Critical Care Obstetrics part 69 ppsx

Ethics in the Obstetric Critical Care Setting 669 Can the patient describe: 1 her current medical problem 2 the therapy suggested for the problem 3 the risks associated with the recommended therapy 4 the risks associated with foregoing this therapy 5 the other available therapies and their risks/benefi ts? (Adapted from [10] ) Annas notes that if the patient is not decisive and treatment is immediately needed to save her life or prevent severe damage, then reasonable treatment can be done as this promotes society ’ s general interest in health. However, if a question persists and non - emergent treatment is indicated, then evaluation of the patient for competency is called for. If the patient is determined incompetent, then a proxy decision - maker must be identifi ed. When psychiatric assistance is needed, it is important to note that psychiatry determines whether the patient is competent to make treatment decisions. The psychiatric evaluation should not play a direct role in determining which treatment to use, but should only be used to determine whether the patient is competent to decide among the different treatment options [10] . Annas argues that the unusual case of a pregnant woman ’ s refusal to consent to an intervention that would benefi t her fetus should always be honored. He notes that this may seem callous to the rights of fetuses, but this is the price society should be prepared to pay in order to protect the rights of all competent adults [30] . Other authors also argue for full maternal autonomy for resolving ethical confl icts that arise during pregnancy. Mahowald bases her arguments on four issues: the right to informed consent, the right of bodily integrity, the questionable personhood of the fetus, and the maternal risks in undergoing forced treatments such as cesarean section. Mahowald agrees with Annas that forcing women to undergo any treatment for the sake of the fetus marks women as “ unequal citizens ” equivalent to “ fetal con- tainers ” [33] . Rhoden also advocates strong maternal autonomy, noting that there is a “ quantum leap in logic ” when using the oft - cited Roe vs Wade decision where prohibitions on abortions were allowed when the fetus reached viability. Rhoden notes that there is a marked difference between prohibiting destruction and requiring surgical preservation [34] ). Harris supports strong maternal autonomy and proposes that fetal needs exist only as a projection by a third party (i.e. the physician). This projection can become problematic. It has been estimated that up to one - third of court - ordered interventions use wrong medical judgment [35] . Advocates of f etal r ights In contrast to those who believe the fetus never has moral status, there are advocates of fetal rights. Strong is supportive of fetal rights in maternal – fetal confl ict cases. He proposes intervention with treatments that pose insignifi cant or no health risks to the mother or treatments that would promote her interests in life/ health. He advocates interventions that protect fetal life or prevent serious harm to the fetus. He surpasses some other authors in fi nding supportive compelling reasons to override maternal countries but in the US it is approximately 24 – 25 weeks. Viability means that the fetus can begin to have “ interests ” that deserve to be protected/promoted by obstetric interventions [32] . The potential protection of the fetus, however, can only occur when the pregnant woman presents the fetus to the healthcare team when she seeks prenatal care. To McCullough and Chervenak ’ s viewpoint, the dependent moral status of the fetus obligates the pregnant woman to take reasonable risks to protect the fetus. She is not obligated to take unreasonable risks [32] . According to this view of fetal moral status, the previable fetus has no claim on the pregnant woman or her physician to remain in utero because the fetus requires the use of the pregnant woman ’ s body to achieve viability. The fetus needs the pregnant woman to make an autonomous decision in order for the “ patient ” status to be conferred during the previable period [32] . The pregnant woman has no ethical obligation to present her previable fetus to her physician. If and only if she presents her fetus to the physician for treatment, is the physician then obligated to protect and promote fetal interests. Thus the previable fetus in this view has only dependent moral status [32] . If the mother is undecided regarding her views toward the fetus, McCullough and Chervenak recommend using Pascal ’ s wager (if you are unsure regarding the existence of God then it would make more sense to act as if God exists) and proceeding in ways that promote full fetal benefi t (until the mother withholds the status from her fetus). This view of the fetus as having dependent moral status provides a useful framework to look at the issues which confront the physician during dilemmas in critical care obstetric settings. Practical a pplications of e thical p rinciples to h igh - r isk o bstetrics Maternal – f etal c onfl ict Advocates of s trong m aternal a utonomy One ’ s approach to the issue of maternal – fetal confl ict is largely defi ned by how one approaches the status of the fetus. Strong maternal autonomy advocates such as Annas argue that it is an assumption in Anglo - American law that every competent adult is at liberty to consent or to refuse any proposed medical treatment. This legal right to refuse treatment is viewed by Annas as part of the common law right to self - determination and associated with the constitutional right to privacy [10] . He notes that forcing compliance with medical advice would give the fetus status as a patient which is not correct as the fetus can only be treated (without the mother ’ s consent) by drastically curtailing the mother ’ s liberties [31] . He warns against using an “ outcome ” approach to judge competency in cases of maternal – fetal confl ict wherein the mother ’ s competency comes into question only when her wishes go against the beliefs of her doctors [10] . Annas outlines questions he considers helpful in assessing patient competency. Chapter 47 670 would not have been called in the fi rst place had she consented for the surgery. The judge agreed and reaffi rmed his order that the cesarean section be performed. Less than 1 hour later, a three - judge panel heard arguments for a stay of the procedure. Angela ’ s lawyer argued that the surgery would likely end his client ’ s life and that it should not be done without her consent. The lawyer for the fetus argued that fetal concerns should outweigh maternal concerns because the mother was clearly going to die soon, but the fetus had a chance for life. It was argued that the fetus had a better chance of survival than the mother. The three - judge panel denied the request for a stay but reserved the right to fi le an opinion at a later date. The fetus was delivered via cesarean section and lived just a few hours. Angela died 2 days later without awakening from the surgery. The D.C. Court of Appeals reviewed the case (although the outcome was long decided) and vacated the lower court ’ s decision, arguing that substituted judgment by one of the family members should have been used if Angela ’ s competency was in question. They ruled against the court - ordered cesarean section (re: AC as noted in Brown, 2001 [41] and Adams, 2003 [42] ). A more recent case has also favored maternal autonomy: Baby Doe vs Mother Doe [43] . This case involved a woman at 36 weeks of gestation who was thought to have placental insuffi ciency so severe that the fetus would die in utero or be severely damaged unless it was delivered via cesarean section immediately. The mother expressed her faith in God ’ s healing powers and declined the cesarean section. The attending physician and hospital took the case to the Cook County State Attorney who brought it to court. The Court of Appeal ’ s decision strongly reaffi rmed the right of a competent pregnant woman to decline invasive medical treatments. They could fi nd no other case in which any person has an obligation to undergo invasive surgery for the sake of another. The Carder case was cited as a precedent (re: Baby Doe as presented in Pinkerton & Finnerty, 1996 [44] ). The Supreme Court has addressed the maternal versus fetal rights issue several times. In 1979, in Colautti vs Franklin, the Court ruled in favor of maternal rights and invalidated a state statute that had protected the fetus by requiring that post - viability abortions be done in a manner least destructive to the fetus [45] . The statute had required that a more destructive abortion technique was permitted only if it were indispensable to the life of the mother. The Supreme Court ruled that this language was too restrictive (Colautti vs Franklin as reported in Rhoden, 1987 [34] ). Cases a ffi rming f etal r ights Several court cases have granted the fetus or neonate certain rights relative to that of the mother. One of the frequently cited cases is Jefferson vs Griffen [46] ). This case involved a woman diagnosed with a complete placenta previa at term. The hospital asked the court for permission to perform a cesarean section and give blood if necessary should the patient present to the hospital. The trial court gave permission for all medical procedures deemed necessary to preserve the life of the unborn child, but the order autonomy. These other reasons include preventing abandonment of dependent children, preserving the ethical integrity of physicians, and promoting the well - being of the community. For instance, he sanctions the transfusion of blood in a Jehovah ’ s Witness at term if the pregnant woman has multiple dependent children and there are no other people to assume care of the children [36,37] . Review of p rominent c ourt c ases Background: Roe v s Wade The groundwork for maternal and fetal rights cases was in many ways laid by the Supreme Court ’ s 1973 decision in Roe v. Wade [38] . Roe vs Wade changes the status assigned to the fetus as the fetus progresses through the three trimesters. In the fi rst trimester, a woman ’ s right to privacy is emphasized. The fi rst - trimester fetus is noted to lack personhood (as defi ned by the 14th Amendment) and no societal obligations to the fetus are granted. This landmark decision establishes that during the fi rst trimester, no states can interfere with the right of the pregnant woman to have an abortion. In the second trimester, increasing regulation of pregnancy termination is permitted to safeguard the mother ’ s health. In the third trimester, stricter restrictions by the states are permitted to protect the rights of the viable fetus. It is this protec- tive language regarding the third - trimester fetus that has been increasingly used by fetal advocates to justify interventions for the fetus at this stage [34] . The Supreme Court has revisited this issue in several cases since Roe vs Wade. Cases a ffi rming m aternal a utonomy Several cases have settled in favor of maternal autonomy. One of the more celebrated of these cases is the Angela Carder case in 1990 [39] . Angela Carder had developed bone cancer at age 13 but was felt to be in remission when she married at the age of 27 and subsequently became pregnant. When she reached 25 weeks ’ gestational age, Angela was discovered to have metastases to her lungs and was admitted to the hospital for further work - up. At 26 weeks gestational age, Angela ’ s condition began to deteriorate and she decided that she would undergo chemotherapy with the goal of reaching 28 weeks before delivery might be indicated. However, her condition degenerated rapidly and 1 day later the question of whether the fetus should be delivered earlier was raised (re: AC [39] as noted in Mohaupt & Sharma, 1998 [40] ). Her feelings about the pregnancy were noted to be equivocal and the hospital sought a declaratory judgment regarding a caesarean delivery for the fetus. A hearing was convened at the bedside but Angela was not coherent at the time and the judge ruled in favor of proceeding with the cesarean section. A short time later Angela and her attending obstetrician had communications that strongly suggested she did not want the surgery performed (re: AC as noted in Brown, 2001 [41] ). A session was reconvened at the bedside. The attending obstetrician and Angela ’ s family were opposed to the cesarean section. The counsel for the District of Columbia suggested that Angela ’ s current refusal did not change the situation because the court Ethics in the Obstetric Critical Care Setting 671 tation, the Court had to modify the fi rst - , second - , and third - trimester framework of Roe vs Wade in order to permit testing as early as 20 weeks [40] . In 1992 the Court again took up the abortion issue in Planned Parenthood v. Casey ( [51] as reported in Lo, 2000 [6] ). In this case, the court affi rmed that states may ban abortions after viability has been reached as long as there are exceptions to protect the life and health of the mother and there are not excessive restrictions placed prior to viability. For example, if the state has parental notifi cation laws, then judicial reviews for juveniles must be made available ( [51] as reported in Lo, 2000 [6] ). Thus the Supreme Court has both affi rmed maternal autonomy, particularly in clearly previable fetuses, and has granted restrictions on the practice of abortion, especially as the fetus nears viability. More recently there have been several court cases which appear to curtail a pregnant woman ’ s right to complete autonomy. Most notable among these is the case of Melissa Rowland. Ms. Rowland was a 28 - year - old woman who was reportedly mentally ill and had been brought to Utah by a Florida adoption agency. She was pregnant with twins and was to give the babies up for adoption [52] . She had six previous children and had had two previous caesarean sections [53] . She was advised to undergo a caesarean section due to concerns regarding the twins ’ well - being. She initially declined the surgery for several days. When she fi nally consented to the surgery, one twin was stillborn and the other tested positive for cocaine and alcohol [53,54] . She was charged with homicide but pleaded guilty to the lesser charge of child endangerment. Multiple observers view this case as a dangerous precedent constricting maternal autonomy [52,54,55] . Others view the case as not abro- gating her autonomy rights, but holding her responsible for her actions regarding the manner in which she chose to assert her autonomy [56,57] . The most recent ACOG Committee Opinion mentions several other recent cases concerning maternal autonomy. These include the January 2004 case of a woman (with pelvis proven to 11 pounds) who declined a caesarean section for macrosomia. Although the Pennsylvania hospital obtained a court order for a cesarean delivery, she and her husband went to another hospital where a successful vaginal birth occurred [52] . There was also the September 2003 case of a 22 - year - old woman who was convicted in Glen Falls, NY after her newborn infant tested positive for alcohol. This was overturned on appeal. Finally, there is the May 1999 case of a South Carolina woman who gave birth to a stillborn infant while using cocaine. She was convicted of homicide and sentenced to 12 years. The South Carolina Supreme Court upheld the conviction, and the US Supreme Court declined to hear it. [52] . Special c onsiderations f ollowing c ase r eviews There are drawbacks to placing an emphasis too strongly on either maternal or fetal rights. This section discusses problems with maternal autonomy and fetal rights viewpoints. A case is then presented in which a seemingly bad outcome (forcibly was only valid if the mother sought admission to Griffen Hospital. The Georgia Department of Human Resources then petitioned the juvenile court for temporary custody of the child. The petition was granted with a ruling that the Georgia Department of Human Resources could give permission for the cesarean section. The Supreme Court of Georgia then ordered Jefferson to undergo a cesarean section due to the state ’ s compelling interest in preserving life after viability. Most accounts of this case note that the patient left the hospital but subsequently delivered successfully via a vaginal delivery [40,44] . The Smith vs Brennan case involved a neonate, but applied to injuries sustained during the gestational period [47] . This case recognized the right of a child after birth to sue for damages for injuries wrongfully infl icted by a third party prior to birth [48] . Some have interpreted this case as a basis for the fetus ’ legal right to develop without injury. The pertinent section said, “ justice requires that the principle be recognized that a child has a legal right to begin life with a sound mind and body. ” (Smith vs Brennan as noted in Nelson & Milliken, 1988 [48] ). Nelson dis- agrees with this view, noting that the case refers to a child after birth who has a right to sue for damages but who had no such rights as a fetus. The wording of the case does explicitly state that this decision applied to an injured, live - born child. The decision makes explicit that it was “ immaterial whether before birth the child is considered a person in being ” that could have defi nite legal rights (Smith vs Brennan, 1960 [47] as referenced in Nelson, 1988 [48] ). In the Maydun case, a 19 - year - old primagravida at term was transferred to Georgetown University Hospital from an outlying hospital following 48 hours of labor with ruptured membranes and failure to progress [49] . She insisted upon a vaginal delivery. She was observed until the duration of ruptured membranes reached 60 hours, at which time a cesarean section was again recommended. The patient and her husband declined the procedure, noting that they understood the infection risk to the fetus and that as a Muslim woman she had the right to determine if a risk to her fetus warranted the risk to her own health from the cesarean section. The hospital then requested from the courts a sanction to allow delivery by cesarean section. The court ruled that, while a competent adult does have the right to refuse treatment on religious grounds, the state has a compelling interest to ensure the health of the viable fetus. The court ruled that parents do not have the right to make a martyr of the unborn child and ordered the hospital to take medically necessary steps, including a cesarean if needed (in re: Maydun as presented in Pinkerton & Finnerty, 1996 [44] ). The Supreme Court has also had several post - Roe - vs - Wade rulings that have supported fetal rights. In 1989, the Court decided in Webster vs Reproductive Health Services that a Missouri statute was constitutional [50] . This law required ultrasound, prior to termination, for gestations of at least 20 weeks. The statute was deemed constitutional because the Roe vs Wade decision affi rmed the state ’ s interest in protecting potential human life after a certain gestational age. To justify this interpre- Chapter 47 672 to induce labor. Internal monitoring found no variability with late decelerations. The scalp pH was noted to be 7.09. The patient was advised that her baby needed to be delivered abdominally, but she declined, stating that she did not want the baby. The hospital attorney was unsuccessful in getting any of the three judges he contacted to hear the case. Oxytocin was begun and the fetal heart tracing continued to worsen with severe late decelerations and longer periods of bradycardia. A sister of the patient was summoned to the hospital but was unable to convince the patient to undergo a cesarean section. A second scalp pH was noted to be 6.71. Labor continued and fi nally a stillborn female infant weighing 2140 g was delivered [60] . Strict adherence to maternal autonomy thus resulted in the death of a viable fetus. Problems with a dvocating f etal r ights In contrast, there have been cases where court orders have affected the opposite of their intention. Strong (1991) cites the case of Barbara Jefferies, a 33 - year - old Michigan woman with a placenta previa who declined cesarean delivery on religious grounds. The court ordered the police to escort the patient to the hospital but the patient had fl ed to another state, thereby increasing risks to the mother and fetus. Thus the court order had the opposite of its intended effect. Forcible r estraint with g ood o utcome There are also cases where severe fetal harm may be avoided with timely court interventions and this outcome was subsequently appreciated by the mother. Elkins reports a case involving a 24 - year - old primagravida who presented at 34 weeks with thick meconium [60] . She had recently left another hospital against medical advice because a cesarean section had been recommended. She presented with severe hypertension (160/110 mmHg) and 3 proteinuria. The fetal heart tracing showed no variability, with recurrent late decelerations and episodic severe bradycardia. The patient repeatedly declined all recommendations for cesarean delivery. She was noted to have a fl at affect and did not wish to discuss her decision. Her mother noted that her daughter had been in a similar state for several weeks during which she would not communicate with her either. Serial fetal scalp blood sam- pling was performed which noted progressive acidemia (pH drop from 7.1 to 6.96). After 4 hours, a juvenile court judge was contacted on behalf of the fetus and a court order obtained to proceed with cesarean section. The patient needed to be restrained while general anesthesia was given. A 4 - pound male infant was delivered with Apgars of 2, 5, and 7 at 1, 5, and 10 minutes. The postoperative course was uneventful, and the infant did well after an initial period of seizures. After the surgery the patient said she now understood why the surgery was necessary. At 1 year follow - up the patient and her child appeared to be doing well [60] . As the cases above have illustrated, there can be problems with either a strict maternal autonomy or fetal rights viewpoint. Maternal advocates may rely on minority bias and ultimately good outcomes for mother and fetus to help justify their position, restraining a woman for cesarean section) ended with a good outcome for both mother and fetus. Problems with e mphasizing m aternal a utonomy v iewpoint One of the strongest arguments for giving priority to maternal autonomy is the seemingly discriminatory nature of the applica- tion of court - ordered interventions for minority women. However, a closer review of the situation highlights concerns about this viewpoint. Many strong maternal autonomy advocates refer to Kolder ’ s study of the practice of court - ordered interventions [58] . This study of court - ordered cesarean sections noted that 81% of the cases studied involved African American, Hispanic, or Asian women. Of this study population 44% were not married and 24% did not speak English as their fi rst language [58] . Harris suggests that the consideration of forced treatment of pregnant women can be regarded as racism masked as fetal protection [35] . Kolder ’ s study is to be commended as it is the most complete review of the demographics of women in the situation of court - ordered interventions. However, a closer look at the study population also reveals the diffi culty in adequately addressing this issue. As Nelson makes clear, Kolder ’ s study only questioned maternal – fetal medicine fellowship heads (preferably in University settings) or (in their absence) residency directors [48] . Although there was an 83% response rate, signifi cant selection bias can be introduced by studying the population in this manner. For instance, there were fi ve states (Alaska, Idaho, Montana, North Dakota, and Wyoming) that were not represented. The patient population of the hospitals studied (preferably university centers or at least those with residency programs) would also have a disproportionate number of minority or non - English - speaking patients. It would be helpful to know if the proportion of patients for whom court - ordered interventions were contemplated dif- fered in general from the patient population in these medical centers. The study is a good fi rst step in quantifying a diffi cult demographic situation, but the use of its demographics to condemn the practice of seeking court interventions does not take into account the biases that may have been introduced by the types of programs surveyed for this study. One must also be cautious regarding the “ reported ” outcomes of the maternal autonomy cases. The Jefferson case is often cited as ending with the safe vaginal delivery of the child. What is not usually presented in this scenario is that the patient voluntarily returned to her original hospital where another ultrasound was obtained several days later. This ultrasound showed the previa was no longer present, and she labored under the care of the original hospital, which had earlier sought a cesarean delivery [59] . When courts decline to intervene, the outcome can sometimes be poor. Elkins reports another case in 1975 where a 27 - year - old primagravida was seen by Planned Parenthood and requested pregnancy termination [60] . She was noted to be 30 – 34 weeks with blood pressures of 180/110 mmHg and was transferred to a tertiary care center. A decision was made the following morning Ethics in the Obstetric Critical Care Setting 673 ment will help or cause minimal harm to the mother. It also requires that there be a high probability of serious harm to the fetus and a high probability that treatment will signifi cantly decrease fetal harm. The statement strongly recommends that an ethics committee be consulted before appealing to a court case. In fact, The Committee on Ethics states “ 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 ” [52] . The Committee on Ethics also strongly opposes the criminal prosecution of pregnant women whose activities cause harm to their fetuses. It notes three relatively recent cases where pregnant women were (at least initially) successfully prosecuted for using illicit substances which were associated with adverse pregnancy outcomes [52] . Chervenak and McCullough are two authors who deal exten- sively with maternal – fetal confl ict. They present a thorough approach to maternal – fetal confl ict that complements the guidelines proposed by ACOG and AAP. Chervenak and McCullough require that: (i) the mortality risk and the risk of disease, injury, or disability to the pregnant woman be reliably low or manageable in order to consider coercing the intervention; and (ii) there be a high probability that the procedure will be life - saving or will prevent serious or irreversible damage to a viable fetus. They expect that the treatment will also reliably have a low mortality or have a manageable risk of serious injury to the fetus [63] . Chervenak and McCullough address the issue of the possible use of court orders in the case of a woman with a well - docu- mented complete placenta previa at term who is demanding to be delivered via the vaginal route. They address the argument that but with a closer examination, these factors may be misleading. The maternal advocate ’ s approach can also result in the unneces- sary death of a fetus that is viable. On the other hand, a strict adherence to fetal rights can result in unintended consequences such as maternal fl ight to avoid a court order. The next section critiques viewpoints that address both issues. Compromise v iews r egarding m aternal – f etal c onfl ict Fortunately, the vast majority of maternal – fetal interactions in the context of a viable fetus do not result in maternal – fetal confl ict. However, the potential for scenarios such as those men- tioned above does exist, especially in the high - risk setting, and the obstetrician must be prepared to deal with complex ethical situations. Three more balanced responses to maternal – fetal confl ict situations should be considered: the ACOG, the American Academy of Pediatrics (AAP), and Chervenak and McCullough. These views are examined in regard to risks to pregnant women, risks to the fetus without the procedure, effect of the procedure on the fetus, and special considerations. The different viewpoints are summarized in Table 47.1 . The APP revised its statement on maternal – fetal confl ict in 1999. The new statement requires that the proposed treatment of the mother against her will should be of negligible risk to the health and well - being of the pregnant woman. The treatment should prevent irrevocable and substantial fetal harm and be effective therapy [61] . The most discussion on maternal fetal confl ict by ACOG is refl ected in its 2005 Committee Opinion “ Maternal Decision Making, Ethics and the Law ” and its document “ Patient Choice in the Maternal - Fetal Relationship ” [52,62] . The Committee Opinion asserts that there needs to be high probability the treat- Table 47.1 Considerations for treatment of fetus without maternal consent. Reference Risk to pregnant woman Risk to fetus without procedure Effects of procedure on fetus Special considerations ACOG, 1999 [85] Committee Opinion High probability that treatment helps or has very little risk for pregnant woman High probability of serious harm to fetus High probability that treatment will signifi cantly decrease fetal harm Always consult ethics committee before considering legal approach AAP, 1999 [61] Statement Negligible risk to health/ well - being of pregnant woman Serious harm Effective treatment that prevents irrevocable and substantial fetal harm No less invasive way to help the fetus Chervenak & McCullough, 1985 [86] Mortality risk and risk of disease/ injury/disability to pregnant woman reliably low or manageable High probability of saving life or preventing serious and irreversible disease/injury/ disability for viable fetus Treatment reliably has low mortality and low or manageable risk of serious disease/injury/disability to fetus Do not force pregnant woman but use court order to help persuade Strong, 1991 [37] Insignifi cant or no health risk or would promote her health Serious fetal harm/death Prevent serious fetal harm Promote well - being of community. Prevent abandonment of dependent children. Preserve ethical integrity of physician Chapter 47 674 organ donor and recipient. Legal issues can also be framed in terms of the legal obligations of parents to their children in terms of child neglect and abuse cases. They conclude that, in cases similar to that of a placenta previa at term, there are cases when ethical and legal court sanctions can be sought for cesarean delivery. Whether physical force can be used to perform the surgery is not clearly defi ned. They oppose the use of force in this situation if there is no time to obtain a court order, but do not address the issue if the court order is obtained. They also stop short of condoning court orders for cesarean delivery in cases where there is no clear benefi t for the mother (i.e. fetal distress cases). Their criteria for intervention include that the mortality risk to the pregnant woman be very low and the risk of injury or handicap be low or manageable. They acknowledge that any attempt to go beyond these criteria faces a “ considerable, perhaps daunting, burden of proof ” [32] . Suggestions for m anaging m aternal – f etal c onfl ict The above sections have dealt with court cases and theories regarding how to deal with maternal – fetal confl icts. In their 1996 article, Pinkerton and Finnerty present a logical outline for pre- paring for and dealing with issues of maternal – fetal confl ict by using a proactive team approach that attempts to deal with these issues across departmental lines [44] . This has become the model at the University of Virginia Health Sciences Center. They developed a subcommittee of the hospital ethics committee consisting of representatives of the departments of obstetrics and gynecol- ogy, pediatrics, anesthesiology, family medicine, ethics committee, and hospital counsel. All subcommittee members reviewed relevant literature on maternal – fetal confl ict, and guidelines were then developed. The guidelines were discussed in the individual departments and fi nally discussed with the full ethics committee. Many diverse opinions were noted and many revisions occurred over the course of 1 year. The guidelines evolved from being a staunch advocate of full maternal autonomy to including references to some instances where court - mandated interventions could be considered. Separate guidelines were developed for incompetent women. The fi nal consensus was that the courts should be used very rarely and maternal autonomy should prevail in almost all instances [44] . The purpose of the guidelines was to provide a framework to foster communication between the patient and the healthcare team members. Unresolved confl icts could then be mediated by the ethics consultation service. If the confl ict remained unresolved then the ethics committee and departmental representatives were available for assistance. Only after these avenues had failed was turning to the courts considered [44] . Although the process of developing these guidelines was long and diffi cult, the end result was a greater appreciation for the nuances of cases and the judicial decisions surrounding them. This increased awareness should decrease the likelihood of resort- ing to the courts for assistance. Should a court order a direct intervention, the policy stated that physical force should not be used in its implementation. The court order should rather be court - ordered cesarean sections can never be ethically justifi ed. They state that no physician should be justifi ed in accepting a patient ’ s refusal of cesarean section in the case of a complete previa at term because of the unreliability of the patient ’ s clinical judgement. They note that physicians are justifi ed in resisting a patient ’ s exercise of her positive right if the fulfi lling of her positive right would contradict the physician ’ s best clinical judgment and negate all benefi cence - based interests of the woman and her fetus. A woman does not have a right to make her physician practice medicine that is against the physician ’ s best clinical judgment. They argue that a court - ordered cesarean in this instance does not treat a woman as a “ mere instrument ” to benefi t her fetus, one of Rhoden ’ s claims [34] , because in this case the cesarean benefi ts the woman as well. There is no violation of her autonomy without justifi cation because a pregnant woman who has taken a pregnancy to term has an ethical obligation to accept reasonable risks on behalf of her fetus. An exercise of someone ’ s positive and negative rights can be limited when the exercise of those rights brings certain serious harm to others. They argue that the woman ’ s fear of surgery cannot be used to justify her claim because her claim is an irrational fear and irrational beliefs disable the exercise of autonomy. Even objections on religious grounds can be overcome in that courts have ordered the treatment of pediatric patients over the religious objections of their parents. Chervenak and McCullough then turn to arguments to justify court intervention in the case of complete previa at term. They note that the use of a state ’ s power to enforce a pregnant woman ’ s benefi cence - based obligations to her fetus at term is justifi ed when the net risk to her is non - existent. Maternal autonomy rights are not absolute in this case and can be constrained by the probability of severe, preventable harm to third parties. Judge Belson stated this obligation succinctly in his commentary in the Angela Carder case: A woman who carries a child to viability is in fact a member of a unique category of persons. Her circumstances differ fundamen- tally from those of other potential patients for medical procedures that will aid another person, for example, a potential donor of bone marrow for transplant. This is so because she has undertaken to bear another human being, and has carried an unborn child to viability. Another unique feature of the situation we address arises from the singular nature of the dependence of the unborn child upon the mother … The expectant mother has placed herself in a special category of person who is bringing another person into existence, and upon whom that other person ’ s life is totally dependent. Also, uniquely, the viable unborn child is literally captive within the mother ’ s body. No other potential benefi ciary of a surgical procedure on another person is in that position. (In re: AC as reported in McCullough & Chervenak, 1994 [32] ) As Chervenak and McCullough state, the primary moral relationship of a pregnant woman and her viable fetus is one of obligation as opposed to unrestrained freedom. The analogous relationship is that of a parent to a child rather than a potential Ethics in the Obstetric Critical Care Setting 675 Pliny the Elder was said to have been delivered by postmortem cesarean in 23 ad . The Babylonian Talmud recommended opening the abdomen immediately to deliver the child of a mother who died in childbirth. Postmortem cesarean section was practiced in Hellenistic times by Roman authorities and in 17th century Venice [66] . In approximately 700 bc Numa Popilus forbade burial of a pregnant woman before the child was removed. This edict, which may have been used to rescue a live child or allow separate burial of the child, became part of the Roman ’ s King ’ s Law (Lex Regia) which in turn became the Emperor ’ s Law or Lex Caesare, which may be the origin of the term cesarean . It is unlikely that Julius Caesar was delivered in this manner because there are references to his mother being alive 40 years later. In 1280 the Council of Cologne required postmortem cesareans to allow for baptism and proper burial of children from mothers who had died [65,66] . Not until approximately 1500 were cesareans performed successfully to save a mother and child. Jacob Nufer, a Swiss sow gelder, accomplished such a delivery [66] . Only in the past century have cesarean sections been used regu- larly to save both mother and child [65] . Ironically, improve- ments in the care of critically ill obstetric patients have brought us full circle, making it now possible to contemplate postmortem sections in which the mother has been brain dead for prolonged periods of time. With intensive care, it is possible to prolong fetal maturation in a mother who would otherwise have been declared dead and taken off life support. Rapid evacuation of the uterus (especially after 5 minutes of a full code with no signifi cant response from the mother) is still recommended in mothers with a fetus of signifi cant size impeding blood fl ow during a code situation. This section deals with cases of fatally ill women who can be stabilized with life support techniques. In some of these cases, care of the mother with monitoring of the fetus allows for fetal growth. The means for providing a rapid abdominal delivery at the bedside is reviewed (Table 47.2 ). There is a signifi cant moral distinction between a rapid postmortem cesarean section and maintaining viability solely for the sake of the fetus. Some would have concerns about using brain - dead mothers as incubators, merely as a means to justify an end. However, the moral value of brain - dead pregnant women can also be viewed as secondary moral status [66] . The brain - dead mother ’ s worth is secondary in that she has symbolic worth and value for others but cannot have actual or potential harm or benefi t directly herself [66] . On the other hand, the fetus has real and symbolic value. Its real moral value is based on its potential for being harmed or benefi ted. The symbolic value can be derived from its role as a symbol of renewal or continuity of life. The concept of “ fl esh of her fl esh ” underscores the continuity of her life and could justify the prolonged use of brain - dead mothers to continue fetal life [66] . The embryo can be viewed as having inherent interests, with the discussion focusing on where those interests lie relative to those of the mother. With a brain - dead mother, her interests still exist, but in a secondary status [66] . With technological advances, there comes an increasing probabil- used to help persuade the patient to agree to the intervention [44] . A common theme among many authors is the responsibility of ethics committees to help mediate in diffi cult situations. To do so in a viable manner for high - risk obstetric cases, the ethics committee needs to have members available on an emergency basis. At Louisiana State University Health Sciences Center (LSUHSC) in New Orleans, one member carries a beeper so that response can be immediate if necessary. Also important in this process is an awareness and appreciation for the role of the ethics committee. The more the ethics committee is involved in service to the hospital community (e.g. by sponsoring workshops and lectures), the more people will feel comfortable approaching the committee. It is also important to let patients and their family members know that the committee is available and to allow, if possible, their direct access to its services as well [41] . Moral differences between the healthcare team and the patient do not have to end up in court. Ethics consultations can sometimes have unexpected results. Gill et al. refer to the case of a couple requesting late termination of a Down ’ s pregnancy. The patient underwent amniocentesis at 25 weeks due to a fi nding of fetal duodenal atresia. The results indicated a trisomy 21 (Down ’ s syndrome) fetus and the parents requested termination. The physician requested an acute clinical ethics service (ACES) consultation. The ACES team met with the obstetrician, social worker and labor ward midwife (the parents supported the process but did not want direct involvement). The ACES team supported the termination of the pregnancy, citing maternal autonomy. However, the ACES team felt this would only work if the mother received further counseling and the labor ward staff agreed to carry out the procedure. The team also recommended involving the hospital ’ s CEO. The CEO recommended a formal psychiatric consultation; that evaluation found that the pregnancy was not a risk to maternal mental health. The CEO further requested that the full Institutional Clinical Ethics Committee meet. No consensus was reached (despite lengthy debate) at the full committee meeting. After input from several sources, the CEO declined to authorize termination of the pregnancy. The couple was advised of this decision which was reached 2 weeks after the initial consultation. The family actually accepted the result and was appre- ciative of the manner in which their case was handled. In fact, they chose to continue obstetric care and deliver at the same hospital [64] . Issues r egarding b rain d eath Background Cesarean sections were fi rst used to deliver the living fetus from dead mothers [65,66] . In Greek mythology, Asklepios (the famous Greek physician and Apollo ’ s son) was said to be delivered from his dead mother in this manner [66] . In the fourth century bc Susruta ’ s Samhita recommended cesarean delivery when the woman ’ s life was in great danger or where she had died. Chapter 47 676 cerebral imaging showed “ toxic injury ” and the EEG was “ severely abnormal ” [68] . She was diagnosed to be in a chronic vegetative state with little chance of recovery. It was decided to withdraw all treatment (except nutrition) and give her DNR status. At 23 weeks, pneumonia was diagnosed and ultrasound showed a normal - size fetus. The ethics committee was reconsulted and met with the obstetric and medical teams and with family members. It was determined that care could be given that would help the fetus as long as there was a chance of a normal outcome. Antibiotics and other medications could be provided. Fetal monitoring was to start at 28 weeks. At 31 weeks late decelerations and vaginal bleeding were noted. An abruption was diagnosed and cesarean section was performed with delivery of a 2240g fetus with Apgars of 4 and 7. The mother died on postoperative day 3. The baby developed bronchopulmonary dysplasia and was dis- charged from the hospital at 2 months of age. At 5 months the child was noted to be “ otherwise apparently well ” [68] . Guidelines for m anagement in the s everely b rain d amaged p regnant w oman For any pregnant patient with severe neurological involvement, an attempt to support the fetus while aggressively pursuing maternal diagnosis and prognosis should be done. As noted earlier, the exception to this management is acute anoxia due to maternal cardiac arrest that is unresponsive to immediate resus- citative efforts. In these cases, rapid delivery of the fetus can signifi cantly improve maternal survival [68] . The etiology and extent of the injury as well as its prognosis are necessary before making decisions regarding fetal status [68] . This assessment may take time, as the improvement (or lack thereof) over time may be crucial in determining the extent of injury as well as the prognosis. A team approach is critical in managing these complex medical and ethical cases. It is important for the obstetric team to discuss and agree on plans and options with the consultants before talking with the family. Frequent discussions are needed to keep the family updated. It is also important to keep the nurses and residents updated on changes in the patient ’ s status [68] . When the patient is deemed incapable of consent, a neurologist should be consulted to assess mental status and to determine the patient ’ s state of chronic brain damage (coma, stupor, or chronic vegetative state) (Table 47.3 ). A commonly used diagnosis of brain death is often the one adopted in 1981 by the President ’ s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research [69] . These criteria called for the irreversible cessation of circulatory or respiratory function or the irreversible cessation of all functioning of the brain (including the brain stem). Table 47.4 describes some of the tests used for this determination. Studies that can be useful for documenta- tion of clinical fi ndings include EEG, brainstem evoked poten- tials, and cerebral blood fl ow studies [70] . When a patient is deemed incompetent, identify who speaks for the patient. If there is no advance directive, the person who is the next of kin should provide guidance for what decisions the ity of success defi ned as a viable infant who is not severely damaged. However, such cases must still be considered experimental, and therefore the risks and benefi ts cannot be clearly outlined. Informed consent from the patient ’ s surrogate decision - maker is critical in deciding courses of action [66] . The job of the high - risk pregnancy team is to coordinate the response and give this decision - maker the information required to proceed. Outcomes r egarding b rain - d amaged p regnant w omen In 1982, Dillon and colleagues presented two cases involving brain - dead pregnant women. From these, he concluded that at less than 24 weeks no continued life support be offered; between 24 and 27 weeks intensive support be considered and by 28 weeks delivery be accomplished [65] . Since that time Bush and colleagues have presented a review of the literature involving 11 cases of brain - dead pregnant women and 15 cases of pregnancies in a vegetative state where the decision to continue support was made [67] . In the eleven cases associated with brain death, 46 days on average was gained with an average EGA of 29.7 weeks achieved. In the 15 cases involving vegetative state pregnancies, 124 days on average was obtained. These authors conclude that it is very possible to obtain good outcomes with intensive management, but families need to be aware of the diffi cult course that can ensue [67] . Decision to m aintain s upport in v egetative s tate with c omplicated f amily d ynamics Webb presented the case of a 24 - year - old G1 P 0, who at 12 weeks of gestation in 1995 declared her desire to have an elective termination [68] . At 14 weeks of gestation, she took an overdose of her mother ’ s insulin. The father of the child was unknown. After several days of care there was no signifi cant recovery of brain function. Some family members inquired about the feasi- bility of an abortion in this setting. They were interested in pursuing this course even if it would not improve the clinical outcome of the patient. The ethics committee was consulted, prompting the patient ’ s mother to have further discussions with other family members. The patient ’ s mother decided not to terminate the pregnancy because she then felt that, had the patient not been depressed, she would not have desired termination. At 16 weeks Table 47.2 Suggested equipment for emergency cesarean in ICU setting . Maternal equipment Infant equipment Surgical drapes Cesarean section instrument tray Suction Bovie with grounding pad (optional) Gloves/gowns/masks Sutures Laps Cord clamps/bulb suction Warmer Blankets Infant identifi cation kit (i.e. ID bands, footprint sheet) Blood tubes for cord blood Cord blood gas kit Suction/laryngoscope/endotracheal tube Neonatal resuscitation medications Ethics in the Obstetric Critical Care Setting 677 develops (such as microcephaly or IUGR), then aggressive versus non - aggressive interventions may be recommended [68] . The mother ’ s autonomy, benefi cence, and non - malefi cence should be balanced. In the brain - dead patient, maternal autonomy concerns remain important (as expressed through maternal proxy) but can be seen as secondary moral claims compared to those of the fetus. One would not wish to violate the tenet of non - malefi cence by prolonging maternal death but should also consider benefi cence - based claims for the fetus. In the case of fi rst - trimester fetuses or mid - to - late second - trimester fetuses with hard to control maternal conditions, the issue of non - malefi cence toward the fetus must be considered. If there is little chance of the fetus reaching viability in a relatively intact state, then the claim of non - malefi cence for the fetus may favor with- drawing maternal life support so as to avoid simply postponing fetal death [68] . As the cases above illustrate, it can be relatively easy to manage a fetus in a patient in a chronic vegetative state but much more challenging when more extensive brain damage has occurred. Counseling for the patient ’ s proxy must then take into account the fetal status just after the injury. Subsequent evaluations of the fetus must be conducted. The gestational timing of the injury is important. Informed consent for the patient ’ s proxy is key to any endeavors involving prolonged maternal support as this must still be considered an experimental procedure in many regards [68] . If it is decided to prolong the pregnancy in a mother with signifi cant brain damage, many obstacles lie ahead. Mallampalli et al. outline these challenges well with suggestions for dealing with them. One must be prepared to provide extensive cardio- vascular, endocrine, respiratory, temperature regulation, nutri- tional and infectious disease treatment to allow for a potentially successful outcome [72] . In summary, the fi rst ethical tasks in these cases are to clarify maternal diagnosis and to assess the prognosis for both the mother and the chances for relatively intact survival for the fetus. An appropriate proxy decision - maker must be identifi ed and provided with appropriate information to guide informed consent. Extensive efforts must be made to educate this person and to empathize with the family [68] . Consultation with the patient would have made. The medical team needs to be updated by legal counsel regarding the right - to - die and living will statutes applicable in their state [68] . Many such statutes have pregnancy clauses that change their interpretation during pregnancy [71] . There may also be hospital bylaws addressing these situations. Requesting input from an ethics committee can also be helpful [68] . Assessment of fetal status is also important. Establishment of estimated gestational age by ultrasound and electronic fetal heart rate monitoring should be performed as soon as feasible. Fetal brain function in the older fetus can be indirectly assessed by beat - to - beat variability, accelerations, or biophysical profi le. Serial sonography may reveal more regarding developmental brain injury. Intrauterine growth restriction (IUGR) can be a sign of early fi rst - or second - trimester injury. Microcephaly can be due to anoxia and decreased cortical growth can cause enlarged cerebral ventricles. Periventricular leukoencephalopathy can sometimes be seen and MRI can be used to assess the fetal brain [68] . The effort spent in keeping the pregnant woman alive for fetal growth must also be assessed in terms of fetal status. If there is no evidence of fetal harm, then directive counseling for fetal benefi t may be appropriate. If evidence of signifi cant fetal injury Table 47.3 States of brain damage . Stupor Coma Chronic vegetative state Brain death Patient can be aroused only by vigorous or continuous circulatory/respiratory stimulation function Patient cannot be aroused by any stimulus Intermediate state Can be initial presentation or can evolve Irreversible cessation of circulatory/ respiratory function or irreversible cessation of all functions of brain, including brain stem (President ’ s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, 1981) [69] Patient has brain stem function without cerebral function. Has sleep – wake cycles, opens eyes to verbal stimuli, normal respiratory control but no apparent understanding or discrete localizing motor responses From Webb G, Huddleston J. Management of the pregnant woman who sustains severe brain damage. Clin Perinatol 1996; 23: 453 – 464. Table 47.4 Brain death criteria and tests. Need to exclude reversible causes of coma (i.e. drug toxicity, hypothermia) Allow time for brain to recover function Cerebral criteria: no clinical response to stimuli Brain stem criteria: No response to cranial nerve testing. Absence of refl exes: papillary/corneal/oculocephalic/oculovestibular/oropharyngeal Apnea test for respiratory function Studies to help document lack of brain function: EEG Brain stem evoked potential study From Halevy A, Brody B. Brain death: reconciling defi nitions, criteria and test. Ann Intern Med 1993; 119: 519 – 525. Chapter 47 678 jeopardizes his or her eternal future but more immediately risks being “ disfellowshipped ” , excommunication and shunning by family and friends. This risk may be infl uenced by how vigorously the member resists the transfusion [74] . It is clear that this tenet of faith is defi nite, absolute, and important to practitioners of this religion [73] . However, several points remain unclear. Why was this tenet expanded to include the routes of intake that were not oral? Why was the proclamation done at this particular time? Who was in charge of the decision for this proclamation? Was it a governing board or an individual? Is it just blood that is forbidden or are certain blood components and organ transplants also forbidden? [73,74] . Can this sin be forgiven? Are they still guilty if they are unconscious and/or it is given against their will? [76] . These issues are not addressed in the tract that Jehovah ’ s Witnesses give to their physicians. Some have even addressed these questions to Church authorities and been given different answers [76] . What constitutes a forbidden product is not entirely clear. Whole blood, packed red blood cells, plasma, and platelets seemed to be banned but the transfusion of albumin, immune serum globulin and antihemophilic preparations, and organ transplants appear to be left to the conscience of the individual member [74] . Even within these guidelines, there appears to be individual variations. For instance, a confi dential questionnaire of one Witness congregation noted that some would accept plasma and one person would accept autotransfusion [74] . Despite their reluctance to accept blood component therapy, Jehovah ’ s Witnesses actively seek medical care and have been in the forefront of developing artifi cial blood components and other pharmacological methods of helping the body increase its blood count (e.g. erythropoietin). There are alternatives that many Witnesses will accept which can lessen the risk of surgeries where a large blood loss is expected. For example, open heart surgery has been successfully performed on Witnesses who underwent extracorporeal dilution of their blood. This technique can be acceptable as long as the blood is always in physical continuity with their circulatory systems. It involves removing a portion of their blood and diluting it with an intravenous solution, then returning it back to their circulatory system. The blood lost at surgery will be more dilute and, volume for volume, the patient will be able to tolerate larger losses of volume during the surgery [74] . Legal c ases r egarding t reatment of Jehovah ’ s Witnesses The issue of court - ordered transfusions in cases of pregnant Jehovah ’ s Witnesses has been addressed. In Raleigh Fitkin - Paul Morgan Hospital vs Anderson, a woman at 32 weeks ’ gestation was thought to be at high risk for hemorrhage prior to birth and a transfusion was recommended [77] . She declined on religious grounds because she was a Jehovah ’ s Witness. The issue went to court and the initial trial court upheld her refusal. The hospital then appealed to the New Jersey Supreme Court. By this time, the woman had left the hospital against medical advice. However, the New Jersey Supreme Court determined that the unborn child was ethics committee and legal guidance as to the applicability of living will statutes in pregnancy can also be helpful. Management of the Jehovah ’ s Witness Patient This last section will address treatment of the Jehovah ’ s Witness pregnant patient. The history of this religious faith and the origins of its tenets regarding blood transfusions are reviewed. Important legal cases regarding Jehovah ’ s Witnesses are introduced. Finally, general guidelines for the management of these patients are given. Background To properly address the ethical issues which accompany the care of Jehovah ’ s Witness patients, the background of their religion and its tenets regarding blood product transfusion should be understood. Jehovah ’ s Witnesses are a fundamentalist Christian sect founded in Philadelphia in 1884 that emphasizes a literal reading of the Bible [73,74] . There are currently about 2 million worldwide members with half of these in the United States [75] . This religious faith concentrates on prophecies regarding the end of this world and the coming reign of Jehovah. Converts tend to come from the working class and have limited educational background [73] . They are characteristically deeply devout with a great commitment to the tenets of their faith. One of these tenets causing controversy is the refusal to acknowledge the authority of any earthly establishment. Therefore, controversies have arisen in the past regarding not pledging allegiance to the fl ag or taking oaths of loyalty. They are also conscientious objectors to military service [73] . Prior to 5 July, 1945 there were no explicit prohibitions regarding blood product transfusion. It was on this date that an article in The Watchtower , the offi cial journal for Jehovah ’ s Witnesses, forbade the taking of blood into the body. The penalty for doing so would be loss of eternal life in God ’ s Kingdom [74] . The basis for this proclamation was the reviewed interpretations of several Biblical passages (Genesis 9: 3 – 4, Leviticus 17: 13 – 14, Acts 15: 19 – 21). The Christian writing Acts of the Apostles restated the Hebrew scripture ’ s prohibition against eating blood or fl esh with blood in it [76] : “ And whatsoever man there be among you, that eateth any manner of blood: I will even set my face against that would that eateth blood and will cut him off from amongst his people ” (Leviticus 17: 10 – 14). The fi rst leaders of the newly founded Christian faith meeting in Jerusalem appealed to this prohibition when they instructed non - Jewish converts to observe Jewish law insofar as it required abstinence “ from things polluted by idols, from fornication and from what is strangled and from blood ” (Acts 15: 19 – 21 as noted in Jonsen, 1986 [73] ). The article in The Watchtower forbids the taking of blood into the body by any route: “ the issue for Jehovah ’ s Witnesses involves the most fundamental principle on which they as Christians base their lives. Their relationship with their creator and God is at stake ” [73] . The Jehovah ’ s Witness who violates this tenet not only . Ethics in the Obstetric Critical Care Setting 669 Can the patient describe: 1 her current medical problem 2 the therapy suggested. of 180/110 mmHg and was transferred to a tertiary care center. A decision was made the following morning Ethics in the Obstetric Critical Care Setting 673 ment will help or cause minimal harm. provides a useful framework to look at the issues which confront the physician during dilemmas in critical care obstetric settings. Practical a pplications of e thical p rinciples to h igh - r

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