Bioethics for the People

Transcript

0:20 

All right.Tyler, I have a new topic for our minisode today.All right.I love these minisodes, by the way, they're pretty fun.I think they're fun too.And they're a little a bit shorter which hopefully our audience thinks is fun too.All right, so Devin what have you been obsessed about this week? 

0:38 

Okay so I got a call recently by a urologist who wanted to talk about vasectomies for 18 year olds.Okay, vasectomies for 18 year olds.Okay. 

0:54 

Yes, so he was saying listen lately, I've been getting a lot more requests from 18 year old men who want vasectomies.He said you know, I'm willing to provide them other urologists in my where I work or not. 

1:14 

I'm okay doing it but I just want to make sure there aren't any big ethical problems that I'm overlooking.Okay, so your ologist gets approached by patient who's 18 and asked to provide a vasectomy. 

1:31 

It's interesting that he would think about like be reflective enough to want an ethical console ethics consult on this, but well, apparently he has an interest.He has an interest in ethics, and then was wanting to talk about it with an ethicist.And so they directed him to me. 

1:47 

Okay, yeah, so okay.So this is not apparently and so I did some like Google searching.This is becoming more and more common is, especially in States, like Texas, where abortion is, not now, basically outlawed more and more very young men who are coming and asking for vasectomies. 

2:09 

Wow.And so let me just try to try to understand the motivation here that then it would free them up to be more sexually active without the consequences of pregnancy is that?Hmm.Yeah.And potential. 

2:24 

Fatherhood because right now.Abortions off the table.Huh.I feel like there are other contraceptive measures short of vasectomy that one might try, right?Yeah, so that's what struck me at first too. 

2:41 

Is, there are lots of really effective contraceptives that don't know that prevent pregnancy.Why wouldn't they go there first?So this was one of my suggestions that, you know, you would expect this to occur anyway, but let's make sure that during the informed consent process Is that these young men know their various options, they probably do at 18 but gosh you never know. 

3:06 

Yeah, I don't think that I would have known what a vasectomy was at 18.Well, I guarantee you that.Okay.So, how did you approach this question?Yeah, so the first thing I did was I went to the Texas state law because I was curious, if there are any regulations already on the books you just never know. 

3:27 

You wouldn't think.So you never know and what I found out pretty quickly is that there aren't except if the patient is a Medicaid patient.And so this is one way and this isn't a legal route but this is one way in which there are special Provisions for patients with Medicaid. 

3:46 

And this is I assume tied to a long history of forcible sterilization.So because our government was Pro Eugenics and pro, forcible sterilization for, you know, a few Decades, we sterilized a lot of people against their Wills.I think that this is a reaction to that to say we want to be really extra careful that we are not forcibly sterilizing, especially poor people. 

4:10 

And so for both women and men, if they are Medicaid patients, there is a separate regulation that you have to follow in order to get reimbursed for these patients.So the regulation for a vasectomy for men is they have to be at least 21. 

4:28 

So a little bit older than most other kinds of treatment older than 18, which is, you know, where we typically put the age of majority and they have to request it, six months prior to receiving it.So there's this lag time of six months, which is a pretty long time, right? 

4:46 

Yeah.And so for young men, that's a burden for young for women.This is much more of a burden because for a tubal, ligation a woman would have to request it.Six months, prior, she often might request it while she's pregnant. 

5:04 

And so, while she's giving birth, it might be easier to do the tubule.Like, if she were to have a C-section, it would, it wouldn't require an extra surgery.And so if she were to go into premature labor or she just couldn't receive it at the same time as the birthing process that imposes sort of an extra surgery on her that wouldn't be necessary otherwise. 

5:27 

So it's More of a burden on women, this Medicaid provision but it's still a burden on men to.So if he were a Medicaid patient, we couldn't do it until he was 21, and we would have to wait those six months.I never asked if this particular patient was Medicaid or not. 

5:42 

The urologist was aware of that provision, but I hadn't been.So it was an interesting learning experience.For me, was this something you were aware of?No, I'm not specifically in the way that you're describing it.I was aware.That of certain Protections in state law is Houghton Michigan. 

6:02 

Where I'm at, where if somebody is under guardianship or conservatorship that they can make basically any and all medical decisions except if they want to do a permanent sterilization, whether it's a ligation or a vasectomy and that actually in the state law is required to go back before the judge and the judge actually has to okay that in the in that type of surrogate situation. 

6:28 

Like that.That's interesting to me that it's tied to the payment mechanism.Yeah, I knew that about.So it's interesting about sterilization for people who have guardians or can't make their own medical decisions, you actually have to get a court order and this I think is also tied to our history of forced sterilization. 

6:45 

So you can just imagine, you know, very vulnerable people being sterilized against their will is not quite the right phrase because if they can't give consent you know it gets a little Complicated there.But I knew it about sterilization of folks who don't make their own medical decisions. 

7:02 

I didn't realize it about Medicaid patients, so it was, but I imagine they're tied to the same Legacy.Yeah.And I don't know a whole lot about forced sterilization history.But I do know enough to be absolutely horrified by it. 

7:21 

Mhm.So, I mean, just in Broad Strokes summary of this, the individuals who were generally, and it's correct me if you know differently, but the patients who are individuals who were generally, intellectually, disabled, or had an intellectual disabilities, were put into group homes or to, some sort of institutionalized care setting. 

7:49 

And then underwent, Aunt, sterilization procedures often without their involved, you know, consent or a center, some anything from the patient.But also often without the family even knowing about what was going on.Is that your understanding? 

8:07 

That's right and it wasn't even necessarily people with intellectual disabilities the famous case and we might do a podcast about this next season with buck V Bell, Carrie Buck.There's actually pretty good evidence.She wasn't intellectually disabled, but she was quite poor. 

8:22 

And she I've been raped and the family that had adopted her, their son was her rapist in, which she got pregnant.This was a good way to sort of get rid of her is to institutionalize her, by saying that she was intellectually disabled.And then this is the case that Rose to the Supreme Court, that allowed states to forcibly sterilized people against their wills. 

8:43 

And hers is a particularly sad case, not necessarily because she wasn't intellectually disabled.I think it's wrong to do that as well.But because of the rape because of the situation she was in it was a really tragic case. 

8:58 

But, yeah, so that kind of inaugurated in the early 20th century.A lot of state laws that allowed for this to happen, that weren't repealed until the 1970s.So something like 60,000 people were sterilized against their will in our country.So just recently, A friend of mine was telling me that he met somebody. 

9:17 

I don't remember as a social setting or whatever, but he mentioned that she had been raised by an aunt.Her grandma because her her mother suffered from severe postpartum, depression was institutionalized and then actually sterilized so she wouldn't have to do it again. 

9:35 

It's unclear whether or not that was consented to or not but then was institutionalized for the rest of this, This Woman's upbringing and was raised by somebody else.So yeah, that's tragic.Yeah, and it was often husbands who are able to institutionalize Their wives against their will, right? 

9:55 

So as long as your husband verified, that you were crazy, you know, wanted to put that already misogynistic history as well.We did force it also forcibly sterilized, men, poor, especially poor men, especially not white men, so it's a pretty tragic Legacy of sterilization. 

10:16 

So you can understand why, some of these Provisions have been put in place at the same time.Some have argued that the pendulum has swung too far and now we're over protecting people.So now there are additional burdens especially on poor people, or people with disabilities to get the kinds of treatments they want because we want to protect them so much we might over protect them. 

10:41 

This is maybe an argument we don't debate, we don't need to have right here but it is a counter-argument to this but I'm curious what you think.I mean do you think we should be giving vasectomies?To 18 year olds.I think one of the concerns, obviously, the first concern is, do they properly at 18 Does a young man properly, understand, all of the long-term burdens and risks of this procedure. 

11:14 

But but at the same time, we allow 18 year olds to go to war, allow 18 year olds to make all types of very important decisions in their lives.And so, what's what's curious about? 

11:32 

The the situation that you're describing is to me, is that there?Is some sort of magic in Waiting three more years.Like, why is 21 their sudden is there some sort of data that they make better decisions that 21 than they do at 18? 

11:49 

Or is it just that we're trying to protect people in some way?And that's the best, the way we can figure it out or I don't know, I'd really like to kind of understand what the motivation is between, you know, in that type of Change in the requirement of change in the regulation. 

12:11 

It's really interesting.Yeah.I mean I'd be surprised if it was based on Neuroscience although that that's true because I mean the best Neuroscience we have right now I think is that your brain really doesn't kind of stopped firing its limbic system to quickly until you're about 25 26. 

12:28 

And so the best decision making happens after that, period.So maybe we should make them wait until then.But like you said, I mean, the age of majority is 18, we make we let 18 year olds make, life-altering decisions on many fronts. 

12:44 

So why would we stop at at this?So this is where like my Mama Bear Instinct is like if this were my son there's no way I would want him to get a vasectomy at 18.Unless there were some other like very compelling reason why he should never have children and they're very well might be but I wouldn't want that for any eighteen-year-old. 

13:05 

I teach 18 year olds, you know, you are around young people to.I don't know that they necessarily always can make the best decisions for themselves that they have the wherewithal to really understand what the future might hold at the same time.That sort of like that ethical judgment, I don't think overrides this other judgment I have is that we have to let people make these decisions. 

13:30 

Like there's not a compelling enough reason to stop them.That wouldn't apply to other things.We allow them to do.So you got this call from the urologist and you did some background reading.So, what I'm curious about your approach, how did you go back and circle back to the urologist?Yeah, so I called him back. 

13:47 

Well, first actually I called Legal just cuz I was curious if they had any extra information because it was a new topic for me.I hadn't thought about before I wanted to make sure there wasn't anything else I was overlooking and they said no.They said I was right about the Medicaid provision, but otherwise, there is no specific like sort of law about this or we didn't have a hospital policy. 

14:12 

I also made sure of that.I did look at some other ha Little policies on this and which basically said, as long as the patient is giving informed consent that this is.Okay.And it's sometimes they would specify. 

14:27 

What what you would need to talk about and things like other ways of preventing pregnancy and possible, reversibility of a secta me.So you'd want to be clear about that. 

14:43 

But otherwise, it they They all basically concur that this was something an 18 year old could consent to as long as they were giving proper.Informed consent.Yeah.So with that I told the The Physician that there was no restriction on this that it was but of course that he or anyone else in his practice could refuse based on kind of a conscientious objection or you know if they didn't want to do it, they didn't have to it's an elective procedure but if he felt Comfortable doing it and he felt comfortable with the informed consent process, then he could go ahead and do it. 

15:21 

Wow, yeah, interesting.So is the reversibility, the potential reversibility of the vasectomy, an important part of this, as you're thinking through it.You know, it's a good question because we went back and forth on this because there's like wildly different reports about how reversible it is, right. 

15:37 

Just like incredibly diverse opinions about this.And so it even looking in the literature, it was like It's either like, or even what reversibility means is, can be defined differently, so I think you should go into it assuming that it is a permanent sterilization. 

15:55 

I don't think you should get a vasectomy.Assuming that it's easily reversed, even if it might be reversed, even if in the majority of cases, it can be reversed.You should treat it as if it were a permanent sterilization.So, in some ways, it doesn't matter because I think if you go into it with that mindset, then that should, that's what should be communicated. 

16:14 

There are other ways to prevent Pregnancy.There are other contraceptive methods.This is a permanent sterilization, are you really sure this is what you want, right?And if they if it is then then you do it.So what are some other ethical objections?Do you think to?So you mentioned conscientious objection, which I'm not sure that we've talked very much on the podcast about what the details of that in the clinical setting might be. 

16:36 

But what are some reasons?Why?Why a physician might not be comfortable doing this outside of those?Of course, it's long as there's legal.It's Not legally prohibited.You know, I think it's for all the reasons that we might sort of our gut might say is that this is a really big life-altering decision made on behalf of somebody who's maybe not prepared to conceive of their future that way conceived as a good pen accidentally. 

17:06 

But I think it's just, you know, you don't really understand what you're doing and there are really good Alternatives that are not so Permanent and so I want you to wait, you know there's a huge difference between a 40 year old in some people's minds, a 40 year old man, choosing vasectomy after he said children is choosing not to have more than an 18 year old who doesn't have children who I think he doesn't want children of 18 but might change his mind in the future. 

17:36 

And so I think that that's what I'm hearing from people is that, that would be the main objection is that you're just too young to be able to make such a permanent decision?Yeah.So we allow 18 year olds to incur tens or hundreds of thousands of dollars of student loan debt which might be equally as life-altering as having a child, but maybe not allow them to have a vasectomy. 

18:05 

Well, I think it's about sort of, I mean this might apply to student loan debt as well, but having an open Future.Yeah, yeah, yeah.So it's something about and this, we that, that Phrase gets tossed around in Pediatric Care quite a bit.Is that you want to like preserve options for an 18 year? 

18:22 

Old is not a child.Although gosh, an eighteen-year-old is awfully close to a child.Yeah.It just met the threshold of not being a child but that you want to preserve open.Futures for young people, so that they can make different decisions.More decisions have more options available to them in the future. 

18:39 

And so you want to preserve that kind of openness and your foreclosing, it with a procedure like this.And whereas we might let people make, I mean, life-altering decisions and other ways about chemotherapy or about treatments, this isn't a treatment this is an elective procedure which for some people makes a difference too. 

18:57 

Yeah, yeah.It would be different and we've we see cases sometimes we're 18 year old or maybe even like a seventeen-year-old once treatment that their parents may not.So I'm thinking about like cancer treatment for example, an older mature 17 year old me Elect to either want or refuse certain treatments that their parents disagree with and yeah, that that principle of preserving or protecting a free and open Futures. 

19:28 

It's Unique to those types of ethical questions, right?Especially in pediatric situations.Hmm.Yeah, so I'll be curious what the listeners think, do you think we should be giving vasectomies 18 year olds?Also, one of my students told me this is a big trend on Tick Tock which, like, maybe even more nervous about it. 

19:47 

So girlfriends, pressuring their boyfriends to get vasectomies and then recording their responses on Tick-Tock.So that's apparently a thing now.Yep.So, today, I'm gonna be spending the rest of my afternoon looking.Yeah.So look it up.Send us some reactions.Let us know what you think. 

20:04 

Great. 

Pinna, Antonio. Photo. NY Times. Aug. 12, 2022. https://www.nytimes.com/2022/08/12/well/vasectomy-contraception-abortion.html

In this mini-sode Devan and Tyler discuss whether it is ethical to provide vasectomies to 18-year-old mean who request them.

More reading on young men embracing vasectomies:

• “In the US, some young men report that legal changes to reproductive rights have catalysed them to opt for vasectomies,” BBC (Oct 23, 2022)

• ‘Snip Snip Hooray’: Vasectomies Among the Young and Child-Free May Be Rising, The New York Times (Aug. 12, 2022)

In this mini-sode Devan and Tyler discuss a proposed bill that would reduce prisoners’ sentences if they donate organs or bone marrow. What could go wrong?

Season 4 is over, but Devan and Tyler are here to wrap things up. What was most memorable? What lessons did we learn? Tune in to find out!

In this episode Devan talks about a case of a man whose family is making disturbing choices, and (twist!) it’s not clear they are even the correct decision makers.

Dr. Birgitta Sujdak Mackiewicz shares a haunting clinical ethics consultation case that raises issues about advance care planning, the preferences of a patient and surrogate decision-makers, and religious commitments. Every patient brings with them a complex set of interests, wishes, values, and commitments. How should healthcare decisions be made when these all come into conflict?

Dr. Birgitta Sujdak Mackiewicz, PhD, is the Regional Director of Ethics at OSF Healthcare, in Central Illinois. She has a doctorate in Healthcare Ethics from the Gneagi Center for Healthcare Ethics at Saint Louis University. Before taking on a Regional role, she was the Director of Ethics at OSFHC Saint Francis Medical Center and Children’s Hospital of Illinois for 15 years.

Some of Dr. Mackiewicz’s Publications:

• Birgitta Sujdak Mackiewicz & Stephen Thompson (2017) When Trust in God Means Preemptive Refusal of C-Section, The American Journal of Bioethics, 17:1, 94-96, DOI: 10.1080/15265161.2016.1251639

• Birgitta N. Sujdak Mackiewicz (2016) Good Ethics Begin With Good Facts, The American Journal of Bioethics, 16:7, 66-68, DOI: 10.1080/15265161.2016.1180447

More Reading about Jehovah’s Witness Beliefs and Healthcare:

• Thomas McCormick (2008) Ethical Issues Inherent to Jehovah’s Witnesses, Perioperative Nursing Clinics, 3:3, 253-258 DOI: 10.1016/j.cpen.2008.04.007

• West, James M.. Ethical issues in the care of Jehovah's Witnesses. Current Opinion in Anaesthesiology 27(2):p 170-176, April 2014. | DOI: 10.1097/ACO.0000000000000053

• Ally McInroy, Blood transfusion and Jehovah’s Witnesses: the Legal and Ethical Issues, British Journal of Nursing, 14:5 DOI: 10.12968/bjon.2005.14.5.17663

In this Episode, Devan and Tyler discuss a challenging case that centers on a pregnant woman, a suspicion of cancer, and lots of uncertainty about what should be done. Although a common topic of discussion in the classroom, actual cases of maternal-fetal conflicts are relatively unusual. This is a case of a true conflict between a mother's interest and the interests of her unborn child.

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Dr. Barrie Huberman joins Devan and Tyler to discuss a haunting ethics consultation involving a conflict about providing life prolonging medical treatment to a patient who attempted to commit suicide.

*Content Warning: This episode includes discussion of suicide and a description of an individual who becomes critically ill after a suicide attempt.

Dr. Barrie Huberman, PhD, is the Clinical Director of Medical Ethics, and Assistant Professor of Medical Ethics at Weill Cornell Medical College. Her training is in Clinical Psychology and prior to moving to current position, she was the Director of Clinical Ethics at Lennox Hill Hospital in New York City since 1992. Dr. Huberman is also directly involved in training future clinical ethicists through the 2-year clinical ethics fellowship in the Division of Medical Ethics at Weill Cornell Medical College and the New York Presbyterian Healthcare System.

Publications:

• Building an Organizational Ethics Program on a Clinical Ethics Foundation.  The Journal of Clinical Ethics (2020).

• Phases of a Pandemic Surge: The Experience of an Ethics Service in New York City during COVID-19.  The Journal of Clinical Ethics  (2020)

• The Work of ASBH's Clinical Ethics Consultation Affairs Committee: Development Processes Behind Our Educational Materials.  The Journal of Clinical Ethics  (2018).

Kevin Dirksen, senior director of the Providence Center for Health Care Ethics, brings a haunting clinical ethics case that highlights the complexity of navigating disagreements between patients, family members, and the healthcare team.

Kevin Dirksen is senior director of the Providence Center for Health Care Ethics and the Andy & Bev Honzel Endowed Chair in Applied Health Care Ethics. His role includes working with the internal medicine and family medicine residency programs in ethics education, as well as providing clinical and organizational ethics consultation throughout the Oregon Region of Providence St. Joseph Health. In addition to day-to-day oversight of the Center, its team, and its operations, Kevin engages in clinical ethics research and scholarship: representing the work of the Center in professional publications and conferences.

Kevin has published in international, peer-reviewed publications on topics including decision-making capacity, clinical ethics consultation, end-of-life care, scarce resource allocation, and public health ethics. He has lectured on a range of ethical topics in patient care and health policy and has presented at national and international conferences.

Kevin holds an advanced graduate degree in biomedical ethics and a professional graduate degree in theology, specializing in ethics and health. He completed two years of clinical training in health care ethics at the UCLA Health Ethics Center as the Arny & Anne Porath Clinical Ethics Fellow and Senior Clinical Ethics Fellow. He has also earned the Healthcare Ethics Consultant Certification designation from the American Society of Bioethics and Humanities’ Health Care Ethics Consultation (HCEC) Certification Commission.

A native to the Pacific Northwest, Kevin and his wife now live in their hometown with their four children. For fun, Kevin excels at stumbling through D-I-Y house projects, watching Seattle Mariners baseball, and reading classics with his children.

Read More from Kevin Dirksen:

• Joseph W. Kaempf & Kevin M. Dirksen (2022) The Birth of Tragedy? Extremely Premature Births and Shared Decision-Making, The American Journal of Bioethics, 22:11, 59-66, DOI: 10.1080/15265161.2022.2123981

• Kevin M. Dirksen, Joseph W. Kaempf & Nicholas J. Kockler (2020) Periviability in a Pandemic: Good Ethics Still Considered Essential, The American Journal of Bioethics, 20:7, 177-180, DOI: 10.1080/15265161.2020.1779394

• Carol Pavlish, Katherine Brown-Saltzman, Kevin M. Dirksen & Alyssa Fine (2015) Physicians’ Perspectives on Ethically Challenging Situations: Early Identification and Action, AJOB Empirical Bioethics, 6:3, 28-40, DOI: 10.1080/23294515.2014.972527

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In this episode, Tyler and Devan talk with Dr. Laura Guidry-Grimes about a case in which a medical team has to decide whether being a victim of domestic abuse disqualifies a patient from receiving an LVAD.

*Content Warning: This episode discusses the reality of domestic abuse, but with no description of any abusive events.

Relevant publications:

Knoepke et al. 2022. “Variation in Left Ventricular Assist Device Postdischarge Caregiver Requirements: Results From a Mixed-Methods Study with Equity Implications,” Circ Heart Fail Aug; 15(8):e009583