They didn’t ask for it

Sometimes, you just have to take a stand! Sometimes, enough is enough! How many times do we read about lawyers –or even judges- wondering about the effect of clothing on sexual assaults?

And it’s not just the criminal justice system that asks the question; I fear that it is a question that floats just beneath the surface of many a speculation –voiced or silently implied.

Blame seems to be a requisite component of justice however, and although it often is a focus for vengeance –sorry, punishment– it is always more satisfying if a reason for an action can be found. After all, an effect requires a cause, does it not? And post hoc, ergo propter hoc makes it even sound erudite. But, although it seems a logical outcome, it is a spider’s web that can be terribly difficult to disentangle unless we are motivated to take the counterintuitive step back from the seductive fallacy.

Admittedly, there are cultural differences that play a role in a society’s willingness to accept or at least tolerate excuses for behaviour, but in terms of the reasons for sexual assault, I would suggest that they are less cultural and more gendered. Excuses, not reasons. And, in these cases,  it is the action that must be examined, not the justification.

I found myself drawn to an article reporting on a woman in India who found an innovative way to draw attention to the issue: http://www.bbc.com/news/world-asia-india-42408844 ‘Indian artist-activist Jasmeen Patheja collects clothes donated by victims as testament to the fact they are not to blame […].’  Her project is called I Never Ask For It. And while the collection may seem a bit creepy, she maintains, ‘”It’s got nothing to do with what you’re wearing, there’s never any excuse for such violence and nobody ever asks for it. […] The project wants to contain and hold space for our collective stories of pain, and trauma.”’

It was a time when ‘[…] street harassment was being dismissed as just ‘eve-teasing’, something that boys do and girls must experience. It was being normalised. There was an environment of denial and silence around the issue, which made it okay to continue it. […] harassment in public places is all too common and almost every woman has experienced catcalls, lewd remarks, touching and groping. And anyone who questions it is told that the fault actually lies with them – she may have done something provocative, she may be wearing clothes that showed skin, she may have been out late at night, she may have been drinking, she may have been flirting: in short, she may have asked for it. “Girls are raised to be careful, we are raised in an environment of fear which is constantly telling us to be careful. We are told if you’ve experienced assault, then maybe you’re not being careful enough, that’s the underlying message we’re given.”

‘She set up the Blank Noise collective in 2003 to “confront” that fear. […]The first step to confronting any fear, Ms Patheja says, is to start a conversation around it and one of the things that Blank Noise does as part of the “I Never Ask For It” project is to gather testimonials from women. […] Almost all women chose to describe what they were wearing at the time of the assault and, Ms Patheja says, that’s what gave them the idea about the museum of garments.

“We found women often wondering about their garments. They’d say, “I was wearing that red skirt’, or ‘I was wearing that pair of jeans’, or ‘I was wearing that school uniform’. So it became a deliberate question at Blank Noise and we began asking, ‘so what were you wearing’? [..therefore..] we ask people to remember their garments, bring them in because they have memory, and in that memory it’s been a witness and it’s your voice.”’

I found that article very moving –especially that the clothes women had chosen to wear with pride at the time of the assaults had become forever tainted by the attacks –that those colours, fabrics, and even styles now made them feel sick. Guilty… Ashamed. They had expected admiration, approval, compliments, for how they dressed –or maybe hadn’t even thought much about their clothes beforehand. But, planned or not, a simple smile would have sufficed to indicate that they, too, could be beautiful. We all have a need for more than the mirror can say; most of us not only dress for ourselves, but in hopes our tastes will be vindicated. That we will be vindicated.

Yes, we often dress for effect, innocent or otherwise, and yet does the first chirp of the stirring robin cause the sun to rise? Are we looking at it the wrong way? Does attraction necessitate response? License behaviour? Does it even necessarily modify it? For some men, that is a vexing question, no doubt –and yet there it is. It has to be confronted. It is not enough for the man to say he was beguiled. That her clothes spoke for her –said what she chose not to say. That they told him all he needed to know… That they asked him and he merely accepted the invitation. Really?  He felt not only that entitled -that privileged- but also that omniscient? Stuff and nonsense!

Of course, how silly it all sounds divorced from the situation. After the fact. Even to other men, it would be difficult to argue his ability to know that he had been granted permission to violate someone else. To be assured that he could really see the world through his victim’s eyes…

As the Scottish poet, Robbie Burns put it: O wad some Power the giftie gie us to see oursels as ithers see us!

Because, no, they didn’t ask for it. And they certainly didn’t deserve it.

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The Justice of Justice

Okay, I’m Canadian; I do not understand the objection to universal health care south of the border. And I certainly don’t know how a society that purports to believe in equal opportunity for all could be so resistant to accepting the inalienable right of every person to access affordable medical treatment, the right to a personal choice as to whether or not to become -or stay- pregnant; and, so long as it does no harm to anyone else, the right to make a decision about what to do with their own bodies. Isn’t that part of the Life, Liberty and pursuit of Happiness in the U.S. Declaration of Independence?

Each person has the right to choose a path for herself. That does not mean that others have to make the same choice –or even agree with it. But they should respect the right to do so. Live and let live; not judge and punish. Life –society- is far too complex; there are too many interactions, too many competing values (each one held and defended by someone) – too much going on for there to be just one direction, just one answer that is forever correct no matter the circumstances.

We all have ideas that we embrace and cherish. Often, one of the hardest things to do is read contrary opinions; we –most of at any rate- are subject to a confirmation bias. That is we tend to read or watch only those things that confirm our opinions. We do not frequently seek to explore those that contradict. We do not usually parse them to discover if there is a way they might be compatible with our own. If the contrary opinion expressed is about a strongly held belief we certainly do not examine it as closely as we might an article commenting on a foreign war atrocity. And religion seems to inhabit an entirely different Magisterium where compromise is considered a form of moral compromise and is anathema. Unacceptable. Wrong.

For what it’s worth, I think the answer to opposing values does not lie in denying them to the point of anger but rather in examining them to discover why they are held, and what benefits might obtain by considering them. Incorporating them, Compromising with them. In fact, it seems to me that even being willing to assess them is a step in the right direction.

What started me thinking about this was a BBC report of a recent 5-4 decision by the U.S. Supreme Court which “found that some corporations can hold religious objections that exempt them from a legal requirement that companies with 50 or more employees offer a health insurance plan that pays for contraception at no charge to the worker or pay a fine.”

 http://www.bbc.com/news/28093756

One has to assume that the Supreme Court is impartial and that its judgements are delivered only after a dispassionate consideration of all the relevant details of the case in point. The fact that all three female justices disagreed with five of their male colleagues does give one pause for thought, however. Is it a coincidence unrelated to the judgement on what can certainly be seen as a comment on the value of a woman’s rights, a woman’s choice -or something else?

But one has to be careful in evaluating the judgment. It’s not really an issue of increasing the difficulty for a woman to obtain contraception, nor even that it should be paid for by a company. Fortunately there are some foresightful provisions that the White House thought to include that may mitigate the ruling –the BBC once again: As the court noted, the Obama administration has already devised a mechanism under which workers of non-profit organisations that object to the contraception mandate could keep coverage without the organisation having to pay for it.

So then, what’s the big deal about the Supreme Court ruling? Well, The decision marks the first time the Supreme Court has found a profit-seeking business can hold religious views under federal law, analysts say. In other words, it suggests that religious beliefs trump individual rights -women’s rights in this case. And no doubt it is the thin edge of a wedge for further disruptive –not to mention religious- challenges.

In a dissent she read aloud from the bench, Justice Ruth Bader Ginsburg called the decision “potentially sweeping” because it minimizes the government’s interest in uniform compliance with laws affecting the workplace. “And it discounts the disadvantages religion-based opt-outs impose on others, in particular, employees who do not share their employer’s religious beliefs.”

And don’t think this is an attitude peculiar to America; Canada is not exempt:

http://www.calgaryherald.com/health/Calgary+doctor+refuses+prescribe+birth+control+over+moral+beliefs/9978442/story.html

We are all subject to our own biases; it’s just when they interfere with the rights of others that I worry.

The internet has exposed us all to a plethora of competing viewpoints. Of course, if we don’t agree we can just read the first sentence, make a judgment, and then move on to another. Or if we’re so inclined, we could even take the time to comment on it. But those ideas with which we disagree require some examination to refute online or the rebuttal seems fatuous. Ill considered. Unrealistic. And it will have little effect. Some of us don’t care, of course: anonymity is a seductive drug. That’s what cyber-bullying is all about: not changing opinions, merely inflaming them. Freedom to speak -or write- is not really freedom unless it makes sense. Connects in some meaningful way. Justifies… I suspect that most of us would not make the same vapid and vituperative comments if our names were appended and we knew that others were judging us. Or if we could be held accountable in the courts, for that matter.

This time Shakespeare (Coriolanus speaking to a group of mutinous citizens): What’s the matter you dissentious rogues, that, rubbing the poor itch of your opinion, make yourselves scabs? I’m not sure that I’ve entirely escaped a confirmation bias here, of course –I’ll have to examine my position- but I think he’s on to something…

 

 

 

 

 

Medical Ethics 1

Ethics in Medicine should be fairly obvious, don’t you think? Primum non nocere – variably translated as something like: ‘Most importantly, do no harm’- pretty well sums it up. And yet even that can be difficult..

Although there have been several formulations of various ethical tenets throughout the years, there seem to be four main principles involved: Nonmaleficence –as I have already suggested above; Beneficence- acting in the best interests of the patient; Autonomy -allowing the patient herself to act in her own best interests; and finally, Justice –acting in a fair and equitable fashion to all.

I’m not an ethicist, merely a practitioner trying to navigate the labyrinth of ethical considerations that obtain in my sometimes lengthy sojourns with patients. I do not pretend to have mastered them, nor do I consciously run through them like a checklist at the end of each visit. But they are there, unstated, like the unseen concrete in a wall. And like the wall, there can be hidden flaws that test its strength.

Trust is one of these. Much of the effectiveness of Medicine throughout the ages has been rooted in Trust as much as in Hope. Without trust, there would be no dialogue; without trust, there would be no hope. And trust, unlike the four ethical principles, is not something that can be taught. It is rooted in ethics to be sure, but not confined to it, or by it. It is a feeling shared, an aura that permeates a room; it is non-verbal.

And yet even trust can be betrayed. That is where Ethics enters like the big sister who listens and watches unseen in the corner. I would like to contextualize her importance in everyday encounters in a medical practice.

Perhaps Justice -the fourth principle in my list, is a good place to start. While it is not often emphasized as much as the others in ethical discussions, it certainly does make the headlines in today’s climate of fiscal restraint. The seemingly inequitable apportioning of scarce and expensive medical resources is frequently brought to our attention as a way of castigating a particular political ideology, or highlighting our slow but inevitable descent into moral depravity. It is the elephant in the room: we realize that something needs to be done, expectations modified, and yet it is difficult to confront without seeming callous and uncaring. As a society, it is to our advantage to be seen as attempting to be just for all, and yet excuses are equally advantageous. And distracting.

Prejudices, often hidden and unstated, can modify responses. Street people are frequent beneficiaries of this penalty, especially if they have had the temerity to step outside the pattern. Drugs are illegal, so any problems they engender are self-inflicted, voluntary… Resources must be sustained, conserved; allocation should be prescriptive and privileged. They are the benefits that accrue to normal behaviour. If exceptions to the equality of largesse must occur, if our resources really are limited, should those who have chosen to depart from the established societal conventions be the first to be rationed? Should that be one of the consequences meted out to those who won’t comply? Won’t play by our rules? One would have to be hard-hearted indeed to subscribe to that, and yet the punishment is insidious and often invisible -or ignored. Rationalized. Like any illness, it is easier for the Well, to pass by on the opposite side of the street rather than dealing with it. Only when they are ill and need the compassion entailed in obtaining a slice of those resources does it enter their lives with any clarity or meaning. Hence the need for Justice in our dealings with everybody -and especially the less fortunate among us who, sometimes through no fault of their own, cannot access medical help.  I suspect that most of us don’t intend to be insensitive to others in need, and yet it is easy to forget what we do not experience. It is easy to be unduly influenced by Media hyperbole. Unexamined claims play to our confirmation biases: there is no pressing need to critically analyse what we have always felt to be true…

But these bold and often unsubstantiated allegations are abstruse and usually peripheral distractions in everyday medical encounters. They engender fear and apprehension in some perhaps, but are almost always secondary to the problems at hand. They are usually forgivable.

Take for example the occasional need to juggle the order of surgical waiting lists to accommodate unforeseen emergencies or more truly urgent cases. The usual marketplace First come, first served is clearly inapplicable in these circumstances; most of us recognize this and hope that we too would be treated the same way if the need arose. The juxtaposition may be inconvenient, even poorly received, and yet it is understandable. Condonable: Justice perceived.

Some are more trivial: the appointment that has to be cancelled, or more probably moved to another time because of an emergency, the arrival at the office later than expected for the same reason… All somewhat minor, perhaps, and pallid in comparison to the larger Health agendas that are so compelling and momentous, and yet in their own fashion, equally exemplary of Justice applied.

And yet there are more serious concerns that arise in practice as well: Justice has many faces. In any system, resources are limited: there are only so many hospital beds available at any given time; only so many operating theatres that can accommodate unanticipated needs. Choices have to be made, some with foreseeable albeit unavoidable consequences. These are obviously trying times and decisions contextual. Blame can explode like fire long after it has died down; embers are never inconsequential. Justice is not meant to be relative, malleable or adjustable and yet in retrospect it often seems so -maybe because it is still an evolving concept. It was once seen merely as an ideal to be striven for: a goal not yet attained or even possible. We now -correctly, I think- view it as a right. Or more: a necessity to treat all with compassion and fairness regardless of their status in the hierarchy. And yet, we can only work with the tools we are given; we can only try -then try again…

As Shakespeare’s Iago said: What wound did ever heal, but by degrees? We can hope.