Ectopic Pregnancy Surgery / Abortion

[OncoCaP]

I agree that if it's the mother's wish, it should be honored. However, I don't think any woman should be expected to sacrifice her own life for her unborn child. In fact, I'm a little offended that the Church made her a saint for that -- the implication is that choosing not to sacrifice your life here isn't a sin, but it's a little inferior on the moral scale, something that I strongly disagree with. Another reason why I'm an ex-catholic. BTW, a good portion of my notions about women-hating patriarchal pro-lifers comes from growing inside the catholic church.

Ah, ok. I'm Protestant myself (raised that way, fell away pretty seriously & came back to it), and I have a brother who is Catholic. My wife is also ex-Catholic (Protestant). I don't have anything against the Catholic church, and I agree with their official positions on some things, but not others. When I was a kid, I was always jealous of my Catholic classmates because they got to do more cool rituals than us plain old Protestants did.

I was pro-choice until I was probably in my mid-20s (it was a gradual transition for me). As I have gotten older, my perspectives about human life have changed a lot, and having my own children played no small role in that. It is a pretty typical religious concept that self-sacrifice is an ideal. I'm comfortable talking with others who don't share my views.

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[deleted87716]

What if the neccisstated abortion vs delivery needed to happen within the 30 day time period you described? Could you still refuse to perform the delivery? Would you just wait until it became emergent and then try to save the mom?

Tough call. Personally, I'd get an ethics consult. Most, if not all, hospitals have an ethics committee for that sort of thing.

 

[enanareina]

I have never heard of annecdotes of a fetus coming to term through an extra-uterine pregnancy. It would be a 1 in a million shot and for all the other 999,999 the ectopic would rupture and cause a surgical emergency for mama.

Here's your anecdote: http://www.ctv.ca/servlet/ArticleNews/story/CTVNews/20050926/miracle_baby_050926/20050927/

The article features a woman who gave birth to a baby who was an undiscovered abdominal pregnancy. It goes on to say only 4 other cases have ever been reported.

Discovery Health Channel ran a program recently on 2 women who had abdominal pregnancies, one who carried to term and one whose baby died, but remained inside her abdomen and literally calcified to stone.

I think if my odds were 5 cases out of untold millions of births, I would probably not choose to carry such a pregnancy to term (if I knew about it in time). I would have to advise a patient of the extreme danger of such a condition, both to the mother's life, and the extreme unlikeliness of the child surviving. I'm pro-choice (but rather anti-abortion), and I do not have a problem or conflict with this decision.

 

[MattD]

Oh Doctor Bagel, I totally agree .

Also, does anyone else find it slightly irritating that the OP who is "vehemently anti-abortion" is a male... I'd love to hear this same opinion from someone who can actually get pregnant.

Wait, so the possession of a penis precludes one from having an opinion about the ethics of the termination of a pregnancy? Are you deluded to the point of thinking that all fertile women are pro-choice? I hate to tell you, but it just ain't true.

The OP isn't saying that he thinks he should just stand back and watch them both die. He's saying that while he understands the necessity of aborting an ectopic pregnancy, he personally feels uncomfortable with the idea of taking the action that will end what he considers to be a life with similar value to that of the rest of us humans. If you had to shoot someone to save your family from that person, wouldn't you feel uncomfortable with the action of taking a life, even though you knew it was the right thing to do? I know I would. Get off the guys case, he's just trying to work out how he feels about the issue. It isn't 'anti-woman', it's just an ethical dilemma he has to work out.

 

[Cologist]

As a woman, yes I do find this irritating that the OP is male, especially when he has problems making the difference between an elective abortion and a life-saving procedure.

I may be the one who will be flamed here but as a physician, you are NOT to let any of your personal values interfere with the care (and in this case the life) of your patients. If you were a Jehovah Witness MD, would you deny your patients life saving blood transfusions?

 

[Doctor Bagel]

Wait, so the possession of a penis precludes one from having an opinion about the ethics of the termination of a pregnancy? Are you deluded to the point of thinking that all fertile women are pro-choice? I hate to tell you, but it just ain't true.

The OP isn't saying that he thinks he should just stand back and watch them both die. He's saying that while he understands the necessity of aborting an ectopic pregnancy, he personally feels uncomfortable with the idea of taking the action that will end what he considers to be a life with similar value to that of the rest of us humans. If you had to shoot someone to save your family from that person, wouldn't you feel uncomfortable with the action of taking a life, even though you knew it was the right thing to do? I know I would. Get off the guys case, he's just trying to work out how he feels about the issue. It isn't 'anti-woman', it's just an ethical dilemma he has to work out.

Honestly, I think it is anti-woman to feel like there's any contest between the life of a mother who's here in this world and the life of an unborn embryo (in this case, it's still in the embryo stage). I'm really offended that it would even be a debate in anyone's moral system to save my life or the life of an embryo if I had an ectopic pregnancy. Frankly, it p&sses me off and scares me. If you were a female who might maybe one day have an ectopic pregnancy, you might get where I'm coming from.

 

[OncoCaP]

As a woman, yes I do find this irritating that the OP is male, especially when he has problems making the difference between an elective abortion and a life-saving procedure.

I may be the one who will be flamed here but as a physician, you are NOT to let any of your personal values interfere with the care (and in this case the life) of your patients. If you were a Jehovah Witness MD, would you deny your patients life saving blood transfusions?

So if the OP was female, the post would have been ok with you?? Somehow I don't think the gender of the OP is the issue here.

Personally, I'm a little surprised as to how well these discussions have gone. Compared to some of the debates I have seen on SDN, things here have been rather civil on the topic of abortion. For those who have not been party to intense discussions, these abortion threads might seem rough, but look around for some rougher ones that didn't get closed (PA discussions, for example). Things could turn ugly at any point, of course. Most people understand that this is a sensitive issue and try to be as respectful as possible on a relevant current issue that really gets people's blood boiling.

I can see where you are coming from in the sense that you would find this thread irritating. I also don't agree with the OP. At the same time, maybe it would be helpful if both pro-life and pro-choice advocates made an effort to discuss the issues rather than the person raising the issue(s); it makes for a much more informative discussion, in my opinion. This is not to say that we shouldn't express opinions that we think others might find offensive or insulting. Rather, I see it as a matter of directing our arguments at the issues rather than people as much as possible. If the OP makes an argument with no support, that can be explained on the basis of the argument alone.

There are a number of women who are equally "concerned" about abortions as the OP. In fact, there appears to be a group of physicians, including women, (but which I know nothing about except what they put on their web site) that cites views on ectopic pregnancies that you would probably not be entirely satisfied with either. They raise a couple of points, including research that suggests that abortions predispose women to ectopic pregnancies. There are health concerns on both sides of this debate. Here are a few that Physicians for Life brings up. The gist is that abortions put the health of the mother at greater risk than pregnancy, and that elective abortions (which almost all abortions in this country are) are an unnecessary risk to the mother. Abortion appears to put women at risk for ectopic pregnancies.

There are several arguments from men and women (including male and female physicians) that abortion in this country is not a good idea for health and moral reasons. There are, of course, many men and women who disagree with that position and it makes for a lively debate anyplace. This is a complicated issue that we will no doubt continue to deal with as physicians for many years into the future.

http://www.physiciansforlife.org/content/view/1279/2/
~PD The unadjusted mortality rate per 100,000 cases was 27 for women who had given birth, 48 for women who had miscarriages or ectopic pregnancies, and 101 for women who had abortions. Thus, the mortality rate from abortion is 101/27 = 3.7 times higher for abortion than for giving birth. Fissler, M, et al., "Pregnancy-associated deaths in Finland 1987 - 1994--definition problems and benefits of record linkage," Acta Obstetricia et Gynecolgical Scandinavica, 76:651-657, 1997.

~PD The Journal of Obstetrics & Gynecology, May, 1985, said that abortion is the sixth leading cause of maternal death in this country.

~PD "Ectopic pregnancy rose from 17,800 cases in 1970 to 73,700 cases in 1986. Nearly 800,000 women have been hospitalized for ectopic pregnancy since 1970. Thirty-six women reportedly died from ectopic pregnancy in 1986." H. Lawson, et al., "Ectopic Pregnancy in the United States," 1970-1986, Centers for Disease Control, Morbidity and Mortality Weekly Report, Vol. 38, No. SS-2, September 1989.

http://www.physiciansforlife.org/content/section/5/26/
"A 13-year study of pregnancy-associated deaths, published in the American Journal of Obstetrics and Gynecology found that the maternal mortality rate associated with abortion is 2.95 times higher than the maternal mortality rate associated with pregnancies carried to term. The study included the entire population of women 15-49 years of age in Finland, 1987-2000. The researchers linked birth and abortion records to death certificates. The annual death rate of women who had abortions in the previous year was also 46% higher than that of non-pregnant women. Women who carried to term (gave birth) had a significantly lower death rate than non-pregnant women. Non-pregnant women had 57.0 deaths per 100,000, compared to only 28.2 for women who carried to term (gave birth), 51.9 for women who miscarried, and 83.1 deaths for women who had abortions. [Gissler M, Berg C, Bouvier-Colle MH, Buekens P. Pregnancy-associated mortality after birth, spontaneous abortion or induced abortion in Finland, 1987-2000. Am J Ob Gyn 2004; 190:422-427. Finland National Research and Development Center]

Although there are male woman haters and female man haters out there, most men really like women a lot (and most women like men a lot) and are willing to do all kinds of things to enjoy each others company (including driving across the south in a diaper and donning a wig). Most do not want their wives, girlfriends, daughters, mothers, etc., to die or suffer needlessly. Many men are also concerned about unborn children and want neither them nor their mothers to die or suffer injury needlessly. Elective abortions that lead to ectopic pregnancies are a concern.

 

[Cologist]

Hey Keg,


2) Yes, participating in this kind of abortion would still bother me. However, my pro-life beliefs and goals stem from a desire to maximize life in all cases. In such a case as this one, where the death of the mother from medical complications is such a strong possibility, I believe that the right thing is to secure at least one of these two lives- even when that means sacrificing the other one. Most pro-life physican's groups agree with this position (see http://www.prolifephysicians.org/ ). That said, I'm sure I'd cry buckets afterward.


The death of the mother is not a strong possibility in the case of an ectopic tubal pregnancy. IT WILL HAPPEN! This is not "a kind of abortion". It is a life saving procedure! In bothers me that you are talking about sacrificing one life for the benefit of another, the 7-week embryo embedded in that tube is NOT viable in any stretch of the imagination. You should cry of joy that the mother is still alive.

 

[OncoCaP]

Hey Keg,


2) Yes, participating in this kind of abortion would still bother me. However, my pro-life beliefs and goals stem from a desire to maximize life in all cases. In such a case as this one, where the death of the mother from medical complications is such a strong possibility, I believe that the right thing is to secure at least one of these two lives- even when that means sacrificing the other one. Most pro-life physican's groups agree with this position (see http://www.prolifephysicians.org/ ). That said, I'm sure I'd cry buckets afterward.


The death of the mother is not a strong possibility in the case of an ectopic tubal pregnancy. IT WILL HAPPEN! This is not "a kind of abortion". It is a life saving procedure! In bothers me that you are talking about sacrificing one life for the benefit of another, the 7-week embryo embedded in that tube is NOT viable in any stretch of the imagination. You should cry of joy that the mother is still alive.

Yes, agreed.

 

[Cologist]

So if the OP was female, the post would have been ok with you?? Somehow I don't think the gender of the OP is the issue here.

No it would have not be ok. But as a woman it does bother me that this male OP brings his values at this female patient's bedside, putting her life at the same "value" of a non-viable embryo. So yes, you are right, gender is not an issue "per say".

For every study you can bring me on how abortions correlates with higher risk of tubal pregnancies and higher mortality rates, I can bring you one that will show you that legal abortions are safer than carrying a pregnancy to term. I would encourage you to search for those on your own but here's a good place to start http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5511a1.htm

You are showing me studies from "Physicians for life" which will tend to be biased and include illegal abortions performed by unskilled providers in unsafe conditions. Furthermore, tubal pregnancies are not linked solely on having an elective abortion...they are also associated with tubal ligations, salpingitis, previous surgeries of any kind and so on....

This is not the issue here. And the issue is not remotely close to being a man-hater.

I do agree with you that there room for informative discussion. Here's one that I heard from a recent MS4C conference last Fall. In the US, one in four pregnancy end in an elective abortion while in Tunisia, this rate is one in 11 despites this country's liberal, on-demand, free access to first trimester abortions. The reason why the rate is much lower than in the US is the fact that Tunisia also emphasized access to birth control and sex education for all, something that is controversial in the US which is now pushing an abstinence only curriculum.

But the bottom line here regarding the OP is the following: Do not bring your values to the bedside. If you don't feel comfortable, the least you can do is to refer.

 

[OncoCaP]

So if the OP was female, the post would have been ok with you?? Somehow I don't think the gender of the OP is the issue here.

No it would have not be ok. But as a woman it does bother me that this male OP brings his values at this female patient's bedside, putting her life at the same "value" of a non-viable embryo. So yes, you are right, gender is not an issue "per say".

For every study you can bring me on how abortions correlates with higher risk of tubal pregnancies and higher mortality rates, I can bring you one that will show you that legal abortions are safer than carrying a pregnancy to term. I would encourage you to search for those on your own but here's a good place to start http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5511a1.htm

You are showing me studies from "Physicians for life" which will tend to be biased and include illegal abortions performed by unskilled providers in unsafe conditions. Furthermore, tubal pregnancies are not linked solely on having an elective abortion...they are also associated with tubal ligations, salpingitis, previous surgeries of any kind and so on....

This is not the issue here. And the issue is not remotely close to being a man-hater.

I do agree with you that there room for informative discussion. Here's one that I heard from a recent MS4C conference last Fall. In the US, one in four pregnancy end in an elective abortion while in Tunisia, this rate is one in 11 despites this country's liberal, on-demand, free access to first trimester abortions. The reason why the rate is much lower than in the US is the fact that Tunisia also emphasized access to birth control and sex education for all, something that is controversial in the US which is now pushing an abstinence only curriculum.

But the bottom line here regarding the OP is the following: Do not bring your values to the bedside. If you don't feel comfortable, the least you can do is to refer.

Keep in mind that the sources are journals, which appear to be legit, so I don't think we can dismiss them because they are listed on Physicians for Life. However, I will agree that there is a lot of debate about these issues and that this is one area where I could see scientific objectivity compromised by personal perspectives and funding sources.

Also, your source says nothing about elective abortions not leading to ectopic pregnancies as far as I can tell (although it does suggest that abortions are safe if you are comfortable with the accuracy of voluntarily reported data). A couple of women (one was a 13 year-old with several abortions) I have come across who had ectopic pregnancies also had abortions prior to their ectopic, but I have not read much on this. I wasn't aware that anyone had reported a link here until I read about it on the Physicians for Life web site (they cited journals).

In my opinion abortion is a relatively safe procedure for the mother. My point is that you'll find women who will say things about abortion that you disagree with, and you agreed that gender of the person making an argument should not be the focus of discussion. When I was pro-choice, I also felt that the mother's life was pretty much the only consideration. However, now I'm pro-life, and I view the child in the womb not much differently than an infant I would hold in my arms. If this baby or its mother had to die, that would be an unpleasant situation, much as it would be if it came down to saving a mother or her infant trapped in a burning building. In almost all cases, ectopics are not viable, so it would make sense to save the mother. However, asking the question as to whether a particular case is fundamentally different is probably not unreasonable.

I can see many of your points above. However, the "Do not bring your values to the bedside" bottom line seems a little bit extreme. Yes, we are going to treat drug addicts, prostitutes, and even wife-beaters and our focus is to be on treating the patient with respect to their wishes. However, to completely check our values at the door seems too extreme.

I can give you an example (not related to abortion) as to why I think this is wrong in the general case. When I was an undergrad, I broke my right ring finger at the joint. I had no insurance and no money. I was referred to an orthopedic surgeon who said we needed to insert a pin and add a cast. It was going to be something like $1800 (I think it turned out to be more than that), which I didn't have. I told him, no, that was too much money. I couldn't afford it, I'll just need to do without the treatment. He then proceeded to talk me into doing it anyway (against my wishes) because for me not to get this treatment was against his values. He said the hospital would work with me on the payments and he would as well. After a certain amount of pressure from him, I went along with his opinion and was glad I did.

However, you do make an excellent point in a more narrow sense. Physicians should be very careful about imposing their values in a situation. An example (besides the ectopic pregnancy concern above) is a situation where a family I knew very well was told that their unborn child is expected to have Down Syndrome. They were advised about having an abortion. In fact, they felt they were being pressured to have an abortion. The decided against it, and the child turned out to be normal.

I'm not aware of a 100% accurate and trustworthy simple formula or slogan by which we can judge on how to apply our values. There are general guidelines, yes, but to some extent we will need to learn when it is appropriate to apply our values and when it is not. My inclination is that when in doubt, I would defer to the patient's wishes.

However, what if a pediatric patient wants to discontinue chemotherapy for a cancer that is successfully treated in this way but leads to greater suffering and premature death if not? I would be inclined to "inform" the patient in such a way to motivate them to take the steps so that injury, suffering, and death are minimized, even if it was difficult in the short-term, and this would be in accord with my values. Ultimately it would be their decision, but these are the kinds of things I hopefully will get some training on and, if necessary, have access to ethics consults.

 

[Wanna_B_Scutty]

The death of the mother is not a strong possibility in the case of an ectopic tubal pregnancy. IT WILL HAPPEN! This is not "a kind of abortion". It is a life saving procedure! In bothers me that you are talking about sacrificing one life for the benefit of another, the 7-week embryo embedded in that tube is NOT viable in any stretch of the imagination. You should cry of joy that the mother is still alive.

I never said it was viable. I also said that I would kill it. But killing it would still profoundly affect me, all the same. Just because I think it would be the right thing to do doesn't mean that I wouldn't feel terrible about the whole thing. I mean, my God, you do realize that by aborting it I would not only have to kill it, but suck out/cut out its teeny tiny little hands, legs, a head, etc? Plus, after the procedure, I'd have to "reassemble" the body parts to make sure I didn't leave anything behind. Like I said, I'd do it, but this must be viscerally disturbing at best. Why shouldn't I cry afterwards? (for photos of what an aborted 7-week fetus looks like, please go here: http://www.abortionno.com/Resources/pictures.html Please note that the pics are authenticated as described here: http://www.abortionno.com/About_Us/lawsuits/authenticity.html )

By the way, I am, in fact, female. You can confirm this fairly easily by clicking back through my post history.

And yes, I would be very, very happy that the mother survived. But if you would be looking for a reaction of complete and unfettered joy about how things went down... that I cannot give you.

 

[OncoCaP]

...
If you view abortion as a violation of the oath to "do no harm," you need not compromise your oath through either participation or referral:
The Medical Training Nondiscrimination Act of 1995 states that "the Federal Government…may not subject any health care entity to discrimination on the basis that--(1) the entity refuses to undergo training in the performance of induced abortions, to provide such training, to perform such abortions, or to provide referrals for such abortions..."

Do you think the recent Kroger policy requiring pharamcists to refer patients on Plan B is a challenge to the "Medical Training Nondiscrimination Act of 1995"? It seems like the Kroger policy suggests that your employer could require you to refer the patient to another pharmacist for Plan B (I realize that pharmacists are not physicians, but they are certainly professionals in health care. (I also realize that not everyone views Plan B the same as an abortion). For example, a medical school might require students who object to abortions to refer the patient to a physician who does not have a problem with referring or ordering an abortion.

 

[Wanna_B_Scutty]

Do you think the recent Kroger policy requiring pharamcists to refer patients on Plan B is a challenge to the "Medical Training Nondiscrimination Act of 1995"? It seems like the Kroger policy suggests that your employer could require you to refer the patient to another pharmacist for Plan B (I realize that pharmacists are not physicians, but they are certainly professionals in health care. (I also realize that not everyone views Plan B the same as an abortion). For example, a medical school might require students who object to abortions to refer the patient to a physician who does not have a problem with referring or ordering an abortion.

I'm going to preface this by saying that I am comfortable with Plan B and do not view it as abortion. I would prescribe it to my patients if asked. That said, no, I don't think it is a challenge on the MTNA for the simple reason that Kroger's pharmacists are not trainees.

However, as I read the MTNA1995 it is not in fact true that a med school can require its students to refer the patient to another physician who would then order an abortion. This would violate the second clause of the Act:

(a) IN GENERAL- The Federal Government, and any State that receives Federal financial assistance, may not subject any health care entity to discrimination on the basis that--
`(1) the entity refuses to undergo training in the performance of induced abortions, to provide such training, to perform such abortions, or to provide referrals for such abortions;
`(2) the entity refuses to make arrangements for any of the activities specified in paragraph (1); or
`(3) the entity attends (or attended) a postgraduate physician training program, or any other program of training in the health professions, that does not (or did not) require, provide or arrange for training in the performance of induced abortions, or make arrangements for the provision of such training.

I am not an attorney, but this seems pretty cut and dry to me.

 

[OncoCaP]

I'm going to preface this by saying that I am comfortable with Plan B and would prescribe it to my patients. That said, no, I don't think it is a challenge on the MTNA for the simple reason that Kroger's pharmacists are not trainees.

...

So, a clinic or hospital could require its physicians (non-trainees) to refer patients who want an abortion (at least with respect to MTNA). Are there any other laws that concern non-trainees (physicians)?

 

[Wanna_B_Scutty]

So, a clinic or hospital could require its physicians (non-trainees) to refer patients who want an abortion (at least with respect to MTNA). Are there any other laws that concern non-trainees (physicians)?

No, a hospital cannot require its physicians or other non-trainees to refer patients for abortions: at least, not if they want to remain eligible to collect Medicare, Medicaid, and any other Federal HHS funds. The Hyde-Weldon Ammendment covers all physicians and other health are workers regardless of trainee status:

Complete Text of the Hyde Weldon Ammendment
(1) None of the funds made available in this Act [the federal Health and Human Services appropriations bill for Fiscal Year 2005] may be made available to a Federal agency or program, or to a State or local government, if such agency, program, or government subjects any institutional or individual health care entity to discrimination on the basis that the health care entity does not provide, pay for, provide coverage of, or refer for abortions. (2) In this subsection, the term "health care entity" includes an individual physician or other health care professional, a hospital, a provider-sponsored organization, a health maintenance organization, a health insurance plan, or any other kind of health care facility, organization, or plan.

However, it would appear that a hospital can probably force a non-trainee to refer to someone else for a referral.

But again, I'm not a lawyer. For deeper questions about the legal ramifications of all of this, you'd have to find someone more qualified than I am.

 

[OncoCaP]

No, a hospital cannot require its physicians or other non-trainees to refer patients for abortions: at least, not if they want to remain eligible to collect Medicare, Medicaid, and any other Federal HHS funds. The Hyde-Weldon Ammendment ...

Thanks for the information! I'm not sure I would refuse to refer a patient who wanted an abortion to an OB/GYN that performed abortions (I couldn't see my refusal to refer preventing anyone from having an abortion), but it looks like it isn't necessary to present abortion as an option unless the mother is in danger of injury or death. I could see that some physicians would not want to refer on the basis of conscience, and I respect that. The patient would need to tell me on their own that they wanted an abortion before I would refer them to a physician that performed them. My starting assumption (bias) would be that a healthy unborn child and healthy mother would proceed to term.

 

[8744]

Second that.

There are plenty of OB/Gyns who are pro-life and will neither perform or refer for an elective abortion. Just do a web search.

However, an ectopic pregancy is not a viable pregnancy and poses a grave risk to the mother so not treating her or referring her for that would be a violation of the standard of care.

Elective abortion is not part of the "standard of care."

 

[tiredmom]

I never said it was viable. I also said that I would kill it. But killing it would still profoundly affect me, all the same. Just because I think it would be the right thing to do doesn't mean that I wouldn't feel terrible about the whole thing. I mean, my God, you do realize that by aborting it I would not only have to kill it, but suck out/cut out its teeny tiny little hands, legs, a head, etc? Plus, after the procedure, I'd have to "reassemble" the body parts to make sure I didn't leave anything behind. Like I said, I'd do it, but this must be viscerally disturbing at best. Why shouldn't I cry afterwards? (for photos of what an aborted 7-week fetus looks like, please go here: http://www.abortionno.com/Resources/pictures.html Please note that the pics are authenticated as described here: http://www.abortionno.com/About_Us/lawsuits/authenticity.html )

By the way, I am, in fact, female. You can confirm this fairly easily by clicking back through my post history.

And yes, I would be very, very happy that the mother survived. But if you would be looking for a reaction of complete and unfettered joy about how things went down... that I cannot give you.

I've seen several ectopic pregnancy removals - never seen anything that resembled distinct parts - at least on gross visualization. It's been stuck in the tube - it's not growing right in the first place... hence the abnormal rise in beta-HcG. It really just looks like pink tissue with clots over it.

And I've also never seen anybody open up the suction canister from D&C's for missed abortions to put parts together.

If you go into obstetrics, you'll have to perform these procedures even if you don't want to perform abortions. If you have a moral/ethical problem with ectopics, I wouldn't do ob/gyn... you're not going to make many friends when your on call and constantly having to call someone else in for an emergent case. I'll be doing ob, and I won't be performing elective abortions, but I have no problem with ectopics. I'm also Catholic (but will be prescribing birth control too ).

 

[DrZeke]

There are plenty of OB/Gyns who are pro-life and will neither perform or refer for an elective abortion. Just do a web search.

However, an ectopic pregancy is not a viable pregnancy and poses a grave risk to the mother so not treating her or referring her for that would be a violation of the standard of care.

Elective abortion is not part of the "standard of care."

It is if you put an IUD in a patient and it didn't work or shifted and they ended up pregnant. Happened to a friend of mine.

BTW, thank you ladies for standing up for what I said earlier. If the OP had been female, I still would have thought that the opinion was kind of ridiculous since ectopic pregnancy removal IS a lifesaving procedure. I still do, however, find it offensive when there are complications to a pregnancy or serious reasons - emotional or otherwise - why someone might not want to have a baby and men can just spout off a list of reasons to have the baby. When you have something growing inside you, then you can come around and talk about it, but until then, I think in legitimate cases, some people should just back the f#ck off. Honestly, not all women that get pregnant unintentionally are idiots and should be "punished" for what they did by giving birth to a child that is unwanted. Yes there are plenty of stupid people out there who should be more careful, but accidents do happen and people shouldn't be screwed over by mistakes.

 

[rabok416]

OP, it may interest you to know that Senator Tom Coburn, M.D. once performed two abortions in cases of ectopic pregnancies. He is very pro-life. I, like you, could never participate in an elective abortion, but I would terminate an ectopic pregnancy if I had to.

 

[kelaskov]

There are plenty of OB/Gyns who are pro-life and will neither perform or refer for an elective abortion. Just do a web search.

However, an ectopic pregancy is not a viable pregnancy and poses a grave risk to the mother so not treating her or referring her for that would be a violation of the standard of care.

Elective abortion is not part of the "standard of care."

Therapeutic abortion is considered the standard of care in some instances.

Post-abortion-care (for illegal/legal induced abortion or naturally occuring) is also standard of care and this can include removing retained tissue from the uterus. (American College of Obstetrics and Gynecologists).

If personal ethical beliefs may prevent you from providing standard of care- you should probably avoid pursuing a career in Obgyn.

On another note- would you be against aborting an anencephalic fetus?

 

[MattD]

All the people irritated at the OP seem to have missed the point. Nobody's putting the life of a non-viable embryo above the life of the mother. The OP was simply stating that he would be bothered and disturbed at the prospect of having to actively end the life of the embryo. Nobody's saying it would be wrong to do so, nobody's saying they wouldn't do it, but where the hell do you get off telling people what they can and cannot FEEL about what they are doing? For the record, I am anti-elective abortion (pro-life and pro-choice are political BS slogans, I don't like using them.) I have no problem with termination of a pregnancy for medically necessary reasons, however I will refer such patients to a more willing physician if there is time to do so. Yes, I would perform the procedure myself if it was absolutely necessary. It is not that I feel that the procedure itself is wrong under those circumstances, it is that I would prefer not to personally perform the procedure, if that is possible. And if I do find myself in the position of having to perform a medically necessary abortion, you better believe I'm going to feel bad afterward. I'll be happy that the mother is going to live, but I will be sad for the child that will never get the chance to be, and I'll be bothered that I had to take that chance away from it. Now, I'm not interested in OB/GYN so the chances of me being in this situation are pretty remote, but I am interested in ortho, and I'm sure times will come where I have to amputate a limb to save a life. I'll be glad I saved the life, but that doesn't mean I can't feel like crap about the fact that I had to hack off someone's leg. Feeling bad about having to abort an ectopic pregnancy isn't anti-woman -- it's simply pro-child.

 

[pillowhead]

I can see many of your points above. However, the "Do not bring your values to the bedside" bottom line seems a little bit extreme. Yes, we are going to treat drug addicts, prostitutes, and even wife-beaters and our focus is to be on treating the patient with respect to their wishes. However, to completely check our values at the door seems too extreme.

I can give you an example (not related to abortion) as to why I think this is wrong in the general case. When I was an undergrad, I broke my right ring finger at the joint. I had no insurance and no money. I was referred to an orthopedic surgeon who said we needed to insert a pin and add a cast. It was going to be something like $1800 (I think it turned out to be more than that), which I didn't have. I told him, no, that was too much money. I couldn't afford it, I'll just need to do without the treatment. He then proceeded to talk me into doing it anyway (against my wishes) because for me not to get this treatment was against his values. He said the hospital would work with me on the payments and he would as well. After a certain amount of pressure from him, I went along with his opinion and was glad I did.

However, you do make an excellent point in a more narrow sense. Physicians should be very careful about imposing their values in a situation. An example (besides the ectopic pregnancy concern above) is a situation where a family I knew very well was told that their unborn child is expected to have Down Syndrome. They were advised about having an abortion. In fact, they felt they were being pressured to have an abortion. The decided against it, and the child turned out to be normal.

I'm not aware of a 100% accurate and trustworthy simple formula or slogan by which we can judge on how to apply our values. There are general guidelines, yes, but to some extent we will need to learn when it is appropriate to apply our values and when it is not. My inclination is that when in doubt, I would defer to the patient's wishes.

However, what if a pediatric patient wants to discontinue chemotherapy for a cancer that is successfully treated in this way but leads to greater suffering and premature death if not? I would be inclined to "inform" the patient in such a way to motivate them to take the steps so that injury, suffering, and death are minimized, even if it was difficult in the short-term, and this would be in accord with my values. Ultimately it would be their decision, but these are the kinds of things I hopefully will get some training on and, if necessary, have access to ethics consults.

I'm sorry but this post really bothered me and indicates how despite good writing, how uninformed you are.

The post about us treating wife beaters, drug dealers, etc--you say that to check our values at the door seems extreme. Maybe I'm misinterpreting you here, but are you saying we should be bringing our negative attitudes towards these type of people when we see them in clinic/hospital? I understand your still premed, right? Perhaps you should try treating a patient like this first in a patient doctor relationship before advising others how to do so.

The orthopedic surgeon who wouldn't let you walk away without treatment wasn't doing so because that would have been against his values. He did that because it would have been against standard of health care to leave such an injury untreated. Values implies decision making based on morality, on frankly grey issues for which pure logic cannot give us the answer no matter how much we want it to. In this case, logic says untreated injury will lead to deformity and disability so it needs treatment. If he gave you free treatment, that would be more of a values based decision and perhaps that is what you meant? But not letting you walk away is simply practicing good medicine.

Finally, a pediatric patient has no right to consent to treatment (assent is a different thing) and therefore no right to refuse treatment and therefore, ultimately it is NOT their decision whether or not to continue chemotherapy. Values can sure make the whole thing difficult but the ultimate legal action is pretty straightforward. That decision belongs to their parents except in cases where the parents are refusing life saving treatment for their child in which case the state takes over medical decision making. There have been too many court cases on this to count. And in fact, we had a teenage Jehovahs Witness patient with aplastic anemia for whom we were giving transfusions on a regular basis. She never missed an opportunity to tell everyone around her that the day she turned 18, she was checking herself out of that place never to get a lifesaving transfusion again. But at 17, it wasn't for her to legally refuse nor her parents since it was lifesaving medical treatment.

 

[psipsina]

I'm sorry but this post really bothered me and indicates how despite good writing, how uninformed you are.

The post about us treating wife beaters, drug dealers, etc--you say that to check our values at the door seems extreme. Maybe I'm misinterpreting you here, but are you saying we should be bringing our negative attitudes towards these type of people when we see them in clinic/hospital? I understand your still premed, right? Perhaps you should try treating a patient like this first in a patient doctor relationship before advising others how to do so.

The orthopedic surgeon who wouldn't let you walk away without treatment wasn't doing so because that would have been against his values. He did that because it would have been against standard of health care to leave such an injury untreated. Values implies decision making based on morality, on frankly grey issues for which pure logic cannot give us the answer no matter how much we want it to. In this case, logic says untreated injury will lead to deformity and disability so it needs treatment. If he gave you free treatment, that would be more of a values based decision and perhaps that is what you meant? But not letting you walk away is simply practicing good medicine.

Finally, a pediatric patient has no right to consent to treatment (assent is a different thing) and therefore no right to refuse treatment and therefore, ultimately it is NOT their decision whether or not to continue chemotherapy. Values can sure make the whole thing difficult but the ultimate legal action is pretty straightforward. That decision belongs to their parents except in cases where the parents are refusing life saving treatment for their child in which case the state takes over medical decision making. There have been too many court cases on this to count. And in fact, we had a teenage Jehovahs Witness patient with aplastic anemia for whom we were giving transfusions on a regular basis. She never missed an opportunity to tell everyone around her that the day she turned 18, she was checking herself out of that place never to get a lifesaving transfusion again. But at 17, it wasn't for her to legally refuse nor her parents since it was lifesaving medical treatment.

I agree wholeheartedly. The physician who leads our touch feely discussions (aka "the science and practice of medicine") whom I greatly respect and have seen in action and is an amazing practitioner, has pretty much beaten us about the heads with the concept of leaving our baggage at the door when we go in to see a patient. He said that if your having an overly emotional reaction to a patient its a sign of an issue within yourself and really has nothing to do with the patient. Our number one duty is to the patient, and your own emotional crap can get in the way of this. This ranges from your religious beliefs to the fact that your feelings towards your aloholic uncle lenny who fondled you when you were a kid (just examples people . . . ) you have to recognize what baggage you're carrying around (and we allll have some) and be able to leave it behind so you can do your best for your patient. You are not there to judge your patients you are there to provide them with the standard of care (i.e. good medicine). And your baggage can get in the way of your duty to them when it causes you to interact differently with them.

 

[Wanna_B_Scutty]

I've seen several ectopic pregnancy removals - never seen anything that resembled distinct parts - at least on gross visualization. It's been stuck in the tube - it's not growing right in the first place... hence the abnormal rise in beta-HcG. It really just looks like pink tissue with clots over it.

Hey tiredmom,

This is really good to know. But I have a question for you: do you know why this happens? I had assumed that such a pregnancy would devlop normally, but that it was just developing in a dangerous place. What is happening during development to cause this?

And I've also never seen anybody open up the suction canister from D&C's for missed abortions to put parts together.

Really? Huh. I was under the impression that this was done for safety reasons. As kelaskov aptly pointed out, body parts can get left behind, thus putting the mother in danger of sepsis, etc.

Obviously I was misinformed. But why aren't they at least checking for the skull and spine?

 

[Wanna_B_Scutty]

I agree wholeheartedly. The physician who leads our touch feely discussions (aka "the science and practice of medicine") whom I greatly respect and have seen in action and is an amazing practitioner, has pretty much beaten us about the heads with the concept of leaving our baggage at the door when we go in to see a patient. He said that if your having an overly emotional reaction to a patient its a sign of an issue within yourself and really has nothing to do with the patient. Our number one duty is to the patient, and your own emotional crap can get in the way of this. This ranges from your religious beliefs to the fact that your feelings towards your aloholic uncle lenny who fondled you when you were a kid (just examples people . . . ) you have to recognize what baggage you're carrying around (and we allll have some) and be able to leave it behind so you can do your best for your patient. You are not there to judge your patients you are there to provide them with the standard of care (i.e. good medicine). And your baggage can get in the way of your duty to them when it causes you to interact differently with them.

So here's a question for you:

I'm sure you've heard about the trade in harvesting and selling the organs of political prisoners for transplant in China, India, etc.
http://www.abc.net.au/pm/content/2006/s1683142.htm

Now let's say you were doing some overseas work in China. One of your patients came in with such serious kidney disease that you felt he needed a transplant. Your patient is a wealthy man, and makes it clear that he is willing to pay any price for the chance to live.

Do you refer him for a transplant from a politcal prisoner? If not, why not? It's legal in China- or at least not illegal.

If you wouldn't make the referral, why not? "If you're having an overly emotional reaction to a patient its a sign of an issue within yourself and really has nothing to do with the patient." After all, "Our number one duty is to the patient, and your own emotional crap can get in the way of this."
Right????

 

[psipsina]

So here's a question for you:

I'm sure you've heard about the trade in harvesting and selling the organs of political prisoners for transplant in China, India, etc.
http://www.abc.net.au/pm/content/2006/s1683142.htm

Now let's say you were doing some overseas work in China. One of your patients came in with such serious kidney disease that you felt he needed a transplant. Your patient is a wealthy man, and makes it clear that he is willing to pay any price for the chance to live.

Do you refer him for a transplant from a politcal prisoner? If not, why not? It's legal in China- or at least not illegal.

If you wouldn't make the referral, why not? "If you're having an overly emotional reaction to a patient its a sign of an issue within yourself and really has nothing to do with the patient." After all, "Our number one duty is to the patient, and your own emotional crap can get in the way of this."
Right????

There is a difference between legality, ethics and emotional responses that you seem to be confusing here. It doesn't matter if something is legal if it is clearly unethical. My number one duty is to the patient, and my duty is to do everything that is ethical to help him. Clearly there is an ethical problem with transplant donations from involuntary donors so this doesn't fall as part of what I can ethically do for my patient. This has nothing to do with my personal emotional response to the patient or to the involuntary donor, its black and white ethics.

An emotional reaction would be doing something like this that is clearly unethical because the patient reminds me of my dearly beloved long lost grandfather and I just can't stand to see him die. Or not giving him an ethically obtained organ because I know he's a registered sex offender. See the difference?

 

[OncoCaP]

There is a difference between legality, ethics and emotional responses that you seem to be confusing here. It doesn't matter if something is legal if it is clearly unethical. My number one duty is to the patient, and my duty is to do everything that is ethical to help him. Clearly there is an ethical problem with transplant donations from involuntary donors so this doesn't fall as part of what I can ethically do for my patient. This has nothing to do with my personal emotional response to the patient or to the involuntary donor, its black and white ethics.

An emotional reaction would be doing something like this that is clearly unethical because the patient reminds me of my dearly beloved long lost grandfather and I just can't stand to see him die. Or not giving him an ethically obtained organ because I know he's a registered sex offender. See the difference?

It sounds like medical school is in the business of brainwashing students into becoming unfeeling robots. I hope I never succumb to that "treatment" or I would consider my education be a complete waste because my most important element -- my humanity -- had been removed from my work. I would be extremely unimpressed by an instructor that try to claim that we are supposed to become robotic advocates of our patients.

Your basic argument, that our number one duty is to the patient, makes sense. Now consider that many physicians (pro-life) consider abortion to be unethical, something similar to causing the death of an infant. Also, consider that pro-life physicians consider not just the mother, but also the unborn child also to be their patient. Thus, you have two patients, not just one. To put this in perspective for someone who is pro-choice and doesn't believe the unborn child is a person, the situation may be compared to conjoined twins, for example. Do you kill one so that the other can survive? Certainly not without trying to save both of them.

Yes, abortion is legal, and yet many people consider it to be unethical. Thus, given that for some physicians it is unethical, how do they deal with it? Do they simply ignore their ethics and the values related to that (that doing the ethical thing trumps the wishes of the patient)? No, they don't. They apply their values in the sense of ethics, as you say.

 

[psipsina]

It sounds like medical school is in the business of brainwashing students into becoming unfeeling robots. I hope I never succumb to that "treatment" or I would consider my education be a complete waste because my most important element -- my humanity -- had been removed from my work. I would be extremely unimpressed by an instructor that try to claim that we are supposed to become robotic advocates of our patients.

Your not supposed to not feel. Compassion is an excellent motivator to have as a physician and a great way to connect with your patient. You are, however, not supposed to let your emotional reaction to a patient in any way allow that patient to not get the care that is in their best interest (i.e. the standard of care). Lets say you go into a room and you see a patient in the orange prison jumpsuit (happens all the time in my schools ER btw) and the thought crosses your mind that this guy might be a child molestor or a murderer and you emotionally react to that, you know you are safe because there are two armed cops in the room with you but you are still disgusted or revolted . . . and it shows on your face and in your demenor as you take the patient's history . . . and he senses this and becomes defensive and argumentative and uncooperative and doesn't tell you things he otherwise might of that would have helped you understand whats really going on . . . and so this patient doesn't get the same quality of medical care because you don't really know whats going on the same way you would if a sweet old granny came in with the same problem and your kind and open demenor got her to open up to you and tell you something you needed to know. This is what they mean by leaving your baggage at the door, not that you can't have feelings, but that you don't let those feelings compromise your patient getting the best care possible.

Your basic argument, that our number one duty is to the patient, makes sense. Now consider that many physicians (pro-life) consider abortion to be unethical, something similar to causing the death of an infant. Also, consider that pro-life physicians consider not just the mother, but also the unborn child also to be their patient. Thus, you have two patients, not just one. To put this in perspective for someone who is pro-choice and doesn't believe the unborn child is a person, the situation may be compared to conjoined twins, for example. Do you kill one so that the other can survive? Certainly not without trying to save both of them.
Yes, abortion is legal, and yet many people consider it to be unethical. Thus, given that for some physicians it is unethical, how do they deal with it? Do they simply ignore their ethics and the values related to that (that doing the ethical thing trumps the wishes of the patient)? No, they don't. They apply their values in the sense of ethics, as you say.

Elective abortions are not standard of care. Therefore if you don't feel comfortable providing one you will never be obligated to. Your feelings keep you from being a provider of this elective service, similar to my objections to liposuction keeping me from every providing that service. You never enter the room so you never have to leave your baggage behind on this one.

If however your patient is going to die or be in serious danger of dying without said abortion, it becomes standard of care and if you couldn't find someone else to do it (hypothetically you are the lone provider in a rural emergent care facility in the middle of the night hours away from any backup) and the patient couldn't wait to be transferred to another facility I do believe you would have the ethical obligation to put your baggage aside and save your patient. If you are an obgyn the mother is your patient. You are ethically obliged to provide her with the standard of care or to transfer her to another doctor who would. To not do so is abandonment. The Neonatologist is the baby's doctor and would be present to attend to the baby if it was anywhere near the possibility of viability. If you are so into the baby perhaps you should chose to be a Neonatologist instead of being an OBGYN.

 

[OncoCaP]

Your not supposed to not feel. Compassion is an excellent motivator to have as a physician and a great way to connect with your patient. You are, however, not supposed to let your emotional reaction to a patient in any way allow that patient to not get the care that is in their best interest (i.e. the standard of care). ...

Very good. I agree with your explanation. Thank you for taking the time to explain this. As you say, compassion is hopefully a key motivator for the physician. You write very well, by the way.

 

[psipsina]

Very good. I agree with your explanation. Thank you for taking the time to explain this. As you say, compassion is hopefully a key motivator for the physician. You write very well, by the way.

blushes . . .

 

[Wanna_B_Scutty]

There is a difference between legality, ethics and emotional responses that you seem to be confusing here. It doesn't matter if something is legal if it is clearly unethical. My number one duty is to the patient, and my duty is to do everything that is ethical to help him. Clearly there is an ethical problem with transplant donations from involuntary donors so this doesn't fall as part of what I can ethically do for my patient. This has nothing to do with my personal emotional response to the patient or to the involuntary donor, its black and white ethics.

I think I may not have been clear enough in my "China" post, and that you may have misunderstood me. I was not confusing emotion with ethics. Rather I was pointing out the fundamental conflict between your statement that "my number one duty is to the patient" with the statement "it doesn't matter if something is legal if it is unethical."

Here is where the problem lies: if your number one duty is truly to the patient, then you should be required to refer your patient for the transplant from a politcal prisoner. After all, if your number one duty is to your patient, then that implies that Patient > Ethics since, after all, the patient is #1.

Think of it this way: imagine that you were in China, you had refused to refer your patient for the transplant, and now the other Chinese docs are mad at you. They say that you have no right to impose your own ethical values onto their culture. You tell them, "It's unethical! The ethics here are totally black and white!" They say, "These ethics are shades of grey. The prisoner is going to be killed anyway... his organs might as well go to save a sick man. And, anyway, your number one duty is to your patient!" You say, "No, this is an atrocity! I cannot be complicit in something like this. This is clearly and utterly wrong." But the Chinese doctors, the Chinese government, and your patient all say, "You cannot push your Yankee values onto our culture. Your first duty is to your patient, and the patient needs the transplant. If you're having an overly emotional reaction to this, then that's a sign of an issue within yourself, and not an issue with the patient. You're working in China, now. You have to recognize the baggage you're carrying around, leave it at the door, and do what's best for your patient. And the best thing you can do is to refer." Now do you refer?

I'm going to take a wild guess here, but I'm betting you would not refer. Thus, I conclude that, whiel you endose a slogan of "your number one duty is to your patient," in truth, you would put Ethics > Patient. So, you see, you are making decisions such that your number one duty is to your ethics, and your number two duty is to your patient.

Frankly, I fundamentally reject the premise that "my number one duty is to my patient." I've heard it many times before, of course, but having it told to me over and over again doesn't make it true. Why should I put a patient before my ethics? Frankly, doing so would be downright dangerous, as in the China transplant example given above. The "number one duty is to our patients" line has been quoted so often that it's essentailly dogma. But I question it. As shown in the China transplant example, if we truly followed the "patient is number one" standard, we would wind up committing all kinds of atrocities. Thus, I'd like to put forth an alternative piece of dogma: "Our number one duty is to behave ethically. Our number two duty is to our patients."

And really, this makes sense, don't you think? Doctoring is unlike any other profession in that doctors truly do have profound abilities to give both help and harm to their patients. If we truly, honestly believed that "our number one duty is to our patients," then we'd roam the hosptials taking kidneys out of other patients to put into our own . But, of course, we don't. Because Ethics > Patient.

All of which brings us back to abortion. Given that Ethics > Patient, we're right back to where we started in our discussion of the ethics of abortion. Since elective abortion is the killing of one developing human at the request of a fully developed human, it's easy to see how at least some Docs are going to have a problem with it. And, since Ethics > Patient, those Docs have solid grounds upon which to refuse to refer.

 

[psipsina]

Here is where the problem lies: if your number one duty is truly to the patient, then you should be required to refer your patient for the transplant from a politcal prisoner. After all, if your number one duty is to your patient, then that implies that Patient > Ethics since, after all, the patient is #1.

I concur that medical ethics trump patients needs. It would be chaos if we didn't have standard ethical guidlines guiding our actions. It is implied that your actions have to be ethical (and legal) when we have discussions about who our duty it to. Ethics isn't an entity to have a duty to, it is the code of conduct that in fact determines who your duty is to.Therefore in discussions of who the duty is to we are usually discussing whether the physician's duty is to the patient, the patient's family, the physicians employer, the physician himself, the drug companies etc. It seems intuitive that out of all these entities the patient is number one, but sometimes it isn't. Thus the battle cry of ethics courses "your number one duty is to the patient."

But I do think that you are confusing ethics with values. Ethics are a standard of conduct, whereas values are attitudes and beliefs. Ethics are standardized for a proffession, whereas values are personal and differ with cultural and religious backgrounds.

So, you see, you are making decisions such that your number one duty is to your ethics, and your number two duty is to your patient.

There is no such thing as "my ethics". There are "my values" which I have no right to impose on my patients and should leave at the door and then there is the code of conduct, or ethics, that are standard and guide everyone in the proffession. So when acting within the code of conduct of your proffession, your number one duty is to the patient. You don't have a duty to the ethics, you have simply agreed to abide by them by entering the proffession. Because you have chosen to abide by this code of conduct, you put your duty to the patient ahead of any other duty's you may feel you have because of your personal values.

All of which brings us back to abortion. Given that Ethics > Patient, we're right back to where we started in our discussion of the ethics of abortion. Since elective abortion is the killing of one developing human at the request of a fully developed human, it's easy to see how at least some Docs are going to have a problem with it. And, since Ethics > Patient, those Docs have solid grounds upon which to refuse to refer.

And this is when your confusion between ethics and values comes into play. Your values (your beliefs) tell you that abortion is wrong. But the code of conduct of the medical proffession requires that you provide the standard of care to your patients, and is some cases an abortion is standard of care. In these situations your duty to your patient trumps your duty to yourself and your values and you do what is obligated by the code of conduct which is save your patients life. When an abortion is not standard of care (i.e. an elective abortion) the code of conduct does not require you to violate your own values (beliefs).

If your values (beliefs) are so strong that you feel like you would be emotionally unable to provide a standard of care abortion, the issue isn't with the patient or procedure, its with your values which is the baggage that every physician totes around and tries not to bring to the bedside. Its ok if you don't think you'll be able to leave this baggage behind, your human and you can't be perfect, but you should consider this when you choose your specialty so that you won't ever be the provider who is put in the position of needing to give an emergent standard of care abortion to save a patients life. I don't forsee anyone in medical school forcing you to do a procedure that made you very uncomfortable because of your values, but once you were the provider you would have certain obligations under the code of conduct.

 

[Wanna_B_Scutty]

But I do think that you are confusing ethics with values. Ethics are a standard of conduct, whereas values are attitudes and beliefs. Ethics are standardized for a proffession, whereas values are personal and differ with cultural and religious backgrounds. So when acting within the code of conduct of your proffession, your number one duty is to the patient. You don't have a duty to the ethics, you have simply agreed to abide by them by entering the proffession. Because you have chosen to abide by this code of conduct, you put your duty to the patient ahead of any other duty's you may feel you have because of your personal values.

For Chinese doctors, the ethics "standardized for the profession" appear to allow for political prisoner transplants. (*disclaimer* I don't happen to have a Chinese Code of Medical Ethics handy right now )
For the sake of argument, let us assume that such a transplant is the standard of care for those who can afford it in China. If this were the case, would you refer? Mustn't you "put your duty to the patient above any other duties you may feel you have because of your personal values?"

But I do think that you are confusing ethics with values. Ethics are a standard of conduct, whereas values are attitudes and beliefs. Ethics are standardized for a proffession, whereas values are personal and differ with cultural and religious backgrounds... The code of conduct of the medical proffession requires that you provide the standard of care to your patients, and is some cases an abortion is standard of care. In these situations your duty to your patient trumps your duty to yourself and your values and you do what is obligated by the code of conduct which is save your patients life.

Which means the ethical thing to do in China is to refer. Right?

Of course not. There does come a point at which it is possible to have something called "my ethics." Ethics may be definied as both "The rules or standards governing the conduct of a person or the members of a profession" AND "A theory or a system of moral values" (consult your friendly dictionary). The great thinkers of medical ethics have now decided to redefine "ethics" as #1 only. This is a really clever move, as it allows ethicists to state that in order to be ethical one must follow their code. Likewise, anyone who does not follow their code is unethical. It's a sneaky, sneaky semantic move and I'm not a fan.

Your values (your beliefs) tell you that abortion is wrong. But the code of conduct of the medical proffession requires that you provide the standard of care to your patients, and is some cases an abortion is standard of care... If your values (beliefs) are so strong that you feel like you would be emotionally unable to provide a standard of care abortion, the issue isn't with the patient or procedure, its with your values which is the baggage that every physician totes around and tries not to bring to the bedside.

But now you're putting words into my mouth (well... into my avatar ) that I didn't say. As I mentioned at least 2 times in this thread, I would perform the abortion for the ectopic pregnancy. Certainly, I noted my initial cognitive dissonance about the physical act of aborting the fetus (though tiredmom's post about profound developmental abnormalities put those concerns to rest), but I never once indicated that I would deviate from the standard of care in that situation. Rather, this thread got a little off topic a while back, resulting in a discussion of elective abortion.

 

[snoozer]

For Chinese doctors, the ethics "standardized for the profession" appear to allow for political prisoner transplants. (*disclaimer* I don't happen to have a Chinese Code of Medical Ethics handy right now )
For the sake of argument, let us assume that such a transplant is the standard of care for those who can afford it in China. If this were the case, would you refer? Mustn't you "put your duty to the patient above any other duties you may feel you have because of your personal values?"


Which means the ethical thing to do in China is to refer. Right?

Of course not. There does come a point at which it is possible to have something called "my ethics-" that is, there must be a point at which you can decide the published professional code is suspect.


But now you're putting words into my mouth (well... into my avatar ) that I didn't say. As I mentioned at least 2 times in this thread, I would perform the abortion for the ectopic pregnancy. Certainly, I noted my initial cognitive dissonance about the physical act of aborting the fetus (though tiredmom's post about profound developmental abnormalities put those concerns to rest), but I never once indicated that I would deviate from the standard of care in that situation. Rather, this thread got a little off topic a while back, resulting in a discussion of elective abortion.

Just to clear things up, you're helping stay on topic by bringing in the China transplant thing... a totally relevant and incredibly similar (please note the drooling w/ sarcasm) idea, RIGHT?

I think psipsina makes a great argument even if she didn't recall that you, yourself, would be willing to perform the procedure in an ectopic pregnancy.

And FRANKLY, I think you keep pushing psipsina to answer your questions about the transplant issues because in some fallible logic of yours, that it relates to abortion and letting your feelings get in the way. And I don't know if that's the case for her, but from whatI've seen it does look pretty cut and dry. You're practicing in China and if the standard of care is to refer, you follow standard of care. If the standard of care is to make up your own mind, hey... then you're right it does boil down to just whatever the heck you feel like doing that day. It depends in large part, on where you practice. Obviously that's a part of the reason why you get an MD in the US and you practice here or if you move to another country you have to retake their boards and maybe pass their ethics exams as well. Cause they could be different!

And the bottom line is, if you use your professional status and power, which you will have if a patient comes to you and knows only you as her physician to deny her a referral to someone who can provide her with care she feels she needs, then you are using your status as a physician to attempt to force political beliefs on others. Good job wanna be scutty.

 

[Wanna_B_Scutty]

And the bottom line is, if you use your professional status and power, which you will have if a patient comes to you and knows only you as her physician to deny her a referral to someone who can provide her with care she feels she needs, then you are using your status as a physician to attempt to force political beliefs on others. Good job wanna be scutty.

Nope, actually I'm exercising my Legal Rights (see law below). I thought you were really big into letting people exercise their Legal Rights, no matter what others may think of them?

1995 Medical Training Nondiscrimination Act
(a) IN GENERAL- The Federal Government, and any State that receives Federal financial assistance, may not subject any health care entity to discrimination on the basis that--
`(1) the entity refuses to undergo training in the performance of induced abortions, to provide such training, to perform such abortions, or to provide referrals for such abortions;
`(2) the entity refuses to make arrangements for any of the activities specified in paragraph (1); or
`(3) the entity attends (or attended) a postgraduate physician training program, or any other program of training in the health professions, that does not (or did not) require, provide or arrange for training in the performance of induced abortions, or make arrangements for the provision of such training.

 

[psipsina]

Just to clear things up, you're helping stay on topic by bringing in the China transplant thing... a totally relevant and incredibly similar (please note the drooling w/ sarcasm) idea, RIGHT?

I think psipsina makes a great argument even if she didn't recall that you, yourself, would be willing to perform the procedure in an ectopic pregnancy.

And FRANKLY, I think you keep pushing psipsina to answer your questions about the transplant issues because in some fallible logic of yours, that it relates to abortion and letting your feelings get in the way. And I don't know if that's the case for her, but from whatI've seen it does look pretty cut and dry. You're practicing in China and if the standard of care is to refer, you follow standard of care. If the standard of care is to make up your own mind, hey... then you're right it does boil down to just whatever the heck you feel like doing that day. It depends in large part, on where you practice. Obviously that's a part of the reason why you get an MD in the US and you practice here or if you move to another country you have to retake their boards and maybe pass their ethics exams as well. Cause they could be different!

And the bottom line is, if you use your professional status and power, which you will have if a patient comes to you and knows only you as her physician to deny her a referral to someone who can provide her with care she feels she needs, then you are using your status as a physician to attempt to force political beliefs on others. Good job wanna be scutty.

The chinese nonvoluntary organ donor example we were discussing involved a US physican "doing some oversees work" which I took to mean medical mission volutneering ala doctors without borders. In that case, since my role would be as a US physician, I believe I would be bound by the ethical guidlines of US physicians. Also the patient who needs a kidney transplant isn't emergent so there isn't an issue of abandonment if they need to seek out a Chinese physician who could make that referal within his ethical guidelines. I personally would never become a physician within a system that I had moral objections to, so I would never sign up to be a physician in a system that allowed nonvoluntary organ donors within their ethical guidelines. If for some reason I did I would certainly be obligated to abide by those ethical guidlines.

I apologize if I lost track of your exact position scutty, I am but a humble befuddled MS1 6 days out from an exam, so stuff happens. I just knew that you were somewhere in the spectrum of the pro life future doctor and therefore tried to cover that spectrum in the discussion of value and ethics and duty. Please forgive my transgression.

 

[snoozer]

Nope, actually I'm exercising my Legal Rights (see law below). I thought you were really big into letting people exercise their Legal Rights, no matter what others may think of them?

1995 Medical Training Nondiscrimination Act
(a) IN GENERAL- The Federal Government, and any State that receives Federal financial assistance, may not subject any health care entity to discrimination on the basis that--
`(1) the entity refuses to undergo training in the performance of induced abortions, to provide such training, to perform such abortions, or to provide referrals for such abortions;
`(2) the entity refuses to make arrangements for any of the activities specified in paragraph (1); or
`(3) the entity attends (or attended) a postgraduate physician training program, or any other program of training in the health professions, that does not (or did not) require, provide or arrange for training in the performance of induced abortions, or make arrangements for the provision of such training.

Legality and ethics are not the same. Did I not say that you should follow the code of ETHICS and laws in China if you are practicing medicine in CHINA? Did I not say that's the EXACT reason if you get your MD in the US, you practice in the US?

Just like it's legal to report (here I'm following your move and going into a totally irrelevant but equally emotionally charged topic) illegal aliens, does it mean you should ethically as an MD report your illegal alien patients?

Legality =/= to ethics. and Yes you may well be exercising your rights, but I think it's more a right to freedom of speech as the bottom line than some ethical standard set up by the board that signs your license.

 

[psipsina]

Nope, actually I'm exercising my Legal Rights (see law below). I thought you were really big into letting people exercise their Legal Rights, no matter what others may think of them?

1995 Medical Training Nondiscrimination Act
(a) IN GENERAL- The Federal Government, and any State that receives Federal financial assistance, may not subject any health care entity to discrimination on the basis that--
`(1) the entity refuses to undergo training in the performance of induced abortions, to provide such training, to perform such abortions, or to provide referrals for such abortions;
`(2) the entity refuses to make arrangements for any of the activities specified in paragraph (1); or
`(3) the entity attends (or attended) a postgraduate physician training program, or any other program of training in the health professions, that does not (or did not) require, provide or arrange for training in the performance of induced abortions, or make arrangements for the provision of such training.

No one has said that you have to refer for elective abortions. Which is what this law is talking about. Saving a woman with a ruptured tubal pregnancy isn't even considered as an abortion within the medical community. There is no way for the fetus to survive and so its considered saving the mother from the ramifications of a spontaneous abortion. The abortion is caused by the fact that the fetus is in the tube, not by the actions of the physician. If you do nothing the fetus dies (and so does the mother). Therefore you are not performing an abortion. The debate is the physicians duty to save the mother despite their personal values that define the procedure as an abortion.

 

[snoozer]

Nope, actually I'm exercising my Legal Rights (see law below). I thought you were really big into letting people exercise their Legal Rights, no matter what others may think of them?

1995 Medical Training Nondiscrimination Act
(a) IN GENERAL- The Federal Government, and any State that receives Federal financial assistance, may not subject any health care entity to discrimination on the basis that--
`(1) the entity refuses to undergo training in the performance of induced abortions, to provide such training, to perform such abortions, or to provide referrals for such abortions;
`(2) the entity refuses to make arrangements for any of the activities specified in paragraph (1); or
`(3) the entity attends (or attended) a postgraduate physician training program, or any other program of training in the health professions, that does not (or did not) require, provide or arrange for training in the performance of induced abortions, or make arrangements for the provision of such training.

In my entire response, I never said what you were doing was illegal. And you're right, people have the right to exercise their rights. I don't think however, that they get to hide behind those rights in the effort to push their own agendas and beliefs on other people and then call themselves being "ethical". I think psipsina is right, "ethics" are governed by a board the helps you set up and obtain your license. "values" are what you are expressing when you refuse to give your patient a referral for an abortion or even if you pressure your patient into an abortion. Both sides of the coin, equally unethical, even if in both situations the physicians are following their values and staying within their legal rights.

 

[Wanna_B_Scutty]

I just knew that you were somewhere in the spectrum of the pro life future doctor and therefore tried to cover that spectrum in the discussion of value and ethics and duty. Please forgive my transgression.

Forgiven.

Here was my response regarding values vs. ethics. As you'll note, my response centers around a challenge of the definition of ethics that you're currently using:

There does come a point at which it is possible to have something called "my ethics." Ethics may be definied as both "The rules or standards governing the conduct of a person or the members of a profession" AND "A theory or a system of moral values" (consult your friendly dictionary). The great thinkers of medical ethics have now decided to redefine "ethics" as #1 only. This is a really clever move, as it allows ethicists to state that in order to be ethical one must follow their code. Likewise, anyone who does not follow their code is unethical. It's a sneaky, sneaky semantic move and I'm not a fan.

 

[psipsina]

Here was my response regarding values vs. ethics. As you'll note, my response centers around a challenge of the definition of ethics that you're currently using:
There does come a point at which it is possible to have something called "my ethics." Ethics may be definied as both "The rules or standards governing the conduct of a person or the members of a profession" AND "A theory or a system of moral values" (consult your friendly dictionary). The great thinkers of medical ethics have now decided to redefine "ethics" as #1 only. This is a really clever move, as it allows ethicists to state that in order to be ethical one must follow their code. Likewise, anyone who does not follow their code is unethical. It's a sneaky, sneaky semantic move and I'm not a fan.

There is certainly a code of conduct that you as lay person scutty use to to guide your day to day behavior. This code of conduct is based on your values. It could change from day to day with your mood or over your lifetime as your beliefs evolve with you. The idea of medical ethics is that its a code of conduct that is clearly defined that every physician follows in their role as a physician. This is what makes being a physician a proffession as opposed to just a job. It is similar to a lawyer who follows a different code of conduct, but may at times have to stray from their personal values i.e. when they would otherwise tell someone what they hear in lawyer-client confidential situations. They too are proffessionals. The cool thing is that when you join the proffession you can become one of the people who contributes to this code of conduct by joining ethics boards and comittees. Of course it is easier to choose a proffession that lines up with your personal values, because then there is never this tugg to step outside your proffessional duties. This is one of the reasons I chose medicine, because it jives with what I already believed. If you chose to enter medicine when this is not the case you need to understand that you are agreeing to act within this code of conduct in your role as a physician even when it does go against your values and therefore your actions if you were just a lay person. You have extra responsibilities that a lay person does not.

If every physician followed their own personal value system it would be chaos. What if a physician decided that doctor patient confidentiality just didn't feel right that day because as a lay person they believe that someone's HIV status should be public knowledge, and so they breach that confidentiality? That patient would feel betrayed and if this type of event occurred enough patients would stop trusting physicians to whatever minimal extent they still do. Its part of the bargain, you come in hear and take off all your clothes and tell me your intimate secrets, knowing that by my being your physician I have agreed to a certain code of conduct that you can expect me to adhere to. If they couldn't trust in that the doctor patient relationship would crumble.

 

[OncoCaP]

psipsina -- If I understand you correctly, I agree with you.

Maybe part of the back & forth argument is that there could be a conflict between two ethical considerations.

Wiki has a nice article on Medical Ethics ... see if you agree: (and you can update it if you don't and have the time) http://en.wikipedia.org/wiki/Medical_ethics
"Medical ethics is the study of moral values as they apply to medicine. In many cases, moral values can be in conflict, and ethical crises can result.

...
"Writers about medical ethics have suggested many methods to help resolve conflicts involving medical ethics. Sometimes, no good solution to a dilemma in medical ethics exists, and occasionally, the values of the medical community (i.e., the hospital and its staff) conflict with the values of the individual patient, family, or larger non-medical community.

Values in Medical Ethics
Six of the values that commonly apply to medical ethics discussions are:

Beneficence - a practitioner should act in the best interest of the patient. (Salus aegroti suprema lex.)
Non-maleficence - "first, do no harm" (primum non nocere).
Autonomy - the patient has the right to refuse or choose their treatment. (Voluntas aegroti suprema lex.)
Justice - concerns the distribution of scarce health resources, and the decision of who gets what treatment.
Dignity - the patient (and the person treating the patient) have the right to dignity.
Truthfulness and honesty - the concept of informed consent has increased in importance since the historical events of the Nuremberg trials and Tuskegee Syphilis Study

"Values such as these do not give answers as to how to handle a particular situation, but provide a useful framework for understanding conflicts. Conflicts in ethical values lead to ethical dilemmas. Many times these conflicts exist between the patient and family, and the medical care providers. Conflicts can also arise between health care providers, or among family members. For example, the principles of autonomy and beneficence clash when patients refuse life-saving blood transfusion, and truth-telling was not emphasized to a large extent before the HIV era.

(read more at wiki if you want)
*************
Something like abortion can brings different values in medical ethics into conflict (at least for physicians who consider the unborn child as needing protections that must be weighed against other issues, such as imminent threat to the mother's life may ultimately be the deciding factor).

An ectopic pregnancy seems like rather simple case in many ways: The unborn child almost certainly cannot survive (barring the more or less miraculous). The mother almost certainly cannot survive either. The ethical solution is to save one life terminate the pregnancy. I can't imagine a physician having an ethical or moral objection to this.

Things get more complicated, of course, if there are other problems, such as the pregnant mother's blood pressure cannot be controlled, her kidneys are failing, etc. It's less clear-cut in my mind than the ectopic pregnancy case even though the proper course of action may be the same.

To me a lot of this comes down to how do you view the unborn child (embryo). If the physician's view is out of step with that of the patient and, for that matter, the community, we have a problem. To put it another way, do you view the unborn child similarly to an infant, with similar rights or not? This comes up in other questions, such as different methods of obtaining fetal stem cells for various potential therapies.

Taking this question about the medical ethics of abortion to a rather touchy extreme, even if our country or another country legalized infanticide (heaven forbid), it wouldn't mean that it was now ethical to engage in such a practice as a physician even if the patient and community thought it was ok if the infant was unhealthy, the stress of caring for the child posed health problems for the mother, etc. Similarly, for a pro-life physician, although abortion is legal, the health and life of the unborn child must still be ethically and morally considered and weighed against other factors. When you get down to the details, there always seems to be a significant amount of interpretation and judgment going on. Physicians are not of one mind when it comes to the more difficult these ethical questions and may even be out of step with a community's wishes. In my opinion, the best we can do is to know what aspects of ethics are more or less worked out and where we can thus proceed with confidence and potential trouble spots where more caution and perhaps additional input and consultation may be necessary (having a process of working out conflicts). It seems like there are good systems in place to deal with ethical conflicts if the physician and/or patient have a concern.

 

[kylek044]

The op stated that he would have trouble treating a patient with an ectopic pregnancy if it meant terminating the life of the fetus. That to me implies that he's not merely unwilling to provide elective abortions. There's a big difference. No one is saying that people who are pro-life shouldn't go into ob/gyn. However, people who are unwilling to perform what is considered the standard of care for a medical condition probably shouldn't go into the specialty where that procedure would come up.

I guess that raises the question if abortions should be considered "standard care." I mean, look at the Hippocratic Oath:"I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art."

 

[stiffany]

I guess that raises the question if abortions should be considered "standard care." I mean, look at the Hippocratic Oath:"I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art."

Some schools have actually taken out the text that forbids physicans from performing abortions from the original Hippocratic Oath. One of the things that I think is important to consider with this change is the fact that, like medical treatment, ethical considerations do change over time. Even in the lifetimes of some/all of the people on this board, certain things that were done without regard for morality (like the Tuskegee trials up until I think 1971 or '73 or the testing of pharmaceuticals in developing countries without providing the normal standard of care afforded in this country alongside them - happened throughout the '90s) are now acknowledged as not only immoral but also a violation of ethics. Plus, as has already been harped on in this thread, there's a difference between elective abortion and the termination of a nonviable, life-threatening tubal pregnancy.

Also extending props to psipsina and snoozer for some great responses about ethics versus personal mortality, societal norms, et cetera.

 

[Wanna_B_Scutty]

You're practicing in China and if the standard of care is to refer, you follow standard of care.

Are you actually saying that you'd refer for an organ transplant cut from a political prisoner just because the standard of care told you to?!?!

Oh my god. That is most horrifying thing I've ever heard.

May I suggest that you have a look at the wiki article referenced by OncoCaP? Despite the thoughtless gruel you may have been fed that simply says "following the rules we give you is ethical and failing to follow those rules is unethical," we are not mindless automatons doing whatever the rules say and always without questioning. At least... I'm not. There are, after all, medical crises in ethics. And all sides will agree that abortion constitutes an ethical crisis.

This is particularly true since, as stiffany pointed out, ethical standards change over tme. I'm sure you recall that in the beginning of this century, the distribution of birth control was unethical. Would you have refused to give someone the Pill if you'd been an MD at that time? Even more importantly, the birth contol example is revelatory in that it shows us that professional codes are often more informed by politics thatn they are by ethics- two related but distinct entities. Thus, professional codes, however much they might like to set themselves up as defining ethics, are always suspect.

And yes, this is relevant to the thread. The issue at hand is basically: what is ethics? Is "ethics" simply synonymous with a professional code? If so, you are quite right that ethics would be doing whatever the code says. However, as OncoCaP's most recent posting points out, it can sometimes be ethical to not follow the code just like it can be unethical to follow it. This is revelant because it reveals that anyone failing to follow the "refer" code is not automatically rendered unethical.

 

[kylek044]

ethical considerations do change over time.

Ethical considerations? I guess it depends on where you get your ethics and beliefs from. I don't think God pulled a "just kidding" between then and now.

Edit: I don't mean to sound rude, but that is as plainly and bluntly as I could put it. In fact, it seems that we share many of the same beliefs (I saw the link to prolife.liberals.com)

 

[psipsina]

Are you actually saying that you'd refer for an organ transplant cut from a political prisoner just because the standard of care told you to?!?!

If you made the choice to practice in a system of medicine where this was part of the code of conduct then you would be obliged to practice within this code of conduct. I don't think he was saying he would actually do this, because like me he would probably never agree to practice in such a system. You have a choice, no one forces you to join a proffession, but by joining you effectively agree to operating within that proffession's code of conduct. If the code of conduct changes at some point you are always free to leave that proffession. If you disobey the code of conduct then they are free to kick you out too (i.e. take away your license).

 

[psipsina]

Ethical considerations? I guess it depends on where you get your ethics and beliefs from. I don't think God pulled a "just kidding" between then and now.

Edit: I don't mean to sound rude, but that is as plainly and bluntly as I could put it. In fact, it seems that we share many of the same beliefs (I saw the link to prolife.liberals.com)

Ethics does not equal morals and therefore does not equal the mandate of god. Ethics is the code of conduct that humans operate under. These codes of conduct can be based on morals and values, but they are not equivalent. As people's beliefs have changed throughout history, the codes of conduct that reflect these beliefs have also changed. Also new ethical dilemmas come constantly for which we have to decide what is the ethical response thereby adding to our code of conduct. An example is the number of issues having to deal with HIV patients that never existed before the 80s. A person has a personal code of conduct that is based on their own personal beliefs, and for you this might in fact equal the word of your god. For me it reflects my beliefs based in western science and the teachings of the buddah, so my personal code of ethics probably looks really different from yours. But both of us, as practicing physicians in the US allopathic system, agree to operate within a code of ethics that has been standardized for all physicians, decided by physicians, reflecting the beliefs of the majority in our proffession. This is to standardize what a patient can expect within the doctor patient relationship to try and strengthen their trust in that realationship. Occassionaly we add to and change this code to try and improve this relationship and to reflect the ever changing beliefs of humanity.