The Business of Being Born?

I know I’m like a decade late here, but having just finished my labor & delivery rotation at the hospital I thought it would be interesting to watch a controversial documentary about hospital births that I remember being told about several years ago. I decided to start with the trailer.

Wow. Okay, so let’s go through this together:

0:10 – “Hospitals are businesses, they want those beds filled and emptied….”

I think the argument here is that we want women in and out in a timely and efficient manner to maximize profits. In reality we were at less than half-capacity the entire time I worked there, and yet we regularly turned women away who thought they might be in labor because they were still a day or two out. I’d have to come back in September when all of those Christmas babies are showing up to see how a full ward influences decision making, but I certainly didn’t see anything of the sort. More on this later.

0:17 – Technology is technology. It’s not stopping, so if you’re going to have good stuff you might as well use it to get the best outcome.

Hey, no disagreements here! Even in just the recent past, if we were worried about fetal anemia (a regularly fatal condition with a variety of causes) the only way to test for it was to use a needle to get a sample of amniotic fluid or cord blood directly: both invasive procedures with a small but measurable risk of miscarriage. Now we can look for patterns in fetal heart rates or in fetal blood flow via doppler ultrasound, both techniques that are vastly less invasive and correspondingly carry a much lower risk of complication to the mother and baby. Just a few days ago we watched a fetal heart tracing gradually become sinusoidal, and performed a c-section to deliver the baby. It came out about as white as the background of this blog, and its hemoglobin level turned out to be just over 3 g/dL. For reference, that means that its blood had less than a quarter of the oxygen-carrying capacity it should have had. The baby had been slowly bleeding into the maternal bloodstream, and if we hadn’t been monitoring it that baby would have died. An urgent c-section and blood transfusion saved its life, both made possible only because mom was in a facility with a trained staff of professionals and cutting-edge technology. So what’s wrong with using technology in the pursuit of achieving better outcomes again?

0:26 – “Maternity care in the United States is in crisis.” “People don’t have the information.”

Sure, education is important. I always try my best to educate my patients on their situation as much as possible. I want them to have access to the best information available, and to the maximum extent possible the ability to make reliable, informed medical decisions. Every single doctor I’ve worked with so far attempts to do this, although to be fair some are better at it than others.

0:32 – “Medical decisions are being made for monetary and legal reasons, not because they’re good for the mother and the baby.”

Wait, what? Over the past several weeks I’ve been privy to a lot of discussions between doctors concerning the options for patient care, and not one single time can I recall the primary focus being on anything other than carefully weighing the risks and benefits of those options for both mother and baby. Financial and legal concerns certainly exist, but in every case they have ever been mentioned around me so far they have taken a distant back-seat to concerns about the health and well-being of those under our care. I’m sure it happens, but it’s definitely not the norm where I’m being trained.

0:38-0:51 – Several completely decontextualized snapshots of doctors talking about administering pitocin, followed by the question “is this an improvement, or are we making things worse?”

That’s an excellent question, and the type of question that doctors following the principles of evidence-based-medicine should routinely ask themselves and seek answers for. As it happens, doctors do routinely discuss questions like this in medical journals, usually with a solid attempt at using evidence, reason, and ethics to approach them from multiple directions. So let’s discuss some of the reasons why we do and don’t use pitocin in various situations, perhaps we’ll find something we can improve on!

0:52 – text display: “The United States has the second-worst newborn death rate in the developed world.”

Wait, huh? I thought we were talking about pitocin! Anyway, citation? Judging from previous experiences I’m guessing that they’re actually talking about the infant mortality rate (a number which includes all infant deaths from birth up to one-year of age), and that’s not exactly a great way to compare the efficacy of obstetric medicine across different countries given that, among other reasons, different countries use very different criteria to establish what a “life birth” is. As one example, something we’re not very good at is substantially delaying pre-term labor. As a result, we deliver and attempt to save a lot of babies at 24-26 weeks of gestation, when their mothers spontaneously went into labor prematurely. All of these babies would have died before the advent of modern interventions like betamethasone and oxygen therapy, and many of them still die anyway despite immediate access to advanced neonatal intensive care because they’re simply too immature. In the US, every one of those counts as a neonatal or infant death. In most other developed countries, they wouldn’t even have counted as a live birth. So there’s some pretty significant counfounding going on, and it needs to be looked at much more carefully and with much more nuance than is being offered here.

0:55-1:02 – To a panel of people wearing white coats: “How often do you get to see a fully natural birth?” Answer: long pause – “Rarely.” “Almost never.”

I don’t know about them, but I saw fully natural births almost every day. If you wanted to ask about hospital births where the only intervention at all is an epidural, than that probably goes up to “most births.” And this is at a major academic hospital where we collect many of the most complicated and risky pregnancies from a population numbering millions. Two of those “completely natural” births even included babies born with gastroschesis, a condition where the abdominal wall fails to close and their intestines were hanging freely exposed as they were born. So I’m not sure what these ladies meant by “rarely” and “almost never,” or if there’s some extra context I’m missing, but I’ve had exactly the opposite experience. And more importantly, we don’t intervene without consent! If your labor isn’t progressing normally and you want an intervention like pitocin, membrane stripping, or artificial membrane rupture to help augment it, then we can give them to you after discussing them and obtaining your permission. If you don’t want them, you don’t have to have them. If you want to discuss the pros and cons of any of those beforehand, I’ll walk you through the relevant studies to make sure you can make the most informed decision possible. That most births don’t occur “fully naturally” isn’t because we coerce you to take all of these unnecessary interventions, it’s usually because women ask for them. I feel like this is an important point.

1:24 – “Cesarean is extremely doctor friendly. It’s 20 minutes, and I’ll be home for dinner.”

Are you kidding me? 20 minutes? At our hospital women usually labor with their friends/family/midwife/doula/etc. present to whatever extent they desire, and they have a nurse that pops in and out to check on them and keep them comfortable. They’re usually free to get up and walk around, drink water, and labor in whatever positions they feel most comfortable, and the longest period of physician contact occurs in the last few minutes before delivery when we gown up and assist in getting the baby out in case there are any problems. 10-15 minutes at most, usually, unless there’s an excessive amount of tearing that needs to be sewn up or a complication like shoulder dystocia. I’ve seen maybe one vaginal birth that took more than 20 minutes for the physicians to attend, and it involved both a significant tear and shoulder dystocia.

The shortest c-section I observed took about 40 minutes, with an average of probably around an hour and fifteen. If an intern was learning it might take 20-30 minutes longer, but 20 minutes just seems very unreasonable to me unless your surgeon is a complete hack who doesn’t care about doing a thorough job. Cesareans take longer for the mother to recover from, there are additional risks to the mother, and she doesn’t get to hold the baby right when it comes out. And now as a doctor you’re two hours behind on all the other stuff you have to do because you just spent it in the OR. My experience has been that the obstetricians I worked with disliked doing cesareans for a number of different reasons, and only performed them when all other options had been exhausted for legitimate, evidence-based reasons. You can’t even ask for one electively unless there’s a medical indication for it, so I’m really not sure where this argument is coming from.

And “I’ll be home for dinner?” Very few obstetricians work in single private practice, preferring instead to form groups that rotate call on a shift-based system because making a commitment to being present for the birth of every single one of your patients is murder on your ability to prevent your profession from consuming your personal life. So even if you decided for some abstruse reason to end a labor early and section a patient for personal convenience (I hope you have a good lawyer), you’re still not going home because your shift isn’t done until it’s done.

1:31 – “Basically, what the medical profession has done is convince the vast majority of women that they don’t know how to birth.”

What?? We offer free classes and tours to expectant mothers specifically to help them understand the process of pregnancy and childbirth, to enable them to become more informed participants in it. We’re not pulling the wool over anybody’s eyes here, and all of the doctors I’ve seen love it when patients ask questions with an earnest desire to learn and understand. A huge part of our job is patient education. One of the papers we hand out to expectant mothers is a study from the 1980s describing how interventions can occasionally lead to a c-section that otherwise wouldn’t have been necessary. We want mothers to know these things, because we think they’re important.

1:39 – “If I could do that, I could do anything. To me that’s the power of birthing. And that’s what we are taking away from women.”

Again, what? If you don’t want an epidural, you don’t have to have it. If you want to do your own research and ask questions to compare that with my professional opinion, I’m thrilled. If you feel comfortable having your breech twins at home, or not getting any ultrasounds and hoping you aren’t unlucky enough to go into labor with a term placenta previa, or if your membranes rupture prematurely and you hang out at home for a few days because you feel that the risk of chorioamnionitis is less important than the risks of antibiotics or the benefits of birthing your child into a bathtub full of coliform bacteria, then go ahead. I’m not going to stop you! But judging by this trailer, this film is nuts. And probably dangerous.

Free Will Theodicy

Take the following question:

If God created Adam and Eve and commanded them not to eat the forbidden fruit as a test of their obedience, then it’s logical to assume that an all knowing God would already know they would fail the test – in a sense, created them to fail. Why would an all knowing, loving God punish his creations for doing exactly what he created them to do?

The existence of evil creates a number of difficult questions for the idea of omniscient, omnipotent, and benevolent gods, and there are a number of ways that people have attempted to answer them. Here are two fairly typical answers that people on Facebook offered to the prompt above:

     That’s an easy question. First of all, the story might be an allegory. Either way, the idea is that without there being an “Adam and Eve,” you don’t have a living entity/being capable of returning love upon their own choice, and taking initiative by their own free will. You would have robots that respond because they were programmed to do so. There has to be an element of possible failure.      – Dennis

If you knew your unborn child would lie to you, fail or be a criminal would you prevent their birth? Remember that God is a Father too and when He tells us he loves us it’s not just rhetoric, he means it. Case in point, Jesus Christ.      – Peter

A serious problem with this response is that it places severe limits on this god that, to me, betray a lack of imagination. What if I knew these things about my future unborn children before they were conceived, as any truly omniscient deity would? What if I knew that if we conceived a baby in April it would turn out to be a sociopath, but that if we waited and conceived in May it will become a successful philanthropist that will touch the lives of millions? Why would anyone with this knowledge not wait and conceive the child in May?

“Positive Parenting Solutions.”

This just showed up on my Facebook feed.

With the caveat that I may have no idea what I’m talking about because my only child hasn’t learned to talk yet, this article rubs me as a little bit too uncompromisingly authoritarian. I get what’s wrong with nagging (and rewarding it by giving in), but why not channel those emotions into mature negotiating skills whenever possible?

When my sister’s oldest boy was about four, they were at a playground and she told them they needed to leave in a few minutes. After a few minutes, she told them it was time to go. Immediately, the four-year-old became distressed and expressed a desire to go down the slide (we could probably reasonably call it ‘nagging’). Rather than immediately turning it into a power struggle, she asked him why he didn’t go when she said they had only a few minutes left. Turns out he had been eyeing the slide the whole time they were there, but hadn’t yet worked up the courage to try it alone. She she told him that she had an appointment to go to and couldn’t be late, but that if he went and used the slide right now that she would still have time. So he did, and everyone left happy.

If you train your children to behave how you want primarily by exerting your authority over them, then what happens when they get a little bit older and decide that they’re more afraid of the consequences of disobeying their peers than they are of disobeying their parents?

Defeating Groupthink

After a few years as a natural science major in college, I found myself confronted with the evidence for evolution–something that I had been raised to believe was an elaborate deception. I quickly realized that I had a choice: I could wave it away through any of a number of excuses, or I could follow my curiosity and see how deep the rabbit-hole went. What ultimately happened was a fairly intense year or two where I ended up reading several dozen books on a wide variety of topics and changing my opinions on a significant number of issues.

The other day I was skimming through this book, and the author made a point about how soon after his father-in-law became a Republican because of the pro-life debate he changed his views on virtually every other political issue to be in line with standard Republican positions. Evolution is a hoax, humans don’t affect the climate, Reagan was a hero of the people, welfare programs discourage productivity and hurt the poor, etc. I realized that I had done basically the same thing in reverse. I’ve tried to be objective and minimize the influence of biases, but I’ve found myself defending Keynesian economics to Republicans and Libertarians when I’ve never taken a single economics class and my knowledge consists of reading a handful of pop-econ books and a few dozen blog posts. Why am I doing this? Why should I expect that Democrats have better economic policy than Republicans simply because I think they’re substantially more on target with other issues like women’s rights? I’ve almost gotten to the point where I feel like I shouldn’t express any opinions at all. I’m almost finished with my second-year of medical school and I can still barely hold a conversation with doctors in most specialties, so what makes me think I can pontificate intelligibly on economics or social science just because most of my peers are politically liberal and I’ve heard their opinions often enough to repeat them?

I want to be able to know that when I’m evaluating the evidence for an argument that I’m doing so as objectively as possible and not letting what I want to be true (because it aligns with the views of those most like myself and thus quells cognitive dissonance) color my evaluation. How do I do that? Learning to recognize fallacies doesn’t seem to be enough, because I know plenty of people on both sides of the American political divide who are brilliant at exposing flaws in arguments that have the “wrong” conclusions, but often fail apply the same rigor to arguments that affirm their positions.

Our Children are Being Indoctrinated!

Todd Starnes has another article up about liberal brainwashing in public schools, and it has been making the rounds on my Facebook page. Go ahead and read it, it’s short.

If you’d rather not, the TL;DR is that the father of a Connecticut eighth-grader found a U.S. Government homework assignment that somewhat uncritically reflects a liberal viewpoint on the Second Amendment. The father is appalled at this apparent attempt to indoctrinate his son.

I don’t understand this reaction.

I think I might partially understand it, but I certainly don’t agree with it and I struggle to understand the mindset of people who do this.

I’d like to think that by eighth grade, my kids will have developed a basic ability to evaluate controversial claims critically. If I were to believe, apparently like many of the people in that article, that there were powerful, dangerous, and fundamentally flawed ideas out there that people were attempting to indoctrinate my children with, I think that I would want my children to be exposed to the most persuasive versions of those ideas while they still had me around to provide some appropriate balance.

Along those lines, I have a hard time swallowing the idea that children of conservative parents can be “indoctrinated” by liberal schoolteachers or textbooks when they spend far more time exposed to conservative ideas at home than to liberal ones in their political science classes. If I found poorly-reasoned or factually incorrect information in my kid’s textbooks, I’d see it as a perfect opportunity to help them develop critical thinking and research skills. After all if my position on an issue is truly the one that is most likely to be correct given our best currently available knowledge and reasoning, then a properly and objectively conducted investigation should support that. And if my position is wrong, then teaching my kids how to think instead of what to think is the best way to enable them to overcome the damaging effects of my ignorance on their education. If my ideas can’t stand toe-to-toe with those of others, it’s time for me to find new ideas.

It seems to me more that people like Todd Starnes and the father in question would rather their children remain completely enclosed in a conservative echo chamber (and refer to the presence of liberal ideas in their children’s textbooks as “indoctrination” without the slightest trace of irony), where their own beliefs are taught as fact and any opposing beliefs are only introduced for the purpose of illustrating why they’re wrong. On that point, my experience with people who advocate the “echo chamber” approach is that they very rarely manage to present their opponents’ views fairly or accurately. I can’t remember the last time I met a creationist who wasn’t saddled with a massive number of fundamental misconceptions about evolutionary theory, and I seriously doubt that many of the conservative commenters on Starnes’ article could list a single difference between socialism and communism.

As far as the government doing the idea pushing, I went to a state university in California and my U.S. Government professor was about as staunchly conservative as they come. I do realize that that isn’t the norm, but the fact that it’s still relatively easy to find successful professors like mine with conservative or otherwise libertarian opinions in the academic heart of a liberal city within a liberal state makes me a little skeptical of the idea that our schools are liberal propaganda factories.

The Relativity of Wrong

I can’t count the number of times I’ve been in a conversation with someone advocating a pseudoscientific position when they’ve thrown out something like “but science has been wrong before….”

Yes, it has, and it certainly will be again. We often know we’re wrong, but just don’t have the data or the technology to do the experiments that might help us be less wrong. The lack of a grand unified theory in physics is a good example.

But there are many ways to be wrong and not all of them are equally wrong, so it’s a fallacy to argue that your unscientific theory is just as valid as as a well-supported scientific one because neither of them can be proven. Such an argument serves no purpose other than to avoid actually confronting the evidence objectively in a way that ranks potential explanations by probability, and it reduces to the bizarre idea that if we can’t know something with 100% certainty then we can’t know anything about it at all.

But enough from me, Isaac Asimov argues the point far more eloquently than I can. If you haven’t read it before, it’s well worth your time.

More on Morality

I’m a little tired of hearing that any sort of objective moral standards are impossible without an extra-human source of moral authority, because choosing which moral authority to rely on strikes me as every bit as subjective as deciding for myself what I think is right and wrong. And people seem to do that anyway, regardless of whether or not they claim to be speaking for their gods.

I really like what most of this guy is saying, especially the bits about consistency. There still seems to be an underlying assumption that minimizing the suffering of organisms capable of suffering is the right starting point to work from, but I think I’m okay accepting that without further justification at the moment. I wish I had more time to dig into the underlying philosophy, here (Kant? Consequentialism? I have no idea).

The Horrors of Unrestrained Science

Steve Riker asserted the following in a comment thread about the interaction between science and religion:

The bigger point here is that religion has played an important role in tempering science. Without moral considerations, science can be used to promote eugenics (the Holocaust), human cloning, forced sterilization and lobotomies, and the wanton killing of unborn children.

Imagine the unmitigated horror of allowing backroom butchers to murder over 50 million children while getting massive amounts of taxpayer dollars. That’s what happens when pseudo-science is allowed to run rampant without moral and ethical checks and balances.

Science is a tool, fundamentally little more than a set of principles and methods related to the acquisition and organization of knowledge about reality. And I agree that like all tools, decisions of where and how you use it should be informed by ethical principles. Without ethics, a hammer could be used for murder!

Where I disagree with Steve is on the implication that religion is the obvious choice to provide those ethical principles. I’m a firm believer in evidence-based-reasoning given its clear advantages over other methods (a good rule of thumb, I think, is to look at how often multiple people from different backgrounds but using the same mode of reasoning tend to arrive at the same conclusion), and I think that ethical guidelines based on a reasoned analysis of quantifiable goals such as the minimization of human suffering are more reliable than systems based on dogmatic adherence to the values we inherit from our individual cultural traditions. There are a number of reasons I feel this way, but first and foremost because the latter includes no mechanism to correct for harmful values or the continually changing reality we live in.

Ah, procrastination.

I managed to do well enough in college by going to classes, taking notes, and studying for 4-6 hours before each midterm. Unfortunately that approach doesn’t seem to work as well here, considering that we get a college-mid-term’s worth of material every few days. In the last four weeks we’ve done almost the entire kidney in pathophysiology (considered by many to be the most difficult aspect of the human body to understand), every major and many minor disorders of the gastrointestinal and genitourinary tracts, the mechanisms, side effects, indications, and contraindications of about 160 drugs, and more than I ever wanted to learn about several dozen parasites.

And because I’m a slacker, I have to learn the majority of it in the five days before exams start. Thank the gods for caffeine.

Update: I passed everything about as well as usual (i.e. still room for improvement), and then spent a few weeks reviewing old stuff for the upcoming Step 1 because it’s a lot less taxing and I needed a break. Now I’m 2.5 weeks behind and 2.5 weeks out from the next set of exams, so I need to get back in the game. The marathon analogy is apt, and I should learn how to pace myself better.

Evolution Books for Kids?

This adorable little book came out within the last few weeks. I would absolutely pay for a hard-copy if someone published it, but I suppose since it’s licensed under creative commons I’d be free to take it down to a local copy shop and get one made for myself. There’s a .pdf link at the bottom of the page.

While I’m on the topic, some other great kids books that deal with evolution are:
Evolution: How We and All Living Things Came to Be
Our Family Tree: An Evolution Story
The Magic of Reality: How we Know What’s Really True