The Science of Being Worried Sick

One of my bugaboos, ever since I learned there was a name for it, is iatrogenic risks: the damage that medicine itself can cause, however inadvertently. A big ole iatrogenic risk made the news recently, as Ivanhoe's medical news wire service reports:

The agonizing wait for breast cancer biopsy results can be harmful to a woman's health. The results of a new study suggests not knowing a diagnosis can lead to stress that may have adverse effects on the immune system.

More than 1.2 million breast biopsies are performed each year in the U.S. -- 80 percent result in non-cancerous findings. In this new study, researchers sought to establish a biochemical marker to assess the physical effects associated with the stress of extended waiting for a final diagnosis. They collected stress hormone [cortisol] samples from 126 women who had just undergone a large core biopsy. Four days later, the scientists learned the stress hormone levels of women with uncertain results were significantly different than women with benign results, but highly similar to women with malignant results.

(The original study is published in Radiology, March 2009, full reference below.)

Any of you who've awaited the results of high-stakes medical tests are probably thinking: Well, duh! The day I got my initial, troubling MRI results, I was in tears for much of the day before I even saw my doctor. I'm pretty sure my cortisol levels stayed sky-high for a several weeks, until I heard that I didn't have MS and that the radiologist who read the scans was probably mostly covering his ass.

So why is there any value in a study like this one? Because even though its findings are glaringly obvious, it points out that most of the women in the study had to wait at least five days for results. The study's authors, Elvira Lang et al., recommend in another well, duh! moment:

It is important to deliver histopathologic results in a timely fashion.

(Source: Elvira V. Lang et al., "Large-Core Breast Biopsy: Abnormal Salivary Cortisol Profiles Associated with Uncertainty of Diagnosis," Radiology 2009;250:631-637.)

Or to put it bluntly, doctors and hospitals need to organize anxiety-producing procedures with the patient's needs in mind, not the organization's. This would be worthwhile even if stress weren't a risk factor for (additional) illness.

By the way, it's not just women who would benefit from faster, healthier, and more humane delivery of test results. Lang et al. cite a larger, better-powered study in which men who underwent prostate biopsy had the most abnormal cortisol levels two weeks after the biopsy, right before they got their results. Like breast biopsies, prostate biopsies are more painful than doctors will generally admit, or so I hear from people who've experienced one or the other procedure. A cancer diagnosis in either case often strikes at a person's identity and sexuality as well as raising fears of mortality. Lang et al. write (again in the full text version):

These authors reported that some of their patients described the waiting period as a nightmare.

That earlier study was published in 1995, and yet people often still wait a week for test results. I'm hoping the new study might make a bigger splash, as breast cancer news tends to attract more media attention.

How long is the waiting period, exactly, before an obvious iatrogenic risk can be diagnosed and treated?

On Medicine and Objectification

Usually when we women's studies types worry about objectification, we mean sexualized objectification: a (usually male) gaze that sees the other as a means to an end, where the end is sexual pleasure. I think sexualized objectification is actually more complex and ambivalent, but for now I'd like to set that aside. Sex is by no means the only area where objectification occurs, and insofar as means-to-an-end logic is always part of it, those other areas ought to draw our concern, too. And so I've been thinking about the relationship between medicine and objectification - partly in honor of today being Rare Disease Day (h/t Shakesville) but mostly in light of my recent experiences.

Modern, scientific medicine has historically objectified people as patients. Indeed, the "modern" and "scientific" elements of it rely on objectification. Modern medicine is founded upon objectification: People become case studies. Their complicated life stories are aggregated into statistics. They're assigned to control or experimental groups, and their individuality melts away.

Medical research as we understand it would be unthinkable without objectification. The techniques I just mentioned are necessary to doing science right, following professional standards. The alternative - drifting in a sea of anecdata - would yield few useful results.

Actually, the alternative might look a lot like the journal articles written a century ago by long-dead German gynecologists. (For my dissertation research, I happily squandered months of my life leafing page-by-page through all the major German medical and gynecological journals and some of the minor ones, spanning about 1905 to 1935.) Typical articles included:

• An outline of a new (and by our lights, scarily unsuccessful and brutal) technique for cesarean section or symphysiotomy.
• Case reports of a needle left behind during surgery.
• Descriptions of rare deformities of the pelvic organs.
• Pictures of pickled uteri.

In other words, the journals reflect a fair amount of objectification but with very little systematization or, well, science. This started to change after 1900. By the 1920s there were more statistical analyses and fewer appeals to the author's "experience." Patients were still objectified, but there's an occasional glimmer of scientific method. We'd still consider most of these studies piss-poor science, but the trend, at least, was toward research beginning to yield benefits for patients, as opposed to mostly boosting the author's career.

(And yes, I joined the objectification party while I was working on these journals. I got so I could distance myself from even the photos of disembodied organs, which were mercifully in black and white. I could down a Snickers bar while looking at this stuff. So I experienced from the inside how medical training can create a distance from the suffering person and at least temporarily suspend empathy.)

Singling out medical research would distort the picture, because patients also came to be treated as objects in ordinary practice. This was especially true in teaching hospitals. I've written about how pregnant women in early-twentieth-century Germany were forced to undergo repeated exams by clumsy medical students, and how they were paraded naked in front of a whole auditorium full of observers while in labor. American obstetrics was no better: Women were strapped down while in labor and knocked out, whether they wanted it or not.

Over the past 40 years, under pressure from consumer advocates, feminists, and medical ethicists, medical researchers and practicing doctors have become a lot more sensitive to problems of objectifying patients. Patients with cancer are no longer kept ignorant of their diagnosis and prognosis. These days, expectant mothers are often encouraged to write birth plans - and yes, I realize those plans aren't always heeded, but that doesn't negate the sea change.

One index of objectification is condescension. They're not the same thing, but condescension generally grows out of the practitioner's conviction that he's in a hierarchical relation to the patient; that he's the subject and the patient is the object. And personally, I've seen a major decline in patronizing attitudes among medical practitioners. In the late 1980s, as a young graduate student, I went to my family doctor with complaints of fatigue, nausea, and dizziness. He told me, dismissively, that I was neurotic and overambitious and just needed to chill. (Another doctor diagnosed me with chronic fatigue syndrome, and after roughly 18 months I felt substantially better.) He projected the person of a folksy old-time GP, but I was just a case to him, and as such, he felt free to load me up with stereotypes about smart, ambitious young women. This doctor ultimately got in trouble for inappropriately touching young female patients - demonstrating that medical objectification and sexual objectification can occasionally overlap. He's now long retired, thank goodness.

My recent experiences at the Cleveland Clinic and the OSU MS clinic were the polar opposite. The doctors listened to me and took my complaints seriously. No one implied that I was hysterical or tense or simply a head case. Overall, I'd describe my relationship with my family doctor, ob/gyn, endocrinologist, and the kids' pediatricians as a partnership. We talk to each other frankly, and they listen to me just as much as I listen to them. The kids' doctors are also wonderful about addressing the kids directly and asking them about their preferences. (A penicillin shot or liquid antibiotics? Gee, that's a tough choice for a four year old!)

I realize I'm likely to get better care than average because I'm white, educated, medically literate, fully covered by insurance, and (heaven help me) sometimes a little pushy. But that's not the whole story. For instance, there's one doctor in our pediatricians' group practice who's still completely old-school. He was on duty in the hospital the day the Tiger was born, and he would not shut up about circumcision. In the end he had to respect my refusal to snip. I know he's very condescending toward people who he assumed are less educated. But this fellow is the exception that proves the rule. He's slouching toward retirement, and all the parents I know avoid him whenever possible. He's a relic of the medical past. Patronizing doctors like him are on a gradual path toward extinction.

One notable exception to this general trend away from objectification is medicine's ambivalence toward sexuality. As I've argued before, too many doctors are embarrassed to discuss sexual problems with their patients. This weekend's Well feature in the New York Times offers a fresh example: a prominent ED specialist reports that one in four of his patients who've had a prostatectomy was not aware until after the surgery that he'd never ejaculate again! This embarrassed silence also interferes with patients getting the full scoop on the sexual side effects of antidepressants. The failure of medicine to deal with sexuality is an effect of shame, embarrassment, and ignorance, as these examples show, but it's also a legacy of medical objectification. Seeing someone as merely as a "case" makes it very difficult to view a patient as a whole person with complex needs and desires. The result is condescension, fragmentation, and silence.

While pressure from our culture as a whole are pushing medicine away from condescension and objectification, there are countervailing structural forces. The most obvious of these is pressure to contain costs, which comes from all directions: insurers and HMOs, employers, and the state. Spending time really listening to the patient - as my doctors have done for me recently - doesn't come for free. The specialists will be better able to recoup this; the MS neurologist I saw, for instance, routinely budgets an hour and a half for new patients, and I assume he's got a billing mechanism that will cover his time. I'm pretty sure my family doctor, by contrast, will not be able to bill for all of the time he's given me. Adding insult to injury, just yesterday my university (the only big employer in town) announced they won't consider his clinic in-network anymore as of July 1. While this is likely a gambit to negotiate new rates, the net effect will be to place even more pressure on local primary-care doctors to curtail the time they spend with patients. Rushed appointments are not conducive to seeing the whole "case," much less the whole person.

Another structural counterweight to more enlightened, anti-objectifying medical attitudes is the march of medical technology. Again, the history of obstetrics provides lots of examples. Chief among them is the fetal monitor. Quite apart from the large body of evidence that suggests routine fetal monitoring increases interventions without improving outcomes, fetal monitors also objectify the laboring woman. Her experience - and the well-being of her child - are reduced to lines and squiggles. I'm not a Luddite about this, because I know that fetal monitoring has legitimate uses, even though it's vastly overused. Yet I know it's not just doctors and nurses who sometimes fixate on a mere artifact - the monitor's output - rather than on the whole person. Laboring women and their partners sometimes do the same.

The MRI is a further example of medical technology that can supplant the person, substituting a series of images that risks turning the person into an object. One example of this, ironically enough, is that study of sexual objectification that made a splash in the media earlier this month. While I'm fascinated with functional MRI, I also know that fMRI just shows brain activity in certain areas. What that means is still up to interpretation. And if the researchers are reducing their volunteers to mere images and not conducting lengthy interviews with them (only a questionnaire was mentioned in the media reports), then we can confidently saw that the research subjects are being rendered objects.

Does all of this mean medicine is evil and we should reject medical objectification whenever and wherever it occurs? Not at all. I'm in favor of medicine being more evidence-based. As I mentioned at the start, today is Rare Disease Day, and all of those orphan diseases cry out for more research. (My dad has had Crohn's for 50 years; my husband had an encounter with an obscure but devastating autoimmune neurological disease called MADSAM. My recent brush with the possibility of MS taught me that the unknowns still vastly outweight the knowns, even for such a relatively common disease. So I hope for more research, not less, and I recognize that scientific approaches to medical research will always tilt toward objectification.

But I also favor acknowledging the legacy of unexamined objectification in medicine. We can look at how it operates in specific contexts and weigh whether its costs are worth its benefits. We can analyze the potential of new technologies to fragment and objectify the patient. Simply bringing objectification out of the shadows tends to mitigate its effects: talking about it can make both doctors and patients more aware of it, and this will tend to promote more equal partnerships. And finally, we can hope and lobby for meaningful health-care reform that would limit the power of insurers to dictate that doctors practice medicine in five-minute increments guaranteed to obscure, fragment, and objectify the whole person.

Legislating Evidence-Based Medicine

Tucked away in the stimulus bill that Obama just signed is a provision that will fund research to compare medical treatments head-to-head. As the New York Times reported last weekend, funding will underwrite research to answer questions such as:

Is it better to treat severe neck pain with surgery or a combination of physical therapy, exercise and medications? What is the best combination of “talk therapy” and prescription drugs to treat mild depression?

This is basically a good idea. Having studied the history of childbirth, I'm vividly aware of how many interventions, from routine episiotomy to fetal monitoring, have been adopted without solid evidence to back up their effectiveness. By now, research has shown both of these interventions to cause a great deal more mischief than good: routine episiotomy increases the number of severe perineal tears, and near-universal fetal monitoring has helped drive the c-section rate into the stratosphere.

And yet, while I welcome policy that would both encourage and enable evidence-based medicine, I worry about how this comparative research will be used. The Times article mentions the problem of factoring cost into calculations of "effectiveness." Knowing how insurers work, I would expect them to refuse to cover more expensive procedures and drugs unless their benefits were overwhelming.

The Times article also highlights the problems of generalizing such research to everyone without regard to racial or sex differences:

“Some drugs appear to be more effective in women than in men, while other medicines are more likely to cause serious complications in women,” said Phyllis E. Greenberger, the president of the Society for Women’s Health Research. “It’s important to look for these sex-based differences.”

But beyond this, health policy needs to recognize that individuals can respond to different drugs in very individual ways. For instance, I've been reading up on the drugs used in multiple sclerosis. This isn't a purely theoretical concern for me, because odds are good that I'll be put on one of them if the neurologist I see next Monday judges me to be at high risk of developing MS. Some people don't respond at all to the basic MS drugs (interferons that try to down-regulate the immune system). Others suffer from side effects that force them to try out medications in a different class. It's really kind of a no-brainer that people with MS need to be able to choose among all the drugs currently on the market, including a couple that can have very grave side effects. Yet it's easy to imagine an insurance company using comparative research to deny coverage of all but the cheapeast drug. This problem will only grow more acute as the experimental MS drugs currently in the pipeline (hopefully) reach the market over the next few years.

I'm not arguing that comparative research shouldn't go forward. We need medicine to be anchored more firmly in scientific evidence. I'm just insisting that we equally need guarantees in law that insurance companies can't use the results of such research to keep tightening the scews on sick people who need treatment.

Cornel West, Love, Justice ... and Me

Well, okay. I didn't actually even shake his hand, much less get to talk with him one-on-one. But I got to hear Cornel West speak at my university today, and I was both moved and impressed.

Impressed: because he's got such an stirring delivery. If I tried to riff on the whole scale of emotion and power that he uses, I'd come across as a screeching, bombastic pedant. (Heck, I'm still trying to get comfy with wielding a microphone when I lecture!) But he's got the voice and presence to pull off the sort of oratory that's otherwise reserved for legendary preachers.

Moved: because he's not just way smarter than me, and he's not just a brilliant showman. He calls us to tend to our own spiritual maturity while committing ourselves to rooting out oppression. He takes Socrates' injunction that "the unexamined life is not worth living," mixes it with the blues, and inspires you to recommit to a better self and a better world. Actually, the better self is the bridge to that better world.

I'm not going to try to summarize all that West said. (He was giving the keynote at a conference on a founder of progressive Islam, Mahmoud Mohamed Taha, a Sudanese visionary executed by his government for his beliefs, whom West grouped with Gandhi, King, and Mandela.) Instead, I'll just share a few of the lines that I found most inspiring, yet pithy enough that I got them on paper - no small thing, because the ideas were flowing so furiously.

Indifference is the one trait that makes the very angels weep. It's the very essence of inhumanity.

Optimism deodorizes the catastrophic. Hope allows us to confront the catastrophic.

These weren't just eloquent yet empty phrases. While celebrating Obama's upcoming inauguration, West called on "Brother Barack" to serve hope, not optimism. To speak out against the carnage in Gaza. To explain why he chose Rick Warren in apparent contempt of his LGBT supporters.

This, however, is the thought I've promised myself to repeat every day until it becomes part of my blood and bones:

Justice is what love looks like in public.

Imagine what the world might look like if that became everyone's mantra. Imagine how different our history would be. How radiant our future.

Of course this is way out of season, but I swear it's posted in a spirit of hope, not optimism. (The flower is a Climbing Peace Rose from early September 2008.)

Laboring by the Insurance Clock

I'm feeling taciturn and mildly mopey today because I have a nasty sinus headache and the Tiger (who has tonsillitis) just yakked up his lunch. So, from the department of "it could be way worse" comes this news about how the recession is stranding people without health care. The New York Times (via Broadsheet) reports that when the Archway cookie factory in Ashland, Ohio (yes, Ohio again!) went belly-up two months ago, it left its employees stuck without health insurance.

While no one has died (yet) as a result, the company's irresponsibility made it shockingly hard for one baby to find its way into the world, as the Times recounts:

[Starla] Darling, who was pregnant when her insurance ran out, worked at Archway for eight years, and her father, Franklin J. Phillips, worked there for 24 years.

“When I heard that I was losing my insurance,” she said, “I was scared. I remember that the bill for my son’s delivery in 2005 was about $9,000, and I knew I would never be able to pay that by myself.”

So Ms. Darling asked her midwife to induce labor two days before her health insurance expired.

“I was determined that we were getting this baby out, and it was going to be paid for,” said Ms. Darling, who was interviewed at her home here as she cradled the infant in her arms.

As it turned out, the insurance company denied her claim, leaving Ms. Darling with more than $17,000 in medical bills.

I couldn't fathom how Starla Darling could be left stranded with those bills if she was still insured. It turns out the company misinformed her - or to put it bluntly, Archway lied. The Mansfield News Journal connects the dots:

On Oct. 4, [Darling] received a certified letter stating that, as of two days from then, she would no longer have a job or health insurance.

Darling says she asked and doctors agreed induce labor the next day, before the insurance expired Oct. 6.

After seven hours, with doctors about to send her home because the effort to induce was not taking, she began hemorrhaging.

"My placenta tore away from the wall and both the baby and I were literally inches away from death," she said. "We were rushed into emergency C-section, with both of us hanging tight to our lives."

Darling said doctors had to cut her open with no time to administer pain medications. Afterward, she learned her health insurance had already expired, despite the certified letter. Archway had stopped paying its part for employee health insurance months prior.

"Apparently, employees were paying their share of health insurance, but it has been reported that the company had not been paying since June," Meghan Dubyak, a spokeswoman for U.S. Sen. Sherrod Brown, told the News Journal on Friday.

Ugh. It's one thing for a company to slide into bankruptcy; it's quite another to lie to your employees. Also, can I just note that the credit crunch only began in September, not June? Archway had a problem for a good long time before credit froze up. It obviously had other mismanagement issues.

Former Archway employees are really stuck. Most can't afford COBRA coverage anyway on their meager unemployment benefits. But even if they could, their former employer's actions have rendered them ineligible. The Wall Street Journal gives more detail (via Michael Panzner at Daily Markets):

Archway was self-insured — and when it filed for bankruptcy on Oct. 6, there wasn’t enough money in its coffers to cover hundreds of thousands of dollars worth of outstanding health-care claims along with all its other debts.

Workers weren’t eligible for Cobra, a federal act that gives certain laid-off employees the right to temporarily continue health-care coverage at group rates. That’s because Cobra doesn’t apply when a company terminates its insurance plan.

This story is disgusting from start to finish. About the only thing Archway is not culpable for is the hemorrhage Darling experienced. To the best of my knowledge, induction of labor is not a particular risk factor for placental abruption.

Otherwise, Darling's story and those of her co-workers (follow the links above for those other stories) demonstrate why health insurance desperately needs to be de-coupled from employment. Insurance costs are bleeding employers (and indirectly, their employees, whose wages are depressed when premiums rise). As Archway's "ethics" show, a few employers can't be trusted to make their employees' health a priority in hard times. Most perniciously, as the recession/depression deepens, the number of uninsured is going to skyrocket.

The Tangled Web of Gestational Surrogacy

Historiann drew my attention to a fascinating essay in last weekend's New York Times Magazine by Alex Kuczynski, "Her Body, My Baby, on the experience and economics of becoming a mother via surrogacy. Historiann rightly raises a bunch of smart questions about how socioeconomic disadvantage encourages women to "altruistically" carry another woman's child:

This family may be an isolated example, but, I wonder: are working-class and middle-class women and girls being driven to sell reproductive services in order to get themselves and their children through college? If so, what does it say about what we value in women–their brains or their bodies? Are women who use the latter to improve the former with the goal of finding work that doesn’t involve their reproductive organs being canny, or are they being used?

(Read the rest of Historiann's post for more.)

Historiann locates a lot of unconscious class-based elitism in Kuczynski's essay, and I don't think she's wrong. But I think Kuczynski is equally driven by her unconscious embrace of the ideology of good mothers/bad mothers and her puzzlement at where she and her surrogate, Cathy, fit into it. She's also nagivating a fraught line between commerce and intimacy. Of course, these tensions are profoundly rooted in social class, too, but they can't be reduced to elitism. Here's the money paragraph:

WHEN WE CAME ACROSS Cathy’s application, we saw that she was by far the most coherent and intelligent of the group. She wrote that she was happily married with three children. Her answers were not handwritten in the tiny allotted spaces; she had downloaded the original questionnaire and typed her responses at thoughtful length. Her attention to detail was heartening. And her computer-generated essay indicated, among other things, a certain level of competence. This gleaned morsel of information made me glad: she must live in a house with a computer and know how to use it.

Historiann sees a patronizing "splendid isolation" here, and I agree. It's not quite on a par with Bush 41's awe at supermarket scanners, but yeah, Kuczynski's apparent surprise that Cathy lives in a house with a computer reflects the limits of a life spent shuttling between her Idaho vacation home and their little nest in Southhampton. It's hard not to see Kuczynski as a poor little rich girl who needs to brush shoulders with the hoi polloi more often.

But I think this paragraph - much as it made me cringe, too - reveals other dimensions of surrogacy and, more broadly, American attitudes toward maternity.

One of Historiann's commenters mentions that she'd considered becoming a surrogate, and that it felt to her like becoming "a reproductive whore of sorts." (She didn't do it.) I can see her point (though I've never been either a surrogate nor a prostitute). Both of these forms of work - and they are work, which should not be stigmatized - seem to me as though they entail selling an intimate aspect of one's corporeality. As I wrote a while ago, I don't see a problem with women choosing to sell these services, especially in a labor market where their other options may be quite bleak; I do see the buyer's position as hard to defend ethically, in part because the client is almost always in a strong position to exploit the seller.

I'm still struggling to work out why surrogacy and prostitution seem so qualitatively different to me than selling one's hard physical labor as a coal miner, say, or one's intimate thoughts as a professor (which Martha Nussbaum claims is in fact at least as ethically problematic). Maybe because surrogacy and prostitution would involve letting others have use of the interior of my body? Maybe because they seem to imply a different, physically and psychically deeper sort of vulnerability than other occupations? Maybe because both surrogacy and prostitution would be far less attractive if women had other lucrative possibilities at their disposal? Yes, I know that there are many sex workers and surrogates who claim to love what they do, and I don't dispute that. I'm still sure that their numbers would drop dramatically if the financial incentives evaporated.

At any rate, Kuczynski's arrangement with Cathy is both contractual and highly intimate. This is not so different from prostitution, either, viewed from the john's side. Susannah Breslin's Letters from Johns collection is rife with examples of men who want much more from a prostitute than just an orgasm. Ditto for Peridot Ash's wonderful blog on the charms and burdens of being a paid escort (here, for example).

To drive the sex work parallel just a little further into the ground: Escorts are generally better paid when they're educated and bright. Clients pay a premium for the privilege/illusion of social intercourse with someone who appears to have something in common with them. Why should surrogacy be any different? From this angle, it's not at all surprising that Kuczynski would look for someone she felt she could connect to, emotionally and personally. The lines that follows the paragraph quoted above are revealing on this point:

In our conference call with Cathy and her husband, Mick — the vice president of marketing for a credit union — we felt immediately comfortable. They had three children, two of whom were in college. Cathy and Mick sounded compassionate and intelligent. ...

I appreciated Cathy’s warmth and straightforward manner. But there was something else that drew me to her — the same thing that caused me to see her computer-generated essay in a different light from the other women’s hand-scrawled applications. She and her husband were college-educated. Her husband graduated from William and Mary. Her daughter Rebecca, then 20, wanted to be a journalist. They lived in a renovated mill house on a creek in a suburb of Philadelphia. They seemed, in other words, not so different from us. Later, during the election season, she and I were unaccountably pleased to learn that we were both planning to vote for Obama.

I have to make a leap of empathy, but in Kuczynski place I think I'd feel the same. Consider daycare providers, an area where I do have some direct experience, and which substantially parallels surrogacy in that you're entrusting your child's care to another person. Personally, I valued the fact that our long-time provider was intelligent in every way - emotionally and intellectually - and well educated. She had good common sense, excellent problem-solving abilities, and an intuitive understanding. Oh, and she supported Obama too! That's not as superficial as it might first appear. It was just one more indication that our values harmonized well.

Now, Kuczynski's situation was different in that Cathy would not be teaching, disciplining, and playing with her child; she wouldn't be molding his character or values. Kuczynski writes:

I know all this should have been irrelevant. Political preferences aren’t passed along through the umbilical cord. Strictly speaking, she was a vessel, the carrier, the biological baby sitter, for my baby, or as she put it in her essay, “I will serve as the ‘foster mother’ to the baby until it is born.” But it was easy to think of her as carrying my baby. She wasn’t desperate for the money, so our relationship wouldn’t have to feel like a purely commercial enterprise, or a charitable one.

In fact Cathy mentions that she's become part of the extended family for another couple whose child she carried. In an ideal world, every surrogate contract would morph into a real relationship, just as birth mothers would find a comfortable relationship with everyone involved in open adoptions. In reality, an awful lot of factors militate against this happening: social and economic differences; the parents' desire to move on with their lives or even deny their neediness; the fact that the arrangement was always about business, first and foremost.

While Kuczynski's desire for someone like herself to carry the baby is perfectly understandable, it also has a shadow side: the desire to control the surrogate as if she were, indeed, "a vessel." This reflects the near-paranoia that has taken hold in middle-class America about women's conduct in pregnancy ever since the publication of the original What to Expect When You're Expecting, with its endless lists of virtuous and evil foods. These paranoid tendencies seem to intensify toward the top of the socioeconomic food chain, where Kuczynski is located. For her, since self-control wouldn't ensure a healthy baby (no matter how many yoga classes she attended), she directed this controlling impulse toward Cathy:

Later in the fall, Cathy went to Las Vegas with her husband, who was attending a conference. I took the news badly. My tiny child — now that there was a sex, an identity, I could think of him as a child — was out there in Vegas at a craps table. I worried about the flight and whether the pressure would harm him. The thought crossed my mind to ask Cathy if it was really necessary to go, but I knew I couldn’t. I had given her my baby, and I would have to give her my trust as well. I hated giving up control, but experience had proved that I had even less control over my own uterus, and trying to exercise any measure of authority over Cathy would cause both of us only grief.

Yikes! I can imagine that making this leap of trust would be hard. I'm not totally unsympathetic. And yet - does Kuczynski really think she would have foregone her trips to Boise if she's been the "vessel"? Pregnant women routinely fly. If they're not experiencing complications or within a few weeks of delivering (or leaking amniotic fluid!), flying is no big deal.

Kuczynski recognizes that she can't control Cathy in any practical sense. What she fails to acknowledges is that her desire to do so isn't just likely to retraumatize herself; it's just plain unreasonable. Why does she object to Cathy playing a few rounds of the craps? Is the baby going to be born with a gambling addiction as a result? Or is it just that Kuczynski has bought into the mythology that a good mother forgoes all pleasure?

Instead of reflecting on how overblown these control issues had become, both in her mind and in our culture, Kuczynski laments her inability to live them out. Given the reflective tone of her essay, I wish she'd found a way to break out of this insanely exacting Good Mother paradigm. Given the control freakery around pregnancy in modern America, it's not surprising that she didn't.

Kuczynski's control issues culminate in her reaction to the baby's delivery, which sounds like a classic case of couvade - the practice in some cultures of the baby's father emulating symptoms of pregnancy and/or labor:

Birth is not a tidy business. As Cathy went into labor, my husband stood respectfully by her head to avoid being on the more visceral end of things. I found my son’s birth to be a terrifying event. When the baby crowned and the top of his skull appeared, my brain did back-flips. There was the mind-bending philosophical weirdness of it all: there is our baby — coming out of her body. And then there was the physicality of it: the torture of childbirth, of being split open, of having your body turned, it seemed, inside out to produce this giant, beautiful baby. Cathy vomited; I vomited.

Watching someone else birth your baby has got to be a profoundly weird experience, indeed. What's missing, of course, is an account of Cathy's experience. That essay - written by the mother who nurtures the baby, then hands her over in an act of blinding generosity - has yet to be published in the New York Times. What are the odds of that ever happening?

Photo by my husband.

Signs of Desperation

Photo by Flickr user gitboy, used under a Creative Commons license.

My Obama yard sign got stolen last night. This was the second one to disappear over the last ten days. I realize that the perps were probably drunken students. That doesn't excuse it. What people choose to do while drunk tends to correlate pretty closely to their values while sober.

And while I don't want to push a metaphor too hard, my pilfered yard signs also strike me as a sign of the times. This week, the presidential campaign turned nastier than I've ever seen, with John McCain and Sarah Palin portraying Barack Obama as an un-American terrorist lover. Even Karl Rove never went quite this far. It got ugly enough that a slew of conservatives are now saying the smears have gone too far.

Yesterday McCain finally tried to calm the mob his team has roused. He was booed by his own supporters for stating that Obama is a decent family man. I'm glad McCain showed us this flash of his own decency, but I worry it won't be enough.

I worry that all this public hating-on will embolden someone to take a shot at Obama. Literally.

It almost doesn't matter whether McCain and Palin are deliberately trying to incite violence, as Jeffrey Feldman suggested earlier this week. I don't suppose that Sarah Palin intended for a supporter to cry "Kill him!" after she linked Obama with former Weatherman Bill Ayers at a rally. It's just that hate speech, terrorist smears, and race-baiting have a way of spiraling out of control. This is how you prod a lynch mob into a frenzy. Even if a latter-day lynching isn't McCain and Palin's intent, violent reactions to such smears can be easily, easily anticipated by any reasonable person.

When their supporters break into open hostility and threats, McCain and Palin need to stop their stump speech and squelch them. Until yesterday, neither of them made an effort to do that. (Let's not forget that this has a longer history: Last winter, McCain didn't discourage his supporters from shouting sexist comments about Hillary Clinton, either.)

The German language has a great, largely untranslatable word for what's happening here: Hetzkampagne. The verb hetzen is used when you set the dogs on someone. It refers to agitation, baiting, hunting someone down. The term "smear campaign" doesn't quite capture Hetzkampagne, because there's no telling what will happen once the hounds of hell are turned loose.

Both McCain and Palin let those dogs smell blood last week. If the worst happened, blood would be on their hands too.

Is it a stretch from my stolen Obama signs to death threats? Sure. They're not the same. Thank goodness! Still, both are on a continuum of "dirty tricks to try when you're losing." They're both signs of the Republicans' desperation and disintegration. Once a candidate abandons civil discourse and fair play, his supporters seem to feel they've been given permission to break the rules and the law in ways large and small.

Is Porn Virtual Adultery?

Does viewing Internet porn amount to adultery? In his column at the Atlantic, Ross Douthat says yes, it does. Basically, Douthat argues that hard-core porn is not fantasy and that the privacy offered by the Internet allows a degree of intense and personalized interaction that could not happen in the good old days when men stashed a magazine or two under their mattress:

Over the past three decades, the VCR, on-demand cable service, and the Internet have completely overhauled the ways in which people interact with porn. Innovation has piled on innovation, making modern pornography a more immediate, visceral, and personalized experience. Nothing in the long history of erotica compares with the way millions of Americans experience porn today, and our moral intuitions are struggling to catch up. ...

Masturbating to a Sports Illustrated swimsuit model (like Christie Brinkley, once upon a time) or a Playboy centerfold is a one-way street: the images are intended to provoke fantasies, not to embody reality, since the women pictured aren’t having sex for the viewer’s gratification. Even strippers, for all their flesh-and-blood appeal, are essentially fantasy objects—depending on how you respond to a lap dance, of course. But hard-core pornography is real sex by definition, and the two sexual acts involved—the on-camera copulation, and the masturbation it enables—are interdependent: neither would happen without the other. The whole point of a centerfold is her unattainability, but with hard-core porn, it’s precisely the reverse: the star isn’t just attainable, she’s already being attained, and the user gets to be in on the action.

I'm not convinced. I have other problems with porn. Most of it objectifies women while being trite and frankly not very sexy, in my opinion. I'd have a problem if a partner neglected me in favor of a tete-a-tete with his computer. I would definitely be squicked if a partner was into barely-legal porn, or fetishes that would gross me out in real life, or the gonzo stuff that implies women get great pleasure from men destroying their orifices. But even then, while it might be represent a serious problem for our compatibility, it would fall far short of what I'd consider adultery.

To my mind, sex by any reasonable definition has to involve more than one person. It has to involve some sort of reciprocal interaction. Otherwise, masturbation would be cheating - and that's just silly.

By this definition, yes, it's possible to have sex online. But Douthat is not talking about cybersex, or phone sex, or any sort of interactive encounter. In porn, the only people interacting are on screen. The guy (or gal) at home is still a viewer. It's not like he's giving the actors direction. It's not like he can say, "Mmm, move a little to the right so I can get a better view." All he can do is open another browser window if the images aren't doing him right. No interaction - no sex.

I don't think porn is adultery. I don't even think it's virtual adultery. Porn is just porn.

I'm curious what you think. Are there any instances where porn would amount to adultery in your book? Please tell me in comments.

The Math of Distraction

While burning some grilled cheese sandwiches for tonight's dinner, I heard an NPR report on the presidential candidates' day. The reports on Obama and McCain were roughly equal in length. They had quite a few sound bites from Obama. At least half of them addressed the "lipstick on a pig" non-issue.**

Virtually the entire report on McCain foregrounded Republican outrage over the "lipstick on a pig" comment.

So: One-half of Obama's report was devoted to this distraction, as was all of McCain's, or

(1/2 x 1/2) + (1 x 1/2) = 3/4.

This is how Rove and his minions get three-quarters of the news coverage to focus on utter crap!

This kind of politics doesn't add up to democracy.

Nor does this kind of media. Especially when the supposedly liberal reporters at NPR frame the day's event as Obama being put "on the defensive" in their lead-in comments.


** Here's Obama's remarks in context, as reported by the L.A. Times:

Obama compared the policies of McCain to those of President Bush.

"John McCain says he is about change too, and so I guess his whole angle is: 'Watch out George Bush, except for economic policy, healthcare policy, tax policy, education policy, foreign policy and Karl Rove-style politics, we're really going to shake things up in Washington.' That's not change. That's just calling the same thing something different.

"You can put lipstick on a pig," Obama said. "It's still a pig. You can wrap an old fish in a piece of paper called change. It's still going to stink after eight years."

Criminality versus Dumb Decisions

Earlier this week Lynn Paltrow, executive director of National Advocates for Pregnant Women, published an open letter to Sarah Palin in Alternet, asking her to reconsider her position on abortion:

According to press reports your water broke while you were giving a keynote speech in Texas at the Republican Governors' Energy Conference. You did not immediately go to the hospital – instead you gave your speech and then waited at least 11 hours to get to a hospital. You evaluated the risks, made a choice, and were able to carry on your life without state interference. Texas Governor Rick Perry worried about your pregnancy but didn’t stop you from speaking or take you into custody to protect the rights of the fetus.

After, Ayesha Madyun’s water broke, she went to the hospital where she hoped and planned to have a vaginal birth. When she didn’t give birth in a time-frame comfortable to her doctors, they argued that she should have a C-section. The doctors asserted that the fetus faced a 50-75 percent chance of infection if not delivered surgically. (Risks of infection are believed by some health care providers to increase with each hour after a woman’s water has broken and she hasn’t delivered).

The court, believing, like you that fetuses have a right to life, said, "[a]ll that stood between the Madyun fetus and its independent existence, separate from its mother, was put simply, a doctor's scalpel." With that, the court granted the order and the scalpel sliced through Ms. Madyun's flesh, the muscles of her abdominal wall, and her uterus. The core principle justifying an end to legal abortion in the US provided the same grounds used to deprive this pregnant and laboring woman of her rights to due process, bodily integrity, and physical liberty. When the procedure was done, there was no evidence of infection.

(Read the whole thing here.)

Paltrow doesn't specify how many hours passed before Madyun's doctors pressed for a c-section. An old New York Times article says she'd been in labor for two days and in the hospital for 18 hours. Rachel Roth's excellent study Making Women Pay: The Hidden Costs of Fetal Rights states it had been 48 hours since her water broke. That's long enough that Madyun's decision starts to look fairly foolish by my standards and by most medical guidelines.

But here's the thing: People do lots of things that are stupid, risky, macho, or otherwise blameworthy. Some of these risk other people's lives as well as their own. Not all of these things are illegal. One example would be driving while very sleepy or distracted.

This is naturally true for childbearing, as well. Some people choose unassisted home birth, where the father catches the baby and no midwife or other trained assistant is present. Many of the people who propagandize for unassisted birth believe that birth, like sex, should only involve the couple; some of them also subscribe to right-wing religious ideologies. This is loony and irresponsible, in my view. (Not to mention it's asking a hell of a lot of the father!) Still, it's not illegal. Nor should it be. Imagine the mess if every baby born after a precipitous labor triggered a court case.

Another example Paltrow cites is of a woman who insisted on a VBAC at home. There are good reasons that no reputable doctor should condone this. If you give birth vaginally after a cesarean, there's a heightened chance of uterine rupture, which endangers the mother's life as well as the child's. If that occurred at home, odds are great that you'd bleed out before you could get help.

This woman, too, was forced by court order to have a c-section. This goes against our law on medical treatment in every other instance. A person cannot be forced to have surgery or undergo radiation even if they would surely die without the treatment. No one can be forced to donate a kidney - even if he or she is the parent of the patient needing a transplant.

If you believe humans have a right to bodily integrity and autonomy, you cannot legislate women's childbearing decisions. You certainly can argue that these people have an ethical obligation to make wise decisions and that some decisions are so irresponsible as to be unethical. However, unless you want to reduce the woman to an incubator and deprive her of basic rights of personhood, the law has no place intruding on ethics.

This is a long-winded way of saying that it's possible to fully agree with Paltrow's arguments and still maintain that Sarah Palin's choice to board a plane while she was at astronomical risk of going into active labor was a foolish decision. She wasn't taken to task for it legally, nor should she be. Her privilege protected her from any legal action. (Women subjected to forced childbearing decisions have been disproportionately young, poor, unmarried, and non-white.) If we trust women to make their own reproductive decisions, we have to acknowledge that while most women are remarkably altruistic and sensible, there will always be some who make decisions that we personally would never countenance.

But Palin's privilege shouldn't stop us from regarding her choice as 1) reckless and 2) completely hypocritical for someone who preaches the sanctity of fetal life. What's legal - and should remain legal - is not always ethical in every situation. We have a right to demand leaders that understand this distinction.

Obama's Thesis and He-Said, She-Said "Journalism"

Last week when I was nosing around for reaction's to Obama's Berlin speech, I came across this gem at MSNBC:

Conservative provocateurs have been hunting for it. Investigative journalists have been on the prowl, too. Even a former professor has been searching through old boxes for his copy of it. But today Barack Obama made it official: He doesn’t have and can’t release any copies of the thesis-length paper he wrote 25 years ago while a senior at Columbia University. “We do not have a copy of the course paper you requested and neither does Columbia University,” Obama spokesman Ben LaBolt told NBC News.

Oh dear. I have copies of student final exams going back a few years. The reason for this is not that I'm obliged to keep them; they can be thrown out after a year. No, it's that my students are generally unmotivated to pick them up once the new term starts, and I'm lazy about cleaning my office. I suppose I'll toss them when I move in my new office at the end of August.

As for actual papers? They go back to my students, with copious but often illegible comments. I make a copy if I suspect plagiarism. Otherwise, I don't keep them on file.

Any professor who'd keep a paper - and that's what this is, a lengthy paper, not a master's or doctoral thesis - for 25 years would need a much bigger office than mine.

But here's how MSNBC reports it. The story begins reasonably enough, telling of a "right-wing hit-man," David Bossie, who's been trying to dig up the thesis. Here's the ad he's been running in newspapers:

Image via MSNBC, reproduced here under fair use provisions of U.S. copyright law.

MSNBC then quotes Obama's former professor from the honors seminar he took on U.S. foreign policy, Michael Baron, who remembers Obama as a stellar student. Remarkably, Baron thinks he actually kept a copy of the thesis paper until eight years ago - but he then trashed it while moving house.

So on one level, the MSNBC report appears to be debunking wingnut rumors. But it's playing an ugly double game. Consider this header:

The dog ate my homework?

And then there's the article's ending, which gives Bossie the final word:

Case closed?

So is that it? Is the Case of the Missing “Thesis” over?

Not so fast, Sherlock.

“If Obama says he doesn't have a copy, I would have to call him a liar,” declared David Bossie, the conservative activist. “Obama has it or knows where it is but no one has pressed him seriously for it,” Bossie said.

In other words, for some, the search continues.

There's a convention in American journalism which requires only that "both sides" of a story be told. This passes as objectivity, no matter how bat-shit loony one side may be. At best, MSNBC is engaging in this he-said, she-said type of journalistic "ethics." (Jon Swift took the piss out of this better than anyone else so far.)

At worst, MSNBC is throwing its weight behind Bossie, becoming complicit with the right-wing hit-men. The fact that the article ends with his words gives some credence to this intepretation.

Either way, this is horseshit, not real journalism. What I learned from this article can be easily summed up:

1. Obama was a more diligent college student than I (who refused to write an honors thesis because it would have required sustained effort).
2. Obama nurtured an interest in the Soviet Union and arms control (not a bad thing in a future president).
3. Obama's former prof sounds like a super-nice guy.
4. Bossie sounds like a world-class Arschloch. (Some of the translations behind the link are rather loose, but all of them apply.)
   
5. MSNBC is no better than Faux News.

Dickens Meets the Drug Industry

Guinea pig photo by Flickr user Johan Larsson, used under a Creative Commons license.

In keeping with my policy of never scooping any real journalists, I want to say a few words about a commentary that appeared several weeks ago in the New England Journal of Medicine. Carl Elliott and Roberto Abadie reported in the NEJM that participants in Phase I clinical trials – the earliest tests of drugs in human subjects – amount to an exploited research underclass.

Over roughly the past decade, Elliott and Abadie write, pharmaceutical companies have begun routinely outsourcing these riskiest of trials. Private entities pay subjects to take part in trials, outside of the traditional university setting where oversight was less likely to be tainted by conflicts of interests:

Payment to subjects has escalated, creating "shadow economies" in cities throughout North America and elsewhere. In 2005, Bloomberg Markets reported that SFBC International, a contract research organization, was paying immigrants to participate in drug trials under ethically questionable conditions in a dilapidated Miami motel. A few months later, nine apparently previously healthy subjects at an SFBC subsidiary in Montreal contracted latent tuberculosis during a trial of an immunosuppressant. In 2006, six healthy subjects required intensive care in a phase 1 trial of a monoclonal antibody at a London facility run by the contract research organization Parexel.

(Source: NEJM)

Elliott and Abadie ask whether it’s ever ethical to pay research subjects to assume incalculable but potentially life-threatening risks. They argues it’s not, because the subjects will be drawn disproportionately from the very poor, who can earn more as perpetual guinea pigs. And this has three ramifications that make such payment unethical, in their accounting, which I think is spot on:

First, poor people are less likely than wealthier ones to get access to the drugs in question, if and when they are approved. Volunteers are unlikely to have full-time employment or, therefore, to have health insurance. ...

Second, the U.S. oversight system is not well equipped to monitor a highly competitive, market-based, multinational research industry. The Office for Human Research Protections has no jurisdiction over privately sponsored studies, and the Food and Drug Administration inspects only about 1% of clinical trials. ...

Third, even though the purpose of phase 1 trials is to test whether new drugs are safe, most sponsors apparently do not provide free care or treatment for subjects who are injured in these trials. In fact, no agency is even tracking injuries in phase 1 trials, much less the long-term health of people who volunteer for many trials over a period of years. A recent study commissioned by the Department of Health and Human Services showed that only 16% of academic health centers provide injured subjects with free care. None compensate injured subjects for pain and suffering or lost wages. Although no comparable data are available for private research sponsors, there is little reason to believe that private sponsors are much more generous; indeed, many include disclaimers in their consent forms indicating that subjects retain responsibility for their own medical care. ...

Sponsors call subjects' payments "compensation" to suggest that they are merely reimbursing participants for expenses and inconvenience, even as they fill studies with unemployed people who depend on trial income to make ends meet. They refer to paid subjects as "volunteers," implying that participation is a freely chosen act of altruism, whereas most subjects indicate that they take part in trials for the money. Regulators allow sponsors to use money to attract subjects but do not require them to provide the kinds of benefits that subjects would demand if they had more power. The result is what one Philadelphia trial subject describes as "a mild torture economy." "You are not being paid to do something," he explains. "You are being paid to endure."

(Source: NEJM)

I’m not especially shocked that this happens, only that it continues today and appears to be getting worse, not better. My own research on women’s experiences of childbirth is largely a story of poor women trading their most basic freedoms to get the most basic care.

An unmarried woman pregnant woman typically lost her job and often her lodgings as well. Her only option, before the advent of maternity homes, was often to seek shelter in a hospital. As obstetrics became more scientific and professionalized, guess who was used as research and teaching subjects?

These were the women who first tested new forms of anesthesia for labor. They were exposed to an auditorium full of male med students while in labor. They had to suffer multiple repeat pelvic exams conducted by the same bumbling students – an experience that must have been akin to rape, for they had signed away their right to say no upon admission.

The full story of these women is too long to tell here. Still, the similarities to today’s research “volunteers” are striking. These women had a choice, too. They could have given birth on a street corner or homeless shelter, and a few did. They could have maintained their independence as prostitutes, and some did. They could have tried to abort the pregnancy, and countless millions did.

So yes, there’s always a “choice.” It’s just that if you’re poor, all your choices may be horrible. And as the economy continues to sour, we can expect the number of “volunteers” to swell. More people will see no better alternative to “being paid to endure.”

Going Along and Getting Along with the Nazis

Sugar Mag is telling some fascinating stories about her grandmother, who was born in Nuremberg, Germany, in 1925, came of age during the Nazi years, and had a brief, doomed engagement to a handsome, wealthy young SS officer. Her stories raise the question of how any of us might respond had we been born into a situation that called for extraordinary courage. In comments, Sugar Mag writes:

My grandmother's parents were not party members but neither did they actively oppose the Nazis, I think they were just trying to get through it.

Based on my own experiences of having married into a German family with a mixed political heritage, I think that this phenomenon – sometimes called “inner emigration” – was widespread indeed. There was a range of accommodation, from simply lying low to joining a party organization in order to fit in or get ahead.

For instance, most young people who were eligible to join the Hitler Youth or League of German Girls (Bund deutscher Mädel, BdM) did so. My mother-in-law has lots of harsh memories of the later war years, but she did have fun with those girls in the late 1930s. The rest of her family responded ambivalently to this. On the one hand, her bourgeois parents looked down their noses at the coarseness of the Nazis, and so they weren’t thrilled about her BdM membership. On the other hand, her father joined the SA (Sturmabteilung, or brownshirts) as a doctor. He was not a true believer but recognized that joining would enhance his professional position, while staying neutral could hurt it. Apparently he thought this would be a lower-profile move than joining the SS, though his exact motives are impossible to reconstruct. He also personally profited when a colleague was forced to sell out for political reasons. He acted opportunistically rather than ethically.

Now, there’s obviously a big difference between this sort of low-level collaboration and inner emigration. Ethically, it’s the distinction between active and passive collaboration. But to be fair, professionals, such as doctors, lawyers, teachers, and judges, came under greater pressure to join the Nazi Party or one of its offshoot organizations than did farmers or manual laborers. Professionals who were Jewish or unfriendly to the regime lost their jobs early on or suffered professionally in other ways. There was a host of repressive mechanisms that fell fart short of the concentration camps, and they cultivated fear among those who weren’t already among those persecuted. Thus, most professionals cut loose their Jewish colleagues (this happened already in the spring of 1933 in law and medicine) and cozied up to the regime just enough to preserve and promote their careers. A substantially small number went on to lead the Nazification of the professions and society. Very few actively resisted - unless they were already being persecuted for political and/or racial reasons.

The other side of my husband’s family illustrates the penalties for not accommodating to the regime. His paternal grandmother was fired from her teaching job because she had a long history of involvement in Catholic politics. Prior to 1933, Germany had a specifically Catholic political party, the Center Party, and she had been an active member. Like most political Catholics, she did not suffer imprisonment but was considered too politically unreliable to hold an influential job. Of course, the Nazis realized that they needed an iron grip on the education system to consolidate their power. The results of this were both political and personal: My husband’s grandmother suffered real financial hardship because she was a widow and needed the income, while her son felt like an outsider at school. In the aggregate, the teaching profession became extremely brown, to such an extent that postwar schools in West Germany often employed large numbers of former Nazis because otherwise there would have been a massive teacher shortage.

Given all the repression, peer pressure, and propaganda, it’s amazing to me that any Germans of that generation grew up with a moral compass. Sugar Mag describes how conflicted her grandmother was when she overheard a conversation that ought to have been reported to the Gestapo (according to her teachers) but would have betrayed family and friends. She made what we would now consider the obvious right choice and protected her loved ones. We can never know how she preserved that nugget of morality in the face of propaganda and massive social pressure.

In her book Eichmann in Jerusalem, the philosopher Hannah Arendt famously wrote of “the banality of evil” – the ordinariness and routine that greased the cogs of the Nazi death machinery. People collaborated, laid low, and sometimes even resisted for reasons that were ordinary or even petty. Bureaucracy and efficiency obviated the need for moral judgments. People just did their duty, and the sum result was monstrous.

But these family stories suggest how the banality of Nazi evil worked on another level, too: If you happened to be born in Germany in the 1920s or 1930s to a supposedly “ethnically German” family, that was just your life. If you grew up surrounded by militarism and anti-Semitism, it was just your girlhood. It was the framework – the lifeworld – in which you played, went to school, fell in love. And when an evil system is that pervasive, normal, and taken for granted, you have to call on extraordinary moral reserves to resist it.

Like most of us, I’d love to think I would have found that moral core in myself, but I’m not sure. Unless we're tested, I’m not sure we’ll ever know. And I hope never to be tested in that way.

By the way, I included the Wikipedia references because they're concise and quite well done, and because they're convenient, but they would not have been allowed on my reading list for my Ph.D. comps. :-)

On the Uses of Confessional Lit

Superior kitteh from I Can Has Cheezburger?

A comment from Jenny Block on my blogging and narcissism post raises an obvious but important question: Well, why do we read this stuff anyway? Why do we provide the sort of bloated audience that makes it worthwhile for magazines to put Emily Gould's or Philip Weiss's navel-gazing on their covers? Jenny further asks where we draw the line between good, affecting memoir and self-indulgent TMI.

Hmm. I can think of three reasons why I read confessions and memoirs. And let's be clear: I'm a huge sucker for the confessional genre, including its excesses.

1) Well-written confessional lit makes me feel less alone with hard experiences and sometimes-taboo feelings. Here, I'm thinking mostly of the burgeoning literature on motherhood. Susan Maushart's wonderful The Mask of Motherhood: How Becoming a Mother Changes Our Lives and Why We Never Talk About It is both analytical and experiential; it made me realize I wasn't just nuts when I had a hard time staying home with my highly demanding first-born. Andrea Buchanan's Mother Shock: Loving Every (Other) Minute of It made me laugh and reassured me that it was okay to just chill out once in a while. The writers at Literary Mama beautifully explore some of the less-well-mapped terrain of maternal experiences, usually from a first-person perspective. I could spend the rest of the day extending this list and making similar ones for sexuality, marriage, health, and so on.

While there's usually an element of confession in these sorts of memoirs, they don't feel like a guilty pleasure. They feel like a way to stay a little saner, kinder, and happier than I might otherwise be. They can also be politically powerful in much the way feminist consciousness groups used to be. They can push us to consider how our supposedly personal little problems might actually be systematic and if not completely socially constructed, at least socially exacerbated. Such is surely the case with motherhood as a largely privatized enterprise.

2) Confessional lit gives me an almost anthropological pleasure in seeing how other people live differently from me. Okay, that's mostly a fancy way of admitting I'm nosy. I'm fascinated by the glimpses I get of my students' lives in my women's studies classes. Though I obviously keep a professional lid on my nosiness and respect their privacy, I still get to learn a lot about them. Much of this fascination comes from their inhabiting the next generation from my own. They give me a peek into the future. They show me different ways of thinking.

Jenny's own writing on her open marriage definitely falls into this category for me. Her domestic arrangement is pretty different from my own, which is outwardly pretty conventional: a husband, two kids, monogamous heterosexual marriage, and a charming (if messy) house in the kind of friendly, front-porch neighborhood that supposedly went extinct by 1970. But then there's my inner life, which is politically quite radical and emotionally turbulent, full of unruly desires and ideas. If I look calm on the outside, it's only deep cover for my restless soul. Reading about how people live out very different choices satisfies my own curiosity, sure. But maybe it also helps me reconcile my own duties and desires by vicariously experiencing other people's less constrained lives.

3) On a base and prurient level, confessional lit lets us feel superior. I react that way even to the grand-daddy of all confessors, St. Augustine: Didn't he realize what a tortured hypocrite he was, trying to dissuade everyone else from sexual pleasure after he'd got his own? People got so riled up about James Frey fictionalizing half his memoirs partly because that sense of smug superiority relied on his exploits having been real. As I read about Emily Gould's exploits and Philip Weiss's inchoate desires, I was looking firmly down my nose at them - more so with Weiss, because he comes across as the sort of sexist pig that ought to be a feminist strawman but sadly isn't. I'm not particularly proud of any of this, but I'm guessing it's a common response.

I think an element of condescension often enters into our response to memoir, even if we're reading mainly in one of the first two modes. To use Jenny's work as an example again: It provokes a lot of judgmental comments. I'll admit that when I read her piece linked above, I too wondered whether her husband was really on board with opening their marriage, or if he went along because he saw no other choice. In the end, I realized that only they can judge that. But plenty of commenters felt they knew enough to condemn her on that score and many others.

Similarly, lots of writing on motherhood provokes judgmental, patronizing reactions. I'm not totally immune to them, either, even though I think I have immense reservoirs of sympathy as an imperfect mother myself. Mothers are just soft targets, I'm afraid.

In the end, I'm not arguing that the confessional genre is illegitimate just because it's possible to read most memoir while straddling a judgmental high horse. But I'm realizing that we'd do well, as readers, to be aware of when we're starting to wallow in our own superiority. As a writer, I suspect that we need less writing of the sort that is an outright invitation to read in this third, judgmental mode. And maybe this suggests one tentative response to Jenny's second question: As long as memoir can be read in the first two modes - as long as it advances our self-knowledge or our understanding of others - it probably has enough redeeming features to survive those readers who will insist on using it to build up their own egos.

I'd love to hear what others think about this, so please add your ideas in comments!

If Narcissus Had a Blog

Narcissicats from I Can Has Cheezburger?

The confession is an old, old literary genre, going back at least to Augustine and his Confessions (which he wrote after he'd committed enough fun sins to be worth confessing, of course). Narcissism is probably even older. At least, it was a big enough deal for the ancient Greeks that they gave it a name and its very own myth.

But the Internet has taken these ancient impulses and not just modernized but amplified them. Most blogs - apart from the big political blogs - have a confessional element. Even the large feminist blogs (Feministing, Pandagon, Shakesville) give us glimpses of the writers' lives, whether it's their pets or relationships or just non-blogging activities.

In moderation, these dollops of the personal make blogging way more fun than conventional journalism for readers and writers alike. And sharing some well-chosen personal details is only rarely narcissistic. Even outright navel-gazing isn't necessarily narcissistic. But blogging crosses that line when the writer exposes other people's personal lives.

Lately, narcissistic confessionalism seems to be mounting a takeover of print journalism, too. This is troubling insofar as it represents further degradation of journalistic standards. It's also compelling in ways much like a full pint of Ben and Jerry's. You can't help opening it; you can't stop yourself from taking just one more spoonful. And when you hit the bottom of the carton, you realize you're feeling just mildly queasy.

Case in point #1: Emily Gould's piece in this weekend's New York Times Magazine, in which she confesses to previous sins of "oversharing" through an 8000-word exercise in, well, oversharing. Gould used to work for Gawker, which I've never really followed since it's such a New York insider thing, but that hardly matters; oversharing has a universal fascination. And this is oversharing on a grand, epic scale.

Within the first dozen paragraphs, we already know why Gould's ex-boyfriend Henry will have to break up with her:

As Henry and I fought, I kept coming back to the idea that I had a right to say whatever I wanted. I don’t think I understood then that I could be right about being free to express myself but wrong about my right to make that self-expression public in a permanent way. I described my feelings in the language of empowerment: I was being creative, and Henry wanted to shut me up.

That's Gould "reflecting" now on how she disrespected Henry's privacy on her personal blog. But see, even as Gould pillories her own past behavior - even as she seems to be confessing to her own prior lack of judgment and discretion - she doesn't acknowledge that she's dragging poor, private Henry into the public arena once again, this time not in a small-potatoes personal blog but in The New York Times Magazine! Even though Gould does seem to be assuming most of the blame for their break-up, millions of people now know that Henry would "sulk" about her blogging. That line between personal oversharing and encroachment on others' privacy? Guess what - you just crossed it again.

We learn, too, about Henry's successor, Josh Stein, and the courtship he and Gould conducted mostly via IM while sitting next to each other at the office. We hear about how they finally became a couple while on a weekend retreat:

Josh and I sat together on the couch, and I put my head on his shoulder in a completely friendly, professional way. The next day, I let him apply sunscreen to the spot in the middle of my back that I couldn’t reach. As a joke, we walked down the wood-plank paths that crisscross the island holding hands. I also remember joking, via I.M. as we worked, about us wanting to cross the hallway that separated our bedrooms and crawl into bed with each other at night when we couldn’t sleep. On our last day, I congratulated myself on having made it through the trip without letting these jokes turn into real betrayal. And then, 20 minutes outside the city on the Long Island Railroad on the way home, Josh kissed me.

We hear about how Gould chronicled their relationship on her blog, Heartbreak Soup, and how when things unraveled between the lovebirds, Gould blogged about those details as well:

A few weeks later, I arrived home in the early morning hours after abruptly extricating myself from Josh’s bed — he had suddenly revealed plans for a European vacation with another girl — and immediately sat down at my computer to write a post about what had happened. On Heartbreak Soup, I wrote a long rant about the day’s events, including a recipe for the chicken soup I made the previous afternoon and the sex that I’d been somehow suckered into even after finding out about how serious things were with the other girl.

Gould lets one of her best girlfriends pronounce the verdict on Stein after he cools it with her: "Emily, he’s so evil." Of course, this is as good a way as any to let all of us, too, know that he's evil, without Gould taking any ownership of the word.

But maybe she's right. Stein actually launched the first volley in their mass-media post-breakup oversharing contest, publishing a long piece of his own called "The Dangers of Blogger Love" in Page Six magazine. (You can read it here, along with Alex Carnevale's sarcastic take-down of it.) Stein tells us that he learned from Gould's blog that she was in love with him; that she used her blog to slam his former girlfriend's taste in magazines; that she routinely read his email.

Eew. If you have any Ben and Jerry's in the freezer, you should haul it out now, at the very latest, if you're clicking on any of these links.

Reading both Stein's and Gould's pieces - and heaven help me, I read every word - it's hard not to wonder if maybe they're both a little bit evil. Or at least deeply amoral, creepy, and, well, narcissistic.

Case in point #2: Narcissism just oozes from Philip Weiss's essay in last week's New York Magazine. Entitled - and I mean entitled! - "The Affairs of Men," Weiss's piece purports to examine the reasons men cheat on their wives. Mostly, though, he gives us an embarrassing yet irresistible glimpse into his own wretched psyche. Picture Philip Roth - minus much of the literary talent and masturbation - but plus TMI on his own marriage.

Weiss lets us know why he's so frantically tempted to sleep with women who aren't his wife. And it's not just that they're younger, tattooed waitresses whom he imagines - delusionally! - might be interested in his man-meat. No, he makes abundantly clear how he views his own wife: as a sexless middle-aged secretary-cum-organizer who mocks him and refuses to grant him the freedom that any French wife would give her husband.

I ... suggested [to my friend] that we could change sexual norms to, say, encourage New York waitresses to look on being mistresses as a cool option. “That’s fringe,” my friend said dismissively. Wives weren’t going to allow it, and we men grant them a lot of power; they’re all as dominant as Yoko Ono. “Look, we’re the weaker animal,” he said. “They commandeer the situation.” He and I love our wives and depend on them. In each of our cases, they make our homes, manage our social calendar, bind up our wounds and finish our thoughts, and are stitched into our extended families more intimately than we are. They seem emotionally better equipped than we are. If my marriage broke up, my wife could easily move in with a sister. I’d be as lost as plankton.

Yeah. Look, Mr. Weiss, if your wife is all that keeps you from reverting to the bottom of the food chain, your marriage has got bigger issues, starting with your own insecurity and incompetence and ending with your inability to view your wife as a sexual being. Feel free to expose your own pathetic douchebaggery. But none of this gives you the right to portray her - and all your friends' wives, too - as castrating scolds, especially when you seem to believe that what's sauce for the gander isn't sauce for the goose. When Weiss proclaims the beauty of non-monogamy to his wife, she gets "agitated," then says:

"Okay. Let’s have an open marriage. And I have to be out Wednesday night."

I said, No thanks.

So why should those of us lucky enough not to be Mrs. Weiss give a rat's ass about any of this foolishness? I mean, I didn't have to read past their first few lines of these essays, which give ample warning of the wreckage ahead.

Responding to Gould's essay, Jonathan V. at Galley Slaves observes:

... there is a difference between expression and exhibitionism. To the extent that blogs encourage the latter--even in thoughtful, professional writers--they are a pernicious force in the culture.

But as Gould's and Weiss's essays show, narcissism isn't just for blogs anymore. Print publications dangle pieces like theirs in front of the blogosphere, knowing they'll drive up traffic to their online incarnations. As we watch bloggy narcissism and exhibitionism bleed into the supposedly respectable press, we're going to see more "articles" like these. If this becomes a larger trend, it will become a race to the bottom. (And yep, I realize that I just did my part to encourage this by first reading this tripe and then linking to it.)

These essays also raise questions for the rest of us who might not want to emulate their oversharing. How much personal information is too much? I've been fairly frank in my own blog about a couple of recent medical experiences - my "deep throat" exam and my UTI-related caffeine deprivation - and at least one long-ago lousy sexual encounter. I've got academic/personal interests in medicine, sexuality, and embodied experience, and so - since these really were my stories to tell, as long as I preserved the anonymity of my partner in bad sex - I didn't see any reason to protect my own privacy. Even though all of these episodes could be construed as oversharing, I wanted to explore those larger issues through them.

The real danger of amoral narcissism lies in violating other people's privacy. I write a little bit about my family here, but when I talk about my kids, it's mostly either very innocuous (like yesterday's post about making more persons) or focused on my own experiences of parenting. I don't want them to be mortified by me later - at least, not above and beyond the normal baseline of adolescent embarrassment. You also won't learn much about my husband and my marriage. If I ever take part in, say, TMI Tuesday (which is often pretty amusing on other people's blogs), you can be sure I'll keep it focused on me.

I'm not condemning people who put a lot more of their lives online than I ever will. I do think, though, that if what they write impinges substantially on other people's private lives, they're ethically obligated to write pseudonymously. And they'd better be careful not to blow their cover.

Augustine famously wrote, "Grant me chastity and continence, but not yet." Were Augustine reborn today as a confessional journalist, he'd have to rephrase it: "Grant me discretion and empathy, but not yet." At least not until he'd bagged a major article deal in a national magazine.

Ohio's Hospitals Failing Rape Victims

NARAL Ohio wrote me an email today (yeah, me personally, because I'm special) announcing something that damn well ought to be a no-brainer - that actually ought to already exist:

On Wednesday, State Representative Dan Stewart will formally introduce a bill that would ensure that sexual assault victims have access to emergency contraception and preventative treatment for sexually transmitted infections (STI) in Ohio emergency rooms. This bill (Compassionate Assistance for Rape Emergencies) is critical for the treatment of sexual assault survivors in our state.
(No link on this, since it's not yet up on NARAL's state-by-state legislation tracker.)

And you'd think that such legislation wouldn't be necessary in the first place because the number of hospitals denying comprehensive care should approach zero, right? Wrong. Oh, so wrong.

NARAL Pro-Choice Ohio's survey of hospital emergency rooms last year showed that 17% of hospitals who participated in the survey do not guarantee access to emergency contraception (also known as the “morning-after” pill) to all sexual assault victims.

That's one in six hospitals refusing to provide legal care that meets the basic standards of modern medicine. Though NARAL doesn't specify, the odds are great that they're virtually all Catholic institutions. But by golly, if I were raped, the first thing out of my mouth wouldn't be "Please take me to a non-Catholic hospital." A victim of assault should be given everything she needs, not forced to advocate for herself while she's profoundly traumatized.

Yesterday I just read the full text of Humanae Vitae, the 1968 Papal Encyclical that reaffirmed the Roman Catholic Church's intransigent rejection of abortion and contraception. I came away from it impressed with the otherworldly idealism of it. I still disagree as deeply as ever with its conclusions, but I do appreciate its warnings against using other humans as a mere means to an end.

And yet, nowhere does Humanae Vitae address the problem of rape and violence and coercion. If the Catholic hierarchy** wants to maintain that sexuality can only be expressed in marriage, in acts that do not run contrary to "nature" (and boy, is that a spongy category), then how does it account for acts of sexual violence? Why should contraception be anathema after an act that violates the spirit of Humanae Vitae on so many levels - the lack of meaningful consent, the clear use of one person as a mere means, the violation of the Church's notion of the natural?

And why - even according to Catholic theology - should a victim of violence be denied emergency contraception? Remember, we're talking about blocking conception, not performing an abortion. This is, in fact, the chance to prevent an abortion, considering that most rape victims will not carry a resulting pregnancy to term.

Yes, I know that Catholicism maintains that fetal life is innocent life, and that the fetus did not choose to be conceived through an act of violence. But nowhere does Humanae Vitae assert this point. Instead, it grounds opposition to "artificial" birth control in the sanctity of married sexuality as always simultaneously serving two ends, unity of the couple and the propagation of humanity. I'm no expert in theology, nor was I raised Catholic. I'm sure other Catholic teachings do address the Church's reasons for opposing EC even in cases of rape. I'm also aware that EC wasn't on the religious/political agenda in 1968 when Humanae Vitae was issued, although doctors were certainly aware of it.

But if the primary Catholic position statement on "life" doesn't provide a rationale for denying EC to rape victims, I see no reason why secular authorities can't impose their own requirements. I do know that the Church affirms the dignity of every human being, and if it takes government intervention to extend that to rape victims, so be it.

** I'm fully aware that most American Catholics will disagree with the Church on this, so I'm taking care to refer to the hierarchy and to official doctrine insofar as I understand it.