Bioethics Discussions: Case 1
My classmates knew that the Bioethics small group discussion was going to be interesting. Days before the actual activity, they were already reminding me not to dominate the session. Something tells me they were anticipating fireworks. Sadly, it wasn’t meant to be. Most -if not all- of my block mates are intelligent, open-minded catholics, christians. secular humanists, agnostics and atheists (yes, you have that much variety in a group of 11 people). Heads didn’t quite roll as people feared/ expected.
We’re not rotating under the Department of Obstetrics and Gynecology. For those who are not yet in the know, this is the department that deals with pregnancy, childbirth and diseases of the female reproductive tract. It is a touchy subject so there are a lot of potentially divisive bioethical cases. We were given to scenarios and we had guide questions to further enhance the quality of discussion. My block proved to be dynamic and despite the differences in opinion, we were still able to maintain and healthy and exhaustive discussion of the salient points of each case.
Here were our cases:
Case 1: *paraphrased to exclude medical jargons*
A 29 year old arrived at the OB Admitting Section at 38 weeks age of gestation (this means she could give birth any time) in active labor with severe abdominal and lower back pain of four hours duration. She was not a registered patient and had two pre-natal consults (check-ups during pregnancy) at a local health center. She was conscious, coherent, oriented and there was no history of incapacity to make decisions. Upon admission, she had a blood pressure of 130 90 mm Hg (borderline hypertensive), heart rate of 92 beats per minute (normal) and the fetal weight was estimated to be from 2.4 to 2.6 kg (normal). On internal examination, the cervix was dilated to 3 cm, 80% effaced, intact bag of waters with the fetal head at station -1.
At the labor room, the fetal monitoring revealed bradycardia (low heart rate!) of 80-90 beats per minute (normal is around 150), which did not change in position of administration of oxygen for 4 minutes. The heart rate then dropped to 60 beats per minute (RED ALERT!!!). A tentative diagnosis of abruptio placenta (a potentially fatal bleed due to premature detachment of the placenta) was considered because of the changes in fetal heart rate (the baby is attached to the placenta so the baby is also bleeding to death) and severe abdominal pain. The patient was strongly and repeatedly advised to have a cesarean delivery due to the rapidly deteriorating fetal condition. The patient adamantly refused and in on going discussion, did not give a reason for the refusal. Because of their strong suspicion of abruption, the obstetric team decided to go ahead and perform an emergency cesarean delivery for fetal benefit without maternal consent. At cesarean delivery, there appeared to be 80% separation of the placenta with 500 cc retroplacental clot (i.e. there really was pre-mature separation, thus the clot). The patient delivered to a live baby boy weighing 2500 grams. Though the baby took 21 days before he could be discharged, there were no residual deficits after the patients spent time at the Neonatal Intensive Care Unit.
Of the eleven people in the class, seven agreed with the decision by the doctors to go ahead without the patient’s consent. Though consent and patient autonomy is one the values enshrined in the bioethical considerations for medical practice - along with beneficence, non-maleficence and justice —seven of us felt that it was more crucial to decide in favor of saving the life of the baby.
The other four felt that it was more pertinent to consider what the patient had in mind and it was more important to establish consent rather than do procedures that are against the patient’s will.
It’s quite hypocritical to uphold cultural and religious reasons while blatantly disregarding a patient’s clear refusal to seek treatment. Paternalism had its time in the past, but should doctors really overstep the autonomy of their patient’s?
Ironically, the preceptor said that if we gave in to what the patient wanted, we would’ve been reduced to mere commodities in the grocery. Medicine is already moving towards that direction. I don’t see why there’s such an attached negative repercussion for a more empowered patient.
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I agree with the doctors’ decision.
You’d wonder what kind of preceptors people get for students nowadays. While there was no case filed, there is an actual criminal case that the state can file in behalf of the patient. Unless the patient were encephalopathic, and unless there were no legal surrogate decision makers present, MDs have no business tampering with the patient and go against her will.
A CS predisposes the patient to uterine scarring, which may rupture on the second pregnancy. It also gives her a scar that she would bear for the rest of her life.
The doctors in this case were blatantly wrong, and a good outcome (LBBB, or LBBG) does not justify their intrusion of the patient’s sovereignty.
as health care practitioners, we cannot do anything against a patient’s will. notwithstanding the principle of autonomy, we will be responsible for any sequelae stemming from a procedure performed against consent.
when faced with this situation, doctors must be able to secure the consent of the patient (through comprehensive explanation) or turf the patient. it is erroneous to say that we are reduced to medical commodities: we are, after all, able to explain to the patient the risks and benefits of any procedure. this is the “art” of medicine that our preceptors refer to all the time.
in order to cover legal bases, the doctors should have had the patient declared mentally unfit to make rational decisions (as certified by the psych rotators), and secured consent from a relative.
Hindi naman ako magiging doktor, pero kung ako, pipiliin ko din ang C-section para ma-save yung baby kahit ayaw nung nanay. What if, the baby dies tapos nagka-complications, tapos hindi na sya maging pregnant ulit? Parang ang liit na kapalit ng scar for the life of a child. Wala lang. Not the issue pero naisip ko lang. hehe.
PS: ang ganda ng colors ng blog mo ngayon. heehe.
The concept of Bioethics has become a standard theme in House, M.D. (I’m sure you’ve heard of the TV show.) And granted that in many occasions Dr. House has managed to save his patients despite his constant violation of “codes and standards,” I believe that some doctors would still have the tendency to operate despite the absence of the patient’s consent.
In the mother’s case, the doctors can credit the operation to the preggy mom’s inability to make a decision due to emotional and mental distress (because of the horror that is placenta bleeding). The mother’s having no specific reason to deny operation is one indication of her lack of capacity to make a crucial medical decision, isn’t it?
Ultimately, isn’t saving lives what really matters in medicine? Methinks bioethics has some wiggle room in such cases as nothing is painted in black and white.
I would have agreed to doing an emergency CS, but not without consent, and especially without a signed consent for procedure.
Like what have been said by the other commenters, the best plan perhaps would have been to ask the husband or the nearest kin to sign consent for the procedure, after due explanations, of course.