OB/GYN Ethics 301

In OB/GYN Ethics 101 I went over topics for medical students, residents rotating through OB/GYN settings, and OB/GYN interns. In OB/GYN Ethics 201 I reviewed topics for OB/GYN residents in generalist settings. Now I need to review a few subspecialty concerns with a fine-toothed comb, especially those not focused on pregnancy and maternal/fetal vital conflicts.

Please remember that I'm not a moral theologian. I'm one resident talking to another, and I am happy to engage in discussion and to retract whatever is in conflict with Church teaching.

REI

Img credit: RWJMS IVF Program, Wikimedia commons.

As in OB/GYN 101, observation of almost everything is okay. Observing gives you a better ability to talk to non-healthcare practitioners (e.g. patients, parishioners, priests, even ethicists) about things they may never see.

You can participate in and perform follicle scans, simple procedures such as transvaginal cyst drainage, medical management with provera (or other progestins), letrozole (or other aromatase inhibitors) clomid (clomiphene), follistim (urofollitropin), trigger shots (b-hCG), GnRH pumps, and anything else that won't have post-fertilization side effects.

You can participate in prenatal genetic diagnosis (or screening) with great caution. PGD is a biopsy of a large percentage of a human embryo's body; it's a significant procedure for that little person, but in itself it's a biopsy, not an act of killing or mutilation. If you know or suspect that the embryo being tested may be rejected (destroyed or cryopreserved), this may be proximate cooperation in evil and you may incur some of the guilt in that act. It's rare that the embryologist would let you do this, anyway.

You can observe but not participate in semen washing, egg harvests, and intrauterine insemination (IUI). These replace or interrupt intermediate steps in sex (semen washing replaces filtering and capacitation of sperm; egg harvest interrupts local motion of eggs; and IUIs replace local motion of sperm after ejaculation. (To clarify for those who have done bench research: semen washing of animal samples or of human samples intended for research does not carry the same gravity, even if the human samples were obtained through masturbation. The participation in masturbation is remote, mediate, material cooperation in the evil and does not confer guilt in the act.)

Family balancing by selecting embryos after prenatal genetic diagnosis is immoral; family balancing that includes embryo destruction is gravely immoral. Selective reduction is gravely immoral. Avoid witnessing destruction of embryos or selective reduction. Counsel against selective reduction.

The standard of care is now clomid/IUI for unexplained infertility, followed by homologous or heterologous IVF with embryo transfer (ET) if that doesn't work. But you'll find a lot of acronyms in Catholic bioethical literature. These are mostly from the early days of IVF when people were attempting to find techniques that boosted success rates. Eventually, REIs and ASRM realized that IVF/ET was easier and nothing else made a difference, except for ICSI (see below). Bearing that in mind, here is a quick list of acronyms, defnitions, and comments that you might encounter from bioethicists:

• GIFT/TOTS: gamete intra-fallopian tube transfer, not permissible because it replaces the marital act, if sex is every involved (e.g. by collecting sperm in a perforated condom) it is only accidental
• ZIFT: zygote intra-fallopian tube transfer, ethically analogous to ET, which transfers an embryo into the uterus (see below)
• LTOT: low tubal ovum transfer, moving an egg from the ovary to the isthmus of the fallopian tube or even to the uterus, without removing it from the body is LICIT when there is intention of fertilizing it with an act of intercourse and not IUI.

Img credit: RWJMS IVF Program, Wikimedia commons.

Intracellular sperm injection (ICSI) injects a sperm directly into an oocyte (see left). It's used for very abnormal or poorly motile sperm and low sperm count. It replaces part of the sexual act and is not licit; do not participate, although you may observe.

Embryo transfer is a slightly hot topic within bioethics. However, I don't see it as that contentious. Fertilization has already occurred, and the sex act has been totally replaced. The local motion of the embryo into the uterus is actually a step in gestation. It seems that ET, therefore, is not illicit and you should actually rejoice that an embryo is being given its rightful place instead of being condemned to that "absurd fate" of cryopreservation.

INVOcell is a new technology being marketed as "mini-IVF," and it basically replaces the embryology lab with a small plastic capsule carried inside the patient's vagina during a several-day incubation period. This conserves funds used to pay an embryologist, maintain sophisticated lab incubators, and maintain multiple federal standards. INVOcell still involves removal of the egg from the patient or use of a frozen egg, masturbation or sperm donation, fertilization outside the body, and ET. It can still involve PGD and embryo destruction or cryopreservation. Treat INVOcell as you would IVF.

Third party reproduction is use of a gestational carrier or use of donated gametes. As a trainee, there is little to nothing you can do about it, as most couples will come to their REI already with a gestational carrier in mind or will elect to use donated gametes without your counseling. If offered the opportunity to counsel on third party reproduction (especially gestational carriers), offer the patient the complex legal truths surrounding these entities, and recommend they speak to a lawyer, to trusted friends and spiritual leaders, and to seriously consider the possibility of adoption.

Transgender medicine is a misguided effort to alleviate real suffering that individuals feel due to a mismatch between their phenotypic sex and their psychological perception of their gender. Hormonal treatment in these cases, like in cases of fertile women seeking contraception, is manipulation of a healthy organ and not medicine. Surgical transition is mutilation of healthy organs. Do not participate.

Sexual Health

There is a lot of material in treatment of orgasmic disorders that amounts to pornography and masturbation. You may teach a woman the location of her own organs with diagrams and even with a mirror, but be very careful to maintain clinical professionalism and (obviously) always have a chaperone in the room. You may explain the function of these organs and how women experience orgasm (including how they experience it differently). With the magnificent teachings of the theology of the body, reassure women that sex is good, that it is meant to be enjoyed.

You may recommend a patient to psychological or psychiatric services for comorbid disorders. Be careful when recommending her to mental health services simply for her sexual dysfunction, as they may recommend illicit methods to become more comfortable with sexuality. Do not refer her to explicit websites or video series. Do not recommend self-stimulation. Do not recommend experimentation with more than a spouse.

Psychiatry

A relatively prominent problem that has come up since I've started this blog is quality of psychiatry services. Some mental health professionals, especially those who adhere to the whims of the APA, not only have incorrect ideas of sexuality but also have incorrect ideas spirituality and medications. Others are incompetent.

I've seen OB/GYN residents and fellows of all stripes struggle with conflicts with consultants. Bottom line is: if you don't think the provider will offer benefit to your patient, don't consult them. Consult someone else. If there is no one else, use experts available in other venues (online, prior institutions) to answer your clinical question.

Vulvar care

As with sexual health, anything amounting to masturbation should be avoided. In general, the other meds, lubricants, behavioral modifications, and hygiene counseling in vulvar care is licit.

End-of-life (GYN oncology)

Futility of surgery: many, many times residents in my program have operated while not being excited about it, although we're young and maybe don't understand everything. If your conscience moves you to protest a surgery based on a patient's medical fragility, say so and consider escalating it to the ethics committee if you have an appropriate way to do so.

Some oncologists do not give percentages for success for treatment unless a patient asks. Others always deliver expectations. If a patient asks for a percentage of success, always give an evidence-based, up to date number or offer to ask someone for the answer and do not rest until the patient gets an answer or says she doesn't want one after all. If you believe someone is being led to chemo or to hospice out of a wrong idea of percentages of success or failure, ask the attending and ask the patient what their view of the situation is, before wading in.

Ethics committees are great except when they're ineffective or pancretist. When faced with an ethics committee that cannot find the moral truth, many trainees are powerless. It is licit to withdraw your opposition in the face of impossible odds, but it is best to make it clear that you still maintain your position and beliefs.

Hospice is great except when its not. Sadly, since I've started this blog I've realized that not all hospice programs are focused on the patient's autonomy. If hospice personnel at the program that will be covered by the patient's insurance demand code statuses that the patient does not want, or demand POLST or other documents the patient does not want, offer to provide similar services (e.g. narcotic and benzo scripts, DME scripts, megace/nutritional scripts, anticholinergics) through the resident clinic or another venue. Never participate in physician-assisted suicide. Counsel actively against it.

Servant and Doctor

As every July intern (and July upper-level) knows, becoming a physician requires a certain authority, almost a certain hubris. While any leadership role requires poise and prudence, the physician is uniquely in charge. Physicians delegate tasks and they're called "orders." Orders are to be followed, or else the physician is to be called and the orders are to be discussed. Healthcare is team-based and multidisciplinary, but there is still a captain of the ship, and his or her orders are the final word.

It is difficult to maintain an attitude of Christian charity and servanthood while executing this role at work. Worse, I get into habits that make it difficult to be an ordinary person in other settings and to be a receptive soul at prayer. I have noticed that I have to intentionally "switch gears" when I am an ordinary parishioner in the Young Adult group, a cantor at Mass, one of the newest and youngest virgins in the Archdiocese or at the convocation. Even more, I have to be humble when I've been in the wrong in a conflict or when I've been a bad friend and have not kept in touch. I would like to integrate the clinical hubris with the virtue of humility (and common sense) but it seems difficult. Perhaps it will become easier when I'm no longer a trainee, when those in my workplace haven't seen me as an intern who knew nothing. Perhaps it will be easier the more comfortable I am with my scope of practice; perhaps I will have to aggrandize less authority and will simply carry it.

But it seems like a long shot to rely on something spontaneously happening to make it easier. I think I'll have to continue to struggle with changing gears for now, and hope that it becomes easier to drive the stick-shift of my soul through all its settings.

Burnout: There is No Fix

I like the contrast between how resigned Simon
is to this situation, and how resigned Christ is.

I couldn't go to the recent CMA conference, but several friends told me it was great. It focused heavily on burnout, as have the past five or so years. One of my parishioners, a family med resident who attended, reported that the talks were very holy and quoted lots of saints, but finally she didn't feel like there was a real "fix" to burnout.

My experience of the last two CMA conferences I've attended have been similar. Lots of discussion of personal holiness and the sacraments. Lots of discussion of holistic medicine and the importance of relationships and integrity in practice. Lots of discussion of hope, courage, and mercy for times of desolation. Not a lot of easy fixes. And I think that reflects the truth.

There is no easy fix for burnout. There's rest, hobbies, leisure, exercise, healthy eating, meditation, good marriages and friendships, and patience through desolation. None of those are easy. You have to force yourself to make time to rest (and then actually use that time to rest), you have to force yourself to exercise, you have to force yourself to develop relationships, you have to force yourself to pray. There is a lot of violence in pursuing the virtuous life. And, if you believe Augustine (and I do), we never get to the easy part of habitual virtue by ourselves. God's grace makes a way for us to become saints.

There's a small amount of relief whenever you acknowledge an unpleasant truth, be it some personal imperfection or some fact you can't control about the outside world. There is no "fix" for burnout, just the continued pursuit of a virtuous life and patience through desolation.

Quaeritur: Is there an obligation for Catholic medical students to become OB/GYNs?

I was recently asked:

If most OB/GYNs were Catholic already, I would not consider the specialty. I certainly enjoyed my OB rotation, but I also enjoyed other specialiteis just as much. Therefore, why not do a specialty that would allow me to spend more time with my my wife and children? Do you think that a Catholic OB/GYN could help women, marriages, and families in a significantly different way than a standard OB/GYN? Is a Catholic OB/GYN that big of a deal and worth all the extra time, effort, and controversy? Do you think by being a Catholic OB/GYN, I could lead more souls to Heaven? Are these questions too spiritual? Should I be focused more on the medicine, my interest in various specialties, and traditional decision making for most medical students?

"The Dedication" by Edmund Blair Leighton
Img credit: Micione, Wikimedia Commons

These are excellent questions. These are the questions you will be glad you asked yourself when residency makes life tough. I do think that a Catholic OB/GYN is a much better doctor for women and for our country than a standard (contraception-prescribing, napro-not-recommending) OB/GYN. I love to persuade people to become strong, Catholic OB/GYNs. But I would not push you that direction.

Your vocation is the way God made for you to become a saint. Your vocation is that of a husband and father, and this will always come before medicine. Your first responsibility is to the salvation of your soul, followed closely by your wife's and your children's. If you save a hundred souls by being a Catholic OB/GYN but aren't available to your family, what good is that?

Most OB/GYNs aren't Catholic, pro-life, or pro-NFP. It is generous for any Catholic medical student to consider the need for more Catholic OB/GYNs, just like it's generous that young men consider the priesthood even if they end up called to marriage. God is so grateful for your generosity. But the existence of a need does not mean you have to meet it. Your family's needs come first. OB/GYN residency is 75 hours a week, on average, and sometimes you're at work for twelve or twenty days in a row.

This calls for careful discernment and a well-trained spiritual director can help open the doors to God's light.

Quaeritur: Transgender follow-up

Img credit: Bill Barrett, Wikimedia Commons

Some time ago a medical student and I had a great interchange on
care of patients with gender dysphoria. The student followed up some time later with the following email:

I’ve come to the conclusion that nobody can change their gender. ...[O]ur maleness and femaleness are defined by our participation in the ability to create life within the marital act. So, “maleness” shouldn’t be defined as a Y chromosome, male genitalia, or a “male brain” (whatever that means). This means that if a man who has fathered a child suddenly claims that he is actually a woman “on the inside", this is an impossibility. The same would probably apply to all people who are born with functioning and properly developed reproductive organs.

With all that being said, I consider all the proposed treatment options for transgender persons not as actually changing someone’s sex or gender, but providing a coping mechanism for their gender dysphoria, which is a mental illness with a biological component. So, I would probable propose the least irreversible “treatments” first such as maybe wearing clothes typical of the opposite gender, and then if the gender dysphoria does not resolve and their mental health worsens, I would even consider some more drastic, irreversible steps such as hormones and/or gender-reassignment surgery.

I understand that many theologians see the concept of changing one’s gender an impossibility and I agree! However, I think that in some cases, especially for a patient with severe gender dysphoria the more drastic measures could be taken following all other options fail.

I know that many moral theologians have difficulties with this topic, and I understand why! I’m still exploring and keeping an open mind, and I know that if the Church were to propose an answer that definitely concluded that these “treatments” are immoral then I will gladly stand behind her judgement!

I really admire that you're committed to obeying the Church's judgment should she speak in a definitive way on this topic. I wish more Catholics were like that. I'm that way about embryo adoption: I think it's licit, and I'm going against some big names in that. But if the Church were to come out and say that I am wrong, I would accept that.

Women with AIS and related DSD.
Credit: Ksaviano, Wikimedia Commons

I agree with you that gender is not modifiable. It's really interesting how you define it! You define it by a person's ability in the marital act. (Did I read you correctly?) If a person is able to father a child with a woman, he is male. If a person is able to conceive a child with a man, she is female. For some reason I think that's amazing. I struggle to identify exactly what gender is. It's not a phenotype, or a set of traits/likes, or even (I hesitate) a genotype. (AIS, anyone?)

I think we disagree on whether medical and surgical transition therapies are good for men and women. (I'm not sure about dressing differently but I even think complete cross-dressing is not a good treatment.) Dysphoria should be addressed at its root and a man helped to love his masculinity, a woman helped to love her femininity. In the process of helping this love, societal roles should be tossed if necessary and clothing/hair should be evaluated objectively and not with too many cultural attachments. But I don't think dysphoria should be palliated by altering or amputating parts of the body or creating imitations of genitalia. Mutilation is wrong.

Quick Takes as Fellowship Comes Closer

#1

Professionals of all stripes use LinkedIn. Basic science researchers use ResearchGate. Private physicians use Doximity. And, of course, everyone still needs a paper CV or resume. This sets up an obvious problem for the (hopeful) academic physician with a strong community presence. Aware that tl;dr has its own meaning, I affectionately call this resume problem "TLDR." Whenever I have something to put on my CV, it has to go in four places: Text, LinkedIn, Doximity, and ResearchGate. (And I haven't even mentioned the fact that NRMP, the "common app" for residency and fellowship, makes you build yet another CV in its system.)

#2

This month I went to wedding, two conferences, and a strategic planning meeting. One of the conferences overlapped with call, so I flew back through recently-flooded Houston the night before I showed up for a 24-hour shift. I feel like I'm always leaving friends and family behind, never present to them. All in all, I am traveling 4 out of the 5 weekends of this month. (I spent the other weekend TLDRing.)

#3

Hello Internet is a podcast by CGP Grey and Brady Haran. I used to watch a lot of YouTube science, so I knew the creators and listened to a bunch of the podcast while collecting data for a research project. One interesting episode talked about time management across four categories: work, family, health, and friends. Grey made these categories analogous to four lightbulbs, and posed the question of time management in terms of how bright (or dim) each bulb is or should be, given limited wattage for all four. He related personally that his "health" bulb hadn't been on in the early years of starting a successful YouTube channel. As I listened to the podcast, madly collecting data, I felt similar. I, too, am self-employed in a way. I'm in that phase in my career that involves aggressive self-improvement. I'm looking for excellent skills, rare opportunities, good connections, advantageous relationships, and strategic projects. And that "health" bulb is really dim! I'm trying to turn it up a little, but the wattage limit and my chronic ambitious habits are making it really hard.

#4

I'm homesick. When I applied to residency, I had few incentives to stay in my hometown because the public hospital rejected my ethical choices, the good private hospital had residents I didn't want to work with, and I thought the other private hospital was a dead-end career choice. Now I might be able to wedge my way back in, and I'd really like to. I don't like being the stranger at Christmas, that "older sister" who is never present to my siblings' lives. I want to be near my parents and be in the city I know and love. I can't tell how important these feelings are, though. Should I prioritize training in this important stage in my career? Should I go somewhere for the sake of a key mentor or a key set of experiences? And the all-important question: will they take me?

#5

You know the fable of the man who started with a piece of straw and ends up a millionaire? I feel that way sometimes. I started in homeschool and traded up to a good private elementary school. This allowed me to trade up to an academically decent but philosophically terrible private high school. From there, I could have jumped academically higher (and philosophically lower) into college, but instead traded overall "up" to TAC. But TAC is a "straw" in terms of the rest of the world. (All the Thomists may now laugh at TAC being straw.) But I was still able to trade up to get into medical school. From a community program, I traded up again to an academic residency. I wonder whether fellowship will be another trade "up," or whether I've maxed out my potential. 

#6

Can I admit something? It relates to "maxing out potential." There is a barely perceptible but real glass ceiling over me because of my moral choices. I can't go to top places because they don't want someone with my "limits." I am not comfortable putting a list of places I'm blocked from online, because I still have steps left in my training and don't want to close doors. But I have this long-lasting frustration with being inferior. I guess it started at TAC: I felt like I took the moral high road, and my high school classmates who had gone to better colleges were getting into better med schools. Then from my state med school, I felt that again I was getting fewer competitive interviews. In any given city, there's a glass wall between me and the big hospital and the big research projects. It makes me irrationally hungry to go to those places and do that research. There is a lot more funding and networking in those places, and I could do more. Wouldn't it be good if I could do some animals studies to further the possibility of ectopic rescue? Wouldn't it be good if I could study methotrexate more?

#7

I look at the last quick take and part of me thinks: "Networking and funding are fancy words for power and money. Don't look to those things. The Lord doesn't want you to do things independently. He wants you to be His Bride and He will make all the rest possible for you, even if it requires more work and you do not meet with success." There is more purity of heart in this response, I think. Less slavishness to ambition and outward things. More peace. Please pray for me, that I can have this peace and trust in the Lord, rather than anxiety over worldly things that I miss because of adherence to the truth. Please join me in that trust, in whatever opportunity you have in your life.

I will start applying for fellowships in July of 2018. I will start preparing my application around December, when interview season for the entering intern class of 2018 is over. Please pray for me! If there are priests reading, please consider saying a Mass for me.

Why is IVF wrong? (Minor premise and Conclusion)

This post is a defense of the minor premise of a syllogism begun in "Why is IVF wrong? (Question and Minor Premise)." The premise is: All conception must be through sex, and this post takes the syllogism to its conclusion.

I just think blastocysts are lovely.
Img credit: Nina Sesina, Wikimedia Commons

In a way, this is the only premise necessary and the syllogism melts into an enthymeme. The original question was "can we use IVF?" and I reply, "no, sex is the only way we should conceive." The major premise was necessary to establish the fundamental difference between sex and ARTs, but this premise is the key. This is also the trickier premise because it relies on natural law and revelation, two things that our culture (and therefore I) are/am not that great at.

For a foundation, we don't prove that revelation is true, we receive it. We hold it with the same faculty that holds a Euclidean proof, but not because we have a demonstration of it. Rather, we hold revealed truths as gifts because the authority they carry is stronger than demonstration (Summa I.1.8). Our only job when it comes to studying and arguing about revealed truths is to defend parts of revelation based on other parts and show that the conclusions are cohesive and holy (for instance, defeat Arianianism by citing John 1:1,14, 1:30, and 8:58, or to point out that the Incarnation is a suitable medicine for our fallen condition for the reasons Athanasius cites). So I cannot demonstrate that sex is the only way which we can conceive, but I can show it in revelation and show that it is cohesive and holy.

To begin formally: reproduction involves creation and thus is a divine act. New embryos' souls are the only instance we still see of ex nihilo creation of a new substance. Like all creation, it is properly a divine act. It is God's to decide how His act proceeds, and He chooses to share it with us in a certain way. The way he shares it involves sex, so sex is like Him (it's life-giving, exclusive, and faithful as intended) and it's like us (surprisingly animal, but sublime). "Say," you might object, "how do we know that sex is the 'way' He chose? Maybe He just chose sperm egg fusion, in which case IUI and GIFT would be okay. Or maybe He just chose pronuclear fusion, in which case ICSI would be okay. How do you know He didn't choose something less inclusive?"

Img credit: Rugby 471, Wikimedia Commons

Actually, He chose something more inclusive: He chose marriage, including preparatory chastity and intramarital fidelity. We know this from revelation, especially Genesis, the Song of Songs, Mathew, and the letters of St. Paul. The revelation cited above is best expounded in Dignitas Personae, Donum Vitae, section 8 of Persona Humana, and Man and Woman He Created Them (in decreasing order of high- to low-yield as far as time spent reading the entire thing). Persona Humana, Man and Woman He Created Them, and Donum Vitae in particular cite scripture and magisterial authority. So revelation supports the premise.

Moreover, it is also cohesive with the rest of theology. This whole plan is like God: fiercely, uncompromisingly faithful, especially in its faithfulness to children. For this reason, neither marriage nor sex can be intentionally interrupted or replaced by a third party or nonsexual act. Sex looks so ordinary to us but it's on the level of angelic war--it's God's other way of making saints. Cloaked in normalcy, sex is actually a mechanisms of salvation history that is almost beyond our human capacity. This is why the Church seems so preoccupied with sex--it's hard to see what is right and wrong!--and why it seems to say "no" to so much. But this is why divorce, contraception, IVF, and surrogacy are wrong.

The final syllogism is a second-figure Cesare with a slightly complicated predicate in the minor premise.

No ART is a sexual act.

All conception must be through a sexual act.

Therefore, no conception can be through a sexual act.

In addition, remember that there are other big concerns with IVF (embryo construction predisposes to seeing people as products/things rather than persons, embryo destruction, and embryo freezing), but you asked about the act itself, as if it were used in the best possible circumstances: a sacramentally married couple with good intent and who only desire embryos to be made who will be implanted and refuse to destroy embryos (success rates probably less than 40% with those caveats).

Why is IVF wrong? (Major Premise)

Img credit: Mr. J Conaghan, Wikimedia Cmns

Recently a very articulate medical student, with the mind of faith, asked about the Catholic doctrine oHumana Vitae's prohibition of contraceptives. Why can't infertile couples have the procreative aspect of sex using a medical procedure? Isn't this being open to the procreative aspect? The difference in time (if having the procreation through IVF) is not willed by the couple. Isn't this the same or better than leaving one component entirely missing through a failing of nature?
f conception, asking why the Church does not permit artificial reproductive technologies or techniques (ARTs). The student accepted that sex is unitive and procreative and meant for marriage; moreover, the student agreed with

I really love hearing from medical students who are seeking understanding in the mind of faith. As the student pointed out, an infertile or subfertile couple does not disobey God's law by having sex, even though there is a disorder inhibiting the fruits of the procreative aspect. But the reason why the Church teaches that IVF is wrong is that sex is the only act which is legitimately procreative, the only way we are meant to conceive. We can syllogize to this conclusion with two premises. The major premise is that ARTs are not sex.*

Img credit: Cancer Research UK, Wikimedia Commons

Let's establish an analogy between sex and eating. Eating has two aspects, the gustatory (analogous to unitive) and nutritive (analogous to procreative). One is the enjoyment of food that only a rational creature can have, while the other is an important but more biological motivation. Just like infertile or subfertile couples, some people can't taste very well or can't taste at all, but that doesn't make eating wrong for them. I propose an imaginary neck cancer patient who physically has trouble eating and has a tube placed through his skin and into his stomach (a PEG-tube or G-tube). He tastes nothing, but he stops losing weight and he's receiving appropriate nutrition through tube feeds.

I thought it was interesting that the student called ARTs (e.g. IUI or embryo transfer) "procreative acts" in the original question. This is exactly right! These things can lead to babies, so they're procreative acts. But they are not sexual acts: they are professional, medical acts without foreplay, climax, orgasm, etc. Our G-tube patient gets liquids pushed through his tube (a nutritive act), but he's not eating. Medical parlance and common sense reflects this: we won't say "he's eating" until he's using his mouth. G-tube feedings aren't eating; ARTs aren't sex or sexual acts.

Moreover, ARTs cannot be aspects of sexual acts. When our G-tube patient starts a tube feed, he's nourishing himself, but he's not doing "the nutritive aspect of eating." He's not eating at all, and he can't complete aspects of one action while doing a related but separate action. Similarly, if an infertile or subfertile woman has an IUI, she may be procreating, but she's not doing "the procreative aspect of sex." They are separate acts and one's intention to view the acts together do not knit them together. ARTs cannot be viewed as aspects of sexual acts.

The minor premise, "All conceptions must occur through sex," is defended in the next part.

---

*By "sex," I mean heterosexual sex using reproductive organs, not oral or anal intercourse.

Quaeritur: Postpartum LARCs and mental illness

I was recently asked:

I recently looked up your article about encouraging a LARC for a drug addicted patient and your subsequent examination of conscience. I have a 27yo G2P1 bipolar patient with current benzo/meth/etc addiction who's 32 weeks and planning on getting a tubal ligation. I did not disagree with her decision, and was considering the morality of this. Did you ever find a conclusion to this "absurd state" of using contraception for those in addiction or mentally impaired patients (mental retardation, schizophrenia, etc)? Did you find any Catholic discussion regarding this? Humane Vitae and the discussion in Catholic Health Care Ethics book all are geared towards a typical person.

 Okay, let's take this apart. I want to say first that I did not encourage that patient in my blog post down any particular path. I never discussed postpartum family planning with her because we were always trying to ground her in the reality of her pregnancy and in circumstances surrounding her safety. It was only after my attending made a comment about contraception and I went to a St. Louis CMA guild event on LARCs in the mentally handicapped that I started to think about HV's possible limitations. (There's a post about that one, too, which you've probably seen.)

There is no good answer that I can find on this issue. The best that we came to at the guild event was temporary sterilization with filshie clips, but the Church is clear that not even temporary sterilization is acceptable. There are a few sets of articles from the Linacre that touch on it (from most to least relevant):

The articles that overtly deal with contraception in the mentally disabled adult or adolescent:

• Contraception for the Mentally Disabled: A Contraceptive Act? (Napier, 2013)This paper argues that in certain circumstances, a Catholic institution that cares for disabled persons can ensure that some of them conform to a temporary sterilizing intervention. The argument proceeds by observing that the Church permits temporary sterilizing interventions for rape victims, because such interventions are not contraceptive acts, but rather, acts of defense. For similar reasons, some mentally disabled persons cannot consent to sexual intercourse and since rape is defined as unconsensual intercourse, some mentally disabled persons are proper candidates of temporary sterilizing interventions. These interventions do not count as contraceptive acts either. This is the case even if the disabled person in question desires the intercourse. This is so because consent is an intellectual act and desire is a passion. Desire does not entail consent. Although the conclusion reached may look "liberal" or "heretical" the argument shows that it is consistent with firm Church teaching.
• The demands of human dignity: Sexuality in the young person with intellectual disabilities (Fernandes, 2014)The topic of sexuality among the disabled is often ignored within Catholic seminaries; within pediatrics, it is treated as a “problem” where the best solution is contraception or sterilization. In this article, the authors argue for an approach to sexuality in disabled youth that is grounded in the inherent dignity of the person, borne out of Christ's own humanity. Because sexuality is a part of the human person in his or her totality, it cannot be ignored or obscured; on the other hand, it cannot also be the overriding “problem” which defines them. Rather, by friendship, love, and covenantal solidarity with the disabled person, we can begin to set an example for them and for society that there are goods to be strived for beyond the physical. The demands of dignity require practical changes in seminary and medical education and practice.
• Contraceptives for Victims of Rape and for the Mentally Disabled: A Reply to Stephen Napier (Tollefson 2013)In this paper I argue for the following claims. First, contraceptive acts are intrinsically wrong, and not merely always wrong within the marital context. Second, in consequence, the defense of the administration of contraceptives in case of rape must be understood under the rubric of the principle of double effect. Third, the existence or threat of rape is therefore not a sufficient condition for the permissible administration of contraceptives; the intention must be upright. Fourth, in the case as described by Stephen Napier, the intention with which contraceptives would be administered is almost certainly contraceptive; thus this administration would be an instance of an intrinsically evil act. Recognition of why this is so is the key to understanding why, despite a prima facie agreement, as noted by Napier, between his own position and that of Germain Grisez, there is nevertheless a rather deep disagreement. I articulate that disagreement, and indicate why I believe the question has not been fully resolved by Napier's essay.

The use of hormones in sexually active patients

• No Justification for Using IUD to Treat Menorrhagia (Raviele)
• The Mirena® Levonorgestral-Releasing Intrauterine System and Its Application to the Treatment of Menorrhagia: A Moral Opinion (Mulligan)
• Levonorgestrel in cases of rape: How does it work? (Raviele 2014)
• Does levonorgestrel emergency contraceptive have a post-fertilization effect? A review of its mechanism of action (Peck et al, 2016)
• Mechanism of action of levonorgestrel emergency contraception (Kahlenborn et al, 2014)
• Appreciation for analysis of how levonorgestrel works and reservations with the use of meloxicam as emergency contraception (Schneider et al, 2016)

The HIV/condom debate

• “Validity” and “liceity” in conjugal acts: A reply to Stephen Napier on the HIV-condom debate (Arias)
• Condoms and HIV: The State of the Debate (Newton)
• The Missing Premise in the HIV-Condom Debate (Napier)
• Condoms and AIDS: Is the Pope Right or Just "Horrifically Ignorant"? (Wills)

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Question used with permission.

Quaeritur: Care of Transgender Patients (Part 2 of 2)

This post is a continuation of a conversation about Catholic teaching applied to transition for transgender patients. A medical student asked whether gender dysphoria could licitly be relieved with medical and surgical therapies. Following my reply, the student wrote back. I'm going to interject my responses outside of the block-quoted text from the student.

My initial reaction is that I completely agree with your succinct assessment: “The Popes have said that we are born male or female, and that is our gender. Any distress we feel about our gender is a disorder.” My thought is that for the vast majority of us, this is a clear cut statement. For persons with intersex conditions (and I would add transgender as well), they suffer from a disorder.

I’m going to take intersex cases an example before approaching transgender persons: Some of them are born with ambiguous genitalia and chromosomes. Determining their correct gender is a difficult clinical task involving input from the physicians, parents, and children. I’m sure that Pope Benedict would probably agree that due to the brokenness of the human condition, persons are sometimes born with mixed features from both genders. The existence of intersex persons doesn’t disprove or say anything about Catholic teaching regarding sex and gender, it just confirms for us that we live in a fallen world. Another analogy would be that persons are born with down syndrome, schizophrenia, and many other illnesses that impair intellectual capacity. The existence of these persons obviously does not disprove the existence of the “intellect” or the “will” that human beings, as rational animals, possess. These cases are just more examples of the brokenness of the human condition in our fallen world.

I think (hope?) that the above paragraph isn’t particularly controversial. I’m sure that most Catholic theologians would probably agree with my statements.

"Intersex" is a colloquial term, not a medical one. In medicine we refer to people with ambiguous genitalia, and I think that's more helpful in this discussion, because it's only a physical (and pretty external) defect. "Intersex" is a more emotive term that tends to lead the hearer to believe in a spectrum. Since I know that sex is binary, I find it an unhelpful term, much like "gender-fluid" or "bisexual." These terms refer to things that exist (e.g. a woman who has periods in life or even periods during the day in which she feels more like a man, or a man who finds himself attracted to men and women), but the words themselves tend to make us think of reality wrong. Words should help reveal the way things are; doubtless, many people today believe that "intersex" and "bisexual" reveal the way things are, but since we believe that humans are male or female, I would disagree. I don't mean to be picky, but I do want to draw your attention to the use of a term that is non-medical and possibly unhelpful. I agree, however, that persons with ambiguous genitalia do not prove that sex is non-binary.

I’m going to (try) to apply the same principles to some (maybe not all) persons that identify as transgender. My understanding is that the current scientific theory about gender dysphoria is called the “brain sex” theory. Essentially, it confirms what we Catholics have been saying for a while: Sex and gender are deeply ingrained properties of the human experience. They are the result of many neurological and hormonal puzzle pieces that have to fall into place during development. For most people, all the puzzle pieces align and our biological sex and neurological sex are congruent. Most males feel as though they are male, and most females feel as though they are female. However, like most of human development, there are many other environmental factors that come into play. I am sure, as you have pointed out, that for transgender patients, the experiences of "broken early relationships or abuse, self-hatred, misunderstanding of femininity or masculinity) as well as the co-morbid conditions (domestic violence, high risk sexual behaviors, mood disorders, substance abuse, etc)” are all contributing factors into why they experience gender dysphoria. So, my conclusion is that for these people, they really do have a physiological justification for why their body does not feel right for them. They have a mismatch between their neurological sex and their biological sex.

I think this is likely correct, although the lines between neurological and psychological are difficult to pin down.

Now, this doesn’t necessarily justify any of the treatments or therapies I will describe below for this disorder, but I think that it makes an argument for why these persons may have a biological/neurological basis for their gender dysphoria. I have heard some relatively influential Catholic commentators use the term “gnostic” to describe these persons, and I really do think that this could be a mischaracterization of the conditions these persons face.

I don't understand why people use the term "gnostic."

So, moving on to therapies for gender dysphoria. I completely agree with you that these patients probably do need therapy to help them with: "broken early relationships or abuse, self-hatred, misunderstanding of femininity or masculinity) as well as the co-morbid conditions (domestic violence, high risk sexual behaviors, mood disorders, substance abuse, etc)”. However, and I certainly do not consider myself an expert in this vast and complex field, but my understanding is that there is little evidence that these reparative therapies for gender dysphoria actually work. From my understanding, the APA and American Academy of Pediatrics appear to be against using reparative therapies. Now, certainly, there is a political agenda with these groups and they are fallible organizations, but they are the experts in these fields and I haven’t found any convincing studies that would tell me why I should ignore their advice on these matters (if you know any, please shoot them my way!).

Finally, with regards to some of the more “dramatic” and irreversible therapies such as sex reassignment surgery and/or hormone therapy, my initial thought is that they would be similar to a preventative mastectomy/hysterectomy. The intent would be to relieve the patient of their severe mental suffering, and the sterilization would be the secondary effect in this case. I know that my thinking here is not as clear, but I don’t know if I necessarily agree with the comparison to elective abortion. Elective abortion is a grave evil precisely because it destroys a human life, which has infinite human dignity. There has been crystal clear teaching on this issue throughout Church history, beginning with the Didache. However, with regards to persons suffering from gender dysphoria, I sort of see this an attempt to help relieve them in some way of a neurological/biological mismatch that they are experiencing between their physical appearance and inward state. I sort of see it as a last ditch effort which does have proven clinical efficacy. I don’t like the fact that these patients have to mutilate themselves and recreate their bodies according to their “neurological sex", but I haven’t seen any therapies that are more effective.

Now some clarification: I am not a proponent of reparative therapy, which I understand to be largely in reference to people with SSA. SSA is just a desire and is not a sin, and reparative therapy is not the answer that the Catholic church extends. Unfortunately, many other Christian denominations with less philosophical patrimony, don't understand this yet. My hope is that they can, and the strange well-meaning punishment of people with SSA can stop.

If you're extending the concept of reparative therapy to those with gender dysphoria, you might be referring to therapists who don't help them through "transition" to the other sex. These therapists might try to redirect the person to their biologic sex or (dishonestly) promise transition therapies initially and put up walls, never intending to fulfill their promise. Before I go further, is this what you are referring to? I ask because I've never heard anyone refer to refusal-to-transition as reparative therapy.

I guess to put my point bluntly, I am wondering if (some, maybe not all) persons who identify as transgender could be allowed to undergo the sex-reassignment surgery and/or hormone therapy to relieve them of their distress? It seems to be clinically efficacious. I guess all the long emails before that were trying to justify why I reached this point. I know that this is definitely risky, uncharted territory in terms of Church ethics, which is why I was trying to use analogies to persons with ambiguous genitalia and down syndrome. If I am wrong, could you explain to me why? I am not trying to go against the Church’s teaching, and I also want to help these people and do what is best for them.

I and many theologians would bluntly reply that no persons who identify as transgender should be allowed to undergo sex-reassingment surgery or hormone therapy. Very bluntly: these patients' comorbidities should be managed and they should undergo significant psychotherapy for their dysphoria. Like other patients who are deeply uncomfortable with aspects of themselves (DID patients, body dysmorphic disorders), they should be helped to understand who they were created to be.

Here is my explanation for why. Our gender/sex is sacred and is inseparable from our soul. It's part of the way God makes us to be saints. Men and women are irretrievably different in ways we can only clumsily understand. Philosophers have tried and failed many times to identify what category of quality "gender" is. Poets and thinkers have tried to articulate what "masculinity" and "femininity" are but only come up with generalizations and analogies. This is a hard thing to understand! It's no surprise that people think that gender is something we decide on.

The same thing happened with sex and procreation in the 1960s, when Pope Pius VI commissioned faithful Catholics like yourself to research the idea of birth control. The so-called "birth control commission" concluded that our fertility is something we should manage rationally, like we do every other aspect of our lives. There were parts of the physical universe (chemicals/hormones) that we could use as sons of Adam to change our lives. Shouldn't we do this?

It is hard to see the truth: gender, sex, and fertility are sacred ground because they more than anything in the physical universe are signs of who God is and are avenues to make saints. Luckily Pope Pius saw the truth about contraception in 1968. I think you and I are called to see the truth about gender now. It can seem like a big "no," but just like contraception/NFP, it's a strange and important "yes."

Quaeritur: Care of Transgender Patients (Part 1 of 2)

Recently a medical student emailed me a long and well-considered question.

I have a question regarding the care of transgender patients. Before I begin, I just want to say that I consider myself an orthodox, pro-life Catholic who is trying to follow Church teaching on this issue. I am not attempting to undermine Church teaching, and I do not want to be spreading heresy. Also, when I speak about transgender persons, I want to differentiate them from intersex persons (who actually do have ambiguous genitalia).

From what I have been reading about Church statements and Church teaching (from Pope Benedict and Pope Francis), there is a consistent condemnation of “gender theory”. This is something that I completely agree with. There is no such thing as “multiple genders” and those who claim there are are incorrect. During many of my LGBT lectures, they have included slides on how there are many different genders that someone can “define themselves” as. I think that for many people in the Church, this is what the transgender movement represents, and this is why there is such a strong backlash against many of its beliefs and ideas.

However, there are people suffering from gender dysphoria who are caught in the middle of this fight. Reading a lot of the stories of persons who really suffer from gender dysphoria breaks my heart. Many of these persons have co-morbid psychiatric illnesses, and many attempt and/or successfully commit suicide. They face a lot of abuse from family, friends, and sometimes Catholics/Christians. I didn’t provide the links with this email, but my understanding is that the current medical techniques to help some of these transgender patients are very effective for the majority of patients. Most transgender patients who undergo the hormone therapy and/or sex reassignment surgery really do experience psychological relief. I included a link here from a blog of a transgender Catholic who discusses Church teachings on this issue....

**Also, I want to clarify. My understanding is that most children who experience gender dysphoria grow out of it later in life, so if the Church were to approve of certain medical procedures, they would only apply to later in life.**

With all this being said, what do you think our role is as Catholics and healthcare providers for future transgender patients? Do you think it is ethical to help some, maybe not all, patients undergo hormone therapy? What about sex-reassignment surgery? Also, my understanding is that different transgender people cope in different ways. Some of them do not even want any medical interventions and prefer to cross-dress or just identify as the opposite gender, while some do have these interventions and then regret them in the future. The Catholic Church, from what I understand, does not have a clear teaching on this, but we are going to be in the front lines helping patients struggle with gender dysphoria.

This is a very important question. First, I am grateful that you are striving to be faithful to the truth and follow Church teaching. I understand that your questions is about persons who suffer from gender dysphoria (e.g. genetically XX individuals who feel male, or genetically XY individuals who feel female), not people who have physically ambiguous genitalia or people with SSA.

Let's clarify what Pope Benedict meant by "gender theory." In your email you define "gender theory" as the idea that there are multiple genders. (I'll stick with Benedict because he is a philosopher by training and was first among popes to articulate arguments about gender etc.) In his 2012 Christmas address, he used the word "theory" to describe the idea that our gender is not an innate property. The "theory" is that maleness and femaleness are not congenital, but societally or personally determined. I pasted the relevant paragraph from the address below my signature line for you. This means that what the Pope condemned is not only that male and female is binary (he states that this is a "duality" in the Christmas address); he also condemned that maleness and femaleness is something an individual can interpret or assign themselves. It's part of their nature and their nature does not lie. To make it very clear: the popes have said that we are born male or female, and that is our gender. Any distress we feel about our gender is a disorder.

I am not saying (and neither are the popes) that people suffering from gender dysphoria aren't suffering. They are, as you point out, in distress and sometimes constant revulsion, fear, or self-hatred. They do, as you point out, often suffer rejection and abuse from others. And they can experience psychological relief with transgender medical and surgical treatment.

Tell me what you think of this: the fact that someone is suffering and experiences relief after a certain therapy may not mean that the disorder causing the suffering should be treated that way. An easy example is elective abortion: it relieves the enormous distress of the threat to self and lifestyle that a mother-to-be faces, but it is not the right approach to that distress. If not all treatments that result in relief are the right treatments, then trans medicine and surgery may not be right for people with gender dysphoria. Indeed, many believe (as I do) that the right treatment for gender dysphoria is to dig to the root of the dysphoria and treat the cause (broken early relationships or abuse, self-hatred, misunderstanding of femininity or masculinity) as well as the co-morbid conditions (domestic violence, high risk sexual behaviors, mood disorders, substance abuse, etc).

The medical student sent me a response back, which is to follow in the next post.

Third party reproduction

About a year ago, a gestational carrier of twins was admitted to our antepartum wing. Her condition required a long-term stay and she was not in her home state. To make matters more complicated, the presenting twin was not vertex. There was heated disagreement between the intended parents and the gestational carrier about mode of delivery because my attendings recommended a cesarean section for the twins. The carrier did not want a C-section. The physicians' hands were tied: we couldn't do a C-section on a non-consenting woman without committing assault and battery. But the agreement signed (while not designed for this state) did specify that the gestational carrier was to comply with physician recommendations on mode of delivery.

To translate into colloquial terms: about a year ago, a surrogate carrying twins for a gay couple came to our hospital while out of her home state. Because the first twin was not head-down and for a few other reasons, my attendings recommended a C-section for delivery. There was a painful, days-long disagreement between the surrogate and the couple, because the surrogate didn't want to have a surgery. We couldn't do a C-section without the surrogate's consent, but the contract signed by the surrogate and the couple said we should have been able to. ("Surrogate" is not a term preferred by the ASRM or third party reproduction lawyers.)

The ethics committee was, as I recall, rather unhelpful. No member of the healthcare team ever saw the agreement signed between the intended mothers and the gestational carrier. All residents whose names were not already in the chart were encouraged not to open the chart or see the patient out of concern for legal repercussions. The intended mothers of the children became rather forceful, asking that the healthcare team discuss matters with them before discussing them with the patient and lurking around the floor to catch any healthcare providers who might be discussing the case of their children. When it once appeared that the twins might suffer some adverse neurologic outcomes because of the disagreement, one of the mothers stated she did not want the child if there was brain damage.

All of this was a rather unpleasant ethical case that ended as well as it could, since the gestational carrier agreed to a C-section eventually and both babies were born. I have many dissatisfied feelings about the way all five people's lives changed during this pregnancy episode. I began to wonder whether the true nature of things (a contract about goods belonging to the adults) came out in the unpleasantness.

Recently my program has been adding more IVF experience for us. A few months ago I drove out to the IVF clinic of the new professor we'll be working with. As luck would have it, there wasn't much on the schedule and I didn't have to explain much. Although I've written about being "inside IVF" before, this one afternoon included actual experience of ARTs (two IUIs and an embryo transfer). Since I know how these procedures are done, in a way it wasn't earth shattering. But in another way, it was painful. By the end of the morning I felt nauseous and had to talk aloud with the Lord in the car about the experience.

Unfortunately, this isn't the end of this topic. I haven't covered it much on my blog, as I've mostly focused on contraception and sterilization. But now that I'm becoming a third year resident, who will spend two consecutive months on the REI service, it will become a topic of much more discussion.

Residency pre-Fellowship is Different (A Rant)

You know I work an average of 70 hours per week, and you can guess that making time to study is hard. You might not know how much there is to study. And did you also know that I'm expected to go to one conference per year and publish 1.5 peer-reviewed publications per year?

Let's start with the stuff that ACOG puts out. There are 79 Practice Bulletins and 236 Committee Opinions. Those are usually three- to fifteen-page documents, including references and tables. That sounds almost manageable, but then the Guidelines for Women's Health Care is 907 pages long and the Guidelines for Perinatal Care is 599 pages long. There are also seven Task Force documents, only one of which I've even opened (the Hypertension in Pregnancy report, which is a hundred pages long). Te Linde's is 1300 pages, Gabbe's is 1200, as is Creasy's. And then there are landmark papers that we are supposed to know.

Our program recently started giving us "homework" because our CREOG scores went down. I do not think this is the right answer for me. The answer is no more wasted lecture time, let me privately study and read. Don't give me extra materials, let me work through what I'm responsible for first.

And I'm also supposed to study obstetrics and gynecology while researching and furthering the field. This seems stupid in several ways, and I suppose the old way of doing it was that attendings did research and used medical students and residents as peons so that they could learn how to do it. I can't memorize study designs and statistical tests while also trying to memorize pelvic anatomy! In fellowship you have to do your own statistics and are usually responsible for higher-level study types (e.g. randomized controlled trials, bench science, etc), but you get a year without clinical responsibilities to do it. This week I clocked 70 hours and I presented a poster and submitted a manuscript.

Time spent researching is time not spent studying. Time spent reading a practice bulletin is time not spent reading a textbook (viewed by my program as better). Time spent reading a textbook is time not spent praying. This truth goes on and on for cleaning the house, sleeping, cooking, exercising, and recreating.

Recently I had a mentor meeting and we talked about the juggling act. "Residency is a different animal for you, compared to your peers who don't want to do fellowship," she said. "It's a fundamentally different thing." In my opinion it's fundamentally crazy. </rant>

Cholera isn't the Plague

There is a scene in the Italian movie about St. Guiseppe Moscati that gives a good image for the Catholic bioethicist.

We know that St. Guiseppe had a role in addressing the 1911 cholera epidemic in Naples. His research prompted him to make public health recommendations to prevent its spread. In the movie, this is summarized dramatically in one scene. The saint finds city officials burning the furniture and belongings of cholera victims in order to stop the spread of disease.

St. Guiseppe commands that they stop, insisting that cholera isn't the same as the plague. (Cholera is spread by fecal-oral transmission, and is therefore much less contagious than diseases droplet or airborne vectors.) The solution to the cholera epidemic was hygiene and effective plumbing, not quarantine and destruction.

I think of this scene when I am considering bioethical issues. Many theology teachers cautioned me never to think about practical ethics in terms of what I could get away with. Others reminded me not to conclude that we should stay far away from anything possibly problematic. The first approach is irresponsible; the second, Pharisaical.

I try to take St. Giuseppe's approach. His research into the true nature of things permitted him to see what he and others ought to do. That way, he could place legitimate restrictions on people while also freeing them from unnecessary burdens.

I post these when I put something through peer review, partially to celebrate but partially to explain why the current blog content might not have been as stimulating. Praise God!

A Plea for SSPX

My coworkers are primarily practical atheists. But even most of my Catholic friends find it hard to get all the Catholic culture right. Not everyone can keep FSSP and SSPX straight, or Miles Christi and Regnum Christi separate. I guess I should be glad they have heard of Dominicans. There are few that know about Carmelites.

Honestly, there is a spectrum of knowledge of Catholic gossip. A few of the retired virgins I know seem to be familiar with every bishop, cardinal, church scandal and church document, and they will remark on what each one has said about each other one. Honestly, I don't know what Cardinal Sarah said last Tuesday or that such-and-such did an irregular thing and now has such-and-such canonical status. Not that it's bad to care about these things. The Church is the way to salvation and the mother of souls. Of course Church happenings matter. But I don't keep track of a lot of them.

However, there is something that is near to my heart. I love the extraordinary form. Irreverent and ill-prepared liturgies make me sad and angry. I have had classmates and coworkers in SSPX. So for my part, I would love for SSPX to come back into complete union with the larger Roman Rite. Please, please help the rest of your brethren understand the majesty of the Eucharist. Please spread the patrimony of the ages built into the 1962 Missal. Breathe into us your love for chant, your attentiveness to God, and your awareness of the differences between women and men and children. It's more important than we can comprehend.

Eleven Cents

I am struggling with a frustrating reality: a person hoping to do research to build up the culture of life has to do twice as much work as a person who hopes to do amoral clinical research. Becoming a clinician-scientist is hard enough. They have to see enough patients, do enough surgery (when applicable), and earn enough grant money to make their institution value them. This means they have to stay on top of their clinical game. And like it or not, this usually means they have to choose result- and revenue-generating research topics.

Becoming an academic physician who also builds up the humanity of the unborn or builds up the science behind FABMs is even harder. Those topics don't make money and don't make friends, so these people either can't overtly do this research (i.e. they have to cloak it as MIGS or MFM) or they have to do amoral popular research in parallel. In my limited experience of successful pro-culture-of-life physicians, there is a proportion involved: the more pro-life/pro-family research you do, the more amoral research you do. The more you cloak your pro-life/pro-family research, the less you have to lead two lives to put bread on the table.

This initially made me very frustrated. Why should I have to do twice as much work as other people in order to do the research I care about? In this age of non-discrimination, why should I be effectively treated differently because of my beliefs? Of course, I realize that I'm not alone. I'm sure there are hundreds of MDs and PhDs who have pet topics that are non-fundable because they are too obscure, too unstudied, or not flashy enough to earn grants. But still! This is different. Want to do research that builds up humanity and saves the world? Tough luck.

This makes me think of a story from my childhood. I was at a big family reunion as an early teen. I have a lot of cousins that span almost two decades in age, and we were all at the pool. There was a wading pool for the little cousins and a regular pool for the "big kids." Most of the kids who could swim were in the big kid pool. Then the reunion held an event: all the adults tossed coins into the pool and the kids could keep any that they picked up.

The competition in the "big kid" pool was fierce! I was bumping into people and the coins I was diving for would get picked up by someone else. I think I ended up with a penny and two nickels. I was actually pretty pleased with myself.

I was pleased, that is, until I went over to my dad, who was with my younger sister by the wading pool. My younger sister was with the little kids and had collected almost a dollar, just by bending over and picking up coins. She hadn't even gotten her face wet. I was so angry! I worked so hard to get eleven cents and my younger sister, who had no appreciation for money anyway, had easily collected almost ten times what I got! And I hadn't even realized that the wading pool was an option. My pleasure turned into hurt.

My dad took the chance to teach me something I have thought about several times since then. "There will always be people who get eleven cents with lots of work and people who get dollars without doing much," he said. Later in life, he would add, "We're called to be faithful, not successful." So I'll try to apply this attitude to work. I will do what I can to pursue my calling faithfully.

Stories from Vacation: Bedbugs

I have encountered bedbugs before. But I have never encountered bedbugs in my next door neighbor's apartment. My next door neighbor is a retired policeman my grandfather's age. When I first moved in he gave me a new microwave oven, a re-gift he didn't need. I picked it up and as I was leaving with it, I noticed a semi-automatic rifle mounted on the back of the front door. "That's in case some guy I sent to prison comes knocking," he said.

"Ah," I replied, not sure what else to say. Was my neighbor paranoid?

"No, I mean it," my neighbor said. "There one particular guy who sent me letters and called me telling me he's coming for me now that he's out of prison."

"Sir, do you tell all your neighbors these things?"

"Well, I guess not," he mumbled. "Well anyway, I'm pretty sure it's not gonna happen but it'd be a good story if it did."

Img credit: houstondwiPhotos mp

My neighbor was full of stories. "My step-son," he'd grumble, "was a disaster as a kid. He'd get drunk and get into fights and do drugs. I was always afraid that me and my wife were gonna get the call that he was dead. One time--" he started to laugh, "one time he called me, you know, once there were cell phones. He called me from the bathroom of a bar and said, 'Dad, come get me. I'm in this stall and the whole rest of the bar is out there ready to kill me.' I was in favor of him getting in trouble. His mom wanted me to go get him. She said 'He'll be arrested, and then he'll have a record.' And that gave me an idea. So I said, 'All right, son.' I got on my uniform and got my gun and a pair of handcuffs and went to the bar. Sure enough, there was a riled-up crowd shouting for him to come out and trying to bang in the door. Poor bouncers. I moved through them and banged a little myself. I shouted, 'You're under arrest!' And I put handcuffs on him, the works. We left and I took 'em off in the car and we went home. I hung up my uniform and he went to bed. Everyone was happy."

I thought my neighbor was hilarious. I would bake bread for him occasionally and I took him to Mass once or twice. He gave me a tablecloth and an end table, and he made mechanic recommendations. We'd see each other as I went to and from work and make small talk. I knew that he helped the others, too.

Then I learned he'd been diagnosed with cancer, but couldn't be debulked because of his coronary artery disease. He had a combined triple CABG and cancer surgery. He came home in a wheelchair with an incision as long as my arm. Home health visited three times a day. I went to see him and found out that he had bedbugs. First, he told me the fact. "Thanks for comin' over," he said. "Don't mind the exterminator who'll be here in a bit."

"You're brave," commented his step-son, who dropped in to bring groceries in the middle of my visit. "When I visit him, I sit on a wood chair."

I soon learned why. I flicked away no fewer than five bugs of at least two different species (or different life cycle stages?) while I was sitting on his living room couch. It was tricky to be cordial and let him decide when the visit was over! He was clearly bored and wanted some company, and my visit lasted three hours. As I walked to my door when I finished, I vowed that I was going to wash every thread I wore with steaming water and dry it on super hot. As I was taking off my hoodie, I saw and crushed a blood-filled bug.

Img credit hiroo yamagata

Luckily, after that there were no signs of bedbugs in my apartment. Then a few days later, I noticed that the hand sanitizer at our secondary hospital really bothered my hands. I was itching like crazy. As I was driving home, I realized it wasn't the hand sanitizer. I had several discrete red bumps on my hands. "Oh good, it's just bug bites," I thought, "I can still use the sanitiz--OH NO. I HAVE BEDBUGS." I immediately called my apartment manager and he sent a home debugging bottle, complete with personal spray wand for the tough-to-reach spots.

I don't think I ever had bedbugs, though.  I got those bites just sitting with my neighbor. Happily, he's now bedbug free, too. Please pray for him as he recovers. Pray especially for his return to Christ and his conversion.

Baptizing Daughters (Hope for Heather)

I waited a long time to tell this story because I didn't want to change many details. What follows is an accurate but anonymized version of my two encounters with "Heather."

The other day I was in clinic and a young teenager (think junior high or early high school) came in for her new OB visit. She was there with her "mother," but the mother was probably fifty years older than the patient, and she was of a different race. I don't know why that was--perhaps this was a grandmother or a foster-mother--but I didn't ask. This is how I met "Heather" and her mom.

Heather was in her late first trimester and pregnant with twins. When I saw her in our MFM clinic, she had just had been told from an ultrasound that she had two daughters and that they were monochorionic/diamniotic, meaning that they were at risk for twin-to-twin transfusion syndrome. They were at risk for a lot else, but TTTS is what most of our initial conversation was about. Heather had not planned this pregnancy and she had thought about abortion, but her mom talked her out of it. Heather herself really wanted the babies now. Her boyfriend was not in the picture. Heather told me in the presence of her mom that she had experimented with cocaine. But she was obviously tough. She had accepted the fact that she would be pregnant at school and finish a year late. She was clear on her new policy about drugs and sex: "One giant nope." This made me hopeful for her.

Heather's mom was suffering, but it was almost imperceptible. She was clearly not the type that engaged in drugs or sex at such a young age. Her hair was grey, she was plump, she wore grandma shoes and pastel pants, and she had perfect grammar. (In fact, she was eerily like one of my apartment neighbors, who is a nun.) I could tell that Heather's mom was working hard to accept Heather and her choices, but that those choices were very far from what she wanted for her daughter. She was never openly disappointed with Heather during our visit, and asked many helpful questions to support her daughter during the beginning of pregnancy. This made me even more hopeful for Heather.

I tried to cover basic obstetrics and adjusted it for an adolescent, mentioning by requirement that Heather was legally the one to make the decisions about her pregnancy, any birth control, and her daughters' care. I closed my visit with Heather cordially, planning ahead for six months of careful TTTS screening in addition to routine prenatal care. Our MFM clinic is not a continuity clinic (super bummer), so I did not expect to see her again.

A few weeks later, I was working labor and delivery and the upper level resident was in a C-section with the L&D intern. I was sitting at the L&D desk in her stead. The details of this next part of the story are fuzzy because there were about eight phone calls/conversations about how Heather should come to L&D and how she was asking for me by name.

The charge nurse called me over and simultaneously, my zone phone rang. On the phone was the triage intern. "The ER is sending up are seventeen-week twins, apparently super uncomfortable." The charge nurse, meanwhile, wanted to ask me whether the seventeen-week twins in the ER should come right to L&D. I said to start them in triage. Then the triage RN called the charge nurse and asked that I come to triage. The charge nurse was in the middle of asking me to go over, explaining that they knew me by name, when the intern called me again. "I'm sending this seventeen-weeker over, she's five centimeters. She's also...asking for you?"

Readers probably know that a woman in labor near term has to dilate to 10 centimeters. You might not know that tinier babies don't need 10 centimeters of dilation. Seventeen week twins would certainly and easily fall out of a five centimeter cervix.

Heather was given the room next to the statue of Mary. Mary is at the end of the L&D hall and those rooms are the quietest and frequently used for women losing children.

Heather was having a very difficult time due to pain. She also didn't know what labor at seventeen weeks meant! She had texted friends to come visit her because she was having her babies. They were all excited. She asked to get some pain medicine before they arrived.

When I heard this, I started her pain control and then explained to her that her daughters would die today after they were born, unless they had already died in her womb. She was in shock and this did not appear to faze her, but she at least registered it. Now she was on emotional overload, with confusion, mixed sadness and relief (now she would be able to finish high school without maternity leave).

I prayed that her daughters could be born alive for baptism. I delivered her first daughter alive. I asked her if she would like the baby to be baptized before she died. "I don't know," she said, "I've been thinking about that. But my mom's Catholic, and she wanted it."

I knew this little daughter had very little time on earth, but I also knew about the validity of sacramental baptism. "Heather, this is your daughter. You must ask for baptism."

After a small pause, Heather said, "all right then. Can we baptize her?"

The nurse had called the chaplain, but sometimes they take forever to come. They don't realize the urgency of the matter and come after reviewing the mother's chart. Often, I think they don't see the difference between baptism and blessing the baby's body. Frequently, they see their job as more of a crisis emotional counselor. So I called for sterile water (and yes, I did say the word "stat").

I asked Heather what the little girl's name was. She had already picked out first and middle names for both daughters. The nurse handed me a bottle of sterile water. I poured a little water into the bottle cap, mentally making sure I knew the words to say for a conditional baptism, in the case that the baby showed no signs of life by the time I turned around. I touched the baby and noticed that she recoiled, so I baptized her with the formula for living people. Shortly thereafter, the second daughter was born, and I baptized her as well. (Between baptisms, Heather's high school friends came to visit and I sent them packing to the waiting room.)

The chaplain arrived after everything was over. I pronounced Heather's daughters dead that day and filled out two birth certificates and two death certificates. But I know there were two saints praying for their young mother. I prayed to them immediately after their deaths, and I still pray to them every once in a while. I have not seen or heard from Heather since I discharged her postpartum day two. But in a tiny way, these are my spiritual daughters, so I talk with them to keep in touch with their other mother.

There are two saints praying for Heather. Strangely, I am very hopeful for her now.