HealthLawProf Blog

Child Support from Sperm Donor

Interesting case from Pennsylvania concerning the right of a private sperm donor to contract away his right to make child support payments.   From the Associated Press,

The Pennsylvania Supreme Court ruled that a woman who promised a sperm donor he would not have to pay child support cannot renege on the deal. The 3-2 decision overturns lower court rulings under which Joel L. McKiernan had been paying up to $1,500 a month to support twin boys born in August 1994 to Ivonne V. Ferguson, his former girlfriend and co-worker.

“Where a would-be donor cannot trust that he is safe from a future support action, he will be considerably less likely to provide his sperm to a friend or acquaintance who asks, significantly limiting a would-be mother’s reproductive prerogatives,” Justice Max Baer wrote in the majority opinion issued last week.

Arthur Caplan, chairman of the Department of Medical Ethics at the University of Pennsylvania, said the decision runs counter to the pattern established by similar cases, where the interests of the progeny have generally been given great weight.  “It sounds like the Pennsylvania court is trying to push a little harder into the brave new world of sperm, egg and embryo donation as it’s evolving,” Caplan said.

McKiernan’s lawyer, John W. Purcell Jr., said Wednesday an adverse decision against his client would have jeopardized the entire system of sperm donation.  “That wouldn’t just include Pennsylvania, because we found out in the course of this trial that many doctors order their sperm for their artificial inseminations out of state,” he said. . . . .

Courts found that the two agreed McKiernan would not have to pay child support and would not have visitation rights, but Ferguson later changed her mind and sued.  A county judge said it was in the twins’ best interests that McKiernan be required to support them. In addition to monthly payments, McKiernan also was ordered to come up with $66,000 in back support. The appeal reverses that order. . .

Justice J. Michael Eakin, in a dissent, said a parent cannot bargain away a child’s right to support. “The children point and say, ’That is our father. He should support us,”’ Eakin wrote. “What are we to reply? ’No! He made a contract to conceive you through a clinic, so your father need not support you.’ I find this unreasonable at best.”

The case is: IVONNE  V. FERGUSON v.  JOEL L. MCKIERNAN, [J-60-2005], which is available on the Pennsylvania Supreme Court website.

Intensive Care Revamped

Atul Gawande has a great article in the December 10th New Yorker (ok, yes, I am a little behind on my reading - something about grading . . . ) concerning the use of checklists in intensive care and the impact such helpful lists may have on improving the quality of health care in general.  He writes,

                                                    

                                                                                                                                                                                                               

The damage that the human body can survive these days is as awesome as it is horrible: crushing, burning, bombing, a burst blood vessel in the brain, a ruptured colon, a massive heart attack, rampaging infection. These conditions had once been uniformly fatal. Now survival is commonplace, and a large part of the credit goes to the irreplaceable component of medicine known as intensive care.

It’s an opaque term. Specialists in the field prefer to call what they do “critical care,” but that doesn’t exactly clarify matters. The non-medical term “life support” gets us closer. Intensive-care units take artificial control of failing bodies. Typically, this involves a panoply of technology—a mechanical ventilator and perhaps a tracheostomy tube if the lungs have failed, an aortic balloon pump if the heart has given out, a dialysis machine if the kidneys don’t work. When you are unconscious and can’t eat, silicone tubing can be surgically inserted into the stomach or intestines for formula feeding. If the intestines are too damaged, solutions of amino acids, fatty acids, and glucose can be infused directly into the bloodstream. . . .

On any given day in the United States, some ninety thousand people are in intensive care. Over a year, an estimated five million Americans will be, and over a normal lifetime nearly all of us will come to know the glassed bay of an I.C.U. from the inside. Wide swaths of medicine now depend on the lifesupport systems that I.C.U.s provide: care for premature infants; victims of trauma, strokes, and heart attacks; patients who have had surgery on their brain, heart, lungs, or major blood vessels. Critical care has become an increasingly large portion of what hospitals do. Fifty years ago, I.C.U.s barely existed. Today, in my hospital, a hundred and fifty-five of our almost seven hundred patients are, as I write this, in intensive care. The average stay of an I.C.U. patient is four days, and the survival rate is eighty-six per cent. Going into an I.C.U., being put on a mechanical ventilator, having tubes and wires run into and out of you, is not a sentence of death. But the days will be the most precarious of your life.

                                            

                   

A decade ago, Israeli scientists published a study in which engineers observed patient care in I.C.U.s for twenty-four-hour stretches. They found that the average patient required a hundred and seventy-eight individual actions per day, ranging from administering a drug to suctioning the lungs, and every one of them posed risks. Remarkably, the nurses and doctors were observed to make an error in just one per cent of these actions—but that still amounted to an average of two errors a day with every patient. Intensive care succeeds only when we hold the odds of doing harm low enough for the odds of doing good to prevail. This is hard. There are dangers simply in lying unconscious in bed for a few days. Muscles atrophy. Bones lose mass. Pressure ulcers form. Veins begin to clot off. You have to stretch and exercise patients’ flaccid limbs daily to avoid contractures, give subcutaneous injections of blood thinners at least twice a day, turn patients in bed every few hours, bathe them and change their sheets without knocking out a tube or a line, brush their teeth twice a day to avoid pneumonia from bacterial buildup in their mouths. Add a ventilator, dialysis, and open wounds to care for, and the difficulties only accumulate. . . .

Substantial parts of what hospitals do—most notably, intensive care—are now too complex for clinicians to carry them out reliably from memory alone. I.C.U. life support has become too much medicine for one person to fly. 

Yet it’s far from obvious that something as simple as a checklist could be of much help in medical care. Sick people are phenomenally more various than airplanes. A study of forty-one thousand trauma patients—just trauma patients—found that they had 1,224 different injury-related diagnoses in 32,261 unique combinations for teams to attend to. That’s like having 32,261 kinds of airplane to land. Mapping out the proper steps for each is not possible, and physicians have been skeptical that a piece of paper with a bunch of little boxes would improve matters much.

In 2001, though, a critical-care specialist at Johns Hopkins Hospital named Peter Pronovost decided to give it a try. He didn’t attempt to make the checklist cover everything; he designed it to tackle just one problem, the one that nearly killed Anthony DeFilippo: line infections. On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting a line in. Doctors are supposed to (1) wash their hands with soap, (2) clean the patient’s skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a sterile mask, hat, gown, and gloves, and (5) put a sterile dressing over the catheter site once the line is in. Check, check, check, check, check. These steps are no-brainers; they have been known and taught for years. So it seemed silly to make a checklist just for them. Still, Pronovost asked the nurses in his I.C.U. to observe the doctors for a month as they put lines into patients, and record how often they completed each step. In more than a third of patients, they skipped at least one.

The next month, he and his team persuaded the hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask them each day whether any lines ought to be removed, so as not to leave them in longer than necessary. This was revolutionary. Nurses have always had their ways of nudging a doctor into doing the right thing, ranging from the gentle reminder (“Um, did you forget to put on your mask, doctor?”) to more forceful methods (I’ve had a nurse bodycheck me when she thought I hadn’t put enough drapes on a patient). But many nurses aren’t sure whether this is their place, or whether a given step is worth a confrontation. (Does it really matter whether a patient’s legs are draped for a line going into the chest?) The new rule made it clear: if doctors didn’t follow every step on the checklist, the nurses would have backup from the administration to intervene.

Pronovost and his colleagues monitored what happened for a year afterward. The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from eleven per cent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths, and saved two million dollars in costs. . . .

The checklists provided two main benefits, Pronovost observed. First, they helped with memory recall, especially with mundane matters that are easily overlooked in patients undergoing more drastic events. (When you’re worrying about what treatment to give a woman who won’t stop seizing, it’s hard to remember to make sure that the head of her bed is in the right position.) A second effect was to make explicit the minimum, expected steps in complex processes. Pronovost was surprised to discover how often even experienced personnel failed to grasp the importance of certain precautions. In a survey of I.C.U. staff taken before introducing the ventilator checklists, he found that half hadn’t realized that there was evidence strongly supporting giving ventilated patients antacid medication. Checklists established a higher standard of baseline performance. . . .

I called Pronovost recently at Johns Hopkins, where he was on duty in an I.C.U. I asked him how long it would be before the average doctor or nurse is as apt to have a checklist in hand as a stethoscope (which, unlike checklists, has never been proved to make a difference to patient care).

“At the current rate, it will never happen,” he said, as monitors beeped in the background. “The fundamental problem with the quality of American medicine is that we’ve failed to view delivery of health care as a science. The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is insuring those therapies are delivered effectively. That third bucket has been almost totally ignored by research funders, government, and academia. It’s viewed as the art of medicine. That’s a mistake, a huge mistake. And from a taxpayer’s perspective it’s outrageous.” We have a thirty-billion-dollar-a-year National Institutes of Health, he pointed out, which has been a remarkable powerhouse of discovery. But we have no billion-dollar National Institute of Health Care Delivery studying how best to incorporate those discoveries into daily practice.

Year's Top Ten Science and Tech Stories

Will Saletan at Slate.com presents his list of the top ten "Human Interest" stories of 2007.  Quite frankly, some of them were a little scary and some do provide hope for the future.  For example, these two I found quite hopeful -

1. Cellular rejuvenation. Say goodbye to the stem-cell war. In November, two research teams announced that they had turned regular body cells into the equivalent of embryonic stem cells just by injecting four genes. Everyone agrees this is better than conventional embryonic stem-cell derivation or cloning: It's easier, avoids the human egg shortage, kills no embryos, is eligible for federal funding, and can produce tissue customized to each patient. Now the fight is over whether conservatives deserve credit for pushing the idea of nondestructive stem-cell derivation—or blame for impeding the original stem-cell research that made this breakthrough possible. (Related: Human Nature's previous takes on the new method.)

3. Regeneration. In November, doctors announced that they had restored amputees' sensations of lost limbs by relocating the severed nerves to other parts of the body. They concluded that through mechanical transmission of stimuli to re-innervated skin, "An amputee may one day be able to feel with an artificial limb as although it was his own." Meanwhile, the U.S. military is trying to go beyond artificial limbs altogether. It's testing a way to regrow lost body parts using "extracellular matrix," the material that tells cells where to go and what to become. One man photographed his finger's regrowth (after losing the last three-eighths of an inch) over four months. (Related: regeneration through embryo farming.) .
. . . .

These next two - not so much hopeful as why are we trying this??  I, for one, will not be purchasing a talking hamster for my son anytime soon . . .

4. Humanized animals. In September, British regulators approved the creation of human embryos with animal DNA. The usual method is to substitute a human cell nucleus for an animal cell nucleus in an animal egg, thereby cloning embryos for stem-cell research without having to get human eggs. Britain's Academy of Medical Sciences reported that scientists have created "thousands of examples of transgenic animals" carrying human DNA, largely to study the effects of diseases and drugs on human systems without involving actual human beings. In a separate experiment, researchers improved eyesight in mice by inserting a human gene. Everyone agrees that these mixtures are scientifically useful. But the moral complications are drawing concern, including from Catholic bishops, who are now demanding human rights for "interspecies embryos." (Related: Humanized animals are the future of medicine.)

5. Cyborgs. First U.S. military researchers put computer chips into moths, allowing them to be remotely controlled. Then Chinese scientists remotely controlled a flying pigeon. By implanting electrodes in its brain and activating them from a computer, they operated the bird as though in a video game. Another research team immobilized a moth and attached an electrode to its brain so that the moth's eye movements steered the robot. Now the U.S. military is merging artificial intelligence with humans, including a helmet that, according to its manufacturer, delivers "a visual readout for combat commanders showing the cognitive patterns of individual soldiers." In humans, unlike animals, the cybernetic component hasn't become internal or dominant. Yet. (Related: Voluntary cyborgs.)

Bleak Bioethics Forecast for 2008

Writing at MSNBC.com, Arthur Caplan predicts a bleak year on the bioethics front for 2008.  He writes,

Biggest disappointment

One of the most exciting breakthroughs to occur last year was the simultaneous discovery of how to make a type of skin cell behave as if it were an embryonic stem cell. Teams in Japan and Wisconsin announced that they had induced pluripotency in skin fibroblasts, meaning the cells had the power to turn into virtually any kind of human tissue. Most of those in the United States involved in the national hair pull over the morality of using human embryos as a source of stem cells for medical research heaved a huge sigh of exhausted relief.

Who on either side could stand one more round of overly heated debate? Inducing pluripotency to turn skin cells in embryo-like cells is a compromise we can all support, right? 

Well, kind of. While plenty of research will get done on this new source of stem cells in 2008 and beyond, it will quickly become evident that the techniques used to switch on the genes in adult skin cells are fraught with problems that make transplanting induced pluripotent cells into the human body a highly dangerous and highly unlikely thing to try. As a result, we'll be back to human embryos and cloned human embryos as the most promising sources of transplantable cells. It will be back to the new president and the new Congress to figure out whether they are going to spend money in this area or watch as the rest of the scientific world passes by the USA.

Easiest to predict disappointment

It is obvious that the American health care system is broke. It costs too much and for too many yet too often delivers poor quality of care. As the presidential campaign moves along, many are looking forward to an intelligent debate about how finally to fix it. Uh, not so fast. 

The American health care system has been broken for the past three decades and nothing radical has been done to fix it yet. Moreover, the nation is running a huge debt from its overseas wars and profligate loan and credit habits. This is not a formula for fixing anything about health care anytime soon. . . . .

Biggest continuing frustration

In a recent column I noted with some sadness that the latest trial of an HIV vaccine by Merck had to be stopped prematurely due to a higher rate of deaths in the placebo arm of the study. I did not get this right. Instead there was a higher rate of HIV infection among those who got vaccinated than in the placebo group. Analysis of what actually happened is expected in 2008. It is still not likely to be good news. . . . .

And it continues . . . . well, I myself preferred listening to the Science Friday on NPR's Talk of the Nation about the biggest science stories of this past year - even if I am being naive (and I should note that it wasn't focused exclusively on bioethics issues so more positive stories were included) - it was a big more hopeful about the future.

Surrogacy International

Shakesville links to a recent associated press article discussing the use of Indian women as surrogates.   The article raises many issues about the use of money to hire women from developing countries to bear children for other women.  Shakesville states,

Commercial surrogacy is the latest job being outsourced to India, as dozens of women just in the western city of Anand are currently carrying babies for couples from around the globe.

Commercial surrogacy has been legal in India since 2002, as it is in many other countries, including the United States. But India is the leader in making it a viable industry rather than a rare fertility treatment. Experts say it could take off for the same reasons outsourcing in other industries has been successful: a wide labor pool working for relatively low rates.

…"It raises the factor of baby farms in developing countries," said Dr. John Lantos of the Center for Practical Bioethics in Kansas City, Mo.

Gee, ya think?

Dr. Nayna Patel, who runs a clinic matching willing surrogates with infertile couples in Anand, to which young women are lining up to serve as surrogates, naturally defends her dubious matchmaking service by pointing out what a pragmatic solution it is to both infertility and poverty: "There is this one woman who desperately needs a baby and cannot have her own child without the help of a surrogate. And at the other end there is this woman who badly wants to help her (own) family. If this female wants to help the other one ... why not allow that? ... It's not for any bad cause. They're helping one another to have a new life in this world."