Ethical Reasoning About Allogeneic Bone Marrow Transplantation and Patient Eligibility Based on Psychosocial Criteria.

Purpose: Bone marrow transplantation has been given insufficient attention as a context for clinical ethics. Of concern are the patient and family who disagree with a BMT program’s “do not proceed” decision based on psychosocial issues and who request an ethics review. In follow-up to a 2006 national survey in which patients were determined not to be appropriate candidates for allogeneic (allo) BMT based on select psychosocial risk factors, this study reports on whether ethicists agreed with decisions of their oncology colleagues and how they justified their agreements/disagreements.

Methods: A self-administered questionnaire was sent to chairpersons of ethics committees at hospitals with a BMT Program that does adult allo BMT, is accredited by the Foundation for the Accreditation of Cellular Therapy, and is designated as a National Marrow Donor Program Transplant Center. The questionnaire included six case vignettes on which oncology physicians, nurses, and social workers in the 2006 study agreed not to proceed with allo BMT based on a patient having one of the following psychosocial risk factors: suicidal ideation; use of addictive, illicit drugs; history of non-compliance with treatment; lives far from the hospital and has no caregiver; drinks daily and is told he is an alcoholic; and has mild dementia from early onset of Alzheimer’s disease. In each case allo BMT is the only curative option, the patient has leukemia, has a matched donor, and both patient and family want to proceed.

Results: The survey response rate was 37%. On average, ethicists were older than professionals from each of the three other groups. Percentage of male ethicists was higher than nurses or social workers, but lower than physicians. Ethicists’ years of experience were similar to physicians, but more than nurses or social workers. The opinion of ethicists regarding whether or not to proceed with BMT differed from the other three professional groups on one case only, a patient with mild dementia from early onset of Alzheimer’s disease. For this case, 27% of ethicists recommended not proceeding with BMT; this was significantly lower than the do not proceed recommendation from nurses (68%, P<0.001), physicians (63.5%, P<0.001), and social workers (51.9%, P= 0.05). As with BMT clinicians, ethicists’ decisions in all six cases were often conditional but appealed more to ethical ideals, especially in the case of patients with mild dementia; thematic were concerns about doing good (beneficence), avoiding harm (non-maleficence), potential for quality of life, and a fair allocation of resources (justice).

Conclusions: Access to health care is commonly understood to be an ethical issue, but the gravity of BMT as a potentially life saving decision adds urgency to the issue. BMT clinicians can be reassured that, for the most part, ethicists concur with their “do not proceed” decisions. That ethicists appear reluctant to attempt to over-rule clinicians, except in the case of mild dementia, may reflect the ethicists’ ideal of maximizing potential to do good in conflict with the clinicians’ bedside reality of minimizing potential harms to a patient who lacks decisional capacity and may be unable to comply with difficult treatment protocols. Ethics consults may prove a helpful resource when patients/families disagree with BMT programs’ decisions to base eligibility on psychosocial as well as biomedical criteria.