The National Catholic Bioethics Quarterly

Children and pregnant women are often excluded from clinical research. This has resulted in a paucity of evidence on how medicines work for fetuses, neonates, infants, and adolescents. It also raises bioethics, scientific, and public health concerns. For over half a century, doctors have prescribed medicines to children largely on the basis of how they work in adults, despite children’s varied physiologies and differences in how their bodies absorb and metabolize drugs. Regulations and legislation have led to an increase in the number of pediatric studies and to better drug labeling. However, children at all stages of their lives often remain “therapeutic orphans” owing to insufficient evidence about how medicines work for them.

The concept of wrongful birth, which is based on the premise that a person would have been better off never having been born, is a serious mat­ter for Catholic obstetricians, especially in the context of prenatal screening. This principle, in conjuncture with the belief that individuals with disabilities have a decreased quality of life, has been used to promote a eugenic mentality. Consequently, prenatal screening tests often are used to identify fetuses with disabilities, who subsequently are aborted. Not only is this practice ethically reprehensible, but its presuppositions about quality of life find little support in the medical literature. In fact, in the case of Down syndrome, there is consider­able evidence to the contrary: individuals living with Down syndrome have a high quality of life and are accepted by their families. These data illuminate the discrepancy between how physicians portray Down syndrome to expect­ant parents and what the literature shows regarding this condition.

Despite unprecedented medical advancements and the near eradi­cation of many serious diseases, there are growing epidemics of preventable illness brought about in part by the overemphasis on individual autonomy and the neglect of obligations to others. Insofar as these diseases develop because of individual choice, this permissiveness hampers the moral analysis of growing epidemics like childhood obesity. While society has contributed to its rapid progression, childhood obesity finds its origins in lifestyle choices implemented at home. Consequently, parents have an unparalleled duty to prevent and correct obesity and unhealthy lifestyles in their children. Failure to do so undoubtedly violates a parent’s duty and suggests medical neglect. However, our current understanding of medical neglect is too narrow to be applicable to chronic, preventable illnesses. Relevant principles of tort law may broaden our understanding of neglect to better reflect the nature of parental and societal liability in preventable illnesses.

The ethics of adolescent decision making is a complicated mine­field with laws that vary from state to state. The case of a fourteen-year-old girl, who simultaneously was diagnosed with cancer and discovered she was pregnant, highlights several weaknesses in our current approach to adolescent decision making in the context of pregnancy. In addition, adolescents with life-limiting conditions face similar challenges that can be examined through the framework of Catholic doctrine.

Adolescence is an important yet vulnerable period of transition from childhood to adulthood. An increasing number of studies support the traditional Catholic view, which sees teens as prone to making poor decisions when influ­enced by emotions or peer pressure but capable of thriving when guided by parents and religion. However, newer policies of medical societies undermine the traditional supports of family and faith with a permissive approach toward sexual exploration. To counter this unhealthy trend, which seems to be based more on postmodern ideology than robust science, Catholic physicians should become experts in adolescent behavior and sexual health. Physicians should be sensitive to opposing viewpoints but participate only in treatments which are ethical and beneficial for their patients. Specifically, Catholic physicians must avoid contraceptives, abortion, and “gender-affirming” therapies. By using good science and emulating the models of service, Socratic dialogue, and accompaniment, physicians can guide adolescents toward a virtuous, healthy adulthood.

Clinical guidelines now recommend hormonal and surgical interven­tions together with social affirmation for children who experience a gender identity that is discordant with their biological sex. However, fundamental questions regarding the safety, efficacy, and ethics of these approaches remain unanswered. There is an urgent need for high-quality research to establish the overall risks and benefits of the current treatment paradigm. While acknowledging the complexity of the problem, competing interests, and logistical challenges, ethical imperatives and acceptable boundaries for scientific investigation can be set by considering the ultimate good of both the individual person and society as a whole. Within established guidelines for human experimentation, alternative approaches to treatment of gender dysphoria in children can be explored without compromising the dignity and bodily integrity of affected individuals.

The transition from the paternalistic paradigm of the Hippocratic tradition to the present model of shared decision making has altered the patient–doctor relationship. This change has engendered conflicts between patients and physicians, especially in pediatric medicine, where the patients are depen­dent on their parents because of their inability to consent to an intervention independently. Navigating this complex relationship can become particularly fraught when medical futility is invoked. This situation is complicated further by the divergent approaches to shared decision making among physicians and the ethical perspectives these positions reflect. Catholic doctrine on the role of parents in medical-ethical decision making provides insight into navigat­ing these difficult clinical issues and ideologies.

The increased interest in exorcisms and demonology should be moderated by a proper understanding of the relationship between psychology and spirituality. There is an important link between psychological aberrations and possession, but too often and too quickly, a person’s mental health is dismissed or overlooked in favor of a diagnosis of demonic possession. The Church’s ritual of exorcism can be properly used only after psychological discernment, episcopal approval, and personal assent. Most priests are not prepared for the role of exorcist and should spend their time more effectively addressing pastoral needs. The belief in demons is part of biblical witness and Catholic history. At the same time, we must avoid any tendency toward redemption by exorcism.

David Albert Jones recently proposed an analogy between adoption and gender transitioning. Jones notes that adoption grants a child a social identity that is distinct from the natal identity and suggests that a similar situation might obtain in the case of gender transitioning. According to this proposal, a biological male who wishes to be called a woman is not assuming a false identity. Adoption and gender transitioning are significantly different, however: adoptive sonship participates in natural sonship in a way that is not true of the relationship between a biological woman and a man who wishes to be called a woman. Attention is given to different forms of analogy, leading to the conclusion that the use of the word woman for a biological male would be either a metaphor or a very weak analogy. In contrast, the term son as applied to an adopted boy fulfills the fundamental signification of that word.

In response to a growing movement opposed to conscientious objection in medicine, the medical profession should resist the privatization of conscience in general and accept the challenge, presented by conscientious objection, of rethinking its practices and being true to its calling. These claims are informed by the traditional understanding of conscience and the thought of Jürgen Habermas on the relevance of religious truths in public debate and the legitimacy of public dissent.

An emerging ethical dilemma in light of the opioid crisis, repeat cardiac valve replacements for patients diagnosed with endocarditis from intravenous drug use presents specific challenges to Catholic health care organizations. While secular health care is tasked with the allocation of scarce resources, Catholic institutions must address additional considerations when balancing stewardship of scarce resources, human dignity, and patient accountability. A recent ethics consultation illustrates the issues involved in multiple valve replacements for substance-addicted patients from a Catholic ethical perspective. The discussion includes policy recommendations and ethical reflections.

Is postlapsarian sexual desire primarily altruistic or disordered? This paper utilizes the resources in the thought of St. Thomas Aquinas and in the contemporary magisterium to argue that recent phenomena such as the #MeToo movement underscore the inherently unstable and aggressive nature of sexual desire when it is uprooted from its natural end (i.e., is end-less). Aquinas highlights three aspects of desire that more sex-positive accounts of sexuality would do well to heed: its natural infinity, its self-referential nature (grounded in amor concupiscentiae), and its power of rationalization. By directing the motor of desire toward its natural ends, virtue—led by reason—can redirect desire away from self and toward the good.