The recent South Dakota law banning almost all abortions is clearly intended as a strategic move in an effort to allow and newly-anti-choice Supreme Court to overturn Roe v. Wade; the content of the law or its supposed justification are almost beside the point, and its backers have hardly pretended otherwise. It is still somewhat startling, however, to read the actual words of the rube who wrote this law. The gasping scientific ignorance, legal confusion, and sheer dunderheadedness they betray is almost as dismaying as the law itself.

(more…)

I posted earlier about the spreading fear among women and their supporters that the right wing’s drive to roll back women’s rights through the courts is reaching fruition with the Bush nominees. What is increasingly apparent is that the right wing also thinks its time has come.

(more…)

You come alert on a subway train in a bleak part of town you’ve never seen before. You don’t know why you’re there or how you got there. Thinking about it some more you realize you can’t recall anything that’s happened to you recently, or in fact anything that has ever happened to you, or what your own name is. You’re carrying a backpack; you open it up and it contains no ID or money, nothing with your name on it. It holds only a few cryptic items, a set of keys you don’t recognize, and a scrap of paper with a name and phone number you also don’t remember. The train stops. You’re at Coney Island, early in the morning, and you don’t know why you’re there, or who you are.

Now what?
(more…)

Much hangs on the upcoming Supreme Court decisions on the dilation-and-extraction ban and the no-doubt-to-be-challenged South Dakota abortion ban. Everybody is watching to see which way the court breaks with its two new stealth-anti-choice Justices now seated. Just the fact that they granted cert in Carhart is ominous, given the law’s obvious extremism and the fact that it has now been held unconstitutional in five federal courts and three federal appellate courts. The South Dakota law is, of course, a deliberate attempt to provoke the court into overturning Roe entirely, by giving them a test case that violates virtually every remaining vestige of that decision. The results in these two cases will probably paint the full picture of abortion jurisprudence under the current Court.

The suspense is killing us – in some cases literally. “Back-alley” abortions have been reported even throughout the period of legal abortion, and in almost every case they are prompted by fears that a legal abortion would be unobtainable or bring repercussions from the violation of the patient’s confidentiality. With the possibility that abortion will be even more severely restricted than it now is, and on a nationwide basis, women are beginning to imagine what a post-autonomy world would look like.

One sign: the realistic consideration of the need for an “abortion underground” again. Women on the Waves offers detailed advice (with plenty of safety warnings) on how to self-administer a medical abortion with misoprostol (one of the ingredients of RU-486) up to the 9th week of pregnancy. Molly, of Molly Saves the Day, attempts to fill the need for a new “Jane“-style abortion network by providing detailed instructions for D&Cs by non-professional caregivers. (CAUTION: These instructions are not vetted by professional review, and in some places lack considerable detail. For instance, it instructs operators to “don’t be afraid to scrape [the uterus] fairly hard”, but nowhere at all does it mention the possibility of perforation – still less how to recognize it or what to do about it.)

I appreciate these women’s concerns, and the service they are providing to other women. However, I would much prefer to see hands-on training by professionals of non-professionals in a one-to-one setting before people blithely set out doing this on their own. At some point, experienced non-professionals could then start mentoring others, as the Jane network did, but the thought of somebody reading sketchy instructions off a Web site and then setting up as an abortion provider is exactly the reason we need abortion to remain legal! But women know this, of course. They prefer to get healthcare openly, without denial of services or deliberate misinformation, with respect for their autonomy, and from trained professionals backed by a non-punitive healthcare system. They prefer their healthcare professionals to care for women’s freedom and women’s bodily security. They prefer abortion to remain legal. The fact that they are willing to seek other avenues to preserving their freedom – and are doing so already – merely underscores how far the assault on women’s independence has already undermined their sense of security – not to mention the actual availability of healthcare services.

Just how bad things are going to get – they are surely going to get worse, whatever happens – remains to be seen. We will know much of what we need to know in weeks or a few months. But the fact that women are now planning to find the least unsafe method to preserve control of their bodies and their lives is testimony to the climate of fear the right wing has created, aside from actual practical inroads it has made on sexual freedom. This fear is one of the tools they use to control women – it’s part of the reason they seek to ban procedures that are safer than the alternatives, why they oppose realistic contraception education and access, and why, increasingly, they seek restrictions on abortion that make no exception even for direct threats to a woman’s health. The more dangerous pregnancy and abortion are, the more women are punished for their sexual activity (and, it is claimed, the less likely they are to choose to be sexually active, though the empirical facts demonstrate that this is not the case).

“Fear Up” is the name for one of the torture strategies used at Abu Ghraib – a method of breaking the enemy by threatening the most grievous bodily harms (accompanied with some physical abuse, lasting injury, and the occasional death). It appears to be the strategy adopted by the anti-sex right toward women’s autonomy, and it appears to be working.

Hat tip: Amanda at Pandagon.

I hesitate to mention it, but . . . Sufficient Scruples has been nominated for Koufax Awards in the following categories:

Best Writing

Best Post (twice! – for this and this)

Best New Blog

Best Single-Issue Blog

and

Most Deserving of Wider Recognition

Thanks, Mom!

(Seriously, thanks to whoever did the nominating. I’m very flattered that one [or more] of you thinks that highly of the blog, and honored to be in the company of some really great blogs among the nominees. You read me! You really, really read me!)

Wampum, who run the awards, are doing their usual great job, and at considerable expense. (Apparently they’ve had to pay for computer repairs, at least one of them has taken a whole week off to coordinate the awards this year, and last year bandwidth alone during the awards season ran them over 4 figures.) Please consider dropping them a dime through the PayPal link on their awards page. And please peruse the categories and the nominees, and vote for the most deserving. Polls open soon, and there are a lot of great candidates to choose from. Recognition really makes a blogger’s day.

Thanks again.

Almost a year ago, Art Caplan waded into the prenatal genetic testing arena with this variation on an old trope: “Would you allow Bill Gates to be born?” I’m a bit slow on these things, so I’m just getting around to answering him. (And my answer is: given how screwed up my Windows computer system is, I’d abort Gates right now if I had the chance.)

Caplan muses:

If you could go back in time and stop the birth of the world’s most famous nerd, would you?

You probably answered my question with a “no.” Whatever Gates’ sins may be, he is the father of a computer revolution that has brought much good to many people throughout the world. Add to that achievement his current generous philanthropic activities supporting some very worthy causes, such as vaccine research and a center for autism research in Seattle, and the case for having Bill with us becomes pretty persuasive. . . .

But what if I told you it’s possible that Gates has a medical condition that accounts, in part, for both his tremendous achievements and for his “nerdiness?” Gates is widely reported to display many personality traits characteristic of a condition known as Asperger’s syndrome. Asperger’s is a mild version of autism, a more serious condition that renders many children unable to talk, be touched, communicate or socialize. While I certainly do not know if Gates has Asperger’s, his difficulties in social settings are nearly as legendary as his genius, so it’s possible. . . .

The drive for more genetic tests continues unabated. Undoubtedly the genes for autism and Asperger’s will soon be found. When they are, my question — would you have stopped Bill Gates from existing? — will take on a very real meaning.

Fewer geniuses?
There are many in the autism and Asperger’s community, like the newly formed Aspies for Freedom, who worry that the minute a genetic test appears, it will spell the end for a lot of future geniuses, like Gates. Maybe there will be fewer Thomas Jeffersons or Lewis Carrolls — remarkable thinkers who also fit the profile for Asperger’s.

(First, let me say that I am both wary of and uncomfortable with this business of “diagnosing” psychological or medical conditions in famous figures on the basis of a few imagined personality traits. I don’t think there is any reliable evidence to base a claim that Gates has Asperger Syndrome – observations about his “difficult personality” are no more than long-distance stereotyping. I also think it’s an abuse of professional insight to broadcast such claims, whether or not reliable. I have no great sympathy for Gates, but it’s still rude and insensitive to make remarks like this, and in some circumstances – public figures, for instance – it can be quite dangerous.)

I find it odd to see Caplan endorsing this line of reasoning. It’s an old one, most commonly found in anti-abortion arguments, and notoriously weak; Caplan should know better. To put it simply, if the argument against preventing certain births (by abortion, IVF embryo culling, genetic engineering, or what have you) is the utilitarian one that some people with the target condition could turn out to be great geniuses, the counterargument is that they could just as well turn out to be great villains. Medical testing does not give us diagnostic precognition (and if it did, we would undoubtedly choose to abort only the villians – making the case for doing so even stronger). Since there is no way to know that certain births will turn out to be greatly utilitarian for the world, there is no weight to an argument that we should not prevent them for that reason. (Another implication of this argument is that we should not practice birth control, and in fact should attempt to have as many children as biologically possible – since any child not conceived could be a lost genius just as much as any embryo not gestated. Unless we think we are really obligated to become desperate breeding machines seeking the inventor/entrepreneur jackpot that is the apparent raison d’etre of human reproduction, we are entitled to not to have any child we choose.)

Another problem is that this argument ties the anti-[whatever] stance to the utility of the births in question (something that even most Utilitarians – autonomy-loving libertines that they are – would not do). Thus it seems to imply that it is OK to systematically prevent births that are socially disadvantageous – perhaps not in cases of Down Syndrome, or Aspberger Syndrome, or what have you, but in other more severe cases. This is almost invariably not what the “anti-’s” have in mind, and apparently not what Caplan has in mind in raising fears of genetic euthanasia.

The “anti-” argument has got to be made on other grounds. The strongest argument is the pro-autonomy one: that the lives of people with [whatever condition] are just as rich and valuable to them as the lives of people without it; there is no reason to deprive them of life for their own good (that justification virtually never works, since virtually nobody would prefer the alternative for their own good), and you may not deprive someone of life purely for someone else’s good, so they may as well live. (To put that more simply: the lives of people with “disabilities” – however we may conceive that term – are almost always a net positive benefit to them – they do still want to live; thus, the only reason not to let them live would be to benefit someone else, which we normally say we cannot do.) This argument falters when you consider that the lives that are going to be ended are not those of persons with the condition in question, but of embryonic non-persons who have no interests to take into account. Ending the life of an adult person with [whatever condition] who still wants to live would be a grave injustice, but ending the life of an embryo that is not a person, and wants nothing at all because it has no consciousness, is no harm at all, and so is permissible. The response to this argument is that systematically eliminating all births with the chosen condition is tantamount to genocide – to casting the existing generation with that condition adrift by not letting any new members of their “community” arrive – essentially declaring war on people with that condition not by attacking them directly but by genetically cutting them off as a barren community. And, finally, the response to that argument is that there is no obligation on the part of prospective parents to have any particular type of child simply so that others like that child will have a thriving community. (There we will have to let the argument stand for now. It’s a vital topic, but not for this post.)

Whether or not there is a good “anti-” argument against systematic elimination of embryos with a given “disability”, the point is that doing so directly harms no living person. Harms to imaginary future persons, in the sense that they do not come into existence, are of no moment. (An embryo that is aborted “suffers” just as much as one that was never conceived, or one – say, the hypothetical offspring of Benjamin Franklin and Britney Spears – that never could have been conceived. We are not morally obligated to any of these non-persons.) And so I am puzzled to imagine what Caplan – or the many who share his fears – are upset about. The “future genius” argument that Caplan foregrounds is absurd, and the “discrimination” argument makes no sense – not least because, at the early-embryo stage, there is no one there to be discriminated against.

We may well worry about the world we create in seizing domination over our own genetics, but the problems to be feared come not from the fact that certain imaginary people will not come into being. The real problems are the familiar dysutopian scenarios – clone armies, Delta-minus worker slaves, complacent feudal drudges, raving military savages, universal genetic conformism, loss of hybrid vigor – that threaten from attempting to manage a planned genetic economy. These are possibilities to be considered, and avoided by proper planning. (How do you avoid the danger of a clone army? Don’t make one!) But that is something we can do – something that does not depend on diagnostic precognition to prevent us aborting hypothetical geniuses, or equates not having a child with a given condition to killing another person with the same condition.

Mediagirl has an outstanding survey of this issue from many angles.

Once again, I couldn’t say it better, so I didn’t. Go look.

Iocaste, guest-blogging at Majikthise, quotes the below Wall Street Journal Op-Ed at length:

“The belief that there are such things as witches is so essential a part of the faith that obstinately to maintain the opposite opinion manifestly savors of heresy.” So begins “Malleus Maleficarum” (“The Hammer of Witches”), a book commissioned by Pope Innocent VIII and published in 1484. For three centuries “The Hammer” was the principal reference for witch hunters determined to punish sorcerers and rid them of the world.

A no less sweeping manifesto recently appeared in the Journal of the American Medical Association (JAMA). It called for total extermination of contemporary witchery — “financial conflicts of interest” — caused by the malign influence of pharmaceutical and device manufacturers in academic health centers. It argues that these companies pervert altruism, misinform physician education and cause breaches of scientific integrity in medical research. . . .

The [American Board of Internal Medicine] Foundation, like the medieval church, liberally taxes without consent [by charging certification fees] to fund its crusade against “profit-seeking in medicine.” . . .

In their zeal, both “The Hammer” and the JAMA cited scripture selectively. “The Hammer” trolled the Bible and ecclesiastical works for references to support the existence of witches and witchcraft, which remained uncontested until the retraction of anti-witch doctrines centuries later. The JAMA article baldly states that “a systematic review of the medical literature on [industry] gifting . . . found that an overwhelming majority of [commercial] interactions had negative results on patient care,” although the source it cites explicitly says: “No study used patient outcome measures.” The JAMA piece reminds us that industry marketing influences the prescribing habits of physicians. But it repeatedly neglects documented evidence that physicians frequently fail to prescribe appropriate drugs according to evidence-based guidelines for nearly all diseases.

WSJ scores a minor point by noting that the studies mentioned in the editorial did not include clinical data. But they engage in apparently deliberate equivocation by using that point to discredit the actual claim made, regarding the much broader concept of “negative results on patient care” – which can easily be demonstrable without clinical outcome data (though would be better demonstrated with it). The point about sub-optimal prescription patterns is simple misdirection – the (well-documented, and much-criticized) fact that most doctors write the same prescriptions over and over, without close adherence to best-practices standards, will hardly be improved on if they shift to letting perky former college cheerleaders tell them what to prescribe in exchange for a paltry bribe.

What’s really interesting about this, though, is its place in the growing anti-science stance of the right wing. The Bush administration’s outright medievalism on scientific questions is well-documented, as is their wholesale dismissal and distortion of data on science-related policy issues, in favor of positions dictated by their religious or corporate supporters. But it is important to recognize this as a characteristic tactic of the right wing in general, not just the Bush fringe.

The basic position of the right wing on scientific issues that cut across their religious or economic interests is that nothing is ever believable. Distorting the honorable scientific position of keeping all questions open to new data, the right holds that this means nothing science tells us is ever true, or should ever be accepted. The fact that a question can be raised about a given scientific claim means that that claim is “controversial” – whether or not the question raised has actually been answered in a way that implicates the prevailing consensus, or answered at all, or even has any data whatsoever behind it. (Cf. William Hurlbut’s imaginary “altered nuclear transfer” cells, or “intelligent design”, for examples.) Thus every scientific question is controversial, since science allows that challenges can always be raised. Thus, it is always true to say that “science hasn’t proven _____”, and never proper to regard a scientific claim as reliable; for the right wing, “proven” means necessarily true (a category philosophers generally regard as populated only by purely logical constructs), while “reliable” means “proven”. (In clinical-ethics terms, right wingers are in “clinical equipoise” about every scientific fact ever discovered, where the alternative is anything they want it to be no matter what. Now that’s keeping an open mind!)

Thus, the great thing about being a right-wing critic of scientific consensus is that you never have to back up your own claims. To support their points, those advocating for change, or for the adoption of any new policy of any kind, must “prove” (in the right-wing’s impossible sense) whatever they are claiming, while those opposed to change merely have to repeat, after every new study, “it still isn’t ‘proven’”. Conservatism being defined as opposition to change, this is a strategy that works perfectly for conservatives, and has the bonus of making them sound like sophisticated philosophers of science while requiring absolutely no scientific knowledge at all.

From there, it’s simply a matter of putting the rhetorical touches on it. Creationists like to claim science is infected with “a naturalistic bias”; WSJ prefers the historical analogy of equating science with witch-hunting. Since factual claims have no meaning, none of this has to make sense; still, the arrogance of it is breathtaking. The JAMA editorialists cite studies showing impact on patient treatment from the non-patient-directed interference of pharmaceutical advertising; WSJ admits that the advertising is actually effective in distoring doctors’ treatment patterns, then calls this fact-based criticism a witch-hunt. (The alleged reason is that the studies could have been made stronger with more data – a point that makes little difference since WSJ conceded the main point anyway.) Witches, of course, don’t exist. WSJ is not merely calling for more data (and more data, and more data . . . remember how much data it takes to “prove” anything to the right wing?): they are claiming that there is no such thing as deleterious interference with doctors’ prescribing decisions. (But they said the advertising was effective . . .)

This is true in the same sense that there is no such thing as global warming, evolution, or tobacco-caused cancer. Only in the latter case have corporate shills been this shameless in declaring science irrelevant to science policy. That level of intellect, and discourse, is now the conservative standard for evidence-based decisionmaking. It’s going to hurt if we let them get away with it.

PowerBlog has this collection of ultimata from the previous Pope regarding an “objectively so profoundly unlawful” crime that, well, you just better not, that’s all. It is, of course, the unlawful, the unspeakable, the profound crime of . . . using a Jimmy Hat on your Johnson when you do the Wild Thing.

On September 17, 1983, Pope John Paul II told a group of priests that “contraception is to be judged objectively so profoundly unlawful as never to be, for any reason, justified. To think or to say the contrary is equal to maintaining that, in human life, situations may arise in which it is lawful not to recognize God as God.”

On June 5, 1987, the Holy Father warned clergy and theologians of their grave obligation to faithfully transmit the Church’s teaching on this subject: “. . . The Church’s teaching on contraception does not belong to the category of matter open to free discussion among theologians. Teaching the contrary amounts to leading the moral consciences of spouses into error.”

Pope John Paul II also explained that contraception contradicts and is opposed to true love: “Thus the innate language that expresses the total reciprocal self-giving of husband and wife is overlaid, through contraception, by an objectively contradictory language, namely, that of not giving oneself totally to the other. This leads not only to a positive refusal to be open to life but also to a falsification of the inner truth of conjugal love, which is called upon to give itself in personal totality.” (Familiaris Consortio, #32)

The Holy Father has explained that when contraception is used, the marital act ceases to be an act of love: “. . . [When using contraception} the conjugal act, deprived of its interior truth because it is artificially deprived of its procreative capacity, ceases also to be an act of love.” (General Audience of August 22, 1984)

The constant teaching of the Church was again stated on March 1, 1997 when the Vatican’s Pontifical Council for the Family issued a Vade Mecum for Confessors Concerning Some Aspects of the Morality of Conjugal Life. Included in this document is the following statement: “The Church has always taught the intrinsic evil of contraception, that is, of every marital act intentionally rendered unfruitful. This teaching is to be held as definitive and irreformable. Contraception is gravely opposed to marital chastity; it is contrary to the good of the transmission of life (the procreative aspect of matrimony) and to the reciprocal self-giving of the spouses (the unitive aspect of matrimony); it harms true love and denies the sovereign role of God in the transmission of life (n. 24).”

As Pope John Paul II has stated, “The heart has become a battlefield between love and lust. The more lust dominates the heart, the less the heart experiences the nuptial meaning of the body. It becomes less sensitive to the gift of the person, which expresses that meaning in the mutual relations of the man and woman.” (General audience of July 23, 1980)

OK – I’ll say it: this is insane.

The basic cultural conflicts of our time are at heart conflicts between moral visions grounded on incompatible values (and to some extent incompatible factual beliefs). It is difficult to criticize values from a neutral standpoint, but we can at least notice the weird ends some of them lead us to – and that’s as good a reason for rejecting them as any. Nonsense like the above is just nutty – that’s all. People who think like this are nutty, and there’s no reason to take them, or their beliefs, seriously. Aquinas’s Five-Fold Proof be damned – all we need to know is this: a religion that is grounded on a profound disgust for humanity in its simplest and most definitive expressions of itself isn’t worth taking seriously, and a religion that is this perversely hysterical over sex is . . . well, nutty.

Commenting on a story about moves to allow pharmacists to prescribe emergency contraception, the editor of CovenantNews.com offers the following:

Editor asks, What does the future hold for a nation possessed by the Spirit of Murder? With each expansion of death comes escalation. Local churches hold silent prayer vigils outside Eckerd Drugs? Anti-abortion protest at local drug stores? Drug Store ‘Escorts’ volunteer at CVS Pharmacies? Off duty cops moonlight at abortion-drug stores? Local Right to Life director opposes protesters and graphic pro-life signs at drug stores? Operation Rescue holds sit-in at abortion-drug store? Court creates ‘Buffer Zones’ around abortion-drug stores? U.S. Congress adds ‘Pharmacies’ to the Freedom of Accsess to Clinic Enterance Act, President said he will sign bill into law? Fire guts local drug store, FBI suspects arson? Pharmacist is keynote speaker at NARAL fund raiser? Pharmacists wear bulletproof vests?

That’s interesting.

Why would a “pro-life” blogger imagine that providing safe and legal contraceptive services would result in protests, blockades, security details, harassment, sit-ins, arsons, and shootings? We were told over and over that those tactics – rampant at abortion clinics, with deadly results – are not representative of the anti-choice movement, that they (in their thousands, over and over, year after year) were each and every time spontaneous aberrations caused by a few “bad apples”. Now “pro-lifers” themselves are predicting “escalation” of the characteristic violence of the anti-choice religious right in response to the newest reproductive-health technology.

I suspect many supporters of women’s rights have the same expectation, but it would sound accusatory if we said it. I think we should take “pro-lifers” at their word – and prepare for the worst.

Here’s another story of politically-appointed FDA brass overruling the overwhelming consensus of its own scientific board to make a scientifically dubious decision on approval of a marketing application. The best-known – and previously unique – example of behavior of this kind was the bizarre saga of Plan B emergency contraception; now another case has surfaced involving experimental therapeutic usage of a surgical-implant device that FDA reviewers say – on the basis of the manufacturer’s own data showing no statistical difference between the experimental and control groups – is worthless. The division Director unilaterally approved the device anyway.

If “two data points is a trend”, this establishes a very puzzling and very disturbing trend at the FDA. It is fast squandering its reputation as “the world’s most reliable medical safety agency”.

A top federal medical official overruled the unanimous opinion of his scientific staff when he decided last year to approve a pacemaker-like device to treat persistent depression, a Senate committee reported Thursday.

The device, the surgically implanted vagus nerve stimulator, had not proved effective against depression in its only clinical trial for treatment of that illness. As a result, scientists at the Food and Drug Administration repeatedly and unanimously recommended rejecting the application of its maker, Cyberonics Inc., to sell it as such a treatment, said the report, written by the staff of the Senate Finance Committee.

But Dr. Daniel G. Schultz, director of the Center for Devices and Radiological Health at the agency, kept moving the application along and eventually decided to approve it, the report said.

That approval did follow the backing of a divided F.D.A. advisory committee. Still, the Senate committee, which for two years has been investigating the decision-making processes at the F.D.A., could find no previous instance in which the director of the center had approved a device in the face of unanimous opposition from staff scientists and administrators beneath him, the report said.

There is no explanation what the “divided advisory committee” refers to. It is clear that the actual scientific review committee was unanimously against the device, and it’s not hard to see why:

The vagus nerve stimulator is surgically implanted in the upper chest, and its wires are threaded into the neck. Batteries in the device stimulate a nerve leading to the brain.

The nerve stimulator has been approved since 1997 for the treatment of epilepsy in some patients. Common side effects include voice alteration, increased cough, shortness of breath, neck pain and difficulty swallowing. The device has also been linked to rare reports of death, heart problems and vocal cord paralysis.

When some epilepsy patients reported that their moods had changed after receiving the devices, Cyberonics, based in Houston, implanted them in 235 depressed patients and turned the machines on in half of them. After three months, the two groups were equally depressed. The trial had failed.

Cyberonics then turned the devices on in all 235 patients and determined that 30 percent showed significant improvement after six months or more. Without a control group, however, it was impossible to determine if the device had caused the improvement.

Cyberonics is now defending the device as “the only safe and effective treatment option ever specifically developed, studied, F.D.A.-approved and fully informatively labeled for the treatment of chronic or recurrent treatment-resistant depression.”

This is shocking. If the description above is correct, the company not only failed to demonstrate any therapeutic effect from their device, they actively manipulated the trial to obscure disconfirmatory data and then claimed a positive result based on an uncontrolled trial which they had purposefully initiated after the controlled trial failed. This goes beyond a merely questionable device: based on this news report (which may not be reliable, it is important to remember), this appears to be deliberate scientific fraud.

The company’s behavior is absurd: they deliberately eliminated the control group and then claimed a positive result that was only apparent in the trial group when no control group was available for comparison – doing so after the controlled trial demonstrated no distinct effectiveness in the experimental group! This is just outrageous. And their claimed “benefit” is laughable – famously, about one-third of untreated psychiatric patients show improvement over time, and at any rate you would expect some percentage of the experimental group to get at least somewhat better after 6-9 months; to openly embrace the post hoc fallacy by claiming it was due to your device simply because something happened (as if nothing would have happened without the device – when we know patients change naturally), is nonsense. (Based on the company’s reasoning, it would be equally valid to claim that the device prevents improvement in 70% of patients!) Again, this is indistinguishable from fraud.

Even ignoring the company’s outrageous behavior, however, that an FDA Director overruled the scientific panel, and in such an egregiously obvious case!, is worse yet. It’s hard to tell what motivation this Director would have had – it doesn’t appear to be a case of pandering to the right wing, as with Plan B – and there is yet no reported evidence of payoffs or conflicts of interest. But clearly something went very wrong on this case, and clearly, too, the FDA has become the kind of organization at which such things can and do happen.

Once that would have been unthinkable. Under the current administration – anti-science, pro-business, and with a conviction that truth is what you say it is – it appears to have become policy.

Kathryn Hinsch makes a good point at the Women’s Bioethics Project blog:

Much of the “assisted death” debate gets reduced to two questions: “Do people have a right to commit suicide?” and “Should we allow physicians to assist in hastening death?” But before we tangle with those tough public policy questions, it is important to ask “how might people’s different life circumstances impact the issue?”

Looking at these questions from a gender perspective will be imperative as we move forward in crafting new laws. There are some key facts that make a woman’s end-of-life decision quite different from a man’s—women on average live longer than men. Additionally, women are more likely to be impoverished, receive inferior health care, experience poorer pain relief, and are two times as likely to suffer from depression as men. Women, who have often lost their life partner by the time they face debilitating disease, may feel a stronger cultural pressure not to be a burden on their families. All these factors must be considered when crafting a policy to allow “physician assisted death.”

Looking at gender implications is just one step in a thorough public policy analysis of this issue. We also must look at the implications of physician assisted death for disabled, poor, and minority populations. From some groups, the fear that death with dignity could quickly lead to duty to die is not an unfounded fear and something we must be vigilant to prevent.

She’s right that it’s traditional to boil bioethics issues down into clashes of abstract principles. Feminist philosophers in particular have been invaluable in demanding “thick descriptions” of cases, to situate them in a fuller human context and identify the systematic inequities and pressures that impinge on the people affected. Just as career opportunities turned into the double burden of a full-time job plus sole responsibility for homemaking, for many women, the “empowerment” of autonomy may merely mean the reduction of support systems in the healthcare setting if the real burdens people face are not kept in mind.

As someone who is partial both to strong autonomy rights and to the “airy principlist” approach to ethical problems, this is a useful reminder that principles do not play out in real lives the same way for everyone. The practical impact of general principles must always be the touchstone for practical policymaking.

I have here a “blast fax” – one of those spam fax that spew out of your own fax machine overnight at your expense. This one is from some no-name stock market tout, puffing the latest greatest thing. Normally it would be trash, but just as I was crumpling it up I happened to notice some of the buzzwords. You don’t get a whole lot of bioethics stock recommendations.

Stem Cell Research Without All the Controversy! . . .

It seems like for every positive application scientists believe will come from [stem cell] research, moral issues counter them. If only there was some way to bypass the moral issues and allow this life-saving research to continue . . .

That’s precisely what [Worthless Biotech Company] offers. [Worthless Biotech Company] is the emerging leader in a radical new process of collecting, processing and storing of stem cells from something called cord blood. . . .

Stem-cell research could lead to treatments for two-dozen degenerative diseases such as cancer, heart disease, Alzheimer’s and Parkinson’s disease. . . . [Worthless Biotech Company] is at the forefront of saving lives – which translates naturally to a healthy profit. . . .

And so on. Excitingly, the “analyst” is predicting a 500% increase in stock price over the next year!

The overhype is familiar to both the worlds of stem-cell research and penny-stock flogging (in particular, Alzheimer’s is widely agreed to be a poor candidate for stem cell therapy, but repeatedly comes up in discussion, even from people who should know better). And the casual observation that “saving lives . . . translates naturally to a healthy profit” says volumes about biotech as a business. This may be the first time I’ve seen ethical controversy cited as a distinct investment factor, however.

Looking further into this subject, though, I found almost exactly the same comment made by a more respectable analyst. Indeed, it’s hard to deny that public agitation surrounding a company’s technology would be a factor investors would be concerned about – it’s not unreasonable to base investment decisions on the presence or absence of such controversy. (Doing so can even be a form of activism, as witness the “divestment” campaigns aimed at various reprehensible governments.) But to see issues of great moral import appearing as line-items on an investment analysis summary somehow seems as startling as the equation of lifesaving and profit. What this tout sheet seems to imply is that there are investors scouring the biotech stocks for companies that occupy some specific niche at the intersection of new technology and low moral controversy – a form of “technical analysis” that even the most dizzy-eyed day trader has probably not considered.

I don’t know that I have any great moral lesson to draw from this. Seems odd, though.

It just occurred to me what it means to take some of the right wing’s wackier policies literally.

Among their most visceral phobias are gay marriage and “illicit” sex.

Across the nation, “abstinence only” policies are increasingly mandatory, and they are the official policy of the George Bush administration (beginning with his term as governor of Texas). Christian groups are increasingly outspoken against sex of whatever form – outside lifelong monogamous heterosexual marriage, that is. (Among other crusades, “abstinence” is the major part of the administration’s official policy on AIDS in Africa: they believe it is their business to tell adult Africans whether they may or may not have sex, not just legal minors in the US public school system. There is also some sort of weird vengeance movement afoot to nullify Michael Schiavo’s Catholic marriage to his long-time fiance, apparently as revenge for having thwarted the right wing’s designs on his late wife’s healthcare.) The point is clear enough: nobody falls outside their authority to dictate – mostly to prohibit – sexual behavior, and only religiously-defined marriages within the conceptual purview of their understanding of the “meaning” of those marriages is a valid context for sex.

And, of course, gay marriage is right out – no way, nohow, no circumstances.

Add them up and it means that the official policy on sexual relationships for adult gays – throughout their entire lives, no matter the circumstances or the relationships in which they find themselves – held by the evangelistic right wing is identical with that held by the Catholic church hierarchy: no sexual behavior of any kind whatsoever at any point in one’s life is allowable or deserving of respect or protection. (Note that this is Scalia’s position as a matter of Constitutional law.) You can only have sex if you are married, and gays may not get married – in both cases because the right wing wants it that way.

Aside from the perverse psycho-sexual discomfort and simple bigotry this betrays, its arrogance is breathtaking. It is astounding to imagine that other people’s most personal life choices are regarded as fair game for intrusive and coercive policymaking based upon nothing more than one’s own personal preference. Of course I realize how naive it is to say this – this is exactly the way policy has been made for decades, if not centuries, in the areas of heterosexual sex, birth control, abortion, gay sex, inter-racial sex or marriage, and on any number of other issues. It is obvious how much “irrational animus” drives the anti-marriage movement. It is surely no discovery of mine to carry those policies to their logical conclusions.

But when you consider the breadth of breathless Nosey-Parkerism the right wing considers its god-given mandate, the results can sometimes leave you reeling. The United States of America has, as its official foreign policy on one of the most significant international crises the world has ever faced, the position that adult Africans must be encouraged not to have sex? The US has any policy on whether adult citizens of other countries should or should not have sex? Who dreams up this crap? Who goes into foreign policy with the intent of regulating the sex lives of adult citizens of other nations? And finally, is there not a hint of “sex-crazed African savages” stereotyping caught up in this policy? At the same time, why is it the government’s business whether its gay citizens have sex or not? Why is it the government’s business, at all, whether or how anyone has sex? Is this an appropriate exercise of constitutional democracy in a liberty-loving country? Should we not ask why the functionaries of our government – in the midst of a budgetary crisis of their own making, a looming Social Security shortfall they are actively deepening, and the never-ending quagmire of what they persist in calling a “war” – are spending time and money dictating people’s sex lives?

One of the anti-abortion groups mentioned by MediaGirl (see post below) is CareNet of Texas. Their Web site offers a check-off box online screening test for “post-abortion syndrome” – you check any feelings or issues you may be having after having had an abortion, and they tell you your risk of exhibiting this “syndrome”.

Aside from the dubious professionalism of offering an anonymous, online questionaire of vaguely-worded generic items as a real pyschological exam, it is especially odd to see a screening test for a “condition” that doesn’t actually exist. The “post-abortion syndrome” nonsense has been floating around for decades now, repeatedly debunked, but never eliminated from the armamentarium of the quacks and propagandists who seem to gravitate to the anti-choice brigades. Famously, Surgeon General C. Everett Koop stated decisively that there was no such “syndrome” detectable in the clinical literature after President Ronald Reagan practically ordered him to find one. The American Psychiatric Society’s official policy position is that abortion rights are an important aspect of mental health; even a splinter group of psychiatrists opposed to abortion officially holds that it is simply not an issue for psychiatry, not that it is psychologically dangerous. The American Psychological Association has officially published a book on the sociology and psychology of the abortion conflict that concludes – citing recent research – that abortion is not a mental health threat.

But why heed longstanding and documented research results? Apparently, if you really, really believe something, you can just claim it is true – even down to the level of naming and testing for psychological illnesses that no one but your ideological compatriots even believes exists.

And the test?

The “Post-Abortion Stress Test” consists of a panel of 42 check-boxes labeled with a grab-bag of feelings, behaviors, or things you might “feel unc0mfortable with”, including such highly specific diagnostic predictors as “guilt”, “disappointment”, “trouble sleeping”, “helplessness”, “hopelessness”, “avoiding sex”, “having multiple sex partners”, “weight gain/loss”, and “crying” (as well as a host of more specific “symptoms” specifying various terrors of having an abortion, such as “fear of harming my other children” and “fear of God’s punishment”). Apparently, you’re crazy after having an abortion unless you are neither hopeless nor helpless, have neither gained nor lost weight, and have had sex with exactly the right number of people (whatever number that might be); you might still, of course, go whacko and kill all your kids, or God might do it for you, so you’d better watch out for those just in case.

Having checked off whatever among this list of common feelings you personally might have experienced (no timeframe is specified), you can click a button to “Take the test” and receive your diagnostic score: a pop-up box appears telling you how many of the checkboxes you marked, and what the mental health implications of this might be. In every case, the box reads:

You have checked X symptoms, and may have a ______ form of post-abortion stress.

The “X” corresponds to the number of your check-marks, and the blank is filled – in every single case – with either “mild”, “moderate”, or “severe”. Checking even a single box prompts the “diagnosis” that you “may have a mild form of post-abortion stress.” Checking anywhere up to 5 boxes gives the same result; check 6-15, inclusive, and you are told you may have a “moderate” form of post-abortion stress; anything over 15 puts you in the “severe” category. (The different “symptoms” do not appear to be weighted for relative seriousness.)

Of course, some people have no adverse effects at all following abortion. Surely having no symptoms would be a sign of health, right? What if you leave all the boxes blank and just push the “Take the test” button?

You have not checked any symptoms, but may still have a mild form of post-abortion stress.

Yes, post-abortion stress syndrome is stranger than you thought! It’s not just a non-existent illness – it’s a non-existent illness that it’s impossible not to have! (And why not? In view of the crying, sleeplessness, helplessness, and completely unsatisfactory sex life, it’s obvious that I have post-abortion trauma syndrome, certain disconfirmatory biological pre-requisites notwithstanding.)

To be fair, these “diagnoses” are, strictly speaking, accurate: you may have almost any condition, so I suppose you may have this one too (if we indulge a bit of metaphysical stretching to imagine that you may be the subject of a predicate that doesn’t actually apply to anyone). But if we are to take this diagnostic nonsense seriously – if we are to take these CareNet people as seriously as they ask us to – we can’t believe this is anything but the most idiotic manipulation. And that of course is precisely what it is – the continued insistence on bogus “psychology” that has been repeatedly denounced even by anti-choicers, the pseudo-scientific “screening test”, the absurdly vague “symptoms” and a diagnostic standard that it is impossible not to meet, coupled with the pervasive stereotypically anti-choice language (“child”, “baby”, “victim”, and repeatedly negative images of abortion, sex, and non-motherhood) makes it clear that this is no more than a propaganda tool intended to create discomfort with abortion. After diagnosing every person who takes the “test” as mentally disturbed, the pop-up boxes in every case give the phone number of the anti-choice center, for further information. The test is simply a recruiting tool for their real anti-choice suasive pressure – but they never drop the guise of actual psychological legitimacy.

This is a compounded fraud – fraudulent information packaged in a fraudulent professional setting for misleadingly manipulative purposes. So much anti-choice information is of this kind, but there seems to be no accountability for it.

Mediagirl does an excellent job surveying ongoing coordinated campaigns to propagandize against abortion, and the links many of them have to aggressively proselytizing Christian groups (often taking advantage of federal funding).

I don’t usually do “link only” posts, but this is an important topic and she covers it better than I could. Go look.

The FDA has instituted a much-publicized “voluntary” program, involving manufacturers, doctors, and – whether they like it or not – patients, aimed at preventing birth defects resulting from use of Accutae (isotretinoin ) for severe acne.

[A]s of the beginning of this year, the companies that make isotretinoin, together with the Food and Drug Administration, have imposed mandatory prescribing rules. Any woman of childbearing age who is given the drug must meet several requirements. Before starting the medication she must have negative pregnancy tests two months in a row. While taking it, she must either promise in writing to abstain from sex with a man or else use two forms of contraception, one of which must be a highly effective kind like birth control pills or the injectable Depo-Provera. Each month during her treatment (usually five months) she must take a pregnancy test. And she must document every step she takes by logging onto iPledge, a national online database.

The new rules are meant to prevent isotretinoin-related birth defects once and for all. But the rules are so strict, some doctors say, they might discourage or even prevent many patients from using the drug, the only treatment that can erase severe acne. Many dermatologists say the iPledge program is overkill.

“It’s one of the worst things that’s happened to our specialty,” said Dr. Ranella Hirsch, a Boston dermatologist who is the vice president of the American Society of Cosmetic Dermatology & Aesthetic Surgery. “We’re taking a very good drug that is for many people the only real choice out of reasonable access.”

The risk is real: first-trimester fetal isotretinoin exposure often causes a suite of severe birth defects including hydrocephaly, microcephaly, cleft palate, mental retardation, and developmental abnormalities; it often causes spontaneous abortion or infant death. Prior to the “iPledge” registration program, Accutane access was controlled through an aggressive patient-education program that involved repeated pregnancy testing and a sticky label placed on prescriptions to indicate to pharmacists that testing had been done and the patient was not pregnant. The program significantly reduced pregnancy rates among the user cohort, but not to zero. Mama’s Health has a good summary of the best available study on the matter:

Shortly after the Pregnancy Prevention Program began, Roche sponsored a survey of women taking Accutane to assess compliance with the program, and the company encouraged doctors to enroll patients. Run by the Slone Epidemiology Unit at Boston University’s School of Public Health, the survey set out to track pregnancy rates and outcomes, patients’ awareness of risks, and patient and physician behavior.

Of the 500,000 women enrolled in the Slone survey from 1989 to 1998, there have been 958 pregnancies, 834 of which were terminations (either elective, spontaneous or due to ectopic pregnancies), 110 that resulted in live births, and 14 patients that had unknown outcomes. Of the 60 infants with available medical records, eight had congenital abnormalities. Since Accutane’s approval, Roche has received close to 2,000 reports of Accutane-exposed pregnancies, 70 percent of which occurred after the PPP began.

According to FDA, exactly how well the PPP has worked is unclear. Experts say the PPP is a significant program that has prevented many pregnancies and is the first of its kind initiated by a pharmaceutical company. Roche has made extraordinary efforts to educate patients that they must not become pregnant while taking Accutane, says a Roche spokesperson.

At a September 2000 meeting of FDA’s Dermatologic and Ophthalmic Drugs Advisory Committee, a Roche representative reported that from the company’s perspective, pregnancy rates have declined. Amarilys Vega, MD, an FDA medical officer, agreed. However, because use of the product has increased over the years, the actual number of pregnancies occurring while taking Accutane has not declined. One limitation is that the survey is voluntary and only captures about 30 to 40 percent of all patients on Accutane. So there’s no way to know exactly how many pregnancy exposures there have been, according to FDA experts.

The FDA makes the point that compliance rates among women who did not respond to the survey may not be the same as among those who did (meaning you cannot simply extrapolate from the 30 – 40% response rate to get a total figure). This is a good point, but, still, as a ballpark we are looking at something like 3,000 pregnancies, and maybe 50 congenital birth defects, over a 10-year period under the voluntary-compliance regimen. Double those numbers and they’re still small.

For comparison purposes, we can look at Trisomy 13, a (usually) spontaneous chromosomal abnormality with clinical results very similar to those of Accutane teratogenicity. The CDC estimates its prevalence is 1.3 per 10,000 live births, and the annual number of cases is about 530. This prevalence is vastly lower than that of Accutane-linked birth defects (about half of live births), but only because the latter are so commonly aborted. In absolute numbers, the prevalence is something like 100 times as high – yet we almost never hear anything about Trisomy 13. (It’s #17 on the CDC’s list of the 18 most-common sources of birth defects – not all of which are life-threatening.)

Obviously, the two situations are not comparable, because there is no easy way to prevent trisomies, and there is no situation in which it is known that they are particularly likely to occur. Thus, imposing heavy-handed preventive regimens on women “at risk” for that condition is not an option. But it is interesting that a nation-wide, mandatory, sexual-behavior-registration program is being imposed for a potential condition that results in so vanishingly few cases, compared with the natural rates of birth defects that are not even visible as national health problems.

Whenever women’s sexuality enters the health-policy picture, under the current administration and under this FDA, we are forced to consider ulterior motives as likely policy drivers. The utterly bizarre history of OTC emergency-contraceptive approval is all the proof needed. In that light it is suspcicious – in a way it might not be under a more rational and professional regulatory regime – how perfectly a number of hot-button ideological factors line up on this issue:

• A compliance method so absurdly overbearing – mandatory registration on a third-party Web site; multiple and ongoing pregnancy testing; “chastity vows”; reporting of sexual behavior to multiple parties; mandatory compliance by manufacturers, distributors, doctors, patients, and pharmacists – that many experts predict it will simply drive patients away from an effective medication.
• Irrationally suspicious treatment of birth control and credulous belief in “abstinence” (sexually-active patients must use two forms of birth control and undergo extensive “counseling”; women who claim they would never, ever, certainly not have sex are taken at their word).
• Continuous monitoring of women’s pregnancy status and reporting to a widely-accessible Web site.
• Authorized denial of services at any point by anyone in the distribution loop who detects “illicit” sexual status.
• Almost-unprecedented denial of access to effective medication based on women’s reproductive status.
• Staggering imbalance between harm to fetuses prevented (approximately 5-10 cases per year) and women’s healthcare access restricted or denied (50 – 100,000 cases per year).

Speaking somewhat cynically, it’s as if they mixed up the worst aspects of abortion restrictions, “conscience clauses”, Taliban-style denial of women’s healthcare, Margaret Atwood-style sexual slavery, and “for the children” emotionalism into a slurry of rejectionist thinking about women’s sexuality and women’s healthcare. The Web site and multiple stages of sexual monitoring look uncomfortably like a slut registry, while their persistent touching faith in abstinence vows as a guaranteed prevention for pregnancy continues unabated. The total absence of any sense of proportionality – the idea that any level of birth defects, no matter how small, is worth a persistent, painful infection resulting in disfiguring scarring for tens of thousands of women per year – further betrays the ideology that makes such policies seem reasonable: the ideology that holds that no benefit to any number of women is worth any harm to even one fetus.

It is hard not to think that the issue of abortion creeps into this decision as well. Given the almost immeasurably-small level of birth defects recorded during the monitoring program, it is possible to suspect that what this program really aims to prevent is not the 5 birth defects per year but the 250 abortions. It is not clear how many of those were elective, but no doubt a large fraction were. And it is a certainty as well that those incidents were regarded not as adjunct therapies serving to further reduce the incidence of birth defect from Accutane, but as added “tragedies” swelling the death toll from the drug. So the apparent purpose of this policy – as we cannot avoid suspecting – is not simply to prevent women from conceiving fetuses with some probability of birth defects, but rather to prevent women from conceiving fetuses they would then be likely to abort.

Perhaps this is too cynical. Perhaps the crafters of this policy sincerely felt that reducing birth defects from 5 per year to something closer to zero was justification enough to impose an extensive and intrusive monitoring regimen on up to 100,000 women per year – even if likely driving significant numbers of them away from the only drug that can cure their ongoing infections and prevent life-long scarring. Perhaps this was “for the children” thinking in its more benign aspect, and not by way of using children as a weapon against the women who bear them. And perhaps the program will even work – most women will choose to comply, pregnancy rates will drop near zero among Accutane users, and the slut registry will not be breached or misused. But I find it curious that it is so easy, and so readily seized upon as policy, to make the most onerous inroads on women’s health whenever they are found engaged in “non-approved” sex, or whenever a (potential or even imaginary) fetus raises its tiny head.

As the Olympics near, the question of performance-enhancing procedures for athletes gains social salience. MSNBC has run two articles recently on the ethics of performance enhancement, one by venerable mediagenic bioethicist Art Caplan, and the other addressing biotech advances that may allow new forms of enhancement.

The biotech article really caught my attention. It discusses the possibility of somatic-cell genetic engineering as a means of performance enhancement – perhaps to boost operation of erythropoietin-making genes (to increase oxygen-carrying capacity of the blood), or to provide other, unspecified advantages. According to the article, experts believe the scenarios are closer on the horizon than I had imagined:

In March of 2002, the World Anti-Doping Agency (WADA) . . . met with genetic scientists to ask if athletes and their handlers would soon be altering their very genomes in an effort to soup up their performance. Was the age of the genetically-enhanced athlete upon us?

The meeting resulted in a good deal of speculation and public fretting, both by pundits and by WADA. But much of that fretting, said experts in genetic science, was misplaced. Using genes to enhance athletic prowess was still far away.

The second meeting to assess the future of genetic tinkering in sport was held in December in Stockholm, but now, says Theodore Friedmann, one of the world’s leading experts on gene therapy to treat disease and the chairman of WADA’s gene-doping panel, “I’m not so sanguine as I was that this is far off in the future.” Scientists studying genetics, Friedmann reports, “often say they are approached frequently by athletes, trainers, entourage-type people asking what is available.”

Still, all that proves is that athletes are motivated. But is the technology really ready?

Probably not, but, says Larry Bowers, the senior managing director of technical and information resources for the United States Anti-Doping Agency (USADA), the sports world has its eye on the Beijing summer games. “By 2008 there may be tempting possibilities. That might be the time we really need to be more concerned.”

2008 sounds pretty damn close to me. Recognize, also, that there is at this time not one single somatic-cell genetic therapy in clinical use, even against seemingly-tractable conditions such as sickle-cell anemia or cystic fibrosis. The few therapies that have been tried have shown limited results and often came with horrendous side effects. If they are seriously talking about potential performance-enhancing technologies in less than two years – presumably procedures that have gotten far less research attention than have cures for genetic diseases – that suggests remarkable breakthroughs very close to completion. But whenever it happens, it will surely happen. The question is what to do about it.

For obvious reasons, genetic enhancements are being treated as a form of illegal “doping” – the “drugs” in question apparently being the poly-peptide products of engineered genes. The real parallel, of course, is the common theme of “tinkering” with the body to increase the performance available from the inborn “hardware” alone. If blood-doping or erythropoietin injections are illegal – using substances naturally occurring in the body, or even produced by that athlete’s own body – then it is not so far a stretch to suggest that taking advantage of proteins produced by and remaining within the body should also be illegal, where those proteins are the direct product of technological interventions far more intrusive than mere blood transfusion.

However, I think we are entering territory in which we are forced to split hairs more and more finely. What if – to take a hypothetical, and likely impossible, example – an athlete has a naturally-inherited genetic condition that produces a certain substance when and only when (as in the case of PKU) the athlete eats a certain diet, and this substance happens to be highly performance-enhancing? Would the athlete be prohibited from eating that diet? What if it was a very strange diet that no one would likely eat, and that has no nutritional benefit, other than in the case of possessing this enhancing allele – would the athlete then be allowed to engage in a practice that clearly serves only to provide a unique genetic benefit?

The MSNBC story recounts the history of Eero Mantyra, a Finn who owned Olympic cross-country skiiing in the 1960s; he had a genetic mutation of his erythropoietin gene that gave him a much higher-than-normal red cell count. No one questions that he was entitled to compete and win his medals; in fact, the mutation story laid to rest rumors that he had been blood-doping. But that is the oddest fact of all: he was entitled to compete with an abnormally high hematocrit resulting from a natural genetic mutation, but would have been severely punished for competing with the same hematocrit resulting from a transfusion of his own blood; now, apparently anyone else will be prohibited from competing after using genetic engineering to acquire the same genetic mutation Mantyra had, while presumably any of Mantyra’s descendants who have the mutation will still be allowed to compete as long as they inherited it “naturally”. Simultaneously, athletes who train at high altitudes to force their bodies to produce more red blood cells are allowed to compete, but simply injecting those blood cells into your body is illegal. The standard for “purity” seems to be not that you may not take advantage of biological characteristics outside the human norms, but rather that you may only compete with the biological characteristics you inherited (or acquire through training), not those that were acquired by “technology”.

This is an odd standard in two ways: first, it treats “technology” in some mythical, and false, fashion. The technology used in training top athletes, let alone in producing their equipment, is far more sophisticated and cutting-edge than that used in “blood doping”, which is an ordinary blood transfusion, or in some forms of chemical enhancement which use chemicals naturally occurring within the body. And some of that training technology is bodily invasive – scans, blood tests, internal monitoring devices – so the distinction cannot be between internal and external applications. Furthermore, training itself is intended to enhance the body, and training makes far more difference in an athlete’s performance than any enhancements do. (A highly-trained athlete can compete at the top level without enhancements, but a completely untrained person cannot compete at all even if given maximum enhancement therapies.) To think of “enhancements” as different from the other explicitly-enhancing practices – training, body building, special diets and supplements, artificial pressure and oxygen environments, and the like – is simply to indulge in an intuitionistic, largely emotional distinction between “natural” and “unnatural” that breaks down upon even cursory inspection.

The second problem with this “inherited characteristics” standard is that it seeks to oppose what the normal process of training and skill-development – practices that essentially define serious athletics – are explicitly intended to promote. The purpose of enhancement is identical to the purpose of the training and developmental practices that are accepted as legitimate: to improve performance. Most enhancement-limiting regulations in sports impose “leveling” limits – boundaries that give every competitor an “even playing field” to ensure that the contest is determined by skill on the field and not differences in basic “hardware”. (Examples include NASCAR “stock” performance definitions, balancing weights in horse races, and handicaps in golf games.) It is difficult to tune bodies to a stock performance standard, but focusing instead on the means by which performance is enhanced – declaring some means illegitimate and others legitimate, based on a wholly illusory distinction between “natural” and “technological”, when those means each seek exactly the same end – is an exercise in futility.

On a similar note, the goal of limiting enhancement – ensuring “fair play” – is itself illusory. The whole point to prohibiting enhancements is to prevent some players from obtaining “unfair advantage”. But at the top levels of international sport, there are no unfair advantages: every country has access to the same technologies and can provide them to its athletes if it chooses. (And most “enhancement” technologies used today – blood doping, artificial erythropoietin, and steroids – are trivially cheap anyway.) Athletes are also trained to near-peak personal performance levels. Competition then becomes a test to determine who has greater bodily gifts – whose “top end” is higher. But we place arbitrary limits on what means they can use to achieve that top end. Competition thus devolves to a test to determine whose top end can be raised higher using some, but not all, of the available enhancement techniques. But why is this interesting? What makes a distance race between one runner who was born at high altitude, another runner who moved to high altitude t0 train, and a third runner who happens to have a naturally high hematocrit resulting from an inborn genetic mutation, a viable and inspiring athletic competition, but the same race a dirty sham if it includes a fourth runner who injected the same amount of extra blood cells as the others enjoy “naturally”, or a fifth who used genetic engineering to achieve the same thing? (Note that it cannot be a question of rewarding “athletic spirit” or hard work – two of the first three athletes above achieved their blood-born advantages without any effort on their part, yet we still accept their achievements as legitimate, while excoriating those who used a blood transfusion or genetic engineering to achieve exactly the same bodily capacity. And the inborn mutation is – we’ll stipulate – genetically identical to the somatic-cell enhancement acquired through genetic engineering, but again one is acceptable and one is not. This is absurd.)

There are other possible objections to enhancement – it may encourage drug use by teen athletes; it will entice many hopeful athletes into dangerous practices, though only a few of them will enjoy successful competitive careers; it may indirectly encourage abuse of other drugs; perhaps others. But these are mostly regulatory issues, not really questions of competitive “appropriateness”.

Caplan takes a different approach in his moral objection:

My view is that it is wrong to use a drug to improve performance if that drug is dangerous, risky or unsafe. Since most drugs have very real risks, it is hard to justify allowing their use simply to go farther on your skis or get downhill faster on your skeleton.

(Note these are the only two sentences in his entire column-length article that address the moral question. Much of the rest is devoted to sled jokes.)

Now, obviously, Caplan can’t really mean what he says here: many drugs “improve performance” and they all carry risks. By his lights, it would be immoral to use any drug at any time (or at least any that “improves performance”). Even ordinary medical treatments for athletes’ illnesses “improve performance”, and surely those are legitimate. Obviously, he means “any drug that only improves performance in athletic competition, and serves no larger clinical purpose” – but he ought to say so. More importantly, he offers a one-sided test of moral righteousness: a drug is bad “if that drug is dangerous, risky, or unsafe” (I have no idea what the differences between those three things are – surely if a drug is any one of them it is all the others as well) – no matter what its benefits may be. This is even more absurd, and Caplan knows better. Here he argues like those who only list the risks of abortion or marijuana use, and then conclude they are obviously immoral because so many bad things come from them – without ever mentioning that the alternatives may be even more dangerous, or the benefits may be justificatory. Caplan, a highly respected ethicist, is not one of those people, but this is a bad piece of writing. It is not for him to say whether “simply . . . go[ing] farther on your skis” is a good enough reason for anyone else to choose to accept the risks of using a drug to do so. For some reason he abandons basic principles of proportionality and autonomy to propose a blanket ban on something he simply doesn’t like, used for purposes he simply doesn’t value – not the kind of thinking we expect of him.

This does bring us closer to the real issue at hand, though – not athletic competition itself, but body enhancement as a practice and a human enterprise. The idea of “going beyond” your “natural” endowments is distinctly off-putting to many people in particular contexts. There is now an entire movement dedicated to opposing body enhancement of certain kinds (while actual “body-modders” go about their business within their own community, largely ignored – or treated as unimaginable freaks – by the larger society). Like the distinction between “natural” and “non-natural” athletic performance enhancement, there are greatly arbitrary distinctions made between other kinds of enhancement as well (artificial breasts: good; artificial horns on the head: bad). I tend to think of the athletic enhancement debate as merely one instantiation of the building confrontation over bodily enhancement – and the role and purpose of medical science and medical practice – in general. Clearly, there is a great deal of confusion waiting to be cleared up.

Hat tip: AJOB/bioethics.net

The Well-Timed Period quotes the definition of “conscience” from the Illinois “conscience clause” statute:

(e) “Conscience” means a sincerely held set of moral convictions arising from belief in and relation to God, or which, though not so derived, arises from a place in the life of its possessor parallel to that filled by God among adherents to religious faiths;

This is fascinating. Not only have they written religious beliefs explicitly into law as a defining factor in healthcare practice, but they’ve added a backdoor inclusion for non-religious meddlers that is as inane as it is intrusive. “The place in one’s life parallel to that filled by God among religious adherents”? Aside from figuring out what a “place in one’s life” is such that it is “filled” by a belief (a place in the brain?; some particular brain state?), or how two such “places” can be “parallel” between different people (note: not “analogous” or “corresponding to”, but apparently defined by lines that do not touch in some sort of inter-personal moral geometry), the statute apparently equates the religion-inspired beliefs of religious persons with the beliefs of non-religious persons that arise from a “parallel place”. What beliefs would those be? That there is no god? But what moral convictions arise from the lack of belief in a god?

You can see what the dimwit legislator who drafted this mess was trying to do: define “conscience” as religiously-inspired moral beliefs or moral beliefs of non-religious persons that are inspired by what they take to be their personal source of moral guidance (and since it goes to such lengths to negate the role of religion as a source, it could much more simply just have said “moral beliefs”). But the language use betrays such desperate confusion that the thing cannot be intrepreted without simply rewriting it. (For one thing, “conscience” does not mean “a sincerely held set of moral convictions”. The statute begins by defining its central term so bizarrely that it has no relation to the actual meaning of that term – or to the moral concept that motivated these statutes in the first place.) For that matter, it appears to be so slapdash that it was never edited before being enacted – nor apparently was that any barrier to its being accepted by the Legislature.

The unnecessary – and in fact gratuitous – inclusion, then negation, of the role of religion also betrays the origin and intention of these statutes. They perform two functions: placating religious extremists who want to impose their views on others, and serving as a barrier to reproductive healthcare services. That the language of the statute first explicitly cites religion as a justification for refusal of services testifies to how clearly that issue was in mind when the statute was drafted; that it negates this motivation in the succeeding clause broadens the statute (and seeks to avoid certain Constitutional challenges) to allow for even more challenges to patient care from more sources. (Oddly, by mentioning these motivations at all, the statute hampers itself. If this language is to be taken seriously, refusersmust have a religious motivation [or its "parallel" equivalent] for their refusal – for instance, they cannot just happen to think birth control is immoral but for reasons not “arising from belief in and relation to God” [or a "parallel" thereto].)

I suspect, however, that this gibberish-level language will not be taken seriously. No challenge to a (non-religious) refuser to prove that their beliefs are “parallel” to a belief in God will be accepted (though, to be fair, there are unlikely to be any non-religious refusers). The tangled prose above will not be questioned; the “implicit intent” of any statute that imposes barriers on women’s sexual autonomy will be regarded as self-justifying. But it is worth nothing just how bad the thinking is that goes into these laws, and how low a standard – in terms of reasonability, or even comprehensibility – proponents of such intrusive restrictions on women’s autonomy set for themselves. The people who wrote, and voted in, this mindless blather are the people who will be judging and constraining women’s decisions and women’s (and men’s) liberty under the new reproductive legislative regime currently building.

W. Bradford Wilcox, one of the “marriage advocate” crowd, argues in the New York Post today that the recent spate of high-profile child-abuse cases is evidence that marriage per se is a good thing.

SEVEN shocking child deaths in the last four months: Liyah Atkinson, Quachaun Browne, Nixzmary Brown, Josiah Bunch, Dahquay Gillians, Sierra Roberts, Michael Segarra. This staggering death toll from abuse or neglect has focused justifiable attention on malfeasance at the city’s Administration for Children’s Services. But another thread tragically links these kids: All were living outside of an intact, married family. . . .

Consider the empirical evidence. A recent study in the journal Pediatrics found that preschool children in homes with an unrelated adult were nearly 50 times as likely to die because of physical abuse, compared to children in intact, married homes.

In a recent report, “Why Marriage Matters: 26 Conclusions from the Social Sciences,” an interdisciplinary team of 16 family scholars that I chaired found that children in single-parent homes are almost twice as likely to be sexually abused, compared to children in intact, married families.

We also found that children living with stepparents (usually a stepfather) are more than 40 times as likely to be killed or sexually abused, compared to children living in an intact, married family.

Bottom line: Children are much more likely to be abused or neglected in a single-parent, cohabiting or stepfamily situation than they are in an intact, married family.

Leave aside his use of anecdotal evidence (7 cases in four months – hardly a landslide in a system with close to 30,000 children in foster care alone – and no mention whatsoever of cases of abuse in two-parent families). What these statistics really add up to is a strong prima facie argument for liberalized divorce.

Assume just two things: that it is the most troubled marriages that end in divorce, and that abuse is more likely in troubled homes (regardless of marital status). If this is correct, then in a society with liberal divorce laws (which New York is not, but it’s at least not uncommon here), the population of two-parent families will consist, almost by definition, of those families that are relatively stable and untroubled compared with those who have divorced. And the population of single-parent families will consist in significant part of families whose homes were troubled before divorce separated the parents.

The inevitable result, again assuming that abuse is more likely in tense and difficult family environments, is that abuse will be less likely in two-parent familes, not because having two parents makes abuse less likely, but simply because potentially abusive (i.e., troubled and overwhelmed) parents are less likely to remain in two-parent marriages. In other words, Wilcox’s data equally well support a conclusion that the causative pathway is completely the opposite of the one he assumes: that it is not divorce that causes abuse, but that abuse and divorce are caused by, and thus subsequent to, the same set of difficulties in the marriage. And that conclusion has the advantage of tying abuse to the known prevalance of tension in the marriage (as witnessed by the eventual divorce) rather than some magical property that attaches to saying “I Do”. From this perspective, abuse will be linked with single-parent status, and lower levels of abuse with stable marital status, by the logic of the link between marital discord, abuse, and divorce alone.

From that perspective also, simplistically advocating marriage, in and of itself, without reference to whether the marriage is happy or stable or the partners want to be married, as a way to prevent child abuse, is like advocating wearing a bathing suit to make the sun come out. The fact that most bathing suits are worn on sunny days doesn’t mean they cause the sunny days. Wilcox’s blindly pro-marriage argument, on the basis of such a classically naive statistical mistake, would actually lead to the worst of all possible outcomes: children trapped in unhappy, unstable homes with two incompatible parents – a recipe for abuse that none of them are allowed to escape because Wilcox and his ilk have determined that marriage is so good for them.

What liberal divorce laws do is ensure that those marriages that remain are stable and happy – that the bad ones are ended quickly so the partners can try to find better mates, or at least to reduce the tension in the home and its attendant threat of abuse. Financially, it is well known that most women and children suffer greatly through divorce (while most men benefit), but it is likely that many divorces put women and children in calmer, and likely less-abuse-prone, physical environments. Simply reducing the tensions between parents, and removing an abusive or threatening parent where necessary, is a benefit of divorce additional to its role in ensuring that only inherently stable marriages (not forced unions in which all parties are trapped against their wills) persist.

Wilcox does notice that conditions in the home are relevant to the prevalence of abuse:

Married parents have enduring legal, moral and social ties to each other and to their children. Such ties increase the likelihood that each parent will monitor and support the other’s parenting. So, for instance, when mom is at the end of her rope with her kids, a married dad can step in and take over. A single mother doesn’t have that option, and a mom’s live-in boyfriend isn’t likely to be a conscientious caretaker . . .

(It’s a rare concession from conservatives that single mothers do face difficulties – but, characteristically, that concession comes in the context of an argument that they should not be allowed to be single mothers, not as a reason to make their lot any easier.)

But if it is conditions in the home that contribute to the likelihood of abuse, then it is not the mere state of being married itself. Wilcox falls back on his observation that married couples have it easier (there is less abuse, and a greater investment by fathers in their children), but, again, if it is the case – as it obviously is – that the couples who stay married are the ones who have stable home lives to begin with, then he is saying nothing more than that those couples who have stable home lives have more stable home lives than those couples whose home lives have broken up – and that the former is better for everyone.

It hardly takes much research to know that, and in fact he could have been told that by any advocate of no-fault divorce. But there is no link at all that justifies going from “having a stable marriage brings benefits” to “everyone should be forced into whatever marriage is most convenient to hand, and kept there once married regardless of conditions” – which is his implicit argument, and the explicit argument of advocates of marriage-dependent social benefits and stricter divorce laws. That violates both logic and common sense – a deficit that no amount of anecdotal outrages will overcome.

The Cook County (Chicago) Republican organization has issued a press release claiming that the Democratic party is conducting genocide against black Americans by supporting abortion rights. The language is unbridled, and the explicit appeal to racial animosity is as stark as anything seen in the days of Jim Crow. (It is progress, I suppose, that they are now race-baiting in favor of blacks, but it’s hardly less ugly.)

The Democratic Party, true to its pro-slavery past, recently defined another group of human beings as non-citizens, thereby excluding them from legal protection under the law. This group of Americans is the unborn. In the tortured reasoning of the 1973 Roe v. Wade decision, unborn children are essentially property. And just as the Dred Scott case predominantly (though not exclusively) affected African Americans, the Roe v. Wade decision has paved the way for a veritable black genocide.

Here the GOP unveils its “Dred Scott” codeword. Prominently, but puzzlingly, used by George Bush in the 2000 debates, “Dred Scott” evokes a trope among evangelical Christians that has it that abortion is the equivalent of slavery. Interestingly, it has been almost exclusively white conservatives who make that claim or use that analogy; the GOP is now testing it out on black constituents.

The “genocide” claim is:

Recent statistics indicate that since 1973, abortion has reduced the black population by over 25%. Because abortion has been aggressively peddled to inner city black communities, black babies today are three times more likely to be killed in the womb than white babies. Abortion kills twice as many black babies as AIDs, accidents, violent crimes, cancer, and heart disease combined. Although it is possible that Planned Parenthood and its ilk are racially blind, 80% of planned parenthood facilities are located in minority neighborhoods. What’s the point of all these gruesome statistics, and what do they have in common with the Dred Scott case of 1856? Plenty.

The result of Dred Scott was to strip African Americans of their standing under the law and thereby prevent them from ever exercising political power for the good of their people. Roe v. Wade subtly accomplishes the same ends by a different means. The black population is curbed by convincing black mothers that their unborn children are only property which will financially destroy them so it is in their interests and the interest of society to kill them. African Americans can thank the Democratic Party and its unyielding support for Roe v. Wade as well as its insidious influence in our public school system for today’s veritable black genocide.

This claim, of course, implictly holds that black women have been conducting genocide on the black community. Of course, they were misled by those wily Democratic genocide planners, who “convinced [them] that their unborn children are only property”. Necessarily, this suggests also that black women – misled as they are – have not correctly understood their own interests, and that they have reduced their own decisions over abortion to financial calculations about “property”. This seems both offensively condescending and, likely, rather out of touch with the lived experiences of many black women; it remains to be seen whether these women will reject the “deluded, incompetent victim” role assigned to them.

The language pushes several other, highly calculated buttons as well: “aggressively peddling abortion” plays to a theme common in the anti-choice community, namely that Planned Parenthood somehow acts to increase abortions in order to make money off them (its support for contraception is actually support for abortion, because contraception fails, thereby leading to more abortions by all those women who would never have had sex at all if Planned Parenthood hadn’t given them contraception); that Planned Parenthood preys on minorities (its clinics are in low-income neighborhoods not because low-income persons need low-cost health services, but because that’s the way to kill all those black babies); public schools are somehow to blame for unplanned pregnancies (playing off widespread dissatisfaction with public schools, while indirectly pitching for religious schools and an end to sex-ed). And, finally, of course, it uses the – true, and shameful – history of the Democratic party prior to the Civil Rights Movement to hang a “racist” label on Democrats today (carefully not using the words “Southern strategy”, “affirmative action”, “Civil Rights movement” or “Trent Lott”).

As a piece of propaganda, it’s bold and likely provocative. Presumably the GOP in Chicago – traditionally a rough town politically – thought it could get away with language of this kind, at least as an opening shot (I suspect we’ll see some backpedaling when the inevitable complaints roll in). In the sense of “all PR is good PR”, it may be an effective move. But as a contribution to understanding either the politics or morality of abortion, it is despicable. To use this most personal and heated of issues in such a dishonest fashion for nothing more than a partisan power grab makes a mockery of this issue and the feelings both of those who care about abortion and of the black constituents they claim to be concerned for.

To begin with, the “genocide” charge is nonsense on its face. I presume it goes without saying that the existence of abortion is not a coordinated campaign of genocide; the idiocy of the charge is its own refutation. Similarly, too, with claims that abortion clinics are selectively placed in minority neighborhoods (they are selectively placed where healthcare services are lacking – if that happens to correspond to minority neighborhoods, perhaps the GOP should give some though to public health funding). But even the pretended factual claim at the heart of this charge is false. Here are the white and black population trends, from the Census Bureau’s 2000 data (race definitions were changed in 2000, so later data are not comparable):

The thick lines represent population overall (in thousands) for whites (dotted blue line) and blacks (black line); the thin lines are annual growth rate (%) for each. The white population grows faster in overall numbers, because it is larger to begin with, but notice that both white and black show no visible change in growth rates after 1973. In fact, the slope from 1975-2000 for blacks actually increases by 14% compared with 1960-1972: the long-term black population growth rate is higher after abortion was legalized than it was in the 12 years previously (it declines by a similar percentage for whites). [Census Bureau data for blacks as a distinct category do not go back beyond 1960.] In other words, the “effect” of legalization of abortion on population growth is . . . that there is no discernible effect at best, or possibly that it actually increases the birth rate for blacks! So much for “black genocide”!

Notice, too, on the above graph that year-to-year changes in annual population growth rate for blacks and whites almost exactly parallel one another, and the black growth rate is consistently higher than that of whites (0.69% per year higher, on average 1960-2000). If there is a “black genocide” going on, it involves the black population growing almost two-thirds faster, proportionately, than the white population, and both groups being “wiped out”, in response to the same environmental factors, in almost exactly the same way! Note also that both groups show extended simultaneous increases, not just in total population, but population growth rate for periods of 6-8 years following the legalization of abortion. Again, it is a strange “genocide” that results in its “victims” possessing a consistently increasing population, the highest population growth rate of any major ethnic group in the society in question, and extended periods of accelerating population growth during the period of the “genocide” – while exactly the same factors influence the growth rate of the majority population in exactly the same way! (Note: the overall population growth rate trend is downward for both groups, but it always remains positive – both populations are growing, and sometimes increase their rates of growth as well.)

The following graph superimposes the growth rate lines from the one above for comparative purposes. (That is, the graph below is the same as the thin lines from the graph above, with the line for blacks moved downward 0.69% – the average difference between black and white growth rates on the graph above – to superimpose them. The units are on a relative scale, because the absolute numbers have been adjusted in that way.)

As you can see, black and white annual population growth rates changes are virtually indistinguishable (though, remember, the black rate is significantly higher in absolute terms); even the year-to-year change does not differ between them more than about 0.2% in any year. So whatever causes year-to-year changes in birth rates – and thus would tend to depress birth rates for a population undergoing genocide – affects blacks and whites almost identically. Again, it is absurd to imagine this is some sort of campaign of “genocide” by whites against blacks that affects them both the same way (and leaves blacks with a much higher overall birth rate)!

The reasons for these results are simple enough (aside from the fact that abortion is not “genocide”): abortion does not “reduce the population” in the simplistic way these claims make it out. The 25% figure is, obviously, the proportion of pregnancies among black women that have been ended by abortion over the years since Roe v. Wade – a proportion that is virtually identical to that of the national average. But it is the grossest statistical error to claim that this results in a 24% reduction in the total black population that would otherwise exist. (The same error is made by “Freakonometrician” Steven Levitt, with his “abortion eliminates black criminals” theory.) Most women who undergo abortion also have – either before, after, or both – full-term pregnancies from which they raise children. Abortion does not “eliminate” births as much as it spaces them out into appropriate times in the women’s lives. (A theoretical aside: this may provide some empirical plausibility for Peter Singer’s “replacability thesis”.) Whether women who have had any abortions have significantly lower total lifetime fertility than women who have never had one is not clear, but it is mindless to claim that one abortion = one less in the population. It is likely that abortion plays a role in the overall decline in fertility rates in industrialized countries, but even then it is not clear that that role would not be taken up by more-stringent birth control, voluntary sterilization, and other methods of birth spacing, if abortion were not available. So there are few or no grounds for concluding that population growth is impeded by abortion – especially in the face of well-documented trends toward lower fertility arising from other causes – and still less reason to claim that the ethnic group with the highest rate of population growth is facing an “abortion genocide”.

There is much more to be said about this offensive argument: the manipulativeness of it, the open race-baiting, the propaganda and the code words, and on and on. But when the simple factual data underlying the argument are so badly used, and so disingenuously, we can easily know what to think about the moral rhetoric it employs as well.

Suffice it to say this is, if not a new low, at least a particularly shameless low in abortion politics. And that the issue addressed is not even abortion – but mere partisan positioning for vote strength – is only one more outrage in the context of an issue that deserves far more mature and sincere treatment.

UPDATE: I overlooked at first the charming fact that the Cook County Republicans chose to date and issue this press release on the day of Coretta Scott King’s funeral. Very classy.

In a bit of utilitarian logic that seems overdue (though I admit I hadn’t seen it coming), a group of mental health nurses in the UK is debating the introduction of a “harm reduction” strategy to deal with self-mutilating behavior among mental health patients. Specifically, they are talking about providing clean “sharps”, and potentially advice on how to perform “cutting” safely, to patients who cut their skin in response to internal tensions. Some nurses have even been sitting with patients to comfort and monitor them during this procedure.

NURSES want patients who are intent on harming themselves to be provided with clean blades so that they can cut themselves more safely.
They say people determined to harm themselves should be helped to minimise the risk of infection from dirty blades, in the same way as drug addicts are issued with clean needles.

This could include giving the “self-harm” patients sterile blades and clean packets of bandages or ensuring that they keep their own blades clean. Nurses would also give patients advice about which parts of the body it is safer to cut.

The proposal for “safe” self-harm — which is to be debated at the Royal College of Nursing (RCN) Congress in April — is likely to provoke controversy.

At present nurses are expected to stop anyone doing physical harm to themselves and to confiscate any sharp objects ranging from razor blades to broken glass and tin cans.

However, Ian Hulatt, mental health adviser for the RCN, said: “There is a clear comparison with giving clean needles to reduce HIV. We will be debating introducing a similar harm-reduction approach. This may well include the provision of clean dressing packs and it may mean providing clean ‘sharps’.

To some – especially those who oppose harm reduction for drug users, or condom distribution to prevent AIDS or unwanted pregnancy – this may seem a reductio ad absurdum of utilitarian health policy. What could be more antithetical to healthcare ethics than helping patients hurt themselves? At the very least, this is another example of complicity in behavior that should not be condoned in the first place – of focusing on the immediate consequences of the behavior rather than eliminating the harmful behavior itself. (And from that point of view, this may be an even starker example of a misguided policy than needle exchanges or condom distribution. There is a value to safe sexual behavior in itself, beyond merely the good of remaining disease-free, that is promoted by condom usage, and there are those who argue for an abolition of drug laws on the same grounds – that taking drugs is a personal decision that should be supported, not opposed, where it is voluntary. Self-harm, though, is . . . harmful.) Even from a more rational view of healthcare ethics, there can be something startling in this policy: the idea that behavior that is by definition self-destructive should be encouraged as long as it is merely less harmful, especially when the alternative, under current policy, is active intervention to prevent the behavior. It sounds like a policy of advising suicide jumpers to try a lower window. Add in the question of dubious decisionmaking capacity (these patients are, again by definition, mentally troubled to the point of making self-destructive decisions), and the idea of enabling and supporting the behavior in question can seem shocking. (I am a very strong autonomy advocate, but not only did I not see this proposal coming, when I first encountered the story on a conservative blog I assumed it was a parody.)

However, understanding this policy requires understanding the behavior it addresses. “Self-mutilation” is a complex behavior that often has nothing to do with suicidal ideation, or with a true intention to harm oneself as the patient sees it. “Cutting” and other pain-infliction methods (hair-pulling, scratching the skin, piercing, etc.) are often a way of reducing internal tensions or the feeling of losing control of oneself due to psychological pains. This has a sound physiological basis; pain sensations do reduce the felt intensity of competing pain sensations, a fact which is taken advantage of clinically and informally. Dentists use “pressure anaesthesia” (pinching or pushing on the gums) to reduce the pain of needles, and “piercers” – people who pierce their skin either as a demonstration or for S&M purposes – do the same thing. “Cutters” report that their tensions ease and they feel calmer – and feel less need to do other, more extreme things to themselves – when they inflict pain. The wounds cutters inflict are often very superficial – barely breaking the skin, as opposed to truly suicidal cuttings which often go very deep. Viewing cutting only in respect of the physical damage it does to tissue, and not in terms of its psychological importance to the patient, or its calming effects, gives a very distorted perspective. (It’s important not to be too glib about this, though. Many patients making “suicide gestures” inflict superficial wounds, either because they do not truly intend to die or because they don’t know how to go about it or can’t force themselves to do so. Similarly, many “cutters” do inflict more serious wounds, and many are left with lifelong scars. It would be a mistake to say that “cutting” cannot be truly life-threatening, or that superficial injuries do not betray very serious self-destructive impulses. It would be a serious mistake to say that “cutting” and suicide are mutually exclusive impulses. And, most importantly for this blog, I am not a clinician or a mental health expert, and this material should be read with an accordingly skeptical mind.)

Seen this way, it is a mistake to insist that cutting is by definition self-destructive, or “harmful”. For one thing, the actual injuries it involves may be no more severe than those undergone – willingly – by persons receiving tattoos or participating in BDSM play. More importantly, the intent behind the act is very different from an actual intent to harm oneself – to make oneself worse off, or less healthy. The intention of many cutters is to make themselves more healthy by aleviating a pain that is not responsive to ordinary analgesics. To the extent that it succeeds in this way – and is not, in fact, an expression of truly self-destructive desires or a half-hearted attempt at suicide – cutting is a coping strategy – a way of pushing away the tensions and needs that otherwise haunt the patient – and in that sense not so very different from what getting a fix is for an addict. Seen in this light, a harm-reduction strategy towards cutting may be as reasonable as a needle exchange for drug users.

This is not the last word on this policy. The matter of distinguishing cutting which reduces a patient’s psychological symptomatology from that of self-destructive behavior which could exacerbate into truly dangerous acts is of paramount concern. The question of mental capacity is also an important one (though, again, for “cutters” the act in question is not self-destructive or counterproductive, but is in fact a supremely rational – and staggeringly desperate – reaction to conditions). But, assuming these questions of clinical fact can be addressed and managed, the idea of harm reduction for cutting makes sense, however sad and despairing an act cutting itself may seem.

What this issue brings up – as do so many matters of healthcare ethics and policy – is the question of the role of the healthcare professions in general. Predictably, in response to the suggested policy above, a traditionalist view of healthcare provision was held up against it:

However, Ian Hulatt, mental health adviser for the RCN, . . . admitted there would be significant opposition: “Some nurses will not support this because our code of practice says we should not do patients any harm. But this may be less harmful than patients using dirty implements. There are mental health units that already allow the use of sterile implements.”

But this view of healthcare defines provider roles independently of what is actually good for their patients. One can only suggest that “harm reduction” violates a proscription on doing “harm” (as adherents of the dwindling Hippocratic school often do) if one defines “harm” in some absolutist, prescriptivist sense, and not in terms that reflect the patient’s own values. If patients themselves decide where their own interests lie, then effective harm reduction must be the proper policy (assuming no “harm elimination” policy is achievable), even from the point of view of non nocere. The claim that providing safe sharps to people who are going to cut themselves anyway is a “harm” is only defensible if the fact of the behavior is taken as the harm in question, and not the relative magnitude of its consequences. And that kind of absolutist categorical thinking underlies an entire school of healthcare ethics in which the patient, and the patient’s own values, make only fleeting appearances. That, I suggest, is a real harm to be reduced.

Virginia is currently debating a state equal-protection bill that includes a sexual orientation non-discrimination clause . (The state currently has no non-discrimination law. There is a traditional non-discrimination order issued by each incoming governor, but it is up to the will of each governor in turn. The previous governor, Mark Warner, added sexual orientation as a protected category, and the current governor Kaine, renewed it; now they are trying to finally write the order into law.) There is also a non-discrimination clause appended to the state budget bill. Democrats are hoping that Republicans who voted for the state’s anti-gay-marriage amendment will support the anti-discrimination bills as a way to reduce their Bigotry Quotient just a bit.

Good enough, as it goes. But superloon state Delegate Mark Cole is opposed, on this unique ground:

“Sexual orientation is a broad term,” said Del. Mark L. Cole (R-Fredericksburg), who has proposed amending the budget. “There are eight different sexual orientations, including pedophilia and bestiality. I think we’d be opening up Pandora’s box and allowing judges to interpret what that means.”

(The article notes the bill explicitly exempts “orientations” defined as “deviant” by the DSM.)

OK, skipping right over the human rights angle, let’s get to the juicy stuff: eight sexual orientations, “including pedophilia and bestiality”? Huh?

Try as I might, I can’t figure this out, or even find out where it comes from.

It harkens back to an old game of trying to define sexual categories – a practice we are increasingly finding is a forlorn hope. People’s desires seem to elide seamlessly from one focus to another – a little bit more of this, less of that – and encompass a broad range of sexual outlets, not all of them involving sex play with human partners. (In this, the likes of Mark Cole and Rick Santorum are correct, though not in a good way.)

“Sexual orientation” seems more a convenient shorthand than anything. In fact, we find here another parallel between sex-identity discrimination and racial discrimination: both depend upon membership in categories which it is impossible to define scientifically, but which have real social meaning. Being “gay” or “straight” tells us little about a person, and in fact is not necessarily a predictor of who they commonly, or ever, have sex with. Similarly, race is notoriously difficult to define other than as a set of broad genetic patterns. But in both cases society pins group-membership labels on individuals, and individuals themselves embrace or reject the labels as seems best to them. That the labels are vague demarcators, and surely not behaviorally dispositive, does not mean they cannot impose compelling identity boundaries – ones that are not necessarily limiting or unwelcome, but which also can be the basis of real – and in no way vague – discrimination.

So the hunt for a finite number of clearly demarcated sexual categories is a waste of time – but also a pursuit that has been indulged in by many, often with good intent. It’s probably time to put that aside, and if it isn’t, Mark Cole’s mean-spirited and ignorant stupidity has surely pushed us closer to that day when “gay”, “straight”, and “bisexual” will sound as quaint as “octaroon”, “quadroon”, and “mulatto”.

Even so, I still want to know what his eight categories are! If two of them involve children and animals, that leaves six others . . . . Perhaps male and female categories for each of “gay”, “straight”, and “bisexual”? But we don’t usually think of the male and female “versions” of those categories as different sexual identities, just different sexual practices. Perhaps, instead, we can assign one category to fetishism, and three more to the usual triumvirate. That gives us a total of six categories accounted for (of which half do not involve an adult human partner) – and two more remaining which are, presumably, even more exotic than bestiality or fetishism. (Maybe I’ve misjudged Mr. Cole – he’s a pretty swingin’ dude!) Incestiality? (Or, perhaps, “insectiality”? Do the “beasts” of bestiality have to be mammals?) Onaniality? (That would suggest that most people have at least two sexual identities, however, since they rarely give up this one after initiation into another.) I just don’t know.

C’mon, Mr. Cole – don’t keep us waiting! What are the “other” categories? We could throw a hell of a party in your honor if you’d only come clean!

UPDATE: I have sent the following e-mail to Delegate Cole’s office. I’ll let you know what response I get.

Date: Mon, 6 Feb 2006 15:47:55 -0500 (EST)
Subject: Delegate Cole’s Anthropological Discovery
From: “Kevin T. Keith”
To: DelMCole@house.state.va.us

Dear Delegate Cole:

You are quoted by the Washington Post (http://www.washingtonpost.com/wp-dyn/content/article/2006/02/05/AR2006020500943.html), in the context of pending bills to provide non-discrimination protection to Virginia citizens under state law, making this remarkable statement:

“‘Sexual orientation is a broad term,’ said Del. Mark L. Cole (R-Fredericksburg), who has proposed amending the budget. ‘There are eight different sexual orientations, including pedophilia and bestiality.’”

Could you please identify the eight categories and provide some sort of instructions for the more exotic ones?

Thank you,

- Kevin T. Keith

“Jane Galt”, a libertarian economics-motivated political blogger, has an interesting discussion of contraception policy from the point of view of price theory:

[F]ree contraception programs produce only very modest results where they are tested. Consider these highlights from Planned Parenthood:

* The most successful adolescent pregnancy prevention programs in the U.S., which combine sexuality education with direct access to or information about contraceptive services, have increased contraceptive use among participants by up to 22 percent (Frost & Forrest, 1995).

* More boys who participated in a high school condom availability program in Los Angeles reported using condoms every time they engaged in vaginal intercourse during the past year (50 percent) than the year before (37 percent), and more boys reported condom use for recently initiated first vaginal intercourse (80 percent) than the year before (65 percent) (Schuster et al., 1998).

* Condom use among students in New York City public high schools that have condom availability programs is five percentage points higher than in Chicago, where no such programs exist (Guttmacher et al., 1997).

In other words, if we give birth control to students for free, and tell them how to use it, and urge them to do so, we might increase the number of students using birth control regularly by 22% [memo to study neophytes: that 22% figure does not mean that out of 100 students, 22 more of them are now using contracpetion; it means that whatever smaller group were previously using contracption is now larger by 22% of itself--so if 50% were previously using contraception, 11 more students are now using birth control than were before.]. That’s pretty damn underwhelming. And that’s the best study Planned Parenthood can come up with, the one that is probably the outlier on the normally distributed bell curve of such study outcomes. I’ve no doubt that the abstinence folks have grabbed whatever study lies at the other end of the bell curve, and are using it to claim that contraception-based sex ed actually increases the number of pregnancies by teaching students that it’s okay to have sex.

I do believe that educating people about sex and giving them contraception for free increases contraception usage somewhat, and lowers unwanted pregnancy. But how much it reduced unwanted pregnancies depends on how many of today’s unwanted pregnancies result from ignorance or lack of access to contraception; if these are not the primary cause of unwanted pregnancy, then the effect of such laudable programmes will be modest. And based on the studies so far done, that effect seems to be pretty trivial–too small to make more than a small dent in the number of unwanted pregnancies.

This leads me to conclude that the monetary cost of contraception is, at best, a small contributing factor to unwanted pregnancy in this country. . . .

My primary argument, based on that tired old UChicago price theory, is that the reason that we will not significantly reduce abortions is that the non-monetary costs of birth control–acquiring and remembering to use it, and the unpleasant side effects, medical or otherwise (insert “raincoat in the shower” jokes here), so far outweigh the monetary costs that even giving people birth control for free has only a limited impact on their usage.

This is part of a running argument she is having over William Saletan’s much-criticized Op-Ed on abortion. One of her conclusions (it’s a long post) is that we need to find some policy other than contraception distribution to address abortion, because contraception distribution makes only a small contribution to changing abortion rates.

She makes a good case. However, there are a few things to note:

• As she points out later in the post, one reason increased contraception usage wouldn’t affect abortion rates even in areas with currently very low rates of contraception use is that those are also areas with virtually no access to abortion. But this is hardly a satisfying point. She notes that assuming large-scale changes in social mores or public policy as a component of smaller policy prescriptions (“distribute condoms and create more support for abortion access!”) are pipe dreams, but she seems to accept too readily the barriers currently in place, then cites them as reasons why changes in policy can’t work. If the reason contraception does not reduce abortion is that (essentially) nobody is permitted to get an abortion at all, that is not a reason to oppose contraception, or to simply accept the fact that abortion access is blocked.

  Further on this point, if the question is what policies we should support in regard of sexual health, it is worth noting that contraception and abortion are conceptually linked issues in the minds of many activists. That is, the people who oppose contraception are the same ones who oppose abortion, and vice versa for the group that supports access to each. So, changing contraception policy both requires and is part of changing the entire complex of attitudes and policies that affect abortion policy as well. And if we have to work on both those issues together – and if we can do so with at least some success – the barriers to abortion that undermine contraception’s impact on abortion are not reasons to oppose contraception distribution, but simply part of the large and difficult project of supporting it.

• Similarly, she seems to overlook the question of access (and of public support for abortion rights) as a contributor to abortion rates. She cites a list of the states that are above the national mean for abortion rate, noting they are all decidedly liberal – with “dense populations, and high levels of spending on public health, as well as lots of Planned Parenthood clinics” – as evidence that contraception availability and sex education do not reduce abortion. But this comes immediately before noting that the low-abortion-rate states have unsupportive social mores and few abortion clinics! So her list tells us nothing other than that states that are anti-contraception are also anti-abortion-rights, and similarly for states that are pro-contraception – certainly nothing about how the relative degree of contraception availability in those states is a factor influencing unplanned pregnancies in those states.
• She buys into Saletan’s priority of reductions in abortion alone as the goal of contraception policy – putting her (despite her denials) strongly in the punitive wing of the anti-choice camp. To be fair, this is a discussion of Saletan’s article, so perhaps she is not required to explore broader policy issues. But to conduct the entire discussion in terms of contraception as a contributor to abortion rates, with virtually no recognition of the benefits of contraception as prevention of unplanned pregnancy and a factor in safer sex, takes sexual health and sexual autonomy out of the picture and casts the entire issue as merely a matter of discouraging a particular disapproved health option – exactly as the anti-choice campaign does. (She says, rather snidely: “If you want to go ahead and start another clinic to give kids the Pill, be my guest. Add a shuttle service, education classes, and for all I care a pedicure station. I’ll applaud your efforts, and throw in a little of my own hard-earned cash to boot, since I think it’s a worthy cause. But I will be surprised indeed if we see a meaningful drop in abortions as a result.” She then immediately states: “I’m not denigrating providing contraceptive access as a project . . . .” Oh, no?)
• She ignores secondary effects. Making contraception more widely available, and thus somewhat more used, also increases the social expectation that it will be used (by changing people’s thinking; by making it seem the usual or expected thing; by giving girls a choice of boyfriends who will use it if others refuse . . .). Providing universal and appropriate sex ed destigmatizes sex and contraception. Creating clinics and other forms of sexual health access where there were none not only provides needed services but makes those services come to be expected and seem normal. Thus adopting policies with limited effectiveness lays the groundwork for increases in effectiveness as those policies become more widespread – a tipping point I think we haven’t reached even in liberal areas of the country.

Galt is smart, argues well, and has some useful points to make. Her libertarian-indifference streak surfaces too often for my taste, but she is worth reading most of the time. On this issue, however, narrowly defining successful policy in terms only of satisfying the demands of the anti-sex reactionaries (i.e., reducing overall abortion statistics), and not in terms of expanding sexual safety and autonomy for women or providing the best opportunity for safe sexual development for girls in their exploratory phase, not only plays into conservatives’ hands but ignores the moral values at the heart of policy development. It’s the reason “that tired old Chicago price theory” misses so much of what economics is about.

Jill at Feministe hits the nail on the head with this post on healthcaregiver “conscience clauses” – with regard both to their basic conflict with the duty to the patient, and the truly frightening extremes many of these new laws go to.

I couldn’t have said it better myself, so I didn’t.