ETHICAL PERSPECTIVES IN NEUROLOGY

Abstract

The practice of neurology presents a series of ethical challenges for the clinician. These rarely have simple or straightforward solutions, but require careful consideration by the neurologist. This section of , written by colleagues with particular interest in the area of bioethics, provides a case vignette that raises one or more ethical questions related to the subject area of this issue. The discussion that follows should help the reader understand and resolve the ethical dilemma. NOTE: The following scenario is hypothetical. A 27-year-old woman has been treated by her neurologist for the past 5 years for migraine with aura. She has experienced migraine with aura since age 15. Prior to seeing the neurologist, she had six to eight migraines per month, each lasting 12 to 48 hours with visual aura, nausea, vomiting, photophobia, and phonophobia. They were disabling, as she missed many days of school and work. Her neurologist prescribed several prophylactic therapies, which were all discontinued due to either unfavorable side effects or lack of efficacy. However, divalproex sodium extended-release 1500 mg every night has been effective. Her migraine frequency has been 2 to 3 times per month for 2 years. She has had no side effects except for a very mild tremor, which she tolerates. She uses sumatriptan 20 mg nasal spray, which aborts her headaches if she takes it at onset of the aura. At a routine visit with her neurologist, the patient discloses that she and her husband want to start a family. Her neurologist counsels her to stop the divalproex before attempting pregnancy because of the known risk of developmental anomalies with divalproex. Once she is pregnant, he will prescribe antiemetics and low-potency narcotics for the migraines instead of sumatriptan. She agrees to this plan but returns in 2 months because her migraine frequency has increased significantly and she is missing work again. She wants to restart the divalproex because she is at risk of losing her job (and thus her medical insurance). She also discloses that she is 6 weeks pregnant and intends to carry her fetus to term. She says she is willing to accept the risks associated with the divalproex in order to reduce her migraine frequency. The neurologist feels uncomfortable with her choice because of the risk of fetal malformations, but he is also sympathetic to her plight. Moreover, the neurologist is troubled by the following ethical quandaries: (1) Should he concern himself only with the well-being of his pregnant patient, or should he consider that her fetus is also his patient? (2) How should he counsel her about the use of a potentially teratogenic medication during pregnancy? Is it ethical for him to express his opinion that he thinks her choice is wrong? (3) How should he balance the benefits of the treatment to a pregnant patient against the potential risks to the fetus?