Yesterday, the Susan G. Komen Foundation  – the “pink ribbon” breast-cancer research and treatment organization – announced it was ending its long-standing annual grants to Planned Parenthood clinics to perform breast-cancer screenings and referrals for low-income women. The given reasons are as disingenuous as they are shameful: in short, SGK hired a new Vice President who, in a recent losing bid for the governorship of Georgia, had explicitly pledged to defund healthcare services at Planned Parenthood in that state. Within months of her hiring at SGK, SGK just happened to create an internal rule declaring that it would not fund any programs at organizations that were under Congressional investigation; that policy just happened to apply only to Planned Parenthood, which just happens to be the target of a fishing-expedition investigation by a virulently anti-choice member of Congress. So: the right wing has been demonizing and targeting PP for years; one jackass Congressmember creates an investigation simply to grandstand; SGK hires an avowed anti-choice opponent of PP; SGK then creates a new rule about “investigations” that applies only to PP; SGK then abandons its own PP-mediated cancer screening programs and claims it had no choice because of the bogus investigation. Well played, but hardly subtle.

This is as sickening as it is tragic. The results will be, literally, death for a predictable number of women who would have been referred for mammography and received a positive cancer diagnosis, and appropriate treatment, following examination at Planned Parenthood, but who will now go undiagnosed after those screening programs are shut down (assuming adequate replacement funding is not obtained).

I’d like to encourage SGK to reverse their decision – to consider all the benefits that come from these screening programs, and the need there is in the community for the irreplaceable medical resources they provide. I’d like to remind them that Komen Affiliates have funded breast health services through Planned Parenthood programs that have provided breast health education and breast screenings for hundreds of thousands of low-income, uninsured or medically under-served women, and that, in some areas, Planned Parenthood may be the only local source of breast health care. I’d like to point out that women served at Planned Parenthood may receive a clinical breast exam, and when further screening is needed, a referral to either a state program or a private mammogram provider. It would be useful to consider that because SGK only works with non-profit organizations, these women’s  mammograms may be paid for by the Komen-Planned Parenthood grant, since many mammography providers are for-profit but Planned Parenthood works on an entirely non-profit basis for all its services.  Surely they recall that during the past five years up to 2011, Komen Affiliate grants to Planned Parenthood paid for:

• Breast cancer and breast health education for nearly 160,000 women
• 139,000 clinical breast exams
• 4,866 mammograms
• Detection of 177 breast cancers

But I may not need to tell them all that. They already know it. I’m sure of that because every bit of the above information comes from a letter SGK itself posted, on their pink-ribboned letterhead, on their own website, back when the religious right was pressuring them to cut off cancer screening to low-income women as part of their misogynist anti-sex witch hunt.

In that letter – aimed at deflecting criticism from anti-Planned-Parenthood crusaders, and written before SGK hired its own anti-choice crusader as VP – SGK extols its work with Planned Parenthood, and rightly notes not only that the screening programs it funds serve hundreds of thousands of women, and identify thousands of previously undetected potential cancers, but that these programs are carried out in many cases by the only provider willing or available to do them, and thus are literally irreplaceable. In publishing that letter, SGK took a strong stand in defense of women, and of those who provide the vital – in the most literal sense – services that no one else will or can do. It openly and forthrightly documented the need women – almost exclusively low-income women, and disproportionately women of color – have for Planned Parenthood, and the great benefits they got from the Planned Parenthood programs made possible by SGK’s funding. The letter expresses a clear and unambiguous commitment to serving women (even while mush-mouthing on the issue of abortion), and takes a bold stance in the face of harassment and misogynist bullying.

That letter is no longer available on the Susan G. Komen website.

In fact, as of this writing there is no news whatsoever on SGK’s on website regarding its abandonment of the cancer screening programs it once supported Planned Parenthood in providing, and a search for “Planned Parenthood” on that site returns only a single, obscure, broken link. That link turns out to be the page that once held the letter mentioned above. It’s not accessible or advertised. Some careful Googling, however, locates the letter in an unlinked section of SGK’s site. The letter defending Planned Parenthood, its patients, and SGK’s support for them, still exists – but they won’t let you see it.

Here it is, in its original full-color form: Susan G. Komen letter describing benefits from Planned Parenthood cancer screenings.

I’d like to think that “as long as there is a need for health care for vulnerable populations, Komen Affiliates will continue to fund the facilities that meet that need.” After all, they said so – barely 8 months ago. But obviously they’re no longer willing to stand by their word. In fact, they’re no long willing to admit they ever gave their word. They’ve shown us what courage and fidelity to women truly amount to – for them.

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

This is a common, but relatively recent, dodge for anti-choicers. Throughout history, in the US and many other countries, when abortion was illegal (and it was not always or universally, or even commonly, so), women who sought abortion were held guilty of a crime; a woman who successfully obtained an abortion was often jailed, and women who were injured in illegal abortions were arrested when they sought medical treatment. This was a major contributor to the death rate from illegal abortion: not only could women not find safe providers, but they were fearful of seeking treatment when their unsafe abortions went wrong. This was never, for the anti-choicers, a reason not to make abortion illegal. But it was viciously cruel, and that cruelty became part of the justification for legalizing abortion. The deadly legacy of the lack of choice has likewise been part of the motivation to keep abortion safe and women out of jail, against the misogynistic war to reverse both those developments.

Yet, there is a logic (if not a “metaphysics”) to the war on women who procure abortion: if abortion really is the horrible crime the right wing claims, it’s hard to grant impunity to people who plan, solicit, and participate in that crime. If abortion is murder, surely the one who knowingly seeks, requests, pays for, and submits to an abortion, deliberately, by choice and preference, knowing its meaning and consequences, must be a murderer, at least as much so as the medical professionals who perform the procedure (and surely more so in the case of medical abortion, in which the professional’s only role is to write or fill a prescription, but the woman’s intentional agency is just as extensive as in a surgical procedure). And the idea that someone who solicits, hires out, and participates in a serious crime – let alone “murder” – is not guilty would be a travesty of the law in the case of any real crime.

The willingness to absolve women of initiating, paying for, and participating in a crime for which the person they paid, who acted on that woman’s own body at her request, will be punished under law reflects no sensible understanding of criminal guilt. It is a purely political move intended to head off a backlash against the anti-choice movement for victimizing women legally as well as medically. It is an attempt to evade the public’s revulsion at the right wing’s treating uppity women as the criminals the wingers say that they are – and to prevent the spectacle of women languishing in jail for simply claiming their own fertility through an act that one out of three women in the US has undertaken in her lifetime. It is a deliberate decision to void their own moral judgments for political expediency – to let a category of so-called “crimes” go unprosecuted to avoid drawing scrutiny to the ways the criminalization of healthcare affects women in general, and thus maintain that oppression in broader effect. It is an all-but-explicit declaration that the ideology that they claim justifies their persecution of women is itself expendable if it would get in the way of persecuting women – that making women suffer is more important than consistently and honestly applying the ideological framework that they use to rationalize that suffering.

But beyond the craven dishonesty and political expedience of the misogynist anti-choice crowd, there is a deep contempt for reality itself. To rationalize their insistence that abortion is a crime, and simultaneous refusal to hold women accountable for their choice to commit that “crime”, they have to characterize the act as criminal but the deliberate commission of it not. Who commits criminal acts but is not a criminal? People who are mentally incompetent, or coerced. Thus: “I see women in this case as a victim”.

This is another popular trope of the misogynist right: women are incapable of agency in their own disapproved choices. The idea that women are commonly “pressured” into abortion is a staple of anti-choice activism, as is the idea that they don’t really know what they are doing. This, of course, makes no sense legally: whether or not you are “pressured”, you can’t plan, schedule, show up for, pay for, and participate in a crime – after extensive discussion, preparation, and informed consent! – and claim you were acting under duress. (It didn’t work for Patty Hearst, and she was truly coerced.) Nor can you claim, after all that, that you didn’t know what you were doing, nor – the legally important part – does that claim matter as a defense to a criminal charge. (“Ignorance of the law is no excuse.”) For women to be exculpable of crime for a crime they planned and participated in, they have to be not just unknowing, or a “victim”, but actually mentally incompetent – a mental child, lacking legal autonomy, unable to give consent for her own choices.

That is the characterization the right wing puts on women – any woman having, or even seeking, an abortion – as their out for criminalizing the act but not the actor. That is how Rick Santorum – and all his Wingnut Woman Hater’s Club fellows – describe every woman who makes a choice they disapprove of: incompetent, non-autonomous, “victimized” by choices they themselves have freely considered, endorsed, and enacted.

But these are not simply more of the crazy opinions and perverse perspectives on women and the world that the right wing wallows in. They are claims of fact – claims about what it is actually like to be a woman who wants an abortion, or simply be a woman who believes abortion is one of the tools she can use to control her own life, take care of her own body, and achieve her own goals. To be a “victim” of one’s own choices and goals, it must be true in fact that you are mentally deficient, not capable of decision-making about yourself as the owner and inhabitant of your own life and body, oppressed by circumstances to the point that you cannot, in literal fact, think straight about yourself. These are claims of psychological fact – claims about the actual mental states of women attempting to assert sexual autonomy – claims about all such women (since the get-out-of-abortion-free card is made available to all women on these grounds).

It is simply impossible that such a claim could be true. It is patently obvious that it is not, in fact, true even about most or very many of the women who choose abortion. (All such women undergo intake counseling and an informed consent discussion. Repeated studies have shown again and again that they are at least as mentally healthy after the fact as are women who have not had an abortion.) The actual facts are clear: women who choose abortion are not mentally deficient, mis-informed, or incapable of making their own decisions. The claim Santorum and his ilk rely on to absolve themselves of the consequences in public opinion of their own misogyny is simply not true. But since it was never intended to be true – only to sound like something that would help them if it were true – that has no effect on their willingness to keep saying it.

What this cashes out as, for me, is the absolute necessity to put women and women’s needs at the center of any discussion about abortion. A third of all women in this country will have an abortion in their lifetime – and that’s with the grinding barriers and hurdles the right wing has put in their way. Tens of millions of them have already had abortions – women from every part of the country, every ethnic and religious group, almost certainly every extended family. In the same way that the “I had an abortion” T-shirt makes that army of normal, everyday, free and independent women visible, and forces the misogynists to question how far they are willing to go in targeting their own friends and family members, we need to make it clear also that those women are not “victims”, nor criminals.

Unless you are willing to call some vast percentage of women in the country – family members, co-workers, the women who raised all those children, taught all those classes, earned all those college degrees, held down all those jobs, accomplished all that they have accomplished and are still doing, and in the course of it knowingly and deliberately and self-affirmingly chose to abort an unwanted pregnancy and were better off for it – mentally ill, mentally incompetent, not in control of their own lives or choices, unable to control their own lives and choices, then you cannot claim their are victims for having made those deliberate and conscious choices. You will have to confront the reality that the women who choose abortion are, in largest part, strong, self-aware, competent, autonomous, and fully responsible for their own lives, values, goals, choices, and actions. And that being anti-choice is an assault on those women and their status as independent and autonomous persons.

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.

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.

The Tidal Wave

The savagery of the current GOP sex-panic is numbing. Literally hundreds of anti-choice bills have been introduced in Congress and the state legislatures since the 2010 election, and their extremism exceeds previous bounds almost day by day. There are not just the usual things like bogus restrictions on healthcare clinics, intrusive requirements for unnecessary ultrasounds and false “counseling” (in some states, through mandatory visits to religious-right “crisis pregnancy centers”), waiting periods and other barriers; in several states there have been bills banning abortion in every case, including when the patient is actually dying, and bills authorizing religious-nut providers to literally let their patients die by withholding services and refusing to transfer them to a real caregiver. This, of course, on top of the raving, libelous assault on Planned Parenthood as a proxy for Title X services across the board, the shamelessly mendacious and sensationalized fictions of Breitbart and his media minions, and the really nasty crap about black women committing racial genocide by having abortions, or how forced childbirth is a feminist cause because fetuses are (seriously) “little, tiny women”.

The viciousness of it is just sickening, but not surprising. The utterly murderous hostility to women that drives the anti-choice/anti-contraception/anti-sex education/anti-sex crowd has never been difficult to see. The bald lies and persistent distortions that make up anti-choice rhetoric are a chronic illness of the right wing. Nothing that is coming out in these recent bills, or the rest of the hucksterizing and demonizing that has welled up into greater media prominence in recent months, is in any way new. What is new is that the insanity has been openly endorsed and propagated through legislation by the relatively mainstream elements of the GOP political class. Used to be you had to troll the real backwaters of the Southern state legislatures to find people as crazy as the ones who are now driving the Republican party. But now the most extreme – even, literally, fatal – excesses of misogyny have become mainstream legislative agendas at the highest levels of the GOP.

The Reason

The question, then, is not why there is a sex panic on the right wing, but why it has now become operationalized as a legislative agenda that the GOP leadership is willing to put front and center – even to bet its electability on. (The last time they threatened to shut down the government it ruined them for the next election cycle, but it was at least a consequence of the policies they had committed themselves to in the previous election cycle. This time it was over a berserker plan from their own margins to defund gynecological care by way of attacking Planned Parenthood. The GOP is just as fond of over-reaching as before, but the substance has gotten weirder.) What makes the backlash such a compelling tactic right now, when it has – as a die-hard legislative agenda – been largely back-burner for most of a generation?

The answer, I think, is that the sex panic and war on women have not suddenly grown in salience all by themselves. Instead, the political conditions have shifted such that the anti-woman wing, though no larger, now has a power and prominence it hadn’t had before. There are several contributing factors.

Contributing Factors and Dynamics

Obama

The most significant is the absolutely crazed reaction on the right to the election of Barack Obama. “Reenfranchising little tiny women fetuses” is hardly the only nonsense coming out of the right: birtherism and its many paranoid variants, the dark mutterings about madrassas and Kenya and “Hussein”, the re-emergence of red-baiting and absurd charges of communism and Nazism (often simultaneously), and many of the familiar lunacies of ’50s-era reactionism have all been created or in many cases simply dusted off in response to the claims of a confident, unapologetically (semi-)progressive black man to political legitimacy and the power of the Presidency. The effect has been to embolden many of the more-distant arms of the right wing, whom the “respectable” Republicans had been pandering to but not inviting into the halls of power. Obama’s election prompted waves of rumors about “gun-grabbing” and sudden shortages of ammunition as the result of gun nuts stockpiling in anticipation of their cold-dead-hands fantasy scenarios finally coming to life; militias and survivalists then became more welcome in mainstream right-wing circles as the less-extreme gun enthusiasts suddenly found themselves sharing the same apocalyptic delusions. The anti-Muslim bigots of course had a field day with the election of a non-white President with a Muslim middle name, son of a Muslim, who had attended Muslim schools in a Muslim country and was all like Muslimy and stuff (and right in the middle of our War on Muslim Terror!); open religious bigotry thus became not merely respectable but actual policy, and the religious extremists who fought their imaginary battles against “sharia law” brought their other religious obsessions with them into the GOP mainstream. In addition, the tone of the Obama-vs.-the-Heartland election also created its own forms of backlash: the rejection of Sarah Palin became, oddly, a kind of civil rights issue for stupid people, such that actually expecting someone to know something about their own supposed field of expertise, and to speak the truth about it, was pegged as discrimination on the part of “elitists” gripped by an evil obsession with knowledge, competence, and honesty. Thus, the election of Obama brought the marginals, the back-woodsers, and the drunk uncles of the GOP back into the Big Tent, dragging their issues, obsessions, and hostilities with them, and making the general climate on the right, and within the GOP, more hospitable to factions that had been an embarrassment just recently.

Immediately thereafter, the fears of the Obama-haters were ratified by the passage of the Affordable Care Act. No matter how weakened and compromised, the coming of communistic, anti-business, godless liberal socialized subsidies for private-market health insurance was both a death-blow to America as we know it and proof positive of everything that had ever been said about Obama. It was also a galvanizing event for virtually every strain of conservative, and a coordinating issue for the entire conservative bloc in Congress, as well as many activist groups among the general public. The immediate determination to cripple or repeal Obamacare was a practical issue every conservative could get behind, and generated a focus of legislative effort aimed at healthcare issues that every conservative in office (at both federal and state levels) could contribute to.

Teabaggers

A similarly welcoming air emerged within the Tea Party. With its badly-veiled racism and populist resentment of the “elites”, it created an environment in which extremist positions were no longer seen as a liability. By stoking disaffection pure and simple, teabaggers were able to swell their ranks with angry rightists from across the spectrum: gun-toters waving AR-15s at Obama to prove their point about responsible self-defense; teat-suckers from the oil, corn, and beef industries ranting about socialism; religious segregationists raving about the worldwide Muslim conspiracy; economic doomsdayers raving about the worldwide Jewish conspiracy; racial segregationists pining for their own Berlin wall in Arizona; goldbuggers, Galt Gulchers, godbags and every other thing. Keeping that coalition together, and at maximum size, meant not imposing any membership test. Since anything goes, everything went. Careful non-questioning of the ideological underpinnings of the movement, or any of the many fears and fantasies its members indulged in, allowed mainstream politicians to actively cultivate support from teabaggers who might at best have been thrown some rhetorical raw meat in previous years, but never indulged with a risky photo-op featuring visibly crazy right-wing counterculturists. This week’s Republican Presidential campaign debate was officially sponsored by – I shit you not – the John Birch Society, an organization that once set a record of sorts by having been declared too crazy for mainstream conservatism by no less than William F. Buckley, now not only on the bandwagon but helping to drive.

The teabag tidal wave was especially significant given the success of their declared adherents in the election of 2010. Not all teabag candidates won, but a surprising number did, and others polled far higher than the fast-dying “rational actor” school of political analysis would have suggested. Most importantly, several candidates spurned by the mainstream ran as independents, and some actually won. This prompted a recalibration of the right-wing Pandermeter: the lunatic fringe could no longer be counted on to vote Republican on autopilot – they were organized (loosely) now and could command serious tribute both at the polls and by way of their affiliated elective legislative bloc. Though not all the Congressional GOP first-termers of 2010 were explicitly teabaggers, many were far-gone ideological conservatives with little taste for compromise or the procedural niceties observed by more experienced legislators.

The Gathering of the Wingnuts

Thus, the right wing as a whole was both energized and consolidated by the election of Obama and the political events – legislative and electoral – that flowed from it. After the right-wing wagons had been circled, the traditional distinction between “fiscal conservatives” and “social conservatives” seemed to be moot. (Despite some confusion over where the “small government” teabaggers and libertarians stood, it became obvious that the conservatives howling about the federal deficit were (a) ignorant of economics, and especially of the contribution the Affordable Care Act would make to actually reducing healthcare expenditures, and (b) as devoted to social reactionism as any old-line conservative, and often more so. Hardline libertarians Ron and Rand Paul, supposedly devotees of personal freedom and self-determination, were among the most rabid sex-panickers in Congress, sponsoring, among many other things, bills for zygote personhood, absolute prohibitions on abortion in all cases, and to strip the Supreme Court of authority even to review the constitutionality of laws regarding personhood, abortion, or gay marriage.)

When the GOP gained a majority in the House of Representatives, their odd partnership of old-liners, teabaggers, libertarians, religious wingnuts, and others realized they could dominate the chamber, but only if they all worked together. And they did. The flood of radical, and often simply crazy, bills that emerged – anti-choice, anti-union, pro-gold-standard, anti-sharia, etc., etc. – was the result of an orgy of back-scratching, in which GOP Congressmembers all dutifully voted for each other’s bills regardless of substance or sanity. Something similar happened at the state level, where GOP governors appeared to be in a contest to solidify their credentials for reelection or a later Presidential race by introducing the most radical bills they could conjure up, on the most galvanizing issues they could identify.

One final factor, I think, is the general increase in partisanship that has been growing since at least the Clinton years, and to a considerable extent the Nixon years. The GOP in particular is incensed at the very existence of any Democratic President, and determined to de-legitimize both the Democrats and even the political process itself. Both parties have become more hostile to the other as well, and since the election of Obama the GOP seems to have made the determination that it simply will not do anything whatsoever with the Democrats, no matter how destructive the consequences. (The Democrats, of course, continue to surrender at every opportunity – making the destruction of Democratic policies the only truly bipartisan effort in Washington.) This has the effect of pushing GOP legislative efforts further to the right, almost without limitation. Since they’ve given up on working with the Democrats at all, there is no reason for them to move at all centerward, and every reason to move toward the far right where their center of mass is increasingly drifting.

The True Believer: The Nature of Mass Movements

Given all these factors and dynamic pressures, the otherwise unbelievable storm of misogyny and hostility to ordinary healthcare that has erupted in the last few years, and especially since the last election, seems almost inevitable. It is important to recognize that, as bad as it is, this reactionary legislative blitzkrieg is not focused solely on women; the GOP is equal-opportunity crazy, and is moving backwards across the board: protection for BP after the oil spill; protection for banks who’ve committed mortgage fraud; continued subsidies for oil, coal, and agribusiness; global-warming denialism; the gold standard; opposition to unemployment benefits and economic stimulus; the war on union labor; the war on teachers and public education; the war on immigrants . . . . They hate women – viciously, and fearfully – and they hate sex and they hate sexual freedom. But they hate unions, workers, Hispanics, and just about everybody else who’s not one of them, also. And those hatreds are not new.

What has happened is that the most-rabid hate faction has grown somewhat, and it has been bolstered by a cooperative alliance with other radical factions on the right. The “Rockefeller Republican” is essentially dead, and the GOP has tied itself to a passle of far-right activist groups that acknowledge no limits on how far they should go. Given the general outpouring of right-wing fanatacism that began with the Clinton election, was inflamed by Bush and 9/11, and reached the fever stage with Obama, there is no brake – practical, electoral, or moral – that what passes for a reasonable Republican can apply anymore. The GOP deliberately stoked fanaticism and hatred by making gay marriage an electoral issue in 2000 and 2004, putting the religious-right’s pet issues at the forefront as they never had been before; the intense fight over stem cell research under Bush had the same effect. But now, with the rise of the teabaggers and Obamaphobia rampant, the GOP is having trouble riding its own tiger. The wingers have control now, and, with no limiting factor in place, they’re letting it all hang out.

So what we’re seeing on the women’s-issues front, just as with what we see on the labor, employment, education, race, and environmental fronts, is what happens when the radical fringes coalesce and feel their combined strength. None of what they are doing is new; what is new is that they can now get it past the sanity-check previously imposed by older hands with more political experience. This is the face of conservatism that conservatism previously kept hidden. It’s always been there. Now they’ve merely discarded the mask of normalcy.

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.

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.

The anti-choice “Live-Action Blog” has prominently posted a short video clip of Planned Parenthood CEO Cecile Richards explaining the impact of the GOP proposal to gut all Title X (federal reproductive healthcare) funding as well as any funds specifically for treatment at Planned Parenthood clinics. (This is the budget amendment to “defund Planned Parenthood” that has been much talked-about, but it is important to note that it kills all Title X funding entirely, as well as any other treatments at PP specifically from all other funding sources). As Richards notes, entirely correctly:

What’s gonna happen, if this bill becomes law, millions of women in this country are going to lose their healthcare access, not to abortion services, [but] to basic family planning, mammograms . . .

I don’t know what else she said, because they cut that off. The clip just repeats the word “mammograms, mammograms, mammograms” over and over – as if they’ve broken some kind of scandal in proving that the head of a women’s health service would be concerned with access to a basic and universally recommended women’s healthcare procedure.

The clip then goes on to include secretly-recorded conversations at a couple of dozen PP clinics in which . . . another scandal! . . . the receptionist confirms that Planned Parenthood doesn’t provide mammograms, but offers to refer the deceptive “patient” to a facility that does. They’ll even help you get an appointment and fill out the paperwork for a subsidy for the cost. This, the wingnut blogs are breathlessly screaming, is a immense “scam”.

So, these anti-choice “activists” have broken a really big expose of Planned Parenthood, right? (OK – if you couldn’t have guessed the answer to that without even reading the story, you haven’t been paying attention.)

They certainly think they have, or at least claim so: Live-Action blares “Planned Parenthood CEO’s False Mammogram Claim Exposed”; Left Coast Rebel claims that “Cecile Richard’s, CEO of Planned Parenthood, lied and did more to limit access to mammograms than defunding” (the latter part appears to be some convoluted argument that PP is actually denying women mammograms by referring them to facilities that provide mammograms – this is right-wing thinking on healthcare); the always-wrong Erick Erickson repeats that claim, asking “Does Supporting Planned Parenthood Increase The Risk of Breast Cancer?” (um, no – it increase your probability of being referred for a mammogram, at an appropriate facility); David Brody calls this “The Mammogram Scam”. And there’s more. Around the blogosphere, yet another coordinated Planned Parenthood “sting” is taking place, broadcasting false and just bizarrely distorted secret and misleadingly-edited tapes that mean almost the opposite of what they are twisted to say.

You have to ask: are the media going to fall for it again? Time after time, these false tapes have been dutifully repeated in the news without the slightest critical inspection (one of them was the reason for the “defund Planned Parenthood” bill – now another equally false one just happens to pop up claiming that the impact of that bill is actually evidence of a financial ripoff by Planned Parenthood itself). We can only hope this persistent and organized campaign of distortion and outright dishonesty will be recognized this time. (The Washington Post already failed.)

Let me make one point about this ridiculous “denying care” argument, before pointing out what the tape actually did say. Planned Parenthood clinics do not provide mammograms on-site; they do make referrals of patients requesting (or who have been recommended to receive) mammograms to other facilities that provide them. In some cases of these fake patients requesting them over the phone, they wound up having to call a couple of numbers to find a place where they could get a procedure that that Planned Parenthood clinic does not provide. The argument here is that it is apparently Planned Parenthood’s fault they didn’t provide instant access to a procedure a random caller requested from a facility that doesn’t offer it. On-site, some of these clinics (depending on the clinic and the state) apparently can help patients get mammograms elsewhere by providing referrals and forms to request funding from a state program that also subsidizes those procedures. The argument about this is apparently that PP is taking federal funding for mammogram services and using it merely to shunt patients off to some other facility where the procedure is funded some other way. This is nonsense in both cases, obviously. Every medical facility of every kind has a specific range of services it provides, and will refer patients to other facilities for other procedures; the fact that a given clinic does not have a specialized and expensive facility on-site, that only some of its patients need, and which requires a dedicated technician to operate, is hardly surprising and in no way unusual. As for Title X, it does provide funding for mammograms among many other things, and PP does get funding for some services under Title X, but obviously that funding is not for particular services they don’t provide, it is for the services they do provide. PP clinics do not get any funding for mammograms; what they get is Title X funding for the many other services that can be provided in an OB-GYN clinic, and which they do provide. In many cases they cooperate with cancer screening programs run by other facilities, including well-respected groups such as the Susan Komen Fund. There is no wasting of Title X funds on patients who get mammograms from X-ray facilities outside PP offices; and no denial or delay of care – if anything, the patients get mammograms faster and more readily, thanks to PP, because PP provides them with access to internists or OB-GYNs who recommend such screenings and provide referrals for them – exactly the services that the GOP is trying to kill off.

As to what the tape actually does show: Richards doesn’t say that Planned Parenthood provides mammograms; she doesn’t even mention Planned Parenthood in the edited clip they show. PP clinics do not provide mammograms for a very good reason: a mammogram, while routine, is a specialized radiological procedure that requires an X-ray suite and a trained technician. Most OB-GYN clinics don’t have an X-ray suite. They send women to X-ray facilities for that. (Your doctor doesn’t have a medical lab, either – they send your blood and urine to a specialized facility and get the results back by computer. This is standard.)

What Richards does say, correctly, is that the GOP cuts to women’s healthcare will prevent vast numbers of women from getting basic care, including mammograms, from many sources or providers. The GOP proposal cuts all funding for Title X, which does fund mammograms (at X-ray facilities, not gynecological clinics, because mammograms involve X-rays, therefore they’re done at X-ray facilities . . . am I going too fast for you, right-wingers?), and will have a considerable impact on the availability of mammograms, as well as other forms of care, for women nationwide.

Richards was pointing out the impact of this vicious bill on women’s healthcare across the board, not just in respect of her own organization, and she did so honestly and perfectly correctly. The anti-woman contingent couldn’t be bothered to understand what she was saying, or provide the context of the question she was answering, or even the full sentence in which she answered it, before whipping up another howling storm of falsehood and deception.

[UPDATE: Title X funds "breast and cervical cancer screening according to nationally recognized standards of care", which in practice means manual breast exams for individual patients during office visits, and referral for mammograms for patients with a positive manual screen. It does not appear to fund routine mammograms, though their Web site is so vague it is hard to tell exactly how it works.]

Conservative politicians often seem to me to be in [a] web of contradiction. On the one hand, they laud the consequences of generous public subsidies for the consumption of health care services and darkly warn of the perils of rationing. Then on the other hand, they insist that the projected rate of increase in government health care spending is far too high. Which is it?

- Matt Yglesias

Yes – and add to that the simply dishonest obliviousness to market-based rationing that makes the US healthcare system worst among developed nations in total-population average outcomes for many aspects of care, and the weird categorical thinking that makes government-paid care somehow bad or immoral and private-paid care good or virtuous, for exactly the same care from the same providers, and you have an entire political wing that is simply cognitively incompetent to make policy decisions.

A phenomenon that is not restricted to healthcare, it might also be noted.

The child at the center of this case is an infant born with an unspecified “neurodegenerative disease” that has rendered him ventilator-dependent and in a “vegetative state”. (No press source I have seen has used the term “persistent vegetative state”, which has an exact clinical definition, and no doctor has been quoted on the patient’s actual condition, so it is not entirely clear what his status is.) It seems to be agreed that the condition is terminal. The family has had one child with a similar condition, who was brought home from hospital and died six months later. They are requesting to do the same with this child, but his vent status complicates this.

Here is a reasonably clear explanation of the background of the case:

The hospital precipitated the standoff last month when it sought the family’s permission to remove Joseph from his ventilator. This would have led to suffocation due to his progressive neurodegenerative disease, which his doctors say is fatal anyway.

The Maraachlis want to bring Joseph home to die, but to do so he must be removed from his ventilator and given a tracheostomy.

The hospital has refused to do a tracheostomy, insisting “it is not a palliative procedure. It is an invasive procedure in which a device is installed in a hole cut in the throat.”

For its part, the family refused permission to disconnect, then went public over it, then viral, with a save-baby-joseph Facebook page, a petition site by the same name and YouTube videos showing the baby, who the hospital claimed was vegetative, responding to tickling.

The story crossed the border when a Detroit hospital initially agreed to examine Joseph but then reneged. Fox News jumped on the story anyway, and in the resulting furor the staff at London Health Sciences Centre was subjected to death threats and accusations of murder and euthanasia.

The hospital has secured favorable rulings from both a judge and the Ontario Consent and Capacity Board, but the family has nonetheless gotten the hospital to hold off. Now the latter is insisting it was always willing to let Joseph go home — without a tracheostomy.

The hospital also offered to assist with a transfer to another facility willing to accommodate the family, but none could be found. Every hospital contacted, or which agreed to look into the case, refused to accept the transfer – a situation that is common in cases in which families demand medically futile care.

Today, a Catholic group known for grandstanding on end-of-life cases has apparently arranged a transfer to a US facility; Fox News helpfully inflames the issue with its usual journalistic integrity:

The baby who was hours from being pulled off life support at his Canadian hospital has been rescued by the national director of Priests for Life and taken to the U.S. for treatment.

Thirteen-month-old Joseph Maraachli, who is currently kept alive by a respirator and was recently denied a transfer to a Michigan hospital to undergo a tracheotomy, arrived in the U.S. early Monday morning with Fr. Frank Pavone and other Priests for Life staff.

“Priests for Life staff toiled through the night for many nights, working in concert with dozens of people to make this possible,” Father Pavone said in a statement. “Now that we have won the battle against the medical bureaucracy in Canada, the real work of saving Baby Joseph can begin.” . . .

“The medical board overseeing his case is apparently convinced that giving proper care to ‘Baby Joseph’ is futile,” the [Priests for Life] website reads. “They don’t mean that the medical care won’t help him. They mean his life in its current condition isn’t worth the trouble.”

(The patient was not “denied a transfer” by his current hospital – a hospital in Michigan was contacted, reviewed the case, and refused to initiate futile treatment, just as the current hospital has done. And note that nobody is going to “save” this patient – he is dying, and even his family recognizes that. Note also that “the medical bureaucracy in Canada” are the ones who have kept the patient’s body alive this far, and were still doing so at least as of last night. And, finally, note that nobody has said, and surely nobody believes, that caring for this patient “isn’t worth the trouble”; what they mean is in fact precisely that the requested care – a debilitating intervention prolonging a hopeless case for an unconscious patient – “won’t help him“. The loathsome Pavone is deliberately inflaming the issue to grind his personal axes regarding termination of treatment and universal healthcare. As in every case of futility, the problem here is that the further treatment the family is demanding won’t do any good, but doing no good is pretty much Pavone’s mission in life, so it was inevitable he’d insert himself and start shooting his mouth off.)

The case is, sadly, another familiar example of a fairly common clinical tragedy, in which a family, for emotional or religious reasons, wants an outcome that may not be possible or optimal, and right-wing ghouls descend to distort the facts and make use of the family’s tragedy for their own religious and political ends. Predictably, Michael Schiavo Bobby Schindler has gotten aboard, still complaining about the case of his sister Terri Schiavo and making wild accusations, and the usual range of suspects is also clamoring for attention.

Before moving on to the larger implications of this otherwise ordinary case, however, it’s worth giving some thought to what is actually going on here, and trying to understand the interplay of interests and moral principles that are relevant.

Reasons for Refusal of Treatment

Almost the only information available about the case has come from the family, their lawyer, and the media-hungry agitators who are making it a political issue, so it is very hard to know what the actual facts are. But the case does seem unmistakably to be one of medical futility: the patient has no hope of recovery, further treatment will offer no change in his clinical condition, and the treatment demanded imposes costs and burdens without hope of changing the overall clinical course. Under these circumstances, the hospital recommended termination of treatment, and when the family refused the hospital waited a certain period and then moved to terminate treatment under a futility doctrine. I don’t know the exact terms of such policies in Canada (or whether they fall under national, local, or the hospital’s own authority), but in broad brush this is a familiar course of events.

The reasons for termination of futile treatment should be obvious, but are worth rehearsing again: Inevitably in such cases, there are accusations that the hospital is doing this “for the money”. (This is especially popular among American right-wingers when the hospital operates under a governmental single-payer system, as in this case. But of course US hospitals, for-profit or otherwise, are equally budget-driven, and nobody ever stops to mention the millions of Americans who never get into this situation because they simply have no access to care in the first place. But if red herrings were outlawed, there wouldn’t be a right wing at all . . .) Certainly financial resources are an important consideration – every dollar spent doing no good in a hopeless case is a dollar not spent helping a patient who could benefit. But conflicts over futility are not necessarily, or even mostly, triggered by financial considerations primarily; other resources can be equally or more important: a vent-dependent patient is taking up a ventilator, which is an expensive piece of equipment in limited supply, as well as an enhanced-care or ICU bed, nursing staff, and a part-time respiratory technician, all of which are likewise expensive and stretched thin in most hospitals. Regardless of financial issues, all this represents resources that other patients may need, and which at busy times may mean the difference between life and death for someone who could benefit in a tangible way from resources being used to provide no tangible clinical benefit to a vegetative patient. In some cases, families demand literally unlimited care for patients who can experience no benefit at all. In addition, if a given treatment is literally futile, continuing to impose that treatment may be a harm to the patient (since almost all treatments cause some degree of disruption or discomfort, and in the case of futile treatments this is not justified by any expected benefits). Clearly, limits have to be set; it seems just obvious that limiting treatments that are actually futile would be the first and least objectionable place to start.

In this case, the family does seem resigned to the fact that the patient’s case is terminal. What they are asking for is – apparently – not a miracle cure but the opportunity to care for the patient at home for as long as possible before he dies. This is more realistic than in some of these cases, and you can sympathize with the family’s desires. It’s reasonable to ask why the hospital objects, since the intervention needed to facilitate this request is not difficult to perform, and the patient would then no longer be taking up a hospital bed. Because the case has been so poorly reported, it is not clear exactly what the hospital is thinking, or why they oppose a terminal discharge to the patient’s family’s home. But it appears to me there are two issues at hand:

First, although the patient would be leaving the hospital, he would still require extensive outpatient services. The news stories do not bother to mention this, but he cannot “just” get a tracheotomy and go home – since he’s vent-dependent now, he’s not going to develop spontaneous respiration just because he’s got a hole in his throat. The tracheotomy is preparatory to placing him on a portable ventilator, which he will remain on until he finally dies. It’s easier to manage a home ventilator with a trache than with an endotracheal airway, but he’s still going to be vent-dependent for the rest of his life. As such, he will also need nursing and respiratory care, and physician oversight. Some of this can be managed by the family, but the patient will still need considerable resources from the local health authorities. It is possible that the hospital regarded this – equally clinically futile – care as an unwise use of resources, whether or not the patient was still hospitalized. Second, as the hospital notes, a tracheotomy is an invasive procedure that does significant damage to the patient’s airway, and in this case will provide no overt clinical benefit. Although this might allow the patient to go home, and that seems on its face to be a good thing, it’s important to remember that the patient himself is not going to experience any benefit from that. If this patient is truly vegetative, he is not going to be consciously aware of anything that happens, including whether he is at home or in a hospital. Sending the patient home – as natural as that seems – is purely for the family’s benefit in terms of any conscious experience any of them might gain from this. It seems to me that the hospital might be taking the line that the trache procedure cannot be justified on these grounds because it is not for the patient’s own personal benefit; the family, however well-intentioned, is clearly asking for a surgical procedure for this patient for reasons of their own – a request that directly violates the most basic accepted principles of decision-making for non-autonomous patients (i.e., that the decision-maker must act for the patient’s benefit alone, and especially not for their own benefit). This second consideration looms large: because this is a congenitally neurologically damaged infant, there can be no question in this case of “what the patient wants”, or even “what the patient would have wanted” (since the patient in this case has never, and apparently would not ever have, wanted anything). And given that the patient has no conscious experiences, good or bad, anything done in this case can only be to gratify other parties’ wishes (the family’s, and increasingly those of the growing crowd of right-wing religious agitators who continually turn these cases into fodder for their cultural jihad).

Viewed from these two perspectives – that continued intensive home care for a terminal, vegetative patient is equally as futile as continued hospital care; and that the family’s request for a surgical intervention in order to take the patient home with them is motivated by their own emotional needs, not an anticipated benefit to the patient -  the refusal of the family’s request not only makes more sense, but would in fact have to be regarded as correct, barring other factors that haven’t been made clear.

[Note: there are some factors of the case that aren't clear, and make it harder to figure out what all is going on here. First, the article at top says the hospital did, late in the game, state that the patient could go home without a tracheotomy. This doesn't change the fact that continued intervention is futile, but it weakens the objection regarding non-beneficial treatment (the tracheotomy). Futility doctrine has not generally been taken to the point of forcing families to terminate treatment if an alternative could be found; it's not clear why, if they could discharge the patient without surgery, they didn't do so. At the same time, today's intervention - transferring the patient to another hospital in a different country - also does not accomplish the family's goal of taking him home with them. It may be that they decided they would rather seek continued life support in a hospital setting if they could not get the home-care option they preferred, but that makes the case a more typical futility scenario of a family demanding open-ended treatment that produces no clinical benefit, rather than one of them just seeking help in finding a more congenial terminal setting. Interestingly, both of these developments minimize the significance of the tracheotomy as the sticking point in the case (unless he's going to get a tracheotomy in the US, and then go back to Canada to die, which would create a complicated administrative conflict - are Canadian providers obligated to pay for after-care for procedures in foreign countries that they had previously refused to authorize at home?). With so much unexplained about the case, it's hard to know how or why any of this is happening.]

Alternative Considerations

For the same reason that the tracheotomy will not benefit this patient, however, it should be noted that it will not severely harm him either. Ventilator dependency is uncomfortable, and a tracheotomy generally destroys the patient’s larynx, making it impossible for them to talk. But, since this patient – if he is truly irreversibly vegetative – cannot feel or speak anyway, those are not major issues. The patient is not going to experience any conditions, at home on a vent, worse than he currently experiences in a hospital on a vent (which is to say, nothing at all). This suggests – again extrapolating from the vague descriptions in newspaper stories, mostly from very biased sources – that the objection to the tracheotomy, though properly based on considerations of preventing the imposition of unbeneficial harmful procedures on the patient, may be overstated; this procedure may be futile, but it would not be a harm that the patient was actually conscious of.

Given that observation, the objection that the family is acting out of their own interests is likewise well-taken but perhaps rather formalistic: they are not acting strictly in the patient’s interests, but the patient has no (consciously felt) interests and can (consciously) experience no harms, so what is gained by insisting on strict adherence to that principle here?

At this point it is also meet to introduce the question of subjective benefits of treatment. Throughout the discussion above, I have been careful to focus on “clinical changes” from treatment, and “conscious experience” of benefits and harms. These are the objective consequences of treatment: actual changes in the patient’s clinical condition as determinable by examination, and the actual experience of and reaction to events by the patient themselves as consciously felt by them. I have been careful not to specify what clinical changes actually constitute a benefit, and I have avoided the question of subjective benefits that might conceivably accrue even to an unconscious or vegetative patient. But it’s fair to acknowledge that some people might regard clinically futile treatments – treatments that do not produce a significant change in the patient’s clinical condition – as beneficial, if they serve non-clinical interests the patient may have. Some patients have a personal or religious desire to live as long as possible, regardless of clinical condition; this is valid where it represents an authentic desire of the patient. (It is in no way mandatory, still less anything that religious reactionaries can be allowed to impose against a patient’s will, as in the Schiavo case and so many others. And of course the mere existence of that desire does not constitute an obligation on anyone else to provide the resources to fulfill it.) Some patients may want to die at home rather than in a hospital; some may want to meet specific goals in life (live to see a meaningful event in their lives, spend time with their family before the end, wait to have final meetings with friends or family members, etc.). And some may have religious beliefs about the right way or right time to die. All these may require continued treatment in otherwise clinically hopeless cases, and they are certainly valid interests of some patients that can be met through continued treatment. It is important to remember that all treatment – whatever its clinical consequences – is valuable only because it serves some interest of the patient; the clinical impact of any treatment – however great or minimal – means nothing except in the light of what the patient themselves wants. And so, clinical treatments can only truly be considered futile if they fail to serve the goals of the patient in seeking treatment, not simply because they do or don’t produce a cure or any other particular clinical outcome. This consideration is meliorated in the Baby Joseph case by the fact that the patient himself, as noted above, holds no such desires. But we should remember that it’s too simplistic to treat “futility” as simply a matter of clinical efficacy in a technical sense.

Summing Up

Given the considerations above, and reading between the lines of the news reports a bit, the situation seems sad and confounding, but far from a scandal. That hasn’t kept the vultures from whipping up their usual “death panels” frenzy, of course, but we don’t have to play along.

The family wants to bring their child home to be with them; possibly also they want to prolong his life as far as possible regardless of his condition, but that part’s less clear. Either way, it’s easy to understand, and perhaps sympathize with, their wishes. But we must also realize that this is their desire, arising from their own needs and interests; it cannot be an individual desire on the part of the actual patient. This is not to accuse the family of being uncaring or manipulative; no doubt their desire is to care for their son the best way they can, which means as closely a part of their family as they can manage. It’s just that, in the nature of things in this case, that desire cannot arise from or be shared by the son himself, and so the family’s sincere desire to provide the best possible treatment runs up against the facts that this patient cannot expect any overt clinical benefit from prolonged treatment, and cannot form or hold any personal, subjective values or goals that would be served by continued treatment. Thus, the family’s plans do not actually serve the patient’s own, personal good, no matter how sincerely they intend to do so. (Note particularly that the religious value some place on prolongation of life cannot be an issue in this case, since the child has no religious – or any other kind of – beliefs of his own.)

The hospital wants to minimize the expenditure of clinical and financial resources without benefit (on an inpatient, and possibly also an outpatient basis); in this case continued treatment of this patient will produce no clinical benefit other than prolonged stasis in a vegetative state. The hospital also apparently objects to performing an invasive procedure on a non-consenting patient with no hope of clinical benefit, in response to a third party’s wishes – though here also their precise reasoning is less clear. Since the patient has no personal desires to be accommodated, the issue of possible subjective benefits from clinically futile treatment does not arise. Thus, the hospital is acting in keeping with obviously reasonable priorities and well-recognized principles of patient autonomy, and is not acting contrary to the desires or interests of the patient himself.

In light of this balance of interests and principles, the hospital’s objections to continued or increased treatments in this case are not unreasonable. Even so, given that the patient cannot suffer conscious harms by more-aggressive intervention, it may seem that the hospital is being unnecessarily nit-picky. It may seem reasonable that, even though the patient cannot benefit overtly and has no desires regarding possible subjective benefits, it might be reasonable to “give the family the benefit of the doubt” and let them do what they want. The problem with this is multi-fold: (i) it establishes a principle whereby unconscious patients without advance directives can be treated whatever way someone else wants, for the other party’s benefit – thus voiding the established consensus on substituted judgment; (ii) it elevates parents’ religious or personal beliefs above patient interests for minor patients – an already-contentious issue in decision-making for children by parents; (iii) it would essentially void the entire concept of medical futility by making virtually any articulated desire by family members (or other third parties) a sufficient ground for prolongation of treatment no matter how hopeless (and it is easy to suspect that this is in fact the goal of the right-wing interlopers who have jumped on this case). Even if we are tempted to void ethical principles in this case, where it seems there are few or no direct interests of the patient at stake and the patient has not expressed any prior preferences that might be violated by continuing treatment, and even if we are willing to disregard any questions of competing priorities or limitations on resources (which the hospital understandably is not), agreeing that principles can be voided, and resource limitations should be overlooked, is a dangerous step when so many such cases arise, and especially in the face of a coordinated movement to hijack patient-centered care for religious and political reasons.

Further Observations

One feature of this case that does call out for sympathy is the obvious concern of the family for their son. And this is common in many such cases, not only involving children but dependent adults, elders, and others. It is understandable that in these cases the family’s interest in soothing their own feelings is not distinct from, but to a large degree indistinguishable from, their love for the patient and their desire to do the best for that patient themselves. It seems cold to insist – even if technically true – that taking a family member home to die does not serve that patient’s own interests (because, as cognitively diminished, they may have none). I am tempted to speculate about a possible limited exception to the rule of substituted judgment in the patient’s interest: in cases where the patient has literally no countervailing interests of their own, is it reasonable to allow decision-makers (specifically, family members) to act for their own interests in relation to the patient, by bringing them home to die or maintaining life support for non-suffering patients even when there is no hope of cure? The dangers seem to me significant, and the possibility that such exceptions would be further misused by political interests almost inevitable. Still, it’s worth thinking about in cases like that of Baby Joseph: where the family is clearly acting out of love for the patient, but not in the patient’s interests, would it be wrong to indulge their desires if it at least doesn’t harm the patient?

Worth discussing, perhaps.

UPDATE: Fixed mistake in the name of Terri Schiavo’s brother, Bobby Schindler. Thanks to Barry in comments.

The U.S. healthcare reform law will worsen a shortage of physicians as millions of newly insured patients seek care, the Association of American Medical Colleges said on Thursday.

The group’s Center for Workforce Studies released new estimates that showed shortages would be 50 percent worse in 2015 than forecast.

“While previous projections showed a baseline shortage of 39,600 doctors in 2015, current estimates bring that number closer to 63,000, with a worsening of shortages through 2025,” the group said in a statement.

“The United States already was struggling with a critical physician shortage and the problem will only be exacerbated as 32 million Americans acquire health care coverage, and an additional 36 million people enter Medicare.”

To their credit, they are not positioning this as a criticism of the increase in access to healthcare, rather as an indication of the need for more trained physicians. But Reuters of course found a way to point blame (“Health reform to worsen doctor shortage”), and already the wingnut blogs are piling on.

Hot Air:

the [healthcare reform] bill will have a big impact on an expected shortage of physicians over the next few years — by amplifying it . . . The artificial cap on reimbursements — a form of price-fixing — will be the main culprit.

Note of course that the actual press release explicitly cites the relative projected growth of the patient and physician populations – a straightforward mathematical ratio – and says nothing at all about reimbursement caps; it also cites both Medicare eligibility – a demographic phenomenon – and the health bill as the sources of that growth. (And, of course, the bill does not specify a global cap on reimbursments, contractual provider payment maximums are not “price fixing”, and the for-profit insurance industry universally specifies maximum reimbursements in its contracts already. But mere conceptual confusion and knee-jerk wrongheadedness are only the ordinary level of stupidity at that blog. And Conservative Reading Comprehension Disorder, of course, rages on.)

This projected shift in provider/patient ratios is an obvious – and remediable – result of providing more access to healthcare to tens of millions of people who now have little or none. Of course there’s going to be more demand for doctors if a bunch of people who don’t have access to one suddenly have a means of getting access. What is striking is that the right sees this as a reason not to provide that access.

The implicit – and at times explicit – conclusion drawn from the fact that more patients means a need for more doctors is that we should not provide access for more patients. The right’s actual, quite literal, reaction to the possibility that they might have to wait longer to see their doctors is to keep other people from seeing doctors, reducing the size of the patient pool rather than increasing the size of the provider pool, literally demanding that others should suffer for the right’s personal convenience. It staggers me that these nasty creeps are even listened to, let alone taken in any way seriously, on healthcare or any subject that touches people’s vital needs.

First, Planned Parenthood does not have an “abortion business”. (They’re a non-profit – they aren’t a business at all.) Abortions (just 3% of PP’s annual clinical visits, nationwide) are provided by PP at rates generally below cost – they are subsidized by donations. (This – and their non-profit status – defeats the lie that PP is making a “profit” on abortion services.) Funding for other services is also heavily subsidized, and also in part paid for under government aid programs for healthcare for low-income people – typically Medicaid or SCHIP. That is, low-income patients who qualify for subsidized care can get that care at PP – while many for-profit providers simply refuse to take such patients at all – and PP is reimbursed, just like any clinic, under the appropriate plan. Those fees pay only for the services rendered, at the government-mandated rates, which are so low that, again, most mainstream providers simply refuse to accept them or the patients that are thereby covered. PP makes up the difference from its donation revenue – the government payments are so low they not only do not fund other PP activities, they don’t even fund the activities they nominally are supposed to pay for. (This defeats the lie that low-income healthcare reimbursement subsidizes abortion services.)

All this can easily be verified by looking at PP’s publicly-posted annual reports, which clearly show that a large portion of its clinical costs are subsidized by donations (24% of all revenue, in 2007) - no source of fee income for clinical services, whether abortion-related or not, government or private, is sufficient to actually pay for those services; all such fee income is used up in costs of the care itself, and then some.

But beyond this, the actual effect of the funding cut, as mentioned above, is to force closure of a clinic that did not provide abortions. The entire dishonest grandstanding really targeted ordinary healthcare and reproductive health services for low-income patients, largely women but some men. It had nothing – financially, practically, or even geographically – to do with Planned Parenthood’s abortion services, or the availability of abortion in New Jersey in general. But anti-choice ideology was a convenient stalking horse for the GOP’s anti-woman, anti-healthcare, anti-sex hatred, and it worked perfectly in this case.

What Planned Parenthood of Southern New Jersey actually does do – and which is no longer available from the clinic that is shutting down – includes, among other things:

Women’s Reproductive Healthcare:

• All methods of contraception, prescriptive and non-prescriptive
• Complete GYN physical exam
• Treatment for many GYN problems
• Laboratory screening
• Cancer screening (Pap test, breast self exam)
• Testing and treatment for Sexually Transmitted Infections (STIs)
• Emergency Contraception
• Colposcopy & cryotherapy
• Pregnancy testing & counseling
• Pre-Natal Care
• Gardasil  (HPV vaccine) 
• HIV testing & counseling
• Hepatitis B vaccine
• Vasectomy

And:

Male Services (25 and under)

• Condoms / Contraceptive Education
• Sexually Transmitted Infection (STI) screening & treatment
• HIV Testing & Counseling
• Health Screening

And:

Pre-natal care plays an important role in providing a comprehensive package of medical and health support services for the pregnant woman. Pre-natal care promotes optimum health, prevents disease and provides a mechanism to manage potential problems and can have a long lasting positive effect upon the family. At PPSNJ, we provide the following pre-natal services: 

• Medical exams
• Laboratory services
• WIC Program
• Pregnancy support and education
• Nutrition education
• Adolescent parenting support groups
• Delivery at Cooper University Hospital or other referral

And:

[C]omprehensive, age appropriate sexuality education and training for pre-adolescents, teens, families, schools, community groups, faith-based settings, other social service organizations and healthcare providers. 

• Workshops and Professional Training
• Speakers and classroom presentations
• Curriculum Development
• Teen Programs
• Fathers Group

None of that is available now, at one of their primary locations, thanks to the “pro-life” assholes of the Republican party. Their ideology is made clear by the fact that the elimination of this funding not only has no affect on the funding of abortions (see above), but in fact directly impacts a clinic that does not even provide abortions. What it does eliminate is a local source of low-cost healthcare for the financially needy population, most of it focused on reproductive health and pre-natal services. That was their target, and that was their effect. The abortion nonsense – aside from being an outright lie – was a red herring.

The GOP hates women, hates the poor, and hates people who make their own decisions about sex and reproduction. Today they’ve eliminated healthcare for thousands of them, while having absolutely no impact on abortion, although banking on and claiming a political payoff for anti-choice ideology as a means to that end.

More of their standard, repulsive, dishonest and hateful same.