Note from the Editor: This is a guest post about the difficulties trans* people often encounter when seeking medical care.  Medical care can be difficult to navigate in the best circumstances, but when your gender and documentation don’t agree, or your gender presentation and your body clash, it can be not only difficult but emotionally damaging to interact with medical professionals.  Sayer Johnson is a run-of-the-mill Midwestern transgender man trying to navigate basic healthcare and share his human experience.


Today I was reminded. Not in the sweet way that comes from a child fusing a new name with a new beard. Not in the quiet acceptance of a neighbor who, without skipping a beat, went from my old name to Papi. Not in the funny way that can come from the mouth of my always insightful six year old. Nevertheless reminded. Reminded in the bitter way that the media often reminds me. Reminded in the unfortunate way that  humanity sometimes does.  Reminded in my own community. Reminded why I continue to live my life out loud.

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Girl Rising

October 11 was the International Day of the Girl Child. I have to admit that I wasn’t very aware of it until one of the mailing lists to which I subscribe sent me a reminder, along with details of a screening of Girl Rising in Sydney. Girl Rising is a film about nine different girls, who, against the odds, survive the discrimination and injustice that precludes them from school, commits them to lives of servitude, treats them as second class citizens, discards them as worthless and otherwise denies them an equal place in society. The stories are true, in that each is about the life of a specific individual girl. Writers from the same country have been paired with each girl, to tell their stories. The film is beautifully shot, with each girl’s story having its own visual style. As one would expect, the stories are harrowing. Six year old Suma was forced into bonded labour in Nepal at the age of six, while her brothers went to school. She visits the houses of her three masters where she spent her primary school years, describing her life as a domestic drudge and worse. Amina in Afghanistan was sold to her husband to pay for a second hand car for her brother. She spent her childhood simmering with rage while fetching water “so men could wash their hands.” Sokha is an orphan, surviving on the pickings from a dump in Cambodia until chance brings her to a new life. Despite the horrors, there are moments of hope. Ruksana’s father is committed to providing an education for she and her sisters despite the hardships of life lived on the pavements of Kolkata. Azmera’s brother supports her when she wishes to stay at school rather than marry a stranger at 13. Senna channels the warrior princess after whom her father named her.


The stories of the girls are separated by facts and figures, about the deprivations heaped upon girl children – their exclusion from education, sexual abuse and high rates of pregnancy-related harms. There are also facts and figures about the economic benefits of educating girls such as the dollar value that every year of female education adds to a country’s GDP. The interludes detract from the film, but I had some sympathy with the film-makers’ aims to hit their message home as hard as possible – the film is a fundraiser.

Of course I was aware of discrimination against girls, but this film put names and faces to that vague awareness. It is a jarring reminder that girls are dying daily, being forced into sexual relationships, having their childhoods stolen from them. These are not complex moral issues requiring careful and detailed analysis in bioethics journals: they are just plain wrong.

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Just One of the Ways Austerity Can Kill

8 Food Risks Going Unmonitored During the Shutdown

Of course, the shutdown isn’t just austerity, but it’s part of the overall package. Now that there is good support for the position that austerity fails to achieve the benefits predicated of it by its proponents, it’s past time to dismantle it from the moral perspective. Many of austerity’s proponents now implicitly accept that the consequentialist arguments made for it don’t work, which is, I suspect why we’re seeing a resurgence of Social Darwinist arguments. Us philosophers surely need to be playing some role in helping to point this out, and emphasize that it is fully legitimate for government to protect citizens from wealthy and powerful individuals and corporations that would otherwise exploit us and destroy the very basis for human civilization and survival. I wonder who decides which philosophers/topics get into the public realm in such venues as The Stone (NY Times). . . .

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Reproductive Tourism in India: Is Surrogacy Ethical?

Originally posted on the The Doctor’s Tablet

The use of gestational surrogates in India is a booming business, but is it ethical?

This growing practice involves individuals and couples from countries in Western Europe, North America, Israel, Japan and elsewhere who work through brokers to have their genetically related offspring carried through pregnancy and birth by Indian women.

An estimated $500 million to $2.3 billion (U.S.) changes hands among commissioning couples, infertility clinics, brokers and Indian women who choose this way of earning money.

Ethics guidelines for surrogacy have been in place in India since 2005, but they do not have the force of law and tend to favor the fertility clinics and the commissioning couples from abroad, rather than the Indian women who serve as surrogates. A bill prepared in 2010 to regulate surrogacy legally is currently before the Indian parliament. Critics argue that the provisions of that bill, like the current guidelines, lack appropriate protections for the women who act as surrogates.

Several ethical questions arise about this practice, including these:

  • Is reproductive tourism in surrogacy arrangements different, in principle, from commercial surrogacy carried out within a country?
  • Are Indian women exploited by this practice?
  • Do they consent freely to serve as surrogates?
  • Are their rights and welfare adequately protected?

Some critics argue that commercial surrogacy in India is ethically wrong in principle. Some condemn it on the ground that it involves commodification of the human body; others contend that the Indian women are coerced financially.

There is a different approach, however, which examines the empirical facts surrounding the practice in India. How are surrogates treated during and after their pregnancies? Are their lives actually better off when they receive more money from serving as surrogates than they could by any other means?

The main arguments against commercial surrogacy are flawed. Those who argue that paid surrogacy treats women’s bodies as commodities need to explain the difference between the use of women’s bodies to gestate babies and the use of human bodies for paid labor for a variety of tasks, which may be riskier than going through pregnancy and childbirth: backbreaking work loading trucks; working on oil rigs; cleaning up toxic waste. The argument that poor Indian women are being exploited is odd, given that they are paid more as surrogates than they could possibly earn in other jobs, which would likely be more unpleasant.

Perhaps what is meant by exploitation is that these women are not being paid enough. But that argument runs directly into the opposite worry: that women are being “coerced” by receiving more money than they could obtain by other means. This latter objection relies on a mistaken notion of coercion. Coercion involves confronting people with two undesirable choices, each of which would make them worse off: “Your money or your life.” The Indian women who serve as surrogates are offered a desirable option: the chance to obtain money they could use to put more food on the table or educate their children. However, coercion could occur by other means; for example, a woman’s husband or mother-in-law could wield power and force her into making a surrogacy arrangement.

Evidence from research conducted on surrogacy in India reveals the opposite situation. Women often have to convince their husbands that surrogacy is an acceptable option, since the practice is sometimes misunderstood to involve a sexual encounter rather than the use of advanced medical technology to transfer an embryo to a woman’s womb.

My own view is that there is nothing wrong, in principle, with the practice of paid gestational surrogacy. The ethical acceptability of reproductive tourism in India depends on an array of factual circumstances:

  • Is the woman properly taken care of if something goes wrong in the pregnancy?
  • Is there insurance or guaranteed medical care for complications that may persist after the birth of the baby?
  • Does the woman have access to legal representation in case the broker or commissioning couple fails to come through with the funds?

These are precisely the items a law designed to protect the rights and welfare of surrogates should contain. Those who would restrict the autonomy of poor Indian women with few options need better arguments to justify their paternalism.

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“Your Half-Eaten Sandwich’s Dirty Secret”

From Mother Jones:

“A full third of the world’s food is wasted. According to a new report from the UN’s Food and Agriculture Organization, discarded food accounts for a staggering amount of planet-warming greenhouse gas emissions. In fact, if food waste was a country, its 3.3 gigatonnes of emissions would make it the third highest-emitting country in the world, after China and the United States”

Read the full article here

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Breaking Bioethics

(Warning for those who have not yet seen Breaking Bad’s conclusion:  this contains SPOILERS!)

Now that Breaking Bad has reached its tragic end, we can focus with more perspective on some of the aspects of the show that have been unexplored relative to some of its other, more sensational, themes.  Good and evil; redemption and damnation; family and isolation; honor and betrayal; forgiveness and indictment — all of these, and more, have been a part of the Breaking Bad phenomenon.  All, except for that one particular topic – the one that actually started Walter White down the road to Heisenberg:  the cost of health care in America.

There is a popular internet meme out there that goes something like this:

Without getting into the otherwise complicated details of the Canadian health care system, it is oddly compelling.  Think about it:  Would there even be a Heisenberg, his meth lab, his rapidly rising body count, or Jesse Pinkman chained up in a neo-Nazi meth-producing compound if all Walter White had to do was show up the next week for the beginning of his cancer treatment?  Would his first thoughts, upon receiving his diagnosis, be about survival, the future of his family — or about the abject fear of their coming financial ruin, given the costs of the course of treatments his physician prescribed?  Would his long-suffering wife, Skyler, wince with fear and dread upon receiving Walt’s medical bills?  And would she be automatically suspicious that something is very wrong when they were nearly paid off, given the hundreds of thousands the payoff represented?

And what about Hank Schrader?  Walter’s brother-in-law DEA agent, facing horrible injuries that led to a permanent limp, had to simultaneously face his medical insurance company, which refused to pay for the many thousands of dollars’ worth of necessary physical therapy and some hospital bills.  While most of the media commentary focused on Skyler’s guilt-ridden, manipulative lies that finally convinced Marie, Hank’s wife, to accept financial assistance for Hank’s therapy, perhaps we might want to consider the other moral disaster on full display — the one where a seriously-injured DEA agent would be left without the ability to walk without great pain, save for the millions earned by a cancer-stricken relative’s medical bill-motivated meth trade.

Some observers have suggested that Breaking Bad is revolutionary both in its style and its subject matter. However, David Sirota found something a bit deeper, and much darker, and wondered out loud why here in America, its subversive and somber notes were received with the fervor of recognition.  Sirota argues:


The most obvious way to see that is to look at how Walter White’s move into the drug trade was first prompted, in part, by his family’s fear that he would die prematurely for lack of adequate health care. It is the kind of fear most people in the industrialized world have no personal connection to — but that many American television watchers no doubt do. That’s because unlike other countries, Walter White’s country is exceptional for being a place where 45,000 deaths a year are related to a lack of comprehensive health insurance coverage. That’s about ten 9/11′s worth of death each year because of our exceptional position as the only industrialized nation without a universal public health care system…

Walter’s fear of bankrupting his family is also familiar. The kind of medical bills Walter faced are hardly rare in America — they are, in fact, the country’s single largest cause of bankruptcy. And again, this makes America exceptional because, alas, medical bankruptcies basically do not exist in the rest of the industrialized world.


As far as we know, before Heisenberg built his empire, Walter White did the right thing:  He earned an advanced degree, he worked as a schoolteacher, he supported his family — in other words, he dutifully played by the rules.  So did his brother-in-law Hank.  And yet when both were at their lowest points, when both needed a collective response to their personal tragedies, the only help came in the form of bundles of cash, courtesy of desirable blue meth.  So when we debate the nature of the tragic flaws that led a mild-mannered chemistry teacher to become the best cook in the Southwest, the answer might at first include all kinds of meditations on masculinities, ego, a desire to feel, and to be, a man of action — to matter.  But, it also should include an acknowledgement of a much more basic desire to simply be  —  to live, and not have the price of one’s life be the future and well-being of one’s family.  But, as Americans, on the eve of “Obamacare,” this is exactly where we find ourselves today:  wandering in the desert, wondering where we buried that something that would rescue us from Heisenberg’s fate.

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Philosophy of Nursing

I recently attended the International Philosophy of Nursing Conference, which is associated with the International Philosophy of Nursing Society (IPONS).  It was my first time at the conference and I was very impressed by the quality of the papers and discussions.  It was a small meeting, but with an exciting diversity of topics and approaches.  It’s also definitely a feminist-friendly environment and I would recommend that anyone doing work on nursing consider submitting an abstract to next year’s conference.

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“Penn State Administrators Target Women Employees”

“Penn State Administrators Target Women Employees”

From the Centre Daily Times: “Under Penn State’s new employee wellness program, a health risk assessment questionnaire asks female employees if they plan to get pregnant in the next year. If the employee doesn’t want to disclose that and opts out of completing the assessment, she’ll incur a $100 fee each month. That’s $1,200 over the course of the year.”


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Private Imaging in Alberta

Canada’s single-payer health system is the envy of some Americans. Under Canadian Medicare, every province runs a single public health insurance plan with very low administrative overhead: in this sense, the system is efficient. It is also a natural fit for the goal of health equity: everyone is in the same plan; everyone has the same benefits.

A single-payer system is no panacea, however. Much rides on what the single payer covers and does not cover. For example, Canada scores poorly on international comparisons of health equity. This is largely, but not entirely, the result of what we exclude from Medicare: prescription drugs, as well as non-physician care (physical therapy, dental care, speech language pathology, etc.—any function not performed by physicians), in the community. As a result of these exclusions, Canada has a high rate of private health insurance for extended benefits, and one of the highest levels of private expenditure among universal health care systems. If you need rehab, or have on-going prescription drug costs, moving to Canada might or might not save you from American-style inequities in access to care.

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To Re/Member

In this NPR blog, Barbara J. King reflects upon potential extensions of Susumu Tonegawa et al’s recent experiment in creating a fear-based memory in mice. While the ability to physically alter memory could have benefits (e.g. healing PTSD), King raises important ethical and material complications. She notes the nature of memory as unreliable, and considers the possible evolutionary benefit of this: creativity and problem-solving. Also, and most interesting to me, she pushes beyond the seeming boundaries of neuroscience and the isolation of the brain to consider the embodied, embedded nature of memories, existing in our flesh and “our social networks.” Memory (and consciousness, and social interaction, and existence itself) is not merely in our neurons. This reminds me of one of my favorite quotes from Canguilhem:

“To act, it is necessary at least to localize….As if one could determine a phenomenon’s essence apart from its conditions! As if conditions were a mask or frame which changed neither the face nor the picture!” (from The Normal and the Pathological)

Canguilhem’s localization is not that of neuroscience, but of seeing a being in specific context (as opposed to a broad definition of normal/pathological). The ethics of tinkering with the brain must be understood within the contexts — the conditions — of our bodies and lives.

“Can We Foresee The Dangers Of Messing With Memory?”

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“TX women bring abortion fight to world of video games”


“The game Choice: Texas, a Very Serious Game is a text-based browser game in which players will assume the role of one of five Texas women facing crisis pregnancies. In a video posted to the crowdfunding website indiegogo, the game’s creators described it as ‘an interactive fiction game designed to raise awareness of the financial, geographical and other barriers facing women seeking an abortion in Texas.'”

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The Cost of Blocking Imperfect Solutions: State-based Obstacles to Implementing the Patient Protection and Affordable Care Act (PPACA, AKA Obamacare)

Sandhya Somashekhar’s recent article in The Washington Post, “States find new ways to resist health law”, provides a nice overview of some of the ways that states are throwing up obstacles to effective implementation of the Patient Protection and Affordable Care Act (PPACA). With the Affordable Care Act set to be implemented, blocking its effective implementation raises serious moral issues. Though it is an imperfect solution, I believe that these state-based obstacles to its implementation are deeply morally problematic because the costs of non-compliance fall on individuals while the politicians who have put these obstacles in place face little or no personal or political cost, and indeed stand to gain.


While I am arguing here that blocking implementation of the PPACA is deeply morally problematic, it is important to acknowledge that it is an imperfect solution to America’s glaring problem of uninsured persons and expensive, inefficient provision of health care.  The PPACA or ACA, known colloquially as “Obamacare”, will work to get more Americans into the health care market and provide more access to preventive care for high- and low-risk patients, alike.  Aside from the very valuable limitations on health insurers’ ability to refuse to provide coverage for high-risk patients and stop providing coverage for ill patients, it is still based on the for-profit health insurer model as evidenced in part by the early elimination of a government-based “public option” which would have competed with insurance industry plans.  In addition, a large number of Americans who get insurance through their employers, yet find the premiums taxing and fall into otherwise-subsidized income ranges, will not have access to the federal subsidy system which is designed to give financial support to those entering the market through the health insurance exchanges.

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