Sufficient Scruples

Bioethics, healthcare policy, and related issues.

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.

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.

(more…)

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.

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 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!)

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 . . .

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Familiar Disinformation Assault on Planned Parenthood Now Building

by @ 3:15 PM. Filed under Access to Healthcare, Global/Community Health, Healthcare Politics, Provider Roles, Reproductive Ethics, Sex, Women's Issues

Right-wing sites are loudly touting yet another of their doctored videos and deceptive recordings to vilify Planned Parenthood – this time with an accusation so blatantly misconceived it hardly makes sense.

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.]

“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 24, 2011

Medical Vengeance: Interminable Detention for Mental Patients

by @ 11:06 PM. Filed under Autonomy, Disability Issues, General, Healthcare Politics, Provider Roles, Theory

Patti Davis – daughter of Ronald Reagan – has an opinion article in Time Magazine today, arguing against the release of John Hinckley from the psychiatric hospital where he was confined after attempting to assassinate Reagan 30 years ago this week, in the throes of a psychiatric obsession that led him to seek fame through violence. The piece is calm and rationally written, and sympathetically conveys the suffering of the several victims of the shooting and their families. But it’s a perfect example of the dangers of confusing punitive and rehabilitative detention, and of treating medicine and psychiatry as tools for governmental control of citizens’ beliefs, values, or behavior.

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Not Waiting to Exhale

by @ 2:24 PM. Filed under Access to Healthcare, Autonomy, General, General Science, Healthcare Politics, Provider Roles, Reproductive Ethics, Women's Issues

Here’s an interesting peer-to-peer phone-line support service for women who have had an abortion and want to talk to other women about it.

Exhale serves women who have abortions, and their partners, friends and family. We respect the cultural, social and religious beliefs of all our callers.

Apparently they’ve been in operation for about 8 years, and claim to have taken close to 20,000 calls; I’m embarrassed to say I’d never heard of them before. Their Web site makes them sound like a neutral listening post for those who want to talk about their experiences and feelings about them, regardless of what those feelings might be or what the caller’s perspective on the whole issue is. I have no direct experience with this group, so I can’t say how accurate this is or how well it works, but the Web site seems to me like it takes just the right tone:

  • Exhale views each individual as a “whole person,” respects their belief system and strives for cultural competency.
  • Exhale believes that self-awareness, self-care, and knowledge can empower individuals.
  • Exhale seeks to transform oppression by challenging its roots and empowering each other and our communities.
  • Exhale values the spirit of collaboration.
  • Exhale believes abortion can be a normal part of the reproductive lives of women and girls.

The problem, of course, is that the entire notion of abortion “counseling” is generally a deception perpetrated by anti-choice groups to trick women into being manipulated with slut-shaming and false information. That makes me leery of any group – however honest and above-board – that sets itself up to provide such counseling. And, given the documented fact that abortion is not uniquely associated with psychological trauma, and since we don’t normally set up support groups for every individual outpatient surgical procedure (“Expel seeks to transform colonoscopy . . .”), the implication that there needs to be one for abortion specifically also smacks – just a bit, perhaps – of a negative, or at least defensive, stance toward abortion in general. But their Web site specifically disclaims this, and, without direct knowledge, I’m willing to take them at their word.

It is valid to recognize that abortion can be an emotionally fraught experience. While it is an important, useful, and sometimes life-saving procedure, abortion is unusual (though hardly unique) in that it is a treatment for a condition that is often regarded as actually desirable, and that most women, including most women who have abortions, will seek voluntarily at some point in their lives. There is no contradiction in the fact that pregnancy can be wanted under some circumstances and unwanted under others, and it makes only the most obvious kind of sense that there should be treatments available for those cases in which it is unwanted, and that many women will want “an abortive remedy” when that serves their needs and interests under their particular circumstances. But it is understandable, too, that an unwanted pregnancy may call up thoughts about pregnancies they patient may want or embrace under other circumstances, and that a particular pregnancy may be unwanted due to immediate circumstances that the patient wishes she could change, and would be wanted under those changed circumstances. So it’s easily understandable that some women’s feelings about their abortions would be complex, even while they are firm in their conviction that having one is/was right under the circumstances at the time.

Given the virulent campaign to make women feel guilty for making their own decisions about pregnancy, and to use that manufactured shame and guilt as a tool to keep them from doing so, even admitting that women may have conflicted feelings about abortion, or indeed that it is possible to be conflicted about one’s decisions without that fact undermining the right to make one’s own decisions at all, is the kind of frank discussion of fact that becomes so dangerous in the face of organized campaigns of falsehood that consistently distort facts to attack women’s independence. But an honest discussion of abortion, and honest, respectful, and welcoming acknowledgment of the women who have abortions, requires treating simple facts in a true and honest way. It in no way undermines the pro-choice principle – even if it will be used as a dishonest political attack – t0 say that women may have complicated feelings about pregnancy and abortion and may want to talk about them, and it serves those women more fully and respectfully to address that need openly and provide a tool for meeting it.

One bit of the Exhale Web site took me aback, and then left me even more impressed with their apparent devotion to honest and value-neutral service to women. They say:

If you have been diagnosed, or have self-diagnosed, as having Post-Abortion Stress Syndrome, Exhale understands that having a name for what you’re feeling and experiencing can feel important.  Many women find the experience of identifying with this syndrome as positive and affirming.  It is also important to know that having feelings about a significant life event doesn’t mean that you have a major psychological condition that requires medical care.  For many women, naming and expressing their emotions, and having the space and support to do so, can be more empowering than being identified as having a disorder.  Whether or not you think you have PASS, the most important thing is that you get support for what you’re feeling, not what someone else thinks you should be feeling.  Exhale trusts you to know what feels right for yourself.

Exhale follows the findings of the American Psychological Association, which has not found a link between feelings that follow an abortion and a psychological condition in need of medical care.

This is startling, but strikes me as exactly right. “Post-Abortion Syndrome” is a wholly imaginary and deeply dishonest “diagnosis” invented out of whole cloth by anti-choicers. It exists (actually, is claimed to “exist”) only to discredit abortion – a procedure that serves women’s health and autonomy interests in a centrally vital way, and is actually safer than childbirth in almost all cases – as somehow pathological, in open defiance of established data (yet another example of a tactic that is pervasive on the right wing). The campaign to tout this fraudulent “syndrome” as a real condition has misled many women, often the youngest and most vulnerable among them; this is not just a travesty of medical science but an assault on women and their freedom. But the fact that some women have been conned into worrying about this fake disease, or mistaking their own natural complexity of feelings, or even regret, for some sort of illness on their part, must be met sensitively and with respect for the women who have those feelings, and the feelings they have.

It is unconscionable to participate in or endorse the deceptions the misogynist right practices against women and women’s independence, but it is vital to meet those women themselves, where they are and as they are feeling, and to validate their own perceptions of their situations and help them deal with them on their own terms. Exhale seems to walk this line bravely (given how easily such a stance can be misconstrued and used against them) and sensitively (given the difficulty of managing such a delicate distinction).

From what I see here – and again, I have no direct knowledge – the group hits the nail right on the head, in terms of acknowledging the range of women’s experiences and prioritizing their own perspectives on their situations, without downplaying every woman’s right to make her own decisions about reproductive health. (Including family and friends, including men, in their services is also a sign of a sensitive and realistically broad approach.) Healthcare has more and more come to recognize the importance of a wholistic approach to patients’ needs and experiences, including post-treatment support. In a field in which any admission of need is turned into yet another attack on women’s strength and claim to independence, simple decency and understanding can become a liability. By refusing to play those games, the approach that Exhale seems to embody returns the truly important issue – women’s need for service, support, acceptance, and respect – to the center of the abortion issue where it belongs.

I’d be interested in hearing what others think or have seen, regarding Exhale or similar services. Has anyone who is willing to discuss it here participated in such counseling, or served as a facilitator? How significant is this sort of support, and does it help?

UPDATE: Wow, am I a dumbass! Somehow I completely forgot about this organization, after I had previously blogged about it back when they were first starting up! Guess I should read my own blog more often.

Additionally, I have heard from well-respected sources that Exhale is legit – they will talk to anyone in a non-judgmental way, but are in no way anti-choice.

March 14, 2011

More Ghoulish Posturing in a Vegetative-State Case

by @ 4:03 PM. Filed under Access to Healthcare, Autonomy, Child-Rearing, Disability Issues, General, Global/Community Health, Healthcare Politics, Provider Roles

The “Baby Joseph” case has been making the rounds of the right-wing press for some time, and is now in the mainstream press due to a confluence of right-wing hype and a predictably distorted Canada-vs.-US angle. As always, bad cases make good press releases, and rational standards of care suffer.

(more…)

October 1, 2010

“Duh” Headline of the Day: Patients Without Doctors Will Need Doctors

by @ 2:05 PM. Filed under Access to Healthcare, General, Global/Community Health, Healthcare Politics, Provider Roles

The Association of American Medical Colleges released a report yesterday that reaches a fairly obvious conclusion: increased healthcare coverage through Obamacare and the Baby Boomers’ entering Medicare will result in an increased demand for physician services, and thus worsen the current imbalance between providers and patients.

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.

September 23, 2010

Republican Anti-Choice Assholes Reduce General Healthcare Availability . . . Again

by @ 12:51 PM. Filed under Access to Healthcare, Autonomy, General, Global/Community Health, Healthcare Politics, Provider Roles, Reproductive Ethics, Sex, Women's Issues

Today the wingers are hugging themselves over the fact that the New Jersey state legislature failed to override Gov. Christie’s veto of family-planning funding for low-income women in that state. The funding reduction particularly targets services provided by Planned Parenthood – the nation’s largest single non-governmental provider of reproductive healthcare to the poor. Naturally, this was trumpeted as an attack on “Planned Parenthood’s abortion business” – a claim as false as it is stupid. Not only were the funds in question earmarked for services that have nothing to do with abortion, but they provide no indirect support of abortion, and the clinic that was affected does not provide abortions! What the Republicans did manage to do was shut down basic and necessary reproductive healthcare services – of virtually all kinds except abortion – for thousands of low-income patients, while crowing about their non-existent and deliberately disengenuous anti-choice “coup”.

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.

September 20, 2010

Doctor Knows Best

by @ 11:04 AM. Filed under General, Healthcare Politics, Medical Science, Provider Roles, Theory

This is an odd story from the ongoing saga of the miners who have been trapped underground in Chile for more than a month now, with still some time expected before their rescue.

A small shaft has been drilled to their location, and they have been supplied with food and water, and other amenities, through the tube; at first they were stressed and suffering, but are now apparently in better health. They are also in communication with the surface by phone and video, and are frequently being interviewed and monitored by a team of psychologists who are trying to help them get through their long confinement. But the management of the mental health portion of the rescue effort seems to have degenerated into a power struggle between the psychologists and the miners, with the doctors imposing their own standards of behavior through petty disciplinary actions, provoking the anger of both the miners’ families and the miners themselves, whom they are ostensibly trying to help. The doctors are supported in this by NASA psychologists who have been called in to consult, due to their experience with crews under isolation and confinement for long periods on space missions, but it’s not clear the NASA people have any reasonable sense of how to handle things either. The linked article, which as usual offers few details and no explanatory rationale, seems to hint that this conflict has been staged by the psychologists in order to give the miners a focus for their tensions and keep them from taking things out on each other – which would be a bold but questionable strategy if true, though it’s impossible to tell from this article what’s really going on. At any event, this seems to be a very strange and fraught situation.

”The honeymoon is over,” explains Alberto Iturra, the lead psychologist in the operation to free 33 men trapped 700 metres deep in San Jose mine. As point man for the psychological health of the trapped men, Mr Iturra is at the receiving end of the rage of relatives of the miners who are upset at the Chilean government’s refusal to deliver letters considered ”psychologically inappropriate”.

The widespread censorship of letters to and from the miners – which the government now claims has ended – acted like a spark to ignite what was already a simmering conflict: family members ever more desperate for their loved ones to be rescued and the government medical team battling to keep the miners psychologically united and working as a group.

”The honeymoon lasted two weeks,” said Dr Jorge Diaz, the lead physician in charge of monitoring and maintaining the health of the 33 men. ”Now the men are starting to demand certain things and we begin to restrict others. We are measuring each other’s strength.”

With their health improving and patience expiring after six weeks underground, the 33 miners are restless. On several occasions, they have refused to talk to psychologists, cancelled a series of meetings with doctors, delayed implementation of vaccinations. The men have few problems, however, making their desires clear: cigarettes and wine.

Over the past 10 days, the Chilean government’s psychological team has ceded to certain demands. Last week, the initial delivery of cigarettes was sent down the 700-metre tube that is essentially a lifeline to the trapped men and widely known as the ”umbilical cord”. . . .

In an effort to dominate the miners, the team of psychologists led by Mr Iturra has instituted a series of prizes and punishments. When the miners behave well, they are given TV and mood music. Other treats – like images of the outside world are being held in reserve, as either a carrot or a stick should the miners become unduly feisty.

In a show of strength, the miners have at times refused to listen to the psychologists, insisting that they are well. ”When that happens, we have to say, ‘OK, you don’t want to speak with psychologists? Perfect. That day you get no TV, there is no music – because we administer these things,”’ said Dr Diaz. ”And if they want magazines? Well, then they have to speak to us. This is a daily arm wrestle.”

After weeks of demands, the miners are now focusing on a few precious requirements – they want daily letters from their families and wine to celebrate Chile’s Independence Day today, particularly noteworthy this year as Chile celebrates its bicentennial.

While NASA experts brought to Chile as advisers have recommended sending the wines and withholding the cigarettes, the Chileans have done the opposite, saying the miners have nearly two kilometres of ventilated tunnels to smoke a cigarette and relax (as opposed to the confinement of space travel) while further noting the average miner consumes large quantities of alcohol. . . .

Despite rising tensions, the medical and psychological team is content, and they have received glowing reviews from the team of NASA psychologists. Furthermore, many of the symptoms now being shown by the miners are typical of group dynamics when people are placed in confined and stressful environments for more than six weeks.

”NASA told us we have to receive the arrows, so that they don’t start shooting the arrows at each other,” said Dr Diaz.

”So we are putting our chests forward – now they can target the doctors and psychologists.”

It seems as if the psychological team has taken it upon themselves to impose their own view of optimal healthy behavior for the miners: no smoking, no alcohol, no psychologically stressful communications. But of course the miners prefer to live as they have chosen to on the surface, whether or not it’s optimal for their physical health – as in fact we all do, under ordinary conditions. Normally, these doctors would have no say in how the miners live; only the fact that they now physically control the miners’ access to the things they want gives them the opportunity to impose their own choices, and they have assumed the authority as experts to do so. But as the doctors themselves acknowledge, it’s apparently not actually dangerous for the miners to smoke or drink underground when they’re just waiting to be rescued and have an adequate air supply, so there appears to be little reason not to give them what they want. The doctors have responded to the miners’ insistence on making their own decisions by imposing punishments, actually withholding things that would be to the benefit of the trapped workers, and essentially behaving like the wardens of an accidental prison.

It’s worth noting that “crew mutinies” have been a frequent feature of NASA space missions – and NASA has generally responded punitively as well (deliberately destroying the careers of a number of astronauts while pretending that everything was OK). There is obviously a complex psychology to being confined in a small space under dangerous conditions (especially, I would think, as the result of accident), and it’s clear that the “experts” know little about it, cannot predict its consequences, and have developed only the most limited and heavy-handed tools for managing it. The authoritative mindset that allows doctors to assume that they have to “manage” other people’s emotional states in the first place encourages experts to demand obedience in even the smallest things, to defend their prerogative to do so by citing a dubious scientific justification, and to enforce their demands with tyranny and retribution. That NASA supports that approach in this case may be grounded on a real basis of experiential knowledge, but their own history suggests they have only limited skills or insights in such matters.  (The fact that NASA didn’t appreciate, in this case, that there’s a difference between a space station with a recirculated air supply and a miles-long underground tunnel with unlimited air, or between military-style missions by highly trained crews sworn to obedience operating in technological environments and the rough-and-tumble world of hard-rock mining, also calls their insights into question.)

The suggestion that this is to some degree planned – that the doctors are deliberately antagonizing the miners in order to unify them against the doctors themselves and prevent intra-group tensions – is the most provocative aspect of the situation. If this is true, the seemingly punitive measures the doctors have taken are more understandable, but still require justification. First of all, these kinds of “reverse psychology” power struggles seem more like clever tricks than real psychotherapeutic techniques. I don’t know if there is any research showing that withholding privileges to miners trapped underground is in fact likely to increase their psychological strength, as opposed to, for instance, increasing their stress and causing them to break down, but unless there is a real reason to think this sort of thing actually works, it amounts to nothing more than a risky and cruel experimental exercise by the doctors. And even if there is some reason to think it could help, it’s also not obvious why we can’t just trust the miners – people who depend on each other while risking their lives in that mine every day – to take care of themselves.

It’s possible that this incident is being handled with sophistication and professional dedication, by doctors who have boldly made themselves the instruments of their own “patients’” salvation. But it’s also possible – and more than plausible – that this situation has gone out of control due to the self-aggrandizing and scientifically ungrounded lust for power of petty tyrants who resent being thwarted by those they claim authority over. What seems certain is that the miners themselves know their own wants and needs, and those wants are not unreasonable; that it is simply assumed to be out of the question to let them manage their own health, physical and mental, under conditions in which they are dependent on others for the means to do so, is as telling as whatever the actual outcome of this situation may be.

July 30, 2010

Convenient Double Standard on Drug Use

by @ 10:54 AM. Filed under Disability Issues, General, Healthcare Politics, Provider Roles

USAToday reports a study of the high rate of suicide and drug-related deaths in the military. The report concludes that such deaths have increased because soldiers, particularly during wartime, are “inclined toward risky personal behavior”.

After nine years of war, the Army attracts recruits ready for combat but inclined toward risky personal behavior — a volatile mix that led to more deaths from suicide, drug overdoses and drinking and driving than from warfare, an Army review concludes. “Simply stated, we are often more dangerous to ourselves than the enemy,” says the 15-month study, released Thursday.

 Commanders have failed to identify and monitor soldiers prone to risk-taking behavior, the report says. As a result, suicides among soldiers have soared. . . .

Many recruits join the Army knowing they will be sent to combat, so they may “even be more comfortable accepting high levels of risk and uncertainty in their lives,” the report says. . . .

Chiarelli commissioned the review 15 months ago as the Army suicide rate exceeded that for civilians. The study says poor command decisions helped contribute to a record 160 suicides by active-duty soldiers last year and an additional 146 deaths resulted from risky behavior such as drug or prescription medication abuse. Seventy-four of those deaths were overdoses.

Randall McElroy III, at The Distributed Republic, has a useful comment:

Internal investigations by government agencies always seem to turn out this way. It’s not the multiple deployments, the stress of fighting in a conflict where you can’t tell who wants to kill you until they’re doing it, the moral burden of shooting at innocent people, the vagueness of the goals of the conflict, or any of that. In other words, it’s not the essential part of what soldiers do these days.

It’s that, for some reason, without any causes, soldiers are engaging in risky behavior, and their commanders are just too darn earnest about prosecuting the war to notice.

However, I wanted to note the way drug- and alcohol-related deaths are handled in this story.

Half of all such deaths in this study, and a quarter of all “risky behavior” deaths for last year, were caused by drug overdoses. Soldiers are taking illegal drugs and dying from them, at higher rates than among civilians. Had these been civilian deaths, the narrative would have been simple: junkies OD and die. Surely far more than 74 civilians fatally ODed last year (though the per-capita rate is still lower); you don’t see many stories about this growing menace. What you certainly don’t see are civilian drug users characterized as “risk takers” or “comfortable accepting high levels of risk and uncertainty in their lives”. Convulsing to death with a crack pipe in your hand, if you’re a soldier, however, is apparently something like fastroping into a hot LZ or charging a machine-gun with a bayonet – the sort of thing those gung-ho heroes do because, you know, they just can’t help being so macho.

I wouldn’t mind this so much, if it were in any way honest. Identifying psychological factors that contribute to drug-taking, in fact, is a welcome step forward (even if slightly implausible in this case; chalking drug use up to simply being “prone to risk-taking behavior” is not only vague and one-dimensional, but even in some way circular). If the government were to take its own treatment of this issue seriously, and begin to sincerely probe the psychological and circumstantial factors that lead some people to drugs, we might be able to approach the issue of drug use in a more rational and realistic way. But of course that’s not what is being done here.

Characterizing drug-using soldiers as “risk-takers” is simply assigning a convenient euphemism to behavior, and its tragic consequences, that are relentlessly condemned in other circumstances. This is convenient in several ways: as McElroy notes, it lets the military off the hook for putting these soldiers under the stresses that, indirectly, killed them; it also preserves the unchallengeably heroic facade that the military is allowed to hide behind in all circumstances; and it gives these soldiers a pass on the judgmentalism that otherwise greets mental illness or drug use. Even outright suicide is treated as “risk-taking” – an absurd circumlocution that neatly obviates the inquiries into soldiers’ mental states, and the effect that military service has on them, that would otherwise be inevitable. In this way, behavior that would certainly be categorized as pathological, illegal, and disreputable in anyone else is folded into the military’s self-assumed and deliberately promoted ethos of heroism and rugged virtue.

Nobody is going to go on from here and say “Hey, you know, civilians also experience stress, self-medicate to deal with it, and exhibit a range of coping mechanisms influenced by their own psychology and their propensity for risk-taking. Maybe we should lighten up on the moralistic rhetoric about drugs and start recognizing the real-world factors that influence behavior, so we can respond more sympathetically and effectively. Maybe some proactive interventions with people at risk would help them out. Maybe our leaders have a responsibility to create better living conditions and offer better interventions to people at risk to help prevent self-destructive behaviors ahead of time, rather than sending millions of people to jail for being heroic, macho, rugged risk-takers.” Because the people who are painting military junkies and suicide cases as heroic, combat-ready risk-takers don’t really believe that and don’t really give a shit about people’s problems, in or especially out of the military. They certainly have no investment in being accurate, honest, realistic, or sympathetic about stress, pathology, and self-destructive behavior. Sugar-coating America’s Heroes to sweep a military-related drug problem under the rug avoids dealing with drugs realistically in any venue – which is the one thing any of our drug programs can never do.

June 30, 2010

Kagan Trifecta: Conservative Reading Comprehension Disorder, Utter Mendacity, and the Noise Machine

by @ 12:31 PM. Filed under Access to Healthcare, Autonomy, General, Healthcare Politics, Medical Science, Provider Roles, Reproductive Ethics, Sex, Theory, Women's Issues

There’s a lot of blogging today over a sensationalistic post at NRO by Shannen Coffin, a former Bush lawyer who was responsible for anti-choice litigation surrounding the so-called “partial birth” abortion ban. She He notes a 1996 memo from the files of the Clinton administration, predating Clinton’s veto of the anti-choice bill, in which Elena Kagan, then a Clinton legal advisor, recommended a change in language in the policy statement eventually issued by the American College of Gynecologists supporting their opposition to the bill. They originally stated that “in the vast majority of cases, selection of the partial birth procedure is not necessary to avert serious adverse consequences to a woman’s health”, and that they “could identify no circumstances under which intact D&X would be the only option to save the life or preserve the health of the woman”, but – on Kagan’s recommendation – clarified that by also noting that it “may be the best or most appropriate procedure in a particular circumstance to save the life or preserve the health of a woman”. (Note that ACOG explicitly reaffirmed this policy, using the same language, at least three more times, in 1997, 2000, and 2003). That policy statement was later referred to by at least one federal judge, in litigation on the constitutionality of the ban later enacted by Bush.

Quelle horreur!

Coffin’s conclusions are that this is a “distortion of science”, that “language purporting to be the judgment of an independent body of medical experts devoted to the care and treatment of pregnant women and their children was, in the end, nothing more than the political scrawling of a White House appointee”, and that “Miss [sic] Kagan’s decision to override a scientific finding with her own calculated distortion in order to protect access to the most despicable of abortion procedures seriously twisted the judicial process” – naturally she he rolls this up into the ongoing Kagan Supreme Court confirmation hearings as well. The right-wing idiotocracy is all a-Twitter, too, natch: Powerline declares this is a “smoking gun” and “shocking”; Riehl calls it “misrepresenting science” and “dishonest”; the risible Betsy, of Betsy’s Page, reads this and concludes that “there was a doctors’ opinion that said that partial birth abortion was not necessary and she, with no medical background at all, drafted a statement that said the exact opposite”. Yuval Levin, the severely bioethics-challenged former staff manager of Bush’s Presidential Council on Bioethics, declares this to be a “war on science”, “astonishing”, and “easily the most serious and flagrant violation of the boundary between scientific expertise and politics I have ever encountered”.

This sort of nonsense is particularly astounding from Levin, who was a central player in the workings of an “ethics” commission that remains a watchword for right-wing distortion and duplicity, whose major policy statements drew dissenting opinions from its own most scientifically-qualified members, and which then censored, and later fired, those same members. Levin – a political scientist and former Bush White House policy staffmember who has spent his entire career crafting right-wing bioethics policy - also castigates Kagan for her lack of medical expertise and her involvement in healthcare policymaking. You really just can’t make this stuff up.

It’s especially disingenuous for people like Levin and Coffin – political hacks whose entire career consists of trying to influence policy to fit their ideological leanings, from both inside and outside the government – to claim that there’s something untoward in political policy staff conferring with the policy-making boards of professional organizations to shape language on statements issued in clearly political and legal contexts. That sort of thing goes on all the time, and it’s appropriate for such bodies of experts to confer with political authorities to ensure that their statements are effectively written and focused. It would be inappropriate for them to turn themselves over to the political authorities as tools of policy, and to issue statements they did not believe were true, but it’s not inappropriate to get guidance on language and emphasis in order to convey an effective message. (As Coffin herself notes, ACOG already opposed the anti-choice bill. Obviously they would want their policy statement to reflect the reasons why.) To suggest that a policy expert drafting language for a policy statement endorsed by a professional body is somehow scandalous – let alone unusual – is simply stupid. And to suggest, as Coffin and others have recklessly done, that ACOG is somehow compromised or tarnished in doing so, is not merely stupid and dishonest, but libelous.

Aside from the completely manufactured, and fictional, scandal that the right-wing noise machine is busily whipping up over this, there is also the simple fact that the language Kagan suggested does not replace or contradict the language previously present. The statement that there are “no circumstances under which intact D&X would be the only option” is entirely compatible with the claim that it “may be the best or most appropriate procedure in a particular circumstance to save the life or preserve the health of a woman” (emphases added). It’s simple, really: the fact that something is never the only option in no way means that it is a bad option; the revised language not only implicitly acknowledges this but clarifies for the dim-witted (i.e., conservatives) the even more important point that it is in fact sometimes the best option. (Obviously, Intact D&X is never the only option: you can always perform an unnecessary Cesearean section or force the woman to deliver a fetus that may be dying and may possibly kill her - options that are much prefereable, for conservatives, than allowing a woman to choose the safest option on her own authority. ACOG’s point, which Kagan nudged them towards, is that there are often better  options – and that women should have the right to choose them.)

The fight over Intact D&X was particularly nasty because it encapsulates so much of right-wing misogyny, so clearly: it was not a ban on abortion, and it was not a ban on late-term abortions; in fact, it did not ban any abortions under any circumstances. It was only and entirely a ban on one particular procedure for performing abortions. It banned the procedure that was preferable in specific circumstances – leaving abortions entirely legal under those circumstances but forcing women to submit to a procedure that was less safe and more debilitating for them. It was straightforwardly an attempt to punish women by making them accept higher risks and a lower standard of care, as the price for choosing a procedure the right wing disapproved. And ACOG’s policy statement implicitly recognized this: it notes that there are always alternatives to the ID&X procedure, but that in some circumstances those alternatives are worse, and ID&X is, in those circumstances, the best or most appropriate procedure. Kagan’s contribution – appropriate, useful, and highly pro-woman – was to encourage them to clarify that distinction. (Note, again, that ACOG explicitly reiterated this policy, and the important distinction it makes, three times after Kagan supposedly “overrode” their scientific judgment in the matter by forcing them to include language that does not contradict that judgment.)

Raising this issue is simply another example of the right-wing’s reflexive insanity over sex and abortion, coupled with their inherent inability to read and comprehend basic logical statements. (Note “Betsy”‘s analysis: “there was a doctors’ opinion that said that partial birth abortion was not necessary [no, there simply wasn't] and . . . [Kagan] drafted a statement that said the exact opposite” [no, she didn't].) Honestly, the relationship between “not the only” and “sometimes the best” is really not that tricky. It’s too tricky, of course, for the average right-winger, and for people like Coffin and Levin, whose deficiencies were all too apparent back when they were writing policy for Bush, but to people of normal intelligence and reading comprehension, this entire farce is an obviously groundless, and all-too-familiar, political hackery.

The right wing is also up in arms over this because, as Scott Lemieux at Lawyers, Guns, & Money notes:

the only point of this feeble “smoking gun” is to allow Senate Republicans to mention the phrase “partial birth abortion” a lot [and] I should note once again that for reasons Judge Posner and Justice Stevens have explained the entire issue is a farce. The distinction between D&X abortions and other abortion procedures is wholly arbitrary, and for people who have supported irrational laws making such a distinction to pretend to care about rigorous medical science is nothing but comedy of the lowest form.

Mahablog was fast out of the blocks on this, in a post I wish I’d written:

if you actually understand the issue in question — which leaves out righties, naturally — you’d know there is no “there” there. . . . Somehow, in the fevered imagination of righties, a professional organization representing 90 percent of U.S. board-certified obstetrician-gynecologists was duped by Kagan into telling a lie, or something, and because this wording came from Kagan it must not actually reflect the views of ACOG. . . . no scientific finding was “overridden,” just clarified, and ACOG must have agreed with the statement or they wouldn’t have continued to repeat it in their position papers ever after.

Lemieux gets the content issue exactly right:

There’s no contradiction between the two drafts, because D&X abortions are, in fact, not medically necessary in a majority of cases. But this fact doesn’t mean that they are never medically necessary, and indeed the original statement implies that there are cases where D&X abortions are necessary or preferable for a protecting a woman’s health. Adding a statement to clarify what was implicit in the first draft doesn’t “distort” anything, and of course if ACOG didn’t think the statement was accurate Kagan had no power to get them to change it. There’s nothing here.

UPDATE: Corrected pronouns referring to Coffin; he’s a “he”, not a “she”. My apologies to Coffin for the mistake.

UPDATE: Another right-wing website breathlessly announces that Kagan “pressured a second group” on its wording of its pro-choice policy. That group was the AMA. Their claim: “Kagan discussed with other Clinton administration officials whether the AMA could reverse its policy saying there is not an identified situation in which partial-birth abortion is the only appropriate method of abortion. The AMA also noted ethical concerns with partial-birth abortions and said that it should not be used unless it is absolutely necessary.” Note that this repeats exactly the same mistake all the other commentators made about the first memo: the two positions described are not contradictory, and there is no “reversal” in evidence! And Kagan’s particular crime: she wrote an e-mail saying “We agreed to do a bit of thinking about whether we (in truth, HHS) could contribute to that effort . . . . Chuck and I are meeting with the AG on Tuesday; Donna offered to send over some doctors this week”. They don’t even identify who the e-mail was sent to (obviously it was internal), or whether any such meeting ever took place, let alone had any effect. (Apparently the AMA does the bidding of any government staff lawyer who offers to “contribute” to their policy development.) Truly, the stupid knows no bounds with these people.

April 5, 2010

Physician, Do Not Heal Thyself

by @ 3:08 PM. Filed under Autonomy, General, Global/Community Health, Provider Roles

The New York Times today has an interesting profile of Dr. Desiree Pardi, a palliative-care specialist in New York who was diagnosed with breast cancer in her early 30s, and refused palliative care – while still working in palliative care professionally – during her prolonged and painful death.

Dr. Pardi had gone into the field because she thought her experience as a patient would make her a better doctor. Now she came face to face with all the ambiguities of death, and of her profession.

She remembered patients who complained to her that she did not know them well enough to recognize that they were stronger than she had thought. Now she discovered that she felt the same way about her own doctors. “I think they underestimated me,” she said in an interview last summer.

She came to question the advice she had been giving. She thought about quitting. “I just decided I have to believe in what I’m saying,” she said.

It’s tempting to see her treatment choices – demanding extensive low-probability and experimental treatments – as being in some way hypocrtical for someone who had made a point of encouraging others not to continue with therapeutic treatments near death. At times she was quoted expressing anger at doctors who recommended palliative care or hospice, and at times she is described by others as being “in denial” about her own condition – much in keeping with her own attitudes toward palliative care and patients’ beliefs, as seen from her professional perspective. The article at times seem to imply that there is in fact a contradiction there.

But I think, and I think most people in the field would agree, that there is no tension between active therapy and palliative care – that both are available options that different people will choose for different reasons, or even that a given patient will choose under differing circumstances. The idea that some patients would reject palliative care is hardly new; the fact that one such patient would turn out to be a palliative care specialist is merely a coincidence, ironic at most, and hardly that. (Nobody claims that palliative care is right for everybody.)

From that perspective, I was a bit annoyed with this article, because it seems to imply that there really is something wrong in the way Dr. Pardi practiced as a physician, or worse, that there is something wrong with palliative care – that it “underestimates” patients, that it is something that palliative care workers try to impose on others but reject for themselves, or even that it is the sort of “death panel” that the insane right wing keeps conjuring up. Also annoying is the tone attributed to Dr. Pardi herself (she was dead when the article was written): that palliative care was in fact something to be avoided; that she herself questioned whether it was right for her to offer it to her own patients. It’s not clear how authentic this is, but I hope Dr. Pardi was not as much “in denial” about her own profession – let alone her health status – as the article seems to imply; if not, the problem then is not that there is something wrong with palliative care, but that a doctor in that field had not thought deeply enough about what is right with it before it became an issue for her personally.

The meaning of the piece for me was that people’s personal choices are unique and not always predictable, and that this is the reason patients must be allowed to choose the terms of their own treatment. (Dr. Pardi – an MD/PhD with extensive experience – chose to allow her husband to be the point of contact with her own caregivers, and never knew the extent of her own disease, though she was adamant in her choices about how aggressively to treat it.) There is a reminder here of the degree to which aggressive treatment might serve some patients’ needs (Dr. Pardi’s final course took barely a year and a half from her last remission to her death, but it is likely that she extended that period somewhat by refusing palliative-only care and insisting on a high-calorie diet) – though that hardly renders palliative care unnecessary, or argues for returning to the days when painful aggressive treatment was the only option available.

April 2, 2010

“Do No Good”

by @ 1:53 PM. Filed under Access to Healthcare, Global/Community Health, Healthcare Politics, Provider Roles, Theory

Dr. Jack Cassell, in Florida, is getting press today for the cranky, obnoxious note he posted on his office door:

Dr. Jerk

The text reads: 

If you voted for Obama . . .
seek Urologic care
elswhere

Changes to your healthcare
begin right now
not in four years

He apparently also fills his waiting room with anti-Obama literature, signs about what “the morons in Washington have done to your healthcare” (NB: nothing has changed about any of his patients’ healthcare; he is the only one who has done anything so far), and explicit instructions on who they should vote for.

In response to concerns that he might be politicizing his care just a tad, he argues “I’m not turning anybody away — that would be unethical. But if they read the sign and turn the other way, so be it.” So of course he’s not actually doing anything to make patients feel uncomfortable by explicitly telling them to leave his practice because he disapproves of their politics; they just happen to choose to seek another doctor for reasons unrelated to his behavior or his treatment of them.

There’s been commentary over whether this infringes any laws or principles of medical ethics. His supporters claim he is justified in behaving this way because doctors, like everyone, have a right of free speech. There’s a lot to be said about that – most notably that the whole point to medical ethics is that professional practice and the professional relationship impose standards more stringent than those  incumbent on ordinary citizens. Simply having a right of free speech does not justify acting like a jerk toward your patients; the treatment relationship is one-sided, predicated upon the doctor’s commitment to service of the patients’ needs, not their approval of the patients’ politics; admission as a professional is predicated upon acceptance of those standards, and a willingness to put one’s personal inclinations aside in the professional arena.

But aside from that, what strikes me about this situation is the general attitude it reveals. Not only does this doctor fail in the face of any of the above standards, but it seems obvious he simply conceives of medical practice as something that does not in fact entail the authority of such standards or commitments. Doctoring is apparently a job, to him – something he can do if and as he chooses, and which does not impose on him any obligations he does not happen to want to meet. He is – to all appearances – essentially the doctor in Ayn Rand’s Atlas Shrugged, who joins with the amoral capitalist runaways to form a free-market society founded on hard money and ethical egoism. Being a doctor does not require him to do anything for anyone if he doesn’t feel like it, and it doesn’t require him to accept as a patient – or even keep as a patient anyone he has already accepted – who does not personally agree with him on any matter of his choosing.

What I fear, but perceive, is that this attitude is becoming more widespread. Doctoring is just a job, it seems, in the minds of more and more doctors, and in the minds of the right-wingers who are so afraid that Obama is going to destroy healthcare by making it less capitalist. (As usual, facts are of no moment to the right-wing panic apparatus: it is this doctor himself who is “changing” healthcare for his patients – his own sign says so  – but he still manages to blame it on Obama. And it is this doctor who has made healthcare hostile and unwelcoming for his own patients – he is, not a death panel exactly, but a one-man jerk panel to his personal caseload – but they deserve it, he seems to think, because they voted wrong.) Whatever the consequences of Obamacare, I fear that it will be simply impossible to destroy medicine in the US because there will be no medical profession left to destroy – just a bunch of entitled, self-absorbed jobsworths whining about how much less they like their jobs now that the glamor and remuneration has started to fade and they’re left with nothing more than providing better care to more people, which is such an imposition.

Democratic Congressmember Alan Grayson, who represents that district, was notorious for (accurately) characterizing the Republicans’ healthcare policy as “Die quickly”. He notes about Dr. Cassell: “Maybe he thinks the Hippocratic Oath says, ‘Do no good.’” That’s about the size of it.

November 13, 2009

Insurance Companies: Greatest Profits Lie in Blocking Access Reform

by @ 3:17 PM. Filed under Access to Healthcare, Autonomy, General, Global/Community Health, Healthcare Politics, Provider Roles, Theory

Goldman Sachs has just issued a helpful report for the insurance industry, identifying the profit potential for them in various likely outcomes of the current healthcare access reform initiative. Their conclusion: the best thing for the insurance companies is no reform at all, followed by the weakest possible reform; the worst thing for them is real reform with universal access and a publicly-backed plan option.

In other words: the current disaster of a system is the one that provides the greatest possible profit potential to the insurance industry; any effort at increasing access to care is against that industry’s interests, and a robust and successful reform effort is the worst possible thing from an industry whose profits are entirely dependent on charging the highest possible premiums and delivering the least possible care.

The Senate Finance Committee bill, which Goldman’s analysts conclude is the version most likely to survive the legislative process, is described as the “base” scenario. Under that legislation (which did not include a public plan) the earnings per share for the top five insurers would grow an estimated five percent from 2010 through 2019. And yet, the “variance with current valuation” — essentially, what the value of the stock is on the market — is projected to drop four percent.

Things are much worse, Goldman estimates, for legislation that resembles what was considered and (to a certain extent) passed by the House of Representatives. This is, the firm deems, the “bear case” scenario — in which earnings per share for the top five insurers would decline an estimated one percent from 2010 through 2019 and the variance with current valuation is projected to be negative 36 percent.

What the firm sees as the best path forward for the private insurance industry’s bottom line is, to be blunt, inaction.

The study’s authors advise that if no reform is passed, earnings per share would grow an estimated ten percent from 2010 through 2019, and the value of the stock would rise an estimated 59 percent during that time period.

The next best thing for the insurance industry would be if the legislation passed by the Senate Finance Committee is watered down significantly.

Coincidentally, no doubt, the report arrives from Goldman Sachs – recipient of uncountable billions in public bailout dollars for their executives’ bonuses, from the Obama administration – just as the healthcare access reform plan being pursued right now by that same administration is nearing its final legislative conflict. Goldman helpfully notes in a disclaimer that the firm “does and seeks to do business with companies covered in its research reports.”

All you have to do to see how utterly repulsive the healthcare insurance industry is is to simply watch how they talk about their own business. It is impossible to be disgusted enough by an industry that – uniquely in the industrialized world – treats people’s bodies, health, and lives as saleable commodities in a free market in misery.

November 9, 2009

Terrorist Crusade Parades Itself Openly – Who Will Care?

by @ 6:43 PM. Filed under Access to Healthcare, Autonomy, General, Global/Community Health, Healthcare Politics, Personhood, Provider Roles, Reproductive Ethics, Sex, Theory, Women's Issues

The AP reports that Scott Roeder, the terrorist who killed Dr. George Tiller, publicly and in cold blood, last May, has openly confessed to the crime and justified it with the usual religious-radical gibberish about “unborn children”. In the article, he explicitly equates fetuses with independently-living persons and claims that killing to prevent abortion is justified if at least one forced pregnancy results; he encourages others to perform similar terroristic murders, and states he intends to base his legal defense on an argument for a religious-political justification for murder. None of this is new, except possibly that he has stated all this on record now.  It confirms what we knew about him, anyway.

The real question is whether those who are so agitated about real or imagined terrorism of other kinds (especially by Muslims), and who have been so complacently accepting of anti-woman terrorism in the US for decades, will condemn or even acknowledge an open statement of Christian religious-terrorist ideology in the case of yet another anti-choice fanatic.

Just this week we’ve seen a terrible mass murder committed by a Muslim military officer who was apparently distraught over the war in Afghanistan and his possible deployment. Literally before the bodies were cool, various right-wingers jumped in to denounce “Muslim terrorism” and to cite vague links between the suspect and Al Qaeda (he visited a mosque which was also visited by someone who knew someone who was connected with Al Qaeda); however, it is not clear that the apparent perpetrator’s motives were intended for a political end at all – as opposed to merely an outburst of personal anxiety – and there is little to suggest that it was terrorism in any reasonable sense. The murders of doctors by anti-choicers, beyond any question, are defined by the features of terrorism found in most of the commonly-used definitions: they are acts of violence committed against civilians for the purpose of inciting fear in other, third-party individuals, to promote a particular political end. We heard nothing of this at the time of Dr. Tiller’s death (nor of any of the previous murders and other acts of violence); will we hear it acknowledged now that the terrorist has so openly proclaimed his murderous religious ideology?

Anti-choice terrorism is intended to prevent women from exercising a legal and moral right involving their bodily health and autonomy, by terrorizing those women and their healthcare providers – it is violence intended not merely against its chosen (often random) targets, but to terrorize and thus paralyze a larger group, to further the religious and political ideology of the perpetrators and their vast army of supporters and admirers within the religious right. Yet it has never been acknowledged as such, and the large subculture on the right wing who have made a profession of terrorism scare-mongering have never acknowledged the persistent anti-choice terrorism ongoing in the US. (Nor has the FBI: fake anthrax attacks had been staged on almost 700 abortion clinics in the US in the days before 9/11 – not one of them resulted in an arrest, or any obvious urgency about the issue, and they were not treated as domestic terrorism. One person was charged with terrorism for fake anthrax attacks on clinics in the wake of 9/11 and the Congress anthrax mail attacks – the first and only such charge in the entire history of anti-choice terrorism. None of the anti-choice murderers, including Roeder, have been charged as terrorists.)

Now we have an admitted terrorist openly advocating further political killings to promote his religious obsessions. If Roeder were a Muslim and his targets were not women and their healthcare providers, the shrieking loons of the right would be off their heads screaming about his crime, his religious beliefs, his unrepentant stance, his advocacy and rationalization of violence, and his links to other extremists with similar religious and political beliefs. Will we see even the slightest acknowledgment of Christian anti-choice religious terrorism and its dangers in this blatant case?

November 7, 2009

Historical Juncture Turned into Anti-Woman Hatefest by Congressional Republicans, With Democrats Lighting the Torches

by @ 9:38 PM. Filed under Access to Healthcare, Autonomy, General, Global/Community Health, Healthcare Politics, Personhood, Provider Roles, Reproductive Ethics, Sex, Theory, Women's Issues

At this moment, debate is proceeding on the House votes on the landmark healthcare bill. I haven’t blogged about it, because, frankly, it was overwhelming and I didn’t know what I could say that would help. (The Democrats’ stealth approach to bill-crafting, while possibly politically astute, made it hard to get a clear handle on the thing, too.) This will be, without question, one of the most important legislative events of my lifetime; if the bill passes the Senate and is finally voted into law in a reasonably intact form, it will be the most significant development in American history that I will see. More importantly, it will be – largely, though not entirely – an end to crippling insecurity and lifelong anxiety for hundreds of millions, and of irremediable pain and suffering for tens of millions who now live in the only affluent country that permits its business class to sell life itself for profit.

The bill on offer is far from optimal. It locks in the profiteering on death and misery that the vast majority of the country is burdened with, and is needlessly complicated and limited in what it offers to the rest. It deliberately cripples its own modest offering by restricting it only to those whom the profiteers have absolutely refused to serve at any price, prohibiting the rest of the country from accessing healthcare organized on any saner and more humane basis. But worst of all, the bill is being held hostage by the insane and vicious anti-choice army that infests the right wing and has wholly captured the Republican party. And, too predictably, the omnipresent contingent of grandstanding asshole Democrats is giving them exactly what they want, as they always do.

Right now, the “Stupak amendment” is being debated: an amendment that will prohibit any person enrolling in the government-backed “healthcare exchange” – which is to say, the poorest and most desperate, who are the only ones eligibel to enroll in that plan – from being offered a full range of healthcare services in cases of unwanted pregnancy. For those people, the “public options” will be forced pregnancy, death in childbirth, or an abortion that she likely can’t afford and the right-wing terrorists have likely made unavailable anyway. The Republican House caucus has already stated explicitly that they will refuse to vote for the healthcare bill in any form. But they – with their unconscionable Democratic allies – are holding up the bill to demand the anti-choice amendment in a bill they will not support even if they get it. And enough Democrats are equally indifferent to women’s lives and women’s needs to help them do it.

Democratic women are putting up a good fight – and their male allies deserve thanks, too. The Republicans have shrunk from merely legislative misogyny to outright thuggery, as they so commonly do. Michele Bachman led crowds of right wingers through the Congressional office buildings earlier today, invading offices and screaming at people to, in her words, “scare” them away from supporting women and healthcare for all. House Republicans staged an organized disruption on the floor today, systematically interrupting Democratic women as they spoke in favor of women’s interests and full healthcare coverage. The healthcare debate is being conducted the same way the Florida recount was in 2000: in the face of Republican assaults and intimidation, and without regard for the truth or significance of the actual substantive issue.

I have little to say about the whole thing. I feel helpless – particularly frustrating in the face of an issue so central to my personal and professional concerns – and am waiting as on election night for the outcome of votes that will – with great good luck – mean so much to so many, and move American one huge step closer to the decency and commitment to humanity that has been so sadly lacking in so much of our history. I can only wait and hope, like everyone else. In the meantime, there is an organized, vicious, and relentless minority that is fiercely dedicated to their own hostility to any notion of a decent regard for others, and to the freedom of others to live their own lives unconstrained by that minority’s backward and reactionary values. They are fighting – in the most literal sense – right now to keep tens of millions of people at the mercy of any illness they may suffer, to keep hundreds of millions at the mercy of an insurance system that rivals only those reactionaries themselves in its hostility to the needs of the people they nominally serve, and to keep every woman in America at the mercy of the nasty and bitter men who despise them and their bodies.

I can’t stand watching this unfold. And I can’t say, can’t express even fractionally, how much, how gut-wrenchingly much, I hate and revile these disgusting creeps.

UPDATE: Rayne at Firedoglake reports “Stupak Amendment Passes: 64 Dems Ask for Primary Opponents“. That’s exactly how I feel about it. I had already promised myself that I would contribute to the primary opponents of any misogynist Democrats; I’m saddened, and shocked, that there are so many of them. I will certainly target all that I can afford to. Read the rest of the post; it’s exactly right.

UPDATE: The final bill has passed, 220 – 215. Exactly one Republican voted in favor – 39 Democrats voted to withhold healthcare from over 40 million Americans. This is a great – but very partial – victory. There still remains the Senate bill – which will be a far tougher fight, with looser rules and a larger percentage of heartless and misogynist Democrats in the mix – followed by the conference committee and the final vote. The Republicans and reactionaries will do everything they can to destroy other people’s hopes for a decent life, and their control over their own bodies and life plans – the rioting, disruption, demagoguery and thuggery seen today are just a taste of what is coming. And this step, momentous as it is, comes bitterly. The discussion in the followup post at Firedoglake captures it perfectly; as one commenter put it: “It’s like winning a huge battle, but half of your friends were killed or wounded.”

UPDATE: I’ve added the reference to Democrats in the headline. I didn’t make it clear above that Bart Stupak, who led the charge to destroy healthcare reform for over 300 million Americans if they didn’t let him destroy autonomy for 150 million female Americans, is a Democrat. Along with 63 other misogynist traitors, he put the people’s party against 51% of the people, to indulge their personal medieval religious obsessions. Fuck him and all of them.

UPDATE: Scott Lemieux at Lawyers, Guns, and Money gets the power dynamic exactly right: “Certainly, there are many potential criticisms of how Democratic leadership has dealt with health care, although when you actually care about expanding access to health care it’s hard to negotiate with the Stupaks of the world who don’t, but want to use other people’s progressive impulses to attack women.”

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