The Right to Uninformed Consent?

Mrs. Z is a widowed 70-year-old mentally competent Russian immigrant who lives independently in a suburb outside Washington, DC. Her doctor discovers that she has an operable tumor and has her admitted to the hospital for surgery. Because she does not speak English, her 45-year-old son Boris Z translates for her but adamantly refuses to tell her that she has cancer. He tells her only that she needs surgery, because he says that "it will destroy her" to know the truth. The surgeon and other staff members argue that she must be told why she needs surgery in order for them to obtain informed consent for the procedure, but Boris will not allow the hospital's Russian translator to enter Mrs. Z's room. Boris explains that in his culture, the man of the family (in this case, the eldest son) makes the decisions and that his mother is quite willing to have surgery without knowing what it is for. Indeed, Mrs. Z has shown no curiosity about the nature of her disease, and is willing to undergo the procedure simply because the doctor says she needs it. Boris is absolutely convinced that knowing the truth that she has cancer will be detrimental to her health and peace of mind, and continues to refuse to explain it to her. The Hospital Ethics Committee meets and decides to get around the issue of informed consent by having Mrs. Z. sign a form stating that she refuses the hospital's translating services and would prefer that her son be her translator. [Actual case- thanks to Steven S for bringing it to our attention]

Can someone forego the right to be informed? Should the hospital inform her anyway? What do you think of the Ethics Committee's solution? 

Moderator: At-Risk Home Birth: Whose Right Is It?

On the issue of high-risk home birth, the VCOM community members who commented on the blog were not in consensus. However, there does seem to be a strong contingent voicing support for the mother’s autonomy to make decisions about her delivery. Elective home births and non-hospital births (such as at a birthing center) are on the rise in the US. Most women who choose home birth rely on a trained birth attendant (such as a midwife) to help her deliver. There is a growing movement of women who choose not to utilize a birth attendant. In the literature, this is called “free birthing.” An opinion article was recently published in the Lancet on the ethical considerations of high-risk home birth, causing quite a stir in the home birthing community (see below).

In Virginia, there are laws governing midwives attending home births. A recent legislative attempt to prevent reimbursement to midwives attending high-risk deliveries did not make it out of committee. However, Del. Matt Lohr, R-Harrisonburg, has introduced a bill to the General Assembly that would require midwives to inform patients of the potential risks associated with delivering at home. The idea of the bill was brought to Lohr by an obstetrician and gynecologist in Harrisonburg, VA, who was concerned about the safety of high-risk home births. Lohr reports concern due to recent cases of midwives whose licenses were suspended by the Virginia Board of Medicine after they attended high-risk home births and the babies did not survive.

Thanks to everyone who joined the debate! Please keep it going in the comments section if you have more to say.

Read More
Home Birth—Proceed with Caution, The Lancet, 31 July 2010 (Vol. 376, Issue 9738, Pages 303). Full article here

Midwife legislation in Virginia
Sally Voth, “Legislation Would Impose New Rules on Midwives,” The Northern Virginia Daily, 17 February 2009. Full article here

"Free-birthing"
Madison Park, “Home Births: No drugs, no doctors, lots of controversy,” CNN, 09 August 2010. Full article here

High-Risk Home Birth: Whose Right Is It?

Mrs. R is a 39-year old woman who is three months pregnant with her first child (her age makes her “high-risk”). She would like to deliver the baby at her home with a midwife present. Mrs. R does not have any other significant risk factors for an unhealthy delivery. She lives 25 miles away from the nearest neonatal intensive care unit (NICU).

What kind of ethical issues are involved in this case? Should a midwife agree to attend Mrs. R’s home birth? What should a physician advise? Mrs. R believes she has a right to decide where and how to give birth. Does the baby have rights? Is legislation appropriate?

Ground Rules Reminder:
1. Feel free to post anonymously if you wish but please use a consistent pseudonym so that people can respond to your comments without having to scroll up to see which anonymous/time stamp they are referring to.
2. Discussion is moderated- but no posts will be edited, and all posts will be accepted unless the author is grossly off topic (for example we’re discussing abortion and you want to talk about how much you hate the military), ad hominem (= insulting other people instead of addressing their arguments), or profane.

Moderator: Posthumous Sperm Retrieval

Thanks to everyone who joined the debate! You are welcome to keep it going in the comments section if you have more to say. We will have a new topic for debate on Monday.

The purpose of this post is just to sum up what we as a VCOM community came up with, and to point those interested in this topic to more fleshed out arguments by the experts. The issue of posthumous sperm collection has been widely debated throughout the world, and different countries have passed various laws about it. Even in our small community we have not been able to reach a consensus. Overall, the commenters on this blog seem to fall into two general camps- those who think that not giving the sperm to the fiancee would violate her reproductive rights, and those who believe that giving her the sperm would violate Mr. P's autonomy (through lack of consent). As seems always to be the case in bioethical debates, it is a question of conflicting rights. Other issues discussed in the literature concerning this subject include: child welfare, paternity/inheritance legalities, terms of storage, physician obligation, religious objections, persistent vegetative status vs death, etc.

Articles*
1. Strong C, Gingrich JR, Kutteh WH: Ethics of postmortem sperm retrieval: Ethics of sperm retrieval after death or persistent vegetative state. Human Reproduction 15 (4):739-745, 2000. full article here

2. Orr RD, Siegler M: Is posthumous semen retrieval ethically permissible? Journal of Medical Ethics 28: 299-302, 2002. full article here

3. Stanford University website on infertility has an interesting section on posthumous reproduction.

*These provide a good overview. For those of you with abundant spare time, just type "posthumous sperm retrieval" into PubMed. You'll get at least 19 hits.

Topic 1: Harvesting A Dead Man's Sperm

Mr. P is in a coma, has been declared brain dead, and is on artificial ventilation after an automobile accident. Fiancee, family, and doctors are all agreed that his machines should be unplugged and he allowed to die on his own. However, the fiancee, Ms. M, wants to be artificially inseminated with his sperm and states that the two had been trying to conceive prior to his death. Should Ms. M be allowed to use Mr. P’s sperm? What are the ethical ramifications of using a dead/dying person’s reproductive tissues? How do you define consent in this case?
(Actual Hospital Ethics Committee Case)

Debate (di-bate), Verb: To engage in argument by discussing opposing points

The first debate topic will go up on Monday. Here are the ground rules:

1. Feel free to post anonymously if you wish but please use a consistent pseudonym so that people can respond to your comments without having to scroll up to see which anonymous/time stamp they are referring to.
2. Discussion is moderated- but no posts will be edited, and all posts will be accepted unless the author is grossly off topic (for example we’re discussing abortion and you want to talk about how much you hate the military), ad hominem, or profane.
3. Please email us (vcombioethics at gmail.com) with any topics you'd like to see debated in the future.

As a reminder- the basic principles of medical ethics to consider include: justice, beneficence, nonmaleficence, and respect for autonomy.

Essay Contests and Places to Publish Your Work

We will update this listing as we receive more information. Please let us know if you know of any more contests or venues for medical student writing and we will add them to the list.

AOA Bureau of Osteopathic History and Identity 6th Annual History Essay Competition
Prizes: $5,000 first prize, $3,000 second prize, and $2,000 third prize.
Requirements: Contestants are asked to focus their essays on one of the following principles from the bureau's "Core Principles for Teaching the History of Osteopathic Medicine." Maximum length 3,000 words. For full details, please see the full information on the competition at http://www.do-online.org/TheDO/?p=20961
Deadline: September 13, 2010.

Bander Essay Contest in Medical Business Ethics
The Bander Essay Contest is supported by the Saint Louis University Bander Center for Medical Business Ethics. The contest is meant to encourage scholarly inquiry into business ethics within the practice of medicine or the conduct of medical research.
Prizes: Author of the best essay will receive $5000. If more than one exceptional entry is received, up to three runner-up prizes of $1,000 each will be awarded. Winning essays will be published in the AMA's Journal of Ethics, Virtual Mentor.
Eligibility: Medical students, resident physicians, fellows, and physicians are eligible.
Requirements: Essays must be 2,000 words or fewer, typed, and double-spaced. The author’s name, address, telephone number, e-mail address, and affiliation (medical school and class, private practice site, hospital affiliation, etc.) should appear on the cover sheet only—not on the essay pages.
Deadline: Midnight CDT, December 15, 2010. Submit essays as email attachments to Faith.Lagay@ama-assn.org.
See their website for full details and to see the prompt: http://virtualmentor.ama-assn.org/site/aboutbander.html

Osler Medal Essay Contest
http://www.histmed.org/osler_medal.htm
The William Osler Medal is awarded annually for the best unpublished essay on a medical historical topic written by a student enrolled in a school of medicine or osteopathy in the United States or Canada. First awarded in 1942, the medal commemorates Sir William Osler, who stimulated an interest in the humanities among medical students and physicians. The writer of the winning essay will be invited to attend the 2011 AAHM meeting, April 28–May 1, in Philadelphia, Pennsylvania, where the medal will be conferred. Reasonable travel expenses will be provided, as will a two-year complimentary membership in the AAHM. If the Osler Medal Committee also selects an essay for honorable mention, its author will receive a certificate and a two-year complimentary membership in the Association.
Deadline: January 15, 2011.

Global Pulse Journal
This is AMSA's international health journal (AMSA = American Medical Student Association), dedicated to demonstrating that American medical students are concerned with the health of the international community.
Subject matter accepted: GPJ publishes content related to global health that is relevant to health professionals in training. We adopt the definition set out by the Consortium of Universities for Global Health:
“Global health is an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasizes transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population based prevention with individual-level clinical care.”
Submissions to Global Pulse Journal should be engaging and readily understood by medical students unfamiliar with topic material.

Who can submit: GPJ publishes material written by medical and pre-medical students, residents, and other health professionals in training.

Check out their website for more information.

HERE
That's right. This blog. We're looking for original writing from VCOM medical students on all aspects of medical school, and would especially like to hear from 3rd and 4th years about their experiences on the wards. We can't offer you any money (yet) but we can offer you an audience for your writings and our own admiration for your writing prowess.
Please email vcombioethics at gmail.com with questions and submissions.

Hello World

Welcome to the Bioethics and Humanities club (BAHM) blog! We are here to debate, argue, and trade in ideas. We have an exciting year planned- Friday afternoons at Carillion's bioethical committee meetings, hopefully a talk from an anthropologist specializing in Appalachian culture, weekly telecast live broadcasts of biomedical programming from other schools, arts nights. We are here to remind you that you are much more than a student doctor/scientist-- you are an individual with hobbies, interests, thoughts that don't have anything to do with the biochemical pathway for PKU. Remember the things that make you human and that make you you. It is through these that you will truly connect with your patients.

One of the most exciting things about this club is that you can participate without attending meetings. That's the purpose of this blog. We want debate, we want heated discussion, we want the whole VCOM community to think. Your opinions matter here, and we'll have a new bioethics topic every week or two for you to discuss and post your comments. Yeah, its moderated, but only so that we all stay on topic and nobody gets ad hominem. By the way, nobody's opinion is more important than anyone else's on this site- not the club officers, not any administrator/faculty member who happens by, not 4th years or 2nd years more than 1st years.

Welcome. Please come back often. We look forward to your thoughts, opinions, suggestions.

Yours truly,
Lisa Mitchell & Emily Bruce, MS II
vcombioethics at gmail.com