Kavita Shah Arora

Ritual Male Infant Circumcision and Human Rights

Opponents of male circumcision have increasingly used human rights positions to articulate their viewpoint. We characterize the meaning of the term “human rights.” We discuss these human rights arguments with special attention to the claims of rights to an open future and to bodily integrity. We offer a three-part test under which a parental decision might be considered an unacceptable violation of a childs right. The test considers the impact of the practice on society, the impact of the practice on the individual, and the likelihood of adverse impact. Infant circumcision is permissible under this test. We conclude that infant circumcision may be proscribed as violating local norms, even though it does not violate human rights.

Female genital alteration: a compromise solution

Despite 30 years of advocacy, the prevalence of non-therapeutic female genital alteration (FGA) in minors is stable in many countries. Educational efforts have minimally changed the prevalence of this procedure in regions where it has been widely practiced. In order to better protect female children from the serious and long-term harms of some types of non-therapeutic FGA, we must adopt a more nuanced position that acknowledges a wide spectrum of procedures that alter female genitalia. We offer a revised categorisation for non-therapeutic FGA that groups procedures by effect and not by process. Acceptance of de minimis procedures that generally do not carry long-term medical risks is culturally sensitive, does not discriminate on the basis of gender, and does not violate human rights. More morbid procedures should not be performed. However, accepting de minimis non-therapeutic f FGA procedures enhances the effort of compassionate practitioners searching for a compromise position that respects cultural differences but protects the health of their patients.

Triggers, bundles, protocols, and checklists–what every maternal care provider needs to know

The rise in maternal morbidity and mortality has resulted in national and international attention at optimally organizing systems and teams for pregnancy care. Given that maternal morbidity and mortality can occur unpredictably in any obstetric setting, specialists in general obstetrics and gynecology along with other primary maternal care providers should be integrally involved in efforts to improve the safety of obstetric care delivery. Quality improvement initiatives remain vital to meeting this goal. The evidence-based utilization of triggers, bundles, protocols, and checklists can aid in timely diagnosis and treatment to prevent or limit the severity of morbidity as well as facilitate interdisciplinary, patient-centered care. The purpose of this document is to summarize the pertinent elements from this forum to assist primary maternal care providers in their utilization and implementation of these safety tools.

Clinical, Ethical, and Legal Considerations in Pregnant Women With Opioid Abuse.

The rising prevalence of women with opioid addiction in pregnancy necessitates understanding of medical, ethical, and legal considerations on the part of obstetricians. In addition to briefly reviewing the medical care of opioid abuse in pregnancy, we offer a careful consideration of the stigmatization of addiction and resultant medicolegal sequelae. We advocate for improved access to opioid maintenance therapy and social services as a means of improving healthful pregnancy outcomes and decry recent trends in the criminalization of addiction nationwide.

Uterus Transplantation: The Ethics of Using Deceased Versus Living Donors

Research teams have made considerable progress in treating absolute uterine factor infertility through uterus transplantation, though studies have differed on the choice of either deceased or living donors. While researchers continue to analyze the medical feasibility of both approaches, little attention has been paid to the ethics of using deceased versus living donors as well as the protections that must be in place for each. Both types of uterus donation also pose unique regulatory challenges, including how to allocate donated organs; whether the donor / donors family has any rights to the uterus and resulting child; how to manage contact between the donor / donors family, recipient, and resulting child; and how to track outcomes moving forward.

Bits and pieces: The ethics of uterine morcellation

Intensive media and policy attention has been focused on the ongoing controversy surrounding uterine morcellation in gynecologic surgery. What has been missing from this impassioned discourse is an objective analysis of the ethical implications of uterine power morcellation in gynecologic surgery. This article discusses competing ethical duties of physicians, industry, the U.S. Food and Drug Administration, and the media to develop a more robust and nuanced understanding of informed consent for the use of morcellation in benign gynecologic surgery. Ultimately, as physicians, we must remain steadfast in our dedication to the use of evolving technologies to better patient health in a safe and ethical manner that is well-studied, informed, and implemented with appropriate training and precautions.

Speak No Evil? Conscience and the Duty to Inform, Refer or Transfer Care

This paper argues that the type of conscience claims made in last decade’s spate of cases involving pharmacists’ objections to filling birth control prescriptions and cases such as Ms. Means and Mercy Health Partners of Michigan, and even the Affordable Care Act and the Little Sisters of the Poor, as different as they appear to be from each other, share a common element that ties them together and makes them fundamentally different in kind from traditional claims of conscience about which a practical consensus emerged in the 1980s and 1990s. This difference in kind is profoundly significant; so much so, we contend, that it puts them at odds with the normative basis for protecting conscience claims in United States health care settings in the first place, making them illegitimate. Finally, we argue that, given the illegitimacy of these contemporary claims of conscience, physicians and other health professionals must honor their well-established standing obligations to provide informed consent and refer or transfer care even if the service requested or needed is at odds with their own core moral beliefs—a requirement that is in line with the aforementioned practical consensus on traditional claims of conscience.

Punishment of Minor Female Genital Ritual Procedures: Is the Perfect the Enemy of the Good?

Female genital alteration (FGA) is any cutting, removal or destruction of any part of the external female genitalia. Various FGA practices are common throughout the world. While most frequent in Africa and Asia, transglobal migration has brought ritual FGA to Western nations. All forms of FGA are generally considered undesirable for medical and ethical reasons when performed on minors. One ritual FGA procedure is the vulvar nick (VN). This is a small laceration to the vulva that does not cause morphological changes. Besides being performed as a primary ritual procedure it has been proposed as a substitute for more extensive forms of FGA. Measures advocated or taken to reduce the burden of FGA can be punitive or non-punitive. Even if it is unethical to perform VN, we argue that it also is unethical to attempt to suppress it through punishment. First, punishment of VN is likely to cause more harm than good overall, even to those ostensibly being protected. Second, punishment is likely to exceed legitimate retributive ends. We do not argue in favor of performing VN. Rather, we argue that non-punitive strategies such as education and harm reduction should be employed.

What Brings Physicians to Disciplinary Review? A Further Subcategorization

Background: Medicine, like most professions, has the privilege and responsibility of self-regulation. Evidence about physician discipline comes largely from state medical boards’ actions and reports. However, medical professional associations also participate in the review and, when necessary, discipline of physician behavior. This study analyzes a longitudinal series of cases brought to the American Medical Association (AMA) Council on Ethical and Judicial Affairs (CEJA) for review, providing a national view on what sorts of behaviors lead to disciplinary review. The study also presents a more detailed taxonomy of behaviors leading to disciplinary action, which is of particular importance for physician education. Methods: The study sample consisted of 5 years (2004–2008, inclusive) of disciplinary cases brought to the CEJA for initial and dispositive review, representing 298 cases and 293 individuals. Open coding in an iterative fashion led to a codebook of categories and subcategories of reasons for disciplinary review. Each case was then coded by two authors. Disagreements were discussed and reconciled as a group. Results: The two most common categories of behavior that led to disciplinary review were substance abuse disorders (28% of cases) and controlled-substance violations (27%). Negligence/incompetence (21%), criminal activity (20%), fraud/misrepresentation (19%), and boundary violations (12%) were also common reasons for which physicians were brought before the CEJA. Subcategories illustrate a range of behavior within categories; for instance, boundary-violation subcategories included romantic relationship with a patient, treating family members as patients, and having sexual contact with a patient. Conclusions: Physicians were reviewed by a professional medical disciplinary council for a variety of reasons. While the broad categories of alleged behavior are similar to those found in other studies, this study identified subcategories that demonstrate the complexity of actions that lead to physician disciplinary review. Physicians and physicians-in-training should be educated regarding this subcategorization in order to decrease the rate of discipline and improve patient care.

Eliminating Perinatal HIV Transmission in the United States: The Impact of Stigma

infants are born to mothers with unknown HIV status at time of delivery (ACOG 2015). The CDC and the American Congress of Obstetricians and Gynecologists (ACOG), among others, recommend universal HIV screening in pregnancy precisely because modern therapies have the ability to make such a dramatic health impact (ACOG 2015). The CDC revised its previous guidelines in 2006 in favor of universal screening, though the patient may opt out, to ensure timely diagnosis and treatment and to destigmatize the testing process. This recommendation would have been unfathomable early in the course of the HIV epidemic, when HIV’s association with stigmatized subgroups and a prognosis of certain death justified written informed consent and regulated requirements for post-test counseling (Cock and Johnson 1998). While HIV exceptionalism was thus initially ethically supportable, changes in the societal perception of HIV and advances in HIV medical care have made such exceptionalism unwarranted and unethical (Cock and Johnson 1998). MTCT prevention programs represented the first instance of transition from a paradigm of HIV exceptionalism to one of normalization (Cock and Johnson 1998; Bayer and Fairchild 2006). The 2006 CDC guidelines included HIV testing as a component of routine prenatal labs and recommended against separate, written consent documents, as was commonly required in many states and hospitals at the time. Many states have gone further, now requiring universal testing in pregnancy unless specifically declined by the patient (Bayer and Fairchild 2006). While the move by the CDC to universalize HIV testing was partially based on a desire to destigmatize the disease, HIV continues to remain a highly stigmatized disease given that it is perceived as: