December 24, 2015 | Posted By Paul Burcher, MD, PhD

I was surprised to read recently in the New York Times that a woman has undergone a cesarean section despite her refusal to consent to the procedure.  While the details of the case are not entirely clear in the article, so I do not want what follows to be understood as a specific comment on this case, my surprise arises because I thought the ethics of refusal of consent were not in dispute.  The American College of Obstetrics and Gynecology has taken a clear position of this: it is not justifiable to perform surgery on a patient with decisional capacity without her consent. ACOG’s committee opinion, “Maternal Decision Making, Ethics, and the Law,” strongly discourages even attempting to seek a court order for treatment when a pregnant woman refuses cesarean section, and concludes with a statement that:

Pregnant women's autonomous decisions should be respected. Concerns about the impact of maternal decisions on fetal well-being should be discussed in the context of medical evidence and   understood within the context of each woman's broad social network, cultural beliefs, and values. In the absence of extraordinary circumstances, circumstances that, in fact, the Committee on Ethicscannot currently imagine, judicial authority should not   be used to implement treatment regimens aimed at protecting the fetus, for such actions violate the pregnant woman's autonomy. 

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.

December 22, 2015 | Posted By Zubin Master, PhD

The STAP stem cell fiasco still continues. In January 2014, Haruko Obokata in the Center for Developmental Biology at RIKEN in Kobe, Japan reported that she was able to convert mouse cells to a pluripotent state in a very simplistic fashion by exposing cells to stress. This procedure was called stimulus triggered acquisition of pluripotency (STAP). Soon after its publication, allegations of plagiarism, and figure manipulation and duplication were reported. Other researchers were unable to reproduce the STAP experiments and it seemed that the STAP cells were the result of contamination (Cyranoski, 2015). An investigative committee at RIKEN found Obokata had committed research misconduct while she defends her results admitting to sloppy science but not deliberate misconduct.

Shortly after the scandal was reported, Waseda University, where Obokata received her doctorate, revoked her PhD on a probationary basis. The concerns over Obokata’s thesis surrounded plagiarism and inaccuracies (Cook, 2015). The University however made multiple efforts to help Obokata redo her dissertation by providing revision instructions and required she take an online ethics training course which she completed. And while some revisions to the thesis were made, these were ins

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.

December 18, 2015 | Posted By Lisa Campo-Engelstein, PhD
Last month I attended the Oncofertility Consortium conference and gave a talk titled “Ethical Considerations of Fertility Preservation in Adolescents.” The goals of this talk were to describe the common ethical considerations of fertility preservation (FP) for adolescent cancer patients and to explore the different medical and social considerations for adolescent females and males due to sex and gender.

Like any medical intervention for the adolescent population, there is the question of whether adolescents are able to assent or consent to FP. Should the decision to pursue FP rest in the hands of the adolescent or the adolescent’s parents/guardians? On the one hand, adolescents may choose to forgo FP because they do not understand the value of their fertility may have them later especially since, at their age, they are bombarded with messages about avoiding pregnancy. On the other hand, adolescents may feel pushed to undergo FP due to parental pressure (e.g. their parents/guardians want to be grandparents in the future).

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.
December 14, 2015 | Posted By Wayne Shelton, PhD

The role of family surrogates in providing a voice for incapacitated patients is of crucial importance. Usually, surrogates have the best interests of the patient in mind and try to work with the physician in charge to provide the best treatment possible for the patient. In most cases there is agreement between the surrogate and the physician about the treatment plan and the goals of care. But as those of us who do clinical ethics consultations know, there are some cases, maybe 5% or fewer, where there are serious conflicts between surrogates of patients lacking capacity and physicians. I want to briefly explore a type of conflict that we seem to be seeing more often—when the surrogate attempts to get too involved in the medical management of the patient. Let me use a couple of sample cases to illustrate the type of conflict I have in mind.

The first is the case of an elderly patient with dementia and with multiple medical problems, including severe pressure ulcers. This patient requires regular dressing changes for the pressure ulcers in order to keep them clean and well managed, requiring the patient to be turned, which causes her significant discomfort. When these dressing changes happen, the standard of care is to make sure the patient suffers as little as possible, so a small amount of morphine is given. But the family surrogate informed the nurse that she should not use morphine, as she wanted the patient to remain as alert as possible at all times. When the nurse tries to perform the dressing changes without giving morphine the patient groans, grimaces, and appears agitated and in pain. The nurse feels distraught that she is causing the patient to suffer unnecessarily.

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.

December 8, 2015 | Posted By Bruce White, DO, JD

On Friday, October 31, 2015, the chief medical officer of the Centers for Medicare and Medicaid Services announced a final rule which details how Medicare will pay practitioners to have conversations with patients about how they would like to be cared for at the end of life. Under the regulation, the patient is not obliged to have these conversations after a terminal diagnosis is made, or shortly before death is anticipated; the conversations may take place at any time, even before the patient becomes ill. The conversation may include discussions about life-sustaining treatments before they may be necessary, and about advance directives and the identification and appointment of a legally authorized representative to participate in the shared decision making progress if the patient were to lose decision making capacity. The rule, which will take effect in January 2016, creates new codes for reimbursement under the Medicare physician fee schedule.

It may seem remarkable that there should be any question about reimbursement for these often-time-sensitive, patient-directed conversations or discussions at all. But because Medicare payments have traditionally been tied to physicians completing and documenting finite “tasks” or “procedures,” these conversations have been “bundled” with other inclusive duties or responsibilities (such as taking a history or performing a physical or developing a treatment plan). The idea that Medicare should pay specifically for the service comes from the belief that if physicians received fairer compensation for providing the conversation and discussion, they would be better incentivized to comply. (Of course, this may or may not be the case, since many physicians clearly have been doing this all along as evidenced by the increased referrals to palliative care and hospice providers and services over the years.) But from 2013 Medicare data about terminally ill cancer patients, only about 47% of these patients receive hospice care, and the average length of stay in hospice is about 17 days. The statistics vary greatly from state to state with the better hospice and end of life care being provided in the Pacific Northwest and the worst in Alaska, Florida, North Dakota, and New York.

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.

November 30, 2015 | Posted By Jane Jankowski, DPS, LMSW

Risk, defined in the dictionary as the “exposure to the chance of injury or loss; a hazard or dangerous chance,”   finds a home in the daily dialogue of bioethics when we weight the consequences of decisions, usually related to healthcare decision making. Environmental factors are not commonly prominent in our discussion of risk considerations – we leave these decisions to the architects and designers who create healthcare spaces. In treatment spaces where deeply personal and intimate life experiences take place, we may need to consider the importance of a multi-stakeholder perspective when new spaces are created or existing spaces are re-designed.

Birth experiences, end of life experiences, and acute crises mark the psyche of patients and families permanently. People come into hospitals with expectations of safe, high quality, accessible care. Birth centers and maternity units increasingly offer family centered care with multiple security measures to assure that newborns, neonates, and family members are as safe and protected as possible. End of life experiences may be enhanced by privacy, increased flexibility in time spent at the patient’s side, physically comfortable surroundings, and appropriate levels of emotional support. Times of acute crisis are less well honored in the physical setting of hospitals, as evidenced in behavioral health care crisis units, which seem to be a lagging priority when it comes to assuring patient centered needs of health and healing are enhanced by environmental considerations.

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.

November 24, 2015 | Posted By Valerye Milleson, PhD

“I will not cease to be myself for foolish people. For foolish people make harsh judgments on me. You must always be yourself, no matter what the price. It is the highest form of morality.” – Candy Darling

November 24 this year marks the 71st anniversary of the birth of Candy Darling. She was an actress, an icon, and an Andy Warhol Superstar; she inspired two songs by Lou Reed/The Velvet Underground; she had cameos in movies with Jane Fonda and Sophie Loren; and she performed in a number of stage plays, including one by Tennessee Williams. She was glamorous and stunning, even in her deathbed photos, and Zsa Zsa Gabor reportedly referred to her as “one of the world’s most beautiful women.” She was also openly and publicly transgender in an era when being so was in some ways even more dangerous than it is today.

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.

November 20, 2015 | Posted By Benita Zahn, DPS

I like watching a doctor drama as much as the next person. But I don’t watch it like my friends. That’s because I’m always on alert to the bioethical issues playing out on the small screen. Often the show writers get the issues right and the program, along with its entertainment value, serves as an educational tool for the community. But when they get it wrong my forehead wrinkles and I grit my teeth. And that’s just what happened while watching a recent episode of the long running ‘Grey’s Anatomy’.

The show centered around a female patient who was diagnosed with a pituitary tumor that was causing her to add inches to her height but more importantly, threaten her life. She was given two options: surgery or probable death. The chief of surgery, the persuasive and powerful Dr. Miranda Bailey ( played by Chandra Wilson) made a clear case for surgery. But the patient wasn’t buying it and wanted to be released from the hospital. Here’s where my brow began knitting. The good Dr. Bailey wouldn’t let her go.

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.

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.

November 11, 2015 | Posted By Paul Burcher, MD, PhD

A couple of weeks ago I was I was the faculty attending on Labor and Delivery. We were inducing a woman with severe pre-eclampsia and an IUGR fetus. Things went well until she was five centimeters dilated, at which point the fetal tracing went rapidly from category one to category three (reassuring to really bad). I quickly explained the situation to the patient with a resident and a nurse in the room. She heard the reasons I was recommending a cesarean section, a brief discussion of its risks, and an even briefer discussion of the alternatives (continue labor placing the fetus at risk of permanent injury or death). She had no questions, and since she had already signed a cesarean consent at the beginning of the induction, we proceeded to the operating room to perform a cesarean.  She needed general anesthesia because her platelets were low, so it was too risky to give her a spinal anesthetic. During the induction but before intubation, the circulating nurse announced that she couldn’t find the “informed consent” and that we could not proceed. My response involved a reference to male cattle manure, and the comment that informed consent had just happened and that she had witnessed it herself. The anesthesiologist agreed, and the cesarean section occurred without delay.

This case exemplifies the ambiguity around “informed consent.”  The nurse was referring to a document, a signed piece of paper; I was referencing a conversation, a process involving sharing information and answering questions. From a legal perspective, informed consent would seem to represent the document, whereas from an ethical perspective it is the process, not the paper that embodies informed consent.  Of course, ultimately, both have a role to play, and in the case of a significant procedure it is best to have both sides of this informed consent coin documented.  But what I would like to suggest is that the signed document represents an artifact—a physical symbol that two parties agree that the real nature of informed consent has been fulfilled.  The piece of paper is derivative, and a signed document that lacks the ethical underpinning of a complete and valid consent discussion is meaningless. A lawyer would probably give a slightly different answer, but this is an ethics blog, not a discussion of medical malpractice.  

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.

SEARCH BIOETHICS TODAY
SUBSCRIBE TO BIOETHICS TODAY
ABOUT BIOETHICS TODAY
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.
TOPICS