The Medical Student

She was not old for a medical student I suppose, although her face spoke of experience far beyond her years. But how do you measure age in a profession that cherishes the wisdom and equanimity that so often accompany Time’s passage? No, she was not old, but nor did she possess the naïveté that so often colours the awkward period of youth; she was, in a way, just Maria: confident, inquisitive, but neither gullible nor easily swayed from an opinion once she had weighed the evidence.

Short, with straight brown hair to match, she was dressed in what I would call an unobtrusive fashion –not meant to draw attention to herself but to enable her to emerge from the shadows with dignity should it be required. Only the short white coat so indicative of her student status and which I suggested she remove before seeing patients, would have marked her as out of place in an office that otherwise spoke of the ordinary. I’ve always felt that patients would be more accepting of the student’s presence if they were perceived as being part of the process of consultation with a specialist, not an artifice. Not an appendage. Not an add-on.

Maria sat politely against the wall, legs crossed and a smile tattooed on her lips as she listened to the first of my patients describe how she had finally decided she needed another checkup and a pap smear. For some reason, her family doctor had not felt comfortable in acceding to her request. Maria studied her so intensely it made me nervous.

“What are you using for contraception?” I asked as part of the history.

Janet, who looked  forty or so, but was really 28, just shrugged. She was comfortable with the question; she was comfortable with men who asked them. “I try to get them to use condoms, but…” Maria’s eyes opened wide at this, but she refrained from saying anything. I could see it was an effort for her, though.

As I progressed through the history, it became obvious that Janet was struggling with many issues, but I was impressed that she was trying to solve them bit by bit. Life was not easy for her but she was obviously trying to take control of what little she could. I was just one stage in that process…

After I had examined her, done the pap smear and cultures for infection, and given her the form for the lab to take some blood to rule out other conditions to which her lifestyle had made her unduly susceptible, I sat her down in the office again to discuss her needs.

A broad smile creased her face and her eyes narrowed almost seductively. “Is this where you try to convince me to stop the drugs, and follow the straight and narrow, doc?” There was a fatalism in her tone; she’d heard it all before –many times. Too many times. “…‘Cause you know it’s not gonna happen. I’m just trying to keep myself alive until I decide to change. If I decide. Nobody understands…” Her expression didn’t waiver, but I could tell she was on the brink of tears as she reached for the faded coat she’d draped over the chair. “And there’s nothing you can do until I decide, you know.”

And she was right –all I could do was support her until she was ready. We lived on separate sides of a river that was so wide in most places that it couldn’t be bridged. I felt like reaching across the desk and touching her hand to show her I understood, but I stopped myself. However well-intentioned my gesture, it might be misinterpreted –it was a prologue for most of the men she had encountered… So I just smiled in a lame attempt at encouraging her. “If you ever need to talk, Janet…” I said as she stood up before we could discuss anything further. I don’t even know why I said that -it seemed so utterly inadequate to her needs. I told myself I was only a gynaecologist and that she would require far more than I could ever hope to offer. But I still felt humbled and my specialist arrogance melted away as she left the room.

But just as she was about to leave, she turned and smiled briefly at me. Not seductively –not even out of politeness- but there was gratitude in that smile. Maybe she was just happy that I hadn’t tried to change her like her GP, or that I was willing to wait for her -treat her like an adult capable of making her own decisions. I fancied I could see some hope in her eyes before they hardened to face the world outside.

I’d intended to engage Maria in the conversation with Janet but it all happened so quickly I didn’t get a chance.

Maria stared at me as Janet disappeared through the door. She seemed angry. “So what are you going to do now?” It was not said with kindness. It was not said out of curiosity; she had embedded an accusation in it. A condemnation. The tone was polite, but the insinuation was contempt. I was reminded of that speech by Macbeth: ‘Curses, not loud but deep, mouth-honour, breath which the poor heart would fain deny and dare not…

“Janet has to want to change,” I said. It was a weak reply, but I already felt depressed.

“And until then..?” She said it sweetly enough, but I could hear the anger in her voice.

I sighed and looked at her. “What would you do, Maria?”

I sensed she wanted to throw up her hands and pace around the room, but I could see she was trying to control herself. “Well, talk to her social worker, for one thing…”

“And tell her what, exactly? That Janet took a small first step to help herself? That she seems to be developing a little bit of insight? That I, for one, see the glimmerings of hope that she will change?”

Maria’s eyebrows shot up. “Change?” –she almost spit the word at me. “How can you say that? We’ve been facilitating her, not trying to help her!”

I took a deep breath and relaxed my face. Maria was not as mature as I had thought. “We’ve been listening to her, Maria.” I smiled to diffuse her eyes. “How often do you think somebody has actually listened to her before? Not tried to change her, warn her, or use her?” I softened my expression even more. “The initial step in any change is actually hearing what the other person has to say. Hearing what she thinks and why. Listening; not judging. Not continually interfering, continually trying to impose our idea of the world on her.”

Maria’s whole demeanour tensed with the injustice of it all. “But we didn’t even get a chance to listen! She walked out of here before…”

“Before I had a chance to advise her? Tell her what she should do?” I shook my head slowly.

“But…”

“But sometimes we have to be patient, Maria. Advise when asked; help when needed.” I shrugged to indicate how hard that was. “She may never change –never want to change. We need to try to understand that… Understand her.”

I don’t think Maria understood; I don’t think she felt her own opinion was acknowledged either. I could tell that in her eyes, I had failed as a doctor. Failed as a person. I had committed with her the same sin that I had committed with Janet: not acting on what I had heard.

Maybe she’s right; maybe one’s own principles should be subsumed in those generally held by a society. And yet… And yet I can’t help thinking of Shakespeare again -this time, Polonius in Hamlet: This above all: to thine own self be true, and it must follow, as the night the day, thou canst not then be false to any man… –or woman, in this case

If age has taught me anything, it is that we live in our own worlds for a reason… I think we must sit with the door open. And if Janet wanders back..? Well, I will be here.

Cohabitation?

Cohabitation is the bête noir of some cultures and the realization of a belle époque for others. Lascivious as it sounds, it doesn’t necessarily exemplify freedom and liberation, though -it is a direct and unsubtle abnegation of long held moral and religious values for many. But why? Why would the decision to share one’s life need justification? Exculpation? And who should even dare claim the authority? Or, for that matter, the need to consecrate it? Given the rising divorce rate –even in strictly Muslim countries such as Iran where the rate currently sits around one in five- one would think it would make sense to recognize the need for more experience of the shared responsibilities of relationship, more knowledge of the partner, more time to adjust before a final commitment.

I have to admit that I approach the concept of relationship from a liberal Western perspective –more particularly, a Canadian view- where there are state-sanctioned civil ceremonies that bypass the need for a religiously approved union, and where once cohabitation has existed for more than 18 months, with dissolution, there are requirements to divide and allocate any assets –including children-  as if a legal commitment had been undertaken. A recognition, in other words, that because cohabitation is likely to occur whether or not sanctioned by some authority, there are still legal responsibilities that accompany it. From my perspective, that seems a fairly pragmatic and ecumenical way to mete out justice for something that, whether or not officially blessed, cannot be prevented.

So why the resistance? An unwillingness to acquiesce to moral depravity? A fear of loss of authority, either secular or religious? The all-pervasive concern of elders that the old ways are under threat? Or maybe just an underlying distrust of other ways of doing things, other ways of being in the world? After all, societies that have segregated themselves and become distinct have developed customs that are also distinct. Their foundational myths and folkways have hardened into inviolable practices that others don’t share. It’s what binds a culture together –like the nation state, like patriotism, like the sure and certain knowledge that the forbearers had a reason to think and act as they did- a deeply held belief that others are not like us.

We are all like this to a greater or lesser extent. We fear what is new, or different –especially if it comes to us from them. With their seal of approval. And unless we want to become like them, and assume all their mistaken and misguided beliefs –in essence actually become them- we must resist. And resist with the guidance and blessings of whatever authority we most respect. Indeed, it is their duty to justify and sanctify our resistance.

But I am drawn ineluctably to the notion of relational or relative values: the idea that what a society or group determines is appropriate, also determines the values of members of that group. A simple and organic concept to be sure, but one that is too often neglected in our assessment of the beliefs of the larger society to which the group belongs. Or perhaps more importantly, of the beliefs of the authorities who purport to speak on behalf of the state. Of the constraints they impose -or attempt to impose…

Of course, many will argue that some things are simply wrong; to think of them in any other way is self-evidently immoral –sinful, if the concept of sin as opposed to iniquity exists in the cultural framework. But that merely pushes the argument into another dark alley: why is something immoral in one culture and acceptable –or at least tolerated- in another? Is the other culture necessarily and unequivocally mistaken –even depraved- by default? If one side is right, is the other side therefore completely wrong? Partially wrong? Or just different?  It seems to me this is an important distinction: difference can be tolerated as a rule; being wrong cannot. It opens too many other doors. Escape routes for the less committed. The fringe-dwellers.

And yet, history has shown that if enough people begin to do something –even something that was anathema to previous generations- it can dwell unmolested in the shadows, camouflaged in the background and eventually emerge as something new and exciting for the young, its offence muted by a generational wink.

It seems to me that Iran, among others, may be changing like that.

http://www.bbc.com/news/world-middle-east-3039159

Homogeneity is deceptive; immerse yourself in a culture, dive below the surface and it is boiling, fermenting, swirling with difference that is often invisible from above. Generalizations about it are just that: macroscopic observations that miss the microscopic, the constituent parts that are so essential to the whole.

So, is the cookie the result or the cause of the recipe?

Should IVF be denied to Obese Women?

Obesity has a long and chequered history. Different cultures have both defined it and viewed it differently: in some it was a sign of wealth and was seen as desirable; in others, a sign of weakness, dysfunction, sloth. I use the past tense advisedly, given the rise of fast food outlets throughout the world and their putative role in the rise of obesity in all social strata. Adiposity wears different clothes today.

The classification of weight is now largely dependent on measurement of the Body Mass Index (BMI) -(calculated by dividing the person’s mass -weight- in kilograms, by the square of their height in meters. i.e. M/H x H). In North America, at least, ‘Normal’ weight is less than 25; Overweight is 25-30; Obese is greater than 30. The levels assigned for each category are somewhat arbitrary, however, and various countries -perhaps reflecting differences in diet, genetics, or their own studies- have defined them quite differently.

Obesity, then, is a chimera -a culturally enhanced improvisation; there is little argument about the extremes, but much debate in the middle ground, and therefore about the value at which to begin an intervention -and the resultant stigmatization- if it is solely on the basis of BMI. Not all large people are unhealthy, and neither hypertension nor diabetes, for example, are restricted to that population. So, to base important judgements -with their attendant far-reaching effects- on the measurement of BMI alone is more of a societal bias, a cultural bigotry, than a well-founded and scientifically validated decision.

I am not arguing that excess weight is healthy -or even desirable- but suggesting that to justify treatment decisions on BMI alone risks applying generalizations that are useful when dealing with large populations, but inadequate when considering individuals. No one of us is the herd. And the distinction is an important one.

For example, there seems to be a constantly-shifting move afoot to deny fertility treatments -especially in vitro fertilization (IVF)- to obese women.  Canadian MDs consider denying fertility treatments to obese women   It is based, apparently, on several factors: success rates tend to be lower in this group; the procedure is technically more challenging, and the woman is more likely to suffer complications in the pregnancy that may jeopardize both her and the foetus. The fact that in some jurisdictions, the first one or two treatments may be covered by a government subsidy, suggests that there might also be a feeling that the taxpayer’s money could be better spent on projects more likely to succeed. Or perhaps on issues that benefit more of the electorate.

I have to admit I am conflicted in this. One likes to hope that funds -be they private or public- will be well spent. That there is a reasonable likelihood of success. That the risk/benefit ratio is weighted in favor of the funder. And if this is not the case, then it should be made perfectly clear at the start; the outlook honestly explained, lest expectations trump reality.  http://www.creatingafamily.org/blog/obese-women-banned-vitro-fertilization/

But hope is often unquenchable no matter the argument, so what is an infertility clinic to do? Obviously there have to be some standards for IVF. BMI may well be one of them, but as I have suggested, this is likely only a rough guide to success and seems to have discriminatory overtones, no matter the data.

In medical ethics, decisions are often guided by a few simple principles: Autonomy -the right of an individual to make an informed decision; Beneficence -promoting the health and well-being of others and attempting to serve their best interests; and Non-Maleficence -not intentionally doing them harm (primum non nocere). It is the last of these that seems the most problematic for the IVF clinics. Should they knowingly embark upon a treatment -an elective treatment at that- which may have adverse consequences for their patient? The argument has been raised that doctors don’t apply the same values with respect to dealing with, say, smokers or alcoholics that they do with obese infertile women -all of whose problems are often considered to be self-inflicted, at least by society at large. The argument, of course is specious: the condition of infertility, however unfortunate, is not comparable with emphysema, lung cancer, or liver failure…

I think that a more reasonable approach would be to divide the risks both to the obese woman and her foetus into what I will term heedless risk and assimilable risk. It would be irresponsible, for example, to consider IVF in an older woman, obese or not, with severe, unstable and longstanding insulin-requiring diabetes with hypertension and end stage renal failure -the risks are far too great and the outcome unpredictable at best. Contrast that with a large woman -otherwise healthy- whose only risk is her weight. Yes, there may be technical challenges for the IVF, and each of these would need to be assessed on its own merit and risk; and yes, obese women do have a higher likelihood of pregnancy complications, but so do normal weight women who have, say, pre-existing hypertension, or SLE (lupus). And what about obese women who have become pregnant on their own? We struggle through pregnancies with them…

So I suppose the issue is not so much the risk as the guilt of complicity. The sin of acquiescence: collusion with the woman’s dreams of having a baby. Of actively fostering it. Stepping out of the role of omniscient parent and into the character of enabler. But to see it this way, is to be blind to the other equally important, and yet often forgotten ethical principle: Autonomy. If the risk is assimilable, does the patient not have the right to participate in the decision? Is this not also a requirement of that third principle, Beneficence: serving what she perceives to be in her best interest?

It’s a difficult issue, to be sure, and there’s likely no algorithmically valid approach to its resolution. But in the end, we’re humans, not flow charts -our minds simply do not function well that way. Decisions are not unidimensional, because we are not. Let judgements be based not on the letter of the textbooks, not on the litany of complications, nor on the statistical analyses of non-players, non-actors in the drama. As with the Law, let us consider the spirit in which it was written; details are important, but so are people. Even if they happen to be obese.