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Reproductive Endocrinology

Reproductive Endocrinology

Not OK (la-ho-ma): A shocking new abortion bill

February 28, 2017 • By

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!”

 

Reproductive Endocrinology

Weiner Issues: Revelations from a Male Birth Control Study

October 31, 2016 • By

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?

 

Reproductive Endocrinology

Undue Burden Aborted

June 30, 2016 • By

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.

Reproductive Endocrinology

Olympic Sized Concerns over Zika

May 31, 2016 • By

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.

 

Reproductive Endocrinology

Why Biology is Destiny in a Republican World

March 31, 2016 • By

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.

Reproductive Endocrinology

Mosquitos and Reproductive Ethics

February 29, 2016 • By

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.

Reproductive Endocrinology

Planned Attack on Women’s Reproductive Healthcare

September 30, 2015 • By

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.

 

Reproductive Endocrinology

Preimplantation Genetic Diagnosis: Safe Sex in a Gattacan World

July 24, 2015 • By

Earlier this month, 60 Minutes re-broadcast a segment called “Breeding out Disease” which discussed the ethical implications of preimplantation genetic diagnosis (PGD), a technique already in use for several adult onset diseases. You can watch the segment here: http://www.cbsnews.com/news/breeding-out-disease/

This aired a day after Independence Day, perhaps to imply the ultimate in reproductive freedoms and procreative liberty. The ASRM Ethics Committee endorses the use of PGD for adult onset disorders in its 2013 Opinion under certain conditions, which most bioethicists would agree with (see: “Use of PGD for Serious Adult Onset Conditions” here: https://www.asrm.org/EthicsReports/).

But the recommendation by the experts interviewed for the 60 Minutes segment goes farther: that natural breeding should be discouraged in favor of using PGD to breed out known genetic diseases. Lee Silver, Co-Founder and Chief Science Officer of GenePeeks, stated: “ I see a future in which people will not use sex to reproduce. That’s a very dangerous thing to do.” This certainly puts a new spin on the term “safe sex”.

For years, I’ve been teaching the 1997 film, Gattaca (http://www.imdb.com/video/imdb/vi3722551321) as a springboard to discuss the unintended ethical, legal and social implications of “breeding out” natural breeding. In 1997, Gattaca spoke to cultural anxieties about the new reproductive technologies that were defining reproduction for millions, particularly in the areas of sex selection. The film was released before the complete mapping of the Human Genome. Here is the original 1997 New York Times review on the film’s release: http://www.nytimes.com/movie/review?res=990DE4DD103EF937A15753C1A961958260

The slippery slope is that PGD could become eugenics “on steroids” once breeding out “undesirable traits” is on the menu. Endocrinologists are already familiar with parents who insist on medically inappropriate growth hormone so their children can be taller. What happens when we can identify specific genes on the autism spectrum? Would we be breeding out future Newtons, Einsteins, or Edisons — all reported to have had Asperger’s?

We already have a society in which the poor die of preventable diseases (note how many cases of renal failure are related to untreated and undiagnosed Type 2 diabetes). Imagine how the gap could widen where half the world selectively breeds using PGD and the other half throws the genetic dice through natural breeding (often unintended). That dystopian world may be closer than we think.

It’s certainly easy to see the benefits of preventing a harmed life; some bioethicists have argued that in select cases, it may even be “unethical” to have a baby if you’re knowingly passing on a terrible disease. In the endocrine world, PGD can have vast implications, including breeding out identified RET mutations in MEN 2 families (See Recommendation 12 in the 2015 MTC guidelines: http://online.liebertpub.com/doi/abs/10.1089/thy.2014.0335).

The President’s Commission on Bioethics provided an opinion on PGD in 2004:

https://bioethicsarchive.georgetown.edu/pcbe/reports/reproductionandresponsibility/chapter3.html

This  opinion stands the test of time: “Biology is not destiny…The ability to affect the genetic make-up of the next generation may also exacerbate the tendency to assign too much importance to genetic make-up, and so may promote an excessively reductionist view of human life. These new practices may lend undue credence to the notion that human characteristics and conditions are simply or predominantly genetically determined—a too-narrow understanding of human freedom, agency, and experience, and a simplistic understanding of human biology.”

Reproductive Endocrinology

Leggo My Embryo: It’s Not a Frozen Waffle, but a Potential Person

May 11, 2015 • By

Endocrinologists are very familiar with Sofia Vergara, who is the Spokeswoman for a major brand of levothyroxine sodium, after her total thyroidectomy for thyroid cancer:
http://www.huffingtonpost.com/2013/04/17/sofia-vergara-thyroid-cancer_n_3103089.html

But her thyroid gland is not the only thing that’s out of her body.  She’s making bigger news in an unusual reproductive ethics case surrounding ownership of frozen embryos she created with her ex-fiancee, Nick Loeb. Recently, the issue aired on the Today Show:
http://www.nbcnews.com/news/latino/what-are-legal-issues-around-nick-loeb-sofia-vergara-embryo-n355881

The law is clear that embryos are not legal persons, even when created by celebrities. Personhood occurs at birth. But there is such a thing as “embryo patienthood.” This is a concept that grew out of the “fetal patienthood” framework developed by bioethicist Lawrence McCullough and OBGYN, Frank Chervenak.

So what is the moral status of frozen embryos? It all depends on whether they are patients.  McCullough and Chervenak assert that patienthood status is determined by the parents. If the embryos are intended to be future children, they are patients to which physicians owe beneficent-based obligations. If they are not presented as patients, they do not need to be morally considered.

But what happens when paternal and maternal interests clash? When Dad says the embryos are patients, and Mom says they are not? Reproductive endocrinologists need to ensure their couples have clear Advance Directives before creating potential persons. In the same way that we advocate for Advance Directives for End of Life decisions to avoid family conflicts over dying patients, we need Advance Directives for Beginning of Life decisions, too.