Bioethics Maternal-Fetal Conflicts Julius Ceazar Reyes MD January 17, 2011

Who’s Life Should Be Saved?

No direct answer.

What if both have the same chance of survival?

Save the mother and allow the child to have a natural death.

But if you can save both, save both the mother and fetus

GENERAL GUIDELINES 1.Maternal and fetal conflicts include complications, surgical complications and invasive diagnostic procedures during pregnancy. The conflict is between the mother and fetus.

GENERAL GUIDELINES 2.Principle of double effect should be applied

GENERAL GUIDELINES 3.In assessing risk, the physician should provide the patient with accurate objective observation of her disorder and known data gathering.

GENERAL GUIDELINES 4.The physician should as accurately as possible, quantify benefits and risks. This should be communicated in a manner accepted to our Filipino culture and appropriate to the particular patient.

GENERAL GUIDELINES 5.In risk acceptability, the physician must allow the patient to make her own decision.

GENERAL GUIDELINES 6.Unless specifically requested by the patient, her family should be given the same information and be involved in the decision making process.

GENERAL GUIDELINES 7.A physician has the right to withdraw from the case if what is decided by the patient conflicts with his own personal values or the institution’s values

GENERAL GUIDELINES 8.In an emergency situation, the physician should serve as the surrogate decision maker and exercise his therapeutic privilege.

CASES

ECTOPIC PREGNANCY 1. When the tube is so damaged to constitute a serious threat to the maternal life, the tube may be removed as a traumatized pathological tissue. The principle of double effect is applied

ECTOPIC PREGNANCY Wrong Mentality – Remove the tube because the fetus won’t live anyway Right Mentality – The tissue of the tube is traumatized pathological tissue, therefore should be removed

ECTOPIC PREGNANCY 2.In a rare case when the pregnancy was advanced to a stage approaching viability, the element of proportion in the principle of double effect has to be given special consideration and attention.

ECTOPIC PREGNANCY Proportion is between the risk of expectant treatment for the mother and chance if soon delivering a viable fetus.

ECTOPIC PREGNANCY 1.If no hemorrhage  Viability  Cesarian Section

ECTOPIC PREGNANCY 2.In actual crisis of dangerous hemorrhage, surgical intervention to control the bleeding is morally permissible under the principle of double effect, provided no direct attack is made on the fetus

ECTOPIC PREGNANCY As long as rupture has not occurred and as long as the mother’s life is not in imminent danger from her traumatized tissue, one could not justify surgical intervention on the ovary while there remain some real hope of delivering a viable fetus in the future.

ECTOPIC PREGNANCY 1.Direct attack is immoral 2.Surgical intervention upon dangerously pathological tissue may be done under the principle of double effect.

ECLAMPSIA 1.The principle of double effect can’t be applied because the evil effect is necessarily directly willed, since it is envisioned as a necessary means to producing the good effect

ECLAMPSIA 2.What could be done if the patient is in eclamptic crisis is to control the eclampsia MEDICALLY until the fetus is viable and can be delivered.

CHORIOAMNIONITIS 1.The only morally accepted removal of the fetus would be into an environment which would offer as good or as better environment than it already is.

CHORIOAMNIONITIS Wrong Mentality: Remove the fetus because it will going to die anyway. Correct Mentality: If we do empty the uterus, both mother and baby will live longer.

H-MOLE 1. If the H-mole has advanced to such a stage that it is incompatible with the presence of living fetus, dilatation and curettage, hysterotomy or hysterectomy are morally acceptable

H-MOLE 2.1. If the uterus, even probably contains a living fetus, expectant treatment must be maintained until the positive diagnosis of H-mole is established and the presence of a living fetus is ruled out.

ABRUPTIO PLACENTAE 1.When it occurs near term or at onset of labor, all should be done to save both mother and child 2.It is morally acceptable to prematurely remove a viable fetus

ABRUPTIO PLACENTAE 3.If fetus is not viable… a.Hemorrhage is mild and doesn’t endanger the mother’s life, no steps can be taken that would considerably endangers the life of the fetus

ABRUPTIO PLACENTAE 3.If fetus is not viable… b.Even if the hemorrhage becomes serious, the direct removal of non-viable fetus is never permitted

ABRUPTIO PLACENTAE 3.If fetus is not viable… c.When the maternal life is in danger, it is morally permissible to control the hemorrhage by drug therapy, tamponade, even if it is foreseen that it will result in premature labor or in fetal death from some other cause (principle of double effect)

ABRUPTIO PLACENTAE 3.If fetus is not viable… d.Laparotomy and amputation of the uterus in the presence of a fulminating placento- uterine hemorrhage, even with a non-viable fetus in situ, is morally permissible (double effect)

CANCER 1.Before 3 rd trimester, the Cancer is treated. Any adverse effect on the baby is not intended but merely permitted

CANCER 2.In the 3 rd trimester, as much as possible, the pregnancy must be brought to term. If this is adverse: a.Remove the fetus if it is already viable b.Treat the Cancer if it is not yet viable

CANCER 3.Viability is in bottom line, and the treatment is necessary, the principle of double effect is applied

Bioethics Sterilization Julius Ceazar Reyes MD January 17, 2011

Why is it unethical?

Because it stops pregnancy

What is allowed?

Indirect Sterilization

2 Types 1.Direct – the purpose of the procedure is to render the patient infertile

2 Types 2.Indirect – one which results as a side effect of medical therapy aimed at specific pathology affecting a person (Principle of Double Effect)

PRINCIPLES 1.Sterilization may not be used as a means of contraception.

PRINCIPLES 2.Every action which either in anticipation of the conjugal act or in accomplishment or in the development of its natural consequences proposes to render procreation impossible IS NOT PERMISSIBLE only when needed.

PRINCIPLES 3.Procedure that induces sterility are permitted when: a.They are immediately directed to the cure, diminution or prevention of serious pathological condition, then the procedure may be done.

PRINCIPLES 3.Procedure that induces sterility are permitted when: b.A simpler treatment is not reasonably available, sterility, and is permitted

CASES (Morally Permissible)

 Primary gonadal pathology – oophorectomy  Hysterectomy is permitted when it is sincerely judged to be a necessary means of removing some serious uterine pathological condition. In these cases, the pathological condition of each patient must be considered individually. Care must be taken that a hysterectomy is not performed merely as a contraceptive measure.

3.Hysterectomy in the presence of pregnancy and even before viability is permitted when directed to the removal of a dangerous pathological condition of the uterus of such serious nature that the operation cannot be safely postpone until the fetus is viable.

4. Hysterectomy for prolapse of the uterus; considerations:  a possible conservative repair (so that pregnancy is possible)  The patient’s choice  The trauma and expense of conservative surgery, with the likelihood of a less than fully satisfactory result, and future need for more extensive surgery, may not be proportionate to the temporary preservation of fertility

4. Hysterectomy for prolapse of the uterus; considerations: d.Each case is an individual case and depends on:  Details of each case  Prudent judgment of the gynecologist  The reasonable wishes of the informed patient

5. Elective hysterectomy following bilateral oophorectomy; reasons why it is morally justified: a. to leave a “clean pelvis”; b. uterus is functionless c. principle of totality; d. understood to involve no real additional surgical risk; e. does not in no way additionally impair the functional integrity of the patient.

SPECIAL CASES

Uterine Damage in Multiple Cesarean Sections Premises:  That the uterus is badly damaged  That the uterus cannot be repaired to support another pregnancy safely Morally permissible:  Hysterectomy – because of damaged and dangerous tissue within the uterus itself  Tubal ligation – if the clinical condition of the patient contraindicates the added trauma of total hysterectomy

Moral Bases:  No moral difference between uterine isolation and uterine removal  Principle of totality – damage in the uterus  Principle of double effect – sterilization is not intended but a moral “by-product”  Pregnancy is the occasion of the serious danger, the cause of which is the damaged uterus itself.

Thank You