Monday, May 27, 2019

finding balance in the abortion debates

Finding a balance in the abortion debates
by Martina Nicholson, MD
I am a retired Ob-Gyn, and a Catholic.  I majored in philosophy in college, and I have always had an intense interest in ethics.  I was trained to believe life is sacred, but I also watched my male college friends grapple with being sent to Viet Nam, for a war we did not believe was either reasonable or just; and at that time we grappled with "The Just War" arguments given to us, for consideration in trying to get an exemption for conscientious objection.  At the time, women were safe from the draft, so I did not personally have to consider being sent to fight in a war.   I also joined the Peace Corps right after college, and that also informed my sense of social justice.  The real limits of choices and moral distinctions for people,  due to poverty and unjust governments were very obvious to me, in my travels and life learning.

Since those early years, in which I was much more grounded in theory than in the problems of real life, I have come over and over to the problems in a crisis pregnancy, and what to do about it; what would be of best help to the particular woman, in this particular time.   I was often assisted in dealing with crisis in a particular woman’s pregnancy by a supportive family, but sometimes, no community of advocacy and support was available.  This is the greatest heartache, and for the woman who is pregnant, the greatest need.   Love should be the context for a new life.

We were taught in my philosophy classes,  to dislike the idea of modifying an ethical opinion for a particular situation.  "Situational ethics" seemed somehow wobbly and undependable.  I now think this is all that matters, to find the most ethical action in a particular person's situation, and to try to help that person carry it out.  I think sometimes it is helpful to use the popular question "What would Jesus do?"   We know that the only people Jesus condemned were the high priests and religious lawyers.  He said "You whited sepulchers, you impose a heavy burden you yourselves will not carry."  Everything Jesus did was based on love.  What he told us about the Father was all about love.  He did not bully anyone.  He said  "Abide in me, in my love, and the Father who loves me will come and abide with you, so that our love may be complete."  Every human action he did was stretching out to do something for someone, with love.

It seems incredible to me that theology treatises did not start with questions about who you are, what family and gender you belong to, and who you love.  And most of all, do you have a higher power, loving and gentle, giving you spiritual strength and support to help you?   To be told that you are not allowed to love the person you love, or that God doesn't want you to love that person, seems to me to be completely twisting the character of God out of all recognition from the one Jesus describes for us.  It destroys the internal radar of people who need to feel their Higher Power's guidance and support.   Motherhood is one of the ways we are called to grow much bigger than the self we are now... and we need help.  

And then there is history.  In Roman times, there were many virgin-martyrs.  This was not about sex, it was about the duty to the state, to have sons who would grow up to be Roman soldiers, to fight Rome's wars.  Women who refused to marry and be pregnant were considered traitors to the state, and went to their martyrdom.  The woman for whom I was named,  St. Martina, was one of these brave virgin-martyrs of the early church, around 300 AD.  They tried to burn her at the stake, but it rained.  They tried to get lions to tear her apart, but the lions sat down quietly.  So finally, they chopped off her head.  This gives poignance to the title of virgin-martyr.

So what I now think about the right of the state to protect the unborn is complicated with the question of the right of the state to send that child after it is reared, to be a soldier for the state.   Since Dorothy Day, I think there have been legitimate questions about whether ANY modern war can be considered a just war.  More and more, the wars we have fought are to get oil or natural resources away from a different country.  Many of our wars are to topple governments which actually were "the will of the people."  The story of Viet Nam, and the role of Ho Chi Minh after WWII is instructive.  And this foreign policy twisting goes down to what we are now doing in Venezuela.  And possibly the instigation of a war with Iran, which could quickly escalate to nuclear holocaust, if not the end of life on Earth.  All for reasons which have nothing to do with self-determination as a people.  

My belief is that the life in the womb is important, and that the woman who is becoming a  mother is also important.  She is not just a carrier, but a human being,  and her natural dignity and worth do not depend on motherhood.   Her talents, her desires for her own life, and the partner who helped to conceive this child also matter.  God has given her life, and her life also should not be devalued.   The life in the womb is organic, and grows to become a child.  Any limit, in any attempt to find a place that one's ethical rule can become categorically clear, is not possible, in this continuum, I believe.  It is not that it is a pre-child one minute, and a child the next minute.  God brings new human life into the world through women and pregnancy, but it is a continuum of growth and development.  So, trying to nurture and protect it seems reasonable and important, and part of our duty to God, as much as stewardship of the earth through being good gardeners and good farmers.  We have a saying in our field of obstetrics, based on data, that $1.00 in prenatal care saves $3.00 in pediatric care for premature or unhealthy babies.  
Medically, you cannot have an abortion after 24 weeks, because 24 weeks is the beginning of possibility of life outside the womb.  Before that, the lungs are not developed enough to hold air and pass oxygen to the blood.  Even if you try to put a tube into the infant’s airway to help it breathe, the lungs cannot fill yet.  This may be the source of some people’s concern that a very premature baby is “gasping for air” and the doctors are not trying to help save it.  The instinct to gasp for air is there, but the lungs are incompletely formed; they are more like liver tissue, than the honeycombs of lungs, with pockets for air.  It is like a butterfly being torn too soon from the chrysalis, and unable to fly.  There are stories of babies born below 24 weeks who make it through the months in the NICU to become capable of leaving the hospital.  Most of them probably have been wrongly dated in the length of their gestation.  Yes, miracles do happen, but they are very rare.   Another situation is when the fetus has no kidneys, so that it will not be able to live without dialysis all its life.  These fetuses often also do not have full lung capacity, and also may “gasp for air” as a reflex, even at later gestational ages,  but attempting to resuscitate them is usually unsuccessful.  Neonatologists are educated in fetal anomalies, and are aware, when a lethal anomaly is present, that it is not “life-enhancing” to try to give full resuscitative care.   Neonatologists are also now required to give parents a realistic assessment of the chance for the premature infant at this gestational age to be able to grow up, and become a child with full capacity.  The earlier the premature fetus is born, the higher the risk for lifelong disabilities, especially cognitive delays and impairments.  
Because of this, most hospitals which do not have a Tertiary level NICU will send the pregnant mother  with very premature impending deliveries, to the nearest center, before the delivery, if possible;  in order to give her the appropriate counseling, and to help the baby be born in the best center to treat extreme prematurity if it is viable.  

Recently there was a poll taken that 76% of Americans would like to see abortions limited to under 12 weeks.  The problem with this, medically, is that lethal anomalies may not be detected with ultrasound scanning,  until 18-20 weeks.  Such problems as anencephaly, or severe cardiac malformations, or absence of kidneys, may make the ongoing life of this fetus seem an unbearable burden to some mothers.   
Medically, also, a mother may develop a serious medical condition which threatens her own life.  Cardiac problems, severe kidney disease, or cancers are among the conditions which may make it necessary for a mother to consider termination of pregnancy.  In these cases, there are Ethics Committees in hospitals, where doctors and a team of people help to discern what is the best possible answer in keeping with the beliefs and concerns of the mother.  If a mother with a medical illness needs to terminate a pregnancy, her very life is at stake, and she must have the best possible medical care during and before and after this procedure.  The abortion must be done by one of the most skilled surgeons.  Problems with cardiac output and blood clotting disorders make the procedure even more dangerous, and if the mother does NOT have the procedure she also might die.  These women need to be given the best care we can give them, and often the heartbreak of losing a desired child is an added trauma.  

If a fetus is born before the 24th week, in most places with a sophisticated NICU, the parents are given the choice of comfort care.   When the preemie baby is born, the pediatric neonatologist determines clinically, whether there is potential for life-outside the womb, whether there is a chance for resuscitation to be successful.  If the mother has asked to “do all possible” and there is potential for viability, in a tertiary care NICU, this help will be given.  But if the fetus is insufficiently mature for the resuscitative efforts to be of any use, the parents will be counseled that comfort care is “the best thing to do.”
The baby is wrapped in warm blankets and given to the parents to hold.  Most physicians believe this is the least traumatic and best way to serve families with the difficult and painful loss of a very premature  infant.  

We have 60 years of data that millions and millions of women and couples have been able to successfully plan families and carry these families healthily, with smaller human families being the norm.  Being able to feed and clothe and house the family is a normal part of the duty and desire of parents.  Choosing how many children to have, and trying to choose what an optimal time is, for when to have children, is also a reasonable and wise part of stewardship of the gift of fertility.  We would not want farmers to ignore the weather and the needs of their land in planting crops.  We want our societies to be stable and our families to be sources of love and mutual support and care.  Using scientific technology and birth control methods which have been shown to be safe, effective and helpful for couples in planning families is sensible.  I have been waiting a long, long time for the reversal of the ban on contraception, by the Catholic Church, which has cruelly treated women and couples who have been prudent and modest in their desire to raise healthy families, by saying that the Church thinks it is sinful and implying that God doesn't love you if you are using birth control.   For some people it is impossible to see that this is a bullying position, not one which actually allows the freedom to the couple to choose what is best for them.  At least in theory, the Catholic ethical position is that God has given us freedom of choice.  We are to be allowed, (even encouraged!), to exercise our consciences, in living.   Jesus said "I came that you might have life, and have it more abundantly."  He did not say women had to have as many children as the body can bear.  He did not say that men have the right to rape women, or force women to carry more children.  It is interesting that Mary his mother, only had one child.  This is a model which is even more helpful now, as human population burgeons all over the planet.  

So, over time we have to keep asking ourselves, what the right answer is, about abortion, and why.  We are a political society and land of multicultural diversity.  We have laws which enshrine the belief that all people are equal and that we are a country based on the rule of law.  I think we have to understand that ethically,  in medicine, the primary priority is autonomy.  In political society, I believe the proper ethical role of the church in our country is in moral suasion, rather than forcing or bullying women to carry children.  And that leaves us with what should be legal.  I believe abortion should be legal.  I believe we need to protect the physician's right, to not do abortions, and to do them, without legal sanctions, or criminalizing either the doctor or the patient.   There is no middle ground ethically, to reconcile people who think pregnancy is sacred,  with people who think the right of the woman over her own body is sacrosanct.   I believe we have to let women choose whether to continue a pregnancy.  We can try to persuade a woman that it would be better to carry this child, and we can try to make it more bearable for her by helping her with the other corporal needs;  housing, food, safety, healthcare,  the means to exist as a parent, and also in dealing with possibly violent or cruel people who surround her.  
Our proper role is to help women grow into mothers, by supporting them emotionally and spiritually, as they take on this task.  No woman feels completely ready or capable of becoming a good parent, her self-doubt can be excruciating.  And helping the women with their needs in pregnancy is the proper role of the family and community.  The community becomes even more important when the family cannot meet the woman’s real needs.  
If you ask “Who is the advocate for the unborn child?” it is the family, the community, the people surrounding the pregnant mother.  The natural best advocate would be the father.  But some men do not take the role of fathering as a sacred trust.  Others are incapable.  So the community becomes the support for the woman in a crisis pregnancy.  This is NOT the state.  It is more variable, more fragile.  But it is REAL, and it understands that a child will need more support and advocacy as he or she grows.  For someone to insist that the state take on that role is unrealistic, I think.  

The highest amount of domestic violence is aimed at vulnerable pregnant women.   Many women seek abortions because of rape, or incest, or partners who are violent or addicted to substances which make their behavior cruel, life-threatening, and unpredictable.  Women want to be able, when bringing a child into the world, if possible, to give the child a stable home.  We should applaud this instinct in women, instead of condemning it.  For some women, their own parents and family can provide that safety and home, allowing her to get on with her life as a single mother.  Some women are dynamic and courageous enough to work through all the vulnerabilities of being a single mother with almost no social support.  But not all women have that ability and strength.  If the society and the church community wish to be of service for women in crisis pregnancy, they will be more creative, finding ways to support pregnant women with housing and safety and medical care.  The mandate for the Christian community is TO LOVE.  We love each other by providing for the needs of each other.   The society at large also DOES have a stake in the healthy raising of children.  We now have 20-25% of children being raised below the poverty line, often in unsafe housing and unsafe situations.  This is compounded for mothers who themselves are afflicted with mental illness or addiction.  And it is severely complicated with fathers who are violent, drug-addicted, locked up in prison and so unable to be helpful in real time to the mothers and children, and also in social situations of unsafe housing and communities without adequate safety for children and families.  The USA is now considered one of the top 10 places in the world for violence against women to occur.  Women and children refugees and homeless people needing shelter are even more vulnerable to violence; abuse, rape,  torture, human trafficking, and death.  

In the long run, I believe we will do the best we can with the difficulties of crisis pregnancies if we confine the actions of the Christian community to trying to LOVE instead of bullying women.  And in our national laws, we will do best by protecting the women's right to pregnancy terminations.  As medicine evolves, new methods and more effective methods of family planning have come and will keep coming, and we should do our utmost as a society to make these methods available for all women to use and to choose.  By giving women and couples the right to decide what is best for their own families, we put family life on the surest footing.   

In the rest of the world, and before the advent of modern contraception, the only real means to solve overpopulation were war, famine and plague.  But now we have medically safe and prudent ways to help families, to help make childbearing and child-rearing the best it can be, in spite of all the difficulties, risks,  and uncertainties of modern life.    For those who think this is not pro-life, I say that we also allow capital punishment and killing in war, in spite of the 5th commandment, which has no sub-clauses.   God knows the amount of slaughter going on in the world, and how many millions of children die of hunger, malnutrition and curable diseases due to lack of access to medical care.  What we should be striving for is TO LOVE.  Jesus' mandate, and his message was pretty clear-- "this is how people will know you are mine, that you LOVE ONE ANOTHER."

Thursday, April 11, 2019

books of poetry

I am excited that now all my books are on the Kindle/Amazon site.  Although I would rather someone had the "real" book to read,  at least they are now accessible. 
I am also glad to be still working toward getting up to speed with the blog and the webpage, although I am not there yet.  The new blog is martina2u@  It seems to have the same problem as this one, for trying to give an address.  I am thinking about what I need for a website.  Since it is not really something which I consider a commercial venture, it is hard to know what works best. 
I have been thinking about making a book of the "flowers photos" from Filoli, and adding poems for them.
For anyone who wants the new book of poems, "Melody, memory and Silence,"  you can send $12 to me at po box 890. Soquel Ca 95073.  I will mail you the latest book.  You can have the previous 5 books for $6 each, which is $30 for all of them. 

Monday, February 11, 2019

Protecting the pregnant woman's life: concerns about laws which would not protect the attempt to save the life of the mother

by Martina Nicholson, MD, FACOG:
I have always felt that my vocation was to try to stop women from bleeding to death, in childbirth. The biggest cause of loss of mothers is hemorrhage. Placentas which do not come off the wall of the uterus, called "placenta accreta", or placentas which are placed over the cervix obstructing the path for birth of the baby, called "placenta previa" are the biggest causes of this maternal mortality. But there are also issues of what used to be called Toxemia, where the pregnancy becomes toxic to the body of the mother, with high risk of stroke, heart attack, blindness and blood clots or hemorrhage. Mothers need to be protected when their lives are at stake. Often there are other children at home, and other family members to whom these women are precious and sacred, in their role as mother. In Obstetrics there must be priority made for the life of the mother. We can not allow a law which excludes from consideration the life of the mother. Doctors and patients in these life-threatening situations must be given the right and the scope, legally, to do what is best in a given rare situation. Many factors may affect the answer of what to do, but politicians should never be allowed to outweigh the medical decision-making.
I am going to add to this by trying to defend doctors. We are speaking about the LAW. Moral authority and religious fervor about personal behavior, and the exhortation to live up to the gift and the grace of pregnancy are a different issue. I feel very strongly that it does not serve us to be blindly pious in our attachment to the sacredness of pregnancy. We have to be realistic when considering the LAW. We can have ideals and goals and moral support and courage for people doing hard things, but we should not criminalize something that you and I know is a hard decision made by layers and layers of scientific and historical knowledge of what to do in rare complications. We need the LAW to be clearly backing up the medical decision-making. And I will add that the protection of the specialists who can do a medical procedure for a person who is in advanced heart failure or kidney failure, or leukemia, not responding to treatment, should be carefully protected and respected for their medical skill. NO woman will ever be forced to have an abortion, and many will choose their own death, rather than undergo what they consider to be killing their own child. But we have to protect the right to life of the mother, and the medical decision-making to try to give mothers that fundamental help.

Monday, February 4, 2019

Contraception, and the problem of Natural Law

a reflection about contraception and the concept of "Natural Law": by Martina Nicholson MD. 
I love the theology of my faith, but I have borne with the doctrine about contraception for almost half a century, out of respect for the pastoral concern that marriages be meaningful and supported, and that the blessing of children be recognized as one of the most important gifts of a benevolent God. But lately, I am beginning to come to the opinion that we have to accept that God is infinitely creative and immensely provident, in the ways of Creation. I think that the concept of "Natural Law" on which this doctrine is built, is too narrowly understood. The plethora of ways to BE in nature show us that just like in every other field of medicine, this area of sex and relationships should be governed by our minds, our cooperative intelligence, and our understanding of how we as individuals, couples, and families fit into the society and world around us. We must accept and use modern medical technology for problem-solving, and for dealing with issues which are the everyday concerns in our world. I learned something important from watching the movie about RBG (ON THE BASIS OF SEX). We can hope for better solutions, and we must apply them, using the skill and intelligence of the age, and we should also notice when progress in civilization has occurred. We have had 50 years to see that contraception not only works, but it has beneficial side-effects, like lowering the rates of cancer of the uterus and ovary. We also have had that same amount of time to see whether these tools can be used to strengthen and help real families in forming good family lives. The data shows clearly that the answer is yes. So we need to accept this, and HELP more women to get access to medical technology and care, and also to be educated to use the talents and strengths each woman has been given. The data coming from the Netherlands help us see that young women can be wise and sensible, and that the prevention of unintended pregnancy is reasonable and possible if we use the medical technological expertise at our disposal. I have had a lot of experience in helping women through pregnancy, and through the process of raising children. I do not believe that contraception has destabilized marriage. The strains and stresses we see in marriages are most often about the needs of the family for decent wages, housing, pensions, healthcare and education. Emotional immaturity and various addictions are also a big factor in the breakups of marriages. Recently I read an article which spoke about the serious problem of young men spending huge amounts of time watching pornography, since it is so available in cyberspace. This also is a big factor in destabilizing relationships, by teaching young men to think of women as sex objects instead of creative and intelligent subjects and potential partners. Tonight I was watching the film about the life of John Adams. There was a moment when he had to decide where he believed the law was most truly embodied, and he courageously decided to become an American, instead of remaining a loyal subject of the English king. This also was a teaching moment for me.

Tuesday, January 1, 2019

New Year's Eve Interfaith service and prayer for peace, 2018, Santa Cruz


The wonderful interfaith service in Santa Cruz for this year was presided over by Rev. Beverly Brook from the United Church of Christ, who is a chaplain at the local jails.  She told a very poignant story of a young man who is incarcerated, wanting to thank her for the only peace he gets, in his life in prison.  When she comes to sit and pray with him, the chaos and noise around him fall into the background, and he can feel peace.  I was very moved by her witness to this need for peace in a place and a person which is starving for it. 
The hall at Holy Cross church is a lovely space, and it was lit with magical little lights;  and the big candles, lined up for the ritual of each pastor lighting a candle, was like a set of Hannukah candles.  We all said the prayer of St. Francis together, which begins "Lord, make me an instrument of thy peace...".  We said Namaste to our neighbors, and also Shalom in an Arabic Muslim greeting.  There was a canvas labyrinth spread out on the floor to one side, and we were encouraged to walk it, if we were moved to do so.  I have loved the labyrinth, and when I am in it, I feel like I am in the mystical rose, at the heart of space and time.  In every way, it mirrors and magnifies our earthly pilgrimage, and our twistings and turnings toward and away from our neighbors and families.  I have not been looking forward to the year ahead, and this pilgrimage into the labyrinth has given me more hope, more recognition that the ways of the Lord are far above our own ways, and that infinite creativity is the province of God, and making all things new is  God's delight, as the universe moves toward the future, drawn by that infinite source. 
There was a Hindu scriptural reference from the Vedas, and a song calling and responding to God, which starts with "I am Thine".  In between each pastoral presentation, there was a gong-bell, to call us to silent prayer, peacefully being in the presence of our neighbors, wishing for peace.  The Jewish song was "Spread over us wings of peace, Wings of peace, shalom".  The person Mountain Eagle, who was also present at the 2012 service, spoke movingly about the human family, calling us to be closer to our brothers and sisters and to the earth.  He is working with another brother from Standing Rock, and a Mayan time-keeper, weaving dream catchers which are huge 40 foot meditation domes, and the plan is to build them all over the world, working together to imagine a new human family future.  His song was also very beautiful, and we sang along.  His voice reminded me of Johnny Cash,  full and beautiful and strong.   The Baha'i prayer was lovely, and also the Buddhist chant from the Zen center, which contained the hope that all beings be free of suffering, and that we all be in right relationship. The pastor of Holy Cross church gave a small talk about the use of repetitive prayers, and the origin and use of the rosary.   He also invited everyone to the mass following the service.  Although it was not explicitly about peace, it was an attempt to offer a tool for going deeper into that meditative state in which peace flows from the heart and soul into the daily life of the prayerful person.  His song about Mary's open-heartedness was also lovely. 
What is most amazing to me about this event is the respectful generous listening and witness to each other's traditions and faith.  No one is trying to convert anyone or argue about dogma.  We are all simply trying to extend ourselves in good will to our neighbors, and to be in right relationship to the Holy.  As we were called deeper into contemplative silence, in between the presentations, it truly felt that we were in solidarity and peace, with minds quieted and sweetened by love of God.  I think it is a true miracle, that this event can exist, in our difficult and loud and clashing cultural surrounding.   I am grateful to Sylvia Deck, who helped make it possible, because the "sangha" which has been an anchor of Holy Cross's meditation and prayer life for 2 decades is the underlying impetus for the event.  I am grateful for the good will of many people of faith traditions, who might have found an excuse NOT to come and participate, but made the effort, and came to the event in generosity and willingness to pray for peace together. 

Wednesday, September 19, 2018

Theology and Relationships

Theology and relationships

I am not sure what exactly the focus of the big meeting planned for February 2019 at the Vatican will be, but I hope that there is actually a forum and quorum for the issues of relationships as evolving and dynamic, and not static.   We need to have language which articulates respect for each person, and that people are never to be treated as an object. 

Most of the theology of sex and sin when we were young centered on single acts, not on relationships.  For more than 40 years, we have had theologians who are Teilhardians in the assessment of progress of human culture and well-being.  We have been able to discuss the theology of marriage, and of good theology in general, as a deepening conscious integration of the love of God, and the knowledge that goes with that love of God.  Thus, the issues of honesty, vulnerability, respect, compassion, tenderness, humor, caring, generous listening, accountability, forgiveness, boundaries, self-esteem, etc, which were never covered in discussions about moral theology in the past, are now at the forefront of  how we should be able to form good healthy relationships in safety with other people— not just sexual intimacy but emotionally satisfying friendships, spousal relationships which mature over time, parent-child relationships which also mature over time,  and other kinds of interactions which may contain emotional, spiritual and physical components of intimacy. 

I think it is a good time for us as a church to retire the wrong thinking which got embodied in the encyclical “Humanae Vitae” as a proscription against birth control.  Sensible family planning decisions need to be left to the conscience of the couple, as they plan their lives and take on the burdens of parenthood.  I think we need to address how to include gay people in a respectful way, which recognizes that sex is part of intimacy and love relationships of many kinds.  We need to have informed theology which leans on modern psychology and the best spiritual guidance about being a healthy human being.  We need to aim at protecting people from STDs and traumatic side-effects of having a sexual event which is disrespectful and not loving, such as incest, rape, abuse of a minor, sexual assault, etc.  We need strong proscriptions against sex trafficking, and concerted efforts all over the world to provide shelter for people who are at risk for this modern slavery.  I believe this is actually something our Church should be doing. 
I certainly hope that international agreement will happen in making sure there are always 2 adults when children are present, to lessen the risk of a child being injured or taken advantage of in any way.  We need to have strict protocols in place, to protect children from sexual predators.  We also need to do ongoing surveillance and rigorous assessment to keep pedophiles from having access to children;  and to protecting our schools and parishes, with reasonable oversight of committees which include laypeople and parents.  Since sexual assault is a crime, we also need to be sure that predators go to jail, and are not promoted or hidden within the church. We need to have  full cooperation with the law and the police. 

We also need to have  credible pastors, who are attempting to live their own vows in a healthy and humble way.  For this reason, I am even more hopeful that we will now move to have the clergy have the option of marriage, and also that women will be given a wider role in pastoral care.  

Maybe this time, in which my friend Tim’s daughter Katie has embarked on the vocation of becoming a Poor Clare, can be a time of great growth in the Church, equivalent to when Galileo said that the movement in the heavens is such  that the earth rotates around the sun.  

Thursday, August 16, 2018

Anna Karenina

Every 10 years or so, I re-read my favorite book, by Tolstoy.  It was written in 1877, and that is an amazing thing; that it was around the time of our Civil War, and the advent of expansion of railroads across the continent, and also mirrored the expansion of railroads across Russia.  Tolstoy's amazing skill at writing this book remains, in my estimation, without parallel. 
In my 20s, I loved the book, envied and admired Kitty, and wanted to find a spouse like Lewin.  In my 30s, I was absorbed with the worries about the scope of women's lives, and especially about women like Dolly, with several children and a husband who was both a spendthrift and chronically unfaithful.  In my 40s, I loved the passion in the love affair between Anna and Vronsky, but also I began to consider the change in the relationship to the land and the way the peasants were affected with the advent of railroads, and the thought that the book preceded the Russian revolution by at least 30 years, while they grappled with how to become a more effective government.  I had sympathy for Alexis Karenin.
In my 50's I could really feel like I understood all the characters, and what affected me most was the death of Lewin's brother Nicholas, of Tuberculosis, also called Consumption.  Almost no Americans have ever seen anyone dying of TB, but I have.  Because of my time in the Peace Corps, and travels, I deeply identified with Kitty trying to help this bitter dying brother of her husband's.  I admired Varenka, who is a prototype for women in medicine who are skilled and practical, and self-effacing, and very good at helping solve problems for patients. 
Now I am in my 60's, and my dislike of Vronsky has washed away, and I pity him, and admire that he built a modern hospital in his district, and tried to become an effective member of the political arm of the landlords, as he was also trying to become a good steward in managing his estate.  And I come to the book now with so much more admiration for the mind of Tolstoy, who could describe Anna's thoughts so clearly, as she descends into the hell of her self-obsessed, isolated, emotionally feverish attempt to hold Vronsky with her attachment, without any social ballast.   I admire his ability to describe the mind of a morphine addict.  I admire his ability to show the enormous 2-faced social miasma around Anna, and how it contributed to her suicide. 
There are many things in the book which bring big questions for reflection-- about how to educate people, what to do about governmental systems so that they are effective instead of burdensome tangles, the differences in the classes which Tolstoy presents so clearly, and we have not eliminated, although it is hard to speak truly about what we DO have, and the economic burdens of consolidated power and money in a shrinking upper class.  And there is Lewin's joy in working in the fields with his scythe, just for physical joy; and his hunting, and his attempt to be a better steward and make worthwhile improvements in the farming of his estate.  I LOVE this book.  If you haven't read it, I really recommend it, and I also love the audiobook format.  My eyes get tired now, and listening to it also is a pleasure.