nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
See here for more discussion.

Tuesday, July 27, 2010

Ethics Of Posthumous Egg Donation

Interesting case in medical ethics.  When is it justifiable to take germ cells from individuals with terminal illness or injury, for the purpose of producing a child by that individual?

We're not talking about someone who learns of a fatal illness and has time to procreate in the usual way.  Not even those cases where a woman attempts to carry a pregnancy forward to childbirth before succumbing.  This is where the situation is more immediate.  No pregnancy can be underaken (by self or surrogate) in the time remaining.  In fact, in some cases, the individual may be on life support without the possibility of recovery, and the question is, do we allow cells to be harvested before removing life support.

It seems pretty straightforward that an individual who knows they are dying can make the decision to permit spermatozoa or oocytes to be collected and stored, if the partner wants to attempt to have children after the spouse has died.

But there are a couple of complications:
1.  What if the terminally ill person is not able to convey their wishes (coma) or made no verifiable statement about their wishes on a prior occasion?
2.  If what's needed are eggs from a dying woman, the process of stimulating the ovary to release oocytes would take about two weeks.  The process itself could be harmful to a comatose patient, hastening death.

The New England Journal of Medicine reports on just such a case (July 15).  A 36 year old woman collapsed in-flight, had a cardiac arrests, and was resuscitated.  After 11 days she was deeply comatose, with little brain activity.  Consultation was made with the family, and the breathing tube was removed.
"Several hours later, in the middle of the night, the family approached the on-call physician and asked that maximal medical therapy be resumed, to permit consideration of oocyte retrieval from the patient, for the purpose of posthumous conception of future offspring."
The question for the ethics committee was whether there was any evidence that she would have wanted this.  The husband admitted she was on birth control, but they had talked about having children later in life.  He also admitted that he had not wanted children prior to the mishap.  No testimony that was reliable and objective could be elicited from family or friends.  "We think she would have wished this, had she thought about it, but she never did"  is not good enough.

Secondly, the two week process to harvest an egg would be uncertain, and in any case, would required her to lie flat in bed which would worsen the brain swelling that had brought her to this vegetative state...and most likely kill her before the two weeks were over.

One final note:  preserving eggs and embryo's by freezing has improved in the last five years, but is still not extremely reliable.

In the end, all the doctors, ethicicsts, and lawyers couldn't make a case that it was in the interests of the victim that they accede to the family's request.  Terminal care was resumed until the patient died.

There are some other wrinkles here that will certainly come up in the future.  What if the patient had been male (no two-week period needed)?  What if the patient was female, and HAD given consent, but still the two-week period would have killed her?   Finally, consider all the political and social implications of other unique cases:  what if this was a same-sex couple?  What does the law say about that?  I don't know.

In any case, if you have specific desires for how you want things to occur should you be so afflicted, it's critical to think it through and get it down on paper...ahead of time.

...unpleasant as it may be to contemplate.

Doc D

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