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Establishing the Problem: Texas Abortion Laws Marginalize Low-Income Women

It’s Sunday afternoon in a sleepy town in the Rio Grande Valley. By all accounts, it is a day like any other day. Quiet and somewhat removed from today’s advancing world, this place is the essence of anachronistic. Humid memories linger in the air and hopes of a better life line the weed-cracked sidewalks and narrow unpaved roads. Unused train tracks sit forgotten, overtaken by grass and brush. Dented signs, rusted by harsh years, stand on the corners forever offering direction. A dilapidated and empty corridor of houses tilts to stare at the ground as a teenage-painted water tower bows before the sky in the distance. Fresh yet dusty-faced children, invigorated by the freedom of the weekend, play a game of tag next to a field. Only a solitary fly appreciates their presence. A single engine plane flies over this nearly invisible spot of the world. As its relaxing buzz floats away, the machinery passes over a small house at the end of the street. Outwardly, there are no signs that anything is amiss here. If only reality were as simple as a game of tag.

Inside the house, a petite Hispanic woman lies supine and blood-soaked on the floor of her living room. As she glances around, perception skewed by position, she is filled with regret. A sudden realization that she might die flashes into her brain like a searing lightning strike. The sound of a clock echoes in her skull, an audible reminder that our time on earth is perilously finite. She has called an ambulance, but cannot shake the feeling of impending doom. Her heart pounds with the ritual, rhythmic dance of the second hand. As she listens to her time tick away, she recounts the events of the past 36 hours. It’s Saturday morning. The woman, driven by fear and desperation, has found herself at a flea market with a very specific goal in mind. She is not there for home furnishings, produce, or crafts. She watches families bustle about in slow motion around her. A child’s laughter in the distance becomes a mocking song. As she turns her intended purchase over and over in her trembling hands, she wonders if she can really go through with this. It has to be dangerous. What if it doesn’t work? Surely there must be an easier way. Then she remembers her fiancé, his mercurial anger, and his escalating threats. A bolt of fear shoots through her, and she knows in that moment that she has no choice. She pays the elderly vendor. Her money is heavy in her hands, and she does not know if she can lift them. A knowing look of sadness passes between the two women alongside this seemingly innocuous exchange of goods.

She has just purchased twenty-four tablets of Mifepristone. When she arrives home, she will take all of them. Mifepristone, also known as RU-486 and a component of the “abortion pill”, is an anti-progesterone agent that also possesses anti-glucocorticoid properties (Vallerand, Sanoski, & Deglin 2013). Physiologically, this drug induces endometrial bleeding and, if taken in excess, has the potential to alter levels of hormones essential for regulation of metabolism. This unfortunate woman is now suffering excessive bleeding and vital dysregulation. What will happen to her? In this situation, it is difficult to know. Perhaps she will be transported to a medical facility in a timely manner and receive necessary blood transfusions. Then, if she is lucky, she will only have the emotional scars from this traumatic event to contend with. Perhaps a more sinister possibility: that her time runs faster than the paramedics. This will be her last memory.

As morbid as this conceptualization might seem, it is nowhere close to far-fetched. It is, however distressing, one of the less horrifying accounts of what women will resort to in the absence of sufficient access to reproductive services. These kinds of desperate acts were fairly commonplace at one point in America’s history, and were a driving force behind the monumental Roe vs. Wade decision. The court’s opinion, authored by Justice Harry Blackmun, invalidated a Texas statute that made administering an abortion a felony in most cases. In his statement, Blackmun asserted that the detriment the State would impose upon the pregnant woman by denying this choice was altogether apparent (Roe, 1973). In the years prior to Roe vs. Wade, illegal and potentially unsafe abortions were a dire public health problem (Calderone 1958). Research compiled by the Guttmacher Institute, a non-profit organization concerned with advancing reproductive and public health, supports this. In 1930, abortion was listed as the cause of death in nearly 2,700 cases. This accounted for a staggering 17% of all maternal deaths that year. This mortality rate declined slowly over time, likely as a result of advancement in antibiotic therapy, but the percentage of deaths remained largely unchanged. In 1965, 18% of maternal deaths were attributed to consequences resulting from illegal abortions (Valenti 2013). These are only reported numbers; it is likely that the actual number is much higher.

While this is a part of America’s past, recent legislation passed in Texas threatens to again make this flawed and dangerous status quo a frightening reality. The culmination of a progressive assault on reproductive health, HB 2 bans all abortions after 20 weeks, even in the case of rape or incest. Abortion clinics must now meet the same standards as ambulatory surgery centers. The physicians performing these procedures must have admitting privileges at a hospital within 30 miles of the clinic (Sweany 2014). All over the state, clinics unable to meet these stringent and arguably punitive requirements have begun to close. Despite vehement protest, the status quo in Texas closely resembles the sociopolitical culture before Roe. This will only intensify as time passes (Feldt 2013). Women in this state, particularly the young and the poor, are now faced with the very real consequences of society’s failure to learn from its mistakes.

The woman’s story referenced herein may have been fictionalized in the name of anonymity, but its roots lie in poignant truth. The fact that a box of flea-market abortifacients has been someone’s reality is altogether unacceptable. If the past is any indication, this is only one example of the horrific consequences that will come to pass as a result of this legislation. It is debatable whether this is a result of malignant ignorance or willful marginalization, but that question deserves its own thesis and will not be examined here. For the sake of succinct and fair argumentation, a candid dissection of the rhetorical and ethical implications of the status quo will focus solely on the legislation as it is presented. At this time, such an examination is of critical importance, and will expose this bill for what it is: a poorly constructed policy that infringes on women’s autonomy, causes undue harm, and sets the stage for far-reaching societal stagnation.

Stay tuned. My next post will dissect the rhetoric of the bill, and why it is flawed. You cannot argue with academics and data.

References:

Calderone, M. (1958). Abortion in the United States. New York, NY: P. B. Hoeber.

Feldt, G. (2013). Crow after Roe: How Separate but Equal has Become the New Standard in Women’s Health and how we Can Change That. Brooklyn, NY: IG Publishing, Inc.

Roe v. Wade 410 U.S. 959. (1973). Retrieved from LexisNexis Academic. Web.

Sweany, B. D. (2014). A Long and Bitter Fight. Texas Monthly, 42(3), 24-28.

Vallerand, A., Sanoski, C., & Deglin, J. (2013). Davis’s Drug Guide for Nurses. 13th ed. Philadelphia, PA: F. A. Davis Company.

Valenti, J. (2013). Abortion and Magical Thinking. Nation, 296(26/27), 10.

Abuse of Autonomy: Paternalism in Politics

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         We all begin our journey on this earth as a blank canvas: a clean slate void of corruption, fear, or opinion. With a palette comprised of circumstance and choice, our lives and thoughts are painted as we age. Vibrant colors and crisp lines replace white space and blurred edges. Ideally, knowledge supersedes uncertainty; with the passage of time, the genre of our worldview is revealed to us. The term worldview will be used herein to refer to a system of beliefs that are interconnected, much like the pieces of a jigsaw puzzle (DeWitt 2010). When something in our external environment happens that does not coalesce with our value system—especially if the specific belief in question is central to our worldview—we have a few options, namely: remain in a state of uncomfortable cognitive dissonance, or take action to change the offending external event. In the United States, and certainly in the socially conservative state of Texas, it is unlikely that few issues cause as much dissonance or call to action as the matter of abortion.

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          For over thirty years, catalyzed by the controversial Roe v. Wade decision, the abortion debate has grown exponentially (Annas 2010). Pro-life collaborations rise up against clinics, physicians, and organizations that support abortion. These groups, empowered by their worldviews, act with certainty of residing on the absolute moral high ground. And yet, even in the historically conservative south, there remains a strong vein of support for the pro-choice movement. One of the core beliefs of these groups may be summarized in this way: “the right to an abortion may be a matter of standing law, but its legal underpinnings are being hacked away at an alarming rate, so that many women in this country, particularly the young and the poor, are having to resort to desperate measures we never thought we would see again… In many ways, we are back to where we were then, with a two-tiered system: women who have the means to travel to get a safe abortion could do so, and the others suffered illegal, unsafe abortions or unplanned pregnancies (Feldt 2013).” The recent passage of controversial abortion legislation in the state of Texas has made this speculation on unintended consequences a tangible possibility. Texas HB 2 (previously SB 5) stipulates, among other things, that abortion should be banned after twenty weeks gestation and that centers performing them meet the same requirements as ambulatory surgical centers. Proponents of this legislation have cited protection of fetal life and protection of maternal health as the motivation for the change that will inevitably result from this law. On the surface, these seem to be respectable claims. However, a thorough deconstruction of the stock issues and rhetoric here will expose this bill for what it is: infeasible, ripe with a plethora of negative consequences, and a very thinly veiled endorsement of paternalism.    

            The literature is very clear on the bioethical connotations of paternalism. This insidious concept can best be described as the limitation of the autonomy of another exclusively on the grounds of benefit to the person in question (Tong 2007). Respect for patient autonomy is broadly understood as recognition that patients have the authority to make decisions about their own health care, and is pervasive in bioethics literature (Sherwin 1998). On a more intimate level, it can even be said to underlie the basis of human dignity (Gaylin 1994). While a pragmatic approach to bioethics suggests removing autonomy from the forefront of the gold standard of care (Childress & Fletcher 1994), abortion is one arena where the implications of overriding autonomy are far-reaching and dangerous. The reasoning was succinctly explained by beloved Justice Harry A. Blackmun regarding his stance on Roe v. Wade: “Few decisions are more personal and intimate, more properly private, or more basic to individual dignity and autonomy, than a woman’s decision… whether to end her pregnancy (Flavin 2009).” Legislative interjection in this arena not only carries negative connotations for the state of women’s health; it carries negative connotations for the state of women’s rights (Orentlicher 2011). In a dynamic and ever-evolving society, we must be aware of the dangers of enlightened paternalism: dogmatic habits that do not adequately account for the changing environment and culture and misunderstand the place of intelligence and community in medical encounters (McGee 1999). To this end, even the most pragmatic interpretation of bioethical literature does not excuse the actions of the Texas legislature. Whatever the justification, talk of protecting women from harm caused by their own decisions is a marked recapitulation of paternalistic stereotypes, and in direct conflict with modern egalitarian ideals (Suk 2010).

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Rally at the Texas Capital, July 2013

          A thorough investigation of case construction, stock issues, and bioethical principles is likely to support this unpleasant truth: the actions of the Texas Legislature are wholly unethical. To some degree, politics has no place in the exam room. The doctor-patient relationship is a sacred one, and lawmakers affecting the inner workings of clinics makes about as much sense as doctors sitting on the bench to issue judgments and penalties. All educated individuals have a scope of practice: a skeleton system of acquired knowledge and vales. This is fleshed out over the years with experience and blossoms into expertise, much as a canvas transforms into a painting. The sprawling masterpieces that adorn the Sistine Chapel were certainly not painted in a day, or even a week. How can it possibly make sense that merely days of debate and a limited understanding of fundamental principles of bioethics are deemed sufficient to make such important decisions regarding women’s rights? Passionate ideology and moral empowerment do not a good decision make. The same principle that governs distributive justice can be slightly altered and employed here: from each according to expertise, to each according to need. In such a strange and volatile time in our world, it seems prudent that lawmakers stay within their jurisdiction: they belong in our courtrooms, not our clinics.

References:     

Annas, G. (2010). Worst Case Bioethics: Death, Disaster, and Public Health. New York, NY: Oxford University Press.

Childress, J. & Fletcher, J. Respect for Autonomy. The Hastings Center Report, 55-56.

Dewitt, R. (2010). Worldviews: an Introduction to the History and Philosophy of Science. 2nd ed. Malden, MA: Blackwell Publishing, LTD.

Feldt, G. (2013). Crow after Roe: How Separate but Equal has Become the New Standard in Women’s Health and how We Can Change That. Brooklyn, NY: IG Publishing, Inc.

Flavin, J. (2009). Our Bodies, Our Crimes: The Policing of Women’s Reproduction in America. New York, NY: New York University Press.

Gaylin, W. (1994). Knowing Good and Doing Good. The Hastings Center Report, 193-198.

McGee, G. (1999). Pragmatic Bioethics. Nashville, TN: Vanderbilt University Press.

Orentlicher, D. (2011). Policy and Politics: The Legislative Process is Not Fit for the Abortion Debate. The Hastings Center Report, 41(4), 13-14.

Sherwin, S. (1998), The Politics of Women’s Health: Exploring Agency and Autonomy. Philidelphia, PA: Temple University Press.

Suk, J. (2010). The Trajectory of Trauma: Bodies and Minds of Abortion Discourse. Colombia Law Review, Vol. 110, No. 5, 1193-1252.

Tong, R. (2007). New Perspectives in Healthcare Ethics: An Interdisciplinary and Crosscultural Approach. Upper Saddle River, NJ: Pearson Education, Inc.

 

From the Shadows to the Frontlines: Combating Healthcare Worker Bias and Improving Patient Outcomes

      The first rule of medicine seems a simple one: “Primum non nocere”, or “Above all, do no harm”. Students, physicians, and educators alike believe and uphold this unspoken law to preserve the integrity of medical and nursing practice. This fundamental axiom seems to appear around every corner: it is engraved on plaques, transcribed on certifications, and carved into doorframes. The words reverberate down the halls of our hospitals, clinics, and courtrooms, as if the walls themselves speak them in whispers. First, do no harm. It seems straightforward enough, does it not? After all, what doctor, technician, or nurse would intentionally inflict damage on a patient? The very soul of healthcare seeks to cure the sick, diagnose the ill, and medicate the ailing. However, I present to you an ugly truth: we can only treat what we can fully comprehend. Unconscious ignorance and pre-formed judgments have the potential to be far more dangerous than an errant needle puncture or pharmacological mismanagement. One of the most misunderstood issues facing the medical community today is that of mental illness, and the connotations are far reaching. Over the years, great strides have been made to eliminate the stigma associated with such afflictions. However, mental disorders largely remain a shadow-filled alley that no one wants to venture down. It is only by illuminating the darkest corners of the human psyche that we can begin to combat the shame and fear that reside there.

Historically, treatment of the mentally ill has left much to be desired. Patients were institutionalized and classified as lunatics. Many were chained to the floor, and allegations of abuse and neglect ran rampant. Complete isolation and rest therapy were common ways of handling these individuals. While we now know empirically that placing patients in circumstances of congregate stress can exacerbate their illnesses and retard effective treatment (Freckelton, 2011), society had no explanation for certain behaviors. Loved ones were sent away to insane asylums, mainly because that was easier than having to explain erratic behavior to friends and family. As the number of these asylums increased, and mental illness became more prevalent, science began to look for further explanation and treatment for these conditions. Sadly, inhumane and deadly remedies began to become commonplace (Chung, 2010). Patients were submerged in ice baths until they lost consciousness. Early forms of electroshock therapy began to emerge. Probably the most frightening of all these barbaric treatments involved a form of partial exsanguination. The belief was that if all the bad blood were drained from an individual, they would be able to return to a state of mental health. Instead, this practice killed a horrifying amount of people. Even this could not compare to the rise of the trans-orbital lobotomy in the mid-1900’s. Despite the advances made in medication management – Thorazine made its debut around the same time (Carpenter & Davis, 2012) – the complications and deaths associated with these radical procedures are unarguably deplorable. Eventually the medical community realized that treatment practices were undermining the very science of psychiatry; a paradigm shift was underway (Horwitz & Grob, 2011).

While we have come a long way from the therapeutic nihilism that has dominated psychiatry in previous generations (Patterson, 2012), mental illness remains one of the most stigmatized health conditions (Verhaeghe & Bracke, 2012). This stigma is present not only in generalized society, but also in healthcare professionals. Far too often patients in the throes of a manic or psychotic episode receive nothing but irritation from the hospital staff delegated to their care. Nursing staff members argue amongst themselves on who is going to receive the problem patient. On understaffed and busy medical/surgical units, it is all too easy to reject a sense of empathy in the name of efficiency. The implications of this are numerous and far reaching. It is an understood fact of neuropsychology that the behavior of an individual is not completely a conscious cognitive function. (Bargh & Morsella, 2008). Instead, our minds resemble icebergs, with only a small portion of our neural processes occurring in a place where we can thoughtfully acknowledge them. Holding onto preconceived notions or biases affects the way that we view and treat others, even if we are not completely aware of it. This is causing a decrease in the quality of care patients with comorbid psychiatric conditions receive. It has been established that patients with comorbid psychiatric diagnoses undergoing treatment for acute myocardial infarction are statistically more likely to be sent to lower quality facilities (Cai & Yi, 2013). Patients suffering from a severe mental illness are less likely to engage in preventative and annual health care (Lord, Malone, & Mitchell, 2010). The amount of time that nurses spend in the room of a mentally ill client is notably less than the time spent in the room of a client without a psychiatric disorder. Even social workers, while they tend to exhibit more permissiveness and self-reporting empathetic behaviors, are not immune to cognitive bias (Richmond & Foster, 2008).

Obviously, this presents a serious concern. As aspiring nurses, we are currently studying—and should be bound by—the same ethical standards of those that are in practice. If it is the aim of nursing to treat patients in a holistic and all-encompassing manner (Portillo & Cowley, 2011), where does healthcare worker bias fit in? What can we do to change the way that we think, and in turn, the way that we behave? Our role is supposed to be that of a patient advocate: we assess, diagnose, and intervene on behalf of those we serve. It is impossible to completely fulfill this role if we allow ourselves to be carried away by subconscious fear of what we do not completely understand. While this tendency is innate to human nature and not unique to nurses, we are on the front lines of patient care and must hold ourselves to a higher standard for the sake of those we have promised to attend to. Stigma hurts; it is our obligation as aspiring medical professionals and members of society to ease this pain. We must stand together, rise up against preconceived notions, and shout from the mountaintops that it is ok to seek help. We must eviscerate the body of societal stigma, the inner darkness of our own minds, and honestly confront our own fears. More than one paradigm shift has already occurred in the mental health sphere; it is more than time to catalyze another. No more shall patients fail to seek treatment due to fear of judgment. No more shall our opinions of someone be shaped by a diagnosis. It is time for mental illness to leave the roll belts and back rooms and step out into the sunlight. We have come a long way both as a medical community and a society, and the time has come to keep moving forward. Together, we can make a difference: one day, one interaction, and one patient at a time.

References:

Bargh, J., & Morsella, E. (2008). The Unconscious Mind. Perspectives on Psychological Science, Vol. 3, No. 1, From Philosophical Thinking to Psychological Empiricism, Part I (Jan.,                    2008), pp. 73-79

Cai, X., & Li, Y. (2013). Are AMI Patients with Comorbid Mental Illness More Likely to be Admitted to Hospitals with Lower Quality of AMI Care?. Plos ONE, 8(4), 1-7. doi:10.1371/journal.pone.0060258

Carpenter, W., & Davis, J. (2012). Another view of the history of antipsychotic drug discovery and development. Molecular Psychiatry, 17(12), 1168-1173. doi:10.1038/mp.2012.121

Chung, D. S. (2010, March). Biomedical Approach is Not Good Enough for Treating Severe Mental Illness. East Asian Archives of Psychiatry. pp. 4-5.

Freckelton, I. (2011). The Architecture of Madness: Insane Asylums in the United States, by Carla Yanni. Psychiatry, Psychology & Law, 18(1), 160-162. doi:10.1080/13218719.2010.521484

Horwitz, A., & Grob, G. (2011). The Checkered History of American Psychiatric Epidemiology. The Milbank Quarterly , Vol. 89, No. 4 (December 2011) , pp. 628-65

Lord, O., Malone, D., & Mitchell, A. J. (2010). Receipt of preventive medical care and medical screening for patients with mental illness: a comparative analysis. General Hospital Psychiatry, 32(5), 519-543. doi:10.1016/j.genhosppsych.2010.04.004

Patterson, P. (2012). What Insane Asylums Taught Us. USA Today Magazine, 141(2806), 62-64.

Portillo, M., & Cowley, S. (2011). Working the way up in neurological rehabilitation: the holistic approach of nursing care. Journal Of Clinical Nursing, 20(11/12), 1731-1743. doi:10.1111/j.1365-2702.2010.03379.x

Richmond, I. C., & Foster, J. H. (2008). Negative attitudes towards people with co-morbid mental health and substance misuse problems: An investigation of mental health professionals. Journal Of Mental Health, 12(4), 393.

Verhaeghe, M., & Bracke, P. (2012). Associative Stigma among Mental Health Professionals: Implications for Professional and Service User Well-Being. Journal Of Health and Social Behavior, 53(1), 17-32.