Wednesday, May 27, 2015

Old Interests

The central issue of my thinking in high school was the compatibility of faith and reason (or, as I initially phrased it, religion and science). As I'm packing to move out of state for residency, I'm digging through  all this stuff from high school and college. Take a look:

I was also struck to find the first article I ever read in a medical course (our medical careers class in high school), which was about doctors having to close practices because of the cost of malpractice insurance. I often remembered this article as I pursued my undergraduate and profession degrees, but always remembered the article as a problem of insurance payments, not malpractice. 

I was surprised (first of all, that I had kept the article, and second) to see that it was about malpractice, not insurance. The article is a little time capsule: medical malpractice is no longer such a big monster, at least where I intend to to practice, thanks to tort reform. In its stead, insurers and government fees are now lined up to make bank from patients and their physicians, in the country's newest industry. And hauntingly, there's a little news piece about Ella (before it was Ella) attached to some clip I saved about ethics. 

Wednesday, May 20, 2015

When do we Truly Twin?

Many use twinning as an argument that life does not begin at conception/fertilitzation/gamete fusion.

Although what we do know of the inner workings of cells is tantalizing and beautiful, cells are still black boxes. The single-celled human zygote is the blackest (and most interesting) of these boxes. We have known for decades that there is early asymmetry in the zygote that later shows up in the division of the inner cell mass (ICM) and the trophectoderm.

We also know that intracellular components are moving as soon as sperm affects egg (cortical reaction, pronuclear migration events, etc). There is a great deal of mechanical action taking place, by which this tiny organism's body is quickly building infrastructure by which it will direct the rest of its development. Such organized activity promoting the development of a single organism is directed, like all operations of a living body, by a soul. This indicates (for those who don't realize this), that ensoulment occurs "at conception" (in non-scientific language), during fertilization, or at/around sperm-egg fusion.

But what about twinning? Complete twinning cracks a complex, tiny body into two between days 0 and 13 of life. Depending on when the cleavage occurs, the twins share zero, one or more tissues.

Twinning is a natural and normal process. We can tell this because a) it occurs frequently, and b) there is a falling-short of it--conjoined twinning.

What causes twinning? I propose that infusion of two souls occurs at conception/fertilization/sperm-egg fusion. These two organizing principles begin directing development of a single zygotic body. There are too many cooks in the kitchen, leading to an unstable union, perhaps because the processes directed by the two new souls don't place adherent components (e.g. desmosomes) where single souls would. This results in fracturing of the conjoined body (a process disrupted by some defect in the material in the case of conjoined twins).

Technology probably won't allow to see the difference between the intercellular workings of single-soul-driven and multiple-soul-driven zygotes for many years. Nevertheless, we can observe the end effect (what appeared to be a single body breaking in two parts and surviving, forming two complete sets of parts) and work back to the presence of two directing principles working from the outset on their completely totipotent cell.

Friday, May 15, 2015

Avoiding Eugenics: It's Easy!

I want to prevent inheritable disease. I think we should explore pre- and perinatal therapies as part of this. And not all the therapies I can imagine are approved by Church officials. Am I a eugenicist?

It the original sense of the word, no. I'm not a member of a "social movement claiming to improve the genetic features of human populations through selective breeding and sterilization." But more recently, the eugenics ideal has gone underground, and motivates some (not all) uses of prenatal diagnosis and abortion (related to race and mental disability). It creeps behind the language of "every child a wanted child," "working together for stronger healthier babies," and "healthy babies are worth the wait."

What if you could freeze oocytes (not morally illicit per se according to Dignitas Personae) and inject them later (e.g. after chemotherapy) in a woman's ampulla and allow conception to occur after natural intercourse? We'd need to learn more about construction of a zona pelucida and cumulus oophorous, but I bet we could do it.

What if you could CRISPR the ΔF508 out of all of a man's sperm, not only preventing this from being passed onto his sons, but also assisting the act of procreation, allowing him to build working sperm? This is germline gene therapy.

What if you could engineer a neo-ovary for a BRCA-positive woman, with her genome, minus the affected gene? That way, her offspring would not carry her genetic predisposition to breast and ovarian cancer. CRISPR would make it possible, and bioprinting would could make it real.

I don't think any of these things are eugenic in themselves (per se). Eugenics is marked by the erroneous equation between essential dignity and accidents like quality of life, health, beauty, intellect, usefulness, etc (paragraph 319 in the link). This error affects the intention behind the action, and the selection of means to the end of promoting those separable accidents.

None of the techniques I just listed are evil in themselves (malum in se). Printing tissue is not immoral, even printing tissue to replace reproductive organs. (Even though the reproductive system is set apart as half of a whole, meant to be used with a complementary system by a couple in a very sacred act, replacing an organ is a medical act that promotes the natural act of the human body.) Freezing cells, thawing them, and implanting them without IVF might be a roundabout way to assist fertility, but is not evil in itself. And germline therapy (I'm arguing something that not everyone agrees about now) is no different from somatic cell therapy, since it assists, rather than replaces or demeans, procreation and the health of offspring.

But any of those actions could be used with eugenic motives. A woman who wants to "clean up" her family tree or her society should re-examine her motives for neo-ovary creation. A woman who wants to freeze her eggs so that she doesn't use "the Down's duds" at the end of her reproductive life needs to re-think her intentions for egg freezing (and don't get me started on women who do this for their careers; that's a disaster of mixed priorities and apparent goods). A woman who plans to use germline therapy because she doesn't want to raise a child with mental retardation, or lose a child early, or pay for expensive drugs, needs to reconsider her reasons for germline gene therapy.

With a loving intention to contribute to the health of children conceived, and an attitude of acceptance of whatever children are conceived, we can avoid becoming eugenicists when we use morally neutral means to achieve a good.

Sunday, May 3, 2015

Stacy's Story

This post conforms to the blog rules.A patient I met and, in the wash of clerkships, left behind, left an incredible impression on me even though I barely knew her. Almost every detail about this person is altered to protect her.

"Stacy" was a middle-aged woman who became pregnant under extremely bad circumstances. Her family started to notice that she was acting strange. To their alarm, she began to tell them she saw and heard things they could not see or hear: she was hallucinating. The duress of her pregnancy had affected her so severely that she had become disconnected with reality. She went to the emergency room after suffering a psychogenic seizure, and I rounded on her her shortly thereafter.

As I flipped through her chart before going to see her, I asked the nurse what was going on.

"It's crazy," the nurse said, speaking of the situation. She gave me more and more details as I went through the records, underlining hCG values and the ER course. "And her family doesn't want to keep it," the nurse finished.

I froze. Doesn't want to keep it. They wanted an abortion.

"What does she want?" I asked.

The nurse shrugged. "She can't say, most of the time. She has these good times when she makes sense, but sometimes she babbles and acts bizarre. Sometimes she doesn't know she's pregnant when you ask her."

I continued reviewing records mechanically, and went to see the patient, wondering what I could do. The first time I spoke with Stacy was during one of her lucid times. After introducing myself and seating us in a private and comfortable place, I told her I wanted to talk with her briefly and then gently asked her, "What brought you here?"

She gazed at me innocently, almost emptily, with warm brown eyes. "I'm pregnant," she said simply.

"That's right," I said.

"I'm eight weeks," she added.

"Exactly," I said with a smile. "Do you know what that means?"

She shook her head.

"It means your baby's heart is beating," I said, "and he has all his fingers and toes."

"Oh," she said, her voice inflecting for the first time, a little flicker of a healthy mind. "Maybe I'll keep it."

Those were her exact words, and I cannot forget them. The interview went on, and I wrote my progress note and left. At rounds a few minutes later, the story became even more nightmarish as I discovered that my attending and my fellow students were all hoping that she could get an abortion. Perversely, we carefully looked up what psychiatric drugs she should most safely take in pregnancy and consulted a psychiatrist with experience in that. Even as we hoped that Stacy's embryo would be eradicated, we protected that embryo from possible adverse effects of the medicines we prescribed.

The week churned on and I moved away from Stacy's floor while other students worked on her care. I heard new of her remotely when students would talk about her, and the reports were not good: she had fewer lucid times and finally none at all despite changing her medicines. Meanwhile, her family was trying to arrange for an abortion. I stormed heaven and asked friends and family to do the same.

Stacy's case became very complex and the hospital system ethics committee met over a weekend, weeks after her admission, to decide whether she could have an abortion. Her case was described in detail at our rotation's grand rounds, where another student presented and the general feeling among my peers and professors was annoyance that the "stupid" hospital was keeping this woman from her healthcare. I felt dizzy sitting with them, as if I were in a horror movie or some barbaric country.

After that rotation ended, I texted Stacy's attending and asked about Stacy. It was then that I discovered that the first ethics committee did not approve her abortion, but she ended up having one somewhere else.

I have so many sad thoughts about this case, including things like, should I have insisted on seeing Stacy beyond my time on her ward? It wouldn't have been impossible. Should I have talked with her more about her baby? I didn't want to be coercive but I might have saved a life. Should I have at least documented her desire to keep the pregnancy? I'm sure it might have meant something to the ethics committee if it didn't to her attending and my peers. I was afraid to write it, because I worried that her flip-flopping between options would be seen as a sign of worsening psychosis (which wouldn't be good for the baby's survival or for her), and because I didn't want to be accused of disturbing her "decision."

What a hard case! Please pray for "Stacy" and her family, and her little child. She is apparently back to her normal self and out of her psychosis, but she is not finished dealing with what happened to her this year.

This post was a draft for over a year. I marked it as a "perpetual draft," one of a set of posts that will never be released to protect my career and to protect vulnerable patients. But I decided to release it after I matched, and since it has been such a long time since this occurred.

This post was a draft because I experienced a bit of resistance in my psychiatry clerkship from a pro-choice fourth year (who couldn't believe someone wouldn't do this patient's abortion) and from professors (who called me into an impromptu meeting when I asked too many questions about homosexuality and gender identity disorder). Now, I'm putting it out.