Cura personalis

Hey guys.  I haven't written in eons, but I had a conversation quite recently that has sent me racing back to my little blog, anxious to share my indignation with anyone who will listen.

This was what transpired:  I had a patient last week, a nice, older male, armed with a full set of nice, older male "family values."  Towards the end of our encounter, he told me happily of a story he had heard on the news.  To be brief, the story centered around a young pregnant woman with cancer, who forewent chemotherapy in order to deliver a healthy baby.  Due to the delay in treatment, she died soon after giving birth, a decision my patient lauded and defended.  Lest I doubt his thoughts on the matter, he added:  "Isn't that just great?  So many women would be selfish and put themselves first, and so many would even throw their babies away and have an abortion!"

http://www.turnbacktogod.com/virgin-mary-pictures-06/

Now, who knows what particular instance this man was referencing.  There are countless instances of pregnant women choosing to put the well-being of their fetuses above their own.  Choosing being the operative word.  All well and good.  Yet once this decision becomes expected of women, once we as a society make the Rick Santorum-approved assumption that a woman - endowed with hopes, dreams, life experiences, the abilities to enjoy life an to contemplate death - is worth less than the fetus she is carrying, we have come to a dangerous conclusion.

There is already a disturbing history of Catholic hospitals (which, by the way, comprise 13% of healthcare providers in the U.S.) denying life-saving care to pregnant women.  It is the Church's official policy not to provide therapeutic abortions even in cases of ectopic pregnancy.  Under the auspices of the so-called "Protect Life Act," these hospitals could continue to withhold treatment while still receiving federal dollars!  Catholic hospitals which do perform such procedures may face loss of funding, excommunication, and general Catholic self-righteousness.

Fittingly, just as I had this issue on the brain, I interviewed this morning at Georgetown's (Catholic) School of Medicine.  After a long speech about Georgetown's philosophy of "cura personalis," the "respect for the individual humanity of every patient," we sat in on a class on, of all things, complications of pregnancy.  The descriptions of ectopic and molar pregnancy were not followed by mention of treatment, in good Catholic form.  Question:  Could I really attend this school?

Answer:  Even if I don't, society's views on motherhood and the rights of women extend, alas, far beyond the nunnery walls.

A Free Lunch

I have great news for those of us who would like to keep our uteruses vacant for the time being.  This past week, the Institute of Medicine released a much-anticipated report defining contraceptives as "prevention," categorizing birth control along with such services as mammograms or childhood immunizations.  No shit, Sherloch, right?  But the awesome implication of this classification is that, if the federal government accepts the report's findings, birth control, IUDs, and birth control injections will now be offered by insurance companies without copays.  Free at last, free at last.

http://philip.greenspun.com/images/pcd0155/gay-parade-19

The IOM now recommends that birth control methods be made available free of charge in order to stem the high number of unintended pregnancies (and yes, abortions) that occur in the US each year.  And shockingly, according to a recent poll, about 71% of Americans agree with this suggestion.

http://moneywatch.bnet.com/economic-news/blog/daily-money/will-new-health-care-bill-mean-free-birth-control/1473/

Childhood immunizations are one of the primary intro economics examples of a positive externality:  protecting the majority against infection will lessen the overall population's risk of infection, making us all healthier as a result. Thus, immunizations are offered without copays and are considered to be worth the cost.  Preventing unwanted pregnancies, by comparison, is a positive externality in the same vein.  Fewer unwanted pregnancies spell lower Medicaid costs, better career prospects for women, and fewer kids with shitty childhoods.  According to a 2010 Norwegian study, free birth control greatly decreases the rate of unintended pregnancy, and halves the abortion rate.  If these projections hold true in America as well, then both the pro-life and pro-choice sides should have something to celebrate.  This, America, is compromise.

Now, let's not get too excited just yet:  we are already hearing from the Catholics, and I have no doubt that the chronically pugnacious Republicans will soon be chiming in.  But nevertheless, I am elated, and not only because I might soon be saving around sixty bucks a month.  First, maybe mainstream attitudes towards contraceptives are not as medieval as my Negative Nancy self had believed.  Second, this report forecasts a very positive and palpable shift in women's health.  No-cost birth control will not only save taxpayers an enormous amount in the long run, but will also produce a profoundly positive trickle up, down, and around effect.  Margaret Sanger is smiling.

A Call to Arms (and to Scalpels)

Three cheers for America's judicial system.  It may be the least-appreciated branch, the "Holy Spirit" of the federal government, so to speak, but for almost 40 years now it has firmly upheld Roe v. Wade against countless legal attacks to repeal and undermine it.  In the past few decades, however, slander, intimidation, and yes, even pro-life terrorism have been much more successful than legislative initiatives at chipping away at the right to choose. The pro-life side has managed, through numerous back-door approaches, to make obtaining an abortion difficult and humiliating, if still technically legal.  Today, the biggest threat to abortion rights in the US is not the legality of the procedure, but rather the logistical access to abortion services, due in large part to the near crisis-level shortage of practicing abortion providers in the US.

Abortion remains one of the most commonly-performed procedures in America, and is certainly one of the most often discussed.  Therefore, it probably surprises most people to learn that physicians who perform abortions (or "abortionists," as they are so often called) are few and far between.  As in "entire states of separation" far between.  If you need an abortion and live in Wyoming, Missouri, Mississippi, or, God forbid, Hawaii, you are shit out of luck:  these four states lack a single abortion provider.  Even in states with relatively progressive abortion laws access to abortion is hindered merely by the scarcity of providers.  In fact, the 1.21 million abortions performed in 2008 were provided by just 1,793 facilities, with half of these services provided by just 2% of OB-GYNs.  In contrast, the nation is blanketed by well over 4,000 crisis pregnancy centers.

http://www.catholicvoteaction.org/americanpapist/index.php?tag=pro-life

It's not difficult to imagine why so few physicians provide abortions.  Clinic bombings, "abortion hit lists," Bill O'Reilly's abortion witch-hunt, and the 2009 assassination of Dr. George Tiller have all achieved their intended effect:  terrifying physicians out of providing a legal and judicially-protected procedure.  There are additional factors at play as well.  Catholic hospitals, which employ around 16% of American doctors, prohibit their employees from performing abortions even to correct an ectopic pregnancy or other life-threatening complication.  Many OB-GYNs aren't even trained in the procedure, as fewer than half of residency programs require this training.  And even physicians who identify as pro-choice may be reluctant to perform abortions due to societal pressures and the awkwardness of rarely being able to discuss their work in polite conversation.

http://worstgenerationseed.blogspot.com/2009/03/truth-truck-meets-tiller-killer.html

As a very pro-choice pre-med, these matters have been on my mind for some time now.  The nation needs abortion providers.  Women need abortions, and they will not stop needing (and procuring) them just because their doctors are incompetent or untrained.  I will someday need a specialty, and I believe in providing a service that millions of women want and need.  Of course, now is not the time to commit to a career:  even by the most optimistic estimates, it will be more than five years before I have my MD.  And regardless of how passionate I am about the cause, I'm not sure whether I'm prepared for a career that will spell a lifetime of harassment, fear, disdain, and maybe even a bullet to the head.  But it's something to consider.

http://www.theologyonline.com/forums/showthread.php?t=66908&page=2

Crisis

http://www.impact73.org/Lifeboards.php

Project Lifeboard offers you "options," but not "choice."

This week there was some good news in the world of Choice.  According to the NYC city council, Crisis Pregnancy Centers, pro-life organizations which disseminate ads like the one seen above, must now specify in their ads 1) what specific services they provide, and 2) whether or not they hold a medical license.  Baby steps, but steps in the right direction.  This is some progress, but I am far from satisfied, for numerous reasons.

These centers usually present themselves as medical clinics offering abortions and other pregnancy services, though their true purpose is to dissuade girls experiencing an unwanted pregnancy from having an abortion, and often to win Christian converts along the way.  Most centers are in fact unlicensed and staffed solely by religious volunteers and medical assistants – people who have had less than 6 months of medical training.  The only services offered are pregnancy tests and ultrasounds.  Even more absurd are the tactics used to wheedle girls into choosing to keep a baby:   “patients” at these centers are shown footage of a fetus’ beating heart, are encouraged to marry the baby’s biological father, and receive blatantly incorrect medical information about the dangers of having an abortion. 

According to the website of Ramah International, an alliance of pregnancy centers,  there are a few things I should know if I am considering an abortion:  1)  Abortion is a risky procedure, often performed in unsanitary conditions.  2)  Following an abortion, I am 33% more likely to experience an ectopic pregnancy, 50% more likely to develop breast cancer, and 600% more likely to experience abruptio placenta. 3)  Following an abortion, I have a 50% chance of developing “Post-Abortion Syndrome,” which leads to depression, anxiety, and suicide.  4) My fetus can feel pain beginning at 9 weeks.  And, most ridiculous, 5) I should first take a pregnancy test at the center, because THE DOCTOR WHO TOLD ME I WAS PREGNANT MAY HAVE LIED IN ORDER TO SELL ME AN ABORTION.

These claims are all false, as well as ridiculous (honestly, has a doctor ever told someone he had cancer in order to “sell” him a surgery?)  It is one thing to run an establishment dedicated to spewing hellfire and damnation of the religious variety on women who are in genuine distress.  It is quite another, however, to disseminate deliberately false medical information in an effort to terrify and manipulate women into making what will probably be one of the most important decision of their lives.  Imagine a scared, pregnant 16-year-old girl entering what she thinks is a medical clinic, being told that she has a ~50% chance of dying from the long-term effects of an abortion, and making a decision to keep and raise a baby based on that information.

But lest you think that this is the last stop on the Crazy Train, 20 US states currently provide funding for these Crisis Pregnancy Centers (my own native Georgia being one of them).  These are tax dollars, being spent on a service that masquerades as something it’s not and then lies directly to its clients.  This is like spending state money on a fire station which pretends to be a restaurant and then tells customers that too much friction during sex will cause a forest fire.  And these are the tax dollars we can’t afford to allocate for family planning.

Though NYC has voted to begin regulating its centers’ advertising and similar measures have been enacted in Maryland, such legislation has failed in most staes.  Nationwide, crisis pregnancy centers outnumber abortion clinics 4 to 1, and receive approximately $25 million of state and federal assistance.  Using tax funds to encourage teens to marry and raise children, without providing them with the appropriate pre- or post-natal care or contraceptive options?  Makes fiscal sense to me.

Pregnant?  Alone?  Confused?  For the love of God, go to a real doctor.

Dividing Cells, Splitting Hairs

In his 1968 encyclical Humanae Vitae, a treatise condemning the use of contraceptives, Pope Paul VI famously established the Catholic church's official stance on all matters procreative.  In the 40-odd years since the publication of Humanae Vitae, the Church has not budged it its contra-contraception position, and Pope Paul VI's treatise has been lauded as "prophetic"for how it anticipated today's issues of reproductive ethics.  These aren't just echoes of the "be fruitful and multiply" argument, however.  Supporters of the Church claim that the Pope's views on birth control are even more relevant given that chemical contraception is "known" to induce abortions through preventing implantation of a fertilized embryo.  Thus contraception is not a lesser, separate evil, but is tantamount to abortion itself.

http://stemcells.nih.gov/info/scireport/appendixa.asp

A life begins... OR WILL IT????

It's not just the Catholics who have voiced this condemnation of the "abortifacient" properties of birth control.  The Evangelicals who fill the ranks of the pro-choice movement are similarly quick to criticize any use of "unnatural" hormonal contraceptives.  There is the outstanding example of the Duggar family, who believe that their use of the Pill caused the miscarriage of one of their pregnancies back in the '80s, and have spent the past two decades atoning for this crime by pushing the limits of human reproductive capacity.  Just a quick Google search will yield a bevy of emotionally-charged, poorly-researched, and often blatantly deceptive websites devoted to defaming all birth control use and equating contraceptives with murder.  (Notable examples including Birth Control is a Sin, Birth Control Causes Abortions, AbortionFacts.com, and perhaps most horrifying, PoisonedByThePill).  A common thread throughout these websites is that of deliberate deception at the hands of doctors and pharmacists.   Readers are urged to "read the fine print" and "wake up" - as if the entire medical profession were aligned in some giant conspiracy to kill Evangelical embryos for the good of Science and Atheism and Richard Dawkins.

From this movement has grown a plethora of misconceptions and taboos about the "Morning After Pill" and oral contraceptives.  Many women worldwide are misinformed about emergency contraception and its mechanism of action:  some actually mistake the Plan B pill with RU486, the "abortion pill."  Pro-life lobbying on this issue has also spawned “the Pharmacist’s Conscience Clause,” a provision which allows a pharmacist to withhold oral contraceptives and the "morning after pill” on moral grounds. A recent study estimated that 6% of American pharmacists actually withhold contraception - which probably makes it pretty difficult to purchase birth control in Kansas.  This poor understanding of emergency contraception deters many genuinely well-meaning women and couples from choosing Plan B following unprotected intercourse - which, of course, is the intended effect of the religious fear-mongering. 

Now, Pope Paul VI was not a doctor or a biologist, so I was interested in how he arrived at his understanding of the mechanism of action of birth control pills and emergency contraception.  So I popped on over to PubMed to see what relevant (and unbiased) information medical researchers had discovered on the topic.

But first, a little background on early embryonic development: the human embryo typically implants in the uterine wall at the blastocyst stage, approximately one week after fertilization, when it consists of 32 cells.  To prevent a subsequent pregnancy, the ovaries begin secreting progesterone, a hormone which inhibits further ovulation.  Progesterone also inhibits the process of sperm capacitation, which enables a sperm to fertilize an egg.  In addition, this hormone thins the lining of the endometrium - just like it does during the luteal phase, i.e. a menstrual period.

Both oral contraceptives and older versions of the Plan B pill (which is essentially a higher dose of the same thing) rely on progestrin, a synthetic form of progesterone, essentially to trick the body into believing that it is already pregnant.  Thus, ovulation and sperm capacitation do not occur, and the endometrial lining thins.  It is this capacity of progesterone which has conservatives jumping down throats and splitting hairs about what constitutes prevention vs. termination of pregnancy, and losing sleep over the fate of the human blastocyst.

http://www.glowm.com/?p=glowm.cml/section_view&articleid=2&SESSID=evpji2lnn7ah65gbjah4bgnc40

So let's see what a few decades of medical research have to say on the matter.  First, newer Levonorgestrel-based contraceptives (such as Plan B One-Step) can apparently only prevent ovulation, and cannot prevent pregnancy once ovulation has occurred.  No studies indicate that Levonorgestrel has any "abortifacient" capabilities.  Thus, Levonorgestrel is only 80% effective at preventing pregnancy.  The results of studies on progesterone-based pills are a little bit hazier:  some report "with mild confidence" that progesterone prevents implantation, while others deny this to be the case.  Most review articles state that the prevention of implantation is "possible in theory," but do not provide relevant statistics.  In contrast, the post-coital insertion of an IUD has been shown to prevent implantation of an embryo; Mifepristone, the "abortion pill," can be taken in small doses to produce the same effect.

The general medical consensus:  certain forms of emergency contraception (Mifepristone and IUDs) have the secondary effect of preventing embryonic implantation.  However, the most commonly-used form of emergency contraception (Levonorgestrel), does not act in this way.  In regards to the Pill, it is possible in theory that these contraceptives prevent the implantation of a fertilized embryo, but no study to date has strongly indicated that this is the case.  I speculate that the findings of such studies are complicated by the fact that, even in the absence of birth control, at least half of fertilized human ova do not successfully implant.  Here's a little graph I threw together about the prevalence possible fetal fates in the U.S.:

Needless to say, these stats are going to make Georgia Rep. Bobby Franklin's job very difficult if he in fact intends to investigate and press charges for every miscarriage that occurs in his state.  The majority of fertilized oocytes to not make it to be full-fledged humans, even without medical or chemical interventions.  Ultimately, it is difficult to determine how often emergency contraception prevents an embryo from implanting when God Himself is already doing such a good job of it.