Listen: Why I Left the U.S. for My Surgical Procedure

No Easy Answers in Bioethics logoNo Easy Answers in Bioethics Episode 21

What would you do if you needed surgery, but seeking care would mean $25,000 or more in medical debt? Would you consider traveling to another country to receive the same surgery at a fraction of that cost? Would you put off seeking care entirely, until it became an emergency situation?

These questions related to access to care, health insurance, and medical tourism are explored in this episode, which features Center for Ethics and Humanities in the Life Sciences faculty members Len Fleck and Larissa Fluegel. Dr. Fluegel, a clinician born and raised in the Dominican Republic, shares her personal experience of needing gallbladder surgery, and the reasons why she traveled from Michigan to the Dominican Republic to receive that surgery. It may not be surprising that the main reason was cost. Discussing the healthcare systems in both countries, Drs. Fleck and Fluegel explore the challenges that under- and uninsured individuals in the U.S. face when seeking care.

Ways to Listen

This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: “While We Walk (2004)” by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License. Full episode transcript available.

About: No Easy Answers in Bioethics is a podcast series from the Center for Ethics and Humanities in the Life Sciences in the Michigan State University College of Human Medicine. Each month Center for Ethics faculty and their collaborators discuss their ongoing work and research across many areas of bioethics. Episodes are hosted by H-Net: Humanities and Social Sciences Online.

What social and ethical challenges are presented by female cosmetic genital surgery?

bbag-blog-image-logoFemale Cosmetic Genital Surgery: Social and Ethical Considerations

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In recent years, there has been an upsurge in plastic surgery for women who wish to alter the look and feel of their genitalia. The women who undergo these procedures claim they are empowering, but critics worry such surgeries pathologize normal genital appearance. Several surgeons are also using social media to document these surgeries, granting them greater visibility and legitimacy. This talk will discuss the latest innovations in female cosmetic genital surgery, the history behind the medical community’s involvement in defining women’s sexuality, and the ethical and social challenges these surgeries present.

March 13 calendar iconJoin us for Dr. Stahl’s lecture on Wednesday, March 13, 2019 from noon until 1 pm in person or online.

Dr. Devan Stahl is an Assistant Professor of Clinical Ethics in the Center for Ethics and Humanities in the Life Sciences at Michigan State University. She received her Ph.D. in Health Care Ethics from St. Louis University. Dr. Stahl teaches medical students and residents in the College of Human Medicine and performs ethics consultation services at hospitals in Lansing, Michigan. Her research interests include medicine and the visual arts, theological bioethics, and disability studies. Dr. Stahl’s recent book, Imaging and Imagining Illness: Becoming Whole in a Broken Body, examines the power of medical images and their impact on patients and the wider culture.

In person: This lecture will take place in C102 Patenge Room in East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.

Online: Here are some instructions for your first time joining the webinar, or if you have attended or viewed them before, go to the meeting!

Can’t make it? All webinars are recorded! Visit our archive of recorded lecturesTo receive reminders before each webinar, please subscribe to our mailing list.

Would you ever consent to have your medical procedure broadcast on social media?

No Easy Answers in Bioethics logoEpisode 10 of No Easy Answers in Bioethics is now available! This episode features Dr. Devan Stahl, Assistant Professor in the Center for Ethics and the Department of Pediatrics and Human Development, and Dr. Christian Vercler, Clinical Associate Professor of Plastic Surgery in the Department of Surgery at the University of Michigan and Co-Chief of the Clinical Ethics Service in the Center for Bioethics and Social Sciences in Medicine. Drs. Stahl and Vercler address a trend known as Snapchat surgeons – plastic surgeons who amass sometimes millions of followers on the social media platform Snapchat by posting uncensored videos of operations they are performing. Together they offer their insight and expertise on the issue, and discuss whether these Snapchat performances are ethical. They also delve into the societal norms and power dynamics at play, and address how to move forward within the profession of plastic surgery in a world where social media seems to be here to stay.

Ways to Listen

This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: “While We Walk (2004)” by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License. Full episode transcript available.

About: No Easy Answers in Bioethics is a podcast series from the Center for Ethics and Humanities in the Life Sciences in the Michigan State University College of Human Medicine. Each month Center for Ethics faculty and their collaborators discuss their ongoing work and research across many areas of bioethics—clinical ethics, evidence-based medicine, health policy, medical education, neuroethics, shared decision-making, and more. Episodes are hosted by H-Net: Humanities and Social Sciences Online.

Dr. Stahl presents at International Academy for Bioethical Inquiry

Devan Stahl photoOn July 16, Center Assistant Professor Dr. Devan Stahl presented “Ethics Beyond Autonomy: The Case of Snapchat Surgeons” at the International Academy for Bioethical Inquiry (IABI) Summer Symposium, held at Saint Louis University. Based on her recent publication in AMA Journal of Ethics, Dr. Stahl discussed the rise in vaginal cosmetic surgery performed on the social media platform Snapchat and its implications for our cultural conceptions of ‘normal genital appearance.’ Dr. Tobias Winright offered a response to the paper, which was then thoroughly discussed by the conference attendees.

Ethics in Surgical Research and Publication

Marleen Eijkholt photoCenter Assistant Professor Dr. Marleen Eijkholt co-authored the chapter “Ethics in Surgical Research and Publication” in Ethical Issues in Surgical Care, a fall 2017 publication from the American College of Surgeons Division of Education. Dr. Eijkholt’s co-authors are Lance K. Stell, MA, PhD, FACFE, and Richard B. Reiling, MD, FACS.

Chapter summary: Surgical research is the foundation of evidence-based surgical practice. The question “what makes research ethical?” entails particular challenges for surgical research. For example, uncertainty and controversy exist in areas of research methodology, given the unique circumstances of each surgical intervention. Placebo control groups and randomization practices, too, raise major methodological issues in surgical research. This chapter discusses controversies in surgical research and publication thereof. The chapter follows the submission of a hypothetical research study through the institutional review board, to highlight areas of ethical controversy, and describe such issues too for the publication of such studies.

For more information on Ethical Issues in Surgical Care, please visit the American College of Surgeons website.

Transplant Headaches: Head transplant on the horizon

Bioethics-in-the-News-logoThis post is a part of our Bioethics in the News series

By Marleen Eijkholt, PhD, LL.B/LL.M

On May 1, 2017, the Daily Mail reported on a successful head-transplant involving rats, as a “practice run for [a] controversial human experiment.” Indeed, this run would seem timely and perhaps minimal pertaining only to rats, given the proposed timeline toward the first-ever human head-transplant (HHT). Some reports suggest December 2017 as the date for the HHT, while others report that December is unlikely, and that the procedure would have to be delayed.

With the first HHT on the horizon, guttural yuck-reactions, and references to the ethical questionability of this procedure abound. A famous ethicist suggested that the surgeon is “out of his mind.” But I am unsure if this rejection is fair. If we have allowed the development of kidney, heart, hand, face, uterus, and penis transplants, why would this new area of transplant medicine raise prohibitive concerns?

Several areas of ethical concerns have been identified, and I want to address three reflections briefly here. Although many more could be identified, including the concern that a ‘body transplant’ also means that its other organs cannot be used for other purposes, I will not go into these issues due to word limitations. I offer thoughts for further discussion, drawing on parallels from other controversial (surgical) interventions, i.e. stem cell interventions for spinal cord injury (SCI) and deep brain stimulation (DBS). Often ethics is seen as a prohibitive ‘science’ but I do not want to endorse this idea. Instead, I hope to ask how we can ensure that this development proceeds as reflectively as possible.


operating room photo
Image description: two surgeons are shown in an operating room while performing a transplant procedure on a patient who is out of frame. Image source: Scott & White Healthcare/Flickr Creative Commons

The history of HHT up to this point is described in many places. In 2013, an Italian surgeon, Canavero, first suggested his willingness to do a HHT, causing outrage and interest. Canavero has given a TED talk in the meantime, published several manuscripts [3, 19] and protocols [1, 2] on the procedure. Initially, one Russian individual, Valery Spiridonov, came forward to undergo the HHT and is now considered as potentially the first patient, while others have started to line up. Spiridonov has a degenerative and incurable muscle disease (Werdnig-Hoffmann) and is confined to a wheelchair. Cost-estimates of the procedure include a 7.5-20 million dollar, 36-hour operation, with a team of 150 people. The community has expressed serious reservations about the scientific feasibility. Still, we read that the first head-transplant in monkeys occurred in 1970 and that several dogs and mice have undergone the procedure. These were mostly as proof of principle, and not focused on long-term survival. Currently, there is no substantial proof that the recipient can be ‘kept alive’ long-term.

Informed Consent (IC)
A primary concern is whether Spiridonov can offer informed consent. Given his vulnerability, suffering Werdnig-Hoffmann disease, and based on reports about what Spiridonov said, these concerns are real. Spiridonov’s desire is to be like the “first man on the moon,” generate knowledge for future generations, and that the HHT will help him. Hence, he seems vulnerable to therapeutic misconceptions and risk-mitigation biases, especially in the light of a surgical learning curve that will challenge the first HHT [10]. Spiridonov’s narrative refers to the first man on the moon—who successfully made it—failing to mention the others who did not make it. Another part of this concern relates to identity problems that transplant individuals might experience with an alien body (part), where HHT concerns a whole body and an irreversible transplant [17].

These areas of concern have been dealt with at length, in reference to transplants and other emerging (surgical) interventions. I do think these concerns can be addressed, provided a thorough shared decision-making process, like in DBS [7]. Why would it be different in the HHT context?

Necessary Evidence
It seems an incredible leap to move from rat experiments to human interventions, without bigger animal models. However, such leap is not unprecedented, and might not automatically be condemned. Geron, a company that injected stem cell derived products in the spinal cord of SCI patients, moved from rat trials to humans. They skipped large animal models in assessing feasibility. Their decision was met two ways. One set of arguments stated the unacceptability of this practice as humans would now be exposed to unacceptable risks, based on insufficient knowledge. Another set of arguments was perhaps less outraged, suggesting that animal rights arguments might favor such direct application. Sacrificing large animals could not always be justified, especially if evidence in large animals may still not apply to humans [9]. Would it be in the HHT case?

Medical Need
A final question is: How to go about the risk/benefit assessment for someone whose medical need is not immediately life threatening? Spiridonov does not suffer an immediately life threatening illness, unlike liver failure, so some might argue that the risk/benefit profile of this experiment is disproportionate. Aside from concerns about the patient facing risks, executing novel risky experimental interventions may entail a loss of trust in the field if they go wrong. We have seen this in the tragic story of Jesse Gelsinger, gene therapy trial participant. So, some could argue that Spiridonov’s medical need does not warrant a loss of trust in science. But in response one could propose that for a proper risk/benefit assessment, weighing many factors is required. We see that for many composite allograft transplant areas as well as for DBS, the focus is on improving quality of life, not providing a cure. References to medical need and life-saving interventions are social constructs. If interventions like penis transplants were justified and marked as life-saving, referencing suicide concerns, life-limiting conditions like Spiridonov’s condition could put these concerns into perspective.

Although HHT are a new transplant territory, many of the headaches are familiar ethical concerns to the domain of novel transplant medicine and emerging surgical interventions. I am unsure that HHT is very different than the first heart transplant, which was met with huge skepticism, involving concerns about survival, IC, and identity. Heart transplants have offered huge progress in medicine, by generating new knowledge and applications for patient well-being. What makes us say that this body/human head-transplant is going to be less of a revolutionary intervention, and should be stopped before it even begins?

Marleen Eijkholt photoMarleen Eijkholt is an Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Obstetrics, Gynecology and Reproductive Biology in the Michigan State University College of Human Medicine. Dr. Eijkholt is also a clinical ethicist at Spectrum Health System.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, June 22, 2017. With your participation, we hope to create discussions rich with insights from diverse perspectives.

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