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.