One of my most prized possessions is a heavy jade bracelet that I’ve never worn. It is a beautiful piece, held together with an elaborate gold clasp. It is precious because it was willed to me … by one of my patients.

Mrs. H was an elegant, aristocratic woman in her 70’s who was slowly wasting away from colon cancer. I met her initially when I was an intern on the general surgery service. She had been admitted for yet another surgery to remove yet another metastasis from abdomen. The surgery did not go well. They could not remove the entire tumor. At that point, she was so weakened by her disease and the unsuccessful treatments of the prior years that she could no longer care for herself. She had no close family and no friends to help her. She was sent to a nursing home, a rather nice nursing home, but a nursing home nonetheless.

As an OB-GYN intern, I did what was known as a rotating internship, several months each in various parts of the hospital. Therefore, I was working on the medical service when Mrs. H was admitted a few months later because of intractable nausea and vomiting. She was assigned to me and I went to her room to examine her and complete the paperwork that always accompanied a hospital admission.

I was saddened by her appearance. She was rail thin and obviously in a great deal of discomfort from the nausea. I ordered anti-nausea medication and she began to feel better. I examined her and excused myself to attend to the paper work. To my surprise, she asked me to stay a bit longer. She needed to talk to me, she said.

I sat in the chair by her bed, and much to my surprise, she took my hand.

“I want to ask you for a favor,” she said. “It’s a very big favor, though, so I will understand if you say no.”

“I’m dying,” she continued. “I know I don’t have much time left, maybe a few weeks. Please don’t send me back to the nursing home.”

I started to protest. I was as low in the medical hierarchy as could possibly be. I didn’t have the authority. I couldn’t do it.

“Please,” she whispered. “I have no family or friends who can take care of me. The nurses on the oncology floor have become my family over the last few years. They are kind to me and they make sure I am not in pain. I want to die with them. Please, can you try to help me?”

Against my better judgment, I let myself be convinced. She also extracted a promise from me that I would do whatever I could to be sure that she did not die in pain. I warned her, though, that I did not have much power. I also warned her that we might need to use a bit of deception to escape the roving eye of the dreaded UR, Utilization Review. Utilization review sent nurses through the hospital each day to look for ways to save money. One of their most important functions was to identify patients who were running up costs and transfer them out of the hospital.

Thus began my daily campaign to avoid or circumvent Utilization Review. Fortunately, I was not alone, or I never could have accomplished it. Mrs. H had enlisted a senior surgery resident who had cared for her in the past. He was no longer directly involved in her care, but he gave me ideas for ways to deceive Utilization Review. I would end every working day with Mrs. H, planning our strategy. After I finished checking up on her, she would check up on me. How had my day been? Was I getting enough rest? How was my husband and my life outside the hospital?

Within two weeks I ran out of tests to order and results to track down. Utilization Review had caught on and they made arrangements to transfer Mrs. H back to the nursing home. The surgery resident had a suggestion. Mrs. H could no longer eat, because her intestines were blocked with tumor. She was dying of malnutrition. That’s not a bad way to die and there was really no reason to treat her malnutrition, since treatment would only prolong her life to no purpose. The resident suggested that I arrange for placement of an indwelling catheter in Mrs. H’s chest to provide for intravenous nourishment. That would certainly buy a few more days of hospital time and she was dwindling quite rapidly at that point.

Mrs H and I discussed it. She was enthusiastic even though I warned her that the placement would be painful, and that she really didn’t need the catheter at all. She insisted that she wanted it, if that’s what it took to prevent the impending transfer.

There was just one hurdle in the way. I had to ask permission from Mrs. H’s personal doctor, the one who was really in charge of her care. I sought him out and began my rehearsed explanation as to why Mrs. H should get an indwelling catheter to ward off malnutrition. He listened politely and then looked me in the eye.

“Don’t think I don’t know what you are doing,” he said.

I froze, and readied for the tongue lashing that I knew was coming.

“Don’t think you fooled me. I’ve known what you’ve been doing all along,” he said, not unkindly. “You’ve been trying to trick Utilization Review into letting Mrs. H stay in the hospital to be with the nurses when she dies.”

That was it. I was caught. But I was unprepared for what came next.

“I approve.” He smiled. “I’’ve known Mrs. H for 35 years. She was one of my first patients when I started my practice. She’s a good woman and she has no one to care for her. The nurses are like her family. We can’t make her better; the least we can grant her last wish.”

“I approve of the catheter,” he said. “And I approve of anything else you try to do to keep her here until the end.”

Mrs. H got her catheter. The insertion was uncomfortable, but once it was in, it didn’t seem to bother her. It also turned out to have an added benefit, besides allowing her to receive nutrition that she didn’t need. It was an excellent route for the ever greater quantities of morphine that she required in the last few days.

Everyone worked together at the end to be sure that Mrs. H was comfortable and supported by the nurses whom she loved. I was not there the night she died. I had gone home for the evening, but the surgery resident she was fond of was with her as she drew her last breath.

I was sad that she was gone, but elated that I had been able to fulfill my promise. Mrs. H had had the death that she wanted.

A few weeks later I was paged to the lobby of the hospital. I had never been paged to the lobby, and couldn’t imagine why I was needed there.

A young man was waiting for me. He introduced himself as Mrs. H’s great nephew. He handed me a jewelry box.

“We read my aunt’s will,” he said, “and she wanted you to have this. Thank you for taking care of her.”

The bracelet is heavy and elaborate. It is not my style of jewelry, so I haven’t worn it. But even after 25 years, I still keep it in the top drawer of my dresser and think of Mrs. H.

My first experience with denial in cancer care came with the very first patient I met as a medical student. It was the end of the second year of medical school and we were given our white coats and taken into the hospital to meet patients. I was assigned to an elderly woman with advanced lung cancer.

I had pored over the woman’s chart, so I was prepared for her poor condition. She sat upright in bed, struggling to breathe. Even though she was getting supplemental oxygen, her lips and fingernail beds were tinged blue. I cautiously made my way into the room and introduced myself.

“How are you feeling today?” I asked.

The woman brightened. “Oh, my arthritis isn’t so bad today. Thanks for asking.”

I spent almost an hour with this woman, discussing her hospitalization and medical history. Not once did she mention lung cancer. She acted as if she didn’t have lung cancer at all, and I was afraid to confront her directly. She was in denial.

In her case, denial was a useful coping strategy. She was not so mired in denial that she refused care for her cancer. Indeed, she had accepted state of the art cancer care complete with surgery immediately after the originally diagnosis, and chemotherapy along the way. But denial allowed her to put the frightening reality of end stage cancer out of her mind, and live the rest of her life in psychological comfort.

Sometimes, though, denial becomes a life threatening problem. It’s not hard to imagine why. Cancer patients face the paradigmatic case of being stuck between a rock and a hard place. They are told they have a disease that might kill them if they do nothing, and they must undergo brutal treatment in an effort to save their lives. The temptation always exists to pretend that they don’t have cancer, or that they don’t need arduous treatment to recover. Sometimes, the psychological pressure is so great that patients are tempted to run away from their cancer … literally.

That is what has happened in the tragic case of Daniel Hauser, a 13 year old boy with a highly curable cancer, whose mother has run off with him in an attempt to avoid the awful treatment. Obviously, they are running from the physical threat that the state of Minnesota will force Daniel to undergo the unpleasant treatment. Equally if not more importantly they are running away from the psychological threat that acknowledging the existence of the cancer and its life threatening nature poses.

As a mother myself, I cannot imagine anything worse that hearing that your child has a life threatening illness, and needs brutal treatment with no guarantee of survival. The mere thought of explaining that to a child, forcing a child to endure chemotherapy and witnessing his or her suffering makes me sick to my stomach. I don’t doubt that the reality is far worse than my worst imaginings. The only other choice is to pretend that the whole thing is not happening; it is just some perverse mistake; that the cancer will go away by itself or with gentle, “natural” treatments.

Daniel’s mother clings desperately to that belief. For her, it is an absolutely essential psychological coping mechanism. Unfortunately, it will almost assuredly result in Daniel’s death. This case is being reported in the media as a battle over who has the right to decide treatment for a child, the parents or the State, and legally, of course, that is exactly what it is. But psychologically, it is something else entirely, and it is important that everyone analyzing this case take note. In reality, it is about the mother’s need to protect herself psychologically from devastating news vs. her son’s right to receive life saving treatment.

That’s why the State is right to vigorously pursue the Hausers and force Daniel to have the brutal, but life saving treatment. Mrs. Hauser does not want to hurt her son; she loves him desperately and her willingness to single handedly defy the State of Minnesota proves it. Yet ultimately, the decision to run away is about her and her needs, not about Daniel and what is good for him. She needs to believe that he doesn’t have cancer, or that his cancer is not serious, or that she can treat him “naturally.” She may need to believe that, but it does not give her the moral right to forfeit his life to make herself feel better temporarily.

That’s what’s really at stake here: a mother’s need to protect herself by pretending that her child is not deathly ill vs. a child’s right to life saving treatment. In the best of all possible worlds, someone would be able to break the thick shell of her denial and get her to acknowledge reality. Her child is dying, no amount of pretending will prevent his death, and medical treatment represents the only chance to avert the disaster that she cannot bring herself to contemplate.

Daniel’s mother doesn’t realize it, but she and the State are in total agreement. More than anything else, she wants Daniel to live. More than anything else, the State of Minnesota wants Daniel to live. Her denial of reality is completely understandable, but that’s what it is: denial. And no child should have to die because his mother cannot face reality.

Before a doctor starts out in practice, he or she has had years of rigorous training. In the case of an obstetrician, that means four years of medical school, the first two in the classroom, the last two in the hospital working with patients. It also means four years of additional training when you are a doctor, but working under supervision. During those four years, you work 80+ hours a week, care for thousands of patients, and make hundreds of major decisions. Nonetheless, in the back of your mind, you know that you are not ultimately responsible. You can always ask the attending (senior physician).

Therefore, it comes as something of a shock the first time a nurse looks to you for the decision in the midst of a crisis. Your first thought, sometimes even said aloud, is “let’s ask the attending,” before you realize that you ARE the attending. Most doctors learn over time to automatically accept responsibility for whatever is happening, and some, like me, learn the hard way.

One of my first patients in practice was a woman expecting her third baby. Her pregnancy was uneventful, but at every doctor’s visit, her baby was in a different position. That’s pretty typical at first. Until the last months of pregnancy the baby has lots of room to move, and can easily do somersaults if so inclined. Toward the end of pregnancy, the baby takes up one position, typically head down, and no longer has enough room to change position. In this case, even in the final weeks of pregnancy, the baby was still changing position. One week it would be breech (bottom down); next it would be head down; occasionally it would even be sideways (also known as transverse, and a very unusual position).

In the last few weeks, the baby seemed to stay in the transverse position. A baby in the transverse position is undeliverable. The baby can come through the pelvis only head down or bottom down. It simply will not fit sideways. Prior to safe C-sections, women who labored with a baby in the transverse position simply died, and the baby died with them. Nowadays, the standard method of delivering a baby in the transverse position is a C-section. Sometimes, though, you can coax the baby from the transverse position to the head down position. This is called “version.” It involves using your hands to literally turn the baby to the proper position.

That’s what I discussed with this patient. She had had two uncomplicated vaginal deliveries. It seemed a shame to perform a C-section when we might manipulate the baby to the head down position.

The patient was very enthusiastic about the idea of version, even after I explained that a version was not without risks. Manipulating the baby through the walls of the uterus can potentially damage the placenta, necessitating an immediate C-section. Getting the baby to turn can potentially cut off blood flow to the baby if the turning causes an unsuspected knot in the cord to tighten. Once again, an emergency C-section would be necessary. For these reasons, versions are done in the hospital, with an OR team ready to go if needed.

We made a plan. If the version were successful, and I was able to turn the baby from transverse to head down, we would start induction of labor immediately thereafter, so that the baby would have no opportunity to turn back to an unfavorable position. If, on the other hand, I were unable to turn the baby, we would proceed directly to C-section, since the inability to turn the baby would mean that a C-section was unavoidable. I hadn’t considered that there were other possibilities.

The patient showed up for her version on the appointed day, and the baby was still transverse. Under ultrasound guidance, I gently manipulated the baby and had no trouble getting it into the favorable head down position. While we were celebrating our good fortune, the baby flipped back to the transverse position. The nurse and I could easily see it happen by watching the patient’s abdomen, and the patient could feel it. That was unexpected.

I tried again. Again I had no trouble getting the baby to move, but it promptly popped back to the transverse position. I turned it a third time, and again it turned back. I told the patient that we would need to give up. It wasn’t going to work, and we should proceed to a C-section, just as we had planned. I left the room to round up the surgical team.

A senior obstetrician was sitting at the nurses’ station and I casually related the story to him. He offered to examine the patient and give his recommendations. I was relieved. Here was someone with excellent clinical judgment and decades of experience. I would not be making the decision alone. He examined her and we stepped out to consult.

“Don’t do a C-section now,” he said. “The baby is small. You saw how it could easily be turned. Just leave her alone and I guarantee that she will be back in a few days, in labor, with the baby in the head down position.”

I was relieved, but somewhat skeptical. “Do you really think so? Maybe I should just do the C-section now like we planned.”

“I’m sure of it,” he replied. “I’ve seen it happen many times.”

I talked to the patient, and she happily agreed to the plan. She wanted to avoid surgery if at all possible.

Sure enough, the senior obstetrician was right. The patient returned two days later in labor, and the baby was head down … and dead.

After the delivery, we could easily determine the cause. There had been a true knot in the umbilical cord. While the baby moved of its own accord into the head down position, the knot had tightened, depriving the baby of blood flow and oxygen, leading inexorably to the baby’s death. Telling her that the baby had died was one of the hardest things I’ve ever done. Knowing that her baby was dead, she still had to go through labor.

It often seems that when disaster strikes, it is inevitably followed by more disaster. It’s hard to imagine how this situation could have gotten worse, but it did. The baby was big, and during the delivery, the mother experienced a very unusual complication. She ruptured her symphysis, the piece of cartilage that holds the two halves of the pelvis together in the front at the pubic bone. Much to our horror, the nurse and I literally heard it pop. The patient could not walk for months thereafter.

The patient also developed a raging infection that required a week-long hospitalization for IV antibiotics. She ultimately went home to a long course of oral antibiotics, a walker, and months of physical therapy to help her as her ruptured symphysis healed. I must have apologized to her a thousands times, but, of course, I couldn’t change what happened.

What did I learn from this dreadful experience? I learned that if I was going to have to take responsibility for bad outcomes, I ought to be sure that it was my decision and not someone else’s. I had felt at the time of the failed version that the C-section was the right thing to do, but I allowed myself to be talked out of it. It’s true that the senior obstetrician had more experience than me, but I had been looking for a way to avoid responsibility for performing a C-section on a woman who had had two previous vaginal deliveries.

The recommendation from the senior obstetrician allowed me to push off the decision, and I had naively thought that no harm could come from pushing it off. Either she would show up in labor with the baby head down, or she would show up in labor with the baby in the transverse position and we could do the C-section then. I had never considered the possibility, albeit rare, that she could show up with a dead baby.

A recent paper in the Journal of Adolescent Medicine reveals what every gynecologist knows. Young teen girls generally regret early sexual activity. Over the years that I practiced gynecology, I met hundreds of women who wished they had waited to lose their virginity, and I never met a single girl or woman who said, “If I had it to do over again, I would have lost my virginity at a younger age.”

The paper is entitled Joining the Sex Club: Perceptions and Experiences of First Sexual Intercourse in Australian Adolescent Females, by Smith, Skinner et al. The authors interviewed 68 young women ages 14-19. They found:

Feelings of readiness were more prominent in teenagers who were older and had postponed intercourse until a context of ‘right time, right person’. Reflecting with disappointment and regret, others spoke of conforming to peer norms, coercion from sexual partners, and being intoxicated as the reason for their premature and sometimes unwanted first encounter.

Dr. Skinner explained the findings to the Australian newspaper, The Age:

…[S]ex-education classes tended to focus on how to prevent sexually transmitted infection and unwanted pregnancy.

Often neglected was the importance of teaching young women negotiation skills so that they could resist pressure from their peer group and partners…

The girls who were younger when they first had sex were more vulnerable to peer pressure and pressure from their partner …

Being drunk or tipsy at the time was also common…

The longer intercourse was postponed in a relationship, the more likely girls reported feeling ready.

Young women have always experienced pressure from young men to engage in sex. What’s changed in the last few decades is that the culture at large sends teen girls the message that early sexual activity is desirable. In contrast to previous generations of women who were counseled (and warned) how to avoid sexual pressure, contemporary sex education focuses only on the medical facts, not the psychological issues.

As a gynecologist, I’ve had unique opportunity to view the consequences of increasing sexual openness. It appears to be a bonanza for young men, generally at the expense of young women. Men get all the benefits; women carry all the risks. Regret is not the only problem. Men get laid, get action, get lucky and women get pregnant, get sexually transmitted diseases, get infertile, get cervical cancer.

Young women face significant and life threatening risks that young men simply do not face. Pregnancy may be an inconvenience and a financial drain for men, but it does not put their lives at risk. Abortion, while not as dangerous as pregnancy, still poses significant risks to health and life.

Sexually transmitted diseases (with the exception of HIV) rarely threatened the health or fertility of men, while they are responsible for significant illness and death among women. According to Sexual behavior: related adverse health burden in the US:

Overall, in the United States, in 1998, about 20 million adverse health events (7532 per 100,000 people) and 29 745 deaths (1.3% of US deaths) were attributed to sexual behaviour… If HIV related mortality were excluded, more than 80% of sexual behaviour related mortality would be those among women. Among females, more than half of the incident events were contributed by curable infections and their sequelae… Cervical cancer and HIV are the leading causes of [unsafe sex related] mortality among females …

Although young women may learn about protective measures in sex education classes, those who are pressured into early sexual activity often fail to use contraception and condoms because they were not planning to have intercourse in the first place. This is especially true of sexual activity that occurs when they are under the influence of alcohol or recreational drugs.

Teen virginity has become a highly underrated commodity in our culture. However, those who care about the health, both physical and psychological, of young women should be advising them to wait until the later teen years before embarking on sexual relationships. Many young women are hurt by giving in to pressure for early intercourse, but no one ever regretted waiting.

Addendum: I’ve noticed that this post is being discussed on several websites and some people suggest that it is sexist. That is absolutely not its intent, so I want to elaborate a bit more.

It is important to recognize that for almost all of recorded history, women’s sexuality has been controlled by men for their own purposes. Virginity, and chastity were valued by MEN much more than by women, because enforcing those values assured a man that the children of his partner were actually his children. It is men who decided to stone women for adultery, and men who made up the myriad rules that governed every sexual decision a woman might make. And of course when it came to social inferiors or victims of war, men felt free to rape women simply because they wanted to.

Now, in an age where birth control and paternity testing make it possible for a man to be sure which children are genetically his, it is not surprising that the strictures on women’s sexual decisions have been lifted. Female chastity is simply not as important to men as it used to be. Access to willing females is more important, and it is not surprising that the culture has changed to pressure women into believing that they should be sexually available, whether that is what they truly want or not.

The crumbling of any marriage is a tragedy, usually played out among a small circle of family and friends. The details, undeniably painful to the children, are not shared with the world at large. Unfortunately for the 8 children of Jon and Kate Gosselin, whose personal lives are routinely exposed for the world to see on the television show Jon and Kate Plus Eight, the dissolution of their parents’ marriage is also a public spectacle.

It didn’t have to be this way, but Kate felt compelled to grant an interview to People Magazine to publicly air “her side.” Rather than making her a sympathetic figure, it demonstrates an extraordinary lack of insight into her own behavior and motivations. By the end of the interview, the reader wonders not why Jon is straying from the marriage, but how he managed to stay with Kate until now.

Only a person with no insight into her own behavior and motivations would do the following:

1. Invite People Magazine to discuss the intimate details of her marriage and its breakdown. It is clear from the outset that Kate is trying to justify her own behavior and has no regard for saving the marriage.

2. Opt for the celebrity glamor look. Kate has undergone an extraordinary transformation in the years since the show started. She has literally become a “cover girl” complete with elaborate cut and colored hair artfully styled for the camera, provocative pose, and excessively airbrushed countenance. That’s fine for someone who aspires to be a celebrity, but hardly reassuring in a woman who claims that her primary interest is supporting her family.

3. Miss Mother’s Day with her children in order to come to New York City to give the celebrity interview.

4.Acknowledge that it is the glare of the public eye that has harmed her marriage and then declare that under no circumstances will she give up the public exposure, insisting:

“… My point is that I could care less if this all died tomorrow, for my sake. It’s for my kids. I feel if we put ourselves out there, it’s got to be worth it, for them.”

Perhaps that might justify the show itself, for which they receive from $25,000 to $50,000 per episode, in addition to the income from the DVDs and the free trips and products. With that level of income, it is difficult to justify the books, book tours and paid speaking engagements that involve Kate alone. As Kate says about Jon:

“He hates to speak, he doesn’t write, he doesn’t do public appearances — all those things I love. And now he’s resenting me for it.”

Yes, he resents you for spending so much time away from him and the children for projects that are all about you when you don’t need the money.

5. Whine about all you’ve done and complain that no one appreciates you.

Kate says she’d been doing her best to support her husband, as he grew disenchanted with their increasingly high-profile life. “I walked through this with him for six months… First he said he’s unhappy, he needs a career. ‘Great’ I said ‘Go get a part-time job… Never happened. So I said, ‘Go back to school! …’ that never happened. Originally, we’d speak together [on tour] on weekends. But then he was saying, ‘I don’t like to speak, you do most of the speaking anyway, so why don’t you just go.’ So I started carving him off engagements so he could stay home with the kids…”

In other words, Jon is floundering in his role as TV dad, without a real career, and doesn’t want to spend his weekends making more money instead of being together as a family.

6. Rule out the one option that might save your marriage and family life:

Of course the one option that hasn’t been tried is walking away from the show. “Everybody says, ‘Oh, quit and go away,'” Kate says. “But I’m hesitant to do that because I don’t think that’ll make Jon happy either. And therefore I step up for the needs of my kids. I have a huge weight on my shoulders. This needs to go on because I need to be able to provide for my kids.”

7. Criticize Jon as if he were a child, not another adult:

“Do I prefer that he was feeding them pizza instead of the organic meals I prepared in advance? No. Do I prefer that these people I do not know are at my house? No. It’s a huge disappointment to me. I’m really suffering…”

Well if you don’t like those things, perhaps you should be there to make sure that the children eat the organic meals that you prefer, and that Jon has the adult companionship that he clearly craves.

8. Be absurdly defensive:

But Kate noticeably bristles at any suggestion that her tightly wound temperament somehow drove Jon to act out. “Oh, it’s still my fault ..,” she says, rolling her eyes … I did not cause this. It’s ridiculous, really, it’s pathetic. Are you kidding me? I drove him to that?”

Jon is responsible for his own actions. No one drove him to make the irresponsible choices he made. However, that does not absolve Kate of blame. Her choices have led to his choices and she needs to own the decisions she has made and the consequences that have resulted.

Her husband has told her that he does not like the way that their family and personal lives have spun out of control. He does not enjoy being a public figure, and he resents giving an ever larger portion of their time to the pursuit of money and fame. And Kate has made it spectacularly and publicly clear that she is not willing to compromise, not even to save her marriage.

The People Magazine interview is a terrible public relations mistake for Kate Gosselin. She reveals herself to be obsessed with celebrity and money, and unwilling to examine her own role in the crumbling of her marriage. I have a suggestion for Kate:

The next time you want to justify your behavior as your marriage crumbles, make an appointment with a therapist, not People Magazine. Talk to someone who can help you understand your own behavior and take responsibility for your actions, not a magazine that will eagerly accept your offer to exploit your personal tragedy. You owe it to Jon, and most of all you owe to those eight children you brought into this world. They didn’t ask for and don’t need celebrity, even if you do; they need a father.

Parental medical neglect is in the news again. On Friday a Minnesota judge ruled that parents cannot refuse chemotherapy for a child because of religious or cultural beliefs. Daniel Hauser, 13, was diagnosed with Hodgkin’s lymphoma in January. Hodgkins is among the most treatable forms of cancer and indeed, Daniel’s tumor shrank after his first round of chemotherapy, but Daniel’s parents were so distressed by how sick the chemo made him, they refused further treatment. Daniel’s cancer has begun growing again.

According to MSNBC:

[His mother] has been treating his cancer with herbal supplements, vitamins, ionized water, and other natural alternatives she learned about on the Internet — despite testimony from five doctors who agreed Daniel needed chemotherapy. Daniel told the judge during closed testimony that he has also been eating “green food” such as broccoli and beans, as well as eggs and fruit.

Fortunately the Court has intervened in this case and Daniel will restart treatment soon, but other children have not been so lucky. Eliza Jane Scovill died in May 2005 because her mother prevented her from getting appropriate medical treatment.

Three year old Eliza died of AIDS related pneumonia. When Eliza became ill, her mother, Christina Maggiore, neglected to tell the doctors that both she and Eliza were HIV positive. It is not clear that Eliza could have been saved by the time she was brought to the hospital, but without an accurate medical history, doctors lost valuable time in determining the causative agent, and therefore, the appropriate treatment for Eliza’s pneumocystis carinii pneumonia. Pneumocystis is an otherwise harmless bacteria that causes pneumonia only in people who are severely compromised by AIDS or other immunologic failures.

Why did Christine Maggiore withhold this critical information? She did it because she was an activist who believes that HIV does not cause AIDS.

Maggiore had a homebirth with Eliza because no doctor would care for her unless she agreed to take medication to prevent the transmission of AIDS to her unborn child. She was counseled not to breastfeed Eliza, but she did so, and published pictures of herself breastfeeding Eliza to show her confidence in her belief that HIV does not cause AIDS. She never allowed Eliza to be tested for HIV, because she felt that there was “no need”.

After her daughter’s death, Maggiore gave interviews claiming that she did not mention her HIV status, and the fact that her daughter was almost certainly HIV positive, because she did not want the doctors to “discriminate” against her daughter. Although the autopsy report and the slides of the pathology examination have been released publicly, Maggiore insisted that Eliza died of an anaphylactic reaction to antibiotics, not of pneumocystis pneumonia.

According to the American Academy of Pediatrics position paper Recognizing and Responding to Medical Neglect:

Several factors are considered necessary for the diagnosis of medical neglect:

1. a child is harmed or is at risk of harm because of lack of health care;

2. the recommended health care offers significant net benefit to the child;

3. the anticipated benefit of the treatment is significantly greater than its morbidity, so that reasonable caregivers would choose treatment over nontreatment;

4. it can be demonstrated that access to health care is available and not used; and

5. the caregiver understands the medical advice given.

Reasons for medical neglect include: poverty, lack of access to care, family chaos, lack of awareness, lack of trust in health care professionals, and caregiver’s belief systems:

Some caregivers have belief systems that are inconsistent with Western medicine. A parent of a child who has a serious illness may decide to rely on untested remedies or alternative medicines. Some caregivers will seek healing through religion rather than medical care…

Just as there is no special status granted to religiously motivated medical neglect, there is no special status granted to medical neglect motivated by belief systems such as AIDS denialism or “alternative” health.

Eliza Scovill died because of the beliefs of her mother and Daniel Hauser is at risk of dying for the same reason. Because of the imminent risk of death, the Court has intervened in Daniel’s case, but many other children are victims of less dramatic forms of medical neglect but there is no one to protect them.

And what of Christine Maggiore who endured the death of her daughter. It did not change her AIDS denialism and the result was a forgone conclusion. On December 27, 2008, Christine Maggiore died of AIDS related pneumonia. To the very end she insisted that HIV does not cause AIDS and refused the medications that could have saved her life.

Oprah Winfrey’s decision to publicly support Jenny McCarthy is bewildering. Why would Oprah, who appears to care passionately about the health and well being of children, support quackery that can only result in the death and permanent injury of children?

Some have speculated that it is due the financial bonanza that McCarthy could represent. But Oprah does not need more money or more fame. I don’t doubt that Oprah’s support for McCarthy is real. Both women are bound together by a belief in magical thinking.

Magical thinking does not mean believing in magic. It means believing that thoughts and actions have the power to affect unconnected events. Magical thinking is at the heart of the success of books like The Secret, also an Oprah favorite. Once you believe that your thoughts can affect reality, it is but a small additional step to believing that you can construct your own reality.

Oprah dreamed of stardom unheard of for an African-American, a woman, a child of abject poverty, and single handedly turned her dreams into reality. That is the essence of her appeal to millions of women across the nation. She holds out the promise that their lives can be better than they are, and that they can make it happen.

Books like The Secret send a similar message. You can control your destiny by your thoughts and dreams. A relentlessly positive attitude has the power to create a relentless positive life. Yet somewhere along the way, Oprah has managed to elide a key difference between herself, and believers in The Secret. Oprah worked to bring about her new reality.

Oprah didn’t simply dream of being a superstar; she did the grunt work and paid her dues. Her dreams gave her the strength to do the work, but it is the work that made her a star. Oprah seems to have forgotten that key point.

Jenny McCarthy, like all purveyors of pseudoscience, believes in the power of magical thinking. Fundamentally, magical thinking in healthcare is a coping mechanism. Researcher Yannick St. James explains:

… [M]agical thinking … involves imparting moral meaning to a situation, reifying and externalizing one’s control over the situation, attempting to symbolically influence this powerful, mystical entity that is vested with control, and interpreting scientific symbols as objective signs from this entity…

…[W]hen faced with situations of uncertainty, loss, absence of control, or inability to attain a desired outcome … people often engage in magical thinking by creating and using meaning-based connections to understand and influence situation outcomes.

Autism is definitely a situation of uncertainty, potential loss, and absence of control. No one, not the parents nor the doctors, can control the process or even predict the outcome. The potential always exists for a devastating result: inability of the child to achieve, even in the most basic ways, the milestones of growth to successful adulthood.

In the face of this uncertainty, the most people have turned to science to understand autism. As St. James notes, integral to the practice of science is the impact of “chance, probability and randomness”. This is, in fact, what statistics tell us. Autism will affect some children; we can predict the probability of autism in a population, but its occurrence in an individual child is essentially random.

Vaccine rejectionism, in contrast, imparts a reason and moral meaning to autism. Children aren’t autistic because of random (probably genetic) accidents. The cause is vaccination, and the moral meaning is that evil vaccine manufacturers and doctors have conspired to withhold the connection between vaccination and autism from the general public.

Magical thinking holds out hope that may not exist in reality. As St. James comments:

Whereas scientific thinking seeks to empirically validate or invalidate possibilities to classify them as reality or fantasy, magical thinking creates and maintains ambiguity around what is possible in order to provide meaning and sustain hope in the context of stressful situations.

Hence, although it has been repeatedly demonstrated that vaccines do not cause autism, vaccine rejectionists persist in insisting that we “don’t know” what vaccination really does. Although it has been repeatedly demonstrated that autism cannot be cured, vaccine rejectionists persist in believing that they can rid their children of autism. The key point is that magical thinking within the context of vaccine rejectionism provides a way to manage the uncertainty and fear associated with autism.

Jenny McCarthy and the vaccine rejectionists use magical thinking because they believe it can change reality. Oprah Winfrey believes that thoughts can lead to a new reality. That is why Oprah is supporting Jenny McCarthy, even though, as Oprah must surely know, wishing does not make it so.

When I announced my fourth pregnancy to my boss, I was startled by her response.

“What’s the matter with you? You’re a gynecologist; if anyone should know about birth control, it’s you.”

“It wasn’t an accident,” I replied. “We want a fourth child.”

I have never forgotten her look of disbelief.

She was not the only one who was amazed. For every person who congratulated us on the news, there was another who offered “condolences.” For them, the decision to have another child was bewildering. Why would anyone make that kind of commitment?

It is this amazement that is at the heart of America’s current fascination with big families. TLC (The Learning Channel) has led the way in catering to that fascination. From Jon and Kate Plus Eight, to Table for 12, through The Duggars: Eighteen and Counting, we can’t seem to get enough.

Why are we fascinated? It’s not about the cute children, since the newer shows have teenagers and young adults, as well as a severely handicapped child. I suspect we are fascinated because we stand in awe of the commitment required to deliberately choose a large family: the commitment to parenting as a lifestyle choice and the commitment to marriage that lies at the core of the decision to have many, many children.

In contemporary America, such a commitment is not only unfashionable; it is unfathomable.

If contemporary America could be distilled to one imperative, it would be this: The highest calling is self-actualization. Or, more colloquially, “it’s all about me.” In other words, being happy (and being happy is considered the highest state of being) requires doing what you want, when you want to, unfettered by obligations and commitments. Children are an obligation, a temporary detour on the road to a life devoted to self.

The Pill has been cited as the central reason for the shrinking of American family size, and that’s true as far as it goes. The Pill has allowed American parents to choose the size of their families, instead of making do with unintended results of sexual activity. Yet the Pill is not responsible for the belief that a smaller family is better. That is a product of our philosophy.

When the highest calling is following every personal wish and whim, commitment to someone else can seem exotic indeed. Half of married couples can’t manage to maintain a commitment to the person they promised to love, honor and cherish forever. Last year almost 40% of women giving birth couldn’t manage to meet the most minimal commitment to their newborn, that of providing a father to support and nurture that child.

Even within a secure marriage, most couples cannot fathom willingly undertaking the sacrifices necessary to support and nurture more than two children. Children are important accessories to a “good life” but very few Americans seem to believe that children represent a “good life” in and of themselves. Having more than two children makes about as much sense to them as wearing more than two socks at a time. Why would anyone bother?

To watch the day to day life of parents who have committed to large families is like watching an exotic animal in its native habitat. Look, they put children’s needs ahead of their own, and they enjoy doing it. Wow, they’re not obsessed with following their own desires and whims. Amazing, the parents are not obsessed with having as much discretionary income as possible.

What feeds our obsession with super size families is not the logistics of caring for so many children. It is the commitment, to spouse, to children, to the family itself that undergirds the decision to have a large family. Octomom Nadya Suleman misunderstood that crucial point. She thought that by having a mega family she would be guaranteed a TV show and lots of merchandising opportunities. She didn’t understand that no one wants to watch a selfish, mentally disturbed woman who collects children as if they were trinkets. They want to see adults who value and live commitment to others.

That’s also why we’re obsessed with the state of Jon and Kate’s marriage. Husbands cheat on wives every day of the week, but this is a special case. We thought Jon and Kate were more committed to their family than to themselves as individuals. We’re disappointed in Jon because he turns out to be just like everyone else.

The current popularity of TV shows following large families is not about the children; it’s about the parents. In a world that values self actualization as the highest human aspiration, adults who put others before self, who believe that marriage is forever and children are not “accessories” to life but are life, inspire curiosity, admiration and fascination.

It’s been many years since the magazine Cosmo has spoken to me. Cosmopolitan Magazine, the ultimate achievement of editor and writer Helen Gurley Brown (Sex and the Single Girl) is aimed at women 18-30 and concentrates on the old fashioned pre-occupation of landing a man. Of course landing a man used to mean getting him to marry you; Brown’s great innovation was to insist that “landing” him simply meant getting him into bed. Setting the bar a lot lower made the chances of success a lot higher.

Fortunately, Gurley-Brown has not forgotten older women like me. Her books offer advice for how to keep a man, once you have landed him. The principle is the same; only the specific tactics need to be modified.

What is the principle? Simply put, sex is all about him. Women exist primarily for the sexual satisfaction of men. Not coincidentally, that is the central premise of pornography. As if the objectification of women in men’s magazines were not bad enough, women’s magazines like Cosmo emphasize the point: Your sexual needs and desires are irrelevant, ladies. What matters about your sexual needs is not their fulfillment, just the effect that your fulfillment has on men’s enjoyment.

Case in point, a typical Cosmo cover featured Total Body Sex, the Naked Quiz, The Trick that Attracts Hot Guys Like Crazy, and, my personal favorite, Your Orgasm Face; What He’s Thinking When He Sees It. Not only are women being judged for sexual attractiveness (evidently the only characteristic of concern), they are being judged on how they look during sex. You might be pretty, you might be thin, you might be well endowed, and that will convince him to take you to bed, but he’s still entitled to judge your performance during sex and finding you lacking. Because, repeat after me, ladies: Sex is all about him.

Gurley-Brown thinks it is important for “older” women to understand that while the principle is the same, the tactics must be modified. In the section Lovemaking for Grown-up Girls (from her book I’m Wild Again), she explains:

When a woman is, say, up to thirty, all she has to do is show up for the lovemaking, cooperate and be adored… When she is fifty, sixty, maybe only forty, the most successful lovemaking is her doing things to him…

At that advanced age, sex is all about his penis:

…the stroking, loving, sucking, handling and, most of all, the admiring thereof… [He might] prefer a younger, less puckered up body but hands belonging to that body wouldn’t do the things we can and will do so adroitly…

Thank goodness that women in an advanced state of decrepitude (over 40) have at least one advantage over the younger and less puckered.

Gurley-Brown claims to be a feminist, and perhaps when Sex and the Single Girl was written in 1962, sexual openness passed for feminism. However, it seems to me that Gurley-Brown has confused explicitness with empowerment. She may be willing to discuss sex openly and explicitly, but sex in her mind is still all about men and what she presumes to be their needs.

In the supposedly repressed 1940’s and 1950’s, sex was a wife’s “duty” to her husband in exchange for marriage and economic support. In the early 2000’s sex is still a woman’s duty, though it is no longer rewarded with marriage and economic security, merely the presence of a warm body in bed. That doesn’t sound like progress or feminism to me.