I spent some time over the weekend scanning physician responses to this ethical conundrum.
An endocrinologist was caring for a man who spent years taking anabolic steroids. He developed hypogonadotropic hypogonadism with a low sperm count. He was now living clean and ready to start his family.
The endocrinologist replaced the patient’s testosterone and achieved optimal levels. He then gave the patient HCG injections to help restore his sperm count. Despite 6 months of treatment, the sperm count on the most recent analysis was low: 20,000/cc.
The patient came to his appointment to discuss the results and clinical strategy.
His partner came with him.
Before the doctor could say anything, the patient was gushing with gratitude. The happy couple was pregnant. Thanks. Thanks. A Thousand thanks.
The endocrinologist was thinking there’s almost no way his patient is the biological father. Still, the couple was beaming with joy.
Almost 100 physicians weighed in on “what they would do.”
The vast majority said they’d do nothing. Let the happy couple be happy. As Thomas Gray wrote in 1742, “Where ignorance is bliss, ’tis folly to be wise.”
The collective response surprised me.
While I wouldn’t expect the endocrinologist to blurt out “You know your partner must have been impregnated by someone else”, the long term ramifications of silence need to be thoughtfully considered. The doctor’s obligation is to his patient. And while the patient has a right to not know something, he also has a right to decide what he wants to know.
First, it is possible the child is his. A low sperm count is not the same as a zero sperm count. Further, it is possible that the sperm count was low because the couple had sex the night before, and his baseline sperm count is higher. If the patient is the true biological father, then gently alerting the patient to your nagging doubts might push for a definitive paternity test. A confirming test would be good news. If the patient developed nagging doubts, he would also experience good news. It was a miracle.
Next, it’s possible the child is not his, and the patient already knows. Maybe the patient’s partner knows he knows. Maybe not. Maybe they’ve agreed subconsciously to this elaborate ruse because they’ve both prioritized starting a family higher than any other goal. Here, if the doctor expressed his concern to the patient, he’s likely to take no action. But, here, the patient would have made a decision based on knowledge. In this part of the decisional matrix, as long as the doctor has discussed it privately with the patient, I do not see any downside of such a conversation.
The final alternative is the patient is not the biological father. And he is unaware. If the endocrinologist follows the wisdom of the bulletin board crowd, he’d say nothing, and let the blissful couple remain happy. But, what if the patient later learns the facts. What if in the delivery room the baby looks nothing like the couple? Perhaps a different race – alerting everyone the man with the camcorder is not the daddy. Will the couple still be happy? Is the family off to a good start? The patient might be angry with his partner. That anger will eventually be directed to the doctor. A lawsuit is not out of the question.
Medical ethics often puts competing principles in tension. One guiding principle is respect for the patient’s autonomy – letting them make decisions that affect their health – whether or not you, the doctor, agree with those decisions. Another guiding principle is to do no harm – or minimize harm.
In the case study, these principles are in tension. There’s no perfect answer. My vote would be to gently plant the seed (no pun intended) of doubt into the patient’s mind to see how much information he might want. But, others might vote differently.
What do you think?
Feeling the pressure? Learn how we can protect you…
We know your time is valuable. Spend a few minutes with us and discover how membership protects what’s important to good medical practice – and does away with what’s detrimental…
It depends of characteristics of the marriage, personalities involved, etc. The information will likely impact different people, differently (redundancy noted).
My response as a reproductive endocrinologist (fertility specialist) would have been – Wow! Congratulations. You guys have won the lottery. In my 25 years of practice, I’ve never seen anyone with such a low count get pregnant without IVF.
To me speaking out violates patient’s trust and confidentiality. Besides ,miracles can happen. What is any one accomplishing by sowing seeds of doubt?
Silence!
Kevin Doody’s response is perfect. It communicates the fertility specialist’s concern, while leaving open the possibility, however unlikely, that the male partner is indeed the father. The message is truthful, but optimistic. If the man with the low sperm count has concerns, it leaves the door open to further questions. If they want to just be happy that she’s pregnant, it leaves that door open as well, in a very non-judgmental way.
Agree with Dr. Desoer: Doody’s response is spot on. I wish I were smart enough to come up with it. But perfect is perfect. No way to improve on it.
Agree with Doody, though maybe not quite so bold. Maybe something like, “You guys definitely beat the odds. I would not have expected a successful conception with such a low sperm count. Congratulations”
Dr. Doody – perfect choice of words and empathy!
Honesty no matter how it hurts is the best policy always. Gently, in private to the patient admit it is unlikely but possible he is the father and allow him to proceed with the information from that point. If by some chance he is not the father and finds out after 10 or 15 years of child support the courts will likely make him continue with support as their is precedence at which point he can sue the physician for not alerting him to the fact the child is not likely his. Honesty is always the best policy.
Most physicians tend to “credit” their patients with a higher knowledge and sophistication than they actually have. Chances are the husband will eventually realize the baby is not his, or that the likelihood is minimal.
If the marriage is destroyed as a result of the wife’s infidelity that is NOT the doctor’s fault.
More to the point, it is WELL PAST TIME to stop shielding patients and their families from the fallout of their own bad decisions. When you do, you join into the Karpman Drama Triangle. Then, YOU will likely become the “next” victim.
Michael M. Rosenblatt, DPM
20,000 swimmers per cc sounds scant, but I’m not sure if this may preclude a viable insemination. If the likelihood of insemination should be relayed to the the happy couple, and it’s not unreasonable to ask the female “partner” (presumably not wife) – “is there any possibility this could be someone else’s baby?” If the female states there is no chance of another father, there may be no need to do anything except document her words on the chart, and alert the patient’s OB of your concerns.
If the female had an inter-racial affair, she may have some splanin’ to do after the delivery.
Given that there is uncertainty and that the patient could indeed be the father, Dr. Doody’s response is correct. It conveys the necessary information. It conveys the doubt. It conveys what he knows. It does not delve into the realm of speculation. We should deal with the facts as they are and what is possible. Doesn’t anyone believe in miracles anymore? Especially medical miracles?