Ethical treatment requires a delicate balance

ETHICS MADE REAL

Gordon Self

October 25, 2010

I was confronted by this fictitious case once: a 17-year-old presents to our emergency department with complications related to her newly discovered pregnancy. She has told no one she is pregnant.

In this case, staff felt she had legal decision-making capacity as a mature minor, insisting they do not contact her parents. She then went on to ask if we could terminate the pregnancy. The emergency department staff consults ethics. What should we do?

I clearly remember my first response was not saying what we won’t do, that is, abort her baby. Nor did I merely cite references from our Catholic Health Ethics Guide, despite providing authoritative moral guidance regarding termination. But I recall saying what I would do.

I first needed to go to Emergency and talk with this person. I imagined how lonely she must feel, keeping so much to herself. I wondered what lay behind her request to terminate. I questioned what kind of family she had making her reluctant to tell them, perhaps fearing judgment or abuse.

I imagined how staff might be torn in respecting her wishes not to call family, but also seeing her on a stretcher, alone. I wondered if the patient might be miscarrying and was grieving. No matter how this situation unfolded, her life would change, and she was alone to face it.

MORAL BOUNDARIES

Towards the end of my response, someone challenged: “Would you consider aborting?” Without hesitation, I said “no.” Clearly, there are moral boundaries about what a Catholic hospital can or can’t do.

While this is the appropriate response, there are other responses that are also appropriate. Real ethics is messy, and requires a pastoral response to listen to people’s stories, and not stop short simply at offering principles and prohibitions. When staff call for an ethics consult, they are looking for how best to support a person and finding a way forward in keeping with Catholic teaching. If it is only about saying “no,” they can easily do it themselves.

In responding to this fictitious case and many such real life dilemmas in the years since, I am mindful that we cannot abandon people, even if the answer is not what people expect to hear. The pastoral dimension of doing ethics builds on what I have discussed in previous articles — making sure we don’t make assumptions, staying engaged with conflict, weighing benefit and harm, and so forth.

NO COMPROMISES

I would like to add one more important ethical consideration. While we cannot abandon the person in our care, we also cannot abandon or compromise our own conscientious beliefs in the process, either.

The exercise of conscience must be respected and preserved. To expect someone to participate in an act that goes against their beliefs and moral centre can cause irrevocable harm. In talking to the young person in the emergency department, I must listen to both her story as well as my own conscientious beliefs to form my pastoral response. We must stay engaged with both to find a way forward that allows us to remain true to ourselves.

This is not always easy, especially in a publicly funded health care system in which Covenant Health operates. Patients and residents may have different religious and cultural beliefs from the hospital. The person may not be satisfied waiting until specific criteria are satisfied before it is ethically justified from a Catholic perspective to induce labour, for example.

Some patients may not want to wait and instead request referral to another facility where such procedures can be done.

Here the dilemma regarding the exercise of conscience becomes more complicated. Is it ethically justified to refer them to another provider without becoming complicit in the termination of life?

Conversely, is it ethically justified to just ignore the patient’s request and impose our own personal or organizational beliefs on them? Can we even disclose factually relevant information to the patient to help them inform their own conscience?

AUTHENTIC RESPONSE

I have yet to find one Catholic ethics guide that clearly spells out an answer for every possible nuance to such dilemmas. But through dialogue and reflection we have found ways to respond authentically that uphold Catholic teaching, respect conscientious beliefs of all parties, and without leaving moral residue.

Seldom do such responses begin by just saying “no.” It requires moral courage, creativity and willingness to be present to people. We can neither abandon patients, nor staff.

(Gordon Self is vice president, mission, ethics and spirituality for Covenant Health and can be reached at mes@covenanthealth.ca.)