This article may be unbalanced toward certain viewpoints. Please improve the article by adding information on neglected viewpoints, or discuss the issue on the talk page.(November 2021)
The principal purpose of the treatment was to improve Ashley's quality of life by limiting her growth in size, eliminating menstrual cramps and bleeding, and preventing discomfort from large breasts. The combination of the surgery and the estrogen therapy attracted much public comment and ethical analysis in early 2007, both supportive and condemning.[3][4]
Ashley's parents granted their first written interview to CNN Health in March 2008,[5]
and their second to The Guardian in March 2012.[6]
In addition, The Guardian published two interviews with mothers of a girl[7]
and a boy[8]
who had completed the treatment. A 2014 TV program and article tell the similar story of a girl in New Zealand.[9][10]
A survey on growth attenuation among pediatric endocrinologists was published in July 2015.[11][12]
Background
Ashley was born with a severe brain impairment of genetic cause,[2] termed a "static encephalopathy" because it does not improve. Although she sleeps and awakens, and breathes on her own, she is unable to raise her head, sit up, hold an object, walk, or talk, and must be tube-fed. Nonetheless, she is alert and responsive to her environment, particularly enjoying the music of Andrea Bocelli. Her parents have nicknamed Ashley "Pillow Angel", because she always remains where she is placed, which is usually on a pillow.[2]
In 2004 when Ashley was six and a half years old, she began to show signs of puberty[2] and her parents and doctors began to anticipate a variety of issues common in children with severe neurological impairments. As these children grow larger, it takes more strength to move them and provide basic bodily care, raising the risk of pressure sores from immobility. Precocious puberty is common in children with various forms of severe brain damage. The early appearance of secondary sexual characteristics is often distressing to parents and caretakers. Many parents of severely disabled children explore possible ways to avoid having to deal with menstruation and fertility in a diapered child.[citation needed] A variety of treatments have been used over the last several decades to deal with these issues.
Ashley's story first broke in October 2006, in the Archives of Pediatrics & Adolescent Medicine. In January 2007, her parents, who wish to remain anonymous, set up a blog to explain their reasoning for their decision and to share their story with families of other children who might benefit.[2]
Arguments for the treatment
The parents state that they sought such treatment for the best interests of their daughter, namely, to enable them to personally continue constant care for her at home; to maximize her inclusion in family activities; to avoid the cramps and discomfort associated with menstruation; and to avoid the discomfort from large breasts (which runs in Ashley's family) while lying down or strapped in the chest area while in her wheelchair. Furthermore, they cited additional side benefits: to reduce the risk of bedsores; to prevent breast cancer and fibrocystic growth (both of which have occurred in her family); to prevent pregnancy; and to prevent appendicitis, which occurs in 5% of the population and which would be difficult to diagnose in Ashley as she would be unable to communicate the symptoms. They also believe that without secondary sexual characteristics, Ashley will be less vulnerable to sexual abuse[2] by future caregivers when her parents will no longer be able to care for her.
In an article published in June 2009 on Growth Attenuation, two pediatric endocrinologists and two bioethicists concluded as follows:
Our analysis suggests that growth attenuation is an innovative and sufficiently safe therapy that offers the possibility of an improved quality of life for nonambulatory children with profound cognitive disability and their families. Pediatricians and other care providers should include discussion of these options as part of anticipatory guidance around the age of 3 years so that, if elected, potential clinically meaningful benefits of growth-attenuation therapy can be realized.[13]
The two bioethicists from the previous article also published an article in January 2010 cataloging and countering the criticisms that targeted the Ashley Treatment, and concluded as follows:
The purpose of this paper is to provide a brief review of the [Ashley Treatment] case and the issues it raised, then address 25 distinct substantive arguments that have been proposed as reasons that Ashley's treatment might be unethical. We conclude that while some important concerns have been raised, the weight of these concerns is not sufficient to consider the interventions used in Ashley's case to be contrary to her best interests, nor are they sufficient to preclude similar use of these interventions in the future for carefully selected patients who might also benefit from them.[14]
Results
After a year, Ashley's parents considered her treatment a success: She will never experience menstrual discomfort and cramps, she will always be flat chested and avoid breast related discomfort and other issues, and with her growth plates closed, she has reached her adult height of 53 inches (135 cm, or 4 ft 5 in) and weight of 63 pounds (29 kg), an estimated reduction of her potential height and weight of 20% and 40%, respectively.[tone][15]
Reactions
In the United States, Arthur Caplan, of the University of Pennsylvania's Center for Bioethics, has criticized the Ashley Treatment in an MSNBC editorial, arguing that it is "a pharmacological solution for a social failure—the fact that American society does not do what it should to help severely disabled children and their families."[16]
Three renowned bioethicists spoke in support of the treatment and discussed different aspects of it in opinion statements presented by Scientific American.[17]
Ashley's parents reported that 95% of the 5,000 emails they received were in support of the treatment, many of these testimonies and support emails are posted on Ashley's blog.[2] The parents indicated that there was especially strong support among parents and caregivers of children with similar conditions to Ashley's, those who have the direct experience. They cite several ethicists in support of the treatment, including
George Dvorsky,[21]Peter Singer,[22]
Norm Fost,[23] and
Doug Diekema.[24]
In the United Kingdom, the British Medical Association stated, "If a similar case occurred in the UK, we believe it would go to court and whatever decision was ruled would be in the best interests of the child." Dr. Peter Hindmarsh, Professor of Paediatric Endocrinology at Great Ormond Street Hospital was troubled by the treatment decision being taken by a hospital ethics committee. "'I am not sure the ethics committee was the right place to decide,' he said, adding that it was not clear who represented the child's interests when it went before the committee."[25]
In Canada, ethicist Arthur Schafer's nationwide opinion piece[26] defending the operation as justifiable considering Ashley's comfort engendered criticism from disability rights activists such as Dave Hingsburger[27] of the York Central Hospital and Keenan Wellar from the LiveWorkPlay self-advocacy organization. In a rebuttal,[28] Wellar attacked the notion that Ashley's limited mental abilities justified the decisions made on her behalf: "Infants have human rights even though they can't speak for themselves. Why should Ashley have received any less consideration?"
On May 8, 2007, an investigative report done by Disability Rights Washington (formerly The Washington Protection and Advocacy System) in conjunction with The Utah Disability Law Center criticized the hospital that performed this controversial procedure for violating Washington State law,[29] which is disputed by the family's attorney.
^Gunther, DF; Diekema, DS (2006). "Attenuating growth in children with profound developmental disability: a new approach to an old dilemma". Archives of Pediatrics & Adolescent Medicine. 160 (10): 1013–7. doi:10.1001/archpedi.160.10.1013. PMID17018459.