Telling porkies

by Dominic Wilkinson (@Neonatalethics)

One of my registrars asked an interesting question this morning. A commonly used life-saving medicine in newborn intensive care is derived from animal products; should parents be told?

Very premature infants are commonly given a medication into their lungs that helps them to breathe. This medication, surfactant, is often derived from animal products. Surfactant is one of the most effective forms of treatment in neonatal intensive care. It significantly reduces the risk of death for premature infants with breathing trouble as well as reducing a number of serious complications.

One commonly used form, poractant alfa (Curosurf) is derived from minced pig lung. Another form, beractant (Survanta) is made from minced up calf lung.

However, some parents of premature infants might have concerns about the animal derived origin of this treatment on religious or ethical grounds. Muslim or Jewish parents might object to the use of porcine surfactant, while Hindu parents could object to the use of bovine surfactant. Vegan or vegetarian parents might have concerns about the use of either surfactant.

So should parents be informed about the origin of this drug?

Parents of extremely premature infants are counseled about many elements of their child’s treatment. If there is time they often receive counseling before the child is born. After delivery, neonatologists will often spend considerable time talking to parents about their infant’s progress, and obtaining informed consent for major treatments that are felt to be necessary.

However, doctors in newborn intensive care do not regularly discuss with parents the possible origin of surfactant – even where parents’ religion is evident, and they might be anticipated to have concerns. In one survey, from North America, only 2% of neonatologists routinely discussed the animal origins of surfactant.

Why don’t neonatologists discuss this issue with parents?

One reason might be that true religious objections to surfactant would be likely to be rare. There have been clear statements by religious leaders from all major religions that animal derived medication are allowed in emergency and life-saving situations. For example, orthodox Jewish religious tradition permits many religious strictures to be broken where this would save a life (see here, here,  here.) However, even if most religious parents would accept animal derived surfactant for their child, there could still be some who would not. Furthermore, religious exceptions may only permit the use of the prohibited animal where there is no alternative. Yet there is an alternative. Hindu parents may prefer to use porcine surfactant, while Muslim parents may prefer bovine surfactant.

A more significant reason not to inform parents of the origin of their infant’s treatment is because there may be no available alternative. In one survey, only one out of 10 neonatal units in England and Wales stocked both bovine and porcine surfactant. The rest stocked one or the other. Where there is only one type of treatment available, there is relatively little to be gained from informing parents about the nature of this particular medication. Parents cannot choose to have the alternative form of surfactant because it isn’t stocked. And they cannot choose for their child to forego surfactant because of the urgent and potentially-life-saving nature of the treatment. Just as for Jehovah’s Witness parents declining a blood transfusion for their child, doctors would almost certainly deny a parents’ request that their child not receive surfactant (on the basis of religious objections), and would seek a court order if necessary. In that setting it seems unnecessary, perhaps even cruel to inform parents about the animal origins of surfactant. It could only cause distress in some parents (who perhaps are unaware or do not understand the religious rulings that would permit bovine/porcine surfactant), without giving them any real choice in the matter.

The more tricky question then is whether neonatal units should stock more than one type of surfactant in order to allow parents to make a choice. Perhaps neonatal units should routinely stock bovine and porcine surfactants? There are even some newer totally synthetic surfactants that contain no animal products and might be acceptable to strict vegans.

If there were no downside to stocking multiple surfactants, then it would seem straightforward that neonatologists should be providing parents with these options. However, there are potential downsides. There have been conflicting results in trials, yet it appears that porcine surfactant may be more effective than the bovine version, with meta-analysis showing a reduction in deaths, and duration of treatment. Furthermore, the costs of different surfactants vary.  Synthetic surfactants are currently more expensive than available animal-derived versions (though they might save money in the long run if proven to be more effective). There are also significant pharmacy costs in stocking multiple different versions of a medication.

This leaves us with questions that are perhaps harder than the one that we started with. Giving parents choices that would respect their religious or ethical values might come at the cost of worse outcome for infants, or just at higher financial cost. How much are we willing to pay to respect or promote parental autonomy?

Image by ceejayoz from wikimedia commons