dilemma for patient and clinicians
http://www.100md.com
《英国医生杂志》
1 Bioethics Research and Teaching Unit, Geneva University Medical School, 1211 Geneva 4, Switzerland
Correspondence to: S A Hurst samia.hurst@medecine.unige.ch
The story of Maria Tomasa is deeply moving.1 Tommy went through a difficult process to find support in her wish to have a child. Then she risked her health in this pregnancy. Finally, she accepted that her story be told and commented on by strangers. All three steps show admirable courage. The authors must also be commended for publishing a case highlighting several issues on which reasonable people may disagree. Without attempting definitive answers, we comment on a few points illustrated by this story.
One salient element is that the decision to go ahead with assisted reproduction was so much harder than that of supporting a naturally occurring pregnancy. Yet opposing natural pregnancy to assisted reproduction may not be ethically relevant. No woman becomes pregnant without an intervention by another human being. What changes is who acts and the fact that technology is required. But technology is not clearly "unnatural". It obeys the laws of nature and was invented by the human mind, which is itself a product of nature. Uses of technology can, of course, be good or bad, but that is a different question.
Who acts, however, is a relevant point. With assisted reproduction, the tools of medical decision making come into the picture. The true difficulty of this situation lies in their limitations.
Firstly, the imperative to "do no harm" is not straightforward in this case. As Trisha Greenhalgh points out, there are risks involved whatever choice is made, and the weight that should be given to these risks is a personal assessment.2 So the imperative not to harm is not clearly in contradiction with patient self determination.3 Tommy knows best what would be most harmful to her: the possible adverse outcomes of pregnancy or not having this child.
Credit: FINE ART PHOTOGRAPHIC
This also reminds us that evidence based medicine is a source of factual knowledge. No less, but no more. It will not, by itself, solve ethical difficulties. Knowing what should be done certainly includes knowing the facts—the team was correct to go to the literature with such care—but the difficulties do not end there.4
This difficulty with medical decision making is not, of course, Tommy's problem. Her decision, whether to endanger her body in order to give birth, is one that women were already facing long before people started writing about it. Only recently did inventions of the human mind make this risk more distant and less generally accepted.
Contributors: SAH wrote the first draft of this commentary. Both authors contributed to the intellectual content and approved the final version. SAH is the guarantor.
Competing interests: None declared.
References
Piccoli GB, Mezza E, Grassi G, Burdese M, Todros T. A 35 year old woman with diabetic nephropathy who wants a baby: case outcome. BMJ 2004;329: 900.
Greenhalgh T. How strong is the evidence? . BMJ 2004 http://bmj.com/cgi/eletters/329/7468/7293.
Buchanan AE, Brock DW. Deciding for others; the ethics of surrogate decision making. Cambridge: Cambridge University Press, 1990.
Eddy DM. Clinical decision making: from theory to practice. Anatomy of a decision. JAMA 1990;263: 441-3.(Samia A Hurst, maitre ass)
Correspondence to: S A Hurst samia.hurst@medecine.unige.ch
The story of Maria Tomasa is deeply moving.1 Tommy went through a difficult process to find support in her wish to have a child. Then she risked her health in this pregnancy. Finally, she accepted that her story be told and commented on by strangers. All three steps show admirable courage. The authors must also be commended for publishing a case highlighting several issues on which reasonable people may disagree. Without attempting definitive answers, we comment on a few points illustrated by this story.
One salient element is that the decision to go ahead with assisted reproduction was so much harder than that of supporting a naturally occurring pregnancy. Yet opposing natural pregnancy to assisted reproduction may not be ethically relevant. No woman becomes pregnant without an intervention by another human being. What changes is who acts and the fact that technology is required. But technology is not clearly "unnatural". It obeys the laws of nature and was invented by the human mind, which is itself a product of nature. Uses of technology can, of course, be good or bad, but that is a different question.
Who acts, however, is a relevant point. With assisted reproduction, the tools of medical decision making come into the picture. The true difficulty of this situation lies in their limitations.
Firstly, the imperative to "do no harm" is not straightforward in this case. As Trisha Greenhalgh points out, there are risks involved whatever choice is made, and the weight that should be given to these risks is a personal assessment.2 So the imperative not to harm is not clearly in contradiction with patient self determination.3 Tommy knows best what would be most harmful to her: the possible adverse outcomes of pregnancy or not having this child.
Credit: FINE ART PHOTOGRAPHIC
This also reminds us that evidence based medicine is a source of factual knowledge. No less, but no more. It will not, by itself, solve ethical difficulties. Knowing what should be done certainly includes knowing the facts—the team was correct to go to the literature with such care—but the difficulties do not end there.4
This difficulty with medical decision making is not, of course, Tommy's problem. Her decision, whether to endanger her body in order to give birth, is one that women were already facing long before people started writing about it. Only recently did inventions of the human mind make this risk more distant and less generally accepted.
Contributors: SAH wrote the first draft of this commentary. Both authors contributed to the intellectual content and approved the final version. SAH is the guarantor.
Competing interests: None declared.
References
Piccoli GB, Mezza E, Grassi G, Burdese M, Todros T. A 35 year old woman with diabetic nephropathy who wants a baby: case outcome. BMJ 2004;329: 900.
Greenhalgh T. How strong is the evidence? . BMJ 2004 http://bmj.com/cgi/eletters/329/7468/7293.
Buchanan AE, Brock DW. Deciding for others; the ethics of surrogate decision making. Cambridge: Cambridge University Press, 1990.
Eddy DM. Clinical decision making: from theory to practice. Anatomy of a decision. JAMA 1990;263: 441-3.(Samia A Hurst, maitre ass)