Medicine and Ideology

Some things are more definitive than others –less ambiguous, more predictable. Reliable, in other words. They lend themselves to yes-no answers, right-wrong judgements, good-bad characteristics. And some people prefer to see the world in black and white like this. Uncertainty is uncomfortable for them; they crave cognitive closure in the opinion of Arie Kruglanski, a professor of psychology at the University of Maryland.

It would seem that there are times in a life –usually inter regna, times of transition- when this eschewal of indeterminacy is more powerful: adolescence, retirement, divorce, and so on. And at those times, when everything seems unstable and unfamiliar, shelter from the maelstrom under any unmoving roof seems prudent. Rules and unequivocal, unchanging answers are tempting accessories. That something is either right or wrong can be comforting in times of stress.

One problem with this bichromatic need however, is that things are rarely static. They are continually modified by circumstance and context; the questions that need to be asked, and especially their answers, expand and mutate. They evolve over time, in other words. So, for example, that someone is, or is not pregnant, may be unambiguous and beyond dispute. But whether that pregnancy continues or miscarries, is healthy or complicated is not. Things change, are unpredictable, and answers –facts?- obtained at one stage may not obtain later. Life is flux -an ever moving current.

And, of course, context is almost as relevant as substance. Nothing is separate from its surroundings. A pregnant woman, say, is a member of a group –however tenuous- or at the very least, a member of a society. A culture. There are obligations and expectations unique to her milieu that may not be immediately apparent –especially to someone not a member of that group. And these conditions do not often lend themselves to a one-time appraisal, a permanent and unbending judgement, or a right/wrong approach. A rigid doctrine -established on whatever principles- does not always work. In fact it imprisons; it imposes an unchanging view on a constantly unfolding reality. It is dogma.

So it was with some concern that I read an article in the Sept.16/14 Canadian Medical Association Journal –in the news section- entitled ‘US politics and ideology enter exam rooms’. In it was outlined some of the requirements in certain states that seem to impose political or moral ideologies on both patients seeking assistance, and medical staff trying to provide it –an arena that one would expect to be free of bias and coercion.

There are some American states, apparently, that require a woman seeking a pregnancy termination to be shown –not just offered-  a view of the ultrasound of her fetus. In my opinion, this is just cruel –a punishment thinly disguised as help. Disclosure. An admonition clothed in the scarily garish colours of useful information. That there may have been extenuating circumstances –whether personal or social- that led to her decision to terminate would seem to be irrelevant. The choice the woman has to make is a painful one –it is seldom capricious, rarely if ever carelessly taken. That someone should be available to help her with her decision and counsel her before and after if she wishes is a given. But it should not be an impediment.

As the article observes, ‘In such cases, it’s not just the doctor and the patient in the room. In effect, it’s the state government, too.’  This is the not-so-thin edge of a wedge that seeks to modify behaviour –even behaviour condoned in law- by mandating seemingly reasonable adjuncts to the process. ‘What could be wrong with offering to show the woman her fetus on an ultrasound?’ one can almost hear them pontificate mellifluously with fists all the while clenched tightly behind their backs. But the operative word here is ‘offer’. The term suggests choice.  Not coercion. Bullying. Threat.

I recognize that I’ve chosen a contentious issue –pregnancy termination- to illustrate a much more fundamental point: the relational autonomy that should be a cornerstone in our dealings with others. And yet it forms –must form- an essential foundation if we are to reach out to those who, constrained by their own beliefs or cultures –their own experiences- are reluctant to seek our help. It seems to me that it is only humane to enable them -actively encourage them- to access whatever aid we are able to provide. It is not merely magnanimity on our part. Not generosity. Not accommodation. It is empathy; a recognition that despite our differences, we are all struggling. All seeking some path through the chaos of one transition or another. And the cognitive closure need not be punitive. Nor dogmatic.

In fact, it can be instructive. Insightful. As Shakespeare observed, It is not in the stars to hold our destiny, but in ourselves. And we must help others to see this. We must enable them, and so enable ourselves.

Sex Selection… or Any Selection

Another day, another march. This time it was the March for Life in Ottawa where the usual Pro-Life rhetoric was rebranded as being against sex-selection abortions. A worthy cause, for sure, and probably more universally palatable than condemning all abortions -whether done for medical, genetic, or even social reasons- as they have in the past. And by aligning themselves with the Feminist movement -protecting female fetuses and ‘more progressive human rights movements’ as the news media report it- they are no doubt hoping to appeal to that segment of the public that has hitherto merely watched from the sidelines.

As a member of that Public for many years now, I am intrigued to say the least. I am -and remain- firmly pro-choice, and yet I cannot deny my concern about sex selection. Quite apart from any argument about the sanctity of life or the morality of abortion, sex selection seems a self-defeating concept. I don’t wish to state the obvious here: like the huge loss of potential, the necessity of a female perspective to balance that of -what?- Testosterone? Or even the more obvious one: who would have the next generation’s children if there were no women? I just think it is inappropriate and short sighted to select on the basis of gender. It simply does not make any sense to me; it wouldn’t in a male-dominated society either: why would they want even more competition..?

I realize these are rather superficial observations on a topic that deserves a much deeper analysis, but I am struck by the emphasis in all this protestation on what we do not have in common. It is perhaps one way to capture attention and engender Media headlines but I would submit that confrontation usually entrenches positions more solidly. If nothing else, it defines an us and a them –a line to cross. It necessitates a backing down by one side -a loss of face, if you will- before there is a victory. And indeed, even to see it as a victory rather than a change is to diminish the other side and those that were adherents. In a way, it is to colonize that other world.

Drawing attention to a cause is one thing; convincing and educating an otherwise indifferent opponent is another. I think that all too often, the terms of battle are such that winning means incorporation: absorption of the entire spectrum of views and opinions of the successful side, and denigration -or at least abandonment- of those of the opposition. Colonization by default, if you will. It’s all politics: you have to convince the Public before you legislate. No smoke-and-mirrors. If there is an imposed settlement, rather than one achieved by both enlightenment and then consensus, it is a short term gain and one that will likely be resisted and maybe even eventually overturned again.

Even my dim recollections of History attest to the wisdom of compromise after conquest: the Roman empire was stabilized over the years almost as much by the accretion of foreign customs and religions as by the continued imposition of force.

I’m not trying to assert that obtaining such important and inalienable goals like Women’s Rights -or Human Rights- are somehow akin to foreign conquests; that we must always be satisfied with compromise. That we must always and forever sacrifice some issues to achieve others. But let’s face it, there truly is a wedge effect: achieve one thing and it often makes it easier to move on to the next on the list. I suspect that those gender selection protesters in Ottawa are well acquainted with that possibility.

But you know, even if it stops somewhere -as it always must in a diverse, multicultural and multifaith society like ours- it is an accomplishment. A blend of opinion, a mixture of viewpoints is ultimately to everybody’s advantage: no one will accept everything -our society is simply too heterogeneous to be of one mind. And ultimately, hopefully -probably, even- in the fullness of time, we and even our presently-held viewpoints might become different shades -ripples- in the melange that bathes us all.

If I may be allowed to cut-and paste from Shakespeare (Antonio in The Tempest): We all were sea-swallow’d, though some cast again (And by that destiny) to perform an act Wherof what’s past is prologue. We must resist the things we cannot abide and advocate for change. But whether, as things progress, we still feel the same or even settle on a middle ground, the expression of the opinion is what is important. A Society grows by increments; it is a work in progress -never finished, never complete. Nor are we, the Public, meant to be displayed for all time in a stone carved years before.

As with Evolution, whatever happens can only be judged in context and we -and even our opinions- in the larger scheme of things, are contingent…

The Stand

“So, do you have a stand on that, then?” She was smartly dressed in jeans and what looked to be an expensive white silk blouse and divided her eyes between my face and a little notebook in her lap. Whenever I said something she liked, she would scribble furiously and noisily in it. Otherwise it was silent -a non-attributable form of media manipulation? The noise amused me more than anything.

“I thought we’d already established that I like to hear what the patient is saying and then try to diagnose…” -I thought I’d sprinkle a few medical terms at her- “… what it is that she is trying to tell me.” I stared at her silent notebook and then added: “There’s more to conversation than words.” Her face took on the look of a dog that hears a noise it can’t locate. I could tell I was losing her. “You know: tone of voice, cadence of speech, body language…”

Her expression softened, and there were a few cursory scratches of pencil on paper. “A bit wish-washy. I’m trying to get at what you actually believe.” She said the word as if there were discrepancies in my answers so far.

“I believe…” –I thought I’d italicize the word as well- “…that it’s important to understand what my patient believes -read between her lines, if you will.”

“Her lines?”

Well, that metaphor was lost on her. “The lines, then.” Silence: pen gripped tightly but motionless, eyes fixed, breath held. More was expected: an addendum. “I mean that sometimes a person says one thing , but actually means something else that they’re afraid to say… Or maybe haven’t really decided what they think.”

Her brow crinkled -rather cute,  I thought. “But you’re the doctor! Wouldn’t you have an opinion on what she was telling you?”

I took a deep breath but tried to disguise it in case that would somehow get translated into pencil scratches. “If I knew what she was telling me, I suppose it might help me to direct my subsequent questions more appropriately…”

“But,” she interrupted, pencil at the ready, “let’s say the woman has already come in to see you with… a situation…” I suspect she thought she was being sensitive with that choice of words. Politically neutral. “Wouldn’t that in itself give you the information you need?”

I shifted into my bland I’m-not-sure-what-you-mean mode that I often find helpful in the office. “Information, yes; solution, no.”

“But…”

I’m still not sure why I had agree to be interviewed. Not really. Superficially I suppose it was because one of my colleagues was doing abortions and had a recent complication with the procedure -through no fault of his own, I might add. The woman had tried to self-induce a termination of her pregnancy, failed, become seriously infected, and then sought medical help from my colleague. He performed his job admirably and saved her life through his own skill and knowledge, but someone had leaked the ‘complication’ to the press and the whole event had been misconstrued. So perhaps I’d wanted to set things straight. But that’s not what this journalist saw as her mission. I suspect she actually wanted to know the opinion of a gynaecologist who worked in an ostensibly Catholic hospital.

I’d tried to dissuade her from that approach at the start, but to no avail. Now I was becoming a little annoyed at her persistence. But if the truth be recognized, it was her agenda that bothered me the most. I put on my best doctor smile and sat back in my chair. “Perhaps it might be a good time for you to be more specific. What is the question that you are leading up to?” Somewhere inside I blushed at my ending the sentence with a preposition and wondered if that might be one of the few sentences that she would quote in her article.

She gripped the pencil tightly; I could see the bones in her hand standing at attention just under her skin. “Doctor, you work at a Catholic hospital, do you not?” I nodded, but it was one of her conditions for the interview in the first place. “What do you think of abortions, then?”

My smile continued without interruption. I knew that was what she wanted, and had expected it at the beginning. And yet the question, at least for me, was irrelevant: where I work does not determine what I think. And what I think does not interfere with how I manage a patient with a problem. The journalist was staring at me, pencil poised, a subsequent question rolling around in her mouth just waiting for my answer. “Would you care to contextualize that?” I said, knowing full well she would have no idea what I meant.

“Pardon me?”

I crossed my arms and leaned forward on the desk that I had been careful to sit behind at the start of the interview. “You asked me what I thought of abortion. You might as well have asked me what I thought of fibroids…”

“I… I don’t see…”

“No, you don’t do you? Well let me put things into context for you, then. Abortions? I wish they were unnecessary. But then I also wish that people only became pregnant when they chose. And if they chose. In life, things happen, and not always for the best. I don’t much approve of smoking either, but that doesn’t mean that if a person were to become ill because they smoked I wouldn’t try my best to help them. Or in my own field, if they were to develop chlamydia or gonorrhea that I wouldn’t help them because they hadn’t used a condom, or maybe adhered to my own person moral preferences.

“Am I an ethical relativist? You might better ask me if I am a doctor. If you were to walk through that door looking for help, my first question would not be whether we had the same belief systems or the same cultural norms. No, it would be what can I do to help you? In other words, how are you suffering? And if I asked you about your sexual practices, or preferences it would not be to criticize, but to help in the diagnosis and treatment of the condition for which you had sought my help.”

“Are you Pro-Choice then?” I could see the words forming on her lips before she uttered them.

“We all have choices and I respect that. It’s not for me to interfere; I am not the person who has to make them. But I prefer to think of myself as Pro-Help… Perhaps I am the sounding board that helps you to make the Choice for yourself.”

With that she tucked her pencil and the notebook in a little shoulder bag and stood up. She sighed deeply and demonstrably. I had wasted fifteen or twenty minutes of her time. Now she was going to have to find another doctor to interview, I supposed. I stood up and extended my hand to shake, but she took it somewhat reluctantly, I think. “I’m sorry you decided not to commit yourself, doctor.”

I’m assuming it was a subtle put-down, but I allowed my smile to dance a moment longer on my face until I tucked it carefully away. “Actually, I think I did,” I said, and ushered her out of the room.