Friday, May 21, 2010

Another Ethical Dilemma

The ethics of modern medicine has always fascinated me, and Pediatric Oncology has provided me with more than my fair share of ethical issues to contemplate. I want to share today’s, and see what people think about this particular, emotionally charged, situation.

I received an email today from a colleague in another state. He trained under me, and I guess he thinks I did a good job, since he emails me for advice from time to time. He met a new patient today – a 23 year old woman with a new diagnosis of osteosarcoma. Unfortunately, she is 20 weeks pregnant.

One of the mainstays of osteosarcoma treatment is high dose methotrexate. Methotrexate is a very effective drug for terminating pregnancies, and this is where the ethical dilemma begins. The patient has a choice to continue her pregnancy or not. Except that the state in which she lives does not allow medical assistance funds to be used to terminate a pregnancy, and she has Medicaid as her sole source of health insurance. She cannot afford to pay for an abortion herself. If she chooses to continue the pregnancy, either out of necessity or out of desire to do so, giving her methotrexate will be fatal to the baby inside of her.

If the patient chooses to remain pregnant, my friend has some very difficult decisions to make: should he wait to treat her until the baby is born? This would give the tumor as much as 4 months to spread before treatment, a huge risk to the patient. Should he begin therapy early, maybe once the third trimester begins, and just not use methotrexate? This would allow the baby to develop to full term prior to delivery, and only delay beginning chemotherapy a few weeks, but would provide less than optimal care to his patient. Could an obstetrician ethically deliver the baby early, say at 30 weeks, a time when the child’s development is likely to be normal (but, of course, may not be) despite being premature? This would allow him to use methotrexate almost 3 months earlier than if the baby is delivered at full term.

I told him what I think I would do, but I’m glad that for me this is just an ethical puzzle, instead of a real situation where I have to make real decisions.

Related Posts:

The Irony of Patient Autonomy
Thank Goodness for Ethics Committees


rlbates said...

Tough choices all around.

Empy said...

One of the many complexities of a case like this is that most people (especially young people) have a hard time comprehending just how deadly and aggressive osteosarcoma is. It is hard to convey to a patient the difference ten or twenty weeks of delay could make, but from everything I have seen, it is a very significant difference. In the end, it seems to me that the patient needs to understand that she very well may need to choose what is more important to her - to have this baby, or to have her own health and life. If she delays treatment, is there a father and family there to raise the baby while she goes through nearly a year of chemo, surgery and more chemo? Is there a support network there that she trusts to raise the baby if she is not around?

I am pregnant now. I personally cannot comprehend having any chemotherapy while pregnant and planning on having the child. I can only imagine the damage that chemo would do to the child. Even if she does not have methotrexate, the other chemos have all kinds of risks that are very serious. If my osteosaroma returned tomorrow and I needed chemotherapy, I am afraid I would choose to lose the child. I don't want to bring a child into the world without a mom. AND I don't want to put a child in my womb through chemotherapy and then watch it try to live suffering the effects of that chemo. It is a horrible decision either way, but I just could not bring a child into the world like that. If it was another kind of cancer that was more survivable and less aggressive, it might be a different story.

Anonymous said...

I am not a medical professional, but it seems to me that this patient must be helped to understand that she cannot both treat her illness in the most effective way and also have a baby right now. Sometimes people get into a state of wishful thinking, believing that if they just try hard enough, their body will do the impossible. She is essentially choosing between sustaining the pregnancy at the cost of losing her own life (in which case she needs a plan for who will care for the child and their wholehearted agreement) or treating her illness, knowing that one of the terribly sad consequences of that will be losing the baby. I hope her doctor does not imply that an in-between approach (treating the disease with a less effective regimen) might give her both her health and a healthy baby. It might well lose her both. This is only my opinion, but her body sounds like it just isn't in a condition where she can grow a baby. Pregnancy demands more than her very ill body can offer right now unless she gave so much that she died. I am so sorry that she is facing this situation.

Cancer Treatment said...

Good one. Nice sharing of your life experiences here. Keep posting more.
Do stay in touch.

Anonymous said...

hey..can i ask you a question...are u a doctor? cuz i am really worried if i got hepatitis c form my grandmother by using her tweezer...what are the chances of getting it? she had used to one day ago and it wasn't even disinfected.

Janice Ladden said...

This doesn't sound so complicated specially like what Empy said how deadly and aggressive osteosarcoma is. Treat the mother. She is already a living person with a family (and a bright future being only 23 years old) while the baby in the womb is a nonentity.
The pregnant mother's situation is similar to having a physical therapy. I am undergoing
physical therapy in Texas and I have seen patients like myself try to get treatment. The longer one delays treatment, the more difficult the condition will become.

Alison said...

What are her chances of even making it to term? If you are using the methotrexate as treatment for the osteosarcoma, would the insurance not pay? Fetal demise would be a side effect of the treatment, with the desired result being remission, not an abortion. Obviously I am not a doctor or a lawyer, but can this be put in legalese to get her treated?

Prachi said...

I would wonder if she really is in a psychological / emotional state to make a sound decision about having the baby or not. Given her circumstances, I think almost everyone would advice her against having the baby. Obviously, no one can force her to do anything. But I would encourage her to seek therapy to try to figure out whether her desire to keep the baby comes from the denial of her own illness. Obviously, I know only what you have written here, but my instinctive response to this is that her decision to have the baby would be an extention of her own life. Perhaps at some level she does realize the seriousness of her illness. Given that, she probably does not want to voluntarily kill the life fostering inside her, not realizing the dangers involved in that, to the baby as well as herself. Tell your friend to encourage her to seek therapy for this issue.

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It is quite hard to make a decision. Probably her situation as a mother she will prefer to have the baby but it would increase the probability that she will die. If she sticks to that I would do the best that I can to help her.

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