Tuesday, May 4, 2010

Transfusions and operating room ethics

So I was chatting with the anaesthesiologist during Susan's caesarean section this morning (while peering over the shield to boggle at what all was going on over on the other side). There was some risk that Sue might wind up needing a transfusion as things got a bit complicated.

[Note: Stress and nervous tension are now serious social problems in all parts of the Galaxy, and it is in order that this situation should not be in any way exacerbated that the following facts will now be revealed in advance. Susan and the wee girl are fine. While the caesarean took a while, all wound up all right in the end. In order that some sense of mystery should still be preserved, no revelation will yet be made concerning the second decimal place of the girl's weight, the first digits of which were 4.3 kilograms. The second decimal place may safely be made the subject of suspense since it is of no significance whatsoever given measurement error.]

As I'm O negative, I noted that should Sue only need a small top-up, I'd happily provide. The anaesthesiologist said that would not be possible. The rest of the conversation went roughly as follows:
Me: Why not?
Her: Well, we'd need to do the blood tests to make sure it was all clean for transfusion.
Me: So, that would take too long then?
Her: No, that's not the problem. Rather, if we ever found something that the other partner might find cause for concern, we'd then face an ethical problem. So there's a rule banning these kinds of husband-wife transfusions.
Me: Ethical problem?
Her: Imagine the case where we find the one partner has an STD which the other partner would find out about because we wouldn't be using the blood.
Me: So if Susan needed a kidney and I were a match, I'd be banned from giving it then?
Her: No, we'd just make sure there were proper pre-counselling available so everyone were ready in case such a thing were found.
Me: Is there anything that ethicists don't completely screw up?
Her: Well, it's a complicated issue. I suppose if someone jumped up and down a lot and got a lawyer in...
In a rare instance of clarity, I realized that arguing medical ethics with the anaesthesiologist during the caesarean section might not be the very best idea, especially as things were starting to look very busy on the other side of the sheet and as the anaesthesiologist almost certainly wasn't the one responsible for the policy.

There is, of course, a dead simple mechanism design solution to the ethical problem here. The blood is taken, the donor and the recipient both signing a form that if any ethically troublesome problem is found in the blood, blood from the standard donor pool would instead be used without additional notice to the recipient; the donor would later confidentially be informed of the ethical problem encountered. Problem solved. The doctors don't need to tell the recipient of the donor's possible philandering while in the middle of surgery; the donor finds out about any blood problems; and, if there's a blood problem, the recipient is no worse off than would have been the case had they just gone to the standard pool in the first place. It's not that far from the solution they had a while back allowing folks from high risk groups to donate blood while ticking a box indicating that their blood really shouldn't be used.

Why the hell anybody lets ethicists ban things before they ask an economist for a mechanism design solution to the purported problem....

If we wind up finding that Sue comes up a bit anemic and tomorrow needs a transfusion, I may jump up and down a bit arguing for my solution through mechanism design.

And now we can safely reveal, without ethical dilemma about the risks of imposing stress on you our dear reader, the number in the second decimal place was 1.  4.31 kg; head circumference 39 cm, length 55 cm.
Her name, however, will not be revealed as yet. Those who care may follow my Twitter feed for updates of that sort.

24 comments:

  1. Congratulations!

    And bonus points for making a H2G2 reference in your baby announcement blog post!

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  2. Oh and the link was not necessary - it too easily gives the reference away to non-believers. ;)

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  3. Excellent work. Congrats.

    And also: arguing medical ethics with the anaesthesiologist during the caesarean section is a splendid idea indeed. There's no such thing as a bad time for an ethics debate.

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    1. In mny experience, there is no good time for ethics debates, because they put collegiality at risk. Most of us are happy to have our ethics handed down from on high, to forestall discussion and collegiality meltdowns. The only exception to what I write here is... the blogosphere!

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  4. Congratulations to you and Sue.

    "If we wind up finding that Sue comes up a bit anemic and tomorrow needs a transfusion, I may jump up and down a bit arguing for my solution through mechanism design."

    God, you must be a fun guy to have around in a crisis. I'm sure there's a "An ethicist, an economist, and a nuclear physicist walk into a bar" joke to be had here somewhere, but I can't quite find it.

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  5. Congrats - especially to the wife, who was doing all the work while you were chatting up the anaesthesiologist, tsk, tsk. Medical ethics conversation, eh? I'll have to keep that one in mind for the next time I have some explainin' to do.

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  6. Congrats to you and Sue!

    How does Ira feel about the new addition to the family?

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  7. Congratulations all 4 of you. Glad to hear all is well, and that small Crampton emerged successfully. Would love to have been a fly on the wall had the ethics discussion continued... Safe to say we're not seeing you tonight then :)

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  8. How things have changed. When I was about to have a transfusion before our daughter's birth 25 years ago the nurse joked about AIDS. She then reassured me that it would be okay because pregnant women only got blood from female donors.

    I second Lemmus and the work hasn't finished. A Caesarean is major surgery which requires rest for recovery.

    Wishing you all joy and wonder.How blessed your wee daughter is to have parents who love each other and her.

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  9. Congratulations to you, Susan, Ira, and little Miss Crampton. It's great to hear that everyone is healthy and that you maintained your usual demeanour in the delivery room.

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  10. How did it become unethical to tell a wife that her husband is cheating on her?!

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  11. @Robin: I completely agree with you. On that one, I suppose I can understand doctor-patient confidentiality issues; however, if the husband EXPLICITLY WAIVES confidentiality, and especially if the transfusion request has come from the husband rather than the wife, that does seem more than a bit odd.

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  12. Congratulations Father Crampton.

    I'm sure you'll work out a slick design solution to the purported problem--after al,l you'll have to do something while you're lying awake nights listening to baby howls. :-)

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  13. It's been a while since I've been involved in medical ethics discussions, but I suspect that there may be a sticking point around the husband explicitly waiving confidentially when the implications of the data being released are not yet clear. Evidence of congenital abnormality? Evidence of STD? Evidence that he's exposed his wife and child to a potentially lethal disease for some time?

    Like it or not, marrying someone doesn't give you legal access to their data.

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  14. Bah. Typo. s/confidentially/confidentiality/

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  15. @Roy: You'll note, of course, that my proposed mechanism deftly avoids all such problems. I'd go further and argue that I ought to be able to explicitly allow Susan access to my details if I wish, regardless of potential implications. But the mechanism is sufficient to get the desired result.

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  16. Congratulations to you both. I'm sure Ira will make an excellent big brother.

    Regards the ethics, your solution seems nice and elegant - ethics committees obviously need economists on them :). However in relation to spouses and blood donation, I've seem some comment that husbands donating to wives increases risks of complications during future pregnancies. Maybe the anaesthesiologist was just thinking ahead...?

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  17. Congrats :)

    I am pretty sure that arguing with people is the best way to keep them on their toes - small distractions force people to pay attention rather than rolling through cruise control :P

    Regarding the ethics I think it could be the medical service following a rule of thumb that protects cheaters in the face of a shortage in the necessary pool of blood - as if everyone was allowed to get tested we would either have a seperating eqm where cheaters get caught, or a pooling eqm where they get caught as well.

    Not sure this is either socially optimal or even a realistic reason - but that is often the way with arbitrary policies.

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  18. @Duncan: If there were a decent medical reason, I'd be happy enough. But the suggestion was that it was ethics that was the binding constraint.

    @Matt: She did an excellent job of keeping Sue just out of pain's way during surgery, so maybe you're right on the first part. Not sure I get the second: I could buy it if the random donor would risk having status disclosed to spouse, but not where it's folks asking to donate as a special case for their spouse where they wouldn't otherwise be donating. (And before folks ask why I'm not currently donating, I gave about 5-6 pints while an undergrad and have as yet made no withdrawals...)

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  19. I wonder if it is because direct donation of blood to a spouse could be seen as less safe?

    Typically blood donation has a strong self-deferral culture - don't donate if you meet any of the following criteria for exposure to nasty things. That's backed up by the blood testing performed by the labs, but there maybe some things the labs can't/don't test for and simply try and screen out with the self deferral. I'm guessing that's why your only payment for blood in NZ is a cup of tea and a biscuit - cash probably weakens the self deferral part of the system.

    With a spouse being the recipient the self deferral mechanism is probably also weakened. Unless you've got that special tickbox that you mentioned earlier for 'take my blood and then bin it cos I've been a bad puppy'

    And I guess different rules apply with organ donation simply because the supply pool is that much smaller than with blood.

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  20. Congrats Eric and family! Six months ago I was in a similar situation but all my efforts were focused on stopping myself from fainting - they even had an orderly stand behind me on catching duty.

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