Case 5) Invasive mole of 18 year old female (Patient's privacy and the selection of therapy)  

<Case5> 18 years old woman

  When the patient was graduated from high school, she became
pregnant. She didn't want her baby, she went to the local
OB-GY clinic to have abortion. As she didn't want to marry with
the partner, she didn't tell her pregnancy to him.
  At that abortion the partial mole is doubted. So she was referred
to the hospital. Chemotherapy was started because the HCG level
was over 100000I.U. and invasive mole was highly suspected.
  The usual chemotherapy (MTX) was done but it was not effective
for her.
  The total hysterectomy or strong combination chemotherapy was
thought as the next therapy.
  Only her father knew the fact that patient was pregnant.
  She is young and she wants to have her own baby in the future.

<Question>
  1) Should the doctor talk about the pregnancy to her family?
To explain invasive mole, the former pregnancy was needed
to be mentioned.
  2) Strong combination chemotherapy will make some
side-effects on her reproductive system. The total
hysterectomy will be done, she will not have her baby.
If the patient deny these therapies, how should the doctor to
do for her?



Analysis of this case by the student using 4-Box analysis

PjMedical adaptation
1: diagnosis and therapy
The diagnosis was partial invasion mole.
In most cases, chemotherapy (MTX) is effective and selected as a first
therapy. But in this case the chemotherapy is not effective and operation or
combined severe chemotherapy will be indicated.
Operation will make her unable to make her baby in the future.
HCG level is the indicator of this disease.
As for chemotherapy, some side effects, such as; anorexia, fever,
bone marrow suppression will happen.

2: prognosis
If the simple chemotherapy (MTX) is effective(more than 90%) , she will be
able to be pregnant after 3 years control of hCG level without chemotherapy.
Owing to the paper,3 years passed after chemotherapy, there is no difference
between the frequency of teratogenesis from the general birth.

But this simple chemotherapy does not work, the more strong combined
chemotherapy is indicated.
As this patient is young, the operation therapy is usually avoided for the future
pregnancy or make her sterile.
This disease will be easy to relapse, so follow-up is needed every month
over 2 years after the labo-data becomes normal.
 

 Such that almost there is not the influence in pregnancy if it is below the
cut off value (0.5ml/ml) in the progress of the hCG value after it treats it
generally.

QjPatient Preference
The patient and her family accept the present chemotherapy.
But it is not explained in detail in such as; if the present therapy is not effective,
hysterectomy or stronger combined chemotherapy will be needed as a second step.
The patient hopes an early discharge because her work is settled after her graduation
from her high school.

RjQOL
The patient must visit a hospital in the long term and it will make her life restricted.
If hysterectomy is needed, not only a medical but also psychiatric or social care
will be needed.

SjContextual Features
She has 4 family members, father, mother, and younger brother.
There are no serious problems before the patients disease.
The patient was scheduled to be employment after graduation from her high school.



Jim DwyeriDepartment of Philosophy, New York University)

Thanks for sending me the case study of the young woman.  It is a sad and
difficult case.  When I got a chance, I gave the case some serious
thought.  Attached are a few comments.  Let me know what you think and
feel about the case.

A Few Comments

1.  The Human Aspect.  This is a sad case.  The woman is so young, and her
life is going to be difficult, no matter what she chooses to do.  I think
we need to keep the sad aspect of this case in mind.

2.  An Unwanted Pregnancy.  The first ethical issue that strikes me is
that the pregnancy is unwanted.  Although I do not know the details of the
case, I think we need to focus more attention on the moral responsibility
of men.  Too many men act like pregnancy is the woman's problem.  Men need
to take more responsibility for preventing unwanted pregnancies.

3.  Abortion.  The woman has to decided whether to terminate the
pregnancy.  I would encourage this woman to discuss her decision with
other people (her parents, her partner, a close friend).  I think people
make better decisions after good dialogues.  Indeed, dialogues help people
to understand themselves  what they want to do.  I would encourage good
dialogue, but I would not require it.

4.  Treatment.  I am not sure when the cancer (the invasive mole) was
discovered: during the pregnancy or after she had terminated the
pregnancy.  In either case, the doctor needs to explain the whole problem
to the woman and to discuss the treatment options with her.  I would
encourage, but not require, the woman to involved her parents in the
discussion.  It would make me angry if the doctors decided such and
important and personal matter by themselves.  It would make me sad if the
young woman has to decide the matter by herself.  There is one point I am
not sure about: might it be possible to explain the problem (to the
parents) without discussing the pregnancy?

5.  Hysterectomy.  The doctors need to explain to the woman why they think
a hysterectomy is the best form of treatment.  They need to discuss all
the woman's concerns: her desire to bear a child in the future, her sense
of herself as a woman, and any fears and hopes she has.  The doctors
should explain that even if she loses her uterus, she can still become a
parent.  She may be able to adopt a child or to use a surrogate to bear a
child for her.

6.  Her decision.  I don't know how to balance the threat to her health
against the loss posed by a hysterectomy.  I think the woman should make
this decision after she consults her doctors, her parents, and other women
who have faced similar situations.

7.  A Sense of Humility.  Cases like these always leave me with a deeper
sense of humility.  I realize the limits of my insight and knowledge, and
the difficulties that life poses.  I wish you well.  I wish the young
woman well.  Take courage.



Tomoko Matsuo
(Ph.D. student in University Heidelberg.Germany,
Ph.D. student in Kyusyu university, Legal Philosophy)

Confidentiality of pregnancy
If the patient doesn't want to let the family know her pregnancy, the
doctor should not say this. The problem lies now not on her
pregnancy but on her present health. The patient couldn't be in relief
mentally, if the family is informed of her pregnancy. In Japan
pregnancy before marriage, especially if in her teenage, is not yet
liberalized and psychological burden of the woman could not be small.
Her mental calm is important for the coming strong chemotherapy.

Consent to treatment
The treatment should be done if the possibility of overcoming the
grave situation is big, although she rejects it. Of course here is
necessary to persuade her into it. When now her life itself is or
would be at risk, her rejection looks wrong or would be changed.
But if so severe treatment comes to point, the patient's disease
should be well enough examined.



Summary of this case discussion by the student

  In this case we discussed not only the medical but also psychological,
social aspect of juvenile pregnancy and the meaning of operation to
uterus for young woman.
  It is not easy for the teenagers to make their baby. Although the birth
rates of teenager in Japan is lower than that of other foreign countries.
But the rate of artificial abortion rate is very high.
The abortion of young woman will make not physical but also mental trauma
in the future.
  So the education "Not to make their baby till they want to and can be able
to grow up their children" for the young generation.
  It is not realistic to inhibit their sexual impulse. So the safety contraception
such as Condom should be taught for teenagers. It will also helpful to prevent
STD such as AIDS.
  In this case, doctor should not only to do the therapy of the disease but also
to help her to face difficult realities and decide to send significant life.
  The teenagers' pregnancy have various problems, not only physical, but also
social and psychological problem. So Doctors can not help the patient all by
his/herself. So various medical staffs (including psychologist, not so common
in Japan) and her family will help her.

  In this case, the chemotherapy was not effective, and tumor hump removal
was done at the end. Now her hCG level is under control and followed up
in outpatient department.
  If her hCG level below normal for 3 years without no relapse, she
will have a chance to have her own baby. We hope so.



Stuart Sprague, PhD
Associate Professor of Family Medicine
AnMed Family Practice Center
Anderson, SC USA.

Case 5
     In this case the patient has reached the age of majority, or responsibility
for her own health.  Since her father knows about the pregnancy, I believe it
is appropriate to ask her if she would like to involve him in the discussions.
She could open it to others if she wished.  Often moral support of family can
be of help in such cases.  Her decision about that should determine whether
others are involved in the discussion.  As in the case above, use of a
counselor can be helpful in her process of deciding what to do and with
whom to discuss the issues.
     From the beginning it should be clear to the patient that the
consequences of her condition can be grave.  Left untreated, it can be fatal.
Also, time is an important factor.  Waiting unnecessarily can make the
condition and its effects even worse.  The failure of the initial chemotherapy
is a bad sign.  As with any medical treatment, there is not 100% assurance of
the diagnosis or of the prognosis.  There is a certain amount of inevitable risk
.
     The decision about the second stage of treatment is also not free of risk.
One of the physician's obligations is to be as truthful and complete as
possible in laying out both the options and the uncertainties for her. If she is
not able to decide or resists either of the options laid out for her by the
physician, this case is similar to others.  Under what circumstances are you
willing to force treatment on an individual?  There are certain rare instances
in which one might seek a court order or some other coercive measure to
force treatment for which permission is not given.  But these are very rare and
clear criteria, announced in advance, are preferable in such cases.
     Often denial of the facts can be a method of coping with a difficult
decision.  If this is the case, referral to a counselor who can help the patient
to see this is appropriate.  If the doctor has skill in this area, he or she can
help the patient to see this, but there may not be time in the schedule for
such a lengthy visit.  The doctor should be honest, realistic, and assure the
patient she will not be abandoned whatever her decision.


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