Ashley Treatment

The Ashley Treatment refers to a controversial set of medical procedures undergone by an American child, 'Ashley X'. Ashley, born in 1997, has severe developmental disabilities due to static encephalopathy; she is assumed to be at an infant level mentally and physically. The treatment included growth attenuation via high-dose estrogens, hysterectomy, bilateral breast bud removal, and appendectomy. In June 2016, after 18 years of searching, Ashley's condition was determined to be the result of a de novo (not inherited, i.e. a mutation) and non-mosaic Single-nucleotide polymorphism in the GRIN1 gene, which is implicated in neurotransmission.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.The purpose of this paper is to provide a brief review of the 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. The Ashley Treatment refers to a controversial set of medical procedures undergone by an American child, 'Ashley X'. Ashley, born in 1997, has severe developmental disabilities due to static encephalopathy; she is assumed to be at an infant level mentally and physically. The treatment included growth attenuation via high-dose estrogens, hysterectomy, bilateral breast bud removal, and appendectomy. In June 2016, after 18 years of searching, Ashley's condition was determined to be the result of a de novo (not inherited, i.e. a mutation) and non-mosaic Single-nucleotide polymorphism in the GRIN1 gene, which is implicated in neurotransmission. 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. Ashley's parents granted their first written interview to CNN Health in March 2008,and their second to The Guardian in March 2012.In addition, The Guardian published two interviews with mothers of a girland a boywho had completed the treatment. A 2014 TV program and article tell the similar story of a girl in New Zealand.A survey on growth attenuation among pediatric endocrinologists was published in July 2015. Ashley was born with a severe brain impairment of genetic cause, 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. In 2004 when Ashley was six and a half years old, she began to show signs of puberty 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. A variety of treatments have been used over the last several decades to deal with these issues. In July 2004, Ashley had a hysterectomy (to prevent menstruation) and surgical removal of her nascent breast buds (to prevent development). She also underwent an appendectomy (because Ashley wouldn't be able to vocalize symptoms). The surgery was performed at Seattle's Children's Hospital and Regional Medical Center. In addition, in December 2006 she completed estrogen therapy through dermal patches, which sped up the natural closure of her growth plates. 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. 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 by future caregivers when her parents will no longer be able to care for her.