Tough Choices: A Blurb About the Difficult Choices Facing Many Couples in Their Quest for Fertility

Posted on: October 31, 2009  |   Author: David
Filed Under: Drug & Device, HMOs & Health Plans, Health Information, Hospitals & Health Systems, Insurers/Payors, Technology   |   Leave a Comment

It may be one of the hardest decisions an expectant parent would have to make: Reduce the number of fetuses you are carrying or risk losing them all.

Sadly, that is exactly the decision Thomas and Amanda Stansel had to make. After undergoing the popular process of intrauterine insemination in which sperm is injected into Mrs. Stansel’s uterus following hormone injections, Mrs. Stansel received shocking news – she was carrying not one, not two, but six fetuses. However, the Stansel’s excitement was soon crushed when their fertility doctor gave them some additional startling news. Due to the increase in fetuses, the likelihood of delivering six healthy infants was near zero. To save some, he recommended reduction – through a process known as “selective reduction.” The Stansels decided not to reduce, instead relying on their faith to protect them and in August, Mrs. Stansel gave birth to all six babies. Unfortunately, at 14 weeks premature, all weighed in at roughly one pound. The hospital fought valiantly, but three babies died within two weeks. A few months later, another was lost. The two babies remaining continue to struggle, still attached to ventilators and feeding tubes and under constant care in the hospital neonatal intensive care unit.

For couples having difficulties becoming pregnant, there are several options available. First, most doctors recommend utilizing low-potency fertility drugs in order to stimulate the process. If unsuccessful, the next step is intrauterine insemination with hormone injections or in vitro fertilization. This decision is often influenced by two related factors: insurance and costs. The cost of in vitro fertilization costs between $12,000 and $25,000 while intrauterine insemination only costs $2,000 to $3,000 per attempt. As such, many insurance companies will cover multiple rounds of intrauterine insemination before one round of in vitro fertilization. The preference though, is not without drawbacks. Intrauterine insemination, while front-end cheaper, can present significant problems. Excessive hormone injections can lead to an overstimulation of the ovaries which in turn can lead to the increase in probability of having multiples. In fact, the Centers for Disease Control and Prevention supported this theory when it found that the intrauterine insemination process was more likely to result in multiples than in vitro fertilization. And with increased multiples, come increased risks, especially with premature births which carry the risk of long-term complications and disabilities. Multiples, like the Stansel babies, who arrive early, require the highest level of acute care for a longer time than any other patients. This can add up to astronomical financial hardships in the long-run. In addition to money, multiples with increased risks of complications can put families in very difficult decision like the one faced by Thomas and Amanda Stansel- whether to abide by religious beliefs against the perception of abortion or a doctor’s recommendations to reduce.

The current position taken by insurance companies is baffling. Intrauterine insemination is largely undocumented today, but has been shown to be less successful and more dangerous (with respect to increasing risks for premature multiples) than in vitro fertilization. The main upside, cost. Due to the less invasive nature of intrauterine insemination there is a significant cost difference between the two procedures leading many insurance companies to favor the treatment. In doing so, insurance companies may be overlooking two major issues. One, as this procedure becomes more popular, the costs associated with premature multiples will also grow- likely at a much higher rate than the cost of the initial fertility treatment. Second, many couples attempting to start a family do not understand the possible consequences of their actions – the psychological and financial considerations of having a tragic result. Insurance companies have long acted as a gatekeeper in providing medical treatment and should take a second look at their current preference towards intrauterine insemination.

The New York Times, October 11, 2009.

Problems with Consensus-based Diagnosis of Vegetative State

Posted on: August 8, 2009  |   Author: Kathryn
Filed Under: Bioethics, Technology   |   Leave a Comment

A recent study found that many diagnoses of vegetative state (VS) made using a clinical consensus-based method should actually have been diagnosed as minimally conscious state (MCS). The line between VS and MCS has never been clear, but it seems that diagnosis using a standardized neurobehavioral assessment, such as the JFK Coma Recovery Scale – Revised that was used in this study, is more sensitive and more accurate than consensus-based diagnoses made by a research team based on daily behavioral observations. The study found that 41% of MCS cases had been misdiagnosed as VS.

The distinction between VS and MCS is ethically and legally significant in making end-of-life decisions. Patients in VS are thought to be entirely unaware of their surroundings, while MCS patients show some evidence of limited awareness and have better prognoses for recovery. The CRS-R is specifically designed to distinguish between VS and MCS and does so by including items in the scale that reflect MCS diagnostic criteria.

Considering the importance of an accurate diagnosis, the study concluded that “systematic use of a sensitive standardized neurobehavioral assessment scale may help decrease diagnostic error and limit diagnostic uncertainty.”

Commentary: This study, along with other studies describing recent advances in neuroimaging, raises concerns about decisions made regarding end-of-life care. Whether a patient shows awareness of his/her surroundings is a crucial factor in determining whether it is in the patient’s best interests to withdraw life-sustaining treatment. It also affects the interpretation of advance directives because it requires a determination of whether a patient could have anticipated his/her exact medical situation. For example, is it likely a patient would have considered being diagnosed as in a vegetative state, but having an fMRI that tentatively suggested some a degree of mental awareness? It will be interesting to see how courts interpret and apply this new medical evidence in end-of-life decision-making.

Science Daily, July 21, 2009.

Open Market for Organs?

Posted on: August 7, 2009  |   Author: Daniel
Filed Under: Access to Care, Bioethics, Fraud & Abuse, Health Information, Hospitals & Health Systems, Liability & Litigation, Public Health Policy, Technology   |   Leave a Comment

In New York, the average waiting period for a kidney transplant is nine years. The only legal option for those who choose not to or cannot survive this extended period of time is to find someone willing to voluntarily donate an organ. The options are limited based on the fact that, currently in the United States, it is illegal to buy and sell organs. Despite similar bans in most developed countries, there remains a worldwide market for transplantable organs. As such, the World Health Organization estimates that 10% of the 63,000 kidneys transplanted worldwide each year from living donors have been bought illegally.

In 2008, authorities in India broke up an illegal ring involving doctors, nurses, paramedics, and hospitals that had performed 500 illegal transplants of organs to wealthy Indians and foreigners. Among the donors, most were poor laborers who were paid as much as $2,500 for a kidney, while some were forced to surrender their organs at gunpoint.

Recently, a Brooklyn businessman and self-proclaimed “matchmaker,” was arrested in New Jersey for trying to broker the purchase of a kidney for $160,000. Levy-Izhak Rosenbaum told an undercover investigator that he had been successfully brokering the sale of organs for 10 years. Rosenbaum would concoct a fake relationship between the donor, usually from a poor community, and the recipient, so that the donor could pass the hospital’s psychological screening interviews prior to surgery.

Dr. Michael Shapiro, the chief surgeon at Hackensack University Medical Center’s transplant unit, said he suspects that many would-be live donors are looking to be paid for their body parts, but fear getting caught. According to Dr. Shapiro, sometimes it is necessary to sit down with the donor and receive assurances that he or she knows that it is illegal to sell organs. However, as doctors are becoming more aware of the practice of selling organs, many feel powerless in deciphering the true motive of the donors. He notes that doctors are not educated in interrogating donors to prevent schemes like Rosenbaum’s.

Living organ transplantation has opened up a Pandora’s Box of questions that no government has been able to answer. For years, the World Health Organization has been weighing the possibility of legalizing organ sales, but the issue continually sparks intense debate.

Commentary: The average person waits five years for a new kidney, which is an amount of time that many cannot afford. An estimated 10-20 people die every day waiting in vain for their new organ. If voluntary organ donations were sufficient to satisfy the donation list, the supply of organs would be large enough to satisfy demand, and there would be no need to change the present system. However, with the demand for organs far outnumbering the number of donors, many economists and health care professionals are taking a controversial stance by urging the adoption of market-based innovations. It is the opinion of this blogger that, in the United States, there are already markets for blood, semen, human eggs, and surrogate wombs. Merely extending markets to include other organs, which can be obtained with reasonable safety, could be beneficial. An open American market in organs would sharply curtail the present black market and ensure the highest-quality medical care. However, there must be a systematic approach to eliminate coercion and establish a fair market price. This would protect those who are currently most vulnerable and ensure that all parties involved would receive the intended benefit.

N.Y. Times , July 29, 2009

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