Weight-loss surgery for teens: a disturbing trend
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Posted on by April 3, 2018
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We bloggers and readers been writing and talking amongst ourselves lately about children, weight, fat shaming, and concerns about policing and medicalizing kids’ bodies. Once you start down this path, it’s really hard to stop. And where does this lead? To increased health and fitness, an end to worries about body appearance and function and social acceptability? Not if you read the studies.

The recent news (and blog posts like this, this, and this) about Weight Watchers targeting children with their new teen diet programs has been a hot topic around here. I wrote here about what I don’t like about diets for children even when they’re informed by extensive research. In short, I don’t like weight loss programs that set up kids with possibly unattainable goals that also may not be necessary for them to live healthy and long lives.

But in the realm of kid weight problem concerns, nothing worries me like the increasing push to use both weight-loss drugs and bariatric surgery on children.

Let me repeat this last part: bariatric surgery on children.

What?

No, really, this is a thing now. Here’s Columbia University’s Center for Metabolic and Weight Loss Surgery’s take on age minimums:

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In case you missed it, ACOG’s guidelines on reproductive sterilization were updated last year
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Posted on by March 23, 2018
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Feminist bioethics is, of course, about more than reproductive ethics. But it is also about reproductive bioethics.  One of the big issues with reproductive bioethics from a feminist perspective is the tension between who is dissuaded from or prevented from accessing sterilization or other forms of contraception, and who is encouraged to use or coerced into accepting sterilization or other forms of contraception.  IJFAB Blog contributor Alison Reiheld has addressed this in the past with respect to some European countries’ policies of mandatory sterilization for transgender people seeking a legal change of gender, and contributor Anna Gotlib has considered coercive sterilization practices in modern US prisons more than once.

In case you missed it, the revisions in April of 2017 to the American College of Obstetrics and Gynecology’s (ACOG) guidance on sterilization procedures for women addressed this tension between preventing some people from getting sterilized and targeting others for sterilization.

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ABSTRACT: Sterilization is the most common method of contraception among married couples, with nearly twice as many couples choosing female partner sterilization over male sterilization. Although sterilization is among the most straightforward surgical procedures an obstetrician–gynecologist performs, it is enormously complex when considered from a historical, sociological, or ethical perspective. Sterilization practices have embodied a problematic tension, in which some women who desired fertility were sterilized without their knowledge or consent, and other women who wanted sterilization to limit their family size lacked access to it. An ethical approach to the provision of sterilization must, therefore, promote access for women who wish to use sterilization as a method of contraception, but at the same time safeguard against coercive or otherwise unjust uses. This Committee Opinion reviews ethical issues related to the sterilization of women and outlines an approach to providing permanent sterilization within a reproductive justice framework that recognizes that all women have a right to pursue and to prevent pregnancy.

For more on this topic elsewhere on the internet, check out the superb documentary No Mas Bebes on the sterilization of latinas without proper informed consent, this 2017 article on the difficulty of accessing sterilization in Canada for young women who do not ever want to become pregnant, and this 2012 article on the same issue in the US. One need only Google “forced sterilization international” to see a raft of articles on the how the issue manifests in Brazil, with the Roma in Europe, and with disabled and HIV+ women around the world.

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Intimacy Without Reciprocity: How Researchers Working With Transgender Humans Can Do Better
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Posted on by March 16, 2018
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Editor’s Note: This blog comes to us from Sayer Johnson, who blogged for IJFAB Blog in the past on the issue of how clinicians respond to trans patients. Here, Mr. Johnson reaches a frustrated breaking point with the way that researchers wanting to work with trans persons behave in the process of recruiting their research participants. The alert reader will note echoes of important research ethics work on community participant research, especially that done with indigenous communities and with other ethnic minorities and with the disability community (“nothing about us without us” is a good slogan for any researcher to keep in mind). This is just as relevant for working with transgender persons. Yet as Mr. Johnson illustrates, the message isn’t getting through, and the lessons research ethics has already learned are not being implemented well and pervasively.

Mr. Sayer Johnson, social worker, Papi and husband, lifelong activist, and co-founder and Executive Director of the Metro Trans Umbrella Group. He worked with MTUG and the University of Missouri St. Louis to create and sustain an annual conference on the needs of the transgender community and has just released a documentary called TransGeek. He is the founder of the Queer Trans Flat, which provides housing in St. Louis for queer trans humans who have had difficulty finding stable housing. He is working to create power for trans persons in the St. Louis area.

Get ready. This is an early morning rant on being inundated with asks for lab rats AKA research participants. Researchers often start by contacting local advocacy organizations like us (the Metro Trans Umbrella Group, or MTUG, which serves trans humans in the St. Louis Metro Area). Fine. But the way it’s done is a big ethical problem.

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New issue is out! And don’t miss the University of Toronto Press Blog based on an article from the new issue of IJFAB
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Posted on by March 7, 2018
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The new issue of IJFAB is out with some spectacular articles on topics ranging from childbirth to epistemic injustice to patient noncompliance to Saudi Arabian bioethics. Scroll down to the bottom for the table of contents!

The UT Press Blog also has a short blog, “When Concepts Function Badly: Distorted Thinking and our Understanding of Combat Trauma” by Mary Catherine McDonald, to whet your appetite for the new issue which I have copied here in full and in italics.

In her wonderful essay, “Philosophical Plumbing” – in which Mary Midgley compares philosophy with, well, plumbing – Midgley writes, “when the concepts that we are living by function badly, they do not usually drop audibly through the ceiling or swamp the kitchen floor. They just quietly distort and obstruct our thinking.” It’s a haunting idea – that conceptual mistakes can be so invisibly insidious and corrosive. When we think about things like oppression, we often focus primarily on the victims of that oppression, as we should. But we also need to pay attention to the fact that oppressive structures do not only impact individuals – they infect our ideas, and by extension everything that is touched by those ideas.

Something that I struggle with when teaching the philosophy of gender is getting my students to understand the ways in which structures designed to oppress women or other minority groups eventually impact all of us. Though women are certainly oppressed by the stereotyping, fragmentation, and objectification of patriarchal society, the damage does not end here. The oppressive structures of power also influence the concepts within that patriarchal society, giving birth to all sorts of other flawed ideas. Because we are still so focused on who is oppressed and who is to blame for that oppression, we miss the way in which gendered norms infect all areas of our lives.

How are the concepts that we are living by functioning badly? And how might we fix them? To continue the plumbing analogy, we first must find the source of the leak. It is in this spirit that I began thinking about the history of combat trauma, and the ways in which our ideas of trauma in general have their roots in pernicious concepts about gender and weakness. If our current classification of PTSD begins with hysteria – a diagnosis deeply rooted in misogyny – how might this impact the way that we understand the phenomenon?

In the paper, I explore the ways in which we have used the oppressive structures at work within our understanding of PTSD to systematically undermine those who suffer from it. To silence them, negate their experience, and prolong their suffering. It’s not the gender of the soldiers at issue here – it is the way that gender informs our understanding of combat trauma. How do conceptions of femininity (in a pejorative sense) and weakness get imported from history into clinical and societal understandings of trauma today? Finally, what might happen when we free our understanding of combat trauma from these insidious concepts? We come to see it as it really is: an adaptive response to an overwhelming experience that is rooted in an impulse to survive, a response borne of strength, not weakness.

Mary Catherine McDonald’s full IJFAB article, “Hysterical Girls: Combat Trauma as a Feminist Issue”, is available open access by clicking on the linked title in this sentence.

You can find the full table of contents for the new issue online here. It has clickable links to the articles. But if you love a good look-see as much as I do, here are the other articles in the issue:

ESSAYS

  • Childbirth is Not an Emergency: Informed Consent in Labor and Delivery by Allison B. Wolf and Sonya Charles
  • Appropriations of Informed Consent: Abortion, Medical Decision Making, and Antiabortion Rhetoric by Heather Lakey
  • Self-Governed Agency: A Feminist Approach to Patient Noncompliance by Ruth Tallman
  • Should Pregnancy Be Considered a (Temporary) Disability? by Devora Shapiro
  • From ‘She Would Say That, Wouldn’t She?” to “Does She Take Sugar?” Epistemic Injustice and Disability by Jackie Leach Scully
  • Beyond Sacredness: Why Saudi Arabian Bioethics Must Be Feminist by Ruaim A. Muaygil

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Click on through to the table of contents in the above link for these essays, reviews of books on sexuality and reproduction and disability, and more.

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Larry Nassar, Sexual Assault by a Physician, and an Army of Women: IJFAB editors’ take from within the MSU community
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Posted on by March 9, 2018
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Written by Robyn Bluhm of MSU with input from, and speaking for, the other MSU-affiliated IJFAB folks: two Editors of the International Journal of Feminist Bioethics (Jamie Nelson and Hilde Lindemann) and the Editor of the IJFAB Blog (Alison Reiheld).

IJFAB is currently hosted at Michigan State University (MSU). Three of the Journal’s editors and the editor of the blog have close connections with the university (one Professor Emerita, two current faculty members, and one Ph.D. alumna). We therefore feel that we should comment on recently disclosed events at the university. Many readers will already be aware that hundreds of children and young women were sexually abused by Larry Nassar, a doctor affiliated with MSU as a faculty member who practiced at MSU’s sports medicine clinic. Nassar used his authority as a physician to molest his patients while telling them that his actions were a medical treatment.

Larry Nassar alone is responsible for his actions. However, the responsibility for the creation of the institutional systems, professional regulations, and social structures that enabled his crimes is widespread. MSU is currently under investigation to determine the extent to which Nassar’s crimes were known by his colleagues and by university administration. There is some evidence that complaints were made about his behavior dating back over 20 years.

A person whose face is not visible holds a sign, which occupies most of the image. Written on it in big black marker is “Nassar Enablers. WE’RE COMING FOR YOU.” A chiron at the bottom says “Hundreds of MSU Students Rally to Support Nassar Abuse Survivors” and bears the logo of a local Detroit, MI TV news station.
IMAGE CREDIT: wxyz.com

Bioethics, frankly, has little to tell us about Nassar’s actions; we don’t need ethical analysis to tell us that what he did was horrible beyond words.  But bioethics, and feminist bioethics in particular, may help us to understand how he was enabled to do so. For example, it has been suggested that

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Objection! Sustained
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Posted on by March 7, 2018
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Editor’s Note: This blog entry by special guest author Dr. M. Sara Rosenthal is part of our miniseries on conscientious objection including the Editor’s introduction and blog entries by Ruth Groenhout, Karey Harwood, and Laura Guidry-Grimes on this subject.

This month, the Trump Administration introduced a mechanism through HHS for healthcare providers to object to performing procedures they find morally distressing or objectionable based on their religion to “ease the way for doctors, nurses or other medical professionals to opt out of providing services that violate their moral or religious beliefs.” For more information see:

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HHS will soon create the Conscience and Religious Freedom Division — an entire division devoted to conscientious objection.  The vast majority of bioethicists find this announcement to be cause for concern because it introduces further barriers to healthcare for many groups already disenfranchised or vulnerable. But it also violates what bioethicists see as clear duties of care inherent in the medical profession. (See: https://www.reuters.com/article/us-usa-healthcare-religion/u-s-government-to-shield-health-workers-under-religious-freedom-idUSKBN1F7262)

I have mixed feelings about this new division, which may become a cautionary tale for the Trump Administration. Moral diversity and “moral objection” swings many directions, and by creating an official conscientious objection division, the Trump Administration must now allow for a wide range of moral protections for practitioners.  In some ways, this could provide unanticipated protections for the very groups the Administration seeks to deride.

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Conscientious Objections, Professional Limitations, and Hard Realities for Hospitals
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Posted on by January 29, 2018
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Editor’s Note: This blog entry is part of our miniseries on conscientious objection including the Editor’s introduction and blog entries by Ruth Groenhout and Karey Harwood on this subject.

The newly formed Conscience and Religious Freedom Division of the Office for Civil Rights in HHS raises a host of questions that should be considered from multiple angles. I want to address this issue as a clinical ethics consultant who has been involved in conscientious objection (CO) policy discussions at multiple hospitals in different locations in the U.S. I have also served on Healthcare Equality Index initiatives and trained hundreds of staff on ethical care for LGBTQ+ patients. Because my experiences are in acute care hospitals, I will not comment directly on the ethically urgent issues that arise in other contexts, such as EMS and fertility clinics.

It is worth noting some important ambiguities and unknowns related to this Division’s role and powers. Based on the Division’s website and their recent press release, the Division will evidently force hospitals to give protections to healthcare professionals (HCPs) who claim CO, which could mean that HCPs cannot be fired for refusing to provide care to certain patients on the basis of conscience or religious conviction. It is unclear how much flexibility hospitals will have in training staff and promising protections for patients. For example, the Division welcomes complaints from HCPs who “feel pressured by employers to ‘perform, accommodate or assist with’ procedures that violate their beliefs.” Depending on what is meant by “pressuring,” hospitals could be tightly restricted in how they train staff on LGBTQ+ patient care, legal abortion care, or potentially other areas of cultural competence. Additionally, hospitals might not be permitted to ask staff to make reasonable referrals inside or outside the institution when they invoke CO, or even train staff on how to make such referrals, since doing so would presumably pressure them to accommodate patient requests.

A hospital should be a safe space for anyone to receive care, period. A hospital should actively take steps to ensure that they are not rendering patients vulnerable or compounding their vulnerability. Continue reading →

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On the common good and medical conscience claims
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Posted on by January 23, 2018
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Editor’s Note: This blog by Associate Professor of Religion Karey Harwood is the second in our miniseries reflecting on the Trump administrations’s support for expanded conscientious objection in medicine. For background readings, see the Editor’s introduction to the series. For another view, see philosopher Ruth Groenhout’s contribution to the miniseries.

The Trump administration’s new Division of Conscience and Religious Freedom in the Department of Health and Human Services aims to protect the rights of health care workers who refuse to do part or all of their jobs based on an alleged conscientious objection.  Such an objection could include anything from a pharmacist who refuses to fill a legal prescription for birth control based on his religious beliefs about artificial contraception to an ambulance driver who refuses to drive a transgender person to the hospital based on… Is anyone prepared to argue seriously that an ambulance driver’s distaste for transgender persons rises to the level of a “conscientious objection”?   Such individual acts of contrarian self-expression, whether they are based on church teachings or mere prejudice, are a breach of the social contract and do not deserve protection.

The Hastings Center puts the matter simply: “Conscientious objection in health care cannot be framed solely as an issue of individual rights or beliefs because it always affects someone else’s health or access to care.”

But in addition to disregarding the real harm conscientious objectors may do to others, framing conscientious objection in terms of individual rights and beliefs obscures the bigger picture: what is owed to the common good.

We see a valley and a river through a small village at the base of a large dam, holding back the river. It has cracks in it. On the damn is written "THE COMMON GOOD."

Art by Frits Ahlefeldt

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The conflict in conscientious objection isn’t what we think it is: how religiously-based objections to providing medical care might undermine Christian faith
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Posted on by January 21, 2018
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Editor’s Note: This is the first entry in our short series of blogs reflecting on the medical conscience policy of the current US President and his Administration. See the Editor’s introduction to this miniseries for more background on both this issue and bioethical considerations of conscience claims.

The Trump administration has just announced that it will form a new division within the Department of Health and Human Services, called the ‘Conscience and Religious Freedom Division”. The new department will be charged with reviewing complaints by medical professionals about institutional failure to protect their freedom to refuse to perform procedures that violate the professional’s conscience.

The formation of the new department does not change the law. Physicians have had the right to choose who they will accept as patients since the 1952 decision in Findlay, and courts have recognized the right of all medical professionals, from physicians to nurses to pharmacists, to refuse to participate in procedures they find morally unacceptable as well. This right is limited—emergency treatment cannot be refused on the basis of conscience, and if a care giver is the only professional available (as when a pharmacist in a rural area has no substitute) and providing treatment is within the normal professional expectations of the job (imagine our pharmacist being asked to dispense birth control), then the professional cannot make it impossible for the client to access the requested treatment, and may be required to dispense it in spite of personal beliefs. But there is already extensive legal protection for conscientious refusal in medicine.

Nor does there seem to be a desperate need for an entire new department to handle cases of this sort—the Washington Post reports that during the entirety of the Obama administration, only ten cases were filed, though there have been 34 already in the first year of Trump’s administration. These numbers hardly seem large enough to justify the formation of an entire new department; forming the department, instead, is seen by many as a gift to religious conservatives, particularly the white Evangelical voters who provide solid support for the Trump administration.

Critics of the new department note that without a corresponding emphasis on the right of patients to equal access to care as well as access to needed treatment under emergency conditions, the emphasis on the right of religious believers to refuse treatment poses a real danger. In a 2011 case, for example, nurses in New Jersey filed a case arguing that they had the right to refuse pre- and post-operative treatment for women undergoing abortions, even when the women required emergency care. Religious conservatives have also claimed a right to refuse care to lesbian couples, transgender individuals, and others who offend their sense of morality. Because there are often limited providers in any particular geographical region, and because it is the provider themselves who decides what offends their conscience in any given case, patients seeking medical care can face serious harms to their health and to their dignity by caregivers who invoke conscience clauses.

This image shows a a book lying on a flat surface. It's spine and cover bear the words "Holy Bible." The black leather cover is worn. On top of the book is a coiled stethoscope of the sort health care providers use to listen to patients' heart and lungs.

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IJFAB Blog series: Responses to the Trump Administration’s policies on medical conscience claims
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Posted on by January 19, 2018
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As you may have heard, the Trump Administration has announced an expanded policy on conscientious objection in medicine, with institutional support in the form of a Department of Health and Human Services office that will be responsible for protecting objectors. It will be called the Division of Conscience and Religious Freedom.

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There are many possible responses to this, ethically speaking. Over the coming week, IJFAB Blog will be running several responses. While these will focus on the US context, this issue is by no means limited to the US. Women in Italy, for instance, have a remarkably difficult time accessing abortion even when it is allowed because providers have such a high rate of refusal, rising from 59% in 2005 to 70% in 2016.

Regardless of where you live or practice medicine or do bioethics, I encourage you to check in regularly to see the array of considerations.

Before we get started, some of you might want to learn a bit more about the current situation and about medical conscience claims AKA conscientious objection.

Here are some links if you want to learn more about the current situation:
And here are just a few links/cites to prior IJFAB, IJFAB Blog, and some useful bioethics work on conscientious objection. Many of these strive to balance respect for conscience claims against the interests or rights of patients. There is so much more out there. But these are a decent place to start.
In addition, Carolyn McLeod has a forthcoming book from Oxford University Press called The Power of Conscientious Objectors that you might want to seek out in the future.
I am excited about the posts we will have in this series. Stay tuned.

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Everything Old Is New Again: Patient Dumping in the United States
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Posted on by January 18, 2018
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A recent, though smaller than deserved, furor erupted in the US over a video of a non-white female patient being dropped off via wheelchair at a bus stop by hospital personnel during freezing temperatures wearing only a hospital gown (you can read more here and here). It was recorded by a mental health professional whose office in Baltimore, Maryland, was across the street and was stunned to see the disoriented woman left alone to fend for herself.

This is part of an old practice known as “patient dumping.” This term dates back at least to a New York Times article from the 1870’s (yes, 1870’s, not 1970’s) which described a practice of hospitals transporting patients by horse-drawn ambulance to Bellevue Hospital, the city’s primary public hospital at the time. These were patients who could not pay for private hospitals or were unprofitably sick (for more on this practice, see Emily Abel’s 2010 article covering patient dumping in New York City from 1877-1917). Such practices have long been a problem in Los Angeles, for a complex array of reasons, and have been documented in other states including Alabama and Nevada.
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Do other nations also experience patient dumping? What factors contribute to patient dumping?  Is patient dumping ever ethically acceptable? If not, how does the system need to change to make it easy to provide care? What can you contribute to the discussion?

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Keisha Ray makes an important analysis of black women’s maternal health disparities in the US
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Posted on by January 16, 2018
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This image accompanied Keisha Ray’s original blog entry at bioethics.net

Over at bioethics.net, bioethicist Keisha Ray addresses the maternal health disparities experienced by black women, in particular. In her blog, “BLACK WOMEN ARE DYING IN DISPROPORTIONATE NUMBERS DURING AND AFTER GIVING BIRTH AND NOT EVEN CELEBRITY SERENA WILLIAMS IS SAFE” Ray gives an overview of a few other health disparities black folks experience in the US including sleeplessness and pain management, and then moves on to maternal health. Ray says,

In my research on racial disparities in health care I have found a troubling trend among bioethicists and that is a reliance on a connection between poverty and lack of education that black people experience to explain their poor health and racial disparities in health care. As the typical argument goes, black people tend to be poorer and have less education than white people and since wealth and level of education are some of the social determinants of health, it is expected that they would experience adverse health issues such as high death rates during pregnancy and child birth.

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This attempt to explain poor black health by focusing on social factors is problematic for many reasons, including it misleadingly contributes to the narrative that all black people are poor and it ignores an increase in black wealth. But more importantly this argument ­relies on assumptions that are not backed by data. For instance, according to a 2016 study that analyzed 5 years worth of data on pregnant women in New York, “college-educated black mothers who gave birth in local hospitals were more likely to suffer complications of pregnancy or childbirth than their white counterparts who never graduated from high school.” This study disproves the traditional narrative in bioethics that education can be equated to better health and better health care. This may be true from some people, but as a general rule it is not true for black people, specifically black women giving birth. Just as more education does not always equal better health and better health care from practitioners for black women giving birth, neither does income. 

Ray goes on to note the widely publicized story of how tennis star Serena Williams, herself, had to be her own health advocate in the face of serious maternal health issues and nearly did not receive the treatment she needed.  As Ray says, “If Williams had a hard time convincing her doctors that she knew her body and knew something was wrong, we can image just how hard it would be for another black woman who does not have the accolades or wealth of Williams to convince a suspicious nurse or doctor.”  But we don’t have to imagine, for Ray goes on to detail several examples. I recommend you click through to the blog article for more.

What narratives drive our ethical reflections on health disparities? When is the narrative of poverty and lack of access to health  care the whole story, and when is it only part of the story? How do narratives shape our responses to ethical issues and, perhaps, lead us astray?

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