Visual cortex is organized into discrete sub-regions or areas that are arranged into a hierarchy and serves different functions in the processing of visual information. In retinotopic maps of mouse ...cortex, there appear to be substantial mouse-to-mouse differences in visual area location, size and shape. Here we quantify the biological variation in the size, shape and locations of 11 visual areas in the mouse, after separating biological variation and measurement noise. We find that there is biological variation in the locations and sizes of visual areas.
Photo by Renè Müller on Unsplash
INTRODUCTION
Forced sterilization of women around the globe is a human rights violation and bioethical concern. In the past, countries enacted laws to forcibly ...sterilize women deemed unfit to procreate. Although many of these laws have been retracted, the practice persists under the guise of public health. More recently, women living with HIV have been targets of nonconsensual sterilization. Consent is frequently obtained while under duress or threat or not obtained at all. Nonconsensual sterilization has been documented in Chile, the Dominican Republic, Mexico, Namibia, South Africa, and Venezuela.1 In 2015, three women who were sterilized without consent sued the Supreme Court of Namibia, which did not find evidence that the doctors engaged in discrimination by performing or recommending the procedures due to the patient's HIV status.2
l. What is Forced and Coerced Sterilization?
Forced sterilization is any sterilization that takes place without a patient’s informed consent. In healthcare settings, it occurs when women seeking sexual and reproductive health care are sterilized without their knowledge or the opportunity to provide informed consent. The practice is used as a means of permanent contraception. Surgery is the most common sterilization method. Women may unknowingly have a hysterectomy, the blocking and severing of fallopian tubes, or they may be administered a medication that causes the fallopian tubes to seal, thus preventing fertilization. Nonconsensual sterilization may result from misinformation, financial incentives, or intimidation tactics obliging women to approve of the procedure.3
ll. Namibia: A Case Study
Namibia presents a crucial bioethical injustice despite its perceived legislative success in curbing forced sterilization. In 2008, the International Community of Women Living with HIV/AIDS (ICW) and the Namibian Women’s Health Network (NWHN) documented mass violations of sexual and reproductive health rights. The report recorded breaches of informed consent when testing for HIV, denial of information to women with HIV, and divulging or risking confidential patient information.4
Between 2005 and 2007, three women were coerced into bilateral tubal ligation when seeking reproductive health care. In 2012, the women filed a suit against the Namibian Government for constitutional violations.5 Their claims included infringements of their rights to dignity, liberty, and to make decisions about starting a family. In addition, the women claimed the procedures were discriminatory due to the women’s HIV status. In 2015, the Namibian High Court ruled in the women’s favor and rendered the sterilizations unlawful. However, the Court failed to conclude that the acts were discriminatory. 6
lll. Autonomy
In the traditional Western view of bioethics, autonomy is defined as self-rule, freedom from the control and limitations of others. Autonomy requires informed consent and the absence of coercion. If a person’s choice is based on manipulation, coercion, or compulsion, consent is not truly voluntary, and if it is based on misinformation, it is not informed, violating autonomy.7
Eight hours into labor, a nurse informed one of the plaintiffs that she must undergo a hysterectomy. The plaintiff was presented with official documentation to consent to the procedure, which was not explained to her. The documentation referred only to the sterilization procedure using an abbreviation. She was dependent on the clinician’s assistance in the birthing procedure. She was not aware of the nature of the procedure because she did not understand the options and consequences in the consent document. The healthcare workers made no effort to inform the woman of her right to abstain from the procedure, which she did not understand was a sterilization procedure. She did not learn that she was sterile until returning to the clinic to obtain retroviral medication for her child.8 The consent was neither voluntary nor informed, undermining autonomy.
lV. Beneficence
The principle of beneficence consists of the moral obligation to do good and has been described as requiring one to act for another’s benefit or to further a patient’s interests. What constitutes the patient’s good is related to both the patient’s view of her good and what allows her to pursue her own conceptualization of “good.” Beneficence from a physician’s viewpoint might also concern what the physician thinks is good or best for the patient. Studies asking women, “have there been any positive or good changes in your life ever since you found out that you were sterilized,” report no positive outcomes.9 By ignoring the interests of patients, beneficence is abandoned.
By performing forced sterilizations, healthcare workers deprive women of the right to bear children in the future. This directly violates the notion of prioritizing a patient’s interests. In Namibia, patriarchal cultural values about reproduction, marriage, and child-rearing instill expectations on women to bear and rear children.10 Forcibly sterilizing women ignores heightened cultural pressures and the psychosocial outcomes for women who cannot become pregnant. Sterilization risks discrimination against women with HIV. In addition, a woman who is forcibly sterilized may suffer abuse from a spouse who was excluded from the decision, leading to compounding adverse effects on physical and psychological well-being.
Beneficence also calls for ending discrimination. Coerced sterilization is partly based on mistaken beliefs about vertical HIV transmission.11 Although proper medication can prevent mother-to-child transmission, clinicians who are ill-informed about transmission resort to sterilization.
Women subjected to forced sterilization suffer immense physical harm at clinicians' hands. Consequential physical health problems include heavy menstrual bleeding, severe abdominal pain, and lower limb weakness. These physical health problems increase financial difficulties and the need for health services, placing additional financial, physical, and emotional stress on patients. Clinicians’ disregard for the socio-cultural consequences is non-beneficent and a bioethical lapse. The sterilizations come under the backdrop of pervasive victimization of women, discrimination, and gender-based violence, made worse in the aftermath of sterilization.12
Among women forcibly sterilized in Latin American countries, pregnant women with HIV are six times more likely to be forcibly sterilized than pregnant women with HIV whose diagnosis was unknown to themselves and their physicians.13 Equivalent findings have been documented in Southern Africa.14 By perpetuating HIV-discriminatory beliefs that deem women unworthy of reproduction, clinicians subject patients to harmful discrimination and freely discount the principle of justice.
V. Through a Human Rights Lens
Nonconsensual sterilization is recognized as an “act of torture, and cruel, inhumane, and degrading treatment” by the United Nations Human Rights Committee. Torture is defined as intentionally inflicted suffering on a person for an improper purpose or if that purpose is based on discrimination. 15 The United Nations has condemned forced sterilization as a violation of the rights to health, bodily integrity, freedom from violence, freedom from torture, freedom from discrimination, and to decide the number and spacing of their children. The right to health is guaranteed under the International Covenant on Economic, Social, and Cultural Rights (ICESCR).
The right to information is guaranteed under The International Covenant on Civil and Political Rights (ICCPR).16 There is also a long recognized right to informed consent under which healthcare practitioners provide the information necessary for people to make an informed choice. Practitioners must disclose the risks and benefits of a procedure. In the actions leading to the 2015 lawsuit in Namibia, the women were unaware that they had been made sterile until they returned to a healthcare facility. They had not been given a choice. The doctors told them they ‘must’ undergo the procedure. The clinicians failed to provide clear and comprehensible information and did not confirm that the patients understood the consequences of the process.
Using the patient care framework (HRPC), healthcare facilities and governments can reduce stigma and discrimination. HRPC acknowledges the systematic nature of forced and coerced sterilization and calls for seeking out and trying to eliminate involuntary and coerced sterilization. To comply with the HRPC, countries must investigate and abolish all instances of coerced sterilization in an effective and just manner.
In the courts, better human rights argumentation and the ability to challenge legal deficiencies would improve plaintiffs’ ability to win cases.
CONCLUSION
The bioethics community should take action to end coerced sterilizations as they violate the four principles of bioethics set forth by Beauchamp and Childress. In Namibia, the case of the three plaintiffs demonstrates the need for more bioethical attention, as the disregard for autonomy, beneficence, nonmaleficence, and justice were clear. Employing a human rights framework emphasizes the structural origins of the practice and calls for governments to seek out and end coerced sterilization. If coerced sterilization does occur, courts that prosecute it can be a deterrent and can work toward righting the wrong through the justice system.
-
1 Open Society Foundations, “Against Her Will: Forced and Coerced Sterilization of Women Worldwide.”, (2011): 2-10 (accessed August).
2 Nyasha Chingore-Munazvo, Katherine Furman, Annabel Raw and Mariette Slabbert, “Chronicles of communication and power: informed consent to sterilisation in the Namibian Supreme Court’s LM judgment of 2015,” Theoretical Med Bioethics 38 (April 2017): 145-162, https://doi.org/
Photo by Renè Müller on Unsplash INTRODUCTION Forced sterilization of women around the globe is a human rights violation and bioethical concern. In the past, countries enacted laws to forcibly ...sterilize women deemed unfit to procreate. Although many of these laws have been retracted, the practice persists under the guise of public health. More recently, women living with HIV have been targets of nonconsensual sterilization. Consent is frequently obtained while under duress or threat or not obtained at all. Nonconsensual sterilization has been documented in Chile, the Dominican Republic, Mexico, Namibia, South Africa, and Venezuela.1 In 2015, three women who were sterilized without consent sued the Supreme Court of Namibia, which did not find evidence that the doctors engaged in discrimination by performing or recommending the procedures due to the patient's HIV status.2 l. What is Forced and Coerced Sterilization? Forced sterilization is any sterilization that takes place without a patient’s informed consent. In healthcare settings, it occurs when women seeking sexual and reproductive health care are sterilized without their knowledge or the opportunity to provide informed consent. The practice is used as a means of permanent contraception. Surgery is the most common sterilization method. Women may unknowingly have a hysterectomy, the blocking and severing of fallopian tubes, or they may be administered a medication that causes the fallopian tubes to seal, thus preventing fertilization. Nonconsensual sterilization may result from misinformation, financial incentives, or intimidation tactics obliging women to approve of the procedure.3 ll. Namibia: A Case Study Namibia presents a crucial bioethical injustice despite its perceived legislative success in curbing forced sterilization. In 2008, the International Community of Women Living with HIV/AIDS (ICW) and the Namibian Women’s Health Network (NWHN) documented mass violations of sexual and reproductive health rights. The report recorded breaches of informed consent when testing for HIV, denial of information to women with HIV, and divulging or risking confidential patient information.4 Between 2005 and 2007, three women were coerced into bilateral tubal ligation when seeking reproductive health care. In 2012, the women filed a suit against the Namibian Government for constitutional violations.5 Their claims included infringements of their rights to dignity, liberty, and to make decisions about starting a family. In addition, the women claimed the procedures were discriminatory due to the women’s HIV status. In 2015, the Namibian High Court ruled in the women’s favor and rendered the sterilizations unlawful. However, the Court failed to conclude that the acts were discriminatory. 6 lll. Autonomy In the traditional Western view of bioethics, autonomy is defined as self-rule, freedom from the control and limitations of others. Autonomy requires informed consent and the absence of coercion. If a person’s choice is based on manipulation, coercion, or compulsion, consent is not truly voluntary, and if it is based on misinformation, it is not informed, violating autonomy.7 Eight hours into labor, a nurse informed one of the plaintiffs that she must undergo a hysterectomy. The plaintiff was presented with official documentation to consent to the procedure, which was not explained to her. The documentation referred only to the sterilization procedure using an abbreviation. She was dependent on the clinician’s assistance in the birthing procedure. She was not aware of the nature of the procedure because she did not understand the options and consequences in the consent document. The healthcare workers made no effort to inform the woman of her right to abstain from the procedure, which she did not understand was a sterilization procedure. She did not learn that she was sterile until returning to the clinic to obtain retroviral medication for her child.8 The consent was neither voluntary nor informed, undermining autonomy. lV. Beneficence The principle of beneficence consists of the moral obligation to do good and has been described as requiring one to act for another’s benefit or to further a patient’s interests. What constitutes the patient’s good is related to both the patient’s view of her good and what allows her to pursue her own conceptualization of “good.” Beneficence from a physician’s viewpoint might also concern what the physician thinks is good or best for the patient. Studies asking women, “have there been any positive or good changes in your life ever since you found out that you were sterilized,” report no positive outcomes.9 By ignoring the interests of patients, beneficence is abandoned. By performing forced sterilizations, healthcare workers deprive women of the right to bear children in the future. This directly violates the notion of prioritizing a patient’s interests. In Namibia, patriarchal cultural values about reproduction, marriage, and child-rearing instill expectations on women to bear and rear children.10 Forcibly sterilizing women ignores heightened cultural pressures and the psychosocial outcomes for women who cannot become pregnant. Sterilization risks discrimination against women with HIV. In addition, a woman who is forcibly sterilized may suffer abuse from a spouse who was excluded from the decision, leading to compounding adverse effects on physical and psychological well-being. Beneficence also calls for ending discrimination. Coerced sterilization is partly based on mistaken beliefs about vertical HIV transmission.11 Although proper medication can prevent mother-to-child transmission, clinicians who are ill-informed about transmission resort to sterilization. Women subjected to forced sterilization suffer immense physical harm at clinicians' hands. Consequential physical health problems include heavy menstrual bleeding, severe abdominal pain, and lower limb weakness. These physical health problems increase financial difficulties and the need for health services, placing additional financial, physical, and emotional stress on patients. Clinicians’ disregard for the socio-cultural consequences is non-beneficent and a bioethical lapse. The sterilizations come under the backdrop of pervasive victimization of women, discrimination, and gender-based violence, made worse in the aftermath of sterilization.12 Among women forcibly sterilized in Latin American countries, pregnant women with HIV are six times more likely to be forcibly sterilized than pregnant women with HIV whose diagnosis was unknown to themselves and their physicians.13 Equivalent findings have been documented in Southern Africa.14 By perpetuating HIV-discriminatory beliefs that deem women unworthy of reproduction, clinicians subject patients to harmful discrimination and freely discount the principle of justice. V. Through a Human Rights Lens Nonconsensual sterilization is recognized as an “act of torture, and cruel, inhumane, and degrading treatment” by the United Nations Human Rights Committee. Torture is defined as intentionally inflicted suffering on a person for an improper purpose or if that purpose is based on discrimination. 15 The United Nations has condemned forced sterilization as a violation of the rights to health, bodily integrity, freedom from violence, freedom from torture, freedom from discrimination, and to decide the number and spacing of their children. The right to health is guaranteed under the International Covenant on Economic, Social, and Cultural Rights (ICESCR). The right to information is guaranteed under The International Covenant on Civil and Political Rights (ICCPR).16 There is also a long recognized right to informed consent under which healthcare practitioners provide the information necessary for people to make an informed choice. Practitioners must disclose the risks and benefits of a procedure. In the actions leading to the 2015 lawsuit in Namibia, the women were unaware that they had been made sterile until they returned to a healthcare facility. They had not been given a choice. The doctors told them they ‘must’ undergo the procedure. The clinicians failed to provide clear and comprehensible information and did not confirm that the patients understood the consequences of the process. Using the patient care framework (HRPC), healthcare facilities and governments can reduce stigma and discrimination. HRPC acknowledges the systematic nature of forced and coerced sterilization and calls for seeking out and trying to eliminate involuntary and coerced sterilization. To comply with the HRPC, countries must investigate and abolish all instances of coerced sterilization in an effective and just manner. In the courts, better human rights argumentation and the ability to challenge legal deficiencies would improve plaintiffs’ ability to win cases. CONCLUSION The bioethics community should take action to end coerced sterilizations as they violate the four principles of bioethics set forth by Beauchamp and Childress. In Namibia, the case of the three plaintiffs demonstrates the need for more bioethical attention, as the disregard for autonomy, beneficence, nonmaleficence, and justice were clear. Employing a human rights framework emphasizes the structural origins of the practice and calls for governments to seek out and end coerced sterilization. If coerced sterilization does occur, courts that prosecute it can be a deterrent and can work toward righting the wrong through the justice system. - 1 Open Society Foundations, “Against Her Will: Forced and Coerced Sterilization of Women Worldwide.”, (2011): 2-10 (accessed August). 2 Nyasha Chingore-Munazvo, Katherine Furman, Annabel Raw and Mariette Slabbert, “Chronicles of communication and power: informed consent to sterilisation in the Namibian Supreme Court’s LM judgment of 2015,” Theoretical Med Bioethics 38 (April 2017): 145-162, https://doi.org/
Photo by Reproductive Health Supplies Coalition on Unsplash
INTRODUCTION
Emergency contraception is formally recognized as the only effective way to prevent pregnancy after sexual intercourse by the ...World Health Organization.1 The word emergency is used due to the brief time during which it is efficacious. It is useful only when administered within 72 hours of a sexual encounter.2 When pharmacists withhold emergency contraception, they permanently eliminate the only window of opportunity in which the emergency contraception can take effect. If patients do not find another source of contraception, they may become pregnant. Yet, both abortion and pregnancy present more risks to patient health than emergency contraception.3 Conscientious objection deserves heightened scrutiny. In light of both Dobbs v. Jackson Women’s Health Organization4(allowing states to limit access to abortion) and the COVID-19 pandemic, emergency contraception is an important tool that people must be able to access to prevent pregnancy.
ANALYSIS
So why are providers allowed to bar access to such invaluable care? Conscientious objection is the refusal to perform a task because of a personal value or belief. Conscientious objection to the dispensing of emergency contraception is legal in several states including Idaho, Arkansas, Georgia, Missouri, Arizona, and South Dakota.5 There are no exceptions made for sexual assault. In Texas, which also permits pharmacists to refuse to distribute emergency contraception, there were 13,509 forcible rape cases in 2020, the highest number in all fifty states.6 With many states imposing strict limits on accessing abortion care, emergency contraception is more important than ever. Emergency contraception is also an important tool for people who oppose abortion for themselves, but whose health would be endangered by a pregnancy. Conscientious objection to emergency contraception considering Dobbs could be even more punitive to women who need or wish to avoid pregnancy. Once pregnant, women in some states may have few options. Emergency contraception also avoids the moral conundrum that abortion creates for many pregnant women. Avoiding pregnancy is generally far safer, simpler, and less morally charged than abortion care.
Advocates supporting conscientious objection frequently mistake emergency contraception for an abortifacient. However, emergency contraception does not terminate a pregnancy. Instead, it prevents fertilization or implantation from occurring. Some argue that distinction should negate religious rationales.7 However, religion is a common rationale for conscientious objection to providing emergency contraception.
In the initial months of the government-mandated COVID-19 lockdown, rates of sexual assault and rape escalated.8 Rape crisis centers surveyed across the country reported a 40 percent increase in demand for their services.9 Societal repercussions of COVID-19 include economic insecurity, social isolation, quarantine, and job loss, all of which have been associated with an increased risk for sexual assault.10 In the context of strained hospital resources and limited in-person medical and mental health resources, access to emergency contraception became increasingly important for sexual assault victims during the pandemic.
Several arguments have been set forth to justify placing limitations on conscientious objection.11 First, pharmacists choose to enter a profession bound by fiduciary duties. These duties demand that pharmacists respect the autonomy and dignity of individual patients.12 A pharmacist that withholds emergency contraception is infringing on a patient’s autonomy. Secondly, pharmacists are expected to prioritize the needs of their patients over their own. The principle of beneficence obligates clinicians to act in the interests of their patients.9 In the act of requesting emergency contraception, patients express their intentions and interests. A pharmacist’s denial of emergency contraception violates the principle of beneficence and directly counters patient interests. States allowing pharmacists to withhold emergency care risk contributing to increasing rates of unwanted pregnancies. They fail to recognize the wrongdoing to patients by prioritizing the rights of the withholding pharmacists over the rights of people seeking emergency contraception.
Denying patient access to emergency contraception neglects the principle of nonmaleficence, as this objection significantly compromises patient health. Patients denied contraception after sexual assault face increased mental and physical health risks. COVID-19 exacerbated the risk of psychological harms as social isolation impacted rates of anxiety and depression.13
COVID-19 further exposed social and political unrest, racial and other forms of discrimination, and widening health disparities.14 Sexual and reproductive health services were scaled back and essential support services including hotlines, crisis centers, protection, and counseling services were disrupted.15 The limitations disproportionately burdened patients who lack access to alternative healthcare channels.16 For example, patients in rural settings may not have access to the alternative healthcare channels available in metropolitan or suburban settings.
Counterarguments include that pharmacists deserve autonomy. Forcing them to provide emergency contraception infringes the pharmacist’s ability to make an autonomous decision. However, emergency contraception is significantly different from other types of birth control pills due to the rushed timeframe. A pharmacists’ refusal to dispense emergency contraception imposes the pharmacist’s moral and social values on patients who are in immediate need of care. If pharmacists choose to prioritize their own social and moral values above their professional duties, they fail to fulfil their job obligations. One solution, or middle ground, would be allowing the objector to recommend a nearby pharmacy as long as there is one that is open and convenient. Many support that stance despite its inconveniencing the patient. Other alternatives may entail pharmacists switching shifts to times when emergency contraception is least in demand or working in groups to avoid personally dispensing emergency contraception. Yet, absent these simple alternatives, conscientious objection that causes a person to become pregnant who otherwise would not have is ethically impermissible.
CONCLUSION
In conclusion, conscientious objection to emergency contraception should be eliminated, especially considering the other hardships posed by the pandemic. Conscientious objection of emergency contraception under the circumstances of COVID-19 is an unethical stance that violates the bioethical principles of autonomy, beneficence, nonmaleficence, and justice.
-
1 World Health Organization. 2014. “Emergency contraception.” World Health Organization, November 28, 2014. https://www.who.int/reproductivehealth/topics/family_planning/ec/en/
2 Cu-IUDs are highly effective as emergency contraception (283) and can be continued as regular contraception. UPA and levonorgestrel ECPs have similar effectiveness when taken within 3 days after unprotected sexual intercourse; however, UPA has been shown to be more effective than the levonorgestrel formulation 3–5 days after unprotected sexual intercourse Glasier AF, Cameron ST, Fine PM, et al. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. Lancet 2010;375:555–62. http://dx. doi. org/10. 1016/S0140-6736(10)60101-8external iconPubMedexternal icon. Raymond E, Taylor D, Trussell J, Steiner MJ. Minimum effectiveness of the levonorgestrel regimen of emergency contraception. Contraception 2004;69:79–81. http://dx. doi. org/10. 1016/j. contraception. 2003. 09. 013external icon
3 American College of Obstetricians and Gynecologists. 2019. “Access to emergency contraception.” ACOG, December 2019. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/07/access-to-emergency-contraception
4 597 US _ (2022)
5 National Conference of State Legislators. 2018. “Pharmacist conscience clauses: Laws and information.” National Conference of State Legislators, September, 2018. https://www.ncsl.org/research/health/pharmacist-conscience-clauses-laws-and-information.aspx
6 Statistica. 2021. “Total number of forcible rape cases reported in the United States in 2020, by state.” Statista, June 30, 2021. https://www.statista.com/statistics/232524/forcible-rape-cases-in-the-us-by-state/
7 Planned Parenthood. 2016. “Difference between the morning-after pill and the abortion.” Planned Parenthood, 2016. https://www.plannedparenthood.org/files/3914/6012/8466/Difference_Between_the_Morning-After_Pill_and_the_Abortion_Pill.pdf
8 Katherine A. Muldoon et al. “COVID-19 pandemic and violence.”
9 Taylor Walker. 2020. “A second, silent pandemic: Sexual violence in the time of covid-19.” Primary Care Review, May 1, 2020. http://info.primarycare.hms.harvard.edu/review/sexual-violence-and-covid
10Katherine A. Muldoon et al. “COVID-19 pandemic and violence.” BMC Med, February 5, 2021. https://doi.org/10.1186/s12916-020-01897-z
11 Beauchamp TL, Childress JF. Principles of biomedical ethics, 5th ed. New York City, NY: Oxford University Press; 2001.
12 Ken Baum and Julie Cantor. 2004. “The Limits of Conscientious Objection – May Pharmacists Refuse to Fill Prescriptions for Emergency Contraception.” New England Journal of Medicine, November 4, 2004. https://www.nejm.org/doi/full/10.1056/nejmsb042263
13 Min Luo et al. 2020. “The psychological and mental impact of coronavirus disease 2019 (COVID-19) on medical staff and general public - A systematic review and meta-analysis.” Psychiatry Research, Sep. 2020. https://doi.org/10.1016/j.psychres.2020.113190
14 Tai, D., Shah, A., Doubeni, C. A., Sia, I. G., & Wieland, M. L.
Photo by Reproductive Health Supplies Coalition on Unsplash INTRODUCTION Emergency contraception is formally recognized as the only effective way to prevent pregnancy after sexual intercourse by the ...World Health Organization.1 The word emergency is used due to the brief time during which it is efficacious. It is useful only when administered within 72 hours of a sexual encounter.2 When pharmacists withhold emergency contraception, they permanently eliminate the only window of opportunity in which the emergency contraception can take effect. If patients do not find another source of contraception, they may become pregnant. Yet, both abortion and pregnancy present more risks to patient health than emergency contraception.3 Conscientious objection deserves heightened scrutiny. In light of both Dobbs v. Jackson Women’s Health Organization4(allowing states to limit access to abortion) and the COVID-19 pandemic, emergency contraception is an important tool that people must be able to access to prevent pregnancy. ANALYSIS So why are providers allowed to bar access to such invaluable care? Conscientious objection is the refusal to perform a task because of a personal value or belief. Conscientious objection to the dispensing of emergency contraception is legal in several states including Idaho, Arkansas, Georgia, Missouri, Arizona, and South Dakota.5 There are no exceptions made for sexual assault. In Texas, which also permits pharmacists to refuse to distribute emergency contraception, there were 13,509 forcible rape cases in 2020, the highest number in all fifty states.6 With many states imposing strict limits on accessing abortion care, emergency contraception is more important than ever. Emergency contraception is also an important tool for people who oppose abortion for themselves, but whose health would be endangered by a pregnancy. Conscientious objection to emergency contraception considering Dobbs could be even more punitive to women who need or wish to avoid pregnancy. Once pregnant, women in some states may have few options. Emergency contraception also avoids the moral conundrum that abortion creates for many pregnant women. Avoiding pregnancy is generally far safer, simpler, and less morally charged than abortion care. Advocates supporting conscientious objection frequently mistake emergency contraception for an abortifacient. However, emergency contraception does not terminate a pregnancy. Instead, it prevents fertilization or implantation from occurring. Some argue that distinction should negate religious rationales.7 However, religion is a common rationale for conscientious objection to providing emergency contraception. In the initial months of the government-mandated COVID-19 lockdown, rates of sexual assault and rape escalated.8 Rape crisis centers surveyed across the country reported a 40 percent increase in demand for their services.9 Societal repercussions of COVID-19 include economic insecurity, social isolation, quarantine, and job loss, all of which have been associated with an increased risk for sexual assault.10 In the context of strained hospital resources and limited in-person medical and mental health resources, access to emergency contraception became increasingly important for sexual assault victims during the pandemic. Several arguments have been set forth to justify placing limitations on conscientious objection.11 First, pharmacists choose to enter a profession bound by fiduciary duties. These duties demand that pharmacists respect the autonomy and dignity of individual patients.12 A pharmacist that withholds emergency contraception is infringing on a patient’s autonomy. Secondly, pharmacists are expected to prioritize the needs of their patients over their own. The principle of beneficence obligates clinicians to act in the interests of their patients.9 In the act of requesting emergency contraception, patients express their intentions and interests. A pharmacist’s denial of emergency contraception violates the principle of beneficence and directly counters patient interests. States allowing pharmacists to withhold emergency care risk contributing to increasing rates of unwanted pregnancies. They fail to recognize the wrongdoing to patients by prioritizing the rights of the withholding pharmacists over the rights of people seeking emergency contraception. Denying patient access to emergency contraception neglects the principle of nonmaleficence, as this objection significantly compromises patient health. Patients denied contraception after sexual assault face increased mental and physical health risks. COVID-19 exacerbated the risk of psychological harms as social isolation impacted rates of anxiety and depression.13 COVID-19 further exposed social and political unrest, racial and other forms of discrimination, and widening health disparities.14 Sexual and reproductive health services were scaled back and essential support services including hotlines, crisis centers, protection, and counseling services were disrupted.15 The limitations disproportionately burdened patients who lack access to alternative healthcare channels.16 For example, patients in rural settings may not have access to the alternative healthcare channels available in metropolitan or suburban settings. Counterarguments include that pharmacists deserve autonomy. Forcing them to provide emergency contraception infringes the pharmacist’s ability to make an autonomous decision. However, emergency contraception is significantly different from other types of birth control pills due to the rushed timeframe. A pharmacists’ refusal to dispense emergency contraception imposes the pharmacist’s moral and social values on patients who are in immediate need of care. If pharmacists choose to prioritize their own social and moral values above their professional duties, they fail to fulfil their job obligations. One solution, or middle ground, would be allowing the objector to recommend a nearby pharmacy as long as there is one that is open and convenient. Many support that stance despite its inconveniencing the patient. Other alternatives may entail pharmacists switching shifts to times when emergency contraception is least in demand or working in groups to avoid personally dispensing emergency contraception. Yet, absent these simple alternatives, conscientious objection that causes a person to become pregnant who otherwise would not have is ethically impermissible. CONCLUSION In conclusion, conscientious objection to emergency contraception should be eliminated, especially considering the other hardships posed by the pandemic. Conscientious objection of emergency contraception under the circumstances of COVID-19 is an unethical stance that violates the bioethical principles of autonomy, beneficence, nonmaleficence, and justice. - 1 World Health Organization. 2014. “Emergency contraception.” World Health Organization, November 28, 2014. https://www.who.int/reproductivehealth/topics/family_planning/ec/en/ 2 Cu-IUDs are highly effective as emergency contraception (283) and can be continued as regular contraception. UPA and levonorgestrel ECPs have similar effectiveness when taken within 3 days after unprotected sexual intercourse; however, UPA has been shown to be more effective than the levonorgestrel formulation 3–5 days after unprotected sexual intercourse Glasier AF, Cameron ST, Fine PM, et al. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. Lancet 2010;375:555–62. http://dx. doi. org/10. 1016/S0140-6736(10)60101-8external iconPubMedexternal icon. Raymond E, Taylor D, Trussell J, Steiner MJ. Minimum effectiveness of the levonorgestrel regimen of emergency contraception. Contraception 2004;69:79–81. http://dx. doi. org/10. 1016/j. contraception. 2003. 09. 013external icon 3 American College of Obstetricians and Gynecologists. 2019. “Access to emergency contraception.” ACOG, December 2019. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/07/access-to-emergency-contraception 4 597 US _ (2022) 5 National Conference of State Legislators. 2018. “Pharmacist conscience clauses: Laws and information.” National Conference of State Legislators, September, 2018. https://www.ncsl.org/research/health/pharmacist-conscience-clauses-laws-and-information.aspx 6 Statistica. 2021. “Total number of forcible rape cases reported in the United States in 2020, by state.” Statista, June 30, 2021. https://www.statista.com/statistics/232524/forcible-rape-cases-in-the-us-by-state/ 7 Planned Parenthood. 2016. “Difference between the morning-after pill and the abortion.” Planned Parenthood, 2016. https://www.plannedparenthood.org/files/3914/6012/8466/Difference_Between_the_Morning-After_Pill_and_the_Abortion_Pill.pdf 8 Katherine A. Muldoon et al. “COVID-19 pandemic and violence.” 9 Taylor Walker. 2020. “A second, silent pandemic: Sexual violence in the time of covid-19.” Primary Care Review, May 1, 2020. http://info.primarycare.hms.harvard.edu/review/sexual-violence-and-covid 10Katherine A. Muldoon et al. “COVID-19 pandemic and violence.” BMC Med, February 5, 2021. https://doi.org/10.1186/s12916-020-01897-z 11 Beauchamp TL, Childress JF. Principles of biomedical ethics, 5th ed. 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Melatonin is an endogenous hormone primarily known for its action on the circadian rhythms. But pre-clinical studies are reporting both its radioprotective and radiosensitizing properties, possibly ...mediated through an interaction between melatonin and the regulation of estrogens. Melatonin pre-treatment prior to ionizing radiation was associated with a decrease in cell proliferation and an increase in p53 mRNA expression, leading to an increase in the radiosensitivity of breast cancer cells. At the same time, a decrease in radiation-induced side effects was described in breast cancer patients and in rodent models. This review examines the potential for melatonin to improve the therapeutic outcomes of breast radiation therapy, specifically estrogen receptor positive patients. Evidence suggests that melatonin may offer a novel, non-toxic and cheap adjuvant therapy to improve the existing treatment modalities. But further research is required in the clinical setting before a clear understanding of its therapeutic benefits is determined.
To understand how the brain processes sensory information to guide behavior, we must know how stimulus representations are transformed throughout the visual cortex. Here we report an open, ...large-scale physiological survey of activity in the awake mouse visual cortex: the Allen Brain Observatory Visual Coding dataset. This publicly available dataset includes the cortical activity of nearly 60,000 neurons from six visual areas, four layers, and 12 transgenic mouse lines in a total of 243 adult mice, in response to a systematic set of visual stimuli. We classify neurons on the basis of joint reliabilities to multiple stimuli and validate this functional classification with models of visual responses. While most classes are characterized by responses to specific subsets of the stimuli, the largest class is not reliably responsive to any of the stimuli and becomes progressively larger in higher visual areas. These classes reveal a functional organization wherein putative dorsal areas show specialization for visual motion signals.
Despite recent advances, there is still a major need to better understand the interactions between brain function and chronic gut inflammation and its clinical implications. Alterations in executive ...function have previously been identified in several chronic inflammatory conditions, including inflammatory bowel diseases. Inflammation-associated brain alterations can be captured by connectome analysis. Here, we used the resting-state fMRI data from 222 participants comprising three groups (ulcerative colitis (UC), irritable bowel syndrome (IBS), and healthy controls (HC), N = 74 each) to investigate the alterations in functional brain wiring and cortical stability in UC compared to the two control groups and identify possible correlations of these alterations with clinical parameters. Globally, UC participants showed increased functional connectivity and decreased modularity compared to IBS and HC groups. Regionally, UC showed decreased eigenvector centrality in the executive control network (UC < IBS < HC) and increased eigenvector centrality in the visual network (UC > IBS > HC). UC also showed increased connectivity in dorsal attention, somatomotor network, and visual networks, and these enhanced subnetwork connectivities were able to distinguish UC participants from HCs and IBS with high accuracy. Dynamic functional connectome analysis revealed that UC showed enhanced cortical stability in the medial prefrontal cortex (mPFC), which correlated with severe depression and anxiety-related measures. None of the observed brain changes were correlated with disease duration. Together, these findings are consistent with compromised functioning of networks involved in executive function and sensory integration in UC.
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