Insurance Coverage Post-Class Reflections

I think that our group had a pretty stable (mock) health insurance company! Other than denying payment for all ART, we generally chose to cover doctor approved treatments up to a set amount of money or a percentage of the treatment cost.
This decision was disputed by another group who questioned why our insurance company had the right to deny payment for ART but still allow coverage for PGD (pre embryo diagnosis). Our decision was made in a more economical sense rather than an emotional one: if the couple could not afford a full reproductive treatment, there is much less chance that they will be able to take on all the expenses that will come with those treatments in the future. However, if you can pay for your full treatment initially, then our insurance company would pay for you to have your embryos diagnosed to see which one would be the most viable, producing the healthiest baby, lowering the cost to our insurance company in the long run. Is it okay for us to assume that if you cannot pay for the initial treatments then we don't think you should have them? This is correct. Some other groups had our same stipulations and views on insuring for ART, but they also provided insurance over less expensive infertility drugs, meeting patients half-way. I can see how this could be a valid option, but where do you draw the line on where the infertility drugs will get as expensive as ART, basically nullifying the reasons that we discarded the idea of insuring ART in the first place?
Our idea behind setting up a sort of financial 'barrier' to the assisted reproductive treatments is that in the long run this will ensure that our clients who decide to enter onto this long road of the new technologies is well prepared, (financially, and thereby emotionally) to endure the trials that may come with using these technologies. If someone has prioritized getting pregnant to the extent of paying for IVF, then they are well prepared to face dealing with the decisions that come later in the journey of testing and cycles.
But does this frame of mind discriminate against the people who cannot pay for ART? Is it fair to deny them the chance to have a child because they cannot pay for the treatment? The people who would get the treatment would be the people who could pay, inevitably prioritizing the upper class, and insurance companies have never been able to regulate who becomes pregnant or is financially equipped to become pregnant in the past. However, this is exactly how everything else in life works. If I wanted a BMW but was making the wages of a cashier, I would have to REALLY want that BMW and therefore have to save for many years to afford it. Just because it may be painful and seem unfair not to have the amount of money for these reproductive treatments, it is always possible to save. And it may help you in the long run that these treatments are so expensive -- you realize how much money a baby can be, and may decide that you are not ready yet. Studies have shown that a baby costs around 11-14 K in their first year, so realizing the costs early is actually a good thing!
I guess talking about it in class brought up the more 'is this a humane way of thinking' more than actually thinking of insurance companies like they are- companies. For profit companies. They want money to pay off their stockholders and in general are comprised of businessmen and women who are primarily thinking about the financial aspect of the business when describing the rules rather than focusing on if they are offering equality across social classes in their coverage. So in this respect, our mock insurance company did a good job at focusing on the profit side of the insurance business, and some other groups did a good job of focusing on how patients would respond.

Technology Update

After class one day last week a small discussion occurred talking about the technologies we are using in this class. Many students were saying how they didn't sign up for a technology-heavy class, and they thought that the portfolios were just going to be something on the side, and not the main focus of the course. They said " I would have signed up for a web design class if I had wanted to do this much technological work". I do agree that it has been more tech-savvy than I am used to, but unlike some of my peers, I have definitely gotten a lot out of having to make a website. Even though it was tough navigating my way around Wordpress, I feel like I now have a grip on how the site is run, and I can easily make more websites like it in my future. This skill is something that a course taught purely for the purpose of web-design may not have given me, so I am grateful. However, I think that many of us are feeling lost in what Dr. Case would like on our websites, and we feel terrible with how busy she is, but we would like some more direction on how we are being graded and what we should prioritize in terms of references vs. web design vs. content vs. citations vs. class discussion research vs. blogging etc. In the end, I am trusting that Dr. Case will see the effort and grade accordingly, but I think that the layout of the grading should be defined more so that we can figure out how to allocate our time.

Born to American mom, in-vitro twins denied citizenship

Born to American mom, in-vitro twins denied citizenship
Should the in-vitro twins be given American citizenship? They do not have biological ties to America whatsoever, except that the woman was the gestational mother. So, the real question lies, does being a gestational citizen give the children that citizenship, even though they have never been to that country?
The woman is claiming that the laws are not keeping up with the technology. I would claim that if there is no biological connection to the citizen, then there should be no citizenship granted to the children. However, since in this case the children were the gestational children of the woman, they have a more legitimate case to be citizens. If by law we recognize that the gestational mother, the one that gives birth to the children, is the lawful mother, then isn't it logical that they receive the same priorities as children born from an American mother but are not from IVF?
For my media section of the website, I wanted to highlight how it describes the humiliation of IVF described in the news story;

“I have been embarrassed, humiliated, horrified, ashamed,’’ Lavi told NBC News.
When Lavi went to the U.S. Embassy in Israel to register her children, she said she was asked over a loudspeaker in a crowded room by an embassy official how she conceived the children.
“It’s an outrageous question,’’ she said, recalling the experience. She later left the embassy in tears after more questioning.

This sense of embarrassment felt by a satisfied user of IVF brings to light how women are still not comfortable with the knowledge that they have had to use ART. Clearly, they do not think that it is socially acceptable yet. Women reading this article contemplating undergoing IVF treatment may be more hesitant because they feel like they may be seen differently, and they have a reason to feel humiliated.
Along with this humiliation, new IVF users may shy away because they are afraid that the laws are indeed not keeping up with the technology. Not knowing how the law has adapted to new ART's can be scary for some, causing hesitation with having the treatments.
Soon we shall see if this situation gets figured out--whether children who are products of IVF in the future will receive citizenship of their gestational mothers.

Reporting Mistakes in ART-- Post-Class discussion

From the twitter class discussion it seemed as though a lot of people agreed that ART physicians have an obligation to tell the parents when there has been some sort of mix up or mistake in their treatment. There is really no completely good reason not to tell a couple. The only thing that comes close would be if the physician discovers late in the child's life that there was a mix up. Therefore, the family bonds would have already been deeply set, and telling the parties involved may end up being more harmful than anything, but doesn't delay the fact that the correct information should be put out into the open. I think that there should be some sort of society that all the ART physicians should join (run by physicians) that would have rules and regulations that are required to be followed by all physicians in the society. This would include a stipulation about being upfront to the patients about all treatments and mistakes, as well as safety and ethics information as well. The 'teeth' that the societies would use for enforcement could be a combination of a couple things if the misdemeanor is detected: suspension of license, permanent suspension of license, bad marks on overall report, or even the shut down of their clinic. Because this would be assigned by the peer-run society, they would have a better insight into how bad an infraction was, and they would understand the circumstances to a better degree than any state or federal mandate for ART. Right now, reporting to the CDC is voluntary, meaning a lot of information that clinics would not like the report is able to be swept under the rug. In these societies, reporting clinic information would be mandatory, and there would be more information required than was required for the CDC.
Another reason against state and federal mandates would be that it would most likely stunt the growth of these technologies. If more and more bars are put up against expanding the horizons, there will be less discoveries of new techniques and services that may have proven very helpful to the medical society of the future.
One thing that the state should have enforcement over would be patient well being, access to services and consumer protection (i.e. drug safety).

Kate mentioned something in class in terms of how physicians would handle telling the couple the truth if there was a mix up in the IVF treatments-- using a M&M Committee to be able to explain the situation and allow them to help the physician know how to go about the next steps. This would give the physician an outlet where he/she is not judged/accused, but allow him/her to get further insight into the best manner to inform the couple of the truth.

Post-Case 4 and 5 Discussion

Though we had to rush through Cases 4 and 5, the discussion in class was very tough, as these two cases were definitely the hardest for me of the 5.
Can parents be more clinical about their decisions concerning their own children's life?
I believe that the parent goes through multiple stages of teeter-tottering between being more medically minded to more emotionally minded when their child is going through life-altering treatments. First, they are solely emotional: they have little idea what is going on medically and keep that clinical decision making in the hands of the doctors. They deal with the emotional consequences and do whatever they can to save their child. Then, when things get worse, treatments get more risky, the parents begin to weigh in more of what the actual procedures are doing, and want to see how they can alleviate those treatments to make sure their child is in the best care possible. Then in terminal situations, the hardest cases, parents must use both clinical outlooks on the situation and block the emotional side, but this is the hardest stage to do. The pain and uncertainty of the child's wellbeing takes over, and many times parents can go into overdrive making sure that their child survives. In our case, case 5, the parents have employed their idea of the clinical side a little too late, and figure that it's okay to pull the plug after the physicians have said that that decision was warranted.  I hate to put this much pressure on the physicians, but when more professional medial experience says to do something, that should be the method followed, and parent autonomy should be halted. What the parents in case 5 need to understand is that they have already driven the situation so far into a painful situation for the child that they cannot turn back. They need to do everything in their power to save their child.
In the twitter discussions, parent autonomy was a popular topic, seeming to range from where on the spectrum the parents lose the ability to make decisions concerning the time of death of their child. I would question whether or not along that scale does the parent lose control of recognizing the clinical thoughts concerning their child and their decision on the overall well-being of the child: if the child is already in so much pain, why stop treatment now?
But that brings us back to the idea of when does the hospital stop paying for treatment. I would argue in that case when the doctors decide that further treatment would do nothing to further alleviate the pain of the patient, treatment should be halted.
This is obviously another case where you could go around in circles with spectrums of opinions.

Cases 1,2,3 Post-Class

Today's twitter was especially interesting, I think because we covered so many different topics in one class period. The most pertinent and interesting conversations were on the use of contracts and the use of foetal tissue for a preacher's child. In case 1, where the couple had signed 7 contracts saying the wife would have the right to use the frozen embryos was especially interesting because the contracts were thrown out of the picture in comparison to the husband's right not to reproduce. Contracts should be enforced at the embryo freezing clinics, but there should be a preface to the clients that tells them how the contracts cannot defy one's rights to reproduce/not to reproduce, as seen by all the case laws that have considered them null. After all, the contract cannot replace the possibility that the client may change his/her mind of deciding to/not to reproduce at a later time in their future. If these more complicated cases come up, it is fair that their rights be reviewed as higher in priority than the contracts signed x number of years before. But why make contracts then? As we said in class, if extraneous circumstances arise, like the death of a parent or a major court dispute, the contract can stand in as a benchmark of the client's intent at that point in time, either validating or invalidating their court case. Because of this, the more detailed the contract, the better, but the client's overall basic rights will trump if the debacle is between those who signed the contract.
The other interesting aspect of the class involved more religious undertones, so it ended up coming out more in the twitter conversations. In general it appeared as if the class was torn on the fact that the preacher and his wife decided to take the foetal tissue instead of regarding the thoughts of their parish in higher degree than their own desires. Does using foetal tissue to save your child mean that you are indirectly supporting abortion? This is the line that most of the class disagreed on. I believe that by using the tissues, you are not supporting abortion, but rather saving a life by using another's life. This is walking on a very thin line though-- if women choosing abortion knew that their actions may be used to save another's child, I bet you these women would be so happy and relieved, and their emotional pain and guilt would be alleviated to some extent. This indirectly may be helping the case for abortion, as it does not make the women feel the full extent of the guilt if their actions were merely murdur. In somewhat teh same way, a person's death is not as bad if their organs were able to save others. The death was seen as a donation, sort of, and on the surface that is what this case was dealing with.
My cases were 4+5, so we'll see how those go on Thursday!

Reflection on NICU issues

Regarding this issue, I have been having a tough time coming to terms with how my faith merges with the issues of the NICU. I know that all life is sacred, and that we were given these life saving technologies, so why not use them to save human lives? But I also know that some infant lives would not be lives unless they were constantly fixed to a machine, so does that mean we should have the right to prolong their life, even when they are painfully degenerating while on machines? I have asked my bible study leader these same questions but unfortunately I have not come to terms with how the church would feel with these issues.

I want to try to go deeper into the economics of it all. On the twitter feed, one student commented that the issue of NICU expense should have no factor into how we address these cases. While it is noble to think that we can just set economics aside and be purely moral creatures, life still goes on while the infant is being treated in the NICU, whether he/she dies or lives. If a couple is using their own money for the procedures of keeping their child alive, they should be able to go as long and far as they want with their child's treatment because they are still somewhat weighing the cost/benefits in their own minds: use up savings because my child has a 60% chance of living, or use up savings because there is a 20% chance of living, the choice is theirs and they can weigh those costs. However, when the parents are having the hospital take up the bill, a parent is solely focused on ensuring their child will live, now that finances is out of the way. Again, though this is ideal, a parent is most likely to say 'yes' to every procedure that will save the infants life, and the hospital in turn must dive into its funds, or be ridiculed for denying life saving services to a patient. This is the dilemma a hospital runs into--where do they draw the line on not allowing a parent to tell them what to use their money on? 

In these situations, I have to think about one of my friend's cousin, who was born at 24 weeks, very unstable at birth, and now miraculously is a healthy baby boy. She told me that the care for her cousin was extremely expensive, and the hospital was going to help out her aunt and uncle with the costs of treatment. I was happy about it. I think this happiness stems from the fact that a child was being saved by our recent technologies, which allow us to rescue a child who would probably have died. I was also thankful for the expertise of the physicians who were caring for him. However, now I have no doubt in my mind that these physicians probably went through a tough time deciding whether to carry on treatment or stop it all-together because the cause was futile. I hope to believe that the doctors weighed the costs in their minds, taking in the financial burden it would cost the hospital, and continued to move forward because they saw that there was still hope that the baby boy would make it out of the hospital with little to no future pain after he left-- the treatment would end at one point. 

I think that is where I would draw some form of a line in determining whether or not treatment in the NICU should be continued. If a child has a chance to live a life that is not hindered by sickness and continued treatments, physicians should use every resource they are given in order to save the child's life. Where that "chance" mathematically lies, and how to calculate that, I am ill-equipped to tell. 

I am glad that there are hospital ethics committees that can be called upon in when dealing with decisions on NICU cases, and the doctor is not the only one deciding these life changing choices.