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…

Please and Thank you

Please and thank you –isn’t that what we were all taught? Perhaps it was my prairie upbringing, but it seemed the norm when I was growing up. There was no asking why –no need to, in fact- we all just did it. Indeed its absence was noticed and noticeable –like maybe wearing a suit without a shirt. Nothing dangerous, nothing threatening, but just not done, all the same. Maybe in another culture or in a different era, it might have been passed off as an eccentricity, or perhaps mental illness –but not in my youth. And not now either, I had assumed. Polite is polite. Period.

But mores and folkways are fickle creatures, it seems -pragmatic at best, capricious at worst. At times, they seem rooted in tradition and ancestral wisdom, but increasingly, they smack expediency, fashion –borrowed from somewhere else like a hat for an occasion. And as with trends on social media, they are ephemeral –tales told by an idiot full of sound and fury, signifying nothing…

Or am I being too critical? Too unwilling to accept change? Too… old?

*

Judith was an angry person –or maybe I just met her on an awkward day. But she held her body stiffly, as if any movement might reveal a secret. She had an accent I couldn’t place, but her demeanour didn’t really invite my inquiring about it -another secret she needed to conceal, I suppose. The referral note said only that she had pain but had refused to let her doctor examine her. Judith wouldn’t let me examine her either; she was certain it was caused by an ovarian cyst and she just wanted to talk about it.

I could see her peeking at my computer screen with suspicious eyes. The way I’ve had to configure my temporary desk to accommodate both the ability to access the monitor as well as well as the patient’s face, lends a certain intimacy to the little makeshift office. No longer can I afford to write a note to myself that the patient I’ve been asked to see seems unduly anxious or irritable; I dare not suggest that she is being evasive in her answers to my questions; I cannot even intimate that she doesn’t appear to trust me. All is open to scrutiny during a renovation.

And that’s fine. She can have access to her chart; I have nothing to hide. But as well as her answers to my questions, what I write are merely impressions, conjectures: colours. The subsequent consultation letter to her referring doctor is a collation of these -a considered appraisal of what I have observed and heard. The initial chart is a first draft of things that will later become an opinion. An assessment.

But Judith was persistent. Like someone reading my book over my shoulder on a bus, I have to admit I did feel some boundary issues. I toyed with the idea of turning the screen so she could read it more easily, but my long-held prairie rules of decorum prevented me. Instead, I contented myself with an obviously self-conscious stare at her face. She paid no attention to my discomfort except to wrinkle her face at what I had just written.

I was filling out the reasons for ordering a pelvic ultrasound –outlining what questions I hoped could be answered, and what, specifically, I hoped they would address: The patient has complained of right lower quadrant pain for several months. She may have a right ovarian cyst. Please assess ovaries and characterize cyst if present. Thanks. It seemed a perfectly straightforward request, but I could see Judith shaking her head.

“You’ve got to be more forceful in your request, doctor,” she said, her face tight with concern. “I told you I have a cyst so why don’t you just say so?”

Her response took me by surprise. “I was just outlining my suspicions for them to confirm or refute on the ultrasound…”

Her eyebrows stayed lashed to her hairline. She was shaking her head again, but whether in disapproval or disbelief I couldn’t tell. “And why do they have to know about the pain? That seems to be a breach of patient confidentiality, don’t you think?”

I sighed quietly. “It’s not a breach of confidentiality, Judith, it’s a medical document outlining the questions I want answered, and so it has to have pertinent details about the condition. If it is an ovarian cyst, not all cysts cause pain and not all pain is caused by cysts. I need to know the details of what they see.”

You’d think that would have appeased her but I could tell she was still troubled by what she saw. “And why do Canadians insist on using ‘please and thank you’ all the time? It’s just a request for an ultrasound…”

I sat back in my squeaky chair and smiled. “What would you write, Judith?”

She thought about it for a moment, obviously caught off guard. “Well… How about: I’d like you to describe the cyst on her right ovary.”

“ ‘I’d like you to..?’ Isn’t that just a longer way of saying ‘please’?”

Her eyes narrowed and I could almost hear the gears grinding in her head. “Then… why not just: Assess the pelvis?

I squeaked my chair again. “Seems to me that’s just a command to do something without explaining why. The more information they have, the more they are able to tailor their study.”

A little smile fought for the stage on her face. She was getting into this. “Okay, so: Cyst suspected in pelvis. Confirmation and characterization required.”

I nodded, then turned back to the screen to amend it. “I can accept that, Judith,” I said, as I typed her words onto the requisition. “But I can’t say I agree with it.” I looked up at her. “It seems  too impersonal and uncaring, somehow.”

Her face softened with bewilderment and I could feel her eyes searching my face for an answer. “What do you mean?” she asked after sifting through my words for clues.

I shrugged, not at all sure I could explain. “I guess it’s sort of like the Golden Rule: If a person is standing in a doorway talking to a friend and I want to get past, I could say ‘Get out of my way!’ or I could smile and say something like ‘Would you mind if I squeezed through?’ Experience tells me I’m likely to get more cooperation with the second way. Maybe even a smile…” My chair squeaked again. “I like smiles, even if I’m not there to see them.”

Suddenly her whole body relaxed and a laugh lit the room like the sun coming out from behind a cloud. She reached out in the tiny room and touched my arm. “When I said I didn’t want to see a male gynaecologist, my family doctor said you were different…” She sat back in her chair looking the most relaxed I’d seen her. “Put the ‘Please and Thank you’ back in the form if you want. I think I’d like to see the smile on the technician’s face when she reads it, too.”

The prairie in me sighed. I suppose she meant well- meant it as a compliment… Thought she had gained a unique perspective on a world she had never trusted and maybe never thanked. And yet I don’t think she really understood. What I considered thoughtful, she saw as weak. Not polite. And it bothered me. Am I really so different in being accommodating and respectful when I request a service from someone? Is the concept now so unusual that it draws attention to itself? Attention to me? Thank you, but I cannot let myself believe that. Please let me be right…

Nudging Childhood Obesity

When I was a kid, obesity was not the norm. Admittedly, this was a long time ago, and no doubt I only remember brief and highly selective snippets of the time –modified, no doubt, to serve whatever demands are required in the present. But in these unexpurgated, sketches, I have memories of labeling the occasional child in the playground as ‘fat’. Whoever it was stood out from the rest –ex gregis in the true etymological sense of the word ‘egregious’- and so through the insouciance of childhood, were forever condemned to wear the epithet like a poorly fitting sweater.

Maybe we just didn’t have enough to eat in those halcyon days of early Winnipeg; maybe the winters were too severe and the necessary clothes too heavy to allow the accumulation of excessive girth. But let’s face it, normal is what we see around us. It is parochial. It is the statistics of one box. And yet, isn’t that how we judge: by what we know? If I am obese, and my child is too, then what’s the problem? And if all his friends, and all my friends are large, then how am I to adjudicate another norm? Thin is aberrant, not fat.

I came across an interesting article in Forbes magazine reporting about a study –several studies, in fact- demonstrating the inability of parents to judge whether or not their child was overweight: http://www.forbes.com/sites/alicegwalton/2015/03/30/can-you-tell-if-your-child-is-overweight-most-parents-cant-study-finds/

This is worrisome, to say the least -unless of course you change the definition of what weight is normal… But no matter the norm, health risks for diabetes, hypertension and cardiovascular disease generally increase with increasing BMI (Body Mass Index -which is the weight in kilograms divided by the square of the height in meters: kg/m2).

And it is difficult to rationalize the increasing prevalence of corpulence in the population as an evolutionary process. It’s hard to understand how plumpness would be of any survival benefit, or why it would be selected for in a gene pool. There exist islands of controversy in this, of course: http://www.bbc.com/news/magazine-28191865  But I think most analyses would suggest that obesity (BMI >30 -at least in North American population studies) adversely influences health and life span. So it would make sense to attempt to correct the issue as early as possible.

As an obstetrician, I am drawn to the idea that management of pregnancy and birth weight are important. I was intrigued by a prediction model I saw reported in the BBC from 2012 suggesting the risks for subsequent obesity of a child could be predicted at birth with about 80% accuracy: http://www.bbc.com/news/health-20509577  I haven’t seen much about this recently, so I don’t know how well it has stood the test of scientific scrutiny, but at least it was an interesting thesis. A start.

Recently, the Canadian Task Force on Preventive Health published an update on childhood obesity guidelines: http://www.cbc.ca/news/health/child-obesity-charts-open-door-to-treatment-1.3014832  It contains the usual admonitions against junk food and physical inactivity, of course, but advocates some innovative strategies, I think. For example, because the circadian rhythms of teenagers have been found to differ from the adults who are teaching them, it recommended starting classes later in the morning and suggested breaks in each class. And walking to school, where feasible, as part of the exercise regime… Dr. Brian Goldman, host of CBC’s ‘White Coat, Black Art’ program, while agreeing with the guidelines, detected some downsides to the recommendations however: http://www.cbc.ca/radio/whitecoat/blog/the-cure-for-childhood-obesity-parents-will-hate-1.3014981

The contributing factors to obesity –let alone childhood obesity- are legion: genetics, dietary habits, social milieu, parental influences, environmental conditions, Media, socioeconomic status, and peer group expectations, to name a few. None are solely responsible, but unless there are some counteracting forces –incentives- all are important. Behaviour, habits, and expectations are learned phenomena and it may be something as simple as imitation of parents or friends that starts it off and then sustains it.

When faced with uncountable opponents and overwhelming odds, how can Society possibly succeed in changing things? Well, simplistically, it needs to change attitudes. Change what the majority considers acceptable. Change the mythos. It is slowly changing the acceptability of smoking as a norm; even the legitimacy of drinking and driving is under scrutiny –not only in the courts but also in the minds of drinkers. Some things are just not seen as cool nowadays.

But, given the importance of preventing childhood obesity for the health and well-being of future generations and given the relative lack of success so far, I think we need a new (old?) approach. There is a freshly-named, although age-old practice, termed ‘Nudge Theory’. It is a euphemism that my mother would have simply called manipulation because, although cleverly disguised, that’s really what it is. Wikipedia has succinct explanation: Nudge theory (or Nudge) is a concept in behavioral science, political theory and economics which argues that positive reinforcement and indirect suggestions to try to achieve non-forced compliance can influence the motives, incentives and decision making of groups and individuals, at least as effectively – if not more effectively – than direct instruction, legislation, or enforcement. Here are two introductions –take your choice:  http://www-2.rotman.utoronto.ca/facbios/file/GuidetoNudging-Rotman-Mar2013.ashx.pdf or http://www.businessballs.com/nudge-theory.htm

Education, and early identification and treatment of those at risk of becoming obese are obviously important and desirable, but I think we need something more. Something with a proven track record, albeit in different fields. Maybe ad campaigns and directed manipulation –sorry, nudging– would be valuable adjuncts. We are media savvy nowadays, and used as a tool for change, it seems ideal. As long as we are certain of our goals, and the science is correct, I think it is an ethically acceptable approach, and one with great potential.

I did, though, run across a light-hearted, but nonetheless cautionary article about nudging in the Toronto Globe and Mail: http://www.theglobeandmail.com/globe-debate/im-an-adult-stop-nudging-me/article20925672/

However, we have to take advantage of all the tools at our disposal. My mother’s manipulation was unsubtle and in my face; nudging is not. If we are going to be successful in stopping the steadily increasing tide of obesity, we need to revise expectations, and change what we accept as normal. We have to alter folkways and mores –in other words the rules that society uses to guide behavior. Nudge them, I suppose…

We need the courage to try novel approaches. There is a quote by Erasmus that is germane: A nail is driven out by another nail. Habit is overcome by habit. Okay, so let’s change them. Nudge them. No! I hate the verbal evasion. Let’s mold them.

Menstrual Taboos

Culture shapes behaviour, attitudes and beliefs -or is it the other way around? The chicken or the egg? This has puzzled me since I was a child wondering why everybody I knew wore jeans but in pictures the people living in, say, India did not. And the members of my family –uncles, aunts, grandparents, cousins- all went to church and sat in seats. None of them prostrated themselves on little rugs on the ground. Did each of us have to be Protestant? Was there a choice? Or, was there something about my family that made them that way? I don’t remember choosing.

Why do we end up believing or doing something that seems arbitrary when compared with other parts of the world? Why do we often think that only the way we do things is appropriate? Correct? How many correct ways are there..?

Could imitation be something akin to an infection? If everybody we know does the same thing, why would we even suspect it? Maybe it’s contagious and causes a psychological compulsion to fit in –like fashion, or expresssions in language that identify us as a member of a group or region. We seldom question it, but then again, there is no reason to: everybody around us is doing the same thing so it infrequently rises to a conscious concern. It’s an outrageous thought experiment of course and yet such curious congruity does give one pause for thought.

But in our islands of similarity we do notice difference; it makes us feel uneasy –as if perhaps there was a choice. Another way to do something. Another way to be in the world. And depending on the status of the innovator, we may see the novelty as interesting but peculiar –perhaps even something we should adopt for ourselves- or we may consider it simply wrong. Strange. Evil. Something to be shunned, avoided at all costs -even at the expense of the defector. Even if the apostate is tolerated under other circumstances when seemingly adhering more closely to the accepted norms.

I use the word apostate advisedly. Society is a religion, and one that is often disdainful of heretics, aberrations that tug at the pattern in the fabric. Anomalies. Discrepancies sometimes strain cohesion and make us question who we are and why we have come to behave the way we do. We are creatures of custom.

Of course I realize it is difficult, if not impossible, to apprehend difference without judgment. Even curiosity suggests analysis: comparison and evaluation. Some things, however, seem difficult to assign merely to custom; the difference is more appropriately attributable to fear. Unintended ignorance. Naivete.

The menstrual taboo is a case in point. There have been some recent articles in both the BBC News: http://www.bbc.com/news/world-asia-29727875?print=true and the Huffington Post:   http://www.huffingtonpost.ca/sabrina-rubli/menstrual-education_b_5689072.html that discuss problems surrounding menstruation and how it interferes with education for young girls especially. Menstruation is a natural process for renewing the uterine lining every month: shedding the old cells to make way for new ones that may be required to grow a baby. But natural does not necessarily mean acceptable or discussable for everybody.

Culture deems some things embarrassing, things best kept private or at least not shared outside a family or circle of friends. Bodily functions and intimate relations probably top the list. And yet necessity sometimes trumps personal feelings; where adequate facilities do not exist, an accommodation, a compromise usually springs up to fill the need. So while communal ablution may never rise to the level of a societal norm, a variation of it may be tolerated under some circumstances. Safety and vulnerability constrains many compromises, with strict gender separation often necessitating extreme measures such as waiting until the relative safety of darkness for a woman to relieve herself. Even this atrocious compromise is fraught with danger, as recent reports of rape and sometimes murder in parts of rural India attest. That the practice should even need to exist is unconscionable to most of us; that those with the authority and power to change it in the region have not managed to remedy it is worse.

But let’s not allow the unreasonable social diminution of women in one area blind us to an even more pervasive inequity in many developing nations around the world: the cultural taboo about menstruation. Femme International has documented some of the more egregious offenders in its website http://www.femmeinternational.org/the-issue.html

Culture is a tricky thing. Both intriguing and covert, it exerts an inordinate amount of influence on thought and action. The sources of its traditions are often historical, bound in a delicate weave with myth and legend, and are at best opaque. To question it, therefore is difficult and usually seen as insulting and provocative –it is what separates us from them, precluding further analysis, further understanding. “It’s just how we do things,” is the usual response to questions from foreigners. “You wouldn’t understand.”

The menstrual taboo is like that… and not. Attitudes are seldom fodder for experimental investigations, and yet occasionally there are aspects that are historically discoverable. The enforced seclusion or restrictions on the activity of menstruating women are usually ascribed to ignorance –lack of education about the function and meaning of menstruation- or fear of some theological punishment.  And yet Femme International, political correctness notwithstanding, has intimated there may be a more obvious, historical reason for the concern, albeit uncomfortable to state.

Traditionally, menses have been a source both of embarrassment as well as inconvenience for a woman –especially if she is required to be in public places such as the market -or school in more modern days- for any extended period of time. How to cope with the menstrual blood? Only recently have effective measures been available, but even these are priced beyond the means of many girls in isolated villages. In Kenya, for example, the BBC article reveals that the cheapest package of sanitary pads costs almost half the average daily wage, so they may be seen as more of a luxury item than a necessity. ‘As a result, girls will resort to using alternative methods of menstrual management, such as rags, leaves, newspaper, bits of mattress stuffing, even mud.’ The Femme International again: ‘Menstruation is the number one reason why girls miss school. Sometimes girls will attend school on their periods, but will refuse to sit down, or once seated, refuse to move. Many schools do not have appropriate latrine facilities, and girls are unable to wash themselves during the day. When latrines are shared between boys and girls, they are teased and mocked during their period.’ Indeed it has been suggested that because of some of these practices, the odour alone may have given rise to some of the fear of contagion and restrictions placed on the menstruating woman.  For example, the BBC reports than in ‘regions of Kenya, girls are forbidden from touching livestock, preparing food or consuming animal products for fear of contamination.’ And in India ‘there is generally a silence around the issue of women’s health –especially around menstruation. A deep-rooted taboo feeds into the risible myth-making around menstruation: women are impure, filthy, sick and even cursed during their period.’

Femme International has suggested at least one acceptable option: menstrual cups. ‘Menstrual cups provide an affordable and sustainable solution to menstrual health management. A menstrual cup is made of medical grade silicone and is worn inside the vagina during menstruation to collect fluid. Menstrual cups are more cost-efficient and environmentally friendly than tampons as they can be washed and reused for up to 15 years. Unlike [expensive] pads and tampons, the cups only need to be emptied every 12 hours. Thus girls can attend school without worrying about the availability of private washroom facilities, or revealing their period to peers.

There are other remedies of course and they, too, need to be pursued. Once again the Femme International: ‘Young women who lack the knowledge and resources to safely and effectively manage their periods not only miss school but face stigma and shame from their male and female peers. When girls do not understand why their body menstruates each month, they easily believe that it is something to feel shame about, something to keep hidden and something that is a source of humiliation. This type of behaviour is strongly influenced by the widespread stigma that surrounds menstruation in the majority of communities. When women are unable to manage their periods, they are less able to participate in daily life. Addressing the issue of menstruation through health education, positive reinforcement and the provision of management materials reduces these gender specific barriers.’

Yes, it’s a step to be sure, but one that may require a generation to succeed. We must not give up because the progress seems slow and the task insurmountable. Attitudes do shift, cultural mores and folkways change, governments fall. And with the almost ubiquitous availability of social media, one hopes the results might be noticeable even in our time. The curtain of mystery that has always separated the two sexes need not be rent asunder, though –mystery, after all, can be a source of awe and wonder. And not all mysteries have to be solved -sometimes just acknowledged and appreciated for their charm and excitement. No, the fabric need not be torn -merely parted enough to reveal that what differences do exist between the sides -between males and females- are nothing to fear. We were made for each other, after all.