Paternalistic Physicians

The Cleveland Clinic has recently begun successfully transplanting uteri (uteruses) into cis women who were born without them or whose uteri are damaged. This is super cool! It’s also risky, of course. It’s an organ transplant. Duh.

Doctors are ethically, morally, and legally obligated to make sure that any patient undergoing any procedure understands and consents to the risk. Furthermore, in order to have progressed to human trials, the procedure (inclusive of more than the surgery) has to have withstood a slew of scientific, moral, and ethical tests. The ongoing trial is, of course, subject to IRB protocol. The patients are required to complete extensive counseling before being green-lighted for the procedure. They’re also required to have a support network that can help them through the particular challenges associated with this option.

As a result, what this breakthrough is absolutely not is a chance for abusive or controlling husbands to force the surgery on their infertile wives, nor for mentally unstable women to act out body-dysmorphia-type desires to have a uterus or obsessive desires to bear children. (Read up if you want to fight me on the sufficiency of the protocols and I’ll happily hear you out on what could be improved.)

When news of this advance broke, my social media news feeds were mostly filled with positive reactions, including some women wanting to know if they can be live donors.

One person with whom I’m Facebook friends, however, posted a link to the NYT article with the accompanying text, “It’s called adoption.OUCH. But here’s the kicker: Dude’s in med school. (I have no idea what his specialty will be, nor do I know whether the other two women commenting are medical professionals.)

As someone whose own fertility status is unknown, but who has PCOS (unless I actually have endometriosis and they read the ultrasound wrong), I was… well, pretty fucking offended. This is definitely not purely theoretical to me. I commented on the status with a link to How Not To Be A Dick to Your Infertile Friend.

Thus started a thread of mansplaining, lulztastic “feminism,” and concern trolling. The TL;DR (though I very much encourage you to R) is that Dr. Phil and his friends think that they know better what women should do with their own bodies because they (Dr. Phil and friends) are educated enough to know that society exerts pressure on women in various ways (including expecting them to be maternal) and so no woman can be sure enough what her motives are when making family planning decisions. I will go so far as to say that there is no other logical extension of any of their arguments except that women cannot be trusted to make their own choices about their own reproductive health.

(I’m Ashley, in the pink, if you’re one of my, like, 3 readers who doesn’t know my name.)

Uteri

Adoption

Let me be clear: I think it’s fantastic when adoption is on the table. But sometimes, for financial, legal, or mental health reasons, it’s not the right choice for a couple or an individual. Trying to shame infertile or subfertile women into adopting instead of seeking out options that you consider radical or inappropriate in order to have a biological child is no less fucked up than society telling women that their value is in bearing biological children. Hell, it might be worse. This is not a discussion of society trying to force children upon women or couples who don’t want them, so, whether for their own, potentially acceptable (in the eyes of Dr. Phil and friends) reasons, or because of society, the women in question very, very much want children. A woman who only wants children because she internalized society’s expectations of her but who thinks these desires are now her own will feel no less distraught if she is unable to have kids for being told that her desires were influenced by society. The desire and the anguish are both givens in the case of the women who would be seeking out the transplant rather than, or in addition to, adopting. If they don’t want to adopt, however, then comments like those made by Dr. Phil and friends are absolutely are foisting a normative burden on them that basically says, “A good woman/feminist/human would want/do this (instead).”

Is adoption a moral good in the abstract? Yes. But no one gets to assign that moral duty to individuals. Just like donating an organ to someone in need is a moral good, but you cannot force a specific person to be a donor against their will [without accepting that you are obliterating their right to self-determination].

Self-Determination

This post would be even longer if I went comment by comment and point by point, plus, I’ve already made several arguments in the thread. My overall stance is this: You do not, especially as a doctor who potentially has the power to influence these things, get to concern troll a woman’s uterus. You just don’t. I don’t care what the Common Core taught you about oppression or how much de Beauvoir you read. If all the IRB protocols and extensive screenings would have cleared a specific woman for a procedure, but you won’t tell her about the possibility in the first place* because she may have internalized some societal BS and so she can’t be 100% sure of her motives, you are a paternalistic asshole. (Also, you probably shouldn’t practice medicine if you don’t trust medical ethicists.) If you have issues with the protocols, take them up with the appropriate persons and do not force your will on patients while lobbying for changes.

(*Dr. Phil, at least, conceded that he would tell his patients about the option. The other women took the more radical stances in the name of “feminism,” actually. Again, I don’t know whether or not they’re medical professionals.)

Paternalism

In my view, maximizing the self-determination of individuals is the only logically consistent flavor of feminism. It’s intersectional, it’s equally good for men, and most importantly, it’s free from paternalism. If thinking of paternalism as the natural enemy of feminism seems crazy and wrong to you, I would be fascinated to know what the hell you think feminism is.

I think that individuals (acting as individuals and not in a professional capacity, which I address separately below) are obligated not to limit the freedoms of others, with the moral burden to do so increasing with the import of the situation. For instance, stealing the last cookie is not the same thing as stealing someone’s identity and ruining their credit. Because they are “victimless crimes,” I believe that drug use, sex work, and a right to die should be legal, so long as the industries/pipelines are not coercive (big “if,” undoubtedly requiring regulation) and so long as no substantial harm is posed to others. If, for instance, you could demonstrate to me that specific drugs incline people toward violence, I might be inclined to say that the risk to innocents is too great to legalize those drugs. If you can show me that a plan to legalize sex work doesn’t sufficiently protect against girls and women from being coerced into sex work to meet demand, then I’d have a lot to weigh in deciding whether I support that plan.

In a world of maximized self-determination, will some people make the wrong choices for themselves? Absolutely. Will the world ever be totally free of coercion? Nope. Will everyone have perfect knowledge and understanding before making decisions? Clearly not. But so long as a person is past the age of majority (whatever society has deemed that to be, which may vary by circumstance), we have to trust individuals to make the right decision for themselves. Not all of them will, but how could you have known which ones would choose wrongly (and thus, some would argue, should have had their choices made for them) ahead of time? Where and how would you draw the line, beyond which someone is definitely unqualified to make decisions that affect them? IQ? Education? Personality test?

Under this paradigm, freedom from coercion and the knowledge to make informed decisions are paramount. In service of maximizing self-determination, I view any increase in the number of choices available to an individual as neutral or better, assuming no coercion. A proliferation of options that are strictly worse than those already in existence shouldn’t change outcomes.

It sounds to me like the pre-procedure screenings and protocols for the uterus transplant do an excellent job of making sure patients are informed and making sure they are not being unduly coerced (i.e. by more than ~Society~). Further, mental health is taken into consideration and, in the respect that one has to be able to understand the risks, the intelligence of potential recipients has a lowerbound. (To be perfectly frank, I have no idea how to ethically maximize self-determination in neurally diverse people and those with impaired or delayed cognitive function, so this discussion is not about them.)

Some Philosophy

Does this mean I think doctors or policymakers are morally obligated to be complicit in bad or harmful decisions so as not to limit self-determination? No, I think they are morally obligated to follow laws and guidelines as set forth to govern their actions as professionals.

This is a gray area, to be sure, but I think that the reason we allow paternalism in the form of laws, policies, and protocols is because (a.) those things have to be set in order for societies like ours to function at scale, and (b.) lawmakers, policymakers, and ethics committees are ultimately beholden to society. (I am of the opinion that the arc of the moral universe bends toward the greater justice.)

I’m not an expert on ethics, and certainly not on research and medical ethics. That said, I think that if society finds a lack of moral stringency in the protocols set forth by these bodies, the protocols will eventually change. That’s certainly the goal of those who lobby against animal testing. This requires transparency, of course. In other words, it requires access to knowledge and information; you could think of this as one of the prerequisites necessary for society’s self-determination, just as it is for individuals’.

It’s tautological to say that society tells members of society what to do. Thus it’s meaningless and idiotic to say that it’s bad that society tells society what to do. Especially when “society” is actually a large, messy, overlapping, contradictory set of in-groups and out-groups. (Back to individuals for just a second: You’d have to view an individual as the complete product of his/her tidy environment in order to think that he/she cannot make decisions for him-/herself in view of societal pressures. I honestly just don’t know what to do with anyone who thinks we lack free will.)

Okay, so society regulates the regulators. Is the status quo always right, then? Right for an individual? Right for a particular subset of society? On the right side of morality? Hell no. That’s why activism is a crucial part of democracy. I’ve written elsewhere that in the legal sphere, social movements are what happens when the spirit of the law does not resonate in the bosom of society. Attack the monolith of tradition and culture! But never force an individual to take up that mantel if they pose no harm to others. Educate, educate, educate, and do all you can to eradicate coercion, but then let individuals decide their own paths.

Paternalism in Medicine

Paternalism is all around us, so why I have I written an epic rant on this example? Easy: Paternalism (beyond regulations, etc.) in medicine is an undue abuse of power. It is coercion.

Some doctors think they know better than patients because they are smarter and more educated. Some doctors think they know better than patients even when they are less intelligent and less well versed on a particular topic. If you don’t believe me, look for cancer researchers who’ve had cancer and ask them about that experience. People like Stephen Hawking see doctors, too. In fact, he probably sees more than most. I’d be willing to bet that he’s perfectly capable of understanding as much as his doctor with regard to research and other knowledge that pertains to him. Is every patient Hawking? No. Is any patient’s IQ listed in their medical chart? Probably not. Do a lot of people think they’re smarter than their doctors who actually aren’t smarter than their doctors? These days, almost certainly. Regardless of intelligence, does being an expert in what it’s like to be you “count” in a medical context? Absolutely.

Paternalism in medicine says, “You’re a woman; your pain is exaggerated,” when a woman’s ovary is torsed. It says, “Every problem you have would go away if you lost weight,” in cases when that’s not true. And now it apparently says, “Society has brainwashed you, so you don’t know your own motives in wanting to have kids. Maybe this new, risky, arduous procedure shouldn’t even be presented as an option for you (pending tests and screenings) because I don’t trust you to make the right choice for yourself, even with safeguards in place.”

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