Clinical Ethics Case Study 9: Should we inform our patient about animal products in his medicine?

Abstract

Referral to the CEAG: deriving drugs from animal sources and considerations of religion A 70-year-old patient of Middle-Eastern origin (Mr D) is admitted for management of exacerbation of obstructive lung disease. Mr D has capacity to consent to, or refuse, medical treatment. As he is likely to be bed-bound for several days, hospital policy (reflecting national guidance) is that he receives prophylactic heparin to reduce the risk of potentially fatal venous thrombosis. The standard drugs used for prophylaxis against blood clots are various forms of heparin, which is given via subcutaneous injection. All heparins are derived from pigs. A junior doctor has asked her consultant whether she should ask Mr D if porcine-derived heparin is acceptable to him. We are concerned about how we should proceed. The animal origin of some drugs may not always be known to staff prescribing or administering these drugs. Patients may be even less likely to have this knowledge. Further, information is not easily available to patients or health professionals who may wish to know more. For example, although the ‘Summary of Product Characteristics’ required to be published about any drug includes this information, it is not readily available to prescribers (particularly as Internet 2 access is not always available on the ward) and would have to be sought on each occasion that a patient is prescribed a new drug. A proportion of patients will be members of certain religious faiths that prohibit the ingestion of certain foods. While we need to be careful about making assumptions about whether particular patients are members of these faiths (and if so whether they follow its doctrines strictly), religious doctrines may be interpreted by some patients to extend to prohibit the ingestion or other use of pharmaceuticals derived from specific animals. Similar views may also be held by people who choose to follow a vegetarian or vegan diet. If we talk with Mr D and make the porcine origin of this drug known to him, he may choose to decline this drug. However, to not administer it would be contrary to national guidance (although within Mr D's legal rights) and could affect clinical outcomes. We could perhaps instead prescribe one of the newer clot-preventing drugs that are entirely synthetic. These may also be easier to administer and monitor, but are more expensive. Some may also have to be prescribed outside of the product licence, with less available evidence of effectiveness. A further issue is that the use in this case is for prophylaxis as opposed to treatment. Heparin is recommended to prevent a complication which, while potentially serious (including fatal), may also not occur at all. That said, such administration is increasingly viewed as medically essential. We are approaching the ethics committee with the following questions in mind: 1. Should we feel a moral obligation to disclose the derivation of heparin to Mr D (or indeed to all patients)? 2. If not, is it sufficient to honestly answer questions if he raises them? 3. Is there a morally relevant difference between patients who object to certain animal products on religious grounds and those who have strong concerns about animal welfare? 4. When considering purchasing drugs like heparin, would the ethics committee be happy to recommend the purchase of alternative non-animal-derived products which may be more expensive?