Objectives
At the end of the session, the student must be able to:
- Conduct informed consent
- Maintain confidentiality
- Describe issues of justice relating to access to obstetric and gynecologic care
- Apply a systematic approach to ethical problems based on ethical principles and integrate with the medical decision
- Discuss ethical dilemmas in obstetrics and gynecology
Table of contents
Ethical Dilemmas
C-Section
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There is an increased incidence of cesarean section.
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The WHO global study 2005 revealed that a high rate of cesarean section does not contribute to an improved pregnancy outcome, rather is associated with increased maternal morbidity and mortality with a higher incidence of newborn illness due to low birth weight.
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Delayed decision of C/S must be avoided as this may lead to undesirable situations like obstructed labor causing maternal and fetal morbidity and mortality.
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Inform and counsel women in this matter.
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Performing Caesarean section for non-medical reasons is ethically not justified.
20 years old 20 weeks PG requests elective c/s baby because of fear of pain and cosmetics Being physician what is your role?
ETHICAL ASPECTS REGARDING CAESAREAN DELIVERY FOR NON-MEDICAL REASONS
- Many factors, medical, legal, psychological, social and financial have contributed to this increase.
- Efforts to reduce the excessive use of this procedure have been disappointing.
- Caesarean section is a surgical intervention with potential hazards for both mother and child. It also uses more health care resources than normal vaginal delivery.
- Physicians have a professional duty to do nothing that may harm their patients with clear evidence of a net benefit to health.
- Recently obstetricians have had increasing requests from women to be delivered by Caesarean section for personal rather than for medical reasons.
- Though we have hard evidence on the relative risks and benefits of term Caesarean delivery for non-medical reasons, as compared with vaginal delivery.( normal vaginal delivery is safer in the short and long term for both mother and child) but what about patient rights?
- Surgery on the uterus also has implications for later pregnancies and deliveries.
Contraception and Sterilization
Anomaly scan on 20th week found out that the baby is having deformity and chances are that the baby will be abnormal. Patient is shocked to hear the news as she was not expecting anything
How can you help the women?
Discussion
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Women carrying a fetus with severe congenital anomalies or one at high risk for long term severe disability have the right to discuss and access a termination of pregnancy. ( Religion ,Law, Believes)
- The decision to continue or terminate the pregnancy should always rest with the Woman/Couple
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Regardless of the legal availability of termination of pregnancy, there remains a responsibility to inform and counsel women about the risks and benefits of available fetal diagnostic testing, which may reveal severe congenital anomalies.
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As part of the counselling, a discussion of the benefits and harms of that knowledge should be done when options for management including termination are sometimes limited.
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If she agrees to carry out testing, her consent should clarify which details of information she would like to receive.
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It is unethical and, in many countries, illegal to permit sex of the fetus to influence the decision to terminate a pregnancy.
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In a situation of a multiple pregnancy, when one fetus has severe congenital anomalies, the decision for management of the pregnancy should always consider the well being of the normal fetus first.
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Termination of pregnancy after 22 weeks should follow ethical guidance in “Ethical aspects of termination of pregnancy following prenatal diagnosis” , what about in Islam?
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Following termination of pregnancy, consent should be obtained to confirm the fetal malformations and parents should be informed and counseled.
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To assist the grieving process, parents should be offered the option of viewing the lost fetus as well as to perform the last rites as per their wishes.
Drugs in pregnancy and lactation
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Though only a small group of drugs are known to be harmful to the fetus;
- Wise precaution is to avoid vast majority of drugs; if not genuinely indicated, if there is less evidence of fetal safety.
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FDA recommendation of drug should be followed.
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NOT to use off- license drugs (If damage occurs; he will be blamed of negligence when a licensed alternative drug is used)
IVF
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Prior to agreeing for IVF, COUPLE must be informed and counselled about the risks and benefits of the proposed techniques.
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Women consenting to the use of prenatal diagnostic procedures should be asked in advance whether they want any ensuing information to be withheld from themselves and/or others during the remainder of the pregnancy.
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Decisions about treating or refusing to treat patients should reflect the balance between patients’ autonomy, and the clinical team and patients’ responsibility to the future children.
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Services should not be provided to anyone who is incapable of giving a valid consent, or has not given a valid consent to examination and treatment, or storage and use of gametes or reproductive tissues when required.
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Clinicians should be encouraged to refuse to initiate any treatment option they regard as having a very poor prognosis, provided that they fully inform the patients and offer information about referrals, if appropriate.
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Ensuring high success rates by not treating patients with poor prognoses should be regarded as unethical.
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There is increasing litigation following the adverse outcome of multiple pregnancy, with criticism of poor counselling and overoptimistic forecasts, especially in the financial driven private sector.
Reference
Hacker & Moore 6th edition, Introduction, A Life-Course Perspective for Women’s Health Care: Safe, Ethical, and Effective Practice, Title: Ethical Practice of Obstetrics and Gynecology