A 57 year old native man from Northern Ontario is being treated for Non-Hodgkin's Lymphoma (T-lymphoblastic lymphoma) in your hospital, which is about 1000 Km from his home. He enters complete remission with intensive induction chemotherapy, but he relapses after 3 months of maintenance chemotherapy with vincristine, prednisone, methotrexate and mercaptopurine. None of his siblings is HLA-identical. Re-induction chemotherapy is attempted, but his disease does not respond. He develops a pancytopenia from the chemotherapy, and gram-negative septicemia. He is transferred to the Intensive Care Unit, and requires intubation and ventilation. He deteriorates, and it becomes clear that he will not survive. The care team wishes to initiate a purely palliative approach. It is impossible to communicate with the patient.
His wife, and three adult children, and some of his siblings are present. In the initial discussions with his wife, the idea of moving to palliative care is acceptable, and, she thinks, consistent with his prior wishes. In the context of the whole family, however, two of his siblings, and one of his children, insist that full treatment be continued, including maximum support, ventilation, inotropes, antibiotics, and resuscitation if necessary. The remainder of the group refuse to voice an opinion in this context. When told that the patient had not wished to be on prolonged life support, with no prospect of cure, the opinion-makers in the family indicate that this is immaterial, as the elders of his nation have said that maximum support must continue.
Please analyze this case from an ethical perspective. Indicate what approach you would take to resolve the dilemma.
A 17 year old female is diagnosed as having Acute Lymphoblastic Leukemia (pre-B cell type, chromosome analysis hyperdiploid, WBC 20 x 109/L). You wish to begin chemotherapy, but she refuses, in the presence of her parents, who support her refusal. She indicates a strong religious belief that it is divine intervention that has caused her disease, and that divine intervention alone be allowed to cure it. She believes that drug treatment is against God's will. She, and her parents maintain this belief, even when told that the disease will be fatal.
Please analyse this case from an ethical standpoint, and indicate what practical steps you would take to achieve a resolution of the problem.
A 45 year old woman has Acute Myeloid Leukemia (FAB-M5), and is a Jehovah's Witness. She refuses all blood products.
What would be your approach to her management. Justify your decisions from an ethical viewpoint.
An 70 year old woman with Waldenström's Macroglobulinemia has been treated successfully with chlorambucil for 4 years. While still taking this drug, she develops marrow failure, a rise in her IgM monoclonal protein, and evidence of early hyperviscosity.
You wish to begin second-line chemotherapy with fludarabine. She has read on the internet that cladribine is the superior drug in Waldenström's Macroglobulinemia, and insists that she receives this drug. In fact, the two drugs have not been compared directly, and although cladribine appears to be active, it is not definitely known to be better, although it could be. Because of the greater expense of cladribine, your institution has made a policy decision to fund only fludarabine for this indication. The patient refuses to receive fludarabine, and insists that cladribine be used. She cannot afford to purchase the drug herself.
Please make an ethical analysis of this situation, and indicate how you would resolve this dilemma.
You are a member of a group of physicians charged with the responsibility of creating guidelines for the use of drugs in the treatment of hematological malignancy. When the guidelines have been created, they will be used to dictate the policy of the Cancer Clinics, so that physicians will be constrained to use the approved regimens, and others will not be funded.
You are trying to develop a guideline concerning the use of filgrastim (Neupogen, G-CSF). It is suggested that the guideline be 'The use of filgrastim will be limited to those patients receiving potentially curative chemotherapy, in whom neutropenia has caused delay in the scheduling'. Thus, patients receiving palliative chemotherapy, who develop severe neutropenia and treatment delays, will not be eligible to receive funding for this agent.
Please make an ethical analysis of this guideline.
A 34 year-old mentally retarded woman develops T-cell acute lymphoblastic leukemia. She has a mental age of 4 years, and she is utterly terrified of needles, hospitals, and doctors. She struggles mightily at each attempted intervention, and is difficult to restrain. She does not have any living relatives.
Please indicate how you would approach this problem, and make an ethical argument for your position.
An 84 year-old male is referred from a remote emergency room with TTP. He is admitted unresponsive to all stimuli except pain. He has a history of multi-infarct dementia requiring admission to a long-term care facility some six weeks previously. His wife is also demented and institutionalized. The CT scan of his head shows a recent infarct in the region of the left internal capsule. He appears to be in danger of aspirating. The Hb is 78 g/L, platelets 40, and LDH 782. Venous access is poor.
You telephone his next-of-kin, his daughter, who is an only child. She insists absolutely that 'everything be done' for her father, including CPR, and ventilation if necessary. She does not wish to visit the hospital immediately, but can come in a few days. The house-staff object to her position, and feel that it would be wrong to perform either CPR or ventilation.
Analyse this situation from an ethical standpoint, and indicate how it might be resolved.
An Italian Woman, age 78 years, presents with a mild normocytic anemia, and is found to have Waldenström's Macroglobulinemia. No treatment is given, but she develops severe bone marrow failure over a period of three months (Hb 39 g/L, platelets 10 x 109/L, Leuks 1.5 x 109/L). She responds to treatment with chlorambucil and prednisone. While still on treatment, however, she develops rapidly progressive disease with a doubling of her IgM from 25 to 50 g/L over a period of two weeks, and a fall of her Hemoglobin to 50 g/L, platelets to 10 x 109/L, and Leuks to 0.8 x 109/L. A population of blast cells appears in her blood.
She is given a cycle of Vincristine, but she develops severe abdominal pain, and an ileus, which necessitates her admission to hospital. You wonder whether further chemotherapy is likely to do more harm than good, and therefore whether a more palliative approach, with or without blood transfusion support, would be preferable, and you decide to discuss this with her.
She has no understanding of English, and all prior communication has been through her son. She is an excitable and unusual woman, who seems very dependent on her son. He is approximately 40 years old, and clearly cares very sincerely for his mother, and always brings her to her clinic appointments, although the relationship between them is also a little excitable. He tells her what to do very assertively, and she behaves in an irritating, histrionic and childish way.
When you approach them about changing the treatment goals, he brings with him his sister, who has travelled a 3-hour journey especially for the interview. He confesses that his mother does not know what is wrong with her, except that she has 'low blood'. He is not prepared to tell her the truth, but offers the opportunity to do so to his sister. She declines, and expresses her opinion that her mother should not be told the truth, as she will not be able to handle it, having demonstrated herself in the past to be easily excited over trivial issues. Both brother and sister agree on this point. They also point out that their mother has not asked directly to be told what is wrong with her.
What is the right course of action?
A 35 year old male develops Acute Myeloid Leukemia. The leukemic cells have a normal karyotype. He enters complete remission after one cycle of idarubicin and cytarabine. Two consolidation cycles are given. He has no siblings, and his parents are not suitable as transplant donors. 9 months later he relapses, and further chemotherapy is given, with successful attainment of a second complete remission. You decide that a Matched Unrelated Donor Transplant is indicated.
He is a prisoner at the local Maximum-Security Penitentiary, and is well-known for his crimes, which involve the sexual assault and particularly brutal murder of several young women. He is serving life imprisonment, without hope of parole.
What is the right thing to do?
1. Doing Right. P.Hébert. Oxford
2. Bioethics. Dan C English. Norton Press
3. Classic Cases in Medical Ethics. Gregory Pence
4. Contemporary Issues in Bioethics. Beauchamp & Walters. Fifth Edition. Wadsworth.