Incidentally… avoiding the problem of incidental findings
A new study from the Mayo clinic in the United States points to a frequent problem in certain types of medical research. When healthy volunteers or patients with a given condition take part in research studies they may have brain scans, CAT scans, blood tests or genetic tests that they wouldn’t otherwise have had. These tests are not done for the benefit of the individual, they are designed to answer a research question. But sometimes, quite often according to the authors of this new study, researchers may spot something on the scan that shouldn’t be there, and that could indicate a previously undiagnosed health condition. These ‘incidental findings’ generate an ethical dilemma for researchers. Should they tell the research participant about the shadow seen on their scan? Do they have an obligation to reveal to a research participant that they have found them to carry a gene increasing their risk for breast cancer, or Alzheimer’s disease? There is much agonising by ethics committees, ethicists and researchers about the problem of incidental findings, but there is a simple way of avoiding the problem. Anonymise research databases and tests so that there is no possibility of determining which participant has the breast cancer gene, or the lump in their kidney.
When you prick me do I not cry?
A fascinating study in the Lancet this week has suggested that a very commonly used and simple analgesic in newborn infants may not actually be preventing them from experiencing pain. The study’s authors suggest that this medicine should no longer be used routinely in newborn infants. A headline in the Guardian reads “Newborn babies should not be given sugar as pain relief”. But there are scientific, philosophical and ethical reasons why this conclusion, though possibly correct, is premature.
A law that should not be
In New York state last week legislators passed an extraordinary bill that, effectively, indicts the practice of New York doctors. That the bill was thought necessary, and, even more so, that it was opposed by the Medical Society of New York is a sad reflection of medical practice in that part of the world.
Should doctors come clean? Religion makes a difference to end-of-life decisions
In a paper released today in the Journal of Medical Ethics, a large survey of UK doctors found that doctors’ religion influenced their views and practice of end-of-life care. Why does this matter? A number of headlines highlighted that atheist or agnostic doctors were more likely to report having participated in “ethically contentious end-of life actions”: ie taking part in terminal sedation or in actions that they expected or partly intended would hasten the patient’s death. But other headlines emphasised the obvious flip-side: doctors who identified themselves as ‘very religious’ or ‘extremely religious’ were about 35% less likely than non-religious doctors to report having taken this sort of step.
Demedicalising and decriminalising drugs
Is drug addiction a disease? Substance Dependence appears as a diagnosis in the influential Diagnostic and Statistical Manual of Psychiatric Disorders (DSM-IV). There are medical specialists in the field who use a range of different drug and non-drug treatments for patients who are addicted. There are hospitals and clinics where those who are addicted can seek help. But if it is a disease why is it treated as a crime? After all we do not lock people up because they have cancer, or hepatitis, or heart disease.
Between Life and Death…
A powerful BBC documentary, “Between Life and Death”, screened this evening on BBC One. The documentary (which can be viewed online for the next week in the UK) examined the life and death decisions made for critically ill patients with severe brain injury. Neuro-intensive care provides a way to interrupt the process of dying for such patients. But it raises difficult questions for medical staff and for families about the wishes of patients, the wishes of family members, and about uncertainty. Should treatment continue at the risk of the patient surviving in a severely impaired state? Or should patients be allowed to die, with the risk that perhaps if treatment had continued they may have recovered?
Critical Care ethics series – the ethics of maxiple pregnancies
by Dominic Wilkinson
Quads, Quins, Sexts, Septs, even Octs!
High order multiple pregnancies such as the Suleman octuplets in California generate enormous media attention. However, they also raise some unique ethical questions. In the second of a series of seminars on critical care ethics, the neonatal grand round today looked at ethical questions arising from 'maxiple' pregnancies. These include questions about the normativity of conception decisions, the moral status of fetuses, selective feticide and lifeboat-type dilemmas. Around the time of delivery these pregnancies generate enormous practical and ethical questions for neonatal intensive care relating to their impact on capacity and the potential need to balance claims on intensive care beds between different infants and families.
Here is a copy of today's
presentation (pdf 4.6MB).
Further reading…
The Suleman Octuplet Case: An Analysis of Multiple Ethical Issues. Women's Health Issues (2010) vol. 20 pp. 260-5
Evans et al. Update on selective reduction. Prenat Diagn (2005) vol. 25 (9) pp. 807-13
Daar. Selective reduction of multiple pregnancy: lifeboat ethics in the womb. Univ Calif Davis Law Rev (1992) vol. 25 (4) pp. 773-843
Pector. Ethical Issues of High-order Multiple Births. Newborn and Infant Nursing Reviews (2005) pp. 8
Will you live to 100? Should we tell people that they have (or lack) the genes for long life?
In the news today – scientists have identified a cluster of longevity genes. From the Daily Mail
A genetic test which tells whether you will make it to your century has been developed by scientists.
The computer program will give individuals their odds of reaching the age of 100 – and tell them whether their chances are higher or lower than average.
Its inventors, from the respected Boston University in the U.S., say it will allow those not blessed with the cocktail of 'centenarian genes' to make changes to their lifestyle to maximise the time they have.
Professor Julian Savulescu, an Oxford University ethicist, said: 'I believe it is highly in your interests to have this information because even if there is nothing you can do about it, it can help you plan your life.
What do you think? Is it a good thing to know if you are predisposed (or not) to long life?
What if this discovery led to many of us being able to live to 100? Would that be a good thing?
other reports: New York Times
A costly separation between withdrawing and withholding treatment
by Dominic Wilkinson
Television child star Gary Coleman died recently following a severe brain haemorrhage. He was taken to an intensive care unit, but the next day was taken off life support because of the severity of his brain injury.
Decisions like the one made by Gary Coleman’s doctors are common in intensive care. Many deaths follow decisions to stop intensive treatment because it is believed to have no chance of succeeding or because of the burden of illness even if the treatment does work. One question raised about cases like these is about the importance (or risks) of living wills. A separate question (and one that was raised during the critical care grand round earlier today) is about the difference between stopping treatment and failing to start treatment.
Critical Care ethics grand round
by Dominic Wilkinson
Today I gave a talk at the John Radcliffe Medical Grand Round on Advance Directives and treatment withdrawal decisions in intensive care – based on a case I was involved in last year.
A middle-aged patient presents with acute respiratory failure, and is intubated and transferred to the intensive care unit. After admission he improves, but it transpires that he has a progressive neurodegenerative disorder and has previously expressed a wish not to have intensive life support measures provided.
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