"Individual choices or medical strategies?"
Under the direction of Elise de La Rochebrochard, this issue of the Cahiers
de l'INED proposes an analysis on "the explosion of medical consumption" in
the field of the "reproduction" (contraception, abortion, prenatal
screening, "treatments" against infertility, sexuality) and deals with the
role sharing between physician and patient. "When the acts of the
intimate life are in the hand of medicine, what is the place left to the
patient? Is he still controlling his choices regarding reproductive and
sexual life?"
Health / Happiness
The authors start to determine the contours of this runaway medicalization.
Statistically, the growth of the medical offer is net: We counted 1
physician for 1,000 inhabitants in 1960, against 1 physician for 332
inhabitants in 2000. The conquest of the medicine is also done
sociologically and linguistically. This way, the term "medicalization"
which expressed in the past these figures, today means more "a process
leading to redefine and treat the non medical problems as medical problems,
generally in term of troubles or disease" (Conrad, 1992). From which its
important growth during the 19th century and the acceleration of this
expansion these last 40 years, within all fields of the existence. Meanwhile
we observe an evolution of the definition of the term "health". In
the past defined by the absence of disease or disability, health is now
characterised, according to World Health Organisation "by a state of full
physical, mental and social well being" (preamble to the constitution of
WHO, adopted in June 1946 and come into force in April 1948). It is a short
way to identify happiness to health and 30% of French people have done it,
according to an Ifop survey of 1987.
Medicalization of pregnancy
The field where medicalization gained more ground is undoubtedly this of
“reproduction”. From the medical follow-up of the delivery to reduce the
maternal and infantile mortality, today it is the entire pregnancy which is
medicalized. Women have in average 8.9 prenatal medical visits and 4.5
ultrasounds. And, from the good follow-up of the pregnancy we passed to the
“quality control” of the fœtus (according to an expression the
authors borrowed from Roegiers) by resorting to screening and prenatal
diagnosis, in particular for Down syndrome. This screening raises specific
problems in term of freedom left to the couple. The authors cite Wertz and
Fletcher who, in a publication of 1993, leave few doubts about mother’s
freedom: "It is extremely difficult, and maybe impossible for mothers, to
choose refusing the technologies agreed by obstetrical professionals. Once
the test available, rejecting them equals to refusing the modern faith in
the science and also rejecting the modern thought according which women
should do their best for the health of their future child”. In the
second part of the book: "The individual and her physician: Who decides?",
the authors will develop this idea showing in particular that the
information made to women regarding screening and prenatal diagnosis is
insufficient. "At the legislative level, the proposal of the screening
for Down syndrome with dosing maternal serum markers or prenatal diagnosis
is subject to an information obligation to the pregnant woman, whose terms
are in a unique way defined by decree." But information on the
consequences remains unknown or incomplete. Thus we learn that, according to
a 2004 study done in the Paris region, 37.1% of women who resorted to serum
screening for Down syndrome, did not think that this could possibly lead
them to be faced with the decision to terminate or not their pregnancy. This
figure rises to 49.8% for ultrasound screening. But, women must make this
complex decision rapidly.
Medicalization of the infertility
Then the authors mention the growing requirement of planning births by
couples and thus the development of resorting to medically assisted
procreation (MAP). According to a study presented in these pages, almost
half of the couples who did not have children visit from the first year of
infertility, after stopping the contraception. 1.4% of births in France come
from in vitro fertilisations (IVF) (de La Rochebrochard, 2003). This
medicalization of the infertility little by little conducts the couple in a
spiral of acts of which they seem not to control and which can heavily
affect them. The third and last part of the book is dedicated to these
painful experiences.
Experiences and pains
"Collection of infertile sperm in laboratory: medical or sexual practice?"
The confusion of erotic and medical meanings of the laboratory sperm
collection is subject to this article. After a survey of men who faced with
and mentioned their embarrassment and their shame, the authors wonder about
the trivialisation of the masturbation in the medical scientific universe
and the absence of other less "veterinary" methods of sampling. They
assume that, condemned by traditional religions, this practice only became
possible in a laboratory thanks to the relative obliteration of the couple
from the centre of the procedure. The instrumentalisation of the user has
desanctified the sexual activity. Yet the man remains destabilised with the
“feeling of a deprived and exposed intimacy”. From one hand, the
erotic gets into the hospital universe and, from another hand, the
bio-medical gets into the sexual intimacy.
IVF: an uphill struggle
This thought on the intrusion of the medicine in the intimacy of the couple
carries on in this chapter. Without forgetting the painful discomfort of
some treatments, here the authors mention the difficulty for the couples to
withstand invasive medical acts, in particular the medical team which
inquiries into the couple intimacy and seems to govern their relations. "What
it is difficult is to decide which role has to play the medicine, knowing
that it is first an equilibrium into the couple, how to interfere in what
will exchange a couple, it is delicate but finally it is the fundamental
problem (...) may the medicine intervene here, I don’t know",
says a man involved in IVF process. A woman also mentions the fate of her
embryos: “we do not realize the maternal instinct women can have on the
embryos they leave, and it is true that I had the feeling to have them
abandoned”. The responsibility of physicians, who sort the embryos to
replace in the maternal uterus, substituting to the natural selection, is
also underlined. The journalist Brigitte Fanny Cohen shows her own
experience in her book "Un bébé mais pas à tout prix" : "I cannot
stand the idea to make a baby with sperm. As since a long time, I do not
have anymore the feeling to have a child with my husband. The man in the IVF
process is reduced to the state of sperm. He gives his spermatozoids. That’s
all. (...) To such a point that sometimes I have the strange and
uncomfortable feeling to have a baby with the physician rather than with my
husband. The woman, the husband’s sperm and the gynaecologist: Here is the
new Saint Trinity".
"The pink and the black"
The medicalization transformed the man into a health actor: "the homo
medicus" is born. This transformation is a knowledge transfer from the
physician to the patient, but above all and paradoxically, a seizure of
power of the physician over the patient, until the innermost recesses of his
existence, until the procreation. Between a pink vision of physicians
“uninterested heroes” and a black vision of a dehumanised medicine which
transformed into a mean of social control of the individuals, what is the
legitimate place of the medicine? The development of the medicalization
enabled transforming the passive patient into a health actor, and yet his
explosion tends to deprive the patient from himself/herself and this is
possible only because the patient erases his personality faced with the
requirements of the medical team, the significant example of the book being
the IVF.
We have to note and appreciate a certain freedom of tone on the themes which
are usually treated in a unilateral way. Indeed it is rare to read such
reservations on generalised medical practices. Undoubtedly the choice of the
authors to explore “the other side of the picture” was the good one.
We would like to have again this freedom of analysis and expression on the
reality of abortion. An entire chapter is thus dedicated to the pain of
women after an extra-uterine pregnancy, and another one to the satisfaction
index of the woman according to the VTP method. We would have like a study
on the choice (myth or reality?) of the women regarding VTP or MTP and why
not on the pain of women who has to face it?
1- De la pilule au bébé-éprouvette – Sous la direction
d’E. de La Rochebrochard - Les cahiers de l'Ined N°161, 2008, 264 p., 25 €
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The challenges of the next revision of the
laws of bioethics will be complex and determining: this new legislation will
fundamentally direct our society in matter of health and research. The
debates which will precede this revision, organised within the framework of
General States in 2009, will concern all citizens, and as a priority health
professionals, public actors, advisers, students and training managers
involving an ethical dimension.
In this perspective, the Léon Harmel political institute and the Jérôme
Lejeune Foundation created a master (fifth-year university degree) in
medical ethics dealing with the most emblematic themes: biological and
philosophical status of the embryo; problem of the gestation for third
people; voluntary termination of pregnancy (VTP) and medical termination of
pregnancy (MTP); organisation of prenatal screening; democratic eugenics;
challenges of the research on stem cells and cloning; thought on death;
organisation of palliative care…
Taught buy health professionals, jurists, philosophers, psychoanalysts, the
training counts among its intervening parties:
- Tony Anatrella, psychoanalyst;
- Dr JM. Gomas, coordinator physician of the functional unity Pain and
Palliative care of the APHP;
- Fabrice Hadhadj, professor of philosophy and writer;
- Pr. Alain Lejeune, president of the international Federation of catholic
pharmacists;
- Marguerite Peeters, ethicist and director of Interactive Information
Service;
- Me Jean Paillot, lawyer;
- Pr. Emmanuel Sapin, head of paediatric surgery department (University
Hospital of Dijon) ;
- Monette Vacquin, psychoanalyst;
- Dr Pauline de Vaux, addictologist.
As one day or another we will have to face decisions involving our
responsibility, this master gives keys to understand the philosophic and
anthropologic challenges of health issues; acquiring basic ways of thinking
regarding medical ethics; stopping suffering from ideological pressures
faced with dramatic cases and put at life’s and suffering human person’s
service.
Information and registration at the Léon Harmel political institute:
3ème cycle de bioéthique Jérôme Lejeune
176, rue du Temple - 75003 PARIS
Phone: 08 77 97 57 86 / 06 25 37 62 83
www.iplh.fr
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