MMI - consent

[wizzed101]

Mike, 9, is in need of a bone marrow transplant within 3 days or he will die. His twin brother, Jack, is a 6/6 donor ready to save his brother. Unfortunately, Jack comes down with an infection, which means he is not eligible unless cured (otherwise, the transplant will kill his brother). You are the attending in charge of figuring out what is ailing Jack and hopefully cure him in time.

After a day, you find out that Jack has an infested mistral valve. Standard treatments include giving him antibiotic for a month and he should be fine with no adverse effects. Mike, however, doesn't have a month. Within 2 days, only 4/6 bone marrow is available. Using that will put Mike in grave danger and a miserable life full of agony.

There is another option: do an open heart surgery to cure the infested valve then flush Jack's system with antibiotic to get him ready. The catch is that this will effectively put Jack on a life long regimen of blood thinners and other medicine. Jack is an aspiring athlete and this surgery will put an end to his hopes and dreams.

The twins' parents plan to consent to Jack's treatment without telling him, and even if they tell him, you have learned, they are unlikely to relent on the surgery regardless what Jack's consent. Again he is a minor, so technically, regardless of his feeling, he cannot consent to anything.

What should you do? Do you think this constitutes child abuse? You have an option to contact CPS to put an end to the entire venture.

Spoiler

You may have seen this somewhere....

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[kb1900]

I've only had 1 mmi so far but this is an insane scenario..........right?(?)

 

[hubbsbubbs]

Is there a correct answer here? Or are interviewers just looking to understand the process by which you consider a dilemma and the kind of values you have?

 

[Pusheen]

This situation seems unrealistic. A child isn't a candidate for a marrow transfusion one day after open heart surgery. I can't see a surgeon agreeing to do open heart surgery in this situation anyway.
I think this scenario needs to be presented a bit differently

 

[Gurkhali]

I've only had 1 mmi so far but this is an insane scenario..........right?(?)

Ya I doubt you would ever get this. One, because who tf is going to read this all in 2-3 minutes and form an outline in their head of what to say? And two, because its too complex for a question and the job of assessing an applicants personality or critical thinking skills or communication skills can be done better with a simpler question.

 

[Dr. Jan Itor]

.

 

[Lawpy]

What should you do? Do you think this constitutes child abuse? You have an option to contact CPS to put an end to the entire venture.

I'm probably misunderstanding something, but I can't find any instances of child abuse in your scenario. So i don't know why that question was posed.

 

[Geriatrix]

A 9 year-old is mature enough to understand the implications of his decision if information is presented in age appropriate manner.
This scenario though dire is not a medical emergency and the doctors is not obliged to proceed with treatment which will definitely harm one child in order to save the other.
I'd impress upon the parents the importance of informing the well 9 year old and seeking his assent to the treatment.


Sent from my iPhone using SDN mobile

 

[freak7]

Spoiler

You may have seen this somewhere....

Yeah I met Satan a little bit ago and he shared with me this exact dilemma

 

[Pusheen]

I'm probably misunderstanding something, but I can't find any instances of child abuse in your scenario. So i don't know why that question was posed.

The idea is that if they supposedly do open heart surgery on one kid and put him on bunch of dangerous medications for life, he can (maybe) save the other kid.

imo, that's a kinda terrible thing to do

 

[LizzyM]

Long story short: A kid needs a treatment or he will die in 3 days. However, this treatment requires that the kid's twin brother undergo a dangerous surgical procedure that will limit the twin's life going forward. The parents want to go forward even though it means needing to sacrifice one child's future health to save the other's life. Would you accuse the parents of child abuse? What would you do?

 

[Matthew9Thirtyfive]

The idea is that if they supposedly do open heart surgery on one kid and put him on bunch of dangerous medications for life, he can save the other kid (maybe, marrow transplants aren't 100% for sure either)

imo, that's a kinda terrible thing to do

They're not.

 

[Lawpy]

The idea is that if they supposedly do open heart surgery on one kid and put him on bunch of dangerous medications for life, he can save the other kid (maybe, marrow transplants aren't 100% for sure either)

imo, that's a pretty terrible thing to do, and I don't see a surgeon agreeing to that

Long story short: A kid needs a treatment or he will die in 3 days. However, this treatment requires that the kid's twin brother undergo a dangerous surgical procedure that will limit the twin's life going forward. The parents want to go forward even though it means needing to sacrifice one child's future health to save the other's life. Would you accuse the parents of child abuse? What would you do?

I'm puzzled by the following: "Within 2 days, only 4/6 bone marrow is available. Using that will put Mike in grave danger and a miserable life full of agony." How does performing a dangerous surgical procedure ensure the 6/6 outcome necessary for the twin can save the other twin's life? Wouldn't the procedure actually reduce the transplant outcomes (I figure a dangerous procedure would also be high-stakes and error-prone)?

So it looks like the procedure would put both twins at great risk, whereas the 4/6 bone marrow outcome would put the bone marrow recipient twin at risk. I don't see the point of carrying out the surgical procedure.

 

[Matthew9Thirtyfive]

I'm puzzled by the following: "Within 2 days, only 4/6 bone marrow is available. Using that will put Mike in grave danger and a miserable life full of agony." How does performing a dangerous surgical procedure ensure the 6/6 outcome necessary for the twin can save the other twin's life? Wouldn't the procedure actually reduce the transplant outcomes (I figure a dangerous procedure would also be high-stakes and error-prone)?

So it looks like the procedure would put both twins at great risk, whereas the 4/6 bone marrow outcome would put the bone marrow recipient twin at risk. I don't see the point of carrying out the surgical procedure.

You're missing the forest for the trees. Whether or not the details of the question makes sense is irrelevant. The crux of the question is what do you think of parents forcing one child to sacrifice quality of life to save another child's life? Focusing on the minutia is just avoiding the question.

 

[Pusheen]

They're not.

I get that for this scenario it's supposed to work for sure and the point of the question is whether or not it's ok to sacrifice the health of one twin for the life of another. But open heart surgery and an immediately subsequent transplant are so risky on their own, it defeats the purpose of the question because now both twins are at serious risk instead of one.

 

[Goro]

That doesn't matter. We don't expect you to have insider knowledge.

We DO expect you to have common sense. Many of these questions have no right answer, but do have wrong answers.

This situation seems so unrealistic. A child isn't a candidate for a marrow transfusion one day after open heart surgery. I can't see a surgeon agreeing to do open heart surgery in this situation anyway.
Did you come up with this or was it in a prep book?

 

[Lawpy]

You're missing the forest for the trees. Whether or not the details of the question makes sense is irrelevant. The crux of the question is what do you think of parents forcing one child to sacrifice quality of life to save another child's life? Focusing on the minutia is just avoiding the question.

It's actually related to the overall question, because it doesn't make sense to carry out the operation that would put both twins at risk. The parents think the procedure is actually helpful, when it isn't. So this would mean to dissuade the parents by showing how the said operation = dangerous outcomes for both twins. Getting the CPS involved and accusing the parents of child abuse accomplish nothing because they're acting emotionally and doing what's best to save their kids.

 

[Matthew9Thirtyfive]

I get that for this scenario it's supposed to work for sure and the point of the question is whether or not it's ok to sacrifice the health of one twin for the life of another. But open heart surgery and an immediately subsequent transplant are so risky on their own, it defeats the purpose of the question because now both twins are at serious risk instead of one.

Yes. This scenario is completely unrealistic. But the point isn't to see if you can catch that. It's to see how you respond to moral choices. The details are just there so you can get a sense of plot.

 

[Matthew9Thirtyfive]

It's actually related to the overall question, because it doesn't make sense to carry out the operation that would put both twins at risk. The parents think the procedure is actually helpful, when it isn't. So this would mean to dissuade the parents by showing how the said operation = dangerous outcomes for both twins. Getting the CPS involved and accusing the parents of child abuse accomplish nothing because they're acting emotionally and doing what's best to save their kids.

Yes, but this is a prompt, not real life. Saying it's unrealistic or ridiculous isn't an answer. If the prompt implies that the sequence of procedures will work, you have to suspend your disbelief because that isn't the point of the question.

 

[Pusheen]

Yes. This scenario is completely unrealistic. But the point isn't to see if you can catch that. It's to see how you respond to moral choices. The details are just there so you can get a sense of plot.

That doesn't matter. We don't expect you to have insider knowledge.

We DO expect you to have common sense. Many of these questions have no right answer, but do have wrong answers.

That makes sense, I guess I just expect a patient scenario to be at least somewhat realistic so that I talk about it in practical terms. Otherwise, we may as well just get a theoretical bare bones problem, such as what LizzyM described above.
What's the point of all this elaboration if it doesn't make sense anyway?

 

[Lawpy]

Yes, but this is a prompt, not real life. Saying it's unrealistic or ridiculous isn't an answer. If the prompt implies that the sequence of procedures will work, you have to suspend your disbelief because that isn't the point of the question.

? If the prompt relies on something that doesn't make sense, the default answer would be to stick with least-risk and most sensible outcome. Which in this case is to wait 2 days and put the one twin with the 4/6 bone marrow, and give the other twin the normal antibiotics.

 

[Matthew9Thirtyfive]

That makes sense, I guess I just expect a patient scenario to be at least somewhat realistic so that I talk about it in practical terms. Otherwise, we may as well just get a theoretical bare bones problem, such as what LizzyM described above.
What's the point of all this elaboration if it doesn't make sense anyway?

I don't disagree with you. I'd rather just have a bare bones prompt. I think the point of having all the extra info though is to see if you can parse out what's important and show a logical train of thought. That's much easier to do with just a simple prompt.

 

[Matthew9Thirtyfive]

? If the prompt relies on something that doesn't make sense, the default answer would be to stick with least-risk and most sensible outcome. Which in this case is to wait 2 days and put the one twin with the 4/6 bone marrow, and give the other twin the normal antibiotics.

That can be part of your answer since you're working in the bounds of the prompt, I think. But the parents want the surgery because 4/6 will still put Mike at severe risk. So what happens when you lay out your plan and they tell you they want the surgery anyway?

 

[Lawpy]

That can be part of your answer since you're working in the bounds of the prompt, I think. But the parents want the surgery because 4/6 will still put Mike at severe risk. So what happens when you lay out your plan and they tell you they want the surgery anyway?

I assume the parents would have been informed that the procedure would put both kids at severe risk, and they agreed to it anyways? Because the prompt assumes the parents chose surgery since it's the least-risk outcome for both kids and ideally better than 4/6 outcome.

 

[Pusheen]

I don't disagree with you. I'd rather just have a bare bones prompt. I think the point of having all the extra info though is to see if you can parse out what's important and show a logical train of thought. That's much easier to do with just a simple prompt.

The extra info isn't just a part of the story though, it's relevant to the outcome. If we're suspending disbelief that a transplant and open heart surgery m a child is risky, then we can ignore it in the dilemma I suppose. Anyway, I just think this prompt needs to be constructed differently to get to the same dilemma

 

[Matthew9Thirtyfive]

I assume the parents would have been informed that the procedure would put both kids at severe risk, and they agreed to it anyways? Because the prompt assumes the parents chose surgery since it's the least-risk outcome for both kids and ideally better than 4/6 outcome.

So you would do it?

 

[lpp06]

The producers of House would like their plot lines back

 

[Pusheen]

So you would do it?

In this scenario, no, because the risks are far too great for the twin undergoing surgery.

Even if it was just a serious long term health issue, I don't think it's ok to do that to a child who is not fully capable of understanding the lifelong repercussions of this decision. Your child is not ''spare parts'' for your other child.

 

[Pusheen]

Haha sorry @Matthew9Thirtyfive I thought you were asking me

 

[Lawpy]

So you would do it?

Probably not. I want to minimize risks whenever possible, and the surgery will put both twins at grave risk.

The extra info isn't just a part of the story though, it's relevant to the outcome. If we're suspending disbelief that a transplant and open heart surgery m a child is risky, then we can ignore it in the dilemma I suppose. Anyway, I just think this prompt needs to be constructed differently to get to the same dilemma

The prompt defeats the question. If surgery is high-risk, there is no reason to pursue it, and the parents will understand and avoid it, since they don't want to endanger both kids. Calling in the CPS and slamming the parents of child abuse is nonsensical.

 

[Pusheen]

The prompt defeats the question. If surgery is high-risk, there is no reason to pursue it, and the parents will understand and avoid it, since they don't want to endanger both kids.

But you're not supposed to know that or take it into consideration, which is why it's a stupid prompt

 

[Lawpy]

But you're not supposed to know that or take it into consideration, which is why it's a stupid prompt

wait what. is that what @Matthew9Thirtyfive was referring to when he talked about suspending disbelief?

Yes, but this is a prompt, not real life. Saying it's unrealistic or ridiculous isn't an answer. If the prompt implies that the sequence of procedures will work, you have to suspend your disbelief because that isn't the point of the question.

I thought he just meant that the procedures will work, but nothing much about the actual risk involved.

 

[Matthew9Thirtyfive]

wait what. is that what @Matthew9Thirtyfive was referring to when he talked about suspending disbelief?



I thought he just meant that the procedures will work, but nothing much about the actual risk involved.

From my experience in MMI style boards and interviews, they don't expect you to know anything that isn't in the prompt. So if the prompt doesn't say it is a high risk surgery, you shouldn't assume that to affect your answer.

 

[Pusheen]

From my experience in MMI style boards and interviews, they don't expect you to know anything that isn't in the prompt. So if the prompt doesn't say it is a high risk surgery, you shouldn't assume that to affect your answer.

I.e. You're not allowed to poke holes in the story based on your own knowledge

 

[Pusheen]

I assume the parents would have been informed that the procedure would put both kids at severe risk, and they agreed to it anyways? Because the prompt assumes the parents chose surgery since it's the least-risk outcome for both kids and ideally better than 4/6 outcome.

If the open heart thing is done, the marrow will be good and Mike won't be at any risk at all (presumably). Jack, however, will be screwed

 

[Lawpy]

From my experience in MMI style boards and interviews, they don't expect you to know anything that isn't in the prompt. So if the prompt doesn't say it is a high risk surgery, you shouldn't assume that to affect your answer.

I.e. You're not allowed to poke holes in the story based on your own knowledge

... I said high-risk from what was stated in the prompt itself:

There is another option: do an open heart surgery to cure the infested valve then flush Jack's system with antibiotic to get him ready. The catch is that this will effectively put Jack on a life long regimen of blood thinners and other medicine. Jack is an aspiring athlete and this surgery will put an end to his hopes and dreams.

And from LizzyM's summary:

Long story short: A kid needs a treatment or he will die in 3 days. However, this treatment requires that the kid's twin brother undergo a dangerous surgical procedure that will limit the twin's life going forward. The parents want to go forward even though it means needing to sacrifice one child's future health to save the other's life. Would you accuse the parents of child abuse? What would you do?

So, I just inferred that dangerous = life-long regimen of medications = high-risk procedure.

 

[Pusheen]

... I said high-risk from what was stated in the prompt itself:



And from LizzyM's summary:



So, I just inferred that dangerous = life-long regimen of medications = high-risk procedure.

Right, so you're choosing between the death of one kid and a high risk/lifetime of medication/poor health of the other

 

[Lawpy]

If the open heart thing is done, the marrow will be good and Mike won't be at any risk at all (presumably). Jack, however, will be screwed

Wait, so basically, the prompt resolves to this:

No surgery: Jack = safe (it's just antibiotics), and Mike = screwed (because 4/6 = bad)
Surgery: Jack = screwed (because long-term blood thinners), and Mike = safe (because somehow open heart surgery = good marrow)

Question: what would I do?

 

[Pusheen]

Wait, so basically, the prompt resolves to this:

No surgery: Jack = safe (it's just antibiotics), and Mike = screwed (because 4/6 = bad)
Surgery: Jack = screwed (because long-term blood thinners), and Mike = safe (because somehow open heart surgery = good marrow)

Question: what would I do?

Yes. I pointed out that the open heart surgery itself is a huge risk and seems foolish given the scenario, which I am supposed to overlook

 

[Lawpy]

Yes. I pointed out that the open heart surgery itself is a huge risk and seems foolish given the scenario, which I am supposed to overlook

Right, so you're choosing between the death of one kid and a high risk/lifetime of medication/poor health of the other

Well, at least the good thing is, everyone here agrees the prompt is basically stupid.

But the question is an important one: is it okay to let the parents sacrifice the quality of one kid's life to save the life of the other kid?

 

[Pusheen]

Well, at least the good thing is, everyone here agrees the prompt is basically stupid.

But the question is an important one: is it okay to let the parents sacrifice the quality of one kid's life to save the life of the other kid?

To me, that's just icky

 

[Lawpy]

To me, that's just icky

Yeah I don't disagree. I'm still picking the alternative of minimizing risks of both kids, since I think such a question is based on a false dilemma.

 

[Matthew9Thirtyfive]

Wait, so basically, the prompt resolves to this:

No surgery: Jack = safe (it's just antibiotics), and Mike = screwed (because 4/6 = bad)
Surgery: Jack = screwed (because long-term blood thinners), and Mike = safe (because somehow open heart surgery = good marrow)

Question: what would I do?

Well, at least the good thing is, everyone here agrees the prompt is basically stupid.

But the question is an important one: is it okay to let the parents sacrifice the quality of one kid's life to save the life of the other kid?

You got it. ****ty prompt but great underlying question.

 

[ChrisMack390]

MMIs are nothing like this.

 

[libertyyne]

Mike, 9, is in need of a bone marrow transplant within 3 days or he will die. His twin brother, Jack, is a 6/6 donor ready to save his brother. Unfortunately, Jack comes down with an infection, which means he is not eligible unless cured (otherwise, the transplant will kill his brother). You are the attending in charge of figuring out what is ailing Jack and hopefully cure him in time.

After a day, you find out that Jack has an infested mistral valve. Standard treatments include giving him antibiotic for a month and he should be fine with no adverse effects. Mike, however, doesn't have a month. Within 2 days, only 4/6 bone marrow is available. Using that will put Mike in grave danger and a miserable life full of agony.

There is another option: do an open heart surgery to cure the infested valve then flush Jack's system with antibiotic to get him ready. The catch is that this will effectively put Jack on a life long regimen of blood thinners and other medicine. Jack is an aspiring athlete and this surgery will put an end to his hopes and dreams.

The twins' parents plan to consent to Jack's treatment without telling him, and even if they tell him, you have learned, they are unlikely to relent on the surgery regardless what Jack's consent. Again he is a minor, so technically, regardless of his feeling, he cannot consent to anything.

What should you do? Do you think this constitutes child abuse? You have an option to contact CPS to put an end to the entire venture.

Spoiler

You may have seen this somewhere....

1. Look for alternative donors.
2.Look for any therpy that would enable the transplant to occur while the infection is still active- less invasive.
3 Call Ethics Consult
4. Call CPS
5.Cry alone at home.
6.Cry alone at home.
7. Cry alone at home.
8. Follow parents will if all other options have been exhausted.
9. Cry alone at home.

 

[Lawpy]

3 Call Ethics Consult

Sigh... I wish that would be the default answer to all MMI ethical prompts.

 

[libertyyne]

Sigh... I wish that would be the default answer to all MMI ethical prompts.

Im still going to use it!

 

[Matthew9Thirtyfive]

MMIs are nothing like this.

I've been in some MMI style boards and none of them had prompts remotely this ridiculous.

 

[wizzed101]

Wait, so basically, the prompt resolves to this:

No surgery: Jack = safe (it's just antibiotics), and Mike = screwed (because 4/6 = bad)
Surgery: Jack = screwed (because long-term blood thinners), and Mike = safe (because somehow open heart surgery = good marrow)

Question: what would I do?

Do nothing = Jack gets best quality of life. Mike will be dead in 2 days/ be in great agony to boost.
Surgery: Jack at great risk and will not be able to play sports. Mike = best quality of best coz identical twin 6/6
@Pusheen
Jack had some unknown infections. You can spend months to test it then Mike will be dead by then. They found a cyst (idk what is the correct term but you get the idea) in his heart so they can biopsy it and pinpoint the type of infection and use the right antibiotics to clean him. The problem is the size of the cyst indicates that it will take at least a month even if they have the correct antibiotics.

They have to get Jack ready in 2 days. So they decide to manually clean the cyst by open heart surgery and then flush his system with antibiotics to bring make him infection free. That was the prompt solution to the dilemma. Is it risky? No **** Sherlock. That is why the question of child abuse arose in the first place. Now if you are so so smart, can you propose a way to get Jack in shape in 2 days?
Caveat:
_No other donor available.
_The 4/6 core blood transplant will likely fail (let say they have done testing).

 

[libertyyne]

Do nothing = Jack gets best quality of life. Mike will be dead in 2 days/ be in great agony to boost.
Surgery: Jack at great risk and will not be able to play sports. Mike = best quality of best coz identical twin 6/6
@Pusheen
Jack had some unknown infections. You can spend months to test it then Mike will be dead by then. They found a cyst (idk what is the correct term but you get the idea) in his heart so they can biopsy it and pinpoint the type of infection and use the right antibiotics to clean him. The problem is the size of the cyst indicates that it will take at least a month even if they have the correct antibiotics.

They have to get Jack ready in 2 days. So they decide to manually clean the cyst by open heart surgery and then flush his system with antibiotics to bring make him infection free. That was the prompt solution to the dilemma. Is it risky? No **** Sherlock. That is why the question of child abuse arose in the first place. Now if you are so so smart, can you propose a way to get Jack in shape in 2 days?
Caveat:
_No other donor available.
_The 4/6 core blood transplant will likely fail (let say they have done testing).

Easy.
Stem Cells.