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Precocious Puberty and Ethical Decision-Making

A Catholic mom recently sought my advice on a weighty medical decision for her young daughter with which she and her husband are struggling.  Although the specifics of the case are not so common, the form of the underlying ethical question is, or will be, faced by most every parent.  I thought that I would share with CLF readers an elaborated version of the reasoning that I offered her.

She sent me the following email.

My 8-year-old daughter was diagnosed last year with “precocious puberty.”  If my husband and I do not intervene, she will reach full puberty this year.  We are considering a medication to slow or reverse her physical development. 

Is this morally justifiable from a Catholic perspective – to essentially intervene with my child’s ‘natural’ developmental course?  Sometimes I feel a little like I’m playing God, and this makes me doubt myself.  My parish priest has also expressed reservations: “why,” he asked, “would you deliberately slow your daughter’s growth?”  I would be grateful for any help you can give me on this question.
Terri, Bismarck, ND

Dear Terri,

I understand your reticent feelings (and your priest’s), but you should not take these feelings as an adequate indicator of what is right or wrong in this situation.  Since I am not a physician, I cannot advise you on the risks and benefits posed to your daughter by this particular treatment.  I can, however, assist you to understand how to go about making a good decision.

When considering an uncertain course of action like this, we begin by asking: “Is this act—in your case, the administration of medicines intended to slow a child’s inordinate development—intrinsically wrongful?”  If it is, then, of course, it can never be chosen in a way consistent with the genuine welfare and happiness of our dependents, our community or ourselves.  If, for example, in response to a girl’s unplanned pregnancy, someone recommends to her parents that she should have an abortion, we know at the outset that we cannot consent to this, since intentionally killing a baby can never be consistent with the real welfare of our daughter, or anybody else.

In your case, however, we are not dealing with anything wrongful in itself.  In the language of moral theology, we can say that the “end of the act” (i.e., the purpose for which you are considering doing it) is to correct a form of disorderly development (i.e., to bring healing); and the “means” is the administration of a medication intended to slow premature sexual maturation.  The end is good, and the means are legitimate if there is serious reason for adopting them.

But isn’t it bad to interfere with a ‘natural’ process like sexual maturation?

If your daughter’s developmental cycle was unfolding in a healthy way, then there might be no adequate reason to interfere with it.  But, if because of some disorder she is not developing normally, then an intervention could very well be justified.

But this therapy can have harmful side-effects.  How do I decide if an intervention is justified? 

You must answer the following question: “Are the harms that the therapy risks legitimate to accept in light of the benefits that it promises?”  We might reword the question in the negative: “Given my daughter’s condition, would it be unjust to subject her to the risks posed by this treatment?”

How do I answer this? 

You begin by securing the best medical information available on the benefits and burdens of this type of treatment.  In other words, you get the facts.

Risks of accepting the treatment 

Given reliable clinical data, what is the probability that this type of drug therapy will do what we want it to do?  How will it affect my daughter’s body?  Her psyche?  Are there any alternative treatments that are less harmful?  How long will it take?  Is it very painful?  What are its dominant side-effects?  How much school will she need to miss?  Can we afford it?

Risks of not accepting it 

What are the risks of not pursuing this therapy?  What will be the course of her sexual maturation without it?  How will this affect her present and future physical health?  Emotional health?  Interpersonal relationships?  Self-image?  Success in school?  Fertility?  Etc.

Medical, not moral questions

You will see that these are not yet moral questions.  They are empirical questions.  To answer them we don’t go to priests or popes or theologians.  We go to trustworthy medical experts.  As Thomas Aquinas said, “I’d rather go to a skilled doctor who is non-Christian than an unskilled doctor who is Christian.”

Get the best available facts and be tenacious about it.  And don’t worry if your assertiveness makes your doctor uncomfortable.

Why do I feel like I’m doing something wrong if I go ahead with the treatment? 

We feel this way because we are more or less aware that the alternatives we are considering—including doing nothing—have undesirable consequences.  Although we don’t intend these consequences, we know they are likely to occur.  And they are likely to occur precisely if we adopt the alternative under consideration.  We are also aware that certain undesirable consequence might be avoided if we choose differently.  And so we can feel that we are doing harm in a morally relevant sense when we adopt one alternative over the other.

But if choosing differently truly promised all of the goods we were interested in and none of the harms we wanted to avoid, then there would be no reason to consider this particular alternative.

In other words, you realize that both alternatives—accepting and not accepting this treatment—risk harms that you are most eager to avoid.  And, of course, you don’t want any harm to come to your beloved daughter.  But harm and suffering are sometimes unavoidable.  And so you must do your best to minimize the harms that you can.

Ethical Decision-making

After you secure the relevant facts, you face the specifically ethical question: Should we do this?  You answer it by comparing the reasons for pursuing the treatment (namely, the goods you are trying to achieve and harms to avoid) with the reasons against pursuing it (namely, avoiding the harms that the therapy risks).  Your daughter is still young, but she should certainly be included in the decision-making process, since she has the keenest interest in her own long-term good and will be the one who suffers most immediately from any harm that comes to her as a result of adopting either alternative.

After consultation, discussion and prayer, you then adopt the course of action that you believe will realize the goods in which you are interested while having the least-harmful consequences.  In other words, you adopt the alternative that you believe is in the best interests of your daughter.  And then entrust the decision into Jesus’ kindly hands.

Constant Reassessment

Obviously, if you decide to pursue the therapy, you should constantly reassess your decision in light of the unfolding evidence: “Is it accomplishing our purposes in the least harmful way?”  If your daughter begins to suffer from complications you didn’t expect, or suffer more severely than you thought from complications you did expect, you might say at that time: “we need to stop for a while, or even indefinitely.”

To Sum Up

If doctors and parents judge that some serious intervention is medically indicated to correct some serious problem, and presuming the intervention is not intrinsically evil, then it may be morally licit or even obligatory to pursue it.  Hasty decisions should be avoided.  And second (or third) opinions of experts are often a good idea.