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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?

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