AGBONES, KEVIN CYRIL O.

MD3 ETHICS

1) CASE 1
A 29-year-old woman had a pelvic ultrasound at 33 weeks to follow-up a previous finding
of low lying placenta. Although the placental location was now acceptable, the amniotic
fluid index (AFI) was noted to be 8.9 cm. Subsequent monitoring remained reassuring until
38.5 weeks when AFI was 6 cm. The patient declined the recommendation to induce labor
and refused further monitoring, stating that she did not believe in medical intervention.
Nevertheless, she continued with her prenatal visits. At 41 weeks, she went for an
ultrasound and AFI was now only 1.8 cm. She and her husband continued to decline the
recommendation for induced labor.

Doctor’s Perspective
There are studies that have found that an AFI <5.0 cm increase the risk of fetal distress and
a caesarian delivery, notwithstanding the pregnancy is already post-term. There is now
onset of oligohydramnios which has a poor prognosis for the fetus which could develop,
besides the prior mentioned, cord compression and diminished fluid during labor. Several
congenital anomalies can also ensue, including cardiac problems, central nervous system
defects, skeletal defects, and even hypothyroidism. The mother can opt for caesarian
delivery, despite her hesitations, if she wants the baby to have the best odds of surviving.

Patient’s Perspective
Caesarian delivery is an “unnatural” process and is a clear medical intervention that goes
against the beliefs of the mother. Despite the statistics that say that prolonging the
pregnancy in this way will be detrimental to both the fetus and the parent, there are still
odds that a normal delivery without complications can ensue. If the patient is strongly
determined to holdfast on her beliefs, then the small chance of uneventful labor can be all
she needs.

Society’s Perspective
The husband can be presumed to hold the same beliefs as the mother. If that is the case,
then he will support his wife with the decision to continue with the pregnancy without
intervention. If his beliefs are not congruent with hers, then it can be expected that he will
be against withholding medical treatment and would try to convince his wife to change her
mind.

From the perspective of the family, if they hold the same beliefs as the mother then they
will most likely support her decision to not undergo treatment. However, if they do not
agree with her, they will most likely push for a medical intervention against her will not
only to save the baby but to also save her as she is also putting her life on the line.

Society will likely see the situation as reckless as the mother is actively endangering both
her own life and that of her child. Such behavior will be condoned by the community. If the
pregnancy does resolve without death, the child may be born with significant morbidities
which could affect his or her life. The mother may also be permanently impaired by the
complications of such a pregnancy and could negatively impact the community around her
as well as her family.

The Ethical Dilemma

The core issues of the problem revolve around the mode of care which could harm either
the mother or the baby or both, which is covered by the Principle of Double Effect and is
in direct violation of the Principle of Non-Maleficence, and the refusal of treatment by the
mother, which is within her rights because of Principle of Autonomy and which goes
against the Principle of Beneficence.

Numerous studies have delved into oligohydramnios in post-term pregnancies and have
pointed to conflicting modes of treatment. Intrapartum amnioinfusion has been proposed
to be prevented of fetal mortality due to meconium-stained fluid associated with the
disease. There has been no consensus as to the overall benefit of such a procedure as there
have been documented successes and failures over the course of its existence. If the
mother acquiesces to medical intervention, then intrapartum amnioinfusion may be
detrimental not only to her but to her fetus but carries with it a good possibility of keeping
the baby alive.

Caesarian section is indicated for this kind of pregnancy. It, too, carries a risk of morbidity
(a two-fold increase in maternal morbidity according to Villar and associates [2007]).
Furthermore, this procedure also lacks a definitive consensus as to whether it is ethically
advisable to perform even with the indication that the likelihood of the pregnancy
proceeding with less complications when undergoing such.

Patient autonomy is still within bounds as the mother is not incompetent to be unable to
make a sound decision nor has her family been misinformed about the gravity of the
situation. In this scenario, the physician does not become the primary decision maker in
this case, e.g. the mother can continue on with her wishes of withholding medical
intervention. This violates the Principle of Beneficence as this decision benefits none of the
parties involved—the mother and her child may die, the family may lose one of their own,
and the physician may have lost a patient.

How To Resolve This Case and Balance All Scenarios

Amidst the plethora of issues brought about by the complicated pregnancy, the one
decision that could bring about resolution to the case is that of the mother’s. She alone
can decide whether or not a non-natural delivery will be of benefit for her and her beliefs.
In such a way, her autonomy is unhindered.

The physician can opt not to be involved in the case if he feels that he has exhausted all
means to convince the patient of the pros and cons of her on-going stance and has done
all within his power to aid the patient within her demands.
2) CASE 2
A 22-year-old woman in her 1st pregnancy with an unremarkable prenatal course presents
with preterm labor at 28 weeks AOG. Her contractions were successfully stopped with
terbutaline. Discharge planning was reviewed with her and she was instructed to follow a
regimen of bedrest and oral terbutaline. She reported that she did not intend to comply
with these instructions. She believed that God would not allow her to go into labor unless
it was time for the baby to deliver and she indicated that He (God) had communicated this
to her.

Doctor’s Perspective
Terbutaline was given to the patient specifically to stall labor as at that age the fetal lung
may not be mature enough and other aspects of the baby may not have fully developed
yet. The potential baby can have a plethora of short-term and long-term complications
that can severely impair daily living. If the patient continues to refuse treatment, the
physician can assess the patient for indications of a preterm birth. In this sense, the mother
and her family are fully informed of the consequences of the action.

Taking into consideration the questionable mental state of the mother (claiming to have
been spoken to directly by God), the physician can invoke a psychiatric screening of the
mother to ascertain whether or not she is of sound mind and that she can undertake
rational decision making. If she is found to be incapable of making a sound decision, the
physician can now ask the family to make a decision for the patient based on the prior
assessment of an eminent preterm delivery.

Patient’s Perspective
The patient in this case is of the persuasion that she is being instructed directly by a divine
being to not delay her pregnancy. In her perspective, her decision to risk the life both of
her child and her own is within the realm of religion and is non-negotiable. It can be
presumed, though without any scientific merit unless an investigation is taken, that the
patient is not of sound mind.

Society’s Perspective
Her husband, if present in this scenario, either supports the view of her wife or that he is
aware of the absurdity and the risk of death for both her and their child. If the former were
true, he would also equally dismiss the treatment as contradictory to their beliefs. If the
latter prevailed, the husband can seek consult with the physician as on who will now carry
on with the decision-making. If the wife is proven medically to be incapable of rationality,
he can take over for the decision to stall labor for as long as required.

The family is of equal measure with the husband to the decision making if both he and his
wife are not of sound mind. The husband trumps the family decision, however.

The hospital administration can see the potential repercussions of the case. If the mother
is allowed to carry on with her decision, death may ensue to either her or the fetus or to
both of them. The hospital can receive serious backlash from the public for allowing it to
happen. The community can be expected not to have a consensus, however, as to when
does a mother stop being a mother per se, i.e. when does the responsibility of the mother
to make a decision for herself become void.

The Ethical Dilemma

The main issue here is that of autonomy—does the mother hold autonomy? What if she is
proven to be incapable of logical reasoning? Is it the physician or is it the kin who have
autonomy in that matter?

The physician and the hospital faces the issue of violating the Principle of Non-Maleficence
if they carry on with the wishes of the mother (thus harming both the fetus and the
mother).

In this situation, if the mother is officially deemed incompetent, her autonomy is

immediately voided and it is now passed on to the next appropriate person depending on
the gravity of the labor. If it progresses into an emergency case, the physician (and by
extension the hospital) has now free-reign to exercise within all ethical means all that can
be done to save both mother and child.

How To Resolve This Case and Balance All Scenarios

Autonomy has to be voided by the mother for any reasonable intervention to save both
fetus and woman can be done. If in the scenario that cannot be done, then the physician
can opt out of the case as he will be unable to relieve anyone and will only be doing harm
to the patient, his career, and the reputation of the hospital.

A psychological assessment of the mother is not a breach in her autonomy. However, if

she is found to be psychologically unstable, her autonomy is handed to more capable
decision makers. Ethically, this is the most reasonable means of preventing any
complications and mortalities.