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‘Whose life do I prioritize?’ A choice no parent wants to make
By Christopher HartnickAug. 30, 2022
When an obstetrician or midwife cuts the umbilical cord after a child is born, the room is filled with tense silence until the baby’s first cry is heard.
I once heard this silence in an operating room where 32 people were bustling around, all awaiting the birth of a baby with a massive growth covering her neck and jaw that might make it difficult — if not impossible — for her to breathe on her own.
As a pediatric otolaryngologist, I was there to help her breathe. My memories of that day, and her mother’s difficult choices about whose health to prioritize, have re-emerged as I think about challenges parents and clinicians now face as they talk about difficult decisions in a post-Roe world.
The baby’s parents, Jessica and Paul, had known this day would come. A routine prenatal ultrasound, when Jessica was 22 weeks pregnant, revealed signs of a complication that would make for a very difficult birth, one requiring a difficult and possibly hazardous C-section on the mother’s part and a potentially life-threatening problem for the child. At that moment, the couple had a choice about carrying the child to term and decided to do that, come what may. They had simply hoped it would come a few weeks later, when the plan we had developed together could better unfold. But now we were all doing the best we could.
In the operating room, the silence stretched on as the obstetrician cut the cord and handed me the newborn, covered with amniotic fluid tinged red from a cesarean birth. One of the nurses gently cleaned the baby while I and the neonatal intensive care unit team inspected her. The mass I had seen on an MRI, which had brought so many medical professionals to this room, appeared even larger in real life. The baseball-sized teratoma, an uncontrolled growth of skin, muscle, bone, and other tissues, obscured the baby’s neck and jaw line. She struggled to draw in a breath, but there was no path in her neck through which air could reach her lungs. Her chest heaved with increased effort, but to no avail.
Nearly two decades ago, surgeons first described the ex utero intrapartum treatment, or EXIT for short. This procedure is designed for treating a newborn with a mass obstructing its mouth, neck, or chest that would make it difficult or impossible for the baby to breathe on its own once the umbilical cord had been cut. In an EXIT procedure, an obstetrician performs a partial cesarean birth, keeping the baby attached to the umbilical cord until a pediatric airway surgeon can safely place a breathing tube in the newborn’s mouth or surgically make a hole in the neck to place a different form of breathing tube — a tracheostomy tube — to bypass the obstruction. Once that has been accomplished, the baby can be fully delivered and the umbilical cord cut.
In this procedure, the mother temporarily becomes a heart-lung machine for the partially born child. If this seems the stuff of science fiction, welcome to the world of modern-day medicine.
While the EXIT procedure holds the promise of providing a medical miracle, it is also fraught with risk and entwined with ethical conundrums.
In a routine cesarean section, the anesthesiologist gives medicine to constrict the blood supply to the uterus just before the incision is made into it to deliver the baby. That medicine significantly lowers the risk of maternal bleeding and death during the procedure. In an EXIT procedure, though, the mother decides with the team to prioritize the baby’s health, so instead of constricting blood flow, the anesthesiologist delivers medicine to keep oxygen-rich blood flowing briskly to the uterus, through the placenta, down the umbilical cord, and into the baby, keeping the baby alive.
“Whose life do I prioritize?” is a difficult decision no parent ever wishes to make.
I write this having worked as a physician for years before the Supreme Court’s Dobbs vs. Jackson Women’s Health Organization decision removed federally protected access to abortion, and in a state where abortion remains legal. As difficult as these decisions are in my hospital, I am aware of how much more charged they will be in states where a fetal ultrasound may identify an abnormality and the mother may not be able to choose whether or not to carry the child to term, where she will no longer have the opportunity to weigh her own risks and benefits with those of her unborn child.
Jessica and Paul were aligned in their desire to move forward with the pregnancy in hopes that an EXIT procedure would help their daughter survive. They had made that choice at 22 weeks, when they decided to carry on with the pregnancy, a decision that is now even more complicated in many states. They understood Jessica’s increased risks, but felt they needed to do everything in their power to save their child.
Given the size of the teratoma, we made the decision to wait until the fetus was either 32 weeks old or weighed 2 kilograms, as that would allow for the even more dramatic possibility of placing the baby on a cardiac bypass machine if I could not secure an airway. But those milestones were never reached: Jessica went into preterm labor at 29 weeks.
Another set of decisions needed to be made, and quickly. An EXIT procedure in a woman who is contracting is even more risky for the mother, due to the risk of increased bleeding, and the outcome for the child is less predictable, as the placenta may not remain fully attached to the uterus for long enough for oxygen to flow freely while the EXIT is carried out. The medical team’s recommendation was to perform a standard cesarean section to deliver the baby and then do our best to secure a safe airway for it. Jessica tearfully agreed with this choice. I heard the guilt in her voice, and sensed her feeling that she was prioritizing her risk and her life over her child’s.
I felt then, as I often do, the unfairness when parents are forced to make such terrible decisions. I reiterated to Jessica that, from a medical standpoint, her decision was sound and that her medical team supported it. That was how I came to be looking down on a newborn with a mass obstructing her neck, her eyes closed, and her chest heaving.
I opened her mouth and used an instrument called a laryngoscope to see her vocal cords, hoping I could place a breathing tube through them. The teratoma had pushed the cords far to the left, but at least I could see them. The breathing tube, though, would not go through them; it was as if there was no air pipe below. As I tried again, one of the obstetrical nurses whispered in my ear that I should try for as long as I felt necessary, but that if the infant girl was not going to live, then it was very important to let her mother hold her while she was still pink. I was taken aback by this brutal candor, which could only come from someone immersed in a field such as high-risk obstetrics, where death was so much a part of life.
I asked an assistant to lift up the girl’s chin to extend her neck as much as possible, then used a scalpel to cut through the skin below the mass in a long vertical line to get down to her air pipe. But it was nowhere to be found. I put my fingers in her neck to feel, and felt right down to her spine. Nothing. Perhaps the teratoma had prevented her airway from developing.
The nurse was in my ear again. “If she isn’t going to make it, we need to get her over to her mother, but clean,” she whispered urgently. I knew I had to stop, and immediately began stitching up the baby’s neck. The nurse cleaned her, put a woven cap on her head, and swaddled her in a clean blanket in such short order that, just as I was cutting the last suture, she lifted the child from the bed, made sure that one tiny, still-pink hand was visible, and brought her to her mother.
Twice in just a few weeks, Jessica had needed to make a choice between two lives: hers and her unborn child’s. At first, she chose to risk herself for the sake of her child. As part of her medical team, I supported and fully endorsed her decision. Then everything shifted when the baby arrived early. The set of risks had changed, and Jessica was forced to choose again. This time, she chose to prioritize herself.
None of us could have known then what we know now, that she would give birth to a child anatomically incapable of life. The great majority of time, doctors and patients simply don’t get such information when we are in the moment and making real-time decisions. Without a clear-cut answer, Jessica had to trust her inner voice, and her medical team needed to support her choice, even if it ran counter to the one that had been recommended.
Not long ago, I met with a mother and her partner to discuss an EXIT procedure, the options and the risks, and how they wanted to proceed. She was crystal clear: “I know some mothers might choose differently and I respect that. I am just not them. I have a two-year-old child home who needs me too. I want to try to save my baby, and want to try this EXIT procedure. Please do all you can. But if something goes wrong and if choices have to be made during the operation, I choose me.”
EXIT procedures may be rare, but the critical decisions that people and their doctors make together are not. As a pediatric surgeon, I see my “patients” both as the children I treat and their parents. But other than in EXIT procedures, I rarely have to engage in discussions of “Whose life should be prioritized?” and “Whose life should be put at risk?” where the primal choice to be made is between mother and child.
Through caring for Jessica and working with her through her choices, one of them in the face of crisis, I was given a window into what has today become an even more constrained environment for making choices about the lives of mothers and babies. In some states, a mother could have an ultrasound showing that something is terribly wrong with her baby and, no matter how painful and difficult the next set of decisions might be, will not have a say in them.
I hope voices like Jessica’s are never silenced, but forever find a way to be heard, even in states where it has become difficult to legally engage in these kinds of patient-focused discussions and decisions.
Christopher Hartnick is an otolaryngologist; director of pediatric otolaryngology and director of the Pediatric Airway, Voice and Swallowing Center at Mass Eye and Ear in Boston; and a professor of otolaryngology–head and neck surgery at Harvard Medical School. This essay reflects the author’s present recollections of experiences over time. Some names and characteristics such as age and sex have been changed to anonymize the characters, and some events have been compressed.
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Seneca, Marcus Aurelius, Epictetus and Cleanthes
In days of doubt and painful reflection, it is useful to re-read the Stoics (a group of ancient philosophers, which included Zeno of Citia, Lucius Annaeus Seneca, Marcus Aurelius and others). It was not without reason that Stoic philosophy was studied and popularized by Byron, Brodsky, and Schwarzenegger. Journalist Nikita Soldatov chose both topical and quite timeless quotes from ancient philosophers, who are usually referred to in almost every world crisis.
rules of life
Of the things that exist, some are in our power, others are not. In our power is opinion, aspiration, desire, deviation — in a word, everything that is ours.
If you love the potty, say «I love the potty.»
If you are told that someone is talking bad about you, do not try to justify yourself. On the contrary, answer: «This person did not know about my other vices, otherwise he would not have limited himself to only these.»
If you want to live peacefully and cheerfully, try to make acquaintances only with good people.
Is your olive oil leaking? Is your wine stolen? Tell yourself at the same time that for such a price dispassion is bought, for such a price serenity is acquired, and nothing is given for free.
Whenever a raven croaks something bad, don’t be carried away by your imagination, but immediately sort it out with yourself and say: «This does not portend anything to me, except perhaps for my body, property, my good name, my children, wife, but for me, if I want, portends only good things. After all, it is in my power to benefit from everything that happens.”
You will be invincible, if you do not participate in competitions that you cannot win.
Perfection of character is expressed in spending every day as if it were the last in life, being free from fussiness, inactivity, hypocrisy.
No matter what anyone does or says, I must remain a good person. So gold, emerald or purple could say: «Whatever anyone says or does, I must remain an emerald and retain my color. »
Don’t do anything like a sheep. Otherwise, a person is lost anyway.
Humanity is not so good that the majority vote for the best: a large crowd of adherents is always a sure sign of the worst.
Even if we face suffering, what good is it to run towards it? When it comes, you will immediately begin to suffer, but in the meantime, count on the best. What will you gain from this? Time!
Two things must be got rid of : fear of the future and memories of past suffering. The second has already passed, and the first has not yet arrived.
Let’s understand and admit that there are two states. One is ruled by true sovereigns, great and common to all, embracing gods and people, where we are not shown corners beyond which we cannot go, but the borders go beyond the horizon with the rays of the sun. Chance attributed us to the other: it fell to us to be born in it.
A wise man will not be ashamed of his small stature, but still he would prefer to be tall and slender.
What nature requires, is available and attainable, we sweat only for the sake of excess.
One cannot be like the evil ones because there are many of them, one cannot hate many because one is not like them.
Everyone rushes through life headlong, yearning for the future, tormented by disgust for the present. On the contrary, the one who uses every moment of his time for his own benefit, who arranges the schedule of each day as if it were his whole life, he expects tomorrow without hope and fear.
The wise needs no one but himself. But even though he is satisfied with himself, he still wants to have a friend, and a neighbor, and a comrade.
A few are held by slavery, the majority are held by their slavery.
There are things that hurt the sage, though they cannot defeat him: bodily pain and weakness, the loss of friends and children, the collapse of the fatherland, engulfed in the fire of war. There are things that can hurt him, however, having received a wound, he defeats it, pinches it and heals. Invulnerable is not the one who does not receive blows, but the one to whom they do not harm.
One should once and for all put an end to discussions about what a person should be and just become him.
When, due to circumstances, the balance of the spirit is disturbed, restore your composure as quickly as possible and do not remain in a depressed mood for too long, otherwise you will no longer be able to help.
Do not forget in case of any event that plunges you into sadness, rely on the main idea: «This event is not a misfortune, but the ability to endure it with dignity is happiness.»
Whoever wants, fate leads him, whoever does not want, drags him.
100 most relevant quotes about programming
Programmers are famous for their imaginative thinking. And in confirmation of this — our selection of the 100 most striking quotes about programming.
0. Programming today is a race of software developers striving to write programs with more and better idiot resistance, and a universe that is trying to create more selective idiots. As long as the universe wins.
1. A low-level language is when you need to pay attention to things that have nothing to do with programs in that language.
Alan J. Perlis
2. C programming is like dancing fast on a freshly polished floor of people with sharp razors in their hands.
3. Don’t worry if something doesn’t work. If everything worked, you would be fired.
Mosher’s Law of Software Engineering
4. It was a mystery to me for a long time how something very expensive and technological could be so useless. And I soon realized that a computer is a stupid machine that has the ability to do incredibly smart things, while programmers are smart people who have a talent for doing incredibly stupid things. In short, they found each other.
5. In good design, adding something costs less than the thing itself.
Thomas C. Gale
6. In theory, theory and practice are inseparable. In practice, this is not the case.
7. Perl is the language that looks the same before and after RSA encryption.
8. I invented the term «object-oriented», and I can say that I didn’t mean C++.
9. Sometimes it’s better to stay home on Monday than to spend the whole week debugging code written on Monday.
10. Measuring a programmer’s productivity by counting lines of code is like judging an aircraft by its weight.
11. Debugging code is twice as hard as writing it. So if you write code as smart as you can, then by definition you are not smart enough to debug it.
Brian W. Kernighan
12. Many of you are familiar with the virtues of being a programmer. There are only three of them, and of course this is: laziness, impatience and pride.
13. Most programs today are like Egyptian pyramids of a million bricks on top of each other and without structural integrity — they are simply built by brute force and thousands of slaves.
14. Most good programmers do their jobs not because they expect to be paid or recognized, but because they enjoy programming.
15. Always write code like it’s going to be accompanied by a violent psychopath who knows where you live.
16. Programs should be written for the people who will read them, and the machines that will execute these programs are secondary.
17. People who think they hate computers actually hate bad programmers.
18. If you give a person a program, you keep them busy for one day. If you teach a person to program, you will keep him busy for life.
19. A language that doesn’t change your understanding of programming is not worth learning.
Alan J. Perlis
20. We are seeing a society that is increasingly dependent on machines, but uses them less and less efficiently.
21. Sometimes the best programs are written on paper. Programming them is a secondary thing.
22. Debugging code is like hunting. Hunting for bugs.
23. Any fool can write code that a machine can understand. Good programmers write code that humans can understand.
24. Programming is about breaking something big and impossible into something small and quite real.
25. Programmers are not mathematicians, as much as we would like them to be.
Richard P. Gabriel
26. Programming is hard. The basic rules on which everything is built are very simple, but as the program develops, it itself begins to introduce its own rules and laws. Thus, the programmer builds a labyrinth in which he himself can get lost.
27. Functions that produce values are easier to combine in new ways than those that produce side effects.
28. Simplicity is the key to reliability.
Edsger W. Dijkstra
29. If you want code to be easy and fast to write, make it easy to read.
Robert C. Martin
30. If you’re good at debugging programs, you’ve spent a lot of time doing it. I don’t want to be good at debugging programs.
Michael C. Feathers
31. Working? Do not touch.
32. You can easily shoot yourself in the foot with C. With C++, this is harder to do, but if it does, your whole leg will be torn off.
33. The latest innovations in C++ were created to correct previous innovations.
34. Java is C++ with all guns, knives and clubs removed.
J ames Gosling
35. If Java really did have garbage collection, most programs would delete themselves the first time they were run.
36. There are only two types of programming languages: those that people swear at all the time, and those that no one uses.
37. The method’s bad name is akin to politicians’ election promises. It seems to be talking about something, but if you think about it, it’s not clear what it is.
38. A program that doesn’t work is usually less harmful than a program that doesn’t work well.
39. How much easier it would be to write programs if it wasn’t for the customers.
R. S. Martin
40. Young specialists do not know how to work, and experienced specialists know how not to work.
41. Ask yourself the question “What should I hide?” and you’ll be surprised how many design problems melt away before your eyes.
42. Premature optimization is the root of all evil.
43. To write clean code, we first write dirty code and then refactor it.
44. In addition to mathematical ability, the vital quality of a programmer is an exceptionally good command of the native language.
Edsger W. Dijkstra
45. For every complex problem, there is a solution that is quick, easy, and wrong.
H. L. Mencken
46. Access control mechanisms in C++ provide protection against accident, but not against fraudsters.
47. I think the art of programming is a little more complicated than other human skills. Programming makes you better in the same way that learning a foreign language, math, or reading books helps you develop.
48. Just as painting a picture is an art for the soul, writing a program is an art for the mind.
49. Testing does not detect errors such as creating the wrong application.
50. Some people think, «Why don’t I use regular expressions?» while solving a problem. After that, they already have two problems …
51. I can’t take screenshots because I usually work in text mode on my computer.
52. It’s very easy to walk on water and develop programs to specification. .. if they’re frozen.
Edward V Berard
53. I think Microsoft named the technology .NET to keep it from showing up in Unix directory listings.
54. Given the current deplorable state of our programming, programming is definitely still black magic, and we can’t call it a technical discipline just yet.
55. It is much easier to port a shell than a shell script.
56. Learning to code is to designing interactive systems as learning to touch typing is to writing poetry.
57. Learn the science of programming and all theory first. Next, develop your programming style. Then forget everything and just program.
58. The hard part about working with a programmer is that you can’t figure out what he’s doing until it’s too late.
59. I have been asked twice [MPs]: “Please, Mr. Babbage, what happens if you enter the wrong numbers into the machine? Can we get the right answer?» I can’t even imagine what kind of confusion in the head can lead to such a question.
60. C has the power of assembler and the convenience of… assembler.
61. UNIX is incredibly simple, but it takes a genius to understand that simplicity.
62. You can’t trust code that you haven’t written entirely yourself.
63. Restricting a language to prevent programming errors is dangerous at best.
64. If you find C++ difficult, try learning English.
65. Whatever we create, we must enable people to move from old tools and ideas to new ones.
66. Small programs randomly compile and run correctly the first time they try. But if this happens to any non-trivial program, then it is very, very suspicious.
67. Modularity is a fundamental aspect of all successful large systems.
68. Proving by analogy is cheating.
69. A program that has not been tested is not working.
70. Programming is not a science, but a craft.
71. People think security is a noun, something that can be bought. In fact, security is an abstract concept, like happiness.
72. If I were asked to choose a modern language to replace Java, I would choose Scala.
73. The problem with C++ is that you need to know everything about it before you can write anything in it.
74. Programming language design is like a walk in the park. Jurassic Park.
75. I think this will be a new feature. Just don’t tell anyone that it happened by accident.
76. It’s hard to improve code that has been improved many times before.
77. Laziness is the main virtue of a programmer.
78. To understand the algorithm, you need to see it.
79. I have a hunch that unknown DNA strands will be deciphered into copyrights and patents.
80. If you enjoy the tools you use, the job will be done successfully.
81. Remember that there is usually a simpler and faster solution than the one that comes to mind first.
82. If you optimize everything you can, you will be forever unhappy.
83. The Euclid algorithm is the grandfather of all algorithms, because it is the oldest non-trivial algorithm that has survived to this day.
84. It is easier to invent the future than to predict it.
85. Programming is usually taught by example.
86. Programs are getting slower faster than hardware is getting faster.
87. I call it my billion dollar mistake. Invention of the null pointer in 1965.
88. Some problems are best avoided, not solved.
89. One accurate measurement is worth a thousand expert opinions.
90. People are allergic to change.
91. We cannot blame our mistakes on the technologies we use.
92. Laziness is a programmer’s natural state, after which he gives birth to a good algorithm.
93. Magic ceases to exist after you understand how it works.
94. Programming is like punching yourself in the face: sooner or later your nose will bleed.