Review the clinical scenario presented and respond to questions.

Consider the ethical dilemmas inherent in the following case study:

Andrew, an 8-year-old boy, was diagnosed with leukemia 3 years ago. Initially treated with chemotherapy, his disease went into remission for several months but now has relapsed. The initial round of chemotherapy was very difficult for Andrew, and he experienced all the major side effects, including persistent nausea and vomiting, mouth ulcerations, hair loss, decreased white blood cell count with infections, and generalized muscle wasting and weakness. He developed a deep fear of needles and IVs and still has ecchymotic areas from the bone marrow aspirations. Andrew was and still is unable to play with his friends because of the fear of infection, is 2 years behind in school, and generally feels that his life is worthless.

The physicians have told his parents that further chemotherapy would be dangerous and probably not effective and that a bone marrow transplant is the only realistic hope for a cure. The family and Andrew have been informed of what is involved in a bone marrow transplant, including massive doses of chemotherapy and radiation to destroy his bone marrow, marrow transfusions, and 4 to 6 weeks of reverse isolation in the ICU after the procedure. Because of graft-versus-host rejection, there is a 40 percent chance of success and a 15 percent chance that the child will die from the procedure itself. In addition, the family's health insurance will cover only about 25 percent of the $500,000 cost of the procedure. Andrew's father already took out a second mortgage on his house to help pay for the chemotherapy.

1. Which factors would be key in making a decision about whether or not Andrew should receive a bone marrow transplant?
2. How do the percentages for survival and success figure into your decision? What if the success rate were 90 percent? What if there were no risk of death?
3. If the parents asked you "What do you think we should do?" how would you answer that question?
4. Who besides the parents, physicians, and nurses should be involved in the decision? How do Andrew's feelings affect the decision?