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January 4, 2008
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
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.
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.
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. . . . .
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. . .
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.
January 4, 2008 | Permalink
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January 3, 2008
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,
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
“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
January 3, 2008 | Permalink
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January 2, 2008
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.)
January 2, 2008 | Permalink
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January 2, 2008 | Permalink
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December 31, 2007
Bleak Bioethics Forecast for 2008
Writing at MSNBC.com, Arthur Caplan predicts a bleak year on the bioethics front for 2008. He writes,
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.
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?
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.
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.
December 31, 2007 | Permalink
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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.
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?
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."
December 31, 2007 | Permalink
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