Conscience For Me But Not For Thee: The Case for Pro-Life Docs and Pharmacists

August 22, 2008

In two recent threads over at Pharyngula, one about a poll and the other about some recent comments from HHS Secretary Mike Leavitt, I’ve gotten myself caught up in some pretty heated exchanges over the issue of pro-life doctors, and their impact on reproductive choice and access to health care.

This controversy has been building for some time, as legislatures and now licensing boards are increasingly confronting the question of whether, and to what degree, the consciences of anti-abortion doctors should be protected. More and more women are startled to find local doctors and pharmacists refusing what they had assumed were basic and perfectly legal prescriptions.

Now, as far as the original issues go, most of the things that anti-abortion docs, pharmacists, and their advocates are currently pushing for are indeed overboard. The idea that a doctor can refuse to refer a patient to another doctor, or refuse to even give them information, is unjustifiable. And if a CVS pharmacy wants to offer the pill to its customers, then it has all the cause in the world to only hire and retain staff that are willing to dispense it. It’s simply not unjust discrimination to fire someone if their conscience prevents them from doing what the employer needs done, and no reasonable (reasonable on the employer’s terms) accommodation can be found.

Unfortunately, many of my pro-choice compatriots have, I think the wrong idea themselves, asserting principles of their own that go far beyond the right of employers to set the conditions of employment. When it comes down to it, it seems that many people believe that doctors who refuse on ethical and/or religious grounds to prescribe birth control pills, pharmacists that refuse to fill such orders, or even, it seems ob/gyns that resist performing elective abortions should either ignore their consciences or essentially leave their chosen professions. But the justifications given for this harsh ultimatum are, I think fatally flawed.

Two principles in particular are, I think twisted or misapplied to this situation: the idea that pro-life doctors are forcing things on their patients, and the idea that pro-life doctors and pharmacists aren’t doing “their job.”

Doctors Have No Right To Force Their Choices on People

As general principle, this idea Is central to most cannons of medical ethics and medical license boards. And justly so. It’s based, first and foremost, on the idea that people of sound mind have an absolute right to accept or refuse medical care, and to pick the treatment plans they are comfortable with under the advice of the physician. It’s based on a laudable ethic of not forcing something on someone without their consent.

The problem is that this ethic seems to fall by the wayside whenever people start considering the views of people they don’t like. Or it gets implausibly twisted, so that the “forcees” are claiming to be the victims. It takes a true mangling of language to assert that someone not doing something for you constitutes forcing you to do anything. But that appears to be precisely what it going on here.

Consider the common assertion that doctors who refuse to prescribe birth control, especially when they practice in far-flung areas and stats that offer little choice in doctors to begin with, are “forcing” their own preachy choices on the patient. But are they?

When a family doctor sets up a shingle in a small town, people’s access to health care improves in real terms. But now suppose that the doctor refuses to prescribe birth control or perform elective abortions. Has the doctor actually “forced” anything on anyone? His or her values? His or her services?

In virtually all routine situations, no. The people in the town are certainly no worse off than they were before the doctor arrived. The doctor’s existence provides some benefits, but perhaps not all the benefits they’d want. Demand that the doctor violate his or her conscience or else find another profession, and you might well end up with no nearby doctor at all. The same goes for a hypothetical “pro-life” pharmacy.

Yes, people in that situation lack access to things they want and need, and are protected by law. But that’s the exact same situation they were in before the anti-abortion/anti-pill doctor set up shop.

So what’s the solution? Well, if we really care about access to birth control, if that’s really something we consider to be a moral value or even an assured, positive right, who has the responsibility to supply it? Does that responsibility fall almost entirely on the doctor who thinks it’s immoral, just because he happens to be the most local? Or does it fall on all the people who think it’s a basic right? If you answered the former, I have to admit that I’m simply flabbergasted.

The situation here is a little like the often confused outrage at “scalpers” who, during a disaster, offer things like water bottles for sale at ridiculously inflated prices. These people are routinely condemned as greedy, and they certainly are. But somehow it never occurs to all these outraged moralists that, if people in a disaster have some sort of positive right to receive water (free or cheaply), that this right cannot possibly be a burden and a responsibility that falls on some people more than others. At least the scalpers are offering water for sale at all. Rarely have any of the outraged people rushed over to offer even a drop of their own water, at any price. If the scalpers are as greedy as their inflated prices, then the moralists shaking their heads are themselves infinitely greedier.

Blaming the scalpers for a lack of available water, or blaming pro-life doctors for lack of available abortion services and birth control, is, in the end, nothing more than crude scapegoating. It takes the focus, rather conveniently I might add, off of the collective failure for which the moralists themselves are implicated.

And the further irony is that the moralists’ proposed solutions often wouldn’t really help anyone overall. Scalping only works when there is an extremely limited water supply: i.e. there’s too little water to go around in the first place. If scalpers simply gave away all their supplies for free, there would still be too little water: in fact, in the end, there would be exactly the same number of people with and without water. All that would be different is the method by which these people would be chosen (and the usual alternative, first come=first serve, is arguably no more “fair” than rationing the supply by price, which at least has some built in mechanism for assessing people’s relative need for the water).

Likewise, if anti-abortion/anti-pill physicians and pharmacies left the business, as their foes seem to suggest they should, there would still be the same shortage of medical care and lack of access to birth control that we started with.

From where I sit, that makes this issue look a heck of a lot more like an act of partisan revenge than a sound policy or pro-patient principle.

If They Don’t Want to Do What (I Say) the Job Entails, They Should Find Another Job!

This second principle, uttered as if it were an obvious truism, is in fact an utterly bizarre essentialism. Obviously, if we are talking about an employer defining what “the job entails” and finding someone wanting, there’s no problem. But this isn’t the sense in which some people mean “the job.” They mean it in a more cosmic sense: turning mere convention into Platonic form.

Who says that the role of being an ob/gyn, a family doc, or a pharmacist must involve prescribing or dispensing contraceptives? What defines that role such that it’s supposedly essential to this or that specialty? Is this some sort of immutable law of the universe? No. To the extent that they are set and regulated at all, the required roles of various professions (and the permitted variations) are set by committee or political process, not fate. And those debates have to deal with the very political and ethical questions we’re already considering.

Thus, asserting that elective birth control must be part of the role of certain doctors is little more than a begged question. If you regard a fetus or even a fertilized embryo to be a being with moral rights, then harming it without dire need would not legitimately be part of the role of any physician. Reject that idea, and it’s a legitimate part of reproductive health and choice. I certainly have my opinions, but I also have a respect for the importance of social pluralism. And we cannot simply presume anyone’s opinion from the get go when determining what medical ethics demand or deny.

A more reasonable question is: can anti-abortion doctors be reasonably accommodated into our medical system with their existence causing serious additional harm to anyone? I think the answer is yes.

My opponents disagree. They imagine Jehovah’s Witnesses as ER docs who then refuse to transfuse blood to car accident victims. But these examples are absurd. No one would hire such a doctor to such a position in the first place, and if one did, it’s unlikely it could be licensed to accept emergency patients (who are often in a very different situation than a person seeking a physician or going to a pharmacy). On the other hand, plenty of people in the United States not only would have no problem with seeing an anti-abortion ob/gyn, but would favor going to one. Is denying the possibility of this choice even in keeping with the respect for autonomy that underlies pro-choice politics in the first place? I think not.

The early pioneers of reproductive choice knew that making it a reality meant actually physically and financially getting doctors and products out to women everywhere. If choice is a positive right and not just a negative one (i.e. not merely something that the government cannot ban, but something that must actively be ensured, presumably by society itself) then it’s going to take a tall order of money, time, and resources to supply it. Butting heads with anti-abortion doctors and pharmacists, or demanding they conform or go out of business, isn’t even remotely the same thing.

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Measles Making a Comeback as Vaccine-Hysteria Builds

July 16, 2008

Measles has already become a resurgent epidemic in England, and now, via Orac, I see that the once nearly-eradicated disease has gained a new foothold in the US as well: 127 cases since this May, springing up in 15 different states. According to the news coverage, that’s the largest spike in cases we’ve seen in a decade.

What gets me is that children in the Third World are literally dying in the hundreds of thousands because of lack of access to vaccines. It’s only here in the states that we even have the luxury to indulge in fact-free scare campaigns against vaccinations. Few people here have any sense of the real cost these sorts of diseases bring with them:

“What you have to remember is that 250,000 children die from this virus every year,” Alvarez added. “So, vaccinations have to be a priority for parents because at the end of the day if you get measles, you can live through it, but in some particular cases you’re going to have complications.”

About one in five measles sufferers experiences more severe illness, which can include diarrhea, ear infections, pneumonia, encephalitis, chronic neurological deficits and even death.

Instapundit Glenn Reynolds has a nice article summing up the problem for anyone not clear what the stakes are, and why the “anti-vaccination” movement is so potentially dangerous. Reynolds doesn’t mention, however, that his presumably preferred Presidential candidate, John McCain, is unfortunately pretty definitively on the wrong side of this issue.


Obama Against “Mental” Exceptions to Late-Term Abortion Bans

July 4, 2008

Obama’s stance on abortion is pretty much in the mainstream of the Democratic Party, but with one critical difference when it comes to late-term abortions (i.e. abortions post fetal viability). And, luckily, for him, it’s precisely the exception I would make. Obama doesn’t think that “mental distress” should qualify as an exception to bans on late term abortions. This position puts him at odds with pro-abortion rights groups and members of his own party.

Still, I think it’s the right one. Anti-abortion groups have a legitimate fear that sufficiently vague “mental” health exceptions could undermine the point of the ban entirely: any person can develop “tremendous emotional toll” even from a normal pregnancy. But that really doesn’t fall under the same situation as health exceptions in general, and in practice, this exception can basically serve as an end-run around the ban. Groups like NARAL, of course, paint things differently:

The official position of NARAL Pro-Choice America, the abortion rights group that endorsed Obama in May, states: “A health exception must also account for the mental health problems that may occur in pregnancy. Severe fetal anomalies, for example, can exact a tremendous emotional toll on a pregnant woman and her family.”

This is yet another situation in which I wish people on both sides of the abortion divide would just express what they actually mean: what specific conditions is NARAL talking about? Conditions like anencephaly, where the brain essentially has not formed properly, and the baby has no higher brain function and no chance of survival beyond a few weeks? (I’m in favor of allowing abortion in such cases) Or does it mean Down’s Syndrome, a missing arm, or a partially malformed gut? All of the latter could be called “severe anomalies,” but such babies are essentially normal in terms of their capacity to feel and suffer. (I’m against abortion in such cases) The details matter.

In any case, while he’s sure to take fire from liberals on this, Obama has about as much chance of getting any honest credit for his stance as the New York Mets do of winning the Superbowl. Anti-abortion groups are, of course, having none of it:

David N. O’Steen, the executive director of National Right to Life, said Obama’s remarks to the magazine “are either quite disingenuous or they reflect that Obama does not know what he is talking about.”

“You cannot believe that abortion should not be allowed for mental health reasons and support Roe v Wade,” O’Steen said.

O’Steen is technically right here: a companion case to Roe was Doe v. Bolton, which defined “health” exceptions very broadly, including considerations of “emotional, psychological, familial” factors. But O’Steen is still essentially dissembling: the definition, while broad, is also vague enough that someone like Obama could reasonably believe that those other factors could almost never, on their own, justify an exception.

O’Steen, of course, has no reason to be charitable and honest in how he portrays Obama. Even if Obama really is closer to his own stance on this issue (which he already has a decent reason to doubt), Obama’s party taking power in the White House is far far more important to his chosen issue (outlawing abortion) than giving him credit for a minor agreement and risking rank-n-file anti-abortion voters potentially seeing Obama more favorably.


More Sex Meant Safer Sex in Thailand: Counterintuitive Economic Theory

June 19, 2008

Steven Landsburg has to be one of my favorite authors: contrarian in all the right ways, ruggedly skeptical, utterly unafraid to buck conventional wisdom. There’s never guarantee that you’ll agree with what he argues (at least at first), but you will be entertained, engaged, and forced think of issues from entirely new angles.

His most recent book (sadly not that recent) was More Sex Is Safer Sex: The Unconventional Wisdom of Economics, in which he argued (among many other things) that there were social situations in which increased promiscuity amongst the sexually prude could actually reduce the transmission of disease. Indeed, he argued that prudishness was, in some cases, as much a socially harmful vice as sleeping around.

His argument was essentially theoretical, but it wasn’t entirely out of the blue: it was based on research by another economist, Michael Kremer and some pretty solid models of sexual behavior and disease transmission.

And now, it seems like it’s no longer even just hypothetical.

That’s because, according to Marginal Revolution blogger Alex Tabarrok, the recent history of Thailand provides a real world example of more total sex leading to a reduction in disease transmission. A drastic, culturally driven increase in normally chaste women engaging in premarital sex coupled with a (not causally unconnected) drop in the number of men going to prostitutes cratered the rates of HIV transmission: even in sex workers.

And to top it all off, the place where Alex Tabarrok discovered this little gem? Elizabeth Pisani’s new book called “The Wisdom of Whores.” It’s all enough to make social conservatives scream.

Of course, in all seriousness, those conservatives have plenty of worthwhile concerns. And just as a disclaimer before you run out and lose your virginity in the service of public safety: the particular effect here relies on a particular sort of sexual situation that may or may not have any relevance to your society. And in any case, it still unavoidably involves the former prudes taking on more risk to their own health in order improve the lives of others. So, please, read the books instead of rushing out to do anything foolish and frisky just on my word.

Elizabeth Pisani explains it all herself here:

Isn’t counter-intuitiveness grand?


FDA to Crack Down on Phony Cancer Cures?

June 17, 2008

Apparently the FDA has decided to start targeting internet businesses that have been making bogus medical claims about alt-med cancer cures. If so, it’s about time. I’m not against adults being allowed to imbibe whatever they want to believe will help cure them. I’d counsel strongly, strongly against it, but I don’t think it should be against the law. Companies, however, that prey on desperate folks like this deserve little mercy.

The letters criticized unproven claims made about these products including the ability to “destroy the enzyme on DNA responsible for cancer cells,” and the power to “neutralize” carcinogens. One product’s Web site had a testimonial claiming it had cured a patient’s skin cancer in three days, according to one of the letters.

I’m not even sure what “the enzyme on DNA responsible for cancer cells” is supposed to mean, exactly. I wouldn’t be surprised if the person who wrote it has no idea either. And that’s precisely what’s so screwed up about this entire market. While I’m sure some part of these sellers are sincerely convinced that their powders, chemicals, and rubs have some sort of cancer-fighting powers, they don’t actually know that they do. They believe. Alternative medicine is nothing more than medicine that hasn’t been vetted or tested to see if it actually works.

And in this context, that’s no better than handing someone a gun and telling them that it isn’t loaded… when they haven’t actually bothered to check. As good ole’ Abe Lincoln once said:

It is an established maxim and moral that he who makes an assertion without knowing whether it is true or false is guilty of falsehood, and the accidental truth of the assertion does not justify or excuse him.


The New Age “Secret” in Hawaii: You Created Your Cancer Circumstance!

June 8, 2008

In my opinion, Hawaii is the best and most beautiful of our 50 states. But while I was down there blissfully schooling with reef fish, I also happened to notice that the local media seemed saturated with the New Age/New Thought nuttery known as “The Secret.” Many of its luminaries were offering talks, conferences, and workshops throughout the summer, with tickets that ran as high as $250 for “V.I.P.” seats.

For those not duly acquainted with this stuff, it’s essentially a self-help/motivational speaking movement that has proudly leaped off the deep-end with mystical pronouncements about the nature of thought and reality. Namely, they claim that the entire universe is shaped by people’s thoughts, and that a “Law of Attraction” allows you to draw the things you want to you just by thinking about them. The whole shebang is, in the end, pretty standard pseudoscience: lots of very vague claims, few falsifiable, coupled with the attitude that any skeptics are party-poopers messing up all the magic with their negative nancyings.

Wishing got me this hatAnyway, one of Hawaii’s local papers featured an interview with one Mike Dooley “former Hawaii Marine brat,” former tax accountant, T-shirt salesman, and now multi-million dollar motivational mufti for the Secret movement. His trademark idea is that “Thoughts Become Things.” He even, without any sense of self-parody, has some sort of super-adventure club called TUT.com to promote it.

How did he come to conclude that he (and maybe you, if you can afford the 130$ workshop) could recreate reality with his mind?

Not finding answers in the mainstream, including the religion I belong to [I was] a good old Catholic boy. I was left to draw conclusions–deductive reasoning. For instance, [that] we’re powerful, loved, eternal, that time space must be illusions. These were my inner suspicions. We are divine creators. What we focus on, we ultimately manifest. Books helped me confirm my inner suspicions about life.”

I’m not sure how or why “deductive reasoning” got downgraded to “inner suspicion” halfway through this paragraph, but the idea that time and space are “illusions” is a pretty darn extravagant claim. And it’s one that I’m not so sure you can use an “inner suspicion” to discern the truth of. Entirely within the confines of your own mind, it’s perfectly possible to think of the universe, and everything that happens in it, as illusion. That’s because it’s the ultimate in unfalsifiable beliefs: any possible evidence to the contrary can simply be classified as part of the illusion.

But what does it really mean to assert that time and space are a mirage… and then try to simply move on from there as a being within that false reality? If everything is fake, what’s real, and how does Dooley know?

Worse still, Dooley promotes his approach by insisting that his method can deliver all sorts of material wants: money, cars, worldly success. But that’s bizarrely out of step with his own philosophical assertions. If reality is a distracting illusion, then all these physical goodies would themselves also be a distracting illusion. What sense does it make to declare reality a complete fantasy and then spend so much time demanding cold hard cash out of it? At least when most Buddhists tell people to let go of any attachment to existence, they mean it whole-heartedly: not merely as a means to a materialist payday.

So, while Dooley calls his insights a philosophy, insisting that what he’s selling is neither religion nor a cult (and thus wonderfully compatible with either), it’s a woefully incomplete and vague sort of philosophy. This is especially so when he runs up against the obvious problem with his few coherent claims: if people create their own reality, then why would anyone choose to suffer? Wouldn’t this mean that individuals are all 100% to blame for any circumstance they find themselves in? When you get sick, is it merely because of a lack of will? Are cancer patients to blame for their colon killing them and their chemo treatments torturing them?

Well, according to Dooley, in addition to the Law of Attraction, there are “other parameters, none of which take away our power, but do explain the disparity we see in the world.” He doesn’t list any, or explain them further. Instead, he sort of slides around the implication without really answering it:

“Fault is not a word that would be used spiritually. We choose our lives, the stage, knowing ahead of time that there could be hardships. Irrelevant of the circumstances, we are creators. Why was such a circumstance created. Every person that has cancer has it with their own intents, rationale, and motivation. To say “Is it their fault?” is taking the whole thing out of context. They are master creators. There are reasons. Whether or not those reasons can be pinpointed doesn’t take away our ability to recognize that we are creators and that things do not happen to us by chance or accident.” (emphasis added)

“There are reasons”? We have cancer with “our own intents”? I’m not sure what the heck that means, but it sure sounds like cancer patients are indeed due little sympathy for their self-inflicted sufferings.

Give me old-time theodicy any day of the week. It doesn’t make any sense either, but at least it isn’t quite as vague and off-the-cuff.

Why isn’t “fault” a word that can be “used spiritually” anyway? We’re back to my usual complaint here: tossing the word “spiritual” or “supernatural” into a concept does not magically alleviate one’s need to explain what the heck you’re claiming is going on. Or, in this case, why a concept like “fault” can’t apply to the idea of people apparently choosing their circumstances. And it doesn’t explain how Dooley can know or “recognize” that nothing happens by “chance or accident.”

Traditional motivational speakers don’t dabble in metaphysics like this: they teach people how to improve on their circumstances, find explanations for things after the fact, repurpose lemons into Fruitopia. They teach positive thinking because it can help lead one to more positive behavior, not because it’s some sort of magic incantation.

I know enough about even the traditional “self-help” methods and movements to be highly skeptical of them, and advise the same skepticism for others. But the kooky claims of this Secret stuff positively scream “scam.”


New Study: “Abstinence Only” Education Fails Again? Or Not.

June 8, 2008

Ed Brayton is making the case that a new study of high school students provides even more evidence that abstinence-only education has failed in its primary purpose: the reduction or delay in teen sex and disease transmission. The study, which looks to be quite good in terms of dataset and design, basically shows that the steady decline in teen sexual activity and the steady increase in condom use have both leveled off, and both changes came during the time in which abstinence-only education came into its heyday (the early and mid 2000s).

I’m no fan of abstinence-only policies, which are essentially a “pro-ignorance” approach to education. But I’m not so sure we really can take any clear policy conclusions away from this data.

The main reason is that, in the social sciences, we’d expect just about ANY trend to level off naturally whether there were other policy effects or not. Whatever the cause for the decline in teen sex since 1991, there’s only so much you can reduce teenage sexual activity in the first place before diminishing returns set in. The more you reduce teenage sexual experimentation, the harder and harder further decreases become.

This especially makes sense in terms of teens and sex. If we imagine that there is a sort of standard cohort of teens with a natural range of character traits and attitudes towards sex in each generation, then any external effect (like the AIDS scare) which reduces sexual activity is going to be more effective on some students, less effective on others. As this effect increases its influence on each cohort of kids, you’ll effect all the low hanging fruit first (the kids most scared of disease and ambivalent about sex to begin with), and the trend will be fairly large. But as you proceed, you’ve already dropped the sexual activity of many of the prudes down to 0 (and can’t go any further with them), and now what you have left to work on are the kids that are amongst the hardest to convince not to have sex in the first place. Even if the original effect increases dramatically (i.e. AIDS gets more and more scary), it still might not be enough to effect enough of the horniest kids fast enough to keep up the overall trend, year after year.

For all we know, this could be what’s going on here: major social changes in the early 1990s (AIDS, widespread contraception knowledge and availability) spent a decade spreading through the population, and now they’ve pretty much done as much as they can do. Buried underneath these larger trends, abstinence education could have had a positive effect, negative effect, or no effect at all.

All we really can say for certain, from this data, is that abstinence-only education hasn’t sparked any sort of dramatic or obvious revolution in teen prudishness. Other studies, which more directly compare the effects of abstinence-only education to other programs or no program at all, are far more relevant to the debate than this one.