Tuesday, February 4, 2014

Trick Question

What follows is a rambling reflection apropos of not much more than the heartbreakingly sad state of affairs in America on February 4, 2014.

I got a forward from a resident at one of the more prestigious medical schools in the country.  The subject was one of those interim exams, designed to test the resident’s knowledge of care in his specialty.  Without boring you with the arcane medical details, the problem posed was of a young woman with a chronic illness whose severity makes it risky for her to get pregnant (think Steel Magnolias).  This patient presents to her physician pregnant and the residents were asked what the proper course of care might be.

I think the results are telling.

Nearly half of the residents indicated that they would monitor the pregnancy carefully and recommend caesarean section at a time when the child would be viable and risks minimal.  But the “correct” answer was to recommend elective termination of pregnancy.  I do take heart that only about a third of respondents picked that answer, but that’s a third too many.  (One commenter mused that the question was posed simply for the purpose of measuring the acceptance of casual abortion among medical residents. I am just enough of a conspiracy theorist to believe that just might be true.)

As bad as the recommended answer is, the reasoning behind it is worse: Pregnancy in these patients is associated with a 30-50% mortality.

Let me recast this: pregnancy in these patients is associated with a 50-70% survival rate of the mother.  Abortion is associated with a 100% mortality of the child. 

Politicians and propagandists have long known: control language and you control the argument.  The moral reasoning aside, there’s a medical issue, one of intellectual honesty, that no one has bothered to look at in the midst of all this. 

I spent a long time working in the fields on oncology.  In those fields a 70% chance of survival is pretty good, worth shooting for, at least worth shooting for, especially when balanced against the 100% risk of  loss of life for the child.

Too often these cases-both in the halls of medicine and the daily newspaper-- are cast in terms far more dire and far more certain than the medical data support, I suspect for purposes of polarizing the argument and directing the answers.  The worse the situation is for the patient the doctor can see, the easier it is to ignore the patient he can’t yet see.  It’s a subtle and effective way of dehumanizing the baby.

It underscores the need in these situations to pause long enough to really assess the medical situation rather than rely on what “everyone knows.”  It’s equally important in  these situations not to wield bioethics like a mathematical formula; the details of the situation matter as much to morals as they do to medicine.  When mechanical ethics meets melodramatic medicine and the results are predictably horrific.  The harder the question, the greater the need for good, detailed information and thoughtful discussion.  Fear too often drives us and when it does, it tends to drive us away from God and from each other and into the hard, cold silence of our own prejudices.    

A woman who hears “you have a 30-50% chance of surviving” will react differently from a woman who hears “you have a 70% chance of surviving, and here’s why.  Here’s what we can do to keep you healthy long enough to have your baby.” A physician who encounters an ethicist willing to enter into the grey areas of life is more likely to be open to alternate—and more acceptable—plans of care.  And anyone who knows that there are safety nets—economic, emotional and social—in place to help people struggling with medical tragedies is more likely to risk alittle of self in return.

But the default in medicine has become elective abortion, for many reasons.  In part because that’s the mentality of society.  In part because aborting the child is less risky for the doctor than managing a complicated pregnancy that has a real chance of ending badly and spawning a malpractice suit.  In part because that care is expensive and abortions are cheap.

Sadly, the more I tease out the problem, the more complicated the moral answers become.  One malpractice suit can wipe out a lifetime of work; it takes incredible strength to risk that over and over by caring for high-risk, pregnant patients in flagrant disregard of the “standard of care,” however immoral that standard is.  In an age when insurance coverage is shrinking and care for expensive conditions is likely to decrease, the odds of third party coverage for managing such a pregnancy are diminishing and the choice to maintain such a pregnancy might bankrupt a family.  If we ever get to the era of government-controlled care, even the option to choose to risk the mother’s life to bear the child may be gone as treatment options narrow because of mandated care paths. 

It is a tragic reality of modern life that—in the course of a generation—abortion has become the quick, cheap way of avoiding a whole slew of medical and societal problems, ranging from our hypothetical lady who should not get pregnant to parents who feel unprepared to raise a child with Down syndrome to—God help us!- trying to reduce poverty my reducing the number of people born in neighborhoods.  (The rich ones are doing a pretty good job of enforcing negative demographics all on their own.)  Life has become at once both cheap and too expensive for modern America to tolerate. 

Fixing that isn’t just a matter of reversing Roe v. Wade.  It’s a matter of fixing hearts and re-educating minds and being willing to give up something of our selves to each other to make the journey together.

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