Hippocrates' Decree

Today I give myself up to Humanity.

I offer my life, my entire existence - for the purpose of aiding other lives.

So that the strong remain strong and the weak and small find shelter under my wings.

I resign myself to being a humble supporting character in a play,

an architect of a prestigious town, even the combat medic on the field of

War.

    Quiet, silent, and unnoticed. Enabling others to achieve their dreams.

    I give myself so that others can fight their battles

    While I heal them. The war is long, injuries will accrue.

But I promise myself to live for them.

To provide my support: mental, physical, spiritual.

    So long as I “first do no harm.”

Today I surrender my energy, life and soul

To the healthier future generation of tomorrow.

    For when there exists peace and my role considered decrepit and useless

                Only then is my mission accomplished

                And I may rest at last.

Yesterday

Radiant mother, bespeckled with sweat

Will vaginally deliver, barring no threat

“Through my blood proudly come to your start

I’ll always love you, till death do us part”

One hour pushing, doctors mention

C section

Two hours of pushing, doctors threaten

C section

C section

Three hours. Mamma has strength. Baby is fine.

C section

C section

C section

Risk for infection demands dissection

“Time is what we need”, nurse disagrees

Mom cries, “my body is not my own”

Doctor’s decisions aren’t crafted to please

Of course.

She was trained to say no.

Avoid death and lawsuits; a quid pro quo.

Meds, curtain, disconnect mind from torso.

Surgeons stained satin, splatter bleached floor

Uterus outside chest, refugee in a war

of knives and sutures. Baby’s once home

bloody, battered, bandaged. Glory dethroned.

Same moment

Frozen in time, beautifully grotesque

Mother holds baby girl close to her chest

Tired baby sleeps on tired moms warm breast

Father, tear stained cheeks sing ineffable bliss

Heart full, gives his little angel a kiss

Radiant mother, bespeckled with sweat

Has delivered despite some grave threat

“Through my blood you’ve proudly come to your start

And I will love you, till death do us part

Cesarean sections in the United States have risen to 50 percent in the past two decades. We continue to have the highest risk of maternal and neonatal mortality in developed countries.

Osterman, Michelle, and Joyce Martin. "Trends in Low-risk Cesarean Delivery in the United States, 1990–2013." National Vital Statistics Reports 63, no. 6 (November 5, 2014): 1-16. Accessed October 23, 2016. http://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_06.pdf.

Ode to Humanity

I was created, framed and pristine.

           A trophy of cells, of carbon and stardust of perfect geometry. The perfect shell and automaton.

Machinery, creaking aluminum cogs and wheels, gears that whirl

in unison – Man.

           Sinew and elastic rubber bands, our extensions flushed.

A body of artifice, of false truths and illusory fog.

I learned to be made of actual steel,

           for skin and muscles, even bone, decay. Cold to

touch, reflective, impenetrable.

                                   But

You melted my soul, freed my newfound beating heart, the sacred flame

burned away the arm and leg He gave me, leaving my

Humanity to escape from its temporary prison.

Love and kindness, hatred and despair, creativity and inspiration. I felt it all – liberated.

The essence of human life beyond the steel.

           I bared my ribs, titanium white and color burst forth from the prism.

           Showering down in a pitter-patter of eternal rain drops that left

my body corroded in the scrap heap.

           I was sculpted by Him in His image. I am free and omniscient.

Yet why am I broken?

The West is failing to enforce anti-FGM laws: Perspectives

Female Genital Mutilation (FGM), also known as Female Genital Circumcision (FGC) or “cutting” to those who practice it, is the intentional partial or total removal of a female’s genitalia. The World Health Organization (WHO) estimates that over 200 million women have undergone this practice in 30 countries, mostly in the Middle East, Asia, and Africa. In the past three weeks, two major world players made bold comments regarding FGM, attracting the attention of international media. On September 15th, a committee of British MPs in the House of Commons declared in their report Female Genital Mutilation: Abuse Unchecked, “it is beyond belief” that while about 137,000 girls were subjected to FGM in 2011 in just Wales, there has not been one successful prosecution. FGM was made illegal in the UK 30 years ago[1]. According to the scathing report, when this “horrific crime” and “violent child abuse” is inflicted, it causes “severe physical and psychological pain and leaves survivors with lifelong health consequences.”

On the opposite end of the spectrum, an Egyptian MP stated on September 7th that women must undergo female circumcision in order to limit their “sexual appetites” and help curb men’s “sexual weakness” due to the widespread impotence of Egyptian men[2]. Though the practice was made illegal in 2008, the MP’s remark is indicative of the widespread cultural imperative within Egyptian society that demands female circumcision in return for societal acceptance. According to a 2015 Egyptian’s Health survey, 87% of women reported being cut[3]. Though Egyptian FGC has existed since the Pharonic period, there has recently been a slight decline among younger women, possibly in response to the 2008 prohibition.

FGC is thousands of years old and is practiced across thousands of unique cultures and tribes. The techniques and symbolic meanings vary drastically, therefore the the physical and emotional implications on the lives of women do as well.  According to some proponents, female circumcision is used to promote the health, beauty, and protect the virginity of a woman. As reported by Dr. Moges, many supporters claim medical benefits, such that FGC, “enhances fertility, controls and prevents waywardness of girls... the clitoris is dangerous and hinders intercourse, creates impotency, and kills baby at delivery”[4]. Those who oppose female genital mutilation cite that this practice is a massive violation of human rights, resulting only in lifelong harm. Western feminists critique that FGM is an extreme form of control over a woman’s sexuality. WHO (an organization that values Western medicine) recently released a report stating that FGM causes, “severe bleeding, pain with urination, later cysts, as well as complications in childbirth and associated with death of the newborn”[5].

Bettina Shell-Duncan is anthropology professor who specializes in FGC and speaks on the need to clarify cultural misconceptions. First and foremost, emphasizing that this practice is largely done by and for females. Unbeknownst to those unfamiliar with nuances of the practice, a great number of women feel pride partaking in this cultural tradition and in joining the ranks of their mothers, sisters, and ancestors. Even if a father does not wish to subject his daughter to “cutting”, his personal opinion is largely irrelevant as cutting is a collective decision made by a community, deeply embedded in societal function. Shell-Duncan believes that fostering a contextual understanding of motive is the first step the West should take to eradicate FGM. She claims it is imperative to realize that parents subject their daughters to the practice because they want the best possible future for their children – like most parents do – and they believe cutting will ensure this.

Shell-Duncan notes that when many refugees come to Europe they, “very quickly realize that … the future for their girls might not be best secured by being circumcised any longer”[6]. This is reflected in a recommendation from the MP’s House of Common’s report. The report calls for a commitment from those who come into contact with children-  especially those trained in health, education, and social work – to identify and report FGM. They assert that, “prosecutions will not be possible if we wait for daughters to report their parents to the police, which is unlikely to happen”[7]. Studies have found that many community workers ignore FGM when they see it. It is vital that community workers are properly educated so that they will to foster a commitment to identification and reporting.

The report admits that new policies on education and even the practices of targeting  girls and their parents through the legal system has proven to be ultimately unsuccessful. Shell-Duncan goes further in identifying that eradication programs need to reach out to extended families and authority figures in these communities who have influence over the acceptance of the practice within their cultural enclave. Female circumcision is a sacred cultural tradition that allows a girl to enter into the realm of womanhood. The Egyptian MP comments speak to how deeply embedded this tradition remains in the social order. If the West wants to eliminate the practice, it will require a massive shift in the way a culture understands women, physicality, and rites of passage.

___

In America there have been no prosecutions under the federal anti-FGM law since 2012, and only one criminal prosecution of FGM related activity[8]. According to the Center for Disease Control and Prevention, at least 150,000 to 200,000 girls have undergone FGM in the United States and these numbers remain in an upward trend. A recent report released by FBI estimated that at least 500,000 women in America are at risk of undergoing the procedure[9]. Both the UK and America publicly condemn FGM as a serious legal offense, whereas Egypt and other similar countries recognize FGM as a legal offense, but fail to publically condemn it. The UK is the primary Western country beginning to recognize the realistic challenges in actually  prosecuting FGM. This may lead anti-FGM cultures to creatively implement more effective policies that mustbegin with the refusal to see FGM as reductively barbaric, rather as a diversely practiced and deeply embedded social act.

References:

[1] United Kingdom, Parliament, House of Commons. (2016). Female Genital Mutilation: Abuse Unchecked. London.

[2] Egyptian MP: Women must undergo FGM to control men's desires. (2016, September 7). Middle Eastern Monitor. Retrieved September 20, 2016, from https://www.middleeastmonitor.com/20160907-egyptian-mp-women-must-undergo-fgm-to-control-mens-desires/

[3] Egypt, Ministry of Health and Population. (2015). 2015 Egypt Health Issues Survey. Cairo.

[4] Moges, A. (2003, September 15). FGM: Myths and Justifications. Lecture presented at Eighth International Meropolis Conference in Austria, Vienna.

[5] New WHO guidelines to improve care for millions living with female genital mutilation. (2016, May 16). World Health Orginazation. Retrieved September 20, 2016, from http://www.who.int/mediacentre/news/releases/2016/female-genital-mutilation-guidelines/en/

[6] Khazan, O. (2015, April 8). Why Some Women Choose to Get Circumcised. The Atlantic. Retrieved September 20, 2016, from http://www.theatlantic.com/international/archive/2015/04/female-genital-mutilation-cutting-anthropologist/389640/

[7] United Kingdom, Parliment, House of Commons. (2016). Female Genital Mutilation: Abuse Unchecked. London.

[8] Female Genital Mutilation in the United States: Protecting Girls and Women from FGM and Vacation Cutting [Scholarly project]. (2013). In Sanctuary for Families. Retrieved September 20, 2016, from http://www.sanctuaryforfamilies.org/wp-content/uploads/sites/18/2015/07/FGM-Report-March-2013.pdf

[9] FBI Reaching Out About Female Genital Mutilation (13 May 2016).  In Federal Bureau of Investigation. Retrieved September 21, 2016, from https://www.fbi.gov/news/stories/fbi-reaching-out-about-female-genital-mutilation

The Existence of Pragmatism in Futility of Care

    In a meeting today I was reminded of how pragmatism and futility of care collide.  A colleague pulled me aside and asked for my opinion on a case.  I agreed to listen and as I listened I began to understand how experiences, the truth, and hope collide with the concept of futility of care.

    The case, an older patient, diagnosed with an aggressive form of cancer, refuses to follow medical recommendations.  The patient is at a point where radiation and chemotherapy will not help.  There is no cure.  After much discussion, the patient agreed to palliative care and receiving intravenous feeding.  The patient, despite the prognosis, believes this treatment will help strengthen them so they may receive chemotherapy.  The family and the medical team understand the intravenous feeding will not bring about a recovery.  There is no reprieve, no beating this form of cancer but the patient believes otherwise.  My colleague’s query was: Is there an ethical obligation to intervene and stop any care which is futile?  My answer was: there is an ethical obligation to understand the patient’s truth and respect their decision for treatment.  To do this, we must examine the concepts of pragmatism and futility of care.

    What we perceive, form judgments on, and then mold into our belief system comes from external experiences.  William James, a Pragmatist, describes how, in the normal case, we have an established body of views and opinions, and issues about what to believe arise when a new experience puts them under strain. We will accept a new opinion when “[I]t preserves the older stock of truths with a minimum of modification, stretching them just enough to make them admit the novelty, but conceiving that in ways as familiar as the case leaves possible.”1  It is the patient’s experience and therefore their truth that treatment of any kind will strengthen the body allowing for further treatments which address the cause of the patient illness.  In this case, the patient believes intravenous feedings will help them in their goal to fight cancer.  They don’t have any reason not to think this because previous experiences with medical care have made them better.  For the patient, medical care represents hope, and this is a form of truth which makes the patient comfortable.  While the family and the medical team understand intravenous feeding is futile because the cancer is aggressive and will not let the patient heal enough to fight, the patient, despite the prognosis, remains faithful to an older form of truth.  Forming truth out of experience creates a problem because, while, the patient has experienced better health through medical intervention facts gathered by the family and medical team has shown all care is futile.

    Richard Rorty, a philosopher, may have the answer to the dilemma the family, patient and medical team are facing.  Rorty said: “What pragmatists teach us about the truth is that there is nothing very systematic or constructive to say about truth at all. In particular, this concept does not capture any systematic or metaphysical relation between our beliefs and utterances, on the one hand, and reality on the other….sometimes we might find it useful to express our fallibility by saying that some of our beliefs may not be true”1  We are fallible.

    We want our beliefs to be true because the truth we believe in gives us hope.  In this case, the patient’s belief in intravenous feeding gives hope despite the growing realization there is none.  Is the care futile?  No.  The intravenous feedings provide comfort to the patient who is coming to terms with their prognosis of death.  Futility of care exists if there is harm done to the patient.  There is no harm, and one could argue there is a benefit to the intravenous feedings because they’re providing hope to the patient, however, false it may be in the family and medical team’s opinion.  There are times when if there is no harm to the patient and care is benefitting the patient, in this case allowing the patient to hold onto hope, care must continue.  To remove treatment is to remove hope, and once removed, care becomes futile.

References: 

1.  Pragmatism (Stanford Encyclopedia of Philosophy), http://plato.stanford.edu/entries/pragmatism/ (accessed October 03, 2016).

Should Religion Play a Greater Role in Bioethics?

A perennial theme in bioethics has been whether, and to what extent, religion ought to play a role.  Recently, Timothy Murphy has gone so far as to propose an “irreligious bioethics,” built upon a “disregard for religion or even a degree of hostility” (Murphy, 2012, 3).  A common critique against positions such as Murphy’s is that they attempt to achieve an irreligious, ametphysical, view from nowhere, which is now widely regarded to be a fiction.  I call this the argument from inevitable presuppositions (AIP).  Consider the following passages:

“All moral theories come with traditions just as convoluted and troubling as those one might find in a religion […] We encourage Murphy to examine the possibility that the irreligion he espouses is just as much a cultural artifact as shamanism” (Crane & Putney, 2012, 29)

“[T]he ideal of secular medicine as a realm of reason and therefore as untroubled by deep metaphysical and moral disagreements is a fantasy” (Biggar, 2015, 1)

“No philosopher, politician or humanist marches into the contest armed only with the sharp sword of reason, stripped naked of the costume of any moral culture” (Cahill & Callahan, 1990, 14)

The AIP consists in making the charge that the liberal, scientific, naturalistic viewpoint taken up by Murphy and others is just as full of presuppositions and metaphysical troubles as any other tradition.  The attempt to obtain a more rational perspective by which to judge religion as irrational is impossible.  Charles Camosy makes the point this way:

Consider that secular utilitarian traditions are defined by their authoritative, faith-based and transcendent answers to the following kinds of questions. What is that about which we should be ultimately concerned? Maximizing good consequences. How are we to determine what counts as good consequences? Some will say “pleasure over pain”; others will talk about preferences satisfied over preferences thwarted”; still others “happiness over unhappiness.” How do we aggregate consequences? “One counts as one and none more than one.” But who counts as one? Do future or potential persons count? […] Answers to these (and many other) big questions are derived from the authoritative, transcendental, faith-based, first principles of traditions like hedonistic and preference utilitarianism (Camosy, 2012, 14).

    Timothy Murphy has responded to these “tu quoque” replies by arguing that the difference between religious and nonreligious standards is that the presuppositions of religious standards are “accessible only by logically prior commitments to certain theological claims” (Murphy, 2012, 7).  Murphy contrasts the Vatican’s view excluding gay marriage on the grounds that marriage between a man and woman is “something wisely and providently instituted by God the Creator with a view to carrying out his loving plan in human beings” (Faith, 2009) to an argument that claims “same-sex marriage is a threat to the psychological well-being of children.”  Murphy’s claim is that whether same-sex marriage is a threat to the psychological well-being of children is a claim that can be “analyzed and evaluated without any prior assumptions that are logically inaccessible by all” (Murphy, 2012, 7).  

This is precisely the claim murphy’s detractors will not allow him to get away with, as “well-being” is always tied up with “prior assumptions” that may very well be logically inaccessible to others.  Because the concept of well-being must be grounded in thick commitments of some kind - utilitarian, deontological, virtue ethic, naturalistic, etc -what seems like a relatively innocuous concept like “well-being” is always already deeply entangled in metaphysical, “logically prior” assumptions.  Because of this, I have decided to take a different approach than arguing that some metaphysical claims are more metaphysical than others.  Rather, I aim to show that the particular metaphysical claims of standard theism are incompatible with the AIP.  Standard theism is the conception of God as a personal, omniscient, omnibenevolent, omnipotent, creator, transcendent being (Peterson, 2013, 10).  It seems one could posit the AIP or standard theism, but not both.    

    The AIP can be read as leading to epistemic relativism. The relativistic reading sees no way to adjudicate between various sets of presuppositions.  All reasoning proceeds from fundamental moral-metaphysical claims, what one comes to believe as rational will be relative to the presuppositions from which one begins. Reason cannot get behind one’s presuppositions to determine which set of presuppositions is the correct or rationally superior set. Chris Durante claims that the best one can hope for in terms of being “rational” on this view is a mindfulness of the presuppositions and limitations of one’s view” (Durante, 2012, 20).  

    Aside from the traditional philosophical problems that haunt relativism, I think there is a special kind of incompatibility between relativism and belief in standard theism.  If God exists and issues moral commandments that he wants us to know, then he would not have created a world where we are forced to accept a set of presuppositions without any means to rationally adjudicate among them.  Why an omnibenevolent, omnipotent God would have created a world where we have no basis for choosing one set of assumptions over another remains a mystery.  How could we be blamed for selecting the “wrong” starting assumptions and for never coming to know the correct moral commandments which he has issued?  The epistemic reality described by a relativistic reading of the AIP is incompatible with the notion of a God that created the world with specific moral principles by which he wants us to live.  If God has important truths he wants us to know, then we should expect a better way of knowing than what epistemic relativism provides.  

     In sum, there may be good reasons for religious belief to have greater influence in bioethics, but the AIP is a problematic strategy for reaching that conclusion—as it describes humanity in an epistemic situation incompatible with the God of standard theism.  

References:

Biggar, N. (2015). Why religion deserves a place in secular medicine. Journal Of Medical Ethics, 41(3), 229-233. doi:10.1136/medethics-2013-101776

Cahill, L. S., & Callahan, D. (1990). Can theology have a role in `public' bioethical discourse? Hastings Center Report, 20(4), 10.

Camosy, C. C. (2012). The Role of Normative Traditions in Bioethics. American Journal of Bioethics, 12(12), 13-15. doi:10.1080/15265161.2012.725349

Crane, J. K., & Putney, S. B. (2012). Exorcising Doubts About Religious Bioethics. American Journal of Bioethics, 12(12), 28-30. doi:10.1080/15265161.2012.719274

Durante, C. (2012). Extending the Hermeneutics of Suspicion Beyond Irreligiosity. American Journal of Bioethics, 12(12), 19-20. doi:10.1080/15265161.2012.719276

Faith, C. f. t. D. o. t. (2009, September 3, 2016). Instruction dignitas personae on certain bioethical questions.   Retrieved from http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_20081208_dignitas-personae_en.html

Murphy, T. F. (2012). In Defense of Irreligious Bioethics. American Journal of Bioethics, 12(12), 3-10. doi:10.1080/15265161.2012.719262

Peterson, M. L. (2013). Reason and religious belief : an introduction to the philosophy of religion: New York : Oxford University Press, [2013] 5th ed.

Egg Preservation and the Changing Medical Landscape

Sperm preservation, primarily in the form of sperm donation, has moved into the American mainstream in recent years. Yet its counterpart, egg preservation, has generally remained off the radar, despite the fact that the first pregnancy as a result of cryopreserved eggs dates back to 1986 (Chen, 1986). The procedure is primarily used as a starting point for future in vitro fertilization, and has played a role in allowing women to gain more control over their reproductive futures. However, cryopreservation of eggs is expensive, impeding widespread development and use. Even today, over 30 years after the inception, procedures cost upwards of 15,000 (Hamblin, 2016). Fortunately, a new fertility clinic, through lower costs and improved safety, might be reshaping the field.

The clinic, called Extend Fertility, was founded by a group of entrepreneurs and physicians with efficiency in mind. Utilizing a process dubbed “super-specialization,” the scientists can focus solely on egg cryopreservation, and avoid much of the overhead cost that would be associated with a more general fertility clinic (Hamblin, 2016). This economic efficiency has led to a bold business model: if a woman is young and in good health, she pays a flat sum (a little under $5000) and the clinic promises at least a dozen eggs (Hamblin, 2016). That is, even if the procedure does not work the first time, it will be repeated until it is successful for no additional charge.

However, claims of lower costs have been somewhat unfounded.  In reality, the egg retrieval process is only a piece of the cost. The hormone therapy and longer term storage, which are required for the success of the procedure and for the practical use of the eggs in the future, drive up the actual price of the process to somewhere near the current market price (Hamblin, 2016). Regardless, the group has stated that its method will eventually decrease costs and improve outcomes.

The establishment of such a clinic, beyond its specific purpose and outcomes data, presents a set of interesting and important questions for the medical community. Primarily, when steep prices are involved, the medical field must ask itself whether or not economic inaccessibility may lead to differential health outcomes. Specifically, it has been well documented that younger women, and younger eggs, have better IVF success rates (Wang, 2011). If this model is successful in lowering prices, it could help equalize IVF opportunity. Additionally, this hyper-specialized form of health care, where providers become incredibly well-versed in a single procedure or small subset of procedures, has been seen in other branches of the healthcare field, especially with specific orthopedic surgeries, and suggests a direction the field field as a whole might be moving in (Hamblin, 2016). There are, of course, field specific implications, including a need for additional, rigorous research about the effects of egg cryopreservation, donor age, and IVF success, but only time will tell what this small clinic means for the field as a whole.

Resources:

Chen, C. (1986, April 19). Pregnancy After Human Oocyte Cryopreservation. The Lancet, 327(8486), 884-886. doi:10.1016/s0140-6736(86)90989-x

Hamblin, J. (2016, September 15). One Clinic Is Promising to Cut the Cost of Egg Freezing in Half. Retrieved September 16, 2016, from http://www.theatlantic.com/health/archive/2016/09/how-one-clinic-is-cutting-the-cost-of-egg-freezing-in-half/500144/
Wang, Y. A., Farquhar, C., & Sullivan, E. A. (2011). Donor age is a major determinant of success of oocyte donation/recipient programme.Human Reproduction, 27(1), 118-125. doi:10.1093/humrep/der359