There are not many heartwarming stories about death, and even fewer about suicide. That small number is destined to grow with the addition of the true story of Sir Edward and Lady Downes, and elderly couple who chose to end their lives together as she faced imminent death from terminal cancer.

From The New York Times:

…[O]ne of Britain’s most distinguished orchestra conductors, Sir Edward Downes, [flew] to Switzerland last week with his wife and joined her in drinking a lethal cocktail of barbiturates provided by an assisted-suicide clinic.

Although friends who spoke to the British news media said Sir Edward was not known to have been terminally ill, they said he wanted to die with his ailing wife, who had been his partner for more than half a century.

According to their children:

Sir Edward, who was described in a statement issued earlier on Tuesday by [their son and daughter] as “almost blind and increasingly deaf,” was principal conductor of the BBC Philharmonic Orchestra … [and] a conductor of the Royal Opera House at Covent Garden in London, where he led 950 performances over more than 50 years.

Lady Downes, who British newspapers said was in the final stages of terminal cancer, was a former ballet dancer, choreographer and television producer who devoted her later years to working as her husband’s assistant.

“After 54 happy years together, they decided to end their own lives rather than continue to struggle with serious health problems,” the Downes children said in their statement.

What could be more natural or more romantic? An elderly couple who had an unusually long and happy life together faced only debility, decline and life apart. They viewed this prospect as insupportable and chose to take control of their destiny by ending their lives now instead of suffering longer. Their deaths were quiet and peaceful, just as they had planned

…[T]he children said, they watched, weeping, as their parents drank “a small quantity of clear liquid” before lying down on adjacent beds, holding hands.

“Within a couple of minutes they were asleep, and died within 10 minutes,” … the couple’s 41-year-old son, said in the interview after his return to Britain. “They wanted to be next to each other when they died…”

Of course Britain, like the United States, does not permit an elderly couple to control the timing and method of their own deaths, even when those deaths are inevitable. Sir Edward and Lady Downes were forced to leave their home and travel to Switzerland, where the organization Dignitas helped arrange the suicides.

Predictably, the news of the deaths has ignited controversy back home. The British Medical Association, in their wisdom, voted recently to deny the terminally ill the option of assisted suicide.

Not surprisingly, though, in a society that forces the terminally ill to live even if they are suffering, it is Sir Edward’s death that has sparked the most outrage. He may have been 85 years old, almost blind and losing his hearing, he was not terminally ill. He had lived a long time, longer than most men, and was satisfied with his length of life, but the British, like Americans, believe that death is far too serious a matter to be controlled by the person who is dying.

That’s the source of the outrage. It is certainly not about the deaths of this elderly couple for natural deaths at the very same moment would have provoked no concern. The outrage is directed at the temerity of Sir Edward and Lady Downes in arranging the time, place and manner of their deaths instead of taking their chances with cruel fate.

The concern is not for them, of course, but for us. As Rod Dreher writes on Beliefnet:

We shall very soon proceed from the “right” to die to the “duty” to die, when one is seen, or made to see oneself, as a burden on the living.

In other words, Sir Edward and Lady Downes’ continued suffering is a regrettable necessity to protect the rest of us. If they are allowed to die, the inevitable next step would be to force others to die. It’s the classic slippery slope argument. But as students of logic know, the slippery slope argument is an intellectual fallacy. The slippery slope is a fallacy because it denies the possibility that a middle ground can and does exist.

It does not follow logically that allowing people to control their own deaths will lead to forcing people to die. It is possible, but those who wield the slippery slope argument are obligated to prove a connection, and thus far, no one has done so.

Moreover, the slippery slope argument in this setting is incredibly cynical and selfish in the extreme. The underlying supposition is that any amount of suffering of any number of other people is allowed in order to prevent the chance that one of us may suffer inadvertently in the future. In other words, for Dreher, the Downes’ suffering is the price they have to pay to protect Dreher from a theoretical future where he might be forced to die.

But his fear of theoretical future suffering is not a justification for the very real and ongoing suffering of terminally ill and elderly people who are ready to die but are forced to live. I applaud Sir Edward and Lady Downes for having the strength of character and purpose to make their own most intimate decisions and carry them through. And I have deep respect and admiration for the intense love that makes surviving alone an unbearable prospect.

The blogosphere is abuzz with the news that Midwifery Professor Denis Walsh has declared that labor pain is good. According to the Daily Mail:

In an article for Evidence Based Midwifery, published by the Royal College of Midwives, Dr Walsh said the NHS was too quick to give in to requests for pain-killing injections.

He said: “A large number of women want to avoid pain, but more should be prepared to withstand it. Pain in labour is a purposeful, useful thing which has a number of benefits, such as preparing a mother for the responsibility of nurturing a newborn baby.”

Dr. Walsh recycles an entirely fabricated claim:

[Epidurals] also led to lower rates of breast-feeding. He added: “Emerging evidence showsthat normal labour and birth prime the bonding areas of the mother’s brain more than Caesarean or pain-free birth.”

The belief that pain in labor is beneficial has a long and sordid history. A large body of scientific literature shows that women’s pain (of any kind) is much less likely to be taken seriously than men’s pain.

The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain (Journal of Law, Medicine & Ethics, 29 (2001): 13–27) provides a disturbing description of the ways in which the pain of women is systematically devalued, disbelieved and undertreated.

…Women who seek help are less likely than men to be taken seriously when they report pain and are less likely to have their pain adequately treated…

The study by McCaffery and Ferrell of 362 nurses and their views about patients’ experiences of pain found that while most of the nurses (63 percent) agreed that men and women have the same perception of pain, 27 percent thought that men felt greater pain than women… The same study also found that almost half of the respondents (47 percent) thought that women were able to tolerate more pain than men …

These erroneous attitudes are particularly prevalent in regard to childbirth:

Bendelow found that “the perceived superiority of capacities of endurance is double-edged for women — the assumption that they may be able to ‘cope’ better may lead to the expectation that they can put up with more pain, that their pain does not need to be taken so seriously.” Crook and Tunks point to the influence of the psychoprophylaxis movement in the United States with its implicit assumption that it is good to experience childbirth without the aid of analgesia… [A]ccording to the authors, “these attitudes imply that we have a value system … that suggest women should be encouraged to keep a stiff upper lip.”

The authors believe that people discount women’s expressions of pain.

A deeper examination of why women are treated this way is explored by several feminist authors. They attribute it to a long history within our culture of regarding women’s reasoning capacity as limited and of viewing women’s opinions as “unreflective, emotional, or immature.” In particular, in relation to medical decision-making, women’s moral identity is “often not recognized…”

…These findings are consistent with studies reporting that female pain patients are less likely than their male counterparts to be taken seriously or are more likely to receive sedatives than opioids for the treatment of their pain.

It is not a coincidence that the philosophy of “natural” childbirth was promulgated by men steeped in the ethos that women’s pain was not worthy of serious consideration. Their claims that women can and should manage childbirth pain through psychological means, that women are “empowered” by pain or that the pain is “beneficial” are simply elaborate justifications for not acknowledging and not treating the pain of women.

Walsh’s claims are just the 21st Century version of the willingness to dismiss the pain of women. He has dressed up his claims in scientific jargon to make them more palatable to a more sophisticated audience, but there is no scientific basis for his claims. There’s NO scientific evidence that unmedicated childbirth is better, safer, healthier or superior in any way than childbirth with pain relief. And the claim about endorphins and bonding is entirely fabricated; it was made up by Michel Odent.

Walsh is merely the latest update in an endless string of men (and sometimes women) who discount, dismiss and disbelieve women’s suffering. The original reaction was to claim that pain was all in a woman’s head; the updated version is to claim that if she cared about her baby and herself she would gladly embrace the pain and be a better mother and woman for the experience.

Curiously, no one has been able to find a form of male pain that supposedly benefits men. I suspect that it is more than mere coincidence that the only pain that is supposedly beneficial is pain that only women can experience.

Many years ago I regularly received a free monthly publication called “Doctor, I’ve read …” Unlike much of what doctors receive for free, it was both interesting and extremely useful. It was a compendium of excerpts from newspapers and women’s magazines about women’s health. It alerted me to what my patients were reading so I would be prepared for the inevitable patient questions, and because I had read the same article, I could explain to the patient whether it was reliable or not.

I often thought that there should be a similar publication for patients, showing them how they could evaluate medical claims found in newspapers and magazines. Such information is even more important today when medical claims are widely disseminated on the web. There is a great deal of excellent medical information available on the web, but far more information is erroneous and even dangerous.

Unfortunately, there is no magazine like that, but there are publications for lay people explaining how to evaluate scientific claims. One of the best is Risk in Perspective: A Consumer Guide to Taking Charge of Health Information prepared by the Harvard Center for Risk Analysis. Although it’s geared specifically toward risk, it has valuable information about any health claims.

It’s worth reading in full, especially because the cartoons are very funny. The text is serious, though.

Health information can be based on untested claims, anecdotes, case reports, surveys, and scientific studies. Scientific studies, which take samples and apply the results to the whole population, often provide the best clues about health. Nonetheless, many studies are needed to be confident about an answer. The following are some factors that might help you judge information:

Less reliable (less certain)	More reliable (more certain)
One or a few observations	Many observations
Anecdote or case report	Scientific study
Unpublished	Published and peer reviewed
Not repeated	Reproduced results
Nonhuman subjects	Human subjects
Results not related to hypothesis	Results about tested hypothesis
No limitations mentioned	Limitations discussed
Not compared to previous results	Relationship to previous studies discussed

If you read these guidelines, it is not difficult to understand that most of the “alternative” health literature falls into the category of less reliable, and is almost always superseded by scientific evidence that is more reliable.

So, for example, anecdotes, the mainstay of vaccine rejectionists, are not reliable since they tell us nothing about what happens to most people. Those ubiquitous “clinical studies” not published in peer review scientific journals, often used for touting herbs and “natural” remedies, are not reliable compared to information that has been published in a peer reviewed journal. Bits of information scavenged from a variety of studies that were unrelated to the claim being discussed, a favorite of “natural” childbirth advocates, are far less reliable than actual studies of the specific claim.

The first step in evaluating any claim is to ask some basic questions. Is the claim based on a few observations or a scientific study? Was the study published in a peer reviewed scientific journal? Have the results been repeated by anyone else? Do the authors discuss the limitations of their own study? How do the results of this study compare with other, similar studies?

If the claim is supported only by anecdote, has not been reported in the scientific literature, has not been repeated by others, and it inconsistent with existing scientific literature, the claim deserves the deepest skepticism.

Lobbyists for private package delivery services have been wining and dining members of Congress in an effort to undermine support for the US Postal Service.

“It’s an outrage, actually,” declares their spokeswoman Louise Harry. “The US Postal Service is practicing socialized mail delivery.”

A Republican Congressman agrees: “Because of its monstrous size, the Postal Service has an unfair competitive advantage. They can deliver mail from one coast to the other for less than 50¢ per letter. There’s no way that private enterprise can compete with that.”

A Republican Senator concurs and warns, “Socialized mail is just the first step to destroy America as we know it. No one can deny that the US Postal Service has taken choice away from consumers. Can you choose any stamp you want? Oh, no. Every American is forced to use only government-approved stamps to send their letters. It’s an outrage!”

In an effort to fight what it perceives as an unfair competitive disadvantage, private delivery services are rolling out a new program of mail insurance, ChoiceMail. For a flat monthly fee, private delivery services will provide all the mail service you need, subject to a few minor restrictions.

“As the name indicates, we feel that the most important component is choice,” explains Louise Harry. “The consumer will be free to affix any stamp of his choosing, and we will deliver that letter!”

We were able to obtain a copy of the ChoiceMail contract to share with our readers. For a flat monthly fee, ChoiceMail provides unlimited delivery from coast to coast, and you are not required to use only government-approved stamps. You can use any stamp of your choosing. We asked Ms. Harry about the restrictions.

“Yes, ChoiceMail does reserve the right to determine whether your letter needs to go to the address on the label. We’ve found that a consumer may think that a letter should go to Aunt Irma in Oregon, but cross country mail service is expensive. It’s more cost efficient to send the letter to Uncle Ed who lives in the consumer’s own state. If the news is important, he can call Aunt Edna to tell her.”

Ms. Harry emphasizes that ChoiceMail can offer unlimited choice for a flat monthly fee because they do their utmost to control costs. As Ms. Harry explains:

“You might think that you want to send a letter to your old high school friend Billy to tell him about your new baby, but that’s wasteful. After all, you’ll see Billy at the high school reunion next year and you can tell him then. That’s why we check every letter and send only the ones that we feel need to be sent.”

Ms. Harry is particularly proud of ChoiceMail’s most innovative form of cost cutting, charging the mail recipient:

“Sure, Grandma Sue wants you to send a birthday card. It costs her nothing to receive that card, and she benefits from every card she gets. Why should we pay for the consumer to send a card to Grandma Sue? Let Grandma Sue eat the cost if she thinks getting a birthday card is so important.”

Ms. Harry concludes:

“The most important thing is choice. The US Postal Service is socialized mail and it restricts consumers’ choice to government-approved stamps. ChoiceMail allows consumers unlimited choice of stamps. Sure, we might not deliver your letter to the person you specify in the address or we might decide that it doesn’t need to be delivered at all. But you’ll rest easy knowing that you have sent your mail by private enterprise, the patriotic way, the American way.”

This post originally appeared in March 2009.

It’s the holy grail of contemporary marketing: getting consumers to pay more for something that is worth less. When it comes to organic food, marketers have hit the jackpot.

How have consumers have been enticed to pay more for products that are potentially less safe than their conventional counterparts? The organic food scam depends on tapping into cultural myths about nature, playing upon widespread misunderstanding of risk, and flattering consumers into believing that those who choose organic food are “empowered.”.

The word “natural” is widely used to sell products. In Packaging as a Vehicle for Mythologizing the Brand researchers explore the connotations of “natural” in contemporary culture and the ways in these connotations are exploited to sell products.

Marketers of organic products depict the modern world as a deeply distorted reflection of what it originally was – the garden before agro-chemical technology. While the values of the past include family, tradition, authenticity, peace, and simplicity, the current era is associated with broken family ties that need to be restored, scientific “advances” that pose threats, constant pressure on the well-being of humans, and unnecessary complexity in everyday life.

Consider the concept of “naturalness”:

Naturalness appears as a rich emotional construct that connects with positive contemporary images of nature… People do not want to remember that nature can also be destructive as in deadly hurricanes and poisonous mushrooms … In a natural health context, Thompson also finds nature to be a positively framed powerful mythic construction; and his informants attribute magical, regenerative powers to nature. They firmly believe that aligning with what nature has to offer for one’s health lets them assert control over their lives and bodies versus losing control by being complicit in a scientized medical system.

There is nothing inherently better about “natural,” but contemporary mythology assumes that there is. The organic food industry exploits this mythology to imply that organic food is inherently better.

In addition, marketing professionals exploit the lack of understanding about risk. We routinely panic about insignificant health risks (high tension wires, X-rays) and routinely ignore large health risks (driving without a seatbelt, tanning). Hence, consumers routinely obsess about insignificant health risks that have never even been shown to occur (pesticides, hormones) and routinely ignored large health risks (foodborne illness caused by bacteria like E. coli and salmonella in the animal waste used as fertilizer) that have been associated with widespread outbreaks of illness and even death.

David Ropeik discusses the causes of misperception of risk in his article The Consequences of Fear. Two factors, control and origin, are especially relevant for understanding the misperception of food risks.

Risks over which we feel as though we exercise control are routinely perceived to be smaller than risks that are imposed from outside.

… Roughly 20% of Americans still do not wear safety belts in motor vehicles… [T]his is, in part, because we have a sense of control when we are behind the wheel, and the risk of crashing is both familiar and chronic—factors that make risks seem less threatening…

In other words, people not only tolerate the substantial risk of not wearing a seatbelt, but they perceive the risk to be relatively small, when, in fact, it is relatively large compared to risks that evoke more fear, like the risk of a plane crash or a terrorist attack. Similarly, consumers of organic food tolerate the real and substantial risk of illness from pathogens in manure, but fear the effects of pesticides, which have never been shown to cause illness.

Origin is important to consumers, too. The risks of technology are widely perceived to be greater than risks from nature, neatly dovetailing with the culture mythology surrounding “nature.” For example:

…many people fail to protect themselves adequately from the sun, in part because the sun is natural … However, solar radiation is widely believed to be the leading cause of melanoma, which will kill an estimated 7,910 Americans this year.

Hence the imagined and undocumented (and possibly non-existent) risk of pesticides in food are perceived as greater than the real and documented risks of serious illness and death associated with the bacteria found in manure fertilizer.

Ultimately, these myths are joined in service of the over-arching myth, that of the “enobled and empowered” consumer:

… [A]ll the significance attached by [marketing professionals] to the products transforms otherwise powerless consumers into the powerful marketplace players. As a result, newly empowered consumers can temporarily escape imposed world conditions by shaping their personal myths and servicing their individual lives. Thus, myths of the past are meaningfully used to serve the present.

Marketers of organic food are not allowed to claim that the food is safer or more nutritious, since it is neither. However consumers are led to believe that by choosing “natural” food grown with “no pesticides,” they are making an “empowered” choice of safer and healthier food. In that way, they can be induced to pay more for food that may actually be worth less.

Consider:

A young rural father was recently arrested and charged with felony child endangerment for smoking in the presence of his infant son. Police called to the home to investigate a domestic disturbance observed the father smoking cigarettes although a 6 week old infant was present in the same room.

Officers responding to the home reported that the smoking was a chronic problem. One noted that the home positively “reeked” of stale smoke indicating an long term, ongoing habit.

Parental smoking is known to increase risk of infant wheezing, respiratory disease and even death. As the police chief pointed out, “increasing the risk of infant death is clear evidence of felony child neglect. Our officers had no choice but arrest the father and file charges.”

If convicted, the father faces up to 5 years in prison.

This incident never happened, but it ought to happen all the time if the case of Stacey Anvarinia, the woman arrested for breastfeeding while drunk, is a precedent. I was quoted in a recent Associated Press article about this case, expressing outrage that a young woman was arrested for a made-up crime. The reaction to my comments indicate that many people feel that Ms. Anvarinia got what she deserved.

Why then would the same people would probably recoil in horror at the idea of arresting men who smoke in the presence of their infants? Fundamentally, it is the result of the American inability to understand relative risk.

Most Americans unthinkingly accept all sorts of risks that are familiar, while simultanously expressing outsize alarm at risks that are trivial in comparison. We like to pretend that we would never expose our infants to risk, but simply putting them into a car to drive to the store represents a risk far larger than the risk posed by breastfeeding while drunk (which is merely theoretical) or the risk of smoking in the presence of an infant (which is an all too real risk of illness and death).

Simply put, some risks, though large, are judged to be acceptable, while others, trivially small or non-existant, excite outrage. Those who throwing proverbial stones at Ms. Anvarinia for breastfeeding while drunk are living in glass houses. Many routinely expose their own infants to the far greater risk of travelling in a car.

Unfortunately, there’s an element of discrimination, too. The risk that smoking poses to an infant is far greater than any theoretical risk of breastfeeding while drunk. Yet I suspect that people would react with outrage at the idea of a smoker being arrested for smoking in the presence of his or her infant. Smoking is socially acceptable, while breastfeeding, for all its known benefits, is still considered slightly strange and suspect.

We need to be honest with ourselves about our own prejudices. When it comes to children and risk, we cannot pretend that we are unwilling to accept risk, because the reality is that we consider some risks, even large risks, acceptable. Moreover, we treat some risks as acceptable because they are socially acceptable. Smoking in the presence of an infant is more dangerous than breastfeeding while drunk. Unless we are willing to arrest and charge parents who smoke in the presence of their infants, we should stop self-righteously condemning Ms. Anvarinia.

I’ll be traveling intermittently for another week, and will occasionally repeat an old column. This article originally appeared on my Open Salon blog in March 2009.

Sometimes an event is so ineffably sad that it almost defies comprehension. That was how I felt after a phone call on a bright Saturday morning in my last year of medical training.

As a chief-resident in obstetrics and gynecology, I was responsible for handling phone calls from patients who did not have a gynecologist of their own. On that Saturday morning, I took a call from a local women who was in her early 20’s. She sounded distraught, and at first, I couldn’t understand why she was calling.

“It’s about my 5 year old daughter,” she said. “I’m having a disagreement with her doctor and I want you to talk to him.”

“Okay,” I replied warily, “but I’m a gynecologist, so I’m not sure I could be very helpful.”

“No, no, you’re the right kind of doctor,” she insisted. “It’s a female problem.”

The mother proceeded to describe her daughter’s symptoms, vaginal itching and a greenish, malodorous discharge. The little girl’s pediatrician had examined her and gently taken a sample of discharge to look at under the microscope. When he returned to talk with the mother, he was very grim.

The microscopic evaluation of the discharge had reveal that the little girl was suffering from gonorrhea. It would not be difficult to treat; a simple shot of antibiotics should do the trick, but it could not end there. The pediatrician enquired if the mother knew where her daughter had contracted gonorrhea. It could only have come from sexual contact, which meant that someone had been sexually abusing the child.

The mother was aghast. She insisted that there was some mistake. There was no way her daughter could have been abused by anyone. The doctor disagreed.

The pediatrician informed her that, under the law, he had no choice but to file a “51A” The mother understood that a 51A was a legal document alleging child abuse. It would set in train an investigation by child protection officials, and might result in her child being removed from her custody. The mother protested, but the doctor was adamant.

Now she wanted to know if it were possible that her daughter’s vaginal infection was something other than gonorrhea. I explained that seeing the bacteria under the microscope was quite reliable, but, in any case, the doctor had taken a culture. That meant that the laboratory would also identify the bacteria. The culture results would be virtually 100% accurate, and, I cautioned her, would almost certainly confirm the diagnosis of gonorrhea.

“Well, even if she has gonorrhea,” inquired the mother, “couldn’t she have picked it up from a towel or a toilet seat?”

I explained that that was highly unlikely. The gonorrhea bacteria could not survive outside the body for very long. Neither towels nor toilet seats were likely to be the source of gonorrhea.

Suddenly, her voice brightened.

“I know, I know,” she said, “My little girl got it from me!”

“From you?” I didn’t understand.

“Yes, from me,” she replied. I had gonorrhea a few weeks ago. My daughter and me, we take baths together all the time. That’s how she must have gotten it.”

She was quite relieved. “I knew it,” she declared. “No one has been messing around with her. She caught it from me.”

I wasn’t so sure.

“You had gonorrhea?” I asked with trepidation. “How did you catch gonorrhea?”

I knew what was coming.

“Oh, I caught it from my boyfriend. He had it and he gave it to me. We both got antibiotic shots and now it’s gone.”

My heart sank.

“No, Ma’am, your daughter didn’t get gonorrhea from you.”

“She didn’t? Of course she did,” the mother protested. “Who else could have given it to her?”

I tried to be gentle, but how can you gently tell someone that her boyfriend has been sexually abusing her daughter?

The mother burst into tears. “That means the doctor is right, doesn’t it?”

“Yes, he is probably right.”

The mother continued sobbing. “I’m sorry,” she said. “I’m so sorry I bothered you. I just thought that there had to be some other way.”

I assured her that it had been no bother, though I had been shaken to the core.

“I’ve got to go now,” she wept. “I can’t talk anymore. I don’t understand. I just don’t understand. What am I going to do now?”

More than 10,000 American women each year choose planned homebirth with a homebirth midwife in the mistaken belief that it is a safe choice. In fact, homebirth with a homebirth midwife is the most dangerous form of planned birth in the US.

In 2003 the US standard birth certificate form was revised to include place of birth and attendant at birth. In both the 2003 and 2004 Linked Birth Infant Death Statistics, mention was made of this data, but it was not included in the reports. Now the CDC has made the entire dataset available for review and the statistics for homebirth are quite remarkable. Homebirth increases the risk of neonatal death to double or triple the neonatal death rate at hospital birth.

As this chart shows, the neonatal mortality rate for DEM (direct entry midwife, another name for homebirth midwife) assisted homebirth is almost double the neonatal mortality rate for hospital birth with an MD. This is all the more remarkable when you consider that the hospital group contains women of all risk levels, with all possible pregnancy complications, and all pre-existing medical conditions. An even better comparison would be with the neonatal mortality rates for CNM assisted hospital birth. The risk profile of CNM hospital patients is slightly higher than that of DEM patients, but CNMs do not care for high risk patients. Compared to CNM assisted hospital birth, DEM assisted homebirth has TRIPLE the neonatal mortality rate.

The chart shows the data for 2003-2004, but the data for 2005 has recently become available. Homebirth death continues to be far higher than death in the hospital for comparable risk women. In 2005 the neonatal death rates were CNM in hospital 0.51/1000, MD in hospital 0.63/1000 and DEM attended homebirth 1.4/1000.

No wonder the Midwives Alliance of North American (MANA), the trade union for homebirth midwives, is suppressing their safety statistics. From 2001-2008, they have collected the single largest repository of data on homebirth. The data is publicly available, but only to those who can prove they will use them for the “advancement” of midwifey, and even then, a legal non-disclosure agreement must be signed as part of the process. MANA’s data almost certainly show that homebirth with a DEM has triple the neonatal mortality rate of hospital birth for comparable risk women in the same year.

What is also notable is that the results are consistent with all existing scientific studies, including the Johnson and Daviss study. Johnson and Daviss actually showed that homebirth with a CPM has a neonatal mortality rate almost triple that of hospital birth for low risk women. The latest statistics are the most recent and most reliable confirmation of that fact.

There really is no question about it. Homebirth with a homebirth midwife dramatically increases the risk of neonatal death.

I’ll be traveling intermittently over the next two weeks, and will occasionally repeat an old column. This article originally appeared on my Open Salon blog in November 2008.

Waiting in the drugstore recently, I was startled by a glimpse of the cover of Cosmopolitan Magazine. No, it was not the display of copious cleavage, nor the breathless tone of the article titles. It was the title of one article in particular: Your Orgasm Face; What He’s Thinking When He Sees It.

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. Men get laid, get action, get lucky and women get pregnant, get sexually transmitted diseases, get infertile, get cervical cancer.

And all in exchange for what? Young men are almost always sexually satisfied by their relationships. Young women? Not so much … because young men are often inexperienced lovers more concerned about their own enjoyment than anything else.

The idea that women exist solely for the sexual satisfaction of men is the basis of pornography. What is surprising and depressing is that young women are being encouraged by other women to believe that they exist only for the sexual satisfaction of young men.

Pornography is the objectification of women, generally described as:

Portraying women as physical objects that can be looked at and acted upon, and failing to portray women as subjective beings with thoughts, histories, and emotions. To objectify someone, then, is to reduce someone exclusively to the level of object.

In pornography, the objectification of women is sexual. Women are physical objects that can be looked at and acted upon sexually. They have no thoughts, feelings or needs of their own.

That does not, in itself, mean that pornography is bad. As long as the viewer understands that it is fictional and unrealistic, it can be viewed as nothing more than a sexual outlet. The problem occurs when people begin to believe that it is a realistic depiction of women, and that women do exist only to satisfy the sexual needs of men and have no sexual needs of their own.

The relentless use of sexual imagery to sell products and gain attention can be blamed for giving young women the idea that their role in life is to satisfy the sexual needs of men. It is an unfortunate, and unintended consequence of sexualizing large swaths of contemporary culture. Altogether more disturbing, because it is intended and explicit, is the way that women’s magazines have encouraged women themselves to believe that their chief value is as objects for the sexual gratification of men.

There are many offenders, but Cosmopolitan Magazine tops the list, for its sheer variety and lack of subtlety, if nothing else. The cover of this month’s Cosmo includes articles on Total Body Sex, the Naked Quiz and The Trick that Attracts Hot Guys Like Crazy. But even Cosmo has reached a new low with the featured article Your Orgasm Face; What He’s Thinking When He Sees It.

As if the objectification of women in men’s magazines were not bad enough, encouraging men to believe that women exist only for their sexual pleasure, women’s magazines are emphasizing the point: Not only are your sexual needs and desires irrelevant, ladies, but you will be judged if you dare to express them. What matters about your sexual needs is not their fulfillment, just the effect that your fulfillment has on men’s enjoyment.

Cosmo reminds women that not only are they being judged for sexual attractiveness (evidently the only characteristic of concern) by breast size, weight and facial features, now 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. That’s not where it ends, though. He’s still entitled to judge your performance during sex and finding you lacking.

I don’t get it. Why do we tell young women that they are free to be soccer stars or astronauts, and then barrage them with signals that the only thing that really matters is sex? This relentless “pornification” of women violates everything we claim to believe about gender equality.

What does he think about your orgasm face? Why should any woman care? Only someone who believes that she exists for the sexual satisfaction of men would consider the question to have any relevance at all.

I recently read that the prestigious surgery training program at Massachusetts General Hospital is in danger or losing its accreditation. It’s not because it has failed to properly train surgeons, or because of mistakes. The program may lose its accreditation because the trainees, also known as interns and residents, have worked more than the maximum of 80 hours per week. The hospital seems to have clearly violated the rule, but I find myself strangely ambivalent about both the rule and the punishment.

My ambivalence is rather surprising because I suffered under a program that had no limits on hours. As an OB-GYN in training, I spent five months on the surgical service during my internship year. I routinely worked about 105 hours per week, and I was awake for all 105 of those hours. The schedule required each intern to be on call every 3rd night. Therefore, the schedule was arrive at the hospital at 5 AM on the first day, work all day, then through the night on call, meet the rest of the team at 5 AM the next morning and work another full day until 7 PM (38 hours straight). The I would go home to sleep and return at 5 AM the next day and work until about 7 PM (14 hours). The 3rd day was another 14 hour day, and then the cycle would start again.

You don’t know what tired is until you have repeatedly worked shifts of 38 hours. Surprisingly, the long hours results in very few, if any, mistakes, but it turned idealistic medical students into jaded, impatient doctors. And it resulted in some very bizarre episodes. On more than one occasion I fell asleep standing up while holding retractors during surgery. It didn’t matter that much since my job was simply to stand there, but it did result in me getting chastised. One night while checking lab results on the computer, I fell asleep on the keyboard and woke with the imprint of the keys on the side of my face.

My most notable transgression while sleep deprived, though, was when I began hallucinating during surgery when I was one of the surgeons. It was a relatively minor case, and my role was simply to assist, but I kept forgetting where I was and talking to people who were not there. This resulted in gales of laughter from everyone else in the operating room. When the case was finished I was allowed to go home early (5 PM) since I clearly could not be trusted to care for patients.

The system was brutal in the extreme … and yet. And yet it taught me to be a doctor, to take complete responsibility for someone else’s life, and to never give up, no matter how long it took, until the best possible result was achieved. It was drilled into me that the patient came first; my comfort: my hunger, my tiredness was meaningless. All that counted was what the patient needed.

Looking back, I still think that 105 hours per week was too many, but I am honestly not sure if 80 hours a week is enough. At 80 hours per week, the interns and residents are essentially doing shift work, going off regardless of whether the patient is doing well or poorly. It also allows interns and residents to kick the can down the road, to slough of what should be done for the patient today, figuring that the next person can do it tonight. Finally, it is not clear that 80 hours per week allows enough exposure to different patients, different surgeries and differing ways that patients manifest illness and get well.

The surgery program at Massachusetts General Hospital has violated the rules, and if the rules mean anything, the hospital must be reprimanded and possibly punished. The real question, though, is whether 80 hours work weeks lead to better doctors and better patient care, or simply fewer hours.