tradition, which does not mention anyone’s rights. From this time onward, the principle of respect for patient autonomy has been on the ascendency.

“Whether respect for the autonomy of patients should have priority over professional beneficence directed at those patients is a central problem in biomedical ethics” (Beauchamp & Childress, Principles of Biomedical Ethics, 2009). In this case John expresses his autonomy right by requesting that his doctor order the expensive test if only to put his mind at ease. The doctor, in turn, applies the principle of beneficence by denying the request because in his professional judgment the test is not indicated in John’s case. Moreover, he applies the principle of non-maleficence by refusing to subject his patient to the danger of unnecessary radiation. How can this conflict be resolved?

The answer to this conflict lies in the principle of distributive justice. Health care spending in the United States is spiraling out of control. New technologies are a major driving force for this increase. The principle of distributive justice refers to an appropriate, equitable, and fair distribution of health care resources. It is not appropriate for a doctor to order unnecessary tests that subject patients to danger. It is not equitable for one person to receive expensive diagnostic testing, merely for peace of mind, while 50 million uninsured Americans cannot afford the costs of basic health care. In addition, it is not fair to burden society with unnecessary costs.

Daniel Callahan, an expert on bioethics, argues that solving the current crisis in our health care system – rapidly rising costs and dwindling access – requires replacing the current “ethic of individual rights” with an “ethic of the common good”. In a similar vein Newsweek columnist, Robert J. Samuelson wrote: “We face a choice between a society where people accept modest sacrifices for a common good or a more contentious society where groups selfishly protect their own benefits.”