Prophylactic Salpingectomy to Reduce the Risk of Cancer: Ethical Considerations

FROM THE FIELD

A Case May a salpingectomy be performed in A 28-year-old patient is 25 weeks conjunction with a C-section to reduce the pregnant with her second child. She is risk of cancer? scheduled for a C-section. She has two relatives who had ovarian cancer, one of Ministry Perspectives whom passed away from the disease. She knows that this family history increases Rev. Gerald D. Coleman, S.S., Ph.D. her risk of ovarian cancer. Vice President, Corporate Ethics Daughters of Charity Health System Ovarian cancer grows slowly. Pre-invasive Los Altos Hills, Calif. and early stage disease often go [email protected] undetected. Many patients have malignancies more than four years before Salpingectomy is a prophylactic, ovarian cancer is detected. By the time of preventative or cautionary surgery to diagnosis, the cancer is often advanced remove the fallopian tubes for women at and aggressive growth has already high risk of ovarian cancer. Between 1 in occurred. As a result, the five year survival 400 and 1 in 800 people in the U.S. rate is only about 45 percent. population carry one of the causative mutations, and salpingectomy has become At her last appointment, the patient tells the “standard of care” in these cases.1 her OB that she read that removal of the Ovarian cancer is a significant issue in fallopian tubes and the ovaries might help women’s health and the overall survival to prevent ovarian or breast cancer. The rate at five years is only about 45 percent. patient explains that she does not want For women with increased risk of ovarian removal of her ovaries, which will cancer, the lifetime risk ranges from 16 to prematurely cause menopause; however, 54 percent, and often involves an she asks whether she could undergo a risk- increased risk of breast cancer. Last year reducing salpingectomy (removal of the actress Angelina Jolie chose to have a fallopian tubes) in conjunction with her double mastectomy and reconstructive C-section. She is very concerned about her surgery after learning she had an 87 risk of cancer and has become increasingly percent risk of breast cancer because she anxious about her health after the birth of carries the BRCA1 gene.2 her child. Although salpingectomy will cause sterilization, the patient accepts that Ovarian cancer is not a single disease she will not be able to have another child. process arising on a single site or from a She is most concerned about reducing her single cell type. The most common risk of ovarian cancer. subtype has been identified as serous

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(epithelial ovarian cancer), and the healthy organ removes the “field of fallopian tube is often the first place of growth" and dramatically diminishes the involvement. This subtype is most risk of life-threatening disease. commonly found in BRCA1/2 mutation carriers3 and up to 20 percent of these Regarding prophylactic mutilation, Pius cancers occur in women with germ line XII stated that "by virtue of the principle BRCA1/2 mutations.4 of totality and the right to use the services of the organism as a whole, each person A woman with BRCA mutations can can permit individual parts to be chose risk-reducing surgery to excise her destroyed or mutilated when the good of fallopian tubes and sometimes her ovaries the whole requires it. This may be done to (oophorectomy). When pathologically ensure life, as well as to avoid or, examined after surgery, about 10 percent naturally, repair serious and lasting of women undergoing salpingectomy were damage that cannot be otherwise be found to have an early cancer. The avoided or repaired."10 Healthy organs, majority of early cancers were found in the therefore, may be removed for the good of distal fallopian tubes and not the ovaries. the whole whenever their functioning Due to its location in the fallopian tubes, poses a physical risk. The decisive moral the cancer metastasizes to the ovaries and element is that the preservation of the surrounding pelvic structures. organ or its functioning poses a direct or indirect threat to the body.11 While salpingectomy is standard medical treatment, is this surgery in line with Consequently, salpingectomy is morally Catholic moral teaching that places permissible. Even though the surgery significant value on the preservation of the renders the generative faculty incapable of whole of the human person, stresses that a procreation, this is not its sole effect, or pathology must be present in order to the primary intention. Rather, the act of remove an organ,5 views mutilation of a removing the fallopian tubes (and healthy organ as intrinsically evil,6 and sometimes ovaries) is in itself sufficient for condemns direct sterilization?7 a notable clinical benefit conferred directly to the patient and this constitutes the Pope Pius XII delineates three conditions primary intention. when it is permissible to remove a healthy organ:8 the functioning organ is causing Categorizing salpingectomy a "drastic serious damage or constitutes a menace to measure," National Catholic Bioethics the whole organism; clear evidence Center's Director of Education Fr. Tad confirms that the damage will be Pacholczyk draws a helpful distinction remediated or measurably lessened by the between the importance that the integrity mutilation; and the negative effects of and order of the human body be respected mutilation will eliminate the danger to the and not unduly violated (the Principle of whole, ease the pain, or secure positive Integrity) and whether or not an effects.9 In other words, a removal of a individual organ or part of the human

FROM THE FIELD body may be sacrificed for the continued 7 ERDs, op. cit., no. 53. 8 survival of the whole person (the Principle Barina, op. cit., 72, referencing “Removal of a Healthy Organ” in The Human Body, Boston: of Totality). Salpingectomy lies Daughters of St. Paul, 1960, 277-279. "somewhere in the middle, with emphasis 9 This same conclusion was reached by Thomas J. being placed upon the weightier Principle O’Donnell, “Definitive Pelvic Surgery: A Moral of Totality."12 Evaluation,” Theological Studies 22:4 (1961), 652- 653. 10 Pope Pius XII, AAS 44 (1952), 782. Pacholczyk rightly concludes that a 11 See Gerald Kelly, S.J., "Pope Pius XII and the woman can surely make a prudential Principle of Totality, " Theological Studies 16: 2 judgment that she carries a serious risk of (1955), 373-396. breast cancer due to BRCA1/2 mutations, 12 Fr. Tad Pacholczyk, "'Drastic Measures' and as well as considering other factors such as Cancer Decisions,'" (November 7, 2014), http://ncbcenter.org/page.aspx?pid=1101. a strong family history of breast cancer, 13 See Victoria Colliver, "UCSF Study To Look at the absence of a full-term pregnancy, Effects of Premature Change As A Result of abortion or miscarriage in the first Preventive Breast or Ovary Removal," Health. pregnancy, or a male relative who SFChronicle.com and SFGate.com, November 19, develops breast cancer.13 2014.

Salpingectomy is prudential management medical treatment and morally permissible Emily Trancik, Ph.D. (c) surgery. Ethics Fellow Ascension Health 1 Consult: Rachelle Barina, “Risk-Reducing St. Louis Salpingectomy and Ovarian Cancer,” The National [email protected] Catholic Bioethics Quarterly 14:1 (2014), 67-79 and John F. Tuohey, “Surgical Prophylactics for Cherie Sammis Ovarian Cancer (SPOC): An Ethical Inquiry,” Vice President, Mission Integration Linacre Quarterly 65:3 (1998), 77-96. 2 Jolie's mother and aunt both died of breast St. Mary's of Michigan Medical Center cancer. She chose this surgery as her risk of breast Saginaw, Mich. cancer was higher than her risk for ovarian cancer. [email protected] 3 http://www.cancer.gov/cancertopics/factsheet/Risk Becket Gremmels, Ph.D. (c) /BRCA 4 Gynecologic Oncology Statement Regarding Executive Director, Ethics Salpingectomy and Ovarian Cancer Prevention, Saint Thomas Midtown Hospital November 2013, https://www.sgo.org/linical- Nashville, Tenn. practice/guidelines/sgo-climnical-practice- [email protected] statement-salpingectomy-for-ovarian-cancer- prevention/. 5 NCCB, Ethical and Religious Directives for The fear and emotional angst many Catholic Health Care Services (ERDs), 2009, no. women experience from a heightened risk 53. of developing ovarian cancer can be 6 John Paul II, Veritatis Splendor (1993), no. 80. overwhelming, especially if they have lost See also Thomas Aquinas, Summa Theologiae I-II, family members to this dreaded disease. q. 65, a. 1.

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Since Catholic health systems carry a physician. Rather, its purpose is to reduce moral obligation to care for the whole the risk of cancer in the face of danger. person, attending to such fears and anxiety Finally, the sterilizing effect is not the is essential when ministering to these cause or specific means used to reduce the patients. The difficult decisions these risk of ovarian cancer. women and their families face requires our support and the best medical care we can Although prophylactic salpingectomy offer. At the same time, Catholic meets the first three conditions for double ministries must respond in a way that effect, it is more difficult to determine ensures respect for human dignity and the whether the good effect outweighs the whole human person, including the gift of bad. Attaining absolute certitude that the fertility. benefits of prophylactic salpingectomy are greater than the risks is not possible, nor In light of this background, we consider required in the Catholic moral tradition. prophylactic salpingectomy for a patient at One need obtain only moral certitude, or increased risk of ovarian cancer. Pope Pius the certitude of prudence. Burdens to XII acknowledged that the Principle of consider in this analysis include the Totality can justify removing a healthy unintended effect of loss of child-bearing organ if “its continued presence or potential, the surgical risks, a continued functioning cause[s] either directly or risk of ovarian cancer due to the presence indirectly a serious menace for the whole of the ovaries, a possible increase in risk body.”1 Applying this same principle, the for ectopic pregnancy, and bleeding from Ethical and Religious Directives for Catholic this highly vascularized tissue.4 Moreover, Health Care Services (ERDs) states that it is uncertain that she would actually ever “the functional integrity of the person develop ovarian cancer. This raises the may be sacrificed to maintain the health question of whether the danger or risk or life of the person when no other constitutes a proportionate reason for morally permissible means is available.”2 undergoing the surgery. Both of these sources are clear that the Principle of Totality does not apply to The anxiety caused by an increased risk of direct sterilization.3 However, we believe ovarian cancer could limit a person’s that prophylactic salpingectomy for moral resources. For example, a young patients at increased risk of ovarian cancer mother might want to do everything can rightly be characterized as an indirect within her power to see her children grow sterilization, per the usual conditions of up. This psychological and social benefit, the Principle of Double Effect and Pius grounded in the real possibility she will XII’s note on the Principle of Totality. develop cancer, are indicators of the Though sterility is foreseeable, it is an increased burdens and risks that might unintended secondary effect. Such effect is justify undergoing the procedure. neither the direct object (proximate However, the same fear might motivate intention) of the salpingectomy nor the someone to request prophylactic surgery remote intention of the patient or when less invasive interventions (e.g.

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counseling, screening) may be more [in order] to prevent any new conception and the appropriate. The personal decision to grave dangers which could arise therefrom either to the health or life of the mother; these dangers arise proceed with prophylactic salpingectomy from other unhealthy organs—kidneys, heart, should occur on a case-by-case basis only lungs—whose condition would be aggravated in after careful conversations between the case of childbearing…The appeal to this principle patient and her physician. here is unjustified…” (op. cit.) The Ethical and Religious Directives state, “Procedures that induce sterility are permitted when their direct effect is the Ultimately, obtaining moral certitude cure or alleviation of a present and serious about this case would require detailed pathology and a simpler treatment is not information about the patient’s medical available.” (op. cit., n. 53) history, genetic testing, personal history, 4 The last two risks are not specified in the clinical race and ethnicity, and other clinical risk practice statements recommending prophylactic salpingectomy concurrent with an unrelated criteria. Thus, we must assume we have abdominal surgery; Society of Gynecologic moral certitude that the risk of developing Oncology, “SGO Clinical Practice Statement: cancer is high enough to outweigh the Salpingectomy for Ovarian Cancer Prevention,” burdens of surgery and infertility but not November 2013. Society of Gynecologic the burdens of early menopause, else the Oncology of Canada, “GOC Statement Regarding Salpingectomy and Ovarian Cancer Prevention,” ovaries would be removed too. September 2011.

Further specification of what constitutes a proportionate reason in this case would Erica Laethem, Be.L., Ph.D.(c.) aid in obtaining moral certitude. This case Regional Director of Ethics reveals a need for further consideration on OSF Saint Anthony Medical Center the risk-benefit analysis for women at Rockford, Ill. population risk of ovarian cancer. These [email protected] considerations are vital for Catholic ministries to continue to uphold the The moral question of whether risk- dignity of all women at risk of ovarian reducing salpingectomy (RRS) or risk- cancer. reducing salpingo-oopherectomy (RRSO) could be permitted as means of preventing 1 Pope Pius XII, “Removal of a Healthy Organ” ovarian cancer (OC) is a relatively new (October 8, 1953), The Human Body: Papal Teachings, pp.277-279. one. While Ethical and Religious Directive 2 United States Conference of Catholic Bishops, (ERD), no. 53 prohibits “direct Ethical and Religious Directives for Catholic Health sterilization” and states that “[p]rocedures Care Services, 5th ed, no. 29. that induce sterility are permitted when 3 In “Removal of a Health Organ,” Pope Pius goes their direct effect is the cure or alleviation on to say, “We would like, however, to draw your attention to an erroneous application of the of a present and serious pathology and a principle of totality which we have enunciated. It simpler treatment is not available1, it does not rarely happens that, either when gynecological not address whether a currently non- complications demand an operation, or quite pathological reproductive organ can be independently of such complications, the healthy removed if there is evidence that it is likely fallopian tubes are removed or put out of action

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to endanger a woman’s health or life, but removing potentially life-threatening is not (yet) presently and seriously tissue. pathological. Not “Direct Sterilization” Not Illicit “Uterine Isolation” A “direct sterilization” is an action “whose The citation for ERD 53 suggests its sole, immediate effect is to render the scope. The footnote references sole generative faculty incapable of document, the Congregation for the procreation.”4 In RRS and RRSO for at- Doctrine of the Faith’s 1993 “Responses risk women carried out with a on ‘Uterine Isolation’ and Related prophylactic intention, the sterilizing Matters,” which addressed three questions effect is not the sole, immediate effect; that are morally distinct from RRS and rather, there is a second concurrent effect RRSO: 1) a uterus could be removed if it of removing organic tissue that, regardless poses an “immediate serious threat to the of the occurrence of pregnancy, threatens life or health of the mother” even though to endanger a woman’s life or health. sterility may result; 2) a uterus may not be removed if it does not constitute “in itself Permissibility of Removing a Currently a present risk to the life or health of the Non-Pathological Organ woman” AND the intention is “to prevent a possible future danger deriving from That an organ is not currently conception”; and 3) a tubal ligation or pathological does not morally exclude its “uterine isolation” with the intention of removal.5 Pope Pius XII invoked the “averting the risks of a possible Principle of Totality to justify removing a pregnancy” is not permitted. The latter currently non-pathological organ,6,7 two are not permitted because “the including in the context of a meeting with described procedures do not have a urologists concerned about the morality of properly therapeutic character but are castration to thwart prostate cancer.8 The aimed in themselves at rendering sterile tradition has also justified prophylactic future sexual acts freely chosen.2 The removal of currently non-pathological current case study differs from the latter appendices during other abdominal two scenarios in three ways: 1) a known surgeries.9 “immediate serious threat to the life or health of the mother” does not yet exist, Key to the application of the Principle of though there seems to be some evidence Totality is the existence of a proportionate that the woman is at increased risk of reason for impairing functional integrity.10 experiencing a serious threat to her life or The greater the impairment, the stronger health;3 and 2) the fallopian tubes the reason must be. It would be difficult themselves may contain the risk; and 3) to make this case for RRS and/or RRSO sterility is not the means by which risk to a for women without an increased risk of woman’s life would be averted but a side ovarian cancer; however, it seems plausible effect of a procedure directly aimed at in certain cases for at-risk women.

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Requirements of the Principle of Double The Guiding Role of Prudence Effect Prudence may guide the conscience to act RRS and RRSO may be justified by the to preserve life and health in the face of a Principle of Double Effect if: 1) the moral reasonable threat; it does not require a object (removing organ[s] that poses a person to enter into a cancerous state potential serious threat to life or health) is before acting, particularly if waiting until good or at least indifferent; 2) the good the time of diagnosis to intervene could be effect (reduced threat to life and health) fatal. and not the evil effect (sterility) is intended; 3) the good effect (reduced In the sacred relationship between threat to life and health) is not produced physician and patient, the vulnerability of by means of the evil effect (sterility); 4) the pregnant woman should be there is a proportionately grave reason for acknowledged in the informed consent permitting the evil effect.11 The moral process. By nature, pregnancy puts a evaluation of RRS in our case study seems decision for RRS or RRSO accompanying to hinge on the “proportionate reason” a C-section on a timer, and caution is criteria. Among relevant factors are the needed to avoid pressuring a woman to life-threatening nature of OC; the make this permanent decision before she difficulty in obtaining a timely diagnosis has had adequate time to form her before the disease has become serious or conscience. As a matter of prudence, she deadly; the reliability of methods to should be allowed sufficient moral space predict increased risk of OC in light of the to consider how her current context (e.g. a woman’s genetics, family history, and age; particularly miserable pregnancy or young the average age of onset of OC; medical active children) may influence her and surgical risks and benefits; the readiness to accept that she will no longer existence or lack of alternatives; the be able to have another child or how a effectiveness of RRS and / or RRSO in change in her context (e.g., the death of a reducing the risk of OC; a person’s duty child, widowhood and remarriage) may as steward to preserve her life and health; cause her to weigh the sterilizing side her fertility; and her vocational effect of the intervention differently. responsibilities (such as that of a mother These contextual considerations are to care for her existing children). Beyond discerned by the woman herself and favorable medical and surgical risk / therefore should to be brought to light as benefit ratios, there is no mathematical part of the informed consent process. formula to determine whether a morally proportionate reason exists. Such A Catholic health care institution could discernment should be carried out on a encourage prudential discernment by case-by-case basis, with the most up-to- making available genetic counseling12 and date medical available, and from the ethics consultation13. To prevent abuse perspectives of the acting persons. that could arise with an unregulated policy regarding RRS and RRSO, the Catholic

FROM THE FIELD health care institution may consider naturally, to repair serious and lasting damage requiring prospective and/or retrospective which cannot otherwise be avoided or repaired.” English translation available at case review. To mitigate scandal, it http://ncbcenter.org/page.aspx?pid=1238 . Here should be prepared to explain the moral the words “ensure” and “to avoid” seem to suggest distinction between RRS/RRSO and a prophylactic intervention. direct sterilization. 7 Pope Pius XII, “Address the Twenty-sixth Congress of the Italian Association of Urologists,” 1 United States Conference of Catholic Bishops, AAS 45 (1953): 674–675: “Three conditions Ethical and Religious Directives for Catholic Health govern the moral licitness of surgical intervention Care Services, 5th ed. (Washington, D.C: United which entails anatomical or functional mutilation. States Conference of Catholic Bishops, 2009), no. First, the continued presence or functioning of a 53. particular organ causes serious damage to the 2 Congregation for the Doctrine of the Faith, whole organism or constitutes a threat to it. “Responses on ‘Uterine Isolation’ and Related Secondly, the harm cannot be avoided or notably Matters,” AAS 86 (1994): 820-821. reduced except by the mutilation which, on its 3 The case study itself does not indicate the risk in part, gives promise of being effective. Finally, one this particular woman in light of her reported can reasonably expect that the negative effect—i.e., family history. Here, the ethicist relies on medical the mutilation and its consequences —will be judgment. offset by the positive effect: removal of danger to 4 Congregation of the Doctrine of the Faith, the entire organism, palliation of pain, etc. The “Responses to Questions Concerning Quaecumque decisive point here is not that the organ which is Sterilizatio” AAS 68 (1976): 738-740, no. 1. removed or rendered inoperative be itself diseased, 5 Thomas O’Donnell, S.J., “Definitive Pelvic but that its preservation or its functioning entails Surgery: A Moral Evaluation,” Theological Studies directly or indirectly a serious threat to the whole 22, no.4 (December 1961): 652-653: “[W]ith body. It is quite possible that, by its normal regard to the removal of non-pathological tissue, function, a healthy organ may exercise on a there was a fairly widespread opinion in the past diseased one so harmful an effect as to aggravate (based perhaps on a misinterpretation of St. Thomas’ treatment of mutilation) which the disease and its repercussions on the whole demanded that an organ be diseased before its body. It can also happen that the removal of a removal was justified. This is incorrect. It is a healthy organ and the suppression of its normal distinction not even mentioned by many of the function may remove from a disease—cancer, for standard moral theologians, and expressly denied example—its area for development or, in any case, by others, and is clearly incompatible with the essentially alter its conditions of existence. If no following statement of Pope Pius XII in his address other remedy is available, surgical intervention is to the Twenty-seventh Annual Convention of permissible in both cases.” Italian Society of Urologists.” 8 See ibid. 6 Pope Pius XII, “Address to the First International 9 See Thomas J. O’Donnell, S.J., Morals in Congress on the Histopathology of the Nervous Medicine, (Westminster, MD: Newman Press, System,” (September 14, 1952): “Because [the 1959), pp. 85-86. person] is a user and not a proprietor, he does not 10 See ERD 29, and Gerald Kelly, S.J., “Medical- have unlimited power to destroy or mutilate his Moral Problems,” (St. Louis: The Catholic Health body and its functions. Nevertheless, by virtue of Association of the United States and the principle of totality, by virtue of his right to Canada,1958), p. 36: “Since mutilations vary in use the services of his organism as a whole, the degree, the reasons justifying them must also vary. patient can allow individual parts to be destroyed The cure of a slight danger may justify a slight or mutilated when and to the extent necessary for mutilation, whereas the removal of an important the good of his being as a whole. He may do so to part or the suppression of an important function ensure his being's existence and to avoid or, requires a very serious reason.”

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11 Joseph Mangan, “An Historical Analysis of the and definitive data on its efficacy does not Principle of Double Effect,” Theological Studies, 10 exist.3 (February 1949): 43.

12 See ERD 54. 13 See ERD 37. Because these factors increase women’s vulnerability, it is crucial to remember the Rachelle Barina, Ph.D. (c) implicit power that physicians hold. System Ethics Consultant When a physician presents an option, SSM Health many patients hear that option as a Saint Louis recommendation. While RRS may be [email protected] morally permissible, I am concerned about expectations generated from physicians’ When this patient undergoes risk- support of risk-reducing procedures. reducing salpingectomy (RRS), the nature Undertaking preventative care is generally and purpose of the act is disease seen as responsible patient behavior. prevention. Although RRS will render her While RRS obviously differs from routine incapable of procreation, inducing sterility preventative care, physician is not the purpose of the procedure or the recommendations could contribute to a intention of the patient in the case at perception that RRS is the responsible hand. Consequently, I believe RRS reaction to evidence of inherited risk. The constitutes a permissible, indirect belief that undergoing a preventative sterilization for this high-risk patient.1 procedure is a responsible act generates a Although a more thorough and systematic subtle and implicit suggestion that most ethical reflection on the act of RRS is patients should undertake it. Although this appropriate, I would like to focus this sentiment is hard to control when commentary on two long-term ethical physicians offer or recommend a considerations that become especially procedure, it subtly pressures women into relevant if Catholic health care accepting an invasive surgery that is organizations are willing to perform RRS: morally and clinically optional. In fact, 1) offering and/or recommending RRS, evidence has already shown that many and 2) the meaning of pathology and women feel a responsibility not only for other related concepts. knowing and sharing their genetic risk, but also undertaking actions to reduce In the present case, this highly informed their risk caused by inherited factors.4 patient asks about RRS, which obscures the question of whether clinicians should Thus, conversations about how and when offer or recommend RRS. Many patients to counsel women about RRS are with higher than average risk will not necessary. A population health approach know about RRS. Moreover, people to RRS might attempt to quantify and (including physicians) tend to understand target patients for RRS. Considering and appreciate risk very poorly.2 Concern Catholic teaching on bodily integrity and about the potential risks of RRS persists, the possibility of generating a sense of preventative responsibility for inherited

FROM THE FIELD risk, we should be wary of linking risk- hereditary risks depend upon these reducing procedures and population concepts and will profoundly influence health. Instead, Catholic health care our anthropology and ontology. organizations should enable conversation not only about if, when, and how to While many people might support a RRS prudently and selectively discuss RRS, but for the patient under consideration, also about how to prevent the spread of an clinicians, ethicists, and organizations implicit moral imperative that women at need to be cautious when approaching high-risk of ovarian cancer undergo RRS. RRS on a wider-scale. The way that we approach RRS—clinically and The case at hand also raises questions conceptually—will have profound about the meaning of pathology. Per ERD implications for our communities and 53, procedures that result in sterilization patients. are allowable if their “direct effect is the cure or alleviation of a present and serious I would like to thank Paul Scherz and pathology and a simpler treatment is not Devan Stahl for helping me to develop my available.”5 This directive was likely ideas about RRS. written without considering the difference between a harmful malignancy and high 1 I have previously made a more lengthy argument risk of malignancy. Should intrinsic risk in favor of permitting risk-reducing salpingectomy. See “Risk-Reducing Salpingectomy and Ovarian and the possibility that a malignancy Cancer: Chasing Science, Changing Language, and already exists be considered a pathology? Conserving Moral Content.” The National Or, given new scientific information, Catholic Bioethics Quarterly, 14 (1), Spring 2014. should this language be revised? Austriaco 2 For example, see research by Gerg Gigerenzer argues that a genetic mutation is sufficient described in Risk Savvy: How to Make Good Decisions. Penguin Group, 2014. to consider reproductive parts “already 3Tanner EJ1, Long KC, Visvanathan K, Fader AN. 6 diseased.” Performing RRS under the “Prophylactic salpingectomy in premenopausal assumption that intrinsic risk is disease women at low risk for ovarian cancer: risk- and/or pathology has far-reaching reducing or risky?” Fertility and Sterility. 100(6), implications, including theological 2013. 4 For example, see Nina Hallowell’s article: “Doing implications about human nature and the right thing: genetic risk and responsibility.” embodiment. Even if we are confident Sociology of Health & Illness. 21(5), Sept 1999. that RRS is a permissible, indirect Hallowell interviewed 40 women who underwent sterilization, we should think carefully genetic counseling for hereditary breast/ovarian before claiming RRS fits within the cancer. She found that the women perceived a sense of responsibility to their family to undergo language of ERD 53. In dialogue with testing and manage risk, even when risk scientific perspectives, new theological management practices involved negative side scholarship needs to explore the effects. She effectively argues that the construction differences between risk, disease, of genetic risk is a deeply moral issue because of pathology, malignancy, and mutation.7 the way it forms the feelings and choices of women. Personal, ecclesial, and organizational 5 ERD 53 of the Ethical and Religious Directives for decisions about invasive responses to Catholic Health Care Services. 5th edition, 2009.

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6 Nicanor Pier Giorgio Austriaco provides a helpful and scientifically adept Catholic moral discussion of risk-reducing procedures that result in sterilization in his book, Biomedicine and Beatitude: An Introduction to Catholic Bioethics. Catholic University of America Press, 2011. see pages 219-221. Quote from page 221. 7 This research should also examine if/how genetic risk factors differ from environmental or behavioral risk factors.