It's like that song from Avenue Q, "Everyone's a Little Bit Racist."
Today we talked about 'functional somatic syndromes' in our doctorin' class. These are syndromes, ahem, "defined more by suffering and symptomology than by any consistently demonstrable pathophysiology." Which sounds a lot like saying "it's all in your head." Which, to me at least, sounds kind of paternalistic and dismissive--medicine as an entity and doctors in particular putting the burden of 'un-understandability' on the patient rather than admitting that Western medicine doesn't totally have its shit together with the whole mind-body connection. A little like hubris, I feel. In one of the articles we read for today, the authors listed 'side effects from silicone breast implants, irritable bowel syndrome, repetitive stress injury and vaginismus' as among these functional somatic syndromes. The paper was written ten years ago. In 2009, we have official diagnostic criteria for IBS and fibro; everyone and their sister knows that carpal tunnel DOES, in fact, exist; and I'm gonna go out on a limb here, but I doubt that even in 1999 a reasonably intelligent person would say, "Have 500 ccs of potentially allergenic, if not carcinogenic, material pumped into each of my breasts? Don't mind if I do!" As for vaginismus being an issue of mind over body--yeah, possibly, but that doesn't mean the suffering isn't real, and telling women to just relax about it doesn't address the problem. I guess what I'm saying is, we don't know everything there is to know about the world, and it's kind of pompous to say that if we don't, it's the world's fault. After all, just 50 years ago doctors were still telling women that dysmenorrhea was all in their collective heads (and had, apparently, been a form of mass female hysteria since time immemorial).
Our group leader described his thought processes well--when prescribing a tricyclic antidepressant for a woman with irritable bowel, it's common to be met with the dismayed cry, "Doctor, you think I'm crazy! I'm not crazy!" At which point he then points out, "Your gut is very special--it's the only organ system that has a complex 'brain' of its own...(explain about the enteric nervous system, neurotransmitters, la ti da ti da) and I think that these drugs, even though they were originally prescribed for depression, might have some usefulness here." Meanwhile, he says, 'I'm thinking, yeah, I do think you're a little bit crazy, but so's everyone.' So that's a nice message to keep in mind next time someone's acting like a whack job and being really frustrating--everyone has their own particular flavor of crazy. It's like the world is a huge Baskin-Robins, but with neurosis instead of ice cream.
Showing posts with label politics. Show all posts
Showing posts with label politics. Show all posts
Wednesday, December 2, 2009
Sunday, October 4, 2009
Does she or doesn't she?
Only her reproductive endocrinologist knows for sure.
The 'so, do I have PCOS?' circus continues. Altered hormone levels, especially high androgens (male hormones)? Check. Irregular periods? Check. Increased (ahem) body hair? Yeah, fine, check. Obesity? Well...no, but the comorbid eating disorder could have something to do with that. So what's the most distressing? Honestly, the hair (this from someone who hasn't shaved since middle school). I feel like I'm either going through puberty again or turning into a wolf. Or possibly both. Wasn't there a book during the eighties called 'I was a teenage werewolf?' I think there was.
Americans have really...effed up responses to female body hair. When I wear shorts, I catch people staring. A lot. I wish, if they were really that curious, that they'd have the testicular fortitude (ie balls) to come up to me and say, "Hey, I think your particular style of bodily presentation is really different and kind of cool. Would you tell me a little bit about why you do things this way?" Then I might not want to disembowel them with a spoon for tee-heeing with their friends behind my back at the Metro stop. Y'know, the way I do now.
In a 1998 study, 125 undergrads of both sexes were shown 2 videos of a woman drying off after a swim. In one she was clean shaven, and in the other she had hairy armpits and legs. The unshaven woman was rated as less: moral (?!?), relaxed and fun; she was rated as more assertive, aggressive, serious and 'in better physical condition.' This was the same woman, mind you. The only difference was the presence vs. absence of hair.
A few days ago, on what I generally consider to be a feminist blog, one of the commenters (in discussing her feelings about fat acceptance vs. fatphobia) brought up the subject of choosing with whom one associates, and said, "For instance, I think women have the right not to shave if they don't want to, but I still think it's abnormal and weird and I probably wouldn't want to spend a lot of time with them." REALLY? AYFKM? (Think it out...Are You F*cking Kidding Me?) Just having looked at me, without so much as a hello, you know you don't want to chill with me based on the state of my hair follicles? Not to mention that it's NORMAL for women to have body hair--IT GROWS THERE AND WILL BE THERE UNLESS YOU ACTIVELY REMOVE IT--and so the whole "It's abnormal/weird" argument is proof positive that you've bought into the consumerist/patriarchal/western beauty complex.
The excess hair associated with PCOS is called 'hirsutism,' and it really isn't so much an excess of hair (though it can be) as it is a male-pattern hair growth--ie, on the chest, the lower stomach, the shoulders, upper lip and chin, lower back. Most people bleach it/electrolyze it/shave it. Some people, like Circus Amok performance artist Jennifer Miller (google it...you'll like it) don't. It's all part of the pulchritudinous plethora of personalities we call life. So for now, I'm going to discreetly pluck a few places...and leave the rest.
The 'so, do I have PCOS?' circus continues. Altered hormone levels, especially high androgens (male hormones)? Check. Irregular periods? Check. Increased (ahem) body hair? Yeah, fine, check. Obesity? Well...no, but the comorbid eating disorder could have something to do with that. So what's the most distressing? Honestly, the hair (this from someone who hasn't shaved since middle school). I feel like I'm either going through puberty again or turning into a wolf. Or possibly both. Wasn't there a book during the eighties called 'I was a teenage werewolf?' I think there was.
Americans have really...effed up responses to female body hair. When I wear shorts, I catch people staring. A lot. I wish, if they were really that curious, that they'd have the testicular fortitude (ie balls) to come up to me and say, "Hey, I think your particular style of bodily presentation is really different and kind of cool. Would you tell me a little bit about why you do things this way?" Then I might not want to disembowel them with a spoon for tee-heeing with their friends behind my back at the Metro stop. Y'know, the way I do now.
In a 1998 study, 125 undergrads of both sexes were shown 2 videos of a woman drying off after a swim. In one she was clean shaven, and in the other she had hairy armpits and legs. The unshaven woman was rated as less: moral (?!?), relaxed and fun; she was rated as more assertive, aggressive, serious and 'in better physical condition.' This was the same woman, mind you. The only difference was the presence vs. absence of hair.
A few days ago, on what I generally consider to be a feminist blog, one of the commenters (in discussing her feelings about fat acceptance vs. fatphobia) brought up the subject of choosing with whom one associates, and said, "For instance, I think women have the right not to shave if they don't want to, but I still think it's abnormal and weird and I probably wouldn't want to spend a lot of time with them." REALLY? AYFKM? (Think it out...Are You F*cking Kidding Me?) Just having looked at me, without so much as a hello, you know you don't want to chill with me based on the state of my hair follicles? Not to mention that it's NORMAL for women to have body hair--IT GROWS THERE AND WILL BE THERE UNLESS YOU ACTIVELY REMOVE IT--and so the whole "It's abnormal/weird" argument is proof positive that you've bought into the consumerist/patriarchal/western beauty complex.
The excess hair associated with PCOS is called 'hirsutism,' and it really isn't so much an excess of hair (though it can be) as it is a male-pattern hair growth--ie, on the chest, the lower stomach, the shoulders, upper lip and chin, lower back. Most people bleach it/electrolyze it/shave it. Some people, like Circus Amok performance artist Jennifer Miller (google it...you'll like it) don't. It's all part of the pulchritudinous plethora of personalities we call life. So for now, I'm going to discreetly pluck a few places...and leave the rest.
Tuesday, September 8, 2009
More on Fat Acceptance...
Great article on eating disorders in the Fat Acceptance movement from my absolute favorite magazine, Bitch: Feminist Response to Pop Culture.
An article which begs the question, what exactly makes an eating disorder? Obviously it's a subjective diagnosis, whether you're talking about anorexia or binge eating disorder (yes, there are 'physical,' objective indicators of eating disorder status...a BMI below 17.5, or amenorrhea for more than 3 months for anorexia, for example) but then again, even the DSM-IV includes "overvaluation" of weight as a symptom of EDs. Think about that. In 2009, in the United States, one could reasonably argue that most women 'overvalue' their weight. Not because we're stupid or shallow or have a diagnosable eating disorder, but rather because that's what we're trained to do from elementary school on. Despite the positive spate of articles in teen-oriented magazines like Seventeen, there are still 'Summer Tone-Up Specials' published every May, showing 13 year olds that the best (and perhaps only) way to be a real woman is to watch those calories and do 100 crunches a day.
We have a slew of television shows like 'Bulging Brides' (I almost fell off the treadmill at the gym when I saw that title a few days ago) and 'The Biggest Loser' that focus exclusively on weight loss. Magazines at the check-out stand offer ways to drop 20 pounds in a month--assuming that every woman wants or needs to lose the equivalent of a small child--then, in another article a few pages later, exhort women to love themselves whatever their shape. Then, in the 'Health' column, another admonition that a body fat percentage over 20 means you're headed for an early, deep-fried grave. The whole mess is--well, a mess.
The primary point is that eating disorders occur in people of all shapes and sizes--something that most people would benefit from knowing. Officially, anorexia requires a certain percentage of weight be lost--yet I've known 'normal' and overweight people who followed profoundly restrictive diets. For a period during college, I was running ten miles a day and eating 600 calories--but it wasn't until my weight plummeted past 100 lbs that I was 'officially' anorexic. Bulimics can be any weight. Someone can binge-eat and weight 80 pounds, or 380. The fat acceptance movement is right on in encouraging people to care for their bodies--but an eating disorder, whether manifest in starving or bingeing, is profoundly unloving. For a woman attempting to heal that damage to be rejected by the very movement that purports to champion body-love is both counterproductive and disappointing. Exclusion and derision hurt, no matter what the 'political' motivations.
An article which begs the question, what exactly makes an eating disorder? Obviously it's a subjective diagnosis, whether you're talking about anorexia or binge eating disorder (yes, there are 'physical,' objective indicators of eating disorder status...a BMI below 17.5, or amenorrhea for more than 3 months for anorexia, for example) but then again, even the DSM-IV includes "overvaluation" of weight as a symptom of EDs. Think about that. In 2009, in the United States, one could reasonably argue that most women 'overvalue' their weight. Not because we're stupid or shallow or have a diagnosable eating disorder, but rather because that's what we're trained to do from elementary school on. Despite the positive spate of articles in teen-oriented magazines like Seventeen, there are still 'Summer Tone-Up Specials' published every May, showing 13 year olds that the best (and perhaps only) way to be a real woman is to watch those calories and do 100 crunches a day.
We have a slew of television shows like 'Bulging Brides' (I almost fell off the treadmill at the gym when I saw that title a few days ago) and 'The Biggest Loser' that focus exclusively on weight loss. Magazines at the check-out stand offer ways to drop 20 pounds in a month--assuming that every woman wants or needs to lose the equivalent of a small child--then, in another article a few pages later, exhort women to love themselves whatever their shape. Then, in the 'Health' column, another admonition that a body fat percentage over 20 means you're headed for an early, deep-fried grave. The whole mess is--well, a mess.
The primary point is that eating disorders occur in people of all shapes and sizes--something that most people would benefit from knowing. Officially, anorexia requires a certain percentage of weight be lost--yet I've known 'normal' and overweight people who followed profoundly restrictive diets. For a period during college, I was running ten miles a day and eating 600 calories--but it wasn't until my weight plummeted past 100 lbs that I was 'officially' anorexic. Bulimics can be any weight. Someone can binge-eat and weight 80 pounds, or 380. The fat acceptance movement is right on in encouraging people to care for their bodies--but an eating disorder, whether manifest in starving or bingeing, is profoundly unloving. For a woman attempting to heal that damage to be rejected by the very movement that purports to champion body-love is both counterproductive and disappointing. Exclusion and derision hurt, no matter what the 'political' motivations.
Monday, August 31, 2009
A physician-to-be looks at Fat Pride
There is a movement called Fat Pride. Marilyn Wann, the author of a book of fat activist essays entitled "Fat?So!" is widely considered to be at the forefront. It supports taking back the word 'fat,' just as the gay rights movement has taken back 'queer,' stripping it of its shameful and painful connotations. As one of my fat activist friends explained to me, "I'm fat. So what? I could say I'm Rubenesque, or generously proportioned, built for comfort and not for speed. But to the rest of the world I'm fat. Why dance around it?"
At a medical school, of course, we are taught that fat (dietary or bodily) is anathema (for those readers who majored in biochemistry and haven't read anything but Cell since sophomore year, anathema means really really bad). Virtually every lecture touches upon it in some way, from last year's biochem lecturer who seemed almost pathologically obsessed with saturated and trans fats (she cut one of her favorite baked goods out of her life entirely when she discovered they contained what I believe was 2 g of trans fat per serving--but then I speak as the person who has a hang up about fiber, which is no less pathological, and has me tallying my 25 grams a day in my daily planner)...to this year's pathology talks on cancer, in which dietary fat intake presents significant increases in malignancy risk. Obesity is a risk factor for cancer, for heart disease, for type II diabetes...yes. This is true. But there are other findings which are not discussed, and furthermore--and more disturbingly, to my mind--there is an atmosphere of...distaste for the obese that permeates our education, and which has no place in the training of future caregivers.
For one (yes, I should cite the study. Go to pubmed, and I have no doubt you'll be able to find it. I know saying 'A study said' without further citation is the gravest sin a scientist can commit. Mea maxima culpa) when overweight but cardiovascularly fit, exercising individuals and 'normal weight' but unfit individuals were tracked for seven years in a longitudinal study...the normal weight couch potatoes were at a higher risk of death. Interesting. Granted, in a social milieu that fosters sedentary life and cheerfully offers to Supersize everything, poor eating habits and inactivity often come together and produce someone who is unhealthy--and who also happens, through the normal workings of thermodynamics, to be overweight. But are all overweight people snarfing deep-fried Oreos and calling Guitar Hero their 'cardio for the day'? Of course not. Look, Grasshopper, and you will see...shades of grey. Yes, I know I spelled it the British way. I like that way better.
As for the distaste for fat people--which we medicalize and sanitize by calling 'overweight or obesity'--that is a much more malignant issue. My medical school class is not a cross-section of society by any means, perhaps most especially (and I find this intriguing) not in terms of body habitus, nor in health habits. Almost a dozen of us--out of 124--ran the St. Louis Marathon last year; many others ran the half-marathon. Today in class, I watched the snacks people were eating: four apples, one bag of carrots/celery, one bag of trail mix, a banana, and numerous diet Cokes. And as for body size, well, we are FAR below the widely cited "1 in 3" obesity statistic. Approaching, in fact, 0%. Perhaps that makes it easy for us to think of the obese as "them": it's something that happens to other people, something from which we (with our daily workouts and carefully planned 1800 calorie, low fat, high-fiber diets) are saved by our superior willpower.
I worry about this.
I worry that this will create physicians who think that nagging, insulting, preaching or condescending will get people to lose weight.
I worry that this will create physicians who think 'fat people' are to blame for all their health problems and are undeserving of sympathy and empathy.
I worry that we haven't found a way to help people who want to lose weight but can't, and that this may be partly because we think fat is a moral failing.
I worry.
At a medical school, of course, we are taught that fat (dietary or bodily) is anathema (for those readers who majored in biochemistry and haven't read anything but Cell since sophomore year, anathema means really really bad). Virtually every lecture touches upon it in some way, from last year's biochem lecturer who seemed almost pathologically obsessed with saturated and trans fats (she cut one of her favorite baked goods out of her life entirely when she discovered they contained what I believe was 2 g of trans fat per serving--but then I speak as the person who has a hang up about fiber, which is no less pathological, and has me tallying my 25 grams a day in my daily planner)...to this year's pathology talks on cancer, in which dietary fat intake presents significant increases in malignancy risk. Obesity is a risk factor for cancer, for heart disease, for type II diabetes...yes. This is true. But there are other findings which are not discussed, and furthermore--and more disturbingly, to my mind--there is an atmosphere of...distaste for the obese that permeates our education, and which has no place in the training of future caregivers.
For one (yes, I should cite the study. Go to pubmed, and I have no doubt you'll be able to find it. I know saying 'A study said' without further citation is the gravest sin a scientist can commit. Mea maxima culpa) when overweight but cardiovascularly fit, exercising individuals and 'normal weight' but unfit individuals were tracked for seven years in a longitudinal study...the normal weight couch potatoes were at a higher risk of death. Interesting. Granted, in a social milieu that fosters sedentary life and cheerfully offers to Supersize everything, poor eating habits and inactivity often come together and produce someone who is unhealthy--and who also happens, through the normal workings of thermodynamics, to be overweight. But are all overweight people snarfing deep-fried Oreos and calling Guitar Hero their 'cardio for the day'? Of course not. Look, Grasshopper, and you will see...shades of grey. Yes, I know I spelled it the British way. I like that way better.
As for the distaste for fat people--which we medicalize and sanitize by calling 'overweight or obesity'--that is a much more malignant issue. My medical school class is not a cross-section of society by any means, perhaps most especially (and I find this intriguing) not in terms of body habitus, nor in health habits. Almost a dozen of us--out of 124--ran the St. Louis Marathon last year; many others ran the half-marathon. Today in class, I watched the snacks people were eating: four apples, one bag of carrots/celery, one bag of trail mix, a banana, and numerous diet Cokes. And as for body size, well, we are FAR below the widely cited "1 in 3" obesity statistic. Approaching, in fact, 0%. Perhaps that makes it easy for us to think of the obese as "them": it's something that happens to other people, something from which we (with our daily workouts and carefully planned 1800 calorie, low fat, high-fiber diets) are saved by our superior willpower.
I worry about this.
I worry that this will create physicians who think that nagging, insulting, preaching or condescending will get people to lose weight.
I worry that this will create physicians who think 'fat people' are to blame for all their health problems and are undeserving of sympathy and empathy.
I worry that we haven't found a way to help people who want to lose weight but can't, and that this may be partly because we think fat is a moral failing.
I worry.
Saturday, May 16, 2009
Abstinence Only?
So, thank God, Bush is no longer in the White House...but abstinence only education is still mandated in much of the US by state law. There are still abstinence-only government sites up on the web, too...the most interesting of which is 4parents.gov, which offers help in talking to your kid "early and often about waiting to have sex." Waiting till when? Til 18? 21? Whatever the age of consent is in your state (it's 14 in Missouri, and in some states as low as 12, to which I can only say...ew)? Til they're paying their own mortgage? No, silly...until their state-sanctioned, Judeo-Christian marriage! Which means that if I'm going to wait to have sex, I'll have to hold out until I have enough money to get my ass to Vermont (oh, wait--I could just go to Iowa, but then I'd have to live there permanently, because my marriage wouldn't be recognized in Missouri! Oh Joy!).
4Parents.gov also talks about the 'emotional' risks of early sexual involvement...for instance, girls who have sex, do drugs or drink are more likely to be depressed (first, this seems like a chicken/egg situation, and second, um, it seems a little...odd to put doing meth and doin' the nasty in the same category). Obviously, a middle-schooler isn't emotionally prepared for the sequelae of going all the way...but they're still going to, and perhaps it would be better to talk about REALISTIC ways to protect themselves--being assertive about their boundaries, using condoms and birth control, having sex with peers rather than falling for exploitive 'relationships' with older teens/adults--than to act as if the Magic Wand of Abstinence can make all these issues disappear.
Speaking of, apparently Bristol Palin and Jamie-Lynn Spears are working with the Candie's Foundation (I thought they sold shoes...WTF?) advocating--I kid you not--abstinence. Because, you know, it worked so well for them. So here's the real deal: Abstinence-only education and signing of chastity pledges generally does delay the age at which teens have their first intercourse (obviously we're talking hetero, lingam-in-yoni here). BUT when they do finally break down/give in to Satan/get coerced/whatever, they're less likely to use protection. And y'know what? The fact that you waited until you were 17 doesn't make you any less pregnant or any less infected if you don't use a condom.
4Parents.gov also talks about the 'emotional' risks of early sexual involvement...for instance, girls who have sex, do drugs or drink are more likely to be depressed (first, this seems like a chicken/egg situation, and second, um, it seems a little...odd to put doing meth and doin' the nasty in the same category). Obviously, a middle-schooler isn't emotionally prepared for the sequelae of going all the way...but they're still going to, and perhaps it would be better to talk about REALISTIC ways to protect themselves--being assertive about their boundaries, using condoms and birth control, having sex with peers rather than falling for exploitive 'relationships' with older teens/adults--than to act as if the Magic Wand of Abstinence can make all these issues disappear.
Speaking of, apparently Bristol Palin and Jamie-Lynn Spears are working with the Candie's Foundation (I thought they sold shoes...WTF?) advocating--I kid you not--abstinence. Because, you know, it worked so well for them. So here's the real deal: Abstinence-only education and signing of chastity pledges generally does delay the age at which teens have their first intercourse (obviously we're talking hetero, lingam-in-yoni here). BUT when they do finally break down/give in to Satan/get coerced/whatever, they're less likely to use protection. And y'know what? The fact that you waited until you were 17 doesn't make you any less pregnant or any less infected if you don't use a condom.
Thursday, November 6, 2008
When do political issues become medical issues?
And I'm not even talking about health plans here. I'll leave aside for a moment tax credits vs. Medicare-for-all vs. universal employer coverage (which, by the way, still isn't analogous to universal coverage). I'm thinking specifically about the recent outcomes of Prop 8 in California (to ban same-sex couples from getting married), and of the Arkansas vote to prevent unmarried couples, gay or straight, from adopting children.
Now, you might say it's a good thing for children to be raised in intact homes. That's true. There are, however, intact and loving homes that haven't been marked with the state's official seal of approval (ie, a marriage license). Add to that the fact that the parents in some intact and loving homes, by virtue of legislation like Proposition 8 in CA, can NEVER become married--and the fact that various agency representatives in AR have said they basically intend to look the other way on the marriage issue "as long as they ain't queers or nothin'" (OK, so I've dramatized a bit) and you have a message of hate masquerading as concern for child welfare, which makes an already regrettable attitude downright despicable.
Am I saying this on account of the fact that I--at some point in my adolescence--'caught the gay?' Well, yeah, in part. But I'm also saying it because I know gay parents who have only managed to be legally recognized as the parents of their offspring through processes like second-parent adoption, and this sort of law threatens the ability of my tribe to create families. So what's second-parent adoption, you ask? Essentially, Mary and Alice are a couple. Mary gets artificially inseminated, maybe with Alice's egg to make the experience more equally 'shared'--but also a damned sight more confusing. So, Mary gives birth to the baby and is thus listed on the birth certificate. But, lo and behold, there's only space for one parent of each sex on the birth certificate, so Alice is S.O.L. until she secures a second-parent adoption, which establishes her as another mother. OK, I lied, it's not actually that confusing--just frustrating and lame.
So let's say (Goddess forbid) something happens to Mary, and there's no adoption, and no marriage. Well, if Mary listed Alice as the child's next guardian, it's all OK (well, not really, because if Mary's parents don't like it, they can contest it in court and in Arkansas chances are they'd win) and the right person ends up with the kid. But if Mary hasn't made a will? If she hasn't been thinking about her mortality, if her death wasn't anticipated, and she accidentally steps out in front of the 29 bus some morning? It would be nice to say that Alice, as the child's de facto other mother, would automatically get custody...but it would only be nice to say, because it wouldn't be true. Mary and Junior are both injured in a car accident and both incapacitated? Guess what--if they live in the wrong state and Alice hasn't officially been invested with healthcare decision-making power for her partner, Alice can't legally make medical decisions for either one of them.
That's when political issues become medical issues, and why a physician with the best interest of the patient at heart must be aware of both.
Now, you might say it's a good thing for children to be raised in intact homes. That's true. There are, however, intact and loving homes that haven't been marked with the state's official seal of approval (ie, a marriage license). Add to that the fact that the parents in some intact and loving homes, by virtue of legislation like Proposition 8 in CA, can NEVER become married--and the fact that various agency representatives in AR have said they basically intend to look the other way on the marriage issue "as long as they ain't queers or nothin'" (OK, so I've dramatized a bit) and you have a message of hate masquerading as concern for child welfare, which makes an already regrettable attitude downright despicable.
Am I saying this on account of the fact that I--at some point in my adolescence--'caught the gay?' Well, yeah, in part. But I'm also saying it because I know gay parents who have only managed to be legally recognized as the parents of their offspring through processes like second-parent adoption, and this sort of law threatens the ability of my tribe to create families. So what's second-parent adoption, you ask? Essentially, Mary and Alice are a couple. Mary gets artificially inseminated, maybe with Alice's egg to make the experience more equally 'shared'--but also a damned sight more confusing. So, Mary gives birth to the baby and is thus listed on the birth certificate. But, lo and behold, there's only space for one parent of each sex on the birth certificate, so Alice is S.O.L. until she secures a second-parent adoption, which establishes her as another mother. OK, I lied, it's not actually that confusing--just frustrating and lame.
So let's say (Goddess forbid) something happens to Mary, and there's no adoption, and no marriage. Well, if Mary listed Alice as the child's next guardian, it's all OK (well, not really, because if Mary's parents don't like it, they can contest it in court and in Arkansas chances are they'd win) and the right person ends up with the kid. But if Mary hasn't made a will? If she hasn't been thinking about her mortality, if her death wasn't anticipated, and she accidentally steps out in front of the 29 bus some morning? It would be nice to say that Alice, as the child's de facto other mother, would automatically get custody...but it would only be nice to say, because it wouldn't be true. Mary and Junior are both injured in a car accident and both incapacitated? Guess what--if they live in the wrong state and Alice hasn't officially been invested with healthcare decision-making power for her partner, Alice can't legally make medical decisions for either one of them.
That's when political issues become medical issues, and why a physician with the best interest of the patient at heart must be aware of both.
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