What You May Not Have Known About Abortion & Some Medical Ethical Issues in Lebanon

You’d think class discussing ethics in medical school are the most boring. The truth, however, is that those classes are the only ones capable of engaging the entire class. The sloths wake up because of a rising tone with their classmates. The conservatives rise because the liberals in class are infringing on their beliefs. The liberals get infuriated at everyone else because they just don’t get it. And the physicians giving the lecture sit back and watch.

Pop corn material? You bet.

Because I am receiving my medical training in Lebanon, we have to also deal with certain aspects of Lebanese law pertaining to these issues and to say our laws are bipolar, nonsensical and surprising is an understatement.

  • Abortion:

We all know abortion is illegal in Lebanon. There’s no pro-life, pro-choice debate. Women have no choice when it comes to this. However, did you also know abortion is illegal even when it comes to congenital abnormalities? In other words, it is illegal for a physician to abort a baby in Lebanon if the baby has, for example, Down’s Syndrome or any other defect which would render his life extremely difficult. The only situation in which abortion can be performed in Lebanon legally is when the pregnancy is endangering the mother’s life – and even that comes with its own baggage of morality clauses.

In fact, any physician who performs abortions that are not indicated – even if they are for what many perceive as common sense causes – can be targeted by the law especially if he rubs a prosecutor the wrong way. Some physicians refuse to do abortions fearing legal issues while others refuse to do so for religious issues. In fact, a physician who is training me said to my face: “I wouldn’t even abort my own sister if the baby was a product of rape.” I was outraged but this is how it goes.

Certain major hospitals in the country do not even do amniocentesis, which is a component in prenatal care and diagnosis to detect certain abnormalities. Their argument? We’re not aborting anyway so what’s the point of the mother knowing if the child has Down’s Syndrome or not? Besides, amniocentesis carries a theoretical 1/250 chance of causing a miscarriage – who needs that risk?

A relevant abortion real life story we were told is when a radiologist missed the absent right arm of her fetus, a condition called phocomelia. She later found out of the condition at a gynecologist’s visit and decided to abort. She then wanted to sue the radiologist for missing the condition but was eventually talked out of it because having the case reach a court of law would get both the mother and physician in jail.

  • Gamete donation:

I daresay Lebanon doesn’t need more fertility. If anything, we need to have population control. But some people just need those little bundles of joy in their lives. Some want to because they feel a need to be parents. Others want to because society looks down upon the women who don’t give their husbands children. Many couples resort to In Vitro Fertilization or other methods of Assisted Reproductive Technology. Insurance companies pay for such practices without knowing so because hospitals cover it up in their charts.

For some couples, however, gamete donation is required for them to have children. Yes, the child wouldn’t be theirs biologically but that’s not all that matters now, right?

Here comes the interesting part, Lebanon-style: There’s absolutely nothing – no religious decree, law – allows sperm donation. It doesn’t matter what the man’s fertility status is. It doesn’t matter if the woman is as fertile as they come. Oocyte donation, however, is an entirely different story that is governed by each person’s sect. Meaning: whether or not a person is allowed to donate or receive donated oocyte is correlated with that person’s sectarian personal status. Move over civil marriage, I guess.

Don’t worry though, the sects agree on this. The Christian, Druze and Sunni sects prohibit this. Shiites are the ones who have gone off the rails – but not all of them. Lebanese Shiites fall under two main branches. There are those who follow Mohammad Hussein Fadalallah in their practices while others follow Iran’s Khamenei. Those who follow the latter are not allowed to donate or receive oocytes while those who follow the former can do so as per a fatwa which he issued shortly before his death. The condition? The oocytes have to donated by someone by the man’s other wives.

  • Embryo Research:

Not a lot of research is being done in Lebanon. This is especially lower when it comes to embryo research – the number is zero. However, who would have thought that the law can actually be interpreted in a way that permits such research?

In fact, the Lebanese law pertaining to this issue stipulates that the embryo is a product of conception and can be manipulated as long as both parents agree. Other products of conception include the placenta. This effectively renders the embryo prone for research. So in a way, we are ahead Western countries in this regard.

Why hasn’t this law gained traction? Mainly because no institutions actually allow such forms of research to happen in their premises. Most of the country’s main hospitals are religious institutes at their base. The law has also passed unnoticed by the radar of sects because they’re all busy elsewhere and we still don’t know if it’s been put into effect. Interestingly though, at least some MP members (Kassem Hachem, I believe) tackled the issue at hand. Meanwhile, women are still waiting on their own domestic violence law.

  • Conclusion:

We were asked the following question about frozen embryos: if you freeze an embryo for 5 years and then implant it, is the fetus one day or 5 years old?

All hell would have broken loose if we hadn’t been a small group in the discussion. I guess it doesn’t really matter where we legally stand from such issues. What is clear, at least to me, is that we are lightyears away from having a decent discussion about them. But I still find them fascinating.

Medicine in Lebanon: The VVVVIP Patients

The following are bits and pieces of things several of my medical student colleagues and I, at many Lebanese hospitals across the country, have lived over the past few weeks. 

“What do you mean I have to deliver in third class? I DON’T DELIVER IN THIRD CLASS.”

Beautiful thing to wake up to in the morning, right? Well, such things are not fiction – they are every day reality in Lebanese hospitals. The woman in question was very very pregnant to say the least. She was also very very angry. Why? Because two emergency C-sections had taken up the first class beds she was promised to welcome her bundle of sunshine into the world.

“We couldn’t help it,” the nurse pleaded. “Those two women just came here in labor!” The nurse was almost begging as I stood there watching.

“I don’t give a shit.” The woman shrieked. “I want first class – I am not a person who can deliver a baby in third class. Take them to third class, they already delivered.”

A few phone calls later, that woman got her way. I guess some vaginas are more precious than others. Literally.

The separate classes in the Lebanese social hierarchy also reflect in its hospitals. There’s really very few things that hospitals can do. They accommodate what they can given how messed up and archaic our health sector financing is. What is bad, however, is the sense with which some people view medicine in this country: it’s not a human right that should be guaranteed to everyone. It’s a privilege, a luxury that only they should be entitled to.

“My ovaries hurt.” I was staring at the face of a supposed emergency condition who had just presented to the emergency room. I could see sunscreen all over her body. She was definitely tanning a few minutes earlier.

“How are your ovaries hurting you exactly?” I had no idea how ovaries could actually hurt a person, not to mention how a person would know where their ovaries actually are. When had the pain started? Well, the pain had happened 6 months ago and had died since but she wanted to know why that pain happened then… now. Bref, there was absolutely nothing urgent with her. But she knew enough people and had enough resources to take away physicians from places where they could be needed and keep them busy for a couple of hours in order to make sure her ovaries are perfect.

And then there are those patients who are so important they book two first class rooms because, you know, what if they got visitors? Can you imagine hosting them in one first class room? They are the patients who are so revered their treating physicians would drag themselves out of bed at times they shouldn’t be at the hospital just to do an exam that I, as a medical student, should be doing – just because it’s that particular patient. Those are the patients who are even treated differently in operating rooms just because they can enforce such levels of fear: “be careful with her… she’s important.” They are the patients on whom we don’t learn simply because they would get “too annoyed” to have that many students in their room. So no one enter please.” That vagina glows of gold, I was told.

Those are the super duper very very important patients that come to Lebanese hospitals: patients whose medical cases are nothing more than mundane, simple and even boring… patients who can turn those cases into a matter of national security. And there’s nothing you can do but smile and the most professional individual that you can be be while you secretly hate on the system that hammers hospitals and medical education alike.

Memorial Hermann, a Houston Hospital, Live-Tweeting Brain Surgery

The day has come where Twitter is used effectively as a learning tool in medecine. Memorial Hermann, an institution based in Houston, Texas is currently broadcasting updates and answering questions during a brain surgery that’s going underway right now. You can check out their Twitter account here.

As a sample of what they’ve been talking, I took the following screenshots:

They’ve also tweeted a few pictures live from the operating room, as well as a brief video of the brain while they operated on it.

I think this is great. While I am familiar with some of the terms they’re throwing around, I think this a great educational opportunity for medical students, current MDs, and knowledge enthusiasts. I hope they do this again some other time as well because it sure is interesting.


To All Med Students: The Rise and Fall of Medicus Studentus

This is an absolutely hilarious video done by medical students at the American University of Beirut (AUB) that was presented during an annual gala dinner which serves as a fundraiser for the Lebanese Medical Students International Committee (LeMSIC).

I was fortunate enough to watch this firsthand at the aforementioned gala dinner and I thought it was totally awesome. Other med students, you will eat this up. For those who have nothing to do with med school, here’s the setting you need to put in your head: cut-throat competition, your med school books are neo-scripture. Caffeine is your BFF. You also hate everyone.

It’s long but definitely worth it. And hey, we have unlimited internet at night now. So why not?

Emergency Contraception in Lebanon: The Morning-After Pill – The Scientific Reality

The picture making the social media rounds

This is a guest-post by Christian Sawma, a pharmacy student at the Lebanese American University, in reply to the Nasawiya post on the matter.

We need to start by differentiating between monthly contraception and emergency contraception. The monthly regimen consists of taking one pill per day, regardless of sexual encounters, in order to suppress the normal monthly period and ovulation; this regimen is used for sexually active women who are not wishing to get pregnant. On the other hand, the emergency contraception is used after an unprotected sexual intercourse in order to prevent pregnancy from happening.

The best choice of emergency contraception is a progestin only pill that increases the cervical mucus production and thickness; hence, inhibiting the sperm passage to the fallopian tubes. It is available as OTC (over-the-counter) in the United States and of course in Lebanon under the brand name of Norlevo (levonorgestrel 1.5 mg) – commonly known as the morning-after pill. The latter drug has no purpose other than emergency contraception; it cannot be used as normal monthly contraception.

Pills containing a combination of low concentration of estrogen and progesterone in one pill are used to suppress the ovulation and normal female cycle, therefore, they are used as a monthly contraceptive technique and prescribed as a once per day pill, taken at the same time every day for this purpose.

In contrast, before discovering the effectiveness of Norlevo (levonorgesrtrel 1.5 mg) as an emergency contraception technique, the regimen used was called Yuzpe (named after its founder Dr. Albert Yuzpe). It consisted of giving the combination of those low concentration estrogen and progesterone pills, discussed above, to inhibit pregnancy (before it happens) after an unprotected sexual intercourse, but they are given as multiple pills per day for the emergency contraception purpose. Now that Norlevo hasn’t been available on the Lebanese market since October 2011, the Yuzpe regimen can be used instead.

Estrogen is highly emetic (induces nausea and vomiting), and that is one of the main problems of this regimen: It consists of giving 2 or 4 tablets, of the monthly contraceptive pills, as soon as possible and repeat the same dose after 12 hours. The number of tablets to take is chosen according to the estrogen concentration in the tablets. For the 30 mcg ethinyl estradiol (EE), 4 tabs should be taken, and for the 50mcg EE, 2 tabs are advised. It is important to mention that the tablets of each dose should be taken all together and not separated.

This is a table that clarifies the aforementioned point:

Yuzpe (Microgynon 30) is effective in 75% of the cases, which is not a good statistical number, making it not a very good alternative to Norlevo. In addition, this regimen shouldn’t be followed without referring to your physician or a pharmacist and if vomiting occurs in less than 2 hours post dose, the dose should be repeated.

On the Lebanese market, a lot of brands containing 30 and 35 mcg EE are available. The one that contains levonorgestrel (Norlevo’s active ingredient) in an acceptable concentration for emergency contraception is Microgynon 30, and it is the best choice in Lebanon for a Yuzpe regimen. According to my knowledge, no 50 mcg EE is available in Lebanon for contraception.

In the case of Norlevo or combined oral contraceptive, the effectiveness is not studied beyond the 3 days period. Although the Yuzpe regimen can be given up to 5 days post intercourse, no safety and effectiveness has been proven. In addition, some studies have confirmed that beyond the initial 3 days, it’s neither safe nor effective to use Norlevo or Yuzpe (Microgynon 30).

Always refer to your physician or pharmacist before using a new drug especially if taking other drugs with it or if using it for its unlabeled use (such as in this case). In case of emergency contraception, it is important to refer to them in any case of bleeding or pregnancy post a dose of a progestin only pill, Yuzpe regimen or Ella pill, a new experimental FDA-approved drug that is not yet available in Lebanon.