The ethical concerns
The ethical concerns that I have related to this dilemma are many. What is the doctor’s responsibility to try to stop the mother’s contractions? What are the limits of the attempts that should be made to save the child? Should the mother be allowed to risk her own life to attempt to save the life of a child that is probably not viable outside the womb? Should the doctor plan a cesarean section despite the fact that the infant will probably die as soon as it is removed from the mother’s womb? I can’t imagine making this decision personally, but many mothers are forced to make it every day. Here is the situation that lead to my ethical quandary.
I have a patient who is 3 week ante partum and has had premature rupture of membranes. This condition could cause hemorrhaging for her and death of the infant in uterus. In layman’s terms, both she and the infant are at risk of death. She is starting to contract and the physician will not do anything since the fetus is not considered viable. The physician has described the issues of having a vaginal birth versus a cesarean section with this patient because the fetus is breech. The patient wants everything to be done to save this baby. As described above, the issues are exceedingly complex. The physician appears to have determined that the child is a lost cause and is thinking only of the health of the mother, but this is contrary to her wishes. Should the mother’s desire to save her child be allowed to override her own survival instincts? And, what role, if any, should the child’s father have in decision-making process?
My literature survey for this situation was amazingly frustrating. I expected there to be a great deal of study materials available regarding this topic. It is, in essence, the quintessential ethical debate: do you save the life of the mother or the life of the child? And, there is the question of the doctor’s ethics. Should he be able to determine the best medical course of action if it is contrary to the mother’s wishes? And, who determines when a fetus is viable? Can we allow it to be based on an arbitrary date?
I found a lot of older research regarding the ethics of abortion and approaching the discussion of fetal viability from that point of view, but there was nothing recent and nothing than dealt with miscarriages as opposed to abortion. And, there was nothing that talked about the discussion of the life of the mother versus the life of the child. I think this would clearly be a great place for additional study. I think specifically the ethical question of whether medical decisions should be made contrary to the patient’s wishes should also be considered.
Right now, as a society, we allow a person to make their own decisions about their health care even though we do not allow them to determine when or how they die. What I did find were several articles regarding the mental trauma that miscarriage and stillbirth inflict on the mother and an interesting article promoting the development of advanced directives regarding pregnancy health care. Of all the articles, this is the one that I found most interesting and directly applicable to the situation at hand.
In this article, Anita Caitlin proposes that obstetricians think outside the box and promote the development of advanced directives for prenatal and delivery care. The proposal is simple, just as a person can create a living will for care during a terminal illness or traumatic injury, a pregnant woman would in her early weeks of pregnancy discuss in depth with her doctor the potential things that could go wrong and develop a plan of action. For instance, a woman would decide at the very beginning of the pregnancy what circumstances would lead to her decision for a cesarean section (Caitlin, 2005).
This would eliminate the need to make the decision during a high stress time, since we can assume that such decision would cause stress, and at a time that the mother’s mental and emotional state is impacted by the high levels of hormones associated with pregnancy. I understand that being able to hold a woman to the advanced directives would be impossible, but a woman could elect to rely on the already issued directive and not add the trauma of making a decision to an already stressful time. This would also allow the person to discuss the eventualities with those whom she believes have a right to have a say in her life instead of just those that the laws say have a right to assist with her decision-making (next of kin, when the patient is incapacitated).
Another article that drew my attention that I found in my literature review was a discussion about the ethical concerns some doctors have about making medical recommendations that are contrary to their own moral and ethical beliefs.
“A growing number of doctors, nurses, and pharmacies are refusing to provide, refer, or even tell their patients about care options that they feel are not in keeping with their own personal religious beliefs,” stated Barbara Kavadias, Director of Field Services at the Religious Coalition and leader of the three-year project that created In Good Conscience. “Institutions are refusing to provide essential care, citing their religious commitments.” (Bioweek, 2007)
This is a growing ethical trend in medical care that I have some major concerns with. Take, for instance, the case of my current patient. If she were (or is) being treated by a doctor who believes all life is sacred, he might be willing to risk the life of the mother in an effort to try to save the child. In this case, it is difficult to determine how a person with these moral concerns might treat the patient. Taking the child via c-section is probably the best for option to preserve the mother’s life. It may result in the immediate death of the fetus. Waiting and trying to abate the mother’s contractions may provide the child with a greater chance of survival, but also puts extra risk on the mother’s life. At that point, what are the criteria used by those with this moral outlook to determine the proper course of action?
These questions are likely to grow in controversy as technology increases and the fetus is increasingly viable outside of the womb. The more that society becomes able to keep a child alive without the benefit of the mother, the more questions regarding the ethics of doing so or not doing so will grow in prominence. It is absolutely possible that with increasing medical technology and the ability to prolong life we will have additional debates regarding who gets to determine what lives are worth saving and what lives are lost.
I believe that a trend toward making informed decisions is a good one and a move in the right direction, taking people away from having to make a decision in a crisis situation. I also think that it is worthwhile to discuss the role of the father in the decision-making process. Because of the trend toward increasing women’s rights and in an effort to prevent a return to the days of the complete male dominance, society appears to be moving away from the rights of a souse to have a say in decisions that affect them.
For example, the birth of a child is an 18-year (minimum) commitment for men as well and in an effort to secure the rights of women, we have completely removed the father from the decision-making process. As a human, I believe that ultimate control of a person’s body should be his or her own, but it is also reasonable to believe that a spouse (or life partner) should have some say in the decision. In the case of m patient, I cannot believe that a loving partner would encourage her to risk her own life for the tiny chance to save a child which would already have been lost if not for technology.
Caitlin, Anita. “Thinking Outside the Box: Prenatal Care and the Call for a Prenatal Advance Directive”Journal of Perinatal & Neonatal Nursing. Frederick: Apr-Jun 2005. Vol. 19, Iss. 2; pg. 169.
Geller, Pamela A. “Understanding distress in the aftermath of miscarriage” Network News. Washington: Sep/Oct 2002. Vol. 27, Iss. 5; pg. 4.
Klier, C. M. , P. A. Geller, J. B. Ritsher. “Affective disorders in the aftermath of miscarriage: A comprehensive review”,Archives of Women’s Mental Health. Wien: Dec 2002. Vol. 5, Iss. 4; p. 129.
‘Religious Coalition for Reproductive Choice; Religious Leaders Call for New Efforts to Reverse Growing Imposition of Sectarian Religious Beliefs on Reproductive and End-of-Life Care” Biotech Week. Atlanta: May 9, 2007. pg. 973