J. Rosser Matthews's Blog
Posted by J. Rosser Matthews
In today’s Washington Post, there is an interesting article on “Patient Pioneers” that discusses the role of fame when a patient is the “first” to receive a new surgical procedure or treatment that constitutes a medical “breakthrough.”
Among the examples discussed by the article are new procedures that can raise ethical issues—the article cites the example of a couple in 2000 who had a second child via in vitro fertilization and then selected an embryo for implantation that, based on genetic testing, would be a suitable donor for their other child who suffered from a deadly bone marrow disease. The broader ethical issues raised by genetically selecting offspring with pre-determined characteristics has been addressed in an article on this site.
The article also, by implication, touches on other issues that has been addressed on this site—namely, how appropriate are market incentives in the arena of medical decision making? The article discusses how the public relation’s departments of hospitals often capitalize on novel procedures for the added publicity--and (presumptively later on) greater revenue.
While the added publicity may benefit the long-term revenue stream of the hospitals (and give them an incentive to undertake novel and expensive procedures), an ethical problem arises because this added publicity may generate psychological pressures on the patients who are thrust into the limelight. While some researchers are cognizant of this issue—the woman last year who underwent the first partial face transplant was required to undergo counseling—there is clearly a need take up this question at the policy level so that the recipients of novel procedures are not required to suffer either unwanted publicity or undue psychological stress.
Posted by J. Rosser Matthews
As noted in an earlier article on this website, ethical issues are always present in clinical trials because the experimental subjects involved are human beings.
In the past, many clinical trials were (and often still are) funded by the government and carried out in academic medical centers; in the United States, one of the principal government funding sources for clinical trials is the National Institutes of Health. In other words, these trials were funded by public monies and designed ultimately to improve the public health.
In recent decades, however, changes in the funding of clinical trials have caused new ethical concerns to arise. In particular, the line between the public and the private in the financing of clinical trials has become much more blurred. Now, university medical centers rely not only on funds from the government, but also on funds from private pharmaceutical companies. As an article in last week’s Washington Post pointed out, “The research centers provide expertise, academic cachet and willing patients for companies developing drugs, while the companies provide income for the institutions and, in many cases, for doctors and faculty members serving as consultants, officers or board members.”
Although the article reported that many patients did not object to this arrangement, this empirical fact does not eliminate the underlying ethical problem with these changes in the funding of research. Rather, it illustrates again the argument articulated by Michael Walzer (and discussed in the article on Social Justice v. Market Incentive) that research in the health care arena might be a “sphere” where the logic of the marketplace should not dominate. Some of the problems with letting the logic of the marketplace dominate in the field of academic research are discussed in a report produced by the American Federation of Teachers in 2004.
Posted by J. Rosser Matthews
As the Associated Press has recently reported in major newspapers such as the Washington Post and the Boston Herald, the woman who received the first partial face transplant one year ago has adjusted to her new face. As she observed, “It may be someone else’s face, but when I look in the mirror I see me.”
The woman became a candidate for the novel procedure when her own face was badly disfigured from a dog bite. As reported last year, there were both medical and ethical concerns with trying this procedure. From a medical standpoint, there was always the possibility that the woman —like any transplant patient—might reject the transplanted material; as a result, the woman had to take a regimen of immunosuppressant drugs.
From an ethical stanpoint, the issues surrounding this procedure are multiple:
- As with other patients who could benefit from transplant procedures, there are questions about how to obtain suitable organs (in this case, the tissue came from a multiple organ donor who was brain dead).
- There are questions about the types of patients on which this procedure should be done (should this done, as in this instance, only on cases of extreme disfigurement?).
- This news story vividly illustrates how, in the arena of medical innovation, technological and psychological developments must both be addressed simultaneously. Although this particular woman appears to have adjusted admirably (after undergoing counseling before being given the procedure), others might not be so psychologically adaptive—especially given how central a person’s face is to self-identity.
Posted by J. Rosser Matthews
Last week, at the American Heart Association conference, scientists reported on the results of experiments in which heart valves were grown from stem cells extracted from amniotic fluid. The fluid was obtained during amniocentesis, a prenatal test for birth defects. The theory behind this experiment was that, if prenatal tests indicated that the infant had congenital heart defects, then the new heart valves could be grown while the infant was still developing and be used as replacement valves when the infant was born.
If this procedure becomes more developed, there are both practical and ethical advantages. As the Associated Press article notes, from a practical standpoint, replacement valves from human cadavers or animals may deteriorate and may not grow as the infant matures—implying the need for additional medical and/or surgical interventions. By contrast, using living cells from the infant opens up the possibility that the valves might grow with the infant.
A major advantage of this procedure, however, is ethical—it involves using cells that the fetus sheds in amniotic fluid, which means that no embryo has to be destroyed to get the stem cells. Given that the destruction of embryos to obtain stem cells has been at the center of political and religious debate about stem cell research, this development may offer a middle ground on which both sides of the dispute could agree.
Posted by J. Rosser Matthews
At today’s meeting of the American Heart Association in Chicago, the results of an NIH funded study demonstrated that heart attack patients who received angioplasty (inserting a balloon into the clogged artery plus the subsequent insertion of a stent) 3-to-28 days after the attack faired no better than those who received only medical treatments. In particular, the study (which was a randomized clinical trial) found that there was no statistically significant difference in the two groups in the subsequent occurrence of death, heart attacks, or heart failure.
What this illustrates from the standpoint of research ethics is the centrality of the idea of equipoise—that is, there must be substantial uncertainty between the treatment options to justify doing the clinical trial to resolve that uncertainty. As one of the leaders of the study, Dr. Judith S. Hochman observed in today’s New York Times, “This is why we have clinical trials.” She also noted that, because many cardiologists are strong believers in the angioplasty procedures, many medical centers refused to participate in the study. This conflict is a classic illustration of the sometimes divergent viewpoints of the clinician and the medical researcher. For the clinician, the primary focus is doing what is beneficial for current patients under his or her care—which would include administering procedures, like angioplasty, which many believe to be efficacious. For the medical researcher, by contrast, the primary focus is on answering a question about which there is scientific uncertainty, which will be beneficial for future patients who will suffer from the same condition.
Posted by J. Rosser Matthews
In today’s Washington Post, there is an article that analyzes the ethical issues raised a new vaccine for cervical cancer, which ideally should be administered to 11-to-12 year old girls; in other words, before they become sexually active. The health benefits from this procedure have been established. This article, by contrast, highlights three major hurdles to the widespread introduction of the practice—parental doubts about whether the vaccine is safe, issues of payment as the insurance industry grapples with whether or not to cover the procedure, and fears on the part of both parents and pediatricians about how to explain the procedure to their daughters and patients respectively.
What this article demonstrates is that the “translation” of a scientific discovery into universally socially and medically accepted practice is seldom straightforward. From the standpoint of public health, the introduction of this practice would seem to be justified. However, when individual parents and pediatricians have to make a decision, situation specific psychological and economic factors clearly play a role.
Posted by J. Rosser Matthews
Earlier in the week, one widely-publicized story that dealt with health issues was the study, which demonstrated that mice on a high fat diet that were given high doses of resveratrol, a substance found in red wine, lived longer and were healthier than their counterparts on the high fat diet that did not receive the resveratrol.
Because there is a problem with the health effects of obesity in most of the developed countries, these scientific results clearly suggest promising lines of research. However, at this stage, this study does not seem to advance any *new* (or ethically compelling) arguments in favor of radical change in alcohol consumption levels on the part of the individual. After all, many previous studies had already established the beneficial health effects of wine consumption in moderation and, as commentators on the study noted, the quantity of wine that a human would have to consume to get the same dose of resveratrol as the mice would be several hundred bottles per day!
In other words, while this study does offer promising scientific leads, it actually reinforces a point that is often made with regard to chronic health conditions brought on, in part, by behavioral choices such as diet and exercise that lead to obesity—namely, the resulting health threats can be reduced more by changing the multiple underlying behaviors (that is, the factors that led to obesity) than by a single change in one specific behavior such as alcohol consumption.