Quick Takes

We're still in pandemic times, so here are some quick but fiery opinions.

#1

Whatever you think of external fetal monitoring, the fetal heart rate strips remind me a little of Adoration. The fetuses have be watched constantly, and the culture of OB/GYN labor and delivery teams is to want someone to watch them. If we're going down to get snacks, we think about who is watching while some of us go. If we get distracted by something, we look up and make sure what we just missed looked okay. If the system breaks down and we can't see the strips the way we usually do, we find a way around this to watch the strips. In Adoration, you can't leave the Blessed Sacrament alone. He is vulnerable. You may not be able to see him as usual sometimes, or you may have to leave, but you're solicitous about Him never being alone. When you get distracted from Him, you check right back in.

#2

I recently heard an argument that it is more merciful to do a KCl termination followed by an induction of a dead fetus, rather than to deliver a live fetus and have it painfully gasping for air. "I couldn't bear watching my baby gasp for air," the argument goes. While I empathize with that emotional response, a KCL termination is different in the objective nature of the act--it directly takes the life of the unborn, and we don't know if it's painful or not. A gentle induction which doesn't take that life directly can be followed by perinatal palliative care. Just like for an actively dying adult patient, morphine can be given for air hunger. Even so, it is not clear if extremely preterm babies feel this, but they can feel pain and much of their skin is not keratinized. (The air hunger question is particularly important because that's the emotional hinge of the argument, but fetuses under OB/GYNs' management are constantly experiencing difficulties with acid-base balance and we don't consider this painful.)

#3

Dear Editor,
NaPro technology is a little bit primitive and behind the evidence-based-medicine times. And it sort of likes that. But it's not really ready for prime time in medicine right now, so let's stop pretending that it is. Instead, why don't we work on getting it there?
Sincerely, a Catholic OB/GYN

#4

I took care of a lesbian patient who was overjoyed to tell me about her coming out. I told her I was glad for every step she took closer to real love. This story happened before the blog issues related to LGBT posts. I'm still angry about this misjudgment of me sometimes. (But forgiveness sometimes doesn't take away all the emotions connected to an experience. So I suppose that's okay.)

Discontent with Arguments against Birth Control

Get ready for some ideas that have been stewing in me for some time, but are coming out now as a rather unedited blog post because we're in the middle of a pandemic. As a board eligible obstetrician and gynecologist, I don't like some of the arguments and language used to explain why contraception is wrong. Comments are open, content is subject to the Church's teaching.

"Birth control is a crutch."

I don’t like the arguments made by certain bioethicists that hormonal birth control is a "crutch," and therefore it’s wrong. This is certainly not the only argument they have against birth control. But let’s think about crutches: they’re actually a really useful medical treatment to take a load off of a healing joint. If this is an apt analogy, then birth control is a really useful medical treatment for...something? What do these bioethicists claim we are bridging towards with birth control? I think their position is actually that birth control is intrinsically problematic and it is being used lazily and problematically. But “crutch” is absolutely the wrong word for that. When making analogies about medical things to medical people, at least make your analogies accurate.

The real scenario is actually more like the analogy and less like the intended meaning. In its best form, birth control is a bridge to something better according to gradualism.

"Birth control is bandaid therapy."

Furthermore, I also don’t like the word “bandaid” in these analogies. Birth control as “bandaid” therapy is an oft-used phrase in Catholic gynecology. Rather than solve the PCOS or dysmenorrhea or whatever (so goes the argument), physicians prescribe birth control to “cover it up.” Can we talk about how this is not a good summary of what birth control is doing here? The best example is PCOS. Certainly, we are not solving PCOS at its root cause, but that is because we don’t know its root cause. And NaPro, regardless of how much more natural it is, also doesn’t address the root cause. A sign of this is that medical NaPro has to keep treating and treating and treating its patients with cooperative E and P. (Ovarian wedge resection is the closest thing we have to addressing the root cause, which is part of surgical NaPro.)

But OCPs being used for PCOS do more than just "cover up the problem." They don’t simply hijack, replace, or cover up a woman’s natural cycle. They interrupt the failed cycling that a PCOS patient has, which is much closer to stopping the problem at its source than the "bandaid" argument makes it sound. PCOS is possibly best conceptualized as a failure to move through the menstrual cycle, instead getting stuck somewhere close to the LH surge, which produces the effects of hyperestrogenism and hyperandrogenism due to aromatase (including abnormal hair growth, endometrial hyperplasia, glucose intolerance, and abnormal blood lipid concentrations).

Birth control (unlike cooperative E and P) puts a stop to this arrested cycle at its origin, the hypothalamus, by suppressing secretion of GnRH. It upregulates sex hormone binding globulin (SHBG) which sops up extra estrogen in the blood and eases the effects of hyperestrogenism and hyperandrogenism. It hits a reset button on the CPU of a woman’s cycle: not natural, but sometimes needed for normal operations. It’s not a bandaid, it’s actually a pretty sophisticated cocktail of shelf-stable hormones that work by a clever mechanism of action to stop dangerous effects that PCOS can have on a woman's body.

I will happily admit that birth control as a "bandaid" is a much more apt analogies for conditions like dysmenorrhea, where it may actually mask conditions like endometriosis. But even here, there is a legitimate role for nonspecific medical therapy before surgical treatment in many common conditions, such as anemia of unknown cause or back pain. Why should we belabor gynecologists for wanting to do something that will most likely be helpful, as long as it's not illicit?

"The pill kills."

We really need to stop saying “the pill kills” as an argument against contraception. This holds no intellectual weight with any kind of opposition. All medications have side effects, and many medications have caused death. Many very important medications cause more death than the pill. The doses of estrogen are lower than the doses in the original pills which could be classified as carcinogens.

True, women don’t need these medications the same way they need warfarin or vancomycin or even Tylenol. And true that even small doses of estrogen can, over long periods, affect multiple body systems and we continue to see effects of hormone therapy in women of all ages. But “the pill kills” as a soundbyte-turned-argument is not serving us well. Admit that the pill is actually a pretty clever and pretty safe medication, and then debate whether its small panel of side effects should be taken on for fertility (a good)—you then have a more robust argument without so many holes, and an argument that better resembles the true problem with hormonal birth control.

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.

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.