1. Patient Relations: Professionalism, informed consent, and abortion MS-3 Case Based Series Gretchen S. Stuart, MD, MPHTM Jennifer H. Tang, MD Amy G. Bryant, MD Family Planning Program, UNC-Chapel Hill 1

2. Objectives To meet the UNC School of Medicine Core competencies Review the principles of informed consent Review the cases from opinions of those who oppose and those who support abortion availability Increase self-awareness about specific patient situations that make you feel uncomfortable To understand the potential for a judgmental reaction or tone to interfere with the patient-doctor relationship and to develop strategies for preventing this interference 2

3. UNC School of Medicine Objectives Professionalism –adherence to ethical principles –sensitivity to patients –maintenance personal health and well-being, specifically: Demonstrate balance between priorities of patient care and personal and professional development Identify and apply theories and principles that govern ethical decision-making to the practice of medicine Advocate for access to health care for members of underserved populations 3

4. UNC School of Medicine Objectives Interpersonal and Communication Skills –Students must demonstrate interpersonal and communication skills that facilitate effective interactions with patients and their families and other health professionals, specifically: Develop empathetic, caring relationships with patients Communicate effectively with patients, patients’ families, colleagues, and other health care professionals. Demonstrate gender and cultural sensitivity in educational and clinical care settings 4

5. Patient interactions to consider Caring for a patient who is :  An alleged crime suspect; an alleged or known abuser of children or women Caring for patients who you don’t feel help themselves:  Alcoholics; non-compliant patients with chronic disease Caring for pregnant patients who you don’t feel care about the wellbeing of their fetus Caring for pregnant patients who want an abortion Working with other physicians who you feel behave unethically 5

6. Autonomy The mother’s prerogorative to make choices or take actions based on her beliefs and values even if these actions are harmful to herself or her fetus 6

7. Conscience The private, constant, ethically attuned part of the human character. It operates as an internal sanction that comes into play through critical reflection about a certain action or inaction. 7

8. Beneficence To promote the wellbeing of others 8

9. Non-Malifecence To do no harm 9

10. Justice Access to care Distribution of resources 10

11. Informed Consent Informed consent is based on ethical and legal requirements. Ethical foundation of informed consent process is the physician obligations of beneficence, nonmaleficence, autonomy and justice. Legal foundations of informed consent are spelled out in statutes and case laws in all 50 states and can often be found through state medical board websites. 11

12. Informed Consent Not just a signed piece of paper to signify “preoperative release”. Aim is for patients to meaningfully participate in the decision making process Medical education of the patient is fundamental to the process. The basis of the informed consent process is to respect and promote the participant’s or patient’s autonomy, and to protect him or her from potential harm. The collaborative physician-patient relationship forms the foundation of the informed consent process. 12

13. Informed Consent Risks and benefits of the intervention and alternative treatments or procedures, as well as risks and benefits of not receiving or undergoing a treatment, should be explained in language that will facilitate patient comprehension. 13

14. Informed Consent A well designed ICF should promote the patient’s understanding and the voluntary nature of their participation in the treatment. Readability and comprehension of the informed consent form must be appropriate. Almost half of all U.S. adults read at or below 8 th grade level but consent forms should be written at least three grade levels lower than the average educational level of the target population. 14

15. Application to reproductive medicine Assisted reproductive technology Contraception Emergency Contraception Abortion Sterilization of mentally challenged 15

16. Some background on abortion In 2005 1.21 million women chose to have an abortion 1/3 of all women will have had an abortion by age 45 More than half (54%) or women who have an abortion report using contraception when they got pregnant 16

17. More abortion information 58% of women say they would have liked to have had their abortion sooner 53% of women having an abortion never had a previous one 17

18. Conscientious refusal and reproductive medicine 18

19. Sterilization for mentally challenged 19

20. Sterilization for mentally challenged 20 At UNC Hospitals requires involvement of Legal Department and usually an ethics consult

21. Emergency contraception Example: A pharmacist rejected a rape victim’s prescription for emergency contraception arguing that dispensing the medication was a “violation of morals” 21 ACOG Committee Opinion Number 385, November 2007

22. Emergency contraception Example –In Virginia a 42-year old mother of two was refused a prescription for emergency contraception, became pregnant and ultimately underwent an abortion she had tried to prevent by requesting the EC. 22 ACOG Committee Opinion Number 385, November 2007

23. Assisted reproductive technology Example –In California a physician refused to perform intrauterine insemination for a lesbian couple, prompted by religious beliefs and disapproval of lesbians having children 23 ACOG Committee Opinion Number 385, November 2007

24. Case Discussions Respond agree/disagree I’ll collect and redistribute Divide into two groups – agree and disagree for each question and defend the card you received. Maintains anonymity 24

25. Discussion Statement completions regarding provision of abortion services 25

26. Case 1 Jane is 17 years old and is 10 weeks pregnant. She comes from a supportive working class family with strong ties to the anti-abortion movement. She has been accepted on an athletic scholarship to UNC and is due to start her first semester in two months. Her boyfriend wants them to get married and have the baby. She doesn’t know what to do and she is in your office crying. MS-3 students will be asked to agree or disagree to this statement, then the answers will be mixed up and redistributed and you will be asked to defend the answer you receive. 26 The abortion option: a values clarification guide for health care professionals, NAF

27. Conclusion 27