In a culture that promotes alternative medicine, natural childbirth, and sometimes-bizarre dietary supplements, it seems strange that natural infertility treatments are not well-known. A natural infertility treatment is not necessarily alternative medicine, but rather a conventional-medicine approach that seeks to cure the underlying cause of infertility, allowing natural conception. It stands in contrast to assisted reproductive technology such as in vitro fertilization (IVF), which is stick a "band-aid" solution that does nothing about the underlying causes of fertility problems.

Why is assisted reproductive technology the current standard of care for infertility? If you type "fertility treatment" into Wikipedia, you are redirected to "assisted reproductive technology." Wikipedia, being written collaboratively by people around the world, reflects the biases and attitudes of those people. Fertility drugs and IVF are what people think of when they think about infertility treatments.

I think the reason IVF is so popular — despite its astronomical cost and mediocre success rate (only 1 in 3 attempts results in a live birth) — is because it is a "magic pill" approach. It is a silver bullet, a straightforward process left in the hands of doctors. Natural fertility treatments are more complicated because they start with diagnostics, rather than jumping immediately into treatment.

Among the diagnostic steps used in natural fertility treatments for women are ultrasound, laparoscopy, and sonohysterosalpingography (SHSG) to look for structural problems in the reproductive organs, as well as hormone level checks. During her menstrual cycle, a woman's estrogen and progesterone levels can change significantly in as little as 24 hours, so daily or every-other-day tests are best. Any underlying disease or structural abnormality that is uncovered is treated to increase the odds of a naturally conceived pregnancy.

How successful is natural infertility treatment compared to assisted reproductive technology? IVF has a maximum success (pregnancy) rate well under 50% (for 27-year-old women), with an average success rate closer to 35%. Statistics for live birth are even worse, with an average of only about 27% of attempts resulting in live births. That means that an average of 8% of attempts result in a miscarriage or stillbirth (or, if the fetus is imperfect, abortion). The poor success rates reflect, in part, the fact that over 50% of embryos conceived in vitro have chromosomal abnormalities, as reported by Rebecca Taylor of Mary Meets Dolly. Natural fertility technology also has treatments for male infertility.

According to the Pope Paul VI institute, a major proponent of natural infertility treatment, so-called "natural reproductive technology" has higher success rates than IVF for various infertility diagnoses. These results are both statistically significant (i.e. not due to chance) and personally significant (i.e. they're a lot higher). For example, for a diagnosis of endometriosis, IVF has a success (pregnancy) rate of about 21%, while natural reproductive treatment has a success rate of about 57%. It reports a 37% success rate for tubal occlusion compared to IVF's 27%. The whopping 82% success rate reported for natural fertility treatment of anovulation (not producing mature eggs) may be due to straightforward treatment of the most obvious cause of anovulation, hormonal insufficiency (although I am speculating here).

I find it amazing that natural treatments for infertility are not better-known, even though they are more effective than current approaches. That's right: for infertile couples, it is more effective to try to conceive a baby the way nature always has than to inject a sperm into an egg under a microscope, with less chance of complications like chromosomal abnormalities and multiple gestation. Who wouldn't choose that first, if they knew it was available?

Image credit: "Test tube baby" by Brendan Dolan-Gavitt. (CC) Some rights reserved.

The youngest Leave the lights on blogger, my 14-month-old son, got three shots last week. He and his brother have had every vaccination recommended by pediatricians. I understand that a lot of parents are hesitant about vaccinations because of fears of their safety. Those parents should fear for the safety of their children if they don't vaccinate.

Vaccines are safe

Most of the fears about vaccinations center on the purported link between the mercury-based preservative thimerosal and autism. But study after study — most recently, one conducted in Italy — have shown that thimerosal does not cause autism. In fact, the original study that suggested the thimerosal-autism link was faked. And even if this evidence is not convincing, thimerosal is no longer used in most vaccinations.

Not vaccinating can be deadly

Last month in Minnesota, a seven-month-old baby died of Hib, or Haemophilus influenzae type b. Hib infections are vanishingly rare in the U.S. because of the routine use of the Hib vaccine, which is given at 2, 4, 6, and 12 months (this is one of the shots my son received last month). The child who died, and two of four other kids who were sickened by the Hib outbreak, were unvaccinated "because of their parents' decisions." In other words, the parents decided not to protect their children against deadly infections.

Of the other two children, one was only five months old and so had not completed the primary 3-shot series. The other had an immune deficiency. When vaccination rates are above a certain "threshold," people like these two children are protected by "herd immunity" (a term that originated in animal husbandry). The disease cannot spread because there are not enough vulnerable individuals in the population. When people choose not to be vaccinated, or not to have their children vaccinated, herd immunity suffers, and people like these two babies can be sickened.

The refusal to vaccinate one's children is a source of frustration for health officials. I cannot understand a parent's reluctance to protect their children against deadly diseases that should only be a memory in the twenty-first century.

It's almost the weekend, so let's talk about TV.

I watch FOX's House regularly. I am losing interest in the program because (besides becoming clichéd and boring) it is not realistic.

The medical cases themselves are full of inaccuracies; one is tempted to uncharitably call them lies. One character is "dying" of Huntington's chorea, which in reality is not a fatal disease at all. A patient died of acute eclampsia a month after giving birth — never mind that eclampsia is cured by delivery of the baby. In one especially infamous episode, a psychiatric condition called "mirror syndrome" was completely invented out of thin air by the writers. (There is a real condition called mirror syndrome which affects pregnant women; this illness was also featured in an episode. Oops.)

Each episode begins with an apparently healthy patient dramatically (and often graphically) collapsing. They are then whisked to Dr. House's hospital, where his team of crack doctors (a bunch who apparently failed medical ethics in school) personally conduct the procedures and tests that are normally done by nurses, radiologists, and other specialists. Dr. House invariably treats the patient more callously than can be imagined, often being deliberately cruel — and clearly delighting in it. At the end, Dr. House (or, less freqeuntly, another doctor, such as the skankily-dressed hospital administrator Dr. Cuddy) has a brilliant flash of insight that tells him the patient's true diagnosis, and treatment after that is quick and easy (unless it is incurable and the patient dies, which happens fairly often).

Scientific American blogger Jordan Lite notes that the cases are often taken from the New England Journal of Medicine's clinical problem-solving column, and that one writer-producer, David Foster, is an M.D. A book has even been written about the show, The Medical Science of House, M.D. But I find the science unrealistic. This is not how medicine is works.

A real mystery disease is usually chronic. A patient with a real "zebra" condition has usually seen many doctors. Once a diagnosis is made, if it is made, treatment is not necessarily quick and easy.

Also, a good doctor is not cruel.

CNN recently featured a story on Dr. William Gahl, who is a real-life diagnostician of rare diseases. Read this story for a realistic picture of how doctors approach medical mysteries. And keep watching House, if you enjoy it. But remember that it's just as fictional with its science as Star Trek and Battlestar Galactica.

CNN recently published an article with the deeply euphemistic title, "Woman in coma to be allowed to die." While technically true, it sounds as if it refers to a person who has begged to be allowed to stop extreme treatment measures in order to be allowed to pass in peace.

This is not true.

In fact, Eluana Englaro, an Italian woman who has been in a vegetative state, not a coma, since 1992, is not under any extreme treatment measures. (See this link for more information about the difference between coma and vegatative state.) She breathes without a ventilator. The nuns treating her are eager to continue to provide care for her for the rest of her natural life.

But Ms. Englaro's own family wants to stop feeding her so she will die of dehydration. This is not a dignified death.

In a letter published in a local newspaper, her caregivers wrote, "We don’t ask anything but the silence and the liberty to love and to devote ourselves to those who are weak, poor and little in return." (Source: Life Site News.)

What a tragic turn of events. Ms. Englaro is not suffering (not that suffering would justify murdering her through deliberate neglect) and not a burden on anybody (not that being a burden would justify it, either). If she is capable of suffering (and I pray she is not), she certainly will suffer in the two to three weeks it takes her to die of dehydration, a miserable, painful, and barbaric way to die.

Catholic Mom, who is also a physician, has a good perspective on the issue of universal access to health care. In a recent post, she wrote:

[T]here is no universal definition of health care. Everyone is shouting for universal health care but I haven’t heard anyone define what that means.…

I do believe that it is objectively possible but politically perilous to define what is basic health care.… I also know that if basic health care is accurately defined based on scientific evidence, there will be great wailing and gnashing of teeth as people find out their favorite medical option is not included in a taxpayer funded medical plan.

That is a harsh reality that any politician trying to institute a national health care system will have to face. How do you devise a plan that satisfies enough Americans to be politically viable, yet which is small enough to remain manageable?

In the United Kingdom, a national health care system was established early, as health care technology and cost first began to increase. The national health care provider network and the government system that paid for it grew together organically, and that is reflected in the way its citizens look at health care.

In the U.S., we look at health care a bit differently. There has never been a baseline standard, but rather a spectrum: at one end, no insurance, followed by sickness and accident plans, high deductible plans, and various PPOs and HMOs. At the far end of the spectrum lie comprehensive plans, some of which pay 100% of the cost of services.

If I put on my idealist's hat, I might say that a panel of experienced physicians and former hospital administrators with absolutely no conflicts of interest -- including no membership in professional organizations that have the ear of Congress -- would sit in a room, isolated from public opinion, and devise a baseline plan. Even a person wholly innocent of cynicism can see that this is not possible, in part because in a physician, "experienced" and "no membership in professional organizations" are mutually exclusive conditions.

We will not be able to ensure affordable yet universal access to minimum health care until we begin an honest national conversation on what it should cover. And with the number and power of lobbying groups that exist in the health care industry, I wonder whether such a conversation is even possible.

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Ascension Healthcare is a non-profit, Catholic health insurer. Its definition of "Healthcare Ethics" succinctly states an answer to the question, "Is there a right to health care?"

From the perspective of Catholic moral teaching, the "right to health care" for all is not an optional stance. Rather, the right to health care is a human right founded on human dignity and the common good. Considered as such, health care is more than a commodity in so far as it is an essential safeguard of human life and dignity that ought to be provided for and to everyone. This absolute right to health care, however, should not be understood as an unlimited entitlement, but as a right that carries with it corresponding duties regarding justice, stewardship and the common good.

According to this stance, there is a right to health care that aims to preserve human life and dignity. I understand this statement as saying that there is also a duty of patients to cooperate with their health care, which answers Mile Hi Mama's concerns about noncompliance.

Years ago, I read a newspaper story about the undue feeling of entitlement shared by many Americans. The author wrote about a woman she had met who was being treated for infertility. She felt the health care establishment should do whatever it took for her to get pregnant, because that is what she needed to be happy, and the Declaration of Independence gives Americans the right to happiness.

Of course, there is no right to happiness in this world. The Declaration of Independence asserts a right to pursuit of happiness. And theologically, complete happiness is a privilege bought with Christ's blood and available only after death.

Similarly, a right to health care should not be confused with a right to health at all costs, as the Vatican's Pontifical Academy for Life pointed out three years ago. There cannot be a right to health at all costs because such a right would be at times contrary to the rights of others and to the common good. For example, a person needing a kidney transplant does not have a right to the kidney of a healthy person; it must be freely donated.

I am adopting Ascension Health's statement as my position on the right to health care. It is balanced by considerations of stewardship over available resources and the common good, and it makes good use of Catholic moral reasoning.

Do you agree with Ascension Health's statement? If not, what do you think is wrong with it?

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Comments in the Right to Health Care series have repeatedly gravitated toward the question of what constitutes "basic" health care. I have not addressed that topic yet because it has not been established that there is any right to "basic" health care at all. But a lot of people think it is important to talk about it, so here are my thoughts.

I would consider a minimum standard of health care, in our affluent and technologically advanced society, to include the following:

• All vaccinations recommended by the various professional organizations, such as the American Medical Association.
• All screening tests recommended by professional organizations, such as cancer screenings as recommended by the American Cancer Society.
• An annual physical, or perhaps biannual for young, healthy adults.
  
• Full prenatal care as well as labor and delivery services.
• Well-baby and well-child exams.
• Treatment of chronic diseases such as diabetes and cancer.
• Surgery to save life, limb, or quality of life.
  

I also consider doctor visits for illness or injury as well as emergency services to be "basic" health care, but would support some way to keep these services from being abused, such as a reasonable copay. Likewise with mental health services.

"Basic" health care, in my opinion, does not include:

• Purely cosmetic procedures, such as removal of moles that are not pre-cancerous.
• Experimental treatments.
  

I would love to know what readers think. What is should be included with "basic" health care and what should be excluded?




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In the post on health care in prisons, MileHiMama asked, "[D]oes ... the government [have] to provide healthcare, or simply ensure unencumbered access to it?"

What constitutes an encumbrance to health care? EMTALA removes the encumbrance of pre-qualification based on ability to pay, but only in emergencies. Most doctors' practices are not affected by EMTALA because they do not provide emergency care.

Medicaid covers people below a certain income bracket. Medicaid recipients have access to routine and preventative care, but people above this income bracket have no guarantee of receiving such care, unless they have health insurance.

Some of these uninsured cannot afford to pay cash for routine care. I see three options for those people: borrow the money, poach from another part of the budget (such as food or transportation), or go without routine care. Do these people have unencumbered access to non-emergency care?




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The U.S. Congress passed the Emergency Medical Treatment and Active Labor Act, section 1867(a) of the Social Security Act, in 1986. It requires three things of hospitals:

• imposes an affirmative obligation on the part of the hospital to provide a medical screening examination to determine whether an "emergency medical condition" exists;
  
• imposes restrictions on transfers of persons who exhibit an "emergency medical condition" or are in active labor, which restrictions may or may not be limited to transfers made for economic reasons;
  
• imposes an affirmative duty to institute treatment if an "emergency medical condition" does exist.

--EMTALA.com FAQ

Particularly notable is the lack of a provision for reimbursement of the hospital. If the patient is not covered by private insurance or Medicaid/Medicare, and cannot pay the bill, the hospital must eat the loss. One way hospitals may offset the loss is by increasing charges for paying patients. Since Medicaid/Medicare has fixed reimbursement rates, and most private insurance also has fixed rates set by contract, that means the uninsured who are able to pay out-of-pocket often subsidize the uninsured who aren't.

Outside the emergency room and EMTALA, medical emergencies are handled by public safety agencies. When a person calls for an ambulance for a medical emergency, states generally require emergency medical personnel to respond, regardless of whether there is an ability to pay.

The principle underlying both EMTALA and the state-imposed duty for EMS to respond is that everyone has a right to be treated in case of emergency. It seems that American society is comfortable with this principle. Do you agree that there is a right to receive emergency medical treatment regardless of ability to pay? If so, who should pay?






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American society already recognizes certain privileges to health care. Considering these would make a good start to a discussion of whether there is a right to universal health care (UHC).

Health care in prisons and jails

Jail inmates who suffer medical emergencies are entitled to receive care, and prisoners also receive basic medical care for chronic conditions while in custody. In some cases, the health care offered by prisons is considered to be quite good. When prisons fail to provide adequate care, the federal government may step in to make sure it is available, as it did in California in 2005; there may also be lawsuits, such as those beleaguering the contractor Prison Health.

There has been some discussion of charging inmates for care they receive while in custody, but no serious programs that do so (to the best of my knowledge). Since inmates are by and large indigent (being unable to work for an income outside the prison), charging them for services seems rather nonsensical.

Arguments for providing care to inmates include the obvious, that their incarceration makes it impossible for them to seek care themselves, as well as the practical, that providing care helps prevent outbreaks of disease. But do they have a right to it?




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The question of a "right" to health care has obsessed my mind for the last several months. Unlike most ideas, which tend to pop in and out, this one has stuck with me, which means I should address it here.

First consideration: Why has this particular question stuck with me? Because, I think, it is the crux of the matter of whether and how universal health care (UHC) should be made available. If there is no "right" to health care, then it is much more difficult for supporters to argue that UHC is in the best interests of the U.S.

Thus I am starting a series on health care rights. If you have an opinion, yea or nay, on UHC, share it in a comment or e-mail me (address in my profile, linked to in the sidebar) if you are interested in a guest post.

Don't miss a post in this series on health care rights! Subscribe now.




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A new drug called Riobant (rimonabant) has been developed to help people lose weight. Users lose an average of ten pounds more over a year than people using a placebo. Story here.

The drug is an "endocannabinoid receptor antagonist," which is another way of saying that it's reverse marijuana. Apparently you lose weight because you get the anti-munchies.

Think for a second what else marijuana does, though: It makes you feel happy. So would reverse marijuana make you sad? Turns out the answer is yes. Users of rimonabant reported a high incidence of depression, anxiety, and insomnia compared to the placebo group.

Normally, a doctor and/or patient would weigh the risks of a drug against its potential benefits. Obesity is a risk factor for deadly diseases such as heart disease, so on the surface it would seem rimonabant might be worth the risk for obese people with unhealthy arteries. Unfortunately, weight loss associated with rimonabant does not improve coronary artery health.

So in my opinion, this drug should not be approved. "Psychiatric side effects" are a huge deal. Depression is one of the leading causes of disability in the U.S. The benefit of slight weight loss (less than a pound a month, remember) does not outweigh the risk of these unwanted effects, if the weight loss has only cosmetic impact.

Anybody disagree? Would losing weight, but not improving health, be worth depression, anxiety, and insomnia?

The National Organ Transplant Act of 1984 banned the sale of human organs and non-replinishable tissues in the United States. Prior to that, "donors" sold organs such as kidneys for transplant, and these donors typically were among the poorest members of society.¹

The ban on the sale of organs means the most vulnerable members of society are not exploited for their body parts. The cost of this policy is that donated organs are scarce; simple economics suggest that many more would be available if the donors could receive compensation. In fact, during the early 1980s, when organ sales were legal, the average wait time for a donor kidney was less than a year, but today it is more than five years.² (Most discussions on the sale of organs center on kidneys because these can be given by living donors, unlike most organs.)

Dr. Arthur Matas, former president of the American Society of Transplant Surgeons, has proposed legalizing the sale of kidneys under a system regulated to protect (he says) donors.² South Carolina State Senator Ralph Anderson endorses a different kind of compensation; he sponsored a bill that would have allowed prisoners to receive reduced sentences in return for donating organs.³ (I was not able to find out by "press time" whether this bill passed.)

While living kidney donors have historically been poor, transplant recipients are more likely to be rich and/or well-insured. While organ transplant lists don't take ability to pay into consideration, the poor and uninsured often don't make it onto the lists at all.⁴

Increasing organ donation and saving the lives of those with organ failure is a worthy goal. And the economics are obvious. But economics are not ethics.

What Dr. Matas and Sen. Anderson don't acknowledge is that nobody has a right to a transplanted organ. It's a privilege to receive body parts from another individual. And providing a material incentive to "donate" is known to result in the exploitation of those in desperate circumstances -- the poor and, in the case of Sen. Anderson's proposal, the imprisoned. How many free, financially secure people would be willing to undergo dangerous surgery to sell irreplaceable body parts? The fact that these vulnerable members are not eligible to receive organs for financial reasons underlines the inequity of these ideas.

It's important for us as a society to protect our most vulnerable members. And that means we cannot consider mutilating them when they are desperate. You could call it Frankensteinian blackmail.

Watch this space for follow-up articles on organ sales worldwide.

Notes

1. "Policy Debate: Should there be a market for human organs?" South-Western College. (http://www.swlearning.com/economics/policy_debates/human_organs.html)

2. "Doctor Proposes Sale of Kidneys." John McKenzie, November 19, 2007. ABC News. (http://www.abcnews.go.com/WNT/Health/story?id=2977619&page=1)

3. "Give a Kidney to Shorten Your Prison Sentence?" Gigi Stone, March 9, 2007. ABC News. (http://www.abcnews.go.com/US/LegalCenter/story?id=2940289&page=1)

4. "Need an Organ? It Helps To Be Rich." Joy Victory, January 20, 2006. ABC News. (http://www.abcnews.go.com/Health/story?id=1514702)

The god Mercury was said to be a messenger. Quicksilver, a fluid metal, shares its name with him. So what message do the media send about quicksilver?

Mercury (the element, not the god) is toxic. In humans, it affects the central nervous system. Certain forms of it are antiseptic and have been used in vaccines to prevent bacterial contamination. Ethyl mercury, also called thimerosal (in the U.S.) and thiomersal (in Europe), is the best known mercury-based vaccine preservative.

The pediatric vaccination schedule calls for a series of shots around 15-18 months. This is a time when children are starting to learn language rapidly, and are also developing socially, becoming more interactive with others. Autism spectrum disorders (ASD) are often first noticed at this age, as well.

Many parents of children with ASD believe the vaccinations and the disorders are correlated. They have zeroed in on thimerosal as the culprit, since mercury affects the central nervous system. This controversial view has resulted in the removal of thimerosal from all vaccinations in the U.S. (with the exception of flu vaccines). It has also, in some cases, resulted in parents refusing to vaccinate their children against childhood diseases.

Studies have shown no link between thimerosal and autism. Most recently, ethyl mercury was shown to be excreted by infants' bodies in far less time than was previously thought. The researchers in this study concluded that the amount found in vaccines simply is not around long enough to do any nervous system damage.

Other research has shown that the rate of head growth in infants who later develop ASD differs from that of neurotypical* children. The growth was measured at ages before ASD becomes apparent, which suggests ASD may be present but (more or less) asymptomatic from infancy.

If this is the case, the 18-month series of vaccines can't be the culprit in ASD. In fact, the first appearance of ASD symptoms occurring around this series of shots must be coincidental. The medical establishment and the media should therefore reassure parents that vaccines are not only safe, but important to avoid childhood diseases, which can kill or permanently injure children.

ABC television apparently feels otherwise about its obligation. Today it debuts a new legal drama, Eli Stone, whose pilot episode involves a jury that finds that mercury caused autism in a child. According to one article, the creators say "not anti-vaccine and would be upset if parents chose not to immunize their children after seeing the show."

What other effect do they possibly believe their show could have? I wonder if ABC's parent, the Walt Disney Company, which is one of the greatest influences on modern culture (as much as I hate to say it), has forgotten the impact it has on society. Airing this program is not just irresponsible; it can do real damage to children's health. It's grossly negligent.

*Normal.

I came across an interesting bit of commentary from Forbes.com, discussing the history of health care in America. Written by one Yaron Brook, it contains both untruths and opinions I ardently disagree with.

First, the obvious lie:

Prior to the government's entrance into the medical field, health care was regarded as a product to be traded voluntarily on a free market--no different from food, clothing, or any other important good or service.... Had this freedom been allowed to endure, Americans' rising productivity would have allowed them to buy better and better health care, just as, today, we buy better and more varied food and clothing than people did a century ago. There would be no crisis of affordability, as there isn't for food or clothing.

This is not true. Prior to the government's entrance into healthcare, the quality of care was drastically lower than it is today. There was no such thing as an MRI machine in 1955. Advances in medical technology have not been cheap. We also have much more powerful and effective, and more expensive, drugs available today. The increased quality of health care has been a major factor, probably the major factor, in its increased cost.

Next, the elitist opinion:

In a system in which someone else is footing the bill, consumers, encouraged to regard health care as a "right," demand medical services without having to consider their real price.

In context, it's clear Mr. Brook believes health care is not a right, but rather should be paid for by individuals (either directly or by purchasing insurance) according to their means. From this opinion, I can infer Mr. Brook is neither sick nor poor.

Taken to its logical conclusion, Mr. Brook is arguing that when the poor get sick, they should be left to die for lack of care they can't afford. If a surgical treatment or prescription drug could save a person's life, and the person was indigent, Mr. Brook believes society should let that person die.

I pray that Mr. Brook's vision never becomes reality, and if it does, I pray for his sake that he never experiences poverty and illness, or his heirs will have to worry about the cost of a funeral.