purpose statement

This blog records the experience of a Catholic medical student.

Sunday, September 21, 2014

I Can't Hide Forever

Me during most of med school.
Credit: CavinLicense
I laid low during medical school. I mean, I started a pro-life med student group, got Maureen Condic to come talk to on our campus, and prayed outside Planned Parenthood in my white coat, but I didn't have a lot of frank discussions with my peers, residents, or attendings about abortion, contraception, and primary sterilization. I stayed in the cocoon of "I don't have to do any of those things, so I don't have to explain why I'm not doing any of those things." (By contrast, one of my friends at another med school started a high-powered NFP group and is always ready to talk about it with poise.)

But I'm beginning to realize that as my responsibilities increase, my ability to hide decreases. A few circumstances have recently brought home how soon my cover is about to be totally blown. Worse yet: I'm about to be required to blow it myself.

Chairman's Letter
When you apply for residency programs through ERAS, you need letters of recommendation; minimum 3, maximum 4. Some programs require a "chairman's letter," that is, a letter from the department head of your chosen specialty. For this reason, I took an elective in the chair's specialty (urogyn) and spent several afternoons in his clinic, trying to show off my clinical skills and seem like an awesome person. I tried NOT to bring up anything related to contraception (should have been easy in urogyn, right??), but the Chair is apparently smarter than that.

Myeughh...why are you so perceptive and direct?
Credit: Niklas. License same.
The first thing he noticed was my cross. I wear the cross of San Damiano every day to remind me to be as humble and pure and excited as St. Francis was to rebuild the church. He asked about it, and he thus learned that I am Catholic. Immediately, he asked me about contraception and abortion. So I explained. 

Later, I arranged a meeting with him to ask for a letter. I forwarded the resume I was going to send to residency programs, which included my pro-life work, degree from TAC, and the Notre Dame Vita Institute. These meetings are one degree above formalities: at them, the letter-writer will inform the letter-seeker that yes, he/she can write a good letter. The writer may ask about career plans and other resume items, or things not on the resume.

He sat me down and said he'd be glad to write me a letter, but he needed to know more about how I would act in a few situations. And then the meeting became like an oral board exam: he pitched two scenarios and asked me what I would do. I knew my letter was hanging on this. Would I help in a C-section followed by a tubal if I was the resident on call for the night, and no one else was there? (Yes to the C-section, no to the tubal; not a great hardship for the attending, I think, if the attending is already scrubbed.) Would I refer to a partner MFM if I, as an MFM, was sent a patient who wanted an abortion? (I would recuse the referral and refer to the front desk.) This caught me slightly off-guard and made me realize that time is coming.

Running the Adolescent Clinic

On one of my rotations (adolescent medicine), I was frequently exposed to sexually active patients requesting hormones, for contraception or otherwise. This made me deeply unhappy and I was not at peace in that clinic, but I deferred management to the attending for the most part, which was easy as the student. I couldn't put in orders without a cosign, so everyone put in their own orders. I would talk around the prescription of oral contraceptives ("She's currently on ortho-cyclen.... She says she needs refills today"). 

One particular attending, an older gentleman, couldn't use the EMR. The residents and fellows usually put in orders for him, but one day there was no resident and no fellow in clinic. As the fellow sent me to clinic from morning rounds, she said, "you're just going to have to put in orders. I'll co-sign them later. Sorry for the trouble; you can figure it out, though."

I was in dread. Happily, a pediatrics resident showed up, so she put in all the orders. There was only one scare: I was the last one to leave clinic (woo-hoo for being a "good" med student), and the nurse ran up to me and said "Someone's order wasn't put in for her depo. Can you put it in?" Luckily I was able to text the fellow. But it's clear that my window of safety is closing.

Preparing for Interviews

I have been repeatedly advised to disclose my "beliefs" to program directors on the interview trail. This makes total sense to me: a residency program is a cross between a large and very consuming practice, a family, and a class. The perspective of a typical OB/GYN resident toward an intern who suddenly announces (after match or just before July 1) that she doesn't do x, y, or z is that the intern is deceptive, lazy, and manipulative. That sort of intern isn't well-liked, and she probably isn't going to get what she wants.

If, instead, the whole package (smiling, interesting, professional applicant with solid CV, grades, and letters, plus some relevant personal beliefs that will require extra work) is sold at once, the bait-and-switch and resulting resentment is all avoided. I might even hope to make the other residents curious about why I've chosen to do what I do.

So the time of hiding is over, and I must know show myself as I am. It'll be hard for me, because I have a strong desire to please, and the "limitations" that I insist on are not pleasing. I need to focus on how true, good, and beautiful my choices are; I need to be unafraid of being misunderstood; I need to be confident that God has a plan (hopefully a residency) for me where I can do His will safely.

Now it's time for courage, which is why I'm so glad that the CMA conference this year is on Courage in Medicine. I'm bending my schedule over backwards to go to it (carving out part of my sub-internship and making a 20-hour drive to my next away rotation), but I want the help. Please help me with your prayers as well.

Wednesday, September 10, 2014

Mitochondrial Transfer: Third Parents? Immoral?

Short answer: no. Long answer requires that we think about cellular anatomy and moral teaching. We will also reply to objections. Busy people read bold.

Cellular Anatomy

A mitochondrion (plural mitochondria) is a cellular organelle responsible for cellular respiration. Organelles are like the "organs" of cells (although they carry less inherent information).

Mitochondria are unique among organelles in that they carry a little bit of unique DNA encoding several key metabolic proteins not coded in the human genome. This may be because mitochondria were, in the distant evolutionary past, symbiotic organisms. These organisms lived inside other unicellular, then multicellular organisms, and eventually lost their independence. This DNA is human because the mitochondria are now parts of human cells, not independent organisms. However, this DNA is technically called "extragenomic."

Moral Teaching: Organelle Donation

There are no other examples of organelle donation apart from cloning (nuclear transfer to an egg before the egg is used in IVF). Cloning is directly addressed in Donum Vitae
Procedures designed to influence the genetic inheritance of a child, which are not therapeutic, are morally wrong. To try to correct a genetic disorder, such as cystic fibrosis, is morally permissible, whereas to manipulate the genetic structure to produce human beings selected by sex or some other quality is wrong. Attempts to produce a "breed" of humans through cloning, twin fission, or parthenogenesis outside the context of marriage or parenthood is immoral. These manipulations violate the personal dignity of the human being and attack his integrity and identity. 
(Emphasis mine.) From this quote, it might at first seem that the intention of producing a breed is the evil to be avoided, but the last sentence makes it pretty unavoidable: cloning violates human dignity.

But look closely at what Pope St. John Paul II says: "Procedures designed to influence the genetic inheritance of a child, which are not therapeutic, are morally wrong." (Emphasis mine.) This explicitly excludes mitochondrial transfer.

Mention is made of cystic fibrosis, which could be corrected cellularly at the early level by extragenomic gene therapy. The only difference between this and treatment of mitochondrial diseases is that the extragenomic DNA in genetic therapy for CF is carried by bacteria, while the extragenomic DNA in genetic therapy for mitochondrial diseases is carried by bacteria. (Makes mitochondrial transfer look downright natural and convenient, doesn't it?)

But this is not just about cells and molecules. It's about gametes and parenting, and that is why most people get antsy--because mitochondrial donors have been called third biological parents.

Moral Teaching: Parents

What is a parent? I'm not planning to hammer out a definition of "parent" today, especially since Catholic Encyclopedia can't. This is a dialectical argument to show you that parenting has to do with raising children, especially with the reproductive capacity at the beginning of the child's life.

Any definition of "parent" should be wide enough to include the following people:
  • a woman who, with her own egg, conceives a zygote in her own uterus (biological parenthood, simply speaking)
  • a man who, with his own sperm and body, fertilizes a woman who conceives a zygote in her own uterus (biological parenthood, simply speaking; this spectrum includes everything from rape to monogamous marriage)
  • a person who raises a child conceived by other persons as his or her own (technically modified by the word "adoptive" or "foster," as in scripture of St. Joseph)
Notice that biological parenthood, simply speaking, is all it takes for us to call someone a mother or father. However, this is based on reproductive tissue (gametes), not DNA. Gametes may have too many or too few chromosomes; chromosomes may have repeats, deletions, or nonsense mutations; eggs may carry many or fewer mitochondria; mitochondria may carry defective extragenomic DNA.

Key point: contribution to the DNA content of the zygote (which determines congenital disorders) does not matter as much as contribution of reproductive tissue. So what about this person:
  • a person who gives his or her own DNA-containing mitochondria for transplant into to a woman's egg before the woman's egg is used in IVF?
This person is donating cellular parts, not gametes (let alone years of time). I argue that this person belongs on a list of people who donate parts. A list like this:
  • a person who gives his or her own undifferentiated white blood cells to a hematology/oncology patient (bone marrow donor)
  • a person who gives his or her own red blood cells, platelets, or plasma to another person (blood donor)
  • a person who posthumously gives his or her own ocular tissue to another person (cornea donor)
  • a person who, living or posthumously, gives part of his or her own body to another person (organ donor)
In short, the person who gives their mitochondria for transfer is not violating human dignity. He or she saves the life of children conceived with mitochondrial disease, but he or she is an organelle donor, not a parent. 

Ghost Heart (Decellularized)
Src: TED.
Replies to Objections

  1. But no other organ donation includes non-genomic DNA.
    False. Every donation that includes mitochondria includes non-genomic DNA. This is everything but decellularized organs, plasma, platelets, and stool.
  2. Okay, so no other organ donation includes only non-genomic DNA.
    True. But there are other organ donations that are exclusively for the purpose of transferring DNA and hoping to replace the recipient's phenotype with the donor's. The best example is bone marrow transplants.
  3. But mitochondrial transfer still requires IVF.
    Very, very true. Although I hold that mitochondrial transfer per se is morally licit, I cannot condone current methods of mitochondrial transfer which involve IVF.

Saturday, August 30, 2014

Organ Donation: Is Your Soul Gone when Your Brain Dies?

I had some experience while on my trauma/acute care rotation with brain death and organ harvesting. One of my good friends was on the transplant service at the same time. "I think there's a harvest tonight," I said to him one day. A patient on our service, who had come in with severe brain damage after a hallucinogen-associated accident, had been declared brain dead. His family had consented to donation. I saw the organ donation representative with his binder and papers hovering around the room. And the patient's name disappeared from our check-out list (the list we keep of the patients so that we can hand them off to the night team). Sure enough, there was a harvest that night.

It sounds macabre, and it is. Late one evening, I was walking down the long hall of operating rooms to get a snack out of the physician's lounge. I passed by the screen at the front of the OR that displays all ongoing surgeries. Each operating room has a row, and the cases stretch out like long ribbons along the row, with every hour taking about three inches on the screen. Because it was 7:00 or 8:00 in the evening, no elective cases were scheduled. There was a laparoscopic appendectomy posted for the near future: it was about eighteen inches long on the screen. But at the bottom of the screen stretched an enormous band of orange, disappearing to either end of the screen. "HARVEST" was the procedure.

I walked down the hall. Outside the room's door were many styrofoam crates with plastic bags labeled "human organ for transplant" and advisories about temperature and transport. There was a liver box, a kidney box, a heart box, a box for blood.... No shades were drawn over the windows, so I looked in. The body on the table looked pale; I later realized that this was because blood was being taken. And instead of a cot or hospital bed waiting outside the door, as in every surgery, there was a long box on wheels. A tank, from the morgue.

The Catechism, in 2296 (in the section on Respect for the Person in Scientific Research) has this to say about organ donation:
Organ transplants are in conformity with the moral law if the physical and psychological dangers and risks to the donor are proportionate to the good sought for the recipient. Organ donation after death is a noble and meritorious act and is to be encouraged as a expression of generous solidarity. It is not morally acceptable if the donor or his proxy has not given explicit consent. Moreover, it is not morally admissible to bring about the disabling mutilation or death of a human being, even in order to delay the death of other persons.
I had heard the horror stories about people (rather than bodies) being harvested. But med school gave us training to recognize legitimate brain death. This included forceful reminders that that two physicians must agree on the criteria. But is brain death a suitable way to determine that the soul is gone?

Maureen Condic, Ph.D. wrote a helpful essay entitled "Life: Defining the Beginning by the End." Published in 2003 by First Things, the essay discusses the beginning of life by considering death. I was already a Condic fan, because of her phenomenal (and unsung) white paper on the beginning of life, and because I was a Vita Institute participant.

Condic highlights the distinction between cellular (or even organ) life and life of the organism. (Busy people read the bold.)
Brain death occurs when there has been irreversible damage to the brain, resulting in a complete and permanent failure of brain function. Following the death of the brain, the person stops...sensing, moving, breathing...although many of the cells in the brain remain “alive” following loss of brain function. The heart can continue to beat spontaneously for some time following death of the brain (even hearts that have been entirely removed from the body will continue to beat for a surprisingly long period), but eventually the heart ceases to function due to loss of oxygen....

The fact that the cells and organs of the body can be maintained after the death of the individual is a disturbing concept. The feeling that corpses are being kept artificially “alive” as medical zombies for the convenient culture of transplantable organs can be quite discomforting, especially when the body in question is that of a loved one. Nonetheless, it is important to realize that this state of affairs is essentially no different from what occurs naturally following death by any means. On a cellular and molecular level, nothing changes in the instant of death. Immediately following death, most of the cells in the body are still alive, and for a time at least, they continue to function normally. Maintaining heartbeat and artificial respiration simply extends this period of time. Once the “plug is pulled,” and the corpse is left to its own devices, the cells and organs of the body undergo the same slow death by oxygen deprivation they would have experienced had medical science not intervened.

What has been lost at death is not merely the activity of the brain or the heart, but more importantly the ability of the body’s parts (organs and cells) to function together as an integrated whole. Failure of a critical organ results in the breakdown of the body’s overall coordinated activity, despite the continued normal function (or “life”) of other organs. Although cells of the brain are still alive following brain death, they cease to work together in a coordinated manner to function as a brain should. Because the brain is not directing the [diaphragm] to contract, the heart is deprived of oxygen and stops beating. Subsequently, all of the organs that are dependent on the heart for blood flow cease to function as well. The order of events can vary considerably (the heart can cease to function, resulting in death of the brain, for example), but the net effect is the same. Death occurs when the body ceases to act in a coordinated manner to support the continued healthy function of all bodily organs. Cellular life may continue for some time following the loss of integrated bodily function, but once the ability to act in a coordinated manner has been lost, “life” cannot be restored to a corpse”no matter how “alive” the cells composing the body may yet be.
If that sounded interesting to you, I encourage you to read the rest. Condic goes on to talk about how this definition excludes persistent vegetative state (i.e. we can't argue that Terry Schiavo should die from agreeing that brain death = death), and that this definition does not hang on consciousness or cognitive function (i.e. we can't euthanize the unborn, the disabled, or the demented because we agreed that brain death = death). I disagree with a few of Condic's assertions, notably that we cease to think upon brain death. (who, with the light of faith on matters like the communion of saints, would say that the soul, separated, cannot think without the brain?) But the rest of her work is medically excellent as far as I, eight months from M.D., can see. This is also philosophically sound as far as I, a bachelor in philosophy, can see.

When I initally got my driver's license, I was still undecided about organ donation. I renewed it recently, and I'm now a donor. I encourage you to prayerfully consider donation, too. Besides saving up to 8 lives, you could also bring closure to your family after your death, all in accord with Catholic teaching, sound philosophy, and accurate medicine.

(Spoiler alert: that's not my license at left.)