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Bone age and minimal brain dysfunction
328
Letters to the Editor
The Journal of Pediatrics August 1975
the will o f the incompetent person is set aside, and the will of the guardian is what determines whether or not a procedure will be carried out. In my pediatric practice, I do not allow the aversion o f a 3 year old to needles to determine whether or not needed procedures are performed, and I do not deliberately allow lawyers and judges to get involved in making medical decisions. The resident who spent so much time trying to get informed consent from the 13-year-old retarded boy was obviously wasting his time. The judge who ruled on the first and second cases was intruding on the practice o f medicine. On the other hand, in the third case, the authors should not have allowed the parents to refuse bone marrow transplantation without having taken the case to court, if, indeed, they felt that such transplantation was desirable. This case is analagous to cases involving cases of the Jehovah's Witness sect and I believe the courts would have allowed transplantation to proceed. I suspect that the real problem underlying these cases is that the authors have reservations as to whether bone marrow transplants are "worth it" in terms of risks and efforts involved. This is a medical question that must be answered by the medical profession. The authors should not ask judges tO make these decisions for them.
mental procedure, whereas a blood transfusion for a Jehovah's Witness represents a clearly established intervention with a predictable successful consequence. I think that Dr. Smith would agree that the use of any new experimental procedure in children (particularly when such treatment may not benefit some children, such as donors) presents us with an unprecedented and complex set of issues. There is no reason why we in medicine should not consult individuals in other disciplines to obtain a broader view and assay the will o f th e community. A t the same time, we must strive to understand and interpi-et the interests of minors and the rights of parents without compromising our committment to seek innovative treatments to benefit future generations of children.
Melvin D. Levine, M.D. Medical Outpatient Department The Children's Hospital Medical Center 300 Longwood Ave. Boston, Mass. 02115
Bone age and minimal brain dysfunction
David L. Smith M.D., F.A.A.P. 529 Balmoral Rd. Middlesboro, Ky. 40965 REFERENCE 1.
Levine MD, Camitta BM, Nathan D, and Curran WJ: The medical ethics of bone mai'row transplantation in childhood, J Pediatr 86:145, 1975.
Reply To the Editor: We can certainly understand the concerns of Dr. Smith in his letter. In all ethical issues, one faces the risk of reducing to absurdity issues such as informed consent. However, when we are confronted with a procedure as unprecedented in medical history as bone marrow transplantation, we are challenged to re-examine the traditional medical models of decision-making. By involving ethicists and jurists in medical moral dilemmas, we are not seeking new "logical contortions." Instead, we are taking a fresh look at the mandate which physicians have been given by the community. What we seek is an interaction, or dialogue, between ethics, the law, and medicine so that the true will o f the community can be expressed in decisions involving more than medical technical judgments. We are all hearing the national cry for truly informed consent in human experimentation. It would seem incumbent upon us as physicians to show growth in this area as we grapple with this concept while continuing the search for new medical knowledge. When Dr. Smith notes the analogy between cases involving persons of the Jehovah's Witness sect and bone marrow transplants, I fear that he fails to recognize the essential difference; namely, that bone marrow transplantation is truly an experi-
To the Editor: The article of Safer and associates 1 on rebound growth after the cessation of stimulant medication for minimal brain dysfunction (MBD) was o f great interest. I felt that Dr. Cohen's 2 comments were even more p e r t i n e n t . We have just published an article 3 o n bone age in children with MBD, showing that they are in fact physiologically immature in that bone age is retarded in a group of 53 at the 0.01 level o f confidence. An extension o f this study involving 105 children is of even more interest in that while one child had a bone age 2 SD above the norm, 20 had bone ages 2 SD below the norm. This tremendous difference shows the problems of estimating growth curves in the age group with which Safer and associates have chosen to work, and emphasizes the point Cohen has made regarding evaluation o f maturation.
Leon Oettinger, Jr., M.D. Associate Clinical Professor Pediatrics U.C.L.A. Clinical Professor Psychology Fuller G?aduate School of Psychology Pasadena, Calif
REFERENCES 1. 2. 3.
Safer DF, Allen RP, and Barn E: Growth rebound after termination o f stimulant drug, J PEDIATR 86:113, 1974. Cohen MJ: Editorial comment: The reference standard, J PEDIATR 86:167, 1974. Oettinger L, Majovski LV, Limbeck GA, and Gauch R: Bone age in children with minimal brain dysfunction, Percept Mot Skills. 39:1127, 1974.
Letters to the Editor
The Journal of Pediatrics August 1975
the will o f the incompetent person is set aside, and the will of the guardian is what determines whether or not a procedure will be carried out. In my pediatric practice, I do not allow the aversion o f a 3 year old to needles to determine whether or not needed procedures are performed, and I do not deliberately allow lawyers and judges to get involved in making medical decisions. The resident who spent so much time trying to get informed consent from the 13-year-old retarded boy was obviously wasting his time. The judge who ruled on the first and second cases was intruding on the practice o f medicine. On the other hand, in the third case, the authors should not have allowed the parents to refuse bone marrow transplantation without having taken the case to court, if, indeed, they felt that such transplantation was desirable. This case is analagous to cases involving cases of the Jehovah's Witness sect and I believe the courts would have allowed transplantation to proceed. I suspect that the real problem underlying these cases is that the authors have reservations as to whether bone marrow transplants are "worth it" in terms of risks and efforts involved. This is a medical question that must be answered by the medical profession. The authors should not ask judges tO make these decisions for them.
mental procedure, whereas a blood transfusion for a Jehovah's Witness represents a clearly established intervention with a predictable successful consequence. I think that Dr. Smith would agree that the use of any new experimental procedure in children (particularly when such treatment may not benefit some children, such as donors) presents us with an unprecedented and complex set of issues. There is no reason why we in medicine should not consult individuals in other disciplines to obtain a broader view and assay the will o f th e community. A t the same time, we must strive to understand and interpi-et the interests of minors and the rights of parents without compromising our committment to seek innovative treatments to benefit future generations of children.
Melvin D. Levine, M.D. Medical Outpatient Department The Children's Hospital Medical Center 300 Longwood Ave. Boston, Mass. 02115
Bone age and minimal brain dysfunction
David L. Smith M.D., F.A.A.P. 529 Balmoral Rd. Middlesboro, Ky. 40965 REFERENCE 1.
Levine MD, Camitta BM, Nathan D, and Curran WJ: The medical ethics of bone mai'row transplantation in childhood, J Pediatr 86:145, 1975.
Reply To the Editor: We can certainly understand the concerns of Dr. Smith in his letter. In all ethical issues, one faces the risk of reducing to absurdity issues such as informed consent. However, when we are confronted with a procedure as unprecedented in medical history as bone marrow transplantation, we are challenged to re-examine the traditional medical models of decision-making. By involving ethicists and jurists in medical moral dilemmas, we are not seeking new "logical contortions." Instead, we are taking a fresh look at the mandate which physicians have been given by the community. What we seek is an interaction, or dialogue, between ethics, the law, and medicine so that the true will o f the community can be expressed in decisions involving more than medical technical judgments. We are all hearing the national cry for truly informed consent in human experimentation. It would seem incumbent upon us as physicians to show growth in this area as we grapple with this concept while continuing the search for new medical knowledge. When Dr. Smith notes the analogy between cases involving persons of the Jehovah's Witness sect and bone marrow transplants, I fear that he fails to recognize the essential difference; namely, that bone marrow transplantation is truly an experi-
To the Editor: The article of Safer and associates 1 on rebound growth after the cessation of stimulant medication for minimal brain dysfunction (MBD) was o f great interest. I felt that Dr. Cohen's 2 comments were even more p e r t i n e n t . We have just published an article 3 o n bone age in children with MBD, showing that they are in fact physiologically immature in that bone age is retarded in a group of 53 at the 0.01 level o f confidence. An extension o f this study involving 105 children is of even more interest in that while one child had a bone age 2 SD above the norm, 20 had bone ages 2 SD below the norm. This tremendous difference shows the problems of estimating growth curves in the age group with which Safer and associates have chosen to work, and emphasizes the point Cohen has made regarding evaluation o f maturation.
Leon Oettinger, Jr., M.D. Associate Clinical Professor Pediatrics U.C.L.A. Clinical Professor Psychology Fuller G?aduate School of Psychology Pasadena, Calif
REFERENCES 1. 2. 3.
Safer DF, Allen RP, and Barn E: Growth rebound after termination o f stimulant drug, J PEDIATR 86:113, 1974. Cohen MJ: Editorial comment: The reference standard, J PEDIATR 86:167, 1974. Oettinger L, Majovski LV, Limbeck GA, and Gauch R: Bone age in children with minimal brain dysfunction, Percept Mot Skills. 39:1127, 1974.