New in the Hastings Center report, November-December 2017
Stemming the Standard-of-Care Sprawl: Clinician Self-Interest and the Case of Electronic Fetal Monitoring
Kayte Spector-Bagdady, Raymond De Vries, Lisa Hope Harris, and Lisa Kane Low
Continuous electronic fetal monitoring is often used during labor to monitor fetal heart rates, but in most pregnancies, the practice may increase risks to mother and baby. Despite strong evidence and professional guidelines that argue against the use of continuous EFM for healthy pregnancies, it persists as the standard of care. One of the main reasons for this is often assumed to be physicians' concerns about liability. This article examines if there are ways to ensure that the medical standard of care is based on the best interests of the patient, not on clinicians' concerns to protect against legal action. Spector-Bagdady is an assistant professor of obstetrics and gynecology, De Vries is the associate director of the Center for Bioethics and Social Sciences in Medicine, and Hope Harris is an associate professor of obstetrics and gynecology at the University of Michigan Medical School. Kane Low is an associate professor of health behavior and biological sciences at the University of Michigan School of Nursing.
Another Voice: Practices like continuous EFM may get "stuck" as the standard of care because the medical profession lacks a mechanism for ensuring that its members stay current with best practices. Instead, medical malpractice law is used to set the boundaries on acceptable practice. And as long as a respectable minority of doctors continue to embrace a given intervention, no matter its efficacy, the law will deem the practice reasonable, writes Michelle Oberman, a professor at Santa Clara University School of Law.
Ending DACA Has Pragmatic and Ethical Implications for U.S. Health Care
Danish Zaidi and Mark Kuczewski
In a letter to Congress earlier this year, the American Association of Medical Colleges wrote that the Deferred Action for Childhood Arrivals (DACA) program initiative would contribute more than 5,000 primary care physicians in the coming decades, many of whom would be positioned to care for underserved populations. This essay, coauthored by the director of medical education at the first U.S. medical school to recruit and accept students protected by DACA, outlines the serious practical and ethical consequences of the recent decision by the Trump administration to rescind the program. It highlights the urgent need for a sustainable solution to safeguard DACA recipients who would otherwise lose protections. Mark Kuczewski is the director of medical education at the Loyola University Chicago Stritch School of Medicine. Danish Zaidi is a doctor of medicine candidate at Wake Forest School of Medicine.
Perspective: "What's in a name?" CAR-T Gene Therapy
When Kodish served on the National Institutes of Health Recombinant DNA Advisory committee, he was repeatedly reminded not to speak of "gene therapy" but instead to use the term "gene transfer research." But in August, the FDA approved CAR-T gene therapy for relapsed childhood acute lymphoblastic leukemia, an intervention that holds great promise but can also cause life-threatening side effects. A pediatric hematologist at the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Kodish asks if it is ever correct to speak of "therapeutic research" when the phrase may promote false hopes.
Also in this report:
- "Public Health and Autonomy: A Critical Appraisal" http://onlinelibrary.wiley.com/doi/10.1002/hast.784/full)
- Policy & Politics: "Real-World Evidence, Public Participation, and the FDA" http://onlinelibrary.wiley.com/doi/10.1002/hast.779/full)
- Special Report: Just Reproduction: Reimagining Autonomy in Reproductive Medicine http://onlinelibrary.wiley.com/doi/10.1002/hast.2017.47.issue-S3/issuetoc
Contact Susan Gilbert, director of communications
The Hastings Center