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Decision Making

Second-hand and second-class organs. Should the patient know?

In a urology journal this month American
surgeons describe transplanting kidneys that would previously have been
rejected as unsuitable. In each case the donor kidneys had been found to
contain a solitary mass during the transplant work-up that was potentially
cancerous. Rather than cancelling the donation the surgeons removed the kidney,
cut out the tumour, and then transplanted the tumour-free organ. This follows
reports from a couple of weeks ago that surgeons are increasingly using ‘risky’
organs from donors who are elderly or who have other serious illnesses.

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A Controversial Use of Taxpayer Funds

The health care reform bill currently being debated in the United States has re-ignited controversy there over abortion, and in particular over the availability of federal government funding to pay for the procedure. Earlier this month, the House of Representatives version of the health care bill passed narrowly, and with a last minute amendment that will restrict provision of abortions. The so-called “Stupak amendment” says that no health care plans receiving any subsidy from the federal government may offer abortions, except in the case where abortion is the result of rape, incest, or to save the woman’s life, and it maintains this restriction even if the government subsidies are kept separate from the private payments made into the plans, and no government subsidy is ever used to pay for abortions. The Stupak amendment represents a tightening over existing policy, according to which the federal government is prohibited from directly funding the provision of abortions, but may provide funds for hospitals, for example, that also provide abortions – so long as the hospitals pay for the abortions themselves by some other means.

The argument for Stupak’s additional restrictions on abortion funding is supposed to be that since money is fungible, the old prohibition does not really work to prevent federal funds indirectly playing a role in providing for abortions. Whatever the merits of this argument, it’s worth noting that many of its proponents in congress make it hypocritically; they are more than willing to accept generous campaign contributions drawn from the profits of health insurance companies that provide insurance for abortions as a component of their plans. But I want to focus here on the question of having any restriction of this kind at all. Can the federal government legitimately be prohibited from funding abortion?

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Should parents decide? The case of RB

In the Family Court yesterday, a controversial case that has been widely reported in the media came to a premature close. The father of baby RB, a severely physically disabled 13 month-old infant, withdrew his opposition to the plan by RB’s mother and doctors to take him off life support. It is believed that in the near future doctors will stop breathing machines and allow RB to die. The court did not, in the end, make a judgement about this case, though a statement of endorsement by Justice Macfarlane yesterday suggests that it would have reached the same conclusion.

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Will Down syndrome disappear?

There are concerns about the impact of the improving accuracy and availability of low risk cheap prenatal tests such as for Down syndrome (DS). Introduction of a noninvasive maternal serum test is expected that might provide a definitive diagnosis of DS in the first trimester at no risk to the fetus. The authors report that the tests should be virtually universally available and allow privacy of decision making. The authors ask whether the new tests will decrease the birth incidence of DS even further. Indeed, might there be no more DS children born? If so, is that a problem?

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The ventilator lottery: rolling the dice in the face of difficult choices

As the winter approaches there has been a surge in the number of cases of swine flu, as well as a number of recent deaths in the UK. Although there is hope that the new vaccine will reduce the impact of the pandemic a number of countries including Canada the UK and the  United States have had to face the possibility that health services will not be able to accommodate the predicted surge in demand. Officials have been contemplating guidelines for deciding who should be prioritised for receiving life saving mechanical ventilation. The hope is that such guidelines will enable doctors to save the greatest number of lives in a pandemic.

But one concern about these guidelines is that they are unfair. Should scarce medical resources such as ventilators be allocated using a lottery instead?

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Non-resisted suicide and depression

In late 2007 a young woman with a history of depression and several previous suicide attempts presented to an emergency department following an overdose. She gave doctors a copy of her living will, written 3 days previously, in which she made it clear that she wanted no measures to be taken to save her life. Earlier this week Roger Crisp and Julian Savulescu argued separately in this blog that the wishes of competent patients to end their lives should be respected. But if we believe that suicide can be rationally sought, and should sometimes not be resisted, should this include those who have been diagnosed with depression?

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Living Wills and Assisted Suicide

Kerrie Wooltorton is believed to have been the first person to use a living will as part of a successful attempt to commit suicide: http://www.guardian.co.uk/society/2009/oct/01/living-will-suicide-legal . The 26-year-old wrote her will, and then three days later took poison and called an ambulance. The will said that no steps were to be taken to prolong her life, and that she desired only to be made as comfortable as possible and not to die alone.

If doctors had kept her alive, they may have been open to legal action. Indeed any interference with Wooltorton against her wishes could have been interpreted as an assault. But might there nevertheless be a moral case for ignoring a living will in such circumstances?

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Premature death or wrongful death?

A headline in the Daily Mail from yesterday highlights the cost of over treatment for extremely premature and marginally viable infants.

    “Parents cause infant to suffer by forcing doctors to give futile treatment”.

Despite doctors counselling a set of parents that their 22 week gestation premature infant (born 4 ½ months early) had virtually no chance of survival, the parents insisted that Warren* be actively resuscitated and treated in intensive care and threatened legal action if doctors refused. Warren received chest compressions in the delivery room and was put on a breathing machine. He developed holes in his fragile lung and had multiple drain tubes inserted into his chest. Warren’s thin skin tore and broke even with gentle handling, and he developed patches of skin loss, like second degree burns, on his trunk and limbs. He developed bleeding in the centre of his brain, and on the 5th day of life perforated his bowel from infection. He died the following day. Meanwhile, 2 infants born prematurely in the same hospital were unable to be accommodated in intensive care because of lack of beds and had to be transferred to another hospital 1 hour away. One of those infants became unstable during the ambulance transfer and developed additional complications. Lawyers representing Warren are now considering legal action against the doctors and against his parents.

But of course, that wasn’t the real headline or case in the Daily Mail, and legal action such as that described is not likely to take place.

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Telling porkies: should the doctor tell her patient where the medicine comes from?

In a column in the New York Times this week Randy Cohen fields a question from an anaesthetist. Should the doctor ask a devoutly religious patient whether he minds that his anticoagulant (heparin) is derived from pigs? In reply Cohen suggests that the doctrine of informed consent requires the doctor to consider the non-medical preferences of the patient and make sure Muslims, Jews and vegetarians know where their medicine is coming from.

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Non-lethal, yet dangerous: neuroactive agents

An article and editorial in Nature warns about the militarization of agents that alter mental states. While traditional chemical weapons are intended to hurt or kill people, these agents are intended to disable. For example, they might induce confusion, sleepiness or calm. The Chemical Weapons Convention contain a loophole for using biochemical agents for law enforcement including domestic riot control, and there is a push from some quarters to amend it to allow novel incapacitating agents. Is disabling agents just an extension of other forms of non-lethal force, or is this a slippery path we should avoid?

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