Yesterday I learned all about Behçet's disease, which is a condition that affects blood vessels and is particularly prevalent in this part of the world. It brought up an interesting ethical dilemma about which Tunisia and Britain have markedly different viewpoints.
The patient was a 30 year-old woman who was a university lecturer, happily married and physically active. She presented with a mild stroke affecting her brainstem. Both the location of the infarct and fact that she had a stroke at all were unusual; however investigations did not reveal anything untoward and she was sent home with aspirin. A few weeks later she suffered another stroke, also affecting her brainstem; this one was more serious. The brainstem is involved, amongst other things, with communicating information between the main part of the brain and the body, and the effect of the second stroke was that, although the "thinking" part of her brain was unaffected, her ability to move and feel the rest of her body was impaired. The doctors were still unable to find any cause of the stroke and she was once again discharged by the neurological team. A few weeks later she suffered yet another stroke. This one knocked out essentially all ability to control or feel the rest of her body; although she could see and hear what was happening around her, she could communicate only by blinking her eyes. A kind of "locked-in" syndrome.
Anyway, finally she was diagnosed with Behçet's disease, which explained the strokes - the disease had led to damage to the walls of the vertebral arteries, which meant that clots were forming there, breaking off and becoming lodged in the small arteries that supply the brainstem. She was started on corticosteroids, colchicine and thalidomide to reverse the damage and try to avoid any further strokes.
Unfortunately after three months of treatment it was discovered she was four months pregnant. You'll probably recognise one of the drugs I mentioned as being a definite no-no for growing foetuses and actually all three are ones to avoid if you're pregnant - especially during the first trimester. So; here comes the ethical dilemma. The Tunisian doctors decided that due to the likelihood of developmental damage to the foetus and also because of the mother's inability to look after the child once it was born (although her husband was still around), they would carry out an abortion without her consent. They were mystified by my view that they should, at the very least, have involved the mother in the decision, and felt that it was really a no-brainer that the baby needed to go. Maybe their approach has its benefits but it seems inconceivable that that would ever happen in the UK, and it must have been a horrible experience for the patient, who - we assume - had full mental capacity throughout.
The patient was a 30 year-old woman who was a university lecturer, happily married and physically active. She presented with a mild stroke affecting her brainstem. Both the location of the infarct and fact that she had a stroke at all were unusual; however investigations did not reveal anything untoward and she was sent home with aspirin. A few weeks later she suffered another stroke, also affecting her brainstem; this one was more serious. The brainstem is involved, amongst other things, with communicating information between the main part of the brain and the body, and the effect of the second stroke was that, although the "thinking" part of her brain was unaffected, her ability to move and feel the rest of her body was impaired. The doctors were still unable to find any cause of the stroke and she was once again discharged by the neurological team. A few weeks later she suffered yet another stroke. This one knocked out essentially all ability to control or feel the rest of her body; although she could see and hear what was happening around her, she could communicate only by blinking her eyes. A kind of "locked-in" syndrome.
Anyway, finally she was diagnosed with Behçet's disease, which explained the strokes - the disease had led to damage to the walls of the vertebral arteries, which meant that clots were forming there, breaking off and becoming lodged in the small arteries that supply the brainstem. She was started on corticosteroids, colchicine and thalidomide to reverse the damage and try to avoid any further strokes.
Unfortunately after three months of treatment it was discovered she was four months pregnant. You'll probably recognise one of the drugs I mentioned as being a definite no-no for growing foetuses and actually all three are ones to avoid if you're pregnant - especially during the first trimester. So; here comes the ethical dilemma. The Tunisian doctors decided that due to the likelihood of developmental damage to the foetus and also because of the mother's inability to look after the child once it was born (although her husband was still around), they would carry out an abortion without her consent. They were mystified by my view that they should, at the very least, have involved the mother in the decision, and felt that it was really a no-brainer that the baby needed to go. Maybe their approach has its benefits but it seems inconceivable that that would ever happen in the UK, and it must have been a horrible experience for the patient, who - we assume - had full mental capacity throughout.
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