Endocrine Ethics Blog

This month, the most restrictive abortion ban in American history, known as the Human Life Protection Act, was passed in Alabama, which has led to a tsunami of similar laws throughout the South and mid-west (see:  https://www.nytimes.com/2019/05/15/us/abortion-laws-2019.html?module=inline. Missouri also passed a controversial bill this month that bans abortion beyond 8 weeks (see: https://www.nytimes.com/2019/05/24/us/missouri-abortion-law.html).

The Alabama law makes it a crime for doctors to perform abortions at any stage of a pregnancy unless a woman’s life is threatened or there is a lethal fetal anomaly (see: https://www.al.com/news/2019/05/alabama-abortion-ban-passes-read-the-bill.html). Doctors in Alabama who violate the new law may be imprisoned up to 99 years if convicted, but the woman seeking or having an abortion would not be held criminally liable. Thus, Alabama’s law severely punishes healthcare providers for terminating pregnancies for any reason unless the patient’s life is threatened, effectively forcing them into wrenching ethical dilemmas and moral distress, and upending common practices in fertility treatment care. The law – which is unethical, clearly violating the Principle of Respect for Autonomy — has effectively left reproductive healthcare in the “fetal position” as such a law will make abortion in Alabama in 2020 – in post-Roe America more restrictive than it was in 1920 – in pre-Roe America. The American Society for Reproductive Medicine has made clear that it opposes the Alabama fetal “personhood” law (see: https://www.asrm.org/about-us/media-and-public-affairs/public-affairs/asrm-position-statement-on-personhood-measures/ ).

Even in pre-Roe America, when abortion was illegal by the mid-19^th century, it was always legal for physicians to perform a therapeutic abortion. The definition of “therapeutic abortion” was never clearly defined and was always left up to medical judgement to define. Typically, psychological and psychosocial harms from an unwanted pregnancy would be frequently considered. Between the 1920s and late 1930s, women could access safe abortions from a number of physicians in urban centers.  Even later in pre-Roe America (1940s-1973) when abortions became more restrictive and cost-prohibitive, hospitals had therapeutic abortion committees that took psychological and psychosocial harms from an unwanted pregnancy into consideration. 

In my own state of Kentucky, abortion was effectively banned in March through two bills: one bill prohibits abortion after six weeks (most women don’t discover they are pregnant prior to six weeks); the other bill prohibits abortion if it’s related to results of fetal diagnosis. The ACLU challenged both laws shortly after passage in federal court arguing it is unconstitutional (See: https://www.aclu.org/blog/reproductive-freedom/abortion/kentucky-just-banned-abortion?fbclid=IwAR17UypgeafdMW-_mYCgPxpt1RkalH1y-xGhJJkjgWQgAs7yu99VxnwtPGA). On March 27, 2019 a judge ordered the laws be suspended indefinitely until the court issues a final ruling on whether they are constitutional. 

But the Alabama law is the new crystal ball for the future of abortion in the U.S. It’s clear that Roe v. Wade has become irrelevant in a post-Casey America. In the 1992 Casey decision, the court clarified that the states could place restrictions on abortion previability so long as it was not an “undue burden”, which led to Targeted Restrictions for Abortion Providers, or TRAP laws.

It is likely that by 2024, the country will be divided into a reproductive justice system of “free states” and “TRAP states” – where poor women are enslaved by their biology, as well as lack of access to hormonal contraception. We all know that abortion access is never a problem for the wealthy and well-connected who can travel out of state or to another country.  Unwanted pregnancy is not just about the consequences of unprotected sex, but of classism and health disparities.

This year is the 50th anniversary of Norma McCorvey’s quest for an abortion in Texas when she was 21, when roughly 10,000 women per year in the U.S. were dying from unsafe abortions. She went to attorneys Linda Coffee and Sarah Weddington, who renamed her “Jane Roe”, and challenged the Dallas District Attorney, Henry Wade. The following year, in 1970, the District court ruled in favor of Roe, stating the Texas law was unconstitutional, but wouldn’t grant an injunction against the law; this eventually led to the Supreme Court decision of Roe v. Wade. By then, Norma had already given birth and put the baby up for adoption. 50 years later we’ve come full circle.

The biggest bioethics story of the year, topping off the 200^thanniversary of the publication of Frankenstein (see: https://frankenstein2018.com) was the announcement by Dr. He Jiankui on November 25^ththat he had just created the world’s first genetically modified babies using the gene editing tool known as CRISPR cas9.  He announced this at the 2^ndinternational gene summit (see: http://www.nationalacademies.org/gene-editing/2nd_summit/index.htm); the story officially broke in MIT Technology Review (see: https://www.technologyreview.com/s/612458/exclusive-chinese-scientists-are-creating-crispr-babies/).

I also discussed this case earlier this month on a University of Kentucky podcast (http://uknow.uky.edu/research/ethics-crispr-twins-week-behind-blue)

What did He do?

Dr. He claims to have eliminated the gene that makes us susceptible to HIV in an effort to create HIV-resistant babies since the father is HIV-positive. (The gene is called CCR5). He also claims to have created another pregnancy which is still in the early stages.

This was a staggering announcement because it means Dr. He reportedly edited human embryos that were implanted back into the mother. This is called human germline editing – also known as human germline engineering. Human germline editing involves changing the DNA of sperm, eggs or embryos – which is passed down through generations, and which have unknown consequences to the human genome overall. Essentially, Dr. He may have changed the human DNA sequence for generations to come by creating a heritable mutation and genetically modified descendants. The babies in question are called Lulu and Nana (pseudonyms); when they grow up and have children of their own, they will pass on this changed DNA sequence to their children, who will pass it on their grandchildren. This could affect untold thousands of people in the future. Nobody knows the consequences of the mutation Dr. He has introduced – it could have altered the genome in significant and negative ways.

Scientific concerns

 Several scientific peers have raised serious questions:

• He has not published his data for scientific scrutiny. Nobody can verify what, exactly, he did, or if he is telling the truth.
• This was conducted without IRB approval, ethical oversight or informed consent. Dr. He’s institution –Southern University of Science and Technology, in Shenzhenhad no knowledge of his work; the hospital where the embryos were implanted and eventually born states it had no knowledge of what he was doing (see: http://asia.blob.euroland.com/press-releases-attachments/1108747/HKEX-EPS_20181127_003332422-0.PDF)
• It will be difficult to get this research published in a peer reviewed journal because it doesn’t meet the publication standard of IRB-approval. There are also several conflicts of interest in his research.
• There appears to be no scientific or clinical rationale for this particular gene edit because there are many ways to reduce HIV transmission in newborns, and HIV experts stated that these babies were at very low risk of contracting HIV in the first place. This trial did not even meet the standard of “unmet medical need”. So even if these girls remain HIV negative life long, we’ll never know if this apparent gene edit was responsible. Dr. He actually introduced new mutations into the babies’ genomes that could alter how CCR5 works. We just don’t know.

Ethical concerns

Ultimately, every bioethicist around the world has called this research completely unethical, including over 100 Chinese scientists who have stepped forward. Dr. He also violated an international moratorium on creating live births with human germline editing. In December 2015, the first international summit on gene editing took place in which the scientific community agreed that while research on human germline editing could be done on discarded embryos– so we could study and learn more about this — it could not be used to create live births because it was years away from practical application. In fact, I discussed this moratorium in December 2015 (see: http://endocrineethicsblog.org/editing-ourselves-2015-and-crispr/).

Creating live births using germline editing is illegal in several countries, including the UK and Canada. China has now declared this illegal, too. In the U.S., federal funds cannot be used for intentionally creating a human embryo that is edited or modified.

The bioethics consensus is that until sufficient public debate surrounding the ELSI consequences  – the ethical, legal and social implications  — of human germline editing takes place, this research is not only premature, but may not even be an acceptable scientific pursuit.

In a year where ethics violations in government without “checks and balances” have dominated the news, it seems the science news was no exception. The CRISPR twin research violated the Nuremberg Code, the Declaration of Helsinki and the Belmont Report.

Although some bioethicists question if we should respond to what “He Says” in the absence of any data, if someone is even claiming to have altered the human genome, science must provide a strong and swift rebuke. Because the last thing we want is (ahem) a copycat.

If you’re an endocrinologist with patients in their reproductive years, then here is a prescription for mandatory viewing: Hulu’s The Handmaid’s Tale, which is to reproductive justice what the 1997 film, Gattaca was to genetic sequencing. Part cautionary tale, and part “we’re practically there.” And soon, “Um…that actually happened last week.”

The premise of the series is that in the wake of decades of unregulated environmental toxins, most American women are now sterile; a small minority are able to conceive. Meanwhile, the political structure of the U.S. deteriorates into an authoritarian state ruled by Christian fundamentalists who assign roles to the females in the population: some are the “wives” of the ruling class in traditional marriages where women are subservient to males; some are forced “domestics” (the cooks and housekeepers); some are forced into reproductive service as “handmaids” to the infertile couples. Handmaids must submit to unconsensual intercourse with the male heads of households to which they’re assigned, with the goal of serving as surrogate birth mothers for the infertile ruling class. What about the lesbians? They are “gender traitors” who have forced clitoridectomies. (For more analysis of the series, see: https://www.newyorker.com/magazine/2017/05/22/a-cunning-adaptation-of-the-handmaids-tale).

Based on the 1985 novel by Margaret Atwood, The Handmaid’s Tale asks a central question in the Trump era: Do women have autonomy or not? And, by extension, do women’s voices mean anything?

In 1985, Atwood was initially writing the novel in the context of the Reagan era, and the “moral majority” which was a movement that inspired her fictional and futuristic version of the United States in which the Constitution is dissolved by a far right, Christian militia, renaming the U.S. “Gilead”. Here is a 1981 New Yorker piece on the burgeoning “moral majority” entitled “A Disciplined Charging Army”: https://www.newyorker.com/magazine/1981/05/18/a-disciplined-charging-army

The 1980s “moral majority” was a feminist backlash movement that wanted to stop women’s social and reproductive progress, which it saw as a threat to the traditional family. But The Handmaid’s Tale was also written during the burgeoning era of artificial reproductive technologies (ART), such as IVF and surrogate motherhood. The “moral majority” eventually became the base of the Republican Party, which now operates all three branches of government. In 2017, to satisfy its base, we watched the Republican Party disband its Constitutional duties of oversight to cede control to the Executive Branch. We watched, too, as our democratic norms once “guaranteed” under the U.S. Constitution eroded. Now, we are living in a time in which the U.S. Congress is actively enabling an authoritarian, illiberal President of questionable decision-making capacity. Ultimately, the Trump era is one where anti-feminist, anti-civil rights, anti-science, and anti-evidence-based policies are fast becoming normalized. Legislators who are proponents of the Trump agenda pride themselves on restricting women’s reproductive rights and the civil rights of the LBGT community; the President is actively trying to ban transgender persons from military service (See: http://endocrineethicsblog.org/the-presidents-gender-bender/)

Of course, erosion of women’s reproductive rights did not happen overnight; state legislatures have been in Republican control for several years due to low voter turnouts in local and mid-term elections during the Obama era. A myriad of abortion restrictions and TRAP laws were introduced between 2011-2016 (See: http://endocrineethicsblog.org/2016/06/), but over 400 more abortion restrictions were introduced in 2017, with some states requiring completely unethical statements be made to the patients seeking the procedures, including (in Utah) a requirement that doctors attempt to medically rescue aborted fetuses when they are removed from the womb. (See: http://www.motherjones.com/politics/2017/04/guttmacher-report-abortion-restrictions-proactive-legislation-first-quarter-2017/#). In April, President Trump signed a new law to withhold public funds used for family planning (see: https://www.npr.org/sections/thetwo-way/2017/04/13/523795052/trump-signs-law-giving-states-option-to-deny-funding-for-planned-parenthood)

Earlier this month we learned that the Trump Administration has now banned the CDC and the Department of Health and Human Services from using certain words, such as “evidence-based”, “fetus” and “transgender”. (See: https://www.washingtonpost.com/national/health-science/cdc-gets-list-of-forbidden-words-fetus-transgender-diversity/2017/12/15/f503837a-e1cf-11e7-89e8-edec16379010_story.html?utm_term=.d1971c7307a8).

Ultimately, despite so many political distractions, 2017 was a very productive year for the erosion of women’s reproductive and civil rights.

On January 21, 2017, the year began with the Women’s Marches across the U.S., and in many other countries the day after the 45^th President of the United States was elected despite his statements on video that he could “grab women by their pussies” whenever he wanted. The iconic symbol of the Women’s Marches became the pink “pussy hat”. But as the year progressed, policies targeting women have been a key part of the Trump agenda. Here is a summary of legislation on the menu in the first 100 days: https://www.americanprogress.org/issues/women/reports/2017/04/25/430969/100-days-100-ways-trump-administration-harming-women-families/).

Additionally, there were multiple attempts to repeal the Affordable Care Act and remove basic access to women’s health. (See: http://endocrineethicsblog.org/kill-bill-volume-1/)

But the most significant achievement in eroding women’s rights was the appointment of Neil Gorsuch to the “stolen” Supreme Court Seat. Gorsuch, a conservative judge, remains a threat to Roe v. Wade. The Trump Administration has also been very busy installing conservative judges on the federal courts (https://www.nytimes.com/2017/11/11/us/politics/trump-judiciary-appeals-courts-conservatives.html), who will surely help to rule in favor of laws that erode women’s reproductive rights and justice in the future. For now, the federal courts have held that women still have reproductive rights. But that could change quickly, particularly with the current Attorney General at the helm, who would feel right at home in “Gilead”. Alas, even if Trump gets impeached, the current Vice President is a character right out of “Gilead”, too. Under a potential Pence Administration, a Gileadian future is even more possible. We have already seen some foreboding signs this year. Undocumented pregnant women have been held against their will by the Justice Department, and prevented from accessing constitutionally protected abortions. In one case, even when the ACLU attorneys ultimately won the case for an undocumented teen to get an abortion, the Justice Department started suing the ACLU’s attorneys. See: https://www.washingtonpost.com/politics/courts_law/undocumented-immigrant-teen-has-abortion-ending-weeks-long-court-battle/2017/10/25/9805249a-b90b-11e7-9e58-e6288544af98_story.html?utm_term=.6930202c44b6

and

https://www.huffingtonpost.com/entry/doj-aclu-jane-doe-undocumented-teen-abortion_us_59fb213be4b0b0c7fa387271

As for Atwood’s dystopian premise of environmental toxins interfering with fertility, that story has been ongoing since the discovery of endocrine disruptors (see: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3845732/) in the wake of weak regulations on organochlorines. Although the Obama Administration began to implement stricter regulations on environmental threats, in 2017 the EPA was effectively dismantled, and its scientists silenced, by the new anti-EPA director, Scott Pruitt. (See: https://www.pbs.org/wgbh/frontline/film/war-on-the-epa/). Between the destruction of the EPA, and the President’s exit from the Paris Climate Accord, it’s “deregulation gone wild” as polluters are granted the freedom to let loose. There is no telling how environmental deregulation will affect reproductive health; children’s health, and public health in general.

We are closer to The Handmaid’s Tale than you think, but there are signs that women are beginning to use their rage to prevent a future that is so tangible, we can taste it. The #MeToo Movement, which erupted in the Fall, closed the year, as women started to call out by name their sexual predators, sexual harassers and uninvited gropers, putting an end to several prominent males’ careers. It remains to be seen if there will be a male backlash. But we need to remember that right now, women’s civil and reproductive rights hang by a thread.

Atwood stated that The Handmaid’s Tale was an “antiprediction” because “if this future can be described in detail, maybe it won’t happen.” Indeed 2017 paved the way for women’s reproductive rage to translate into real legislative power. In Virginia, women were responsible for nearly flipping the state legislature by running for local office and voting out white males. In Alabama, African American women, in particular, were responsible for staving off a white male predator who meets the legal definition of a pedophile, and even stated he was pro-slavery.

The Handmaid’s Tale is too close for comfort; but 2018 may become the year women literally run for their lives (and reclaim their reproductive autonomy). One thing is certain: women will no longer accept “Lock Her Up” when they ask for power.

One of the most enduring and favorite American musicals is Oklahoma!, first performed in 1943 (See: https://en.wikipedia.org/wiki/Oklahoma!). It was turned into a wonderful 1955 film starring, among others, Shirley Jones, Gordon MacRae, and Rod Steiger (See: https://en.wikipedia.org/wiki/Oklahoma!#1955_film_adaptation). In 1943, a timeframe when women were being empowered in the war effort and went to work, the plot was rather shocking, as the main character, Laurey, is the victim of a predatory male who wishes to sexually assault her. In the nick of time, she is rescued from the sexual assault. The Rogers and Hammerstein score is superb, and anyone who has seen one of many stage productions or the film, knows the many popular songs, including how to spell Oklahoma: O-K-L-A-H-O-M-A! Let’s not forget “Oh What A Beautiful Morning” and “Surrey with a Fringe On Top”. Even people who hate musicals love this one: There is no bad number in the production. So there’s no doubt that there is a warm, fuzzy feeling when Americans think of the state of Oklahoma.

It’s important to note that the musical, Oklahoma! was particularly popular because it resonated with female audiences who were often targets of sexual predatory behaviors. The play and film delivered moral rescue from a desperate situation, which culminated in “Poor Jud is Dead” (officially spelled “Poor Jud is Daid” – to maximize the accent). Although the villain, Jud, got what was coming to him, there was also audience empathy for him. He was lonely; he had an unrequited, burning attraction to Laurey, and didn’t know how to curtail it.

Unfortunately all our warm, fuzzy feelings about the State of Oklahoma were ruined this month, as news of an ethically egregious proposed House Bill 1441 — a proposed abortion law with a “fringe on top” — was reported to have advanced in the Oklahoma State Legislature. This Bill upends the woman-friendly plot of the musical, Oklahoma!

House Bill 1441 will require a pregnant woman in Oklahoma to seek written consent and permission of the father to approve any abortion; she would need to name the father, and if the father contested, he could opt for a paternity test.

See: https://www.washingtonpost.com/news/post-nation/wp/2017/02/14/oklahoma-bill-would-require-father-of-fetus-to-approve-abortion/?utm_term=.f53b11099995

and

http://thehill.com/homenews/state-watch/319635-oklahoma-house-advances-bill-to-require-mens-permission-for-abortions

The requirement to name the father is, of course, fraught with psychosocial risks and harms – including to the father, who may be married to someone else. What if it’s a highly secretive (yet consensual) affair?

In many states, including mine (Kentucky), we don’t legally recognize the rights of “baby daddies” who are not legally married to the patient. We don’t recognize them as legal surrogates, nor do we allow them to be surrogates for neonatal patients. At many hospitals, paternity tests are not routinely offered, either. Thus, access to a paternity test could be a problem for a father who feels wrongly named; and finding access could be an additional undue burden.

Bill 1441 does provide an exemption in cases of rape, incest, or when the mother’s health is at stake. This is still problematic as there can be different interpretations of what constitutes “rape”; it’s unclear whose perception of rape would be accepted should this Bill ever become law, as perpetrators could argue it was all perfectly consensual and the woman was just a “girl who can’t say No”. What about cases of domestic violence rape? In such cases, “people will say they’re in love”. But in reality, violence may increase or be triggered by an unintended pregnancy.

This proposed law is unconstitutional, which even its author, Representative Justin Humphrey, concedes. It is also unethical, misogynistic, and logistically impossible. The Bill’s author also stated that prevention of pregnancy is the “responsibility of the woman”. That may be difficult in States where contraception is not taught or accessible. Oklahoma, in fact, has a terrible record with respect to teaching about contraception and making it accessible (see: https://sexetc.org/states/oklahoma_).

It is self-evident that a woman has the right to make decisions about her body; she is not simply a “host” for the fetus, as the Bill’s sponsor states. She is an American citizen with civil rights; as a legal person, her rights “trump” an unborn, potential person with no legal status. A 1992 Pennsylvania law with similar overtones was struck down by the Supreme Court for these reasons. A pregnant patient and her fetus are a single biological entity pre-viability in which the practitioner’s ethical obligations are owed to the mother unless she presents her fetus as a patient. There is virtually no court that would hold that a capacitated pregnant woman does not have the constitutional right to make medical decisions for herself. From a bioethics perspective this proposed law completely violates the Principle of Autonomy and Respect for Persons.

As another song from Oklahoma! goes: “It’s a Scandal and an Outrage!”

A groundbreaking study was published in JCEM last week stating that the elusive hormonal contraceptive for males has, at last, been achieved. You can read the full study here: http://press.endocrine.org/doi/pdf/10.1210/jc.2016-2141

In an Endocrine Society press release, one paragraph launched several acerbic articles by journalists who cover women’s issues:

“Researchers stopped enrolling new participants in the study in 2011 due to the rate of adverse events, particularly depression and other mood disorders, reported by the participants. The men reported side effects including injection site pain, muscle pain, increased libido and acne. Twenty men dropped out of the study due to side effects.”

Cosmopolitan essentially called the study drop-outs “weenies”:

http://www.cosmopolitan.com/health-fitness/a8038748/male-birth-control-study-stopped/

See also: http://www.someecards.com/life/health/men-male-birth-control-study-science-side-effects/ and: https://broadly.vice.com/en_us/article/men-abandon-groundbreaking-study-on-male-birth-control-citing-mood-changes

From a research ethics perspective, halting a trial early due to unacceptable side-effects is an ethically accepted, and expected practice, which is spelled out in The Belmont Report (See: http://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/).

But there is also the issue of distributive justice, whereby the burdens and benefits of research ought to be evenly distributed. In other words, justice demands that women should not solely bear the burdens of risk surrounding hormonal contraception. It is “karmic” that women have little sympathy for the male “drop-outs” in the study. As one Op/Ed points out: “When some women resisted taking The Pill [when it was first introduced in 1960], citing health risks and side effects, Playboy dismissed the women as neurotic prudes who refused to ‘take responsibility’ for contraception.”

(See: http://www.post-gazette.com/opinion/Op-Ed/2013/04/15/Men-women-contraception-Where-is-The-Pill-for-men/stories/201304150142)

Unfortunately, since it is women who bear the consequences of no contraception, they have greater motivation for risk, leading to a “biology is destiny” ethics problem. The term “birth control” – a term that highlights autonomy over reproduction, was originally coined by Margaret Sanger, who died 50 years ago this year (http://www.biography.com/people/margaret-sanger-9471186#synopsis). Sanger made the statement: “No woman can call herself free until she can choose consciously whether she will or will not be a mother.”

Thus, there are gender differences that motivate reproductive autonomy, as males are not biologically burdened with the consequences unless they choose to be. Male hormonal contraception could also be an appealing option for parents/guardians raising developmentally delayed males, or those who may be on the autism spectrum who are not competent to understand the consequences of their behaviors.

And finally, as my blog title suggests, this election has forced us to confront male predatory behavior, ranging from the Anthony Weiner case (which now threatens to upend the election) to Trump himself, whose leaked video confirmed his predatory behaviors. Convicted male predators in some countries are sentenced to chemical castration, which involves Lupron and estrogen, and which has been considered unethical by Amnesty International (https://www.amnesty.org/en/latest/news/2016/10/indonesia-halt-chemical-castration/). With a relatively safe method of at least protection from unwanted pregnancy, could male hormonal contraception become an ethically acceptable regimen for males with established sexually predatory behaviors, presuming they are medical candidates?

June 27, 2016 will stand as one of the most important SCOTUS decisions surrounding reproductive justice and women’s health since Roe v. Wade. I’ve previously blogged about Targeted Restrictions on Abortion Providers, or TRAP laws (See: http://endocrineethicsblog.org/why-biology-is-destiny-in-a-republican-world/). These laws essentially sentence vulnerable or impoverished women to parenting by removing access to pregnancy termination services. Typically, these laws are particularly punishing to women in poverty who were raped or abused, who are unable to travel far.

As of now, the Supreme Court has ruled that these TRAP laws are unconstitutional and pose an undue burden on women seeking safe and legal abortion, which remains their constitutional right.

A fuller exploration of these laws from the perspective of women’s healthcare providers can be seen in the documentary film, Trapped, which debuted earlier this month on PBS. Here is the link to the film. You can freely stream it until mid-July: http://www.pbs.org/independentlens/videos/trapped-full-film/

The U.S. Supreme Court ruled that in the Texas case of Whole Women’s Health v. Hellersted , the TRAP laws being challenged had nothing to do with making abortion safer, or making women’s healthcare safer, and everything to do with making abortion access more difficult, and hence, posed an undue burden on a constitutionally protected right for all women. (See: http://www.scotusblog.com/2016/06/opinion-analysis-abortion-rights-reemerge-strongly/)

For more analysis on this major decision, see the following:

http://www.npr.org/sections/thetwo-way/2016/06/27/483686616/supreme-court-strikes-down-abortion-restrictions-in-texas

http://www.nytimes.com/2016/06/28/us/supreme-court-texas-abortion.html

http://www.npr.org/sections/health-shots/2016/06/27/483698407/fallout-from-supreme-court-ruling-against-texas-laws-abortion-restrictions

http://www.reuters.com/article/us-usa-court-abortion-idUSKCN0ZC0JL

It is virtually impossible to find any bioethicist who does not support a woman’s autonomy in the decision of pregnancy termination pre-viability. TRAP laws help to force postponement of termination procedures past viability. These laws also could force women’s health clinics offering termination services to women to close by imposing onerous requirements that generally have nothing to do with patient safety.

This SCOTUS decision validated constitutional protections for women’s reproductive rights and health. And the absence of a ninth Supreme Court Justice didn’t make a difference in this 5-3 decision.

This month a huge story played out regarding the ethical tensions over the Summer Olympics, Zika, and its risks to women in their reproductive years.

Over 150 experts, including physicians, researchers, and bioethicists sent an open letter to the WHO to urge postponing or moving the Rio games. See: https://www.washingtonpost.com/news/to-your-health/wp/2016/05/27/125-experts-say-olympics-must-be-moved-or-postponed-because-of-zika/?postshare=9471464365992776&tid=ss_tw

The letter proposes there are serious conflicts of interest between the WHO and the IOC: http://www.telegraph.co.uk/news/2016/05/28/who-and-ioc-accused-of-cover-up-over-zika-virus-threat-to-rio-ol/

But then there was push-back from the CDC, which argued that there was no scientific basis for cancelling or postponing the games. See: http://in.reuters.com/article/us-health-zika-idINKCN0YH2IT?feedType=RSS&feedName=health&utm_content=buffer21e3d&utm_medium=social&utm_source=twitter.com&utm_campaign=buffer

There was also the official response from the WHO and the IOC, stating that the Games will go on as planned: http://motherboard.vice.com/read/zika-olympics-who

But the Director of the CDC expressed shock and moral distress at a different kind postponement: funding for fighting Zika. The U.S. Congress has refused to consider funding at this time. See: http://www.nytimes.com/2016/05/25/us/politics/political-battles-color-congressional-feud-over-zika-funding.html?_r=0

What is really playing out here are organizational ethics games, in which decision-making is affected by multiple conflicts of interest at every segment of this story.

If you’re interested in signing this letter, you can do so at this link:

http://rioolympicslater.org

And by all means, pass the torch by sending the link to this letter on.

On March 30, 2016, Donald Trump stated that he would want to “punish women” for seeking termination of their pregnancies (See: http://www.huffingtonpost.com/entry/donald-trump-abortion-punish_us_56fc497fe4b0a06d5804b1ee and http://www.nytimes.com/2016/03/31/us/politics/donald-trump-abortion.html

Within an hour, his campaign quickly tried to edit those comments and qualify that he wishes to, instead, “punish doctors” for helping women end unwanted pregnancies. Here is the statement: https://www.donaldjtrump.com/press-releases/donald-j.-trump-statement-regarding-abortion

Unfortunately, Donald Trump is merely articulating what has been the clear agenda of Republican legislators for years: punishing women by creating a climate in which Roe v. Wade (1973) becomes irrelevant, with the advent of TRAP laws: Targeted Regulation of Abortion Providers.

The result has been a return to the “coat hanger” – as access to safe and legal abortion has disappeared in dozens of states. See: http://www.nytimes.com/2016/03/06/opinion/sunday/the-return-of-the-diy-abortion.html?_r=0

John Oliver recently did a comprehensive piece on TRAP laws, which you can view here: http://www.newsweek.com/john-oliver-last-week-tonight-abortion-law-429026

On March 2, 2016, the Supreme Court began hearing arguments about TRAP laws in Texas in Whole Women’s Health v. Hellerstedt (See: http://www.theatlantic.com/politics/archive/2016/02/us-supreme-court-whole-womens-health-v-hellerstedt/471546/). It will soon decide whether Roe v. Wade has any real meaning anymore when it comes to abortion access. Several editorials about the Texas law appeared earlier this month. See, for example: http://www.usnews.com/opinion/blogs/policy-dose/articles/2016-03-02/supreme-courts-texas-abortion-law-case-is-bad-medicine

and

http://www.chicagotribune.com/news/opinion/zorn/ct-abortion-supreme-court-texas-trap-zorn-perspec-0302-20160301-column.html

TRAP laws don’t just impact adult women; they impact any girl old enough to menstruate who can be raped. Do we really want to force preteen children who are raped and/or victims of incest  to become mothers because they can’t afford to travel to another state? These laws place unfair burdens on poor women and their children by punishing them for being poor and vulnerable by their biology. Contraception is typically inaccessible to many poor women, too, while many school districts even have bans on sex education (See: http://deadstate.org/texas-banned-sex-education-in-schools-now-theres-a-massive-chlamydia-outbreak/).

But the most morally egregious TRAP law was recently passed in Indiana, in which it is now illegal to terminate any pregnancy due to a genetic abnormality. (See: http://www.chicagotribune.com/news/nationworld/midwest/ct-indiana-abortion-ban-genetic-abnormalities-20160324-story.html). This will now force girls and women without means to care for a potentially profoundly disabled child that requires lifelong, complex medical care. But at the same time, the very legislators who support TRAP laws, also support cutting government benefits for the poor.

Many young women probably don’t remember the iconic image of Geraldine Santoro, whose image was the cover story of a 1973 Ms. Magazine. The picture spoke to millions of women trapped by biology and circumstance. Desperate to end her unwanted pregnancy, Santoro and her boyfriend embarked on a DIY procedure, which ended with her bleeding to death alone in a motel room. (See: https://en.wikipedia.org/wiki/Gerri_Santoro). Santoro was not identified until the 1990s, when a film was made of her life (See: http://www.nytimes.com/1995/03/31/movies/film-festival-review-the-woman-behind-a-grisly-photo.html). She died in 1964, and 52 years later, other women living under TRAP laws are at high risk of dying in exactly the same way.

It seems this month was a March to Access.

It’s a good thing February has an extra day this year. I needed it to ponder the unfolding story of the Zika virus, which earlier this month was declared by WHO to be an international public health emergency. (See: http://www.nytimes.com/2016/02/02/health/zika-virus-world-health-) A good review of this crisis was just published in Newsweek today: http://www.newsweek.com/2016/03/11/zika-microcephaly-connection-brazil-doctors-431427.html

When we first heard about this mosquito-borne virus and microcephaly, it was a tragic pediatric ethics story. It echoes in some ways the birth defects eventually linked to the drug, thalidomide. But the thalidomide births (which did not cause brain damage) led to the question of reproductive rights, and whether women had the right to terminate pregnancies they knew were affected, as they felt a moral obligation to prevent a harmed life. One of the most public cases of a woman desiring to terminate a thalidomide-affected fetus was Sherri Finkbine, who traveled to Sweden to have her abortion. See the 1962 story from the BBC here: (http://news.bbc.co.uk/onthisday/hi/dates/stories/august/26/newsid_3039000/3039322.stm). Finkbine was denied the right to an abortion by the Arizona courts before deciding to go to Sweden.

Now, over 50 years later in Brazil, women are facing the same dilemma from an insidious cause that is not a drug, but a bug. In a Catholic country where abortion is not accessible, women without means are having babies with microcephaly, resulting in severe impairment. A multidisciplinary group of Brazilian experts are now petitioning the supreme court to allow abortions for women who have contracted the virus. (See: http://www.bbc.com/news/health-3543568).  In Columbia, where women with the virus have access to abortion, fewer cases of microcephaly have been seen. (See: http://www.nytimes.com/2016/02/16/world/americas/zika-virus-in-colombia-presents-complicated-choice-about-abortion.html). The Zika virus has also ignited feminist ethics questions with respect to unfair burdens on women solely because of their biological vulnerabilities (See: https://www.bostonglobe.com/ideas/2016/02/07/zika-reproductive-rights-issue/U5HBV4u3J5HPscGUcJHefI/story.html).

Clearly, when poor countries are facing epidemic rates of catastrophic birth outcomes that could be prevented, other distributive justice questions are raised, which has forced even the Catholic Church to reconsider its positions. The Pope has declared that birth control is permissible until Zika is under control. (See: http://www.motherjones.com/mojo/2016/02/pope-francis-zika-abortion-contraception-microcephaly).

Talk about a Leap of Faith on this February 29, 2016.

Yesterday, Cecile Richards, president of the Planned Parenthood Federation, testified before Congress regarding the now-infamous doctored videos manufactured by anti-choice activists. (See: http://www.nytimes.com/2015/08/28/us/abortion-planned-parenthood-videos.html  and http://www.c-span.org/video/?c4552968/cummings-planned-parenthood-hearing.)

You can watch the entire testimony here: http://www.c-span.org/video/?328410-1/planned-parenthood-president-cecile-richards-testimony-taxpayer-funding.

Despite the facts, Republican members of the House Oversight and Government Reform Committee continued their line of questioning as if the videos were factual. Their questioning also revealed such alarming ignorance of women’s healthcare, and the organizational structure and funding of Planned Parenthood, that one wonders whether they truly demonstrated an adequate level of decision-making capacity — a basic standard we demand from patients for informed decisions, which requires Understanding, Appreciation and Rationality. Most of the questions asked of Ms. Richards did not meet this standard, including one member asking her if she believed in “selling baby parts”— phrasing that demonstrates stunning levels of medical illiteracy and ignorance of the laws surrounding fetal tissue research (see: http://www.hhs.gov/ohrp/policy/publiclaw103-43.htm.html).

The Chairman of the committee belligerently presented an inaccurate slide from a pro-life organization, claiming it came from Planned Parenthood (see: http://www.c-span.org/video/?c4552966/rep-chaffetz-caught-lie). When Ms. Richards politely noted the source of the slide was from “Americans United for Life,” an anti-choice lobby, and assured the Chairman it was not accurate, he yielded the floor.

Any provider of women’s healthcare should be alarmed that funding for critical reproductive healthcare services are being debated by Congressional representatives who don’t seem to meet the same standards of decision-making capacity we would demand of patients or their surrogates. They do not understand or appreciate the facts of how Planned Parenthood is funded; what fetal tissue research is; or even, at minimum, that the videos in question are not authentic.  Further, they do not demonstrate rationality — an ability to reason with the information provided to them by Planned Parenthood.

The only thing that was clear about this “hearing” was that the Republicans were unable to listen.