Introduction to Medical Ethics in Obstetrics and Gynaecology

Obstetrics abd gynecology

Obstetrics deals with parturition, antecedents and sequeles.

Concerned principally with management of pregnancy, labor and puerperium in both normal and abnormal circumstances.

Broader sense: It is concerned with reproduction of a society.

Intimately related to Gynecology and both are treated as one specialty.

Gynecology: Deals with physiology and pathology of the female reproductive organs in the non-pregnant state.

Ethics

Moral principles that control or influence a person’s behaviour.

A system of moral principles or rates of behavior

Ethical: Morally correct or acceptable.

This lecture will discuss some issues in the obstetrics that has both legal and ethical implication.

Society has great expectation that modern medical technologies will improve longetivity and quality of human life.

Desire and expectation of having a healthy child, leaving the mother also healthy.

Some of the issue to discuss include;

• Consent/confidentiality
• Abortion
• Genetic counselling, screening and prenatal diagnosis
• Fetal research.

Informed consent mandatory

Chaperone essential except in emergency

Consent based primarily on the value placed on autonomy or self-determination. Secondarily on rational decision making.

First requires that individual have the ultimate say concerning whether their bodies will be “invaded” and later require disclosure of certain material information including a description of

• Proposed procedure, risk of death and serious disability
• Alternatives – success rate
• Problems of recuperation.

Controversial. Has several aspects to it; politics, social, religious, medical.

It remains illegal and criminal

It may however be performed if there is

• Serious adverse health consequences to the mother
• Major congenital abnormality incompatible with life.

In some countries;

• Genetic counseling, screening and prenatal diagnosis are readily available, and
• Pregnant mothers has the right to expect obstetrician to fully inform her of any reason the obstetrician has to believe that her fetus might be handicapped.
• Inform her of diagnostic tests to identify presence genetic condition.
• Options to take by couple – abortion, do nothing, fetal therapy.
• Give adequate information to perform chorionic villous sampling or genetic amniocentesis.

Genetic counselling should be morally nondirective i.e. obstetrician should be impartial and objective and it should provide information that will allow competent counselees to make informed decision.

No information should be disclosed to any third party including insurers and employers.

Make policy being followed made clear both verbally if she is not in agreement with disclosure policy.

Pre-test counselling is needed.

Tests may yield information that may ultimately force some unwelcome choices i.e. abortion, adoption.

What is at stake is the right to decide whether or not to have a genetic test.

Right to refuse if potential harm (stigma, unacceptable choices) out weights potential benefits.

Questions to be answered include—

• What information should be given to which patients?
• When should it be presented?
• Who should present it?
• And how and by whom should the result be conveyed?

Goals of screening involve helping personal or family to:

• Comprehend the medical fact, including the diagnosis, probable cause of the disorder, and available managements.
• Appreciate the way heredity contributes to the disorder
• Risk of recurrence.
• Understand options for dealing with risk of recurrence.
• Choose the course of action which seems appropriate for them.
• Make the best possible adjustment to the disorder in an affected family member and/or to the risk of recurrence of the disorder.

Fetal research and its regulation is one of the most controversial and complex areas in human experimentation.

Consent of both father and mother needed.

Could be – therapeutic, non-therapeutic

Purpose of any in utero experiment must be:

• To meet the health needs of particular fetus, and
• Fetus is placed at risk only to the minimum extent to meet such needs.

In non-therapeutic research, the risk to the fetus must:

• Be minimal and the knowledge must be important, and
• Not obtainable by other means.

Feto-maternal relationship is a unique one. It requires Obstetrician to promote a balance of maternal health and fetal welfare – while respecting maternal autonomy.

The decision of competent pregnant woman must be honored in all but “extremely rare and fully exceptional” cases.

Although reasonable steps to persuade a woman to change her mind are appropriate.

Ethics is about the use and abuse of power. The ability of person’s states and systems to change lives and events for good or ill.

Sometimes the effect of such power is discreet, almost imperceptible. At other times it is so overwhelming that it tips into coercion or even violence, verbal, moral or physical.

Professionals have a special responsibility to be sensitive to the way in which the power conferred on them by their professional standing is used.

Professional codes of ethics are largely designed to protect clients and to ensure that inherent inequality in the client-caregiver relationship is not abused.

In general, obstetrician must respect a woman’s informed right of choice and promote the woman’s acceptance of responsibility for the outcome of her choice (forced Caesarean Section).

Obstetrician’s work with women, supporting their right to participate actively in decisions about their care, and empowering women to speak for themselves on issues affecting the health of women and their families in their culture/society.