Occupational asthma - Inherent conflict of interest?

You’ve been Mary’s physician for 10 years. She is now 28 years old with two young children and a recent divorce.  Mary came to you depressed last year because she felt isolated, was unemployed, and didn’t want to become welfare dependent.  She seems much happier today when she sees you, because she’s excited to tell you she’s had a fairly well paying job for the last 4 months. She works at an employee-friendly domestic cleaning service.

Mary tells you that her childhood asthma, which she had kept under control, has become exacerbated on the job because of the cleaning products she has to use.  Her employer noticed her concerning coughs and wanted a physician to check on her, to clear the company of any liability they have for her health.  She has a form for you to fill out regarding her physical wellbeing.  Mary begs of you to clear her for the job and promises to wear a mask over her nose and mouth from now on. She says she’s likely to be fired and lose her decent income if you document her asthma’s exacerbation.

Define the ethical issues involved and describe what you would do as her physician. 

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Moderator: Anencephalic neonates as organ donors?

Thanks to everyone who responded!  Feel free to continue discussing the topic.  Many of members of the VCOM community who commented on this case evoked the utilitarian argument that harvesting organs from our anencephalic neonate is acceptable because it could save the lives of numerous other infants.  However, we did not reach consensus, as various arguments were presented from the legal, clinical, emotional, biologic, and slippery slope stances.

We raised a lot of important questions: What state of a brain is considered adequate for life, and is there a difference between an anencephalic infant and an adult in a permanent vegetative state? Does the law respect the parents’ right to choose what’s best for their child? What are the parents going through, and how can we help them cope? Will there even be an organ donation team willing to harvest the organs of an anencephalic neonate?

Law makers and clinicians have struggled with these same questions for many years. The first successful infant heart transplant in the US occurred at Loma Linda University Medical Center in 1987. The donor was an anencephalic infant from Canada. In the following nine months, the medical center placed a dozen anencephalic infants on ventilators to await their brain death (which could be prolonged because of the intervention) so that their organs could be donated. All 12 infants failed either to arrive at brain death within one week or to be matched with a recipient infant within one week. As a result, the hospital suspended its anencephalic organ donor program under the current legal definitions of brain death.

For those of you interested in further reading, here are two excellent reviews:

Meinke, SA: Anencephalic infants as potential organ sources: Ethical and legal issues. National Reference Center for Bioethics Literature. 1989. Full article

Bard, JS: The diagnosis is anencephaly and the parents ask about organ donation: Now what? A guide for hospital counsel and ethics committees. Western New England Law Review. 1999. Full Article

Sources: 
Goldsmith, MF: Anencephalic organ donor program suspended; Loma Linda Report expected to detail findings. The Journal of the American Medical Association. 1988.
Annas, GJ: From Canada with love: Anencephalic newborns as organ donors? Hastings Center Report. 1987.

Speaker Event: Syphilis Studies in Tuskegee and Guatemala

If you attend the talk, we'd love to hear your thoughts on it!  Leave comments below or email us. 

Susan Reverby, Marion Butler McLean Professor in the History of Ideas at Wellesley College, will be at Virginia Tech on Thursday, April 14, 7 PM, in 3100 Torgersen Hall, Virginia Tech to give a lecture entitled  

"Escaping Melodramas: Reflections on How to Think about the Syphilis Studies in Tuskegee and Guatemala." 

Prof. Reverby  is the author of Examining Tuskegee: The Infamous Syphilis Study and Its Legacy, and recently uncovered U.S. government involvement in a similar "study" in Guatemala. Reverby's work brings together issues of race, gender, and class as she explores the implications of the Tuskegee study in modern memory and modern medicine. Sponsored by the undergraduate Minor in Medicine and Society in the Department of Science, Technology, and Society.