Pregnancy, Modern Medicine, and God (or, My Day at the Office)

Great Debates
1

This is the story of a patient that I saw today as a psychiatry consultation. Names are withheld, obviously, and details have been changed to preserve patient anonymity.

The patient is a 35 year old female, 31 weeks pregnant with twins. She was admitted to the hospital last night for premature labor.

A little background: she has four other children, ages 11 to 2, two of whom she lost custody of due to her abusive husband. She left him and has been in a spouse abuse shelter for four months now, and is trying to get the children back. She has no other family around, and no other contacts in town aside from the shelter.

At 31 weeks, the twins are significantly premature. They will probably make it, but they will be in intensive care for quite some time and face a good chance of long-term problems. The clear, medically sound decision is to delay labor.

However, she refuses. She believes that “God will take care of her”, and if it is God’s will that she should deliver now, so be it. She is fully aware of the risks to the children and is mentally sound. She is very distrustful of doctors, and has refused any medication, including insulin. (Did I mention she was diabetic? Mild and well-controlled with diet, though.)

The question–should the doctors have the right to override her religious beliefs and give her the medication anyway? I don’t exactly know the outlook for a 31 week preemie, much less a twin, (I haven’t had OB yet) but I think they’re likely to make it, with considerable effort and a good chance of long-term deficits.

Another question/can of worms–should money be a factor in the decision? I don’t like to think about financial concerns in medicine, but we’re talking about two NICU beds for what could be months. Does the fact that the hospital will be eating the cost of treatment give them any more say over the decision?

I had to leave before the saga came to a close. I’ll reserve my personal thoughts on the matter for a later post, since this one is long enough already. :slight_smile:

Dr. J

2

Easy part first- the fact that the hospital is likely to eat the cost doesn’t give them any more say in the matter.

Now for the harder question- Should the doctors be able to override her religious beliefs? Since you were ther as a psych consult, and you said she was mentally competent, she gets to make her own decisions, no matter how much anyone may disagree with them, or her reasons for them.

I would like to be able to say the doctors should be able to overrride her decision (and its not a decision I would make), but on what basis? Because she’s pregnant, or because there’s a religious belief involved or some combination?

Can’t say it on the basis that a religious belief is involved because its pretty well established that adults can refuse medical treatment for any reason, including religion.

If you allow the doctors to override the decision because she’s pregnant, that essentially means a pregnant woman can be forced to have any treatment, no matter why she doesn’t want it ( There was a case of a woman forced by court order to have a C-section even though it was likely to (and did) shorten her life (she was already dying of cancer), in the hope that the baby would survive,although premature (it didn’t).

If doctors are allowed to overrride the decision based on the combination of pregnancy and religious beliefs (adults can refuse based on religion except if they’re pregnant, and pregnant women can refuse, except if its based on religion),then you end up with patient A refusing the drug for religious reasons, and doctors overriding her, and patient B making the same decision for different reaons ( I’m more afraid of the side effects than a premature birth, there’s no guarantee the drug will work, and anyway,labor might stop on its own) not being overridden.
Doreen

3

If she is mentslly competent and understands the implications, it is very clearly ethically wrong to interfere for any of the reasons cited: religion, purporting to help the babies and especially money. I see no debate here.

Babies at 31 weeks are generally viable, but would likely require surfactant before delivery and monitoring for a couple weeks or more in an NICU. Delaying labour may be ideal medically, but there is a reasonable chance it is false labour anyway.

Giving her medication could be construed as assault and is a definite no-no in this case.

4

It doesn’t matter to me whether her decision was made on regligious grounds or for other reasons. If she is mentally competent, I find it horrifying that anyone feels that they have the right to force treatment on a woman that she has clearly stated that she does not want.

I think her course is unwise, but it scares me to think that anyone feels that they have the right to force medical treatment upon me against my will. By all means, attempt to convince her that the course of treatment is best for both her and her babies, but do not steal her right to control what is done to her body.

5

I ask the following question not as rhetorical devices, but in more of a Socratic mindset:

  1. Why, doreen, do you say that the hospital has no additional voice in the matter, given their likely unpaid involvement in caring for the severely premature infants? Would the hospital be within its rights to say, “Accept the delay of labor, or get the hell out and have your babies in the street?” Does your answer change depending upon the hospital’s status as fully private, or as a government owned facility?

  2. If the babies suffer long-term health problems resulting from their premature delivery, does anyone believe they should be able to sue their mom - or the hospital, or the doctors - for the incorrect medical decision to fail to delay labor?

  3. If she were convinced that voices in her head were telling her to have the baby now, would she be “not mentally competent” and could the doctors then force treatment on her? If so, then what is the substantive difference between that and holding the conviction that God wants her to have the babies?

  • Rick
6

In the abstract, no, you don’t have the right to force medical treatment on her.

But.

To drag this down from the Empyrean heights of the abstract into the grunginess of an everyday world populated by do-gooders who enjoy sticking their noses into other people’s private affairs and filing troublesome, expensive, time-consuming, and totally aggravating lawsuits on their behalf…

Doc, you need to consider the issue of “fetal rights”. Do a Web search if you haven’t heard the phrase. It doesn’t only mean “abortion” anymore.

http://www.aclu.org/issues/reproduct/fetal.html

I don’t have cites offhand for “forcing women to undergo medical treatment to protect their fetuses”. I’m just saying “watch out”. Talk to some of the other doctors in your area to see if this could be a problem. You’re in rural Kentucky, IIRC? Probably got a lot of folks who could get real upset if they thought Mrs. Doe was being allowed to “kill her babies” by refusing medical treatment.

I have the uneasy feeling that if you don’t step very carefully here, you may end up stepping in something very nasty. We don’t REALLY wanna see you on the ABC Evening News with Peter Jennings, being muscled through a crowd of protestors by your lawyers. :smiley:

7

Everyone who’s posted seems to be able to make some logical judgement on this issue, based on facts and ethical arguments. Applause!

I wish I had more luck doing that. In this case, all I can think of is what a STUPID woman this is. Perhaps the issue IS that she should be able to refuse medication that may have side affect/not do it’s job properly ANYWAY. That’s fine. I would never suggest that a pregnant woman should have no rights over how her infant(s) and her own body were treated.

That said, what kind of an idiot uses God as an excuse to let their infants suffer? To put them at risk for a difficult life with potentially reduced function/quality no matter how small that risk?

Isn’t keeping these babies in intensive care and treating them with whatever they need at that point going to be considered medical intervention on “god’s territory” as well? That would concern me more in this case than refusal to take drugs to delay labor. It’s the implication of how she’ll take care of them after that fact that makes me indignant.

That said, carry on with your rational discussion. I find it fascinating.

-L

8

YWalker sed:

And I find it horrible that someone will make a decision, against medical advice, which will take money out of someone else’s pocket.

Scenario 1: The twins are born early, but perfectly healthy, and go home in a day. No worries.

Scenario 1a: It’s a false labor, and the twins are born at 40 weeks, healthy. No worries again.

Scenario 2: The twins are born early, spend days or weeks in NICU. The Hospital eats the very high cost, passing it on to its other patients in the form of increased costs.

Scenario 3: As above, but an insurance company foots the bill, passing the loss on to all its customers.

Scenario 4: The twins are born with physiological or mental disabilities, requiring care which the mother is clearly not equipped to provide (per the OP). The government steps in, providing help anywhere from food stamps to full time care of the children. Paid for by the taxpayer.
I do not understand why someone would deliberately risk harm to her fetuses. And I do not understand why someone would be willing to make other people pay for that harm.

9

Oh my, what a situation. As long as she’s competent, I think they shouldn’t be able to force her to have medical treatment she deosn’t want…but I say that with great reluctance and concern. What kind of person does this to herself and her children?

Has anyone tried convincing her that God helps those who help themselves, and He gave us brains for a reason, and maybe He thinks medical technology is a good idea?

10

I only meant the hospital has no more right to force the treatment if it’s going to be stuck with the bill than it does if it’s not stuck with the bill.If we, as a society, are going to decide that the hospital can overrule her for whatever reason ( because she’s not competent,for the sake of the babies,or for the sake of her own health),that should apply whether the hospital eats the cost, she has insurance, or she’s a billionaire who can afford to pay for everything herself. If she doesn’t want the treatment and leaves, fine. If they don’t want her to stay when she’s not receiving treatment, also fine. I don’t know of any law requiring private hospitals to provide free non-emergency treatment in all cases.At least around here, private hospitals can transfer stable patients to public hospitals or apply for Medicaid for patients with no funds or insurance, so it wouldn’t actually be the hospital eating the cost, it would be Medicaid (still others paying, but lessens the difference between private and public).

I realize that she’s making a decision that’s ultimately going to be paid for by others (the babies and whoever covers the bill), but I don’t like where you end up going when you take the position that whoever pays calls the shots.If I’m pregnant, and testing reveals expensive birth defects, should my insurance company be able to force me to have an abortion? If I already have three kids should they be able to force me to have my tubes tied because they don’t want to cover any more pregnancies and children? Should the insurance company be able to sign a DNR order because they don’t want to pay for the treatment likely to be needed afterwards?

11

But do you really think that money out of someone else’s pocket is more important than an individual’s rights?

Again, I am horrified by the idea that I attained full rights of citizenship as an adult, but that what you are suggesting is that as soon as I become pregnant, I am no longer allowed to make decisions for myself because of someone else’s financial concerns. Pregnancy would change my status from citizen, with all the rights allowed to all other adults, male or female, to a lower status of incubator, whose medical treatment could be decided by some pencil pusher.

That said, I fully disagree with what the woman is doing. I am similarly disgusted by women who drink or do drugs and create fetal-alcohol syndrome babies and crack babies. However, I don’t think that the value of preventing these problems (or especially a loss of profits for a hospital!) justifies ripping away a woman’s civil liberties once she becomes pregnant.

12

I’m well aware of the issue of fetal rights. There was a landmark court case in Manitoba that makes the precedent clear, here. I’m Canadian, let us never mention rural Kentucky again.

Did you know twins are commonly induced at 36 weeks due to the increased risks of abruptio placenta, especially in a mild diabetic? Twins are a complicated preganacy and the usual rules don’t apply. At 31 weeks, they are likely viable with surfactant. The fetus is not obviously threatened, Mom understands what is going on, you can’t force treatment on a competent person and it breaks all the consent legislation in the book. Punto final.

13

I’m undecided about the fetal issue rights.

As for the cost, I use the following analogy.

A new car has a warranty. As part of that warranty, you are expected to have your car serviced, treat it reasonably, and perform the maintenance procedures prescribed by a qualified expert mechanic.

If you do so, and something goes wrong anyway, you don’t pay to get your car fixed. The company does.

If God tells you not to change the oil, and he’ll take care of it, and you listen, and your engine dies…

Well, let’s just say this is no longer the company’s problem. Presumably God will provide the money to get the car fixed.

This case differs in two respects. We cannot deny care to these children on the basis of their mother’s bad judgement. They are not cars, they are human beings. Secondly, is of course the question of their fetal rights (which I’m not about to try to tackle just now.)

It seems to me that if she is judged a competent and rational person, then she should be held liable for any expenses incurred resulting from her refusal of sound medical treatment as recommended by qualified medical experts.

In short, she has voided the warranty that a compassionate and reasonable society has bestowed upon her through her own foolishness, and is responsible for the financial (and perhaps other,) consequences.

14

:shrug: I dunno. I think we taxpayers have a right not to be taken advantage of. Does that right trump her right to be an idiot? Perhaps not.

And yet . . . you are constrained. As soon as you become a mother, at least. We, the society of which you are a part, will force you to feed and clothe your child. We force you to refrain from hitting your child, or pimping it, or allowing it to work in the coal mines.

Those rules we make, not for financial concern (though it arguably plays a part), but for the rights of the child.

So, then . . . do this woman’s unborn children have a right to a lowered risk of birth defect?

I don’t know that it’s “ripping away her rights.” I think it can be argued that she has a responsibility to those around her.

15

This thread reminds me of this Happy Heretic article.

16

The women has diabetes that are apparently well controlled.

A psychiatric consult in no way means psychiatric disease. It was ordered by the obstetrician.

You know nothing about the “abuse” situation where he children were allegedly removed.

The risk of long-term birth defects is what, exactly? What defects concern you here?

What punishment is appropriate for mothers who smoke or drink occasionally during pregnancy?

What punishment is appropriate for women who fail to make an appointment for pre-natal care before 18 weeks or miss the occasional pre-natal appointment?

What punishment is appropriate for the women who risks birth defects by continuing on her epileptic or blood pressure medication despite being given information?

Who is the doctor to determine what rights the fetus has independently of professional bioethics committees?

Why would the doctor expose "him"self to a lawsuit that is extremely difficult to defend without good cause?

What are the risks of using a tocolytic to suppress labour, which is a procedure with side effects?

In a case such as this, what was shown on internal exam – were there progressive cervical dilation, effacement and descent?

Why wasn’t a biophysical profile/ultrasound done to show if there was evidence of membrane rupture? Was this women going into labour at all? If so, due to a medical reason?

What was shown when doing a Non-Stress test? Were the babies in any distress? Decelerations? Tachycardia?

Was there evidence of toxemia, bleeding, discharge, absence of fetal movement, premature rupture of membranes or symptoms of hyperglycemia? Did the diabetes exist before pregnancy or was it merely gestational?

Twins normally deliver earlier and are induced earlier for reasons of safety. Was this taken into account?

Why should the wishes of a competent patient be refused? Does she not have the right to avoid medications with side effects she finds displeasing?

Get back to me when we have some answers… Fetal rights only exist when the fetus is reasonably threatened by unreasonable actions on the part of Mom. This ain’t it.
OTOH, why was the psychiatric consult obtained?

17

(Hint to DoctorJ for the ethics questions on the USMLE:)

Don’t mention money when discussing ethics.

18

And this caring, compassionate, infinitely humane attitude is why HMO’s rule the roost. One of the reasons “pencil pushers” have been forced into making decisions about medical care options is because society wants infinite care options but doesn’t want to face the hard questions about personal responsibilty and real world resource limits, so costs are contained on an irritatingly inefficient and frustrating ad hoc basis by insurance company gate keepers who are ill equipped to make medical care decisions, but have to because care providers (and society) can’t or won’t make reasonable decision about costs and benefits.

No one has a “human right”, “citizenship right” or any other “right” to receive medical care with being responsible for their behavior or constrained by resource limits. Your “I am horrified” attitude not the insurance companies gate keeping is what infantilizes the pregnant woman.

19

I am personally responsible for this? I had no idea I was so influential.:wink:
During my first pregnancy, I was covered by an HMO. They had a rule that if I traveled outside of a 50 mile radius of my home hospital after I was past the 34th week (out of the expected 40 weeks) of my pregnancy, then they would not pay a thin dime for coverage for me if I had an emergency and needed to be treated at another hospital. A close friend of the family died during this time period; I opted not to attend the funeral (150 miles away) so as not to put my family at financial risk.

I didn’t say she had a ‘“human right”, “citizenship right” or any other “right” to receive medical care with being responsible for their behavior or constrained by resource limits.’ This is where the slippery problem comes in.

I am assuming from the circumstances here, though, that this woman is uninsured, and/or covered by Medicaid. As humane individuals, we do not want to deny her children the care they need, even though we may feel that the mother’s behavior is at least partly at fault. However, why is it that we keep hearing cries that we need to control what women (particularly pregnant ones) do with themselves medically, but I have been unaware of equivalent efforts to control the lives of men? What of a diabetic who does not take his insulin, and keep showing up the ER? What of alcoholics and/or drug users whose habits use up their livers and kidneys? Do we prescribe Antabuse for them, and jail them to ensure that they take it so that we don’t have to deal with their largely self inflicted medical problems? Do we tell someone with an STD that we won’t treat their disease or its complications because they shouldn’t have been screwing around without a condom in the first place? Do we send someone around to watch the behaviour of cardiac patients and the obese, and void their insurance coverage if they are seen eating a diet high in saturated fat after they are warned of the consequences? (To the medical personnel here, it is obvious IANAD. Work with me here.)

It is not only women whose personal decisions can result in costly hospitalizations. Why is it, then, that the only proposals I’ve heard to force treatment on individuals are for pregnant women?

20

This isn’t about the woman’s “right to receive care” but about her right to refuse it, even though it may (and it’s by no means certain) lead to expensive care needed for the babies.It also isn’t about insurance comapany gatekeeping. Gatekeeping, in itself, doesn’t deny people medical care. It just means the insurance company won’t pay for it.It also doesn’t force people to accept care that they don’t want.To repeat an example I used already, does my insurance company have a right to force me to have my tubes tied because they don’t want to cover another pregnancy and child? I don’t think so . They may have a moral right to write the coverage to only cover a certain number of pregnancies, or only a certain number of people under a family plan, and they surely have a moral right to set premiums on a per-person basis, rather than setting a single family rate that charges ten-person families the same as two person families,but they don’t have the right to say “You don’t want it? Too bad, it’s being done anyway.”. That’s what the OP is about.