OB Potpourri

This month’s issue of the medical journal Obstetrics & Gynecology (O&G) has a review of the four best ethics articles that appeared in their journal in the last year. Here are my comments (in italics) on their review (in quotes).

Article title: “Clinical, Ethical, and Legal Considerations in Pregnant Women With Opioid Abuse.” O&G‘s bottom line: “Opioid abuse is a chronic medical illness, not a moral failing. Obstetricians should advocate for pregnant women’s access to opioid maintenance therapy and social services that support healthy outcomes for these women and their fetuses.” Some will quibble about whether the slavery that is opioid addiction should be defined as a chronic medical illness (and remember that some opioid addiction comes courtesy of us physicians who misprescribe opioid medications). However, whether you believe that these women are unable to stop their substance abuse (illness model) or somehow unwilling (moral failure model), from a medical standpoint, treating these women as criminals isn’t helpful for either them or their babies to achieve the best outcomes. We’re doctors, not the police, so acting judgmentally has no role; we should be helping these patients and their babies in any ethical way possible.

Article title: “Evaluation of Ethics Education in Obstetrics and Gynecology Residency Programs.” In this study, 57% of OB residencies had 0-5 hours of ethics training, and 64% of residency directors said their graduates are unprepared or only somewhat prepared to handle ethically challenging situations. O&G‘s bottom line: “Obstetrics and gynecology residencies are behind in creating and evaluating formal ethics education programs. Additional resources and support, including a standardized formal curriculum, are needed to provide all obstetrics and gynecology residents with an adequate baseline ethics education.” In a specialty that regularly comes up against some of the most ethically problematic issues in medicine, it is extraordinary that over half of residencies have a hard time finding even five hours for ethics education during the course of a four-year residency. I could write a lot more about forming professionals vs. training technicians, but space doesn’t permit.

Article title: “The Ethics of Access: Who Is Offered a Cesarean Delivery and Why?” O&G‘s bottom line: “The ethical principles of justice and respect for autonomy require obstetricians who provide cesarean deliveries on maternal request when medically appropriate to discuss this delivery option with all appropriate patients and not just with those patients who request the procedure.” Since I don’t think it’s good medical practice to offer a pregnant woman a cesarean section if there is no medical indication to do one, this article seems to me to be a futile exercise, giving advice on how to perform an unethical act ethically.

Article title: “Prenatal Consultation for Extremely Preterm Neonates: Ethical Pitfalls and Proposed Solutions.” This article addresses the situation of the patient who is at high risk for the imminent delivery of an extremely preterm infant, one whose survivability is doubtful. Often a newborn specialist is called in, who quotes statistics and asks the parents to make an immediate decision regarding whether or not to treat the newborn. The article advocates a more fluid, ongoing process that takes into account the evolving situation. O&G‘s bottom line: “The prenatal consultation process should be viewed as an ongoing, long-term, shared decision-making process that provides desired information, emotional support, and compassion to parents.” As I’ve argued before, the autonomy-trumps-all approach of the physician asking “Do you want us to let your loved one die?” is an abrogation of professional physician responsibility for actions and decisions. This article takes a welcome step away from inappropriately placing the entire burden of decision-making on highly-stressed parents who may not be in a position to make such a decision.

From Marianne Burda, “What is New in Ethical Issues in Obstetrics? Best Articles From the Past Year.” Obstet Gynecol 2016;127:157–8

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