Standard Procedures

I am standing in the waiting room of the ultrasound clinic, speaking with my doctor on the phone. She is telling me that I need to walk out of the clinic and into a hospital. She will meet me there, she says, and I will get the best possible care, the medical standard. A doctor will inject me with chemotherapy drugs, even though I do not have cancer, because those drugs were developed to target rapidly dividing cells, cells growing much faster than any grown-up does. In my case, the target of those cells isn’t a tumor, but a baby.

What my Bump app reports with delight—“Your baby is developing and doubling in size! It’s a poppy seed! An apple seed! A sweet pea!”—is exactly what the drugs would use to find their target. Methotrexate is intended to dissolve the baby as though it had been dunked in lye. Or maybe it just dissolves the outer cells that bind the baby in the wrong place—in the fallopian tubes, not the womb—and the baby will be released from the home it’s found to pass out of my body whole. It’s the kind of thing that it’s hard for science to be sure of.

But my doctor sounds very sure on the phone. Just as she was firm and urgent when she called me in to the emergency ultrasound. I was on a train—she asked me to get off and turn around—I didn’t. I was about to interview someone for a feature—she asked me to leave—I did. When she lays out my options, there really is just one option: the standard of reproductive care. But I have two reasons to say no: I am a Catholic and I am a statistician.

It was faith and reason, the two ways of knowing that St. John Paul II called the “two wings on which the human spirit rises to the contemplation of truth,” that led me to dig in my heels during my third miscarriage. And it was faith and reason that left me frustrated when I read Susan Berke Fogel’s description of religious health exemptions in a FiveThirtyEight feature on Catholic hospitals. Fogel, a director at the National Health Law Program who specializes in reproductive healthcare, takes the position that any exemption from the most common medical practice is, by definition, a substandard level of patient care. According to the feature writers Anna Maria Barry-Jester and Amelia Thomson-DeVeaux, Fogel “finds [exemptions] troubling, because religious exemptions are just that: exceptions to standards that were set by the medical profession to ensure that doctors are giving patients the best possible care. ‘What [religious hospitals] are getting is permission not to meet those standards,’ said Fogel.”

But you don’t have to be Catholic and concerned for the life of the baby alongside the mother to be a little suspicious that the standard of care isn’t always ordered to all patients’ good. When I pushed back against my doctor’s recommendation, I did so in purely secular terms. I knew what she hadn’t bothered to mention yet: that methotrexate is a threat to future pregnancies—I’d have to avoid conceiving for at least three months. And, according to the white papers I’d been staying up to read since my initial diagnosis, somewhere in the range of 50 percent of women with pregnancies outside the uterus miscarry naturally and safely. I was likely to be one of those women, at least as long as my pregnancy hormone stayed below a critical threshold, as it had so far.

I said all this calmly and precisely to the doctor. I was using exactly the tone that hadn’t been as fitting when I told a friend, “Looking at the numbers, it’s not that I expect I’m going to die, it’s that if we knew I’d die in the next two weeks, we’d have a better than usual guess of why.” But here, that flattened, just-the-facts tone won me an exemption. The doctor was clear with me that she thought I was choosing the worse option, forgoing a definitive solution in favor of a risk. But she backed off and, after another week or so of every-other-day blood tests that left me black and blue, we were able to say goodbye to baby Blaise at home, without any further medical intervention.

My spine was steeled as much by Emily Oster’s data-driven Expecting Better as by Philippians 1:21-23. Oster is frank in a way that doctors and anxious mommy forums often are not: There is never a completely safe path that will guarantee your (or your baby’s) safety. Medicine is about balancing (at best) or redistributing (at worst) risk. And, depending on individuals’ tolerance for risk, or what outcomes they want most to avoid, the best medical care won’t be a single standard, but a range of options.

Unfortunately, woman after woman after woman after woman has a story of not being given the room to dissent from a standard of care that is designed for the aggregate but ignores the individual. In some ways, I had the simpler problem—it’s easier to refuse treatment than to demand it (the problem facing women with endometriosis, for example). But it was hardly my first experience of medicine’s rounding off the edges of an individual case to reduce a woman to a more tractable problem.

When I presented the symptoms of PCOS in high school, my doctor sent me in for my first ultrasound. And then she recommended the pill. The artificial cycle of hormones wouldn’t give me a normal menstrual cycle, it would just mask the fact that something was out of whack at an underlying level. But, with regular bleeding, the problem would count as solved.

That didn’t sound like a great proposition to teenaged me, so I declined. And I was glad I had by the time I was married and tracking my fertility, using methods designed for the individual, not the aggregate. I’ve passed my copy of Taking Charge of Your Fertility to non-Catholic friends, too, who have no moral concerns about contraception, but feel that they also benefit from the adaptability of Natural Family Planning.

For their purposes, it doesn’t matter too much whether Catholic interest in the variability of women’s cycles is the result of an alternate claim about the purpose of sex or not. All they care about is that NFP fills a lacuna in mainstream care—it’s a safety net for anyone who isn’t the median patient for whom the standard care was designed.

Any exemption or deviation may be good or bad. But I can’t place my faith in the claim that the standards of care are so trustworthy that doctors exploring alternative avenues are necessarily shortchanging their patients. The discipline of medicine (like most medical treatments) is an art of dynamic tension. Tomorrow’s standards of care will be shaped by today’s fights over what, exactly, each patient needs. The breakthroughs come from the shepherd who seeks his one lost sheep, refusing to be satisfied by the way the standard worked for the ninety-nine.

Leah Libresco Sargeant is the author of Arriving at Amen and Building the Benedict Option.