Controversial U.K. Policy Withholding Surgery from Smokers and Obese Patients

The United Kingdom’s county of Hertfordshire has expanded a controversial health care policy that withholds surgery from patients who are obese or who smoke. The policy was originally implemented in 2011 and, at the time, only applied to hip and knee operations. In 2012, it was expanded to include other non-urgent routine surgeries. Under the policy, patients were banned from having surgery for a specific period of time as an effort to urge them to improve their health by losing weight or quitting smoking in order to become eligible for surgery. However, the most recent expansion of the policy is labeled as an “indefinite” ban on all routine surgeries until the patient’s health is improved.

Proponents assert that the expanded policy will help patients improve their health while also alleviating the county’s health care budget and reducing length of hospital stays. Opponents, however, argue that the policy is unethical.  One professor of psychology, Robert West, has expressed that “[r]ationing treatment on the basis of unhealthy behaviors betrays an extraordinary naivety about what drives those behaviors.” Although reducing obesity and smoking prior to any surgery is beneficial to a patient’s recovery, it remains unclear whether withholding surgery altogether is actually successful in improving overall health.

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Ethical Dilemmas Presented by the Legal Euthanization of the Mentally Ill

Cornelia Geerts, a fifty-nine year old woman who struggled with mental illness in Belgium, asked her psychiatrist to help her end her own life. In 2014, about one year after her initial request, a physician administered a lethal dose of drugs that killed her. Euthanasia is currently legal in only five countries: Canada, Colombia, Luxembourg, the Netherlands, and Belgium, where Ms. Geerts’ death occurred. Euthanasia is not legal anywhere in the U.S., but six states and Washington D.C. have legalized physician assisted suicide, which allows physicians to prescribe lethal drugs to terminally ill patients for patients to administer themselves. Belgium and Luxembourg permit euthanasia of people suffering from terminal illnesses as well as people suffering from mental illnesses, who may not be at the end of life.

The number of patients euthanized because of psychological suffering makes up a small percentage of euthanization cases in Belgium—of the approximate 2,000 euthanasia deaths that occur per year, only about 40 involve those who were suffering from mental illness. Though these cases are few, they highlight the bioethical dilemmas that physicians and lawmakers face in dealing with mental health issues and an individual’s right to make his or her own healthcare decisions. Advocates argue that individuals suffering from mental illness should be afforded the same rights as those who suffer from a physical illness. Yet, others believe that it is nearly impossible to know when a mentally ill individual decides to end his or her own life with sound mental capacity and not as a result of their underlying mental health disorder. Opponents believe that society has a responsibility to help those suffering from mental illness and to find help through means other than euthanasia.

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Hospital Puts Transplant for Two-Year Old Patient on Hold after Donor, the Patient’s Father, is Arrested

Two-year-old A.J. Dickerson, who was born without kidneys, was awaiting a transplant from his father, Anthony Dickerson.  However, after Anthony was arrested just days prior to the scheduled procedure, Emory University Hospital put the procedure on hold.  Even though Anthony was subsequently released from jail and is available to undergo surgery, the Hospital is requiring that Anthony comply with his parole obligations for at least 3 months before they continue with the transplant.

Such decisions to halt a transplant can entail added risk to the patient. Without the procedure, A.J.—who has already suffered a stroke because of his condition—may not survive the 3 month period required by the Hospital, or the long wait to find an alternative donor from the donor list.  A.J.’s family contends that the transplant should not be contingent on the actions of the father, but should focus on preserving the life of the child.

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Tags: Transplant, Donor, News

Sweden Dismisses Investigation of Stem Cell Scientist

Swedish authorities have dismissed claims against Dr. Paolo Macchiarini, an Italian stem cell scientist, who had been under investigation for voluntary manslaughter in connection with the death of three of his patients following windpipe transplants that were made partly from the patients’ own stem cells. The procedure is considered experimental by many researchers and experts. Yet, many scientists and physicians believe it could revolutionize medicine, particularly in regards to organ renewal and growth of new organs in laboratory settings.

The Swedish authorities argued that the use of “artificial” windpipes is negligent and medically unjust. However, there is very little consensus from medical experts regarding treatment and standard protocols that should be implemented with stem cell research. In addition, the Swedish authorities could not establish a direct connection between Dr. Macchiarini’s actions and the deaths of his patients. Without sufficient causation or standard of care protocols, the claims against Dr. Macchiarini were dismissed.

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Catholic Health Services Provider Faces Lawsuit for Denying Transgender Surgery

Seventeen year old Paxton Enstad, a transgender male, sought chest-reconstruction surgery as part of his gender dysphoria treatment.  When his parents, Cheryl and Mark Enstad, sought to obtain pre-authorization for the surgery, PeaceHealth St. Joseph Medical Center, a Catholic organization, denied the services without offering a rationale as to why it was denied.

The Enstads filed suit in U.S. District Court, claiming that PeaceHealth’s refusal to cover the services violates the Affordable Care Act (“ACA”) and the State of Washington’s anti-discrimination laws.  Specifically, they claim that the refusal to authorize the surgery enforces gender stereotypes and amounts to gender discrimination.

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Read Complaint Here.

 

 

 

Healthcare Advocates Push for Improvements in Advance Care Planning

Advanced directives, such as a health care proxies, promote quality health care by allowing individuals to leave specific instructions on how others should make medical decisions on their behalf in the event they lose capacity to do so themselves. Yet, nearly two-thirds of Americans do not have an advanced directive in place, and even those that do are at risk that their advanced directives will not be easily located when needed, as most are not recorded electronically.

Currently, the Centers for Medicare and Medicaid Services (“CMS”) reimburses health care providers for discussing advance care planning with their patients, but advocates are pushing for additional measures that would encourage a greater dialogue about end-of-life care, promote the execution of advanced directives, and ensure that advanced directives are readily accessible to providers and health care proxies. Most recently, a bipartisan bill was introduced in legislature that would require CMS to pay Medicare beneficiaries a nominal amount in exchange for writing and electronically recording advanced directives. Advocates hope that the payment would encourage more individuals to execute advance directives. In addition, CMS would maintain all such documentation online and would ensure that it can be accessed by providers and health care proxies as necessary.

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The National Institute of Health’s Path to “Precision Medicine” and the Barriers Associated with the “All of Us” Study

In connection with a data-gathering experiment known as “All of Us,” the National Institute of Health (NIH) is seeking a pool of over 1 million participants. NIH hopes that at least half of the participants will be made up of individuals who have historically been underrepresented in research studies, including certain minority communities. NIH believes this study can pave the way for “precision medicine,” a more personalized type of medicine with treatments based on a person’s genes. However, due to historical mistrust of researchers by minority communities, NIH knows that it has a challenge ahead to encourage underrepresented individuals to participate in the study.

From Stat News, “To advance medicine’s future, the NIH tries to win the trust of communities mistreated in the past”

Excerpt from article:

“People are afraid of being experimented on . . . Researchers know it won’t be easy to find hundreds of thousands of people who have little reason to let the government sequence their DNA but who might be willing to take a chance for a healthier future for their children.”

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Tags: National Institute of Health, NIH, All of Us, Tuskegee, Henrietta Lacks, mistrust, minorities, minority communities, revolution in healthcare, health research, biomedical research, healthy futures, precision medicine

The Risks of Antidepressants: Suicide and a Lawsuit for Inadequate Labeling on Pharmaceutical Drugs

Stewart Dolin began to take an antidepressant called Paxil five days before he committed suicide. His wife, Wendy Dolin, who had noticed a change in his behavior when he started taking the drug, remembers her husband being abnormally agitated in the days prior to his death. Ms. Dolin alleged that a side effect of Paxil, called akathisia, played a role in his decision to commit suicide. Akathisia brings on a state of acute physical and psychological agitation. Ms. Dolin sued the manufacturer of Paxil, GlaxoSmithKline, claiming that the company had not sufficiently warned of the dangerous side effects.

Evidence that surfaced during the trial brought to light results of early clinical trials conducted on Paxil in 2006. According to the studies, “the frequency of suicidal behavior was higher in patients treated with paroxetine compared with placebo” among adults of all ages with major depressive disorder. Though the label on Paxil had once reflected the risk to adults of all ages, the newer label only stated that the increased risk was seen among people under 25 years old. Both labels failed to capture, however, was the true magnitude of the heightened risk. The frequency of suicidal behavior in patients being treated with Paxil was found to be 6.7 times higher than the frequency for those being treated with the placebo. There have also been studies that have found a correlation between akathisia and suicidal behavior.

Ms. Dolin was successful in her lawsuit against GlaxoSmithKline, and a jury awarded her $3 million dollars in damages. This verdict is particularly unusual, as many lawsuits involving suicides are either dismissed or settled outside of court; it serves as a stark reminder to pharmaceutical companies that labels on antidepressants must adequately reflect the risks associated with them.

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Ms. Dolin started an organization called The Medication-Induced Suicide Prevention and Education Foundation (Missd) in memory of her husband and to raise awareness of akathisia. You can learn more about Missd at:  http://missd.co/

 

 

Opinion: House Approves Bill that Defies Basic Standards of Medical Ethics

by Michael S. Dauber

On May 4th, 2017, the Republicans in the U.S. House of Representatives voted to pass the American Health Care Act, an Act that, if enacted into law, would repeal and replace many central elements of the Affordable Care Act, commonly known as Obamacare. The measure has received widespread criticism from many Democrats and from professional medical associations such as the American Medical Association and the American Cancer Society. Many people have questioned various parameters of the bill. This article questions it from an ethical perspective, and in particular, the potential consequences of abandoning health care protections designed under Obamacare to ensure that the most vulnerable people in society receive the care that they need.

The American Health Care Act would strip away protections that have facilitated access to care for pregnant women, patients with disabilities, patients that cannot otherwise afford health care, and patients with pre-existing conditions. While any attempt to discriminate against the sick and needy is unjustifiably wrong, the Act appears to directly target members of groups that are defined as most vulnerable and in most need of protection under most formulations of ethical practice.

For example, the Act would allow states to opt out of Obamacare requirements that prohibit insurers from charging patients with pre-existing conditions higher premiums for health insurance. It further classifies pregnant women, women who have had C-sections, and victims of domestic violence and sexual assault as patients with pre-existing conditions. It also targets elderly patients by allowing insurers to charge elderly patients up to five times as much as members of younger age brackets. Currently, under Obamacare, insurers cannot charge the elderly more than three times the amount they charge younger patients. The Act also includes plans to gradually eliminate $880 billion in Medicaid funding over the next ten years, funds that could have otherwise been utilized to extend coverage to low-income families.

In short, the Act specifically targets some of the most vulnerable members of society who might suffer immensely without health care and who may not be able to afford to pay the costs that many insurers may demand, or may be unable to pay for other essential expenses after paying their insurance premiums. Ahead of the vote in the House of Representatives, Senator Bernie Sanders called the Act “an abomination” and, in a CNN interview with Anderson Cooper, Sanders said, “thousands of Americans would die because they would no longer have access to health care.” Proponents of the Act argue that it is engineered to reduce the burdens of health care cost on the government and on insurers. Yet, the overall effect will be a higher cost for patients. Many patients will suffer and will lose their access to care because of circumstances beyond their control.

In this regard, the Act conflicts with basic principles of contemporary bioethics.  For instance, the Belmont Report (1979), as a blueprint for ethics in human subject research, stresses the importance of respect for the “dignity of persons” while ensuring protections in accordance with justice. The Belmont Report, though focused on ethics in human subject research, has become a defining document in the history of medical ethics, establishing a system in which patients must be respected and special protections must be given to members of vulnerable populations. If a patient falls into a protected class, health care providers have an ethical obligation to ensure that the patient receives the care he or she needs and that the patient is not denied care solely on the basis of disability, economic status, or prejudice against specific medical conditions.

There is an apparent conceptual link between commitment to protecting vulnerable populations in the clinical and research context and commitment to ensuring that vulnerable populations have access to care. The American Health Care Act has not yet become law. It must first obtain approval in the Senate and be signed by the President. Most recently, the Senate decided to modify the bill before voting on it and, as a result, the bill must be sent back to the House for a second vote. As the Senate prepares its own version of the bill, government officials should recognize that a policy that effectively precludes access to health care for members of vulnerable populations is unethical by virtually every principle of medical ethics.

Heterologous Embryo Transfer Poses Novel Legal Questions

Heterologous Embryo Transfer (“HET”) occurs when a woman, unable to conceive a child, has a genetically unrelated embryo implanted. This form of surrogacy, which has been used for over 30 years, is now being complicated by the trend of embryo adoption.

There are often surplus embryos left over when a couple uses assisted reproductive technology, such as in vitro fertilization. In certain situations, the couple will allow the surplus embryos to be adopted by another couple. However, this raises novel legal questions if an issue of custody arises. There is neither legislation nor court precedent addressing what would happen if the biological parents sought custody from the second couple. As embryo adoption continues to increase, there will surely be legal battles over this.

From huffingtonpost.com, “Heterologous Embryo Transfer: A New Frontier in Parenting”

Excerpt from article:

Bringing a child into the world by traditional means is a process fraught with moral, ethical and emotional complications. Bringing a child into the world by non-traditional means, such as heterologous embryo transfer (HET) increases the complications exponentially, begging questions such as what defines a parent (genes, love, pregnancy and delivery, etc…) and who does the child belong to?

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Tags: Bioethics, pregnancy, parenting