Using animal-derived constituents in anaesthesia and surgery: the case for disclosing to patients

Climate Change, Emerging Vector-Borne Illnesses, and Anesthetic Considerations

As a result of the widespread prevalence of anesthetic usage, anesthesia-related complications are well studied, ranging from benign postoperative nausea and vomiting to potentially fatal complications, such as paralysis, malignant hyperthermia, and death. However, one intersection that still needs further analysis is the relationship between vector-borne illnesses (VBIs) and anesthetic complications. With the advent of climate change and global warming, what were previously endemic vectors have spread far beyond their typical regions, resulting in the spread of VBI. As the incidence of VBIs rapidly increases in the United States, operations for diagnostic testing, and thus the identification and treatments of these VBIs, have significantly diminished. A literature review was conducted to analyze case reports of patients with VBIs and anesthetic concerns with sources from PubMed and Google Scholar databases, and a wide range of complications were found.

Towards halal pharmaceutical: Exploring alternatives to animal-based ingredients

Halal is a crucial concept for Muslim consumers regarding consumed products, including pharmaceutical ingredients, which are essential in modern medicine. To address the issue of using porcine-sourced ingredients in pharmaceuticals, it is essential to search for halal alternatives derived from poultry, animal by-products from meat processing, marine sources, and plants. However, the complexity of this problem is further compounded by the rapid advances in innovation and technology, which can lead to adulteration of ingredients derived from pigs. Other challenges include the sustainability of alternative materials, management of waste or by-products practice, halal awareness, certification, government policies, religious adherence of consumers, food suppliers, marketers, and purchasing of products. The importance of halal and non-halal problems, specifically in the context of pharmaceutical materials, is still rarely discussed, including alternatives derived from poultry, animal by-products, marine sources, and plants. Due to the increasing global population, there is a growing need to increase awareness and concern among Muslim consumers for halal products, including pharmaceuticals. Therefore, this research aimed to investigate the importance of halal and non-halal issues in pharmaceutical ingredients, the potential impact on the Muslim community, as well as opportunities and challenges in the search for alternative ingredients.

Uninformed Origins: Should We Be Advising Parents on the Source of Medicines and Therapies?

Respecting patient autonomy through the process of soliciting informed consent is a cornerstone of clinical ethics. In pediatrics, until a child becomes an adult or legally emancipated, that ethical tenet takes the form of respect for parental decision-making authority. In instances of respecting religious beliefs, doing so is not always apparent and sometimes the challenge lies not only in the healthcare provider's familiarity of religious restrictions but also their knowledge of medical interventions themselves which might conflict with those restrictions. We examine a case of a newborn receiving animal-derived surfactant, a common scenario in neonatology, and present considerations for providers to weigh when confronting when such an intervention might conflict with parent's religious beliefs. We end with strategizing ways to address this issue as a medical community.

Animal products in neurosurgery - navigating informed consent

Informed consent is an ethical and legal requirement integral to modern surgical practice. Clinicians have a duty to consider, disclose and discuss risks and concerns relevant to an individual patient. With medical advances there are now a significant number of animal-derived products and adjuncts available for use in modern neurosurgical practice, which may be relevant when consenting patients for specific procedures if such products are used. This paper highlights commonly used products in neurosurgery that contain animal-derived constituents with the aim of facilitating an informed discussion between the neurosurgeon and patient. We have reviewed the commonly used products in the centres of the authors and their commercial equivalents. The product information is taken from the manufacturer's instructions or the Federal Drug Administration documents regarding the product. Animal products commonly available to neurosurgeons can be broadly categorised into haemostatic agents, dural substitutes, dural sealants and bone cements. Many products contain a variety of animal (or human) derived products. In order to ensure informed consent and shared decision making, it is important to establish any relevant patient beliefs or views regarding the use of animal-derived products. Given the wide availability and use of neurosurgical adjuncts containing human or animal derived products, coupled with the heterogeneity within ethnic, religious, and social groups, each patient must be approached individually to ensure patient-specific concerns are identified and alternatives offered when appropriate.

Are vegans being overlooked in our prescribing practices: An orthopaedic perspective from Bristol, United Kingdom

Aim

Bristol is considered the vegan capital of the UK. The UK vegan index reveals that Bristol has 360,000 Google searches each month for Vegan content. However, the possible animal source of the medications we prescribe is not commonly contemplated. Medications in the UK must pass through animal trials prior to licensing and therefore cannot be vegan. There are, alternatives available for some medications, that do not contain animal products. The aim of this study is to review the presence of content of animal origin (CAO) in common medicines in Trauma and Orthopaedics (T&O) and explore alternatives.

Methods

We evaluated the presence and source of CAO in commonly used medications in T&O practice. The British National Formulary (BNF), our local pharmacy guidelines and the online Summary of Product Characteristics (SPCs) for the medications were reviewed. We also assessed the suitability of current COVID-19 vaccines for patients who have reservations against CAO.

Results

All unfractionated or standard heparin is porcine in origin; Fondaparinux is a simple alternative. Cholecalciferol (vitamin D3) manufacture involves the use of lanolin from sheep's wool. Vitamin D2 (ergocalciferol) is an alternative with no CAO. All widely available Covid-19 vaccines in the UK are suitable for administration to vegans and all religious faiths. Propofol, widely used as an anaesthetic agent, contains egg proteins.

Conclusion

Disclosure of animal content would help patients make informed choices. With an increasingly informed population and ethnic diversity, we should be aware of the drugs that may contain animal products so that we can offer alternatives. Sometimes, pharmaceutical companies cannot guarantee or differentiate the specific sources of animal-derived ingredients, as various suppliers are used in the manufacturing process and the sources can change on a regular basis. Patients are more likely to adhere to prescribed medicines if they have been involved in prescribing decisions.

The Need to Adjust the Informed Consent for Jewish Patients for Treatments Involving Porcine Medical Constituents

In order to obtain full informed consent for medical treatments, it is imperative to provide patients of diverse ethnic backgrounds with all relevant information. Since the pig is considered an impure animal in Judaism, Jewish patients may wish to be informed of porcine-derived substances used in treating. The present study is the first to explore the level of knowledge of Jewish participants as to whether the medical use of pig is permitted by their religion, and the extent to which they believe it should be permitted. 714 Jewish participants completed a study questionnaire that included 15 medical uses of pigs. Findings indicated that the knowledge of Jewish law regarding these uses is a significant mediator in predicting the attitude toward the permissibility of these uses. I conclude with practical recommendations as to how to enhance cultural competence and improve the informed consent process when treating Jewish patients with porcine-derived constituents.

The Use of Porcine-Derived Materials for Medical Purposes: What do Muslim and Jewish Individuals Know and Opine About It?

Porcine-derived medical products represent an effective solution for a wide range of human suffering, yet this may contradict Muslim and Jewish religious prohibitions against consuming pig. The present study evaluated the level to which Muslim and Jewish participants are knowledgeable about the conditions permitting porcine-based treatments and explored their attitudes toward the permissibility of these treatments. A questionnaire that presented fifteen medical uses of porcine-derived products was completed by 809 Muslims and 714 Jews. Neither Muslim nor Jewish participants are knowledgeable about the religious rulings of their religions which permit the use of pig for life saving. Participants of both groups objected to the view that porcine-derived materials should be permitted. The findings imply that the attitude toward porcine-derived materials for medical use is contingent upon the knowledge or lack thereof that individuals have regarding the permissibility of such use. We offer useful recommendations to improve the informed consent process before conducting porcine-based treatments.

Montgomery's legal and practical impact: A systematic review at 6 years

RATIONALE, AIMS AND OBJECTIVES

Six years ago, the Supreme Court judgement in Montgomery v Lanarkshire changed medical law. It introduced a new patient-based standard of care for the communication of treatment risks and alternatives, rejecting the doctor-based standard that had long governed all aspects of medical negligence. This is the first systematic review to analyse the literature on Montgomery. Our aim is to appraise and synthesize the literature on Montgomery's impact on medicine and the law and to identify areas for further academic enquiry and implications for professional guidance and training.

METHODS

Searches were run in Medline, Embase, PsycINFO, Web of Science, Scopus, Westlaw UK, HeinOnline, and LexisNexis. Two reviewers screened papers. Extracted data was analysed and discussed by an interdisciplinary team. PRISMA guidelines were followed.

RESULTS

Of the 1134 papers identified, 100 met the inclusion criteria. These papers revealed significant disagreement on four core sets of issues, focusing on Montgomery's impact on: (1) legal and professional duties; (2) medical practice; (3) the patient experience; and (4) litigation. The first set addresses whether the case actually changed doctors' legal and professional duties, the relationship between GMC guidance and medical law, and the boundaries of Montgomery. The second explores whether the decision has incentivized defensive medicine, its resource implications, and doctors' knowledge of it. The third concerns whether and how the decision has promoted patient autonomy and involvement in their own care. The fourth focuses on whether the case has caused an increase in litigation.

CONCLUSIONS

Despite the abundance of legal and medical literature on Montgomery, many issues remain unresolved. Empirical research is required for many of the questions. Doctrinal analysis informed by medical knowledge is also required to assess whether Montgomery may have unrecognized ramifications-for example, whether it will require the disclosure of risks associated with diagnostic uncertainty, where doctors advise patients without performing procedures.

Conscience and Vaccines: Lessons from Babylon 5 and COVID-19

Babylon 5, like other great sci-fi franchises, touched on important ethical questions. Two ethical conundrums relating to the series' main characters included providing life-saving treatment to a child against their parents' wishes and potential involvement with a highly beneficial but morally dubious medication. I use these cases to discuss some aspects of the COVID-19 vaccines' development and roll-out, demonstrating that people (be it patients or clinicians) might object to some vaccines due to reasonable ethics and safety-based concerns rather than due to an anti-vaxxer mind-set. I highlight that it would be disingenuous to lump these two groups of objections together for not all objections to specific vaccines are objections to vaccination in general. Rather, governments and pharmaceutical companies should seriously engage with the concerns of reasonable objectors to provide citizens with the appropriate products and ensure large vaccination uptake - in the case of COVID-19 this should include giving patients the choice of the product they will be inoculated with.

Why we should stop using animal-derived products on patients without their consent

Medicines and medical devices containing animal-derived ingredients are frequently used on patients without their informed consent, despite a significant proportion of patients wanting to know if an animal-derived product is going to be used in their care. Here, I outline three arguments for why this practice is wrong. First, I argue that using animal-derived medical products on patients without their informed consent undermines respect for their autonomy. Second, it risks causing nontrivial psychological harm. Third, it is morally inconsistent to respect patients' dietary preferences and then use animal-derived medicines or medical devices on them without their informed consent. I then address several anticipated objections and conclude that the continued failure to address this issue is an ethical blind spot that warrants applying the principles of respect for autonomy and informed consent consistently.

The Use of Bovine Pericardial Patches in Vascular Surgery: Where do we Draw the Line in Obtaining Informed Consent?

For a patient undergoing a carotid endarterectomy, induction with propofol, administration of heparin at the time of vessel clamping, use of a bovine pericardial patch for angioplasty, covering the wound with a hydrocolloid dressing and post-operative aspirin administration exposes the patient to animal products at every stage, from the moment they walk through the door. A number of articles have advocated obtaining informed consent when using animal products in healthcare but where should the line be drawn?

METHODS

A narrative review of the literature, specifically focussing on secular and religious beliefs about the use of animal products in healthcare. Application of ethical principles and GMC guidance to formulatea discussion with regards to the use of bovine pericardium in vascular surgery. Advanced literature search carried out using Pubmed and Google Scholar databases comparing patch material used forcarotid endarterectomy.

RESULTS

Disclosing the use of animal derived constituents in surgery is warranted under Beauchamp and Childress' four principals and highlighted in GMC guidance. Obtaining consent for the use of animalderived constituents at the time of surgery is something that should become a fundamental component of the written consent process and alternatives should be sought where available and practicable.

CONCLUSION

This review highlights the evidence available and discusses our current standpoint from both a legal and ethical aspect.

Animal-derived medications: cultural considerations and available alternatives

CONTEXT

Cultural competency is a cornerstone of patient-centered health care. Religious doctrines may define appropriate consumption or use of certain animals and forbid use of others. Many medications contain ingredients that are animal-derived; these medications may be unacceptable to individual patients within the context of their religious beliefs and lifestyle choices. Knowledge of animal-derived medications as a component of cultural competency can facilitate a dialogue that shifts focus from the group to the individual, away from cultural competency toward cultural humility, and away from a paternalistic provider/patient dynamic toward one of partnership.

OBJECTIVES

To explore how animal-derived drug components may impact medication selection and acceptability from the perspective of patients, physicians, and religious leaders as evidenced by studies that explore the question via survey or questionnaire. A secondary objective is to use the context of animal-derived drug products as a component of cultural competency to build a framework supporting the development of cultural humility.

METHODS

A systematic search was performed in the PubMed, CINAHL, Cochrane, and ProQuest databases using combinations of the following terms: "medication selection," "medication," "adherence," "pharmaceutical preparations," "religion and medicine," "religion," "animal," "dietary," "porcine," and "bovine." Studies that reported using surveys or questionnaires to examine patient, physician, or religious leader perspective on animal-derived medications published in English between 1990 and 2020 were included. Review articles, opinion pieces, case reports, surveys of persons other than patients, religious leaders, or physicians, and studies published in languages other than English were excluded. Three authors independently reviewed articles to extract information pertaining to perspectives on animal-based medication ingredients.

RESULTS

Eight studies meeting the described criteria were found that queried beliefs or knowledge of patients, religious leaders, or physicians regarding medications and medical products of biologic origin. Those studies are described in full in this review.

CONCLUSIONS

Knowledge of animal-derived ingredients may help open conversations with patients around spiritual history and cultural competency, particularly for those patients belonging to religious sects with doctrines that define appropriate use of human- or animal-derived products. Further formal study is needed to explore more fully the extent to which religious beliefs may impact selection of animal- or human-derived medications. Guidelines developed from this knowledge may aid in identifying individual patients with whom the discussion may be particularly relevant. More studies are needed to quantify and qualify beliefs regarding animal-derived medication constituents.

Should parents be asked to consent for life-saving paediatric interventions?

Informed consent, when given by proxy, has limitations: chiefly, it must be made in the interest of the patient. Here we critique the standard approach to parental consent, as present in Canada and the UK. Parents are often asked for consent, but are not given the authority to refuse medically beneficial treatment in many situations. This prompts the question of whether it is possible for someone to consent if they cannot refuse. We present two alternative and philosophically more consistent frameworks for paediatric proxy consent. The first allows meaningful consent (parents may say ‘yes’ or ‘no’ to treatment), provided that parents are medically informed/competent and intend the health and well-being of their child. In the second solution, medical practitioners or the state consent for treatment, with parents only being consulted to help give insight to the child’s circumstances. While we contend that either of these two options is superior to the insincerity of the present paradigm, we suggest that the first solution is preferable.

A review of the use of biological mesh products in modern UK surgical practice: a religious and cultural perspective

INTRODUCTION

The UK is an increasingly multicultural society. This change coincides with an increasing use of animal products in medicine and surgery and a change in the UK law of consent. The refusal of Jehovah's Witnesses to accept blood products is well known, but the use of animal products in surgery is a neglected topic. As society becomes more diverse and medicine becomes ever more advanced, there is increasing potential for a mismatch between what is medically possible and what is acceptable from a religious perspective.

METHODS

Surgical products were identified by searching the literature and contacting manufacturing companies. Literature was identified by using PubMed and OVID (MEDLINE). Religious views were established by contacting national bodies for each group.

FINDINGS

The views of common UK religious groups and the constituent parts of biological meshes are summarised in tables intended to be used as a reference during clinical practice. On an elective basis, the Islamic, Hindu. Sikh and Jain leaders contacted had strong views on avoiding animal derived products. The Christian and Jewish leaders contacted did not. All religious leaders contacted accepted the use of mesh derived from human tissue. All products, including those of porcine and bovine origin, were acceptable to all leaders contacted if the procedure was performed to save life. The highlighting of this issue should prompt earlier consideration and discussion in the surgical planning and the consenting process with all final decisions taken by both the surgeon and the individual patient.