‘Mom, I want to die, you can go in the Canada. I want to die in the snow, you can go, mom, in the Canada.’
Editor

This image is a screencap of a CBC video about refugees who cross into Canada from the US. It shows snow-covered ground, with dry brown winter grasses and train tracks poking through the snow. The text at the bottom of the screen says “Cold Crossing.”

Recent developments in American politics continue to exacerbate the migration on foot of refugees from the US to Canada. The Canadian Broadcasting Corporation has been covering this trend, and we at IJFAB Blog have also been watching. In a new CBC article yesterday, we read the words of a toddler who asked his mother to leave him to die in the snow so that she could go in to Canada. They were part of a group of refugees who walked for two hours from 2am to 4 am -20C weather. How many people are making these kinds of dangerous migrations, even in winter?

Canada Border Services Agency’s most recent numbers show 403 asylum seekers illegally crossed into Manitoba between April 2016 and the end of January 2017, many of them entering near the small border town of Emerson.

They come into Manitoba because nearby Minnesota is home to large immigrant populations from Somalia in particular.  This may be legal, and the refugees who find the U.S. to be inhospitable to their attempts to gain legal status may have rights within Canada based on U.N. agreements.

Cross through a snow-covered farmer’s field on foot in harsh winter conditions — like two Ghanaian refugees did in December, losing most of their fingers to frostbite — and the United Nations’ 1951 Convention Relating to the Status of Refugees kicks in.

In related news also breaking yesterday, the United Kingdom’s Home Office announced it would suspend admissions for child refugees with disabilities on the grounds that their needs for care would overburden the UK’s NHS, whose ability to provide care has suffered under repeated rounds of funding cuts.

IJFAB Blog will keep watching this issue of refugees and health as it develops in various nations.

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“You suffer. That is enough for me.”
Editor

Thanks to Gretchen Case for this image of the Pasteur Memorial at Cook County Hospital in Chicago.  It is a timely reminder as the context for global public health shifts, and many powerful nations (US, UK, France, and other European nations) that have been destinations of immigrants seeking freedom and better conditions begin to react against immigration. Physicians, nurses, and other health professionals across the world are likely to find themselves in the position of having to decide whether to turn away patients who are undocumented immigrants, or who are documented but cannot access the health system of the nation in which they reside. Do you think Pasteur had it right?

A bronze plaque bearing English text is surrounded by an ornate stone plinth. It reads “One doesn’t ask of one who suffers, what is your country and what is your religion? One merely says, you suffer. This is enough for me. You belong to me and I shall help you.” Below the text is the name Louis Pasteur.

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International Efforts to Mitigate the effects of Trump’s Expanded Mexico City Policy
Editor

Just a quick update on Trump’s expanded Mexico City Policy AKA the “global gag rule”, which we previously addressed.  The Netherlands are leading an effort to implement a fund which would replace funding stripped from organizations under the expanded U.S. policy.  The aim is to allow the continued functioning of health organizations that might lose U.S. foreign aid from U.S.A.I.D. because they discuss abortion with patients, provide abortions, or advocate the use of abortion as a solution to any women’s health problems.

On Friday, The Guardian announced  that Canada may be contributing to this Dutch-led fund. The Dutch have already committed US$10 million  to the fund and are hoping to solicit more contributions from other nations. At least 20 countries are expected to contributions if negotiations go as planned.  Canada confirmed they will be increasing their support for global reproductive health whether or not they do so by giving money to the Dutch-led fund.  Said Canadian Minister of International Development Marie-Claude Bibeau:

Yes, we will support the [Dutch] effort… Will it be directly through the fund or indirectly, this is not clear yet. But, I assured my colleague, the Minister from the Netherlands, that we will increase our funding to sexual and reproductive health and rights. This is definitely a very important priority for our government.

Keep your attention on this situation as it develops.

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It’s Only Words: On Refugees and Liminality
Anna Gotlib

I sit in front of my computer in New York, contemplating how I am going to speak to groups of people about refugees, narratives, and moral luck in two days’ time.  It is not that I am overly worried about what I am going to say, what arguments I will use, or what philosophical claims I might make  —  I have been doing this for a while now.  What is tearing at me is how I will do this without internally collapsing, without alienating my audience, without weeping openly and uncontrollably.

I am usually not the kind of person who does this  —  I can (mostly) hold it together, even if the subject matter is rough-going.  So why am I so worried this time?

The obvious answer, right?  Trump and his nightmarish reign, only days-old, has thus far unleashed at least the promise of innumerable horrors to come:  the elimination of the ACA, the gutting of any environmental protection programs, the racism, the LGBTQ hatred, the anti-science, anti-truth, -anti-reality, anti-….The anti-immigrant and refugee policies.  The unabashed, public, seething hatred of those who are here, or who want to come here largely out of desperation, and sometimes without the proper documentation.  This is what my talk is about  —  it is about the consequences of the words that paint the immigrant and the refugee as “other.”  It is about why we must be so careful with these words  —  both in saying them ourselves, and in allowing those in power to wield them, to weaponize them.  It is about how these words create moral and political realities that shape identities, destinies  —  lives  —  of others.

So what does liminality have to do with anything?  Simply, everything:  To be a refugee is, in many ways, to be in a state of non-belonging, non-citizenship….sometimes, non-personhood.  It is, as Hannah Arendt noted, a state of not being recognized, not even having a right to have rights.  And it does a number on one’s sense of self, on one’s confidence, on one’s notions about one’s place in the world, and one’s rights to make claims  —  it is the periphery of the periphery.  To borrow a fitting film title, it is “the howling plains of nowhere.”

I should know.  I am a refugee, albeit a long-ago one, from the Soviet Union.  To make a long story short and for reasons that I will not get into here, my family and I did not leave the U.S.S.R. quite via the usual Soviet emigre route of the 1980s.  For a while, we were homeless in that particular sense of the term where your future state of belonging-to is not clear, but what is clear is the door that has just shut behind you  —  permanently.  My memories of that time  —  of the chaos, the fear, the strangers, the fear, the uncertainty, the fear  — haunt me to this day, driving a lot of the work that I do, the anxieties about belonging anywhere that are too often unrelenting, lurking in the background of my life as an academic, a daughter, a wife, a friend.

But as difficult as my experiences were, they pale in comparison to the Syrians and others currently trying to flee circumstances that are not just unbearable socially, economically, physically, but are an existential threat.  And while they try to save their lives, they are openly, publicly storied as other, as dangerous, as subhuman by those with the largest megaphones, on some of the biggest stages in the world.  Nigel Farage of Brexit fame, Trump, Le Pen, Putin  —  the list goes on.  Add to this the audiences that all-too-eagerly grant uptake to the dehumanization, the othering, of the refugee….you get the idea.  And now, we can see the consequences:  American plans barring people from particular regions of the world, people of particular faiths, and others from entering the United States.  Le Pen’s statements about suspending all immigration to France.  Putin’s well-known pan-Slavic nationalism.  And on and on….

So we have to talk about it.  Publicly and loudly.  Even if our voices sometimes catch.

Editor’s Note: This issue has been so in flux over the last few months, after years of Syrian refugees seeking entry to European and North American nations, that we recently had another blog entry on the subject.  Check out Kate McKay’s “A Door Slams in the Night” for another part of the picture.

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Not Business As Usual: President Trump reinstates Mexico City Policy with a substantive addition
Editor

On January 23, 2017, U.S. President Donald Trump reinstated Reagan’s so-called Mexico City Policy, also known as the “global gag rule.”  In the process, he also added text that makes a substantive change going farther than any U.S. national-level anti-abortion policy has ever gone before. This Editor wishes to point out that this is not simply business as usual.

Here is the full text  of Trump’s Presidential Memorandum, in case it disappears from the White House website or later archives, in both text and a screenshot taken January 26, 2017, with a short analysis afterwards:

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A Door Slams in the Night
Kathryn MacKay

Give me your tired, your poor
Your huddled masses yearning to breathe free,
The wretched refuse of your teeming shore.
Send these, the homeless, tempest-tossed, to me:
I lift my lamp beside the golden door.
– Emma Lazarus

I’m writing this post in Toronto, Canada, in a snowstorm. It’s warmed up enough to snow today, which is a relief. The past week has been cold and clear, sun in the day and stars at night. Starry nights in the winter are the coldest, when it feels like the upper atmosphere is screaming straight down onto the surface of Earth and the stars glint like ice illuminated. It’s on these recent nights that smugglers have slid open truck doors, and pushed people into the dark.

There has been a spate of incidents of refugees from Africa-via-United-States conspicuously arriving in or around Winnipeg and Toronto, which is getting attention for two primary reasons. The first is their horrendous injuries due to frostbite. The second is, well, this just doesn’t usually happen.

Refugees don’t need to be smuggled into Canada – they can arrive at any border and they won’t be turned away. These refugees, too, are coming from the United States, so they could have just stopped at the normal border crossings and entered the country. Why are people paying to be smuggled into Canada from the US? Why are they risking and suffering so many weather-related injuries?

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Bioethics Meets Families in The Netherlands this Summer
Jamie Nelson

EDITOR’S NOTE: IJFAB Blog is pleased to have Jamie L. Nelson, of IJFAB’s editorial team and Michigan State University, join us as a regular contributor. Her work has been linked from the blog previously in this entry on Bathrooms, Binaries, and Bioethics. She is the author of many books and articles in bioethics and has shaped IJFAB from the beginning.  We look forward to Jamie’s further contributions to the blog, as well.

People who are ill very often have other people significantly involved in their lives; health care practice and policy have often turned to such people—typically denominated as “family”—to supply information about a patient’s treatment goals or general values, and to perform a steadily expanding array of ever more exacting caregiving. At the same time, medicine has offered those who want to start or expand their families a bewildering set of interventions, which have arguably not only changed who gets to have families, but what families mean, and what it means to forgo reproducing. All of these ways in which medicine and families interact tend to have different, and more burdensome implications for women than for men.

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Repeal and Replace with….?
Editor

trump-146-pm-1-10-17

This image shows a screenshot of a New York Times BREAKING NEWS announcement. A picture of President-Elect Donald Trump is featured. The text reads: “Breaking News: Donald J. Trump wants Republicans to repeal the Affordable Care Act immediately and replace it “shortly thereafter,” he told the New York Times.” Below the image, a headline for an article link reads “Trump pushes republicans for immediate repeal of obama health law.”

EDIT: 19 minutes after this blog posted, the NY Times released this (screenshot taken 1 hr 14 minutes after blog posted).  Keep it in mind as you read.


For the first time in quite some while, the same political party controls both the Executive branch of U.S. government (the President and the agencies and departments whose heads serve “at the pleasure of the President”) and the entire bicameral Legislative branch (the House and the Senate).  This party is the Republican party, also known as the GOP.  As we approach the inauguration on January 20, 2017, of President-Elect of the United States Donald Trump, the  U.S. Congress is also signaling its intentions.

There are many, but the one that most concerns bioethicists regards the Affordable Care Act of 2010, also known informally as “Obamacare.” This complicated law sought to provide near-universal health care not by using a single payer model, but rather by requiring every American to have health insurance either through their employer, through expansions of Medicaid (the U.S. health insurance program for poor people), or by purchasing private health insurance on the open market. For people doing the latter, the ACA provided income-based subsidies so that folks making too much to qualify for medicare but not enough to pay out of pocket for insurance premiums would receive subsidies from the government that would mean their payments would slide from zero at the low end of the scale (with the federal subsidies paying the entire cost of the premium) to 100% at the high end of the income scale (with the insured person being ineligible for subsidies on the basis of their earned income or assets). Anyone not purchasing health insurance, and not falling into exemptions, would be increasingly penalized by the Internal Revenue Service–America’s tax system–every year that they go without health insurance.

As you may know, while Donald Trump campaigned for the presidency, he commonly promised to get rid of Obamacare, referring to it as a terrible law. However, Trump routinely followed this promise in stump speeches and tweets with another: to replace it with something “awesome” that would reduce the cost of health insurance and still preserve popular provisions of the ACA such as not allowing insurance companies to refuse to cover patients with pre-existing conditions, and allowing adult children to stay on their parents’ health insurance until the age of 26.  This came to be known as “repeal and replace.”

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“My death seems to me less bad”: Derek Parfit died January 1, 2017
Editor

Philosopher Derek Parfit was known for many things, though chiefly for his work on identity which is of great interest to medical ethicists. How is that one can say one is the same thing over time?  And how does this bear on notions of harm to persons that might have existed but do not, as such, a topic often raised in discussions of reproductive technologies? What does Alzheimer’s mean for personal identity? And given that we change over time, should our past selves be able to speak for future selves via advance directives? In the event of brain death, are we truly deceased? And can a wrong ever be done to us after we are dead?parfit

The philosophy blog Daily Nous had a nice overview of his work in general, but I want to bring IJFAB Blog readers’ attention in particular to Parfit’s contributions to the bioethical community. For more on how Parfit’s work has been put to use in our field, see the following sources which are by no means exhaustive.

And finally, I leave you with Parfit’s own words when contemplating his inevitable, eventual demise:

My death will break the more direct relations between my present experiences and future experiences, but it will not break various other relations. This is all there is to the fact that there will be no one living who will be me. Now that I have seen this, my death seems to me less bad.

Leave your own reflections, below, in the comments. Links to articles are particularly appreciated, but so are personal reflections on the person or his work.

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Theresa May’s Tory Agenda: All Children Left Behind
Kathryn MacKay

What is happening to our world? Where has our sense of justice and justness gone? It seems like Brexit and The Donald are sounding the death knell of solidarity. They did not cause it; they are, rather, the dead canaries alerting us to seeping poison in the air.

The calamitous election of The Donald (for I shall refer to him in no other way) overshadowed other horrendous and equally calamitous news from November 8, 2016. There was this important report from the World Meteorological Organization on the frightening state of our climate. And there was Theresa May’s introduction of the next stage of the Tory government’s plan to help people receiving income supplements to “do the right thing and move into work.” The ‘help’ on offer is a reduction of housing benefits by £3000 per year in London, and £6000 elsewhere in Britain.

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A Shift in the Anti-Abortion Movement: Are feminist woman-centered values gaining ground?
Editor

In April, the IJFAB Blog editor provided some information on pro-life feminism in an entry called “Pro-Life Feminism: A Catholic feminist philosopher considers the consequences of punishing women for seeking abortions” mentioning both Sidney Callahan’s famous essay on the subject and the recent work of a Catholic philosopher, Rebecca Bratten Weiss. For anyone interested in following this feminist pro-life approach to considering women as whole people in need of support, check out this new article in the National Catholic Register, “Victorious but Wary, Pro-Life Movement Views the Post-Election Landscape: Pro-life leaders say the Republican sweep gives them an opportunity to roll back legal abortion — but others warn the movement risk gains by not investing in their own alternatives to Planned Parenthood.”

Among the anti-abortion tactics familiar to many reproductive rights activists is the rise of Pregnancy Crisis centers. IJFAB Bloggers have addressed anti-abortion tactics in the past including obstetrician Katherine McHugh‘s consideration of, among other things, Missouri’s attempt to publish the names of women who have received abortions, as well as philosopher Alison Reiheld’s reminder that reproductive health clinics aren’t just for abortions.

What strikes this editor as most interesting about the so-called New Pro-Life Movement is that it is concerned by the prospect of removing reproductive choice from women and not replacing it with anything that further empowers women to control their own reproduction, and appears to be genuinely concerned less with reducing access to abortion and more with making abortion unnecessary:

“As a pro-life movement, we need to continue to innovate how we reach out and support women who have unintended pregnancies and are in need of support,” Schleppenbach said, “so no woman ever has to feel that abortion is her only option.”

Other pro-life activists, such as Rebecca Bratten Weiss and Matthew Tyson, founders of the New Pro-Life Movement, believe that the pro-life movement needs to see its work more broadly than ending abortion, becoming more intentional about establishing the dignity of the human person as the bedrock of culture.

“Every aspect of the culture should be supporting life at every moment,” Weiss told the Register. She said the nonpartisan New Pro-life Movement draws its principles from Catholic social teaching on the dignity of the human person.

“Our long-term vision involves providing families with the social safety networks that they need so we truly have a culture that values life, not just laws that say don’t kill,” she said.

Part of their concern is that pro-life leaders speak up to make sure that people do not lose health coverage and that life-affirming measures from the Affordable Care Act, such as prenatal coverage for pregnant women, do not end up on the chopping block along with anti-life measures such as the contraceptive mandate.

“We want to expand what it truly means to be pro-life,” Tyson said.

If this is a genuine commitment to improving women’s lives, it will mark an improvement over the standard pro-life political approach to simply blocking abortion at every turn and in every way possible. In fact, it will more closely mirror the kind of nuanced position on abortion that the Evangelical Lutheran Church in America and some other protestant churches have developed on abortion. The ELCA’s formal position is that women’s welfare is critically important and their aim is to make abortion a “last  resort” to which few women feel the need to resort, but which is available for them nonetheless. Consider the ELCA Social Statement on Abortion, Page 6, IV.B. Ending a Pregnancy (emphasis mine):

This church recognizes that there can be sound reasons for ending a pregnancy through induced abortion. The following provides guidance for those considering such a decision. We recognize that conscientious decisions need to be made in relation to difficult circumstances that vary greatly. What is determined to be a morally responsible decision in one situation may not be in another.  In reflecting ethically on what should be done in the case of an unintended pregnancy, consideration should be given to the status and condition of the life in the womb. We also need to consider the conditions under which the pregnancy occurred and the implications of the pregnancy for the woman’s life.

An abortion is morally responsible in those cases in which continuation of a pregnancy presents a clear threat to the physical life of the woman.

A woman should not be morally obligated to carry the resulting pregnancy to term if the pregnancy occurs when both parties do not participate willingly in sexual intercourse. This is especially true in cases of rape and incest. This can also be the case in some situations in which women are so dominated and oppressed that they have no choice regarding sexual intercourse and little access to contraceptives. Some conceptions occur under dehumanizing conditions that are contrary to God’s purposes.

There are circumstances of extreme fetal abnormality, which will result in severe suffering and very early death of an infant. In such cases, after competent medical consultations, the parent(s) may responsibly choose to terminate the pregnancy. Whether they choose to continue or to end such pregnancies, this church supports the parent(s) with compassion, recognizing the struggle involved in the decision.

Where will  the pro-life movement go from here?  And will its foundational principles be woman-centered? Will they be ones that pro-choice feminists can actually meaningfully engage with?  Is an alliance in favor of women’s reproductive health services possible?  What does a genuine feminist commitment require?

Something is afoot. Something interesting.  Something morally important. It is not for this editor to make a judgment answering the questions above. But it sure will be worthwhile for feminist bioethicists to keep a close eye on the shifting landscape of the abortion debate.

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Midwifery as feminist endeavor: a particular blog entry and a blog recommendation
Editor

Over at Feminist Midwife, the eponymous author writes about the nature of midwifery and why they see it as inherently feminist. In 2014, they also addressed the well-known (by bioethicists) issues with whether informed consent really takes place or whether, realistically, health care providers often constrain and limit autonomy rather than building and supporting it.  The author lists 12 easy ways for any healthcare provider to humanize care.  You can read more about them at “12 Ways to Be A Feminist Healthcare Provider.” I am just listing them here as a quick reference:

  1. Radically listen (hear, focus, don’t judge)
  2. Intrinsically trust (the pregnant woman’s judgment and experience)
  3. Remove assumptions (about food access, partner status, language, sexuality)
  4. Actively consent (it’s an ongoing process)
  5. Recognize power (never push open a woman’s legs in the name of healthcare, etc.)
  6. Practice language (have language prepared in scripts for difficult situations)
  7. Sensitively screen (for high-risk situations)
  8. Enforce #cliteracy (educate providers to not touch the clitoris during digital vaginal exams)
  9. Refer intentionally (find another provider that suits the patient’s individual needs for language, LGBTQ sensititivity, etc.)
  10. Read purposefully (include feminist approaches in your continuing education)
  11. Expedite treatment (closest pharmacy for meds; expedited partner therapy for STDs if allowed in your state)
  12. Advertise yourself! (as a feminist provider)

For anyone with interests in epistemology as it pertains to the patient-provider relationship, or informed consent and refusal, or autonomy, or childbirth, this should be an interesting read. The FM blog also has recent entries on midwifery roles, scripts for feminist discussions of contraception options, scripts for discussing a positive pregnancy tests, and how to make gynecological exams more empowering. I recommend them for your consideration. If you’re not familiar with this blog, there is also a rich archive of prior material on a variety of subjects.

For peer-reviewed scholarly international research on safety, quality, outcomes and experiences of pregnancy, and birth and maternity care for childbearing women, their babies, and their families, see the journal Midwifery.

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