By U. Gunnar. Southern Oregon State College.
Bewley maintains that the regulation of women who have chosen to maintain their pregnancy is also Introduction 5 adiVerent question from the abortion debate buy kamagra gold 100 mg without a prescription erectile dysfunction treatment forums. The concepts which have evolved in the abortion literature are not really relevant to the clinician’s dilemma in dealing with a drug-using pregnant patient buy cheap kamagra gold 100mg online impotence and age. In attempting to develop a conceptual framework which Wts this particular clinical situation, Bewley draws on Frankfurt’s distinction between Wrst- and second-order desires (Frankfurt, 1971). Bewley’s article is a model for what this book tries to achieve – the marriage of analytical and clinical arguments, put forward by a philosophi- cally and legally aware clinician. The British medical lawyer Jean McHale (Chapter 6) likewise considers the manner in which ‘pregnancy over the last decade has become policed by those who advocate responsible motherhood’. As more widespread genetic information becomes available, she warns, ‘it is likely to render us increasing- ly critical of those who make what we regard as being the ‘‘wrong’’ decision in relation to reproduction’. McHale is sceptical of this argument, suggesting that codes of practice stressing parental duties not to reproduce unless the oVspring meet certain criteria are really just rationing tools. The argument that it is unfair for society to bear the ‘costs’ of the couple’s penchant for reproduction, if their children are likely to be handi- capped, meets with no friendlier reception from her. Pressing on beyond these politically motivated arguments, McHale asks whether there could conceivably be any remedy in law for enforcing a ‘right not to be born’. In a previous book, Breaking the Abortion Deadlock: From Choice to Consent (1996), McDonagh sought to unite opponents and proponents of abortion behind an argument justifying abortion not in terms of the woman’s right to choose, but of her consent to further continuation of the pregnancy. Conceding fetal personhood in ar- guendo, as most pro-choice activists do not, McDonagh argued that even if the fetus were a person, its claims would not necessarily ‘trump’ the mother’s right to withhold consent to continuing the pregnancy and giving birth. Dickenson again breaks down the barriers between feminist and antifeminist arguments: ‘The problem of abortion has been deWned by pro-life activists (as we would expect), but also by pro-choice advocates (as we might not expect) on the basis of a very traditional model of motherhood, one invoking cultural and ethical depictions of women as maternal, self-sacriWcing nurturers’. That is, by stressing the way in which unwanted pregnancy forces women into the stereotype of sacriWcial victims, the model of motherhood used by pro- abortion campaigners is actually deeply conservative, and possibly counter- productive. McDonagh’s chapter, like Daniels’s, takes this section of the book out of the conWnes of the dyadic doctor–patient relationship and into the political arena. By contrast, Franc¸oise Baylis and Susan Sherwin (Chapter 18) extend the political power dimension into a very familiar and ‘ordinary’ side of the obstetrician–patient encounter – ‘non-compliance’. Baylis and Sherwin draw our attention to the way in which this apparently value-free term is used to reinforce the physician’s power and to label the patient as an object of concern rather than a partner in the clinical relationship. In some instances, however, failure to follow professional recommendations elicits pejorative judgements of non-compliance, and while these judgements are provoked by a failure to comply with speciWc advice, typically they are applied to the patient as a whole’. By alerting the conscientious practitioner to the ubiquitous presence of ethical issues, Baylis and Sherwin help to counteract the popular media assumption that the only serious questions in reproductive ethics are those about new technologies. The impact of new technologies and new diseases The questions asked by McHale about limiting the rhetoric of responsible parenting recur in a more technology-driven form in the chapter by the American philosopher and feminist theorist Rosemarie Tong (Chapter 5). Likewise, the aims of medicine may conceivably be extended from doing no harm to this particular mother and fetus to producing the best babies possible. As Tong remarks, physicians are unable to resist patient demands for genetic enhancement because there is no Introduction 7 generally agreed set of aims of medicine with which to counter such demands – ‘Medicine, it has been argued, is simply a set of techniques and tools that can be used to attain whatever ends people have; and physicians and other health care practitioners are simply technicians who exist to please their customers or clients, and to take from them whatever they can aVord to pay’. Unless doctors are content to play this passive role, it is essential that they should think through the ethical issues surrounding new technologies and the increased demands to which they give rise. They are also mixed blessings when, while provid- ing a means to desired motherhood for some, they occasion pressures on others to undergo risks they would not otherwise encounter’. Higher-order pregnancies, as a form of iatrogenic harm occasioned by misapplication of fertility technologies, are the particular focus of Mahowald’s attention. This distinction is not merely semantic Wnickiness – ‘fetal reduction’ obscures the fact that some fetuses are being aborted, and yet even a ‘pro-lifer’ might 8 D.
Although the 1989 St hyperglycemia clearly improves pregnancy out- with a body mass index greater than 27kg/m2 parison with human insulin discount kamagra gold 100mg online erectile dysfunction doctor michigan, with improved 1C Vincent Declaration aimed for ‘a pregnancy come15 buy kamagra gold 100 mg without prescription erectile dysfunction doctor new jersey. Multiple daily blood glucose testing is should see a dietitian if they have not already satisfaction and potential benefts with respect outcome in the diabetic woman that approxi- essential to achieve the best possible glycemic received dietary advice8. A severe hypoglycemic episode is being used in gestational diabetes mellitus long-acting insulin analogues: insulin glargine being observed for types 1 and 21. Hypoglycemia treatment should be stopped prior to conception, includ- protamine Hagedorn) by the time of the frst indicated by an HbA of greater than 10%8. Long-acting insu- and colleagues reported a more than 12-fold in HbA1C achieved before conception is associ- unplanned pregnancy in a woman with type 2 lin analogues were designed to provide a lon- increased relative risk of a congenital anom- ated with improvements in outcome. Achiev- diabetes mellitus taking any of these agents, as ger duration of action with a less pronounced aly associated with an HbA1C of greater than ing an HbA1C of below 7% without driving it their safety has not been formally assessed in peak of action compared to isophane insulin. In the absence of safety data, some Insulin glargine and insulin detemir both have panying this, signifcantly higher rates of with longstanding diabetes, especially those people still use these agents. The need for The prevention of toxemia is a complex issue isophane insulin, especially nocturnal hypo- A recent American study also suggested a the preconception administration is because and is discussed elsewhere in this volume. Baseline measurements of renal and assessment should be assessed to determine dation that women with diabetes take the thyroid function should be taken. It is the authors’ practice anomalies in thyroid hormone levels can greater risk of developing pre-eclampsia than Women with diabetes often take a range of to continue all other antihypertensive medi- impact early fetal development, it is essential the general population (see below), a point medications prior to pregnancy. Unfortunately, the ideal plinary team allows these medications to be ing pregnancy depending on the blood pres- agent to accomplish this task has not yet been reviewed so that appropriate changes can be sure at that time. It is phylactic antiplatelet agents (mainly low-dose have clinically diagnosed hypertension prior dopa or labetalol for blood pressure control as essential for all women with diabetes to have aspirin) suggested a 10% decrease in relative to pregnancy and are taking antihypertensive these are the medications with which British a retinal assessment prior to conception to risk of developing pre-eclampsia38 and con- medication(s); many also have long-term dia- obstetricians have the most experience. If low-dose aspirin is to be used, it diabeticsareprescribedangiotensin-converting to provide long-term protection against car- ment also provides a baseline for further should be started once a woman has a positive monitoring during each trimester. However, the available evidence is far tial investigation of prophylactic high-dose tion of retinal disease, and sudden improve- or changed prior to pregnancy, or once it is from conclusive, but since statin use is preven- vitamins C and E (antioxidants) appeared to ment of glycemic control should therefore be confrmed. Calcium supple- cluded that there was no evidence of terato- drugs when they are planning to conceive and retinal changes require urgent referral for oph- genicity with methyldopa, beta-blockers, cal- to restart them once they have fnished breast- ments are currently being investigated, and thalmologic review and should receive treat- cium channel blockers and hydralazine27. Optimal control of blood glucose be considered a relative contraindication to by two- to three-fold during the frst trimes- nopathy in 5% of pregnancies and observed and hypertension protects against develop- pregnancy. Appropriate education diabetic nephropathy, both of which are betes that can lead to end stage renal failure more light on risk factors, including diabetes. In a retrospective analysis of still- optimal glycemic control preconception, but should be considered during the preconcep- births occurring in women with type 1 diabe- to have a negative impact on long-term renal tion assessment for all women with longstand- also in preparation for the early weeks of preg- tes, a six-fold higher incidence of nephropathy function in women with diabetic nephropathy ing type 1 diabetes and all women with type nancy. Assessment of renal function creatinine) in contrast to those with low cre- 47,48 should be considered if other risk factors are Due to the increased frequency of hypogly- with serum creatinine, estimated glomeru- atinine clearance before pregnancy. Prompt return to normogly- be performed in all diabetic women prior to Other complications of diabetes Eating disorders associated with diabetes cemia, after hypoglycemia, may help to reduce conception. Sensorimotor The possibility of disordered eating patterns, between hypoglycemia and congenital mal- neuropathy in women with diabetes rarely including binge eating and insulin restriction formations, but this has not been confrmed causes problems during pregnancy and does 53 to avoid weight gain should be considered dur- in human studies. Autonomic neuropathy is associ- First-line hypoglycemia treatment should be Normal Unknown ated with hypoglycemic unawareness, which Hypoglycemia, usually defned as blood glu- consumption of fast-acting carbohydrates such <30 mg/24 hours can be aggravated by pregnancy. Women need to be aware Once blood glucose levels have recovered, fur- 30–300 mg/24 hours who have developed gastroparesis as a compo- that the tight control required before con- ther hypoglycemia should be avoided by con- Macroalbuminuria Increased pre-eclampsia nent of autonomic neuropathy often have poor ception, and in pregnancy, may predispose sumption of longer-acting carbohydrates such >300 mg/24 hours 49,50 metabolic control and inadequate nutrition.
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