Case Study – A Sister for Joshua

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Case Study: A Sister for Joshua

Mr. and Mrs. S are a successful young professional couple. They have two sons: Joshua, who is five years old, and Matthew, who is two. Nine months ago, Joshua was diagnosed with Acute Lymphocytic Leukemia (ALL). He responded well to his initial chemotherapy and quickly went into remission. Last week, however, Josh’s oncologist detected the early signs of a relapse of his leukemia. Although secondary therapy is available, it involves drugs with significantly higher toxicity and much less certainty of a second remission. The oncologist has also told Mr. and Mrs. S about a research study that requires a bone marrow transplant and a new (experimental) drug that will aid engraftment and deter rejection.

Joshua’s two-year old brother, Matthew, is not a histocompatible donor for the transplant. So, the parents consider having another baby and begin discussions with an endocrinologist who specializes in in vitro fertilization. The specialist explains the procedures for in vitro fertilization and pre-implantation genetic testing. If Mr. and Mrs. S have any incipient doubts about what they are doing, they do not raise them with one another. Their conversations are only about the process – about what is to be done next.

Mrs. S’s eggs are retrieved and impregnated with Mr. S’s sperm. Then, while tests are being made to discern histocompatibility with Joshua, an outspoken friend asks Mrs. S, “Are you having this new baby simply as a means to give Josh a new lease on life?” Mrs. S finds herself unable to answer immediately. “No,” she says finally. “We are going to love this new baby all for herself, and she will be happy knowing that she has helped her older brother.” But that afternoon, when she meets her husband at the clinic, she bursts into tears.

Can Mr. and Mrs. S resolve their conflict? How will they talk to the new baby when she is old enough to ask about the circumstances of her birth? What if Josh responds poorly to the transplant and dies? Will she feel that she contributed to her brother’s death? Under what conditions might this case be the subject of an ethics consult?

Questions for discussion

1. There are such emotional overtones to this case that it might be helpful to use Immanuel Kant’s recommendation: What if everybody performed the action with the same purpose in mind?

What if every child were conceived as a means to prolong the life of other living persons? What would this do to our society and to the self-esteem of children as they progress to maturity?

2. Another approach that helps in emotion-laden actions is to consider the action from a perspective that all would consider acceptable. (List all the reasons this action could be beneficial.)

Then consider the action from a perspective that all would consider perverse. (List all the negatives against the action.)

Compare. Which is the stronger approach?

3. There is a social dimension to being human; there are even stronger social dimensions to being part of a family. What is ethically permitted in this case? What might limit us from doing all that is ethically permitted in this case?

4. How long will Mr. and Mrs. S’s third child be used as a donor for Joshua? Will there be a limit placed on what she will donate (blood, bone marrow, a kidney?)

5. Consider the role played by the physician in this case. Is the goal of medicine to prolong life as long as possible, no matter what means are used? In geriatrics, this is often referred to as “overtreatment,” prolonging life at all costs. Is the same charge relevant here?

6. Or consider the decision of the parents from the perspective of risks/benefits, both on the part of the mother, Joshua, Matthew, and the child-to-be.


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