Topic: Oncology
November 16, 2015 | Posted By Lisa Campo-Engelstein, PhD

As I have discussed in previous blogs, fertility preservation for cancer patients can be quite expensive and insurance companies do not cover it. Fertility preservation for cancer patients is excluded because cancer patients are generally not currently infertile, but instead they have anticipated infertility due to their cancer treatment. I have argued that insurance companies should cover fertility preservation because it is not ethically different from other treatments for iatrogenic conditions currently covered for cancer patients. For example, insurance covers other quality of life treatments such as wigs for alopecia and breast reconstructive surgery following mastectomy. Like these treatments, fertility preservation is not lifesaving, but can significantly improve quality of life, as infertility can lead to depression, anxiety, and distress. Since much of medicine today focuses on improving quality of life for people with non-life threatening conditions (e.g. poor vision, back pain, seasonal allergies, sexual dysfunction, etc.), it does not make sense to exclude fertility preservation on the basis that it is not life saving.  

However, some question whether fertility preservation for cancer patients is a just use of finite health care resources based on economic reasons. One cycle of IVF is on average $12,400 and estimates for ovarian tissue cryopreservation range from $5,000-$30,000. Furthermore, annual storage fees for frozen gametes and embryos can run up to hundreds of dollars a year While ART are very expensive on the individual level, they are not on the broader social level: in fact, they account for only 0.06% of the total health care expenditure in the United States. The lack of insurance coverage for fertility preservation raises the justice concern that only certain individuals will be able to utilize it, namely those who can pay out-of-pocket for it. These individuals are most likely from the same demographic as the primary users of ART: white, educated, and middle- and upper-class. While 14 states currently have mandates requiring insurance companies to cover some types infertility treatments, there are no similar laws for fertility preservation. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

January 23, 2015 | Posted By Lisa Campo-Engelstein, PhD

Although life-saving, cancer treatments (e.g. radiation, chemotherapy, and surgery) can also lead to infertility in both women and men. Established reproductive technologies for women and men like gamete freezing and embryo freezing allow cancer patients to preserve their fertility in case they want to become biological parents in the future. 

Unfortunately, patients are frequently not adequately informed and sometimes not informed at all about fertility preservation. Some oncologists don’t consider fertility preservation to be an important issue, as they are more focused on saving the patients’ lives and see fertility preservation as a secondary consideration. Research has shown that even when oncologists refer their patients for fertility preservation they often do so based on social factors (they are more likely to refer wealthy, white, heterosexual, married patients) rather than purely on medical indications. Even when health care providers discuss fertility preservation with patients, many patients say that once they heard the word “cancer” as a diagnosis, they didn’t absorb much else from their initial conversation with their provider. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website. 

September 17, 2013 | Posted By Lisa Campo-Engelstein, PhD

Testicular tissue cryopreservation is a neglected topic in the fields of fertility preservation and bioethics not only because reproduction is usually associated with women and girls, but also because sperm banking is an established, easy, and cheap method that works for the majority of male cancer patients. However, norms surrounding fatherhood are changing, with more men interested in active fatherhood, and consequently fertility preservation is becoming and will continue to become increasingly important to male cancer patients.

When compared to the number of studies demonstrating the importance of fertility to female cancer patients, the literature focusing on male cancer patients’ perspectives on fertility is minimal. However, there are more researchers examining the latter topic today than in the past. Contemporary research on gendered perspectives on fertility preservation reveals a shift over time: although older studies generally found that female cancer patients value their fertility

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

June 10, 2013 | Posted By Jane Jankowski, LMSW, MS

In a recent CNN article, it was reported that American women are requesting double mastectomies at vastly increased rates – up 150% among women with early stage breast cancer according to one 2007 study. With Angelina Jolie’s New York Times Op Ed piece hitting newsstands on May 14, 2013 the spotlight that has shown on breast cancer and its ancillary campaigns shines bright once again. There can be no doubt that breast cancer awareness, research, and treatment have become recognized beneficiaries of phenomenally successful fundraising campaigns. Yet, if we peel away the pink stickers, pins and flags, do we find empowerment of women or pressure to take action out of fear? To that end, what are the obligations of providers when faced with patients who demand mastectomies where there is no disease and no elevated risk?

In general, a patient’s demand for removing healthy body parts is considered ethically problematic. Is an orthopedic surgeon obligated to amputate a foot because it may someday be broken? This type of request would be declined on the grounds that the risks of surgery and ensuing debility are not worth the benefit of an unconfirmed and unlikely harm. Does our discomfort lessen if it is the amputation of a foot belonging to a diabetic patient out of fear it may someday loose circulation, become infected or gangrenous, and need amputation down the road anyway? The potential for complications related to diabetes may be genuine, but far from certain. Surveillance, lifestyle choices, and early intervention can mitigate the need for such a surgery and would be considered the standard of care for a concerned patient. For patients with BRCA mutations, prophylactic surgery and chemoprevention are added to the list of options. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

March 28, 2013 | Posted By Paul Burcher, MD, PhD

Two articles in the New York Times raise a disturbing question regarding the ethics of cancer treatment in this country.  The first on ovarian cancer treatment noted that despite significantly better survival data with intraperitoneal chemotherapy (IP) over intravenous chemotherapy (IV) for ovarian cancer, most oncologists were still using IV chemotherapy. The reason given is that IP chemotherapy is more difficult to give, and more labor intensive, but is not reimbursed at a higher rate.  That is, physicians are routinely withholding the more effective treatment for economic reasons.  Another recent article describes how oncologists tend to choose more expensive chemotherapy even when it is not more effective because they are paid a percentage of the drug’s cost. 

It is an often-repeated truism that physician behavior will follow economic incentives perfectly—if you wish to reduce physician procedures capitate patient care, if you wish to increase patient procedures, pay physicians on a fee-for-service basis.  While this has been empirically demonstrated, it is a bit hard to accept that this adage remains true even when physicians seems to be crossing the line into unethical behavior in order to follow the almighty dollar.  The IP chemotherapy issue is most troubling because it represents physicians giving care they know to be inferior because the better treatment costs more to deliver, and this reduces their own income.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

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BIOETHICS TODAY is the blog of the Alden March Bioethics Institute, presenting topical and timely commentary on issues, trends, and breaking news in the broad arena of bioethics. BIOETHICS TODAY presents interviews, opinion pieces, and ongoing articles on health care policy, end-of-life decision making, emerging issues in genetics and genomics, procreative liberty and reproductive health, ethics in clinical trials, medicine and the media, distributive justice and health care delivery in developing nations, and the intersection of environmental conservation and bioethics.
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