Birthrights

  ** Names and details have been changed to protect patient confidentiality, privacy, and dignity ** 

Yesterday, the Associated Press published a story (here) regarding a 21 year old pregnant woman, "P" in London who has "a significant learning disability" and whose mother has petitioned the court to have a tubal ligation performed after delivering her child. P's mother fears that, since she is already raising 1 child, P will continue to have children, and the state will take custody. Coincidentally, one of my recent patients had similar circumstances.

My patient's name was Casey. Casey is a 16 yr old female with borderline MR (IQ of about 65). Every few months, Casey's mother brings her to the doctor for "vaccinations"; also known as Depo-Provera. Both my attending and her mother have hidden the fact that she is on birth control. Casey engages in frequent "high risk" sexual activity (multiple partners, short-term relationships, little to no condom/contraceptive use), and does not wish to amend her behavior.

My knee-jerk reaction to this was one of shock, having been steeped in the newer philosophies of patient autonomy and women's reproductive rights. However, like most issues in medicine, there are always multiple angles.

What if, instead of birth control, Casey was receiving injections of olanzapine (antipsychotic for schizophrenia) or lacosamide (antiepileptic for seizure control)? What if Casey didn't have MR, but a medical condition that would severely jeopardize her life if the pregnancy were to continue? What if Casey had severe MR instead of mild? What if Casey is being sexually abused or manipulated? Would these circumstances change the approach? Is Casey's health better protected by giving her birth control? Should she have the right to conceive a baby, even if she has a history of irresponsible behavior?

On the most extreme level, some physicians and parents choose to create "pillow angels"; the most famous being Ashley (read her story here), who was born with severe physical and cognitive disabilities and was given high doses of estrogen in order to retard her growth and prevent menstruation. Ashley also received a hysterectomy and breast bud removal to keep her at a prepubescent stage of development. Ashley is thought to have an infantile mental capacity, and will not improve. Was this the right decision? Where should the line be drawn?

I have read multiple arguments from physicians on both sides of the issue. Some claim that the patient should be the ultimate stewards of their bodies, while others hold the guardian as the decision-maker. In medicine, I have come to learn that most ethical decisions cannot be determined by blanket protocol. Casey, Ashley, and P are all individuals, and what is right for Casey and her family may not be appropriate for P. Maybe Ashley is living a more fulfilled life than she would have as a fully developed woman. Perhaps an IUD would be a more ideal option for P. Perhaps Casey may choose to plan for a family as she gets older and more stable. I pray that the physicians supervising the care of these women consider the options, and treat the patients for their own good.

And what would I do if a patient came into my clinic with a similar conundrum? I really can't say.

Nulligravida

As I near the end of my Pediatric rotation, I can say that I have seen close to 200 parents with their children, and at least half of them have asked if I have children, or plan to have them. I'm always surprised at the reaction I receive after disclosing my plans to remain nulligravid. Even the most liberal, who accept homosexual parenting, abortion, and artificial insemination, seem to find it unacceptable that I have made this decision. Typically, the response is some combination of shock, confusion, and condescension. Some insist that my youth clouds my judgment, and I will feel differently as I age. Others say that my maternal instinct will engage once I find a viable mate. Another percentage relates my decision to a troubled childhood or negative experience. None of these are the case.  

I have never seen myself as a future mother. My goals have always been directed towards finding my calling, and using the gifts I was given by the Most High to make the world a better place. I have come to find my ultimate purpose in global and rural health. With this premise, there is no room for the requisite sacrifice, commitment, devotion, and patience to be a parent. My time has been invested into medicine, and I expect to use my attained MD to heal and educate, not to stay at home changing diapers, if even for a year. I have immersed myself in the practice of medicine, and intend to continue this mission. To me, the opportunity costs are far too great to spend time raising a child. When a natural disaster occurs, such as the 2010 earthquake in Haiti, I want to be prepared to help. It becomes exponentially less feasible to travel overseas while pregnant, or with prior obligations to children.

I frequently hear the argument that I should "leave a legacy", something to be remembered for after I expire. That being an only child, I owe my mother grandchildren based on the sacrifices she made for me, and to continue the family name. I disagree with this premise. What great person is remembered for their children? Rosa Parks never had children, but is certainly remembered for her contributions to the Civil Rights Movement. Many famous women have not had children, and are perfectly content with the legacy they have left through their work, including Mother Theresa, Harriet Tubman, Florence Nightengale, Susan B. Anthony, Dr. Elizabeth Blackwell (first female doctor in the United States), Dorothea Dix, Mary Eliza Mahoney (first African-American professional nurse), and Jane Addams. Even entertainers and businesswomen such as Helen Mirren, Margaret Cho, Oprah Winfrey, Betty White, Stevie Nicks, Rita Rudner, Katherine Hepburn, Dolly Parton, Coco Chanel, Julia Child,  and Joan Jett are content with their choices not to have children. Will these womens' contributions be forgotten since they never bore children? 

Some suggest that I should have a child, since there are many women who cannot. This follows the skewed logic of finishing dinner for the sake of the starving Ethiopian children. One situation has no bearing on the other. Every woman is granted the choice of what to do with her body. Simply having the capacity to reproduce does not mandate that it occurs. I have also heard the inference that my decision stems from an inability to find a worthy husband who would father the children, or that my decision would change if my husband wanted children. My feeling is that a man who desires children would not be a compatible match regardless of other attributes, and if a man could manipulate my decision to suit his wants and needs, the relationship itself is unhealthy and should be relinquished.

Over the past year, I have noticed a drastic increase in the number of blog posts, websites, and discussions authored by women who have chosen not to have children. Gradually, this option is becoming more accepted. Choosing not to have children is generally an educated, well-thought-out decision. It is not simply a whim to be discounted or attributed to a bad relationship or lack of experience. Not reproducing is a reproductive choice, yet most physicians refuse to implement permanent birth control to women who are under 35, and who have never had children. Hopefully, as more and more light is shed on this topic, women who choose not to have children will not be judged and ostracized, but respected and accommodated for their reproductive choice.