'Father of test tube baby' wins Nobel Prize for medicine

We all probably know someone who was conceived by in vitro fertilization (IVF). The "father of the test tube baby," Robert G. Edwards, won the Nobel Prize for medicine. On 25 July, 1978, the first "test tube baby" was born. You can read about Louise Brown on Wikipedia.

It's quite amazing to see that advances in medical technology have contributed to over 4 million births through in vitro fertilization. What will be next? There's no doubt that we'll eventually face some deep ethical and moral issues as we try to control human reproduction.

Quadriplegic man receives the right to refuse food and die

Here's a medical ethics case: An Australian high court ruled that a quadriplegic man has the right to refuse food and water and can be allowed to die. The ruling means that the nursing facility in which Christian Rossiter has lived since November 2008 cannot be held criminally liable for allowing the patient to die, the Supreme Court of Western Australia said. Watch this video clip (if you can't view the video, click here to view the video on MedicineandTechnology.com)

Click here to read this story on CNN.

Should "older" women get pregnant? Fertility and ethics

I don't plan to define "older." However, we know that older women can conceive (especially if they go through in vitro fertilization or IVF), but should they? What are the ethical issues involved? Modern medical technology has advanced infertility treatment, but when do we start crossing ethical boundaries? CNN's Diana Magnay explores some of these issues in this little video.

DNA testing in children, talents, and privacy in China

In China, scientists (probably along with some government officials) are performing genetic tests in young kids to identify skills and talents by analyzing their DNA. That's right, no personal privacy issues here. Submit a DNA sample to see what talents your parents should cultivate. Is this ethical? This is a fascinating video.

Treating multiple myeloma when the patient is a Jehovah's Witness

During medical school, we're often faced with clinical case vignettes where we get to practice problem solving skills. Such cases also often involve issues surrounding medical ethics. Anytime you get a case where the patient is a Jehovah's Witness, you know you'll be dealing with something ethical (that probably involves blood transfusions).

According to Wikipedia, "Jehovah's Witnesses are not permitted to accept red cells, white cells, platelets or plasma, though they may accept fractions made from these components at their own discretion."

How do you treat a patient who has multiple myeloma if that individual requires blood transfusions but refuses? This is being discussed on Sermo by various oncology physicians. It's a very difficult situation because what is medically necessary isn't an option if the patient competently refuses that treatment. Will a combination of various anti-cancer drugs (such as Thalomid or thalidomide, Velcade or bortezomib, and Revlimid or lenalidomide) and growth factors (such as Procrit or epoetin alfa and Aranesp or darbepoetin alfa) help an individual who has progressed so far in this illness? Or, are such strategies medically futile?

I think one of the most difficult things to face is a dying patient who refuses medical care. It's more than a mental exercise. When you know that you can do something to help that person and that person is willfully refusing (it may be for a variety of reasons), that just becomes a very challenging situation. Alternative medical options may be futile. Do you try them anyways? Sometimes there are no practical options that won't endanger the patient further. You can't just walk out or abandon that type of patient. Do you suggest hospice? At what point do you discontinue futile efforts?

Ethics of concierge medicine

Concierge medicine is often referred to as boutique or retainer-based medical practices. We have seen a surge of physicians and medical groups converting to this type of model over the last several years. Why? Because you can get paid more for seeing fewer patients. Sounds almost ironic, doesn't it? In a typical concierge practice model, patients pay an annual retainer fee outside of insurance to gain greater access to their physician. What does this mean? It means that you may be able to call your doctor directly. Forget about answering services. Also, it may mean that you doctor will see you in the middle of the night if you develop chest pain. Forget waiting in the ER if you need to get admitted by your physician.

If political leaders like presidents can have concierge-type medical care, then is it unethical to offer it to other rich and powerful people? If a billionaire hires you to live and work as a personal doctor for his/her family, would it be unethical to do that? I think the bigger issue revolves around the accessibility to care. If you're the only doctor in a 50 mile radius and you decide to convert your practice, then there may be some ethical issues concerning the accessibility to care and medical need. A related topic deals with the acceptance of Medicaid insurance. Many physicians are choosing not to accept Medicaid because the reimbursement is so low. Eventually, a cash-only model may become the prominent model (especially if the government steps in and offers some level of universal health coverage).

Let's evaluate the ethics behind concierge medicine:

• Autonomy: Probably not an issue.
  
• Beneficence: "the act of doing good things." Well, as long as you offer good care to those who are paying you, you're fine there.
• Non-Maleficence: "do no harm." Well, this is where concierge medicine may have a problem. If you move to a brand new area to set up your concierge medical care, then you may be fine. However, as I mentioned above, if you're the only doctor in a remote area and you decide to convert your practice, then there may be some ethical issues concerning the accessibility to care and medical need. You may be "harming" those who are unable to afford your prices.
  
• Informed consent: Don't see any issues here as long as your contract is well-written.
• Confidentiality: Probably not an issue.

The AMA Principles of Medical Ethics ends with this statement: "A physician shall support access to medical care for all people." Hmm, not sure how this relates to concierge medicine.

However, the AMA Principles of Medical Ethics also has this statement: "A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care."

Alternative Cancer Care in Mexico

According to CNN, there are many cancer patients escaping to oasis-type of cancer centers in Mexico to receive alternative care for their illness. To many, the idea of receiving alternative medicine for cancer may sound absurd. It may be OK to take some herbs and vitamins for benign conditions such as headaches and arthritis. But for cancer? Can alternative therapies like herbs, vitamins, meditation, and relaxation cure malignant tumors? If they do, are we simply seeing cases of spontaneous regression where the body destroys cancer by sensing that something is wrong?

The idea of complementary medicine for cancer has been a really controversial topic lately because of the story of Danny Hauser, a 13-yr-old cancer patient who is receiving chemotherapy because of a court order. He's also receiving alternative medicine, including acupuncture, vitamins, and minerals (among others). Does he have the right to choose what type of cancer care he wants? This gets into the ethics of autonomy, but it gets complicated because Danny is not an adult. Hence, in the world of medical ethics, he doesn't have the same type of autonomy as an adult. It may not sound fair, but the world of ethics doesn't always revolve around fairness (depending on your point of view).

So, if an adult chooses to forego Western medicine for cancer and decides to receive alternative care in Mexico, that's OK (from an ethics standpoint). However, if a child chooses to forego Western medicine for life-threatening cancer, that's when we have some serious ethical issues. That's where the ethics committees get involved and pulls in the judicial system when needed. How do we really know what the child wants? What if the child is only 2 or 3 years old? Do parents have the right to determine what is best for the child? At what age should a child have autonomy over medical treatment decisions?

Maybe you don't like to think about any of these complex ethical issues. If you're an oncologist looking for some lucrative opportunities in a resort-like (think all-year vacation) setting, then take a look at the Oasis of Hope Hospital in Tijuana.

To read the CNN piece about alternative cancer care in Mexico, click here. Image source: CNN