Saturday, June 30, 2012

When the Courts Intervene

These days the news are filled with stories of various laws, bills, and practices brought before the Courts system.  It must be difficult to be a judge, to sit in a position of logic when so many of the arguments brought forth are ones of emotion.  And when it may at first appear that the Courts overstep their boundaries, the reaction can be explosive.

In Germany, a curious ruling was made by a Cologne court: German Ruling Against Circumcising Boys Draws Criticism.  Of course Jews and Muslims are up in arms over this, believing the court overstepped its jurisdiction and invaded religious space.  The court basically ruled (paraphrased) that the child has the fundamental right to bodily integrity and must be able to consent to the procedure if it's not done for medically indicated reasons.  It sounds logical enough.

Now the vast majority of circumcisions are done in infancy or early childhood, when the child cannot of course consent.  By Jewish tradition it happens on the 8th day of life.  Muslim tradition, as I understand it, varies a bit - it could be in infancy or all the way in adolescence (when the child would be able to consent).

So the argument come back, does the child's fundamental right to bodily integrity trump the parents' rights to parent?  To dictate the child's religion?  This is a gray zone, to be sure, and I'm not sure why male circumcision gets such a pass (from a logical standpoint).  Courts have ruled previously that a parent may not tattoo their child.  Courts have ruled that female circumcision (aka female genital cutting/mutilation or FGM) is illegal.  Are those necessarily drastically different?  Tattooing inflicts a permanent mark on the child, but doesn't remove any part of his/her body.  Female circumcision exists on a spectrum - the most "benign" being a simple prick to draw blood from the clitoral hood (or removal of the clitoral hood) to practices way more extreme.

One medical body considered allowing physicians to perform the most benign on the FGM spectrum (pricking the clitoral hood to draw a few drops of blood, symbolically of female circumcision) to assuage parents who come from a culture that practices that, and to ensure they don't take their baby girls to a practitioner who'd do something way more extreme.  That consideration was met with a furious backlash and promptly retracted.  But we're allowed to do more than that to baby boys.  I mean, really now?

For the purposes of this post I'm ignoring the potential medical benefits/risks of male circumcision because the research on that waffles all the time, and whatever potential medical benefits that may be gained are easily achieved with other means (e.g. using a condom, good hygiene, etc).  But these procedures, because they are surgical in nature, do come with very real risks.  In an old Jewish tradition (fortunately not practiced by most - I think - Jews these days), the mohel sucks the blood away from the circumcision wound with his mouth.  This is obviously not sanitary and is against all medical standards.  How 11 New York City Babies Contracted Herpes Through Circumcision.  That's one of the complications of that particular practice.  Now in normal healthy older children and adults, herpes is annoying but nothing more really.  In babies, because their immune systems are next to none, a herpes infection can be deadly.

And when public health officials try to intervene to limit/stop these practices, religious backlash is again furious as they claim they can self-regulate.  Clearly not always.  Circumcision, as my ob/gyn attending once said, has a "narrow therapeutic window."  It's not a difficult procedure to perform, but when you mess up, you mess up big time and you can destroy that kid's life.  That's not a burden I'd like to carry.

If at this point you may think I'm bashing religion, I assure you I'm not.  But when a religion requires modification to a person's body, particularly to a person who cannot consent, there are at least standards that must be met.  I'm in full support of medical/public health/legal bodies regulating such practices to ensure minimal harm.  The Cologne court in Germany may have gone too far, but the issue they bring up is valid: does the parents' rights trump the child's right to bodily integrity?  What if the child grew up and wish he (or she) wasn't circumcised?  What consolation is there then?

On my ob/gyn rotation I met a young first-time mother who asked me, as she was in the last stages of labor, whether her son would get circumcised right after birth.  I tried my best to mask my shock.  I said that the baby must first be observed for at least 12+ hours to ensure he's healthy enough.  I told her if she wished it to be done, it'd happen the following morning.  She asked me again if it'd be done right after he was born.  I reiterated myself.  Her friend suggested she could just leave him uncircumcised, that there's nothing wrong with that - I agreed and said most of the world's men are uncircumcised and the vast majority of them have no health problems because of it.  She considered this for a full 3 seconds before asking me that question again.  I changed the topic, exchanged some polite words, and left.  This mother, in my opinion, shouldn't have had the right to make that snap decision for her son without full consideration of the potential risks/benefits.

Thoughts?  Should logic rule over emotion and tradition?  Did that German court go too far, or simply conform to laws regarding other somewhat similar practices?  Whose rights should respected first?

Thursday, June 28, 2012

Ending with the Crazies

Ya know, I could say how I've been busy and whatnot.  But that'd be a lie this time.  I've just been lazy.  The year has been winding down for some time and I just couldn't be bothered, lol.  And as it is, I end the year with the crazies (aka, psychiatry).

It actually wasn't a bad rotation.  Spent 2 weeks on child/adolescent psych, 1 week on eating disorders, and 1 week on adult psych.  As the director of the place told us several times, "Most of these patients ain't dumb, they ain't crazy, they just have had crazy things happen in their lives and couldn't handle it, and that's why they're here."  On about day 3 I realized how true his words rang.

The vast majority of psychiatric patients I saw aren't crazy.  Most of them aren't schizophrenic, they don't hear voices other people don't hear, they don't see things other people don't see, they aren't foaming at the mouth or anything (that said, the couple of schizophrenics who weren't taking their medications really were sometimes kinda scary crazy).  Most of the people I saw actually had mood disorders - anxiety, depression, irritability, etc.

The best way I can describe most patients' situations is that crazy things happen in their lives - a kid is witness to domestic violence or is abused (verbally, physically, emotionally, and/or sexually), a teen feels out of control when her parents divorce and start restricting her eating, an adult couldn't handle the pain from multiple surgeries and turns to drugs - and their minds just can't take it.  Something inside breaks and they snap.  These people try to resolve things and find an outlet for the trauma of their minds and find themselves repeatedly bashing their heads against a proverbial wall.

And when they're at their lowest, when there's not much further down to go, they come to us at an inpatient psychiatric hospital.  Here we control the environment, take the responsibility out of their hands for a time, talk to them, counsel them, prescribe medications.  And these medications often work (it may take some fiddling around to find the right drug and dose for the right person, but it works out more often than not).  They kind of reset the imbalance in the brain and allow people to think clearer, calmer, and more rationally.  They smooth out the edges of emotions so one doesn't soar as high or dip as low.

Mental health.  It's a real thing.  Sometimes all one needs is some counseling, and sometimes it requires medication.  In that regard, it's not really any different than diabetes or hypertension.
Oh yeah, I'm 3/4 of an MD now!  :-D  Unfortunately the other aspects of my life have been less interesting than the things I witness when I'm in the hospital.  Still a few things here and there worth blogging about in posts to come.

Oh yeah, PPACA (aka, Obamacare) survived the Supreme Court ruling.  Thoughts?  Also for another post, lol.