The Yang of Yin

We are, it would seem, a binary species and we live in a binary world where opposites define each other. Think, for example, of up and down –the one depends on the other for its very existence: there is obviously no up without a down with which to contrast it. Good/bad, in/out, light/dark, near/far… even the code written into our computers -the list of inter-dependent binaries is endless.

Perhaps the most famous –and arguably the earliest- recognition of this interdependence is the Chinese concept of Yin and Yang. Without pretending an esoteric knowledge of historical linguistics or an abstruse Sinological background, the meanings of Yin and Yang can be superficially understood as ‘shady’ and ‘sunny’ respectively, and seem to date from sometime in the fourth century BCE.

I suppose the reason this complementarity is so fascinating to me is the implied rejection of the rule of the Absolute. One would seem to need, say, a seller for the concept of ‘buyer’ to exist. And by extension, perhaps, the presence of evil for good to become manifest –although I recognize that to be a bit of semantic trickery. But at any rate, it is an interesting idea to play with.

Binarity –to neologize- has its limits, however. Or at least its two components can be seen as bookends that confine an entire shelf of not-quites. The concept, as we often find after sufficient investigation, can be that of a spectrum, with intermediates melding imperceptibly into their shelf-mates.

Labels, while they help us to identify things, can also lead us astray. I will cover this idea more fully in a later essay, but suffice it to say that a label can be merely a societal/cultural attempt at categorization –a name that simplifies the issue of what to make of the entity. Where to put it. How to interact with it.

For now, however, I would like to touch briefly on whether or not the hitherto necessary binary assignation of gender is anachronistic. There was a helpful BBC News article that brought this to my attention:  http://www.bbc.com/news/health-35242180  and while I have certainly touched on gender issues in past essays, https://musingsonwomenshealth.wordpress.com/2014/07/03/the-asexual/  and https://musingsonwomenshealth.wordpress.com/2013/01/18/gender/ for example, the idea that gender is a labile concept is one that my generation, at least, often finds challenging.

And yet, if one can step back from the anatomical signposts that have directed us for millennia, is the binary assignation of male or female really all that important a predictor of who, or for that matter, what a person is? We’ve always known that different people manifest different characteristics and we even apply societally accepted terms to allow them to maintain their positions within the otherwise ordained sexual designations. We use such terms as ‘effeminate’ for a man who seems at odds with the perceived norms for masculinity, or ‘tomboy’ for a young girl who seems to run with the other team –although I admit I haven’t heard that word applied since I was young myself (perhaps the term is now ‘butch’ although I find it offensive and somehow demeaning). My point, though, is not what words we use, but that we have always found ways to describe someone who does not quite fit into normative –or what the majority may describe as normative- assignations. In other words, a tacit realization –and acceptance- that gender cannot be captured by genitalia alone.

It is not a new concept in any society as the BBC article attempted to illustrate. Sexuality and, indeed, sexual orientation has always been a fluid concept –and both an intriguing and compelling one, as the recent and untimely death of David Bowie has served to remind us. Maybe the time has come to reconsider things. I wonder why it has taken us so long to realize that what we treasure in people and what we find so important is not their gender, not their sexual orientation, and certainly not their appearance, but their energy. Their spirit, I suppose.

We can never agree on everything, perhaps, but as with Shakespeare in The Winter’s Tale, I say, ‘When you do dance, I wish you a wave o’ th’ sea, that you might ever do nothing but that.’

 

An Obstetrical Edition

Miscarriages –early pregnancy losses- have long been the subjects of research. They are unfortunately all too common, and until very recently, we were only aware of those that occurred after a noticeable menstrual delay –the tip of the iceberg, in other words.

Some progress has been made in understanding why they occur, of course –random genetic mistakes either from development, or from abnormalities in the sperm or egg DNA that happened to be involved, for example. But this type of knowledge is often after the fact -insufficient to predict or prevent the problem, although with in vitro fertilization (IVF) there are often techniques available to detect genetic flaws and guide the choice of fertilized egg to be implanted. This does little to address the issue in the much larger population attempting pregnancy in the more traditional, unaided fashion, however.

I was therefore intrigued by an article in the BBC news: http://www.bbc.com/news/health-35301238 that outlined a proposal to genetically modify some human embryos (not for implantation, be aware) to ‘…understand the genes needed for a human embryo to develop successfully into a healthy baby.’

I realize that, at first glance at any rate, this proposal seems to cross a boundary that has been hitherto sacrosanct: experimenting with human embryos. It seems to trespass on at least two traditional shibboleths. The first one –the more problematic and dogmatically based one- is that from the moment of conception, the embryo –or morula, once the fertilized egg has divided into 16 cells- is a person, or at least entitled to all the respect and privileges of a human being. This is more of a belief, a religious or moral tenet, than a demonstrable attribute of the embryo at this stage, though, and a more neutral consideration of its personhood would have to rely on either arguments from potential or its ability to survive outside of the uterus, should that be required.

The other, and maybe less religiously coloured objection, is the issue of unintended (or even intended) consequences: that to interfere with human DNA is to interfere with humanity itself and perhaps even the reason we are as we find ourselves –evolutionary adaptations that are the solutions to myriad problems of which we may be only dimly aware, if at all; and that we don’t really understand what we’re doing –or how to do it safely –i.e. without inadvertently affecting other things, even if we did. Like any ecosystem, everything is interdependent in one way or another: solve one problem and perhaps create another that you might not have even suspected was being modulated by the initial problem.

This, of course, is the thrust of the UK proposal. One can reasonably study animal models –mice, for example- only if they have comparable genes for early embryologic development. And as Dr Niakan, from the Francis Crick Institute, said: “Many of the genes which become active in the week after fertilisation are unique to humans, so they cannot be studied in animal experiments.” Initially, the study could have more benefits in IVF work – ‘Of 100 fertilised eggs, fewer than 50 reach the blastocyst stage, 25 implant into the womb and only 13 develop beyond three months…’ “We believe that this research could really lead to improvements in infertility treatment and ultimately provide us with a deeper understanding of the earliest stages of human life.”

Convinced? It’s a difficult one, isn’t it? Clearly, we need to understand how things work (as the study proposes) long before we attempt to modify them in any way. And if gene editing on a human embryo can be done, it is inevitable that it will be done by someone, somewhere, but perhaps with less stringent rules and guidelines to constrain it. So, should we just bite our collective tongues, and bow to progress? And is there really a choice?

I’m not sure where I stand on the issue of genome editing; I don’t think there is a one-size -fits-all solution, but I do think there is un bel compromis. The issue must be kept open for discussion, made public, in other words, so that at the very least it is not perceived as being done in secrecy and without identifiable or appropriate input. The pros and cons must be aired and in terms that all can understand. And the opinions of all of the various interest groups -both religious and secular- should be publicly and repetitively solicited. The left hand must know what the right hand is doing.

No, there is unlikely to be consensus; people will divide along predictable lines as I have suggested, but at least there will be a chance for an airing of the arguments, and an assessment of their merits or deficiencies that is available to all who care –a public catharsis. A mitigation…

But in the end, I think we must always be mindful of the dangers that Shakespeare intimated in his Much Ado About Nothing: ‘O, what men dare do! What men may do! What men daily do, not knowing what they do!’

 

 

 

 

 

 

 

 

What is it like to be a…?

I should have known not to answer her question like that. I should have seen the book she was reading; I should have seen how heavy her briefcase was… But I’m getting ahead of myself.

I’m a doctor now -an obstetrician/gynaecologist- but in the beginning I wanted to head in an an entirely different direction: philosophy. And it has remained in the background, nagging at me from time to time -always superficially, of course. My adventures were often confined to a simplistic skimming of the surface of the words, with their all too frequent academic double entendres escaping me completely. But nothing ventured, nothing gained, eh? And I did learn a lot of new phrases that I found I could sometimes slip into my consultations…

Usually I would get away with the occasional philosophical nuance, but I could also be careless at times. One has to be cautious with new patients; there are signs that should be read. For example, it is common sense never to wax philosophical with anyone carrying a heavy book and wearing unstylish, heavy glasses until you know them better. To ignore this maxim is to court embarrassment –or worse, acknowledgment that a boundary has been crossed.

Sandra exhibited all of the danger signs as she sat engrossed in a tome sufficiently heavy to require both knees to support it. A young looking woman with short brown hair and a blue skirt and blouse, she looked as if she were deeply concerned about the meaning of something on the page and as I watched from behind the front desk, she both underlined it and then wrote something in the margin. Even at that distance, I could see she was deadly serious about it. I debated for a moment whether or not to give her additional time to finish her deliberations and see another patient first, but just at that moment she spotted me and smiled.

“Sandra,” I said, walking over to her and wondering how she was going to manage to shake my hand and keep the weighty book safe from the floor.

But she managed it with the skill I would have thought only an older and more experienced scholar could aspire to. And then with a quick, practiced sweep of her other hand, she realigned her glasses further up on her nose, without dropping either the book or her smile in the process.

After that, she, the book and her briefcase followed me to my office and all three of them found a space across from my desk. Once settled, she scanned the room with curious eyes which flitted about like a pair of barn swallows but finally came to rest on a little carved wooden effigy of an African woman holding a baby in her arms.

“What’s it like to be an obstetrician,” she said after examining the woman for a moment.

Although the question seemed simple, it caught me off guard, for some reason and I was suddenly struck with the difficulty of answering something that really had to be experienced to be conveyed, let alone understood. It was almost like trying to describe what its like balancing on a bicycle, or what it would be like to be a police officer walking in a dangerous neighbourhood. It’s a subjective thing that can not accurately be described from the outside.

I’d recently been reading the famous 1974 paper by Thomas Nagel entitled ‘What is it like to be a bat?’ in which he confronts those who would attempt to answer the question by resorting to either physicalism (the idea that everything can be explained by some sort of physical process) or reductionism (by and large that the whole is equal to the sum of its parts): http://organizations.utep.edu/portals/1475/nagel_bat.pdf

I have to admit that I succumbed to the temptation of pretending I understood more of what he wrote than I did. “What is it like to be a bat?” I said -it just slipped out before I could stop it. I suppose that somewhere inside I was thinking I was being clever and that I could then throw out a loose reference to Nagel’s paper –something like his ‘To the extent that I could look and behave like a wasp or a bat without changing my fundamental structure, my experiences would not be anything like the experiences of those animals.’ And so, their experiences being totally alien to me, I would not be able to describe them in words.

But as soon as I said it, I could see by her expression that I had inadvertently crossed a border into the country where she lived. A country where I, perforce, had become a bat. Her bat.

Her eyes immediately hummed with interest. “Fascinating you should ask that,” she said, choosing her words almost as if she were trying to keep them simple –much as we might when speaking to someone from another country. Another culture. “It’s difficult enough to describe what we do to someone in a different field, but an order of magnitude more difficult to describe what it is like to do it…” She smiled disarmingly and then continued. “As Nagel said,” and here she reached down and picked a somewhat lighter book from her briefcase and thumbed through it- ‘Our own experience provides the basic material for our imagination, whose range is therefore limited.’ He picked bats instead of wasps or flounders, he says, ‘because if one travels too far down the phylogenetic tree, people gradually shed their faith that there is experience there at all.’ I suppose he could have chosen dolphins or orcas but… whatever.”

I felt encouraged at her use of ‘whatever’. I thought maybe I could change the subject, but she immediately launched into a description of her position on his argument.

“Me,” she said as if we were sitting in a university lounge discussing the issue over a coffee, “I subscribe to a more intermediate position between reductionism and pure physicalism. I would put myself somewhere in the epiphenomenalist camp.” She looked up from the book and sent her eyes on a brief mission to study my face. The report was evidently not encouraging, so she decided to explain. “Epiphenomenalists posit that mental states are byproducts of physical processes –much as energy and its ability to do work are a product of, say, a steam engine boiling water.”

She carefully replaced the book in its briefcase-vault and stared at me again. Then she shrugged and a mischievous expression gradually conquered the previously academic one. “I think I will rephrase my original question and let you get on with your job. Do you enjoy being an obstetrician?”

“It’s sometimes Hydra-headed,” I said without thinking, and then quickly hid behind the computer screen when I saw her eyes light up once again.

What the Walrus said.

The media are at it again, beating the data-drums for scraps of hope. It’s not that we don’t all long for reassurance and want to believe in the steady march of Science; it’s more that we can’t shake the suspicion that if we wish hard enough, stuff happens. For some reason I am reminded of the legends of the knightly quests for the Holy Grail where, to mix metaphors, ‘Lord Ronald said nothing; he flung himself from the room, flung himself upon his horse and rode madly off in all directions’ as Stephen Leacock would have it.

A bit of a stretch, perhaps, but a news report that I happened upon, brought it to mind: http://www.bbc.com/news/health-35111443 It was commenting on a large study on screening for ovarian cancer reported in the Lancet that looked at the value of a well-known cancer blood test (Ca125) coupled with ultrasound, and contrasted it with the value of ultrasound alone, or no screening at all. They were trying to ‘establish the effect of early detection on ovarian cancer mortality.’ In all, over 200,000 women were studied over a period of four years. And the results? ‘Their initial statistical analysis of the data showed no benefit to screening. But there was a benefit when they removed the data from any women who may have already started to develop ovarian tumours.’ [Bold letters and italics mine] Umm, I thought the whole idea was to find asymptomatic people who might have tumours…  And, as the news report does acknowledge, ‘…the interpretation is a bit messy and the researchers admit it is “controversial”.’ And yet, the article’s title screams: ‘Ovarian Cancer: Screening may cut deaths by a fifth. Buried in the second to last paragraph, however, is the more important point from Dr. Fiona Reddington, from Cancer Research UK: “While this is an important step in ovarian cancer research, we would not recommend a national screening programme at this point.”

I suppose my somewhat cynical point is that one has to read more than headlines to know the world, and that it is probably unwise to believe everything that is offered by the Media anyway… Then, for some reason, I remembered how I had managed to misread Germaine and her wish to be screened.

I like to see people smiling in the waiting room –it makes me want to choose them as the next patient and forget the scowlers or the eye-predators who attempt to capture me even before I make it past the front desk. Germaine imprisoned me with her eyes the moment I saw her –but more like in a flower than a jail. Her smile grew wider, the closer I approached, and almost exploded when I shook her hand to introduce myself.

But it faded slightly even after she realized she had in fact been chosen as the successor to my last patient, and had firmly ensconced herself in the hard wooden seat across from my desk.

The time has come, the walrus said…”. Those were the first words she uttered as soon as she sat down but when she saw the expression on my face, she managed to produce an embarrassed grin. “I’m an English Lit major…” she added, as if that were the definitive explication of the quote.

“The Walrus and the Carpenter -Lewis Carroll, right?” I said, surprised at how quick I’d got it.

I was rewarded with a twinkle from her eyes. “I have come to talk of many things,” she added, and promptly went on to explain. “I want you to check me for everything.” Her face glowed with expectation.

I tried to keep my eyes from rolling, but I’m not sure how successful I was. I then attempted to disguise my reaction further by scrolling through her records on the computer. I had seen her before, but not for a year or two. At that time, she had been referred for a pap smear and a discussion about becoming pregnant. She was now 26 so I assumed she was probably newly pregnant and was coming to me for her first prenatal visit. But the current referral letter said she was not pregnant and hinted at something else –something unspecified. I hate letters like that. I smiled anyway and looked up at her.

“My partner decided to be unfaithful, and said I need to be checked,” she said quite matter-of-factly as soon as she saw she had my attention.

Now we were on more familiar territory for me. I glanced at the screen. “Well, the pap smear your GP did a couple of months ago was normal…”

She looked as if she were about to roll her own eyes. “Well, of course…”

I politely ignored the unexpected reaction. “And you’re not having any symptoms?” Even if she weren’t I would still do the same tests, but it never hurts to ask.

“You mean like with gonorrhoea or syphilis…?” Her eyes narrowed slightly as she considered the ramifications.

I nodded. “Or chlamydia…”

She shook her head vehemently –almost violently, actually. “No, no. That’s not an issue.”

“Well, are you concerned about HIV, or…”
She threw her hands up in a theatrical denial of the very thought. Her mouth managed to roll up this time to complete the rejection. “Doctor!” she almost whined. “It’s not that kind of thing…!” But her sentence trailed off suddenly, leaving me to wonder if there was something she had been hiding from me. Something that she expected me to investigate without actually naming it.

“What would you like me to check then, Germaine?”

She looked down at her lap for a moment, the smile a mere ghost of its former self. She had pasted on another paler version by the time she looked up again. “Can I ask you a question first, doctor?”

“Of course you can…”

“Ahhh, I umm, read somewhere that ovulation drugs can give you cancer… ovarian cancer… Is that true?”

I had to think for a moment. There had been a spate of studies a few years before looking at the risk of ovarian cancer after the use of Clomid (clomiphene is a medication that tricks the pituitary gland into manufacturing FSH and LH which stimulate ovarian egg maturation and subsequent ovulation). The early and smaller studies suggested a slightly increased risk, but later studies either were unable to establish this, or had mixed results. “Well, those early studies were small and somewhat controversial, Germaine, and even with long term use, the risks were still very small…May I ask why you’re worried about this?”

A silent anguish seemed to drift across her face. “Well, what I read was that the longer you take the medication, especially if you don’t become pregnant, the greater the risk.”

“And did someone put you on it, Germaine?” I scanned through my old history but could find nothing to suggest a reason she would be infertile.

She nodded. “My GP did. We’d been trying for pregnancy for almost 6 months with no success.” She glanced at the ceiling for a moment and then out the window behind me. “And I mean the guy has good sperm –it worked before on another woman…”

I stared at her for a moment; I didn’t mean to, but my eyes just seemed to attach to her face. It was a rather odd way to talk about things. I decided to ignore it. “And how long were you on the treatment?”

She thought about it for a moment. “Well about 6 months, I think. But it didn’t work!” She took a deep breath and let it out slowly. “I told Jo -my partner- that I was worried about the risk of the Clomid… Then we both became worried, and that obviously led to the alternate route.”

“The alternate route?”

Germaine stared back at me with a puzzled expression on her face. “Yes,” she said after she’d thought about my reaction. “We both wanted a child and if I couldn’t be the one to carry it, then we’d have to make other arrangements –and it would have to be with someone else.”

Surrogate pregnancy?  I thought that was a little drastic after only 6 months or so of trying and I said so.

She looked surprised. “Oh it’s okay, she didn’t mind.” Then her eyes narrowed and a naughty expression suddenly laid siege to her face. “It was me… I was just a little surprised at the methodology, that’s all…”

By now I was hopelessly lost. Germaine seemed to find my puzzled expression funny and she started to laugh. Then her eyes twinkled again as the truth dawned on her. “I think you should look a little closer at the history you took when you first saw me.”

I pulled it up on the screen again and blushed. It’s funny how you can miss things when you’re searching for something else entirely.

“Even our eyes get caught in ruts, doctor,” she said when she saw my face. “It seems a shame, the walrus said, to play them such a trick…”

The poem again! But I finally understood; Jo had decided to have the baby.

“And my risk of cancer?” She was in a better mood now, and didn’t seem as worried.

The night is fine, the walrus said…” It didn’t really fit, I suppose, but the line had probably lain dormant in my head since university and I had to try it out.

She looked at me for a second and then giggled. “We’re really milking it, aren’t we?”

“You mean the butter’s spread too thick -as the walrus said?”

She nodded and then corrected me. “It was the carpenter…”