Should surgeons promote an aesthetic standard for little girls’ genitals? Pediatric urologist Dix Poppas thinks so, and he’s more than happy to slice and dice away any deviations in the size and shape of your daughter’s clitoris.

This elective butchery of little girls isn’t based on the edict of some Muslim cleric in Yemen or Egypt. Instead, this is medical advice from a respected, board certified Cornell University researcher who performs these partial clitoridectomies on infants and children at New York-Presbyterian Hospital.

Poppas carries out these surgical assaults on girls born with cosmetically atypical genitalia that he deems masculine or ambiguous in appearance.  Some of his patients undergo this cosmetic procedure at under six months of age after Poppas tells their parents that with surgical “correction,” a “normal physiologic, emotional, and sexual development can be achieved.”

But is there evidence that girls with large clitorises are at risk of developmental problems?  Not at all, say Alice Dreger and Ellen K. Feder in a new Bioethics Forum commentary:

For over a decade, many people (including us) have criticized this surgical practice. Critics in medicine, bioethics, and patient advocacy have questioned the surgery’s necessity, safety, and efficacy.  We still know of no evidence that a large clitoris increases psychological risk (so is the surgery even necessary?), and we do know of substantial anecdotal evidence that it does not increase risk. Importantly, there also seems to be evidence that clitoroplasties performed in infancy do increase risk – of harm to physical and sexual functioning, as well as psychosocial harm.

This isn’t the equivalent of surgically treating a disabling cleft palate; it’s the risky, medically unnecessary reduction of a sexual organ.  It doesn’t improve function or hygiene; instead, it jeopardizes future sexual sensation for the frivolous goal of ensuring these girls fit in with the other kids when they play “I’ll show you mine.”

Columnist Dan Savage writes, “There’s lots to be outraged about here: there’s nothing wrong with these girls and their healthy, functional-if-larger-than-average clitorises; there’s no need to operate on these girls; and surgically altering a girl’s clitoris because it’s “too big” has been found to do lasting physical and psychological harm.”  And Slate‘s Rachael Larimore observes, “One doesn’t have to be a doctor to realize that this is nothing less than the same genital mutilation that women regularly undergo in Africa and the Middle East. But it’s happening at one of our top institutions of higher learning.”

Indeed, sterile blades and lip service paid to the preservation of clitoral sensation are the only things distinguishing this genital mutilation from the ritual excisions that permanently scar millions of women around the world.

Dr. Poppas contends that his clitoral reduction surgery isn’t misogynist quackery because it utilizes a “nerve-sparing” technique designed to minimize sexual dysfunction.  How does he know? He uses vibrators to stimulate the girls’ clitorises during followup exams.

At annual visits after the surgery, while a parent watches, Poppas touches the daughter’s surgically shortened clitoris with a cotton-tip applicator and/or with a “vibratory device,” and the girl is asked to report to Poppas how strongly she feels him touching her clitoris. Using the vibrator, he also touches her on her inner thigh, her labia minora, and the introitus of her vagina, asking her to report, on a scale of 0 (no sensation) to 5 (maximum), how strongly she feels the touch. Yang, Felsen, and Poppas also report a “capillary perfusion testing,” which means a physician or nurse pushes a finger nail on the girl’s clitoris to see if the blood goes away and comes back, a sign of healthy tissue. Poppas has indicated in this article and elsewhere that ideally he seeks to conduct annual exams with these girls. He intends to chart the development of their sexual sensation over time.

I guess that’s one way to explain why you have a lifetime supply of Trojan Vibrating Touch personal massagers stashed in your closet:  “But officer, they’re for the children!”

Unsurprisingly, Dreger and Feder were unable to find another pediatric urologist who uses this “ground breaking” post-surgical kiddie diddling technique.  What’s more, Poppas knows that inflicting this sort of trauma on children is far beyond the bounds of acceptable scientific practice.  That’s why he didn’t bother to obtain IRB approval for his unorthodox use of “vibratory devices.”  Dreger explains:

If he had sought IRB approval for the “sensory testing,” the ethics staff might have sat up and asked him what the heck he thought he was doing to these girls, and they would have tried to make sure the parents were informed about the unknowns and risks, and the girls could have refused to participate.

Perhaps Dix Poppas (whose name could inspire an entire Freudian treatise) thinks his work is so important that ethical boundaries don’t apply. Maybe he’s simply a child molester who takes sadistic pleasure in mutilating and traumatizing the most vulnerable among us.  Either way, we can’t allow his battery of little girls to go on, not for one more day.

Contact:

Rosemary Kraemer, PhD
Director, Human Subjects Protections
Weill Cornell Medical College Institutional Review Board
E-mail: rtkraeme@med.cornell.edu
Telephone: (646) 962-8200

And please call on the American Board of Urology and the American Academy of Pediatrics to condemn Dix Poppas’ unethical research and clinical practices.

Thanks to Rachael Larimore and @sarahbellumd for alerting me to this story on Twitter.

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The Misfits are still my favorite band of all time, so I’m excited that Bobby Steele, one of the first guitarists for The Misfits, is now writing for Parcbench.  And not only that, he’s conservative on health care.

It’s like Halloween in February!

Anyway, check out Bobby Steele’s piece on health care reform, and how his childhood experiences as a spina bifida patient gave him firsthand insight into the insurance and medical industries.

This fangirl moment has now concluded.

Democratic consultant Karen Finney called the Stupak amendment “an attack on our personal freedom and liberty as guaranteed by the constitution.” Rep. Barbara Lee (D-CA) said the amendment “attempts to dictate to women how to spend their own money.” And liberal columnist Michelle Goldberg lamented, “Health-insurance reform was supposed to end the sort of hideous cruelties our system inflicts on patients, not create them.”

To call Finney, Lee, and Goldberg tone deaf would be a grand understatement.

The only reason the abortion restrictions in the Stupak amendment are so intrusive is because health care reform is so intrusive. When we increase the role of government in health care, our freedoms and choices become more vulnerable to politics. Period.

Funding for every aspect of the doctor-patient relationship, every medical test and procedure, and every health care guideline becomes susceptible to pressure from special interest groups and moral scrutiny by taxpayers.  If guys who can’t get it up have enough money to throw around, erectile dysfunction drugs make the cut.  If taxpayers think acupuncturists are predatory quacks, no reimbursement for them. And after the reconciled bill is signed by the president, an unelected body will make these decisions for all of us.

Liberals cheered when President Obama appointed an executive pay czar, reasoning that companies like AIG have no right to determine pay packages if taxpayers are footing the bill.  But somehow they missed the obvious lesson.  There are always strings attached to government handouts.

Welcome, liberals, to the hazards of government subsidy.  Either private insurance is restricted by health care reform, as with the Stupak provisions, or abortion receives some form of federal funding, thus changing the status quo.  There’s no in between.

Objectionable restrictions abound when we seek increased state participation in our lives through regulation or subsidy.  Just ask members of a United Methodist Church group that refused to make a beachfront pavilion available to a lesbian couple for a civil union ceremony.  The group lost its state property tax exemption for failing to make the venue available to everyone on an equal basis.  But that’s how it works: if you want state subsidies, you have to play by the state’s rules.

We’ve seen the impact on coverage in states that are experimenting with models of universal health care.  In Massachusetts, legal immigrants no longer have state-subsidized coverage for dental, hospice, and skilled nursing care. And if you’re a Medicaid patient, prisoner, or public employee in Washington state, don’t expect your government to cough up the cash for knee arthroscopy for osteoarthritis – it’s one of several treatments no longer covered.

Speaker Nancy Pelosi has said that “the power of Congress to regulate health care is essentially unlimited.”  Do liberals really believe that those regulations will exist to make their wildest dreams come true, now and forever?

When you invite the government to become more deeply involved in health care, you’re also inviting greater government interference in personal choice. Medical decisions become political decisions. That’s how it works, and it’s why philosophical opposition to the growth of government isn’t the crazy-eyed wingnuttery progressives make it out to be.

Proponents of liberal health care reform deliberately lured a bloodthirsty vampire over their thresholds, and now they’re shocked – SHOCKED – to find they have fangs buried deep in their necks.  I’m not one to blame the victim, but it sounds like they might be getting exactly what they were asking for.

Oh wait, I did. In May I wrote at length about how American mammography recommendations differ from those in places like Canada and the United Kingdom where cost containment goals determine testing guidelines:

Of women who receive annual screening mammography beginning at age 40, six out of 10,000 over a decade will have their lives saved.  Breast cancer will be detected and cured in many more, but regular mammograms will only make a life or death difference for six of every 10,000 women in that group.  Mammograms are of extremely high value to those women and their families, but don’t offer much bang for the buck when it comes to the other 9,994 women.

And wringing more bang from every health care buck is reason enough for Canadian and British recommendations that women wait until age 50 to begin receiving screening mammographies.  In these countries where cost-effectiveness studies influence health policy and medical practice, six saved lives aren’t worth the substantial costs associated with all those extra mammograms and the false positives they sometimes produce.

…

It is hardly shocking that the breast cancer mortality is 9 percent higher in Canada and 88 percent higher in the United Kingdom.  Nine of 10 middle-aged American women (89 percent) have had a mammogram, compared to less than three-fourths of Canadians (72 percent).  And British and Canadian patients wait for care about twice as long as Americans.

There are indeed valid criticisms American health care, but one area in which we excel is that we don’t base guidelines for care on cost-utility analysis. That’s why the U.S. ranks first in providing the “right care” for a given condition and has the best survival rate for breast cancer.

Obamacare may force Americans to give up those bragging rights.

Starting right about … now:

“We’re not saying women shouldn’t get screened. Screening does saves lives,” said Diana B. Petitti, vice chairman of the U.S. Preventive Services Task Force, which released the recommendations Monday in a paper being published in Tuesday’s Annals of Internal Medicine. “But we are recommending against routine screening. There are important and serious negatives or harms that need to be considered carefully.”

Those “important and serious negatives” are anxiety and the risk of false positives. Shockingly, not everyone agrees that the risks outweigh the benefits of early detection.

But the American Cancer Society, the American College of Radiology and other experts condemned the change, saying the benefits of routine mammography have been clearly demonstrated and play a key role in reducing the number of mastectomies and the death toll from one of the most common cancers.

“Tens of thousands of lives are being saved by mammography screening, and these idiots want to do away with it,” said Daniel B. Kopans, a radiology professor at Harvard Medical School. “It’s crazy — unethical, really.“

As I wrote in May, “I’ll be saving up for a date with a mammography machine in one of those thriving medical tourism meccas.”

Memeorandum has much more from the blogosphere on the new federal guidelines. Ed Morrissey reminds us that the very same federal panel developed the mammography guidelines we’ve been using, and Sister Toldjah asks, “What’s changed? Hmmmm….”

Yes, what could it be?

What a crock.

The bipartisan vote was not a Republican coup. It was the final bit of lubrication needed to help the House health reform bill squeak through in a 220-215 vote. Without the passage of the Stupak amendment, Nancy Pelosi would not have had enough pro-life Democrats on board to pass her bill.  So at best, the Stupak amendment was a Pyrrhic victory for pro-life Republicans. But more accurately, it was a demonstration that House Republicans are hopeless marks, skillfully manipulated into providing political cover for pro-life Democrats.

Even with the passage of the amendment, this pro-life “triumph” is destined to be short-lived should the bill make it to conference committee.  More than 40 pro-choice Democrats are threatening to sink the final bill if it contains the abortion funding restrictions, and President Obama wants the amendment language nixed as well.   With weeks or months for House Majority Whip James Clyburn to bargain with pro-life Democrats, there’s a good chance he’ll gather enough votes to pass a final reconciled bill without the Stupak language.  Few Democrats will want to block History in the Making™.

Republicans had just one opportunity to derail Nancy Pelosi’s bill on Saturday: all they needed to do was hold their noses and vote “present” on the Stupak amendment.  But only Rep. John Shadegg (R-AZ) had the stones to do so. The rest voted “aye” and now the Democrats have momentum, courtesy of the House GOP.

Votes in favor of the Stupak amendment amounted to nothing more than pro-life window dressing.  No unborn lives will be saved by this vote, and in the end, all House Republicans will have to show for their “courage” are their pro-life bona fides. The vote was devoid of any true value to the pro-life cause, and if the reconciled bill passes, abortion will no longer be just a right women can choose to exercise; it will be an entitlement.

If a meaningless political gesture is enough to let these politicians sleep at night, it’s time to find new representatives.

Goldhill is a Democrat who recognizes that his party’s proposed solutions are, at best, mommy kisses and a Dora the Explorer Band-Aid applied to a critical systemic illness.  His piece is very, very long, but very much worth your time.  He proposes a transparent, consumer-centered health care market in which comprehensive health insurance is no longer the primary mechanism for financing routine and predictable care.

While Goldhill characterizes his ideas as “radical,” they’re hardly as extreme as, say, tossing out the Constitution and starting over.  I don’t necessarily agree with his implementation recommendations, but the article is thoughtfully constructed and his ideas (thankfully) don’t hinge on the false notion that prevention of diabetes and heart disease would be a cost-controlling panacea.  Here’s a taste:

Some of the ideas now on the table may well be sensible in the context of our current system. But fundamentally, the “comprehensive” reform being contemplated merely cements in place the current system—insurance-based, employment-centered, administratively complex. It addresses the underlying causes of our health-care crisis only obliquely, if at all; indeed, by extending the current system to more people, it will likely increase the ultimate cost of true reform.

I’m a Democrat, and have long been concerned about America’s lack of a health safety net. But based on my own work experience, I also believe that unless we fix the problems at the foundation of our health system—largely problems of incentives—our reforms won’t do much good, and may do harm. To achieve maximum coverage at acceptable cost with acceptable quality, health care will need to become subject to the same forces that have boosted efficiency and value throughout the economy. We will need to reduce, rather than expand, the role of insurance; focus the government’s role exclusively on things that only government can do (protect the poor, cover us against true catastrophe, enforce safety standards, and ensure provider competition); overcome our addiction to Ponzi-scheme financing, hidden subsidies, manipulated prices, and undisclosed results; and rely more on ourselves, the consumers, as the ultimate guarantors of good service, reasonable prices, and sensible trade-offs between health-care spending and spending on all the other good things money can buy.

Take the time to read the whole thing.

Hat tip: Peg Kaplan

It’s also a resource many American doctors use to find medical information.

According to a survey of 1,900 physicians by Manhattan Research, a health care market research firm, nearly half of doctors going online for professional purposes reported using Wikipedia as a source of medical information. That number has doubled in the past year alone.

The threat is obvious. Can you imagine your doctor stepping out from the exam room, tapping away at his or her computer seeking the advice of Wikipedia? Research has documented the danger. A study from The Annals of Pharmacotherapy compared drug information from Wikipedia with the Medscape Drug Reference, a resource whose information is reviewed by pharmacists. Researchers found that Wikipedia omitted important information, including drug side effects. Another entry overlooked a commonly prescribed pain medication’s association with miscarriages.

Forget the debate over single payer health care.  Forget the talk about a public option.  Quality health care is a pipe dream if doctors are cheap, stupid, or lazy enough to rely on a nonauthoritative, easily vandalized resource like Wikipedia for health information.

This week, following the assassination of late-term abortion provider Dr. George Tiller, comes the disturbing suggestion from Hilzoy (via Megan McArdle) that we “[r]equire training in late-term abortion techniques for Ob/Gyn certification.” The idea is to mitigate the risk of violent action against late-term abortion doctors by increasing their numbers, “ensuring that no one person has to take on him- or herself the risks that militant anti-abortionists want to subject them to.”

Hey, while we’re at it, why not launch an Inquisition to purge pro-life doctors from the medical profession?

It’s essential that we continue to train doctors who identify as pro-life, as well as those who are passionately pro-choice.  Here’s what I wrote in my original piece on the subject:

A woman should be able to choose a doctor whose moral compass points in the same direction as hers. Families should know that their doctor shares their values and will remain faithful to them, especially in a life or death situation.  Revoking conscience protections would revoke patient choice, a violation that would offend more pro-choice liberals if they were, at the very least, concerned with being consistent.

Most liberal feminists would balk at receiving gynecological care from a dedicated pro-lifer.  Shouldn’t pro-life women be able to choose a doctor who doesn’t engage in professional practices they find morally objectionable?

There is, without a doubt, a demand for abortion providers in America.  There is also a demand for doctors whose work is informed by a pro-life perspective on abortion, contraception, sterilization, and end-of-life decisions.  It is not the government’s role to decide that one of these categories of professionals should be phased out because it is less valuable than the other.

When did it become acceptable to ask the government to facilitate the subordination of a pro-life patient’s dignity to a pro-choice patient’s dignity?

Mandating that OB/GYNs be able to provide late-term abortions would be a frightening assault on patient choice and dignity.  It’s doubtful that it would save the lives of abortion doctors, but it would most certainly leave millions of pro-life women (and the many pro-choice women who find late-term abortions appalling) without access to medical care that meets their psychological and moral needs.

In the United States, mammography is recommended for breast cancer screening every one to two years beginning at age 40.  The best available evidence suggests that mammography screening among women aged 40 to 74 reduces breast cancer mortality.

But due to a few minor risk factors, three doctors have suggested I undergo a baseline mammogram at 35. I’m not thrilled with the idea of having a technician I’ve never met manipulate my breasts into squishing position, but being felt up and flattened out sounds a lot better than being dead, so I’ll take my chances.

Of women who receive annual screening mammography beginning at age 40, six out of 10,000 over a decade will have their lives saved.  Breast cancer will be detected and cured in many more, but regular mammograms will only make a life or death difference for six of every 10,000 women in that group.  Mammograms are of extremely high value to those women and their families, but don’t offer much bang for the buck when it comes to the other 9,994 women.

And wringing more bang from every health care buck is reason enough for Canadian and British recommendations that women wait until age 50 to begin receiving screening mammographies.  In these countries where cost-effectiveness studies influence health policy and medical practice, six saved lives aren’t worth the substantial costs associated with all those extra mammograms and the false positives they sometimes produce.

Canadian women are offered routine mammograms every two years, but only from age 50-69 because “evidence is not conclusive” that routine mammograms benefit younger and older women.  Doctors have some leeway with regard to high risk patients.

In the United Kingdom, mammograms are recommended every three years beginning some time between age 50 and 53.  Based on guidelines developed by the Orwellian-named NICE (National Institute for Clinical Excellence), the National Health Service insists that for women under 40, “mammograms should only be used as part of clinical trials into screening and that they shouldn’t be used under age 30 at all.”  According to NICE, “Healthcare professionals should respond to women who present with concerns but should not, in most instances, actively seek to identify women with a family history of breast cancer.”

It is hardly shocking that the breast cancer mortality is 9 percent higher in Canada and 88 percent higher in the United Kingdom.  Nine of 10 middle-aged American women (89 percent) have had a mammogram, compared to less than three-fourths of Canadians (72 percent).  And British and Canadian patients wait for care about twice as long as Americans.

There are indeed valid criticisms American health care, but one area in which we excel is that we don’t base guidelines for care on cost-utility analysis. That’s why the U.S. ranks first in providing the “right care” for a given condition and has the best survival rate for breast cancer.

Obamacare may force Americans to give up those bragging rights.

The “right care” may soon be defined in part by how much that care costs. Health care reformers acknowledge the impossibility of implementing universal health care without introducing cost containment measures, and Democrats are enamored with a method used by the British called “comparative effectiveness research” (CER.)

AARP CEO and CER proponent Bill Novelli describes comparative effectiveness research as “a wonky term that just means giving doctors and patients the ability to compare different kinds of treatments to find out which one works best for which patient.”  And at its best, that’s just what CER does.  CER is not inherently bad.  For example, it can help doctors cut through seductive pharmaceutical advertising to identify older, less commonly prescribed drugs that are just as effective as newer, more expensive ones.

But with CER, the devil is in the details.

CER can lead to one-size-fits-all medicine and encourages a purely analytical approach to care that is not always beneficial to the patient. The mythical average patient overshadows the individual patient, leaving most of us with about as many options as a public school cafeteria at lunchtime.

And in the UK, NICE includes cost as a determining factor in the comparative effectiveness studies that inform clinical guidelines.  Determinations about whether citizens will have access to drugs, tests, and procedures are based on cost per quality of life year (QALY.)

The QALY score is a fairly crude metric that takes into account both the number and quality of years a medical intervention is expected to add to a patient’s life.  Here’s the upshot of using QALYs to determine cost effectiveness:

On the QALY scale, 0 means you’re dead, 1 means you’re in perfect health, and varying levels of debility fall in between. Imagine two groups of people, one with a QALY of 1 and the other with a score of 0.5. An expensive technology brings a year of life to both groups. But in the second, that technology would be counted as having provided only six months, and thus be twice as expensive. It may be deemed too costly for that patient group.

The older you are, the sicker you are, the more disabled you are, the less cost effective it is to treat you.  And if the cost per QALY of a medical intervention you need exceeds £20-30,000 (around $32,000 – 48,000), you’re out of luck.  Drugs, particularly end-of-life treatments, are routinely rejected for use due to poor cost-effectiveness.  And screening tests, like the mammograms American women take for granted, are severely restricted to ensure expenditures remain under the cost per QALY threshold.

Liberal proponents of health care reform accuse conservatives of paranoia and fear mongering about health care rationing.  Critics of CER are demonized as extremist spewers of far right talking points who don’t care about improving clinical effectiveness.  Surely a uniquely American flavor of a CER board would never become as proscriptive as NICE.

But it seems conservative anxiety (and perhaps a bit of healthy paranoia) is more than warranted by Washington Democrats singing the praises of cost-cutting comparative effectiveness studies.  Bear with me while I review some of the health care rationing talk in CER clothing coming from inside the beltway.

The stage for CER to become a significant component of health care reform was set when President Obama’s stimulus bill passed with a $1.1 billion appropriation for CER.  In April, Senate Minority Whip Jon Kyl (R-AZ) introduced a budget amendment to ensure that CER would be used appropriately:

Statement of Purpose:
To protect all patients by prohibiting the use of data obtained from comparative effectiveness research to deny coverage of items or services under Federal health care programs and to ensure that comparative effectiveness research accounts for advancements in genomics and personalized medicine, the unique needs of health disparity populations, and differences in the treatment response and the treatment preferences of patients.

The amendment was defeated 54-44.

Last week, members of the New Democrat Coalition proposed HR 2505, a bill to establish a new government bureaucracy called the Health Care Comparative Effectiveness Research Institute.  The Institute would prioritize research based on both clinical and economic factors, including “the effect or potential for an effect on health expenditures associated with a health condition or the use of a particular medical treatment, service, or item.”  This would not be a problem if there were safeguards to ensure that best practices are not interpreted to mean the least expensive practices.

Officials at National Institutes of Health (NIH) recently announced a stimulus-funded initiative to integrate cost-effectiveness into clinical research.   “Cost-effectiveness research will provide accurate and objective information to guide future policies that support the allocation of health resources for the treatment of acute and chronic diseases across the lifespan,” according to the call for proposals.

Back at the Whitehouse, President Obama has been paying lip service to the clinical benefits of CER.  At the same time, he recently lamented that “the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill … there is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place.”  That, he explained, was part of the need for “some independent group that can give you guidance” on the ethical dilemmas involved with rationing end-of-life care.

During her Senate confirmation process, Secretary of HHS Kathleen Sebelius declined to voice her support for prohibiting the use of comparative effectiveness data to withhold care from patients. Her ideas echo those of Tom Daschle, the tax-dodging health policy wonk who wrote in his book that the U.S. “won’t be able to make a significant dent in health-care spending without getting into the nitty-gritty of which treatments are the most clinically valuable and cost effective.”

Then there’s Peter Orszag, Obama’s director of the Office of Management and Budget and a major player in crafting health care reform.  For the most part, Orszag’s commentary on CER has been limited to lauding its ability to improve patient care while reducing waste.  But when asked a few months ago if the Obama administration has a position on empowering the CER board to make reimbursement decisions, Orszag said, “Not at this point.”

But perhaps of greatest concern is a January House report that included the following statement on CER funding:

By knowing what works best and presenting this information more broadly to patients and healthcare professionals, those items, procedures, and interventions that are most effective to prevent, control, and treat health conditions will be utilized, while those that are found to be less effective and in some cases, more expensive, will no longer be prescribed.

Sound familiar?  Cough, NICE, cough, ahem.

And as Jim DeMint explains, “CER is only one step in the Obama administration’s insidious plan to take over American health care … for our own good.”

But would CER really lead to health care rationing in the United States?  Of course.  That’s pretty much the point.  The debate is not about whether or not CER would be used for rationing, but rather, whether rationing is ethical and useful, and how far we’re willing to go to save a buck and level the economic playing field.

If health care reform shapes up as many Democrats anticipate, CER Institute guidelines will initially apply to the public insurance option expected to be the centerpiece of the Democrats’ proposal. But eventually they would slide down the slippery slope into the private sector. A public insurance option would also ride roughshod over the already anemic competition among overregulated private sector insurers, making the survival of private insurance unlikely.  As in the United Kingdom, recommendations will become rules and suggestions will become mandates in order to contain the costs of universal coverage.

To what extent will this result in government control of the doctor-patient relationship?  Ultimately, a bureaucratic board will determine when, how, and whether or not you and your family receive care.

Comparative effectiveness research will no longer be just a political hot potato; it will be the basis for the next great American culture war.  Instead of clashing over God, guns, and gays, we’ll battle over the monetary value of human life, the sanctity of doctor-patient relationships, the right to medical self-determination, and my favorite hot button issue, the duty to die.

Would cases like Terry Schiavo’s be decided based on financial considerations?

Where will fetuses fall on the QALY scale?  How about the elderly or people with Down syndrome?  Will they automatically receive limited treatment due to limited resources?

Will smokers be eligible for chemotherapy?  Will overweight people have restrictions placed on cardiac care?  Will we feel differently about those decisions when we’re footing the bill for everyone?

And you thought the abortion debate was contentious.

Obviously these questions address the most extreme examples of what could happen if we continue on our current path toward universal health care.  But government efforts at cost containment through CER may push us toward debating these issues sooner than we think.  Hopefully we’ll never see the day when questions like these go beyond an academic exercise.

Meanwhile, I’ll be saving up for a date with a mammography machine in one of those thriving medical tourism meccas.  I hear Costa Rica is a breathtaking location for a 35th birthday celebration.

In 2008, the Bush administration issued a rule strengthening the requirements for compliance with the conscience protections set forth in the Public Health Service Act, the Church Amendments, and the Weldon Amendment.  Widely criticized as a nose-thumbing anti-abortion swan song for President Bush, the eleventh hour ruling was actually in the works for most of 2008.

Mike Leavitt, Secretary of Health and Human Services at the time, pushed for the regulation in response to a move by the American College of Obstetricians and Gynecologists (ACOG) and the American Board of Obstetrics and Gynecology (ABOG) to require pro-life physicians to provide abortion referrals as a condition of board certification.  Concerned that the ACOG and ABOG policies violated freedom of conscience and non-discrimination laws, HHS issued the final interpretive rule in December 2008.

The new administration moved swiftly to begin the rescission process when President Obama took office.  But, as Tabitha Hale points out, while the interpretation of conscience laws may change significantly under the Obama administration, it is highly unlikely that pro-life doctors will be forced to perform abortions any time soon.

And that just doesn’t sit well with Jacob Appel.  He’s a storytelling bioethicist with a fever, and the only cure is more abortionists.

You may remember Jacob Appel from his recent call for an abortion pride movement.  His latest lament is that the number of abortion providers has steadily decreased, and yet pro-life medical practitioners are still permitted to take up valuable slots in OB/GYN training programs.  He proposes that medical programs help abortion providers increase their ranks by using a pro-choice litmus test to screen OB/GYN residency applicants.

Using religious and moral objections to abortion to bar qualified doctors from receiving training in obstetrics and gynecology is a clear violation of conscience protection laws, but Appel has an answer for that.

In the case of abortion, the current shortage of providers justifies a limited waiver of conscience exemptions as applied to the training of new OBGYNs.  If we do not act, women may find themselves in a position similar to that of the criminal defendant who in theory has the legal right to counsel, but cannot find any lawyer willing to take her case.

Appel does not bother to address why a doctor who intends to specialize in geriatric gynecology, for example, would need to perform abortions.   He also neglects to consider that pro-life doctors are not the only ones who refuse to terminate pregnancies. Indeed, there are many pro-choice physicians who are just as unwilling to provide abortion services.

But the greatest flaw in Appel’s argument is his contention that he is a champion of patient choice and access.  Appel is only interested in ensuring choice and access for women seeking abortion doctors, not for women seeking doctors who respect their beliefs because they share them.

A woman should be able to choose a doctor whose moral compass points in the same direction as hers. Families should know that their doctor shares their values and will remain faithful to them, especially in a life or death situation.  Revoking conscience protections would revoke patient choice, a violation that would offend more pro-choice liberals if they were, at the very least, concerned with being consistent.

Most liberal feminists would balk at receiving gynecological care from a dedicated pro-lifer.  Shouldn’t pro-life women be able to choose a doctor who doesn’t engage in professional practices they find morally objectionable?

Appel’s essay is not a harmless, isolated intellectual exercise.  His views are shared by many of the liberal feminist chatterati, including some in the medical community.

Dr. Julie Cantor, for instance, feels conscientious objection in medicine has gone awry, and that we, as a society, are far too tolerant of individual conscience.  Like Appel, she believes that “physicians and other health care providers have an obligation to choose specialties that are not moral minefields for them. Qualms about abortion, sterilization, and birth control? Do not practice women’s health.”  She feigns passionate support for putting patients’ interests first, but not so shockingly, that support does not extend to choosing a doctor one doesn’t consider an agent of death.

A doctor’s conscientious refusal to perform an abortion does not strip a patient of her constitutionally protected right to seek an abortion, not even if she has to get an advance on her paycheck and shimmy across the frozen tundra on her pregnant belly to reach the closest abortion provider.  The government is not your mom, your BFF, and your knight in shining armor all rolled into one convenient, omnipresent package.

There is, without a doubt, a demand for abortion providers in America.  There is also a demand for doctors whose work is informed by a pro-life perspective on abortion, contraception, sterilization, and end-of-life decisions.  It is not the government’s role to decide that one of these categories of professionals should be phased out because it is less valuable than the other.

When did it become acceptable to ask the government to facilitate the subordination of a pro-life patient’s dignity to a pro-choice patient’s dignity?