Obstetric Ethics Research Articles

Profil Pasien Morbus Hansen di Poliklinik Kulit dan Kelamin Rspal dr. Ramelan Periode 2016–2021

The code of ethics for healthcare professionals is a comprehensive and integrative guideline regarding the attitudes and behaviors that a healthcare practitioner should possess. Conducting a study on this code of ethics is crucial to ensure its successful implementation by future healthcare professionals. The research aims to determine the effectiveness of the case study and role-playing methods on students' perceptions. The independent variables in this study are the case study and role-playing methods, while the dependent variable is students' perception of the code of ethics. The research hypothesis suggests that there is a difference in the effectiveness between the case study and role-playing methods concerning students' perceptions of the code of ethics. The study employs a quasi-experimental design with a pretest-posttest group design. The research findings reveal that students in the case study group experienced a decrease in perception, whereas those in the role-playing group showed an improvement in perception. After conducting a statistical analysis, it was found that there was no significant difference in perception within the case study group. However, in the role-playing group, there was a significant difference in perception before and after engaging in role-play. It is recommended to utilize various teaching methods, particularly role-playing, when teaching obstetric ethics.

Professional ethics of recommendations: implications for COVID-19 vaccination of women who are pregnant or planning to become pregnant

There has been changing guidance from national and international professional associations, national and international non-governmental organizations, and health officials in national governments for obstetrician-gynecologists about COVID-19 vaccination of pregnant women and women who are planning to become pregnant. in this paper, we provide an ethical framework that provides the needed guidance to decision making about recommending COVID-19 vaccination to these patients. the unique feature of this ethical framework is that it is based on professional ethics in obstetrics and gynecology. We begin with an account of three key components of professional ethics in obstetrics and gynecology and how they are pertinent to the ethics of making recommendations that should be understood in obstetric and gynecologic practice generally. We then identify the implications of this overview for the specific topic of the ethics of recommending COVID-19 vaccination.

Reversing physician hesitancy to recommend COVID-19 vaccination for pregnant patients

Physician hesitancy is said to occur when physicians do not recommend COVID-19 vaccination, and it is a contributing factor for the low vaccination rate for COVID-19 in pregnant women. Physician hesitancy has become a major, unaddressed problem with regard to the quality and safety of obstetrical care. We identify 3 root causes of physician hesitancy and describe how professional ethics in obstetrics should guide in reversing these root causes. They are clinical misapplications of key components of professionally responsible obstetrical practice: therapeutic nihilism, shared decision-making, and respect for patient autonomy. Therapeutic nihilism directs the obstetrician to avoid any clinical interventions during pregnancy to prevent teratogenic effects that might be unknown. Therapeutic nihilism is misapplied when there is a documented net clinical benefit with no evidence of clinical harm. Shared decision directs the obstetrician to only offer but not recommend clinical management. Shared decision-making plays a major role when there is uncertainty in clinical judgment but is misapplied when it becomes a universal model. It does not apply when there is a net clinical benefit. When there is a net clinical benefit, clinical management should be recommended, not simply offered. The ethical principle of respect for patient autonomy plays an indispensable role in decision-making with patients. It is misapplied when it is assumed that respect for autonomy requires physicians not to make recommendations and to defer to and implement patients’ decisions without exception. There is evidence that the obstetrician’s recommendations about the management of pregnancy are the most important factor in a pregnant woman’s decision-making. Simply deferring to the patient’s decisions makes for misapplied respect for patient autonomy. Obstetricians must end physician hesitancy about COVID-19 vaccination of pregnant women by reversing these 3 root causes of physician hesitancy. Reversing the root causes of physician hesitancy is an urgent matter of patient safety. The longer physician hesitancy continues and the longer the low vaccine acceptance rate of pregnant women lasts, preventable serious diseases, deaths of pregnant women, intensive care unit admissions, stillbirths, and other maternal and fetal complications of unvaccinated women will continue to occur. Physician hesitancy should not be permitted to influence the response to future pandemics.

Moral Status of the Embryo in Professional Obstetric Ethics

Moral Status of the Embryo in Professional Obstetric Ethics

Professionally responsible coronavirus disease 2019 vaccination counseling of obstetrical and gynecologic patients

The development of coronavirus disease 2019 vaccines in the current and planned clinical trials is essential for the success of a public health response. This paper focuses on how physicians should implement the results of these clinical trials when counseling patients who are pregnant, planning to become pregnant, breastfeeding or planning to breastfeed about vaccines with government authorization for clinical use. Determining the most effective approach to counsel patients about coronavirus disease 2019 vaccination is challenging. We address the professionally responsible counseling of 3 groups of patients—those who are pregnant, those planning to become pregnant, and those breastfeeding or planning to breastfeed. We begin with an evidence-based account of the following 5 major challenges: the limited evidence base, the documented increased risk for severe disease among pregnant coronavirus disease 2019-infected patients, conflicting guidance from government agencies and professional associations, false information about coronavirus disease 2019 vaccines, and maternal mistrust and vaccine hesitancy. We subsequently provide evidence-based, ethically justified, practical guidance for meeting these challenges in the professionally responsible counseling of patients about coronavirus disease 2019 vaccination. To guide the professionally responsible counseling of patients who are pregnant, planning to become pregnant, and breastfeeding or planning to breastfeed, we explain how obstetrician-gynecologists should evaluate the current clinical information, why a recommendation of coronavirus disease 2019 vaccination should be made, and how this assessment should be presented to patients during the informed consent process with the goal of empowering them to make informed decisions. We also present a proactive account of how to respond when patients refuse the recommended vaccination, including the elements of the legal obligation of informed refusal and the ethical obligation to ask patients to reconsider. During this process, the physician should be alert to vaccine hesitancy, ask patients to express their hesitation and reasons for it, and respectfully address them. In contrast to the conflicting guidance from government agencies and professional associations, evidence-based professional ethics in obstetrics and gynecology provides unequivocal and clear guidance: Physicians should recommend coronavirus disease 2019 vaccination to patients who are pregnant, planning to become pregnant, and breastfeeding or planning to breastfeed. To prevent widening of the health inequities, build trust in the health benefits of vaccination, and encourage coronavirus disease 2019 vaccine and treatment uptake, in addition to recommending coronavirus disease 2019 vaccinations, physicians should engage with communities to tailor strategies to overcome mistrust and deliver evidence-based information, robust educational campaigns, and novel approaches to immunization.

Expanding the concept of the professional integrity of obstetrics during a public health emergency.

The coronavirus disease 2019 (COVID-19) pandemic has placed great demands on many hospitals to maximize their capacity to care for affected patients. The requirement to reassign space has created challenges for obstetric services. We describe the nature of that challenge for an obstetric service in New York City. This experience raised an ethical challenge: whether it would be consistent with professional integrity to respond to a public health emergency with a plan for obstetric services that would create an increased risk of rare maternal mortality. We answered this question using the conceptual tools of professional ethics in obstetrics, especially the professional virtue of integrity. A public health emergency requires frameshifting from an individual-patient perspective to a population-based perspective. We show that an individual-patient-based, beneficence-based deliberative clinical judgment is not an adequate basis for organizational policy in response to a public health emergency. Instead, physicians, especially those in leadership positions, must frameshift to population-based clinical ethical judgment that focuses on reduction of mortality as much as possible in the entire population of patients served by a healthcare organization.

Guild interests: an insidious threat to professionalism in obstetrics and gynecology

Powerful incentives now exist that could subordinate professionalism to guild self-interest. How obstetrician-gynecologists respond to these insidious incentives will determine whether guild self-interests will define our specialty. We provide ethically justified, practical guidance to obstetrician-gynecologists to prevent this ethically unacceptable outcome. We describe and illustrate 2 major incentives to subordinating professionalism to guild self-interest: demands for productivity; and compliance and regulatory pressures. We then set out the professional responsibility model of ethics in obstetrics and gynecology to guide obstetrician-gynecologists in responding to these incentives so that they preserve professionalism. Obstetrician-gynecologists should identify guild interests affecting their group practices, set ethically justified limits on self-sacrifice, and prevent incremental drift toward dominance of guild self-interests over professionalism. Guild self-interests could succeed in undermining professionalism, but only if obstetrician-gynecologists allow this to happen. When guild self-interest becomes the deciding factor in patient care, professionalism withers and insidious incentives flourish.

Analysis of ethics in gynecology and obstetrics teaching under the WEIGHT guidelines

At present, the particularity and importance of ethical consciousness in the teaching of clinical obstetrics and Gynecology has become increasingly prominent while the education of medical students in the ethics and social responsibility is relatively weak. This study explored a series of practical methods under WEIGHT guide through the real cases, conducting clinical training and sides debate, combining multimedia and interview form, in order to strengthen the cultivation of medical students' moral quality and improve the students' comprehensive ability. Key words: Gynecology and obstetrics; Ethics; The Working Group on Ethics Guidelines for Global Health Training (WEIGHT)

The unlimited-rights model of obstetric ethics threatens professionalism.

The unlimited-rights model of obstetric ethics threatens professionalism.

Obstetric Ethics and the Invisible Mother

These mother-told stories of birth, describing disrespectful and harmful care, make the invisibility of birthing women visible. The concerns and needs of women in labor fade in the face of hospital policies and the perceived needs of their soon-to-be-born babies. Bioethics contributes to this lack of regard for mothers by framing the moral problems of birth in terms of maternal-fetal conflict, where the autonomy of the mother is weighed against the obligation of beneficence to the baby. Replacing the principlist commitment to autonomy with respect-an obligation that does not compete with beneficence-is a first step toward correcting the problems in care identified here.

Professionally responsible for counseling Pregnant Women about Abortion and Feticide

ABSTRACT We provide comprehensive, practical guidance for physicians on when to offer, recommend, perform, and refer patients for induced abortion and feticide based on the professional responsibility model of obstetric ethics. We begin by defining clinical terminology and elucidating autonomy-based and beneficencebased obligations as well as professional conscience and individual conscience. The obstetrician's role in counseling the pregnant woman about abortion and feticide should be based primarily on professional conscience, which is shaped by autonomy-based and beneficence-based obligations of the obstetrician to the pregnant and fetal patients, with important but limited constraints originating in individual conscience. How to cite this article Chervenak FA, McCullough LB. Professionally responsible for counseling Pregnant Women about Abortion and Feticide. Donald School J Ultrasound Obstet Gynecol 2016;10(3):321-325.

Virginity testing in professional obstetric and gynaecological ethics

Introduction Doctors around the world might be asked to provide virginity testing. The ethical framework for the assessment of the physician’s role in virginity testing is based on the professional responsibility model of ethics in obstetrics and gynaecology and its three core ethical principles: benefi cence, respect for autonomy, and justice. Benefi cence-based objections are that virginity testing has no clinical indications and has substantial biopsychosocial risks. Autonomy-based objections are that virginity testing might be the result of social and cultural pressures that result in non-voluntary requests and, by being undertaken mainly for the benefi t of others and not the female patient, impermissibly violates the patient’s human right to privacy. Justice-based objections are that virginity testing discriminates against female patients on the basis of their sex and creates clinically unnecessary confl icts of interest that can undercut the primacy of the health of female patients. Here, we aim to present an ethical framework for the assessment of the physician’s role in virginity testing and its implications for clinical practice. Virginity testing is the performance of a physical examination to establish whether a female patient is a virgin. Typically, such testing involves an inspection of a female patient’s hymen, on the assumption that her hymen can only be torn as a result of sexual intercourse. The practice of virginity testing is prevalent worldwide, according to the varying degrees of the perceived importance of a bride’s or girl’s virginity. Obstetriciangynaecologists and other doctors might be asked to provide virginity testing, either by adult female patients, the parents of minor female patients, or by the state. These requests can happen in countries where the practice has been historically accepted or in countries without such a history but to which women have immigrated. If virginity testing is deemed to perpetuate attitudes that accept violence and sex inequality, then allowing it could also result in increased risk of other kinds of violence against women. Women who fail the test are at greater risk of violence by their own families or their husbands to disclose the name of their partner or their sexual experiences. In 2007, a study by the Swedish National Board of Health and Welfare suggested that 600 to 4500 girls were at risk of violence by their families because of honour or virginity related problems. We provide an ethical framework for the assessment of the doctor’s role in virginity testing and its implications on how obstetrician-gynaecologists and other doctors should respond to such requests in clinical practice. This ethical framework is based on the professional responsibility model of ethics in obstetrics and gynaecology and its three core ethical principles of benefi cence, respect for autonomy, and justice. We show that virginity testing is ethically unacceptable, because it violates benefi cencebased, autonomy-based, and justice-based obligations to female patients. We conclude that doctors should refuse to conduct physical examinations for the purposes of virginity testing because virginity testing is incompatible with professional obstetric and gynaecological ethics.

Health care justice and its implications for current policy of a mandatory waiting period for elective tubal sterilization

Tubal sterilization during the immediate postpartum period is 1 of the most common forms of contraception in the United States. This time of the procedure has the advantage of 1-time hospitalization, which results in ease and convenience for the woman. The USCollaborative Review of Sterilization Study indicates the high efficacy and effectiveness of postpartum tubal sterilization. Oral and written informed consent is the ethical and legal standard for the performance of elective tubal sterilization for permanent contraception for all patients, regardless of source of payment. Current health care policy and practice regarding elective tubal sterilization for Medicaid beneficiaries places a unique requirement on these patients and their obstetricians: a mandatory waiting period. This requirement originates in decades-old legislation, which we briefly describe. We then introduce the concept of health care justice in professional obstetric ethics and explain how it originates in the ethical concepts of medicine as a profession and of being a patient and its deontologic and consequentialist dimensions. We next identify the implications of health care justice for the current policy of a mandatory 30-day waiting period. We conclude that Medicaid policy allocates access to elective tubal sterilization differently, based on source of payment and gender, which violates health care justice in both its deontologic and consequentialist dimensions. Obstetricians should invoke health care justice in women's health care as the basis for advocacy for needed change in law and health policy, to eliminate health care injustice in women's access to elective tubal sterilization.

Caesarean section should be available on request: FOR: Responding professionally to requests for non‐indicated caesarean delivery

Obstetricians should respond professionally to requests for non-indicated cesarean delivery (CD). The professional responsibility model of obstetric ethics provides guidance for doing so (Chervenak et al. Am J Obstet Gynecol 2011;205:315.e1–5). This approach to obstetric ethics avoids the gridlock that results when obstetric ethics based primarily on fetal rights collides with obstetric ethics based primarily on maternal rights. The professional responsibility model is based on the ethical concept of medicine as a profession, introduced into the history of medicine by two British physician-ethicists, John Gregory (1724–1773) of Scotland and Thomas Percival (1740–1804) of England. This concept requires physicians to become and remain scientifically and clinically competent, to use their knowledge and skills primarily for the benefit of the patient, and to keep individual and guild self-interest systematically secondary. The ethical principles of beneficence (undertake clinical management, the outcomes of which are reliably expected to be clinically beneficial) and respect for autonomy (empower the pregnant woman to make informed decisions about the clinical management of her pregnancy) translate this concept into clinical practice. The obstetrician has beneficence-based and autonomy-based obligations to the pregnant woman and beneficence-based obligations to the fetus when it is a patient (McCullough and Chervenak, Ethics in Obstetrics and Gynaecology, New York: OUP; 1994). Because the viable fetus is a patient, the ethics of CD requires balancing of obligations the pregnant and fetal patient (Chervenak and McCullough, Best Pract Res Clin Obstet Gynaecol 2013;27:153–64). In the professional responsibility model of obstetric ethics, the pregnant woman is ethically obligated to take reasonable risks to her life and health for fetal benefit, when there is a reliable evidence base for such benefit. Requests by patients for clinical intervention do not, in themselves, create an ethical obligation to fulfill such requests without careful evaluation of them, to ensure that acting on them is consistent with professional integrity (Brett and McCullough, JAMA 2012;307:149–50). Professional integrity requires that implementing such requests will result in net clinical benefit to the patient. There is no net clinical benefit from non-indicated CD (Minkoff and Chervenak, New Engl J Med 2003;348:946–50). The beneficence-based and integrity-based professional responsibility of the obstetrician is to respond to requests for non-indicated CD with a recommendation against it and for vaginal delivery. Non-directive counselling, i.e., offering both modes of delivery as if both passed muster in beneficence-based clinical judgment, is ruled out by the professional responsibility model. These recommendations should be explained to the pregnant woman and discussed with her in the informed consent process. Obstetricians should take a preventive ethics approach to decision-making, raising it as a possibility and making decisions about it well in advance of the intrapartum period (Chervenak and McCullough, Am J Obstet Gynecol 2013;209:166–7). In rare cases, the pregnant woman will not accept the recommendation of vaginal delivery when CD is not indicated and will reiterate her request for the latter. It is ethically permissible to implement an informed, reflective decision for non-indicated CD. None declared. ■

The Professional Responsibility Model of Obstetric Ethics in Clinical Practice

This paper provides an overview of ethical issues in obstetrics and gynecology. We first define two basic ethical principles, beneficence and respect for autonomy. We first apply these principles to gynecologic practice, emphasizing the role of informed consent. We then apply these principles to obstetric practice, utilizing the concept of the fetus as a patient and identifying its clinical implications for directive versus non-directive counseling for fetal benefit.

The fetus, the "potential child," and the ethical obligations of obstetricians.

The right of pregnant women to refuse obstetric interventions is an established tenet of obstetric ethics. However, that does not mean that fetal considerations are inconsequential. Although respect for negative autonomy is largely a settled issue, what is less clear is the degree to which a pregnant woman's affirmative autonomy (the right to demand) should be controlling. We discuss the ethical basis for deciding when a pregnant woman's affirmative autonomy should be decisive. We focus on the ethical consequences when a fetus is considered a "potential child" because of a woman's decision to continue a pregnancy. Her intention determines the relevance and nature of the interests of the future child. Although fetal interests may temporally approach those of a born child, they are, in all cases, still circumscribed by the de facto circumstance of the potential child, ie, the child cannot be treated without treating the mother. That treatment would implicate the pregnant woman's right to bodily integrity. This right is so fundamental to our conception of autonomy that its trespass should give serious pause to all who respect basic human dignity. Accordingly, the future interests of a child should not constrain a pregnant woman's right of negative autonomy (the right to refuse any intervention intended for the putative benefit of the fetus or herself). However, the interests of the potential child may factor into considerations of affirmative autonomy and, in parallel, on a physician's right to refuse a particular intervention or plan of care.

Policy Statement on Planned Home Birth: Upholding the Best Interests of Children and Families

* Abbreviations: AAP — : American Academy of Pediatrics We strongly disagree with Chervenak et al1 that the American Academy of Pediatrics (AAP) policy statement on “Planned Home Birth”2 diverges from its own primary principle, to promote the best interests of the child. First, the statement does not promote home birth. We begin, as the authors note, by agreeing with the statement of the Committee on Obstetric Practice of the American College of Obstetricians and Gynecologists that “hospitals and birthing centers are the safest setting for birth.” In addition, we state that the pediatrician should counsel expectant parents regarding the apparent risks of home birth in the United States. Subsequently, after the infant is born, we specifically promote the best interests of the child who is born at home by setting standards for care that adhere to those delineated in AAP publications.3 The arguments made by Chervenak et al regarding the “best interests of the child” have several notable flaws. First, before delivery, the fetus is not an independent being (child), but a fetus, and the authors inexplicably ignore both the ethical principle of autonomy for the expectant mother and the difficult balance of maternal and fetal benefits and harms. Previous commentary by these authors advocates overriding both maternal and fetal rights, arguing instead for the “professional responsibility model of obstetric ethics, which emphasizes the importance of medical science and compassionate clinical care of both the pregnant and fetal patient. … Address correspondence to Kristi L. Watterberg, MD, Department of Pediatrics, MSC 10 5590, University of New Mexico, Albuquerque, NM 87131-0001. E-mail: kwatterberg{at}salud.unm.edu

Longing to a fetal patient

There are limitations of obstetric estimation of neonatal outcome in extremely premature newborns. Predicting outcomes, survival, and morbidity are often uncertain, such as in cases of extreme prematurity, certain fetal anomalies, intrauterine growth restriction, and intrauterine infection. Informed consent, truth telling, the maternal–fetal conflict, decision making, and the fetus as a patient are the most important issues of obstetric and neonatal ethics. Because the boundary between utility and futility is not clear, the best interest of the mother, the fetus, and the newborn will be subject of discussion every time. Here, we report a case of obstetric patient to discuss.

Planned Home Birth in the United States and Professionalism: A Critical Assessment

Planned home birth has been considered by some to be consistent with professional responsibility in patient care. This article critically assesses the ethical and scientific justification for this view and shows it to be unjustified. We critically assess recent statements by professional associations of obstetricians, one that sanctions and one that endorses planned home birth. We base our critical appraisal on the professional responsibility model of obstetric ethics, which is based on the ethical concept of medicine from the Scottish and English Enlightenments of the 18th century. Our critical assessment supports the following conclusions. Because of its significantly increased, preventable perinatal risks, planned home birth in the United States is not clinically or ethically benign. Attending planned home birth, no matter one's training or experience, is not acting in a professional capacity, because this role preventably results in clinically unnecessary and therefore clinically unacceptable perinatal risk. It is therefore not consistent with the ethical concept of medicine as a profession for any attendant to planned home birth to represent himself or herself as a "professional." Obstetric healthcare associations should neither sanction nor endorse planned home birth. Instead, these associations should recommend against planned home birth. Obstetric healthcare professionals should respond to expressions of interest in planned home birth by pregnant women by informing them that it incurs significantly increased, preventable perinatal risks, by recommending strongly against planned home birth, and by recommending strongly for planned hospital birth. Obstetric healthcare professionals should routinely provide excellent obstetric care to all women transferred to the hospital from a planned home birth.The professional responsibility model of obstetric ethics requires obstetricians to address and remedy legitimate dissatisfaction with some hospital settings and address patients' concerns about excessive interventions. Creating a sustained culture of comprehensive safety, which cannot be achieved in planned home birth, informed by compassionate and respectful treatment of pregnant women, should be a primary focus of professional obstetric responsibility.

Women requesting Caesareans: ethical implications in light of the new National Institute for Clinical Excellence guidelines

As obstetric medicine has become more sophisticated, so Caesarean section (CS) has become safer. It is now seen as equally safe or, in some circumstances, safer than vaginal birth. Under the new National Institute for Clinical Excellence (NICE) guidelines on CS that were published in November 2011, requests for CS are to be given more weight. Women requesting CS can no longer be seen as compromising their control over birth. Rather, they are merely exercising their power, with the new guidelines offering them an increasing role in the decision-making process regarding how they give birth. However, these new guidelines also present new problems, bringing the rights of patients and obstetricians into conflict. In order to mediate these tensions, a virtue-based approach to obstetric ethics is needed as a supplement to the rule- and right-based guidance provided by NICE.