Monday, November 10, 2014

Interviewing for Residency: Fascinating Experience

I've now been on four of the twelve interviews I have scheduled. I am amazed at how formative an experience it has been. I had two pools of programs that I looked at: programs that would be good for innovation and research (and future fellowship) and programs that would be open to my choices not to prescribe, sterilize, and abort. I expected that there would be few to zero programs that offered both. In fact, the program that I thought would be closest to "both" was my home program. I collected names of programs in three main groups:
  1. Did a CMA conference attendee, One More Soul, or another Catholic med student friend recommend it? (If yes: on list until eliminated due to financial concerns.)
  2. Do they have an open fetal surgery center? (If yes: on list.)
I add three token applications: my home programs--the one attached to my med school and the one on the campus I did my clinicals on--and that OB/GYN Mecca, Parkland. I felt that a native southerner who really wanted to go into OB/GYN wouldn't not apply to Parkland.  (Dumb reason to apply.)

I assumed that most of the academic centers would refuse an applicant making my choices. I thought that when I informed them of my decisions, they would write me off. I thought I had to decide on a future in the next eight months: will I be a napro doc or an academic researcher with a different fellowship?

To my shock, the answer might be "both!" I have interviewed at three community programs and one academic center, and three of them have been very open to my choices, including the academic center!

I am learning about myself, too: I like good surgery numbers, I like autonomy, I like peace and serenity. So I like the programs that let residents have a life, I like areas without too much traffic, I like single hospitals and few off-service rotations, I like good relationships with faculty, and I like a rich Catholic (sub)culture. I don't really care about simulation centers, and I don't rate being buddy-buddy with all my fellow residents as a high priority, because I'm a private person. To my surprise, I like pretty hospitals and good weather more than I thought.

I still can't decide whether I think it's important that I be able to do research. I'm still trying to figure out what futures I should prepare for. But I'm encouraged: it looks like I might be able to become a researcher and a pro-life physician. I'm most excited about some future interviews!

Saturday, November 8, 2014

CMA Conference Summary

It has been over a month since the CMA conference. As I proceed through the interview season, I am so glad I went. I actually had an open conversation about NFP with a fellow interviewee on the airport shuttle and was unashamed and excited about it. Thanks, Courage in Medicine.

I'm going to review the five or so talks that I found most meaningful. Check out the entire program booklet here, and order copies of these talks here.

Cardinal Burke: Physicians as Standard Bearers in the New Evangelization
This opening talk was a spiritual alarm clock that I desperately needed. I took copious notes during this talk, and I can't squish it into a short blurb, but here are some pearls:
  • Virtue is the primary method of the New Evangelization.
  • If we have the heart of God, our patient care will transform us, our patients, and the culture.
  • We are not saved by a discovery or work, but by a Person who assumes us.
  • The moral norm isn't an abstract--it's Jesus, so get to know and love Him.
Cardinal Burke urged us to form our consciences with moral study to stave off doubt that there is a moral norm. Since I was thinking of my own timidity and upcoming interviews, the message came through loud and clear that I needed to comfortably, boldly live my faith, reason, and religion as the most formative part of my life. My responsibility (since I've been told the truth) is greatly increased, and I wasn't attending to much of the iceberg of my responsibilities to glorify God.

Mike Aquilina: Challenges Before Us in Historical Perspective
The recent changes in healthcare, pointed out this speaker, are a perfect storm to drive out the people who want to serve. He went through ancient history (especially Roman historians like Tacitus and Pliny) recounting some of the same cultural phenomena we see today, such as the increasing tendency to lavish attention on dogs and to go childfree (to be clear to childfree readers: I list those as two separate tendencies). Mr. Aquilina emphasized that the cultural changes we see now are not original: every time a culture forgot to separate what is good from what is desireable, it excluded some persons (females, elderly, unborn, infants, children, various races, prisoners) from personhood and devalue them. However, Mr. Aquilina also showed that there is a history of the aberration of Christianity upsetting dysfunctional cultures. He concluded that there is no better time for us to be alive and serve; God will equip us, as he has historically.

Father Roger Landry: Bifurcation of Faith and Reason: Unleashing Radical Secularism and Its Impact on Medicine
This priest is remarkable for his use of the word bifurcation and his Latin three-word summary of how we should live. We should live, he says, etsi Deus daretur, as if God was a given. (Obvious as this may sound, it is difficult to do in the sea of relativism that is mainstream education above the sixth grade in this country.) When we live this way, unafraid that robust faith saves and strengthens reason, our lives are integrated. We also reap the following benefits:
  1. We rediscover wonder.
  2. Technological advances don't outstrip moral development. (More on this in a future post, I hope.)
  3. We don't forget the splendor of being a child of God, and we thus avoid devaluing persons.
We should challenge ourselves and our culture: what stands in the way of your practical atheism being carried into Nietsche's will to power? A hazy self-faith, godless altruism, natural law? Impossibly webby barriers to "might makes right." If you don't buy the CD of any other talk, get this one.

Father Robert McTeigue: Moral Courage in Medicine
Chosen to give the title talk at this conference was a very humorous Jesuit priest. Fr. McTeigue charged his listeners with duties to acquire the virtues (which, by the way, are humanizing and good for people). He pointed out that courage exists for the protection of the good. One of the most surprising things he said quoted St. Teresa (I think?) on the two beautiful daughters of Hope: anger and courage. This is why the evil spirit wants so desperately that we despair: when we hope, we have just wrath, and we pounce on evil! We defy it! We unabashedly judge deeds (our own and others'). Fr. McTeigue's final piece of advice: pray "Jesus, I trust in You," and mean, "I don't trust myself."

Dr. Fernandes: Catholic Medical Professionals: Reclaiming Surrendered Ground in Bioethics 
If I wasn't morally awake after Cardinal Burke and the other speakers, Dr. Fernandes would have gotten me out of any relativistic torpor left. This Wright State attending (gently, with humor) lit a fire underneath me. Like Cardinal Burke's talk, I'll just have to give you some soundbites:
  • Make yourself reasonable. Confuse them [relativists and practical atheists].
  • If people are worm food, why should we suffer, delay death, or respect religion as an add-on?
  • Cultural relativism is wrong. What if a culture is intolerant?
  • "Loving" "People" is easier than truly loving persons in front you in the present.
  • Between good and evil, there is no safe place.

Dr. Patrick Yeung: Fertility and Infertility Within a Catholic Moral Vision
Dr. Yeung, who is a professor at St. Louis University and directs the Center for Endometriosis there. He, being a napro-trained OB/GYN, had lots of relevant advice for me. "Do not look at it as a bunch of things you cannot do. Make it green and holistic and positive." "For best results," he also quipped, "follow God's design." One more neat quote: "Optimal medicine is holistic and doesn't solve one problem at the expense of [creating] others."

Wednesday, October 22, 2014

Did a Doctor of the Church Prescribe Abortifacients?

A medical student asks:
I am trying to choose/discern who is my Confirmation saint. A friend mentioned St. Hildegard of Bingen, and I thought she sounded really interesting. In doing more research, I found ... some "sources" [saying] that she was against abortion and contraception and some [saying] that she was in favor of these through certain herbs that are "menstrual regulators." Here are some of the articles I found.
I love St. Hildegard and jumped at the excuse to delve into her Physica and letters. Let's 1) examine her work, 2) review how Church doctrine develops, and 3) mention a fundamental issue at stake. Busy people read bold.

St. Hildegard and Abortifacient Herbs
Does St. Hildegard prescribe abortifacients? In the most relevant part of her Physica, she uses a large group of herbs in a concoction for "obstructed menses."
Let a woman who suffers from obstructed menses take tansy, an equal weight of feverfew, and a little more mullein than either of the others. ... And when she enters [the] bath, let her place these warm herbs on the bench and sit on them. ... Let her do this as long as she sits in the sauna so that her skin and flesh are softened on the outside and in her womb by the humors of these herbs and so that her closed veins are opened. Then let her take bearberries, a third as much yarrow, rue a third as much as the yarrow, birthwort as much as the bearberries and yarrow, and a little more dittany. ... Boil this in the best wine and mix this into the sack with the previously mentioned herbs and thus prepare claret. Let her drink this daily...until she is well.
First of all, the goal of therapy is to make someone well. I expect our medieval mothers were familiar with the subtle signs of pregnancy, and they did not share the modern mindset that it is an illness. But let's not guess at authors' intentions; let's look at the facts. Are these plants abortifacient?

Feverfew has been studied in patients with migraines and is thought to be a vasodilator. A review does not list miscarriage or menstrual effects among observed adverse effects over 245 patients. It caused as many menstrual disorders as a placebo did in a low-powered randomized controlled trial.

Mullein, besides its current uses as a fish poison, has been used for ulcers and pulmonary complaints. Natural Standard gives the evidence supporting its ability to relieve earache a "C."

Dittany has been used for hysteria and uterine hemorrhages in the past; Natural Standard has no evidence on these uses.

Bearberry (of kinnikinnick fame), has "C"-grade evidence for use in urinary tract infections and hyperpigmentation. Natural Standard warns that the berries "in large amounts may induce labor," but gives no evidence to support this.

In a single animal study, yarrow was associated with decreased fetal weight and increased placental weight, but no studies have investigated further. An ethanolic extract of yarrow (200 mg/kg/day, intraperitoneally, for 20 days) and a hydroalcoholic extract (300 mg/kg/day, orally, for 30 days) had severe effects on murine spermatogenesis (a male contraceptive effect).

The only study that mentions tansy as an abortifacient is a 1979 sociological narrative. Although it goes into great depth on some herbs, its short paragraph on tansy explains that it was not used much among the population studied, and the authors didn't know why.

Rue contains pilocarpine, an abortifacient used in horses. (An FDA-approved medication for dry eyes and dry mouth.) Natural Standard cites deaths in women who use rue as an abortifacient. Rue's inclusion in the potion may explain the addition of yarrow and mullein: rue causes a contact phytophotodermatitis, and perhaps the anti-inflammatory or wound-healing effects of the other herbs was thought to be prophylactic.
Contact dermatitis from rue.

Birthwort contains p-coumaric acid and aristolic acid. These are abortifacient in mice with a single oral doses of 50 mg/kg and 60 mg/kg (of the methyl ester), respectively. A sesquiterpene isolated from the roots is abortifacient in 91.7% of pregnant mice at a single oral dose of 100 mg/kg.

I have no information on how much of these chemicals is contained in the raw or dried plant, so I have no idea how much of the plant parts a human being would need to consume to cause an abortion. Fortunately, it doesn't matter that I don't have this information, because St. Hildegard doesn't give absolute quantities, either. It is possible that the doses intended by St. Hildegard are lower than the doses required to produce an abortion.

Are some of the herbs that St. Hildegard uses abortifacient in certain quantities? YES.
Is she intentionally ending a pregnancy? DOUBTFUL.

Would her remedy end a pregnancy? DEPENDS ON DOSAGE.

A Doctor of the Church from the turn of the twelfth century composed an herbal remedy to bring on a late period; we now know this may be an early abortion. Should our adherence to the Humana Vitae come crashing down? Should we picket our chanceries for support of the HHS mandate?

The Church on Medical Ethics in General

No. This shouldn't ruffle any faithful Catholic feathers: it doesn't give us any reason to doubt the Church's teaching on abortion and contraception.

SNARE proteins at work in exocytosis.
(The same proteins underlie sperm-egg membrane fusion.)
St. Hildegard, like St. Thomas Aquinas, knew to protect human life as soon as she could detect it (more on this below the jump). Without microscopes, she could not observe that ovum and spermatid join, and the resulting zygote acts as an independent organism immediately after sperm-egg membrane fusion. If she was wrong about when human life begins and so thought that a remedy to "bring on the period" might be beneficial to a patient, she was invincibly ignorant.

Church teaching always develops as our knowledge develops. As embryology improved (with a French paper in 1879 describing "immediate animation") our mores responded (with protestant-based cultures like the U.S. outlawing abortions beginning in the 1800s), and so did Church teaching.

Female and male pronuclei in a zygote ready to divide
for the first time. Polar body at one o'clock. Src
We are freed by a more complete knowledge to better do what St. Hildegard was already doing: protecting unborn life.

Some still do not recognize that "bringing on a period" (and its more current equivalents) can result in loss of a human life. A Catholic who cannot see this can fall back on the Church's teaching, so that she can at least hold the truth. Unfortunately, those who are interested in potentially-deviant teachings by historical Catholics are often not open to falling back on the authority of the Church.

The Fundamental Issue: Catholic Docility
Something very fundamental is at stake in the discussion of whether St. Hildegard supports this or that. Faithful Catholic discussions about individual theologians must stand on docility. By "docility," I mean a an attitude of ready submission to the truth. This mentality is often missing from discussions of reproductive rights; however, without it, discussion and rights are meaningless.

Discussions are about truth, and rights are about happiness (or achievement of "the good," if you will). No human being can add or subtract to truth, and no human being can fabricate happiness. These are outside us, already determined by Someone else, and therefore "limited," in a way. The "limits" to truth and goodness are like bowling alley rails, helping our intellects and consciences reach perfection. If we bowl within the rails, we stand a chance of knocking down a pin. Without regard for the "limits" (docility) we bowl all over the building, pursuing apparent goods that aren't fulfilling according to opinions that aren't true.

Purely secular docility means regard for our inborn and universal human nature by forming our souls to achieve that nature's greatest good. It means informing our intellect with truths we or others can prove (e.g. that there is a God) or which need no proof.

Revelation adds to nature like General Relativity adds to Newtonian physics. There seem to be more limits, they are more complex, but this means greater freedom. Catholics are docile to the Truth as a God who loves us and left us an institution to help us apply the truth to our lives, so we expand our docility to include the Magisterium. A docile Catholic forms his conscience and intellect with the help of the Church, without which he cannot have faith. This formation and docility 1) helps us avoid sin in the advancement and application natural science; 2) makes conscience and the sensus fidelium accurate barometers of what will bring us happiness, rather than opinions and democratic whim; and 3) helps ground us when human persons say and write confusing things.

St. Hildegard was a great defender of docility to the Church and her headship. In an early letter to Pope Eugenius, she describes the Church as:
...a useful institution, tending toward God (and therefore assisting mankind), providing a light for man’s benefit. ...[M]any teachings and the fragrance of orthodox writing flow from the vigor of truth to it, but some people frequently reject them without justification.
She elaborates on those "people" in another letter to the same pope, complaining that they "disparage everything that prelates do, because they scorn the notion that they are inferior to their prelates...because they are full of the poison of envy." St. Hildegard herself had imperfect superiors; nevertheless, she encourages us to love the Church and be submissive to our superiors.

This attitude of submission grounds us, so that we're not easily ruffled by the behavior, speech or writings of individuals. "Keep calm and carry on," is the docile Catholic's mantra, and St. Teresa of Avila summarizes it well:
Let us look at our own faults and leave aside those of others, for it is very characteristic of persons with...well-ordered lives to be shocked by everything. Perhaps we could truly learn from the one who shocks us what is most important even though we may surpass him in...our way of dealing with others. ...[T]he Lord will take care of these souls.
Maybe St. Hildegard prescribed abortifacient herbs. With St. Teresa, I say "So what?" We can surpass St. Hildegard in our protection of human life. We shouldn't be so scandalized that we fail to learn the more important lessons St. Hildegard has to teach: that human life should be protected, and that we must be docile to the Church.

In conclusion, I am uncertain that St. Hildegard knowingly recommended certain herbs to end an early human life. One of her herbal remedies included chemicals that are certainly abortifacient, though I can't comment on what quantities would be required to cause an abortion and whether St. Hildegard used these quantities. Even if she did, she 1) protected the intrauterine life she recognized and 2) vehemently demanded docility to the teaching Church. If we value St. Hildegard, we would do well to imitate these two choices.

Replies to objections (including more on St. Hildegard's protection of the unborn) and recommended reading below the jump.

Monday, October 20, 2014

For Reference: People Never to Become

The Workaholic
On internal medicine I worked with a resident who terrified me. I don't mean that she was malignant. She terrified me because when I looked at her I saw a possible future self, a self that I could all too easily become. She had just gone through a family death and had obviously thrown herself into her work. She worked almost constantly: at five in the morning she was checking her interns' patients' charts from home, and at nine or ten she finally left the night team alone in the resident lounge.

How could I possibly be attracted to that, you ask? She was incredible! She was constantly energized, she seemed to know everything, and she managed complex patients with ease. She was chic, funny, friendly, and beautiful. 

The first time I encountered her was actually on my OB/GYN rotation. Gyn was consulted on an ICU patient of hers. The patient had widely metastatic cancer, was comatose, and was intubated. The patient looked agonized and the family members looked weary. This resident strode into the room, looked at the people in front of her, and (with grace, directness, and ease) began a conversation about withdrawing from the ventilator. Two minutes later the patient was extubated. Wow, I thought. That's a doctor who gets things done. That's someone who cares about people. 

I was incredulous to find out that this was my upper-level resident on wards. I was so excited. But I soon slipped from hero-worship into terror. Ever since that wards month, I've been careful not to become the Workaholic. It's hard! I have been getting up in the four- and five-o'clocks for all three of my audition rotations. My odd jobs keep me busy, and mealtime and prayer time are constantly threatened. But I've seen the danger at the end of the workaholic road, and it's awful. So I'll fight to make time for deep relationships, character development, and personal enrichment.

The Malignant Attending
Someone please remind me when I'm an attending to build people up. There are two forms of mechanical air exchange and there are two forms of medical education: high pressure and gentle encouragement.

The first model, which we'll call the "Sergeant" method, is horrible. In this model, every mistake is loudly called out and the student is made to feel small. "What are you doing? Use your brain!" my attending on my second away rotation has told me. "That's stupid," and "How many times do I have to tell you?" are commonly heard in his OR. He swats hands instead of using words to say "[give me the] suction," or "off [with the retractor you're holding]." This behavior extends to the OR staff, residents, other physicians, and basically anyone other than the attending. I've seen several very childish displays. My current attending openly champions this form of teaching, stating that it's the sergeant who saves his men's lives by laying instincts into them. But habits don't have to be formed by negative conditioning.

I have always thought that the most effective way to teach is the Socratic method. Applied to clinical education, this would look like a gentle person asking, "Tell me what you read last night," and letting the student talk. This would say, after a student conducted a history or physical or did some procedure: "Tell me what you did right and what you'll do differently next time."

In the OR, the residents and I exchange many looks when we work with this attending. "Never throw your subordinates under the bus," one whispered to me one day when the attending was out of earshot. Mentally, I vowed never to do so. It's horrible. Not only does it make your students feel like dirt and resent you, it leads to passive-aggressive behavior in staff, it makes residents believe you're a senile joke, it makes everyone eager for your retirement, and it makes you habituated to treating people like slaves and objects.

Saturday, October 18, 2014

Odd Jobs for an M4

I had no idea M4 would be like this. I am doing several weird jobs that I don't think most fourth-years do. I'm pretending as much as I was third year!

I'm a hiring manager and a travel agent.
This is something all fourth years do, but I'm adding it in just because it's so different from M3. For this job, I compiled a fancy-looking resume for a US senior medical student and packaged it with a nice personal statement. I scheduled some travel for her so that she has a broader experience to draw from as she interviews, and I tried to sublet her apartment as much as possible so that she doesn't break the bank. I managed her travel and get people to rescue her when she makes mistakes. (And boy is she a mess. She is constantly forgetting stuff at home, forgetting that when you don't change your address your new debit card gets mailed to the subleaser, forgetting that driving halfway across the country takes two days and you need sleep).

I am constantly checking my email for her, because interview invites come in fast and if you don't respond in a few hours, you don't get a spot. This chick's schedule is a mess. She's in Omaha for some NFP training thing for a whole week of primo interview time! And I had to schedule like seven interviews during her ER rotation. Hope she's okay with pulling nights and weekends. Hope she can pay for all the flights she's going to have to take. This residency nonsense isn't cheap.

I'm a biomedical engineer.
A weird twist of events led me to an engineering competition, which led me to a research project in which I am somehow the principle designer for a three-dimensional printed medical device. This is an amazing experience and I'd love to have a patent, but I burst out laughing every time I realize what I'm doing.

The engineering competition was an amazing experience. I didn't even know these things existed, but when I asked my brother (a senior engineering undergrad), he said, "Oh yeah, my roommate walked into one of those for the food. He almost won."

Here's what happened. An email was sent out from the College of Engineering (COE...boy that looks wierd after typing COM for years) with an application to a medically-themed engineering contest. It was sent to all the engineering undergrads and to all the med students. Forty engineering undergrads (out of almost 90 who applied) and as many med students as applied (four) were invited to attend. "Sponsors" (companies who fund the event, and you'll see why it takes so much funding in a second) provide the students with "needs statements" (things they want designed). In our contest, the needs statements were all related to rural and elderly health. In 48 hours, the students have to form teams, pick a needs statement, design and build a product (hardware, software, web or cloud components, prototype), and create a presentation to market it. The students get a chance to be engineers while being fed; the sponsors get free labor. At our contest, there was also a cash prize.

They sent out the needs statements the day before the contest. As I was driving there, I noticed that one had to do with gynecology. "Oh no," I said to myself. "I'm going to end up doing that one, I just know it." It didn't sound terribly interesting, and it also sounded impossible do without a pelvic exam on the person using the device. (Sorry if that was too much information.) I would rather have done one of the flashier projects and I had two favorites picked out.

Long story short: when the competition was only a few minutes underway, three teams had already seized my pet projects and there wasn't room for me on the team except as a consultant. And there were four people hanging around, teamless and needs-statementless. So I pitched the gynecology idea. And they shrugged and went with it.

We had ups and downs. Severe ups and downs. We oscillated between "this is the coolest invention since sliced bread" and "all we have is a smoking heap of circuitry." I wasn't extremely helpful. I can't write code, I can't build circuits, I can't sauder, and I have no experience with CAD software.

But I know how to sell stuff. I made the prezi and I sewed the fabric part of the invention. I sought out a nice mannequin to place our product on. This meant that I called half a dozen department stores and asked them the (probably) strangest question they'd been asked that day. "Hi, my name is mmatins and I'd like to ask your manager about female body forms or legs." Stranger still, I was successful. I carried a male torso model--completely unclothed--out of the back entrance of one store and stowed it in my trunk. I tried hard to remind myself I wasn't doing anything illegal. I then went back for a female torso on a stand, which I carried like some enormous, inappropriate lollipop through the food court and a parking lot.

At the end of the weekend, the COE announced that everyone would take home a small prize of $5-10. I thought, "well, that's nice. It covers part of my gas getting here." Then they announced second prize. "If we're going to get anything," I thought, "it'd be this," even though I pegged the two flashiest projects for first and second. Still, maybe.... Second prize wasn't us, so I internally shrugged. "It was a good experience," I began to tell myself. Then they announced first prize.

We won.

And because I later mentioned that I was at this contest when someone happened to be discussing 3D printing, I ended up giving a presentation on my first away rotation about bioprinting, during which I sounded like I knew something about it. And because I used to foodle around with Google Sketchup (now Sketchup Make), I could throw out a design for the product they wanted pretty easily. Sketchup + Google search + Wikipedia = makeshift engineering degree.

I'm a novice mistress.
Because there is no established curriculum for consecrated virginity in my Diocese, I am sort of making it all up as I go. This used to cause me slight distress, because there is such an emphasis on giving over one's will to another in the works of the Doctors of the Church and other authorities on the religious life. I shared this distress with my spiritual director and he smiled and shrugged. "What else could you do?" he asked.

I'm cobbling together a bunch of online classes and my weekly meetings with the other consecrated women. During these meetings, we cover what they think would help me and what I ask for. Recently, we finished a ten-point curriculum for living in intimacy with Jesus daily. (The love of God for the soul, the will of God, Scripture, love of neighbor, mutual love, Jesus in the midst of "two or three," the Eucharist, Love in community, Jesus forsaken, Mary, the Church, and the Holy Spirit.) We're moving on to forming a rule and leading a balanced earthly life. I asked that we do more on affective maturity and the evangelical counsels next. But I feel sort of like I do when I pretend to be an engineer.

My formal application for consecration is complete and submitted. My bishops are right now deliberating and discerning whether to admit me to the order of virgins. If they do (praypraypray), I will add another odd job: wedding planner.

Tuesday, October 14, 2014

Med School Cultural Immersion

First of all, the ultimate reference for med school memes is whatshouldwecall medschool, a tumblr. Sorry that some of the references are crude. Some also take the Lord's name in vain. Some of my personal favorite references are to gunners and the strange way third-year med students learn.

When the gunner on your team promises
not to take on a lot of patients so that no one
has to work hard and you know it's gonna end like...
A gunner is a med student with too much ambition. There are stories about gunners tearing pages out of textbooks to lower the maximum score of the rest of the class. My classmates joke about people gunning, but I don't know that anyone's really so enthralled and exclusive at my school. Gangnam style and #Selfie parodies exist. The wink at 6:38 in this parody is a gunner move.

For third year, two Let It Go parodies (this one and this one) are brilliant. The second one is part of a whole series. Most of What Should We Call Med School is about third year and it's all true. All of it. I remember when I was really upset by the combination of continuous evaluation, helpless incompetence, and ridiculous expectations created by third year. I went to WSWCM and read memes for two hours. And I felt amazing, because I realized I wasn't alone.

Saturday, October 11, 2014

The Truth Turned Someone Away from an IUD

This post conforms to the blog rules.Because of my conversation with a patient, she chose not to have a hormonal IUD implanted, a form of long-acting contraception that can end a zygote's life. All I had to do was tell her how it worked.

I was on an audition rotation in a pretty pro-birth control clinic. A young patient with extremely severe menorrhagia was failing oral management (i.e. NSAIDs and high-dose birth control pills weren't helping). Her compliance with daily pills was in question and at the last visit my attending, Dr. L, had discussed mirena with her. I would have been comfortable giving her a mirena, except that she was sexually active. And I know that the mirena can cause damage to a zygote ("fertilized egg" to some, but a person nonetheless). So I told her that the attending would be speaking with her about that prescription, but that there were nonhormonal options, too (lysteda or amicar). I counseled her about the nonhormonal options and about mirena and nexplanon. She couldn't decide what she wanted to do.

"What would you do?" she asked. My heart sang.

"HA! She ASKED," I thought victoriously. "I told myself that I wouldn't make my own recommendations in opposition to the attending unless explicitly asked. AND SHE ASKED!"

"Actually," I said aloud to the patient, "I don't recommend mirena." I explained how it affects the endometrium and can cause loss of the cells that forms after sperm and egg fuse. "And when that embryo is lost, that's an early miscarriage. And I don't want that--"

"I don't want that either," broke in the patient.

"--so I won't in conscience recommend mirena to my patients. But Dr. L does prescribe it, so..."

"No," the patient said. "I guess I'll try the other things."

I left the room promising to bring back a pamphlets on those meds. I returned to the charting room and faced the pamphlet rack. As I pulled out a lysteda brochure, Dr. L said, "Tell me about your lady."

I presented her. "This is your 14-year-old African American patient with a two year history of disabling dysmenorrhea. She hasn't had relief with ibuprofen, orthocyclen, or ogestrel; we talked about mirena and nexplanon but she's interested in something non-hormonal. I counseled on lysteda and she wants more information. Physical exam is benign, she's had guardasil, and HEADS survey is unchanged since last visit; same male partner, 100% condom use. No tobacco, alcohol, or drugs."

My attending was pleased with my presentation, but not pleased that the patient didn't want a mirena. Dr. L joined me at the pamphlet rack and began to pull out brochures for nuvaring, nexplanon, and skyla. She stuffed the sheaf into my hands and sent me back into the patient's room.

(Skyla, btw, has the a disturbingly and tragically accurate advertising campaign, featuring sexually-active women explicitly prioritizing activities over children. How can people ignore the identical mindset behind contraception and abortion?)

I showed the patient the whole stack, but emphasized that everything that has hormones works like mirena. I gave her the pamphlet she wanted, and went back to my attending. "She's still going with lysteda," I said.

Then my attending went in with me. I was a little afraid that she might dissuade the patient from her decision. But this attending actually walks the walk when she supports "patient autonomy," so my patient was allowed a limited trial of lysteda. I have no idea what happened after that, but at least for now, that patient is aware of what hormonal contraceptives can do.

Wednesday, September 24, 2014

The Things I Never Wanted to Do

I mentioned that I rarely discussed my choices about contraception, abortion, and sterilization during medical school. I never told my OB/GYN clerkship director, attendings, or residents anything. I think that made it easier to make friends, but it got me into trouble at least twice. I'm telling these stories for future Catholic med students, even those who aren't becoming OB/GYNs. With more forethought than I had, you can save yourself from some dangerous situations.

Cesarean Tubal Ligation

A babcock. Notice that it is made to hold a
tubular organ without crushing the tissue.
On my L&D rotation, I scrubbed in on any C-section that happened. The first time that a woman had chosen to have a bilateral tubal ligation (BTL) after the birth of her baby, I did nothing and nothing happened. The second time, the attending held out the handle of a babcock clamp, which encircles the tube, and told me to hold it. Reflexively, I did; after all, as a med student, you hold any retractor you're told to and wish you had reached for it automatically before you needed to be told. The babcock does not have anything to do with the actual tying of the tubes, but I was definitely participating in a sterilization.

Miserable, I held the babcock in space, wondering what I should do. Should I speak up? I didn't feel empowered and didn't want to be disliked. Was this remote and unwilling enough for me to be quiet and save face? Would speaking up be making a selfish scene? Remember, the patient is awake for a cesarean section; it's sort of too late to discuss ethics, especially when this patient has chosen to do the objectionable thing. But this is grave matter! And I know it to be grave matter! And I am doing it anyway!!
The babcock is at 2 o'clock in this picture.
The other two things are strings being
tied around the tube. The strings are clipped
and the tube between them is removed.
CCC 1857: For a sin  to be mortal, three conditions must together be met: "Mortal sin is sin whose object is grave matter and which is also committed with full knowledge and deliberate consent."
It was over before my analysis was over. So I said nothing. I still didn't cut the sutures. I went to confession before receiving communion. The conclusion of the priest was that this was remote and not "deliberate consent" enough to constitute mortal sin, but I was very, very determined not to let this happen again. It was careless not to say anything to the attending. I did better in the past, when I spoke up discreetly before a mirena insertion. But this wasn't the worst thing that happened.

Birth Control on an Away Rotation

Fourth-year med students occasionally spend weeks at a time at other med schools or residency programs. These "aways" are often done to make a positive impression on the residency program there and are called "auditions" in that case.

I was doing an audition rotation at a school and got waaay too close to prescribing contraceptives. I didn't realize that the clinic would be so pro-birth control, but I found more than 75% of the patients taking some form of hormonal birth control, and a strong culture supporting "safe sex" with 100% condom usage. I was at a loss.

I was on a month-long rotation trying to get people to like me. Med students are always sent into the room first; if I go in first and share all my contraception-why-not knowledge and then the attending goes in, the patient will ask one of two things: "So, is that med student just crazy?" or "Have you been lying to me, doc?" Worse, the patient will decide not to use contraceptives (yay), the attending will ask why (uh-oh), and the patient will explain that "the med student said...," and the attending will (annoyed) have to re-explain all the falsehoods and (red alert) rebuke the med student.

You might argue that this course of action might have been good: it might have created a chance for me to bravely say, "Well, Dr. X, I was actually reading a paper that says (insert pro-family stuff here)...." But I expect those things would fall on deaf ears of the highly experienced, academic, and culturally blinded physicians I was working with. Worse still, I would have confused patients, possibly discredited the arguments against contraception, and possibly eroded their relationship with their physician.

So I clammed up and tried to say true things and not recommend contraception. I tried not to be excited when people were sexually active and using condoms and birth control. I tried to encourage people to think about whether they wanted to be pregnant and let that inform their decision to have sex. I was about the only one in the clinic to continuously tell teens that the most effective way to avoid pregnancy was to avoid sex. 

But I began to echo my attendings' speeches and advice about birth control as I counseled women about "the options," which was a requirement.  I was at fault for not knowing enough numbers to give to patients myself, though. I seemed to morph into someone who was pro-birth control: it decreases the risk of ovarian cancer and uterine cancer, I'd say, and the only side effect is possible irregular periods. When people asked me about future fertility, I said that "our professional organization [ACOG] instructs us that future fertility is not affected." (That was the most painful thing.) Working twelve-hour days in this place for four weeks wore down my defenses.

The ultimate result was the day I was almost running the adolescent medicine clinic and writing notes and plans (only missing the formality of writing the script and signing it) that included birth control of all flavors. After that, I found myself crying in a confessional again. This time, although the priest never said "that was a mortal sin," he did extract a firm purpose of amendment and my intention to say the penance. And he did tell me that I, like pharmacists, lawyers, and some others, stand in danger of losing my soul in my profession. It sounds harsh, but as I knelt in the confessional I felt and knew that he was very, terrifyingly correct.

So, Catholic medical student: discreetly inform your intern/upper-level/attending/preceptor/whoever. If it's too late, you are allowed to say something like, "Oh, I prefer to just observe; I'm happy to explain afterwards." And if you get into a sticky long- but short-term situation like my away, you need to do a little research (I'm hoping to put something up here with quick facts on contraceptives, etc) and be unafraid. Don't break up doctor-patient relationships, but do offer an alternative. I'll share a positive story in the a next post (because I have one).

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. Tl;dr? 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 human organelles. (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.)

Thursday, August 7, 2014

Mini Post: Living downtown is awesome

I haven't been able to sit down and blog for so long! I have a bunch of ideas for posts all piled up on my phone's "To Do" list, but so little time to sit and execute them. I'm on a subspecialty away right now and (aside from the fact that I missed an emergency surgery last night), I'm doing what I need to do with pretty liberal free time.

Therefore, we will now have a moment to spit out all the blog post ideas in miniature.

I've moved several times since I started med school. Suburb 1 (my first location) was very quiet. The only remarkable thing I ever experienced among my neighbors or in my apartment complex was the messy morning relationship fight I accidentally witnessed across the street while on my balcony one morning for breakfast. (It was a lot like the movies: the guy slams out the door with a suitcase, the girl comes out after him very distressed, pleading loudly....) Suburb 2 was even quieter. Now I live downtown in one of the country's largest cities. And I'm living with a different population, since I'm living in a lower socioeconomic area. I see homeless people daily, I see broke people daily, I see mentally ill people frequently, I see people with much narrower prospects than mine all around me.

But I love it. I feel like I'm appropriately living the way an alter ecclesia should live: poor and with the poor.

And sometimes it's pretty funny. While biking home one day, I stopped at a light and smiled at the man sitting at the nearby bus stop. "Wher' yo' husband at?" he asked, without any other greeting.

"I'm married to Jesus," I answered.

"Oh," he replied, not knowing what else to say. "That's coo'."

"I thought so," I answered. The light turned green and I moved on. That was already the second time someone had asked me where my husband was.

Another time, I was finishing a conversation with a homeless man after Mass at the cathedral. I introduced myself and he said, "All ri', mmatins, my holla' sista."

I love to be with the people in my neighborhood. Just being in the same place, shopping at the same stores, using the same laundry machines, putting up with the same pigeons, and walking the same streets is teaching me about how hard these people work and how much love we all need. It's humbling and exciting. (That may or may not be where I'm living; I didn't even check before I used the picture; thanks to Kim Briggs)

Thursday, July 24, 2014

Should Catholic Parents give their Children Gardasil?

Gardasil (and its sister vaccine, Cervarix) received lots of press seven or eight years ago, but I'm retouching the subject because I am getting Gardasil. (I'll explain why later.)

Basic Science (skip if you don't care or already know this)
Gardasil is approved by the Food & Drug Administration (FDA) for prevention of human papillomavirus (HPV) infection in people aged nine to twenty-six. (Gardasil for male and female patients, Cervarix currently for females only.) Like many vaccines for other viruses (e.g. the yearly "flu" vaccine), it innoculates the body with a recombinant protein pulled from the virus, so that the immune system learns to defend the body against that virus in the future. Gardasil is "quadrivalent" and protects against HPV types 16 and 18 (the types most associated with cervical cancer) and types 6 and 11 (the two most common types seen in genital warts). Cervarix is bivalent, offering immunization against types 16 and 18 only.

Morality (don't skip this)
HPV is a sexually-transmitted infection. Cervical cancer is a sexually-associated cancer. This makes Gardasil and Cervarix unlike every other vaccine that a Catholic parent may choose to give their children. Several moral questions arise:
  1. Is it moral to administer this kind of vaccine?
  2. Is it prudent?
  3. Is it imprudent not to receive this vaccine?
  4. Is there ever a case that a person should receive this vaccine?
(The derivation of culture cells from aborted children is beyond the scope of this post, as is herd theory and preference against vaccination. For the remainder, I assume that the parents reading accept the premise behind vaccination in general.)

Is it Moral to Administer HPV Vaccines?
The Catholic Medical Association (CMA) has a position paper on HPV vaccination which I find full of sound medical practice, reason, faith, duty to do what is right, and a spirit of obedience. They answer this question in this fashion:
The fact that HPV is spread primarily by sexual contact does not render vaccination against it unethical. Healing and preventing diseases, no matter what their source, are acts of mercy and a moral good. Prevention of HPV infection is distinct from, and should not be construed as encouraging, the behavior by which HPV is spread.
Per se, HPV vaccination is not an immoral act.

But is it Prudent?
Will we change promiscuity? time will have to tell. It remains true, as CMA points out, that best promote the health and happiness of adolescents, physicians, parents and social institutions should redouble their efforts to promote chastity. Consistent messages about and support for this virtue will not only help to reduce disease, but will help individuals, couples, and marriages to flourish. 
So is it Imprudent Not to Get these Vaccines?
Not really. CMA points out that the HPV vaccine is not the only way to prevent cervical cancer. In fact, cervical cancer is the poster-child cancer for prevention by cheap, easy screening (the Pap smear), which has not been connected with increased promiscuity

CMA also adds that the vaccine's long-term effectiveness isn't proven, and that there are eleven other subtypes of HPV that have been associated with cervical cancer. (These facts are part of the ordinary informed consent that physicians should provide to patients. By and large, I have not seen that OB/GYNs are great about giving all of this information before giving Gardasil and Cervarix. The good ones point out that the patient can still get other types of HPV.)

Is there Ever a Case that Should Receive this Vaccine?
I was spurred to write this post when I chose to "get Gardasil" (as an adult, at the tail end of the FDA's recommendation). Why? Because an attending told me that a colleague in the metroplex had respiratory papillomatosis from inhaling smoke from surgical cautery. In other words: after operating on infected cervixes day after day, an OB/GYN got the equivalent of genital warts in his windpipes! (Not fun.) Not the only case reported, either: a 2005 review cited "A case report [linking] the laryngeal papillomatosis in [a] ... surgeon to virus particles in the laser plume from one of his patients."

Some parents have told me they choose to vaccinate their children considering that you will never know who masturbates without washing their hands before touching your children (a stretch, but parents stretch all kinds of things for their children, and I can't argue--no one loves your children as much as you do). A young man or woman who finds that their intended has had previous sexual encounters may have reason to seek vaccination (I have seen a case of cervical cancer in a monogamous woman from her husband, who was faithful to her after marriage, but had had a previous partner).

In short
HPV vaccines aren't per se illicit. It may contribute to an increase in promiscuity; physicians don't always give water-tight informed consent about things they think are good, patients don't always understand informed consent, and advertising muddies the picture. Time will tell whether people mistakenly take the HPV vaccines to be a ticket to consequence-free sexual license. Ought parents to vaccinate? I can't make the case for all, but I respect each parent who chooses, in love, to vaccinate their children or to allow their children to choose vaccination. Are there cases when people really should? I thought so.

This is respiratory papillomatosis. The whitish globular growths are papillomas,
in the normally V-shaped valley of the larynx. Source: viveromd

In writing this post, I used the full prescribing information for Gardasil and Cervarix.

P.S. At the time the CMA position paper was written, there was much debate about whether HPV vaccines should be mandatory. That's a moot issue now, but I love CMA's answer. The paper points out brilliantly that since non-vaccinated students would not present an increased risk to vaccinated students while in school, as with droplet-communicable infectious diseases (e.g. measles). I have to quote it:
We presume that genital HPV infection is not transmitted while students are in school, and excluding non-vaccinated students from school would not prevent extramural transmission.
Come on, you have to smile. "We presume that schoolchildren are not having sex in the classroom." ROFL.