Tag Archives: Government

Reply turned post, Trisomy 18 and mental masturbation style

I can get really frustrated by people who enter into philosophical arguments about serious medical ethics questions online. Many of these people have a definite agenda, often controlling access to abortion, but try to couch it as some sort of intellectual exercise. Many of these commenters are men who toss around large words like “autonomy” and “qualitative determination.” This happens all over the interwebs, and I know better than to spend my time hunting down every blowhard that litters a comment section with his ideas on viability and fetal rights.

However, I clicked through a link on my Washington Post headline newsletter on Trisomy 18, since it is a topic that genuinely interests me. Presidential candidate and notorious crusader against contraception and abortion Rick Santorum has a daughter with Trisomy 18, one who is questionably lucky to have survived the few years she has, and has been hospitalized yet again. I was generally pleased with the accuracy and tone of the article. I hesitantly stumbled into the comments section, and then happened upon a perfect example of what I like to refer to as mental masturbation, from a commenter named “johnbmadwis”, which he wrote in response to a comment drawing the logical connection between the suffering and medical expense of Santorum’s daughter, and his position on the ability of other families to choose this road for themselves:

But haven’t you just made Santorum’s point and fueled the fire of the pro-life proponents? That is, the pro life advocate’s long held belief that abortion rights advocates are not really talking about rape and incest, but rather personal evaluations of the quality of life of the fetus or externalities such as heartache and expense. Regardless of the condition of the fetus, pro life advocates would say society has a moral interest, they’d say imperative, in preserving the life of such a fetus from individuals such as yourself, who may want to terminate that life due to such condition. At what point, if any, does that societal interest give way to individual autonomy? Would you truly advocate for the ability to terminate that life after birth? in the last weeks of pregnancy? 3rd trimester? viability? Whatever the point, what is the guiding principle? Individual autonomy? Quality of life? (determined, assuredly, by one other than the one whose life is at stake – so, whose individual autonomy?) at what point does one achieve individual autonomy? Does a fetus have individual autonomy At some point the life of the fetus does, presumably, outweigh the individual’s autonomy, right? When? Is individual autonomy equally valid if it were exercised for clearly base purposes such as mere inconvenience or desire, say, to have a boy instead of a girl? Who should make that qualitative determination? Society? The individual carrying the fetus. The affected fetus? The personal choice of a couple does affect the life of another human being in your scenario, so, it is reasonable to ask you when, if ever, do you believe that personal choice must give way to other principles or interests?

My reply, which was thankfully limited by a character limit, is here (I added a few hyperlinks to this version, but otherwise it is unchanged):

@johnbmadwis, these questions have been answered by courts and medical ethicists. There is an obvious glaring difference in autonomy between a child who is already born and a fetus, whose existence depends entirely on the mother, whose life is intimately affected and at risk by carrying a pregnancy. Late term abortions (post viability) are extremely rare, and most states have strict limits on the conditions under which such procedures can be performed.

If you are worried about a slippery slope, it is pretty obvious the slope has been tilting towards restrictive legislation limiting all abortion, not just the dramatic but rare cases you bring up. More than 400 bills have been proposed recently in state legislatures seeking to place barriers on access to abortion, from extended waiting periods for all terminations, overreaching excessive requirements for providers and facilities that don’t extend to other, riskier outpatient surgeries, to personhood bills for fertilized eggs.

Trisomy 18 is a serious condition that is considered mostly “incompatible with life.” Not only is the fetus likely to die in utero, but if it survives, it is likely to die as newborn. The article (mostly) covered this really well. (We do know the “cause” of most trisomy 18 – nondisjunction during meiosis II – which is much more common the longer the egg has been in a suspended state of meisosis, i.e. in older mothers).

Santorum’s daughter is lucky in some ways to be a 1% in more ways than one, but this is more than just some sort of ethical masturbation in a comment section of a blog. This issue involves the emotional and physical challenges to the mother. Have you ever carried a fetus, commenter with a male sounding handle? Have you ever had a stranger put their hand on your belly and ask when you were due, when you knew the fetus would most likely die before birth, or soon after? Then there’s the suffering of the baby if it survives, and the emotional toll such care takes on caregivers – do you have any idea what it is like to work in a NICU on suffering, terminal infants? With major cutbacks in personnel in public hospitals, too.

Not to mention the health care dollars arguably misproportioned here. I got to tell pregnant mothers with no insurance yesterday that they had to pay full price, cash up front for necessary basic lab tests. These are mothers who don’t have husbands flying around the country campaigning for president. These are mothers who may and do skip important labs, or prenatal visits, because they have to choose between knowing if they have hepatitis B or food for their existing children. We got to tell a mother who was having her fourth baby and desired a tubal ligation that there was no funding anymore for it. She could pay $1400 up front to the clinic then pay more in hospital fees. Maybe she could google birth control – oh, wait, she probably doesn’t have a computer.

Enjoy wringing your hands about the autonomy of a trisomy 18 fetus. It’s a luxury.

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Reply turned post, health care reform style

A Facebook friend posted a link to a news story about how insurance companies still say they will fight to deny coverage of preexisting conditions. I replied that I am sickened (no pun intended) by the people throwing bricks through congressional office windows, spitting on politicians, firing bullets into a congressional office, cutting a gas line at a politician’s family member’s house and calling in death threats, all in the name of defending this horrid status quo.

She asked me in reply “What do you think of all this health care stuff?”

I don’t know how much I have written about it recently, even though I have been following the debate avidly. I got turned off one step at a time with each compromise that was made, when each compromise didn’t earn one single Republican vote. What could have been a progressive reform pretty much got turned into a pretty close copy of the Republican’s answer to the Clinton era Democratic reform proposal. In fact, it uses a lot of ideas from the Republican platform in the 2008 election. We scuttled the public option, contraception coverage, put in extra barriers to abortion, cut the minimum of premiums taken in that had to go to actual medical care, removed end of life counseling, put in mandates, etc. etc. Although I think we have a gutted shell of a reform plan, it is still better than the status quo.

Here is my reply:

I am a big fan of the book “The Healing of America” by T.R. Reid. He looks at health care delivery and payment in several “civilized” countries, including countries like Switzerland that made their transition when we failed during the Clinton era.

It is grossly apparent to anyone who looks, apolitically, at health outcomes, disparities and access that the United States has one of if not the worst health care systems in the industrialized world.

I think we could easily switch over to a single payment system by simply expanding Medicare to pay for all, and then use the best elements from all of the health care systems that already work much better than ours. It’s not like there isn’t ample good examples around. Japan’s cost control and ample access to excellent practitioners and treatments (more visits to physicians per year than the US and best in all outcomes, with a fraction of our cost, and universal coverage), Canada’s self referral system, France’s electronic records card and billing (which would save billions in overhead in offices and hospitals) – for the doctors and business owners, not just the government and patients!), England’s subsidized medical education (in fact, most countries have this), and even Germany’s use of existing private insurance companies to organize the care.

What I don’t like is the knee jerk, angry reaction we have to this kind of reform in our country. In Canada, in Japan, in the UK, this isn’t a left/ right issue. It’s a matter of human rights, and it’s hard to find a politician of any stripe who wants to switch to the US system. In fact, it’s a common insult in the UK in parliament to say that another politician would rather have the US health care chaos, and it’s used by both sides.

As a future practitioner, I would hate to have to turn down a pregnant patient like I was turned down as having a “pre-existing condition” when I was pregnant. Fundamentally, I can’t see why anyone in the health care industry would support the status quo.

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Reply turned post, Dr. Amy’s “egregious” post on KevinMD style

KevinMD invited Dr. Amy to write a post about offering VBAC, simply entitled “VBAC should not be a woman’s right”. Keep in mind on both my blog and on Academic Ob/Gyn, she has agreed the evidence supports offering VBAC. But, on this post, she mocks people who support offering VBAC, using no evidence or data, but links to blog posts and, of all things, an ad on the site of a medical malpractice firm.

The reply:

Why don’t you link to scientific evidence instead of blogs and websites of malpractice lawyers? Using inflammatory words like “bizarre” and pretending women don’t have the right to be active decision makers in their medical care is doing nothing to improve communication between physicians and their patients.

Here is the evidence report of the NIH conference on VBACs. VBAC activists are not a small group of blog writers. This is a mainstream medical cause.

Also, the pattern of obstetricians not offering VBAC has a lot more to do with the wording of a specific ACOG position statement and less to do with real medicolegal pressures. I am in Miami, which has one of if not the highest cesarean rates in the country, one of the lowest if not the lowest VBAC rates in the country, some of the worst malpractice rates and payouts in obstetrics, some of the highest malpractice insurance premiums, and really revolutionary tort reform, in that obstetricians can and mostly do “go bare”, which means that they don’t carry malpractice insurance, and effectively limit awards $250,000.

So, the only thing these docs have in common with obs throughout the country is the rocketing trend to refuse VBAC since the ACOG position statement change in 1999. They have their tort reform. They have their low VBAC rates. Their malpractice premiums haven’t gone down. Their malpractice awards and frequency of being sued hasn’t gone down. Our maternal mortality is horrendous. I can provide citations for any of that, by the way. ACOG does a yearly survey on malpractice, and they print numbers for Florida every year.

Here are two scholarly articles one and two that indicate that refusing VBAC isn’t the key to malpractice. It’s proper documentation (including during VBAC, yes I have read the first article, so don’t try to misrepresent what it says about VBAC) and evidence based standards of care. And, the AHRQ statement out of the NIH conference is the most recent, comprehensive evidence review on VBAC.

There is already good literature on risk and decision making during pregnancy if you want to talk about the rights of the pregnant patient. It reads: “These tendencies in the perception, communication, and management of risk can lead to care that is neither evidence-based nor patient-centered, often to the detriment of both women and infants.” The section on VBAC is enlightening, and calls your type of scare tactics unethical. Do you have a similarly well documented discussion published in an equally reputable journal written by practicing obstetricians that takes your point of view, that women don’t have the right to refuse elective repeat cesarean, when the most recent evidence review calls it perfectly reasonable?

I think we all know you don’t, because I have been linking to the Lyerly et al article for about a year now, and you have yet to come up with anything other than your own writing to support your point of view. Why don’t you use well established bioethical principles, and quote ACOG committee opinions on balancing the rights of women to refuse surgeries? Because they support the fundamental bioethical principles of non-malfeasance, beneficence, and autonomy of the patient. I don’t remember seeing CYA listed as a bioethical principle on weighing the rights of patients.

Calling people who are consistent with ACOG bioethics teams and the NIH “irrelevant”, “bizarre”, “Inane”, “egregious” and and “committed to resentment” is, well, bizarre, egregious, inane and committed to resentment. And, it completely ignores the basic fact that a repeat cesarean IS a procedure, and a trial of labor is the REFUSAL of a procedure. That basic inarguable “semantic” fact is the center of why women DO have the right to refuse an elective repeat cesarean. Using inflammatory insulting words doesn’t make your reasoning right NOR ethical, and when discussing rights, that is what is key.

The NIH report concludes “This report adds stronger evidence that VBAC is a reasonable and safe choice for the majority of women with prior cesarean. Moreover, there is emerging evidence of serious harms relating to multiple cesareans.”

Why don’t you work with activists AND the medical establishment to get the ACOG position statement on this, and the presentation of risks, both TO obstetricians about malpractice and TO patients about all risks in pregnancy and delivery in line with evidence and bioethics?

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Commenting policy: I am committed to keeping my comment sections civil. If I criticize Dr. Amy for using verbally abusive, inflammatory tactics, I cannot ethically abide by people using the same in my comments. I am also not interested in people insulting people living with mental health diagnoses by using “crazy” or “forgot to take her meds” as insults for anyone, including me and Dr. Amy.

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Amnesty International takes on maternal mortality in the U.S.

Amnesty International just released a report on maternal mortality (and near misses) in the United States, treating it like a human rights issue. It’s often asserted, including in this report, that infant and maternity mortality are key indicators in the health and social justice of a country.

I need to finish reading the 154 page report (ulp!) so I can get my thoughts together to be a coordinator for local lobbying. I like their proposal to ask Representatives and Senators to call on President Obama and Health and Human Services Secretary Kathleen Sebelius to create an Office of Maternal Health at DHHS, and to improve collection of data on perinatal mortality and morbidity on a state by state level.

Then, I’ll report back, and hopefully get to my cousin Susan’s birth story and the NIH VBAC conference.

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I write letters, White House Style

I wrote a letter to the president:

Health care reform can still pass, and the Democratic image can be regained after this Massachusetts election fiasco.

I would consider scrapping what you have, and throw a curve ball to take over the news cycle from the Republicans.

Pass a simple bill (through reconciliation) that expands Medicare to people 50 and over and 20 and under. Write simple rules for the insurance companies that cover what’s left: 1. no denial of preexisting conditions. 2. At least 90% of premiums have to go to health care. 3. No denial of pregnancy or birth control coverage, or unfair treatment of women.

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Synopsis

I have been really busy lately and overwhelmed with various issues in my real, meat world life.

So, although I don’t have the emotional energy or time to write a full post, I just wanted to say a few things.

Stupak-Pitts Amendment? Makes me furious.

Obama administration’s and other progressive groups’ responses? Disappointed and furious, but not surprised.

What do I think of the chances of the health care (method of payment and abortion) reform bill passing in the Senate? Well, considering the Senate is less liberal than the House, we have “friends” like Joe Lieberman and Ben Nelson, and a pro-life Catholic majority leader in Harry Reid, I am not optimistic.

Oh, by the way, I highly recommend this book: The Healing of America, by T.R. Reid.

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Call to action on breastfeeding

The HHS has a call to action on breastfeeding that is currently open for comments. (h/t to Our Bodies, Our Blog.)

I commented on Maternal and Infant Care Practices: Prenatal, Hospital, and Post-Delivery Care, and Paid Maternity Leave so far, but could easily comment on all of the topics. I hope they get lots of good feedback. Please comment!

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Vaccinations – dipping my toes in the waters

I have wanted to talk about vaccinations for a while, but I have been afraid to broach the subject. I am definitely at a clash between two cultures when it comes to vaccinations. I know how ugly the language can get coming from both sides of the issue. I want to discuss some nuance here. Let’s see if it works.

I got an email from a faculty member at my medical school asking us to make phone calls against Florida SB 242 relating to immunizations, which is on the agenda of the Policy and Steering Committee on Ways and Means April 21st. I am not taking a stand on whether this sort of email is appropriate. I do encourage political discourse. I wish the email had a link to the full text (pdf) of the bill (which is actually hard to pin down. I think there are a lot of proposed amendments, too) or used the original language of the bill. I would like to exercise my same freedom to discuss the issue that my faculty member took, and examine some aspects of the proposed legislation.

The proposal wants to start a registry of vaccines by lot number. Why is this a problem? I know many people swear there is no link between autism and vaccines. Vaccine reactions are supposed to be rare. Why can’t we support this by tracking lot numbers? Autism was not under any form of surveillance in Florida when I wanted to research it five years ago in an epidemiology class. There are supposed pockets of autism here. What’s wrong with a little old fashioned public health research here? Nothing wrong with data. The lot number is an easy enough thing to note. When I administer an HIV screen I note the lot number (with a sticker) in no less than eight places. Parents can refuse to be part of the registry. So, this doesn’t have to be a burden if parents are resistant to having that sort of information recorded. I am a big fan of opt out options. (Although I tend to think there will be some overlap between the parents who don’t want their kids’ vaccines tracked by big brother and the parents who don’t want to vaccinate, period.)

The second recommendation (one of the links above) is to prohibit:

The sale, purchase, manufacture, delivery, importation, administration, or distribution of any human vaccine used for children under age 6 or pregnant women which contains any organic or inorganic mercury compound in excess of 0.1 microgram per milliliter.

There is an exception made for epidemics. I always hear vaccine advocates saying that thimerosal is no longer an issue, it has been removed from virtually all vaccines. So, again, what is the problem. Why defend the mercury? I know some people say dental types who want to defend the mercury in silver fillings are just trying to prevent lawsuits. Is this the same sort of issue? Mercury was in most vaccines up until very recently, and is still present in some, namely the flu vaccine.

Finally, it allows for a modified schedule for vaccine administration. Again, what is the problem? Why the utter inflexibility? It does not say it allows for any new exemptions. Some diseases do not cause outbreaks generally (bacterial meningitis, hepatitis B), at least not in young children. I can still see how a pediatrician can inform the parents, allay fears, and try to set up a schedule that works for everyone. Is the child not going to be in daycare (which may not accept the adjusted schedule) and not exposed to many people? What’s wrong with waiting on a few?

I think my professor is afraid that making accommodations about vaccines in any way gives credence to vaccine critics. I think the opposite. Making sure vaccines are as toxin free as possible and allowing for some parent autonomy, within reason, actually takes fuel away from the extreme anti vaccine crowd.

OK, have at it. Try to be civil or you may get a square on the bingo card.

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If I was in charge of the FDA…

I may not teach at Harvard Medical School like the author of this interesting op-ed in the Boston Globe, but I also have some opinions on what the new FDA should do. I am right with the people who have many complaints about our foreign policy under the past administration, but medicine and health were also gutted and ruined, and the FDA was at the rotten core.

I agree with every recommendation she makes, especially the ones about comparing new drugs with existing drugs in the same category for efficacy, and using clinical endpoints like heart attack and stroke instead of biomarkers like cholesterol. (H/t Our Bodies, Our Blog)

I would go one step further and recommend that all pharmaceutical companies do the preliminary research themselves on new drugs, but contribute to a general fund for advanced trials. Independent scientists would do blinded research, including older drugs for comparison. All results would be published. These companies would have to be damn sure all the kinks were out by the time it got to that stage.

Hey, a girl can dream, can’t she?

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Reply turned post, I’ve heard this song before style

Pretty soon I may actually come up with an original post, and stop doing only replies-turned-posts. I have recently added more sites to my feeder. I deleted some, too, so that may be a moot point. I also just finished classes and S’s birthday party, and am looking forward to a week “off”. I have a lot planned for this week, including a trip to a Medical Students for Choice convention on Friday. I also have to catch up on a lot of business I let slide until this week off. Not to mention, I have a written final in Osteopathic Principles and Practice, and a cumulative practical, on Tuesday after spring break. That includes license and car registration renewals, quizzes for my public health class, plans for my research project, my FAFSA, exercising and gardening…and catching up on hundreds of updates in my blog feeder. This catching up process explains a lot of replies. Some turn into posts. I like doing these because it shares other sites with people who have similar interests, and at least half of my ranting occurs on other sites.

So, this was a reply on a post about the resistance to the increased Medicaid contraception coverage in the stimulus package on RH Reality Check. I am not sure why this was being discussed now, since it happened in January, even though I welcome this kind of an article anytime. I swear, even thought I am backlogged, the post on RH Reality Check and the original article from FAIR were both published yesterday. It may be timely, since this provision as supposed to be added to the budget that just got passed.

Anyway, the reply:

Not only is the corporate media guilty of not challenging talking points or critical attacks by politicians, but this case was even more egregious. The mainstream media, even liberal sources, tend to treat women’s reproductive health, especially contraception and abortion, as a political third rail. It’s automatically “controversial”, so everyone’s outrageous statements are accepted under the umbrella of controversy.

By including women who would qualify for Medicaid if they got pregnant to Medicaid’s contraception program, women would have more control over their reproductive autonomy, not less.

It didn’t even matter that this provision would PREVENT abortions, not increase them, so it could not fund the nonexistent “abortion industry”. It most certainly would not impose them on pregnant citizens like the Chinese government.

I really wonder why Rep. Boehner and his ilk are opposed to contraception if they are supposedly interested in decreasing abortions. They need to add “anti contraception” to their platform. I would be interested in seeing the reaction to that.

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