China’s reduction in C-section rates uses questionable means

18 years after they were criticized by the World Health Organization for having among the highest c-section rate in the world, China has made a significant shift. China’s government sprang into action in 2001 after WHO criticized their 46% c-section rate. The National Health and Family Planning Commission made reducing C-section rates a national priority in their 10-year plan.

China’s c-section rates are now growing at a rate slower than their peers– a significant change to make in only one generation.

This chart shows China's C-section rate is growing at 6.1% between 2008 and 2014.  Brazil is 8.6 and Turkey is 10.7.  Egypt is 24.2.
IMAGE CREDIT: BBC

Some of the change is attributed to an investment in maternity care and the rise of “wellness” culture among the Chinese middle class. Other tactics are less benign: the punishment of hospitals by the state. Hospitals with c-section rates higher than other hospitals in their area are issued fines, denied state subsidies, and may even have their hospital licenses revoked. Physicians understandably resist c-sections even in cases where the patient desires one. Doctors in China are allowed to go against the wishes of women and deny them birthing choices.

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While c-sections are major surgeries that come with risks, patient reproductive autonomy is also extremely important. It is vital that campaigns to lower c-section rates remain committed to patient rights.

There are now compulsory natural birth and breastfeeding classes, retraining for physicians to strengthen obstetrics skills and more midwifery training institutes. But the most striking difference in China’s approach compared with the rest of the world is just how strictly hospitals are held accountable for their Caesarean-section rates.


“Hospitals which offer delivery in a region are compared against each other and fines are issued if targets are not met,” said Dr Liangkun Ma, senior obstetrician at Peking Union Medical College Hospital. Other penalties include linking state subsidies with C-section rates and revoking hospital licences. In 2012, hospitals with high C-section rates in Hubei province were told they would be shut down and “reformed”.

The changes in China’s guidelines had taken choice in the childbirth process away from Chinese mothers, said Dr. Carine Ronsmans, co-author of a study published in the British Medical Journal (BMJ) in 2018.”Part of government policy is something quite unique to China and is something we in the West would worry about – that is doctors are allowed to go against the will of the woman. In the legal guidelines, not just the clinical guidelines, doctors are told they can go against the woman’s wishes,” she said.


In one case that dominated local headlines last year, an expectant mother in labour, Ma Rongrong, jumped out of a hospital window to her death after she was refused a C-section. More recently, a man was detained for assaulting a medical professional after his wife was denied a C-section.


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Profiling the genomes of embryos? It (almost) doesn’t matter if it works or not
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Jackie Leach Scully is Professor of Social Ethics and Bioethics, Director of the Policy, Ethics and Life Sciences (PEALS) Research Centre at Newcastle University, UK

Earlier in February Erik Parens, Paul Appelbaum and Wendy Chung commented on some of the recent claims made about the possibilities of human genome editing, including the highly controversial announcement by Chinese scientist He Jiankui in November 2018 that he had ‘edited’ the genomes of two babies. Thinking about a possible future of manipulating complex behavioural traits like intelligence, Parens et al nevertheless argue that “the pathways from genes to intelligence are just too complex…. [f]or the foreseeable future, editing embryos to enhance IQ is a sci-fi fantasy.” But they go on to say that embryo profiling, which puts together thousands of gene variants in a polygenic score that supposedly predicts the chances of an embryo showing various characteristics, “could be done today” for something like IQ.

Over decades, commentators have criticized the too-easy jump we make from every modest advance in genetics and genomic science, to a predicted future of babies made to order. They note the problem of using characteristics as proxies for something else: for example, it might be possible to genetically profile an embryo’s IQ, but it’s still not clear exactly what link there is between that and whatever we define as intelligence (what IQ scores measure most accurately is the ability to do IQ tests). There’s also the long-rumbling debate over whether the various characteristics we might want to manipulate genetically – diseases, severe anomalies, perhaps some behavioural traits – are important for a flourishing life, or a good society.

Often, as with the Parens et al piece, the discussion ends by acknowledging that the real capacities of genomic science are still very limited. In fact the more we know about the thousands of gene variants influencing complex traits like IQ, the less certain it is that profiling for ‘intelligence’ will be easy or simple in practice. Others have already noted there is little evidence that the polygenic score profiling currently being offered for human embryos is much more than a scam.

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But I want to highlight a different aspect of the debate. Even if the technology for genetically selecting humans (whether through profiling or editing) turns out to be impossible or just impractical in real life – if it never affects people’s lives in practice very much – it can still have a profound impact.

I’ve been working in the ethics of genetic selection for around 20 years, and in public engagement with those issues for almost as long. The general public, at least in the UK, seem broadly positive about genomic science, although with reservations around its misuse for eugenic purposes or potential for deepening social divisions. But overall they also generally believe that genomic medicine can actually do much more than is really the case. Most people get their science information from the traditional and social media, which inevitably highlight the ‘science can now do this’ at the top of the article and buries the caveats (the ‘not quite yet’ or ‘only in mice’) somewhere nearer the end. As long ago as the early 2000s, many of the public groups I worked with believed that ‘scientists’, somewhere, could already manipulate human embryos to achieve super intelligence, strength, or obedience. And this shaped the way they deliberated about scientific regulation, and their expectations of the kind of lives science could help us live.

Developments in technologies like genomic medicine can cause significant cultural shifts in thinking, irrespective of whether those developments are put into routine practice. Every time there is media and public discussion about how genomic profiling can and should be used to enhance human health and happiness, we normalize both the technology and possible pathways of its use. The idea that it will eventually be used becomes familiar, and so does the acceptance of human traits as appropriate targets for choice and manipulation – even if, in the end, those traits turn out to be harder to manipulate than had been hoped.

Of course, this isn’t an argument against transparent reporting of genomics and continued public debate. It does mean that the debates should also be aware of the wider context and possible effects. Parens et al highlight for example that traditional task of parents, to balance shaping their children while at the same time accepting their unique dispositions and talents, is under enormous pressure from twenty-first century market forces that in turn are likely to influence parental and societal evaluations of the use of genomic selection. It is essential that our ethical deliberations about genomics include consideration to and challenge of the political and economic setting as well as focusing on the scientists’ or parents’ responsibilities.

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Climate change events worsen HIV epidemic for vulnerable African women
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A recent study in Lesotho showed that climate change events such as severe drought have been linked to increased rates of HIV in women. This raises concerns of environmental justice, as vulnerable populations who are not the top contributors to climate change are being affected first and affected the worst. Further, these populations lack the resources to counter the effects of climate change. Women are disproportionately affected as most already occupy positions of vulnerability related to education, poverty, and social status.

The study also reinforces the scope of the effects of climate change and the still unknown full range of its effects on human behavior. This further highlights the inseparability of bioethics and environmental ethics and the need for climate change policies to address increases in disease that are the result of climate events.

Using data collected as part of the Lesotho Population-Based HIV Impact Assessment (LePHIA), a national HIV survey of 12,887 people conducted in 2016 and 2017, the researchers also found that young women aged 15 to 24 in areas affected by drought were more likely to have earlier first-time sex, transactional sex and were less likely to stay in school. 

Previous research had estimated an 11% higher HIV incidence after periods of rain shortfall had negatively affected income generation across the region resulting in changes to human behaviour. More specifically, women may be less worried about protecting themselves from HIV in times of food insecurity, as they may instead choose to focus on getting food on the table.

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There are other concerns around food insecurity as they relate to antiretroviral adherence, or even drug absorption in the body in times of malnutrition, which can, in turn, lead to increases in community viral load, drug resistance and onward transmission of HIV.

Despite these concerns, climate change policies do not often include any measures to intensify HIV treatment and prevention programmes.

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IJFAB BLOG NEWS: New addition to the Blog Editorial Team

We have excellent news.

For several years, IJFAB Blog has been helmed by Alison Reiheld. She will now be joined by Kimberly Engels.

Professor Reiheld will continue to oversee original contributions and introduce the occasional news story under the Editors tag, in addition to contributing articles under her own content. Professor Engels will be overseeing news articles with special attention to broadening our attention to global issues in bioethics.

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Please welcome our new and improved IJFAB Blog editorial team.

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We Can Help You, But First…: Reports out of DCR indicate ebola vaccine study recruiters are demanding sex in exchange for enrollment
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In the last few days, allegations of terrible ethical violations have hit the news. These primarily concern Congolese women who are being recruited for the Ebola vaccine trials, and who are seeking vaccination under the “compassionate use” exemptions that allow ring vaccination with this not-yet-cleared-for-use vaccine where Ebola epidemics are occurring. For more on where and under what circumstances the vaccine is being made available, see the World Health Organization site, last updated October 2018.

In January, Foreign Policy claimed that Ebola has gotten so bad that “it’s normal,” and warned that cases were popping up in North Kivu that had no clear chain of transmission, making it very hard indeed to stop the spread of the disease. Two days ago, the death toll from the current Ebola outbreak in the DCR was reported to have surpassed 500 dead.

For more on this issue of women being coerced into sex in exchange for Ebola vaccination, see these sources:

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Of note: aid organizations familiar with corruption and the context of the delivery of medical aid in this region are not even surprised. Also of note: the DRC’s Ministry of Health has hit back, claiming the reporting by Holt and Ratcliffe in the Guardian is “shoddy.” Their argument is that the report showed that women and girls were afraid they would be extorted for sex, and were extorted for sex in relation to other health matters, but none explicitly related to Ebola vaccine access. An RT article on this issue noted that the Congolese government did put out “a public call for residents to report anyone offering treatment or vaccination in exchange for money,” but it is not clear whether there was a request for reports of anyone offering treatment of vaccination in exchange for sex.

Research ethics often focuses on coercion which participants are subjected to in order to get them to consent. Here we have a pattern in which people desperately want to participate and are allegedly coerced into providing sex in exchange for access.

We will be watching this issue and bring you updates as the matter shakes out.

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Shifting Perspectives: A Victim-Centered Account of Microaggressions in Medicine, and Beyond
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This guest blog comes to IJFAB from Lauren Freeman and Heather Stewart, and conveys the core of the argument they render in a recent issue of the Kennedy Institute of Ethics Journal.  Freeman is Associate Professor of Philosophy at the University of Louisville and a core member of the MA in Bioethics and Medical Humanities. Stewart is a PhD student at the University of Western Ontario, whose work in medical ethics focuses on delivery of care to members of queer and trans communities. Freeman and Stewart are co-authoring a book called Microaggressions in Medicine.  

‘Microaggression’ is a term that gets thrown around a lot these days, especially on college campuses. The term refers to routine and seemingly insignificant comments or gestures, sometimes intentional, but mostly unintentional, that convey negative messages to targets, who are members of one or more marginalized group.

IMAGE CREDIT: Screenshot from Fusion Comedy, “How Microaggressions Are Like Mosquito Bites.” https://www.youtube.com/watch?v=hDd3bzA7450

Many people, especially those on the receiving end, know that microaggressions are real. In fact, their everyday experiences are often shaped, colored, and constrained by the negative content of microaggressions, even though microaggressive acts are often committed by well-intentioned individuals, sometimes even by their friends, family members, or colleagues.

But there’s also a large number of people who doubt the very existence or seriousness of microaggressions. These critics claim that what we have on our hands is an overly sensitive generation of snowflakes who just need to calm down, grow a spine, and stop taking everything so personally.

Our recently published article in The Kennedy Institute of Ethics Journal (KIEJ), “Microaggressions in Clinical Medicine,” proposes a new way of understanding microaggressions, one that aims to respond to critics who doubt the reality of the phenomenon. Our goal is to convince critics both that microaggressions are real and also that they can cause serious and enduring harm to those on the receiving end. The context of our discussion is medicine, but we think that microaggressions occur most everywhere.

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ACOG response to recent public rhetoric on the New York state abortion law and other discussions of “late abortion”
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As you may know, the US has recently been in the throes of an impassioned debate over abortion. There has recently been a great deal of discussion of New York’s new abortion law, and on Virginia politicians’ claims about late abortion. Some conservative news sources have claimed that these new laws would make it legal to perform an abortion on a laboring woman (one who is giving birth), or have falsely claimed that the NY law would require nurses to label unwanted newborns with a red ribbon around the toe indicating that the baby should be allowed to die. In Trumps’s February 5 State of the Union address, he falsely claimed that the Governor of Virginia states he would execute a baby after birth.

In response to the general tenor of the debate throughout late January, the American College of Obstetricians and Gynecologists (ACOG) has issued an opinion on the importance of having all the facts before arguing these topics. While some media sources have billed this as a response to the February 5 State of the Union address by President Trump, the letter was in fact posted on the ACOG website on February 1.

IJFAB Blog’s Editor thinks these might be useful to our readers. Since the opinion was issued as a PDF, the Editor is presenting the text here as an image as well as in copy-paste for greater accessibility to folks who might be converting text to audio. The following text is identical to the text in the image of the letter, below.

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February 2019

Facts Are Important Abortion: Care Later in Pregnancy is Important to Women’s Health

Facts are very important, especially when it comes to women’s health.

As with all of women’s health, policy related to abortion care, including abortion later in pregnancy, must be based on medical science and facts. Politicians should never interfere in the patient-physician relationship. These are the facts about abortion later in pregnancy.

Abortion after 21 weeks accounts for slightly more than 1 percent of all abortions that occur in the United States.i Abortion later in the second trimester is very rare, and abortion in the third trimester is rarer still, accounting for less than one percent of abortions. The term “late-term abortion” has no medical definition and is not used in a clinical setting or to describe the delivery of abortion care later in pregnancy.

The need for an abortion later in pregnancy could arise for a number of reasons, including fetal anomalies or complications that threaten a woman’s health. Women, in consultation with their physicians, must be able to evaluate all appropriate treatments and make informed choices about what’s best for their health and their pregnancies. Depending on the circumstance, this might include abortion care, induction of labor, or cesarean delivery. Women’s access to accurate, full information and care must never be constrained by politicians.

Many abortions that occur later in pregnancy involve fetal anomalies incompatible with life, such as anencephaly, the absence of the brain and cranium above the base of the skull, or limb-body wall complex, when the organs develop outside of the body cavity. ii In these cases, where death is likely before or shortly after birth, patients may decide whether to continue the pregnancy and deliver a nonviable fetus or have an abortion. In any case, the focus of medically-appropriate, compassionate care must be on the patient and what she feels is best for her health and her family.

Abortion later in pregnancy may also be necessary when complications severely compromise a woman’s health or life, conditions which may also reduce the possibility of fetal survival. These might include premature rupture of membranes and infection, preeclampsia, placental abruption, and placenta accreta. Women in these circumstances may risk extensive blood loss, stroke, and septic shock that could lead to maternal death. Politicians must never require a doctor to wait for a medical condition to worsen and become life-threatening before being able to provide evidence-based care to their patients, including an abortion.

Sound health policy must be based on scientific facts and evidence-based medicine. The best health care is provided free from political interference in the patient-physician relationship.

The American College of Obstetricians and Gynecologists (ACOG) supports robust, factual debate on issues of importance to the American people. We urge you to call on us to provide expert factual information on women’s health issues. For more information, please contact ACOG Government Affairs.

i https://www.guttmacher.org/evidence-you-can-use/later-abortion

ii https://rarediseases.info.nih.gov/diseases/3251/limb-body-wall-complex

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Thinking about abortion beyond “pro-life” and “pro-choice”
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I have been seeing so much about the New York abortion law debate that I feel almost compelled to say a few words about it.

The law states that a physician “may perform an abortion when, according to the practitioner’s reasonable and good faith professional judgment based on the facts of the patient’s case: the patient is within twenty-four weeks from the commencement of pregnancy, or there is an absence of fetal viability, or the abortion is necessary to protect the patient’s life or health.”

I understand that some people may believe the patient’s life is not worth as much as a fetus’ life or that God will work it out the way God sees fit and so on.

I understand that bioethicists can’t always agree on what the word “health” means. It frightens people to realize that physicians may define health in ways that they disagree with sometimes.

But I don’t understand the complete lack of empathy or compassion regarding some of these cases. How can people hate so hard and be comfortable with such sweeping generalizations?

I keep thinking about a family that desperately wanted a baby discovered after a 21-week anatomy scan that their daughter had bilateral multicystic dysplastic kidney disease. The mother writes,

Her kidneys were not functioning, she had no amniotic fluid and her lungs would never develop properly. Three doctors told us our daughter’s condition was 100 percent fatal due to the early onset of her disease. She would either be stillborn or would not survive long after birth. My own risk would increase sevenfold if I continued to carry her.” They made the decision to terminate the pregnancy. They had to wait 72 hours, private insurance wouldn’t pay for the abortion and the government regulations contributed to the deep trauma of this family.

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I think this is sad.

I think that thinking it is sad and trying to not have laws where people are more traumatized is not ridiculous and selfish.

You may disagree with my position but the memes and posts against the law don’t mention these cases, or the restrictions on these laws. This seems profoundly intellectually dishonest to me.

I wish we could stay away from language such as pro-choice or pro-life simply because these are values that most people cherish outside of the abortion debate. Are we really anti life or anti choice if we don’t hold a particular view? How many of you really believe that a large percentage of human beings are truly haters of life? How many of you really believe that a large percentage of human beings hate the concept of freedom and choice?

This doesn’t seem right and the words have so much emotive content that it doesn’t seem this type of language is likely to lead to a richer understanding of the topic.

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Today is International Day of Zero Tolerance for Female Genital Mutilation
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The UN World Health Organization’s Day of Zero Tolerance for Female Genital Mutilation is today, February 6, 2019.

As the WHO says “#FGM violates women’s and girls’ rights. It must stop now.”

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There is space for a more complicated debate on FGM, such as whether it is a good idea to make physicians and nurses mandatory reporters for FGM because this might lead parents who have allowed this to be done to their daughters to prevent them from seeking medical care for this or other issues. Some ethicists have argued that health care providers should perform FGM as it is the lesser of two evils, assuming the patient’s parents will have it done in the traditional way, regardless. WHO disagrees. And their core claim that FGM violates women’s and girls’ rights is exactly on target.

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When Medical Scheduling Software Doesn’t Follow Medical Ethics Guidelines
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Here is yet another example of the constant violations of our privacy rights we now endure in online settings.

I’m scheduling a medical appointment online right now. There’s no mention of patient confidentiality or HIPAA on the scheduling site–but in order to submit the appointment request, I must check a box stating I agree to the Online Scheduling Terms of Use. Clicking the link to see what I must agree too, I read a long EULA-like form. It includes the following language:

You acknowledge and agree that your Submissions are non-confidential and do not contain proprietary information. InQuicker will not be required to treat your Submissions as confidential, and you acknowledge and agree InQuicker may, in connection with its business, use any of the concepts and ideas contained in your Submissions (including without limitation, product or advertising ideas) without compensation to you, and InQuicker will not incur any liability to you as a result of any similarities between concepts and ideas contained in your Submissions and future InQuicker operations and business.

You acknowledge and agree that by posting Submissions to the site, you grant InQuicker a worldwide, perpetual, royalty-free, irrevocable, transferable, and fully sublicensable right, license and permission to use, reproduce, modify, adapt, translate, distribute, publish, create derivative works from and publicly display and perform the Submissions and any Content contained therein throughout the world in any media now known or hereafter created without attribution for the sole purpose of advertising, promoting, marketing or other exploitation or sale of the InQuicker business or services.

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This is standard sort of language for social media, apps and content-hosting platforms, in which the company is basically saying, “You don’t own your posts or content, we do.” It’s exploitative in the usual setting. It’s nonsensical and violative in this context of trying to book a doctor’s appointment, and having to describe one’s symptoms in order to do so. I am forced to agree that InQuicker can keep my medical description forever and publish it, sell it or use it in advertising whenever it likes. That is totally inappropriate, but I can’t schedule the appointment if I don’t agree.

Yet it seems that nobody has stopped InQuicker, a medical appointment scheduling platform, from including this language. It’s hard to see how to even do that. The patient website employing InQuicker has no link or information about how to note issues or concerns with the platform. And the InQuicker corporate website states that patients should speak directly with their providers. It only provides a contact form for prospective business partners seeking to purchase a license to use the InQuicker platform.

We all encounter these situations all the time. It’s maddening. And it’s difficult for the practice of medicine to adhere to medical ethics when it is intertwined with business and IT systems which do not.

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At last, hormonal birth control affecting sperm production is on the horizon
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For decades, feminists and feminist bioethicists in particular have been pointing out that male responsibility for birth control is essentially limited to barrier methods, e.g. condoms, and to withdrawal. While condoms have the advantage of also reducing the transmission of STIs (sexually transmitted infections), there is much to be said about implantable contraceptives which do not need to be remembered daily as well as about daily hormonal measures that people with uteruses can control and use on their own time without affecting sexual encounters. Contraceptives for people with uteruses include not only barrier methods like female condoms but also spermicides, IUDs (intrauterine devices, either plastic saturated with hormones that release over time or copper), the morning after pill, hormone-lease patches that can be put on skin, and hormone-saturated rods implanted in the arm such as norplant.

However, these methods impose burdens that contraceptives for people with penises simply do not impose. There is the mental load of remembering to take oral contraceptives regularly, the physical load of being exposed to exogenous hormones including side effects for cancer as well as bodily changes outside the user’s control, sometimes loss of libido, pain of implantation, and literal costs. These burdens are disproportionately born by people with uteruses, most of whom are cisgender women and some of whom are transgender men.

Because of this unequal, gendered distribution of burdens, feminists have long hoped for hormonal contraceptives for sperm-producing cisgender men and trans women which can share the burdens more evenly.

Folks, it looks like we are almost there. A male (sperm-production-affecting) birth control pill has passed initial testing.

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What remains to be seen is whether men will take advantage of this opportunity, and whether there will be long-term burdens on those who take this pill which are not apparent from the short term safety testing. After all, the negative health effects of oral contraceptives which affect ovulation and implantation were not confirmed until many years after their introduction.

Nonetheless, this is a promising development for people wanting to have sex with reduced risk of pregnancy, who wish to share the burdens more equally with their partners.

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“Bathroom Bioethics” over at the Hastings Center Report
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Over at the Hastings Center blog Bioethics Forum, Charlene Galarneau (who has written for IJFAB Blog, as well) has a few thoughts on how to broaden our understanding of what “Bathroom Bioethics” should mean.

What do many transgender persons, farmworkers, homeless persons, people with disabilities, and many other persons in the United States have in common? One answer: they/we live and work in spaces lacking safe, accessible, and adequate toilet facilities. Think about that for a minute. Think about how you respond–multiple times each day–to your needs to eliminate your body’s wastes. Think about the distress you feel when finding a bathroom becomes difficult – or impossible.

Virtually all humans have toileting needs and these needs vary, as do our bodies in their social-political contexts. Our particular needs vary by gender, age, pregnancy, menstruation, medical condition, and work, as well as by cis-centric, andro-centric, and ableist societal norms that obscure some persons and their needs as well as the caregivers that some need for toileting. Drawing attention to the global inadequacy of toilets, the United Nations has declared November 19, World Toilet Day. This year’s theme is  “When Nature Calls.”

An extraordinary panel on “toilet justice” at the 2017 American Academy of Religion’s annual meeting explored the nature of toilet justice/injustice in refreshingly candid, inclusive, and insightful ways. (Some of what was said there is available here.) I attended this session because three decades ago I, with other public health workers in Colorado, advocated for “field sanitation,” that is, for porta-potties and drinking water in the state’s agricultural fields. Most farmworkers then and many still now work long and hot days in fields without effective access to a toilet, to hand washing, and to safe drinking water. Working with community and migrant health centers, the state Department of Health, and farm labor groups, we testified to the state legislature on a proposed field sanitation bill. I spoke specifically about the bodily needs of female farmworkers and their children, children who were also working or otherwise present in the fields.

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