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.

Why didn't MM's author fight censorship?

CC Andrela Bohner

As I've described before, Medical Matins was a private blog from December 20, 2017 to February 29, 2020, to fulfill a requirement from my graduate medical education department after my blog was discovered and I went through an administrative process which examined the blog content.

My first reaction was deep shame. I have been conditioned over several decades to please others, and to be disciplined was very difficult. This was also my first reaction when I was called into the office in medical school for bringing a fetal model to a lecture containing material on elective abortion.

My second was confusion. What was going on? Was I really in the wrong, or was this about the truth of my opinions on issues like marriage, transitioning, and contraception? When it was over, I felt outrage. I was censored because of the nature of the blog and what I wrote about. (It is my firm impression that had I held the opposite opinions, I would not have been censored.)

Good came from this, and even during the process I could appreciate it. First, I learned to care a little less about pleasing people. If I have something true to say, I should not be ashamed when people are upset. Second, in a safe space with few or no long-term consequences, I went through my career's first little trial for the truth. Third, I encountered persons who I realized need a great deal of prayer and sacrifice, and I believe it is my duty to pray and sacrifice for these people in particular.

However, I felt that the end result (censorship) was not acceptable in a university environment. I know secondary education's lost its soul, but if the university is not the setting for professional, intellectual exchange, what is? I began to go through channels so that the institution would have some intellectual honesty about the importance of different opinions on issues.

Then, I abruptly stopped, and today I want to write about why. 

Shortly after the blog issue was concluded, a patient was admitted for excision of a cesarean scar ectopic. I was on night float, and at first I heard with trepidation that there was CSP admitted because I feared that there would be an ethical mis-step. However, the surgical plan sounded like it would meet the ERDs' definition of an "indirect abortion" and satisfy the principle of double effect. Relieved that I would not have to get involved, I waited for the scheduled procedure a few days later. Then, a few evenings later, the day team announced that the surgical plan had changed. The new plan involved fetal dismemberment. Aware of the culture that anyone can "stop the line," (link if that one is broken) I nevertheless had to think what I could do to help while I was working at night and going home in the morning. I emailed the director of the Ethics Committee, just to notify him of the change in the surgical plan. 

I came back that evening to anger. The other residents perceived that I had been judgmental, holier-than-thou, obstructive, shifty, and simply wrong. I was corrected by one of the residents in front of everyone at evening hand-off. 

Ultrasound appearance of a uterus after a C-section,
with scar between the yellow arrows.
CC License. Wikimedia Commons.

As in other situations, my first reaction was shame. I was basically silent, although (since no one on my night team knew I'd done this) I did have to offer a half-sentence in explanation to them, which I had not planned to do and certainly not in that setting. Later, I formally apologized to a few attendings and the residents involved. There followed a very uncomfortable month when I felt highly disliked. Stray comments praising BTLs and LARCs and disparaging the ERDs (ordinary fare otherwise) felt sharper.

In this milieu, I felt that just finishing residency without being hated would be great, so I stopped seeking further attention regarding the blog censorship. As of this writing (which occurred originally in March 2018), I just hope to quietly finish residency with no more moral discussion.

Good things came from this CSP episode, too. I had a fruitful conversation with the Ethics Committee meeting that month (which I could only attend because I was on nights and I was off-duty at that hour), and recommended an article on CSPs that I think makes a stab at the truth. And the Ethics Committee saw that there were some communication, personality, and practice concerns surrounding the issue, and my "stop the line" email was not the most concerning aspect of the case. It is a relief that at the end of these two episodes, at least some dialogue occurred. 

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.

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.

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.

A Licit Device to Prevent Pregnancy?

Credit: eglisetraditionaliste.org

Every few years the story about the "nuns in the Congo" that a pope (usually it's Bl. Pope Paul VI) said could take birth control resurfaces. Inevitably there are debunkers and rebunkers. It's very hard to find original documentation on this question, even in the age of the internet, because it was apparently all internal memos from theologians.

The story causes lots of confusion, but probably shouldn't because A) there was more estrogen in pills back then, so they probably were all truly anti-ovulant, B) it wasn't known that pills could even be contra-gestive or abortifacient, and C) emergency contraception (i.e. anti-ovulation or anti-fertilization in nonconsensual intercourse) is even now viewed as legitimate in Church teaching.

Nevertheless, every time the story arises, I think to myself: what sort of intervention could be licit in such a situation?

The problem is this: I need effective pregnancy prevention without post-fertilization effects. An ideal intervention would be anything that prevented fertilization only, such as something that inhibited cervical fructose production, capacitation, or the acrosome reaction. Of questionable permissibility would be something to inhibit the zona reaction (preventing the thick rind of chemicals around the egg from hardening), which would allow polyspermy and lead to a nonviable embryo. If life begins at sperm-egg fusion (which I find compelling) then allowing polyspermy would allow some viable embryos to become nonviable due to increased chromosome content.

But none of that technology exists. Just considering existing technologies, the most effective preventative devices are hormonal, but the only licit ones are barriers, and those mostly rely on male cooperation (or don't prevent STDs, like the diaphram). Hormonal strategies are illicit because they have post-fertilization effects. Going back to the doses of estrogen that pills contained in the time of Pope John XXIII is unsafe for women.

What I'm about to say does not come from an ethicist, a Church official, or even someone with a real degree in theology. 

A diaphragm. Just for clarity: the Catholic Churchis very clear that barrier contraceptives like
diaphragms are gravely sinful in marriage.

So, I guessed, maybe I need a barrier with hormonal-but-not post-fertilization effects. Maybe (this sounds really uncomfortable but hang on) a diaphgram plus or minus a cervical extension designed to go to (but not past) the endocervical os. The device could have a very, very low concentration of  levonorgestrel in it, so low that it had only autocrine effects on the cervical crypts only, and not on endometrial tissue or ovaries. Perhaps levonorgestrel would have too long a half life, and we'd have to synthesize a shorter-acting progesterone or one that had a long half life in an inactive form, then a short half life in an active form.

The result would probably be a ton of mechanical cervicitis. But (maybe) no postfertilization effects and effective pregnancy prevention. You could decrease the rate of cervicitis by using it only during your fertile window. (And maybe the diaphragm part of it could include a BBT thermometer component so that the device itself could tell you when to take it out, or an app connected to the device.)

But is this a good thing? Is it a crutch that would just act like another LARC, or would it help women (especially those who learned to chart so that they could use it only 5-10 days a month)? Would it drive us even deeper into the culture of death by helping people in absurd states (e.g. these women and this woman), or would it help lift us out, until we're more ready for the ideal of everyone-married-and-using-NFP?

And where do I go now? The patent office, or the confessional?

Blogging = Self-Publishing (It Doesn't Count)

I like to think about bioethics, theology, and the philosophy of medicine. I like to write about them on this blog. But I realized a few months ago that burying my essays in a blog is no good. I'm not saying this blog is a waste of time. It's a useful outlet for a verbal processor (me) and a nifty window for a few others to see into the life of a resident. It's also been a tiny hub for OB/GYN residents and students who want to practice according to their consciences.

Having come to this conclusion, I will keep sketching out my thoughts here, but I will no longer keep my thoughts limited to this page. This blog is exactly what the subtitle says: it's my experience. It's an open diary. That's why there are stories, schedules, and random cooking and ulcerative colitis posts.

But to be productive, scholastic dialogue has to happen in existing, professional avenues. That means NCBQ, LQ, Obstet Gynecol, and AJOG. And to be useful, advice on conscience has to be more accessible and more generalized. And that means I'm very excited to announce that I'm helping with a new project. It's called Conscience in Residency, and it's a single place for students, residents, PhDs, and even pharmacists to go for practical advice in following their conscience. (It's technically going live tomorrow, so be excited that I gave you first peek.) Apart from telling you I helped in CIR, I won't ever announce a publication, to protect anonymity. Bummer! Publications are major parties. Maybe every time I publish I'll just put up a picture of fireworks, 0-30 randomly-generated days after acceptance or epub or print? Would that be vain?

This also means you'll see disappearance of a few posts that are being rewritten for publication, or have been published. Sorry if the blog gets a little disorganized and links die! (Rest in peace, links.)

The "Safe Harbor" Idea is a Myth

I am going to apply for a fellowship that doesn't involve contraception. Am I running away?

There are several fellowships off generalist practice that could try to circumvent prescription of contraception. One could to MIGS, and only be a women's surgeon (sometimes management of endo could leave you in a tricky spot). One could to gynecologic oncology, and only operate and give chemo on women with cancer (safest bet, but hardest to get). One could do MFM, and only take care of people who are already pregnant (postpartum concerns especially in the heart failure patients becomes tricky). Am I running away by seeking one of these?

I don't think so. I want to do MFM for another reason: my interest in early pregnancy, ectopic rescue, and placentation. I love complex physiology. I love crises and encouraging women through them. I love life and protecting it. I am going into MFM to bolster the research that supports the embryo and the fetus as a person. I'm doing it to be more effective as a pro-life physician.

It bothers me when people assume I'm doing MFM to avoid contraception. At the same time, I can't hide the fact that it's rather convenient that MFM means my scope of practice isn't as restricted.

A few people I've told about this decision are very happy with it and give the response that makes my skin crawl. "Oh, so the contraception think won't be much of an issue. It's like a safe harbor." I hate being called a coward. (It's too close to the truth, anyway.) Besides, I'm not really escaping anything. MFM is soaked with termination and sterilization. What kind of escape is that? In order of most to least protective, it goes Onc > MIGS > MFM. 

I also dislike that Catholics should have to seek a "safe harbor." We should be able to practice in any field. If we have limits, we're like 100% of other physicians, and we are fortunate (?) to live in a country where the things we don't provide can be provided by someone else. I shouldn't have to go hide in internal medicine or surgery (I thought about it!). I should be able to be an OB/GYN. If we all ran away into safe harbors, who would witness to the truth? Who would challenge the paradigm?

Not only the "safe harbor" idea fundamentally flawed, but it's also a myth. There is no safe place to be a physician who trusts his conscience more than he trusts his lawyer and the guidelines of his professional organization. In the coming decades it will be a growing challenge for anyone who wants to do the right thing, whether or not he plans for a safe career.

OB/GYN Ethics 201

In OB/GYN Ethics 101, I covered the basics for medical students and residents rotating through OB/GYN settings, and a little for OB/GYN residents. This post is about three sorts of hard cases: induction of labor before viability, emergency contraception, and methotrexate.

In OB/GYN 101, I wrote:

Do not induce labor for inevitable abortion, i.e. when fetal death has not occurred

It is true that uncomplicated inevitable abortion should be managed expectantly, especially if there is a question in diagnosis. However, there are situations in which labor can be induced because of the principle of double effect.

Previable chorioamnionitis
If a woman develops chorioamnionitis prior to viability (either spontaneously or because of previable PPROM), the principle of double effect permits induction of labor if chorioamnionitis is clearly present and either is too severe or too remote from delivery for antibiotics to preserve the lives of mother and fetus. Richard White explains:

The early induction of labor...satisfies the four conditions of double effect. First, it can be assumed that the intention of both mother and physician is to evacuate the infected chorion and amnion. Second, in light of the serious infection and its threat to the lives of both mother and fetus, treatment is needed to save the life of the mother; that the mother’s life can only be saved by inducing labor is a proportionate reason to perform the procedure. Third, since the early induction of labor does not target the fetus, but the evacuation of the pathological tissues, the death of the fetus is not a means to achieve the health of the mother. And, fourth, there is no alternate procedure to treat the chorioamnionitis with the promptness required by the situation. (1)

Persistent Eclampsia (or Complicated Pre-eclampsia)

In the case of a previable patient whose seizures and severe-range blood pressures do not respond to magnesium and IV antihypertensives, delivery can be expedited by induction. The same can be true of a mother with worsening complications from previable pre-eclampsia (e.g. renal failure or respiratory distress), or evolving HELLP syndrome. White notes:

The act of inducing labor, in this case, appears to satisfy all the conditions of the principle of double effect. First, the act removes the offending placenta, which is the cause of eclampsia. This action is therapeutic for the mother and is, thus, good. Second, the intention of the physician and the mother are, presumably, directed towards the treatment of eclampsia, not towards the termination of the pregnancy. Third, cure of the condition is not achieved by removing the fetus, but by removing the offending placenta. Fourth, the mother’s life is endangered by the complications of eclampsia, which have manifested; the various threats to the mother’s life that the complications pose are proportionate to the induction’s consequences for the child. Fifth, all other methods of treatment that would not result in the death of the fetus (i.e., expectant management) have been exhausted. (1)

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In OB/GYN Ethics 101, I said:

Do not advise the use of any hormonal contraceptive (e.g. mirena) in sexually active patients. Period. This is because of their post-fertilization effects.

It is true that patients should not use hormonal contraceptives because when used throughout the cycle, they will inevitable have post-fertilization effects. But when you, a physician, are in control of when those hormonal contraceptives are used, you can use them licitly to avoid the post-fertilization effects.

Emergency Contraception
Emergency contracpetion (EC) has its own post. But here's quick a rundown:

1. Hormonal pills: can be licit. Remember that hormones to prevent pregnancy are not proscribed except to the married, and self-defense is licit, even defending oneself against the effects of an act, such as advancing sperm. A pregnancy test is not enough to exclude the potential post-fertilization effects of emergency contraceptives. The Peoria Protocol lays out how to tell with moral certainty that a woman has not ovulated and that the primary effect of EC is anti-ovulatory. It involves serum progesterone (<1.5 is pre-ovulatory, okay to give EC) and urine LH (negative is pre-ovulatory, okay to give EC). Notice I didn't give units. Do not use cutoffs a blog post to determine management of patients requesting EC. You need a working relationship with your hospital lab and you need to be better acquainted with the Protocol's other reference ranges for progesterone before you can use it.


2. Hormonal IUDs: insertion of a mirena or skyla as EC relies not only on the anti-ovulatory effects of the levonorgestrel, but also on the intrauterine effects, which act after fertilization. Although it may be argued that application of the Peoria Protocol could allow these effects to be avoided, a systemic hormone (to reach the hypothalamus) is more targeted than an IUD (which would also have to be removed if the patient is later sexually active.


3. Paragard: this relies on post-fertilization effects (which is why it works up to five days after the act of intercourse), and cannot be licitly used.


4. Plan B: is levonorgestrel, given in one 1.5mg dose or two 0.75mg doses twelve hours apart. Strangely, we can't seem to figure out whether its main effect is primarily anti-ovulatory or post-fertilization. A recent (2015) review of all the data in the Linacre (2) concluded that "arguments used to justify use of [Plan B] as a non-abortifacient drug carry substantial weaknesses; in addition, the preovulatory administration of LNG-EC does not consistently alter sperm or ova flow and function, yet there is absence of clinical pregnancy in cases where fertilization is likely, which suggests that abortion is a likely mechanism of action. Therefore, the claim that moral certitude exists via LNG-EC’s nonabortifacient action is currently indefensible."


5. Ella: ulipristal is a selective progesterone receptor modulator. It is given in one 30 mg dose. It antagonizes progesterone at its receptors on the endometrium, which mean it only has post-fertilization effects. This is the same mechanism of action as mifepristone (RU486, which is given in doses of 600mg for elective abortions). Although package inserts deny that it is abortifacient, this indicates that a 30mg dose is not suspected to have post-implantation effects. For a Catholic who understands life to begin at sperm-egg fusion, ulipristal is extremely likely to lead to loss of embryonic life.

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Ectopic Pregnancy
All the above is generally agreed upon. Going forward, I am about to make some people disagree with me. This is because the magisterium has not spoken on this issue and faithful Catholic theologians (who all agree that life should be protected from fertilization to natural end) can legitimately disagree. This disagreement is good and fruitful.

In short: salpingectomy is fine, principle of double effect applies.

Salpingostomy: also fine, principle of double effect applies. (Alert! Not everyone agrees with me, but some of the theologians who thought this was not licit have come to agree. An excellent article by Christopher Kaczor in the Linacre defended this very soundly (3). I am morally certain that this is permissible.)

Methotrexate: has its own post. The same excellent article in the Linacre did not defend this very soundly at all, but I propose a different defense, which takes into account more embryology, more sonography, and more other examples from medicine than I have seen others do.

Like all sinners who want to be faithful Catholics, I submit every word of this post to the judgement of the Church.

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References not linked:

1. Richard White. "Prenatal Complications." The Linacre Quarterly 2009; 76(3), 304-309. DOI: 10.1179/002436309803889098
2. Chris Kahlenborn, Rebecca Peck and Walter B. Severs. "Mechanism of action of levonorgestrel emergency contraception." The Linacre Quarterly 2015; 82(1), 18-33. DOI: 10.1179/2050854914Y.0000000026
3. Christopher Kaczor. "The Ethics of Ectopic Pregnancy: A Critical Reconsideration of Salpingostomy and Methotrexate." The Linacre Quarterly 2009; 76(3), 265-282. DOI: 10.1179/002436309803889106

Methotrexate

I used to think methotrexate (MTX) was an unacceptable way to treat ectopic pregnancy. Like personal heroes William May and Fr. Tad Pacholcyzk, I saw MTX as a direct attack on fetal cells. MTX was akin to (if not identical to) direct medical abortion.

The question I ask today is: is that true?

Background

MTX inhibits DNA synthesis and has (relatively) selective toxicity to rapidly dividing cells. It appears to select trophoblastic tissue (early placenta) rather than fetal tissue. It is administered for ectopic pregnancies to prevent rupture, which occurs in 0.5% of cases.

MTX can only be given if the mother is hemodynamically stable and if she will be able to follow up with serial hCG measurements. It is considered more strongly if the patient desires future fertility or is a poor surgical candidate. She must have an unruptured ectopic with a gestational sac less than 3.5cm in greatest diameter, there must be no cardiac motion, and the hCG should not exceed 5000-6000 mIU/mL. Further, the following must not be present (these are absolute contraindications):

1. Breastfeeding
2. Immunodeficiency
3. Liver disease (including alcoholism)
4. Blood dyscrasias (e.g. thrombocytopenia)
5. Active pulmonary disease
6. Peptic ulcer disease
7. Renal dysfunction

Double Effect
The fetus always dies in current ways to treat ectopic pregnancy. Thus, any treatment other than expectant management must employ the principle of double effect. The principle of double effect can only apply if:

1. The act in question (or the procedure) must be "good" or "neutral" in its moral quality,
2. The good effect is intended, not the bad,
3. The good and bad effects must occur simultaneously, thus avoiding a situation in which the bad effect becomes a means for achieving the good effect, and
4. There should be a proportionate reason, that is, a sufficiently serious reason, to permit the bad effect.

Can the first criterion of the principle of double effect ever apply to methotrexate? The drug is acting directly on a vital organ of the fetus and as such "“a direct and lethal attack on the body of an unborn child" (1). For many years, this has persuaded Catholic theologians that use of methotrexate is illicit, because the "act in question" is not good or neutral.

Christopher Kaczor attempted to defend MTX in 2009, citing some work by Fr. Albert Moraczewski and others (2). He attempts to argue that most administrations of MTX occur after fetal death*, that MTX might be construed as stopping damage to the tube (a secondary effect, at best), that the trophoblast is not a vital organ of the fetus alone (which I find untenable, since its growth is entirely fetus-driven, even though it makes a barrier between mother and child), and that administration of MTX could be considered not "intentional" destruction of the trophoblast (which I find patently false, as that is the sole reason we're giving it).

I don't think Kaczor knocks down the fundamental point: MTX is the destruction of a vital organ of the fetus. I don't think anyone will be able to knock down this point. It's true.

Ectopia and "Diseased"
MTX destroys a vital organ of the innocent human embryo. Strange (and sad) as it may seem, I don't think that poses a problem.

Ablation or resection of vital organs is at times necessary when such organs are diseased. "Diseased" (like "conception") is not a medical term, and it can be difficult for medical professionals to nail down exactly what ethicists had in mind when the word was chosen for moral teaching. I suggest that "diseased" be taken to mean "not according to nature," or not "always or for the most part" (3). 
Trophoblastic tissue, for the most part, implants in the uterine cavity. I suggest that this means it is "diseased." It's not infected or full of cancer, but "diseased" means more than that. In fact, this early placenta is like a tiny failing heart, because it's not implanted in an area designed for it, with the appropriate architecture and blood supply to support it. 

Not all ectopic tissue requires removal. A benign uterine leiomyoma (fibroid) that causes no symptoms should be left alone. But ectopic trophoblast (as in ectopic pregnancy) can pose a danger to the mother. Moreover, ectopic trophoblasts are not the only ectopic tissue that require ablation or removal. Prolactinomas and other endocrinologically active macroadenomas, undescended testes, ectopia lentis**, and arteriovenous malformations are other examples.

Conclusion
Use of methotrexate is legitimate, because the four criteria of the principle of double effect apply. Most importantly, the use of methotrexate itself is morally good (or at least neutral). Although it is removal of a vital organ, it is not a mutilation, as ectopia represents a true disease state when the misplacement threatens human life (in this case, it threatens the fetus with inevitable death, and the mother with possible death or danger).

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Notes
* In addition, some will argue that not all products of conception are fetuses, therefore methotrexate is legitimate for "abnormal" pregnancies, such as those without doubling of beta hCG over 48 hours. This argument is shaky. The minimum rise in beta hCG in a normal pregnancy is 35% over 48 hours (99.9% CI) and 4.6% of patients (n=1,249) with an hCG rise of less than that still went on to have a normal pregnancy (4). Even if this were not true, we must be cautious rather than miss one case of viable pregnancy. When we don't know whether the product of conception is a person, we must assume it is in order to protect human life at all stages.

** Ectopia lentis does not always require vitrectomy or lensectomy.

Bibliography

1. Charles Cavagnaro cited in Anderson MA et al. Ectopic pregnancy and Catholic morality. NCBQ; Spring 2011;667-684. Here.
2. Kaczor C. The ethics of ectopic pregnancy. Linacre Quarterly; August 2009;265-282. Here.
3. Aristotle. Physics II:2. Here.
4. Seeber BE et al. Application of redefined human chorionic gonadotropin curves for the diagnosis of women at risk for ectopic pregnancy. Fertil Steril 2006;86:454–459. Here.