Julie Cantor, MD, JD, published a disturbing article on “Court-Ordered Care” in the June 14, 2012 issue of the New England Journal of Medicine (NEJM) raising the important issue of maternal autonomy. She begins the piece with a case example of a woman, Samantha Burton, who was admitted to Tallahassee Memorial Hospital by her obstetrician after her membranes ruptured at 25 weeks of gestation. The doctor’s prescription was inpatient bed rest for the duration of the pregnancy.
The patient decided she could not stay in the hospital on bed rest for three months because she had two young children at home to care for and her job to consider. She tried to leave the hospital against her doctor’s advice, but she was physically prevented from doing so.
Then, the hospital started the process of getting a court order to keep her in the hospital. Burton, who couldn’t leave the hospital, had to testify by phone without guidance from counsel. Her obstetrician, according to the NEJM article, became “the unborn child’s attending physician.” (Hmmm…I thought he was Samantha Burton’s doctor.)
The day after the hearing, the judge in the case gave the hospital and its staff permission to “administer any care they deemed necessary to preserve the fetus’s life and health.” Burton’s request to change hospitals was denied and she was ordered to comply with the bed rest order. Within days, not surprisingly, Burton delivered a dead fetus by C-section.
Trying to strive for a live birth of a 25 week fetus, in this case, put the mom at risk for complications including intrauterine infection, deep venous thrombosis, muscle wasting, and other complications of prolonged bed rest. Further, a prolonged hospitalization had potential adverse impacts on the woman’s other two children who would be deprived of their mother’s care and family income if the absence resulted in loss of wages or permanent loss of her job. Further, it is relevant that prolonged bed rest has never been shown that to improve outcomes in cases like this. In fact, there is published evidence that the practice might actually be harmful.
This case raises the question: Do “the rights” of an unborn fetus really trump everything else in the mother’s life, including her own health? Whose body is it anyway? “Why,” as Dr. Cantor writes, “should pregnancy diminish a competent adult woman’s right to refuse care?”
Beneficence and autonomy
According to some respected medical ethicists, it probably does not. Beneficence, the doctor’s obligation to prevent harm, must be balanced with autonomy. Here are some definitions of these fundamental principles of medical ethics from University of California San Francisco’s School of Medicine:
“Autonomy is the ‘personal rule of the self that is free from both controlling interferences by others and from personal limitations that prevent meaningful choice.’ Autonomous individuals act intentionally, with understanding, and without controlling influences…Examples of promoting autonomous behavior [include] presenting all treatment options to a patient, explaining risks in terms that a patient understands, ensuring that a patient understands the risks and agrees to all procedures before going into surgery.”
Beneficence is the physician’s
“obligation to 1) prevent and remove harms, and 2) weigh and balance possible benefits against possible risks of an action. Beneficence can also include protecting and defending the rights of others, rescuing persons who are in danger, and helping individuals with disabilities…Examples of beneficent actions [include] resuscitating a drowning victim, providing vaccinations for the general population, encouraging a patient to quit smoking and start an exercise program, talking to the community about STD prevention.”
Problems arise when a patient’s autonomous decision conflicts with the physician’s view of beneficence. An example is when a patient with heart disease chooses to continue smoking despite the physician’s best effort to convince the patient to quit. What should the doctor do? We are offered this guidance:
“In these situations the autonomous choice of the patient conflicts with the physician’s duty of beneficence and following each ethical principle would lead to different actions. As long as the patient meets the criteria for making an autonomous choice (the patient understands the decision at hand and is not basing the decision on delusional ideas), then the physician should respect the patient’s decisions even while trying to convince the patient otherwise.”
Dr. Cantor provides some additional considerations with these remarks:
“Citizens have no legal duty to use their bodies to save one another; even parents have no legal duty to their children. It follows, then, that ‘a fetus cannot have rights in this respect superior to those of a person who has already been born.'”
Indeed, she goes on to point out that forced care creates a slippery slope where we could end up arresting and jailing women who drink or smoke during pregnancy to protect their fetuses from injurious exposures. Come on folks, where should we draw the line?
So, what should we do?
I believe our fallback needs to be that these are highly personal and difficult decisions that should be guided by clinicians. We can offer information, recommendations, our personal opinion, and psychological support to patients facing these tough choices. But we cannot and we should not make these decisions for them. Forced care, particularly court-ordered care that violates the rights of a pregnant woman, is just plain bad medicine.
As Dr. Cantor concludes,
“Forced interventions undermine the liberty, privacy and equality of pregnant women…they betray foundational legal principles of our free society and the endanger the liberty of us all.”