"Absurd States," Gradualism, and NFP

I'm going to tie two patients together to illustrate a point about the difficulties I'm facing in a post-pill culture. The phrase "absurd state" in the title comes from the phrase used to describe cryopreserved embryos, who need to be maintained in cryopreservation to avoid likely death. It's a state that would never had existed had we not used technology outside of the truth.

I saw a  patient at one in the morning on call a few weekends ago. My diagnosis was round ligament pain, but we spent most of the visit talking about how she was trapped in a cycle of heroin and cocaine use, and she wanted to get clean. She had overdosed twice in the past week, she told me, and she didn't want that for her future. She told me about her plans to get into a suboxone clinic and a maternity home. She impressed me and I told her so.

Exactly twenty-three hours later (I looked at the clock) she was back after being found unresponsive, having overdosed again. She was brought back with narcan and the emergency department sent her to triage to rule out obstetric concerns. In the words of my second-year who was in triage at the time, she was "high as a kite." I was angry at drugs and angry at her for ruining a life that had such potential to turn around. I'd been told that if drug addicts' lips are moving, they're lying. I grew used to that as a fact during my time on the substance abuse service as a third year med student, but it stung to be reminded.

Three overdoses in a week. "She's going to kill herself," I observed softly to my second-year. One of these times, someone's not going to find her, or she's going to make sure she's not findable.

"That poor baby," added my second-year. Both baby and mother were in an absurd state, brought about by drug developments and the breakdown of marriage, families, and mores.

I saw a different patient in clinic a few days later. This one had been addicted to narcotics and benzodiazepines, but had weaned off her narcs by the time I saw her. She complained that she had missed so many prenatal care visits because she'd lost her job and was now living with her two alcoholic parents. I was less impressed with this person from the start, but I sympathized and tried to connect her with social help to get her better situated. Narcotics and benzodiazepines, more than some other drugs, seem to make people childish.

Not a week later, she happened to present to triage in labor, and I saw her with her mother, who looked exactly like mine. I know people can hide alcoholism more than they can hide, say, meth addiction, but I was even less trustful of this patient than before. She was moving her lips when she called her parents alcoholics; was she lying? I saw her postpartum. She was not handling new motherhood well, and I was again unimpressed. I know the postpartum state is uncomfortable (especially when we aren't giving you your xanax), but I felt frustrated by this patient, and I spoke with a little more sternness than I usually do.

"Do you want to be pregnant again?"

"No," she answered. "Unless I meet Mr. Amazing."

I ignored the comment and dug back to the issue. "What are you planning to use to prevent pregnancy?"

"Abstinence," she answered readily.

I had to recover from an instant of shock, because she was completely serious. "Is that what you used before this pregnancy?" I asked, unimpressed in the extreme.

"Yeah," she said, still serious. "It worked really well until one day I just said '**** it.'"

I was pressing my lips together in frustration at this point. "This time," I said, "I want you to think about another way to avoid pregnancy."

"I don't want my tubes tied."

"I don't think you should have your tubes tied," I rejoined. She was under thirty and there was still hope that she'd stop the benzos and go back to a normal life. "But abstinence didn't work last time, so you can't use it again." I gave her a run-down of the available methods of family planning, including NFP. And then came the time in my life I never wanted to come: I advised that someone not use NFP.

"But fertility awareness takes discipline," I said at the end, "and I don't think that's the best choice for you right now." The words were like a knife in my soul, but I went on: "You either need to make big changes in your life so that you can develop that discipline, or you need to use something that will chemically change you so that you can't get pregnant."

Our culture has become dependent on birth control. There are failings in the culture that seem to now need the crutch of birth control to avoid great evils. There are whole swaths of souls in absurd states. Following in the (unfortunately infamous) footsteps of Benedict XVI, I applied the principle of gradualism during that conversation. Was I wrong? I went to confession and the priest was vague; he told me it was grave matter (which I knew), but did not tell me whether I had sinned or not.

It's in these cases where I begin to feel very culture-of-deathish sentiments creeping up in me. Sentiments like "she shouldn't be able to be pregnant any more," or "it would have been better for that child not to have been conceived." But those are lies. A life can be made right and she should keep her fertility. And that life is precious, and should be cared for (by another person, perhaps).

But does gradualism allow us to avoid the objective evil and choose a lesser evil in situations like this? Not because it's good, but as a bridge to what is good? Can I suggest mirena (not as my peers do, as a panacea for all female woes, but) as a rescue until a person's life can grasp the good?

This post doesn't come to a clear conclusion and I'd appreciate comments and suggestions.