Monday marked India's third year without any new polio cases, so the country will soon be WHO-certified as having eradicated the disease. Meanwhile, in neighboring Pakistan, where the disease is still rampant, Taliban are executing vaccinators as possible spies. This is apparently because the US used a fake vaccination program as cover for its search for Osama bin Laden. Aagh!
Tuesday, January 14, 2014
Ventilating the Dead: Update
The Fort Worth Star Telegram is reporting that the family of Marlise Munoz, the pregnant brain-dead woman who is being kept ventilated against the wishes of her family, will sue the John Peter Smith hospital to get her removed from the machinery. The hospital has kept Ms. Munoz on the machinery for weeks, citing the Texas Advance Directives Act, which states that no one can withdraw or withhold "life sustaining treatment" from a pregnant patient. The crucial legal question is whether the statutory restriction can properly be applied to treatment which is not "life-sustaining," because the patient in question is dead. (Family members have said that they've been told Ms. Munoz is brain-dead, but the hospital has made no official statement confirming this.) A hospital spokesman said the hospital was "encouraged" by the lawsuit "because the courts are the appropriate venue to provide clarity, direction and resolution in this matter." That sounds to me as if the hospital's position may be wholly liability-driven, and they're just looking for the safety of a court ruling to justify stopping the mechanical intervention. On the other hand, the hospital's outside council is reportedly one Neal Adams, who led a drive to end abortions at the hospital in 1988 and serves on the advisory board of the Northeast Tarrant Right-to-Life Educational Association, so perhaps more than liability is driving the hospital's position.
Earlier post on this case and on the Jahi McMath case in California here.
Earlier post on this case and on the Jahi McMath case in California here.
Monday, January 13, 2014
New Mexico Judge Finds State Constitutional Right to Aid-in-Dying
A judge in the New Mexico Second Judicial District Court (County of Bernalillo) has found that "the liberty, safety and happiness interest of a competent, terminally ill patient to choose aid in dying is a fundamental right under [the Due Process clause of the] New Mexico Constitution." District Judge Nan G. Nash therefore found that the state's criminal law against assisting in suicide is unconstitutional insofar as it is applied to aid-in-dying for competent, terminally-ill patients. The court's order enjoins prosecution of physicians for aiding competent terminally-ill patients in dying. From the opinion:
The court explicitly declined to distinguish aid-in-dying from suicide: "Through the practice of aid in dying a physician deliberately aids the terminally ill patient in taking of his own life, bringing the practice of aid in dying within the definition of assisting suicide contained in [the criminal law]." But the court went on to find a constitutionally-protected right to suicide for competent, terminally-ill patients, and therefore invalidated the criminal law against assisted suicide insofar as it is applied to doctors assisting in the suicides of such patients.
The case was brought by the ACLU of New Mexico and Compassion & Choices on behalf of two physicians and a terminal cancer patient.
This Court cannot envision a right more fundamental, more private or more integral to the liberty, safety and happiness of a New Mexican than the right of a competent, terminally ill patient to choose aid in dying. If decisions made in the shadow of one’s imminent death regarding how they and their loved ones will face that death are not fundamental and at the core of these constitutional guarantees, than what decisions are? As recognized by the United States Supreme Court in Cruzan “[t]he choice between life and death is a deeply personal decision of obvious and overwhelming finality.” Cruzan, 497 U.S. at 281.The opinion in Morris v. New Mexico only affects prosecutions within Bernalillo County; it will not apply to the whole state unless it is affirmed on appeal by the state's Supreme Court.
The court explicitly declined to distinguish aid-in-dying from suicide: "Through the practice of aid in dying a physician deliberately aids the terminally ill patient in taking of his own life, bringing the practice of aid in dying within the definition of assisting suicide contained in [the criminal law]." But the court went on to find a constitutionally-protected right to suicide for competent, terminally-ill patients, and therefore invalidated the criminal law against assisted suicide insofar as it is applied to doctors assisting in the suicides of such patients.
The case was brought by the ACLU of New Mexico and Compassion & Choices on behalf of two physicians and a terminal cancer patient.
Womb Transplants in Sweden
A team of surgeons in Sweden have transplanted donated uteruses into 9 women who were born without them, or who had lost them to cervical cancer. The aim is to permit the women to bear their own children. From the story:
Perhaps more troubling is the question of how the pregnancies will proceed. Will the developing fetuses be affected by the anti-rejection drugs the women are taking? What happens if rejection occurs part-way through a pregnancy? Will the uteruses be strong enough to carry the fetuses to term safely? Will placental formation and blood flow be sufficient to ensure the fetuses are healthy? At what stage and for what reasons will pregnancies be terminated?
If pregnancy is achieved, doctors plan to remove the uteruses to prevent the women's having to take anti-rejection drugs for life. (The drugs can have serious side-effects.) Two earlier attempts at human uterine transplantation (using uteruses from dead donors) failed: one in 2000 in Saudi Arabia, which had to be abandoned when a blod clot formed; and another in Turkey last year, in which the pregnancy failed at 2 months. Uterine transplants have been done in mice, sheep and baboons, but the baboon transplants did not result in pregnancy.
An American team announced its intention to perform a uterine transplant some years ago, raising some ethical issues, but no such procedure has yet been performed in the US.
"The transplant operations did not connect the women's uteruses to their fallopian tubes, so they are unable to get pregnant naturally. But all who received a womb have their own ovaries and can make eggs. Before the operation, they had some removed to create embryos through in-vitro fertilization. The embryos were then frozen and doctors plan to transfer them into the new wombs, allowing the women to carry their own biological children."There are several ethics issues here, clearly. First, there's the danger to the donors of the uteruses. Doctors said they preferred live uterus donors to dead donors because they could be certain, with live donors, that the uteruses were functioning properly and didn't have any problems like HPV infection. But the uterine donation is a major surgery--more dangerous than a hysterectomy, since it involves removal not only of the uterus but also of surrounding blood-vessel needed to keep the uterus alive in the donee. The procedure thus subjects donors to serious risk for the sake of a donation that isn't lifesaving.
Perhaps more troubling is the question of how the pregnancies will proceed. Will the developing fetuses be affected by the anti-rejection drugs the women are taking? What happens if rejection occurs part-way through a pregnancy? Will the uteruses be strong enough to carry the fetuses to term safely? Will placental formation and blood flow be sufficient to ensure the fetuses are healthy? At what stage and for what reasons will pregnancies be terminated?
If pregnancy is achieved, doctors plan to remove the uteruses to prevent the women's having to take anti-rejection drugs for life. (The drugs can have serious side-effects.) Two earlier attempts at human uterine transplantation (using uteruses from dead donors) failed: one in 2000 in Saudi Arabia, which had to be abandoned when a blod clot formed; and another in Turkey last year, in which the pregnancy failed at 2 months. Uterine transplants have been done in mice, sheep and baboons, but the baboon transplants did not result in pregnancy.
An American team announced its intention to perform a uterine transplant some years ago, raising some ethical issues, but no such procedure has yet been performed in the US.
Thursday, January 9, 2014
IVF Babies at Enhanced Risk. But Why, and So What?
This Australian study in PLOS One shows significant risk of health problems in babies born from assisted conception as opposed to spontaneous conceptions. Compared to spontaneously-conceived singletons, singletons from assisted conception
were almost twice
as likely to be stillborn, more than twice as likely to be pre-term,
almost three times as likely to have very low birth weight, and twice as
likely to die within the first four weeks after birth. Outcomes varied by type of assisted conception. Very low and
low birth weight, very preterm and preterm birth, and neonatal death
were "markedly" more common in births from IVF and, to a lesser
degree, in births from ICSI. Use of frozen embryos elminated the risks of ICSI, but not of IVF. But frozen embryos also had increased risk
of macrosomia.
The study mentions, but doesn't linger on, data showing that kids spontaneously born of parents with untreated infertility problems also have adverse outcomes compared to kids of non-infertile parents. Compared to spontaneously conceived children of women with no infertility problems, spontaneously conceived children of women with infertility problems were nine times more likely to have very low birth weight, seven times more likely to be very pre-term, and almost seven times more likely to die within the first 28 days of birth. Some experts say that this may mean that the problems experienced by children of assisted reproduction may be more due to parental infertility than to infertility treatment.
Let us leave aside the possibility that many or most IVF-related risks are really just infertility-related risks. The sort of data discussed in this study always brings to my mind some variations on the "non-identity" problem invented by Derek Parfit. Suppose a child of IVF is born with low birthweight, and experiences lifelong significant complications which were foreseeable by the parents when they decided to used IVF. Has that child any complaint against the parents? One possible answer is, "No, because the condition of the possibility of that particular child's ever existing at all was his or her parents' use of the IVF which caused both his or her existence and his or her low birthweight. Only a child whose life was so wretched as to literally not be worth living could complain about his or her parents' use of IVF." The argument in this form seems sound but it also troubles me, because (for example) one can easily imagine the circumstances in which one might accurately say to a slave, "You have no right to complain about being born a slave, because without the institution of slavery, you would never have been born at all."
If IVF is risky, and a child of IVF is born with a disability, and the child would not have been born without IVF, what sort of complaint can one mount, from the child's point of view, about the disability?
The study mentions, but doesn't linger on, data showing that kids spontaneously born of parents with untreated infertility problems also have adverse outcomes compared to kids of non-infertile parents. Compared to spontaneously conceived children of women with no infertility problems, spontaneously conceived children of women with infertility problems were nine times more likely to have very low birth weight, seven times more likely to be very pre-term, and almost seven times more likely to die within the first 28 days of birth. Some experts say that this may mean that the problems experienced by children of assisted reproduction may be more due to parental infertility than to infertility treatment.
Let us leave aside the possibility that many or most IVF-related risks are really just infertility-related risks. The sort of data discussed in this study always brings to my mind some variations on the "non-identity" problem invented by Derek Parfit. Suppose a child of IVF is born with low birthweight, and experiences lifelong significant complications which were foreseeable by the parents when they decided to used IVF. Has that child any complaint against the parents? One possible answer is, "No, because the condition of the possibility of that particular child's ever existing at all was his or her parents' use of the IVF which caused both his or her existence and his or her low birthweight. Only a child whose life was so wretched as to literally not be worth living could complain about his or her parents' use of IVF." The argument in this form seems sound but it also troubles me, because (for example) one can easily imagine the circumstances in which one might accurately say to a slave, "You have no right to complain about being born a slave, because without the institution of slavery, you would never have been born at all."
If IVF is risky, and a child of IVF is born with a disability, and the child would not have been born without IVF, what sort of complaint can one mount, from the child's point of view, about the disability?
Medicaid Sterilization Policy Causes Unwanted Pregnancies
Here's an interesting article from the New England Journal of Medicine on Medicaid's policy regarding voluntary tubal ligation. Borrero et al. claim that Medicaid policy is preventing poor women who desire sterilization from receiving the procedure, resulting in tens of thousands of unintended pregnancies annually.
A surprising number of women desire tubal ligation immediately after giving birth; the procedure is conveniently done while they're still in the delivery room. More than 70% of sterilization procedures done within two years after delivery are in fact done in the immediate postpartum period.
Because of our nation's appalling experience with coercive and non-consensual sterilization of minority and poor women in the mid-20th century, however, the US government in the 1970s developed regulations designed to protect vulnerable women. Among these was a requirement for Medicaid patients of a 30-day waiting period between informed consent to sterilization and the actual sterilization procedure.
This well-intentioned regulation, unchanged since 1978, is today preventing women from receiving sterilizations that they actually desire. Some women request sterilization too late in pregnancy to fulfill the 30-day Medicaid waiting period; some are denied sterilization because they do not have their consent form present at the time of delivery; some give birth early, before the mandatory waiting period elapses.
The results of denial of sterilization services to Medicaid patients are very real. Almost half of women who are denied tubal ligation get pregnant within one year after delivery. The authors have found that "Medicaid-policy–related barriers lead to approximately 62,000 unfulfilled requests for postpartum sterilization annually, resulting in an estimated 10,000 abortions and 19,000 unintended births in the subsequent year...."
Both the financial and the emotional costs of these unintended pregnancies are very high. The authors estimate the cost to American taxpayers of the pregnancies at over $215 million annually. And wealthier, privately-insured women face no such policy barriers to receiving the sterilization procedure they desire. It might be time to revisit a policy that is harming the people it was originally implemented to protect.
A surprising number of women desire tubal ligation immediately after giving birth; the procedure is conveniently done while they're still in the delivery room. More than 70% of sterilization procedures done within two years after delivery are in fact done in the immediate postpartum period.
Because of our nation's appalling experience with coercive and non-consensual sterilization of minority and poor women in the mid-20th century, however, the US government in the 1970s developed regulations designed to protect vulnerable women. Among these was a requirement for Medicaid patients of a 30-day waiting period between informed consent to sterilization and the actual sterilization procedure.
This well-intentioned regulation, unchanged since 1978, is today preventing women from receiving sterilizations that they actually desire. Some women request sterilization too late in pregnancy to fulfill the 30-day Medicaid waiting period; some are denied sterilization because they do not have their consent form present at the time of delivery; some give birth early, before the mandatory waiting period elapses.
The results of denial of sterilization services to Medicaid patients are very real. Almost half of women who are denied tubal ligation get pregnant within one year after delivery. The authors have found that "Medicaid-policy–related barriers lead to approximately 62,000 unfulfilled requests for postpartum sterilization annually, resulting in an estimated 10,000 abortions and 19,000 unintended births in the subsequent year...."
Both the financial and the emotional costs of these unintended pregnancies are very high. The authors estimate the cost to American taxpayers of the pregnancies at over $215 million annually. And wealthier, privately-insured women face no such policy barriers to receiving the sterilization procedure they desire. It might be time to revisit a policy that is harming the people it was originally implemented to protect.
Wednesday, January 8, 2014
Bioethics Poetry: Amy Fleury Edition
Ablution
Because one must be naked to get clean,
my dad shrugs out of his pajama shirt,
steps from his boxers and into the tub
as I brace him, whose long illness
Ventilating the Dead: Two Cases
Jahi McMath is dead as a result of a rare and tragic bleeding complication following what was supposed to be a routine tonsillectomy. There is no trace of electronic activity in her brain. By law, she is dead; on Friday California decreed that she had been dead since December 12. But she's dead more than just "by law." She has no feeling, no thoughts, no memories, no dreams, no experiences, no emotions, no responses--and no hope of ever having any of those things ever again. Thanks to mechanical intervention, her heart continues to beat and her body appears warm and life-like. Her parents, hoping for a miracle, went to court to prevent her medical team from removing the life-support machinery from her dead body. They lost the court battle, but found a California nursing facility willing to accept transfer of the dead girl, and to keep her body attached to machines. Presumably the nursing home will charge someone for this service, though it's not clear what state or private insurance would pay for medical care for a dead person. The parents have already received over $50,000 in private donations, but mechanical ventilation costs thousands per day. In any case, Ms. McMath's body will gradually deteriorate even on mechanical support. She is already described by her family's attorney as being in "very bad shape" after her transfer. "We don't know if she's going to make it," he said of the dead girl. "Her medical condition, separate from the brain issue, is not good."
Ms. Munoz collapsed with a pulmonary embolism and ceased breathing. By the time she was discovered by her husband, she had suffered profound brain damage. (Her fetus, which suffered the same lack of oxygen, is likely to be brain-damaged as well.) Her husband, father and mother all agree that Ms. Munoz would not have wanted to be kept on life support in these circumstances.
I wonder if Mike Huckabee thinks that in this case, we ought to respect parents over government and family over hospitals?
Enter former (and future?) Republican presidential hopeful Mike Huckabee:
The former Arkansas governor and ordained pastor began his Fox News show by admitting that he did not have the medical experience necessary to understand 13-year-old Jahi McMath’s condition but he encouraged her family to fight against any attempts to remove her from life support even though doctors said she technically "died several weeks ago.”In other words, "I don't know the facts but I know what to do." Thanks, Mike.
“Every life has value and worth,” Huckabee told his viewers on Saturday.But Ms. McMath is no longer alive, Mike.
“There is no such person who is disposable, one whose life has been deemed by others to be less than others and therefore expendable, I can’t share that.” He continued: “The road that starts that way in deciding that some lives have less value and are unworthy of protection, that leads to a culture that tolerates the undeserved killing of over 55 million unborn children in this country. It leads to China’s birth policy that limits the number of children for a family and enforces forced abortion if they deviate from the state-determined ideal....It’s also that culture that allowed the Nazis to to hideously justify the savage slaughter of millions of Jews, disabled people, old people and those with mental illness,” Huckabee said.Yep, declining to give medical treatment to corpses is just where Hitler started. Give them an inch....
“Let’s hope and pray that the courts continue to do what every court should do, respect parents over government, family over hospitals and, above all, protect Jahi from them all.”Meanwhile, in Texas, a hospital is keeping Marlise Munoz on mechanical ventilation against the wishes of her husband and her parents, and against her own previously-expressed wishes. The hospital is acting pursuant to the Texas Advance Directives Act, which prohibits withdrawal of life-support from any pregnant patient. But at least one doctor has declared the patient brain-dead, so the question arises: is a dead person a "patient"? Is mechanical ventilation on a dead person "life support"? Several legal experts, including two involved with drafting the Texas law, have opined in the press that if she is in fact brain-dead, the hospital is misinterpreting the law in keeping the woman attached to mechanical support.
Ms. Munoz collapsed with a pulmonary embolism and ceased breathing. By the time she was discovered by her husband, she had suffered profound brain damage. (Her fetus, which suffered the same lack of oxygen, is likely to be brain-damaged as well.) Her husband, father and mother all agree that Ms. Munoz would not have wanted to be kept on life support in these circumstances.
I wonder if Mike Huckabee thinks that in this case, we ought to respect parents over government and family over hospitals?
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