Treating Children With Growth Hormone: Moral, Ethical, And Other Considerations

I want to call your attention to two recent articles in the New York Times that might just be of interest to you if you are a physician who cares for short children, if you are a parent of a short child or if you are short or just want to be taller.  Both articles were written by Jane E. Brody.  The first appeared in the Science Times section of the newspaper, Tuesday May 10, 2010 and was entitled “A Plus Side for Human Growth Hormone.”  As an aside, that section of the newspaper had several other very interesting articles including one on mammoth hemoglobin (here I don’t mean big hemoglobin but hemoglobin in prehistoric animals) and another on efforts to teach physicians about health care costs.  The other article was published Tuesday May 11, 2010 and was entitled “Short?  No Worries: Just Ask this Texan.

The first article is an excellent review on the current status of growth hormone therapy in children.  The newspaper article was based on a medical article published in April 2010 by Judith L Ross in the medical journal Pediatrics.  The newspaper article more or less summarizes the medical journal article and, in my opinion, provides an excellent and concise overview of the current status of growth hormone use in short children.  Ms. Brody and Dr. Ross  both danced around the somewhat contentious issue of using growth hormone injections to make normal but short children taller but who is to blame them?

The second article is basically a summary of a recently published book by John Schwartz entitled “Short: Walking tall When You’re Not tall at All.”  The book was published by Roaring Brook Press and, according to Ms. Brody, was written primarily for short teenagers.  I have not read the book yet but I will.  Based on the newspaper article, I think the book (or the newspaper article if you have lots of things “on your plate” at the moment) would be worthwhile reading not only for short teens but also their parents, friends, and physicians.

The Issues

In 1985, The U.S. Food and Drug Administration (FDA) approved the use of biosynthetically derived human growth hormone for children with growth hormone deficiency.  Since then, use of growth hormone has been a major growth industry; world-wide, annual sales of growth hormone are well into the billions of dollars.  The uses for growth hormone, legal and illegal, have expanded dramatically.  At present, only a small percentage of people taking growth hormone injections actually have growth hormone deficiency, as originally defined- some physicians and many pharmaceutical companies believe that growth hormone testing fails to identify many people (children and adults) who would benefit from treatment with the hormone.  I do not want to get into the issues here except to say that the question of whether to treat a person with growth hormone has become a very complicated one, with moral, ethical, and economic factors to consider.

There is no question that most short children who have no demonstrable medical condition responsible for the short stature can be made taller by several inches over their genetic potential (whatever that means these days) if they take enough growth hormone for long enough before their bone growth centers close.  The questions are whether the potential adult height benefit, whatever that might or might not be is worth it with respect to costs and complication risks.  I believe that reading both of the Jane Brody newspaper articles will give you a pretty good foundation for understanding the issues.  I’m not picking sides (at least in this entry) but one important consideration not really addressed in the articles is that whenever an insured patient is treated for whatever and the insurer “covers” the costs, all people covered by that insurer share in the costs.  Is it “fair” to make many people pay to enable a person to gain a few inches in height when the person does not have an demonstrable medical condition responsible for the short stature?   In my view, that’s an interesting question.  We cannot expect companies who sell growth hormone to give us an unbiased answer to the question.  Likewise, we cannot expect a physician who  benefits financially from a relationship with the company, to give an unbiased answer to the question.  Very interesting stuff.  I think I should have taken more philosophy courses in college rather than focusing on pre-med ones. How was I to know?

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