Tuesday, July 15, 2008

A Woman's Right to Choose: Beyond the Abortion Controversy

I have decided to post my paper, which attacks (based on philosophical & ethical grounds) the practice of requiring gynecological prodding in exchange for hormonal birth control. I've been hesitant, since I did turn the paper in for a class, but as I don't plan to adapt the paper for any future classes at this point, I don't mind posting it. Just for records' sake, though, in case professors look online, I turned in this paper for my Medical Ethics course in March 2008, and an adapted version for Advanced Composition in June 2008.

I was prompted to go ahead and post my essay after reading a very helpful post by another woman on her blog. Please visit http://crackerscentral.com/wordpress/?p=57 to read.

“A Woman's Right to Choose"

Beyond the Abortion Controversy

“Our body is a machine for living. It is organized for that, it is its nature. Let life go on in it unhindered and

let it defend itself, it will do more than if you paralyze it by encumbering it with remedies.”

(Leo Tolstoy, War and Peace)

Amid the fight for property, suffrage, and abortion, the right to medical options for women has somehow managed to escape the eyes of society. As a result, women remain almost powerless to determine the best method of gynecological care for them. Restrictions placed on oral contraceptives, widespread insistence on annual invasive examinations, and the enthusiastic following for the new HPV vaccine are socially accepted norms to which physicians rigidly adhere. Although research exists to maintain these standards for certain health reasons, equally strong evidence supports the bending or elimination of these stringent practices in favor of the patient's physical and mental wellbeing.

Most medical professionals recommend that women have an annual pelvic exam for one prevailing reason: The early detection of the human papillomavirus (HPV) and cervical cancer. Prior to the 1950's when the pap test became a regular tool for detecting cancerous and pre-cancerous cells, cervical cancer was the number one cancer-caused death in women. Some studies have shown that use of the test has reduced deaths from the disease by 70% 2. Other reasons include the detection of ovarian, endometrial, and breast cancers, sexual education, and the evaluation of irregular symptoms such as debilitating menstrual cramps, excessive bleeding, and missed periods. Women, according to gynecologists, should begin these annual exams soon after becoming sexually active, but no later than age 21 1.
Research also cites a correlation between long-term hormonal contraceptive use and HPV, with an increased risk of cervical cancer 3. Doctors frequently deny contraceptive prescriptions to patients without a pelvic exam, referencing this medical mantra, as being for the "good of the patient."
However, ethicists are not so willing to accept this hardwired view of "good." Edmund D. Pellegrino, in his book The Internal Morality of Medicine, suggests four individual components to the patient's own good: the medical good, the patient's perception of the good, the good to humans, and the spiritual good. Not surprisingly, the component most frequently found in medical practice is "the medical good," focusing on what will keep the patient most physically healthy. However, Pellegrino writes, "What is medically 'good' simply on grounds of physiological effectiveness may not be 'good', if it violates higher levels of good, like the patient's good as he perceives that good" 4. Physicians must be "concerned with the patient's personal preferences, choices, and values…the balance he strikes between the benefit and burdens of the proposed intervention" 4. For some women, the burdens of mainstream gynecological examinations may include emotional distress, feelings of invasion, and betrayal of religious commitment. In many cases, the benefit of early cancer detection, for which most are not at risk, does not outweigh the harm done on a personal level.
Emergency contraception, which contains the highest doses of the hormones in birth control 5, is not regulated nearly as severely as daily-dose contraception. In fact, adults can acquire the morning after pill as easily as they would Tylenol, simply by driving to a pharmacy and requesting it. Minors in some states require a prescription (given over the phone) or a parent's help to get the pills 5. In Canada, Plan B has been lowered from "prescription only" to "Schedule II (behind the counter)" status, resulting in a greater in-store supply in many pharmacies" 6.
Plan B, effective if taken up to five days after intercourse, can cause the disintegration of a developing embryo. Regardless of the morality of abortion, this is definitely more potent and potentially damaging than low-dose hormonal contraceptives.
Yet, "the American Medical Association and the Society for Adolescent Medicine…recently recommended that physicians provide their patients with emergency contraception before they need it" 5. Advocates for Youth shouts, "Don't wait...go out and get emergency contraception before you need it!" 5. Why isn't this encouragement and ease of access afforded to women who responsibly plan in advance?
Proponents of annual pelvic exams quote statistics of increased cervical cancer rates in users of birth control. Taken appropriately and in the lowest effective dose, however, oral contraceptives can actually improve a woman's health. Well-known benefits include the decrease in menstrual cramps and protection against anemia, ovarian cysts and symptoms of PMS 9. Hormonal contraceptives have also been shown to reduce the risk of endometrial and ovarian cancers by up to 80 percent, especially when taken for an extended period, regardless of the dosage 8.
Cervical cancer, which many experts believe to increase in likelihood with the introduction of contraception, actually may reduce some risk as well. For young women, “evidence of significantly lower incidence of HPV infections in oral contraceptive users than in non-users has been reported” 3. As a long-term benefit, “regularization of menstrual pattern with hormonal contraceptive use could improve mucosal immunity, and, therefore, immunity to HPV infection, and lower the risk of cervical cancer in later life” 3.
In reality, cervical cancer is caused by a few specific factors, which many women do not have. According to the World Book Encyclopedia, the main causes include HPV, smoking or inhaling second-hand smoke, sex as a young teenager, and having sex with multiple partners or a man who has had many partners 7. HIV is also serious indication 2.
Still, the leading cause remains the human papillomavirus. HPV is less harmful than medical professionals readily explain, with 80 percent of people contracting the virus at some point during life. The majority of these cases disappear on their own, often without the carrier ever knowing they are infected. As the Women in Government organization stresses, “An HPV infection rarely leads to cervical cancer. In most women…the body’s immune system destroys the HPV infection” 2.
Professionals stress the cancer’s deadliness due to its lack of symptoms. However, some early symptoms actually exist, among them unusual vaginal discharge, spotting, and pain during intercourse. Even these symptoms do not guarantee the disease, but merely suggest further testing, such as a pelvic exam 2. HPV, though feared greatly as a result of the newly-popular “Will you be one less?” campaign for the innovative vaccine, is more benign than society knows.
In addition to the pap test, new methods of screening for cervical cancer are available, which have been shown to give results more accurately and quickly than the traditional technique. Using the same pelvic exam, a liquid-based pap test can be more accurate, and therefore administered biannually, because the cells are removed from other fluids for close examination. Though not recommended for all ages, an HPV test can be used simultaneously with a pap test for more accurate results 2.
An article in the Journal of the American Medical Association provides shocking news for women hoping to avoid a traditional pelvic exam. Testing of a self-collected test has shown it to be “less specific than but as sensitive as Papanicolaou smears for detecting high-grade cervical disease” 12. The rates of false positives are higher in the self-collected tests, which one could argue makes the test less helpful. However, the more sensitive the test, the greater a tool it can be for detecting a problem and suggesting further, more traditional, testing. To clear up any doubt, the new test was cross-checked for accuracy with four other cervical cancer screening tests, including the pap test 11. “The availability of a noncytologic screening method not requiring a vaginal speculum examination,” suggests Dr. Thomas Wright and his fellow authors, “may reduce underscreening” 12.
The self-collected test also appears to take less time to produce results, often available within two to six days of the sample. Alternatively, pap test results were not given to patients for about eight weeks. “A patient’s aversion to undergoing pelvic examinations may be difficult to overcome. Testing for HPV DNA by self-collected vaginal swabs at the time a woman provides a routine urine sample would eliminate the need for a speculum examination and would convert cervical cancer screening to a simple laboratory test” 12. Doctors, for whatever reason, do not eagerly disclose these alternatives to their patients, providing cause for concern among patients that they are not being shown all of their options.
As a result, some agencies will delay the requirement for an exam for up to a year after contraception is started. Planned Parenthood, through a program called HOPE (Hormonal Options without Pelvic Exam), allows young women to start on any method of birth control after a medical history questionnaire and a blood pressure check. Though they recommend annual exams, this stereotyped organization actually recognizes the uneasiness experienced by women faced with such a procedure. However, Planned Parenthood will supply only one year’s worth of contraceptives through this program, eventually forcing women into the same standard of protocol to which most doctors subscribe 10. Instead, this organization and others ought to recognize the long-term need for their temporary options. If a young woman can start taking a hormone without a diagnostic test to use as the control, there is no reason to insist upon the test if symptoms do not develop.
In the United States today, women have access to emergency contraception as frequently as they need it, they can obtain abortions with little or no counseling, and they can have long-lasting cosmetic surgery without second opinions. Doctors recommend that smokers quit and that heart disease patients diet and exercise, but they can not force their patients to follow their suggested regimens. Instead, they advise, and then work with the individual patient to develop a treatment or prevention plan that fits his or her personal needs. Gynecologists, to fulfill their calling to work for the patient’s good, need to focus on these individual needs more acutely than the ever-prevalent current standard.
Just as extensive cardiovascular tests are not widely recommended for young, active men with no family history of heart disease, we find no pressing need for women without risk factors for gynecological maladies to have tests for such. There is no reason to require a pap test unless the patient has disclosed something to warrant such a procedure.
In fact, a patient's lifestyle may even do the opposite. Married women with no previous sexual partners and a clear family history may be harmed more than helped. "This anxiety may be greater than the fear of pregnancy, and women might…prefer to switch…to condoms" 3. This, however, severely limits a woman's options, when there is no critical medical reason to do so. Consider the abortion issue. Few today would suggest limiting a woman's options to adoption in an unwanted pregnancy. Though it can be argued that nine months of pregnancy and birth are more "inconvenient" than the potential discomfort of a condom, we should remember that the first may involve an individual's promiscuity, while the second may have the effect of punishment for harmless personal preference.
Other groups with deep-seated belief factors are happily accommodated, and rightly so, by the medical community. Some Jehovah's Witnesses will not submit to a blood transfusion for reasons of faith. These people carry cards marked "No Blood Transfusion!" with them, quoting the book of Leviticus. Though the Watchtower Blood Policy changed in 2006, many members of this faith still will not receive blood transfusions 13. However, an injured Jehovah's Witness would be helped in any alternative way possible, with reverence for his personal choices. Women who object to invasive exams for similar reasons should be provided the same courtesy and respect.
Physicians have the right to refuse to provide treatment methods to which they have ethical objections, including denial of prescriptions to women who do not submit to tests. However, perhaps the growing fears associated with passing up routine exams in favor of personal choice would not be so prevalent if knowledge of opposing evidence was more common. Women have come so far in their quest for rights and autonomy, from the right to vote to the "pro-choice" movement. We have these rights, ethical or not, but in striving for them, we have overlooked other fundamental choices to which women should have access. Raising awareness, and fighting for these forgotten freedoms, will bring us one step closer to the indubitable right to choose.

Works Cited

1 “Your First Pelvic Exam: A Guide for Teens.” First Pelvic Exam. 2007. Young Women’s Health. 15 Feb. 2008 .

2 Women in Government. “Frequently Asked Questions About Cervical Cancer & Human Papillomavirus (HPV).” Challenge to Eliminate Cervical Cancer. 17 Feb. 2008 <http://www.womeningovernment.org/prevention/documents/03CervicalCancerHPV.CCFAQ1-26-07.pdf>.

3 Brabin, Loretta and Fiona Barr. “Oral contraceptives and cervical cancer.” The Lancet. 360 (2000): 409-410.

4 Pellegrino, Edmund D. The Internal Morality of Medicine. Pages 569-570.

5 “How to Get Emergency Contraception.” Advocates for Youth. 2008. Advocates for Youth. 18 Feb. 2008 .

6 Dunn, Sheila et al. “Availability of emergency contraception after its deregulation from prescription-only status: a survey of Ontario pharmacies.” Canadian Medical Association. (February 12, 2008): 423-424.

7 “Cervical Cancer.” World Book Encyclopedia. World Book, Inc. Volume 2. Chicago, 2003.

8 “Lowest-Dose Birth Control Pills Provide the Greatest Ovarian Cancer Protection.” International Family Planning Perspectives. 33.2 (June 2007): 89-90.

9 “Birth Control Pills.” Planned Parenthood. 2008. Planned Parenthood. 10 Feb. 2008 .

10 “HOPE: Pills Without an Exam.” Planned Parenthood of the Mid-Hudson Valley, Inc. 2008. Planned Parenthood. 10 Feb. 2008 .

11 “Science Blog.” Columbia University College of Physicians and Surgeons. 2000. Science Blog. 17 Feb. 2008 .

12 Wright, Thomas C. et al. “HPV DNA Testing of Self-collected Vaginal Samples Compared With Cytologic Screening to Detect Cervical Cancer.” The Journal of American Medical Association. 283.1 (January 5, 2000): 81-86.

13 “Watchtower Blood Policy.” 2008. AJWRB. 17 Feb. 2008

The views and information represented above are intended for personal use only.

Any other use of the material must be cited completely.

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Anonymous Deborah said...

Fabulous essay!
I first heard about these exams from my US colleagues.
Absolute horror stories...stirrups, bimanual and rectal exams, annual smears, breast exams, paper gowns or sheet of paper, student clinic's that ignored their requests for a female Dr and/or no medical students...
I was horrified beyond belief.
I was also, amazed to hear that medical barriers prevented access to reliable contraception.
These annual nightmare sessions start from teens and include virgins!

ALL cancer screening has risks as well as benefits...only one person can say whether the risks of the testing is worthwhile...YOU...and that is why doctors MUST obtain your informed consent before performing a smear or mammogram.

Pelvic exams and routine gyn exams are not recommended in any other country in the world (apart from Germany, as far as I'm aware)
The medical thinking in other countries is that these gyn exams are unnecessary in asymptomatic women and in fact, can be harmful. (by leading to even more invasive and possibly harmful testing, psychological issues etc)
The pelvic exam is of low clinical value in the absence of symptoms.

Cervical cancer is uncommon and the smear is unreliable, producing lots of false positives and false negatives. The numbers of women actually helped by smears is surprisingly low AND thousands are harmed by false positives and over-treatment.

Andrew Rouse, Snr Lecturer in Public Health at Birmingham University produced some amazing figures that show women "saved" by screening. You'll find them if you google his name - they were published in a letter to the British Medical Journal. (very low figures)
Dr Angela Raffle, UK cervical cancer screening expert puts the risk of this cancer in perspective...1000 women need regular screening for 35 years to save ONE woman from cervical cancer. Her research is available on line.
To be continued...up to word limit

Thu Aug 27, 10:09:00 AM  
Anonymous Me again! said...

My reading suggests screening before age 30 is likely to lead to biopsies for false positives...one in every 13 smears in the under 25 age group will lead to biopsies. Cancer in this age group is rare.
Virgins are not screened in any other country in the world...just the States. (I have no idea how that can be justified!)
Frequency is important as well...annual and biannual smears lead to lots of false positives and colposcopy.
Annual - a whopping 95% of women will face colposcopy (and usually biopsies) in her lifetime with only a very small number having any sign of malignancy.
Biannual - almost 78% (Australia)
Three yearly - 65% (UK)
The lowest rates of cervical cancer, colposcopy/biopsies and false positives is in Finland.
They offer screening from age 30 and then 5 yearly to age 60. (some stop earlier...50 or 55)

As a very low risk woman, I have always declined smears.
The risks for me far exceed the benefits.
Mammograms also carry risk...
Mammograms before age 50 carry a high risk of biopsies.
The risks at any age include unnecessary biopsies, surgery and other treatment, the dilemma of ductal carcinoma in situ and new research that suggests regular mammograms may increase the risk of cancer...perhaps, the radiation exposure and/or the squashing of breast tissue.
Clinical breast exams are not recommended before your 40's as they often lead to biopsies...and cancer in this age group is uncommon.
Womanhood is not a disease.
I should add that cervical biopsies can cause long term health problems as well...apart from pain, bleeding etc caused by this unpleasant procedure...there is also the risk of infertility, problems during pregnancy & pre-term delivery.
See RMDeMay, "Should we abandon pap smear testing", American Jnl of Cl Pathology, 2000
Angela E Raffle, "Cervical Screening" BMJ 2004, 328:1272-1273
Mammograms...read anything by Professor Michael Baum
We have issues in this country as well...in the UK and Australia, doctors are paid to reach high screening targets that has resulted in some very unethical behaviour. The need for informed consent has been largely ignored by doctors. The General Medical Council (UK)has taken action to halt the unethical conduct of some doctors.
I think the situation in the States is far worse though...only ONE woman needs to go to Court and obtain an Order or Declaration that could change the system straight away. These requirements cannot be justified medically, ethically or legally.
Requiring these exams and test before prescribing birth control amounts to coercion and negates any consent and ignores the need to obtain your informed consent.
I hope you can change a very bad and abusive system.
Good luck to you....

Thu Aug 27, 10:11:00 AM  
Anonymous Samantha said...

The other fact that should be remembered..
The American College of ObGyn's, the World Health Org and the US Food & Drug Admin...ALL say these exams are NOT required for the initiation or continuing use of the Pill.
It seems doctors KNOW these exams are unnecessary and have chosen not to follow these recommendations.
I can only assume this power and control over women keeps waiting rooms full, day procedure lists busy, pathologists rich & all the specialists who deal with the false positives and damage caused by biopsies....gyn's, urologists, high risk pregnancy experts and infertility experts.
What a goldmine!
I also think this is a reflection of the paternalitic practices that still prevail in medicine...that different rules apply to women...we're not entitled to bodily autonomy, privacy and dignity or the right to choose.
We can be manipulated and taken advantage of...
It also has something to do with the fear of being sued...but that doesn't explain it really...
Why wouldn't they be equally concerned about liability flowing from ignoring the need to obtain informed consent and the harm caused to women by the unreliable pap smear?
I guess they feel the risks are greater the other way.
What if they miss that rare case of cancer?
It doesn't matter how many women are harmed in the process.
I think most women have no idea when they walk away from a colposcopy (or another colposcopy!) that the risks of that procedure go through the roof when you're testing virgins, young women and too frequently...they are unaware their doctors assumed risk on their behalf and gambled with their mental and physical well-being.
I also think doctors favour "burning off" so-called "bad cells" so women never know it was a false positive...they prefer them to walk away thinking the test has saved their lives and feed into the circle of fear that dominates our lives.
It seems we're all pre-cancerous until a doctor gives us the annual "all-clear"...
The risk of this cancer is very low...yet that risk is HUGE in our minds because of the vast amount of OVER-treatment.
It was only after I lived in the Netherlands for 4 years that I saw just how damaging our healthcare sytem is to women's health.
Far fewer women are put through colposcopies in that country. They follow the same program as Finland and no woman is pressured to have pap smears.
Of course, there are no routine gyn exams.
NO woman would ever be refused the BCP if she declined testing.
I doubt any other country in the world would try that....yet that still happens in the States every day.
US women are treated by third class citizens...no rights and exploitation, coercion and manipulation is not only acceptable....it's the norm.
I also enjoyed reading your essay...it gives me hope to hear others find this situation disgusting.

Thu Aug 27, 06:22:00 PM  

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