The Case of Lucy Villafane: Ethical Dimensions of Beneficence and Non-Maleficence

Lucy's Background and Medical History

Task:

Lucy Villafane, age nineteen, is attractive, well-adjusted and has just completed her freshman year at a state university which she is attending on a full tuition athletic scholarship.  She played women's basketball and tennis throughout high school and was twice a finalist in regional gymnastics competitions.  She is the only child of older, immigrant, uneducated and minimally English-speaking parents.  They are, however, deeply caring toward and proud of their daughter.

When Lucy was fifteen, her mother took her to a clinic, the family’s only access to the health care system at the time, hoping to discover why Lucy had not yet begun her menstrual cycle.  The physician there referred them to a gynecologist by whom it was determined that although Lucy displayed all the outward physical appearances of a well-developed female, she lacked female reproductive organs.  Lucy had a vagina but no uterus.  Lucy and her mother were told only that Lucy would be unable to have biological children, and no other details were provided by the gynecologist.

The gynecologist did, however, refer her case for further genetic consultation where it was determined that Lucy possessed the XY chromosome rather than the XX and was, therefore, genetically a male.  Although the geneticist reported these findings to the gynecologist, neither relayed that information to either Lucy or her mother.  The gynecologist, in particular, had profound reservations regarding his ability to explain this information to Lucy or her parents and, indeed, their ability to comprehend it. 

Recently–but four years after the initial consultations–while exercising at a local health club, Lucy sustained a severe blow to her lower abdomen as the result of colliding with equipment being used by another person.  The pain in Lucy's abdomen did not respond to pain relievers and muscle relaxants, and her gynecologist (the same gynecologist) ordered a CT-scan of her abdomen. 

That procedure revealed the presence of two undescended male testes.  The physician was perplexed, but he told Lucy and her parents that tests indicated the presence of two “precancerous” masses in her abdomen for which he strongly urged immediate surgical removal.  Lucy and her parents readily agreed.

Lucy is now in the operating suite, and it has become obvious to the surgical staff what is actually being performed as opposed to what Lucy was told would be done and to which she had consented.  Several nurses and the anesthesiologist are visibly upset by what they perceive as intentional deception.  When questioned, however, the surgeon, to whom the gynecologist had explained the entire situation and who agreed to perform the procedure, states, "She has been a girl all her life.  She knows that she lacks reproductive organs and will never have children.  Besides, she needs the scholarship to complete college.  She was never told before; why should we tell her now?  Let’s just finish and close.”  The team proceeds to complete the surgery.

Lucy's parents and her boyfriend are waiting in the family lounge.
 
1.What are the dimensions of beneficence and non-maleficence which are at stake in this case?
2.What “gender” is Lucy? How is that determined and by whom?
3.Would you "undo history," potentially risking severe psychological trauma for Lucy and her autonomy, and tell her that she is actually genetically a male? If so, how would you proceed and when?  If not, how would you justify silence?
4.Regardless of the attitude of the surgeon and the gynecologist, does anyone else now party to the “facts” discovered during surgery have any obligation?
5.What additional resources would you marshal to address the issues in this case?
6.What do you consider the ethically indicated procedure and why?