Surgical Prophylactics for Ovarian Cancer (SPOC): An Ethical Inquiry

See Gerald Kelly S.J. , Medico Moral Problems. Dublin, Clonmore & Reynolds, 1960 edition.

See Struewing JP ; Hartge P ; Wacholder S. “The Risk of Cancer Associated with Specific Mutations of BRCA1 and BRCA2 Among Ashkenazi Jews.” N Engl J Med 336 (1997) 1401–08; Couch, FJ; DeShano, ML; Blackwood, MA;, et al. “BRAC1 Mutations in Women Attending Clinics that Evaluate the Risk of Breast Cancer.” N Engl J Med 336(1997) 1409–15; Krainer, M; Silva-Arrieta, S; Fitzgerald, MG;, et al. “Differential Contributions of BRCA1 and BRCA2 to Early-Onset Breast Cancer.” N Engl J Med 336(1997) 1416–21.

See for example Hankinson SE ; Hunter DJ ; Colditz GA “Tubal Ligation, Hysterectomy, and Risk of Ovarian Cancer: A Prospective Study.” JAMA 270 (1993) 2813–18. Whittemore, AS; Harris, R; Itnyre, J; Collaborative Ovarian Cancer Group; “Characteristics Relating to Ovarian Cancer Risk: Collaborative Analysis of 12 US Case-Control Studies, II: Invasive Epithelial Ovarian Cancers in White Women.” Am J Epidemiol 136 (1992) 1184–1203; Mori, M; Harabuchi, I; Casagrande, JT; Henderson, BE; Ross, RK; “Reproductive, Genetic, and Dietary Factors for Ovarian Cancer.” Am J Epidemiol 128(1988) 771–7.

Ovarian cancer accounts for 4% of all cancers in women. The most common form is endometrial cancer. The incidence of this latter cancer has been increasing over the years, and today accounts for 13% of all cancers in women. See Boring CC ; Squires T.C. ; “Cancer Statistics.” Cancer 41(1991) 19–36.

See Kawai M ; Kikkawa F ; Hattori S ; Ohta M ; Arii Y ; Tomoda Y. ; “Long-Term Follow-Up of Patients with Epithelial Carcinoma of the Ovary.” International Journal of Gynaecology & Obstetrics 44(1994) 259 66; Ansell, SM; Rapoport, BL; Falkson, G; Raats, JI; Moeken, CM; “Survival Determinants in Patients with Advanced Ovarian Cancer.” Gynecologic Oncology 50(1993) 215–20; Malmstrom, H; Hogberg, T; Risberg, B; Simonsen, E; “Granulosa Cell Tumors of the Ovary: Prognostic Factors and Outcome.” Gynecologic Oncology 52(1994) 50–5.

In contrast, up to 80% of patients with endometrial cancer survive five years after diagnosis.

See for example Venesmaa P. , “Epithelial Ovarian Cancer: Impact of Surgery and Chemotherapy on Survival During 1977–1990.” Obstetrics & Gynecology 84 (1994) 8–11; Marchetti, DL; Lele, SB; Priore, RL; McPhee, ME; Hreshchyshyn, MN; “Treatment of Advanced Ovarian Carcinoma in the Elderly.” Gynecologic Oncology 49(1993) 86–91; Fanning, J; Bennett, TZ; Hilgers, RD; “Meta-Analysis of Cisplatin, Doxorubicin, and Cyclosphosphamide Versus Cisplatin and Cyclophosphamide Chemotherapy of Ovarian Carcinoma.” Obstetrics & Gynecology 80(1992) 954–60.

See, for example, Nolan Martin , “The Principle of Totality in Moral Theology,” in Absolutes in Moral Theology, ed. Curran Charles , Washington, DC, Corpus Books, 1968; John F. Tuohey, “A Re-Assessment of the Content and Role of II-IIq. 65, a. 1 in Ethics.” The Irish theological Quarterly, 61 (1995) 294–311.

Ethical and Religious Directives for Catholic Health Care Services, No. 53.

See, for example, Benedict M. , Ashley OP ; O'Rourke Kevin , Healthcare Ethics: A Theological Analysis. 3rd edition. St. Louis, The Catholic Health Association of the United States, 1989.

ST II-II Q.65, a.1.

See Pius X.I. , “Cast Connubii, AAS 22 (1930) 559ff; Pius XII, AAS 44(1952) 779–89. For a discussion of Totality within the tradition, see J.J. Lynch, “Totality, Principle of, The New Catholic Encyclopedia vol. 14, New York, McGraw-Hill, 1967, pp. 211–12; John Gallagher, “The Principle of Totality: Man's Stewardship of His Body”, in Moral Theology Today. Certitude and Doubts, ed. Donald McCarthy, St. Louis, Pope John XXIII Medical-Moral Research & Education Center, 1984, pp. 222–24. The ERD speaks of the bodily and functional integrity of the person at no. 29.

Gerald Kelly S.J. , “Medical-Moral Notes”, The Linacre Quarterly XX (Nov 1953) 116–117. See also Pius XII AAS 44 (1952) 782.

See Pius XII, AAS 44(1952) 779; AAS 46 (1954) 587.

Pius XII AAS 44 (1952) 782. Today, any mutilations done for reasons of health that are performed for a proportionately grave reason are said to be justified, whether they be prophylactic, diagnostic, therapeutic, prosthetic, or palliative. Purely cosmetic mutilations, as opposed to re-constructive surgery, remain a matter of debate.

Charles McFadden O.S.A. , Medical Ethics, third edition, Philadelphia, F.A. Davis Company, 1953, p. 292.

Kelly , Medico Moral Problems 260. See also Thomas J. O'Donnell, Morals in Medicine, Westminster, MD, The Newman Press, 1956, D. 81.

See ST. II-II, q.70, a.2. See also Albert R. Jonsen , and Toulmin Stephen , The Abuse of Casuistry: A History of Moral Reasoning, Berkeley, University of California Press, 1988, esp. pp. 164–75, 250–65.

See Pius XII, AAS 45 (1953) 674.

See Davis Henry , Moral and Pastoral Theology, 2nd edition, New York, Sheed and Ward, 1952, at page 78. See also Jonsen and Toulmin, The Abuse of Casuistry, 165.

For an example, see Kelly's agreement with McFadden (McFadden, Medical Ethics, pp. 292–93) that “[t]here are some special cases in which it seems probable that an individual may justifiably ask for an appendectomy, even though no medical indications are actually present.” Kelly, Medico Moral Problems, p. 253–54. See also Connell Francis , “Surgery for the Healthy”, American Ecclesiastical Review, February, 1947, p. 143. For each of these authors, the general prevalence of appendicitis is cited rather than the statistical probability that varies at different ages. For McFadden and Connell, general economic considerations could make the elective procedure permissible. For Kelly, the fact that one is doing missionary activity or special military service in locations where quality health care may not be readily available could make the elective appendectomy permissible. These are judgments based on a general sense of what might be considered reasonable, rather than on a technical and precise analysis.

It is interesting to also cite the debate at this time regarding the performance of a hysterectomy in cases of a uterus that was in danger of rupture during pregnancy. Kelly holds “the practical probability of the opinion” that this is permitted. Other authors who agree include John R. , Connery S.J. , Theological Studies, (1955) 575–76, John J. Lynch, S.J., Theological Studies (1957) 230–32, speaks of the “solid probability” of this opinion; McReavy, LL, The Clergy Review (1956) 485–89 speaks of the “extrinsic probability” of this opinion; O'Donnell, Morals in Medicine, 108–110 cites opinions for and against the hysterectomy, but favors the affirmative opinion as probable.

Pius XII AAS 45 (1953) 674. See also Pius XII, “An Address to a Symposium of the Italian Society of Anesthesiology.” The Pope Speaks 4(1958) 349.

Pius X.I.I. AAS 45 (1953) 673–79. See also Gerald Kelly, S.J., “Pope Pius XII and the Principle of Totality,” Theological Studies 16 (1955) 373–96.

See “Responses on Uterine Isolation.” Origins 24, (1994) 211–12.

Kelly , Medico Moral Problems, 252.

O'Donnell , Morals in Medicine, p. 81

Lohkamp Nicholas , The Morality of Hysterectomy Operations, The Catholic University Press, Washington, D.C. 195 p. 139, note 135.

Kelly , Medico Moral Problems, 253.

Kelly , Medico Moral Problems, 253.

Minutes of the 36th Annual Meeting of the Bishops of the United States, November, 1954.

According to both James Keenan S.J. , and Kopfensteiner Thomas , consultants to the NCCB for the 1994 edition, the issue of prophylactic surgery was not discussed. Both agreed that this was probably due to a presumed consensus on the appropriateness of the practice and the rationale that informed it. Personal conversation, 6 and 17 January, 1997.

See Gury J.P. , Compendium Theologiae Moralis. New York, Benzinger, 1874, “De actibus humanis,” tr. 1,c. 2,n.9; Herbert C. Kramer, The Indirect voluntary or Voluntarium in Causa. Washington, D.C., Catholic University of America, 1935; Joseph T. Mangan, “An Historical Analysis of the Principle of Double Effect.” Theological Studies 10 (1949) 41–61; F.J. Connell, “Double Effect, Principle of The New Catholic Encyclopedia vol. 4, pp. 1020–22.

See the Catechism of the Catholic Church, no. 2288.

The distinctiveness of these events is further evidenced by the fact that during the period of the flow of steroid-rich follicular fluid, no ovum is available.

This is unlike the case of uterine isolation in which it is the prevention of pregnancy that prevents the event of uterine rupture. (See “Responses on Uterine Isolation.”) In the case of a weakened uterus, the risk of rupture exists solely during pregnancy. Hence, the prevention of uterine rupture is medically and morally tied to the prevention of pregnancy. With ovarian cancer, the risk is independent of pregnancy. There is no known connection between pregnancy and the risk of ovarian cancer. Hence, the prevention of ovarian cancer is medically and morally independent of pregnancy.

See, for example, Paul V.I. , Humanae Vitae, no. 15; “Ethical and Religious Directives for Catholic Health Care Services,” no. 15.

For this discussion, see Pius XII, “Address to the Italian Midwives,” AAS 43 (1951), esp. pp. 835–54.

AAS 45 (1953) 673–79.

Such a conclusion remains open to affirmation or correction by subsequent teachings.

See Kelly , Medico Moral Problems 254. For example, a woman whose family history suggests she may be at higher risk for cancer might desire SPOC independently of some other surgery.

One development which could impact on this judgment may come from research now being done to determine the feasibility of laparoscopy staging patients with incompletely staged cancers of the ovary, primary fallopian tube carcinoma and primary peritoneal carcinoma. Better staging of these cancers could lead to better treatment regimes. However, care must be taken not to respond too quickly to medical information, or to impose too high a standard for what constitutes a reasonable judgment of proportionately grave reason. McFadden bases his judgment regarding an incidental appendectomy in part on the claim that nearly 20% of the population will experience appendicitis. (McFadden, Medical Ethics 292) That figure is now known to be only 7%, yet this dramatic change in risk has had no impact on the moral assessment of the procedure. Kelly uses no statistical information. In fact, when discussing the factors that must be taken into account in making a decision in favor of an incidental appendectomy, he makes no reference at all to the actual risk of having appendicitis. (Kelly, Medico Moral Problems 252) In spite of these lacks, he is still able to come to his conclusion.