Sufficient Scruples

Bioethics, healthcare policy, and related issues.

March 4, 2014

“We Read Your Blog Sometimes, and We Laugh a Little”

by @ 11:05 AM. Filed under General, Meta

How sharper than a serpent’s tooth it is to have a thankless sister

So my beloved sister has apparently been stalking me online. The other day she told me that she had been showing my blogs to her girlfriends, “and we laugh a little”.

So it’s come to this . . .

January 22, 2013

Blog for Choice Day 2013: Decimating Law to Eviscerate Women’s Rights Under the Law

by @ 8:20 PM. Filed under Access to Healthcare, Autonomy, General, Global/Community Health, Healthcare Politics, Provider Roles, Reproductive Ethics, Sex, Women's Issues

January 22: the anniversary of Roe v. Wade, and a perennial high point in the continuing relentless fight for women’s rights. This year is the 40th anniversary of the decision that gave women their own bodies back, and it comes at a time when the autonomy conferred by that court decision, the simple fact of self-governance that ought not to require any ratification or authorization in the first place, is more embattled than it has been at any time since.

There’s much to say about this ugly time, the vicious, bitterly vicious, unrelenting backlash that since the Bush years has been ever more shameless in its naked hatred for women’s independence and, still worse, their sexuality. The truly fascist and deeply dishonest legislative assaults that have erupted in so many states over the past two years are as shocking as they are disheartening. And the creepy and untiring campaign to undermine, by every devious and indirect means, women’s access not only to abortion services, but contraception and all reproductive healthcare, including even breast cancer screenings, is both revelatory and repulsive.

But aside from the infuriating and burdensome details of this multi-front war on women and their bodies, what particularly strikes me is the pervasive bad faith that drives it. Abortion rights have always been threatened by attempts to undermine the laws which make it possible for women to exercise their inherent rights to control their own bodies and lives. But the new face of the war against them is not one of wrong-headed but above-board legislative controversy. It is a persistent and thoroughgoing attempt to turn the law itself against the majority of the citizens it governs – to use the law to make it impossible for law-abiding citizens to exercise the rights guaranteed them by that law.

Bans on funding for non-abortion related services, bans on the provision of factual information about abortion by healthcare providers to their own patients, prohibitions on the provision of abortion and reproductive health services through government programs relied on by women who have no other source of care, disingenuous regulations intended to make it impossible for women’s clinics to function for reasons unrelated to the quality of their services, and so many other restrictive and intrusive regulations, all are uses of the democratic process to make it a practical impossibility for women to exercise their own rights. And all of these are thoroughly and deliberately dishonest: they block factual information, and in some cases even stipulate falsehoods, to women seeking to make an informed choice about their own healthcare; they erect barriers and regulations addressing questions of funding, safety, or other ordinarily-reasonable aspects of healthcare provision for reasons entirely unrelated to their ostensible purposes and with the deliberate intention of making service to patients impossible; they malignantly distort the bedrock principle of medical ethics – informed consent – to harass, intimidate, and manipulate women seeking to make a free and informed choice about their own care, and drive them to a choice dictated by political and religious ideologues motivated by a deep-seated and gnawing hostility to those women themselves.

The enemies of women, having seen that orderly debate, under the framework of rights guaranteed by law, was not their friend in their war to take women’s lives into their own hands against those women’s wills, have adopted falsehood and bad faith as their weapons of choice. Nothing is now what it seems in this fight: informed consent is deception and manipulation; safety regulations are intended to prevent safe access to the services sought (and consequently drive women to seek unsafe alternatives, the rate of which is rising in the United States for the first time in decades); funds for services unrelated to abortion are banned out of nothing more than a virulent hostility to the organizations that provide the funded services because they also support women’s rights to abortion.

So much is at stake in the war against women. But the perversion of this war into a distortion of democracy itself, and the twisting of the law to undermine the law in the lives of one specific, hated, targeted sub-group of the population (the majority of that population, no less, but ever a despised and insecure majority) has broadened its scope, even beyond the lives, dreams, and freedom of more than half the country’s citizens. It has allowed a rabid and unhinged minority of religious berserkers, and the politicians they hold captive, to turn the nation against its own citizens.

It is said “when one is not free, none are free,” but that is truer than ever in the latest total-war assault on women by the religious right. They have adopted scorched-earth tactics against civilization itself – against the law that guarantees the freedom to live under the law, using the law’s defenses as weapons against those whom they defend. No nation can claim to be civilized which terrorizes and enslaves its female population. But the right wing has abandoned civilization even in form, not merely in substance, willingly gutting law itself when its guarantees of freedom thwarted their plans for domination.

What other rights remain, when the right to exercise one’s rights is denied?

September 12, 2012

Thomas Szasz: Opposition Whip

by @ 9:30 AM. Filed under Autonomy, BioLibri, General, Healthcare Politics, Provider Roles

Thomas Szasz, MD, has died at the age of 92.

Szasz made a career as the gadfly of psychiatry, excoriating its role as enforcer of political and social orthodoxy and questioning mental illness as a category of disease. He was driven by both a lacerating exactitude of mind regarding the theories of disease and healthcare, and by the libertarian political ideology which caused him to see all forms of behavior modification as an encroachment on freedom. By tireless effort he established a solid, but not popular, beachhead position against mainstream psychiatry and its role in the legal/medical complex.

I was not a close student of Szasz, but, though I did not admire his politics, I greatly admired his insistence on clear thinking and on holding medicine accountable for what it does to people. His death is a loss to a profession that needed his intelligence and keen critical eye.

A short overview of his career and ideology can be found here; a more detailed, and fascinating, report of Szasz’s early experiences in psychiatry and the development of his ideology is here. My own review of one of his books can be found here.

June 1, 2012

This is Why We Can’t Have Nice Things

by @ 2:19 PM. Filed under General, Meta

So apparently there’s a new trend in spamming: paying wage-slaves who, apparently, couldn’t find a job gold farming in WoW to cruise blogs and hand-type vaguely relevant but meaningless comments with embedded links to spam client sites. The comments are coherent enough that they evade spam filters like Akismet, and the workers are cheap enough that this, apparently, is a profitable form of parasitism.

I’ve just deleted a couple of dozen comment spams of this type, and presumably the problem will only get worse. At some point I may have to implement Captcha or another form of verification. Sorry for the inconvenience, but sleaze rises to the top, and never slows down.

February 1, 2012

Susan G. Komen Foundation: Cowardice and Hypocrisy

by @ 4:46 PM. Filed under Access to Healthcare, Autonomy, Disability Issues, General, Global/Community Health, Healthcare Politics, Provider Roles, Reproductive Ethics, Women's Issues

You’d think one of the most high-profile women’s health organizations in the country would steer clear of misogynist religious-right campaigns to curtail woman-centered healthcare. You’d be wrong.

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January 21, 2012

Ah, Schwyzer. Ah, (Masculine) Humanity.

by @ 9:09 PM. Filed under General, Theory, Women's Issues

I’ve been hesitant to say anything about the Hugo Schwyzer situation.  It’s so contentious, so continually-on-the-boil, and so tedious.  It also brings up a lot of difficult issues regarding the place of allies in liberation movements, and white men particularly, that I feel I need to come to better terms with before commenting. But I find my reactions to it call into question my own understanding of myself as a male feminist, and what I expect or perceive of my place – such as it is – in that movement, and that creates an entirely different can of worms for me.

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December 4, 2011

When Do You Still Count as Human?

by @ 10:16 AM. Filed under Autonomy, Disability Issues, General, Healthcare Politics, Theory

Here’s a really great snippet from “An Examined Life” (which see). Renowned philosopher Judith Butler takes a walk with Sunaura Taylor, talking about the reality of disability and the ways physical impairment is perceived, and disability realized, by society. (One thing that was revelatory for me: Taylor refers to the city of San Francisco as “the most accessible place in the world”. I grew up near San Francisco and, while it’s an incredibly wonderful place, I’ve always regarded it as challenging; the hills and traffic, and narrow sidewalks, would have made me guess it would be one of the most difficult places to use a wheelchair. But Taylor notes that it has extensive curb cuts, good wheelchair-accessible public transportation, and a community that recognizes disability and welcomes people with impairments. This is telling testimony to the overriding importance of social context, rather than actual physical environment, to the reality of disability.)

This video is great in so many ways: Taylor’s discussion of the ways society makes her life with an impairment harder or easier; her description of the psychological burden in going into a coffee shop and ordering coffee, and then having to deal with the difficulties of either trying to carry it herself or asking for help – “it’s a political protest for me to go in”; the simple and lovely depiction of two affectionate people being out together, while not pretending the issue of disability doesn’t affect them; the segment in which they go into a used-clothing store (which charges by the pound! – I love San Francisco!) and buy Taylor a warm sweater, which is both a perfectly simple and normal act, and complicated by the ways impairment affects her ability to try it on and the process of payment – ending with the store clerk’s matter-of-factly accommodating reaction. Taylor works in a useful bit of disability-theory: the distinction between “impairment” (physical limitations) and “disability” (difficulties in living caused by social context or discrimination), and the video underscores that point again and again as Taylor goes about her day and talks about how disability affects her. (I’m not sure I’d go so far as to say that she has “what the medical world has labeled as arthrogryphosis”. I’m very much sympathetic to the notion of individualized definitions of disease and health, but I don’t think that means there’s no such thing as a diagnosible condition. I see no reason to say that she doesn’t really have arthrogryphosis if she meets the diagnostic criteria for it – as, by her own description, she seems to do. Pointedly repudiating her own use of that name, as she does in the video, doesn’t seem to me to gain anything; whether she wants to call it a “disease” is another matter.) There are also brilliant moments of reflection on the nature of embodiment and what it means to live an embodied life in a social context.

Just a beautiful, sweet film with surprisingly profound content, visually and verbally. I can’t wait to see the rest of this series.

Taylor:     When do you still count as a human?

Butler:     My sense is that what’s at stake here is really rethinking the human as a site of interdependency.

. . .

Butler:     [When] you ask for the coffee, or indeed even ask for some assistance with the coffee, you’re basically posing the question “Do we or do we not help each other with basic needs?”

 

HT: sexgenderbody

October 20, 2011

Patriarchal Progressives

by @ 5:09 PM. Filed under Autonomy, General, LGBTQ Issues, Personhood, Sex, Theory, Women's Issues

Jill Filipovic, at Feministe, has a great post up on objectification of women within liberal activist circles. It was prompted by the much-commented assholery of one Steven Greenstreet, who took video footage of female demonstrators at OWS protests and put it up on Tumblr, out of context and with no purpose other than inviting leering at the “Hot Chicks of Occupy Wall Street”.

Jill righteously calls him out for it (as did many others):

The deflecting from legitimate concerns, and the fact that the OWS “public” includes a lot of men who think it’s ok to treat women at a protest like we’re there for their visual fulfillment, troubles me. No one is saying, “Don’t find women attractive.” . . . No one is objecting to the fact that straight men are attracted to some women (fun fact: straight women are also attracted to some men! So really, no one is pissed about attraction, I promise). What people are pissed about is what Rebecca Traister says:

“The larger, simpler argument, outside of consent or permission, is: This video is sexist. It’s an example of women participating in public life — political, professional, social — and having their participation reduced to sexual objectification. That’s what happened here, nothing more, nothing less.” . . .

Emphasis mine. . . . [C]reating a blog and a video dedicated to showing women at a protest with the sole purpose of reminding dudes that women at the protest are hot? That does reduce women to objects of male attention. It’s another reminder, for women, that how seriously we’re taken and how valuable we are depends on how sexually attractive we’re deemed.

Read the whole thing; she’s got good things to say. But the part that really triggered something for me was this:

Frankly, the kinds of dudes who would come to the OWS protests because they heard there are hot chicks there? Are not the kinds of dudes I want to be protesting with. I would hope they’re not the kinds of dudes that most progressives would want to be protesting with — but judging by the lefty-dude reaction to Steven Greenstreet (hi Matt Zoller Seitz, looking at you!), that’s not the case. It’s disappointing.

To say the least. And far too common, from way back. It’s no secret that supposedly “progressive” groups have always been rife with sexism and sexual pressuring, and it doesn’t seem to be getting better. Progressives have never been immune to human failings, including stereotyping and bigotry of the kind that they supposedly abhor but sometimes don’t recognize in themselves; the long fight for acceptance in progressive movements of gays and transexuals is one case in point, and the difficulty many white (and especially male heterosexual) liberals have in recognizing and acknowledging their own privilege is another. But the LGBTQ community, people of color, and other marginalized groups, though still embattled, have by now to a considerable degree been granted by progressives the one thing many persist in denying to women: recognition of the fact that they have real interests, problems, and worth that must be taken seriously. The situation is far from perfect, and not everybody agrees on how the tensions between different progressive constituencies should be resolved, but in most cases they are acknowledged, and the human pain and human interests that lie at their heart are given due deference. Except in the case of women.

To be sure, progressives are not right-wingers. They don’t overtly hate women. They don’t gleefully consign them to death by deliberate neglect at the hands of sniffy sex-negative religious bigots. They don’t dishonestly and cynically strain moral concepts – often ones introduced and championed by progressives – such as “informed consent” to create barriers to the very autonomy they are intended to protect. They don’t penalize the fact of women’s having sexual natures – just the opposite! But in too many cases they don’t grant them the respect and freedom needed to act on their own natures and seek their own good. Just as with conservatives, women exist for far too many progressive men for the purpose of their gratification – an impersonal usage that erases those women as persons themselves.

Which leads me, finally, to the question that came up for me on surveying this latest stupid and distasteful incident: how, exactly, are these dipshit “progressive” men progressives? What goes through their heads, what process takes place in their heads, such that they wind up thinking things like “let’s go to the OWS protest and photograph women’s breasts!”? How, when they are called out for that, do they expend so much energy defending their childishness and sexism? Why do they not care about offending or humiliating their supposed fellow activists – about derailing or undermining the movement they claim to support – about embarrassing that movement by acting in a regressive manner and then elevating their own bad behavior into the limelight? More particularly, what is it that allows progressives to empathize with everyone but women, even women in their own movement? What allows them to hear everyone else’s protests at mistreatment, and dismiss those of women out of hand?

In a way, I suppose it has something in common with the denial and self-absorption that allowed Southern slave-holders to rationalize their own crimes. Patriarchy is its own form of slavery, more complex and less overt, but very real, and it is very hard to acknowledge you are doing wrong when your entire lifestyle, all its comforts and conveniences and pleasures, derives so much from others’ service to your needs. It is easy to protest obvious wrongs that don’t require you to change your own life to amend. But progressive men, in many cases, are no better than the privileged classes of the Confederacy, of apartheid South Africa, of Wall Street itself, at admitting that their own satisfaction depends on bending others to their desires, against their will and at the denial of their basic human personhood.

You can’t be progressive just for causes you aren’t invested in, at the expense of people you don’t like. Being progressive means wanting to live in a better world – not just wanting to take down the most guilty in this one and then carry on regardless. Being progressive means checking your privilege, living the dream you envision, being part of the solution – all slogans that have at their heart the basic truth that you have to be as critical of yourself as you are of others, or more so, since you can only really change yourself.

You aren’t a progressive if you mistreat women. You aren’t a progressive if you think progressivism is defined as rallies, protests, and events, rather than a mindset that is grounded on a world in which people are treated with respect, by everyone, starting with yourself. You aren’t a progressive if you go to events but don’t treat the people there with regard. You aren’t a progressive if you revel in your own privileges at the expense of the pain and diminishment of others, then feel hurt because you’ve decided that whatever superficial support you feel for “the cause” entitles you to use others for your pleasure and then resent it when they object.

If you’re not a progressive for any of these reasons, you’re little better than a reactionary even if you vote the right way. You’re pro-choice? Great. You don’t think being pro-choice encompasses the choice to control, and present, your own sexuality on your own terms? You’re not a progressive, and you’re a pain and an embarrassment to those who sincerely try to be.

October 1, 2011

Complexities of Transexual Procedures, and of Progressive Healthcare

by @ 7:35 PM. Filed under Access to Healthcare, Autonomy, Biotechnology, General, Healthcare Politics, LGBTQ Issues, Medical Science, Provider Roles, Theory, Women's Issues

There’s a great post up at Skepchick, discussing a supposed regimen for “natural” transexual procedures for female-to-male transitioning. Debbie Goddard (@DebGod) responded to a question from a writer who was approaching the FTM transition but was uncertain about surgery and hormone therapy, and had heard about a program of exercise and “natural” supplements similar to that used by “natural bodybuilders”. DebGod’s response and the discussion that ensued fascinated me. I encourage people to read it; then I’ll have some comments to make.

What got me onto this is that there’s just so much cool stuff in this post and the comments thread. I don’t have anything to say about the basic question of natural transitioning, but I want to point out several things that come up in the discussion.

First, it’s interesting that this post arose on a skeptic (i.e., atheist, anti-paranormal) site in the first place. Transexuality isn’t inherently an issue for skeptics, but the questioner identified as a skeptic and was apparently feeling vulnerable as both a transexual and a skeptic, so sought out a welcoming community. He found the right place: DebGod happens to be gender-queer, and is knowledgeable about transexuality and a former bodybuilder, and the community of readers was supportive. From some of the comments, it appears that many perceive the skeptical community as not uniformly welcoming for LGBTQ people – something I hadn’t known or expected. This post included some interesting discussion of LGBTQ issues among skeptics, and raises questions that – especially in light of the recent conflict over misogyny among skeptics (notably involving another prominent Skepchick poster) – I hope the skeptical community will take the opportunity to address.

More importantly, DebGod’s response is a model of careful and helpful analysis. She gives her own background, with appropriate disclaimers, then lays out the issues clearly and concisely. She notes red flags with the claims being made (no professional credentials, buzzwords, trademarked terminology, skeptical responses from people directly affected). She then reviews the suggested procedure, notes that it relies heavily on biochemical supplements, comments intelligently on their purity and efficacy, and discusses the vague distinction between “natural” and “non-natural” that the promoters take advantage of. She seeks information from a more knowledgeable source. Shen then concludes by running down all the issues this analysis raises, categorically, giving pros and cons for each and pointing out dangers. This is a really well-done, intelligent, well-argued analysis, at least as good as that commonly seen from Quackwatch or prominent skeptics like PZ Myers.

What I really like about DebGod’s analysis is that she is carefully value-neutral in all of this. Though it’s clear that there is much to be worried about in this suggested regimen, she never takes it on herself to make other people’s decisions for them. Her final statement is a clear and balanced sketch of the relationship between all the competing factors – health, personal goals, available support, and insurance or income – that influence a decision among the many different options for transitioning; she doesn’t declare any of them right or wrong for any individual, but makes it clear that each may be better or worse under different conditions. She includes just a single sentence offering her opinion that the “natural” process is too risky and low-benefit, but clearly identifies it as her own perspective and doesn’t insist that anyone else has to adopt it. She really gets her role as guide and analyst, as opposed to parent, judge, or dictator – something that so many culture-critic blowhards, and even many licensed professionals, can’t accept.

As she notes:

When it comes to gender identity and transsexualism, where you want to go, who you want to be, and how you want to do it is up to you, of course.

- a message that needs to be heard more widely, and not just regarding transexualism.

That leads to another issue that comes up obliquely, but importantly, in the comments. The medical community’s response to transexualism has been mixed, in ways that have generated a lot of resentment in the T/Q community even when the doctors and psychologists thought they were being helpful. For many years, transexuals seeking medical treatment in the US were commonly required to conform to the so-called “Harry Benjamin Standards of Care” (now the “World Professional Association for Transgender Health Standards of Care”), requiring extensive counseling and explicit authorization from multiple psychologists, and a set period of pre-treatment life in the transitioned gender, before professionals would agree to provide the requested treatment. Those standards have been eased but still exist. Many critics have pointed out that this is not only paternalistic but unnecessary – transexual patients have a higher level of success and satisfaction with their treatment than patients of many other conditions, including cosmetic procedures, that do not involve such heavy-handed gatekeeping. The professional societies – starting in the 1950s, when this work was extremely controversial – saw themselves as protecting patients and preventing harmful mistakes, while also going to lengths to provide treatments that more conservative caregivers would have prohibited in the first place. Patients, however, saw it as condescending, offensive, and wasteful of time and money. (Note that in other parts of the world, clinical standards for transexual therapy are much looser or non-existent; there is no known epidemic of regretful genderflippers.)

There are some very interesting comments from “natalie1984″ noting that the sex-reassignment gatekeeping system has been eroded in recent years, and along with it the stereotyped view of what it means to “really” be transexual or gender-dysphoric in the first place. Not only has therapy become more accessible, but what kind of therapy and what therapeutic endpoint the patient seeks have also been thrown open. As she notes: “Now we’re all able to simply work out for ourselves who we are and what we want from transition, and what will make us feel happiest”. She speaks with understanding of why many healthcare professionals are not current on T/Q issues, and simply encourages patients to find caregivers they are comfortable with. There’s also an interesting exchange further down the thread between her and one of the promoters of the natural therapy. She comes across as uncompromising but smart, thoughtful, and understanding.

There’s more, including the politics of gendered pronouns, but even just this adds up to a rich and complex discussion, with intersections between skepticism, healthcare autonomy, gender issues, and, vaguely, perhaps some philosophy-of-science stuff. What this post brings up for me is the deeply connected ways in which such issues always do surface in any similar debates over the proper application of facts to values – that is, the use of science or medicine to achieve chosen goals in human lives, and the conflicts that arise between those who control the science and those whose goals are at stake. It is common in ethics and philosophy of science to emphasize the “fact/value distinction”, but real cases often dredge up facts – and perceived facts – from many aspects of our lives, and competing values that arise from very different lived perspectives.

In this one issue, the skeptical community provides a useful mindset for analyzing clinical claims, but has also been charged with hostility to the LGBTQ community in whose interests those questions are asked. The “natural health” community offers the autonomy and self-direction that many patients want, but also harbors liars and scammers. The doctors who invented the sex-assignment gatekeeping system that so many transexual people hate did so as a way to make it possible for those patients to get care than had never previously been available. It is impossible for anyone to assert an exclusive claim to the moral or epistemological high ground here.

This stuff is hard, and, like so many progressive programs, requires a dedication to working through all the implications of a given position, and to striving to make one’s positions more defensible, more responsive, and more accepting. Every one of these communities – the skeptics, the healthcare professionals, the alternative-health promoters, and to some degree the LGBTQ population as well – have work to do in that way. Some of it has been done, though, and some of it is being done now, over at Skepchick. Good start.

August 26, 2011

The War on Women: Reality Optional

by @ 3:21 PM. Filed under Access to Healthcare, Autonomy, Child-Rearing, General, Global/Community Health, Healthcare Politics, Personhood, Reproductive Ethics, Sex, Theory, Women's Issues

Rick Santorum – humiliated in his last electoral bid, and trailing badly in the GOP primary polls – knows he needs to keep saying outrageous things to keep himself in the public eye. Plus which, he’s crazy, so saying outrageous things is never difficult for him.

He’s been in the news lately for making bizarre comparisons of gay marriage to beer, a cup of tea, and a paper napkin – all predicated upon the rather obvious but undeniable point that “it is what it is. Right? You can call it whatever you want, but it doesn’t change the character of what it is”. This is a claim on which Santorum congratulates himself by describing it as “sort of metaphysical”, but might otherwise be categorized as “sort of idiotic”. Apparently it means something to him, though, because he keeps saying it – most recently in a just-posted interview on the Iowa Independent Website: “It’s like going out and saying, ‘That tree is a car.’ Well, the tree’s not a car. A tree’s a tree. Marriage is marriage.” He goes on to spew a frothy mixture of crazy in a wide arc: gay marriage “minimizes what that bond means to society” (by letting people . . . form that bond . . .); “you’re gonna undermine religious liberty in this country” (his examples consist exclusively of the liberty to prevent other people from doing things); “we’ve created something that is not what it is” (so much for the tautological metaphysics).

But there’s a particular moment in the interview I want to highlight, because it captures so perfectly the ideological dishonesty, and complete divorce from reality, of the right-wing, and particularly the anti-choice movement.

If your position on abortion prevails and abortion is prohibited, Senator, what should the penalty be for a woman who obtains an abortion or a doctor who performs one?

Santorum: I don’t think there should be criminal penalties for a woman who obtains an abortion. I see women in this case as a victim. I see the person who is performing the abortion as doing the illegal act

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August 9, 2011

Abortion Funding Assistance for Women in Need

by @ 3:49 PM. Filed under Access to Healthcare, Autonomy, General, Healthcare Politics, Reproductive Ethics, Sex, Women's Issues

From “Fund Abortion Now“, the blog of the National Network of Abortion Funds – non-profits that provide financial assistance to women in need of an abortion – comes this list of funding sources by state:

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June 5, 2011

Oy . . . Such Putzes

by @ 1:44 AM. Filed under Autonomy, Child-Rearing, General, Provider Roles, Reproductive Ethics, Sex

This has been getting a fair amount of commentary, and rightly so. There is a citizen-petition initiative on the ballot for the City of San Francisco, this coming November, banning circumcision of male minors except in cases of medical necessity. It is modeled on a similar ban on female genital mutilation already enacted into federal law. It adopts language in the federal FGM law specifically excluding religious beliefs or “ritual” as grounds for exception.

It’s not an unreasonable law, and I think it’s something that probably ought to be done though I have the impression that the issue is overblown from both sides. It’s also obvious that the law would most directly impact Jews (and adherents of some the other smaller faiths,  including some branches of Islam); the largest number of parents choosing circumcision in American are Christian, but they don’t make a religion out of it. (Ha! Haha!) But the debate over “male genital mutilation” – while pretty crazed at times – has mostly not had a religious focus; there are good non-religious reasons to oppose circumcision, and some non-religious reasons to favor it, and both argunents have been beaten to death by combatants on this subject without making it a religious war (other than to the extent that some people support circumcision for religious reasons).

But the group in San Diego that wrote the bill coming up for vote, and pushed the signature campaign that got it on the ballot, somehow stepped on a banana peel just recently, and threw the whole issue down a steep and bumpy flight of steps to an ugly landing (if you’ll excuse an increasingly awkward metaphor). The group has generally followed the “I mourn my penis” line in its “intactivist” crusade for prepuce justice, but for reasons that are hard to comprehend it recently came out with this:

Monster Mohel

This is a page from their “Monster Mohel” comic book, issued in support of their ballot initiative. The comic features a blond, muscular superhero – “Foreskinman” – who bursts in on a group of Orthodox Jews conducting a bris on a struggling boy. The villain – “Monster Mohel” – and his evil minyans (Ha! Haha!*) are wild-eyed, scraggly-haired, and grinning psychotically; one of them holds the child’s terrified mother by force while they cut her baby boy. Just to top off the Jews-as-freaks theme, the mohel gibbers about a “sacrifice to God” while brandishing scissors over the boy’s crotch, and also gushes praise for “the metzitzah b’peh for [sic] which I am about to partake” (the latter being a rare version of the circumcision ritual in which the mohel cleans the penis of blood by sucking it).

So: Jews as savages, religious nuts, and perverts, and their religious rites as violent and forcible; the anti-circumcision types as strong, Aryan, saviors rescuing children stolen from their mothers for bloody Jewish religious rituals. Hmmmm . . . never heard of anything like that before.

Not surprisingly, this has gotten a lot of criticism as anti-Semitic, and many commentators, especially on the right wing, have gone on from there to state categorically that the entire anti-circumcision bill is an exercise in anti-Semitism, and the “MGM” activism movement is just anti-Semitism in disguise.

That seems to me no more than another example of right-wing logical failure. (Are anti-Semites really that hung up on Jewish penises? And would they really go to the extent of funding and promoting years of agitation, and multiple state ballot initiatives, on an issue that makes them sound like cranks while affecting over 90% non-Jews? As far as I’m aware, even Nazis didn’t ban circumcision.) Through some bizarre twist of religio-political fate, the political movement that was forever railroading Jews on false charges and banning them from colleges and country clubs has in recent years decided that Jews are their special project (i.e., a convenient hammer in the Middle East to use against Muslims, and tied up in some loony way with Rapture prophecies – which also foretell the murder or forcible religious conversion of those same Jews, but that part doesn’t get mentioned). So finding an initiative they regard as left-wing that also has anti-Semitic elements is a welcome opportunity for them to paint the left wing as anti-Semitic. Between the fact that there’s nothing leftist about the “MGM” movement (except insofar as it’s anti-traditionalist and anti-religious, so clearly not rightist – but most liberals aren’t het up about foreskins and there’s nothing about them that is particularly associated with liberalism) and that tiresomely familiar hasty-generalization thing, the whole argument just makes no sense to begin with. The fact that one argument against circumcision is anti-Semitic, or even that some opponents of circumcision may be anti-Semitic, doesn’t mean that opposing circumcision is in itself anti-Semitic, especially when, again, Jews are only a tiny percentage of the people in the US who practice infant circumcision. Besides,  if we’re going to ban an entire policy because some of its supporters did something stupidly offensive, there would simply be no right-wing policies at all, so this is an argument form they really don’t want to be throwing around lightly.

But the weird thing about this is that the group forwarding the bill is not, seemingly, anti-Semitic. Their Web site is for the most part filled with the standard kinds of information and arguments about circumcision that you find among most supporters of this movement; religious issues are hardly touched upon and not, where I’ve seen, in an offensive way. The comic book is just absurdly divergent – in tone it’s completely incompatible with the rest of their work, and in content it has nothing to do with the actual substance of the group’s issue. It’s hard to believe it comes from the same group as is running the “MGM Bill” Web site. It may have been an attempt to address the strongest source of the religious-tradition argument for circumcision, that simply came out stupid-bad. Even though it’s hard to believe this sort of thing could have been dreamed up, proposed, produced, and approved without someone raising a flag, still, things do fall through the cracks. I can believe that something this messed up could emerge from a group that does not have overt or overriding anti-Jewish sentiments, in the same sense that I can believe Michael Richard didn’t intend to sound like a racist dick in his infamous comedy-club meltdown incident – sometimes you lose sight of what you’re trying to do, and . . . well, shit happens. It’s a very weak argument to claim that “they’re not anti-Semitic except for the unbelievably offensive anti-Semitic stereotypes in the major publication they just issued”, but, even so, for the reasons given above I think it’s believable in this case that this was an aberration more than a real statement of their policy.

But whatever its genesis, there’s no question that the publication, deliberately or not, is unmistakably anti-Semitic, and trades in ugly and ridiculous stereotypes. (I have to say I do like Foreskinman’s superhero logo, though: a round knob with a slit at the tip, flanked by a thin spreading collar coming up around the sides . . . use your imagination.) For an issue that has plenty of reasonable arguments on its side, including counter-arguments to religion-based adherence to tradition, this is stupid, divisive, offensive, and counterproductive. This really isn’t helping their movement – in fact, it may well kill it in California before the vote is taken – and causes real harm to many people, irrespective of their stance on the circumcision issue. Bad move, and their dismissive reaction to the first complaints made it worse. The MGM people need to start taking stock, and taking responsibility, soon.

 

* Yes, I stole that one.

June 4, 2011

Religious Right Victory: Child Rape and Paternity Rights for Rapist

by @ 4:41 PM. Filed under Access to Healthcare, Autonomy, Child-Rearing, General, Global/Community Health, Healthcare Politics, Provider Roles, Reproductive Ethics, Sex, Women's Issues

I missed this story when it first came out: a 10-year-old girl in Mexico became pregnant after being raped by her step-father. Abortion is legal with restrictions in Mexico City, but hardly at all outside the capital. In most areas of Mexico, including where this girl lives, abortion is illegal at any time beginning with conception; in her state there is a “rape exception” good only for the first 90 days of pregnancy. The girl is being held outside her home, in a state child-care facility, and it appears she or her mother were not even informed of the existence of even this limited right to abortion. Now it is long past time for that option, and of course there is no hope of her traveling to some state or country where she could get care at this date. It appears that she has no hope but undergo a full-term pregnancy against her will, and give birth, at the age of 10, to her rapist step-father’s child.

Note that these abortion laws: forced pregnancy from the time of conception (not the beginning of pregnancy itself); limited or no exceptions for cases of rape or incest; refusal of authorities to assist in obtaining abortion even when it is legal; state coercion and withholding of truthful information to manipulate women and girls out of exercising their legal right of choice; and general hostility to choice in all its forms, and collusion of state officials to impose forced pregnancy outside the bounds of the law, with impunity – are exactly the policies promoted and supported by the religious right in the United States. In Mexico, where the Catholic Church has much greater social and political power, they have been enacted and are in force.

So if you want to know what it looks like to live in the kind of country envisioned by “pro-life” forces in the US (though with a bit less Catholicism), this is exactly what it is: 10-year-old girls raped and subject to incest held in a locked ward by the state to force them to bear the child of their rapist, with virtually no legal rights to make their own choice in the matter, and what little legal rights they do have systematically withheld from them by force and deception, by the state itself. Every aspect of this case has been managed in such a way as to ensure that this girl – note again, 10 years old – is forced to do what the religious right and the culture of patriarchy have chosen for her life and her body: bear children under force and duress, through rape and incest, while held under guard as her rights and her body itself slip away from her control. Once more, these are exactly the laws the US religious right is campaigning for; this is exactly what they want and will get.

Let me make one final point: Recall again that it is the Mexican law that prescribes forced pregnancy for child-rape victims in that country. It is the Mexican Police who are holding this girl to prevent her from exercising the limited rights the law grants her. If she had come to a US Planned Parenthood clinic needing help in this case, she could have gotten an abortion; the US religious right demands that Planned Parenthood turn her over to the police. It is one of their main complaints against PP: that they provide healthcare on demand, rather than violating confidentiality and turning rape victims over to the state – and their families, which may include the rapists themselves. PP trusts women – even girls – to know whether they are willing to be pregnant or not; the religious right demands that they do so.

For Planned Parenthood, what a rape victim deserves is the power and the right to reclaim control of her body. For the religious right, what a rape victim deserves is to bear the rapist’s child. And the younger the better, apparently. They got what they wanted in this case. And they’re coming for more.

May 26, 2011

Ugly Grandstanding on Abortion (. . . Again . . .)

by @ 7:25 PM. Filed under Access to Healthcare, Autonomy, Disability Issues, General, Healthcare Politics, Medical Science, Provider Roles, Reproductive Ethics, Sex, Women's Issues

Today’s news is that an amendment to the Republicans’ medical-residency defunding bill, prohibiting the use of any medical-education funding for “training in the provision of abortions”, was passed in the House by an overwhelmingly partisan vote. The event is not of great practical significance: this amendment is very unlikely to emerge from the Senate, and the bill is almost certain to be vetoed anyway. But it marks yet another front in the right wing’s ceaseless war on women’s healthcare, and yet another point-scoring display of how reckless – or simply antagonistic – they are willing to be with women’s lives.

The amendment is odd, though, and uglier even than it seems. It is so vaguely written that it is hard to figure out just how it would work if it were enacted, but its most likely interpretation would be literally deadly. It also extends the odious “conscience clause” for neglect of patients to every health plan, contract facility, professional group, doctor, nurse, or other staffmember at every medical school and teaching hospital in the nation, through a single sentence in this seemingly minor funding provision regarding training for one specific type of care.

The text of the amendment is here (scroll down). Recall this is an add-on to a larger bill; the parent bill seeks to defund all residency-level training in hospitals and medical schools nationwide, to force a new budget fight for training subsidies every year thereafter, rather than allowing block funding with less meddling. That bill by itself is part of the Republican assault on mainstream medicine – this proposed amendment is just a little anti-choice icing on the cake:

(d) Prohibition Against Abortion.–Section 340H of the Public Health Service Act (42 U.S.C. 256h) is amended by adding at the end the following new subsection:

“(k) Prohibition Against Abortion.–

“(1) None of the funds made available pursuant to subsection (g) shall be used to provide any abortion or training in the provision of abortions.

“(2) Paragraph (1) shall not apply to an abortion–

“(A) if the pregnancy is the result of an act of rape or incest; or

“(B) in the case where a woman suffers from a physical disorder, physical injury, or physical illness, that would, as certified by a physician, place the woman in danger of death unless an abortion is performed including a life endangering physical condition caused by or arising from the pregnancy itself.

“(3) None of the funds made available pursuant to subsection (g) may be provided to a qualified teaching health center if such center subjects any institutional or individual health care entity to discrimination on the basis that the health care entity does not provide, pay for, provide coverage of, or refer for abortions.

“(4) In this subsection, the term `health care entity’ includes an individual physician or other health care professional, a hospital, a provider-sponsored organization, a health maintenance organization, a health insurance plan, or any other kind of health care facility, organization, or plan.”

 

The Meaning – Such As It Is – of the Amendment

The amendment is so badly worded that it’s not clear what it actually does. Section (k)(1) – the central defunding provision – prohibits any residency training money from being “used to provide any abortion or training in the provision of abortion”, but this is far from self-explanatory.

The first part is confused: the funding in question (defined by the parent bill, HR1216, which addresses “funding for graduate medical education in qualified teaching health centers”)  is for post-graduate medical education (i.e., medical residency programs or the equivalent), not actual clinical care, and the infamous “Hyde Amendment” prohibits federal money for abortion care in the first place, so the “provide any abortion” provision here would seem to be superfluous at best.

The real issue – and the way the amendment has been packaged – is the denial of funding to train residents in abortion techniques, with an eye toward making abortion unobtainable by flooding the country with surgeons and OB-GYNs who are simply incompetent to provide this standard care. Since almost all residency training takes place in facilities receiving federal subsidies, this provision, if enacted, would mean the coming generations of doctors would receive no training at all in central aspects of women’s healthcare. (It might be possible to obtain such training at the resident’s own expense, but it’s not clear where that would even be possible, since this amendment would restrict almost all centers even capable of providing the training regardless of who paid for it. The only realistic alternative would be to go overseas – again, at the doctor’s own expense – and even that would not necessarily be availing, because it raises licensing questions and is not a practical option for all residents, even the ones who were willing to go to such lengths.) This is not a new tactic on the anti-choice right wing; at one point, Georgetown University’s Medical Center attempted to ban its GYN residents from obtaining abortion training anywhere, even on their own outside the program – and this when such training was still funded. But making it mandatory, inescapable, and nation-wide, is a step never before taken.

But it also seems that much of the intended impact of the amendment could be escapable. Here, the strange wording of the amendment provides a paradoxical loophole. Section (k)(2) allows exceptions for “an abortion . . . ” involving the usual grudging set of special horrors (rape, incest, death*) that some of the right wing are willing to overlook. But, again, notwithstanding the wording of the amendment, there is no funding addressed by this amendment or its parent bill that would “provide an abortion” under such conditions, since it does not provide funding for clinical care in the first place. So these exemptions for “an abortion”, if they do anything at all, must modify the prohibition on “training in the provision of abortions” – that is, Section (k)(2) apparently grants exemptions for federal funding for “training in the provision of an abortion . . .” in pregnancies involving rape, incest, or the threat of death. But of course all techniques used in abortion may be used in cases involving these exempted situations – so presumably federally-funded health centers can provide any kind of appropriate “training in the provision of abortions” for pregnancies involving rape, incest, or the threat of death - after which it’s the doctors’ own concern how they actually put that training to use!

At least, that’s how it reads, in strict logical terms. That may not be how it would be implemented, however. It’s clear from the legislative history of the amendment – the discussion on the floor before it was voted on – that, regardless of the grammatical deficiencies of its author, it was in fact intended to prohibit all training in abortion techniques.† Probably the courts would interpret it that way, even if that’s not what it says. So in practice the impact of the amendment is (a) to prohibit (with few exceptions) all abortions provided using medical-residency training funds – a category which does not exist, and (b) to prohibit all training in all methods of abortion regardless of likely application.

 

Scope of Ban

The result of all this, as noted, would be to permanently exclude competency in certain standard professional practices from the skill set of all US-trained physicians in all specialties, even including surgery, obstetrics, and gynecology. The skills in question, it should be noted, would almost certainly include, among others, the following methods most commonly used in pregnancy termination:

However, every one of those techniques is used for purposes other than abortion (most commonly, to remove dead tissue left by menstrual troubles, fetal death or an incomplete miscarriage). As noted above, the strict text of the amendment allows training in “abortion” techniques if it is not intended to facilitate abortion, but that’s obviously not what the author hoped for, so presumably it must be interpreted to include any technique that could be used in abortion, regardless of its common application. That would also include:

 

Impact of Ban

What would it mean if doctors were banned from all training in those techniques, for all purposes? Well, among much other harm, it would mean that any woman would face almost certain death from any of the following conditions, for which one the above techniques is the standard treatment:

It would also mean that women would have no access to standard or best practices under any of the following conditions, among others, because those treatments involve techniques that could be used in abortion:

And of course there’s the whole conspiracy-of-silence-about-birth-control thing (see ‡ below).

In short, this ban – if it were enacted and if it were implemented as intended, and as anticipated by its legislative history – would kill even more women in the US, in coming years, than are currently sacrificed every year from the current lack of abortion providers. We would see a return to death from emergencies in childbirth – even for women not seeking elective abortion – at levels equivalent to that in some Third-World countries (since, given that appropriate care would be banned under this amendment, women facing certain labor-related emergencies would essentially be getting Third-World care even though best-practices-level care could have been provided). Many more would suffer, some greatly, from the lack of access to perfectly ordinary and preferred treatments for conditions having nothing to do with abortion. By making it illegal for physicians in training to obtain the necessary skills to treat a wide range of common gynecological conditions, some of them life-threatening, this amendment simply condemns their future patients to death, permanent disability, and other suffering from conditions for which safe and effective treatments were available, and which are universally practiced in every other advanced nation, but which their US-trained doctors were prohibited from learning.

[NB: I am not a clinician. The information above is common knowledge from widely-available sources. I am confident it is accurate; it is likely incomplete - the full impact of this legislation is likely worse than I have been able to describe. For actual clinical guidance or practical healthcare purposes, be sure to consult a knowledgeable clinician who has a full range of professional skills (i.e., one who was trained at a non-misogynistic healthcare center before this ban was enacted).]

 

Comments

As with so much of Republican “healthcare”, it’s hard to imagine this policy could ever be taken seriously, or enacted in any nation that makes a claim to basic decency. But as so often has been the case in the past, it’s best to be prepared to be surprised by what levels of indecency Republicans are willing to reach.

As I noted, the amendment contains inherent loopholes that its legislative history makes clear were unintentional. It may be possible to circumvent some of its provisions nonetheless, by sequestering training in the relevant techniques to programs ostensibly aimed at other conditions: that is, teach vacuum aspiration as a treatment for dysmenorrhea, teach dilation and extraction as a procedure for removal of a dead fetus after incomplete miscarriage, etc. This could work, but only if the ban were confined to overt training in abortion as such, and not to training in any procedure that could be used for abortion. There is no question how vicious, and how hostile to the lives of women seeking abortion, the supporters of this bill are; it remains to be seen if they are willing to sacrifice innocent breeders, too, in their pursuit of death for rebellious hussies. Virginia Foxx, the sponsor of this amendment, is known for her bizarre and incoherent beliefs; I think it is really likely she just does not understand the implications of her own amendment, and it would not in the end be taken to the extreme of a complete ban on all gynecological surgical methods. Or would it?

At any rate, the stupid and ugly thing is not going to pass. But it is worth considering just how serious its sponsors were, and how far they were willing to go, to kill and punish women who sought control of their reproductive organs, through the medium of their own doctors – how far they were willing to go to make the ignorance that characterizes Republican health and science policy across the board in fact mandatory for those who refuse to adopt their values voluntarily. As in so many cases, denial of knowledge is both the substance of, and a weapon for imposing, the right wing’s values as punishment upon those whose crimes are knowledge and independence.


 

* Note that only death – not merely unendurable pain, permanent disability, or traumatic stress – is grounds for exemption. And, too, the section on the woman’s health repeats the phrases “physical disorder . . . physical injury . . . etc.” four times, making it clear that there is to be no sympathy extended to women whose traumas are psychological, whether or not life-threatening, because that’s not part of your “physical” health. Apparently the people who are convinced there is such a thing as a soul are not convinced there is such a thing as a mind.

† This raises another issue: the technique for “provision of abortions” in the case of medical abortions – RU486 or similar medications – is simply to conduct an appropriate examination and write a prescription. The “techniques” for doing so are used in the treatment of every condition, and the specialized knowledge involved in using this particular medication is trivial to acquire independently. So, again by the strict logical meaning of the text, either hospitals are prohibited from teaching residents even to write prescriptions – unless they argue that techniques that merely could be, but are not intended to be, applied to abortions prohibited by this amendment are therefore not prohibited in their non-abortion contexts. And that – again, if logical consistency means anything – would authorize all abortion techniques, medical or surgical, for the reasons I explained in the preceding paragraph. But these are Republicans we’re talking about.

‡ And of course the anti-choice nuts characteristically go so far as to define mere fertilization as a “pregnancy”, and I have no doubt that the supporters of this amendment would argue that its provisions apply not merely to the prescription of abortion by medication, but also to post-coital medical contraception such as Plan B. But . . . Plan B and its like are essentially equivalent to nothing more than high doses of ordinary prescription birth control, and in fact ordinary birth control pills can be used for that purpose without a separate prescription. So presumably this amendment would also prohibit either training in prescription of oral contraceptives, or at least mentioning the fact that they can be used for morning-after contraception. So far does the absurdity extend, if you take this policy seriously.

May 25, 2011

Doctors Censoring Patients?

by @ 12:02 PM. Filed under Access to Healthcare, Autonomy, General, Healthcare Politics, Provider Roles

Latest really bad idea in the medical marketplace: doctors demanding that patients sign a “mutual privacy agreement” that grants copyright to the doctor of any reviews or commentary the patient may ever publish regarding that doctor – in other words, giving the doctor censorship rights over any evaluations the patient may make of the doctor, such as on doctor-rating Web sites.

Even worse, this agreement is apparently the product of some sort of doctors’ legal service called “Medical Justice”, whose purpose is to  “(1) Deter frivolous malpractice claims; (2) Address unwarranted demands for refunds; (3) Prevent Internet defamation, and (4) Provide proven, successful counterclaim strategies to hold proponents of frivolous suits accountable” – which is to say, intimidate patients in order to give doctors a edge over them in any legal dispute. As Timothy Lee points out in the post linked above, their waiver policy is likely useless, and may be fraudulent: copyright assignment is usually granted in return for compensation, but given the somewhat coercive nature of this agreement (his dentist’s office manager actually threw him out of the office when he objected to it) and the lack of an employment-related justification for the claim on copyright, copyright experts he quotes say the agreement is likely unenforceable; also, the agreement claims to provide the patients with privacy guarantees that go “beyond HIPAA”, but in fact the particular (relatively benign) practices it covers are already banned under HIPAA, meaning the promises made to the patient in the agreement are not only worthless but actually false. But most patients won’t know those things, so the agreement still hampers their rights of expression even if it is unenforceable or even illegal. It gets worse: the agreement requires a “loser pays” financial penalty for any lawsuit (in contrast to standard US practice), making malpractice suits potentially financially ruinous for the patient, especially if the doctor’s insurance firm adopts the strategy of deliberately running up their own bills to create risk to the plaintiff  (see Goals #s 1 and 4 above!); thus it hampers the patient’s ability to seek legal redress in addition to imposing on their rights to seek and share information.

It’s hard to count how many things are wrong with this: creating an abusive caregiver/patient relationship as a pre-requisite to treatment; chilling patient free speech and access to information about caregivers; cynically twisting completely unrelated provisions of copyright law to straitjacket the healthcare treatment environment; inequitable restrictions on patients’ rights and legal remedies for harm; not to mention just plain fraud and deception. What seems most unnerving to me is that such a bizarre and intrusive instrument (signing away your copyright?) has entered the healthcare environment at all.

More and more healthcare becomes just like any other marketplace: primum caveat emptor has become the contemporary Hippocratic credo, and deceptive, misleading, and grossly one-sided terms of service rule every aspect of the treatment process, from privacy to quality of care to access to caregivers to prescription drug availability to the ability to seek compensation for mistreatment. Though this particular “privacy” agreement is abusive in new and strange ways, the erosion of patients’ rights and remedies is far, far gone already. Medical “privacy” now means only that you must sign a form granting your caregiver and your insurance company the legal right to violate your privacy at will; access to treatment is deliberately hampered by adversarial gatekeepers who use your own medical history against you; mandatory arbitration for malpractice, on terms favorable to the insurance company or doctor, is now a common requirement of many health plans. You have no choice but to sign away all these rights, since the ubiquity of their implementation in the for-profit medical industry, and the lack of choices most patients have regarding treatment plans and costs, means even those lucky enough to have access to treatment at all usually have no access to treatment under respectful and empowering terms. What is shocking in this new approach is only how bold and shameless it is. What is sure is that there will be more of that coming.

May 21, 2011

If You’re Disabled, Don’t be Different

by @ 9:02 PM. Filed under Access to Healthcare, Autonomy, Child-Rearing, Disability Issues, General, Healthcare Politics, Theory

So there’s a minor news bubble developing over the situation of Stanley Thornton, the “adult baby” recently profiled on a reality-TV show.Thornton lives an “adult baby” lifestyle – he dresses in baby-type clothes and a diaper, and has a nurse/baby relationship with a live-in friend who acts as a mother figure; she takes care of him and he is dependent on her, and they like it that way. There’s a surprisingly large community of such people, including the usual Internet chat rooms, Web sites, and so on. In addition, Thornton receives Social Security disability payments, due to a reported heart condition as well as taking multiple prescription medications. His caretaker is also on disability, for what reason I don’t know. They are not housebound, but neither is apparently employable; at any rate, neither has held a job in some time.

The problem is that they were incautious enough to go on a National Geographic TV special about “taboo” lifestyles. Senator Tom Coburn saw it and has now pressured the Social Security apparatus to investigate this particular person based on his appearance on the show. His ostensible grounds for complaint are that, from what he saw on the show, he believes Thornton appears to be capable of supporting himself:

Given that Mr. Thornton is able to determine what is appropriate attire and actions in public, drive himself to complete errands, design and custom-make baby furniture to support a 350-pound adult and run an Internet support group, it is possible that he has been improperly collecting disability benefits for a period of time.

The first thing to be said about this is that Coburn seems to have a very strange idea of what “disability” consists in, or what is or is not required to hold down a job. There is nothing about being SSI-eligible that implies you cannot “determine what is appropriate attire and actions in public”, or drive a car or take care of personal needs such as performing errands. And there is a vast gulf between being able to do all or any of that and being able to support yourself in a capitalist economy (to say nothing of one in a years-long recession with close to 10% unemployment). Coburn seems to harbor both a very condescending view of what disability is, and a typically hard-hearted view of what self-reliance requires: the disabled are essentially children, mentally non-competent, cannot even choose their own clothes, and certainly cannot act independently in public, drive, or run errands unsupervised; at the same time, anyone who’s not actually bedridden ought to earn their own living or die trying. Coburn’s worldview seems to be taken from a Dickens novel: spastic lunatics chained to the walls in Bedlam, and starving cripples begging in the streets. In addition, Coburn’s apparent belief that anyone who can cobble up a chair out of 2x4s (I’ve seen pictures of Thornton’s furniture; he’s not exactly Sam Maloof) should be working as a full-time woodcrafter is rather absurd, and the idea that maintaining a Web site imputes the ability to earn a living identifies someone who is clearly struggling to grasp the nature of the intertubes.

But for all its confusion, Coburn’s statement at least seems to focus on the right issue: it’s true that Thornton is not qualified for SSI disability payments unless he is actually disabled and partly or wholly unable to support himself, and it’s not unreasonable to ask whether that is true.  Given that Thornton does offer his furniture plans for sale, and he and his friend apparently also offer a paid sleep-over service catering to other adult babies, he apparently does have some income and there may be a legitimate question about his qualifications for disability. As far as it goes, that’s not an unreasonable question to ask.

What gets me about this is that a senior US Senator took the time to pursue an inquiry against one single individual under a program that accounts for close to $13 Billion per year, or more than 20% of the entire national budget. Does he really think that is a productive use of his time? More to the point, was this really prompted by a suspicion that this one disabled guy might have some illicit sturdy-furniture income he hasn’t been reporting, and Coburn is determined to find out how much that is?

It seems obvious that Coburn focused on this case not because this SSDI recipient has made two or three pieces of exceedingly simple furniture (Coburn’s letter notes that one basic chair took him a year and a half just to design – hardly qualification for gainful employment), but because “his choice to live as an adult baby violates societal norms”, as Coburn himself puts it. In fact, although Coburn’s letter ostensibly focuses on Thornton’s possible ability to hold a job, it repeatedly mentions his lifestyle. More than that, Coburn’s official Senate Web page touts the same letter without a single reference to actual qualifications for disability; instead, it proudly notes that Coburn is “requesting an investigation of how people choosing certain lifestyles – focusing specifically on those who live their lives role-playing as ‘adult babies,’ are able to get taxpayer-funded Social Security Disability Insurance (SSDI)”. In short, Coburn is using his position as ranking Republican on the Senate Sub-Committee on Investigations to bring down the heat on “people choosing certain lifestyles” – for which the issue of possible income on the side is only a convenient pretext. And the crowing and mockery this has already generated on the usual right-wing Web sites can easily be imagined.

It’s hardly worth saying that this is ugly and mean-spirited, or that it makes little sense if taken at face value. Whether or not this person is disabled has nothing to do with how he chooses to dress or what kinds of emotional relationships he values. And the nonsense about driving, running errands, or designing furniture is pathetic as an excuse for a challenge to what is apparently a documented medical disability. Coburn has found someone whose lifestyle he disapproves, and is taking advantage of the fact that it’s unusual and off-putting to many people to harm that person while grandstanding on the issue to promote his anti-social, anti-government ideology.

It’s not like he wouldn’t have been glad to cut anybody else’s Social Security benefits (Coburn has consistently voted against virtually every aspect of Medicare, Medicaid, SCHIP, and other healthcare programs, against the SSI “lockbox”, and in favor of privatizing Social Security). But finding someone in the program he can despise, and then inviting (and getting, in spades, from the right wing) open mockery of that person’s lifestyle as a lever for attacking their health benefits, is a right-wing two-fer: hurting people who aren’t like them, while casting social welfare as unnecessary or a fraud. The message, in political or social terms, is clear enough. But the message for the disabled, and those with alternative lives, is also clear: if you’re disabled, don’t be weird, because it makes you a target; and if you’re weird, don’t expect help if you’re also disabled, because you don’t deserve it.

May 6, 2011

Who Let the Loons Loose?

by @ 11:35 PM. Filed under Access to Healthcare, General, Global/Community Health, Healthcare Politics, Personhood, Sex, Women's Issues

Amanda Marcotte (@AmandaMarcotte) asks on Twitter:

Why oh why is our country in the grips of a sex panic? I just don’t get it.

My response was:

Obama backlash was greenlight for all wingnuts; every hate/fear is now OK, unhidden, synergistic.

I’d like to de-Twitterize and unpack that a bit.

(more…)

May 3, 2011

Ask the Ethicist: Can a Non-Spousal Partner Claim Survivor Benefits?

by @ 2:48 PM. Filed under Ask the Ethicist, Disability Issues, General, Provider Roles

Here’s a post submitted to “Ask the Ethicist” by Christopher:

I am gay and for 20 years, I have had a best friend and mentor who is also gay. Besides regular friendship, I have taken care of him when he’s sick, staying at his house, getting him to the doctor. But we do not live together. There has never been a sexual component to the friendship.

He is getting ready to retire. As part of his retirement package, he can designate a domestic partner to receive a payment of over $150,000 a year after his death. He has asked me if I want to do the paperwork to be his domestic partner. As I said, we do not and have never had a sexual relationship. I do not live with him. Is creating this arrangement unethical?

Thanks, Christopher, for your question. It’s an interesting situation; let’s see what readers have to say about it.

My response is below in comments. Readers: feel free to join the discussion!

(And feel free to post your own questions to “Ask the Ethicist” – see link in top right-hand sidebar!)

April 9, 2011

Demographic Trends are Choices on the Large Scale

by @ 11:55 PM. Filed under Access to Healthcare, Autonomy, Child-Rearing, General, Global/Community Health, Healthcare Politics, Reproductive Ethics, Sex, Women's Issues

Interesting comparison from the US Census Bureau:

Gravida Status - US Women, 1976 & 2004

The percentage of women who reach the end of their fertility with zero or one live-born child almost doubled over a recent 28-year period. The fraction who had 3 or more has been cut in half. These are remarkable trends. The fact that nulligravidity has almost doubled, to nearly 20% of women, is especially striking. Forty years ago, childlessness was almost always a product of circumstances; now, for at least about 10% of women and probably far more, it is a choice (i.e., childlessness has grown by 9% in that time; the maximum rate of biological infertility in 1976 – two years before the first “test tube baby” – was 10.2%, but surely at least some of that childlessness even then was chosen; today’s rate of actual biological infertility is likely lower still, thus, most likely, well under half the current nulligravidity rate of over 19% is due to true infertility, with the rest the product of women’s active decisions not to bear children although they could).

In fact, the shift in total lifetime fertility over this period is markedly toward lower numbers at every level: the category of 4 or more children has declined by the greatest percentage, followed by the category of 3; the fraction of women with exactly 2 children has expanded markedly, but the fraction with just 1 has expanded more, and the fraction with 0 has increased most of all. Comparing the categories shows how pervasive the shift to smaller families has become: not only are more women not having children, but few are having very large families (the percentage of women with 4 or more children has plummeted, almost to the fraction of women who had none at all 40 years ago), and with 2 now being the most common choice, but 1 or 0 (combined) even more popular; essentially, most women who might have had 4 or 5 kids are now having 3 or 2, and those who might have had 3 or 2 are in many cases now having 1 or none. As has been widely reported, the overall fertility rate in the US now is about 2.0 – 2.1, which is just below the replacement rate; it has fluctuated at that level for over a decade and shows no signs of changing. (Hispanic women are the only ethnic group with higher fertility, and that is concentrated largely among recent immigrants.) This also is a choice – one that represents a remarkable shift from 100 years ago, when lifetime fertility was about 4 children per woman.

It’s interesting how sensitive to conditions the total fertility number is as well: within less than a generation, it dropped to about 2 during the Great Depression and through WWII, rose sharply to 3.7 during the Baby Boom, dropped to an all-time low well below 2 in the mid-70s, and has slowly risen to its current stable level just below replacement. Thus, average total fertility is capable of shifting, either up or down, by a factor of 2 in as little as 10 years, and has done so several times in the recent past. Women have always made choices about their fertility, but increasing economic security and more-reliable access to birth control has likely made those choices easier and more authentic. From this perspective, then, the currently stable average total fertility rate of 2 can be regarded as what economists would term a “revealed preference” – a choice women have made when they were free to make their own choices. (Another revealed preference: the percentage of women who remain in the workforce after having children has grown by a factor of almost 2 compared to 1976, and more since before then.)

This has many implications for the United States and the world, in terms of population levels, economic activity, demographic shifts affecting distributions by race, class, and age, and so on. But aside from those often-remarked consequences, what this shift, and its historical roots, tell us, is how far voluntary choices about fertility are part of people’s lives and their strategies for dealing with both reproductive and social opportunities. This shift – which parallels that in other developed countries – demonstrates that fewer children, greater control of reproduction, and greater participation in the external economy and other activities, are the life patterns that women (and their male partners) choose when circumstances allow it. (The only major upsurge in fertility in America in the last century was immediately after WWII, when young men who had been displaced by the war returned and began the reproductive lives that had been delayed for a period of years; the long-term trend has been downwards, and temporary upswings have generally been small.) And this in turn emphasizes how important that freedom is to people’s lives and the goals they hold for them.

The most obvious, and currently salient, lesson to be drawn from this, of course, has to do with the importance of effective and available family planning. Just a day after having narrowly avoided a shutdown of the entire US government over a dispute centered largely on continued funding of Title X – the nation’s only dedicated family-planning healthcare program – and the right-wing attack on reproductive healthcare in general, the recklessness of such policies, and their cost to people’s independence and well-being, can’t be overstated. But there are broader lessons as well: people care about and make active choices about their health and reproductive strategies, in huge numbers, and with surprising subtlety. The economy, demographics, and availability of equitable access to social opportunities such as jobs, education, and employment, have powerful consequences for how people live their lives and use their bodies – and the choices they make in response to circumstances demonstrate that the choices others make under other circumstances are not always free or welcome.

Map of countries by fertility rate

Average Fertility by Country

Given a chance, most women in developed countries around the world will choose to have 3 or fewer – often 2 or fewer – children in their lifetimes, and the rate drops predictably with improving conditions. Most women in non-developed countries, and even in affluent ones before the development of effective and available birth control, had many more (in most of central Africa today, it is an average of 5 – 8 liveborn children per woman, and even more total pregnancies including stillbirths; in Afghanistan it is 7). Clearly those choices were not voluntary for most of those women. They were not voluntary for most women in America less than 100 years – just a few generations – ago. Increased economic affluence and urbanization made having fewer children more desirable, but it was the development and availability of modern birth control that made it possible. To remove that access for some of the population now is not merely to endorse certain lifestyle choices or even to make them possible (women have always been perfectly free to have 4 or more children if they choose); it is to eliminate the choices others might make if they could, and constrain them by economic force to a life most of the country, and most of the world, has chosen to flee. It is to return some of the women of America to the conditions of life of 100 years ago, while the affluent continue the path to greater opportunity that was made possible by the economic and medical advances over that time.

April 7, 2011

Burdensome Enforcement, Equal Protection: Is a Woman’s Freedom as Valuable as a Gun?

by @ 7:02 PM. Filed under Autonomy, General, Healthcare Politics, Reproductive Ethics, Theory, Women's Issues

Interesting tactic in the New York City gun-control fight:

A gun-rights-advocacy group sued Mayor Michael R. Bloomberg on Tuesday, claiming that the city fee for obtaining a home-handgun permit was so excessive that it impinged on the Second Amendment.

The group, the Second Amendment Foundation, based in Bellevue, Wash., is focusing on New York’s fees because, according to the group, the city is one of the few places in the country that requires people to obtain permits to keep guns in their homes.

The city’s fee is $340, plus a $94.25 charge for a fingerprint check. The fee in most other places in the state is $10, according to the foundation. Mr. Bloomberg has long been a staunch supporter of gun control and has made efforts to reduce the traffic in guns into the city through sting operations, lawsuits against gun dealers and other antigun measures.

The city’s fee for obtaining a home gun permit has long been in place.

The suit, filed in federal court, claims that the city’s fee is so exorbitant that it “impermissibly burdens the Second Amendment right to keep and bear arms,” and the suit argues that because city residents are forced to pay more than others, the fee also violates the 14th Amendment’s equal-protection clause.

(Just to be clear: New York City, separate from New York State, requires a permit just to have a gun in one’s own home; the process of obtaining one is deliberately made as burdensome as possible, including high fees and an extensive application and testing process designed to make you fail, as a form of indirect gun control. A completely different and vastly more difficult process is required to obtain a concealed carry license, which is rare in NYC.)

What’s interesting to me about this is not the gun-control issue itself, but the legal approach in this suit: they are claiming that the fact that the state (or the city, acting under authority from the state) has erected restrictive procedures that make it significantly difficult to exercise a right that in fact exists under law should constitutionally invalidate those restrictive procedures. And presumably they’re going to argue that the rationalizations the state offers – that they must review applications for reasons of public safety, that this incurs administrative expenses that must be covered, that the city has the authority to act on its official perception of the public interest against the wishes of the people actually affected, etc. – are obviously disingenuous or at any rate insignificant in view of the basic right of people to exercise freedoms that otherwise exist under law.

This reflects is a seemingly simple principle – people have a right to exercise their rights – that actually has considerable legal repercussions. For the most part, the Supreme Court has not recognized that the government has a positive obligation to ensure that people can act on their legal negative rights (i.e., a right that merely specifies freedoms that other people may not ban), but has not usually gotten into the question whether regulatory procedures that constrain but do not entirely vacate a given legal right are for that reason illegal. It’s a difficult problem; obviously, some regulatory restrictions are necessary in many cases, and equally obviously, that regulatory authority can be used to create insuperable practical barriers in cases where the law does not allow outright bans. But, to my knowledge, the Supreme Court has not held that the mere existence of a barrier is the equivalent of an unconstitutional ban. In fact, the Court has often gone out of its way to give deference to government regulations even when their burden on citizens’ rights is grave: the standard test for Constitutionality of a law is that it must show a “rational basis” for its existence, which the Court interprets to mean literally any rationale – however stupid or obviously dishonest – that is not literally logically impossible; the Court also usually rejects “substantive due process” and “equity” arguments, which ask for the application of general principles of law or morality outside the strict “black letter law” of statutes and case precedents. Thus, laws and regulations are typically upheld as written, on the presumption that legislations have wide latitude to act as they choose, and the laws they write are therefore prima facie in keeping with the principles of representative democracy regardless of how burdensome, unfair, or duplicitous they may be.

There are few exceptions to the “rational basis” doctrine, all having to do with Constitutional-level civil rights. The Supreme Court has held that laws directly impinging “fundamental” Constitutional rights, or imposing ethnicity-based restrictions on freedoms guaranteed by the Constitution, must meet the test of “strict scrutiny” – that is, they must not merely have a nominal “rational basis”, but must “advance a compelling state interest”, be “narrowly tailored” to that interest alone, and use the “least restrictive means” to achieve it. Arbitrary distinctions between groups also come in for strict scrutiny, under the 14th Amendment’s “privileges and immunities”/”due process”/”equal protection” clauses. In other civil rights cases, the Court has imposed a doctrine of “intermediate” or “heightened” scrutiny, under which the laws must demonstrate a weaker but still compelling rationale for their restrictions. (Almost all sex- and gender-related discrimination receives only heightened scrutiny, because, you know . . . teh uterus . . . .) In the case of abortion, the Supreme Court has struck down some, but not all, anti-choice laws and regulations that were clearly intended to impose, in its words, an “undue burden” on women’s exercise of their rights; however, others were permitted under heightened scrutiny if the anti-choice state could articulate even a moderately plausible-sounding (as opposed to barely “rational”) reason for the law, even when those laws were obviously intended only as burdens on women, and even when they arose as part and parcel of laws that were otherwise rejected for that reason. So, in general, the Court has not taken the step of saying “this law is obviously intended to void a legal right, and you can’t do that”; it merely subjects burdensome laws to various levels of analysis as to how well they disguise that intention.

What’s interesting about this gun-control case is that the legal theory it relies on (as reported in this short article – hard to tell if this is true) attempts to raise burdensome but otherwise normal administrative regulations to the level of Constitutional infringement – that is, it appears to claim that having to pay ordinary but high fees, and jump through ordinary but complicated procedural hoops, is as much an infringement on Constitutional rights as are poll taxes or racial segregation, or at least as gender-based restrictions on employment. “Unduly burdensome” regulations may be unconstitutional, it’s true, but in this case the regulations are not unusual, even if the fees are high: every jurisdiction (other than a couple of whacko states that have no gun permit laws at all) processes paperwork, assesses fees, and in general requires some kind of procedural rigmarole for getting a gun permit. New York City is an outlier, in that their licensing process is unusually difficult (they make you take a test that includes trick questions), lengthy (it commonly takes months), and expensive (as much as 40 times what other jurisdictions – even in New York State itself – charge). But that is only a matter of degree, which it seems can easily be explained given the City’s political determination that they want to make the process stringent. (The fees, I suspect, are an estimate of the fully-loaded cost of staff time and expenses to process the fingerprints, application, and background check, and are probably slightly, but not hugely, inflated. That’s a bullshit way to calculate fees for a job the government actually exists to perform in the first place, but that’s a different matter.) So the issue here is whether a normal and appropriate government function – processing applications and assessing fees – which nobody suggests is unconstitutional in its typical form, becomes unconstitutional when that function gets so out of hand that it essentially becomes a tool for prohibition of what is otherwise a legal right.

This has obvious implications for the constant barrage of dishonest and hostile regulatory encroachments on fundamental Constitutional rights that have become the favorite tactic of the anti-choice brigades. Unnecessary waiting times, intrusive and unnecessary medical procedures, explicit ideological harassment deliberately intended to discourage people from the decisions they have made, technical regulations intended only to delicense or bankrupt clinics – all these and much more have been commonplace tactics in the anti-woman crusade for years, and they are getting more brazen and more offensive almost literally day by day.

These attacks on abortion rights go much further than New York City’s procedural hurdles for a gun permit. In New York, if you pass the test and pay the fee, they will give you a license (for home possession, at least). The administrative procedures are clearly intended as a bottleneck, and the fee is unfair, but the procedure is straightforward and involves nothing that is not common in the administration of similar governmental functions across the country. Anti-choice regulations, in contrast, commonly apply only to abortion procedures, impose burdens that serve no reasonable purpose or are inflated absurdly beyond what is necessary for their ostensible purpose, or distort ordinary procedures in ways that are intended solely to make abortion unobtainable, unaffordable, or discouragingly unpleasant. Examples include requiring multiple trips on different days to a clinic that is often a vast distance from a woman’s home; applying hospital licensing standards to outpatient clinics for abortion only; requiring medically unnecessary ultrasounds at a cost of hundreds of dollars; requiring scripted and false speeches to deliberately upset patients before a procedure – all of them extraordinary burdens that have nothing to do with the ordinary process of licensing and regulating medical clinics, or ensuring informed consent (which, in every other medical discipline, is intended to help patients get what they want and need).

The gun-rights people do have a point about New York City’s regulations: although those regs are not that unusual on their face, the details of their implementation make the legal right of gun ownership essentially unexercisable by many citizens who lack the money, time, or persistence to overcome a burden that is not actually required by the legitimate government function it purports to arise from. But if that difficulty rises to the level of a Constitutional infringement in the case of gun permits, how can the GOP’s outright and unashamed assault on women’s rights to legal and vital healthcare not be seen in the same light?

This puts the right wing, of society and the Supreme Court, in a pickle. If they agree that burdensome and hostile regulations intended to discourage the exercise of a Constitutional right are impermissible even when those regulations are normal and proper other than in the degree of the burden they impose, then they would have to agree that far more invasive regulations serving no ordinary purpose and deliberately intended to actually void a Constitutional right entirely, and even in cases of life-threatening consequences, are that much more obviously impermissible. On the other hand, if they want to continue their assault on women with any degree of logical consistency, it would seem they would have to throw gun lovers under the bus along with them. It will be interesting to see this play out.

March 31, 2011

Using Their Weapons Against Them? – Not So Good When the Weapon is Women’s Bodies

by @ 8:24 PM. Filed under Autonomy, Child-Rearing, General, Healthcare Politics, Personhood, Reproductive Ethics, Sex, Theory, Women's Issues

I’m sorry to have to say it, but I’m not totally diggin’ this:

Sierra Club: Fetus Toxins

It’s from the Sierra Club’s new ad campaign “to remind our representatives who they are actually hurting when they attack the EPA.” I’m entirely in agreement with the goal of the campaign, and even with the message of this ad (“gutting emissions regulations results in greater release of toxins, which can do their worst damage during fetal development”). But I have reservations about its methods.

The obvious function of the ad, of course, is that it plays to the right-wing’s proclaimed concern for fetuses to the exclusion of all other health issues (including, of course, pre-natal care, gynecology, infant and child care, and other such irrelevancies). And the fact that the imagery plays so obviously and shamelessly off of the right wing’s fetish for pregnant bellies – in this case to prod them to do something to improve people’s health, rather than take away their rights to healthcare, is an amusing irony. But it’s just those points that leave me uncomfortable.

First, there’s something in a way defeatist, or at least pessimistic, about the focus of the campaign: because the GOP only cares about unborn fetuses, we have to couch every issue in terms of its impact on fetuses. (“Wear your seatbelt – so your fetus doesn’t get hurt!” “Support solar power – so your fetus will use less oil!” “Don’t spread deadly poisons in the environment – because it might hurt some of the fetuses of the less than 1% of the population that’s pregnant at any given time!”) But surrendering every issue to the religious right’s fetus-fetish takes everyone else in the population out of the picture. Mercury, dioxin, and other poisons in the environment hurt everyone. It matters that young children who have grown out of the right’s preferred age for adulation (i.e., they’ve been born already) are also vulnerable to developmental delays and all the other effects of environmental toxins; it matters that adults are crippled and killed by heavy metal poisoning; it matters that the women who are carrying these favored fetuses are also affected by the poisons they ingest – in addition to the fetuses that are the focus of concern in this campaign: these are the people who are hurt when the right wing attackes the EPA – why can’t the Sierra Club, of all people, say so? It may be true that the right only cares about fetuses (and then largely as tools for hurting women, who are their real obsession), but allowing them to forget everyone else is to forfeit the major part of the fight to them without contest. When progressives’ campaigns have the same focus, same tactics, and same blind spots as the reactionaries they are campaigning against, much is lost even if those campaigns succeed.

The second, and perhaps more striking, issue that arises for me from this ad is the imagery that is used. When I said it leaves everyone but the fetus out of the picture, I meant it literally. This ad replays in every detail one of the most common, and most offensive, tropes of anti-choice misogyny: the faceless pregnant woman reduced to nothing but her belly. (Can’t say “uterus“, you know!) You see it everywhere (and, as @ClinicEscort points out, particularly in stories about abortion): a woman’s body reduced to nothing but swollen boobs and swollen belly, or often just the belly – the face is always cut off, just out of the frame. The effect – and unquestionably the purpose – is to erase the woman from her own pregnancy. It’s fetus porn, with the woman dehumanized just as badly as, and in some ways even more fully than, in sexual porn (where at least you can often see the face). It’s the kind of misogynist metonymy that at least has come to be recognized (if not eliminated) in product advertising, but apparently still goes unremarked in issue or values advertising – even though its major function is to promote the value of dehumanizing women. That it does reflect and promote the right-wing vision of women goes without saying: women as pregnant vessels who are not even named or acknowledged, and certainly have no interests or needs that deserve to be addressed in their own right, could hardly be better illustrated than by photographs of them as exactly that, used in campaigns aimed at denigrating women’s interests in favor of the “interests” of an unborn fetus.

It’s infuriating to see progressive groups use such images and tactics. This goes beyond simply bowing to the reality of the  right’s indifference to women by finding another “hook” for an issue; this actively embraces and endorses its dehumanizing methods in order to use them for that other issue – exactly what the right wants. What I want is something better than this from nominal allies.

March 30, 2011

HotLips Rides Again!

by @ 9:36 PM. Filed under General, Healthcare Politics, Provider Roles, Women's Issues

I haven’t been paying much attention to the show Nurse Jackie. I have seen other work by the star Edie Falco and admire her as an actor, and I gather her current show is popular, though I haven’t seen it and I don’t know much about it. I vaguely wondered if it really had much to do with nursing or healthcare, and whether it presented any interesting issues, but, as I said, I wasn’t really paying attention.

Just now, however, I happened to open a magazine and find a full-page ad for the new season that began this week, featuring a large color picture of Edie Falco in her nurse’s uniform, and two thoughts popped immediately to mind: (1) “Nice tits!“; and (2) “Wait a minute . . .

(more…)

“Appropriate” Treatments: Categorical, or Situational?

by @ 1:32 PM. Filed under Access to Healthcare, Autonomy, Disability Issues, General, Healthcare Politics, Provider Roles, Theory

There’s a provocative post over at the excellent KevinMD Web site:

Overeating is a behavioral problem, not a surgical one

This may seem to be a statement of the obvious, but the solution to a behavioral problem is not surgery. Overeating is not a surgical problem — it is a behavioral one. The problem is not because the stomach is too big and needs to be made smaller. It is a function of how much food is put into the stomach. Surgical “solutions” should be the absolute last resort measure.

The letter – from an Australian physician who touts himself on the Web as a “DIY health” guru – goes on to make a number of good points about bariatric surgery (mostly stomach-banding), couched in terms of clinical efficacy and relative risk: it does not work for everyone; the campaign to expand the qualifying criteria may include patients who have marginal need or expected benefit; there are known side effects and long-term safety is unknown; the promoters are compromised by conflicts of interest. These are all relevant considerations. But the overall tone in the letter, and even more so the comments, is both judgmental and dismissive. (From commenters: “People are obese simply because of their own behavioral inability to control their diet . . . the solution still lies FIRST in the individual admitting his/her 100% responsibility in the problem weight.” “Obesity results solely from laziness and apathy, which consequently are the same traits that are leading to the devolution of our species.”)

The giveaway here is the headline: yes, overeating is of course a “behavioral problem”, not a surgical one, because in this context “behavioral problem” clearly refers to the etiology of a pathological condition (obesity), while “surgical [problem]” clearly refers to the preferred mode of treatment for that condition. The writer conflates the two categories, and then draws an inference from a logical contradiction of his own making: it’s true that the  etiology of this condition is not its treatment, but that’s true in every case, so that hardly tells against that treatment considered in and of itself. We can reinterpret the sentence to make sense, but only by making it obviously absurd: either “Overeating is a behavioral treatment, not a surgical treatment” or “Overeating, not surgery, is the cause of obesity”. There is a vacuity of clinical concepts here that suggests something else is at work in the writer’s animosity to certain kinds of treatments.

What the writer is really trying to say is this: “Obesity is caused by behavior, and should not be treated by surgery”. And the logical implication of that statement, and the letter and comments that follow, is this: “Obesity is caused by behavior, and therefore should not be treated by surgery”. The clinical counter-indications for surgery (and medical treatments for obesity – he’s against pills, too) that the writer details do not really seem to be the issue in his mind. Instead, certain treatments are ruled in or out categorically, on the basis of criteria of appropriateness that seem to hinge on his view of what health and medicine are fundamentally about, or how they are fundamentally related. There is a sense that diet is better than medical treatment because it is lower-risk, but also a sense that people who brought their conditions upon themselves behaviorally should be expected to work out their own salvation without clinical intervention. There is a clear implication that the writer would still object to bariatric surgery even if it were safer and more effective, simply because it’s not the kind of treatment he thinks this condition should get, in some essential sense (“obvious[ly] . . . the solution to a behavioral problem is not surgery”). Because the condition is behavioral, the treatment should be behavioral: QED.

From this perspective, the choice of treatments for a given condition depends on some sort of criteria of categorical appropriateness – a determination of what kinds of treatments are appropriate to any given condition, only after which do questions of safety and efficacy come into play. (This becomes more obvious in the letter above when the writer airily dismisses the notorious psychological difficulties of dieting with remarks about “responsibility for one’s actions”.) And this is the question that really got my attention about this issue. The concept of “appropriate” treatment is one that gets to the heart of healthcare as a practice, and of the ethical dimensions of such seemingly scientific concepts as the definition of disease, relative risk, and clinical indications for treatment.

To define clinical indications in some way other than in terms of clinical efficacy establishes medicine as a categorically defined practice: a praxis incorporating certain beliefs or techniques that are “just right”, and eschewing others as “just wrong”. The old ethic of “doctor knows best” exemplifies this idea to some extent (in regard of the roles of patient and physician: the doctor prescribes; the patient complies). More broadly, medical ethics based on a perception of distinctly medical virtues and traditions (Pellegrino’s “internal ethic of medicine”) makes all of medicine categorical; more than that, it moves the locus of medical ethics entirely inside the profession, such that what is right or wrong for a given patient is what is or is not in keeping with the behavioral standards applicable to the doctor. Even more modern theories of medical ethics do the same to the extent that they perceive specific types of treatments as right or wrong in and of themselves.

The movement toward patient autonomy and patient-centered care challenges this ethos at a basic level: the whole idea that patients may determine their own interests for themselves necessarily implies that healthcare is defined as serving those interests (or else we get a macabre dissociation between what patients need and what healthcare is for). The patient-centered ethic has fundamentally reformed healthcare practice in many areas, most notably refusal and termination of unwanted treatments, and more indirectly through the rise of cosmetic, nutritional, sports- or adventure-oriented, assisted reproductive, and other forms of “aspirational” (rather than pathology-driven) healthcare. The idea that what patients need is not determined by the pursuit and maintenance of “normal species functioning” – never exceeding its bounds and normal range, either positively or negatively – throws open a potentially unlimited range of possible treatments for any given condition, and indeed a potentially unlimited range of praxis under any conditions, whether or not defined in terms of disease and treatment. (The body modification movement blows the doors off the disease/treatment model, and increasingly off of any old-fashioned notions of normal species functioning.)

From this perspective, it is impossible even to formulate a declaration of the form: Because the condition is ________, the treatment should be ________. Radically patient-centered care does not require a “condition” to authorize a “treatment”, and takes it as fundamental that some patients may deny that an otherwise-recognized “condition” even exists (as in the case of the “fat acceptance” movement), while others may perceive, personally, a pathology in what would previously have been perceived categorically as normal (as with gender identity disorder). In addition, the particular best treatment for any given patient, whatever their circumstances, will be the one that best meets that patient’s interests as they themselves understand them – which may well be a riskier surgical procedure rather than a more burdensome lifestyle change, or vice versa, as they themselves perceive is best for them.

The significance of this non-categorical, patient-centered, situationally-responsive understanding of healthcare praxis is enormous. Aside from the overt impact on practical healthcare that the patient-autonomy movement continues to have, embracing a truly patient-centered ethic of care guides thinking about how to understand patient needs and how to meet them. In particular, it rules out categorical thinking of the type that prohibits providing certain treatments (with due consideration of cost, risk, and expected benefit) for a given patient or category of patient because they do not conform to some generic standard of appropriateness, and it requires that the patient’s own understanding of their goals, priorities, and risk-tolerance, be the determinative factors. Clearly the message hasn’t reached all corners yet.

March 29, 2011

It Works Both Ways

by @ 1:29 PM. Filed under Autonomy, General, Healthcare Politics, Reproductive Ethics, Sex, Theory, Women's Issues

Since the anti-choicers are so very concerned about minority interests that they insist on stealing every woman’s autonomy  because a potential black leader fetus might someday be aborted, it’s only logically consistent to pay attention to the upside of that issue:

Aborting an Anti-Choice Terrorist - Griffin

Aborting an Anti-Choice Terrorist: Hill

Aborting an Anti-Choice Terrorist: Kopp

Aborting an Anti-Choice Terrorist: Roeder

Aborting an Anti-Choice Terrorist: Rudolph

That’s just a fraction of the total, even considering murderers alone. Almost no suspects have ever even been named in the over 200 arsons and bombings, or close to 100 other attempted arsons and bombings, or the literally thousands of vandalisms and chemical attacks committed at health clinics across the US, not to mention the many attempted murders, public “targeting” of chosen victims (some of them later murdered), personal harassment and threats to healthcare providers, and uncountable incidents of on-site harassment and violence directed at clinic staff and patients, that are the stock in trade of Christian anti-choice terrorism.

No person loses their life in an abortion. But here you can see just some of the people who would be alive today if the terrorists above, and others like them, had been aborted before they murdered them. If we’re counting up the possible impact on society, well, there’s only one Obama, but there’s plenty of these shitheads. So, all things considered . . .

[NB: Of course the entire line of reasoning is nonsense. The fact that some unpredictable thing could occur sometime in the future is no reason to force anyone to bring about circumstances that might randomly, but not foreseeably, result in that outcome, even ignoring the fact that it is their decision whether they want to do so. The same reasoning would not only justify mandatory childbirth, but mandatory pregnancy, and in fact mandatory maximum reproduction regardless of risk or cost - since one of those unwanted children might do enough good to offset all the suffering required to produce it. That this is in fact the official policy of the Catholic Church makes it no less insane or misogynist. It's also illogical: there's no guarantee that any child - still less an unlimited number of unwanted children imposed by force - will do more harm than good, so the proposition that there's a harm to society in aborting them is no more provable than that there's a good to society in doing so, as the above images demonstrate.]

March 28, 2011

The Giftie’s Power

by @ 7:04 PM. Filed under General, Meta

Your data suggest a slight automatic preference for Older People compared to Younger People.

I hate taking the Implicit Association Test, but it’s a good thing to do.

Having mentioned it in my previous post (below), I was prompted to go do it again. The test that came up is on age groups; they have a wide range of others. I’ve taken the famous one on race, and it also showed a slight bias; almost everyone does.

It’s important not to read to much into things like this, but it’s important not to dismiss it, too.

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