When Silence is Golden

Silence is golden; it can also be difficult. Many of us find it uncomfortable -awkward if it continues for too long. In communication, silence is a benefit that diminishes with time, a value that becomes a penalty. A schism that is counterproductive.

We all want to be heard; we all need to be recognized, and yet that acknowledgment requires reciprocation. Otherwise, we might as well talk to a wall. Listening is not just silence; it is attending.  Listening is not the same as merely being in the same room.

A doctor is often called upon to be a multifaceted creature: she must first be sensitive to her patient’s concerns, and attentive to the sometimes lengthy explanation. She must demonstrate some empathy and understanding of the problem and yet remain calm and reassuring. Equanimity in the face of seemingly intractable issues is usually seen as a hallmark of competence. But, after a suitable time spent listening and incorporating all of the relevant symptoms into a reasonable diagnosis, it is the doctor’s turn to speak. And the art is so often in the timing.

As soon as I saw her in the waiting room, I could see she was going to be difficult. She was an older lady, probably in her late fifties, who was sitting in the corner by herself like an angry statue. Cemented to her seat, the infants crawling on the rug in front of her might as well have been ants on a lawn for all she noticed. Her face was puckered into a tense scowl, her hands were clasped into a tight, unmoving ball on the lap of her long black dress. Were it not for her short, white hair, she could have been mistaken for a shadowed monument, a memorial placed inconspicuously in the corner so as not to frighten the children.

Only her eyes betrayed her presence and they fixated on me like a hawk as soon as I entered the room.

“Gladyce?” I said walking across the carpet and trying to avoid the toddlers.

Her eyes hardened into marble slits and her face into granite. “Mrs. Ardess,” she said, italicizing the sirname through lips that barely moved. I’m surprised she could actually speak through them.

I extended my hand to introduce myself, but she barely touched it. One of my maternity patients across the room rolled her eyes.

I started to walk down the corridor to my office, expecting Gladyce to follow, but she remained seated, perhaps waiting for instructions. “Mrs. Ardess,” I said, turning to her with a smile. She sighed noisily and stood up. She seemed reluctant, though.

I indicated a seat across from my desk and waited for her to settle into it. And as I busied myself with the computer, I could feel those eyes on me again, burrowing into my skin. I returned the favour once I had opened her chart and discovered there was no referral letter.

I was about to ask her why she had been sent to see me, but before I could even open my mouth, she hardened again. “You doctors never listen, do you?” She almost spat the words through her clenched teeth. “I saw a new GP, and I told her I wanted to see a woman gynaecologist!”

This is not new to me, and certainly not an unreasonable request, but sometimes my female colleagues have longer waiting lists than me. I’ve learned not to take it personally. “There is a woman gynaecologist that works with me in the office,” I said with a slightly forced smile. “Would you like me to…”

“That’s hardly the point,” she interrupted. “I told the GP I wanted to see a woman in the first place, not waste my time being shunted around. Doctors never listen. They ask a lot of questions, but it’s like they just pick out what they want to hear from what I say and discard the rest. My first doctor didn’t even seem to understand that I was really worried.

“I told her I have an itchy red lump and that it’s in an area that is very personal. Very scary.” She scanned my face for a reaction, but I was too intent on what she was saying to react. “I’m not very sexually active anymore, so I try to be careful with my partners. You know, ask them questions, assess the risks…”

I only had time to nod before she continued. “So I was frightened that the lump was related to that… encounter.” She almost whispered the word. “It came up a few days later, so I phoned him to reassure myself again.” She softened her expression briefly and for a moment I saw a different woman. “He was so gentle with me, I didn’t really suspect he’d been lying, but I had to check. I was really worried.

“I waited a few more days thinking everything would go back to normal, but when it didn’t, I began to panic. What if it was syphilis or something? Or that HPV thing everybody’s been talking about?” Her eyes, now far from angry, fastened on my face like birds clinging to a branch. “I phoned my GP, but her receptionist said she couldn’t see me for almost a week. When I asked her to check with the doctor to see if she could fit me in sooner, I could hear them talking and laughing about it in the background.” Gladyce was silent for a second, and even unlatched her eyes from my face.

“Doctor Forster eventually came on the phone to ask me why I needed to come in so urgently… But I couldn’t convince her to change her mind. She just told me to take warm baths for a few days and if that didn’t help, to phone her back.” Suddenly Gladyce pinned me to my seat with a glare. “Dr. Forster was just too busy to listen to my concerns. I could tell she was having a bad day herself. So I managed to find another doctor –another female doctor- at a walk-in clinic.

“Maybe I chose the wrong place, but they were so busy at this one they could only see me for a few minutes.” She looked up at the ceiling for a moment. “Actually ‘see’ is probably the wrong word: the doctor never examined me. Didn’t have time, I guess. And when she asked me why I had come to the clinic, I got about two or maybe three sentences to explain and as soon as she heard the word ‘lump’ and ‘non-healing’ she began mumbling about sexually transmitted infections and grilled me on prevention. Then it was PAP smears and how necessary it was to have them regularly. Finally, she managed to segue into cancer and after hemming and knotting her face up said I needed to see a specialist. When I insisted it be a woman, she merely shrugged and said she’d try but that I needed to see whoever it was as soon as possible.

“But she obviously wasn’t listening either. No time. She had other patients to see…”

Gladyce studied me for a moment, obviously thinking about something, her eyes painting wide swaths across my face and chest. Analysing. Deciding. And then her demeanour suddenly changed and a different person emerged. I thought it might be an opportunity to ask her a few questions –finally meet her, in fact. “Well, Mrs. Ardess,” I started somewhat hesitantly, “I can see why you’ve lost some faith in us…”

“Gladyce,” she interrupted with a smile. “Call me Gladyce.”

Speak up, eh?

In the often dull Gestalt of Canadian politics, it is sometimes difficult to distinguish background from foreground, but every so often a light goes on and shadows spring to life. Shadows we would fain deny, yet dare not, to paraphrase Macbeth as he waits for battle. It is, perhaps, an apt example given that it is the military that so recently stepped into the media’s blazing sun. Soon to retire as the Chief of the Canadian Defense Staff, General Tom Lawson, in a widely watched television interview, said “Sexual harassment is still an issue in the Canadian Forces because people are “biologically wired in a certain way.”  http://www.cbc.ca/1.3115993 And this set off a national forest fire that has yet to be extinguished.

This is not unexpected in light of a recent report on sexual misconduct in the Canadian Forces issued by former Supreme Court Justice, Marie Deschamps who suggested that sexual misconduct in the Canadian military was ‘endemic’. http://www.cbc.ca/1.3055493

And then, predictably, this was espoused by members of parliament –all, not unreasonably, wanting to reflect the mood of their constituents. http://www.cbc.ca/1.3117281

This is as it should be, of course. Neither sexual harassment nor sexual misconduct are tolerable –especially in a military setting where power inequities are inherent to its structure and therefore largely inescapable. The creation of an ‘independent centre for accountability for sexual assault and harassment outside of the CAF with the responsibility for receiving reports of inappropriate sexual conduct, as well as prevention, coordination and monitoring of training, victim support, monitoring of accountability, and research, and to act as a central authority for the collection of data’ as the third recommendation of the Report suggests, would be an important first step in addressing these inequalities. And for those who are not certain of whether to bring it to the attention of their superiors, another of the recommendations: ‘Allow members to report incidents of sexual harassment and sexual assault to the centre for accountability for sexual assault and harassment, or simply to request support services without the obligation to trigger a formal complaint process’. And if this seems inadequate, or difficult -perhaps because the offender was a superior officer-  another of the Report’s ten recommendations, no doubt for emphasis, also mirrors this: ‘Allow victims of sexual assault to request, with the support of the centre for accountability sexual assault and harassment, transfer of the complaint to civilian authorities; provide information explaining the reasons when transfer is not effected.‘ In other words, the ability to be heard. Noticed. Helped. It would be difficult, indeed, to find fault with any of the recommendations as they seek to change attitudes in what, for millennia, was an all-male club. https://www.documentcloud.org/documents/2070308-era-final-report-april-20-2015-eng.html -or for a more succinct listing of the recommendations: http://www.cbc.ca/news/politics/military-harassment-report-10-recommendations-1.3055935

And General Lawson did later apologize for this ‘awkward characterization’ as he termed it on a subsequent CBC interview: “I apologize for my awkward characterization, in today’s CBC interview, of the issue of sexual misconduct in the Canadian Armed Forces. Sexual misconduct in any form, in any situation is clearly unacceptable,” the statement said. “My reference to biological attraction being a factor in sexual misconduct was by no means intended to excuse anyone from responsibility for their actions.”

His original ‘biologically wired’ comment, in the cool light of retrospect, was bound to attract attention of course –especially given the sexual misconduct report and his position as chief of the defense staff. It was a poorly conceived and not terribly clever analogy -definitely not Pulitzer Prize material… But all the same, I worry about the reaction it engendered -the media seemed to focus only on the ‘biologically wired’ part. Context, it seems to me, was either lost or misconstrued -his message was interpreted as naïve at best, camouflage for inaction at worst. And yet, awkward or not, I would like to think the general was not attempting an excuse, but merely an explanation of something that, were we able to say it without fear of backlash, should be evident to everyone. Like it or not, there are biological differences between the sexes, and the military was perhaps the last remaining refuge for unadulterated testosterone -a place where actions truly spoke louder than words. We see some of those actions now as unacceptable -not only ill-considered, but even criminal. Fair enough; I certainly agree. But I also think it is reasonable that I expect, and am willing to tolerate, different behaviour from a soldier than, say, my doctor. I would not accept ethical or moral perfidy from either, and yet each protects me from different things in different ways -and presumably with different world views. Different sensitivities. Let’s face it, those people who decide on a career in which armed combat is a distinct possibility, are not likely to be averse to confrontational situations. But of course, judgement is required: aggression can be multidimensional. Hydra-headed -and inappropriate. It is, I suppose, why there are chains of command: the need to superimpose order on chaos. Training –or should I say taming– those primal instincts.

Of course it will not happen overnight just because we wish it so; not all of the report’s recommendations have been accepted outright… Yet. Perhaps it was felt that there was a fine line to balance, even now. So the report from Justice Deschamps is a recognition of the current reality –the one that requires a Center for Accountability. But to pretend that there is only one acceptable way to talk about the root cause of the problem -one way to name the Devil- is not helpful. There are many ways to acknowledge a truth. Many paths to the sea… And we are en route -but still walking, not running. Maybe senior officers should all be taught communication skills as well as battle tactics. Readings on rhetoric as well as studies of SunTzu might be useful parts of their preparedness strategies. Shakespeare hints at this in Julius Caesar:

There is a tide in the affairs of men. Which, taken at the flood, leads on to fortune; Omitted, all the voyage of their life Is bound in shallows and in miseries.

Kegel Exercises in Pregnancy

Okay, okay, I was wrong! It happens. Sometimes the brain gets in the way of scientific studies –prejudges them. Alters them in little ways so they do not conflict with its own opinions. Or, worse still, is influenced by a confirmation bias that precludes even the perusal of any information that makes it uncomfortable. The brain can be its own editor, redacting reams of otherwise useful knowledge, recusing itself inappropriately. None of us readily admit guilt in this respect, of course. In a sense, we are blind to it… or want to be.

I’m a gynaecologist as well as an obstetrician, so I have long been aware of the value of strengthening the pelvic floor muscles to prevent urinary incontinence amongst other things. There are a set of muscles –the levator ani muscles- that act as a kind of pelvic platform and help support the various organs that transit through the area, notably the bladder, uterus, and rectum. Exercising them was proposed by a Dr. Kegel in 1952, albeit to strengthen their ability to narrow the vagina and hence the ease of orgasm. I think a more frequently admitted use, is to reduce urinary incontinence, however. Indeed, to discover  the correct muscle for training, the woman need only attempt to stop her urinary stream and she has identified the correct one.

Prominent among the levator ani muscles is the pubococcygeus muscle. (The name merely describes where the muscle starts –the pubic bone, and where it ends- the coccyx, or tail-bone. On its journey, it wraps around, first the urethra –the tube that empties the bladder-  and then the vagina, and finally the rectum, like a series of hammocks). The fact that strengthening it can constrict the vaginal diameter when contracted, has always been a kind of two-edged sword for those of us who deliver babies. On the one hand, there is some fairly longstanding and convincing evidence that it can indeed help to prevent the involuntary loss of urine (urinary incontinence). But remember that it not only helps support the bladder and its opening, it is also a hammock that supports and constricts the vaginal canal. Well, that’s what the baby has to squeeze through… So, does the one benefit become a detriment to the other? Are you robbing Petra to pay Paula?

I have to admit that I was one of the exercise skeptics; it made sense to me that the stronger the muscles that surround the vagina -the greater their bulk- the narrower and more difficult the passageway for the baby to pass through at delivery. At the very least, I reasoned, it would take a greater effort on the part of the mother to force her baby through. And all this at a time when she is already exhausted from her labour. Maybe it would make more sense to work on strengthening those muscles in the weeks and months after delivery. Everything in the area was stretched or torn from the effort of actually pushing the baby’s head out, so perhaps the benefits would accrue if those muscles were strengthen then –a sort of postpartum rehabilitation.

In other words, would strong pelvic floor muscles increase complications in either labour or birth? Would there be a higher incidence of Caesarian Sections, for example? Or the need for episiotomy (cutting the skin at the opening of the vagina) to allow more room for the baby’s head to descend? Would there be a greater need for so-called operative delivery (forceps or vacuum extraction)?

Well, here’s where the information from large studies are more helpful than personal experience. Each of us carries a bias –acknowledged, or buried deep within our own reminiscences of similar situations. If I, for example, believe that the Kegel exercises are a hindrance to normal delivery, I am more likely to remember any episodes in my career where that might indeed have played a role –unaware, or maybe conveniently forgetting  (or not even asking about) times when it didn’t. Confirmation bias again. Limited, or selective, observations are not necessarily a valid reflection of the collective reality. They amount to opinions, not proof, and carry only as much weight as the prestige of the propounder allows. In my case, it was never very much…

The benefit of Kegel exercises in pregnancy remained somewhat controversial in the obstetrical community –at least amongst us iconoclasts- until some Norwegian researchers, notably Kari Bo at the Norwegian School of Sport Sciences, decided to investigate it in a large group of women (18,865 primiparous women) who practiced Kegel exercises at various frequencies per week during pregnancy. The group then looked at the outcome and complications of their labours and deliveries. http://www.ncbi.nlm.gov/pubmed/19461423 There was no difference in outcomes between those who did Kegels religiously in pregnancy, and those who did not. Presumably, the pelvic floor muscles –as strong (and bulky?) as they had become- were able to relax enough to allow normal passage of the baby.

I learned a lot from that paper –and a lot about the way my beliefs interpret my experience. A lot, too, about the way many of us travel through our lives, influenced as we are by only limited familiarity or exposure to events, and drawing perhaps unwarranted –or at least unproven- conclusions from them. And although it is inductive reasoning with all of its inherent uncertainty, deriving conclusions that are reliable and from sufficient observations can be a problem. Generalizing, in other words: probabilistic forecasting from limited available data. An example sometimes given is: all the swans I’ve ever seen have been white, so therefore it would seem reasonable to conclude that all swans must be white… until, that is I see a black swan. Obviously, any one person’s experience must be limited, so any conclusions derived from them, must also be limited.

All generalizations are false, including this one, as Mark Twain famously observed. I’m not sure I’d go that far, though. I think George Bernard Shaw was closer to what I have learned about depending on one’s own experience to the exclusion of competing views: Beware of false knowledge; it is more dangerous than ignorance.

The Manopause

The menopause can be a mysterious time, although the mechanism is easily enough defined: the cessation of menses because of the lack of estrogen production by the ovary. The concept may be simple, but the ramifications and folklore that surround it less so. It has always worn its myths like a hood, obscuring the face beneath, confusing the experience like shadows on a rainy day.

Descriptions are legion, but ultimately unhelpful in dissipating the fog the definition drags with it: hot flushes, sleep disorders, irritability, worries about cognition and memory, regrets about the loss of fertility, and concerns about sexual function and desires… And although some symptoms may cross the gender divide, many -if not most- are unique to women. Unique to ovaries.

And the response to the change can be unique as well.

I hadn’t seen Elizabeth for a long time –in fact I couldn’t remember ever seeing her. Memory deficits are not the sole prerogative of the estrogen deficient –although in fairness, when I tried to look it up, it must been well over ten years since her last visit because the chart had been destroyed. The legal limit that we are required to keep records had obviously been exceeded.

She treated it as if it had only been a month or two, and greeted me with a smile usually reserved for someone who is supposed to go over some frequently-repeated test results. Someone she’d seen in the mall last week, and at a restaurant the week before. But there was a hint of suspicion in her smile.

“Elizabeth,” I said, extending my hand when I greeted her in the waiting room. “Nice to see you again,” I continued as I led her down the corridor to my office. She looked at me politely and sat down in a chair by the window across from my desk, perhaps waiting for me to reminisce.

The referral letter said only that I had seen her before and that she seemed angry about something. She was 55 years old, was on no medications, and she had some questions about the menopause.  “So, what can I do for you, Elizabeth?” A rather predictable opening, I suppose, but it didn’t commit me to anything –in other words it didn’t disclose the fact that I couldn’t remember a thing about her.

She probed me with her eyes for a moment, suspecting, I think, that I didn’t recognize her. But if she was disappointed, she didn’t betray it with her face. The ghost of a smile reappeared, and her eyes relaxed enough to twinkle through her glasses.

She didn’t look the merry type, I decided. Her hair was greying and pulled back tightly in a bun. Her outfit was severe: a black, loosely hanging dress that covered her ankles but not her jewelleryless arms. She was a thin, tall woman and sat as straight as a pole in the chair, her white skin even more pallid where it met the dress.

“How will I know when I’m in the menopause?” she said suddenly, as I glanced at the computer screen searching for more clues.

I met her eyes half way, and smiled reassuringly. I hadn’t had a chance to take a history, so I had to be careful with my answer. “Well, in many women, the symptoms can be very subtle, but generally speaking, the usual tip-off is an irregularity of menstruation and eventually its cessation. And, of course, there are often hot flushes, irritability and…

Her face turned smug and her smile condescending. “But I haven’t had a period for years, doctor…” She sat back in the chair and regarded me with some ill-disguised amusement. I must have looked confused, because she sighed both audibly as well as visually –performance art. “You took my uterus out fifteen years ago…”

I did my best to retain a modicum of Aequanimitas: I tried not to blush.

“Big fibroids,” she continued, to add to my discomfort. “You said one of them was the size of a basketball… I thought you’d remember.” I was blushing now, and about to apologize, so she backed off. “It has been a long time, I suppose.”

I attempted a smile, but I think it came out as rather forced and weak. I decided I’d better take a more detailed history before I addressed her concerns. “I’m sorry, but unfortunately I no longer have your records so I’m going to have to ask you a few questions… First, are you having any symptoms of the menopause?”

She frowned a look of concern unrolled onto her face. “Why don’t you have my records? You did my surgery…” Her eyes suddenly tied me to my seat. “Suppose I developed complications?”

I started to feel defensive. “The law requires us to keep the files for only 10 years unless there is an ongoing  attendance,” I said, rounding off the numbers for her. “I haven’t seen you for longer than that, and you haven’t declared any complications in that fifteen years that I know of…”

She lengthened herself to the full length of her spine and glared at me. “My complication may be the menopause, doctor!”

I tried to stay neutral. Professional. “I’m sorry, Elizabeth, why do you think that?”

Her face crinkled into a little wrinkled ball, like a piece of paper someone had crumpled before throwing it away. “You took my uterus out!” She almost spit the words at me, as if I should have known that was the problem.

I sighed in an unsuccessful attempt to duplicate her previous performance. “Did I remove your ovaries as well?” At forty, I wouldn’t have.

She stared at me wordlessly for a moment. “You did a total hysterectomy you said, doctor.” She said the last word as an insult, not as a descriptive, or an honorific title.

I smiled and realized she had not really understood what I had done. “A total hysterectomy merely refers to the act of removal of the whole uterus –the total uterus. A partial hysterectomy, on the other hand, means I’ve only taken part of it out –left the cervix, usually…” Her expression didn’t change. “I wouldn’t have taken your ovaries out at that age, because… Well, first of all because they would still have been working and producing hormones, and secondly there would have been no need to do so.”

I hoped that would mollify her, but if anything, her face crinkled into an even smaller bun. Then why haven’t I had any hot flushes, or irritability?” She could see one of my eyebrows start to raise –it’s really hard to control that- and hissed audibly at me. I think it was a hiss, but maybe she was  just breathing through her teeth.

I tried to relax my expression –a Mindfulness technique. “Whether or not your uterus is present, the ovaries don’t last forever. They eventually stop producing hormones.” I realized I shouldn’t have used the word ‘last’ as soon as I said it; it just sort of slipped out.

She shook her head slowly in her anger. “You men are so insensitive about the ovaries! You just don’t know what they mean to us, do you?” I suppose it was a rhetorical question, because she continued the rant without stopping for a reply. “And I’m surprised to hear that attitude from a doctor!” She stopped talking for a moment and looked at me. “You weren’t like that back then…” The scowl returned. “And to tell you the truth, doctor, I don’t remember you like this at all…” She glanced around the office. “Not even the office.”

I was about to say something reassuring to her –like that I’d probably changed a few things in here over the years- when she suddenly stood up and wrinkled her nose. It was hard to spot in her overall expression, but I noticed it immediately. Her eyes closed briefly as if she could somehow block out everything that she didn’t like about where she found herself. And then, gathering herself up to her full six foot height, she thanked me for my time and stomped out.

You know, I still can’t remember operating on her… and I don’t think she does, either.

To Have, or not to Have

There are two worlds out there, two Magisteria. Two contrasting inclinations that pass each other on the street without a wave. Strangers who sometimes know each other well. They sit, unwittingly close to each other, in the waiting room of my office. They chat and smile obligingly, trusting that their ignorance of the other is no impediment to friendship, however brief. Indeed, there is no barrier, only a perspectival boundary: Weltanschauung.

And yet, I don’t want to make too much of the difference; it is often in flux, and can mutate even as we watch –Time has a way of adjusting viewpoints,  justifying decisions. We all try to vindicate ourselves in the end. Validation requires exculpation, does it not? Absolution in the eyes of those who matter…

So the stronger the tradition, the societal apologue, the more the justification and guilt assigned to those who stray from it. There is a sort of canniness in the collective –or at least strength. Acceptance… And it is easier to regress to the mean, than defy the group. Especially when it comes to attitudes towards pregnancy –or more specifically, the decision whether or not to have a baby.

I’ve just read an incredibly powerful  book, whose title captures some of the agony and guilt attending those who dare to deviate from societal expectations: Selfish, Shallow, and Self-Absorbed. It is a collection of 16 well-written and generally thoughtful essays -13 from women, and 3 from men- about choosing not to have children. None are from paedophobes; and only a few are from those who decry the notion of pregnancy in others. They are not outliers –except perhaps on a carefully constructed Bell Curve- nor could they be construed as deviant. Each has merely made a personal decision not to accept the tyranny of the Norm.

The essays took me back to the early days of my practice, when, as a newly minted obstetrician, the very idea that someone would not want to have a child at some stage in her life, was anathema… Well, perhaps curious would describe it better –memorable, at any rate. And yet, it was not unknown. It was always a difficult decision in those faraway times to accede to a request for sterilization in a young woman. Contraception, yes, and although this closed the door effectively, it did not lock it. We were suffocatingly parental in those days: we knew she might change her mind –she was young and inexperienced, after all. Like a child, she had to be protected; it was our responsibility to keep her future mutable and open. We –society- were the guardians of that door…

But there are surely two issues at play here. It is one thing to criticize a decision made prematurely –before the kaleidoscope of life has fully displayed, when the future is more chiaroscuroid, more obscure and uncertain- and another developed in that fullness of time when a considered, even retrospective analysis of the factors leading to the choice can bear fruit.

This, too, can seem arbitrary, I realize. Is there a difference between a thoughtful twenty-five year old woman who -in her mind at any rate- has weighed the risks and benefits of having a baby and decided against it, and a forty-five year old who, on looking back at the way her life has unfolded, is grateful and reconciled to never having a child? It is a vexing question on several levels, I think.

In these days of autonomy and non-maleficence when it is considered medically paternalistic and politically incorrect to suggest that a decision need not be vetted by experience, we forget the other ethical duty of a health care provider at our –her- peril: beneficence –serving the best interests of the patient. It seems to me that this entails both a mature and non-directive dialogue and a list of other, more malleable options that would not only adequately serve her needs, but would also allow for change at any stage. Some form of reliable and non-intrusive contraception, for example, might respect her desire to avoid pregnancy, and yet enable some flexibility should she change her mind, or harden her decision for a permanent solution.

But I have to confess that I am still troubled. On the one hand, it seems to me that wisdom is the ability to judge a situation based both on knowledge of what it entails, as well as experience of how it usually turned out in the past. It is why elders were revered in the days before the plethora of information technology that assails us today. I am trying not to be Ludditic here but what the elders contributed, that Google often does not, is digestion. Analysis over time and place. Evaluation. Information can be coloured by current trends and bent by traditional assumptions –but of course so can needs. We must not forget that.

I have always been leery of ‘facts’ divorced from context. Are they then still facts or do they inhabit some terra incognita we have yet to fully occupy? A territory of collation, a thesaurus that is able to list endless variations on whatever theme we decide applies to us, so we can pick and choose the reality we prefer?

It is not the decision to have, or not to have a child that should preoccupy us, but rather the reason it has been chosen. And for such an important life-changing resolution, the depth and –dare I say- maturity of  thought that has gone into the consideration is paramount. It is not, nor should be allowed to fall under, the purview of political correctness and thereby escape a more cautious and examined approach. There is no correct answer, no unquestionable myth that can justify any position. We may have a spur to prick the sides of our intent, to paraphrase Hamlet, but it is a different one for each of us. We must take care that we, and those we counsel, are not –Hamlet again- hoisted with our own petards.