Ingrid Hein

May 22, 2017

In obstetrics, complex ethical issues arise day in and day out, and academic centers are helping with increasingly complicated cases, one expert pointed out at the American College of Obstetricians and Gynecologists 2017 Annual Meeting in San Diego.

For difficult decisions, it is important to reach out, in the same way you would if you had a complex clinical problem," said Louise King, MD, JD, assistant professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School in Boston.

Dr King and her team increased the visibility of information about access to ethical guidance, did outreach, and are working on an education program in the division of minimally invasive gynecologic surgery at the Beth Israel Deaconess Medical Center in Boston.

"We also expanded ethical teaching to all fourth-years, and we see they are identifying ethical problems more readily and incorporating this type of analysis more and more," she reported.

Physician Ethicists

Ethics is not something one should avoid or defer to a philosopher for. "As physicians, we can be ethicists as well, and we should not shy away from using our voice," said Dr King.

In reproductive medicine, you often have two patients in front of you, she explained. For example, when you have a woman with diabetes not using her medications appropriately, the risk for stillbirth and other adverse outcomes is high. "How do you maintain a relationship with the patient while protecting the child? How do you go about addressing that in a meaningful way? How far should you go?" she asked.

All ethical decisions are guided by the four commonly accepted principles of healthcare ethics, she pointed out.

Basic Principles of Bioethics
Respect for autonomy


When you have a tool and ethical guideline you can resort to, like an ethical framework, "you can more easily address these issues and not blow them off," Dr King said.

One of the controversies "driving people crazy right now" is home birth, she explained. On one hand, the rate of cesarean delivery is high; on the other hand, the pushback on overmedicalization can lead to dangerous situations.

For women who opt for a home birth, "how do you ensure they get the care and the communication they need on when to come to the hospital?" Doctors often feel like they're "flying by the seat of their pants," she said.

We all care about these issues deeply. "I enjoy going over these ethical problems as part of my work. It doesn't have to be the painful part of the day, it can be the interesting part," Dr King said. As one gets better at making ethical decisions, it gets easier, she added.

"The important thing is to have a formal process," said Lawrence Grunfeld, MD, clinical associate professor of obstetrics and gynecology at the Mount Sinai School of Medicine in New York City, who is codirector of Reproductive Medicine Associates of New York.

"We're not floundering in the dark. We have a basis, with guidelines from our societies," he told Medscape Medical News. "We have a lot of supervisory agencies we can turn to."

"We face ethical issues on a daily basis. Usually these are questions about what a patient wants and what is the right thing to do," he explained.

Uncomfortable Situations

Reproductive therapy for a woman in her 60s is outside the guidelines, for example, so it would be perfectly within the bounds of practice to deny such a woman treatment. There are "serious medical concerns about whether she can tolerate pregnancy. This is where we might have a conflict between a patient and physician," Dr Grunfeld said. "That's a national guideline we can refer to when it's unclear."

But other situations might be less evident, such as a lesbian couple who wants to have a baby using sperm from the carrier's brother and eggs from her partner. "In this case, she's carrying the baby of her wife and her brother — basically carrying her brother's baby."

Although there is no legal reason not to do this, it has the consequence of giving a misleading appearance. "You can do this, but it's discouraged," he said.

No matter what the ethical dilemma, expert advice and guidelines should always be looked at. "No individual practitioner should make a decision that can't be supported by the institution," Dr Grunfeld said.

Dr King and Dr Grunfeld have disclosed no relevant financial relationships.

American College of Obstetricians and Gynecologists (ACOG) 2017 Annual Meeting

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