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Patient Relations:
Professionalism, informed consent, and
abortion
MS-3 Case Based Series
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June 23, 2011
Objectives
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Review ethical principles
Review principles of informed consent
Understand the role of confidentiality in patient care
Describe legal and ethical issues in the care of minors
Describe issues of justice relating to access to obstetricgynecologic care
• Recognize the role of physician as a leader advocate for
women
• Explain ethical dilemmas in obstetrics and gynecology
• Cases
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Review ethical principles
• Autonomy
• Beneficence
» To promote the well-being of others
» Non-maleficence
• Justice – governs access to care and fair distribution of
resources
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ETHICAL PRINCIPLES AS THEY APPLY TO
OB/GYN
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Autonomy
• The mother’s prerogative to make choices or take actions
based on her beliefs and values even if these actions are
harmful to herself or her fetus
• Limited autonomy – the ability of adolescents to have
autonomy only in the area of sexual and reproductive
health, but in all other manners of life they are not
autonomous?
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Beneficence
• Requires doctors to act in a way that is expected to
reliably produce the greater balance of benefits over
harms in the lives of others
» Do the benefits outweigh the risks?
• Must often be balanced with non-maleficence and
autonomy
• Example: should an OB/GYN comply with a patient’s
request for a home birth if he/she knows that that the risks
are greater for both mother and baby?
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Justice
• Implementation of universal screening for sexually
transmitted diseases
• Psychosocial screening should be provided to every new
pregnant patient
• Both these interventions ensure that all populations are
reached and avoids selective screening
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REVIEW THE PRINCIPLES OF INFORMED
CONSENT
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Informed Consent - Background
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Based on ethical and legal requirements
Legal foundations in statutes and case laws
May be available through state medical board
California:
» www.medbd.ca.gov/publications/laws_guide.pdf
• North Carolina
» http://www.ncga.state.nc.us/enactedlegislation/statutes/pd
f/bysection/chapter_90/gs_90-21.13.pdf
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Informed Consent - Definition
Patients to meaningfully participate in the decision making process
Medical education of the patient is fundamental to the process.
The basis of the informed consent process is to respect and promote the
participant’s or patient’s autonomy, and to protect him or her from
potential harm.
The collaborative physician-patient relationship forms the foundation of
the informed consent process.
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Informed Consent
Risks and benefits of the intervention and alternative treatments or
procedures, as well as risks and benefits of not receiving or undergoing a
treatment, should be explained in language that will facilitate patient
comprehension.
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Informed Consent
A well designed ICF should promote the patient’s understanding and the
voluntary nature of their participation in the treatment.
Readability and comprehension of the informed consent form must be
appropriate.
Almost half of all U.S. adults read at or below 8th grade level but consent
forms should be written at least three grade levels lower than the average
educational level of the target population.
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Confidentiality
• Understand the role of confidentiality in patient care:
» Patient-physician relationship
» Legally binding: HIPPA
» How do minors fit in?
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Patient-Physician Relationship
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Confidentiality
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HIPPA
• Health Insurance Portability and Accountability Act (1996)
aims to:
» Improve portability and continuity of health insurance
coverage
» Combat waste, fraud, and abuse in health care
» Reduce costs and administrative burdens by standardizing
the interchange of electronic data
» Ensure protecting the privacy of Americans’ personal health
records by protecting the security and confidentiality of
health care information
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Overview of Privacy Rule
» Gives patients control over the use of their health
information
» Defines boundaries for the use/disclosure of health records
» Establishes national-level standards
» Helps to limit the use of PHI and minimizes chances of its
inappropriate disclosure
» Strictly investigates compliance-related issues and holds
violators accountable
» Supports the cause of disclosing PHI without individual
consent for individual healthcare needs, public benefit and
national interests
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Minors
• State and federal laws govern consent and confidentiality
for minors
• A legally-responsible person must always give consent for
health care
» Usually parent or legal guardian
» Important EXCEPTIONS – especially in reproductive health
care
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Minors and Reproductive Health Care
• Two things to consider:
1. The status of the minor
• Married
• Emancipated
• A parent and <18 years old
2. The type of health care
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Emergency care
Family Planning
STI testing and care
Pregnancy
Abortion
Mental health
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Minors and Reproductive Health
• In all states, minors can give consent for STI, pregnancy,
and HIV/AIDS testing and care
• In North Carolina, consent for abortion must be given by
the minor and one parent or legal guardian, or
grandparent if the minor has lived with him/her for the last
6 months
» Judicial bypass possible
» Exceptions for rape, incest, and medical emergency
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Minors and HIPAA
• A physician giving care based on a minor’s consent may
not share information with the minors parent/legal
guardian without the minor’s permission to do so
• UNLESS: notification is essential for the life or health of
the minor
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What are situations where challenges may be met
specifically in ob/gyn?
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Assisted reproductive technology
Contraception
Emergency Contraception
Abortion
Sterilization of mentally challenged
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Conscience
• The private, constant, ethically attuned part of the human
character. It operates as an internal sanction that comes
into play through critical reflection about a certain action or
inaction.
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Patient interactions to consider
• Caring for a patient who is:
 An alleged crime suspect; an alleged or known abuser of children
or women
• Caring for patients who you don’t feel help themselves:
 Alcoholics; non-compliant patients with chronic disease
• Caring for pregnant patients who you don’t feel care about
the wellbeing of their fetus
• Caring for pregnant patients who want an abortion
• Working with other physicians who you feel behave
unethically
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Sterilization for mentally challenged
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Sterilization for mentally challenged
• In early 1900s, 33 states adopted eugenics programs.
• Most states abandoned the programs after WWII because
too similar to Nazi Germany’s programs for racial purity.
• However, NC eugenics program expanded in 1950s-60s
until it was discontinued in 1975.
• Approximately 7,600 people in NC had forced sterilization
from 1929-1975.
• Because of this legacy, it is now difficult to obtain
sterilization for the mentally challenged in NC.
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Sterilization for mentally challenged
• At UNC Hospital, if a mentally ill or mentally retarded ward
needs to undergo a medical procedure that would result in
sterilization:
» Ward’s guardian must petition a clerk of court for an order to
permit the guardian to consent for the procedure.
» Physician may perform procedure only if:
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1) Court order has been issued
2) Copy of court order is placed in patient’s chart
3) Guardian consents for the procedure
4) Ward consents for the procedure (if he/she can comprehend
the nature of the procedure and its consequences
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Sterilization for mentally challenged
• In addition, the petition must have:
» Sworn statement from an NC psychiatrist/psychologist who
has examined the ward as to whether the ward is able to
comprehend the nature of the procedure and its
consequences and provide an informed consent.
» Sworn statement from an NC physician who has examined
the ward that the procedure is medically necessary & not for
sole purpose of sterilization or convenience/hygiene.
» Name and address of physician who will perform the
procedure.
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Sterilization for mentally challenged
• Example:
» 12yo G0 with high-functioning autism and pervasive
developmental disorder (possibly 2/2 known balanced
translocation) presents with her mother. Patient recently
had menarche and is having panic attacks because of a
severe sensitivity to the odor of blood and tactile sensation
of wearing a pad. Patient says that she does not want to
have children. Mother is concerned because she is 54 years
old, is in poor health (breast cancer), does not think her
daughter could handle pregnancy/childbirth, and is afraid her
daughter will pass on the balanced translocation.
» Patient and her mother both request that the pt has a
hysterectomy to stop menses and for sterilization.
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Sterilization for mentally challenged
• Example:
» Is this an ethical request?
» Does it matter that the patient’s guardian (her mother) is ill
and concerned that after she dies, her daughter may have a
more difficult time petitioning for a hysterectomy?
» Would it make a difference if the patient was 12 or 20 years
old if she is currently at her maximum developmental
capacity?
» Does the fact that she has a known inheritable genetic
disease (balanced translocation) make a difference?
» What are her options?
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ABORTION
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Some background on abortion
• In 2005 1.21 million women chose to have an
abortion
• 1/3 of all women will have had an abortion by age
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• More than half (54%) or women who have an
abortion report using contraception when they got
pregnant
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More abortion information
• 58% of women say they would have liked to
have had their abortion sooner
• 53% of women having an abortion never had a
previous one
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North Carolina Medical Board
The physician who does not want to mention abortion as a
treatment option
State and federal law lets a health provider with ethical or moral
objections avoid participating in abortion.
However, a provider’s withdrawal must not limit a patient’s options. To
satisfy state law on informed consent and, if applicable, the federal
family planning regulations, the physician must refer the patient to
another provider who will counsel her on all options.
http://www.ncmedboard.org/images/uploads/publications_uploads/no301.
pdf
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Conscientious refusal and reproductive
medicine
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Case 1
• Jane is 17 years old and is 10 weeks pregnant. She
comes from a supportive working class family with strong
ties to the anti-abortion movement. She has been
accepted on an athletic scholarship to UNC and is due to
start her first semester in two months. Her boyfriend
wants them to get married and have the baby. She doesn’t
know what to do and she is in your office crying.
The abortion option: a values clarification guide for health care professionals, NAF
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Case 2
• A 24 year-old law student comes to see you. She is two
weeks late with her period, she took a home pregnancy
test and it was positive. She was taking the birth control
pill and is certain she never missed a pill. She knows she
cannot handle a pregnancy or a baby. You counsel her:
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Case 3
• A 17 year-old comes to see you with her mother. She
had sex with her boyfriend and didn’t use anything. She is
pregnant, at 14 weeks. She is in your office because the
local abortion clinic referred her to you since you are at a
tertiary care clinic – the clinic closest to her only goes
through 12 weeks.
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Case 4
• A 38 year old comes to see you. She is devastated to
have learned her fetus has trisomy 18, diagnosed by first
elevated triple screen followed by amniocentesis. She is a
professor at the university, her husband also works full
time, and she knows they do not have the capacity to carry
this fetus to term with an approximately 50% chance of
stillbirth before term, and then only a 10% survival rate to
the first year of life. She desires termination.
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Case 5
• The mother of a 16 year old patient calls you and
demands to know if her daughter is using birth control
pills.
You:
a) Tell her that it is, but you prescribed it for acne.
b) Tell her which pill she is taking, and when she
started taking it.
c) Explain that you can’t tell her anything because the
patient did not give you permission to talk about her
health care with her parents
d) Explain that more than 50% of adolescents have
sex by the age of 18
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Case 6
• A 17 year old presents asking to be tested for STIs. She
states that her mother will be furious if she finds out that
she has an STI.
• You:
» A) Tell her that she will need to tell her parents the results of
her test
» B) Tell her that you will tell her mother that you just did a pap
smear
» C) Reassure her that all mothers react that way
» D) Reassure her that testing for STIs is completely
confidential, and that her mother will not be notified of the
results
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Case 7
• 20yo G1 @ 40+2 weeks presents to L&D in active labor.
She is a refugee from Sudan and has a history of type 3
female genital cutting (infibulation). Her clitoris and labia
minora have been removed and her labia majora have
been sewn together so that she only has a 2-3 cm vaginal
opening. She understands that she will need to be
opened to deliver her baby vaginally and requests that you
“reinfibulate” her after delivery so that she can look
“normal” again, the way she currently looks. She tells you
that if she is not reinfibulated, her husband may not accept
her back and she will be an outcast in her local Sudanese
community. Although there are laws prohibiting
infibulation in the U.S., there are no laws prohibiting
reinfibulation.
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Case 7
• What are the benefits and harms to performing
reinfibulation?
• Does the patient have the right to have reinfibulation
performed given that she is an adult and strongly believes
that is “normal” and even beautiful for women? How can
cultural norms affect our interpretation of beneficence?
• Does the patient have full informed consent given that she
already knows what her condition will be like after
reinfibulation?
• How can we be sure that her decision is autonomous?
• What do you tell the patient?
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Case 8
• 42yo G7P0 @ 23+0 weeks presents with severe preeclampsia and HELLP. This is a highly-desired pregnancy
as she has had 6 prior miscarriages and conceived this
pregnancy after undergoing 3 IVF cycles. Her OB
recommends a Dilation and Evacuation (D&E) abortion to
preserve her health, and possibly her life. Patient
understands that she needs to deliver, but requests a
cesarean section instead. She understands that a 23week delivery is associated with poor outcomes, but says
she won’t be able to live with herself if she ends the
pregnancy. She says she is willing to undergo the
increased risks of cesarean for the potential survival
benefit for her baby.
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Case 8
• What are the benefits and harms to performing the D&E?
• What are the benefits and harms to performing the
cesarean section?
• How do beneficence/non-maleficence apply to this
situation?
• Does the patient have the right to a cesarean section? If
her OB is unwilling do perform it, is he/she required to find
another OB to do it instead?
• Does the patient have full informed consent given that she
knows the risks of cesarean section and the poor
outcomes for a 23-week delivery?
• What do you tell the patient?
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Conclusion
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