Paul Burcher, MD, PhD

 on the use of cell-free DNA screening raises a practical ethical question for busy Ob/Gyn practitioners: How do we adequately counsel our patients before and after these tests in the current practice environment that allocates so little time to a follow-up obstetrics visit?

These tests are difficult to explain to patients and even more difficult to interpret. Practices who employ a genetic counselor obviously have a simple solution to this dilemma, but genetic counselors are in short supply, and few physicians in private practice have one available for consultation.

While this might appear to be more a practice management and communication issue than an ethical one, when we fail to properly educate and counsel our patients, and they make decisions based upon inadequate or inaccurate information, we actually failed to respect their autonomy. Our duty to patient autonomy includes providing them with the information necessary to make good choices predicated in their values. This requires us, in turn, to both give adequate information and to describe all the appropriate choices in a non-directive manner. It is simply ludicrous to believe we can do this in a 10-minute visit sandwiched between the other responsibilities of the follow-up appointment.

Time constraints are only one of the ethical challenges posed by these new genetic technologies. Equally important-and concerning-is our own need to remain abreast of these tests and what they can and cannot do. While Sequenom boasts sensitivity and specificity 

 for the detection of Down syndrome, it is important to remember that positive predictive value is actually much lower than this in a low-risk patient. Scientists and consumer groups have criticized the companies that perform these tests for failing to emphasize that despite higher sensitivity and specificity than previous screening tests, the cell-free DNA test still is not diagnostic.

Few of us remember statistics well enough to explain this clearly and accurately to a patient, and this explanation is crucial to ensuring that patients only terminate desired pregnancies when the fetus actually has the abnormality suggested by the screening test. One 

 cites a follow-up study to abnormal results that found 6% of patients were obtaining an abortion without confirming the results of the screening test. 

I admit when I first saw the impressive accuracy of cell-free DNA screening I thought the amniocentesis had found its replacement, but when you do the math, you see this is not the case. As that 

 describes, in a low-risk population, a positive test result is only correct 50% of the time. Couples are aborting desired pregnancies with normal fetuses because their physicians have not properly counseled them. This is truly tragic. If we do not have the time to educate ourselves about these advancing technologies, then we must find a consultant who can do this counseling for us. Obviously, if we do not understand the science and statistics behind these tests, we cannot possibly guide our patients appropriately.

When training ethics consultants at our institution, I often belabor the point that they must understand the medicine in order to understand the ethics of a particular medical question. The corollary to this, and it is relevant to genetic testing in our obstetrical patients, is that we must understand the medicine in order to appropriately counsel our patients. Failing to counsel our patients properly is a breach of our duty to the patient. We must know the science to be ethical physicians. We must also find the time, or find someone who has the time. These twin responsibilities are crucial and admittedly difficult, but we owe it to our patients to provide them with the information and time to make these vital, life-altering choices.

Articles

This blog discusses how OB/GYNs need not only to understand the science behind genetic screening but also to counsel patients properly about the results.

Ethical Obligations and Genetic Screening

[[{"type":"media","view_mode":"media_crop","fid":"25468","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_2899292681831","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2324","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"line-height: 1.538em; float: right;","title":"Paul Burcher, MD, PhD","typeof":"foaf:Image"}}]]Frank Chervenak, MD, a maternal-fetal medicine specialist from Cornell, has published numerous articles in the last few years arguing that home birth is less safe than hospital birth and that the professional responsibility of physicians is to provide no support or participation in home birth.

 While his data has been contested by many, I would agree with Drs Ecker and Minkoff (of Harvard Medical School and Maimonides Medical Center) that the data are still inconclusive regarding the safety of home birth in America but that home birth in America probably incurs a small increase in absolute risk of poor outcomes for newborns delivered at home.

However, the data seem much more solid if instead we ask whether home birth 

 be safe. An observational study from The Netherlands that evaluated more than 500,000 births in homes and in hospitals showed no increase in adverse outcomes of any kind with home birth in low-risk women.

 So home birth, in ideal conditions where midwives and physicians work together as a team and where transport to hospitals in an emergency is highly efficient, appears as safe as hospital birth. Put another way, the data suggest that if home birth in America is more dangerous than hospital birth, it may be because of contingent factors that can be remedied.

While the distances in The Netherlands from home to hospital are obviously smaller than in many rural areas of this country, if obstetricians want a seat at the table to make recommendations regarding when women should travel to a hospital or birth center because of their remote home location, they are going to need to take a position that acknowledges home birth as a reasonable option that some women will choose. Similarly, physicians should oppose laws that make midwifery difficult to practice, or even illegal, in a home birth setting.

 Since obstetricians as a political lobby are largely responsible for these punitive laws, we should work to have them overturned if we seek to renew the trust of our midwife colleagues.

What, then, are our professional obligations as obstetricians working in hospital settings to women who choose to stay home with a midwife for their birth? At the risk of sounding glib by answering a question with a question, do we enhance the safety of childbirth for all women by shunning home birth or by treating midwives collegially? I believe the correct answer is the latter, and since maternal-child safety was one of the founding reasons for ACOG’s existence, I believe we have an ethical obligation at a minimum to accept transports from home with the respect and professional dialogue we afford our colleagues.

For some of us, the collaboration can include providing consultation and medical advice for home birth clients with medical issues that do not “risk them out” of home birth care. My argument for this is empirical if anecdotal.

I was a speaker recently at the Home Birth Summit in Seattle. Duncan Nielson, the chief of Women’s Services for Legacy Hospitals in Portland, Oregon, described how by implementing a “home birth friendly” institutional culture, they saw a dramatic increase in transports to their hospital system from home birth midwives and that none of these transports were “train wrecks.” That is, by being openly supportive and collegial, they had increased the interactions between the two models of care, and midwives brought in patients who were struggling at home sooner because they did not fear verbal reprisals or nuisance reports to the midwifery board by the physicians accepting care.

We saw a similar trend when we embraced a model of informal collaboration in Eugene, Oregon. We (myself and several of my OB partners) agreed to provide ultrasounds, prenatal consultations, and an occasional script for UTIs and other minor problems in home birth clients, and we encouraged our midwife colleagues to seek consultation early if medical complications arose either in labor or prior to labor. We did a number of medically indicated inductions on midwife patients with pre-eclampsia, gestational diabetes, or IUGR. By inviting the midwife into the hospital and encouraging their participation in the birth, even though we provided the management decisions during labor, we made women who desired home birth more comfortable with their now medically indicated hospital births.

While I realize this level of collaboration is beyond the comfort level of many physicians, I found it re-invigorated my own practice to sometimes share patients with home birth midwives. In turn, the midwives were much less likely to vilify hospital practices when they saw medical interventions used appropriately on their patients.

Home birth rates in America have risen significantly in the last few years. I believe this is driven both by a positive desire to give birth at home and by the negative associations that hospital birth has created, including the popular perception that we are doing too many unnecessary cesarean sections. While I agree with Dr Chervenak that we should make hospitals more accommodating to our patients, if we wish to make birth as safe as possible then shunning our home birth colleagues cannot possibly be the way to achieve greater safety for pregnant women and babies.

In contrast to Dr Chervenak’s views, it is my assertion that our professional responsibility must include supporting all of the birth options women have and to make each as safe as possible. The Netherlands has shown that safety comparable to a hospital is achievable. We should strive to replicate their results.

1. GrÃ¼nebaum A, McCullough LB, Sapra KJ, et al. Apgar score of 0 at 5 minutes and neonatal seizures or serious neurologic dysfunction in relation to birth setting. 

http://www.ajog.org/article/S0002-9378(13)00641-8/pdf

2. Chervenak FA, McCullough LB, Brent RL, et al. Planned home birth: the professional responsibility response. 

3. Minkoff H, Ecker J. A reconsideration of home birth in the United States. 

http://www.ncbi.nlm.nih.gov/pubmed/24282848

4. Ecker J, Minkoff H. Home birth: what are physicians' ethical obligations when patient choices may carry increased risk? 

http://www.ncbi.nlm.nih.gov/pubmed/21508760

5. de Jonge A, Geerts C, van der Goes B, et al. Perinatal mortality and morbidity up to 28 days after birth among 743,070 low-risk planned home and hospital births: a cohort study based on three merged national perinatal databases. 

 Sept 10, 2014. doi: 10.1111/1471-0528.13084. Available at: 

http://www.ncbi.nlm.nih.gov/pubmed/25204886

6. Midwives Alliance North America. Legal status of U.S. midwives. Available at: 

http://mana.org/about-midwives/legal-status-of-us-midwives

In this blog, Paul Burcher, MD, PhD, considers the professional obligations of obstetricians in a hospital setting to women who opt for a home birth.

What's an Ethical Response to Home Birth?

[[{"type":"media","view_mode":"media_crop","fid":"28346","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_5725017213262","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2861","media_crop_rotate":"0","media_crop_scale_h":"150","media_crop_scale_w":"132","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"line-height: 1.538em; float: right;","title":"Paul Burcher, MD, PhD","typeof":"foaf:Image"}}]]I was at a conference last week in medical ethics, and I was surprised by, or perhaps appalled at, the attitude displayed by many of the philosophers regarding the importance of medical knowledge in medical ethical decision making. Several of them proudly announced a total ignorance of the medical issue they were speaking on, and also showed no interest in what I would call “real world” implications of their conclusions.

Although I have a PhD in philosophy, I am not a philosopher in the sense that I am capable of, or interested in, spinning arguments from “thin air” with no grounding in medical facts and no implications for real medical practice. Medical ethics must begin in real-life issues and problems and end with equally real and meaningful conclusions that can be applied-and sometimes even empirically tested.

This is not to say that philosophers cannot make good, or even great, medical/clinical ethicists. But they need to begin with a healthy respect for the way in which the “facts on the ground” inform the ethical decision-making. A brief example illustrates my point. In Hilde Lindemann Nelson’s famous article explaining narrative ethics, she discusses the case of Carlos and Consuela.

Carlos is an HIV-positive gang member wounded in gang violence and recovering from his injuries in a hospital. He is now ready for discharge but needs dressing changes at home. He wants his sister Consuela to do the dressing changes, but he insists that she not be told about his HIV status. While Lindemann Nelson uses this case to make several excellent points about the limitations of principle-based ethics, one aspect of the question, crucial to any ethical reasoning on the case, is (obviously) the transmissibility of HIV infection through dressing changes. This “fact” is an essential aspect that underpins any ethical judgment regarding the case. The conflict between patient confidentiality and duty of nonmaleficence (toward Consuela) pivots in part on the fact that HIV is not readily contagious, and simple universal precautions should make the risk to Consuela essentially nil.

But if it is problematic when philosophers inveigh on issues of medical ethics without a proper respect for the way medicine itself has something to say to ethics, equally frustrating are physicians who think that ethics is just “opinions” or that the principle of patient autonomy is the only thing that decides all questions of medical ethics.

Physicians sometimes use a simplistic unnuanced version of principalism that places patient autonomy hierarchically over other principles of bioethics. This absolute support of patient autonomy is ethically unjustified and often disingenuous in that when physicians claim they cannot overrule a patient’s choice no matter how ill advised or potentially dangerous this choice may be, it often also serves the physician interest as well.

For example, in my specialty, this argument is sometimes invoked when a physician is justifying a hysterectomy that doesn’t meet accepted medical indications or when a physician does a cesarean delivery on patient request. In both cases, the patient and physician interests align, and the physician is justifying his or her decision by claiming to respect patient autonomy while conveniently forgetting that the principles of beneficence and nonmaleficence may also have something to say in these cases.

The questions of medical ethics are wide-ranging, and they require attention to both the medical details and the ethically relevant principles. Being a good ethicist, and being a good clinician, requires sailing between the six-headed monster and the whirlpool (

). There is a successful path between, but it entails attention to both medical facts and ethical theories.

Nelson HL. Context: backward, sideways, and forward. 

Not enough medicine or not enough ethics? Paul Burcher, MD, PhD, shares his thoughts on finding the balance for good medical ethical decision making.

The Scylla and Charybdis of Medical Ethics

[[{"type":"media","view_mode":"media_crop","fid":"25468","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_2845987046603","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2324","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"line-height: 1.538em; float: right;","title":"Paul Burcher, MD, PhD","typeof":"foaf:Image"}}]]I was recently surprised to read in the 

 that a woman had undergone a cesarean section despite her refusal to consent to the procedure.

 The details of the case are not entirely clear from 

 a specific comment on this case. That said, what surprised me was my assumption that the ethics of “refusal of consent” were not in dispute.

The American Congress of Obstetricians and Gynecologists (ACOG) has taken a clear position on this: It is not permissible to perform surgery on a patient with decisional capacity without her consent. In a committee opinion, ACOG strongly discourages even attempting to seek a court order for treatment when a pregnant woman refuses cesarean section and concludes with the following statement

“Pregnant women's autonomous decisions should be respected. Concerns about the impact of maternal decisions on fetal well-being should be discussed in the context of medical evidence and understood within the context of each woman's broad social network, cultural beliefs, and values. In the absence of extraordinary circumstances, circumstances that, in fact, the Committee on Ethics cannot currently imagine, judicial authority should not be used to implement treatment regimens aimed at protecting the fetus, for such actions violate the pregnant woman's autonomy.”

This committee opinion gives six strong and compelling arguments for these conclusions, which I won’t repeat here, but I encourage readers to review them. What I want to address is the thinking that may lead some physicians to believe it’s ethically permissible to override a patient’s autonomous choice.

We teach cesarean section refusal as an ethical case during the third-year clerkship in Obstetrics and Gynecology for medical students. We present a hypothetical case of a young woman with pre-eclampsia and a non-reassuring fetal tracing who refuses a cesarean section on the grounds that she had hoped to have an abortion but presented to a clinic too late for a termination. So, she was carrying a pregnancy that she did not intend and did not desire.

A consistent response from at least one medical student in every group is that the pregnant patient is behaving unethically by refusing to make choices in the best interests of her fetus and, therefore, we are justified in overriding her wishes. Leaving aside the excellent arguments that ACOG makes about the limitations of our own knowledge in predicting fetal outcomes and the arrogance of believing that the physician can address the interests of the fetus better than the pregnant woman herself, there is a simple logical flaw in this reasoning. It is easier to see if you present it as a series of propositions, which are:

1. A woman carrying a fetus beyond viability has a duty to the fetus, including acting to best ensure its well-being.

2. If she is acting against medical advice or refuses a recommended procedure, she is not fulfilling this duty.

3. Therefore, physicians are justified in overriding her autonomous choice in order to ensure fetal well-being.

The ACOG committee opinion on maternal decision making calls into question the second proposition. My issue is actually with the third proposition-the conclusion. There is a logical fallacy here. Namely, it does not necessarily follow that because we believe the woman is acting unethically that we are then justified in violating her right to autonomy and bodily integrity. Put differently, we can agree that pregnant women beyond fetal viability bear some responsibility to their fetuses without leaping to the conclusion that we have the right or duty to compel it.

But isn’t the potential harm of a fetal death a greater harm than the loss of autonomy suffered by the patient? Again, I would refer readers to ACOG’s committee opinion on maternal decision making for an extensive argument against this point, but I will reiterate and amplify one of their responses. The logic that justifies this also justifies the incarceration of pregnant women who have behaviors that jeopardize their fetuses, and it isn’t hard to see where this logic ultimately takes us.

Smoking during pregnancy, by this argument, should be illegal. Maybe even inadequate prenatal care and choosing a home birth could lead to laws or actions that restrict a pregnant woman’s liberty. When critics of this logic argue that it transforms women from moral agents into powerless “baby vessels,” they are only following the argument to its logical but unjust conclusions. This logic isn’t just a theoretical concern; women in several states have been incarcerated for drug use during pregnancy.

It is important to note that it is not drug use per se that got them arrested, it was the state of pregnancy combined with drug addiction (and poverty, and lack of good legal counsel) that resulted in their loss of freedom. Furthermore, it is evidence of our historical prejudices that illegal drug use results in incarceration while tobacco addiction does not. I would suggest that the evidence does not support this demarcation.

It is neither logically necessary nor wise public policy to empower physicians in this way. History is replete with examples of those so empowered abusing it with tragic consequences, and always the victims seem to be the vulnerable. While we may experience moral regret if we are the physician on call when a woman refuses a cesarean section for fetal indication and the fetus ultimately dies or suffers harm, I would rather see this than a woman forcefully sedated or restrained while I deliver her fetus against her will by cesarean section. No concern regarding fetal well-being can justify this act of aggression against a patient. This flagrant violation of “first, do no harm” has no place in the healing arts.

1. Hartocollis A. Mother accuses doctors of forcing a C-section and files suit. 

http://www.nytimes.com/2014/05/17/nyregion/mother-accuses-doctors-of-forcing-a-c-section-and-files-suit.html?module=Search&mabReward=relbias%3Ar&_r=0

2. ACOG Committee Opinion no. 321. Maternal decision making, ethics, and the law. 

http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Ethics/Maternal_Decision_Making_Ethics_and_the_Law

3. Ehrlich JB, Paltrow LM. Jailing pregnant women raises health risks. Septemer 20, 2006. Available at: 

http://womensenews.org/story/health/060920/jailing-pregnant-women-raises-health-risks#.U6NomiiwkgY

Forcing surgery on a patient is never okay. Paul Burcher, MD, PhD, discusses respecting patient choice even when the clinical outcomes may be regrettable.

Paul Burcher, MD, PhD

Articles

Ethical Obligations and Genetic Screening

What's an Ethical Response to Home Birth?

The Scylla and Charybdis of Medical Ethics

Refusal of C-Section: Where Does Your Moral Compass Lead You?