The ART of Getting Pregnant: Benefits vs Risks of Artificial Reproductive Therapy

Assistive (Artificial) Reproductive Technology (Therapy) (ART) is the modern way for women who desire children but are unable to become pregnant can have their wish fulfilled. But as Annie Janvier, BSc, MD, PhD writes in her article “Jumping to Premature Conclusions” in the October 2008 issue of Virtual Mentor there are both financial and human health risks to the way ART is practiced in the United States and Canada. It is all related to the incidence of multiple births and premature births associated with ART leading to the need for neonatal intensive care management and incidence of complications and permanent disabilities of the premature infants. The risks are also related to the tendency for women to wait to their later years to try to become pregnant because of the need for job income and difficulty in managing both a profession and becoming a mother. It is then in these later years that women turn to ART to become pregnant and because of their older age, multiple births and the tendency toward premature deliveries complications arise for both the mother and the babies. Dr. Janvier writes “When a woman decides to have children in early adulthood, does the government provide generous maternity leave, social and economic support for their education, and subsidized, universal childcare services when the child is young? The answer, unfortunately, is no. Society rewards performance, work, and wealth, creating an incentive to delay childbearing. The same women who would receive very limited financial incentives were they to become pregnant at an earlier age when the risks of prematurity were lower end up paying for expensive ART services years later and increasing their risks.”


One of the issues that Dr. Janvier points out is that there is a tendency for multiple embryo transfer in invitro fertilization (IVF) procedures in order to increase the possibility of at least one live birth more promptly so as to avoid the expense (related in part to physician financial self-interests) and physical burdens of repeated attempts. She writes that she “calculated that 17 percent of [neonatal intensive care unit] admissions were multiple gestations following ART. Most of these could have been avoided by rigorously controlling the clinical practices relating to the treatment of infertility. It's easy to envision a public policy to decrease multiple births. Unlike Canada and the United States, some countries—Sweden, Belgium, Finland, and Denmark, for example—regulate and reimburse ART services. In these countries, single-embryo transfer during IVF is the norm. Where financial conflicts of interest related to ART are avoided, patients and physicians seem far less willing to take the unnecessary risk of multiple births in order to become pregnant as quickly as possible. Having children with the least risk for the mother and infant seems to be the morally responsible position.”


Please go to Virtual Mentor and read the entire article and express your opinions here as to the merits of women postponing pregnancy until later years at which time they may need ART to become pregnant. I would also like to read about your views of societal demands on women and the need for change in the way ART is performed and paid for in the United States and Canada as examples. ..Maurice.

Choosing Doctors: Older vs Younger: Who Will Treat You Better?

If you have the chance to pick your own doctor and not many of us have such a chance in this HMO world, who would you pick to manage your health? Who would treat you better, an older doctor or the younger one who is a few years out from final training? And what does “treat” mean? Does that mean more humanistic and sensitive to your concerns or does that mean able to make the diagnosis and begin the treatment more promptly and effectively---or both? Does the additional years of experience which the older doctor includes in his or her medical armamentarium make up for any of the more recent formal medical education which the younger doctor carries?

Researchers have studied this issue and a summary review of the studies was published in the Annals of Internal Medicine 15 February 2005 Volume 142 Issue 4 Pages 260-273. The article titled “Systematic Review: The Relationship between Clinical Experience and Quality of Health Care” by Niteesh K. Choudhry, MD; Robert H. Fletcher, MD, MSc; and Stephen B. Soumerai, ScD. Go to the above link to read the full article, however here is the abstract:

Background: Physicians with more experience are generally believed to have accumulated knowledge and skills during years in practice and therefore to deliver high-quality care. However, evidence suggests that there is an inverse relationship between the number of years that a physician has been in practice and the quality of care that the physician provides.
Purpose: To systematically review studies relating medical knowledge and health care quality to years in practice and physician age.
Data Sources: English-language articles in MEDLINE from 1966 to June 2004 and reference lists of retrieved articles.
Study Selection: Studies that provided empirical results about knowledge or a quality-of-care outcome and included years since graduation or physician age as explanatory variables.
Data Extraction: We categorized studies on the basis of the nature of the association between years in practice or age and performance.
Data Synthesis: Overall, 32 of the 62 (52%) evaluations reported decreasing performance with increasing years in practice for all outcomes assessed; 13 (21%) reported decreasing performance with increasing experience for some outcomes but no association for others; 2 (3%) reported that performance initially increased with increasing experience, peaked, and then decreased (concave relationship); 13 (21%) reported no association; 1 (2%) reported increasing performance with increasing years in practice for some outcomes but no association for others; and 1 (2%) reported increasing performance with increasing years in practice for all outcomes. Results did not change substantially when the analysis was restricted to studies that used the most objective outcome measures.
Limitations: Because of the lack of reliable search terms for physician experience, reports that provided relevant data may have been missed.
Conclusions: Physicians who have been in practice longer may be at risk for providing lower-quality care. Therefore, this subgroup of physicians may need quality improvement interventions.

Worrisome is the following extract from the full article:

Seven studies present data on the relationship between number of years in practice and actual health outcomes. The strongest of these was conducted by Norcini and colleagues, who analyzed mortality for 39 007 hospitalized patients with acute myocardial infarction managed by 4546 cardiologists, internists, and family practitioners. After controlling for a patient's probability of death, hospital location and practice environment, physician specialty, board certification, and the volume of patients seen, these researchers observed a 0.5% (SE, 0.27%) increase in mortality for every year since the treating physician had graduated from medical school.

So there you are with either taking what you get or having a chance to choose. And if you had that chance to choose, what criteria, to you, would be most important? Would the doctor’s age be most important or if not, what? Write about your own experiences in this regard but please don’t name names. ..Maurice.

Graphic: Classic illustrations of physicians, cropped by me for this thread.

Ethical Dilemmas about Economic Aid, Kidney Transplant and Attempted Suicide

Here are some additional ethical dilemmas that I would hope my visitors would take as a challenge to find the best decision. ..Maurice.

1) A first-world nation offers to give a third-world nation equivalent of millions of dollars to provide services and medication to HIV/AIDS victims but with the proviso that 50% of the money is to be used solely for sexual abstinence education programs. That 50% could currently be readily used to enlarge the service and medication programs to cover a greater area and population of the HIV/AIDS patients. What is the ethical conflict here and should the third-world country accept the humanitarian economic aid as stated?

2) Two brothers each have a congenital kidney disease and they are both in the end-stage kidney failure. Both are critically ill at the same time and both need the one donated kidney which is currently available. One brother is rich and can readily pay for the transplant but has a long history of criminal activity including fraud. The other brother is poor, dependent upon the State to pay for his medical care but has never engaged in criminal activity. To which brother should the transplant surgeons provide that kidney?

3) A man has hung himself in his jail cell in an apparent suicide attempt. He was rescued in time to transfer him to a hospital and the intensive care unit. The lack of oxygen has caused what the neurologists say is irreversible severe brain damage but the patient can still breathe on his own and therefore is not “brain dead”. However the patient may never regain consciousness. The family tells the hospital doctors that if he can’t regain consciousness, he should not be given medications to keep him alive and that if his heart stops, the hospital staff should not try to resuscitate him. However, the hospital has religious directives which dictate that the hospital should never aid and abet a suicide. The hospital’s administration tells the family that if the hospital followed the family’s request, the hospital would be going against that religious directive. A hospital ethics committee meeting was held with the family, physicians and administration representatives. What should the ethics committee advise?

GRAPHIC: My ArtRage painting modified with Picasa (Google)

Hope: “Nothing but the Paint on the Face of Existence”

Lord Byron wrote: “But what is Hope? Nothing but the paint on the face of Existence; the least touch of truth rubs it off, and then we see what a hollow-cheeked harlot we have got hold of.”


Not all hope is that grim. Hope is a complex mental process which affects our interpretation of the evidence about ourselves or others. Hope leads us in the direction of some decision. Without hope, there would be no basis to make certain decisions which might change an outcome to our benefit or those of others. But hope has to arise from and be based on evidence-based information to be of value.

False hope, created by misinterpretation of the facts or by receiving information which is without basis in reality, though initially may be supportive to the individual eventually becomes destructive by delaying or preventing the individual to consider all the options still available or the taking of other essential supportive actions.


Though hope is something that can affect our decisions and our feelings about control and accomplishment in various aspects of our lives, hope is an important element in disease and the patient’s management of their disease. Hope plays an important role in most any disease for which treatments are inconsistent in outcome and the consequences are disabling or fatal. Of course, such a disease can be cancer.


Hope, as may be present in a cancer patient, can continue throughout the illness until the patient recognizes that a hoped for cure has become hopeless. Hopelessness may not be accepted by the patient if the patient is awaiting a miracle.


Miracles in the practice of medicine represent clinical responses to hope which are fully unexpected by professional experience or by scientific explanation. When they do occur, they can be explained by scientifically unknown factors in the progression of the disease or occasionally by a misdiagnosis. Unfortunately, waiting for miracles, especially with cancer patients, can lead to making wrong decisions, undergoing unnecessary procedures and treatments, and unnecessarily prolonging the period of suffering before finally accepting hospice management with attention to maintaining palliative comfort care rather than further attempts at a cure.

Recognition of hopelessness at some point must be made for the patient to have the opportunity to finally accept and act on that prognosis both for practical reasons but also to attempt to establish emotional peace.

I would be most interested reading my visitors’ experiences regarding the matter of hope in medical illness, miracles, false hope and hopelessness as experienced by themselves or by family members or friends. ..Maurice.

Graphic: Photograph taken by myself and digitally modified.

Ethical Analysis:Sperm and the Pregnant Dead vs The Politics of Healthcare

Clinical ethicists have discussed issues such as who owns the sperm taken from a deceased husband or what should be done about the fetus of a woman who is pregnant but also brain dead. Some feel that these earnest and analytical discussions about rare events are a waste of intellectual activity by these professionals and that there are far greater social issues that demand the attention of their reasoning. Others may feel that these social issues framed by political viewpoints are purely political and is a discipline separate from ethics.
On the other hand, some like Randy Cohen writing in the March 21 2002 issue of The Nation with the title “The Politics of Ethics” finds ethics and politics related as he writes:

“…the difference between ethics and politics seems to me artificial, if there is a significant difference at all. Sometimes the distinction is a matter of scale. If one guy robs you, it's ethics, but when 435 people rob you, it's politics--or the House of Representatives is in session. But surely the deliberations of that body are subject to ethical analysis. What's more, politics can be a necessary expression of ethics. Often the only way to achieve an individual ethical goal is through group endeavor--i.e., politics.”

In these current days, within the United States, of political discourse within the media and on “Main street”, it may be wise for clinical ethicists not to remain publicly silent with regard to their views of the propositions presented by the political candidates and their parties of important social issues such as the provision of healthcare but to dissect and explain their understanding of the ethics related to them. In the long run, such critical analysis may be of greater import to us all than fretting about sperm or the pregnant dead. What do you think? ..Maurice.

Your Wisdom vs Conventional Wisdom in Medical Ethics: Speak Up!

I have repeatedly stated on this blog that I felt that those who visit here and even those who don't all have views of medical ethics which when expressed are as valuable to consider as those presented by bioethicists. With that in mind, I am eager to present on my blog an exercise to discover what my visitors think about a number of "settled" issues in medical ethics which represent the "norms" or "conventional wisdom" and which physicians use as the guideposts for the management of their patients. There is also "conventional wisdom" markers for medical researchers and the overseeing Institutional Review Boards (IRB).

Franklin C. Miller and Robert D. Truog, writing in the July 2008 issue of the American Journal of Bioethics "An Apology for Socratic Bioethics" discuss the issue whether bioethicists should always go along with the "conventional wisdom" guideposts, often bearing practical values in medical ethics, but instead challenge the norms with a more philosophic analysis of the issues. The authors do suggest that this sort of challenge might end up degrading those practical benefits to the patients.

Here is the exercise. I have extracted from the article a list of examples of medical ethics "conventional wisdom" statements which are recognized and considered by physicians and researchers. Take one or more of them and let us know whether you approve of this medical ethical norm or whether your wisdom suggests something different. I look forward toward your responses. ..Maurice.

About Death and Dying

A. There is no valid ethical distinction between withholding and withdrawing life-sustaining treatment.

B. Intentionally causing death (killing) is wrong; letting patients die is permissible.

C. It is unethical to deliberately hasten death but permissible to provide palliative treatment that risks hastening death under the doctrine of "double effect".

D. Brain death equals death.

E. The removal of vital organs should never be the proximate cause of death of an organ donor. ("Dead Donor Rule")

Research Ethics

F. No patient should be randomized to a treatment known to be inferior (clinical equipoise)

G. Financial payments to research participants are morally suspect because they may be "coercive" or consitute "undue inducement."

H. Financial payment to research subjects is not a benefit to be counted in risk-benefit assessment by IRBs.

Four Elements in Statistics and Their Importance in Ethics of Medical Care

You may wonder why any patient should concern themselves with the statistical terms of specificity, sensitivity, positive predictive value and negative predictive value. I would say to become educated in these four statistical elements can be more meaningful and useful to the patient than the education provided by direct to consumer drug advertising. Drug companies might disagree with me but then educating the public in order to think about, even by those who don't need it, and perhaps get prescribed their new drug is the drug company's primary goal. Educating the public about these statistical elements has no associated conflict of interest and is of importance to all the public.

Back to the statistical elements: Patients are frequently being ordered and submitting to tests and procedures which are designed to help make a diagnosis or provide some scientific basis for appropriate therapy. And this is where the need for not only understanding but finding the data to support these tests is essential for the ordering physician but also should be essential for the patient on the receiving end to be aware. After all, tests and procedures are often expensive but also may take up the patient’s time. Tests and procedures may be invasive to the patient and there occasionally may be a unwanted reaction. Tests and procedures may unexpectedly turn up results that suggest some abnormality not initially considered but later after more tests, more cost, more risk that abnormality was a mistaken impression,not related to the disorder under investigation and was never present in the first place. And finally, with regard to that disorder under investigation, the test or procedure may provide the wrong answer. The disease will be determined as confirmed as present but it really is not present but is a false positive. The disease can also be confirmed as absent but it really is not absent but just missed by the testing and becomes a false negative.

Before the doctor ordering and the patient accepting most tests, both have to understand the significance of the test in the four different statistical elements:

Sensitivity-how sensitive is the test to correctly detect the disease if the disease is actually present?

Specificity-how specific is the test to correctly determine that the disease is absent when it is actually absent.

Positive predictive value- Considering how common the disease is in the population, what are the chances that a positive test result will be correct for a specific patient.

Negative predictive value-Considering how common the disease is in the population, what are the chances that a negative test result will be correct for a specific patient.

What does this all have to do with medical ethics? These days, patients are endowed with the ethical principle of autonomy. They should have the opportunity through information provided by the physician and elsewhere to make their own final medical decisions including the acceptance of tests or procedures for diagnosis. Yes, the physician should be aware of the statistical value of the tests or procedures, he or she advises and should provide some education to the patient regarding the basis and value of such tests. Of course, it is not expected that the patient will have the same education and background experience of the doctor to evaluate any particular test. On the other hand, patients should be aware of the factors that the physician should be considering before giving advice which should include the statistical value of the test (as delineated above) which is part of the benefit but also the risks and burdens involved for the patient such as including side-effects and financial costs and the errors of the test. If a patient is educated about these four statistical factors, the patient can then have some understanding as to what to ask the doctor about the tests if the benefit and risks are still not fully understood by the patient in making their autonomous decision. It’s all about ethics and there is even more.

Beyond autonomy involved in decisions about tests is justice and the use of scarce resources and one of the scarce resources is the cost of medical care in the United States as an example. The statistical elements I have described play an even more important role in this regard when considering screening tests and exams where there are large numbers of the public being screened who do not have the disease being screened or when the significance of the disease with regard to life span or symptoms is trivial in certain segments of the population to be tested. Is there real benefit to the population for screening? Or do the statistical elements and the nature of the disease make for waste of health care dollars, time, physical risks and discovery of disorders which are not present but require additional testing to find that they are false positives?

All patients who are interested in making truly informed consent or dissent, should go to the British Medical Journal Sept. 27 2003 and read the article “Understanding sensitivity and specificity with the right side of the brain” by Tze-Wey Loong where with graphics, Loong helps the reader understand all four statistical elements.

I hope I have shown the importance of some knowledge of simple statistical analysis for all patients and suggest, with that knowledge, patients should consider challenging their physicians if the there is some question about the advised tests or procedures. If you disagree, write your comments here. ..Maurice.

Graphic: Louis Pasteur (1822-1895), Print Collection, Reynolds Historical Library.

Patient Modesty: Volume 6

AS OF DECEMBER 17 2008 THIS THREAD WILL BE CLOSED FOR ALL COMMENTS. DO NOT ATTEMPT TO WRITE ANY FURTHER COMMENTS HERE. PLEASE GO TO "PATIENT MODESTY: VOLUME7" TO CONTINUE COMMENTS. ..Maurice.

Graphic: Photograph of a statue in the statue garden of the Getty Museum, Los Angeles June 2007 and modified by me with ArtRage.