Monthly Archives: December 2016

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How Ethical is Ethical Compromise?

What to do with a minefield? Once it is there, is it sufficient to avoid it while we investigate and map it –mark it off as terra incognita- or must we act immediately to attempt to remove all mines even if we do not fully understand their distribution or destructive capabilities? Even if we may miss some and our initial enthusiasm was deemed naïve?

This is an admittedly inadequate metaphor when applied to ethics, to be sure, but in many ways is illustrative of the pitfalls of being too quick to judge; or, alternatively, of assuming there is only one approach –and that the one chosen is perforce the correct and appropriate one.

Unfortunately, majority opinion often quietly assumes the mantle of indisputability in a culture, no matter its importance or suitability elsewhere. And even to question the legitimacy of the assertion is to question the legitimacy of the social norms to which its members unconsciously adhere. It may not necessarily intend to negate them, or overtly dispute them, but by subjecting them to investigation, it may seem to disparage their sanctity.

It is difficult to step out of our societally condoned patterns of thought and our long-hallowed mores; it is troubling to observe customs that seem to violate what to us are ingrained standards of morality. It is difficult indeed, to accept that we may not be in sole possession of moral rectitude –that there may be alternate truths, alternate moralities, even alternate equally valid perspectives.

I raise this with regard to the increasing awareness and condemnation of female genital mutilation (FGM). To be clear from the start, I do not condone FGM nor feel that it should be perpetuated; indeed I have to confess that I have great difficulty viewing it as anything other than a culturally-imposed abomination -misogyny writ large. I was, however, intrigued by a paper published in the Journal of Medical Ethics that sought to assess the issue in a more critically constructive fashion than I have seen before: http://jme.bmj.com/content/early/2016/02/21/medethics-2014-102375.full  It is really a very thoughtful and enlightening paper and I would strongly suggest that it is worth reading –if only to learn more about FGM and its cultural significance stripped of any pre-loaded societal baggage.

I was impressed by several things in fact. They sought to classify the procedures in terms of degree, medical issues, the ethical underpinnings of FGM, cultural sensitivity, and whether or not any form of the procedure would constitute gender discrimination or the violation of human rights. I will let the reader judge how thoroughly these fields were covered, but caution against our usually self-imposed wall of confirmation-bias that often precludes a dispassionate consideration of views that don’t fully accord with what we ‘know’ to be the correct ones… http://www.cbc.ca/news/health/female-genital-mutilation-legal-1.3459379 -this brief article from the CBC is perhaps a more assimilable and balanced –albeit nuanced- summary of the arguments.

I suppose the issue is not so much whether the practice should ever be acceptable –although neonatal male circumcision seems to have made it through the gate- as whether by outlawing it, the procedure will be driven underground as seems to be happening currently. If it is so important to a culture –whether justified by mores, or religion- that there seems to be an imperative to have it performed to allow an individual’s acceptability to be confirmed in the community, then wouldn’t it be better to acknowledge this, but mitigate the harm?

The authors have attempted a classification of FGM into 5 categories, the first two of which are thought to have minimal if any permanent effects on the girl -no effects on sexual pleasure, functioning, or reproduction. And, of course, if accepted, could be done under an anaesthetic, rather than by test of courage. Its acceptance could serve to assuage the cultural imperatives while essentially eliminating the greater severity and mutilating effects of the more complicated forms of the practice. It would be an intermediate –and hopefully temporary- step on the road to complete elimination of the procedure.

To be sure, the objection raised is often the one of argumentum ad temperantiam –the fallacy of assuming that the truth –the resolution- can be found in the middle ground between the two conflicting opinions. The problem, of course, lies in the validity of the opposing claims. Should one really be looking for the middle ground between information and mis (or dis) information? Sometimes the distinction is easy, but sometimes it is the minefield I discussed above. Primum non nocere –first of all do no harm- is the guide. As the authors state: ‘… analysis of issues in medical ethics generally regards principles as being prima facie in nature, rather than absolute. Therefore, important emotional and social considerations can trump minor medical considerations.’ In fact, because of the extreme and negative connotations of the term female genital mutilation, the authors even propose an alternative, less pejorative name: FGA (female genital alteration).

Without trying to push the concept and its acceptance too strongly, let me quote the summary of their intent: ‘Since progress in reducing FGA procedures has been limited in states where they are endemic and the commitment of people from these cultures to these procedures has led to their persistence [even in] in states where they are legally discouraged, alternative approaches should be considered. To accommodate cultural beliefs while protecting the physical health of girls, we propose a compromise solution in which liberal states would legally permit de minimis [a level of risk too small to be of concern] FGA in recognition of its fulfilment of cultural and religious obligations, but would proscribe those forms of FGA that are dangerous or that produce significant sexual or reproductive dysfunction.’

Compromises are always difficult; no one gets all they want, and yet each gets something. I raise the issue of female genital mutilation/alteration mainly for information but also for discussion. Sometimes, we need to know something about what we oppose. Always, in fact…

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What did you expect?

We have become obligate avoiders, dwellers in the middle of the field well away from boundaries –the just-right-baby-bears of the Goldilocks tale. We seek to protect ourselves from edges, no matter how pervasive, how common, how important they may be. It was for a very good reason that the American folk hero, John Wayne, felt he had to remind us that ‘Courage is being scared to death… and saddling up anyway.’

Most of us seek to insulate ourselves from every extreme: we read about our lives from the safety of a middle page while dreaming of the youth in early chapters –as if there were no beginning or conclusion to the book. I suppose it reads as well in the center as at either end, but that misses the point; the book is a story –our story- and to ignore the epilogue or, for that matter, the introduction is to miss the context in which it is written -the gestalt.

The end of life, is an example –until recent times, most people in Western civilizations died where they lived: in their own homes. Family and friends were usually there to provide comfort and support; it was not treated as an event that necessitated separation, but rather as a communal passage –something that invited witness and provided solace for all involved.  Dying, especially of advanced age, was not something to be hidden away or delegated to strangers, however skilled. Death was visible and inevitable; death was a known, if unwelcome guest in each home.

Birth, the beginning of the story, has also had a somewhat chequered history. It, too, was once relegated to the home, but with sometimes unfavourable results for both mother and baby. This led to it being assigned to areas –or assistants- with more training and facilities in case unexpected -or anticipated- problems arose. And while, as an obstetrician, I feel more comfortable in an institutional setting, there is no reason why a well-trained midwife should not be able to pick and choose the appropriate venue for the birth depending upon her assessment of the risk involved. And there is no reason, either, why family or friends should not be able to witness and support the event.

I was surprised, therefore, to come across an article in the BBC news that treated as, well, unusual, the idea of a mother’s children being present to witness the birth: http://www.bbc.com/news/uk-37020059

Clearly, some vetting might be required in terms of the children’s age and behaviour, but as long as they are prepared beforehand, and there is someone else in the room who could supervise and help them understand what is happening, I think it could be a positive experience. Birth and Death should be presented as they are: natural events –not secrets whispered behind closed doors.

*

I kind of suspected birth was no secret to Loretta’s kids. A third-time mother of six and  nine-year-old daughters, she brought them to every antenatal visit. I asked her one day while her older daughter played doctor with my stethoscope, how she managed to get them out of school each time.

She pointed to her watch. “Ever notice that I always book my appointments around noon?”

I nodded. We’d often joked about our stomachs rumbling each time we met. “But they don’t mind leaving their friends to come here?”

“McDonald’s,” she said and then shrugged. “It’s their reward for agreeing to come with me.” She was silent for a moment and then stared at me, her eyes twinkling. “Don’t look at me like that, doctor. Remember Bill Clinton?”

I nodded, puzzled by the non sequitur.

“I never inhale,” she whispered conspiratorially.

The girls were always on their best behaviour in the examining room –full of questions and wanting to try my equipment on themselves. I suspect that the visits sometimes even cut into McDonald time, but they seldom complained –they were much too curious about the growing baby. They never seemed to tire of asking me how much it weighed, and whether it could hear them through their mother’s tummy –apparently they would sing to it at home. The moment they both waited for, however, was when I would place the Doppler device on the uterine wall so they could hear the heart. Janice, the older one, would even time it with her watch to make sure my device was counting correctly. They were both as involved in the pregnancy as their mother.

One day, towards the end of the pregnancy, Loretta phoned me. “I’ve been thinking of letting my girls see the birth,” she said. I could hear a little hesitancy in her words as she spoke. “Will the hospital allow that? My mother will make sure they don’t get in the way,” she added, almost too quickly.

I smiled into the phone –I’d been expecting her to ask. “As long as they know what to expect Loretta. There’s sometimes a lot of… well, yelling as you push… and a lot of blood –especially when the placenta comes out.” I paused for a second. “They have to be told that none of that means there is anything wrong. I wouldn’t want them to become scared.”

She chuckled into her phone. “They watch deliveries all the time now on YouTube, doctor –complicated ones, scary ones, and even ones that end up in Caesarian Sections. I think they’ll be all right.”

“Then it’s fine with me.” I reminded her that I may not be on call when she delivered, but she merely laughed.

“You didn’t make it for the first two either…”

*

Obstetrical practice nowadays is a hectic melange of joy and crisis, each delivery unique and exhilarating to be sure, and yet strangely merged into the one a few minutes before and blended into the one a few minutes later when on call at the hospital. So I have to admit that I was pleasantly surprised one evening as I was rushing to yet another delivery further down the hall when a nurse informed me that Loretta had just been admitted in labour.

“She’s almost fully dilated and it’s her third baby; she won’t be long…” she yelled as I ran past her to the accompaniment of screams from the room where I was originally heading.

Obstetrics is sometimes an exercise in ad hoc triage, and the screams were becoming louder and more compelling from that room, so I had little choice in the matter. I arrived just in time to exchange the mother’s for the baby’s screams, and allow a placenta to jump suddenly into my lap while she snuggled her precious baby against her abdomen.

In the warmth of smiles and congratulations that followed, I almost forgot about Loretta until the nurse’s face appeared in the door. “They want you in Room 8, doctor,” she said, almost casually.

I removed the placenta from my lap and stood up ready to run from the room.

The nurse shook her head sternly. “Better not show up like that,” she said, pointing to my gown. “You’ll scare the girls…”

I grinned sheepishly from behind my mask. I’d forgotten about the girls.

Loretta’s room was strangely calm when I arrived. Everybody was smiling, the baby already snuggled skin to skin on Loretta’s abdomen, and the girls were standing beside their mother enthralled and staring wide-eyed at the crying baby.

Maria, another nurse, who’d been with Loretta since her admission, was just removing her gloves after making sure the newly-delivered placenta was in its little metal bowl. Even though trained as midwives, the obstetrical nurses rarely get a chance to exhibit their skills except at times like this, and she was smiling from ear to ear. Things had obviously gone well.

“Congratulations, Loretta,” I said and immediately blushed. “Looks like I missed number three as well. I’m sorry…”

“Don’t be sorry, doctor. Maria did a fabulous job.”

Maria glanced at Janice who hadn’t even noticed that I’d finally come into the room then focussed her attention on me. “Actually, I was a bit rusty,” she said with a mischievous smile and winked at me. “Janice kept reminding me what to do next…”

Janice turned her head and stared at me. “Maria did a good job,” she said approvingly, “But she dropped the placenta,” she added, her face turning serious like a teacher unwilling to overlook a mistake. “I told her it’d be slippery…”

 

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Who Wants a Country of Boys?

We mortals seem to be good at assumptions; they are shortcuts that allow us to function without the requirement of constantly checking the validity of beliefs or items in our environment. Part of it is trust; part of it is process, and yet I don’t want to get into a semantic discussion of the manifold vagaries of the word, nor a tedious list of definitions. I just want to concentrate on that very human characteristic of taking something for granted without the need for proof.

But of course that supposes –okay, assumes– that whatever we are considering has been vetted in a way that we are used to. A way that has the common consent of experts in the field, say, or at least something that accords with our experience. It would be acceptable, for example, to assume that if someone is talking about a bus, that they do not need to define it. They will not likely mean a train or a motorcycle…unless, that is, we include metaphors and their ilk -so let’s not.

I want to keep this simple for now. Some assumptions lead to others and so, like the weak link of a chain, conclusions based solely on a trail of assumptions can be a house of cards. At some stage, it would likely be prudent to search for verifiable sources if the issue is important.

I suspect that the trust with which we clothe assumptions is multi-fashioned. Sometimes it is the source, and sometimes it is the subject. Or the wording. Suppose, as an example, we are reading an article purporting to discuss discrepant sex ratios in a country and there is mention of the ‘sex ratio at birth’. (I have covered sex ratios and their definitions in a previous essay by the way: https://musingsonwomenshealth.wordpress.com/2015/08/25/pregnancy-stress/ ) Would we not be forgiven for the assumption that the definitions used would be the commonly understood ones in this context? And that when the ‘natural sex ratio at birth’ is mentioned in the same breath –or in this case, line- as the World Health Organization, couldn’t we relax. A little?

Well, I have to say I was initially seduced by this notion in an article in the BBC News, and then, intriguingly, disavowed of my naïveté. The article was titled ‘Why does Sweden have more boys than girls?’  http://www.bbc.com/news/magazine-35444173  My first thought, of course, was so what? The normal secondary sex ratio for humans would seem to average out around 5 extra boys, for every 100 girls that are born. Various reasons have been proposed to explain this, and I assumed (there we go again) that the article was reporting a new one –or at least new proof.

And then, when that didn’t prove to be the case in the first paragraph or two, I wondered if there were some hitherto unknown problems with northern sunlight, or perhaps residual effects from Chernobyl…

But I quickly became aware that they were using the term not as sex ratio at birth (the secondary sex ratio), but rather the sex ratio at ages 16 to 17 years of age (which would be closer to the tertiary sex ratio). I hadn’t expected this, and so now I had to again switch assumptions.

First of all, they gave a little background: ‘official statistics show that in 2014, there were 108 boys for every 100 girls among Sweden’s 16 and 17-year-olds.’ Okay, 108 boys per 100 girls is not so far off the 105 boys expected. I almost shrugged and moved on to another article until I read the next sentence: ‘But the country now has 123 boys for every 100 girls in this age group’. Whoa, that woke me up. So, not only do they talk in terms of a specific age group, they also report that in one year it has changed remarkably.

Time to examine my assumptions again, I realized. It turns out that the discrepancy is largely explained by immigration –or more accurately, refugees. But am I also to assume that it would be dominated by males -boys, actually? This requires another assumption: that more young men are able to make their ways through the turmoil and suffering of their native lands than their female counterparts. If the family is in dire need, and has little chance of making it out intact, perhaps it sends out the strongest, in hopes he (or sometimes she) will find refuge and then send for them. But is the male preponderance merely related to societal expectations and socially determined male roles?

The article purports to to explain the preponderance of males over females in that age range:  “If you’re underage, first of all, you get housing, you get more financial resources. You also have a lot of staff around you helping you with different issues,” says Hanif Bali, a member of the opposition Moderate Party in the Swedish parliament – which is on the centre right of the political spectrum. “If you need food, clothing, everything, you can go to the municipality and demand this money.” Presumably a young a young girl could do the same if the family had delegated her as the one to leave -but if you were the matriarch or patriarch of that family, would you send your daughter? Or would fear of the probable fate of a young, unaccompanied girl on a dangerous journey with unscrupulous smugglers likely convince you to send your son?

Of course that survivability benefits the young male asylum seeker all right, but what about the family? Were my assumptions about the strength of family ties naïve? Thankfully not. Fascinatingly not: ‘[…] there is another even bigger benefit, which Bali believes is significant. “You have the right to family reunification. So you can bring all of your family to Sweden, if you are underage.” Under 18, that is… And actually make it to Sweden.

So there are huge incentives for getting to Sweden before you turn 18.’

The article turned out to be thought provoking for me on several levels. One I have to attribute to age-naïveté: how does news of this kind of stuff leak out to people in a war-zone, fleeing for their lives? And secondly, how effectively the refugees have been able to use the Swedish social system to allow something on a scale for which it was likely not intended. But it also speaks volumes about assumptions and where they can lead us. You can almost hear the Hamlet-like defence of those 16-17 years olds when confronted with their manipulation of the system: ‘Why, man, they did make love to this employment, They are not near my conscience.’

 

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The Unfallen Yellow Leaf

‘Age, with his stealing steps, hath clawed me in his clutch,’ as the gravedigger in Hamlet says. I’m not so sure I agree –he was speaking about a skull, after all- but I have to admit there are times when I do feel old, and shipped ‘into the land as if I had never been such’; when I do wonder if whatever I have done has gone as unappreciated as a shadow from the moon, as unnoticed as an owl in the night.

I used to think that ‘Aged’ was just a word –but an adjective, not a noun; a descriptor rather than a described -somebody else, in other words… And that makes a difference, even when it is not mentioned in your CV but, rather, implied in the later stages of your career. I prefer to see the years as a kind of parliament where habits, and opinions and experience, all cohabit equitably, calmly debating the memories they were each elected to serve, sifting through them, perhaps, to decide if any merit publication.

And I’m sure there are some memories out there where my face is almost discernible in the background; where at least my voice was recognizable at the time. ‘What you lose as you age is witnesses, the ones that watched from early on and cared, like your own little grandstand’, John Updike wrote in one of his ‘Rabbit’ novels. He’s right, of course –and yet… Sometimes it can happen that you forget the very ones that watched from early on; you forget they cared.

Janice sat giggling in the corner of the waiting room, watching a little child toddle across the room towards her, his legs bowed around bulging diapers, his progress uncertain but determined. I could see her eyes from the reception desk; they glowed with excitement and her head seemed to bob in time to every tottering step. Her entire face became a smile, an expectation living vicariously as the little boy approached, followed closely by his beaming mother.

The consultation request from her GP said she had been referred for antenatal care -as if the rapture in her eyes, and the glow on her cheeks could be mistaken for anything else. Some people wear their pregnancies like jewels. It’s why I love obstetrics.

As I walked across the floor to greet her, she suddenly jumped up and extended her hand. For some reason I had the impression that she wanted to hug me, and would have under different circumstances. Not that I don’t enjoy being hugged, but it did seem unusual from someone I’d never met before. Pregnancy can be an unpredictable gem, though, and I have learned to appreciate its various rewards over the years.

“I’m so happy to finally meet you, doctor!” she bubbled as we headed down the little corridor to my office. “Pregnancy opens so many doors,” she added, smiling at nothing in particular with her eyes.

Indeed, she spoke as much with her eyes as with her mouth as she glanced around the room like a tourist in Paris. They pointed like children in front of each picture hanging on the walls, flitting from pictures to plants and back to pictures again -excited hummingbirds. They finally came to rest on a little terracotta begging lady I’d placed on an oak table in the corner. Pennies dripped from her little bowl, mute testaments to her longevity in the office.

“Where on earth did you get the pennies?” Janice whispered, this time rolling her eyes.

I had to shrug; it was a long story.

“I Googled you before I came, of course, and all your patients seem to mention the begging bowl… Now I see why,” she added shaking her head with what I took to be admiring disbelief.

“And there’s the carving of the woman holding the child and hiding behind the leaves!” she said, excitedly pointing to the little, pot-bound Areca plant on my desk. I was beginning to feel a bit like an employee at a Disney resort.

But then she calmed a little and instructed her eyes to leave the office thermals they soared and perch on my face. I could actually feel them, heavy on my skin, their prey firmly captured. It was almost as if I should understand that they had come back to roost; that mine was the aerie they had once called home. And throughout that first visit, I thought I felt her disappointment –a father finally seen after many years away, that no longer recognizes his child. I could sense a hope for reminiscence, a need for demonstrating familiarity, sharing secrets I couldn’t possibly possess.

Indeed, I got to know her quite well in that pregnancy, and the initial expectation of acknowledgment she had worn, soon blended imperceptibly into an easy friendship. Who once were strangers, now were allies in the weeks, then days, before delivery. But there was always something in the background that I sensed she was disappointed I hadn’t recognized. Something she was now holding as a surprise; something I should have known from the start.

And then, a week before her dates predicted she should deliver, I saw her sitting in the waiting room with an older woman. She’d told me her mother was flying in for the delivery and seemed excited that I was finally going to meet her. I could even feel the italics in the word.

I saw the two of them whispering excitedly in the corner seats Janice always chose, glancing secretly at me as I greeted other patients with earlier appointments. I thought I heard them snickering once or twice, but sometimes people do that when they’re nervous.

They both stood up and glanced mischievously at each other when I approached them. Her mother was a short matronly woman with greying hair that was precariously balanced on top of her head like a silver hay-stack. Her face, though wrinkled, held a pair of familiar eyes that strained at their cage doors just waiting for liberation.

It’s an interesting thing about faces: no matter how much they change, they stay the same… Or is it just the eyes –roses by any other name…?

The waiting room by then was empty, and there was nothing to stop Denise from hugging me, followed, as if on cue, by her daughter.

“So now do you recognize my daughter?” she said, her face an imp, her eyes laughing silently as they flew towards me.

“She’s changed a bit…” I stammered, still flustered by the secret, and admittedly a little embarrassed at being old enough to deliver a patient I had already delivered so many years before…