The Linacre Quarterly

Is medicine losing its way? This question may seem to imply a serious warning, one needing a further explanation. What I mean to say by the title of this paper is that we can detect an undeniable shift in medicine in the last forty to fifty years. Medicine used to focus on what we call “health care” in a classical sense, that is, the treatment of people suffering from diseases, injuries or handicaps, or the alleviation of pain and other symptoms. In addition to this, in the last half century, it has begun to offer more and more treatments aiming to perfect the qualities of people who are otherwise healthy.

In the Gospel we see how people bring the sick to Christ to be healed. As physicians, nurses, and chaplains we are God's instruments bringing physical and spiritual healing to the sick. It is important for those of us who care for the sick to ask them about their religious affiliation and spiritual needs, and then following their cues and in a respectful way to encourage them to pray and, in the case of Catholics, to receive the sacraments. We should also pray for our patients, and when we think they would like it, to pray with them.

The National Institutes of Health (NIH) announced its plans to lift its moratorium on funding research that involves injecting human embryonic stem cells into animal embryos, which would allow for the creation of part-human and part-animal organisms known as chimeras. The NIH allowed only one month to receive public comments in the midst of a presidential election campaign. Lifting the moratorium means that, for the first time, the federal government will begin spending taxpayer dollars on the creation and manipulation of new organisms that would blur the line between humans and animals. Interestingly, this government effort is creating an uncommon coalition between pro-life groups and animal rights activists that oppose this medical research on ethical grounds; the former seeking to ensure the welfare of human embryos and the latter seeking to protect the well-being of animals. Unlike the issue of abortion, this research is complex. Yet, it is important that the pro-life laity and clergy be adequately informed on some of the basic science and ethics that surround this research. To fully understand why this research is unethical and why the NIH is pursuing this particular research, it is important to understand the ethical tenets governing human-subject research and why secular scientists are pursuing this scientific field.

The challenge of decision making in end-of-life scenarios is exacerbated when the patient is a newborn and in a low-income setting. The principle of proportionate care is a helpful guide but needs to be applied. The complex interplay of benefit, burden, and cost of various treatments all need to be considered. In patients with severe neonatal encephalopathy, prognosis can be hard to determine, and a team approach to decision making can help. In low-income settings, or where there are limited resources, the ideal care needs to be incarnated in the real context. Issues of social justice also arise as finite resources need to be used prudently.

Treatment of pulmonary hypertension in pregnancy with a prostacyclin analogue-iloprost and/or calcium channel antagonists appears to improve outcomes and survival. These medications could have been administered to the patient and the response monitored. If the patient did not respond to therapy, this patient may have had either a referral to or transfer to another high risk center with more experience in this type of pregnant patient. There is no literature to support termination of pregnancy improving maternal survival outcomes in these patients, even though termination is recommended by all obstetrical textbooks. Maternal survival, rather, appears to be related to response to therapy, type of therapy, and continuation of therapy.

Cases of a vital conflict, where the lives of both the mother and child are at risk during pregnancy, have been the subject of recent vigorous debate. The basic principles put forth in the Ethical and Religious Directives are reviewed, as is the principle of double effect. An illustrative case of severe cardiomyopathy in a pregnant woman is described and it is noted that the principle of double effect would not apply. Counter arguments are noted, focusing on Martin Rhonheimer who posits that in the case of vital conflicts, such as performing a craniotomy on a baby stuck in the birth canal, taking the baby's life does not constitute a direct abortion because moral norms do not apply in the extreme conflict situation where both mother and child will die. He states that the death of the fetus is not intentional in these cases. He overlooks “how the life is being saved” and that a choice has been made, which implies a moral act, not just a physical one. Rhonheimer wants to make his moral judgment solely on the basis of intention, prescinding from what actually occurs in the physical world of cause and effect. This is clearly against the teaching in Evangelium vitae. Ethics deal with the deliberate chosen actions in space and time of embodied human beings; it deals inescapably with material actions, with specifications of intentions. Rhonheimer states, “a killing or an abortion is ‘direct,’ not because the death of the fetus is caused in some physically direct way, but because it is willed as the means to an end.” However the death of the child cannot be excluded from the act and is therefore of necessity included in it. What the acting person chooses includes what happens physically in this act. If the action theory proposed by Rhonheimer is accepted, it could be very difficult to avoid death-dealing actions from taking place in Catholic hospitals.

Louise Mitchell discusses character in “Integrity and virtue: The forming of good character” (The Linacre Quarterly 82, no. 2: 149–169). I argue that she is mistaken in identifying character as a potency and that it is rather the sum of one's moral habits and dispositions. I establish this by showing that if one correctly applies the division Aristotle presents in the text that Mitchell relies on, it follows that character belongs in the category of habit. I further support this conclusion by considering how people commonly speak of moral character. I then show that the text from the Summa Theologiae Mitchell relies on concerns sacramental character and not moral character; moreover, if we apply the reasoning contained there to moral character, we are again led to see that it should be categorized as a habit. Lastly, I explain that a human being's potency for character lies in the soul's rational powers.

Estrogens and progestins are known to have profound effects on the immune system and may modulate the susceptibility to autoimmune diseases. A comprehensive literature search was carried out using PubMed for any of 153 autoimmune disease terms and the terms contraception, contraceptive, or their chemical components with limits of Humans + Title or Abstract. Over 1,800 titles were returned and scanned, 352 papers retrieved and reviewed in depth and an additional 70 papers retrieved from the bibliographies. Based on this review, substantial evidence exists linking the use of combined oral contraceptives to a lower incidence of hyperthyroidism, an increase in multiple sclerosis, ulcerative colitis, Crohn's disease, Systemic Lupus Erythematosus, and interstitial cystitis. Progesterone only contraceptives are linked to progesterone dermatitis and in one large developing world concurrent cohort study are associated with increases in arthropathies and related disorders, eczema and contact dermatitis, pruritis and related conditions, alopecia, acne, and urticaria. Hormonal contraceptives modulate the immune system and may influence the susceptibility to autoimmune diseases with significant increases in risk for several autoimmune diseases.

This is Part II of a three-part list of books by topic that we would like reviewed. If you would like to review one of these books, please submit a request to the book review editor, Thomas M. Bender, M.D., at lq@cathmed.org.