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Tuesday
Oct042011

FIGO: Ethical guidelines regarding interventions for fetal wellbeing

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By Jill Arnold

 

This report by the FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health titled Ethical guidelines regarding interventions for fetal wellbeing has been available online since August 12, 2011.

 

1.  Most women will make choices to improve their chance of having a normal birth and healthy baby if they have access to the necessary information and support.

 

2.  Extending care to the fetus by giving the pregnant woman the support she needs provides the best hope of enhancing the wellbeing of both the fetus and the mother-to-be.

 

3.  Although the fetus may benefit from health care, it is completely dependent on the mother, and any treatment must be through her body.

 

4.  While the majority of women act in a way that provides a healthy environment and are usually ready to take risks on behalf of their fetus, there may be situations where their interests do not coincide:

•  The mother’s behavior may create risks for herself and her fetus (e.g. use of drugs, tobacco, and alcohol; not attending appropriately provided prenatal care; failure to take available HIV therapy).

•  The mother may choose not to accept diagnostic, medical, or surgical procedures aimed at preserving fetal wellbeing, including cesarean delivery for fetal indications.

 

5.  The medical team has a responsibility to fully inform the mother, to counsel her with empathy and patience, and to provide such support services as are needed to achieve the best maternal and fetal outcomes.

 

6.  However, no woman who has the capacity to choose among healthcare options should be forced to undergo an unwished-for medical or surgical procedure in order to preserve the life or health of her fetus, as this would be a violation of her autonomy and fundamental human rights.

 

7.  Resort to the courts or to judicial intervention when a woman has made an informed refusal of medical or surgical treatment is inappropriate and usually counter-productive.

 

8.  If maternal capacity to choose for medical decision-making is impaired, healthcare providers should act in the best interests of the woman first and her fetus second. Information from the family and others may help to ascertain what she would have wished.

 

9.  The wishes of pregnant minors who are competent to give informed consent regarding medical and surgical procedures should be respected.

 

 

 

SOURCE: International journal of gynaecology and obstetrics [0020-7292] Dickens yr:2011 vol:115 iss:1 pg:92.

 

 

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Reader Comments (13)

Well, yeah.

October 4, 2011 | Unregistered CommenterRS

Well, how's about that?

October 4, 2011 | Registered CommenterANaturalAdvocate

Don't hold your breath waiting for ACOG to jump on this bandwagon.

October 4, 2011 | Unregistered Commenterjust sayin

"Well, yeah."

"Well, how's about that?"

There is some stiff competition for Comment of the Week. Not sure how I am going to handle this.

October 4, 2011 | Registered CommenterJill

Many of them know the rules, in theory, too.. but fail to follow them in practice. I'm sure anyone could tell you, regardless of my fever me yelling at the medical staff while I was pushing "STOP PULLING AT MY CROTCH" and later "STOP YANKING AT THE CORD" (As they were pulling at my crotch and then yanking at said cord) was not some sort of feverish delusional request and should've been honored. I'd told them, and it was in my birth plan, that they should. not. do. that. They did it anyway, and even when I said magical medical lingo at them and made an appeal to my partner, they insisted "I'm not doing that (because, for some INSANE REASON, they thought I couldn't feel what they were doing?". Bullshit. Small example, but, big picture. I wonder what the inner dialogue of that midwife was after my birth. It probably didn't include anything about going against my explicit wishes and against my will.. for her own psychological functioning/happiness state, I doubt highly that it did. (If it did, she must be thoroughly burnt out).

People know all sorts of information that they don't necessarily act because of. It is called dissonance. People know a lot of things yet don't act in accordance with the information. It is not because they are dumb or duhr or anything. It is a psychological thing.

That said, a bunch of pretty rules about consent.. they don't mean anything to people who aren't going to follow them anyway "because of protocol/routine". I guess it could point out information about consent to totallly incompetent people, though, and maybe this sort of information should be afforded to patients .. like .. "Wow... I can (really somtimes is added) say no to/aquestion (not just say no, but, to even question one has been asked) a doctor?" (Actual questions I've received more than even a few times in providing info about BF to lower income women in a rural area (that I live in........ BF is a different subject but really in the same vein isn't it?)..

*trolls about trollishly, too* =p

October 4, 2011 | Unregistered CommenterFogedaboudid

Showdown, ANA!

October 5, 2011 | Unregistered CommenterRS

These guidelines are great and seem self-evident. And yet... somehow we all know doctors who don't come anywhere near to following them. In fact, this website wouldn't exist if all doctors followed them. But why? From my experiences (as a patient), I think there are four main reasons that certain doctors don't follow these guidelines (maybe more)...

First, there are some doctors who haven't given the issue of patient autonomy the consideration it deserves, and see informed consent as merely paperwork that has to be gotten out of the way before they can proceed with the course of treatment they deem best. Maybe they're too busy, burned out, or stretched too thin to devote their time to practicing under these ethical guidelines. I think for these doctors, if it were brought to their attention, they would make some effort towards integrating these guidelines into their practice.

Second, there are those doctors who don't seem to understand the concept of informed consent. "Consent" of course, implies a choice, which in turns implies that the patient was free to accept or turn down any recommended treatment. Instead, there are certain doctors that seem to think the phrase means "I give her the information, and then she gives consent." As if the litany of risks, once given to the patient, is the key to allowing the doctor to proceed on whatever course of treatment they do best. They seem to miss the second step, which is waiting for actual consent from the patient.

Third, are those doctors that seem to truly believe that any patient that turns down the doctor's recommendations is, by default, not competent to make her own medical decisions. After all, any competent person would listen to the experts telling her what to do, right? So it's hard for these types of doctors to take you seriously if you don't follow these recommendations. I once had a doctor spend literally two hours trying to convince me of why she was right and I was wrong. It didn't matter to her what I *wanted* to do. It just mattered that I defer to her expertise.

Fourth, and hopefully most rare, are those doctors who simply don't give a sh*t about patient autonomy or informed consent. To relate a personal anecdote here, last year I was in the hospital under the care of a doctor who was clearly practicing defensive medicine at its worst. He insisted on every "precautionary" unnecessary treatment in the book. Well, I spoke up and said I didn't want to do some of these things. He started berating me, calling me stupid, threatening me with the parade of horribles that was sure to come my way if I didn't do exactly as he ordered. At some point, trying to make it easy for him, I said, "I understand the risks here of not getting the treatment. I accept them and do not consent to the treatment." He said, "Well, I can't let you do that." I said, trying to making it excruciatingly clear, "So you are overriding my consent?" I was so sure this would get him to back down. But he said, "Yes, I'm overriding it." Let me tell you, my jaw dropped all the way to the floor that he would just admit this, bold as brass. So for those (hopefully few and far between) doctors like this, all the pretty ethical guidelines in the world couldn't make them care about patient autonomy.

October 5, 2011 | Unregistered CommenterLeah

I agree with Leah's points, but it's worth mentioning in the specific context of maternal-fetal medicine that there are also some physicians who simply do not believe that women have the right to refuse treatment when the fetus might be harmed, and who see themselves as treating the fetus before the mother. There are all kind of medical scenarios in which appropriate or desired treatment is denied pregnant women based on the religious beliefs of the physician and/or institution (ie Catholic hospitals, for one example). I think that's one of the reasons why we see so much abuse of consent in the area of ob. In addition to which, racism and misogyny also feed into certain physicians' denial of women's bodily autonomy and right to informed consent/refusal (as we've discussed here before). I am 100% behind these guidelines, but I don't see them being implemented in this country anytime soon, especially when we're seeing such strong "fetal personalhood" movements. These are not just about ending abortion, but also entail all kinds of horrors for women - as we've seen, efforts to criminalize miscarriage and restrict the rights of maternal autonomy on just about every level.

October 5, 2011 | Unregistered CommenterErin

Totally agreed, Erin. Very good points on the other sort of barriers to getting ethical guidelines like these implemented.

October 5, 2011 | Unregistered CommenterLeah

Having met someone in person this year who had an honest-to-God forced cesarean section under general anesthesia ("Here, breathe some oxygen..."), there are certainly a few providers who could use a reminder. I think the lack of informed consent is usually subtle. Many times, a provider simply says, "You should do this," or, "We need to do this," and the pregnant woman trusts the provider's advice, even when the advice isn't in her best interest and she hasn't been given any information about the pros and cons. It's not because women are clueless. I think it's just that 1.) we feel we should be able to trust the experts; and 2.) we're more suggestible than usual during labor.

October 5, 2011 | Unregistered CommenterKK
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