Brain Death and Catholic Teaching (2014)

Voices Online Edition
Vol. XXIX, No. 1
Pentecost 2014

Brain Death and Catholic Teaching

by Nancy Valko, RN

Earlier this year, the public was transfixed by two news stories involving brain death. The circumstances of Jahi McMath and Marlise Muñoz were very different on the surface, but the legal and ethical questions concerning the diagnosis of brain death and the use of life support in both women started a firestorm of controversy even within the Catholic Church.

No wonder the average person, Catholic or not, is confused.

It is important to first scrutinize the facts of both cases to begin to understand why there is a lack of unity on such life and death matters even among respected Catholic sources.

Jahi McMath

Jahi McMath, a 13-year-old girl, underwent a routine surgery for sleep apnea in December 2013 at a California children’s hospital. That night she started bleeding and eventually her heart stopped. Her heart was restarted and she was placed on a ventilator to stabilize her condition, but soon the doctors declared her brain dead and prepared to remove the ventilator. However, the family insisted that the ventilator be continued, hoping that Jahi might eventually get better.

The doctors disagreed, insisting that Jahi was legally dead by brain death criteria. The parents went to court to keep the doctors from removing her ventilator but after a series of legal battles lasting weeks, a judge eventually gave Jahi’s family permission to transfer her to another facility that would continue the ventilator.

Virtually all the ethicists and other experts contacted by most  media outlets condemned the family’s actions as denying the reality of brain death. In January the National Catholic Bioethics Center issued a statement that said, in part, “… the determination of death by the rigorous application of the neurological criteria is considered legitimate by the Catholic Church, which accepts the findings of science in such a determination.”1

In a January 10, 2014 USA Today article, ethicist Arthur Caplan, head of the bioethics division at New York University’s Langone Medical Center, condemned the judge’s decision for Jahi’s family, declaring that brain dead people will eventually “start to decompose,” even if the ventilator was continued.2

However, almost 3 months later in a March 28, 2014 interview with NBC Bay Area News,3  Jahi’s mother reported that her daughter now moves her arms, legs, and head spontaneously but “is still asleep” and unable to move on command. Jahi is currently being fed by a feeding tube, sustained on a ventilator on room air (no extra oxygen) and receives physical therapy 3 to 4 times a week.  At the time of this interview, Ms. McMath had just received an award from the Terri Schiavo Life & Hope Network as a relative who protects “a loved one against overwhelming odds.”

While Jahi’s movements described by her mother were dismissed by some experts as merely “spinal reflex movements,”4 it was a foot movement in the 2008 case of Zack Dunlap5 that led doctors to rethink their diagnosis of brain death in him and stop an imminent organ donation. Although Zack made a very fast recovery and Jahi’s continued lack of apparent conscious movement is not as hopeful, critics of brain death point to these kinds of developments as showing how much we still do not know about the human brain and its capabilities.

Although the medical criteria used to determine brain death vary — often widely — from one hospital to another, the definition of brain death is supposed to show an irreversible lack of function of the entire brain and brain stem. In Zack Dunlap’s case, he had more testing, including a test showing a lack of blood flow to the brain, than the average person diagnosed as brain dead.

Marlise Muñoz

Marlise Muñoz was a 33-year-old woman who was 14 weeks pregnant with her second child in November 2013 when she collapsed from a suspected blood clot and stopped breathing at home. She was taken to a Texas hospital and, like Jahi McMath, revived and put on a ventilator. Like Jahi, Mrs. Muñoz was also declared brain dead within a short time; but in this case, the roles of the family and hospital were reversed. Mrs. Muñoz’s husband was ready to remove the ventilator and the hospital objected because of a Texas law, like those in several other states, that prohibits the withdrawal of life support from a pregnant woman so that the baby has at least a chance to survive to birth.

Mr. Muñoz strenuously disagreed, stating that his wife told him she would not want to live in such a state and, in several news reports, voiced his concern that the lack of oxygen and effects from resuscitation might have damaged his unborn child. He went to court to force the hospital to remove the ventilator.

This time, virtually all the many ethicists and experts contacted by the media supported the husband’s decision to remove the ventilator. Many argued that the 1989 Texas law was only meant to apply to pregnant women in conditions like a “vegetative state,” not a brain-dead woman. Some even claimed that removing the ventilator was similar to a legal late-term abortion. As the case wound its way in court for weeks, lawyers for Eric Muñoz eventually claimed that tests showed the now-22-week-unborn child was “distinctly abnormal” with fluid building up inside the skull, a possible heart problem, and lower extremities “deformed to the extent that the gender cannot be determined.”6 In an interview on CNN’s Anderson Cooper 360°, Mrs. Muñoz’s mother “described in agonizing detail in the interview how towards the end, her daughter’s body had begun to visibly deteriorate, making it difficult to look at an empty shell of what had been her beloved daughter.”7

A judge ordered that life support be removed, and on January 24, 2014, both mother and baby died.

While many commentators stated that it was virtually impossible for a pregnant mother declared brain dead to deliver a healthy baby, a 2010 British Medical Journal study reported that “In 12 (63%) of 19 reported cases, the prolonged somatic support [of the mother declared brain dead] led to the delivery of a viable child.”8

In the Muñoz case, virtually all pro-life and Catholic ethicists agreed that giving the unborn child at least a chance to be born was the ethically correct position. And, of course, birth defects do not make a baby unadoptable.

Confusion Among Catholics

The controversy about brain death has been simmering among Catholic ethicists, medical experts, and theologians for many years.

It all started with a 1968 Harvard paper titled “A Definition of Irreversible Coma — Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death.”9 Within a very few years, all 50 states included brain death in the legal definition of death. This allowed brain death criteria to be used for the purpose of organ transplantation. Before this, organ transplantation was virtually impossible in patients declared dead by the traditional standard of irreversible cessation of breathing and heartbeat. In those cases, vital organs were too damaged by lack of blood flow and oxygen to be useful. Brain death allowed organs to be harvested while a ventilator supported breathing and the heart was still sending blood to vital organs.

In 1975, the Committee on Health Affairs of the United States Catholic Conference issued “Guidelines for the Determination of Brain Death,” which concluded that criteria for brain death to provide “moral certainty” of brain death were “morally sound and acceptable.” In 1981, the Pontifical Council “Cor Unum” stated that the determination of the moment of death is a medical, not a theological, judgment.10

The Pontifical Academy of Science studied the question of determination of death in 1985 at the request of Pope John Paul II. The Academy concluded “From the debate it emerged that cerebral death is the true criterion of death, since the definitive arrest of the cardiorespiratory functions leads very quickly to cerebral death.”11  Apparently searching for greater clarity, Pope John Paul II raised the question again with the Pontifical Academy in 1989. The Academy reached the same conclusion.

In 1995, the Pontifical Council for Pastoral Assistance to Health Care Workers under Fiorenzo Cardinal Angelini issued its Charter for Health Care Workers. The legitimacy of neurological criteria was accepted by this body as well, and it concluded, “When total cerebral death is verified with certainty, that is, after the required tests, it is licit to remove organs and also to surrogate organic functions artificially in order to keep the organs alive with a view to a transplant.”12

In 2000, Pope John Paul II gave an address to a Vatican conference on organ donation where he stated:

Here it can be said that the criterion adopted in more recent times for ascertaining the fact of death, namely the complete and irreversible cessation of all brain activity, if rigorously applied, does not seem to conflict with the essential elements of a sound anthropology. Therefore a health-worker professionally responsible for ascertaining death can use these criteria in each individual case as the basis for arriving at that degree of assurance in ethical judgment which moral teaching describes as “moral certainty.” This moral certainty is considered the necessary and sufficient basis for an ethically correct course of action. Only where such certainty exists, and where informed consent has already been given by the donor or the donor’s legitimate representatives, is it morally right to initiate the technical procedures required for the removal of organs for transplant.13

Nonetheless, the Pontifical Academy of Sciences published a statement in 2008 under the title “Why the Concept of Brain Death Is Valid as a Definition of Death.”14

In November 2008, Pope Benedict XVI gave an address to a prestigious international conference on organ transplants in which he stated:

In an area such as this, in fact, there cannot be the slightest suspicion of arbitration and where certainty has not been attained the principle of precaution must prevail. This is why it is useful to promote research and interdisciplinary reflection to place public opinion before the most transparent truth on the anthropological, social, ethical and juridical implications of the practice of transplantation. However, in these cases the principal criteria of respect for the life of the donator must always prevail so that the extraction of organs be performed only in the case of his/her true death.15

In the meantime, other respected Catholic doctors and ethicists like Paul Byrne MD, Alan Shewmon MD, and E. Christian Brugger PhD, as well as other doctors, nurses, and ethicists raised alarms about the validity of brain death criteria, including the lack of standards for testing from one hospital to another and the continued survival of some patients declared brain dead for years. They cite cases where such patients grew, achieved puberty, gestated their unborn baby for months, etc., as well as the reported cases of recoveries like Zach Dunlop’s.

In response to the paucity of such critiques at Vatican conferences, a conference called “Signs of Life,” featuring critics of brain death from all over the world, was held near the Vatican in February 2009.16

Now with more and more people alarmed about the issue of brain death, especially when organ transplantation is involved, it seems that the controversy is far from over.

Personal observations

Back in the 1970s when I was a young intensive care unit nurse, no one I knew questioned the new innovation of brain death. We trusted the experts.

However, as the doctors diagnosed brain death in our unit and we cared for these patients until their organs were harvested, some of us became uncomfortable. For example, doctors told us that these patients would die anyway within two weeks even if their ventilators were continued, but no studies were cited. I asked many questions but was told that greater minds than mine had it all figured out. It was years before I realized that these doctors did not have the answers to my concerns either.

Over the ensuing years, I began to see many more changes in brain death diagnosis and organ transplantation that alarmed me.

These include the innovation in the 1990s of Donation after Cardiac Death (DCD, formerly known as non-heart beating organ donation), in which brain death need not be determined but instead is based on when (or if) a critically ill — but not brain dead — patient stops breathing within an hour after the ventilator is removed with the agreement of the family.

While the general public is mostly unaware of DCD, such organ donor protocols are now policy in both Catholic and secular hospitals. Ironically while so many Catholic ethicists and conferences endorse brain death as the true standard for death, the lack of brain death standards in DCD is virtually ignored. One of the innovators of DCD organ transplantation, Dr. Michael DeVita, even admitted “the possibility of [brain function] recovery exists for at least 15 minutes” after heartbeat and breathing stops but stated that “the 2-minute time span (before organ removal) probably fits with the layperson’s conception of how death ought to be determined.”17

It is frightening but perhaps illuminative that one of the first known potential DCD donors was a conscious woman with severe multiple sclerosis who requested that her ventilator be removed and that her organs be taken when she stopped breathing.18 (In the end, like a significant number of other DCD donors,19 she continued to breathe for too long for her organs to be usable.)

Other developments and proposals were also disturbing: Paying living donors for organs, presumed consent so that only people who signed a paper saying that they did not want their organs taken were exempt, some doctors in Belgium touting their success pairing assisted suicide/euthanasia with organ transplantation20 and even some ethicists proposing that the dead donor rule itself be eliminated in order to get more organs to transplant.21 The dead donor rule is an ethical norm that states that the donor must be dead before organs are harvested and the harvesting itself must not cause the death of the donor.22

On the other hand, I also saw cases where families were told that their loved one was brain dead for the purpose of withdrawal of treatment, not organ transplantation. When I pointed out that some of these patients continued to breathe on their own after the ventilator was removed and thus were obviously not brain dead by any criteria, I was often met with shrugs and comments like “close enough” or “she was going to die soon anyway.” Attitudes like that chilled me to the bone. It seemed that pessimism, hubris, and misplaced sympathy — rather than evil intent — trumped ethical integrity. The secular media often echoes this apathy, especially when it erroneously equates coma or the so-called “vegetative state” with brain death itself. The result can be lethal.

After years of study and prayer, my personal stand is rejection of two extremes: that brain death is settled science and ethics that no one dare even question; and that withdrawal of ventilators with or without organ donation is always tantamount to murder.

I believe that ventilators, like all other forms of treatment, are subject to the same traditional principle: Treatments that are futile in terms of survival or unduly burdensome to the person can be ethically withdrawn according to strict principles ensuring that death is not intended. I believe in the traditional hospice philosophy to neither hasten nor prolong death.

Personally, I have not signed a standard organ donor card because the wording is so vague (death, not brain death or DCD, is all that is mentioned) and in some states that card can even automatically override family decision-making. I have told my family that I agree to the donation of every tissue that can be used after a careful determination of natural death. Tissues like corneas, heart valves, bone, and skin are not dependent on immediate harvesting after determination of death.

I do not take this position lightly. Right now, I have a daughter-in-law who is in desperate need of a kidney transplant, the most common transplant. She has studied the issue and told her doctors that she wants a living donor. Living donors are generous family members, friends, or even strangers who willingly offer one of their two kidneys for transplant after testing for compatibility.

My daughter-in-law’s decision was based not only on ethical concerns about brain death and non-heart beating organ donation but also on the facts that organ availability is greater with living donor kidneys and that such kidneys last almost twice as long as cadaver kidneys and work immediately.23

Unfortunately, it is uncertain whether the controversy over brain death or even DCD will ever be completely resolved, even within the Catholic community of experts and authorities. However, I do have hope that the issue of organ transplantation that is such a prime motivator of brain death determination and DCD may someday become moot.

Not only have treatments like adult stem cell transplants and improved therapies helped many people with end-stage organ disease survive, but great strides are being made toward developing artificial organs. For example, just last year scientists in Australia grew a tiny but functioning kidney using human skin cells.24 If a person’s own cells can be used to grow an organ, that could eliminate the rejection problem that causes so many transplants to fail, as well as the need for the current powerful and expensive drugs used to prevent rejection.

In the meantime, there must be the honest, respectful discussion about the critical issues of brain death, DCD, and organ donation, based on the highest ethical principles and scrutiny.

Notes:

1 “Jahi McMath and Catholic Teaching on Determination of Death.” National Catholic Bioethics Center Resources. January 7, 2014. ncbcenter.org/resources/jahi-mcmath-and-catholic-teaching-on-the-determination-of-death.

2 “Ethicists criticize treatment of teen, Texas patient” by Liz Szabo. USA Today. January 10, 2014. usatoday.com/story/news/nation/2014/01/09/ethicists-criticize-treatment-brain-dead-patients/4394173/.

3 “‘She’s Still Asleep,’ Jahi McMath’s Mother Says of Brain-Dead Daughter” by Lisa Fernandez. Friday, Mar 28, 2014. NBC Bay Area. nbcbayarea.com/news/local/Shes-Still-Asleep-Jahi-McMaths-Mother-Says-of-Brain-Dead-Daughter-252700851.html.

4 Ibid

5 “Was Zack Dunlap’s Recovery a Miracle?” by Nancy Valko, RN. Voices. Pentecost 2008. wf-f.org/08-2-Valko.html.

6 “Brain-Dead Marlise Munoz’s Fetus Is ‘Distinctly Abnormal.’ Please, Texas, Let This Nightmare End” by Emily Bazelon. Slate. January 23, 2014. slate.com/blogs/xx_factor/2014/01/23/marlise_munoz_case_the_ fetus_of_a_brain_dead_texas_woman_is_said_to_be_distinctly.html.

7 “Husband of brain dead woman who sued to have pregnant wife’s life support turned off may be forced to pay for her hospital stay” UK Daily Mail. February 2, 2014. dailymail.co.uk/news/article-2550352/Marlise-Munoz-case-Husband-brain-dead-woman-sued-pregnant-wifes-life- support-turned-forced-pay-hospital-stay.html.

8 “One life ends, another begins: Management of a brain-dead pregnant mother-A systematic review.” by Majid Esmaeilzadeh, Christine Dictus, Elham Kayvanpour, et al. BMC Medicine. 8:74, 2010. biomedcentral.com/1741-7015/8/74.

9 “A Definition of Irreversible Coma-Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death.” Journal of the American Medical Association. August 5, 1968, 205(6): 337-340. hods.org/english/h-issues/documents/ADefinitionofIrreversibleComa-JAMA1968.pdf.

10 “Catholic Teaching Regarding the Legitimacy of Neurological Criteria for the Determination of Death” by John M. Haas, PhD, STL, KM. National Catholic Bioethics Center Quarterly. Summer 2011. Reprinted on CatholicCulture.org: catholicculture.org/culture/library/view.cfm?id= 9719.

11 Ibid.

12 Ibid. (Cf. FAQ on “Brain Death”: ncbcenter.org/page.aspx?pid=1285# receiveOrgan).

13 Address to the 18th International Congress of the Transplantation Society. Pope John Paul II, August 29, 2000, §5. vatican.va/holy_ father/john_paul_ii/speeches/2000/jul-sep/documents/hf_jp-ii_spe_ 20000829_transplants_en.html. Also here, including comments on cloning: ncbcenter.org/page.aspx?pid=1236.

14 “We need to achieve a convergence of views and to establish an agreed shared terminology. In addition, international organizations should seek to employ the same terms and definitions, which would help in the formulation of legislation.” On the Pontifical Academy of Sciences website: casinapioiv.va/content/accademia/en/publications/extraseries/brain death.html.

15 “Address of His Holiness Benedict XVI to Participants at an International Congress Organized by the Pontifical Academy for Life.” November 7, 2008. vatican.va/holy_father/benedict_xvi/speeches/2008/november/documents/hf_ben-xvi_spe_20081107_acdlife_en.html.

16 “‘Brain Death’ is Life, Not Death: Neurologists, Philosophers, Neonatologists, Jurists, and Bioethicists” by Hilary White. LifeSiteNews.com. February 26, 2009. lifesitenews.com/news/archive/ ldn/1990/22/9022604.

17 “The Death Watch: Certifying Death Using Cardiac Criteria” by Michael A. DeVita, MD, University of Pittsburgh Medical Center. Prog Transplant 11(1):58-66, 2001. (Cf. Valko, “Organ Donation: Crossing the Line.” Voices. Advent-Christmas 2011: wf-f.org/11-4-Valko.html).

18 Michael A. DeVita and James V. Snyder, “Development of the University of Pittsburgh Medical Center Policy for the Care of Terminally Ill Patients Who May Become Organ Donors after Death Following the Removal of Life Support” in Procuring Organs for Transplant. Robert M. Arnold, et al, eds. Baltimore: Johns Hopkins University Press, 1995.

19 “Organ Procurement after Cardiocirculatory Death: A Critical Analysis,” Mohamed Y. Rady, MD, PhD; Joseph L. Verheijde, PhD, MBA; and Joan McGregor, PhD. Journal of Intensive Care Medicine. 23(5), 2008. jic.sagepub.com/cgi/reprint/23/5/303.pdf.

20 “Initial Experience with Transplantation of lungs recovered from Donors after Euthanasia,” by D. Van Raemdonck, et al. Applied Cardiopulmonary Pathophysiology. 15:38-48, 2011. applied-cardiopulmonary-pathophysiology.com/fileadmin/downloads/acp-2011-1_20110329/05_vanraemdonck.pdf.

21 “The Dead-Donor Rule and the Future of Organ Donation,” by Robert D. Truog, MD; Franklin G. Miller, PhD; and Scott D. Halpern, MD, PhD. New England Journal of Medicine. 369:1287-1289, 2013. nejm.org/doi/full/10.1056/NEJMp1307220.

22 “Is Organ Procurement Causing the Death of Patients?” by James Dubois. Issues in Law and Medicine. 18(1):21-41. citations.duhaime. org/I/IssuesLMed.aspx 21 (2002-2003); cited in “Dead Donor Rule Definition,” duhaime.org/LegalDictionary/D/DeadDonorRule.aspx.

23 “Living Donor Kidney Transplant,” Barnes Jewish Hospital. barnesjewish.org/living-donor-kidney-transplant.

24 “Kidney grown from stem cells by Australian scientists,” by Jonathan Pearlman. The Telegraph. December 13, 2013. telegraph.co.uk/ news/worldnews/australiaandthepacific/australia/10520058/Kidney-grown-from-stem-cells-by-Australian-scientists.html.

***

Nancy Valko, a registered nurse from St. Louis, is a spokesperson for the National Association of Pro-Life Nurses and a Voices contributing editor. She and her family live in St. Louis.

National Catholic Register 1996: Anencephaly Newest Frontier in Prenatal-Testing, Abortion Battle

Anencephaly Newest Frontier in Prenatal-Testing, Abortion Battle

Sunday, Nov 10, 1996 2:00 PM Comment

EVERY YEAR in the United States, approximately 800 babies are born with a birth defect known as anencephaly. It is a condition where, early in pregnancy, an error in development occurs which prevents the top portion of the brain and skull from forming correctly. Such babies have only a brain stem in place of the entire brain and lack part of the skull. Despite the severity of the defect, about half of such babies are born alive. However, almost all die shortly after birth, with only a rare few living months or years.

In years past, anencephaly was not detected until birth. However, with the advent of routine ultrasound and a newer blood test for the mother called AFP screening, the condition can often be detected during pregnancy.

Although abortion for unborn babies with terminal illness or disabilities has long been condemned by the Catholic Church, in the past few years some ethicists have developed a rationale by which pregnancies involving babies with anencephaly could be terminated by inducing labor as soon as the diagnosis is made.

Such terminations are called “early inductions of labor”rather than abortions by proponents, as anencephaly is usually not discovered until midway through the pregnancy. As justification, these ethicists have cited the possibility of difficulties during labor and delivery, the emotional trauma of the parents, and the apparent absence of mental development in babies who have the fatal condition. Reports of such terminations occurring at Catholic hospitals have prompted anger in the pro-life movement and calls for reexamination of the issue by other ethicists and doctors.

In an ironic twist, at the same time these ethicists were proposing ending anencephalic pregnancies prematurely, the Council for Ethical and Judicial Affairs of the American Medical Association (AMA) proposed the continuation of such pregnancies at the parents’ discretion so that the babies’ organs could be harvested shortly after birth and before death. Earlier this year, the council reluctantly withdrew its proposal after strong opposition from AMA members, legal experts, pro-lifers, and parents of infants with anencephaly. These critics argued that taking organs before death should remain legally and ethically forbidden.

Moral Principles

In a definitive statement issued Sept. 16, 1996 and titled “Moral Principles Concerning Infants with Anencephaly,”the National Conference of Catholic Bishops (NCCB) Committee on Doctrine condemns both practices. The NCCB statement reaffirms the Church’s position that “it can never be morally justified directly to cause the death of an innocent person no matter the age or condition of that person.”

Specifically, the Committee on Doctrine states: “The fact that the life of a child suffering from anencephaly will probably be brief cannot excuse direct causing death before ‘viability'(the ability of a baby to live outside the womb) or gravely endangering the child’s life after ‘viability’ as a result of the complications of prematurity.”

As the statement points out, while it is permitted to treat a life-threatening pathology of the mother even when this has the unintended side-effect of causing the death of her child, “[a]nencehpaly is not a pathology of the mother, but of the child, and terminating her pregnancy cannot be a treatment of a pathology she does not have.”

Because the child has an ultimately fatal condition, the statement says that babies with anencephaly “should be given the comfort and palliative care appropriate to all the dying” but that “extraordinary means to prolong life”can be foregone.

The statement also recognizes that while a wish to help other children by donating organs from babies with anencephaly is commendable, “this may never be permitted before the donor child is certainly dead.”

In the August 1996 issue of the Linacre Quarterly, Father Kevin O’Rourke, director of the Center for Health Care Ethics at St. Louis University, reversed his previously held opinion that premature delivery for unborn babies with anencephaly was justified. He now states that “because intervention in the pregnancy of an anencephalic infant results in a direct killing of an innocent human being, the only suitable, ethical opinion seems to be to allow the pregnancy to go to term, …”thus concurring with the NCCB Committee on Doctrine’s conclusions.

Prenatal Testing and Anencephaly

With the advent of prenatal testing, particularly AFP or “triple screen”testing of the mother’s blood, more and more parents are faced with the possibility of learning before birth that their baby has anencephaly or other birth defects. In 1994, the American College of Obstetricians and Gynecologists officially recommended that a “triple screen”test of the mother’s blood be offered to pregnant patients of all ages.

This implies a legal mandate to practicing physicians who cannot afford the liability of not offering such a test after a national recommendation has been made. This has resulted in “triple screen”testing becoming a common routine during pregnancy.

The “triple screen”test is done around 16-18 weeks into pregnancy when levels of certain substances produced by the baby can be detected in the mother’s blood. An abnormally high result suggests such conditions as anencephaly or spina bifida (an opening in the spine). An abnormally low result primarily suggests Down’s syndrome.

However, the rate of false-positive results is quite high and the vast majority of women with abnormal test results will be carrying perfectly healthy babies. Further testing is supposed to be recommended when an abnormal result is obtained, but there have been reports of mothers being offered the option of abortion after only the initial test.

Routine “triple screen”testing remains controversial. The anxiety engendered in pregnant women by abnormal but usually false-positive test results, the financial cost of testing all pregnant women as well as the costs of retests, and the implicit support for aborting so-called “defective” infants have spawned criticism of this policy. Supporters of the policy point to the potential cost savings of abortion over the costs of caring for infants with severe birth defects and the parents’ right to know all information currently available as justifying the policy.

As the 1987 Congregation for the Doctrine of the Faith’s document Donum Vitae makes clear, the Church’s position is that prenatal testing which does not pose disproportionate risks to the unborn child or mother is permitted if the intention is not to abort but rather to safeguard or heal the child.

Nancy Valko, R.N., is based in St. Louis, Mo.

2009 Mercatornet: Have death panels already arrived?

Have death panels already arrived?

The case against: an experienced nurse worries that Obamacare will entrench an existing quality-of-life ethic.

Nancy Valko | Nov 12 2009 | comment

Medical ethics are concerned with care for a patient’s welfare, something huge institutions are not very good at. The controversy about “death panels” in proposed health care reform legislation is to be expected. As a nurse, despite all the soothing noises from the Obama administration, I do believe there is cause for serious concern.
For example, Compassion and Choices (the name of the pro-euthanasia Hemlock Society after its merger with another “right to die” group) boasted that it “has worked tirelessly with supportive members of Congress to include in proposed reform legislation a provision requiring Medicare to cover patient consultation with their doctors about end-of-life choice.”

“End-of-life choice” might have been an innocent term a generation ago, but now in three American states “end-of-life choice” includes legal assisted suicide. No wonder people were worried when they read these words in HR 3962 (also known as the Pelosi bill). It even includes a whole section on “Dissemination of Advance Care Planning Information” that is problematic and misleading.

In addition, although the idea of health care rationing was originally dismissed as a myth, ethicists and the mainstream media admit that health care rationing is necessary. Government committees have been proposed to set rules for health care services.

Is ethical health care reform needed? Of course. In 2003, I was privileged to serve on a Catholic Medical Association task force on health care reform. Many good ideas, such as health-savings accounts, ways to help the uninsured poor, and strong conscience-rights protections, were discussed. The results were published in a 2004 report entitled “Health Care in America: A Catholic Proposal for Renewal”. The Obama Administration has rejected most of these proposals.

Ethics and health care reform

Since I first started writing about medical ethics and serving on hospital ethics committees, I have seen ethics discussions evolve from “what is right?” to “what is legal?” to “how can we tweak the rules to get the result we think is best?” This attitude is not very reassuring when we are considering a massive overhaul of the US health care system.

Former vice-presidential candidate Sarah Palin has been ridiculed for coining the term “death panels”. But it resonated with me. In 1983 my daughter Karen was born with Down syndrome and a severe heart defect. Even though Karen’s father and I were told that her chances for survival were 80 to 90 percent after open heart surgery, we were also told that the doctors would support us if we refused surgery and “let” Karen die. We refused to allow such medical discrimination against our daughter.

Later on we were shocked to learn that one doctor had written a “do not resuscitate” order without our knowledge. Apparently he thought I “was too emotionally involved with that retarded baby”.

In later years, I was asked if I was going to feed my mother with Alzheimer’s. And then, after my oldest daughter died from an apparently deliberate drug overdose, I was told that it is usually a waste of time to save suicide attempters.

Did evil people say these things? No. These doctors and nurses were otherwise compassionate, caring, health care professionals. But they are just as vulnerable as the general public to the seductive myth that choosing death is better than living with terminal illness, serious disability or poor “quality of life”.

When government committees and accountants take over health care, will things get better?

Common sense and ethics

Health care does not occur in a vacuum. Real people — patients, families and health care providers alike — are affected when economics and new ethical rationales trump basic needs. The Good Samaritan did not ask whether the man lying on the road had health insurance. The Hippocratic Oath established a sacred covenant between doctor and patient, not health care rationing protocols. I strongly disagree with ethicists who contend that new technologies and economics demand new ethics.

I am tired of hearing some of my medical colleagues talk about patients who “need to die”. I am saddened to hear many of my elderly, frail patients fret about being an emotional and financial burden on their families. I am outraged when I read editorials arguing that those of us who refuse to participate in abortion or premature death should find another line of work.

I recently attended a 40th anniversary nursing school reunion. We remarked on how much has changed. Some things are better — uniforms, equipment and technologies, for example. But some things are worse, especially ethics.

People are often surprised that even back in the late 1960s, we had do-not-resuscitate orders and spoke to families about forgoing aggressive medical treatment when patients seemed to be on the terminal trajectory to death.

But, unlike today, we did not immediately ask them whether we could withdraw food, water and antibiotics to get the death over with as soon as possible. Back then, we were often surprised and humbled when some patients recovered. Today, too many patients don’t even get a chance. Doctors and nurses are too quick to give up hope.

Back then, ethics was easily understood. We didn’t ever cause or hasten death. We protected our patients’ privacy and rights. We were prohibited from lying or covering up mistakes. We assumed that everyone had “quality of life”; our mission was to improve it, not judge it.

Medical treatment was withdrawn when it became futile or excessively burdensome for the patient — not for society. Food and water was never referred to as “artificial” even when it was delivered through a tube. Doctor and nurses knew that removing food and water from a non-dying person was as much euthanasia as a lethal injection.

“Vegetable” was a pejorative term that was never used in front of patients or their families. And suicide was a tragedy to be prevented, not an alleged constitutional right to be assisted by doctor and nurses.

Today we have ethics committees developing futility guidelines to overrule patients and/or their families even when they want treatment continued. We have three states with legal assisted suicide. We have even non-brain dead organ donation policies (called non-heartbeating organ donation or donation after cardiac death). Some ethicists even argue that we should drop the dead donor rule.

We see living wills and other advance directives with check-offs for even basic medical care and for incapacitated conditions like being unable to regularly recognize relatives. We are willing to sacrifice living human beings at the earliest stages of development to fund research for cures for conditions like Parkinson’s rather than promote research on ethical and effective adult stem cell therapies.

We are inspired by the Special Olympics but support abortion for birth defects. We now talk about a newborn child as another carbon footprint instead of as a blessing and sacred responsibility.

I could go on and on but I think you get the idea.

Death panels are not the overwrought fantasy of right-wing nut cases. Real “death panels” are already at work. They have been created by apathy, misplaced sympathy, a skewed view of tolerance and an inordinate fear of a less than perfect life. Death panels? In the famous words of the comic strip character Pogo, “We have met the enemy and he is us.”

Nancy Valko is president of Missouri Nurses for Life and a spokeswoman for the National Association of Pro-life Nurses.

2006 Voices: The “Secret of Life”

Voices Online Edition Vol. XXI No. 4
Christmas 2006 – Epiphany 2007

The “Secret of Life”

by Nancy Valko, RN

The first thing I noticed about my elderly patient was her radiant smile. Most of my patients are groggy or anxious after even a routine surgery but this tiny lady was fully awake and entirely comfortable even after her major surgery.

As the night went on, Esther* (*all names of former patients have been changed for privacy) continued to do well, even better than most of my younger patients with the same surgery.

I was impressed but it was the story she had to tell that made her truly unforgettable.

When she was a young woman, Esther was delighted to find out that she and her husband were finally expecting a child. The pregnancy progressed uneventfully until delivery. It was only then that it was discovered that her baby was growing outside her womb. Not many babies survive in those circumstances even today, but Esther’s baby was born a healthy little boy. Even though Esther lost her reproductive organs in the process, she felt blessed by her one “miracle child”, Ethan.

The little boy grew, both in size and character and he was a great comfort to her when she lost her husband.

Then the war came. Esther was terrified when Ethan volunteered for the army. She talked to his recruiter and emphasized that Ethan was all she had. The recruiter promised her that Ethan would be stationed far away from the active fighting.

Unfortunately, death still found Ethan. He died in an apartment fire while saving a baby. Esther’s grief was mixed with pride in her son.

I asked Esther how she coped after suffering such a devastating loss and shared how I too had lost a precious child. She turned the question back on me. I blurted out that I both prayed a lot and laughed a lot, I said. “Exactly!” Esther exclaimed. “That’s the secret of life!”

I’ve thought a lot about Esther since then and how these two “secrets of life” work in my own life but I’ve come to the conclusion that there is a third “secret” that is just as important as the other two.

PRAY A LOT

The importance of prayer cannot be overestimated but I know from experience how hard prayer can be at times.

Personally, my transition from being a stay-at-home mom to a working mom as a result of divorce was frequently overwhelming. In the middle of this, my mother developed Alzheimer’s and, soon after, terminal cancer. Going through a painful divorce, dealing with a lack of consistent childcare, working at multiple jobs, and dealing with chronic exhaustion often left me too drained to formally pray. I tried to offer up all these problems and I did ask friends to pray when I just couldn’t. This did help a bit but it was my friend Marcia who had the best suggestion: pray the rosary daily. At first, I couldn’t imagine adding dozens of prayers at a time when I had trouble even getting through one prayer but I decided to try Marcia’s suggestion anyway.

Initially, I dozed off by the first Joyful Mystery but I rationalized that at least the rosary was proving to be a good sleeping pill.

Slowly but surely, I found ways to incorporate the rosary into my life while driving, walking or doing housework. Soon I began feeling calmer, more hopeful and, best of all, closer to my role model Mary. The repetition of the Hail Mary became a kind of soothing and calming mantra.

In the end, the storm of disasters ended but I still try to say the rosary daily. I now actually feel deprived if I miss saying the rosary, even for one day. And I now realize how truly blessed I’ve been, even during the toughest times.

LAUGH A LOT


After my daughter Karen died, I started working with other bereaved parents who had lost a child with a disability.

Lana was one of those parents. She had lost a little boy with Down Syndrome by sudden death and she was devastated. We talked almost daily but, despite keeping her job and family together, she felt she wasn’t handling her loss well enough.

Lana was surprised when I asked her if she had laughed since her son’s death. Almost apologetically, she revealed that she had laughed at a TV show just the night before.

Laughter, I told her, was the first sign of healing. Eventually Lana came to understand that she didn’t have to hold on to the pain to hold on to the memories of her beloved child. She finally reached the stage where her son’s life instead of his death became her most important memory and she was finally able to allow herself to laugh and enjoy her life.

Over the years, I have come to appreciate the power of even the smallest moments of humor we can find in the middle of tough times. Such humor renews our spirit and perspective.

For example, the first Christmas after my ex-husband left had the potential to be very sad. However, one day during Advent, a group of people from our parish came with a Christmas tree and gifts for all of us. I was touched and a little embarrassed but I noticed that my 10-year-old son was watching with horror on his little face. He knew that our parish did this for the inner city families every year and he whispered, “Mom, are we poor?” I smiled, put my arms around him and said, “Steve, we are very rich in love.”

“Oh, no!” he exclaimed. “That means we’re really poor!”

That comment made all of us crack up with laughter and, more importantly, lifted the pall that had settled over our little family. We had a really good Christmas that year and my son’s comment became a running family joke.

THE THIRD SECRET: FORGIVE


The last “secret of life” is by far the hardest but it is indispensable for a happy life.

“I’ll never forgive him! He ruined my life.” One of my children found it especially hard to live a different kind of life after her father left. She understood that her father had an especially severe mental illness but that fact wasn’t very comforting to her. She was still hurting from her father’s absence.

I encouraged her to pray for her father but she found that impossible unless, as the Bible says, it is like “heaping hot coals” on an enemy’s head. I told her that, as I learned the slow way, forgiveness is a decision — not a feeling. The feeling of forgiveness may come later but at least in the beginning, it is the decision to forgive that is critical.

Even if someone doesn’t mean to hurt us, words and actions can still cause excruciating pain. It is the power of the forgiveness decision that is able to give us at least some relief from the pain and keep us from spreading bitterness.

Forgiveness becomes harder but even more important when the person we have to forgive is ourself.

I learned this firsthand when I was a new nurse caring for a teenage drunk driver. After more than a few beers, Sam swerved into a car containing a young couple and their two children. The wife was dead instantly but our ICU received all the other victims. We were heartbroken when we couldn’t save the children and their father was hanging on by just a thread.

So it was hard not to be outraged when Sam, the 17-year-old drunk driver, was demanding and even abusive to the staff while we treated his more minor injuries. He was going to recover but the young father probably wouldn’t.

Sam was assigned to me and, sure enough, he continued his appalling behavior. I set limits on his nastiness but I still tried to care for him with as much compassion as I could muster. Surprisingly, near the end of my shift, Sam broke down and sobbed, “Why don’t you hate me? I hate myself!”

It turned out that Sam wanted to be punished and his actions were designed to push people away. We talked for a long time about how his self-destruction from guilt would only add more tragedy to an already tragic situation.

Sam had to learn to forgive himself to be able to turn his life around and allow some good to result.

Bad things do happen to good people. Sometimes the bad things happen as a result of sin or avoidable mistakes and sometimes the bad things happen despite all precautions and good intentions.

The important thing to remember is that God is always on our side and that it is not so much what happens to us but rather how we deal with our experiences that can make the difference between being a survivor who thrives or just being a victim.

Nancy Valko, a registered nurse from St. Louis, is president of Missouri Nurses for Life, a spokesperson for the National Association of Pro-Life Nurses and a Voices contributing editor.

**Women for Faith & Family operates solely on your generous donations!

WFF is a registered 501(c)(3) non-profit organization. Donations are tax deductible.

Voices copyright © 1999-Present Women for Faith & Family. All rights reserved.

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2003 Voices: Are Pro-Life Healthcare Providers Becoming an Endangered Species?

Voices Online Edition
Medicine and Morality
Vol. XVIII: No. 2 – Pentecost 2003
VOCATIONS ISSUE

Are Pro-Life Healthcare Providers Becoming an Endangered Species?
by Nancy Valko, RN

At the urging of Planned Parenthood, the Nevada state Assembly approved an amendment in April to stop pharmacists with religious objections from refusing to fill prescriptions for any drug, including abortifacient contraceptives and the so-called “morning after” pill.1 New York City hospitals now require abortion training for all their OB/GYN resident doctors unless they invoke a narrowly written conscience clause.2,3 The Oregon Nursing Association has issued guidelines for assisted suicide that prohibit nurses from making “unwarranted, judgmental comments or actions” to patients, families or other colleagues when patients decide to kill themselves with doctor-prescribed lethal overdoses.4

Slowly but surely, more and more pro-life doctors, nurses and other healthcare professionals are getting the message that they and their views are unwelcome in today’s health care system. But these public items tell only a small part of the story. Intimidation, harassment and coercion are becoming increasingly common as pro-life health care providers try to advocate for both their patients and their professional ethics.

For example, a nurse was threatened with firing after she refused to follow a doctor’s verbal order to increase an intravenous morphine drip “until he stops breathing” on a patient who continued to survive despite having a ventilator removed. An OB/GYN physician was told by other doctors that they would no longer refer patients to him if he continued to sign an annual pro-life ad. Three California nurses were suspended after they reported a doctor who later admitted giving a lethal injection to a child. An insurance company executive speaking on ethics committees at a conference recommended that such committees avoid appointing “family values” members.

Unfortunately, these reprehensible acts are not confined to just secular health care institutions.

A dedicated nurse who cared for elderly nuns in a Catholic facility for over a decade was told she could resign when she objected to the slow starvation and dehydration deaths of two of her beloved nuns. Several doctors and nurses working at Catholic hospitals have personally told me about similar incidents, including other supposedly prohibited actions such as sterilizations, referrals to Planned Parenthood and even some abortions. Amazingly, hospital administrators often told them that these procedures were ethically allowed according to some prominent Catholic ethicists.

Years ago when I was the co-chair of the St. Louis Archdiocesan Pro-Life Committee, I was asked by the late Archbishop May why I didn’t work as a nurse at a Catholic institution. He was shocked when I told him that I felt safer at a secular institution that at least understood the implications of conscience rights rather than at a Catholic institution, which could try to talk me out of them.

I wasn’t kidding.

THE SLIPPERY SLOPE
Before the invention of the Pill and the legalization of abortion, medical ethics principles were relatively simple, unambiguous and, with few exceptions, followed by doctors and nurses. The Hippocratic oath prohibiting abortion and euthanasia was a mainstay of medical education.

However, the beginnings of a drastic change started with the furor over the invention of the Pill and accelerated when the American College of Obstetricians and Gynecologists (ACOG) allowed the redefinition of conception from fertilization to the later implantation of the embryo into a woman’s uterus, thus blurring the distinction between contraception and abortion by ignoring scientific fact.5

The American Medical Association (AMA) softened its long-standing opposition to abortion as state laws on abortion were being relaxed in the 1960s and 1970s. After the 1973 Roe v. Wade decision, the AMA declared abortion to be an ethical healthcare procedure and now opposes almost any restrictions on abortion practice.

With legality rather than principle becoming a deciding factor in medical ethics, the standard of the Hippocratic oath had to be revised and now it is rarely used at all. Both the prohibition of abortion and euthanasia in the oath as well as the sacred commitment of the doctor to the individual patient were seen as obstacles to a more “enlightened” and modern healthcare system. Healthcare is now seen by many as an important part of societal reform to a more “inclusive” and less “judgmental” culture.

Thus, it is not surprising that pro-life health care providers are now portrayed as divisive to their professions and even a threat to patients’ rights when they refuse to conform to the Culture of Death.

When the infamous Roe v. Wade decision on abortion was handed down, it was assumed that healthcare providers would not be forced to participate in abortion. However, the reality of legalizing abortion soon led many states to pass conscience rights legislation on abortion to protect doctors and nurses who object. Unfortunately, this still has not adequately protected doctors and nurses from intimidation, harassment or from obstacles to career advancement because they do not provide what is now called “full service” on “reproductive rights”.

Many pro-life healthcare providers thought they would be safe if they chose a specialty other than OB/GYN or labor and delivery. But with the court decisions and laws legalizing the withdrawal of basic medical treatment, the acceptance of terminal sedation as comfort care, the legalization of assisted suicide in Oregon and the push for such laws in other states, etc., there is now almost no area of medicine where a pro-life healthcare provider can avoid ethical dilemmas.

And instead of unity, the medical professions have now become virtual war zones with many ethical doctors and nurses reluctant to even express their views or reveal that they are pro-life. Unfortunately, the healthcare professions, which rely on universal standards to protect both their members and the public, cannot long be trusted when their members can have diametrically opposed views on life and death. Coexistence of such disparate views ultimately becomes impossible because, as the Bible says, a man cannot serve two masters and must eventually choose one over the other. Thus, conscience rights help but they are not enough.

CONCLUSION
Pro-life healthcare providers are becoming a thin, white-coat line trying to protect both their patients and the public from an ever-expanding Culture of Death. And without such people of principle, there is no possibility of maintaining a pro-life movement.

With the current “politically correct” view that people should not judge the actions of others and the rise of moral relativism in all areas of personal ethics, far too many people are being intimidated into silence or despair. But we must remember that we are called to be persistent and that the ultimate success is God’s.

And there are already glimmers of hope. For example, the efforts of disability, pro-life and other organizations have so far helped to defeat efforts to legalize Oregon-style assisted suicide in other states. The courage of Jill Stanek, the nurse who exposed the scandal of neglecting newborn abortion survivors to death in her hospital and was finally fired, has led to President Bush signing the Born-Alive Infant Protection Act this year. The incident of the nurse who refused to increase a morphine drip to euthanize a patient opened many eyes among her colleagues and recently an entire division of nurses refused to follow a doctor’s order to use morphine to terminally sedate a patient-and the doctor backed down.

The reform of medical ethics has to come from both inside the medical profession and from the public. It is only when the highest standards are insisted upon that the ongoing corruption of the healthcare professions can be stopped and trust restored.

But first we must all accept the fact that evil never limits itself and always seeks to expand. Now is the time to make truly ethical healthcare the norm and stop the Culture of Death. Otherwise, we all can become an endangered species.

NOTES:
1 Ed Vogel, “Assembly Voice Vote: Pharmacists told to heed doctors’ Rx”. Las Vegas Review-Journal, April 4, 2003. Available online at: http://www.reviewjournal.com/lvrj_home/2003/Apr-04-Fri-2003/news/21036565.html
2 “New York City Begins Abortion Training for All OB/GYN Residents Starting Next Month; Supporters Want Program Duplicated Nationwide”, Kaiser Daily Reproductive Report. June 11, 2002, Available online at:
http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=11634 – broken link
3 Michelle Malkin, “Forcing doctors to kill”. Townhall.Com, June 7, 2002. Available online at: http://www.townhall.com/columnists/michellemalkin/mm20020607.shtml broken link 6/27/2005
4 “ONA Provides Guidance on Nurses’ Dilemma”. The Oregon Nurses Association Position Paper on the Death with Dignity Act. Available online at: http://www.oregonrn.org/services-whitepapers-0001.php broken link 6/27/2005

5 Eugene F. Diamond, M.D., “Word wars”. Physician (a Focus on the Family publication), November/December 1992. Available online at: http://www.lifeadvocate.com/mar_97/wars.html – broken link

Nancy Valko, a registered nurse, is president of Missouri Nurses for Life, a spokesperson for the National Association of Pro-life Nurses and a Voices contributing editor.

**Women for Faith & Family operates solely on your generous donations!

WFF is a registered 501(c)(3) non-profit organization. Donations are tax deductible.
Voices copyright © 1999-Present Women for Faith & Family. All rights reserved

Welcome!

Women for Faith and Family has published Voices magazine until 2014, the 30th anniversary of Women for Faith and Family.

I have been privileged to be a contributing editor for this magazine. It has been one of the best experiences of my life.

Women for Faith and Family was kind enough to start a webpage for me with my articles, interviews, etc. and I am preserving these articles on this website.

I have two blogsites, the one here is for my older articles from my Women for Faith and Family webpage titled “Nancy Valko” up to 2014 and one titled “Nancy Valko-A Nurse’s Perspective on Life, Healthcare and Ethics” at www.nancyvalko.com for blogs since June, 2015. Please feel free to visit both sites.

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