Recently, a news article was posted about a young boy who was diagnosed with acute lymphoblastic leukemia in April 2019 (Zurcher, 2019). Acute lymphoblastic leukemia is a malignant transformation along with the abnormal proliferation of lymphoid progenitor cells (Terwilliger & Abdul-Hay, 2017). This type of cancer is commonly seen in children between the ages of 2 and 5 years old (Inaba, Greaves, & Mullighan, 2013). The survival rate of children with acute lymphoblastic leukemia is 90% with standard treatment (Inaba, Greaves, & Mullighan, 2013).
His parents, Taylor Bland-Ball and Joshua McAdams, decided not to continue chemotherapy after the first treatment and instead wanted to try alternative treatments (Zurcher, 2019). These alternative treatments included oxygen therapy and the alkaline diet (Zurcher, 2019).
During solid tumor development, the microenvironment is severely hypoxic (Ikeda, Hisano, Nishikawa, & Nagasaki, 2016). The low-oxygen environment promotes the transition of epithelial cells to mesenchymal cells in the tumor which can facilitate movement and metastasis (Yang et al., 2017). The hyperbaric oxygen therapy is theorized to create an environment high in oxygen that the solid tumors are unable to adapt to (Moen et al., 2009). A study examining hyperbaric oxygen therapy in rats with adenocrcinomas did find a decrease in tumor size and tumor cell proliferation after only 2 treatments (Moen et al., 2009).
Additionally, around 48% of cancer patients pursue popular diets, including the alkaline diet, to try and increase survival rates (Zick, Snyder, & Abrams, 2018). With a high intake in animal meat compared to fruits and vegetables, most Americans are increasing their sodium/chloride concentration and acid loads (Wachman & Bernstein, 1968). An alkaline diet focuses on reducing foods high in acids and increasing the amount of potassium ingested (Wachman & Bernstein, 1968). Because lower pH levels in the extracellular space can promote the invasive potential of cancer cells (Kato et al., 2007), the alkaline diet could lead to a decrease in metastasis.
In May 2019, the state of Florida placed the child in his grandparent’s custody and mandated chemotherapy to be resumed after the parents stopped taking him to his treatments (Zurcher, 2019). This news article brings up questions about who has the right to decide the course of treatment for a child. Ideally, parents and health care workers can come together in order to make that decision but this is not always possible. While doctor are better equipped to understand a disease and treatment options, it can be argued that parents are more motivated to find the best treatment for their child and should have autonomy in making this decision. At what point should the doctor’s plan override the parent's autonomy? Currently, if the state is attempting to override the parent’s wishes, both a high success rate for the doctor’s treatment and long term harm or death if the child is untreated must be proved in order for the court to side with the state due to the value placed on parental decision making (Black, 2006).
Black, L. (2006). Limiting Parents’ Rights in Medical Decision Making. AMA Journal of Ethics, 8(10), 676–680. https://doi.org/10.1001/virtualmentor.2006.8.10.hlaw1-0610.
Ikeda, Y., Hisano, H., Nishikawa, Y., & Nagasaki, Y. (2016). Targeting and Treatment of Tumor Hypoxia by Newly Designed Prodrug Possessing High Permeability in Solid Tumors. Molecular Pharmaceutics, 13(7), 2283–2289. https://doi.org/10.1021/acs.molpharmaceut.6b00011
Inaba, H., Greaves, M., & Mullighan, C. G. (2013). Acute lymphoblastic leukaemia. Lancet, 381(9881). https://doi.org/10.1016/S0140-6736(12)62187-4
Kato, Y., Ozawa, S., Tsukuda, M., Kubota, E., Miyazaki, K., St-Pierre, Y., & Hata, R.-I. (2007). Acidic extracellular pH increases calcium influx-triggered phospholipase D activity along with acidic sphingomyelinase activation to induce matrix metalloproteinase-9 expression in mouse metastatic melanoma: ASMase and Ca2+ influx in acid induction of MMP-9. FEBS Journal, 274(12), 3171–3183. https://doi.org/10.1111/j.1742-4658.2007.05848.x
Moen, I., Øyan, A. M., Kalland, K.-H., Tronstad, K. J., Akslen, L. A., Chekenya, M., … Stuhr, L. E. B. (2009). Hyperoxic Treatment Induces Mesenchymal-to-Epithelial Transition in a Rat Adenocarcinoma Model. PLoS ONE, 4(7). https://doi.org/10.1371/journal.pone.0006381
Terwilliger, T., & Abdul-Hay, M. (2017). Acute lymphoblastic leukemia: A comprehensive review and 2017 update. Blood Cancer Journal, 7(6), e577. https://doi.org/10.1038/bcj.2017.53
Wachman, A., & Bernstein, DanielS. (1968). DIET AND OSTEOPOROSIS. The Lancet, 291(7549), 958–959. https://doi.org/10.1016/S0140-6736(68)90908-2
Yang, S., Zhang, Z., Hao, Y., Zhao, Y., Qian, F., Shi, Y., … Yu, P. (2017). HIF-1α induces the epithelial-mesenchymal transition in gastric cancer stem cells through the Snail pathway. Oncotarget, 8(6), 9535–9545. https://doi.org/10.18632/oncotarget.14484
Zick, S. M., Snyder, D., & Abrams, D. I. (2018). Pros and Cons of Dietary Strategies Popular Among Cancer Patients. Oncology (Williston Park, N.Y.), 32(11), 542–547.
Zurcher, A. (2019, May 9). US parents told boy must have chemotherapy. BBC News. Retrieved from https://www.bbc.com/news/world-us-canada-48220571
This article definitely brings up our four ethical principles into consideration. Non-maleficence and beneficence, for example, are shown here in deciding which treatment would get more harm to the child and which would be better benefit the child.
ReplyDeleteParental authority is to be questioned when there is a possible risk to the child as a result of disagreement about the diagnosis and risk and benefits of treatment (Harrison,2004), which is what we see in this case. When a physician disagrees with the parental decision making that is potentially putting the child at risk, the physician would call the institutional board of ethics consultants. If the healthcare team, ethics committee board, and other non-medical consultants all agree that the parent’s-imposed treatment and/or lack of suggested medical treatment is at risk of the child they would consider a legal appeal to become the decision marker of the child over the parents (Harrison, 2004).
If the physician follows these regulations, I believe that sometimes it is okay for a medical provider to become the decision maker over the parents if it comes down to the risk of the patient and it is what is fair for the child. Especially if the survival rate is 90% with recommended treatment. It would be more understandable if the standard treatment did not work following completion or if it gives more harm to the child to find other routes of treatment.
This situation also gives raise to questions in how physician decision making may conflict with religious, cultural, and/or spiritual beliefs. For example, Jehovah’s Witnesses refuse to get any type of blood transfusion treatment even if it comes to the cost of their life (Sarteschi, 2004). As a future medical provider, how would you go about treating a Jehovah Witnesses, and/or also one's child, when blood transfusion is needed for survival?
References:
Harrison, C. (2004). Treatment decisions regarding infants, children and adolescents. Paediatrics & Child Health, 9(2), 99–103. doi: 10.1093/pch/9.2.99
Sarteschi, L. (2004). Jehovahs witnesses, blood transfusions and transplantations. Transplantation Proceedings, 36(3), 499–501. doi: 10.1016/j.transproceed.2004.02.013
This is a really interesting situation in that both sides seem to have the ethical high ground. According the University of Washington, parental decision making comes down to the best interest of the child. In this case, the medical professionals and the parents involved have conflicting ideas about what is best for the child. From a medical standpoint, the child is most likely to recover and survive with chemotherapy. However, the parents (most likely) see the harmful effects of chemotherapy and want to find a less aggressive way to help their child. The University of Washington posits that "Medical caretakers have an ethical and legal duty to advocate for the best interests of the child when parental decisions are potentially dangerous to the child's health, imprudent, neglectful, or abusive" (Parental Decision Making).
ReplyDeleteThe decision of the parents to seek an alternative to chemotherapy could be considered imprudent, as you indicated that the highest survival rate of the illness is with standard treatment. Yet, this decision could hardly be considered neglectful (as they are seeking some form of treatment backed with scientific evidence) or abusive.
This situation can be compared to those in which a parent refuses to vaccinate a child. In these cases, providers cannot legally override parents, but if a child's life is on the line, the provider can get a court order to provide treatment (Parental Decision Making). If the child's cancer is likely to be fatal without chemotherapy, the provider has every right to step in. In this case, however, alternative options exist that still provide a chance for survival and the cancer is likely to be survived.
Non-maleficence, autonomy, and beneficence come into question here- not just for the health-care professionals but for the parents as well. The child is far too young to make their own choices, so that responsibility lies on the parents. The parents' decision in this case should be respected as though the child had made the decision autonomously. I see how doctors might see it as harmful to not use chemotherapy, but the cancer is not going untreated. It it up to the parents, at least in this case, to decide what is merciful and what is harmful (what is considered maleficence and what is considered beneficence).
Parental Decision Making. (n.d.). Retrieved from https://depts.washington.edu/bhdept/ethics-medicine/bioethics-topics/detail/72
Great blog KristinH610! Whether or not we as physician agree with a course of treatment should not give us the right to deny alternative healthcare option. Autonomy (freedom of choice) is one of the basic principles of medical ethics. Beauchamp and Childress argue that health care professionals should be obligated to inform and increase the options available to patients. Autonomous actions are mainly a result from working hand in hand with the options made available to you by your healthcare provider (Beauchamp & Childress, 2013).
ReplyDeleteIf the hyperbaric oxygen therapies have in fact been validated to help decrease tumor size why shouldn’t this be a viable option? However, autonomy can be overruled if it potentially harms others such as their child (Parker, 2001). If there are no published negative side effects and it has been shown to work I don’t see why they couldn’t choose an alternative form of treatment. On the other hand, if there are more negative consequences should we take away these parents autonomy for the sake of their child?
Take for example the ongoing debate of vaccines. The Institute of Medicine of the National Academies reported that some parents will dismiss highly evidenced benefits of vaccines and choose to fear potential side effects and not vaccinate their children, which has increased a number of diseased like measles (The National Academics Press, 2013). In this case do we choose autonomy over justice? I think you have just inspired my next blog post!
References:
Beauchamp TL, Childress JF. Principles of biomedical ethics. 7th ed. New York: Oxford University Press; 2013.
Institute of Medicine of the National Academies The childhood immunization schedule and safety stakeholder concerns, scientific evidence, and future studies Washington, DC: The National Academics Press; 2013
Parker M. The ethics of evidence-based patient choice. Health Expectations. 2001