The toilet bowl baby

Simply working in a hospital is an education in itself. You see people and things that are totally outside the realm of previous experience: drug abusers, criminals chained to their hospital beds, domestic violence. And every now and then, you see something that is just totally bizarre. The case of the toilet bowl baby falls into that category.

The story began when a young woman sought care at a local clinic one frigid mid-winter evening. The clinic was busy and the woman stood in line for quite some time before even reaching the triage nurse. She told the nurse that she was suffering from abdominal pain, and, oh, by the way, she thought she was 5 months pregnant. She hadn’t had any prenatal care, but she did remember when she had conceived. The clinic was busy, the woman didn’t look too sick, and the nurse told her she would have to wait.

After waiting over an hour, her abdominal pain was worse and she got back into line to speak to the nurse again. When she reached the head of the line, she told the nurse that the pain was worse, coming and going in regular intervals. The nurse pointed to the packed waiting room and told her she just had to wait.

The pain continued to intensify. The woman got back into line. Once again she was told to wait. Now she needed to use the bathroom, and asked the nurse where it was. The nurse never even looked up, but simply pointed to the corner of the room.

Shortly thereafter, the room echoed with screams coming from the bathroom. The nurses and security guard rushed to the Ladies Room. They found the young woman sitting on the toilet, having delivered a premature baby into the toilet bowl. The staff swung into action. They clamped and cut the cord, placed the patient on a stretcher and started an IV. They left the baby in the toilet since the woman had told them she was only 5 months pregnant, far too early for a baby to survive.

The ambulance crew arrived to transport the woman to the hospital. One of the EMTs retrieved the baby from the toilet and placed it in a metal bucket. It was a tiny, but perfectly formed little girl.

They arrived at the hospital well after midnight, and an obstetrics resident went down to the emergency room to examine the patient. Dr. A. had a medical student in tow. They met the patient in an ER cubicle, examined her, and delivered the placenta uneventfully. Dr. A. briefly took the baby off to the next cubicle for a teachable moment with the medical student.

Dr. A. demonstrated the signs of death to the medical student. The baby didn’t have a heartbeat, and wasn’t breathing. The baby had mottled skin and was cold to the touch. Dead. Dr. A. also pointed out that the woman had been wrong about when she conceived. By exam, the baby appeared to at 30 weeks gestation, 7 months along. Dr. A and the medical student returned the baby to the patient’s room and went out to prepare the paperwork.

The medical student, in the way of medical students everywhere, wanted to ask the patient a few more questions. Medical students generally ask massive numbers of questions, many of them irrelevant, because they haven’t yet learned how to focus their efforts. The medical student entered the cubicle and shortly thereafter rushed out to find Dr. A.

“The baby is alive,” he yelled to Dr. A.

Dr. A. looked up from the paperwork. “The baby is not alive,” Dr. A. said, mildly. “I just showed you that the baby is dead. Remember? She had no heartbeat, no respirations. She’s dead.”

The medical student looked frantic. “She’s alive! I’m sure she’s alive! You’ve got to come back!”

Wearily Dr. A. got up to humor the medical student. They went back into the cubicle.

The nurse, in an effort to tend to more than the patient’s medical condition, had carefully swaddled the baby in an infant blanket, putting a tiny stocking cap on her head. She encouraged the fearful mother to look at her baby. The mother was amazed; the baby was so beautiful. The nurse encouraged the mother to hold her baby, having learned that viewing and holding the baby were the first steps to coping with grief. The patient seemed so pleased with the baby that the nurse excused herself to get a camera to take a picture of them together. At least the mother would have this memento.

The mother was alone in the room, still holding the baby when Dr. A. and the medical student returned.

Squeak!

Dr. A. turned to the medical student, incredulous. “Did you hear that?”

Squeak! They heard it again. And it sounded like it was coming from the baby in the bed.

Squeak! Squeak!

Dr. A., now ashen, grabbed the baby from the mother’s arms and raced toward the nurses’ station.

“The baby has come back from the dead! Quick, call neonatology! The baby has come back from the dead!”

The neonatologist rushed down. Sure enough, the baby was alive.

Of course, she had never been dead at all. What was most amazing was that the baby had been kept alive by a series of misteps.

Because she fell into the toilet and was then placed in a metal bucket, the baby was very cold. Keeping her in the metal bucket during the ambulance ride through the frigid winter night had lowered her body temperature even further. Inadvertently, the EMTs had put the baby into a hypothermic state. Her body temperature was so low that her metabolism slowed considerably. Her heart rate dropped to very low levels and she rarely breathed.

Doctors sometimes deliberately induce hypothermia in infant about to undergo complex surgery, such as heart surgery. In that state, the baby is virtually hibernating; oxygen requirements drop dramatically, and there is a much lower chance of the baby suffering oxygen deprivation and brain damage as a result.

When doctors induce hypothermia, they must reverse it very slowly in order to minimize injury. Typically, they gently warm babies over a length of time. The ER nurse, in her effort to be compassionate, had inadvertently done just that. She had wrapped the baby and placed her in her mother’s arms, where she was slowly and gently warming.

When the neonatologist examined her, the baby’s body temperature was still far below normal, but she was very much alive, with a detectable heart rate and detectable breathing. They raced her to the neonatal intensive care unit, where they slowly and gently continued the process of warming.

The mother was joyfully stunned. She had a live baby!

Dr. A. and the medical student were shaken to the core. Each of them, for a brief moment, had imagined witnessing a real miracle, a return from death. Even after they realized what had happened, they could not shake the feeling that something truly extraordinary had occured.

And the baby? The baby did great. Once she was warmed up, she had a relatively unremarkable course. She never needed a ventilator and experienced nothing more than minor pitfalls of prematurity. She was discharge from the hospital when she weighed 5 pounds, only 6 weeks after she had arrived in a metal bucket. She has continued to do well, without any lasting effects from her experience as the toilet bowl baby.

Food is the new sex

Every now and then a scholarly paper comes along that is truly ground breaking. The brilliance of the paper is manifest in the synthesis of trends that we have all observed but never connected to each other.

Mary Eberstadt’s piece in the current issue of policy review, Is Food the New Sex?, is such a paper. It is a brilliant exposition on seemingly unrelated phenomena; at the same time that sexual license is embraced and even glorified, eating has become encumbered with ever more rules. Or as Eberstadt explains: our society has gone from sexually puritanical and licentious about food, to sexually licentious and puritanical about food.

Mary Eberstadt believes that the two phenomena are connected. She offers the following example that will be familiar to all:

…[L]et us imagine some broad features of the world seen through two different sets of eyes: a hypothetical 30-year-old housewife from 1958 named Betty, and her hypothetical granddaughter Jennifer, of the same age, today.

Betty is the stereotypical late 1950’s housewife. She cooks from cans, jars, and even serves frozen dinners. The only fresh vegetable that she serves is baked potato. Betty also has stereotypical moral views. Sex is appropriate only within marriage, and she believes strongly in the religious and social sanctions that penalize those who digress from that value.

The contrast with her granddaughter is remarkable:

…Jennifer pays far more attention to food, and feels far more strongly in her convictions about it, than anyone she knows from Betty’s time.

... Jennifer is adamantly opposed to eating red meat or endangered fish… She also buys “organic” in the belief that it is better both for her and for the animals raised in that way, even though the products are markedly more expensive than those from the local grocery store…

Most important of all, however, is the difference in moral attitude separating Betty and Jennifer on the matter of food. Jennifer feels that there is a right and wrong about these options that transcends her exercise of choice as a consumer. She does not exactly condemn those who believe otherwise, but she doesn’t understand why they do, either. And she certainly thinks the world would be a better place if more people evaluated their food choices as she does. She even proselytizes on occasion when she can.

Jennifer’s view of sex is also radically different from that of her grandmother:

Jennifer, unlike Betty, thinks that falling in love creates its own demands and generally trumps other considerations — unless perhaps children are involved (and sometimes, on a case-by-case basis, then too). A consistent thinker in this respect, she also accepts the consequences of her libertarian convictions about sex. She is … agnostic on the question of whether any particular parental arrangements seem best for children…

Most important, once again, is the difference in moral attitude between the two women on this subject of sex. Betty feels that there is a right and wrong about sexual choices that transcends any individual act, and Jennifer — exceptions noted — does not…

Simply put, Betty feels that there “rules” that should apply to sex, and people should be forced to conform to those rules, for their own good and for the good of society. Jennifer thinks that sex is a matter of personal preferences.

Betty thinks that the choice of what to eat is nothing more than personal preference. Jennifer is sure that there are “rules” that apply to eating, and that people should be forced to conform to those rules, for their own good and for the good of society.

What has happened?

Who can doubt that the two trends are related? Unable or unwilling (or both) to impose rules on sex at a time when it is easier to pursue it than ever before, yet equally unwilling to dispense altogether with a universal moral code that he would have bind society against the problems created by exactly that pursuit, modern man (and woman) has apparently performed his own act of transubstantiation. He has taken longstanding morality about sex, and substituted it onto food. The all-you-can-eat buffet is now stigmatized; the sexual smorgasbord is not.

Are human beings wedded to the notion that at least some appetites must be restricted? Have we transferred our “rules” and moral opprobrium about sex to “rules” and moral opprobrium about food?

It certainly seems that way. The same society that tolerates and even praises sexual licentiousness, despite strong evidence that it leads to serious health problems, is busily legislating against trans fats in restaurants, despite limited evidence that it will have any effect at all. The same people who howl “judgmentalism” at anyone who dares suggest that casual sexual encounters have dangerous consequences are enthusiastically insisting that their judgments about food should be forced on society as a whole.

Is the sad truth that we have made no progress at all? In the end, it is hard to avoid the conclusions that we have simply substituted opprobrium for one appetite with another appetite, replacing “rules” and views about sex with “rules” and views about food.

Don't blame me; the sexually degrading lyrics made me do it

Hundreds of newspapers and websites around the country have been buzzing with the news that sexually degrading song lyrics are linked to early sexual activity. The newspapers slavishly copied the press release issued by the American Journal of Preventive Medicine:

… Brian A. Primack, MD…, states, "This study demonstrates that, among this sample of young adolescents, high exposure to lyrics describing degrading sex in popular music was independently associated with higher levels of sexual behavior. In fact, exposure to lyrics describing degrading sex was one of the strongest associations with sexual activity...These results provide further support for the need for additional research and educational intervention in this area."

Surveys were completed by 711 ninth-grade students at three large urban high schools. These participants were exposed to over 14 hours each week of lyrics describing degrading sex. About one third had previously been sexually active. Compared to those with the least exposure to lyrics describing degrading sex, those with the most exposure were more than twice as likely to have had sexual intercourse…

Similarly, among those who had not had sexual intercourse, those in the highest third of exposure to lyrics describing degrading sex were nearly twice as likely to have progressed along a noncoital sexual continuum compared to those in the lowest third…

There are a lot of problems with this study, but the primary problem is not visible to lay people: the press release was issued well in advance of the publication of the article. In fact, the article is not available until the April issue of the journal is published. Journalists can request an advance copy of the article, but judging by the newspaper articles, most simply copied the press release. That means that the public has no way to independently assess the validity of the study or to determine if the author’s conclusions are justified by the data in the paper.

On its face, the idea behind the study is perfectly reasonable. Early sexual activity among teens leads to significant public health problems like the epidemic of sexually transmitted diseases and teen pregnancy. Identifying factors that promote early sexual activity might be helpful in creating public education programs to prevent it. It is entirely possible that sexually suggestive media promote early sexual activity. Unfortunately, the methodology of this study renders its conclusions highly doubtful.

In the study, Exposure to Sexual Lyrics and Sexual Experience Among Urban Adolescents (no link available), the authors recruited over 700 high school students with varying amounts of pre-existing sexual experience. The authors “inferred” the amount of sexually suggestive lyrics to which each teen was exposed by a convoluted algorithm:

They asked each teen to identify his favorite music artist and how many hours per week the teen spent listening to all music. Then they assumed that the teen’s favorite artist was representative of all music that they heard during the week. Further, they assumed that proportion of that artist’s use of sexually degrading music across his entire repertoire was representative of the teen’s exposure to sexually degrading lyrics.

For example, if a teen reported listening to 21 hours of music a week, and his favorite artist used sexually degrading lyrics in 67% of his songs, it was assumed that the teen listened to 14 hours of sexually degrading lyrics per week. As the authors acknowledge, their method has tremendous potential for error:

 It is possible that an adolescent’s favorite artist does not represent total exposure, either because the adolescent lacks access to that artist’s music (for financial or other reasons) or because the adolescent listens to a wide variety of music…

 In truth, the authors had literally no idea how many hours each teen was exposed to sexually degrading lyrics.

Moreover, the choice of favorite artist who uses sexually degrading lyrics may reflect the teen’s personal values. Those who are sexually active may more likely to enjoy sexually degrading lyrics.

The authors present the results of the study:

Participants were exposed to an average of 31.0 hours of popular music per week (SD=21.1) and an estimated 14.7 hours each week of songs with lyrics describing degrading sex (SD=17.0). Thirty percent of the 711 participants had previously had sexual intercourse…

Compared to those in the lowest tertile, those with the most exposure to lyrics describing degrading sex had greater odds for having had sexual intercourse (OR_2.07; 95% CI_1.26, 3.41). Likewise, compared to those in the lowest tertile, those with the most exposure to lyrics describing degrading sex had greater odds for having progressed further down the noncoital sexual continuum (OR_1.88; 95% CI_1.23, 2.88).

In other words, high exposure to sexually degrading lyrics was associated with a doubling of sexual activity. That sounds impressive until you consider that there were many other factors that were also associated with doubling of sexual activity. Age greater than 15 and rebelliousness doubled the level of sexual activity, and being black more than doubled the level of sexual activity.

The authors suggest that the association between exposure to sexually degrading lyrics and increased sexual activity is important and might even indicate that increased exposure to sexually degrading lyrics leads to increased sexual activity. However, a fundamental rule of scientific analysis is that correlation does not equal causation. Just because something is associated with a change does not mean that it caused the change.

The authors’ data demonstrates the importance of this rule. While age greater than 15 was associated with double the level of sexual activity, it would be absurd to suggest that increased age causes increased sexual activity. Although black teens reported double the level of sexual activity compared to white teens, it would be absurd to propose that black race causes increased sexual activity. Similarly, it is an unjustified stretch to suggest that increased exposure to sexually degrading lyrics causes increased sexual activity.

The authors openly acknowledge that their method of calculating exposure for sexually degrading lyrics has potential for large error and that correlation does not equal causation, and that causation can go both ways, but then they throw caution to the wind:

In summary, adolescents are heavily exposed to lyrics describing degrading sex in popular music, and this exposure is associated with early sexual experience among them in an urban population of youth at high risk for risky sexual behavior. These results provide further support for the need for additional research and educational intervention in this area.

But that’s not what the paper showed. We have no idea of the actual exposure of adolescents to sexual degrading lyrics. While exposure appears to be associated with early sexually experience, the three other factors that are associated with early sexual experience are clearly not causative. Even if there is a causative relationship, it is just as like to be that sexually active teens prefer sexually degrading lyrics, not that sexually degrading lyrics lead to increased sexual activity.

Finally, it was improper for the authors and the journal to send out press releases far in advance of publication of the paper. The press release is supposed to highlight the reasons to read the paper, not substitute for the paper itself. Deliberately sending out the press release in the absence of the paper deprives journalists and the public from the opportunity of actually evaluating the paper. It forces journalists to publicize the authors’ conclusions instead of their own conclusions. Maybe that was the point all along.

Corporate murder: death by syringe

Are corporate murderers evil, stupid or both? How could any corporate executive deliberately release contaminated products into the market and expect to get away with it?

Yesterday, two corporate executives in North Carolina were each sentenced for 4 ½ years in prison for deliberately shipping syringes without bothering to sterilize them. Dushyant Patel, the owner of the company, has fled to India in an effort to avoid prosecution. Thus far 5 people have died, and more than 200 have been sickened, some sustaining injuries such as permanent brain damage.

Patel’s company AM2PAT, doing business as Sierra Pre-Filled, manufactured sterile syringes pre-filled with medication used to keep IV lines open. Pre-filled syringes for IV maintenance are ubiquitous in any hospital and are often used by patients at on long term therapy at home.

According to the Associated Press:

Court documents portray a disturbing recklessness that allowed syringes to ship before they were checked for signs of contamination. Reports detailing the testing were backdated to appear they passed procedure before shipping, and some test results were manipulated or fabricated in an attempt to deceive inspectors from the U.S. Food and Drug Administration, prosecutors said.

Patel’s company sold nearly $7 million worth of heparin and saline syringes in 2006-07. The plant in Angier, about 20 miles south of Raleigh, cut corners so it could maximize profit, including shipping products as quickly as possible without checking on safety …

In an effort to increase profits, the owner and executives of a company conspired to skip the sterilization of the syringes, and then altered the records to deceive inspectors from the FDA who were responsible for routine safety checks.

Not surprisingly, the unsterilized syringes were contaminated with bacteria. Specifically, the syringes were contaminated with Serratia marcescens. Serratia is a bacterium routinely found in soil and water. It can cause wound infections, blood infections (sepsis), and pneumonia, among other things.

Injecting the bacteria directly into a patient’s bloodstream dramatically increases the chance for serious, even deadly, infections. Moreover, all the people who received the injections were, by definition, already ill. That’s why they had an intravenous line in the first place. Shipping unsterilized syringes, ensuring that bacteria would be directly injected into the bloodstreams of people who were already debilitated by disease practically guaranteed that innocent people would die. Yet the owner and the executive of the company did it anyway.

The case is strikingly similar to the recent outbreak of salmonella traced back to one peanut processing plant. There, too, the owner, and possibly the executives of the company deliberately shipped out peanuts that they knew were contaminated with salmonella. Once again, it was virtually guaranteed that a substantial number of people would be sickened, and that some might die.

Leaving aside the moral dimensions (which are huge) for the moment, what were these business people thinking?

That nothing would happen? That’s simply not possible; they had to know that people inevitably would become seriously ill.

That no one would find out? That’s also impossible. Although lax FDA oversight allowed the companies to circumvent FDA regulations, once a pattern of disease appeared, the FDA would inevitably trace it back to the company of origin.

That they get away with it? They know that companies are destroyed and executives are imprisoned when people die as the result of the deliberate decision to introduce contaminated products into the marketplace.

Clearly these corporate executives are evil. They chose to deliberately infect people with serious diseases, simply to maximize profit. Yet, that does not seem like a sufficient explanation for the disasters that have unfolded. They must also be stupid. How else could anyone think they could kill people and get away with it?

When sex kills

 

Mention reproductive conflict and many people will nod knowingly. It is not unusual to find differences in the sexual needs of men and women. Conflict may arise over frequency of intercourse and length of foreplay, not to mention the differing proclivities of partners. Yet that’s nothing compared to the female praying mantis who celebrates successful mating by eating the head of her partner.

 

It may seem nonsensical that what represents sexual fulfillment for one partner leads to the death of the other. However, sexual fulfillment exists only in connection with reproductive success. Whatever behavior leads to greater reproductive success will be favored, regardless of the unfortunate impact on the sex that is victimized.

 

This is highlighted in an article in this month’s issue of Current Biology, Sperm Competition Favors Harmful Males in Seed Beetles. Co-author Goran Arnqvist, discussing the phenomenon of reproductive conflict says:

One especially tricky case involves species where the males have mating organs that are supplied with hooks, barbs, and flukes that cause internal injuries in females during mating. This is extremely common among insects, but it also occurs in many other animal groups. 

According to the press release announcing publication of the article:

Goran relates that the males' mating organ is rather similar to a medieval spiked club and that it causes severe wounds in females during mating. But since it is never a good idea for a male merely to injure a female, the researchers have assumed that these structures serve another purpose and that the injury is an unfortunate side effect.

"Females' injuries as such do not benefit the male she mated with. It has been suggested rather that the injuries are a side effect of other benefits the males reap from the barbs. Now, for the first time, we are able to show that this is the case," says Göran Arnqvist.

Longer barbs cause more injuries to the female, but they also increase the likelihood of male reproductive success. When females mate with two males, the male with the longer barbs is more likely to fertilize the eggs. As in other cases of sexual conflict, the interests of the male and female are different, and it is reproductive success that ultimately determines whose needs are more important.

 

In the past, Goran and colleagues have proposed that a coevolutionary arms race takes place between males and females. Since reproductive success is maximized by an injurious mating organ, it is favored despite injuries to the female. In reponse, female seed beetles evolve reproductive ducts with more connective tissue, minimizing the risk of injury even as the male reproductive organ evolves to maximize it.

 

That makes a certain amount of sense, but, obviously, there are some injuries that cannot be overcome regardless of evolution. The male praying mantis cannot survive long without its head and no amount of evolutionary adaptation can change that. Therefore, there must be a very strong boost to reproductive success than arises from the female eating the male’s head during mating, and indeed there is.

 

The male praying mantis can complete mating after being decapitated. In fact, biting off the male’s head actually appears to improve sexual performance. Decapitating a  male praying mantis causes it to reflexively assume the mating position.

 

Second, the male’s head is an excellent source of protein and nutrients. Ingesting her partner’s head allows the female praying mantis to produce higher quality eggs, and thereby increases the reproductive success of the species.

 

While reproductive conflict may be responsible for unhappiness among human beings, it appears to have significant advantages among animals. The next time any man complains about not “getting enough” he should pause to consider that it could be far worse. Instead of getting his head bitten off figuratively, his partner could make biting off his head the literal consequence of sexual satisfaction.

What's in the water at waterbirth?

Waterbirth has been touted as an alternative form of pain relief in childbirth. Indeed, it is often recommended as the method of choice for pain relief  in "natural" childbirth. It's hardly natural, though. In fact, it is completely unnatural. No primates give birth in water, because primates initiate breathing almost immediately after birth and the entire notion of waterbirth made up only 200 years ago. Not suprisingly, waterbirth appears to increase the risk of neonatal death.

Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey was published in the BMJ in 1999. Out of 4,030 deliveries in water, 35 babies suffered serious problems and 3 subsequently died. It is unclear if any of the deaths can be attributed to delivery in water. However, of the 32 survivors who were admitted to the NICU, 13 had significant respiratory problems including pneumonia, meconium aspiration, water aspiration, and drowning. Other complications attributable to water birth include 5 babies who had significant hemorrhage due to snapped umbilical cord. In all, 18 babies had serious complications directly attributable to waterbirth. The risk of serious complications necessitating prolonged NICU admissions was 4.5/1000.

Hospitals in Ireland recently suspended the practice of waterbirth after a baby died from freshwater drowning after delivery in a waterbirth pool.

The most nonsensical aspect of waterbirth is that it puts the baby at risk for freshwater drowning. The second nonsensical aspect is that the baby is born into what is essentially toilet water, because the water in the pool is fecally contaminated. In Water birth and the risk of infection; Experience after 1500 water births, Thoeni et al. analyzed the water found in waterbirth pools both before and after birth. The water in a birth pool, conveniently heated to body temperature, the optimum temperature for bacterial growth, is a microbial paradise.

The authors were aware that the water system itself can harbor bacteria, given the report of at least two neonatal deaths from Legionella pneumonia, one that occurred in the hospital, and one that occurred at home. Therefore, they tested the water before anyone entered the pool. To their surprise and dismay, analysis of the water itself revealed that 12% of samples contained Legionella pneumophila, 11% Pseudomonas aeruginosa, 19% Enterococcus, 21% coliforms, and 10% Escherichia coli. Most of these organisms can and do cause infections in neonates. After installing a special water filter, and instituting more stringent pool cleaning procedures, contamination of the water by these bacteria was reduced, but not eliminated.

The analysis of the water after birth was shocking. Almost all 200 water samples were heavily (as opposed to slightly) contaminated with various infectious bacteria.

In the samples taken after the birth there was a high rate of contamination with coliforms (82%) and Escherichia coli (64%) with concentrations of up to 105cfu/100 ml; Pseudomonas aeruginosa, Staphylocooccus aureus, and yeasts were found less frequently.

The authors claim that the fecally contaminated water did not affect the rate of infection. First of all, the study is underpowered to reliably detect the impact of the contaminated water on the rate of infection. Second, the authors express their claim in a curious way:

Only 1.34% of children (10 of 741) born in water showed infectious signs such as tachypnea and suspect skin color compared with 3.40% (15 of 440) in the [control] group.

The relevant finding is not which babies displayed signs of infection. The relevant finding is which babies actually had infections. The authors neglect to share that information, suggesting that there was a significant difference.

Waterbirth is praised for its ability to ease pain in some women, but is that really worth the risk of delivering a baby into toilet water teeming with harmful bacteria? What's "natural" about that?

Why do thin people feel superior?

Let’s be honest. Thin people feel superior to people who are overweight. The prejudice is so deep seated that it has affected the practice of medicine. Rarely a week goes by without some scientific paper claiming to link obesity with various dreadful health problems; yet most are shoddy and poorly done, and almost all are debunked.

Why do thin people feel superior? The causes are economic and philosophical. Simply put, being overweight is associated with being poor. In addition, Americans have a deeply embedded strain of Puritanism that holds that those who have misfortunes somehow deserve them.

Many American predilections are grounded in economic status, and weight is no different. When poor people were thin because they didn’t have enough to eat, being overweight was a sign of status. Similarly, when poor people were tanned because of working outside, white skin was a sign of status. When poor women couldn’t afford anesthesia for childbirth, access to chloroform was a sign of status.

That’s changed now. Thin is a sign of wealth, a tan in midwinter (from a tropical vacation) is a sign of wealth, and preference for “natural” childbirth is also closely associated with upper income levels.

Achieving and maintaining the favored body type requires access to healthy food and special diet foods. It also requires exercise equipment or membership in a gym or, most exclusive of all, a personal trainer. All these things cost money, so weight has come to be viewed, accurately, as a sign of economic class.

Much of this is perceived only on the unconscious level. Nonetheless, it leaves thin people feeling superior to those who are overweight, because, economically, they often are superior. Weight has become a proxy for social class.

America was founded by Puritans and Puritanism is a strong strain in our thinking, hence the otherwise irrational impulse to regulate the private behavior of others, particularly others who are poor. Americans take almost fiendish delight in pointing out the “deserved” consequences of smoking, over eating, and marijuana use. They have stigmatized those behaviors in every possible way.

In my town, smoking is banned everywhere, including out of doors. Many cities are busily promulgating laws to regulate the composition of food served in restaurants. Users of marijuana, even those using it for medicinal purposes, are routinely prosecuted and may be jailed.

It is not a coincidence that smoking, over eating, and recreational marijuana use are more common among the poor. That is what leads, in part, to the zeal for stigmatizing, banning and punishing such behavior. Smoke a cigarette and you are forced outside into the cold; put transfats into your restaurant fare and you may face a fine from your city or town. Smoke marijuana and you may go to jail. On the other hand, steal $50 billion and force people into financial ruin and suicide, and you get house arrest in your Manhattan co-op while awaiting your trial.

Being poor is, in and of itself, almost always viewed as the “fault” of the people who are poor. This is an echo of the Calvinist belief in predestination, a convenient belief that those who prosper in this life do so because they are destined for an even better life after death. Therefore, overweight is routinely viewed as a visible sign of personal sloth, and worthy of serious negative consequences. The health problems of the overweight are simply just punishment for their inability to exert self-control.

There are literally hundreds of studies that claim to show that overweight is a major killer. Except that it’s not. The science is shoddy because the outcomes are predetermined by prejudice.

Of course morbid obesity is a serious health problem with potentially deadly consequences. However, simply being overweight is not only safe, but actually appears to be protective compared to “ideal” weight. That’s what the data really show.

Walk down the hallways of any hospital and look into the rooms. Very few people are there because of weight related health problems. We know this to be true in our own lives. All of us know many people who are overweight, but they are hardly dropping dead on a regular basis.

Thin is in, because it is viewed as a sign of economic status, and an indication of personal rectitude. The prejudice against the overweight is not justified by the scientific data, nor by the fact that weight is now a proxy for wealth. Like any prejudice, it is not justified at all.

A Zagat Guide for doctors? Bring it on!

 For years I have bemoaned the fact that there is no accountability for doctors in the way that they treat patients. Make patients wait for 2 hours for a scheduled appointment? Who cares? Offer only clipped, curt answers to questions? Why not? Rush patients through as if they were cattle? What are they going to do about?

I have periodically joked about the need for a Zagat guide to doctors, where patients could contribute evaluations of the doctor’s bedside manner, office policies, and overall treatment of patients. Evidently someone else had the same idea. As a matter of fact, Zagat itself had the same idea.

As reported in today’s New York Times, Zagat has partnered with the insurance company WellPoint to bring WellPoint customers a new guide rating doctors. Predictably, the reaction from doctors has ranged from anger to outrage. As a physician myself, I want to go on record as applauding the move. It is long over due.

The doctors’ criticism can be summed up as the claim that patient evaluations do not take into account the diagnostic and clinical skills of the doctor. A patient with an excellent bedside manner can be an incompetent practitioner, and a nasty doctor can be an excellent clinician. That claim is true, but it is beside the point. Patients are not being asked to evaluate their doctor based on his clinical skills; they are evaluating the doctor on how he treats patients as human beings. The Times quotes Nina Zagat:

Ms. Zagat, who founded the Zagat Survey company with her husband, Tim, said the reviews were not meant to be the main factor in the choice of a doctor. Rather, she said, they could help a patient choose among specialists recommended by her primary physician.

“One patient might say I care more about communications skills,” she said. “To somebody else, having a very modern, attractive office may lead to a different choice.”

The doctors’ whining is depressingly predictable:

“It is curious that they would go to a company that had no experience in health care to try to find out how good a doctor is,” said Dr. William Handelman, a kidney specialist in Torrington who is president of the Connecticut State Medical Society. “It certainly is very subjective.”

In addition, the doctors preemptively blame patients for bad ratings that a physician might receive:

“Patients notoriously ignore their doctor’s advice to eat well and exercise,” he said. “Often they quit taking their pills when they’re feeling better. They usually don’t understand the technologies and skills needed for treatment.”

Those complaints are, in the words of a classic expression, “true, true and unrelated.” Yes, Zagat has no experience in healthcare, but they have tremendous experience in collecting, collating, and disseminating customer opinions. Yes, patients often ignore the advice of doctors, but that has no bearing on whether they are entitled to have an opinion about the manner in which the doctor treated them.

The sad fact is that at this moment, patients currently have no way to evaluate doctors. Internal evaluations by insurance companies and rating agencies tend to be useless for everyone involved. Evaluating doctors by whether they order enough Pap smears, but not too many doesn’t tell us who is a good doctor and who is incompetent. It also doesn’t tell us who is a compassionate caring physician, and who is a mean SOB.

The Zagat rating system will not provide much information about the diagnostic and clinical skills of physicians, but then it is not designed to do that. It will provide information about the other factors that matter a great deal to patients and often seem to be of no consequence to physicians.

Make patients wait for 2 hours for a scheduled appointment? That’s inexcusable and reflects and complete disregard for the value of the patient’s time. A Zagat guide to doctors will let patients know who cares enough to create a realistic daily schedule and who has no idea or interest in how long patients wait.

Offer only clipped, curt answers to patients’ questions? That’s simply unacceptable, and it has a major impact on whether patients comply with their treatment, not to mention a major impact on how patients experience their care. If doctors knew that their behavior would be broadcast to all potential patients, they would give more thought to their responses.

Rush patients through as if they were cattle? Now they will be able to do something about it; they will be able to tell other potential patients. For the first time ever, there will be real consequences for physician actions.

I have a great deal of sympathy for the terrible time pressure under which doctors operate, and I understand how that leads to long waits and short tempers. But there should be consequences for doctors in how they treat their patients. At the very least, it will cause them to take notice of something they now routinely ignore.

A Zagat Guide for doctors? This doctor says, “Bring it on!”

The transplant was successful, but the patient died of shame

Kidney transplantation was pioneered in Boston, at the Peter Bent Brigham Hospital. The first transplants were performed only on identical twins because immunosuppression treatment had not yet been discovered. The donor and the recipient had to be literally identical in order for the transplant to have any chance of success. For the early recipients, it was a case of bad luck and good luck. Bad luck that to have a fatal kidney disease. Good luck that you had an identical twin able to give you a spare.

For the Marsden brothers, it was a case of bad luck, good luck, bad luck. Leon had the bad luck to have a fatal case of glomerulonephritis. He had the good luck to have an identical twin, Leonard, who was eager to donate a kidney. But, more bad luck, because Leonard, at the age of 19, did not meet the legal age of majority in Massachusetts, and, Leon was not expected to survive until they turned 21.

Because Leonard was not old enough to give legal consent, and because he desperately wanted to donate his kidney to his brother, his parents petitioned the courts for help. In Marsden v. Harrison, the court sided with Leonard in his desire to donate. The transplant was successful and both brothers did well. The case highlights the stringent standards that were used in the 1950’s to be sure that donors were not being pressured into giving kidneys against their own desires.

By the time I started my medical training in the 1980’s the pendulum had swung in the other direction. Kidney transplantation was relatively routine and the dangers were smaller. Family members often came under intense emotional pressure to donate even when they were, in truth, quite reluctant.

Chris* was a 17 year old with blond, curly hair, admitted for a kidney transplant early in my internship year. He had a long history of a degenerative kidney disease and had been undergoing thrice weekly dialysis for years. Despite the dialysis, his health continued to deteriorate. His parents vied with each other to donate one of their kidneys, but neither was a match.

His only sibling, his brother Steve* was in his early twenties and just starting out in a demanding career. He had an excellent relationship with his brother and his parents, but he was very reluctant to donate. He was so reluctant, in fact, that the transplant surgeon suggested that they put Chris on the waiting list for an unrelated donor kidney in the hope that Chris could get a kidney without involving Steve.

In the following two years, Chris continued to deteriorate until he was facing death, and still no matching kidney had become available. At that point, everyone began looking to Steve. Steve was still reluctant. Steve was frankly scared about the risks. Kidney donation carries a small, but real risk of death. In addition, no one could honestly tell Steve that he might not come to need, and regret the loss of, his second kidney. Steve balked.

Steve endured unrelenting pressure from his parents. As Chris became increasingly ill, his parents became increasingly desperate. They simply could not understand how Steve could hesitate at giving his brother what was his only chance to live any life, let alone a life free of dialysis.

Faced with his frantic parents, and frightened by Chris’ precipitous decline, Steve relented and agreed to donate. Both Chris and Steve sailed through their surgical procedures. To the great joy of everyone, Steve’s kidney in Chris’ body began to work immediately. For the first time in years, Chris could make urine. A mundane physical process, peeing, became a source of joy for Chris, Steve and their parents. The first few days after the transplant were days of happiness and celebration.

Then, inexplicably, Chris became suddenly and seriously ill. The kidney did not appear to be infected. It was still working well, but Chris developed high fevers, chills and lapsed into delirium.The family’s joy turned to fear, and the fear was compounded by the inability of the doctors to figure out the cause of Chris’ life threatening illness.

Chris slipped into a coma around the time that tests of spinal fluid revealed the cause, cytomegalovirus (CMV) encephalitis. Chris had developed a brain infection caused by a virus that infects those who are severely immunocompromised. Chris certainly fit that description; he was taking massive doses of immunosuppressive medication. CMV had spread throughout Chris’ body and attacked his brain. The chances of recovery were extremely slim.

How had Chris acquired CMV? CMV is transmitted from person to person through close contact with bodily fluids. Special immunologic tests indicated that Chris had acquired CMV only recently. It had almost certainly been transmitted with Steve’s kidney.

How had Steve gotten CMV? The first thought was that Steve, like many people, had had a mild infection of CMV in the past, and the virus had remained dormant in his bloodstream. However, blood tests on Steve revealed a completely unexpected finding. Steve, too, was immunocompromised. That’s because Steve was HIV+.

It was then that the truth came out. Steve was gay. That had been the source of his reluctance to donate. This was at the very beginning of the AIDS epidemic. Most people had not yet heard of AIDS, but Steve, like many members of the gay community, was aware that a new disease was striking down young, gay men. He did not know exactly how AIDS was transmitted, but he did know that he was at risk. But Steve was ashamed that he was gay and he strove to conceal his sexuality from everyone, particularly his parents.

Nowadays the requirements for informed consent have become almost as stringent as they were in the 1950’s. In an effort to prevent tragedies like those of Chris and Steve, potential organ donors are cared for and counseled by doctors who have no role in the care of the recipient. Most importantly, potential donors can choose to opt out for any reason or no reason, and the family will simply be told that the potential donor is not a match. In that way, we can ensure that donors are giving organs of their own free will, and not because of intense emotional pressure from family members or the recipient.

Of course that came much too late for Chris, Steve and their parents. Chris was promptly started on anti-viral therapy that brought the CMV infection under control, but he had already suffered massive brain damage. He lingered on for several months and died, his new kidney still working fine. Technically, he died of CMV encephalitis, but in reality, he died of shame, Steve’s shame. Steve had been so ashamed of his sexual orientation that he felt compelled to conceal it, even from the doctors who cared for him and Chris.

Steve developed full blown AIDS two years later. In the days before protease inhibitors, there was little treatment for AIDS, and inevitably, Steve died after struggling with the disease for several years. Two elderly parents, who for a few brief days in the aftermath of the transplant dared to believe that both sons would live to old age, lost everything.

Everyone agrees: we're outraged at Nadya Suleman

 

Our country may be fractured along political and economic lines, but we can all agree on one thing: we’re mad at Nadya Suleman, the mother of the newborn octuplets.

Ann Curry, who recently interviewed Suleman on the Today Show, referred to her as the “most vilified” mother in America. That’s a bit hyperbolic; most people will readily concede that they consider the actions of women who deliberately harm or kill their children to be far worse than what Suleman has done. However, Suleman has become a lightning rod for anger, resentment and disgust. There are a number of reasons why this has happened.

The first and most obvious is that Suleman expects, indeed feels entitled to, massive financial support for her children. Suleman has already bankrupted her enabling parents, and is making a good faith effort to bankrupt the rest of us. Such behavior would be unacceptable at any time, but in harsh economic times such as these, it adds insult to existing financial hardship.

Suleman is surprisingly childlike in her approach to money. She just assumes it will come from somewhere, as if by magic. Evidently, it always has. She seems to have no sense of what it will cost to raise her children, let alone any realization that she will never be able to support them, even if her fantasy of getting a master’s degree ever comes true.

One of the most difficult tasks of adulthood is to support oneself and one’s children, particularly if you are a single parent. An adult has to go to work whether she feels like it or not. An adult has to take and keep a job that she may despise because she and her children need the money. An adult has to put up with a bullying boss, annoying colleagues and boring tasks simply to continue putting food on the table for her children. Those are the basic rules of life for the millions of parents trying to survive in this economy. Nadya Suleman obviously thinks those rules don’t apply to her.

The resentment of Suleman’s indifference to the basic rules of adult life are increased exponentially by the fact that she clearly expects that the rest of us are going to support her family. The estimated $1.5-3 million cost to hospitalize the octuplets for 6 weeks or more? California will just have to suck it up and pay, or the hospital will just have to write it off. They money needed to buy food for 14 children? No problem; the taxpayers will just have to send more food stamps than they already do. Early intervention and educational support for any delays or disabilities her children might have? Nothing to worry about there either; there are mandates in place that will force the taxpayers to provide those services to her for free.

Second, Suleman has behaved in an extraordinary reckless way, ignoring the well being of her existing children, and the octuplets that she deliberately conceived. Children are separate, individual human beings and they deserve to be treated as such; Suleman clearly does not understand that.

Her stated reason for having so many children is both bizarre and narcissistic. She has been creating and accumulating children in an effort to make up for a childhood that she describes as lonely and dysfunctional.

People have children for many different reasons, good and bad, or no reason at all. But after having one child, most parents realize that the child is a person, separate from themselves, with his own needs that must be acknowledged and met. Suleman has failed to make this basic transition to responsible parenting. Her children are merely collectibles who exist to satisfy a psychological hunger that cannot be assuaged. Simply put, it’s all about her.

Third, and most importantly, Suleman exists in a fantasy world where actions and consequences are entirely disconnected.

Suleman hired publicists to improve her image, with the ultimate hope of profiting from her story. It is difficult to imagine that any public relations people, no matter how gifted, could extricate her from the hole that she has dug herself into. Neither Suleman or her family realized how their actions would be received by other people who live in the real world. While Suleman may have hired publicists, she is apparently ignoring their advice.

Eclipsing the foolish and bizarre statements she has already made, Suleman claimed that she has never been “on welfare.” When, as was inevitable, the press found that she has been receiving Food Stamps for the 6 children she already has, Suleman compounded her mistake, and revealed her penchant for fantasy, by asserting that Food Stamps are not welfare.

Suleman does not feel responsible for her choices, because she refuses to acknowledge the connection between her choices and the consequences: Yes, she has had 14 children, but that’s not her fault because she was lonely. Yes, she has no means to support those children, but that’s not her fault because she is going to get a master’s degree that will magically allow her to support them. It’s true that she receives Food Stamps, but that’s not a problem, because they are not “welfare” and she is entitled to them.

Nadya Suleman is not the most vilified mother in America, but she is sparking anger, resentment and disgust. That’s not because of her mothering, though. It is because of her narcissism, irresponsibility, and penchant for fantasy. As the financial hardship of these tough economic times impacts ever increasing numbers of families, as more and more parents give up their dreams and desires to provide whatever they can for their children, it is painful to listen to the prattle of an immature, selfish woman and it is almost unbearable to consider that we are paying for her folly.

Meth madness: Montana's prevention program increases acceptability of abuse

The film “Reefer Madness” became a cult classic more than a generation ago. Originally produced as a graphic warning against the use of marijuana, it was so overwrought it produced the opposite reaction to that intended. The film tells the story of teenagers lured into trying marijuana and, ending up involved in manslaughter, rape, suicide and an eventual descent into “madness.” By the 1970’s, it had become a cult classic, shown to great enjoyment and acclaim across college campuses.

The transformation from dire warning to joke is well known in the world of advertising and prevention campaigns. It is called the “boomerang effect” for obvious reasons. Typically it occurs when warnings are so dire that they are no longer believable. In fact, people take away the opposite message: the disfavored behavior could not possibly be as harmful as depicted, and therefore is probably safer than previous thought.

That phenomenon may be responsible for the paradoxical results of the Montana Meth Project (MMP). The MMP, the largest advertiser in the state of Montana, may not only fail to decrease meth use; it may actually increase it.

The MMP website proudly reports:

The Meth Project is the largest advertiser in Montana, reaching 70-90% of teens three times a week. This is saturation-level advertising.

The research-based messaging campaign—which graphically portrays the ravages of Meth use through television, radio, billboards, and Internet ads—has gained nationwide attention for its uncompromising approach and demonstrated impact. The campaign's core message, "Not Even Once®," speaks directly to the highly addictive nature of Meth.

Wikipedia groups the 16 television ads by director:

Tony Kaye's spots feature themes of meth-addicted teens' moral compromises and regret, and certain teens' false confidence that they can use meth without becoming addicted… Just Once, That Guy and Junkie Den feature teens who promise themselves that they will only try meth "once"…

Each of the spots directed by Darren Aronofsky features a voice-over spoken by the teen featured in the spot. In voice-over, each teen talks about how strong their relationships are with their friends and family, and how important those relationships are to them. The action on screen demonstrates that if a person becomes addicted to meth, their addiction will destroy even their strongest relationships.

Each of the spots by Alejandro González Iñárritu features a teen or teens who appear to be normal and healthy in the beginning of the spot, but who appear pockmarked, bleeding, and addicted at the end, despite the fact that time passes normally. As each teen encounters their downfall—prostitution, robbery, or overdose—a narrator intones the simple phrase: "This isn't normal... but on meth, it is."

The MMP claims is has produced impressive positive results:

Teen Meth use has declined by 45%

Adult Meth use has declined by 72%

62% decrease in Meth-related crime …

…As a model prevention program for states nationwide, the Meth Project has expanded into Arizona, Idaho, Illinois and Wyoming. Additional states are expected to launch in the coming year.

A new study in the December 2008 issue of the journal Prevention Science takes issue with those claims. According to Drugs, Money and Graphic Ads: A Critical Review of the Montana Meth Project, by David Erceg-Hurn, the campaign has actually resulted in increases in the acceptability of using meth, and decreases in the perceived danger of using drugs. The key finding of the study, though, is that meth use had been declining before implementation of the campaign and there is no evidence that the campaign is responsible for the continued decline. According to Erceg-Hurn:

"Meth use had been declining for at least six years before the ad campaign commenced, which suggests that factors other than the graphic ads cause reductions in meth use. Another issue is that the launch of the ad campaign coincided with restrictions on the sale of cold and flu medicines commonly used in the production of meth. This means that drug use could be declining due to decreased production of meth, rather than being the result of the ad campaign."

As the paper concludes, after an exhaustive analysis of each of the projects claims that the existing data that support or do not support those claims:

The MMP has successfully portrayed its advertising campaign as a resounding success to the media, politicians, and even some researchers. However, claims that the MMP’s advertisements have been associated with positive changes in attitudes to methamphetamine are, for the most part, not supported by evidence. In some cases, the MMP’s claims of efficacy are directly contradicted by data in their own reports. It is very worrying that the MMP has ignored and misrepresented several negative findings, such as increases in the acceptability of methamphetamine use, and decreases in the perceived dangers of drug use.

The Montana Meth Project has had an impact far beyond Montana. It’s approach to drug abuse is consonant with the beliefs of the Bush administration on preventing drug abuse, and it’s report of positive results has encouraged the government to extend the program to other states. Yet the Government Accounting Office (GAO) has reported that despite $1.5 billion spent since 1998 on large scale programs warning of the dangers of drug abuse, there has been no evidence of any impact on drug use. Indeed, some campaigns appear to have increased the use of drugs after repeated exposure to such campaigns.

Methamphetamine abuse is a serious problem, with widespread ramifications for communities across the country. The government should try to prevent drug abuse through public health campaigns. However, there is a danger that graphic and exaggerated advertising will have precisely the opposite effect of that intended. Instead of reducing meth use, the Montana Meth Project may go the way of “Reefer Madness,” becoming a cult classic for a new generation of teens and young adults.

Cosmo warns that an orgasm can kill

 I’ll admit it right up front. I fell for it.

I was standing in line at the drugstore when I noticed the cover of the March issue of Cosmo. The bottom right hand corner declared, “An Orgasm Almost Killed Her.” I’m a gynecologist, and I couldn’t think of what the mechanism might be for an orgasm to be fatal, but they included the subtitle “We Are Not Kidding” so it must be true. Medicine is constantly changing, and perhaps Cosmo might be the first to provide this important new information.

The article detailed the story of a young woman who had a stroke immediately following intercourse. Is it accurate to say that orgasm caused the stroke? It could have, but it is far from clear that there was a direct link between the orgasm and the stroke.

When the young woman who developed symptoms of a stroke shortly after sexual intercourse, her boyfriend rushed her to the hospital. Doctors found that a blood clot had blocked off part of her brain, causing the stroke symptoms. A review of her medical history revealed that she was at particular risk for blood clots because she was on the birth control pill. The Pill increases the risk of blood clots developing in the legs, and anyone who has other risk factors for blood clots should not take the Pill.

This patient had no contraindications to taking the Pill, and had she been like most other people, the blood clot in her leg should not have posed a threat of stroke. Unbeknownst to her, however, the young woman also had a small hole in her heart.

Everyone is born with a hole in the heart, called the foramen ovale (oval opening). The hole is there because the fetal circulation, when oxygen comes in through the umbilical cord instead of the lungs, is very different from the circulation after birth. In the first few moments after birth, the foramen ovale is supposed to be closed off by a flap of tissue. In this woman’s case, the flap did not cover the hole completely.

Because of this small hole within her heart, the blood clot that broke free of her leg vein traveled up to the heart, where it should have stopped, and crossed over to the other side of her heart and began the journey to her head. It lodged there, cutting off the circulation to a small part of her brain and causing the symptoms.

So the Pill caused the blood clot, and the hole in her heart allowed the blood clot to reach her brain, but is it true to say that an orgasm caused the clot to break free? It is possible, but then so are a lot of other things. Change in position like rising from a long period of sitting to standing can cause a clot to break free. Increased intra-abdominal pressure, like that caused by cough, could have also detached the clot. In fact, something as unglamorous as straining at a bowel movement, could also have caused the clot to be released into her bloodstream.

A blood clot is not the only way that you can die from sex. Anyone who has an abnormal blood vessel in the brain is at risk for bleeding into the brain if the blood pressure rises, and sex can cause a temporary rise in blood pressure. For those with heart problems, sexual activity can lead to a heart attack. For those with heart problems who are cheating on a spouse, the risk of a heart attack appears to be even higher. It must be the added effect of guilt on the blood pressure.

I feel a little embarrassed for being tricked by the headline into reading the magazine. However, on further reflection, I’ve decided that Cosmo has performed a public service, in the way that only Cosmo can. Blood clots in the leg are a rare side effect of the birth control pill. Patients receive written information about this side effect, but most probably pay no attention. After reading this story, it’s unlikely that anyone will forget the association between the Pill and blood clots.

That’s Cosmo for you: selflessly searching out stories of sex related medical problems in an effort to keep young women up to date with the latest health news. An orgasm almost killed that young woman. Don’t let it happen to you.

On marriage, a love letter to my husband

Our daughter recently gave us a very fine compliment. Discussing her day over dinner one night, she reported that her high school “Issues” class was studying marriage. The teacher had told the students that a successful marriage has three elements: friendship, intimacy and passion.

“That’s you guys,” she said, looking toward her father and me. “I raised my hand,” she continued, “because I had lots of examples to share.”

I was thrilled, both because of the compliment, and because she has been observing what her parents are trying to teach to her and to her brothers. My first, greatest, and longest lasting joy in life is my husband.

My children, of course, are my heart. They are as much a part of me as an arm or leg. Their joys are my joys; their sorrows are my sorrows (generally multiplied by a factor of two) and their fears are my fears (generally multiplied by a factor of ten). But my husband is the source of most of the good things in my life, and has been for more than the past 30 years.

As the “Issues” teacher said, the basis of a successful marriage is friendship. According to the late, great Ann Landers, “Love is friendship that has caught fire.” That is indeed what happened in our case. We met sophomore year of college as part of a large group living in the same dorm. When I started making my interest known, it was his fear for our valued friendship that made him hesitate. However, after throwing myself at him (there is no more glamorous way to describe it), I wore down his resistance.

Yet as our relationship grew, the friendship remained at the very core. He has been at my side through medical school, residency, work, the births of four children, the struggles we have shared with our children over their challenges, not to mention countless Little League games, Back-to-School nights, and dance recitals. Eight years ago when I stepped out of the MRI scanner and told him that I had brain tumor, his first words were, “I wish it were me.”

There is no one I would rather be with, talk to, read with, or watch football with. We are about a micron apart on the political spectrum, but have managed to have countless heated discussions about it, nonetheless.

Intimacy is also a vital quality for a successful marriage. I can share anything with my husband, including every fear and every embarrassment. He is always in my corner. I can also expect good advice. Although I’d like to tell you that he agrees with everything I do, the truth is a bit different. He’s not afraid to gently chide me, or counsel me to approach a situation differently. He’s a much nicer person than I am; in fact, he’s the nicest person I know, so that makes his advice and criticism easier to take.

There are additional components beyond the three that the “Issues” teacher discussed. Commitment and compromise are vital. A lifetime together involves a lot of momentous decisions, and the ability to compromise is necessary to smooth the way. For example, my husband thought he wanted two children, and I wanted four. So we compromised on four and he is very happy that we did.

That issue aside, there have been a lot of compromises: about careers, about work hours, about whose needs will be met when. If you can’t compromise, a marriage can be sunk. And when compromise seems very distant, commitment to the relationship, to making sure that everything works out, and to hanging on even when it seems like it might not, can tide you over to better times.

Everyone knows about the passion part of marriage. What I didn’t know 30 years ago was that the passion only increases. The boy I married because I liked, loved and was attracted to him is now the man who held my hand in labor, who tenderly nurtured our children, who supported me through my personal crises and who has become a respected and admired professional. I still like him, I certainly love him, and I am more attracted to him than ever, but even that does not adequately express the passion I feel for him more than 30 years after he captured my heart.

I am the luckiest woman alive, and I know it. He made all of my dreams come true, including the most the most important one. He showed me that true love is real.

The lyrics from the old standard, I Remember You,  convey my feelings best:

When my life is through,
And the angels ask me to recall
The thrill of them all.
I will tell them I remember you.

Dear Dr. Amy, I'm 14. Should I go down on my boyfriend?

I have been working on the internet as a freelance writer since before the advent of the World Wide Web. I had one of my most interesting jobs in 2000. That year I went to work for a new start-up called iEmily.com, a health website for teenage girls. I wrote the column Ask the Ob-Gyn.

In advance of the site going live, I prepared a variety of sample questions that I thought might come my way, and I collected research papers on conditions that I though the girls might ask about. I figured that in addition to questions about sex, I’d be asked about weight, about drugs, about drinking and about self-harm.

Surprisingly, over the 12 months or so of the project, virtually all the questions I received fell into one of two categories. The first, and smaller category was weight, specifically “am I fat?” Almost all the girls who wrote had a BMI (body mass index) in the normal range, so it was easy to offer reassurance.

Far more common were questions like this:

Dear Dr. Amy,

I’m 14. I’ve been going out with this cute guy. We just had our one week anniversary yesterday. He wants me to go down on him. I’m not sure what to do. What do you think?

Or

Dear Dr. Amy,

I’m 15 and there’s this guy I really like. All his friends say he will go out with me if I sleep with him. Should I do it?

I always said no. I never said yes. At first I was concerned that the girls would stop writing in because they would think I was too judgmental, but I couldn’t in all honesty say anything else. I was startled to find that the more I said no, the more girls would ask me for my opinion.

There were a variety of reasons why I always said no. First, I figured that if a girl needed to ask a stranger on the computer about such an intimate decision, it reflected the fact that she didn’t really want to do it. Second, I could not and cannot envision a situation in which sexual activity among young teen acquaintances or strangers is ever a good idea. Third, I was concerned about the risks. I developed a little riff on the risks and benefits that went something like this:

Let’s consider the risks: You could get pregnant; you could get gonorrhea; you could get herpes; you could get genital warts and risk cervical cancer down the road.

Now let’s consider the benefits. I personally cannot think of any benefits, can you?

Keep in mind that all the questions and all the answers were visible. Yet every time I said no, girl after girl would write in to ask me whether I thought that she should sleep with her boyfriend despite the fact that I had told the previous 10 girls no. Sometimes I would get 12 or even 15 questions in a row that were all asking the exact same question.

At first, I thought they were checking to see if I would ever give a different answer. Gradually I realized that something else was going on. They wanted me to say no. They wanted someone to give them permission to do what they had wanted to do all along, refuse the demands of acquaintances or strangers. Evidently there was no one in their lives whom they could count upon to watch out for their interests, to remind them that they were worthy of respect, and to tell them that they deserved to be healthy, which meant not taking health risks.

As a clinician and mother, I found the seemingly endless stream of girls asking for permission to say no both touching and horrifying. It was touching that they were so desperate for guidelines that they would ask a woman they didn’t know for advice, and it was horrifying that they did not feel that they had a right to speak up for themselves.

The job ended after a year when the start-up ran out of money. Ever since, I have pondered how it is that we tell our daughters that they can be astronauts or soccer stars, yet when a boy asks them to drop to their knees and “service” them, they don’t feel entitled to refuse. While aiming for career achievement is a worthwhile goal, we should start with the basics.

Every girl should know:

Your body is yours, and being a teen girl does not mean that you must lend it to any boy who asks.

You deserve to be healthy and sex poses serious health risks, especially if you and your partner are unwilling to obtain protection.

A relationship revolves around mutual interests, caring and concern. Any boy who is pressuring you into oral sex or intercourse does not really care about you.

Any boy who refuses to protect you by using a condom does not really care about you.

You are not in a relationship if the boy does not care about your feelings and your health.

There is no "right to choose" octuplets

 Almost all discussions about reproductive ethics are invariably deformed by analogizing to abortion. The train of thought goes something like this: the conclusion of an ethics discussion must result in confirming the right to abortion; anything that limits a woman’s reproductive choices could potentially impact the right to abortion; therefore, there can never be any limits to women’s reproductive choices.

That argument is weak, wrong and does not consider what the “choice” in pro-choice actually means. The “choice” is the decision to have an abortion, and it does not extend to any possible choice in reproductive ethics. That’s why Nadya Suleman had a right to get pregnant, a right to terminate the pregnancy and a right to carry it to term. She had no right to deliberately conceive octuplets, however, and it is a misunderstanding of reproductive rights to claim that she did.

Ultimately the protection for the choice of abortion is rooted in the right to bodily autonomy. No one can interfere with a person’s right to control his or her own body. No one can force an individual to donate a kidney, to accept a particular medical treatment, or even to accept lifesaving care. The individual has no obligation to do any of those things, and always has a right to say “no.” But that does not mean that the converse is true. Bodily autonomy is the right to refuse various measures, but there is no concomitant right to undergo whatever medical procedures one might wish.

Similarly, the right to an abortion is rooted in the right to refuse to continue a pregnancy, particularly because pregnancy has a small but real risk of death. No woman can be forced to remain pregnant against her will.

Bodily autonomy allows the individual to refuse to donate a kidney. It does not allow the individual to have a doctor remove his kidney to sell to someone else. It also does not confer the right to have a leg amputated or an eye put out, simply because the patient might desire it.

  Bodily autonomy means that patients have the right to refuse cancer care even if that might lead to death from cancer. It does not mean that they have the right to receive chemotherapy when they don’t have cancer, because they want to see what chemotherapy is like. Nor does it mean that they have the right to demand unapproved medical treatments or inappropriate medical treatments, no matter how much they believe that they might work, or how desperately they want them.

The right to an abortion implies a concomitant right to get pregnant spontaneously and to carry a pregnancy to term. Yet women who cannot get pregnant have no “right” to infertility care. Moreover, even if they are paying for infertility care, they have no right to dictate inappropriate fertility treatment or unapproved fertility treatment. That means that there is no right to demand an excessive number of embryos to be transferred even if that’s what the patient might want. The current medico-ethical recommendation for women under the age of 35 is two embryos. There is no “right” to demand more, and the right to control one’s own body does not confer the right to demand more.

Nadya Suleman had no “right” to conceive octuplets. She had no “right” to demand that 8 embryos be returned to her uterus, and the doctor had no “right” to put them there. If, as seems more plausible, she conceived octuplets using fertility medication, she had no “right” to take excessive doses of medication, and certainly no “right” to take fertility medication if she did not meet the medical definition of infertility.

In the rush to protect abortion rights, people should not ignore the rest of medical ethics. The right to end a pregnancy does not confer the right to begin one using artificial means. The right to selectively reduce a multiple pregnancy does not confer the right to create a multiple pregnancy of any number of embryos. In fact, the right to control one’s body does not confer the right to demand medical treatment of any kind if it is not medically indicated.

 The “right to choose” is the right to choose to terminate a pregnancy; it does not confer a right to choose anything, even if it is a reproductive choice.