The Cost of Preoperative Pregnancy Testing

Abstract

In Response: We recently reported the results of an institutional review board-approved retrospective review of urine pregnancy tests in adolescents presenting for surgery at a university-affiliated children's hospital [1]. This review has stirred an impassioned reaction. We appreciate the opportunity to respond to some of the issues that have been raised. Contrary to Dr. Battit's assumption, we did not design or conduct a prospective study, for which consent would have been required. We collected the information that was gathered routinely on patients according to our policy at the time. Although that initial policy was advised by our legal counsel, we have since changed our approach to ensure that all patients are informed. In an accompanying editorial, Duncan and Pope [2] also raised objections to our lack of obtaining consent. We submit that the very matter of asking for consent for a pregnancy test poses ethical dilemmas. A patient's refusal may be as telling as a positive test result, as she may suspect she is pregnant. Malviya et al. [3] did not find any positive results in adolescents who consented to the test but reported a 3.3% nonparticipation rate. This refusal rate is comparable to the incidence of positive pregnancy tests we found in adolescents aged 15 years and older (2.4%) and to that reported by Twersky and Singleton in adult patients (2.2%). Therefore, the request for consent places the adolescent patient in a situation whereby her acceptance or refusal of a pregnancy test carries definitive implications concerning her sexual activity. Additionally, the refusal of consent by the patient presents an ethical dilemma concerning the appropriate course of action. If a pregnancy test should not be performed without consent and if a request for consent is in itself a breach of patient privacy, then the alternative approach is the infamous "don't ask, don't tell" policy. Is it then ethical for us, as physicians, to ignore the possibility of a fetal life and to proceed with anesthesia and surgery? The cost of pregnancy testing as calculated by Kettler is over-stated. Hospital charges are different from actual expenses. A pregnancy test kit in our institution costs $2. Material costs for 42 tests therefore amount to $84. Overhead expenses are more difficult to estimate. Each physician must decide if this expense is warranted in his or her patient population. The ethical and financial questions associated with the determination of the reproductive status of patients are indeed complex. However, the main point of our article is that adolescent females presenting for surgery may be pregnant. We trust that no physician will willingly submit a fetus to the possible hazards of anesthetics, antibiotics, and radiographic and operative procedures without due consideration. Many of the drugs in our arsenal have specific warnings that the safety of their use in pregnancy is not demonstrated. In the United States, the medicolegal liability to the anesthesiologist must be weighed. Farid J. Azzam, MD Gurpreet S. Padda, MD James W. DeBoard, MD Jeremy L. Krock, DO Suzanne M. Kolterman, MD Department of Anesthesiology St. Louis University Health Sciences Center St. Louis, MO 63110