Prenatal care weighs needs of 2 patients

A pregnant woman's nonadherent behavior and lifestyle put her fetus at risk and point distinctly toward a riskier-than-average delivery. What ethical and professional principles help in managing this patient's care?

Reply:

Here is an (unfortunately) representative set of circumstances. A newly registered patient presents for prenatal care late in her third pregnancy. Her intake history tells a complicated obstetrical/psychosocial story. She states, "This baby better be born healthy; my first boy has been taken by DSS because my baby girl died inside me, even though those doctors did an emergency C-section. They said it was from drinking and drugs ... they said it was 'abruptio,' whatever that means. I wanted to sue them, but ain't no lawyer wants to take a poor woman's case. But, anything wrong with this baby and I will sue all y'all."

How, indeed, ought the health care professional respond?

Even in the best of circumstances, the praxis of obstetrics retains an element of uncertainty as to outcome. Conscientious, even compulsive adherence to those evidence-based practice guidelines promulgated by our professional organizations (the American Medical Association, American College of Obstetricians and Gynecologists and the American Academy of Family Physicians) does not guarantee perfect results in all situations.

How should the physician -- placed in the tenuous position of caring for the person whose lifestyle choices endanger herself and her developing fetus -- manage the conflicting obligations and duties produced by tensions between the individual and society? How can trust, so vital in the formation of the patient-physician relationship, be developed in an environment perceived as threatening, either to the physician or to the patient?

Attempts to resolve the maternal-fetal conflicts or maternal-societal conflicts challenge the physician's personal and professional ethical compass. One's understanding and application of prima facie ethical principles requires modification, embellishment, balancing and transformation from a primary focus on the individual patient to a broader consideration for societal concerns.

Once a patient-physician relationship is established, each party assumes moral obligations to the other. The physician's primary duty is to the patient, and in this case two patients, mother and fetus. The patient has a reciprocal responsibility to cooperate with agreed-upon treatment plans and to keep scheduled appointments. But as so often quoted from the AMA's Principles of Medical Ethics, members of this profession "must recognize responsibility to patients first and foremost, as well as to society, other health professionals, and to self." In our scenario, the physician has two sets of "dual loyalties."

First there are two patients with moral claims to the physician's professional, nonjudgmental regard and concerned caring.

There also are, dependent on practice locale, statutory requirements mandating certain actions from the physician that may seem to conflict with the patient's interest. These include reporting illegal substance abuse and, possibly, reporting child abuse resulting from maternal failure to keep appointments and from maternal use of legal but potentially hazardous agents, for example, alcohol, tobacco products and prescribed pharmacological agents.

Let us take a brief look at some of the options available to assist in resolving this moral dilemma, recognizing that no one response is totally satisfying to all people.

Option A: Avoidance. Refer the patient to another physician, perhaps one more adept in aiding individuals addicted to drugs or alcohol; perhaps to a tertiary center with enhanced resources and expertise of a teaching institution. The referring physician admits to a lack of training, expertise, and interest in providing care to this subgroup of pregnant patients. No patient-physician relationship is formed; the physician has no obligation to provide care for which he or she lacks the requisite skill. Of course, this choice is an option only if an alternate caregiver can be located. And the patient must be able to easily travel to the caregiver.

Option B: The physician may establish obstetrical care and a patient-physician relationship and treat "by the book," following accepted guidelines for frequency of visits, diagnostic studies, counseling, referrals and mandatory state reporting statutes.

Physicians are held to high standards, codified by professional organizations, and ethical lapses can result in censure. A litigious, nonadherent patient who engages in criminal behavior, as defined by statute, remains a person entitled to consideration for her personal autonomous choices, but only to the point at which her lifestyle decisions put the well-being of her fetus in jeopardy. A violation of the patient's confidentiality, by adherence to mandated reporting, is ethically permissible to protect the fetus (nonmaleficence).

Some writers have expressed concern that we've stepped onto a slippery slope here, compelling maternal behavior in the interests of the fetus alone. Pregnant women might be constrained from using legal agents such as tobacco or alcohol, or perhaps even prescribed psychotropic agents or antibiotics and analgesics.

Another temptation inherent in Option B is to "go beyond the book" in an effort to reduce the tension produced by the litigious, nonadherent, substance-abusing patient who threatens to sue. Many believe practice that employs unnecessary tests and technology is a deviation from sound medical practice. Certainly it consumes more, often public, resources.

Option C: Initiate a caring relationship with a stated, shared goal: healthy mother and healthy baby leave the hospital together after delivery at term.

If a trusting relationship is successfully established, the physician can be confident that the patient will attempt to follow the advice and instructions she receives and will avail herself of referrals for counseling and collaborative management of both obstetric and psychosocial aspects of care. The patient can be assured that her care and care for her developing baby is of primary concern to the physician and that her medically important history, physical and laboratory studies will remain confidential, within the limits of the laws of the state in which the care is tendered.

Some recommend use of signed contracts in Option C as demonstration of the patient's intent to fulfill her obligations. Should the patient not adhere to the contractually agreed-upon plan -- by failing to follow advice or keep appointments or by using illicit substances -- then termination of the physician-patient relationship, with appropriate notification and timely transfer of care and records to another physician, is ethically permissible as a last resort.

The contemporary American woman is most likely aware of medicine's concerns and society's disdain for drug or alcohol abusers. The publicity surrounding prosecutions of those convicted for child abuse or endangerment might prevent her from seeking health care. And the substance abuser's avoidance of prenatal care due to fear of being detected, reported and prosecuted may produce more harm to the developing fetus because her potential high-risk status goes undiagnosed and untreated.

This is one of the reasons for ACOG's 2005 recommendation against use of the punitive legal system to coerce pregnant women into compliance.

The bottom line

What of the possible conflicts in the physician's obligation to society and to self? How can the physician demonstrate respect for laws of society that seem to mandate behavior that might be considered professionally unethical -- such as reporting a patient to legal authorities -- and in violation of the rule of confidentiality?

Perhaps the physician objects to reporting actions that are illegal but that have not been scientifically proven to produce harm to either the mother or her fetus? There is strong evidence, for example, that so-called licit agents such as alcohol, tobacco or prescribed drugs, cause more harm than illegal agents such as cannabinoids or opioids.

The most ethically and professionally sound way to manage these conflicts is to:

• Educate the patient to the known risks associated with fetal exposure to potentially noxious agents.
• Inform the patient of the mandatory reporting laws of the practice's locale.
• Explain how the pregnancy will be monitored during the period of care.
• Be certain that the patient understands repercussions of her lifestyle choices.

It should go without saying that all conversations with patients must be documented.

It is well known that many pregnancies are unplanned, or timed poorly, for a large number of women. Yet, all women who choose to remain pregnant and seek care express a desire to have a healthy child. Those who choose to remain pregnant have obligations to the fetus and the yet-to-be-born child to insure an optimal environment for development to full potential, for example, an environment free of exposure to illicit drugs and perhaps even to licit substances such as alcohol and tobacco.

Our society has even deemed it appropriate, in certain states, to apply coercion, by threat of incarceration, to influence maternal behavior in respect for the fetus, but with total disregard for the mother's autonomous choices.

Physicians, on the other hand, have the duty to respect the ethical and cultural tenets of their patients. Historiography of medical codes, from before the Hippocratic tradition, emphasize the oft-quoted dictum: "the central moral commitment ... is dedication to something other than the physician's self-interest, that something being the primacy of the welfare of the patient."

P.D. Bullard Jr., MD, obstetrician-gynecologist, West Columbia, S.C.; South Carolina Medical Assn. Bioethics Committee chair, Maternal-Infant-Child Health Committee co-chair; completed AMA/Medical College of Wisconsin's online fellowship in bioethics