Monday, September 1, 2008

Cancer, Pregnancy and Medical Ethics

Yesterday's New York Times Magazine has an excellent article by Pamela Paul - "With Child, With Cancer" - about the clinical and ethical dilemmas associated with cancer during pregnancy. It's an important clinical area I knew nothing about. But my reason for encouraging readers to look at the article is that it exemplifies the kind of journalism we need more of.

Cancer in pregnancy creates the most vexing form of ethical conflict - good vs good. Effective treatment is good for the mother, but it may harm the developing fetus. And, information about the impact of chemotherapy on pregnancy outcome is limited.

The article presents vignettes of exemplary ethics process. Three stood out for me:

Paul describes how in 1997 Dr. Elyce Cardonick at Cooper Union Hospital in New Jersey encountered a pregnant patient with cancer. She scoured the literature and found a report from Mexico claiming that chemotherapy in pregnancy could be safe for the fetus. Cardonick brought the question of offering chemotherapy to the hospital ethics committee.

That was the right thing to do. The stakes were high, and while a single case report was suggestive, it proved nothing. Bringing the issue to the ethics committee enriched decision-making with a wider range of perspectives and made the case part of a wider learning process. (The treatment was given and the baby emerged in good health.)

2. In 1995 Patty Murray, 35 years old, was 17 weeks pregnant with her third child, when metastatic breast cancer was diagnosed. With great trepidation she underwent treatment, with happy outcome for baby (now a 12 year old who likes to play basketball) and mother (now 13 years post diagnosis and initial treatment).

Murray used her experience to help others, by participating in the founding of the Pregnant with Cancer Network, an organization that offers information and support to women who face the situation she encountered in 1995. The website is impressive. It emphasizes the importance of registries to track and learn from experience and offers to link pregnant women with cancer with peers who have experienced the same situation.

Metabolizing personal experience as Patty Murray did into opportunities to help others and foster learning in the health system is a key contributor to ethical health process.

3. Finally, Paul gives several examples of thoughtful collaboration between physicians and their patients in trying to craft a prudent clinical approach in complex circumstances. She conveys a picture of risk/benefit analysis in a reader-friendly manner. The underlying message is that physicians, patients and the public need to recognize uncertainty, approach it in as evidence-based a way as possible, and use the values of the patient in weighing the various benefits and risks.

We need more journalism like this to help us approach health policy in a more thoughtful and informed manner. Thanks to Pamela Paul!