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Caring for the “Compound” Patient: Ethical Challenges and Practical Advice for Obstetricians [Insert Name of Presenter] Ethics Resource Center American.

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Presentation on theme: "Caring for the “Compound” Patient: Ethical Challenges and Practical Advice for Obstetricians [Insert Name of Presenter] Ethics Resource Center American."— Presentation transcript:

1 Caring for the “Compound” Patient: Ethical Challenges and Practical Advice for Obstetricians [Insert Name of Presenter] Ethics Resource Center American Medical Association

2 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

3 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

4 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

5 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

6 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

7 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

8 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

9 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

10 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

11 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

12 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

13 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

14 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

15 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

16 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

17 Choose to Continue to Treat Ethics Resource Center American Medical Association 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.

18 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

19 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

20 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

21 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

22 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

23 References For the references to this presentation please see the accompanying handout. Ethics Resource Center American Medical Association

24 This ethics educational presentation was created by the: Ethics Resource Center American Medical Association 515 North State Street Chicago, IL Phone: (312) Fax: (312) Web:


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