Author Archive

What Is Good Health Care?

August 16, 2009

This article in the NY Times yesterday finally gave expression to some thoughts I’ve had for a while.  In particular, I’ve found it interesting that a discussion of health care reform, which ostensibly is about helping more people live longer, healthier lives, devolved into a debate about euthanasia.  In part, this is because we do not have a consensus on the philosophical underpinnings of our health care system.   Here is an excerpt:

The third level [of the health care debate] . . . is an examination of the fundamental dimensions of health care. “How do we think about the ultimate goals of the health care system and even about health itself?” he said.

Existing medical care, he said, is “open-ended, progress-oriented and technology dependent.” Are we doomed, he wondered, to a relentless battle against death in which “nothing will ever count as success”? Won’t “aging societies, expensive technologies and rising expectations about the benefits of medicine” add up to “an impossible cost situation”?

“We don’t have a debate at that level — and we need to,” he said.

Six weeks ago, I had my second son, Reed, at home.  I chose home birth because I believe it was the safest place for Reed and for me to be during his birth.  One thing I have noticed in reading the words of and speaking with other home birthers is that our conception of risk is different from that of the average American.  Most people seem to think that life and death are the only things worth considering when it comes to health care — if you end up alive, that’s success, regardless of what else happens.  So the 99% of American women who give birth in hospitals are willing to subject themselves to a high likelihood of needless, preventable injury, infection, and major surgery in order to hedge against the infinitesmally low likelihood that being a few minutes away from a hospital will make a life or death difference for themselves or their babies.

And when something does go wrong in a hospital birth — which happens more than you would think — sometimes the doctor will be sued.  Because after all, if you’re in a hospital, you’re guaranteed a healthy baby and a healthy mother, right?  Home birthers accept the fact that there is no such thing as a risk-free birth, because we knowingly choose to take a very small risk of death (the same level of risk as exists in the hospital, by the way) in order to avoid the much larger risk of trauma, injury, and infection introduced by the hospital environment.  We know that more technology, more invasive testing, and more interventions do not correspond to better outcomes, as Atul Gawande recently pointed out in a celebrated New Yorker article.

But that’s not the conventional wisdom in the United States today, where the assumption is that more is, if not necessarily, then usually, better, when it comes to health care or almost anything else (and where, notably, doctors are paid based on that assumption).  We have a strained relationship with the idea of mortality and a deep distrust of the idea that sometimes, it might be better to take a hands-off, watch and see approach, and that medical intervention can sometimes create more problems than it solves.

I’m not arguing in favor of euthanasia or passing judgment on people who want to live as long as they can.  But the idea that a whole swath of our citizenry is up in arms because they think that a doctor telling a patient and her family that hospice (i.e., giving up and accepting death, to those who can’t imagine doing so) is an option reveals a deep-seated fear of and paranoia about death.  Perhaps that’s something we as a culture need to work on.

Correcting the Record on IVF

March 5, 2009

Everyone has an opinion about the mother of the octuplets born in California in January.  I’ve been sitting back watching the story unfold, first with interest, then horror, as the media, obviously unschooled in the most rudimentary facts about human reproduction and in vitro fertilization (IVF), has propagated the most shocking sort of ignorance about infertility treatment.  When I heard about the bill that has been proposed in Georgia (more information can be found here and here) based on that ignorance, I said, enough.  I don’t have a media platform, but I have a blog and I’m going to use it.   Settle in, this is a tad long.

First, let’s cover the basics about IVF, because there seems to be a lot of mystery about what it is.   A woman undergoing IVF is injected with hormones in order to stimulate the ovaries to produce several eggs.  The eggs are retrieved surgically and are then taken to a lab, where they are mixed with the husband’s or donor’s sperm to produce embryos that are then matured for three to five days and then transferred (placed) into the woman’s uterus via a catheter.   (Even that description is a simplification, but it’s more than Oprah knows about the process, I guarantee you.  She apparently thinks that eggs alone can produce babies).

Let’s correct the most annoying and common of the media mistakes here — a doctor cannot implant an embryo in a woman’s uterus. Embryos are placed there in a process called a transfer, and whether or not they implant (and they often don’t) is up to nature.   Doctors can try to create a hospitable environment for an embryo by checking and trying to enhance the thickness of the uterine lining before the transfer and prescribing progesterone after the transfer, but implantation cannot be controlled.  If it could, IVF would be a sure thing, and it isn’t — as a quick look at success rates at even the best clinics will tell you.  Success rates for any given transfer generally range from about 40 to 50%.

There is attrition at each step of the IVF process I described above, and some percentage of IVF cycles never make it to transfer.  Different women (and even the same woman in different cycles!) respond differently to the hormones; a few will produce 30 or more eggs in a cycle, a few don’t respond at all (if this happens, the protocol is changed for the next cycle to produce a better result).  And everything in between.  Generally, not all of the eggs retrieved in a cycle are any good (viable).  Even eggs that look viable may not fertilize in the lab.   Even eggs that fertilize may turn out to be crappy embryos that don’t meet the criteria for transfer and have no chance of implanting.  (Embryos are graded on their quality, i.e. their chances of survival, and the best ones are selected for transfer).  So even if you produce, say, 20 eggs, you may only end up with one or two good embryos and be lucky to get any at all.

This is why the Georgia bill is so outrageous, as it would mandate that only two eggs could be fertilized per cycle — meaning that only two eggs could be placed in the petri dish (or whatever they use) with the sperm, vastly reducing the chances of producing even one viable embryo in a given cycle.  It would also prohibit freezing embryos for later transfer.  Thus, women trying to conceive would have to undergo many, many more invasive stimulation cycles in order to produce an embryo that would give them a real chance at pregnancy.  At $10,000-15,000 a cycle.  Whoever wrote this bill obviously has never had a family member or friend who has had to undergo IVF to conceive her children.

Nominally, the bill is supposed to be a response to the octuplets birth, but when you look closely at the facts, it’s obvious that it is both a vastly overinclusive and underinclusive response.  Here’s why:

High-order multiples (triplets or more) very rarely result from IVF. There are several reasons for this.  One is that most reproductive endocrinologists follow their specialty’s guidelines and transfer (not implant!) no more than two embryos at a time in women younger than 35 and no more than three in women over 35.  However, the reason that the guideline does not, and should not, have the force of law is that not all embryos, or uteri, are created equal.  If you have four embryos, none of which look all that hot, for a woman who has had failed IVF cycles in the past, you might transfer all four because the odds of even one of them making it are middling at best, and the odds of all four implanting are one in a million.  Some doctors won’t take even this tiny risk, but I can’t say that it’s reckless to do so for a woman who is on her last IVF cycle or is rapidly approaching 40.   Transferring all four in such a case would give her the best odds of a pregnancy with very little risk of multiples.   This is just one example — there are many factors that affect an individual patient’s situation, and the best person to evaluate how to provide the best treatment is that patient’s own doctor.

Regulating IVF in response to the octuplets becomes even more absurd once you understand that high-order multiples much more commonly result from the use of injectable gonadotropins combined with insemination or sex.  These are the same injectable medications used to stimulate egg production for IVF.  They are also used in women who have trouble ovulating but who don’t need IVF to conceive.  It is very important that injectables be used under the close supervision and monitoring of a fertility doctor, and that if more than a certain number of eggs are produced, the cycle be cancelled.  The goal is always to produce just one or at most two eggs, but since responses to the medication are so variable, sometimes that’s not possible.

Everyone has seen that show Jon & Kate Plus 8.  You know how Kate most likely got pregnant with 6 babies at once?   (I don’t know this for a fact because they’ve never said on the show, but this is the most likely scenario).  They used injectables.  A large number of eggs were produced.  The doctor cancelled the cycle and gave them strict orders not to have sex.  They did anyway, and ta-da!  Six babies.  Which is not to criticize them, because they paid a few thousand dollars for a cycle and wanted a chance at a pregnancy, and even with a large number of eggs the chances of a high-order multiples pregnancy are very, very slim.  (To give some context, I have a friend who did an injectables cycle, produced four eggs, and didn’t get pregnant at all — that’s the more common outcome).  Taking the risk they took was stupid, and I think they acknowledge that, which is why they’ve never revealed exactly what happened on the show.  But my point is that it had nothing to do with IVF at all.  In fact, when I heard this octuplets story, I suspected injectables-plus-sex and was highly skeptical that IVF could have produced this outcome, especially via a frozen embryo transfer.  Frozen embryo transfers are less likely to be successful than fresh cycles, in part because not all embryos survive the thaw and in part because even the ones that do have a lower chance of implanting.

So assuming that the octuplet mom’s story about the conception is true — that six previously-frozen embryos were transferred into her uterus and that all implanted and two of them split to produce identical twins (which does happen sometimes) — it is truly a one in a million occurrence.  Yes, the fact that her doctor (a disreputable quack) transferred six embryos into a 32-year-old woman who had had five previous successful pregnancies through IVF was incredibly reckless, and he should have his license revoked, though even he never imagined or had reason to imagine that octuplets was a possible outcome.  My point is, it’s not as though this kind of thing happens every day, especially not through IVF.  In fact, the percentage of high-order multiples (mostly triplets, anything more than that is quite rare indeed) has declined in the past several years precisely because fertility doctors have made such a vigorous effort to reduce the number of multiple births and because the technology has improved to the point where single-embryo transfers are almost as effective as multiple-embryo transfers in producing pregnancies.

I’m not here to debate whether a single woman of limited means and dubious mental health should be having a lot of children and raising them on the public dole — we’ve pretty much said no to regulating who can reproduce in this country because of a little thing called the Constitution.  There are millions of people out there who you or I might think shouldn’t become parents who do so anyway, and we all live with it in order to maintain our most basic principles as a nation.  What I’m saying is that somewhere between one in 10 and one in 6 couples have difficulty conceiving, and that all those thousands of hopeful parents-to-be who would not be able to have children but for IVF shouldn’t be punished for one doctor’s reckless decision when the vast majority of the doctors out there are practicing their specialty responsibly.

I hope this proposed legislation gets nipped in the bud quickly and is not replicated in other states. However, hearing the public discourse about these topics doesn’t give me much hope.  The extreme ignorance about IVF that is behind such legislation can only be countered with knowledge.  This isn’t much, but it’s my contribution.

Strange Bedfellows

November 9, 2008

Over at Slate, some prominent conservatives are having a post-mortem discussion about what went wrong and where to go from here.  One comment from Tucker Carlson I found interesting:

The various Republican constituencies need some reason to hang together. It’s not obvious what socially conservative, big-government types like Mike Huckabee have in common with economically conservative libertines like Rudy Giuliani. So why are they in the same party? It used to be because they both hated communism. Then it was Bill Clinton. Most recently, it was a shared fear of Islamic extremism. What now? Time to think of something—quick. There’s no natural reason these two groups should be connected. In fact, they sort of despise each other, as you’ll notice immediately if you ever eat with them.

I have long wondered about the odd marriage of these two groups.  I even asked the uber-libertarian guy I work with right now whether he felt at home in the GOP given the Religious Right (he classifies himself as “areligious”).  He said he doesn’t care about feeling welcome, just that economic issues take precedence over social issues for him.  I suspect that is true for a lot of libertarians, and I’ll refrain from giving my views of the characters of such folks.  Anyone have any thoughts about the economic conservative/social conservative partnership and its future?

You Know You’re a Hopeless Lefty When . . .

November 4, 2008

You’re over the moon about the election of a candidate you truly believe in, and yet despite every squirrelly thing his opponent did in the campaign, you feel kind of bad for him and have a hard time watching his concession speech. (I’m just not competitive, folks. Not. at. all.)

P.S. Did the opening part of it say, not in so many words, that this election result means that racism is over and African Americans have nothing further to complain about? Or am I just tired?

Closing Arguments: Wright and Wrong

November 2, 2008

My heart sank this afternoon when I read that the Pennsylvania Republican Party made an ad featuring Rev. Jeremiah Wright, Obama’s former and controversial pastor. The one shred of dignity and honor John McCain has held onto during this campaign is that he kept his promise not to raise Wright as a campaign issue.

A week and a half ago, I was on my way to work when I saw a series of lawn signs in the median. Sprinkled among the signs for various candidates were signs that said “Obama’s Preacher Says God D*** America.” I wanted to stop and collect them myself, but I had to be at work, so I called David and asked him to text me the number of the Obama campaign office in Fairfax. I called them and told them where the signs were, they thanked me for calling and told me they would take care of it, and sure enough, the next day the signs were gone.

I wouldn’t encourage taking down campaign signs lightly. I would never advocate removal of a sign for a candidate, no matter how much I despised him or her. I would never even remove those dopey signs that say “Drill Now. Pay Less. Vote GOP.” But this sign was just too misleading and slimy to be tolerated.

A few months ago, I listened to Bill Moyers’ interview with Reverend Wright, conducted back in April. During the show, he played an extended excerpt from the sermon in question, including the incendiary and misleading quote in question that was played in an endless loop for a few days during the primary. And I have to tell you, I found that sermon very moving. Wright’s message was that Christians should not confuse allegiance to God with allegiance to their government. Governments, he said, often fail to do God’s will. Specifically, the United States government has committed many great wrongs, and he went on to enumerate many of them, slavery and segregation among them. These are acts that God would condemn. So, we say God bless America, but on the contrary, God would condemn America for its wrongs. He wasn’t swearing from the pulpit, for Christ’s sake (leave swearing to heathens like me): he was using the word “damn” in its traditional sense, to mean “condemn.”

Even more disturbing than Americans’ 30-second sound-bite attention spans is the fact that for a significant number of folks, even hearing the expanded version of Wright’s message wouldn’t quell their indignation. For reasons that utterly escape me, a goodly proportion of this nation cannot stand to acknowledge history when it comes to our own country.

Much about the founding of the United States was groundbreaking, laudatory, paradigm-shifting. There was a lot of genius among the Framers. America’s aspirations are basically good, and we have exported those aspirations to other nations. So, yay us.

However. Aside from the good, there are grave iniquities looming large on the landscape of our nation’s history. The extermination of the native peoples who inhabited the land that we stole, for example. The subjugation and enslavement of hundreds of thousands of African Americans with the complicity of government. A shameful century of lynching, segregation, and disenfranchisement after slavery itself was ended. And those most notable wrongs are only the tip of the iceberg. For example, our government has supported, and continues to support, repressive and dictatorial regimes in other places when it suits our economic purposes to do so (see, e.g., Saudi Arabia).

But you can’t bring this up to many Americans without being branded a dirty traitor. Well, I’m already considered a fake American because I live in an urban area and a fake Virginian because I live too close to DC, so I can say whatever I want. And I say, f*** that. I see nothing more patriotic than wanting this country to live up to the ideals it espouses (claims to espouse, used to espouse before 2001?). In order to hope to do that, we must acknowledge the wrongs we have committed. It goes along with the whole removing the plank from your own eye so you can see clearly to remove the speck from your brother’s eye thing. I don’t understand the perspective of people who insist that we pretend that stuff never happened, or worse, that it has nothing to do with what’s happening in 2008. We’ve come a long way, but our history reverberates even into the present moment. Anyone who claims otherwise isn’t paying attention.


October 18, 2008

Let me first say that I am not at all happy about the current financial crisis and recession. Indeed, it has affected me personally — for the past few months I’ve been doing contract attorney work, which is basically temp work for lawyers, and I’ve now been out of work for three weeks with no prospects in sight because contract work dries up overnight when the economy heads south. I am living a few months away from personal economic disaster, and only my confidence that I will get another job before that day comes allows me to sleep at night.

But there is a ray of sunshine here, and it’s one I’ve been on record as hoping for for only the last, like, ten years or so. I’ve always said that what we need is a good depression to reverse the devastating effects of the Reagan Revolution and usher in a new era of semi-progressive politics (hey, I’m realistic — we’re not going to get anything more than semi- in this country no matter how high the unemployment rate goes). It appears that such a thing may be on the verge of coming to fruition. It is unfortunate that it takes the personal tragedy of many hundreds of thousands of people in order to get there, but I for one am willing to endure some anxiety in order to get us back on track to being a better nation than we’ve been for the past almost-thirty years.

So when I read this article, I wanted to stand up and clap. Hurray for sending crotchety old Ayn Rand and her ilk into the dustbin of history!

Much Ado About Nothing (Again)

October 17, 2008

So, this whole ACORN “scandal” is a complete load of crap and I’m tired of hearing about it. Here are three articles explaining why.


This just in:  the inevitable response to the McCain-Palin attacks on ACORN is . . . death threats and vandalism.

Sometimes . . . (Updated)

October 1, 2008

I love being right.

Just sayin’.

Update:  Just finished watching the debate.  Her excessive and forced colloquial speech tested my gag reflex more than once (particularly the use of the incorrect pronunciation “nu-ku-lar” over and over and freaking over again).   I thought she sounded practiced but not responsive to questions, and nervous.  The media pundits (and I’m watching PBS) sound like they thought she did well, which I don’t get at all.  She didn’t run off the stage crying, but I wouldn’t say she came across as compelling or particularly articulate.  But, as Terry pointed out in the comments, the bar was set very low, so, as with her speech at the convention, she might have come off well based on the low expectations.

Good Question

September 6, 2008

I have been thinking for several days now about everything that the Religious Right has sacrificed in its singular zeal for the “pro-life” cause.  (I will only use that term in quotation marks because it’s both overinclusive and underinclusive).  This article on Slate describes what I’ve been puzzling over.   Back in 1980, one of the goals of religious conservatives was to reduce divorce — remember that?  And the furor over Murphy Brown having a child on her own?  What ever happened to conservative promotion of  two-parent families?  Since I know that no one reads linked articles, here’s an excerpt or two:

In fact, these two conservative social goals—ending abortion and upholding the model of the nuclear family—were always in tension. The reason is that, like it or not, the availability of legal abortion supports the kind of family structure that conservatives once felt so strongly about: two parents raising children in a stable relationship, without government assistance. . . .

By vaunting their pro-life agenda over everything else, conservatives are abandoning one of their most valuable insights: that intact, two-parent families are best for children and for the foundation of a healthy society. The evidence here is overwhelming. Children with two parents, whether of the same sex or the opposite sex, are vastly better off. By every measure social scientists have devised, those raised by two parents grow up healthier (physically and psychologically), wealthier, and wiser, on average, than those raised by a single parent, divorced parents, or even a parent and a stepparent.

I understand and sympathize with people who oppose abortion, although I mostly disagree with their public policy prescriptions.  But I am truly baffled by the fact that it seems to trump all other issues for a significant number of voters.  Could someone please explain this to me?  This is a sincere question.  I know that some of you have written me off as part of the domestic axis of evil, and I would like to take this opportunity to ask you to reconsider that position and engage in a real conversation.  I have some guesses, but would like to hear what others think.

Double Standards

September 4, 2008

1. Karl Rove this week: Palin has plenty of relevant experience to be VP. Karl Rove a few weeks ago: Tim Kaine, governor of Virginia, former lt. gov., former mayor of Richmond, VA, does not have adequate experience to be the VP nominee and would have been a “purely political” pick.

2. Right-wing commentators (e.g. Dick Morris and Nancy somebody, McCain’s campaign senior policy advisor) this week: The questions about Palin are “sexist” and she is unfairly facing increased scrutiny because she is a woman. Right-wing commentators when HRC was running (including both of the above and, well, actually, Palin herself back in March of this year): Women running for office should not complain that they are being unfairly attacked because of their gender, they should learn to take it like a man.

3. Bill O’Reilly in December when Jamie Lynn Spears announced she was pregnant: The blame for this is on the parents. Bill O’Reilly this week on Bristol Palin’s pregnancy: Millions of people are dealing with teenage pregnancy, and it is a personal matter. We wish the family well.

So, in summary:

1. Experience or the lack thereof only matters if you are a Democrat and therefore unqualified to hold elected office in any event.

2. Sexism in the media is only wrong if it is directed against a Republican.

3. Teen pregnancy is a reflection on the parents of the teen unless one of the parents in question has just become the great white hope for the Republican party, in which case it’s personal and no one should judge it.

This is precisely the kind of thing that makes my head explode.  How can this kind of hypocrisy be justified?  Personally, I don’t have strong feelings one way or the other on any of the above three issues.  But I don’t think I would think differently based on the politics of the people involved.  Experience as a mayor and governor either matters or it doesn’t.  Women candidates should either be treated fairly or they should buck up and get over it.  Teenage girls getting pregnant either reflects the quality of the parenting they’ve had or just that teenagers are horny and careless.

None of this is to say that people on my side of the aisle don’t have double standards, but isn’t this a tad ridiculous?

Yes, the source of the above facts was The Daily Show from last night (annotated with detailed video clips from those in question). I need my news with a side of snark. How else will I get through the next four years?

Note: this post was edited after it was first posted.  The original version conflated double standards and lying, and my intention was to focus on the former.  Maybe I’ll take up deception another day.