Ethics and pragmatism versus DoH guidelines: what to do?
IM Ibrahim1, E-L Lim1, J-A Coebergh1, A Jenkins2, J Lewis3, D Mitra4 & R Quinton1
Clinical case: A 30-year-old Eritrean presented as an emergency to the orthopaedics surgeons with radicular back pain. Following L3/L4 spinal decompression, he was noted to be classically acromegaloid and was transferred to the Endocrine Unit, where a mild bitemporal upper quadrantinopia was noted. GH was massively elevated at 1200 mU/L, IGF1>130 nmol/L, with associated corticotroph and gonadotroph insufficiencies requiring replacement. MRI showed a large pituitary adenoma compressing the optic chiasm and invading the right cavernous sinus with displacement of the internal carotid artery. We were advised that his initial asylum claim had been refused and that, as an illegal migrant, he was entitled to emergency NHS treatment only.
Discussion: Though our Trust runs a quarterly multidisciplinary Ethics forum, its potential contribution was pre-empted by information from the Home Office. Due to ongoing political instability, “illegal immigrants are simply not “removed back to Eritrea from the UK. Thus, it seemed illogical to defer treatment until he inevitably represented with severe visual failure or pituitary crisis. We were able to justify the need for urgent trans-sphenoidal pituitary surgery for sight preservation. This was limited by tough, fibrous tissue and intraoperative bleeding, though the visual field defect resolved. As the tumour continued to stretch the chiasm radiologically, he received fractionated, multiportal external beam pituitary irradiation. Although his post-operative GH level remained very high at ∼300 mU/mL, with its associated risks, we encountered difficulty justifying further medical treatment.
Conclusion: He awaits the outcome of his asylum application appeal and has recently managed to register with a GP who has formally referred him back to our Unit and is prepared to endorse medical therapy. This case illustrates how ethical judgements are integral to clinical practice in Endocrinology, as we try to carefully balance the most appropriate form of long-term management for this patients acromegaly.