SCOTUS, Roe, Reproductive Rights, and All Our Freedoms: We must act

 

Politico, and now other outlets such as the NY Times,  have reported on a 98-page draft opinion from the Supreme Court that, in no uncertain terms, overturns both Roe v Wade and Casey and removes federal protection for abortion rights. While it is true that this is a draft and individual justices’ final decisions could change, the fact that 5 of the justices (Alito, who wrote it, Thomas, Gorsuch, Kavanaugh, and Coney Barrett) signed on to it makes it unlikely that the final decision will change. The only uncertain vote is that of Chief Justice Roberts, but he is no longer the swing vote he once was; the only difference is whether the vote to say that women have no Constitutional right to control their own bodies would be 6-3 or 5-4.

And, absolutely, let us be clear: that is what overturning the 50-year old Roe decision would mean, that the majority of the justices on the Supreme Court will have ruled that the control over a woman’s body, on whether she has to continue a pregnancy regardless of the circumstances, is in the hands of others. It may be Congress, state legislatures, governors, husbands or other relatives, churches that they may or may not belong to or believe in, petty pettifoggers, vicious misogynists, non-vicious misogynists (?), and folks with their own right-wing agendas, but not the women themselves. When Roe was decided, Justice Blackmun, who wrote the opinion, said abortion should be a decision made by a woman and her doctor. That was itself a bit paternalistic, but it was 50 years ago; I think the way that still should be read is “with adequate medical advice”, understanding the potential (or likely) risks involved in the decision that the woman makes. And ONLY the woman whose body involved should be able to make!

The majority of justices on the Supreme Court obviously do not believe this, along with a substantial minority – but definitely a minority – of the American people (most polls put support for Roe at about 70%). Their anti-abortion movement, well funded by multi-millionaires and billionaires, and supported by both the Catholic Church and many fundamentalist Protestant sects, seems to have finally won their cause after 50 years of reactionary fighting to impose their will on everyone else. It is a coup, be certain of that. It was, most immediately, made possible by the fact that Donald Trump got to name 3 Supreme Court justices, through the hypocritically evil behavior of Mitch McConnell the GOP Senate majority, which decided both to block President Obama’s appointment of Merrick Garland, not even holding hearings, 9 months before his term expired, and then approving Trump’s appointment of Amy Coney Barrett just weeks before the election he lost! This alone should be enough to make everyone who cares about reproductive rights, women’s rights, LGBTQ+ rights, voting rights, any rights, pull out all stops to make sure that the predicted Republican victory in November does NOT happen, that McConnell (and I make no analogies since anything you might compare him to would be insulted by the comparison) does NOT again become Majority Leader. The Democrats are far from perfect, but every justice who voted to repeal was appointed by a Republican, and it was the Republican majority in the Senate that facilitated the appointment of the last three. The SCOTUS opinion will say that the decision is Congress’ and there is no possibility that legislation maintaining women’s rights will get 60 votes in the Senate, or even 50 given Joe Manchin. The pundits and pollsters are all predicting a big INCREASE in GOP seats in November. Unless we do something about it.

Make no mistake: this SCOTUS decision is that the opinions of some people are worth more than the lives of others. No one who is opposed to abortion has ever been required to get one by the decision of Roe. Of course, there were many “mental disabled” people or others judged incompetent who were required to get them in the past, vicious abuse in itself. Ironically, the issue is that the same logic is now being applied to ALL women; they do not have the Constitutional right to make their own decisions about their own bodies.  As Susan Matthews in Slate writes, Justice Alito could not find a justification for the right to abortion in the Constitution because “The Constitution was not written for women”. It didn’t even give them the vote!

Although it does not change the core issue, the choice of words in the debate has been unfortunate; anti-abortion people use the term “murder” of “babies” while abortion rights advocates have used the term “choice”, as if it were a matter of convenience, or what color bedspread to get. It isn’t. It is about the decision to carry a pregnancy, something that is medically risky even in the lowest risk people (but a risk that most people who want to have a baby gladly accept), to give birth, to probably raise a child, to completely change their life, to possibly be unable to care for already-born children, to give birth to a child of a rapist (perhaps incestuous rapist), to give birth to a child already unable to survive because of genetic or other malformations occurring in utero, etc., etc., being only the right of the woman who is pregnant, and not that of anyone else. Consulting them – family, friends, doctors, is fine, but the decision needs to be that of the woman alone, not the state legislature.

This decision, if it stands, will not end abortion in the US, as it will send us back to pre-Roe times when the decision was left to the states (indeed, several states had legalized abortion before Roe). So, abortion will likely remain legal in states like NY, CA, MA, IL, etc. But other states, including of course TX and FL, which have already passed draconian restrictions on access to abortion, will almost undoubtedly make it illegal again, along with many others. It has been estimated that abortions will decrease by 14% (“only”) but if this is true, it has to be taken in the context of geographic access. Women with money from TX, FL, and other states that severely limit access to abortion may be able to travel to another state, but poor women, on whom the burden always falls the hardest, will find it much more difficult or impossible, as will teenagers, including those who are pregnant as a result of incestuous rape (see “Who gets abortions in America”, by Sanger-Katz, Miller and Bui, originally published in the NY Times Dec 21, 2021 and republished on May 3, 2022). Health and healthcare are already incredibly inequitable in the US, and this decision will make it much worse. Jill Filipovic, writing in Substack, provides a number of other concerning likely outcomes,  including that there will be a 21% increase in maternal mortality!

And if that were not enough – more than enough – to get your blood boiling,  get you out to the streets, the likelihood that this will end with abortion approaches zero. Many of the opponents of abortion rights also oppose other reproductive rights, including cheap and easy access to contraception and sex education in schools. This would be illogical if preventing abortions were truly their goal, as it is precisely access to these two factors that are universally associated with lower abortion rates – see ‘Scandinavia’. When abortions were illegal in countries such as Ireland, sex education and contraception were also severely restricted – and the abortion rate was higher than in say, Denmark. But the women receiving these abortions, illegally, were at much higher risk. These arguments, however, get little traction, since those who would restrict all reproductive rights are doing it for other reasons – maybe they hate sex, maybe they hate women, but they surely believe that they know better and freedom is not important to them. If this is hypocrisy – they will fight for the right to own and carry a gun or not wear a mask – hypocrisy is not important to them either.

And it will not end with reproductive rights and contraception. Certainly the rights of LGBT+ people will be even more infringed. And our rights to read books and have our children learn science and history. And our right to vote. Listen to the far-right carry on about restrictions on their freedoms, but think about the freedoms that are at the core of the US and on which we depend.

And most important, these are freedoms we can no longer can passively depend on. If you don’t fight for them, they won’t be there.

Killing our children: Guns, mortality and morality

There is really nothing to write about at this time other than the ongoing carnage in our nation as a result of angry young men (always men!) shooting up their schools, most recently (at least at the time of this writing) with the death of 17 students and teachers at Marjory Stoneman Douglas HS in Parkland, FL. It is hard to write through the tears. This should not be going on. Many people have written pieces on the subject -- sad, or angry, or articulate, or all of these. One of the most moving appeared in the New York Times on February 18, 2018, by a man named Gregory Gibson whose son was killed in a school shooting 25 years ago. The online headline, “A message from the club no one wants to join”, is different from, and in this case is much weaker than, the print headline: “Why wasn’t my son the last victim?”

Why indeed? Twenty-five years ago. And since then, countless school shootings, and other mass murders (such as, if we needed reminders, the Las Vegas country music concert, the Pulse nightclub in Orlando and the First Baptist Church of Sutherland Springs, TX) have occurred, and every parent, every family member, wants to know why the most recent prior child to die was not the last, instead of their child. People are terrified; a friend, a rational physician, embarrassedly admits to looking online for Kevlar backpacks for his children. He does international “mission” work and is taking his 14-year old daughter to Africa; when people ask him if he is worried about her safety there, he says “no”, but he is worried about her safety attending school two miles from his home in an affluent suburban community in the US. His day job includes being a leader for the quality program in his hospital, where he searches the actual data for root and contributing causes to problems; he wonders why this country cannot do the same for gun violence. Arizona Star columnist Dave Fitzsimmons expresses similar fears for his children.

This country could, but so far it shows no sign of doing so. Gibson quotes the author Chester Himes commenting on the lynching of 14-year old Emmett Till in 1955 that “The real horror comes when your dead brain must face the fact that we as a nation don’t want it to stop.” Himes was talking about lynching, but it is clear that the same can be said today, more than 60 years later, about school shootings. We don’t want it to stop. Because, if we did, we would do something about it.

Of course, we do, most of us. Various surveys, asking the question in different ways, find different percentages, but always large majorities, of Americans want stricter gun laws, often up to 90%. Even most people who are members of the NRA and/or are registered Republicans want limitations on who can buy guns based on mental illness and other criteria (always “me, and people like me”, but not the people like you) and some kinds of guns or gun modifiers (like “bump stocks”, used by the Las Vegas shooter to turn his AR-15 semi-automatic – and by the way almost all these shootings involve AR-15s) and armor-piercing bullets. No, the “we” who don’t want to stop it, in this case is, beyond a small minority of zealots, the even smaller minority of those who are politicians, in Congress, in the Executive Branch, and in our statehouses.

Why would they do this? Or, rather, not do anything about gun violence? Well, there is a small minority of this small minority who are, themselves, zealots whose interpretation of the Second Amendment is such that our dead children are just collateral damage in pursuit of the higher cause of unrestricted gun ownership. But, for most, opposition to even the most rational restrictions is tied to money, specifically to money from the NRA. A staffer for Jimmy Kimmel, Bess Kalb, looked at how much each of the Senators and Congresspeople tweeting their sadness and condolences took from the NRA, noting that “In the 2015-2016 election cycle alone, GOP candidates took $17,385,437 from the NRA,” (quoting a tweet from Republican National Convention chairwoman Ronna Romney McDaniel), and that “This is NOT counting the $21 million given to President Trump.” Another article documents the individual contributions, led by $4.4 million to Thom Tillis (R-NC, or, excuse me, R-NRA).

These legislators, and sadly even the President, when not crying their hypocritical crocodile tears and then voting with the NRA to kill any sort of gun reform, talk instead about the need to focus on mental health. This, by the way, is a good idea; the mental health system in this country is terrible; insurance companies cover it inadequately, those who are not insured and need public facilities find them cut back yearly, and there is no shortage of news stories focusing on a poor mentally-ill person pushed out of a treatment facility found wandering the street, or worse. Our jails and prisons have become our new mental hospitals, documented, for example, in this comprehensive Atlantic article from 2015, “America’s largest mental hospital is a jail”. However, it is not the diagnosed mentally ill who commit these murders and mass murders. Most such murderers do not have a diagnosis, although they probably suffer from “anger management disorder” (not in the current Diagnostic and Statistical Manual for Mental Disorders (DSM-IV), but “intermittent explosive disorder“ will be in DSM-V). This is important because it is the angry who commit these murders. An article in Slate by Laura L. Hayes from 2014,”How to Stop Violence; Mentally ill people aren’t killers. Angry people are”, contains this persuasive data:

80 to 90 percent of murderers had prior police records, in contrast to 15 percent of American adults overall. In a study of domestic murderers, 46 percent of the perpetrators had had a restraining order against them at some time. Family murders are preceded by prior domestic violence more than 90 percent of the time.

Hayes concludes that “Violent crimes are committed by people who lack the skills to modulate anger, express it constructively, and move beyond it.” Sadly, this also describes many of the most virulent opponents of gun control.

If anything could be even more sad than the fact that the mass killing of our children is tacitly endorsed through inaction by our political leaders, it is that it is only one face of the epidemic that is child mortality in the US. This January, Ashish P. Thrakar and colleagues published “Child Mortality In The US and 19 OECD Comparator Nations: A 50-Year Time-Trend Analysis” in the journal Health Affairs. The picture was bleak. The first sentence of their Abstract summarizes their findings: “The United States has poorer child health outcomes than other wealthy nations despite greater per capita spending on health care for children.” Guns are part of it, and the “social determinants of health”, a sanitized way of saying that in the richest country in the world there are millions of children with inadequate food, housing, warmth, safety, healthcare, and educational opportunities, are ultimately the other causes. We may be the richest country in the world, but we are also the most unequal in the developed world, and the increases in the wealth of the top 0.1% does not “trickle down” to those in need.

Indeed, even the outrageous and disproportionate child mortality rates in this country are not the whole story. As I have noted before (Rising white midlife mortality: what are the real causes and solutions?, November 14, 2015; Tom Petty, the opioid epidemic and changing structural inequities in the US, January 23, 2018) the US is the only wealthy country in which mortality rates are rising, a completely shocking finding since, of course, it didn’t used to be true. And this rising mortality is driven by the white non-Hispanic population (although, it must continue to be said, that the absolute mortality rate of minorities, and especially African-Americans, still exceeds that of whites), and more particularly, poor whites.

In a terrific effort to try to explain to the international community what is happening in the US, Steven Woolf recently wrote an editorial for the BMJ, Failing Health of the United States. He notes the causes of the increases in mortality (more than opioids, more than guns, although these are major contributors), provides data, and proposes solutions. “In theory,” he says,

…policy makers would promote education, boost support for children and families, increase wages and economic opportunity for the working class, invest in distressed communities, and strengthen healthcare and behavioral health systems.

Politicians need to address these issues, and they need to be made to do so. By us, the people they are supposed to work for, not the huge money contributors like the NRA. But we can only do this if we stay angry, and stay organized. We cannot heed calls to “not talk about this now” while families are grieving, because it will, based on history, not be very long before it happens again.

It is our job and we must take it on. 

President Bush's stent: inappropriate screening and care for the rich, nothing for the poor

One of the recurrent themes of this blog has been the importance of everyone having access to necessary medical care, and how the US compares poorly to other developed countries in that it does not cover everyone. Another recurrent theme has been that many medical procedures are unnecessary, sometimes even harmful, but are nonetheless provided to people who have the money or insurance to pay for them. This is not to say that greed is always the motivator; there is a powerful, if often incorrect, belief that to do something is better than to do nothing.

In this context, it is interesting to read “President Bush’s unnecessary heart surgery”, a Washington Post “Viewpoint” by Vinay Prasad and Adam Cifu published August 9, 2013. As part of his “annual physical”, the former President  (who is “…widely regarded as a model of physical fitness”), received, in addition to (presumably) the screening tests and immunizations recommended by the evidence, a cardiac stress test. Discovering an abnormality on that test led to his having a CT angiogram and finally placement of a cardiac stent.

One interpretation of this story might be “he’s lucky they did the test; they found something wrong and fixed it”. I’m afraid, along with Prasad and Cifu, that this might be the lesson taken from it by many people, and the result could be more people requesting such a test because, “hey, they found something wrong with President Bush – could I also have such a problem?” This would be unfortunate, because it is incorrect. President Bush – based on the information provided – should not have had the stress test and not have had the stent placed.

The key point is in understanding that he was (by all reports) asymptomatic. “Before he underwent his annual physical, Mr. Bush reportedly had no symptoms. Quite the opposite: His exercise tolerance was astonishing for his age, 67. He rode more than 30 miles in the heat on a bike ride for veterans injured in the wars in Iraq and Afghanistan.” While the definition of screening tests is that they are done on asymptomatic people, there are a number of criteria that have to also be present, among them that the test should detect a condition before it is symptomatic, and there should be an intervention that will prevent progression if disease is discovered. So, isn’t that true in this case? He did have the disease, a narrowing in one of his coronary arteries, right? So isn’t it good that it was discovered.

As Prasad and Cifu discuss, however, there is no evidence that stenting a coronary artery prolongs life.  “It is worth noting that at least two large randomized trials show that stenting these sorts of lesions does not improve survival.” Even for higher risk patients than Mr. Bush, survival is not increased. However, if people have symptoms of chest pain that appears cardiac in origin, for whom stress testing may be indicated (not a screening test now; they are symptomatic), treatment by angioplasty, stenting, or even bypass surgery can ease or relieve the pain. That is a good thing. But for Mr. Bush, who had no pain, there can, by definition, be no pain relief. There was some additional risk, however; in addition to the inherent low risk of doing the procedure (such as bleeding and stroke, and even, rarely, death), he now has to take anti-platelet drugs, which also confer some risk. And a stent only holds open the spot it is in; it does not prevent progression of coronary artery disease elsewhere.

The larger issue of the “annual physical” (which I have addressed previously in “ The "Annual Physical": Screening, equity, and evidence”, July 4, 2012, citing Elizabeth Rosenthal’s NY Times article “Let’s (not) get physicals”) was again the subject of a popular article, “The case against the annual checkup” by Brian Palmer on Slate.com on August 20, 2013, which states: “There are two kinds of arguments against the adult annual health checkup. The first has to do with the health care system overall, and the second has to do with you personally.” Palmer does add that

“It’s important to separate preventive care from annual checkups. Only one-half of annual checkups actually include a preventive health procedure such as a mammogram, cholesterol testing, or a check for prostate cancer. (Annual gynecological visits are excluded from these numbers, although the evidence supporting those is not particularly overwhelming either.) More importantly, only 20 percent of the preventive health services provided in the United States are delivered at annual checkups.”

He has a pretty good point, although he includes prostate cancer screening, which is not recommended or beneficial, in his list, something Prasad and Cifu do not. But I would take issue with his suggestion that you only visit the doctor when you are sick, which is in fact when doctors tend to work in the preventive services the other 80% of the time.

There are a couple of reasons for this, but the main one is that there are a lot of people (even older people at higher risk) who do not get sick, or at least sick enough to decide to come to the doctor, or at least sick enough to decide to take off from work and maybe lose income to come to the doctor. And they could benefit from preventive care as well. The list of preventive services changes from time to time, which it should as new evidence emerges, but includes immunizations, screening, and education. The list of conditions for which screening is effective and recommended by the evidence is relatively short (despite our natural desire to have more, more effective, tests) and does not include prostate cancer or ovarian cancer (thus, no reason for an asymptomatic woman to have a “routine” bimanual pelvic exam), but does include Pap smear for cervical cancer, colorectal cancer screening (which can be done with colonoscopy or regular stool screening for occult blood), bone density screening for certain age groups, and mammography. There are also recommended screening for other conditions: hyperlipidemia (mainly cholesterol), abdominal aortic aneurysm (once, in men over 60 who have smoked), HIV and Hepatitis C, as well as some screens for people who are themselves asymptomatic but whose family history places them at higher risk for a condition (e.g., diabetes). (See the Guide to Preventive Services 2012, Recommendations of the US Preventive Services Task Force, on the website of the Agency for Healthcare Research and Policy.)

Immunizations include not only annual influenza shots, but also less-frequent pneumococcal vaccine and tetanus/diphtheria/pertussis boosters, which are often not up-to-date in adults. Education may be the most important: counseling on diet, exercise, smoking, alcohol, drugs, and risk behaviors, as well as identifying victims of violence (domestic or otherwise) should not wait until these conditions have resulted in symptomatic disease.

Perhaps these preventive services should not be “annual”; there is no magic to this number, but it was chosen because it is easy to remember. Certainly many of these preventive services (now including Pap smears, bone density and mammograms) are recommended less frequently than yearly. Perhaps they can be as well delivered by other health professionals as by physicians. But there is benefit to preventive care even for asymptomatic people, and not the least is noted by Palmer: “They build relationships between doctor and patient, and open lines of communication are important in medicine.”  Yes, there are certainly many risks, which I have often pointed out, to over-testing and over-medicalization. But there are also risks to not having preventive care. And, of course, the key point here is equity: those most at risk of “too much” care and too many interventions are the more well-to-do, well-educated, and well-insured. Those most at risk of too little care, too little screening and immunization and education about how to reduce their risks and early identification of disease are the poorer, less educated, and uninsured.

The fact is that health care, like most things in our society, is very different for different socioeconomic classes. Cautioning against overuse by the privileged is one thing; being sure that this does not bleed into justifications for limiting access to necessary care for the less privileged is quite another.