Caring for the “Compound” Patient: Ethical Challenges and Practical Advice for Obstetricians
[Insert Name of Presenter]
Ethics Resource Center American Medical Association
The “Compound” Patient
• In cases of pregnancy, obstetricians are confronted with a “compound” patient in that the welfare of the fetus is directly and physiologically linked to that of the woman. • Thus, a pregnant woman’s decisions about prenatal care have added significance and consequences.
Ethics Resource Center American Medical Association
Reproductive Freedom
Legally, we recognize a woman’s right to:
• Abort a fetus for her own reasons, • Make life-style decisions that are not in the baby’s best interest.
Hence, ethical challenges may confront physicians when the actions of a pregnant woman are counter to medical advice
Ethics Resource Center American Medical Association
Physician’s Role in Optimizing Prenatal Care
To provide good prenatal care, physicians need to:
• Establish trust through good communication, • Protect patient confidentiality, • Respect patient autonomy and obtain informed consent.
Ethics Resource Center American Medical Association
Patient’s Role in Optimizing Prenatal Care
To receive good prenatal care, the pregnant woman must:
• Provide frank and truthful medical and social history, • Adhere to medical recommendations and treatment, especially since non-adherence can have negative health effects on the fetus.
Ethics Resource Center American Medical Association
Challenges to Providing Good Prenatal Care
Challenges to good prenatal care may arise if the patient:
• Refuses to provide consent to determine health status (eg, HIV seropositivity), • Has a history of non-adherence that could place the fetus at risk for significant harm.
Ethics Resource Center American Medical Association
Refusal of Diagnostic Testing
• Patient’s medical and social history (eg multiple sexual partners) may necessitate the need for prenatal tests (eg HIV). • In cases of HIV testing, a pregnant woman may refuse to consent despite good treatment because of concerns about privacy/confidentiality, social stigma, denial, and other factors.
Ethics Resource Center American Medical Association
Perinatal Transmission of HIV
• Pharmacotherapy along with cesarean delivery has been shown to reduce perinatal transmission of HIV to 1.5 percent. • Reporting of HIV seropositivity to county or state health department is required in most states.
Ethics Resource Center American Medical Association
HIV Testing Requirements for Pregnant Women
State requirements for HIV testing of pregnant women are as follows:
• Voluntary - 35 states and DC • Required unless patient refuses - 4 states • Required to offer testing to all pregnant women - 11 states • Mandatory testing of newborns - NY, CT
Ethics Resource Center American Medical Association
HIV Reporting Requirements for Pregnant Women
State requirements for reporting HIV seropositivity are as follows: • Mandatory reporting – Personally identifiable information: 34 states – Personally deidentified: 8 states and DC – Personally identifiable information that is then deidentified: 5 states
• No mandatory reporting - GA, NH, PA
Ethics Resource Center American Medical Association
Confidentiality Dilemma
In light of the clinical need for testing to reduce perinatal transmission of HIV, should the obstetrician consider not disclosing the legal duty to report in order to gain consent for the HIV test? ANSWER: NEED TO DISCLOSE LEGAL DUTY TO REPORT
Ethics Resource Center American Medical Association
Pregnant Women who Engage in Harmful Behavior
A second challenge to good prenatal care arises when a pregnant woman’s behavior:
• Poses grave potential harm to herself or the health of the fetus, and • Is controllable or preventable.
Ethics Resource Center American Medical Association
Harmful Patient Behaviors
Grave potential harm may result from: • Toxins in the fetal environment, • Malnutrition, • An unhealthy external environment.
Ethics Resource Center American Medical Association
Incidence of Harmful Behavior
• Dangerous level of alcohol abuse
– More than 130,000 pregnant women per year
• Cocaine use during pregnancy
– Cocaine-using mothers have given birth to about 1 million babies since mid-1980s
• Intimate partner violence
– About 324,000 pregnant women per year
Ethics Resource Center American Medical Association
Physician Liability in the Face of Patient Non-adherence
As with all patients, physicians can limit liability by properly documenting:
• Discussions and recommendations, • Patient’s informed consent, • Patient behaviors.
In relevant legal cases, patients have been found to be contributors of medical negligence.
Ethics Resource Center American Medical Association
When Non-Adherence Persists
If harmful behaviors persist despite attempts to change them the physician has 3 options:
• Continue care, • Refer the patient to another physician, • Seek legal remedy.
Ethics Resource Center American Medical Association
Choose to Continue to Treat
When: • Treating physician can provide best care, • Attempted referral might “lose” the patient to prenatal care, • Referral may add to patient’s stress and guilt, • Patient’s decision-making capability is not compromised.
Ethics Resource Center American Medical Association
Refer the Patient
When: • Treating physician can identify another physician willing to accept the patient, and • The referral is likely to result in a better patient outcome.
Ethics Resource Center American Medical Association
Seek Legal Intervention
When there is a high probability: • Of serious harm to the fetus, • That intervention will prevent such harm, • That intervention also benefits the pregnant woman or poses relatively small risk, And: • There is no other effective way to prevent the harm.
Ethics Resource Center American Medical Association
Types of Interventions
• Civil commitment • Protective custody • No tort claims (a woman has no legal obligation to her fetus) • Limited criminal remedy
Ethics Resource Center American Medical Association
Conclusion
In the case of a “compound” patient where the pregnant woman refuses to consent for testing or is engaged in harmful behavior, the physician must: • Respect patient autonomy, and • Continue to engage in full and informed consent.
Ethics Resource Center American Medical Association
Conclusion
Conditions that must be met if physician is contemplating court order intervention:
• High probability of serious harm to the fetus, • Intervention will likely prevent such harm, • Intervention also benefits the pregnant woman or poses relatively small risk, • There is no other effective way to prevent the harm.
Ethics Resource Center American Medical Association
References
• For the references to this presentation please see the accompanying handout.
Ethics Resource Center American Medical Association
This ethics educational presentation was created by the:
Ethics Resource Center American Medical Association 515 North State Street Chicago, IL 60610 Phone: (312) 464-4077 Fax: (312) 464-4799 Email: erc@ama-assn.org Web: www.ama-assn.org/go/erc