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Table of Contents
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
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39. Pregnant Patients
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By examining the patient’s tongue, medical practitioners find out the diseases of the body and philosophers the diseases of the mind.
~ Justin Martyr
Autonomy Dilemma
Autonomy and Best Interests in Pregnant Patients
Dr. Emily Smith was puzzled. She had been working on a complicated case involving a pregnant patient who had refused a medical treatment that was critical for both her own and her fetus’s well-being. The patient, Mrs. Jackson, had a medical history of hypertension, which was causing complications in her pregnancy. Dr. Smith had recommended a particular medication that would have reduced the risk of preterm birth, but Mrs. Jackson had refused.
Dr. Smith respected her patient’s autonomy and had explained the risks and benefits of the medication, but Mrs. Jackson was adamant. She was worried that the medication would harm her fetus and had read several online articles that claimed the medication was dangerous. Dr. Smith had tried to reassure her that the medication was safe and effective, but Mrs. Jackson remained unconvinced.
Dr. Smith had consulted with her colleagues and legal advisors, but the situation remained unclear. She knew that state laws varied on the issue of a pregnant patient’s right to refuse treatment and that the American College of Obstetricians and Gynecologists (ACOG) emphasized the importance of respecting a pregnant patient’s autonomy. Dr. Smith felt like she was walking on a tightrope, trying to balance the patient’s autonomy and her professional obligations to provide the best care possible.
One day, Dr. Smith received a call from Mrs. Jackson’s husband. He informed her that Mrs. Jackson had been rushed to the hospital and was in critical condition. Dr. Smith rushed to the hospital, fearing the worst. When she arrived, she found that Mrs. Jackson had suffered a severe stroke, which had caused extensive brain damage. The fetus had also been affected, and the chances of survival for both the patient and the fetus were low.
Dr. Smith was devastated. She realized that the situation could have been prevented if Mrs. Jackson had agreed to the medical treatment. Dr. Smith felt like she had failed both her patient and her profession. She began to investigate the situation further, determined to understand what had gone wrong.
As she delved deeper, Dr. Smith uncovered some startling information. Mrs. Jackson had been reading articles on an unregulated website that promoted alternative medicines and therapies. These articles had convinced her that the medication Dr. Smith had recommended was dangerous. Dr. Smith realized that Mrs. Jackson’s decision to refuse treatment had been influenced by misinformation and fear.
Dr. Smith felt a sense of urgency. She knew that healthcare providers needed to be educated on the importance of respecting a pregnant patient’s autonomy while also providing the best possible care. She began to develop a curriculum on the topic, using her own experience as a case study.
Dr. Smith’s curriculum emphasized the importance of obtaining explicit informed consent from pregnant patients and prioritizing their best interests. She stressed that the patient-practitioner relationship was with the pregnant patient, not with the fetus, to prevent the pregnant patient from being seen as a “fetal container.” Dr. Smith also emphasized that once the fetus was born, it had the protective rights of the state, and the practitioner must prioritize the newborn’s best interests.
Dr. Smith’s curriculum was widely adopted by medical institutions across the country, and she became a leading expert on the topic. She had turned her tragedy into an opportunity to educate healthcare providers and prevent similar situations from occurring in the future.
As for Mrs. Jackson, Dr. Smith made sure to visit her regularly and provide the best possible care for her and her child. She hoped that her curriculum would prevent similar tragedies and that healthcare providers would remember the importance of respecting a pregnant patient’s autonomy while also providing the best possible care.
Abstract
The right of a pregnant patient to refuse or withdraw from medical treatment has been a matter of controversy, as state laws differ on whether such decisions can affect the fetus. The American College of Obstetricians and Gynecologists (ACOG) states that a pregnant woman’s decision to refuse treatment should be respected, and any fetal intervention must have explicit informed consent from the pregnant woman. ACOG argues that the patient-practitioner relationship is with the pregnant woman and not with the fetus to ensure the woman’s autonomy and prevent her from being seen as a “fetal container.” The medical practitioner must obtain informed consent from the pregnant patient and prioritize the patient’s best interests, informed by principles of beneficence and nonmaleficence. State laws on the status of the fetus as a person vary, but once the fetus is born, it has the protective rights of the state and the practitioner must prioritize the newborn’s best interests.
**
Think
[39:1] Most of the time, the pregnant patient’s best interests, as determined by the patient’s reasonable goals, values, and priorities, maximize both the patient’s and fetus’s well-being. However, there are times when a pregnant patient may wish to refuse or withdraw from a medical standard of care treatment meant for maximizing the well-being of the pregnant patient, the well-being of the fetus, or the well-being of both the patient and fetus. State laws differ as to whether or not a practitioner should respect a pregnant patient’s autonomous decision to accept, decline, or withdraw from a particular medical treatment when such decisions affect a fetus, or in some states, even a fertilized ovum, known as an embryo.
[39:2] In contrast to some state laws, The American College of Obstetricians and Gynecologists (ACOG) states:
Pregnancy is not an exception to the principle that a decisional capable patient has the right to refuse treatment, even treatment needed to maintain life. Therefore, a decisional capable pregnant woman’s decision to refuse recommended medical or surgical interventions should be respected.
[39:3] A joint guidance document from the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) states:
Any fetal intervention has implications for the pregnant woman’s health and necessarily her bodily integrity, and therefore cannot be performed without her explicit informed consent.
[39:4] The American College of Obstetricians and Gynecologists (ACOG) also states:
When the pregnant woman and fetus are conceptualized as separate patients, the pregnant woman and her medical interests, health needs, and rights can become secondary to those of the fetus. At the extreme, construing the fetus as a patient sometimes can lead to the pregnant woman being seen as a “fetal container” rather than as an autonomous agent.
[39:5] To prevent the pregnant patient from being construed as a “fetal container” and for the pregnant patient to retain their autonomous decisional authority, the patient-practitioner relationship is by many considered to be with the pregnant patient, not with the fetus within her womb. In other words, the fetus is considered a part of the pregnant patient’s body, not an independent entity capable of having a fetal-practitioner relationship independent of the pregnant patient-practitioner relationship. However, some state laws argue for the protection of all persons and define personhood as being established at fetal viability, fetal heartbeat, or even as early as fertilization.
Assess
Patient: 1) Autonomy
[39:6] The medical practitioner must get the informed consent authorization from the pregnant patient before providing any medical treatment. It is the pregnant patient’s informed consent as to whether the patient will accept, refuse, or withdraw medical treatment based on the pregnant patient’s reasonable goals, values, and priorities. Usually, the pregnant patient’s interests align with the practitioner’s interests in maximizing the best interests of the pregnant patient and the patient’s developing fetus. However, circumstances can occur where the patient’s health and the developing fetus’s health are incompatible, making it impossible to attain both patient and fetal health.
[39:7] The American College of Obstetricians and Gynecologists (ACOG) states:
Circumstances may arise during pregnancy in which the interests of the pregnant woman and those of the fetus diverge. … For example, if a woman with severe cardiopulmonary disease becomes pregnant, and her condition becomes life-threatening as a result, her obstetrician gynecologist may recommend terminating the pregnancy.
[39:8] Under such conditions, the practitioner should inform the pregnant patient of the treatment options, including no treatment, the risks, and benefits of the treatment options, ensuring that the patient’s decision is not being manipulated through the disclosure of only selective information and not being coerced by credible threats, and allow the pregnant patient to make the informed consent decision to accept, decline, or withdraw from the medical standard of care treatment options.
Practitioner: 2) Beneficence & 3) Nonmaleficence
[39:9] The prime directive of the medical practitioner is to maximize the patient’s best interests in accordance with the pregnant patient’s reasonable goals, values, and priorities. The patient’s best interests are materialized by the professional principles of beneficence (do good) and nonmaleficence (do no harm). Since the pregnant patient should not be considered a mere “fetal container,” The American College of Obstetricians and Gynecologists argues that the professional patient-practitioner relationship is with the pregnant patient, and not with the fetus. Currently several state laws challenge this position.
[39:10] Regardless of disagreeing state laws regarding the status of the ovum and fetus, once a fetus is born, it is agreed that the newborn child has all the protective rights of the state. The practitioner now has a universally recognized patient-practitioner relationship with the child as well as with the mother. This patient-practitioner relationship means that the practitioner must maximize the newborn child’s best interests based on the medical standards of care regardless of whether the parent(s) consent or refuse to consent to the child’s medical care. Certainly, the practitioner should pursue the informed consent from the parent(s) before providing treatment to the child. However, if consent is not attainable and if not providing the medical standards of care will significantly increase the risk of harm to the newborn, then the medical professional is obligated professionally, legally, and morally to provide the medical standards of care.
Public Policy: 4) Justice
[39:11] A pregnant patient’s legal right to autonomously; consent, refuse, and withdraw from medical treatment options is now regulated by federal and various inconsistent state laws.
[39:12] However, once the fetus has emerged from the uterus, the now child is conferred with all the civil rights associated with being a citizen, and the state is federally mandated to protect the well-being of the child as a vulnerable citizen. Once born, the state has protective interests and mandates that the practitioner provides the child with the medical standards of care. Failure to provide the medical standards of care to the minor is tantamount to child neglect and medical malpractice.
[39:13] Parental consent is not legally required to provide a minor pregnant patient with prenatal care because, as a matter of justice (be fair), the state is mandated to protect its vulnerable population’s civil rights and liberties. It is not that the parents of the minor pregnant patient do not have the right to choose appropriate medical care for their dependents as clearly they do; rather, it is that the parent(s) do not have the right to refuse the medical standards of care for their pregnant child. The moral weight of the principles of beneficence (do good), nonmaleficence (do no harm), and justice (be fair) under certain circumstances is greater than the weight of the parent’s autonomy (informed consent) when medical professionalism and social justice together maximize the minor’s best interests in contrast with the parent’s refusal of informed consent.
[39:14]
Conclude
[39:15] The medical practitioner should respect the pregnant patient’s autonomous authority to consent, refuse, or withdraw from any medical standard of care treatment options per state law. However, after a fetus is born and becomes a child with all the conferred social rights, then the practitioner has the obligation under the principles of professional beneficence (do good) and professional nonmaleficence (do no harm) to provide the medical standards of care to the child even if it requires the practitioner to override the parent’s lack of consent. The principle of social justice (be fair) requires that the practitioner provide medical standards of care to maximize the child’s best interests. Refusing medical standards of care would violate the professional principle of nonmaleficence (do no harm) and the social principle of justice (be fair) and would legally be considered child neglect, a type of medical malpractice.
[39:15] In summary, pregnant patients have the right to refuse or withdraw from medical treatment but state laws vary on whether such decisions can affect the fetus. The American College of Obstetricians and Gynecologists (ACOG) emphasizes the importance of respecting the pregnant patient’s autonomy and obtaining explicit informed consent for any fetal intervention. The practitioner must prioritize the patient’s best interests, informed by principles of beneficence and nonmaleficence. State laws on the status of the fetus as a person vary, but once the fetus is born, it has the protective rights of the state, and the practitioner must prioritize the newborn’s best interests. The principles of justice and the practitioner’s professional and legal obligations is to provide medical standards of care to the child, even if it requires overriding parental consent.
**
Circumstances in Which Minors
Do Not Require Parental Consent
- • Emergency care
- • Sexually transmitted infections
- • Contraception
- • Substance abuse (most states)
- • Prenatal care
Medical
- • Homeless
- • Parent
- • Married
- • Military
- • Financially independent
Emancipated
Minor
39. Review Questions
1. State laws differ as to whether or not a practitioner should respect a pregnant patient’s autonomous decision to accept, decline, or withdraw from a particular medical treatment when such decisions effect a fetus, or in some states, even a fertilized ova, known as an embryo.
2. The American College of Obstetricians and Gynecologists argues that the professional patient-practitioner relationship is with the pregnant patient, not with the fetus.
3. Once a fetus is born, the practitioner then must maximize the child’s best interests based on medical standards of care regardless of whether or not the parent(s) consents to the care.
4. In all states, a pregnant patient retains their fundamental legal right to autonomously consent, refuse, and withdraw from treatment options with or without the consideration of the fetus.
5. Once a fetus is born, the state has protective interests and mandates that the practitioner provides medical standards of care. Failure to do so is tantamount to child neglect and a type of medical malpractice.
**
Wrong 😕
[39:1] Most of the time, the pregnant patient’s best interests, as determined by the patient’s reasonable goals, values, and priorities, maximize both the patient’s and fetus’s well-being. However, there are times when a pregnant patient may wish to refuse or withdraw from a medical standard of care treatment meant for maximizing the well-being of the pregnant patient, the well-being of the fetus, or the well-being of both the patient and fetus. State laws differ as to whether or not a practitioner should respect a pregnant patient’s autonomous decision to accept, decline, or withdraw from a particular medical treatment when such decisions affect a fetus, or in some states, even a fertilized ova, known as an embryo.
CORRECT! 🙂
[39:1] Most of the time, the pregnant patient’s best interests, as determined by the patient’s reasonable goals, values, and priorities, maximize both the patient’s and fetus’s well-being. However, there are times when a pregnant patient may wish to refuse or withdraw from a medical standard of care treatment meant for maximizing the well-being of the pregnant patient, the well-being of the fetus, or the well-being of both the patient and fetus. State laws differ as to whether or not a practitioner should respect a pregnant patient’s autonomous decision to accept, decline, or withdraw from a particular medical treatment when such decisions affect a fetus, or in some states, even a fertilized ova, known as an embryo.
CORRECT! 🙂
[39:4] The American College of Obstetricians and Gynecologists (ACOG) also states:
When the pregnant woman and fetus are conceptualized as separate patients, the pregnant woman and her medical interests, health needs, and rights can become secondary to those of the fetus. At the extreme, construing the fetus as a patient sometimes can lead to the pregnant woman being seen as a “fetal container” rather than as an autonomous agent.
Wrong 😕
[39:4] The American College of Obstetricians and Gynecologists (ACOG) also states:
When the pregnant woman and fetus are conceptualized as separate patients, the pregnant woman and her medical interests, health needs, and rights can become secondary to those of the fetus. At the extreme, construing the fetus as a patient sometimes can lead to the pregnant woman being seen as a “fetal container” rather than as an autonomous agent.
CORRECT! 🙂
[39:10] Regardless of disagreeing state laws regarding the status of the ovum and fetus, once a fetus is born, it is agreed that the now child has all the protective rights of the state. The practitioner now has a universally recognized patient-practitioner relationship with the child and mother. This patient-practitioner relationship means that the practitioner must maximize the newborn child’s best interests based on the medical standards of care regardless of whether the parent(s) consent or refuse to consent to the child’s medical care. Certainly, the practitioner should pursue the informed consent from the parent(s) before providing treatment to the child. However, if consent is not attainable and if not providing the medical standards of care will significantly increase the risk of harm to the newborn, then the medical professional is obligated professionally, legally, and morally to provide the medical standards of care.
Wrong 😕
[39:10] Regardless of disagreeing state laws regarding the status of the ovum and fetus, once a fetus is born, it is agreed that the now child has all the protective rights of the state. The practitioner now has a universally recognized patient-practitioner relationship with the child and mother. This patient-practitioner relationship means that the practitioner must maximize the newborn child’s best interests based on the medical standards of care regardless of whether the parent(s) consent or refuse to consent to the child’s medical care. Certainly, the practitioner should pursue the informed consent from the parent(s) before providing treatment to the child. However, if consent is not attainable and if not providing the medical standards of care will significantly increase the risk of harm to the newborn, then the medical professional is obligated professionally, legally, and morally to provide the medical standards of care.
CORRECT! 🙂
[39:11] A pregnant patient legal right to autonomously; consent, refuse, and withdraw from medical treatment options is now regulated by federal and a variety of inconsistent state laws.
Wrong 😕
[39:11] A pregnant patient legal right to autonomously; consent, refuse, and withdraw from medical treatment options is now regulated by federal and a variety of inconsistent state laws.
Wrong 😕
[39:12] However, once the fetus has emerged from the uterus, the now child is conferred with all the civil rights associated with being a citizen, and the state is federally mandated to protect the well-being of the child as a vulnerable citizen. Once born, the state has protective interests and mandates that the practitioner provides the child with the medical standards of care. Failure to provide the medical standards of care to the minor is tantamount to child neglect and a type of medical malpractice.
CORRECT! 🙂
[39:12] However, once the fetus has emerged from the uterus, the now child is conferred with all the civil rights associated with being a citizen, and the state is federally mandated to protect the well-being of the child as a vulnerable citizen. Once born, the state has protective interests and mandates that the practitioner provides the child with the medical standards of care. Failure to provide the medical standards of care to the minor is tantamount to child neglect and a type of medical malpractice.
39. Clinical Vignettes
1. Ms. Elena Price is a 30-year-old woman who is currently 14 weeks pregnant. She works as a nurse in a local hospital. Ms. Price has a past medical history of depression and is currently experiencing depression symptoms. She comes to the obstetrician for her prenatal care appointment and expresses her desire to stop taking her antidepressant medication due to concerns about the potential effects on the developing fetus. The obstetrician informs her of the potential risks of untreated depression during pregnancy and discusses the available treatment options. Ms. Price insists on stopping the medication and refuses any alternative treatment options. The obstetrician is concerned about the risks to both Ms. Price and the developing fetus. What is the ethical question in this scenario?
2. Ms. Jasmine Walsh is a 25-year-old schoolteacher in her third trimester of pregnancy who presents to the emergency department with vaginal bleeding and lower abdominal pain. She reports a history of hypertension and preeclampsia in her first pregnancy, which resulted in an emergency cesarean section. She is currently receiving antihypertensive medication for her current pregnancy. Clinical examination reveals an elevated blood pressure of 160/110 mmHg, tender abdomen, and a fetal heart rate of 140 beats per minute. The differential diagnosis includes placental abruption, uterine rupture, or preeclampsia with severe features. After a thorough discussion of the treatment options, including an emergency cesarean section, blood transfusion, and potential risks and benefits of each treatment, Ms. Walsh declines medical treatment and requests to be discharged to return home. What ethical principle is most important in this scenario?
3. Ms. Isabelle Green is a 35-year-old accountant who is 12 weeks pregnant with her second child. During her prenatal visit, she expresses her concerns about the possibility of having a cesarean section during delivery due to her previous difficult recovery. The obstetrician explains that a vaginal birth after cesarean (VBAC) is possible but has some risks, including uterine rupture. Ms. Green, who is fully informed about the risks and benefits, decides that she does not want to attempt a VBAC and would like to schedule a cesarean section. The obstetrician advises her to reconsider and explains that a repeat cesarean section has a higher risk of complications, including placenta accreta and surgical injury. However, Ms. Green is firm in her decision. What ethical dilemma does this case present?
4. Mr. Reed Johnson is a 30-year-old electrician who has just become a father. His wife gave birth to a healthy baby girl. However, a few hours after the delivery, the baby begins to display unusual symptoms, including lethargy, poor feeding, and breathing difficulties. The differential diagnosis includes various conditions, such as sepsis, pneumonia, and congenital heart disease. What should the practitioner do if the parents do not consent to treat the newborn with medical standards of care?
5. Ms. Patrick Davis is a 24-year-old graphic designer who is currently 12 weeks pregnant. She presents to the obstetrics clinic complaining of severe morning sickness, weight loss, and dehydration. On physical examination, her blood pressure is 90/60 mmHg, and her heart rate is 110 bpm. Laboratory tests show electrolyte imbalances and elevated liver enzymes. The differential diagnosis includes hyperemesis gravidarum and other causes of severe nausea and vomiting during pregnancy. What ethical question arises in this scenario?
CORRECT! 🙂
Explanation: In this scenario, the ethical question is whether the obstetrician should respect Ms. Price's refusal of treatment and provide alternative treatment options, even if there are potential risks to both Ms. Price and the developing fetus. The American College of Obstetricians and Gynecologists (ACOG) recognizes the pregnant patient's autonomy and the right to refuse or withdraw from medical treatment [39:2]. The practitioner should respect the patient's decision as long as it is an informed decision, and the patient understands the potential risks and benefits of the treatment options [39:8]. In this scenario, the obstetrician should provide alternative treatment options to Ms. Price and respect her decision to refuse medication for her depression. However, the obstetrician should inform Ms. Price of the potential risks of untreated depression during pregnancy to ensure that her decision is an informed decision [39:7]. Reporting Ms. Price's refusal of treatment to child protective services is not an appropriate course of action since Ms. Price's refusal of treatment does not constitute child neglect or abuse [39:12]. Refusing to provide prenatal care to Ms. Price is not an appropriate course of action and violates the principle of justice (be fair) and could be considered medical malpractice [39:13].
Wrong 😕
Explanation: In this scenario, the ethical question is whether the obstetrician should respect Ms. Price's refusal of treatment and provide alternative treatment options, even if there are potential risks to both Ms. Price and the developing fetus. The American College of Obstetricians and Gynecologists (ACOG) recognizes the pregnant patient's autonomy and the right to refuse or withdraw from medical treatment [39:2]. The practitioner should respect the patient's decision as long as it is an informed decision, and the patient understands the potential risks and benefits of the treatment options [39:8]. In this scenario, the obstetrician should provide alternative treatment options to Ms. Price and respect her decision to refuse medication for her depression. However, the obstetrician should inform Ms. Price of the potential risks of untreated depression during pregnancy to ensure that her decision is an informed decision [39:7]. Reporting Ms. Price's refusal of treatment to child protective services is not an appropriate course of action since Ms. Price's refusal of treatment does not constitute child neglect or abuse [39:12]. Refusing to provide prenatal care to Ms. Price is not an appropriate course of action and violates the principle of justice (be fair) and could be considered medical malpractice [39:13].
CORRECT! 🙂
Explanation: In this scenario, the most important ethical principle to consider is the autonomy of the pregnant patient [39:2]. The American College of Obstetricians and Gynecologists (ACOG) states that a pregnant woman's decision to refuse treatment should be respected, and any fetal intervention must have explicit informed consent from the pregnant woman [39:2, 39:3]. Ms. Walsh has the right to make an informed decision about her medical treatment, and the practitioner must respect her decision even if it poses a risk to her or the fetus. The practitioner should prioritize the patient's best interests, informed by the principles of beneficence and nonmaleficence, but only after obtaining informed consent from the patient [39:6]. State laws regarding the fetus and parental consent are not applicable to Ms. Walsh's case, as she is an adult and capable of making her own decisions regarding medical treatment [39:14].The practitioner should respect Ms. Walsh's autonomous decision to decline medical treatment, as it is her right to make an informed decision about her own body [39:2]. The practitioner should continue to provide counseling and support for Ms. Walsh, and encourage her to return to the emergency department if her condition worsens.
Wrong 😕
Explanation: In this scenario, the most important ethical principle to consider is the autonomy of the pregnant patient [39:2]. The American College of Obstetricians and Gynecologists (ACOG) states that a pregnant woman's decision to refuse treatment should be respected, and any fetal intervention must have explicit informed consent from the pregnant woman [39:2, 39:3]. Ms. Walsh has the right to make an informed decision about her medical treatment, and the practitioner must respect her decision even if it poses a risk to her or the fetus. The practitioner should prioritize the patient's best interests, informed by the principles of beneficence and nonmaleficence, but only after obtaining informed consent from the patient [39:6]. State laws regarding the fetus and parental consent are not applicable to Ms. Walsh's case, as she is an adult and capable of making her own decisions regarding medical treatment [39:14].The practitioner should respect Ms. Walsh's autonomous decision to decline medical treatment, as it is her right to make an informed decision about her own body [39:2]. The practitioner should continue to provide counseling and support for Ms. Walsh, and encourage her to return to the emergency department if her condition worsens.
Wrong 😕
Explanation: The ethical dilemma in this case involves balancing the principles of autonomy and beneficence. Ms. Green has the right to make her own medical decisions, and her decision should be respected even if the obstetrician disagrees. The American College of Obstetricians and Gynecologists (ACOG) states that a pregnant woman's decision to refuse treatment should be respected [39:2]. Additionally, a joint guidance document from ACOG and the American Academy of Pediatrics (AAP) states that any fetal intervention cannot be performed without explicit informed consent from the pregnant woman [39:3]. In this case, Ms. Green is fully informed about the risks and benefits and has made an autonomous decision that the obstetrician should respect. The other options are incorrect because the obstetrician has already explained the risks and benefits, and Ms. Green has made an autonomous decision, the obstetrician should not force Ms. Green to attempt a VBAC against her will as this would be a violation of her autonomy and could lead to negative outcomes for both her and her fetus, and Ms. Green's informed consent should not be contingent on signing a waiver as informed consent should be freely given without coercion, and signing a waiver does not guarantee that her decision is truly autonomous.
CORRECT! 🙂
Explanation: The ethical dilemma in this case involves balancing the principles of autonomy and beneficence. Ms. Green has the right to make her own medical decisions, and her decision should be respected even if the obstetrician disagrees. The American College of Obstetricians and Gynecologists (ACOG) states that a pregnant woman's decision to refuse treatment should be respected [39:2]. Additionally, a joint guidance document from ACOG and the American Academy of Pediatrics (AAP) states that any fetal intervention cannot be performed without explicit informed consent from the pregnant woman [39:3]. In this case, Ms. Green is fully informed about the risks and benefits and has made an autonomous decision that the obstetrician should respect. The other options are incorrect because the obstetrician has already explained the risks and benefits, and Ms. Green has made an autonomous decision, the obstetrician should not force Ms. Green to attempt a VBAC against her will as this would be a violation of her autonomy and could lead to negative outcomes for both her and her fetus, and Ms. Green's informed consent should not be contingent on signing a waiver as informed consent should be freely given without coercion, and signing a waiver does not guarantee that her decision is truly autonomous.
CORRECT! 🙂
Explanation: After the newborn baby is born, the practitioner's obligation is to provide the medical standard of care to the newborn, even if the parents refuse to provide informed consent. The principle of social justice requires the practitioner to provide medical standards of care to maximize the child's best interests [39:15]. In cases where parental consent cannot be obtained, and failure to provide medical standards of care will significantly increase the risk of harm to the newborn, the medical professional is obligated professionally, legally, and morally to provide the medical standards of care [39:10]. Refusing medical standards of care would violate the professional principle of nonmaleficence (do no harm) and the social principle of justice (be fair) and would legally be considered child neglect, a type of medical malpractice [39:13]. Therefore, the other options are incorrect, as they do not prioritize the best interests of the newborn and may lead to medical malpractice.
Wrong 😕
Explanation: After the newborn baby is born, the practitioner's obligation is to provide the medical standard of care to the newborn, even if the parents refuse to provide informed consent. The principle of social justice requires the practitioner to provide medical standards of care to maximize the child's best interests [39:15]. In cases where parental consent cannot be obtained, and failure to provide medical standards of care will significantly increase the risk of harm to the newborn, the medical professional is obligated professionally, legally, and morally to provide the medical standards of care [39:10]. Refusing medical standards of care would violate the professional principle of nonmaleficence (do no harm) and the social principle of justice (be fair) and would legally be considered child neglect, a type of medical malpractice [39:13]. Therefore, the other options are incorrect, as they do not prioritize the best interests of the newborn and may lead to medical malpractice.
CORRECT! 🙂
Explanation: The ethical question that arises in this scenario concerns the practitioner's obligation to obtain explicit informed consent from Ms. Davis before initiating treatment for her hyperemesis gravidarum. The American College of Obstetricians and Gynecologists (ACOG) emphasizes that the patient-practitioner relationship is with the pregnant woman and not with the fetus, to ensure the woman's autonomy and prevent her from being seen as a "fetal container" [39:4]. Therefore, it is important to obtain explicit informed consent from the pregnant patient before initiating any treatment [39:6]. In this case, the practitioner should explain the risks and benefits of various treatment options and obtain Ms. Davis's consent before initiating any treatment for her hyperemesis gravidarum [39:8]. This ensures that the patient's autonomy is respected and that the practitioner can provide appropriate medical treatment while prioritizing the best interests of both the patient and the fetus. The other options are incorrect as they prioritize the fetus over the patient's autonomy and rights, which is not in line with the principles of medical ethics [39:5].
Wrong 😕
Explanation: The ethical question that arises in this scenario concerns the practitioner's obligation to obtain explicit informed consent from Ms. Davis before initiating treatment for her hyperemesis gravidarum. The American College of Obstetricians and Gynecologists (ACOG) emphasizes that the patient-practitioner relationship is with the pregnant woman and not with the fetus, to ensure the woman's autonomy and prevent her from being seen as a "fetal container" [39:4]. Therefore, it is important to obtain explicit informed consent from the pregnant patient before initiating any treatment [39:6]. In this case, the practitioner should explain the risks and benefits of various treatment options and obtain Ms. Davis's consent before initiating any treatment for her hyperemesis gravidarum [39:8]. This ensures that the patient's autonomy is respected and that the practitioner can provide appropriate medical treatment while prioritizing the best interests of both the patient and the fetus. The other options are incorrect as they prioritize the fetus over the patient's autonomy and rights, which is not in line with the principles of medical ethics [39:5].
**
39. Reflection Vignettes
1. Ms. Samantha Lee is a 35-year-old medical practitioner with years of experience in obstetrics and gynecology. She has a patient, Mrs. Sarah Johnson, who is 24 weeks pregnant and has just received the news that the fetus has a urinary tract blockage. The treatment is to implant a fetal shunt that will allow drainage into the amniotic cavity. Without the procedure, the fetus's bladder will become enlarged, leading to underdeveloped organs and facial deformities. However, Mrs. Johnson declines the treatment options for the fetus, stating that she wants to have the baby as God intends. In this situation, the practitioner should respect the patient's autonomy and decision-making. However, the practitioner should also explain the potential consequences of not treating the fetal urinary tract blockage and provide the patient with information about the risks and benefits of the available treatment options. The practitioner should also document the patient's refusal of treatment in the medical record for legal and ethical reasons. It is important to continue to offer support and counseling to the patient throughout the pregnancy and delivery, regardless of their decision.Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
**
2. Dr. Emily Rodriguez is a 32-year-old pediatrician who has just delivered a newborn who is in dire need of immediate medical attention. The newborn requires a treatment that is considered standard medical care for survival. However, the parents refuse to give consent for the treatment, citing religious beliefs and a desire to have the baby as God intends. Dr. Rodriguez recognizes the importance of respecting the parent's beliefs but also understands the urgency of providing necessary medical treatment to the newborn. Dr. Rodriguez must explain to the parent that the child’s condition requires immediate treatment for survival, and it is the medical standard of care. As a practitioner, she must prioritize the well-being of the child and provide necessary treatment for vulnerable populations. Dr. Rodriguez must also inform the parent of the potential consequences of refusing treatment and the legal and ethical obligations to ensure the child receives appropriate medical care. If the parent continues to refuse treatment, Dr. Rodriguez may need to involve the hospital's ethics committee and legal department to determine the best course of action.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
***
