Wednesday, August 13, 2008

Give us this day our daily sin

I don't know who has or hasn't heard about it, but this bothers me quite a bit. Enough of quite a bit that although I honestly do try not to talk about touchy issues such as these, I'm going to rant here about this one. Because, in my mind, it's so absurd.

The story is that Leavitt, at the Department of Health and Human Services, wants to pass a resolution clarifying old legislation. The old legislation basically says that, if you receive federal funds, you cannot discriminate on the basis of opinion -- i.e. doctors who refused to perform abortions and doctors who performed abortions had to be considered on even turf. In addition to calling to attention this legislation, the HHS wanted to clarify the term "abortion":
the Department proposes to define abortion as “any of the various procedures—including the prescription and administration of any drug or the performance of any procedure or any other action—that results in the termination of the life of a human being in utero between conception and natural birth, whether before or after implantation.”
So the notable part here is how an IUD, the pill, and similar hormone-based therapies work most of the time. Occasionally, the pill will stop women from ovulating, thus preventing conception. This is not abortion according to any definition. However, most of the time such therapies work by thickening the secretions on the lining of the uterus, preventing implantation. This would be classified as "abortion" under this definition.

So, for all of you women who have had sex while taking the pill, well, you may have had an abortion.

Another thing to note is that, in nature and unprotected sex, it happens all the time that an egg will be fertilized by a sperm, and for whatever reason will not implant. In this case, my female friends, you will not even notice that you were, supposedly, "pregnant". You will have your period exactly as normal, and it is impossible to tell, if you are having unprotected sex, whether you have had one of these "miscarriages" or not. According to your body, pregnancy starts when the egg implants, not when the sperm hits the egg.

All of which, perhaps, argues that starting pregnancy at implantation rather than fertilization is a more reasonable and valid definition. But really, we can argue about that until the cows come home and it won't matter -- you have your views, I have mine, and no one will change their mind.

What I would argue, however, is that for a medical practitioner to refuse to undertake a known, safe, and useful medical procedure which could save a life and is in no way illegal comes in the way of them being a good medical practitioner, no matter their reasons for refusal. I'm going to use a few other examples, because I think they're clearer and more illustrative.

Take a geometry teacher who is a LaRouchian. LaRouche does not believe in Cartesian geometry; according to his followers, the whole thing is a hoax that allows the Jews to run the world (or some such). Such a teacher would be going against his or her firmly held moral belief if he allowed his students to learn Cartesian geometry. He would, in fact, be giving in to the brainwashing and social fascism of our day. I can understand why such a teacher would have a moral compunction to only teach Euclidean geometry. I can understand why such a teacher would not want students to transfer into a class that taught Cartesian geometry. However, allowing such a teacher to teach children in this country would be a grave disservice to said children. Cartesian geometry is not all of geometry; perhaps the LaRouchian particularly likes Euclidean or Affine geometries and wants to share his joy in these subjects with kids. But without Cartesian geometry, students will fail tests and be incapable of continuing in math and science. Their math education will be flawed, and the service provided by the LaRouchian geometry teacher is by definition, perhaps, not as good as the service provided by a geometry teacher willing to teach Cartesian, as well as other, geometries. In this case, would the government say that telling a geometry teacher he had to either teach the entire cirriculum or not teach at all, despite moral compunctions, be discrimination? Or would it be warranted?

Now, one of the arguments that I will be facing is that being anti-abortion, or even anti-birth control, is a much more mainstream belief than being anti-cartesian geometry. However, freedom from discrimination cannot apply only to mainstream beliefs; it must be universal or else it is not really any sort of freedom at all.

The point of this argument is that all else being equal, a doctor who knows, or talks about, or offers, a wider variety of treatment options is usually better than one who knows, talks about, or offers a smaller variety thereof. Because he or she can deal with a wider variety of patients in a wider variety of situations, and better tailor treatments to meet individual needs. And thus, it seems perfectly legitimate to say "if you want to be an ob-gyn, you have to be familiar with, understand, and talk to your patients about all of their reproductive health options, not just abstinence, condoms, and babies."

That doesn't mean that every ob-gyn has to give abortions, or even prescribe birth control. But requiring that someone discuss the procedures (and maybe even say "personally, I think it's morally wrong") and offer a referral if their patient decides that that is what they want to do with their own body is, I think, eminently reasonable.

Take another example, this suggested by Mango, EMT (and SCUBA diver, and pilot, and researcher) extraordinaire, who will revolutionize the world of medicine as soon as he gets his MD and PhD. An elderly patient comes into the emergency room, having fallen and stopped breathing. The doctor recognizes the patient as someone who has been diagnosed with terminal cancer and has a maximum of three months left to live. The family demands that everything possible be done to revive the patient, possibly costing quite a bit of money that could be used to treat other patients with, admittedly, better prognoses. Arguably, the "moral" thing to do, to save more lives, and the "medically" proper thing to do, is to triage the patient as one who will die no matter what you do, and move on to cases where you can be of help. But most emergency rooms would follow the family's orders, and treat the patient. Which illustrates the following point: it is not the doctor's wishes, morals, or beliefs, which decide therapy. It is the wishes, morals, and beliefs of the patient which decide therapy.

Another example I thought of, along similar lines, is a case where someone is diagnosed with bladder cancer; a certain form of cancer which can be treated in two distinct ways. One uses traditional cancer therapy; surgery followed by radiation and chemo. The other, more experimental therapy, uses a less virulent form of the tuberculosis bacteria, which will kill cancer cells and then be killed by the immune system. The former is much better studied, but has serious ramifications for quality of life afterwards (you know, missing a bladder and all that), as well as very serious side effects during treatment. The latter is a significantly less invasive procedure, but is not as well understood and, in elderly patients or patients with compromised immune systems especially, can occasionally lead to tuberculosis infection. A doctor could have a serious concern about performing the latter treatment option, thinking that the risk of infecting his patients with tuberculosis is too severe for him to take the chance on the treatment (first, do no harm). However, if instead of saying "This treatment is experimental and I do not recommend it because I abhor the chance of an infection" he simply does not tell his patient about the possible therapy, he is not doing his job as a doctor. It should be the patient's choice whether the risk of infection is worth trying the less invasive therapy.

Now, the one argument I can see arising at this point is the argument that in the cases described above, only one life is at stake, while in an abortion, there are two lives involved. Admittedly, this muddies the waters for abortion treatment in general, but I think it's tangential to the point here. The HHS would have us believe that a doctor who refuses to handle birth control or abortion cases due to moral reasons is as good a doctor as one who will. But refusal to discuss or provide a referral for treatment does have an impact on how good or bad a doctor you are, and in just about every case it should be the patient's choice, and not the doctor's choice, what treatment is given. The doctor's job is to diagnose, and discuss with the patient every possible course of action -- regardless of his own personal views or beliefs. As I said above, if you refuse to do something that is in the job description of an ob-gyn, then you should perhaps not become an ob-gyn. After all, if a fireman said he would save cats from trees, but not put out fires, or that he would rescue people from burning buildings but not man the hose, he would not be considered a good fireman. Why should an ob-gyn who refuses to do some of his or her duties be considered as good an ob-gyn as one who will follow-through on the full extent of his or her job description?

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