Michael S. Victoroff, M.D.

Michael S. Victoroff, M.D.

Bioethical issues in women's health mostly revolve around reproduction. Who, why, when, where, and how people reproduce have been sources of discussion and sharp disagreement for a few thousand years. Birth occupies a seat — next to death — in the front row of the great bioethics study hall.

Most ethical questions arise from someone's ability to control something. Today this includes sexuality; fertility and infertility; parental control over children; technological control of gestation; birth; newborns; fetuses; gametes; the power to predict characteristics of offspring before birth or even conception; and an ocean of other capabilities novel in mankind's experience. These changes sweep society along in a furious tide, guaranteeing material for 100 future generations (if we still have "generations") of poets, playwrights and, of course, ethicists.

Because many of the niftier aspects of reproduction take place inside women, it's hard to separate moral, cultural, legal, religious, and physiologic aspects of reproduction from other women's issues.

Suppose they weren't separated? What if human reproduction changed so drastically that the automatic association between women and procreation were uncoupled? What philosophical questions would emerge in a world where "woman" and "man" merely described two ordinary features of physiognomy, like "curly" and "straight?"

Nurture or nature?

For one thing, we would have to think more about when to say, "woman and man," as opposed to "female and male." Rich cultural and literary traditions (not always commendable) are attached to "womanly" and "manly." How much of this luggage is packed with genes, and how much with heritage of another sort?

Then, look at the ruckus that effective birth control has caused in the 20th century. Think of the benefits, responsibilities, hazards, advantages, and philosophical quandaries of women who can detach heterosexual intercourse from pregnancy. What are the meaningful differences between families or cultures where childbearing is voluntary, deliberate, and optional, and those where it is involuntary, unpredictable, and inevitable? What does this mean for men, apart from its meaning for women?

Now, imagine completely severing the cord that ties women (literally) to reproduction. Extracorporeal gestation. ("Honey, could you stop off at the nursery after work and see if the new baby is done yet?") Many ethical problems revolve around our dependence on a human incubator. How long does a fetus need one now? Is it 22 weeks? 26? 32? It depends on how fussy you are about the outcome. Long-term data on the karma of neonatal intensive care unit alumni don't resolve the question.

This uncertainty will be traded for others once we perfect even the most rudimentary artificial uterus. The promise this will offer the desperate — and the freedom it may offer the well-to-do — will overwhelm qualms about its appropriateness.

The proof of this is the current infertility industry, of which the "robowomb" is merely a logical extension. You might as well tell dogs not to bark as tell a society not to adopt a device that gives more control over its children. (The same goes for implantable behavior-control remote guidance command centers, too, when those come along. "Harry, can you hand me the remote? Little Filbert is acting up again.")

Technology's mantra is, "Better, cheaper, faster." How wonderful to apply these principles to family life! However, I'm not sure I clearly see how they improve my relationships with parents, spouse, children. (Well, cheaper might be OK.)

Users and use-nots

Technology tugs irresistibly on those who can afford it, widening a profound rift in every culture between "users" and "use-nots." This makes nonusers controls in a great clinical trial. When is it morally imperative to apply our powers over nature? ("Is it mandatory to resuscitate every newborn?" "Is it permissible to decline an emergency C-section?") When is technology optional? ("We are able to offer you in-vitro fertilization using recombinant platypus ova...") When is it potentially harmful? ("Testing shows you to be 0.0281 percent African/Jewish/Irish/Labrador Retriever...")

Consider the harrowing experiences of parents facing critical decisions about ill newborns. The destinies of those babies exemplify both miracles and tragedies.

For some, choices will be easier, heartaches fewer, as the range of treatments broadens. For others, the opposite. ("We are now able to offer full-organ replacement, psychological testing, body tattooing — to your two-week-old fetus...")

Some decisions leap upon us with no time for thought. Early detection is a great benefit of diagnostic technology, yet it can be a two-edged scalpel.

One of my more memorable consultations was with a woman whose young husband was just showing signs of Huntington's. They had two sons, 6 and 8 years old. She asked for advice about when they should be told or tested. We were grateful that nothing had to be decided that day.

Some things can't be pondered too long. Others shouldn't be pondered too soon. Meanwhile, cost disparities tend to increase.

Technology widens differences between users and nonusers. Compare a Wall Street day trader and an Amish farmer. Who is more robust, in a Darwinian sense? It depends on what the world will be like after a while.

What can prepare our tender sensibilities for the dramatic expansion of social options that seems already to have surpassed comprehension? Talk to your grandparents.

Finally, there is an embarrassing difficulty that arises when we give attention to these enthralling topics, and ignore the mundane. In women's medical care we have solved many of the basic problems.

We know how to reduce cancer, STDs, heart disease, violence, illiteracy, alcoholism, teen pregnancy, traffic death, and osteoporosis. There are no big conceptual questions about whether any of these is good to do. The real question is "What keeps us from doing them?"

Adaptation to catastrophic moral disorientation is surely a survival trait. As Buddha says, "You think this is, like, new?"

Michael S. Victoroff, M.D., is medical director for Aetna U.S. Healthcare of Colorado. He practiced family medicine for 19 years, and has served on numerous hospital and organizational ethics committees. He also chairs the committee on medical informatics of the Colorado Medical Society. The author's opinions do not necessarily represent opinions or policies of Aetna U.S. Healthcare, its management, or its employees.

Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.