The Texas Abortion Law is contrary to women, to science, and to human values

The new Texas abortion law and the Supreme Court tacit endorsement of it is the latest (as of this writing – there will be more!) assault on science, medicine, and the will of the people, in an almost unbroken string of such actions. Another example of this process is the effort to spread COVID by opposing mandates for masking, vaccination, or social distancing, under the pretense of “individual liberty”, by a variety of jurisdictions, mostly at the state level and mostly in Republican-controlled states.

First, a quick review: the Texas law prohibits abortions after 6 weeks without exceptions for anything, including rape and incest, or ability of the fetus to survive outside the womb. It employs a cute (in the sense that the term “cute” can be applied to, say, a giant, mean, ugly, evil, violent ogre) trick to try to get around potential lawsuits that would be based on fact that the Roe v. Wade decision gives women a Constitutional right to abortion. The law does not mandate that state officials enforce it. Instead, anyone, from any state, is empowered to be a “whistleblower” and turn in anyone enabling the abortion (doctor, nurse, counselor, taxi driver) with the potential reward of $10,000 (from the state, of course) if successful.

Neat, huh? The Supreme Court majority thought so too, and, using another trick (called the “shadow docket”) declined to invalidate it. This method obviates the need for a hearing, presentation of arguments on either side, questions from the justices, and thought-out opinions which present the reasoning of the majority and the dissenters. It thus does not require the identification of those voting in the majority (we only know in this case that it was 5-4 and who the 5 and 4 were because each of the 4 issued their own dissenting statement). It also does not allow the lower courts to know what the reasons and arguments were, resulting in inconsistent interpretation of the decision by those courts. This, of course, was on purpose. Justice Sotomayor (one of the 4) put it succinctly “The court has rewarded the state’s effort to delay federal review of a plainly unconstitutional statute, enacted in disregard of the court’s precedents, through procedural entanglements of the state’s own creation.”

Several of the justices who created this problem have defended their action, and Justice Alito, in a speech at Notre Dame, not only defended the shadow docket but portrayed himself and the other members as the actual victims. This is another neat trick, which has been employed by the right, including former president Trump, and billionaires and corporations who have been criticized for such things as underpaying their workers and not paying taxes. The best defense, it is said, is a good offense.

 Let’s review the science:

1.      a large percentage of pregnant women do not even know that they are pregnant, particularly if they usually have irregular periods, before 6 weeks,

2.      the assertion in the Texas law that the fetus has a heartbeat at 6 weeks, thus why they chose that timeframe, is incorrect. In fact, the embryo is not even a fetus at 6 weeks.

There is in fact a lot more relevant science, but let’s move on, since the science is only an issue for those of us who believe in it.

The reason for the restrictive abortion law in Texas (and all the other states’) is not in the least because they have any respect for science or medicine. For different individuals, of course, there are different reasons. For some it is because of their religious beliefs, Catholic or otherwise, that all life is sacred and thus abortion is murder. That this may result in the death of the mother, or that it should then require the same level of commitment to helping the parents ensure that children have a reasonable chance at life (housing, food, clothing, education) may be positions supported by some Catholics, including the current Pope, but is not a corollary of opposition to abortion for most of these people. This is important, because in the case of taking a human life by say, murdering them with a gun, the public is not empowered to sue anyone who might have enabled them, like the gun dealers or manufacturers.

For others, the abortion restrictions are, explicitly or not, about restricting the rights of women and relegating them to their place. This is so essentially the results of such laws and policies that denial of it is virtually always disingenuous. Even those who take the “life is life” Catholic anti-abortion position find themselves in this situation (arguably, this position on women is part of the justification by an entirely male-run church). None of these laws or policies create any penalty or responsibility for the male whose role in creating the pregnancy was central. And 100% of unintended pregnancies are directly caused by men.

Finally, the reason for these laws is political. They garner support for a generally right-wing, pro-corporate political agenda from those who would not support it as such. This trend has always been part of US politics, but more explicitly so since Richard Nixon. Ultimately, of course, whatever the ostensible position of any individual is, the issue is essentially about politics. You put together a coalition, and then you implement the laws you want to. Make no mistake, this is what it is about. Nationally, a large majority of Americans oppose overturning Roe v. Wade (about 60%). In individual states, it may differ. A good history of the right-wing of the GOP looking for an issue that would mobilize the evangelical community in support of them, and their segregationist, pro-corporate agenda, is found in a recent issue of Politico. Abortion turned out to work after other issues didn’t, despite evangelical ambivalence on the issue at the time.

For nearly two decades, [right-wing activist and segregationist Paul] Weyrich, by his own account, had been trying out different issues, hoping one might pique evangelical interest: pornography, prayer in schools, the proposed Equal Rights Amendment to the Constitution, even abortion. “I was trying to get these people interested in those issues and I utterly failed.”

To the extent that the Texas anti-abortion law is about a rejection of science to achieve a political or religious or misogynist agenda, it is not entirely a separate issue from COVID and opposition to mask or vaccination or distancing mandates. The politicians want what they want – mainly power – and are willing to pander to whoever to get it, even fomenting anti-science agendas. Truth no longer matters, and it has gotten beyond an abstract concept to the point where people are dying, and yet others are still unwilling to believe in the cause-and-effect. A recent article in Rolling Stone notes that in parts of Oklahoma, hospitals are not only full of people with COVID and its complications but with people who are overdosing on ivermectin, an anti-parasitic drug that has widely -- and falsely – been promoted as a treatment for COVID. Since ivermectin requires a prescription for people (and it is indicated for certain kinds of worm infestations and actually does work to treat scabies), people are buying it at feed stores where it is sold for deworming horses! If the RS article is correct, many of these hospitals are even too full for gunshot victims!

COVID is a virus, and one that mutates and evolves (whether you believe in evolution or not) and can create more dangerous strains like the Delta variant. It is infectious. Immunization offers great, if not perfect protection; while it is possible to get infected after being immunized, it is less likely and, more important, it is much less likely that you will be hospitalized, ventilated, and die. This is  a fate reserved almost exclusively for the unvaccinated. Masks do help, although they are better at protecting others from being infected by you than protecting you from others – this is why OTHER people wearing masks makes a difference. This is science. On abortion – a “6 week” pregnancy is measured since the last menstrual period, which could easily mean 4 weeks since ovulation, 2-3 weeks since fertilization, and less since implantation, not to mention a positive pregnancy test. A very high percent of women don’t yet know that they are pregnant.

Scientific answers are arrived at through experimentation and re-experimentation; “truth” changes as more information becomes available. It is messy, not simple and easy to understand like a “belief”, or something you read on the internet. If it is one-dimensional and simple it is probably wrong.

But more important, it is usually out there to accomplish another agenda.

"Inconvenient truth", science, politics and USPSTF

There are a lot of things that we can expect to be different in a Trump administration, not only than in the Obama administration but even compared to that of G.W. Bush (my previous gold standard for irrational and right-wing policies). Many of these are important, and dangerous, but are arguably political, such as the change in our relationships with other countries (Russia, China, Europe, Israel). However disastrous these policies will be for people in the world (say, Syria) and even possibly destroy the world (nuclear weapons), they proceed from a different political perspective. Also arguably political will be the domestic changes, in the rights of LGBT citizens (such as marriage, use of restrooms), and access to reproductive health services for women, not only abortion but even contraception. The impact on people will be horrific, but it derives from a different perspective (admittedly one that completely devalues huge numbers of people; majorities in the case of women and non-wealthy people).

There will be other changes, however, that proceed from a rejection of science, or of what Al Gore calls “inconvenient truth”. Clearly the biggest one is the one that Mr. Gore was speaking of, global warming, because this will eventually destroy the planet. Maybe later, as we have already been so slow in implementing limits on warming. Maybe sooner, if his climate change deniers have their way. The title of Mr. Gore’s film has several meanings; it is “inconvenient” for all of us to try to find ways to use fossil fuels less rapaciously, but it is a financial issue for others. I am not talking about the coal miners who will lose their jobs; that is going to happen anyway. I am talking about the Captains of Industry, who, unlike the miners, will never be anywhere close to poor but have the possibility of making fewer billions if we seriously address global warming. Oh, the horror!

While of course the destruction of the environment is a health issue, there are also more prosaic health results from those who will try to make policies, or pass legislation, that benefits themselves or their friends and contributors at the expense of truth. Certainly we have seen this regarding reproductive health for years, especially at the state level, where laws restricting women’s access to abortion (targeted regulation of abortion providers, or TRAP, laws) have been based on what might be generously called phony science, or, more correctly, lies. These have included fetal pain syndrome, need for facilities appropriate for major surgery, need for admitting privileges for doctors doing abortions, excessive waiting periods,  and other made-up justifications for doing what legislators really wanted to do – restrict access to abortion. In Florida, a law was passed forbidding doctors from asking their patients if they had a gun in the home, meaning they couldn’t even have a discussion about how to keep them safe from their children accessing them.

So now we have the probability that Congress will be restructuring the membership of the US Preventive Services Task Force (USPSTF) to include more specialists on a body largely made up of primary care doctors and epidemiologists. The goal of the USPSTF is to dispassionately and objectively evaluate the evidence for the effectiveness of tests and procedures aimed at preventing disease. It gives ratings in easy to understand letters (A,B,C,D,I ) that are not based upon the opinions of the task force members but on the actual data. Unfortunately, this doesn’t always make providers happy; if you provide a service (say, mammography for breast cancer screening) on which you make money, then a recommendation that says it doesn’t need to be done quite so often hits you where it hurts – in the pocketbook. So you might come out against it. And while advocacy groups may not have the same direct financial interest (although if you are such an advocacy group, contributions are usually closely related to how serious how many people think a problem is), it may challenge your long-held beliefs. And then, if you find some doctors who agree with you (for example, those whose income may be decreased) you are more confident you were right.

But the goals of USPSTF recommendations is to synthesize the existing data and base their recommendations on that, not to reach “compromise” between those who want something done more (because they are “true believers” and/or have a financial stake in it) and those who believe it is unnecessary cost with little or no benefit and potential risk. This is why it is not necessary to include specialists on these panels because of their “expertise”. Other scientists can interpret the data accurately; a panel reviewing the data on, say, the frequency with which mammography should be performed in a particular population does not need mammography radiologists and breast surgeons to understand the research. This is not to say that such specialists are inherently biased and shouldn’t be on USPSTF; they could be as objectively good scientists as others. But it is to say that the reason being put forward for them being added to the panel – that they are ‘experts’ in the topic – is wrong. They should not bring their experiences and expertise to ‘balance’ the data. They should be guided by it.

It is not necessarily true that expert specialists are purposely obtuse, that they will advocate for recommendations that will make them more money. It is also true that their perspective is skewed by the populations that they see. Specialists see people with a disease, which is a selected population. Screening is, by definition, testing people who are asymptomatic and are statistically unlikely to have the disease. Therefore different standards are applied for screening asymptomatic people (say, all adult women between 50-75 by mammography) and for following up people previously diagnosed with breasts cancer, or those who are at higher risk (defined as a first-degree relative, mother or sister, with breast cancer, not a great-aunt). And, of course, doctors are not necessarily above advocating for laws to keep their incomes up. When, about 20 years ago, the federal Agency for Health Research and Quality (AHRQ) recommended against a specific type of spine surgery because it didn’t help, was risky, and cost a lot, groups of spine surgeons tried to get that agency defunded! Oh, yes, and AHRQ continues to be threatened with funding cuts because special interest groups don’t like their findings!  With the ACA requiring insurers pay for any USPSTF recommendation with an “A” or “B” rating, the political pressure is on to get such recommendations, whether the data supports them or not. On the positive side, the American Academy of Family Physicians (AAFP) has come out against such stacking of the USPSTF.

Once, when I lived in a good-sized condominium, I was one of the few families with children, and it seemed like they and their friends were often harassed for violation of (sometimes) condo rules and (more often) an individual’s belief of what should be a rule. Even the rules, however, were often, in my opinion, unreasonable; I thought the condo association rules should protect our investment and our safety, but should not be just anything 51% of the owners wanted. On the positive side, while they may have inconvenienced me and my family, they did not try to overrule natural law or science. The same cannot be said for current federal, state, and local efforts to make a law about anything they want to be true. They cannot make global warming disappear by a law, but they can make it illegal! And they can violate the rights and human dignity of our people. And stack federal agencies with anti-science people or at least turn what should be scientifically-driven decisions into a political negotiation.

This is going to be a long battle. Those with money and power are entitled and feel that it is their right to stack the deck. Happy New Year!

The White Coat Ceremony: New medical students and hope for the future

.
I recently attended the “White Coat Ceremony” for entering medical students at the University of Kansas School of Medicine. The entering class, having completed their week of orientation, is welcomed to the school by its dignitaries in front of an audience of their families, friends and loved ones. Then each student walks to the stage while his/her name and hometown are read, and has a white coat placed on them by a member of the faculty. They then take an “Oath of Commitment” (different from the “Oath of Hippocrates” they will take at graduation) and at the end, in a semi-joke, told that “Classes start Monday at 9!”

Hokey? Well, maybe a little when it’s described, but very moving in person. Each one of the 175 people receiving the short white coat (traditional for students) is an individual person who has worked very hard to get there and they are (I assume almost all if not all of them) sincere and committed to helping people and making a difference. If studies have shown a scary drop in empathy in medical students in their 3rd year (Are we training physicians to be empathic? Apparently not., September 12, 2009), that is more than 2 years off. If long hours of classes and studying what will often seem trivia in the biomedical sciences scarcely related to being a doctor will fill most of those 2 years, it is not on the agenda today. Today it is about “keeping their eyes on the prize” but also recognizing it will be hard work. In the Oath of Commitment they pledge to work hard, to know their limitations and seek to learn enough to overcome them, and to be life-long learners. They say:

"I will strive to preserve the dignity, the humanity and the privacy of all my patients, and through my openness and kindness I will seek to earn their trust in turn.
I will treat my patients and my colleagues as my fellow beings and never discriminate against them for their differences; and I will ask that they do the same for me.”

This expostulation of altruism is, obviously, in marked contrast to the mean-spirited negativism that is characterizing the political campaigns of the day in Kansas (and elsewhere) that I recently addressed on this blog (The political campaign and the future of health reform, July 28, 2010), and criticized in the July 30, 2010 editorial in the Kansas City Star, which notes that, while Nancy Pelosi is not running in Kansas, candidates (mostly conservative Republicans) are attacking their primary opponents (mostly conservative Republicans) by calling them supporters of the Speaker, and even (gasp!) the President. In a few cases, such as the Republican primary for Secretary of State, Elizabeth Ensley, the well-qualified, highly-endorsed candidate surprises Star interviewers by "...blurting out 'I’m pro-life.' When asked what that had to do with the record-keeping office for which she was running, she answered, 'Well, nothing, but people always seem to want to know.’ Of course, Ensley could be forgiven for losing focus. Her GOP opponent, Kris Kobach, is trying to define the race as being about illegal immigration. It’s not.”

I really enjoy hearing where the students are from. Some are from surrounding states like Missouri and Colorado and Nebraska, some from farther away like California and New York, and even a few from other countries. But most are from Kansas, and from all over Kansas. Yes, there are higher proportions from the metropolitan areas of Wichita and suburban Kansas City; but also from the “larger” (for Kansas) cities like Lawrence and Topeka and Hutchinson and lots from places like Goodland and Oberlin and Neosho and Medicine Lodge, where maybe, if the people there are lucky, some of them will return to enter practice.

And then the “Doctor’s Notes”, the student a capella singing group, did a beautiful rendition of John Lennon’s "Imagine". It’s a very lovely song, and it expresses sentiments that are very different from those we are hearing on the local and national political scene. Worried about Nancy Pelosi? Barack Obama? They’re nothing but compromising politicians; our students sang Lennon’s lyrics:

“Imagine there's no countries
It isn't hard to do
Nothing to kill or die for
And no religion too,”

Not a position likely to garner a lot of votes in Kansas. I don’t know the politics of the students in the entering class, or their families, are, but having watched the volunteer work of their predecessors, in the student-run free clinic in Kansas City and in work around the world, I wouldn’t be surprised if many of them see some of their beliefs reflected in the verse that says:

“Imagine no possessions
I wonder if you can
No need for greed or hunger
A brotherhood of man
Imagine all the people
Sharing all the world...”

OK, maybe not the “no possessions” part, but caring for others part. And, if we are lucky, they will continue to care. They will maintain their empathy through the 3rd year of medical school and beyond. They will be life-long learners who care for people and about people, and live a life not simply of service, but of brotherhood. They will truly be healers, and not destroyers. It’s way too early to know, but we can hope that they will be.

Imagine.
.