Ectopic Pregnancy Surgery / Abortion

[chocolate-e]

Here is an interesting thought. If life begins at fertilization (the position held by some), then the resulting single cell zygote would be considered to be a single human life (according to those that hold that viewpoint). Correct?

However, when that single human life begins to blastulate it may split at some point, spontaneously dividing into two or three or more separate embryos that may then go on to develop into 2 or 3 or more separate embryos/fetuses/children. Now, did this single individual life split into 3 lives (spontaneous production of new individuals)? Are the 3 lives actually just a division of the one, or are they all considered one life? Or were we perhaps premature in considering the initial zygote/bastocyst an individual life in the context of attributing to it the quality of personhood? If each individual cell has the potentiality to become a separate individual, is the blastocyst in actuality a collection of many potential human lives instead of just one? For simplicity, I have not even begun to try and incoporate the concept of "soul" into this, because then are you dealing with the consideration of soul splitting and so forth? Or even the introduction of new souls merely by the separation of blastomeres?

This is an interesting argument. However, wouldn't another option be that the "person" represented by the original zygote continues after twinning in the form of one of the embryos, and the other twin represents a new "person"--ie, a person whose life, in this frame of reference, began at twinning rather than at conception?

Of course, if twin embryos are presumabed to be equal divisions of the original and alike in every way, it seems a bit strained argue that one represents the original zygote and the other is more of a bud. Yet would also seem a bit strained to think of the blastocyst as "a collection of many potential human lives." Bacteria, after all, reproduce by binary fission, and yet we have no trouble calling a single bacterium a single bacterium, not a collection of many potential bacterial lives. Yet following that line of reasoning, the (pre-twinning) zygote, if attributed personhood at all, would seem to be some sort of interim person ... hmm.

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[OncoCaP]

If I wanted a crock of excuses and nutjob conspiracy theories, I'd finally get that beer with my mailman he's been after.

Wait. Do you think cloning humans isn't possible?

If you have an identical twin you already have a natural clone. I'm not sure what you are getting at. Are you suggesting Dolly is not really a clone?

Here are a couple of simple "lay" articles on human cloning. If you want scientific papers about cloning and what may or may not be possible, I suppose those could be provided to you as well. The article below makes the prediction that we will see a human clone on the evening news within ten years. Whether it's 10 years or 20 years or more really doesn't matter. If you don't think it's possible to clone humans, I wonder why you think it wouldn't be possible.

http://www.howstuffworks.com/human-cloning1.htm
http://en.wikipedia.org/wiki/Panos_Zavos
http://www.zavos.org/index.html
"In January 2001, a small consortium of scientists led by Panayiotis Zavos, a former University of Kentucky professor, and Italian researcher Severino Antinori said that they planned to clone a human in the next two years. At about the same time, the New York Post reported a story about an American couple who planned to pay $500,000 to Las Vegas-based Clonaid for a clone of their deceased infant daughter.
These scientists may be chasing glory in the name of science. Whatever their motivation, it's likely that we will see the first cloned human baby appear on the evening news in the next decade. Scientists have shown that current cloning techniques work on animals, but only rarely do they succeed in creating a cloned embryo that makes it through birth.

If human cloning proceeds, one method scientists can use is somatic cell nuclear transfer, which is the same procedure that was used to create Dolly the sheep. Somatic cell nuclear transfer begins when doctors take the egg from a donor and remove the nucleus of the egg, creating an enucleated egg. A cell, which contains DNA, is then taken from the person who is being cloned. The enucleated egg is then fused together with the cloning subject's cell using electricity. This creates an embryo, which is implanted into a surrogate mother through in vitro fertilization. If the procedure is successful, then the surrogate mother will give birth to a baby that is a clone of the cloning subject at the end of a normal gestation period. Of course, the success rate is only about one or two out of 100 embryos. It took 277 attempts to create Dolly.

http://www.zavos.org/library/RBM_simpson.htm
Toward scientific discussion of human reproductive cloning
Joe Leigh Simpson
Baylor College of Medicine, Houston, Texas, USA
Correspondence: e-mail: [email protected]

Science advances in time honoured ways. First, an investigator generates a hypothesis and then proposes experiments. Concurrently, ethics of the proposed research must also be considered, based on principles of beneficence. Do benefits outweigh risks, for society as well as for individuals? Will the research be conducted under the aegis of the appropriate oversight, Institutional Review Boards in the United States? Next follows the actual study, its publication and eventual validation through replication. Ideally, scientists, individuals, and society synchronize these time-honoured sequences. However, in reproductive medicine we are often accused of deviating. Promising clinical advances are said to be incorporated into practice without prior ethical deliberation. Conversely, others in society would, strictly on ethical grounds, proscribe many advances beneficial to patients. A considerable minority still disagrees with women exercising any reproductive choices, undergoing prenatal genetic diagnosis or availing themselves of assisted reproduction treatment. Many would seem quite happy to turn the reproductive clock back half a century.

The predictable effect of attempting to ban or criminalize reproductive cloning is to drive investigators underground, and cause patients to become complicit. Paradoxically, the result is to hide the science, rather than have it conducted under a spotlight that would generate public confidence. Zavos' (2003) note could have the salutary effect of helping lead us out of this scientific imbroglio. ...

http://imgen.bcm.tmc.edu/molgen/facultyaz/simpson.html
Joe Leigh Simpson, M.D.
Professor, Departments of Obstetrics & Gynecology and Molecular and Human Genetics

M.D., Duke University School of Medicine, 1968
Intern in Pediatrics, The New York Hospital, 1969
Resident in Obstetrics and Gynecology, The New York Hospital, 1973
Fellow in Obstetrics and Gynecology, Cornell University Medical College, 1973

 

[Northerner]

Wait. Do you think cloning humans isn't possible?

If you have an identical twin you already have a natural clone. I'm not sure what you are getting at. Are you suggesting Dolly is not really a clone?

Here are a couple of simple "lay" articles on human cloning. If you want scientific papers about cloning and what may or may not be possible, I suppose those could be provided to you as well. The article below makes the prediction that we will see a human clone on the evening news within ten years. Whether it's 10 years or 20 years or more really doesn't matter. If you don't think it's possible to clone humans, I wonder why you think it wouldn't be possible.

http://www.howstuffworks.com/human-cloning1.htm
http://en.wikipedia.org/wiki/Panos_Zavos
http://www.zavos.org/index.html
"In January 2001, a small consortium of scientists led by Panayiotis Zavos, a former University of Kentucky professor, and Italian researcher Severino Antinori said that they planned to clone a human in the next two years. At about the same time, the New York Post reported a story about an American couple who planned to pay $500,000 to Las Vegas-based Clonaid for a clone of their deceased infant daughter.
These scientists may be chasing glory in the name of science. Whatever their motivation, it's likely that we will see the first cloned human baby appear on the evening news in the next decade. Scientists have shown that current cloning techniques work on animals, but only rarely do they succeed in creating a cloned embryo that makes it through birth.

If human cloning proceeds, one method scientists can use is somatic cell nuclear transfer, which is the same procedure that was used to create Dolly the sheep. Somatic cell nuclear transfer begins when doctors take the egg from a donor and remove the nucleus of the egg, creating an enucleated egg. A cell, which contains DNA, is then taken from the person who is being cloned. The enucleated egg is then fused together with the cloning subject's cell using electricity. This creates an embryo, which is implanted into a surrogate mother through in vitro fertilization. If the procedure is successful, then the surrogate mother will give birth to a baby that is a clone of the cloning subject at the end of a normal gestation period. Of course, the success rate is only about one or two out of 100 embryos. It took 277 attempts to create Dolly.

http://www.zavos.org/library/RBM_simpson.htm
Toward scientific discussion of human reproductive cloning
Joe Leigh Simpson
Baylor College of Medicine, Houston, Texas, USA
Correspondence: e-mail: [email protected]

Science advances in time honoured ways. First, an investigator generates a hypothesis and then proposes experiments. Concurrently, ethics of the proposed research must also be considered, based on principles of beneficence. Do benefits outweigh risks, for society as well as for individuals? Will the research be conducted under the aegis of the appropriate oversight, Institutional Review Boards in the United States? Next follows the actual study, its publication and eventual validation through replication. Ideally, scientists, individuals, and society synchronize these time-honoured sequences. However, in reproductive medicine we are often accused of deviating. Promising clinical advances are said to be incorporated into practice without prior ethical deliberation. Conversely, others in society would, strictly on ethical grounds, proscribe many advances beneficial to patients. A considerable minority still disagrees with women exercising any reproductive choices, undergoing prenatal genetic diagnosis or availing themselves of assisted reproduction treatment. Many would seem quite happy to turn the reproductive clock back half a century.

The predictable effect of attempting to ban or criminalize reproductive cloning is to drive investigators underground, and cause patients to become complicit. Paradoxically, the result is to hide the science, rather than have it conducted under a spotlight that would generate public confidence. Zavos’ (2003) note could have the salutary effect of helping lead us out of this scientific imbroglio. ...

http://imgen.bcm.tmc.edu/molgen/facultyaz/simpson.html
Joe Leigh Simpson, M.D.
Professor, Departments of Obstetrics & Gynecology and Molecular and Human Genetics

M.D., Duke University School of Medicine, 1968
Intern in Pediatrics, The New York Hospital, 1969
Resident in Obstetrics and Gynecology, The New York Hospital, 1973
Fellow in Obstetrics and Gynecology, Cornell University Medical College, 1973

You're a piece of work.

 

[kelaskov]

I would consider it to be one human individual until there was some feature (whether chemical or physical) that would allow us to distinguish one human from another. For example, separate blastulas would be a physical feature.

I'm interested in hearing your beliefs regarding abnormal embryos that develop into anencephalic fetuses or partial molar pregnancies? Do you believe that these are individual human beings? Would you agree with and support/provide a referral for a patient seeking to abort an anencephalic fetus?

 

[kelaskov]

I refuse to believe you cannot understand me, so I'm going to bed after this response:
What I said was that referring a woman to an abortionist is more than the simple dissemination of information. Rather, it constitutes the of teaching of a woman precisely how to kill the fetus within her. And, as I have said, I will not teach someone how to kill.


A women faced with an unplanned pregnancy is caught in an unavoidable and profound conflict of interest. How can she contemplate the moral significance of killing her fetus in an unbiased manner when the proximity of the situation is literally right within her? So no, I cannot trust that a woman will make the right decision when her ability to look out for the welfare of her fetus faces a conflict of interest with her own personal desires.


If by "choice" you mean fetus-killing, then I can only wish that by "witholding information" I could save the life of her fetus. The more likely scenario is that she can figure out how to use a phonebook. Nevertheless, if my unwillingness to refer actually did save her fetus from the fate of the ones in the above videos, I would indeed be joyful.

If she could use a phonebook than she could probably google, "home abortion " or something similar and figure out a way to self abort. If you had to choose- would you rather a woman does a home abortion on herself have a safe abortion done by a physician?

My choice is simple- I'll offer my patient information on the safe and legal procedure and trust she'll make the best decision. I choose life everytime.

 

[OncoCaP]

I'm interested in hearing your beliefs regarding abnormal embryos that develop into anencephalic fetuses or partial molar pregnancies? Do you believe that these are individual human beings? Would you agree with and support/provide a referral for a patient seeking to abort an anencephalic fetus?

This is a tough one for me because many years ago I used to think that even the lives of many people with serious brain injuries or disabilities were not worth living. I had a teenage boy in a youth group whose mother slammed his head repeatedly against fixtures in a bathtub when he was a young child causing a serious permanent brain injury. I remember thinking this kid's life just isn't worth living. Similarly as I walked around nursing homes, I would see this mass of humanity in delirium ... in a life that I just couldn't see standing one day of. After having worked with both this teenage boy and many elderly patients, I have a new respect for life, even when the brain is not functioning correctly. I could say more about this if you are interested. My point is that I now respect life even if it involves living with a severe brain injury. That said, I understand that there are some cases that are medically futile and it is the best of difficult decisions to take steps that end the life. I'm not suggesting that it would be ok to strangle such a patient, but turning off life support and withdrawing a feeding tube would be acceptable to me if the patient will never (re)gain consciousness, for example.

Here's what wiki says about anencephalic fetuses:
http://en.wikipedia.org/wiki/Anencephaly
"Anencephaly is a cephalic disorder that results from a neural tube defect that occurs when the cephalic (head) end of the neural tube fails to close, usually between the 23rd and 26th day of pregnancy, resulting in the absence of a major portion of the brain, skull, and scalp. Infants with this disorder are born without a forebrain, the largest part of the brain consisting mainly of the cerebral hemispheres (which include the isocortex, which is responsible for higher level cognition, i.e., thinking). The remaining brain tissue is often exposed - not covered by bone or skin.

"Infants born with anencephaly are usually blind, deaf, unconscious, and unable to feel pain. Although some individuals with anencephaly may be born with a rudimentary brainstem, which controls autonomic and regulatory function, the lack of a functioning cerebrum permanently rules out the possibility of ever gaining consciousness. Reflex actions such as breathing and responses to sound or touch may occur. The disorder is one of the most common disorders of the fetal central nervous system.

...

"There is no cure or standard treatment for anencephaly and the prognosis for affected individuals is poor. Most anencephalic babies do not survive birth, accounting for 55% of non-aborted cases. If the infant is not stillborn, then he or she will usually die within a few hours or days after birth from cardiorespiratory arrest.

This is indeed a terrible situation for the family. There is no hope of this child ever gaining consciousness

http://www3.georgetown.edu/research/nrcbl/hsbioethics/units/unit1_3.html
"Anencephalic babies are ... not technically brain dead. Yet there is general consensus that heroic measures should not be used to keep them alive. In fact, anencephaly may be one of the few medical conditions that all doctors agree is futile to treat.

Even many Catholics (I'm not Catholic) agree that anencephalic babies can be aborted for many valid reasons:

http://www.lifeissues.net/writers/val/val_05cathethicists.html
"Dr. T. Murphy Goodwin, assistant professor of maternal-fetal medicine at the University of Southern California, writing in the March 1996 issue of Ethics and Medics, notes that "Even in Catholic institutions, early induction has been proposed as a humane option with the reasoning that the proportionate benefit to the fetus of living a few more weeks is outweighed by almost any burden on the mother and the family." But, he counters, "there is rarely any physical risk to the mother of carrying through an anencephalic gestation compared to early induction (of labor)" "Early induction before viability ," Dr. Goodwin wrote, "hastens the death of the child for the purpose of ending the parents' grief."

So, yes, I would refer in this case with the understanding that termination of pregnancy is ethical considering the circumstances here. The child is still a human, but that is not the only consideration. Some parents have carried anencephalic fetuses to term and then donated the organs; however, I would refer for an abortion in this case. I'm not suggesting that this is "no brainer" decision. Just as in the ectopic pregnancy, there are factors besides the child's life that should be considered, in the anencephalic fetus' case, referral for an abortion would be ethical in my opinion. This is the best that I can sort out this issue. Maybe someone has a better idea.

By way of contrast, I would not refer for an abortion in the case of Trisomy 21.

 

[OncoCaP]

If she could use a phonebook than she could probably google, "home abortion " or something similar and figure out a way to self abort. If you had to choose- would you rather a woman does a home abortion on herself have a safe abortion done by a physician?

My choice is simple- I'll offer my patient information on the safe and legal procedure and trust she'll make the best decision. I choose life everytime.

Kelaskov, Are there cases where you would not trust the mother ... I mean would you never question a mother's decision about the life of her child under any circumstances?

 

[Wanna_B_Scutty]

Hi WanBna__Scutty and OncoCap
I am in difficulty understanding your responses because of your tendency to answer a medical (scientific) question with explanations coming from different disciplines. I think there's the confusion.

We have different theo-philosophical backgrounds cultures and belief which makes any answer subjective. But if you or your associates can explain your point scientifically, then it would be again, helpful.

I hope you would understand why the scientific perspective is preferred because we are in the first place in a medical forum

I am truly having difficulty understanding you. Neither of us has brought theo-philospohical beliefs into this at all. My own opposition to abortion stems from my beliefs in (1) nonviolence (2) non-malfeasance and (3) a true "right to life" for each human being. Not once have I mentioned God- and for the record, I am not Catholic and neither is Onc.

Can you, perhaps, isolate areas of our arguments that seem theophilosophical? That might help me out. But for now, I can't address your concerns because I've read through the posts and I truly can't find anything that even hints at opposition to abortion based on religious values. A belief in the rights of the fetus and in nonviolent solutions to unplanned pregnancy is not exclusive to traditionally religious types. Perhaps the explainations espoused by the members of these organizatins might be more clear and/or eloqent than I:
Athiests & Agnostics: http://www.godlessprolifers.org/
Gays & Lesbians: http://www.plagal.org/
Social Justice Advocates: http://www.consistent-life.org/
Feminists: http://www.feministsforlife.org/
Pagans: http://www.geocities.com/CapitolHill/Parliament/8383/index.html

 

[Wanna_B_Scutty]

Dead fetuses aren't really that hard to come by in medschool. We have them for embryo just like the cadavers for gross . . .you really don't need to take a trip if all you want to see is some fetuses. Tulane even has a museum of them I believe.

I was just ribbing kelaskov a bit. Planned Parenthood and other institutions of its ilk insist upon high levels of secrecy. Kelaskov knows that PP would never allow such a thing.

However, I have always believed that if abortion really isn't that bad, PP should make videotapes of abortions at every pregnancy stage easily available, complete with 4-D ultrasound of the "before" fetus, 4-D ultrasound of the fetus being dismembered, and live footage of the dead fetus afterward. That way women could watch these video tapes and make truly informed decisions.

I will certainly say that, as a physician, I would be happy to show any such Planned Parenthood produced video to a client considering an abortion. I truly believe that, if most women could see for themselves how violent abortion really is, they would make life-affirming choices for their little ones.

 

[psipsina]

I was just ribbing kelaskov a bit. Planned Parenthood and other institutions of its ilk insist upon high levels of secrecy. Kelaskov knows that PP would never allow such a thing.

However, I have always believed that if abortion really isn't that bad, PP should make videotapes of abortions at every pregnancy stage easily available, complete with 4-D ultrasound of the "before" fetus, 4-D ultrasound of the fetus being dismembered, and live footage of the dead fetus afterward. That way women could watch these video tapes and make truly informed decisions.

I will certainly say that, as a physician, I would be happy to show any such Planned Parenthood produced video to a client considering an abortion. I truly believe that, if most women could see for themselves how violent abortion really is, they would make life-affirming choices for their little ones.

I dunno, I think many patients would opt against any invasive procedure if they watched a video of what was going to happen ahead of time. I think that grossing them out is not informing them. It reminds me of discussions we've had about the language that we use to describe a procedure to a patient when doing an informed consent. Do you say "would you like us to use CPR to resucitate you in the event that you stop breathing or your heart stops beating, this is what we would do" . . . or do you say "If you stop breathing we are going to pound on your chest probably breaking some ribs and then we are going to shock you repeatedly which will really hurt, is that ok?". Its wrong to frame a medical procedure in a certain way to try to get the patient to make the choice you want them to make. Showing them violent videos of any invasive procedure seems like you would be doing just this.

I think that while its definitely legal for you not to refer, it would be unethical for you to try and influence you patients decision based on your own morality. Thats called paternalism. In the present patient autonomous model of medicine we are supposed to present the patient with all the options and then let them decide. We can give them medical advice, i.e. I think you have the best shot at a full recovery with surgery X rather than surgery Y despite the longer recovery period, but we can't advise them based on personal values, i.e. I think your mom should be left on the vent because killing your mom is morally reprehensible. I think that as someone who is unwilling to provide abortions and unwilling to refer (i.e. find them someone who will) you are still obligated to let the patient know that the option is availible for them to pursue but that it is against your personal values to do it for them. Not telling them it exists or trying to scare them is ethically troublesome.

 

[Wanna_B_Scutty]

I dunno, I think many patients would opt against any invasive procedure if they watched a video of what was going to happen ahead of time. I think that grossing them out is not informing them. It reminds me of discussions we've had about the language that we use to describe a procedure to a patient when doing an informed consent. Do you say "would you like us to use CPR to resucitate you in the event that you stop breathing or your heart stops beating, this is what we would do" . . . or do you say "If you stop breathing we are going to pound on your chest probably breaking some ribs and then we are going to shock you repeatedly which will really hurt, is that ok?". Its wrong to frame a medical procedure in a certain way to try to get the patient to make the choice you want them to make. Showing them violent videos of any invasive procedure seems like you would be doing just this.

Regarding video, I profoundly disagree with your assertion that patients who watch a videotape of an invasive procedure would be unwilling to proceed with it. It is not at all uncommon for the patients in my teaching hospital to actively seek out video of the procedures that they will undergo. Some find such video on the internet, others watch specials on the Health/Discovery Channel, and some (generally the more educated ones) have even been known to ask their surgeon if they could have some O.R. footage. Now, I don't think we gave out the non-public O.R. footage due to HIPAA and liability concerns... but they still asked! Along this vein, I am simply suggesting that if PP and organizations like it truly wish to "educate" women about their options, then they should make video like this available for those women who wish to see precisely what will happen to them and their fetuses.

I agree that framing is a difficult issue and that the manner in which we frame things has a profound impact on people's opinions of them. But therein lies the beauty of the videotape. There is no real "framing." What you see is what you get.

I think that while its definitely legal for you not to refer, it would be unethical for you to try and influence you patients decision based on your own morality. Thats called paternalism. In the present patient autonomous model of medicine we are supposed to present the patient with all the options and then let them decide. We can give them medical advice, i.e. I think you have the best shot at a full recovery with surgery X rather than surgery Y despite the longer recovery period, but we can't advise them based on personal values, i.e. I think your mom should be left on the vent because killing your mom is morally reprehensible. I think that as someone who is unwilling to provide abortions and unwilling to refer (i.e. find them someone who will) you are still obligated to let the patient know that the option is availible for them to pursue but that it is against your personal values to do it for them. Not telling them it exists or trying to scare them is ethically troublesome.

I was never planning on pretending abortion "doesn't exist." Quite frankly, that'd be straight up impossible. It's probably the most nationally devisive issue of our generation, and everybody talks about it! Nevertheless, while I will not try to scare them, I can also assure you that I will be frank about both fetal development and about the nature of what happens to the fetus during abortion.

Now as to the "framing" problems in frankness, this is where a video would be so helpful. A video would allow me to tell my patient, "I have some moral concerns about abortion that may influence my discussion of the subject with you. Thus, if you prefer, I can simply show you what happens during abortion on a silent video." In this way, I could educate my patient about abortion without anyone being able to argue that my framing skills were at all paternalistic.

For that matter, don't you think that deciding on patients' behalf not to provide videotape is paternalistic? Don't you think we should have as many educational options available as possible about abortion so that patients can have the opportunity to learn as much about it as they want?

 

[OncoCaP]

Regarding video, I profoundly disagree with your assertion that patients who watch a videotape of an invasive procedure would be unwilling to proceed with it. It is not at all uncommon for the patients in my teaching hospital to actively seek out video of the procedures that they will undergo. Some find such video on the internet, others watch specials on the Health/Discovery Channel, and some (generally the more educated ones) have even been known to ask their surgeon if they could have some O.R. footage. Now, I don't think we gave out the non-public O.R. footage due to HIPAA and liability concerns... but they still asked! Along this vein, I am simply suggesting that if PP and organizations like it truly wish to "educate" women about their options, then they should make video like this available for those women who wish to see precisely what will happen to them and their fetuses.

I agree that framing is a difficult issue and that the manner in which we frame things has a profound impact on people's opinions of them. But therein lies the beauty of the videotape. There is no real "framing." What you see is what you get.

I was never planning on pretending abortion "doesn't exist." Quite frankly, that'd be straight up impossible. It's probably the most nationally devisive issue of our generation, and everybody talks about it! Nevertheless, while I will not try to scare them, I can also assure you that I will be frank about both fetal development and about the nature of what happens to the fetus during abortion.

Now as to the "framing" problems in frankness, this is where a video would be so helpful. A video would allow me to tell my patient, "I have some moral concerns about abortion that may influence my discussion of the subject with you. Thus, if you prefer, I can simply show you what happens during abortion on a silent video." In this way, I could educate my patient about abortion without anyone being able to argue that my framing skills were at all paternalistic.

For that matter, don't you think that deciding on patients' behalf not to provide videotape is paternalistic? Don't you think we should have as many educational options available as possible about abortion so that patients can have the opportunity to learn as much about it as they want?

It seems like it would be nice to be able to provide the patient with objective information as to why a mother may or may not want to have an abortion and to explain fetal development and alternatives to abortion. An ultrasound where the mother could see her own child would probably be appropriate as well. However, I'm not sure how much time I will have to be able to spend with my patients and I'm still trying to learn about the role of the physician in the physician-patient relationship. There are a lot of unknowns here for me because I'm just getting started on this path. I have had a number of physicians give me very personal advice on a number of subjects, on everything from career advice to health advice. They weren't just giving me information and say 'you decide." Almost without fail, the had an opinion and recommendation. However, I realize that not every physician-patient relationship is the same.

Maybe I'm missing something here, but it seems like it would be paternalistic not to make all information, including videos of the procedure and information about fetal development available to a patient who was considering an abortion. After all, we want to make sure our patients are informed. At the same time, I'm not sure that I would get into an argument with them about it. I would do my best to be kind but informative. To the extent that it was ethical and appropriate, I would explain my own views on the subject. This is a touchy subject and I would approach it with great care if I had to speak to a patient about it (I certainly wouldn't be nearly as casual about it as I am being on this anonymous board). Then again, I would be kind and careful if I suspected my patient was abusing their 4-year-old child but I wouldn't be ambivalent about it; in that case I would have a legal responsibility to do something about it. From a pro-life perspective, abortion is lethal child abuse (physician assisted), although the law does not offer the same protections to unborn children with respect to abuse. The analogy that pro-life groups like to make is what if you were a physician in Nazi Germany in the 1940s? For example, experiments conducted on humans (who were considered subhuman by Nazis much as unborn children are often considered subhuman today) that would not be legal today but were legal back then. Would you participate in such studies that harmed one group of humans so that a better medical understanding could be gained? It would be legal, but not ethical. I personally would not participate in such experiments no matter how much we could learn from them. Similarly, it would be unethical for a physician to work on development of the gas chambers even though the Nazi government thought it would benefit to the country. It's sad that the most dangerous place in America is the mother's womb.

 

[evade]

http://www.howstuffworks.com/human-cloning1.htm
http://en.wikipedia.org/wiki/Panos_Zavos
http://www.zavos.org/index.html
http://www.zavos.org/library/RBM_simpson.htm

OncoCaP, I strongly suggest that if you're going to argue any point (even here!), you consider using nonbiased and reliable resources. Any fool can edit Wikipedia; any fool can make a web page. Would you like to learn about male pregnancy? See? There's a web page on it, so it must be true!

Citing these webpages, as well as the grossly inaccurate anti-abortion ones you have cited earlier in this thread, will not assist you in making your point or convincing anyone. Rather, people will brush you off. Good sources are scientific and unbiased. PubMed is a really good start. And if you can't find reliable, unbiased sources that say what you want to say, then maybe what you think is true really isn't.

 

[psipsina]

Regarding video, I profoundly disagree with your assertion that patients who watch a videotape of an invasive procedure would be unwilling to proceed with it. It is not at all uncommon for the patients in my teaching hospital to actively seek out video of the procedures that they will undergo. Some find such video on the internet, others watch specials on the Health/Discovery Channel, and some (generally the more educated ones) have even been known to ask their surgeon if they could have some O.R. footage. Now, I don't think we gave out the non-public O.R. footage due to HIPAA and liability concerns... but they still asked! Along this vein, I am simply suggesting that if PP and organizations like it truly wish to "educate" women about their options, then they should make video like this available for those women who wish to see precisely what will happen to them and their fetuses.

I agree that framing is a difficult issue and that the manner in which we frame things has a profound impact on people's opinions of them. But therein lies the beauty of the videotape. There is no real "framing." What you see is what you get.

I was never planning on pretending abortion "doesn't exist." Quite frankly, that'd be straight up impossible. It's probably the most nationally devisive issue of our generation, and everybody talks about it! Nevertheless, while I will not try to scare them, I can also assure you that I will be frank about both fetal development and about the nature of what happens to the fetus during abortion.

Now as to the "framing" problems in frankness, this is where a video would be so helpful. A video would allow me to tell my patient, "I have some moral concerns about abortion that may influence my discussion of the subject with you. Thus, if you prefer, I can simply show you what happens during abortion on a silent video." In this way, I could educate my patient about abortion without anyone being able to argue that my framing skills were at all paternalistic.

For that matter, don't you think that deciding on patients' behalf not to provide videotape is paternalistic? Don't you think we should have as many educational options available as possible about abortion so that patients can have the opportunity to learn as much about it as they want?

I think if a patient actively requests OR footage, and you can provide it without infringing upon the HIPPA rights of another patient thats a whole other story and I wouldn't be opposed to it. However, I don't think that a video is necessary for a patient to really understand a procedure, I am willing to describe things that are going to happen (in a non biased way, i.e. we will do some chest compressions, these are the risks of chest compressions, rather than I'm going to pound on your chest and break your ribs) and answer any questions about all of the availible procedures until the patient feels that they fully understand all of their options. That is the definition of respecting a patients autonomy. I know quite a few people personally who would have great difficulty watching surgical procedures on video and it would cause an emotional reaction (rather than a gain in information about it).Trying to evoke emotional responses in patients to alter their choices is paternalistic.

 

[acute2]

Can you, perhaps, isolate areas of our arguments that seem theophilosophical? That might help me out.

Ok, I will underline theo-philosophical terms/concepts which you inject in between medical scientifc arguments you've raised in an attempt to address their posts:

1. "I hold that it is immoral to do harm to any individual human life without that human's consent"

2. "I believe in self-determination. That is to say, each human life should be allowed to live out its existence freely without its life being jeopardized by another, more powerful human."

3. "None of us is truly autonomous. And anyway, why should lack of autonomy necessarily indicate lack of worth or moral status? It is a logical non-sequitor."

I cannot remember anything like those in Developmental Anatomy.
Neither anyone of my professors while discussing Embryology was picking bits and pieces of other concepts borrowed from philosophy or what to prove a point in clinical correlations like the one in question now.

And thank you for the links you have posted

Your positions are welcome. I only find it to be some kind of a pseudo-science extrapolation. You start by discussing scientific medical factoids in the early stages of pregnancy as we've learned in Embryology, but end up with a conclusion of beliefs.

 

[45408]

Ok, I will underline theo-philosophical terms/concepts which you inject in between medical scientifc arguments you've raised in an attempt to address their posts:

Those don't seem like ethical points to you? I don't see how you can argue that ethics doesn't have its place in medical school, so I don't see why an ethical discussion on SDN is out of place.

 

[OncoCaP]

OncoCaP, I strongly suggest that if you're going to argue any point (even here!), you consider using nonbiased and reliable resources. Any fool can edit Wikipedia; any fool can make a web page. Would you like to learn about male pregnancy? See? There's a web page on it, so it must be true!

Citing these webpages, as well as the grossly inaccurate anti-abortion ones you have cited earlier in this thread, will not assist you in making your point or convincing anyone. Rather, people will brush you off. Good sources are scientific and unbiased. PubMed is a really good start. And if you can't find reliable, unbiased sources that say what you want to say, then maybe what you think is true really isn't.

Yes, you have a good point. I'll be more careful about my sources next time. I guess since I have you "on the line" ... do you think that human cloning can be done and if so, do you think we will see it in our lifetimes. You don't need to cite PubMed. I'm just curious about your personal opinion.

Here is a more respected source:

NATURE REVIEWS | GENETICS VOLUME 4 | NOVEMBER 2003 | 855
There are continued claims of attempts to clone humans using nuclear transfer, despite the
serious problems that have been encountered in cloning other mammals. It is known that
epigenetic and genetic mechanisms are involved in clone failure, but we still do not know exactly
how. Human reproductive cloning is unethical, but the production of cells from cloned embryos
could offer many potential benefits. So, can human cloning be made safe?

"The first mammal to be successfully cloned from a differentiated
animal cell was ‘Dolly' the sheep1.Although there
had been previous cloning successes using embryonic
cells, the unique feature of Dolly was that she was the first
mammal to be cloned from an adult somatic (body) cell.
The success of this SOMATIC CELL NUCLEAR TRANSFER (SCNT;
FIG. 1) proved that the differentiation of adult cells (in this
case, derived from the mammary epithelium) does not
involve the irreversible modification of genetic material
that is required for the development of the animal to
term.Dolly survived until six years of age and ultimately
succumbed to a virally induced lung tumour.
Despite this, and other subsequent successes with a
range of adult cells, SCNT cloning is still inefficient.
Clones are lost from the earliest developmental stages and
throughout pregnancy. Some clones that survive to term
die prematurely as a result of a range of pathologies.
Despite this, some healthy animals have been born.
However, we still do not know the main factors that distinguish
these ‘cloning lottery'winners from clones that
do not develop normally.
The precise mechanisms that are involved in the
abortions, neonatal deaths and postnatal diseases that
are associated with cloning have previously been given
much less emphasis than the development of the
nuclear-transfer technology itself.As non-reproductive
cloning (BOX 1) is likely to provide stem cells for research
and therapy, understanding what causes cloning problems
is highly relevant. Of even greater concern are the
continued investigations by some scientists of the possibility
of human reproductive cloning2 (BOX 1).

 

[evade]

I think if a patient actively requests OR footage, and you can provide it without infringing upon the HIPPA rights of another patient thats a whole other story and I wouldn't be opposed to it. However, I don't think that a video is necessary for a patient to really understand a procedure, I am willing to describe things that are going to happen (in a non biased way, i.e. we will do some chest compressions, these are the risks of chest compressions, rather than I'm going to pound on your chest and break your ribs) and answer any questions about all of the availible procedures until the patient feels that they fully understand all of their options. That is the definition of respecting a patients autonomy. I know quite a few people personally who would have great difficulty watching surgical procedures on video and it would cause an emotional reaction (rather than a gain in information about it).Trying to evoke emotional responses in patients to alter their choices is paternalistic.

I completely and totally agree with this. My brother would be one of those people who would have great difficulty watching a surgical procedure. He even has difficulty when I discuss needles or blood. If he were to come down with appendicitis and needed an appendectomy, showing him a video of the surgery would achieve one thing: he would faint. He would faint if you inserted an IV line and he weren't lying down. He can't handle blood, needles, and gore. Would there really be a purpose to showing him a video? He would still need the appendectomy. Showing him a bloody video would be unnecessarily cruel.

For my brother, as well as LOTS of other people, it doesn't matter if the blood is coming from a procedure you consider amoral, or a critical procedure that they will die if they don't get. Blood is blood, and they have a powerful psychological reaction to it. Scutty, it sounds to me like you want to use this to manipulate your patients, and that is completely amoral and unprofessional.

Every woman who obtains an abortion is counseled on the procedure and its potential complications. They are told that it is a destructive procedure, that the fetus is destroyed by the procedure (often in those VERY words). No one is denying that fact. The patients understand this; if they have a problem with it, they can walk out. Further, I can guarantee that each and every one of these patients has had photos of torn-up fetuses shoved in their faces. What on Earth would a video achieve, Scutty, besides punishing your patients because they're doing something you disagree with?

 

[evade]

Yes, you have a good point. I'll be more careful about my sources next time. I guess since I have you "on the line" ... do you think that human cloning can be done and if so, do you think we will see it in our lifetimes. You don't need to cite PubMed. I'm just curious about your personal opinion.

Hmm, that's a good question. I personally don't think we'll see it until some of the problems with cloning are ironed out. As is, we don't know what to do about the problem of shrinking telomeres which, as was the case with Dolly the sheep, caused premature aging. Cloning a human would cause quite enough of a stir; I can't imagine anyone would dare to clone a human who would have a truncated life span like that. No matter if anyone thinks cloning humans is ethical, I think we can all agree that bringing someone into the world that will age and die prematurely solely because of our intervention is not ethical.

If they do fix the telomere problem, and if no other problems are found in animals, yes, I think someone will try to clone a human, just to gain the notoriety (or infamy, perhaps) and say they've done it. I think it will bring on a storm of controversy even greater than that for stem cell research. I think whoever clones a human will lose their status, their funding, and the cloning of humans will be banned on a worldwide scale. I don't think it will ever catch on.

In sum, yes we can clone a human, but it will have the same problems as Dolly. No, I don't think we'll see a fix to the telomere/premature aging problem in our lifetimes. Thus, I do doubt that we'll see human cloning in our lifetime.

 

[OncoCaP]

I completely and totally agree with this. My brother would be one of those people who would have great difficulty watching a surgical procedure. He even has difficulty when I discuss needles or blood. If he were to come down with appendicitis and needed an appendectomy, showing him a video of the surgery would achieve one thing: he would faint. He would faint if you inserted an IV line and he weren't lying down. He can't handle blood, needles, and gore. Would there really be a purpose to showing him a video? He would still need the appendectomy. Showing him a bloody video would be unnecessarily cruel.

For my brother, as well as LOTS of other people, it doesn't matter if the blood is coming from a procedure you consider amoral, or a critical procedure that they will die if they don't get. Blood is blood, and they have a powerful psychological reaction to it. Scutty, it sounds to me like you want to use this to manipulate your patients, and that is completely amoral and unprofessional.

Every woman who obtains an abortion is counseled on the procedure and its potential complications. They are told that it is a destructive procedure, that the fetus is destroyed by the procedure (often in those VERY words). No one is denying that fact. The patients understand this; if they have a problem with it, they can walk out. Further, I can guarantee that each and every one of these patients has had photos of torn-up fetuses shoved in their faces. What on Earth would a video achieve, Scutty, besides punishing your patients because they're doing something you disagree with?

Would you make information such as a sonogram or videos of fetal development available (rather than telling them to get one or to watch them). As in, "Here is information about fetal development. You can have a sonogram done if you would like to better understand the stage of development of your child. Here is information about the abortion procedures. Be forewarned it is rather graphic, so if you don't like to watch surgical procedures or don't like the sight of blood, you won't want to watch this."

 

[evade]

Would you make information such as a sonogram or videos of fetal development available (rather than telling them to get one or to watch them). As in, "Here is information about fetal development. You can have a sonogram done if you would like to better understand the stage of development of your child. Here is information about the abortion procedures. Be forewarned it is rather graphic, so if you don't like to watch surgical procedures or don't like the sight of blood, you won't want to watch this."

All women have a sono done before having an abortion. It's usually done a few days beforehand, at the consultation apointment, and it's done to accurately date the pregnancy. Women are often given the option to look if they'd like. Some do. Some don't. They do have the option. They are given all the information about risks of the procedure, told what the procedure involves, and they have the opportunity to ask any questions about fetal development, the procedure itself, or anything else they might want to know.

That said, why would you give a patient pictures or videos of a bloody procedure? I've already stated my position on this. I would never give a patient who's about to have a coronary artery bypass graft a video of surgeons cracking open a patient's chest. That's in exceptionally poor taste. Most non-medical folks would be disgusted by it. Videos or pictures of abortion procedures are NO different. Besides, as I already mentioned, every single patient who walks into a clinic has seen the goriest pictures that the anti-abortion folks could dredge up.

 

[kelaskov]

Would you make information such as a sonogram or videos of fetal development available (rather than telling them to get one or to watch them). As in, "Here is information about fetal development. You can have a sonogram done if you would like to better understand the stage of development of your child. Here is information about the abortion procedures. Be forewarned it is rather graphic, so if you don't like to watch surgical procedures or don't like the sight of blood, you won't want to watch this."

Since starting med school, every patient I've seen who's had an elective abortion has also had a vaginal ultrasound and was offered the opportunity to see the ultrasound. Some choose to see their ultrasounds and fetuses, some don't but I've never seen anyone change her mind after seeing their own ultrasound/fetus.

 

[OncoCaP]

All women have a sono done before having an abortion. It's usually done a few days beforehand, at the consultation apointment, and it's done to accurately date the pregnancy. Women are often given the option to look if they'd like. Some do. Some don't. They do have the option. They are given all the information about risks of the procedure, told what the procedure involves, and they have the opportunity to ask any questions about fetal development, the procedure itself, or anything else they might want to know.

That said, why would you give a patient pictures or videos of a bloody procedure? I've already stated my position on this. I would never give a patient who's about to have a coronary artery bypass graft a video of surgeons cracking open a patient's chest. That's in exceptionally poor taste. Most non-medical folks would be disgusted by it. Videos or pictures of abortion procedures are NO different. Besides, as I already mentioned, every single patient who walks into a clinic has seen the goriest pictures that the anti-abortion folks could dredge up.

This makes sense to me. Thanks for taking the time to explain it.

 

[OncoCaP]

Since starting med school, every patient I've seen who's had an elective abortion has also had a vaginal ultrasound and was offered the opportunity to see the ultrasound. Some choose to see their ultrasounds and fetuses, some don't but I've never seen anyone change her mind after seeing their own ultrasound/fetus.

I'm glad that these are done. It provides more information for the mother. Although I don't agree with the decision to have an elective abortion, I'm glad that the mother is given the opportunity to view a sonogram if she so chooses.

 

[kelaskov]

Kelaskov, Are there cases where you would not trust the mother ... I mean would you never question a mother's decision about the life of her child under any circumstances?

I don't equate a fetus and a child or a fetus and a woman. I see a fetus as potential human life which uses a woman's body to grow...and not a seperate mini-human living inside/seperate from a woman.

I trust that most women can make their own decisions regarding their bodies, including during pregnancy. Unfortunatly, many people make poor health choices, even while pregnant with a fetus that they intend to carry to term. Even if I didn't trust someone to chose the "healthiest" decision, I still can't make those decisions for them...ie. I can't strap down a pregnant woman to prevent her from drinking..although I know the fetus may be born with FAS.

Just like I can't force a person to donate an organ, blood, etc.-though their donation may save another's life- I also can't force a woman to donate her body and organs to the potential human growing inside her- if she is doesn't want to.

Parents make poor health decisions regarding themselves and their children all the time. I'm appalled when I see abused children in the hospital/clinic. It frustrates me when I see the history of child services in the ped. charts yet many are still returned to abusive parents.

 

[OncoCaP]

I don't equate a fetus and a child or a fetus and a woman. I see a fetus as potential human life which uses a woman's body to grow...and not a seperate mini-human living inside/seperate from a woman.

I trust that most women can make their own decisions regarding their bodies, including during pregnancy. Unfortunatly, many people make poor health choices, even while pregnant with a fetus that they intend to carry to term. Even if I didn't trust someone to chose the "healthiest" decision, I still can't make those decisions for them...ie. I can't strap down a pregnant woman to prevent her from drinking..although I know the fetus may be born with FAS.

Just like I can't force a person to donate an organ, blood, etc.-though their donation may save another's life- I also can't force a woman to donate her body and organs to the potential human growing inside her- if she is doesn't want to.

Parents make poor health decisions regarding themselves and their children all the time. I'm appalled when I see abused children in the hospital/clinic. It frustrates me when I see the history of child services in the ped. charts yet many are still returned to abusive parents.

Yeah, I see what you mean. I was pro-choice in my past so I can relate to what you are saying in terms of the life of the unborn child (or fetus as you call it and as it is more properly called from a medical standpoint). As long as people view this little tyke (whatever you call it) as just another growing mass of tissue, it makes it ethically possible to go through with an elective abortion without too many ethical concerns. I would also go a step further and say that even if you viewed the fetus as a human life deserving of many rights, you still may be in favor of elective abortions. After all, most people would agree that not all human life has equal value (comparing say the life of a serial child molester/murderer with that of a reputable and ethical physician, for example). Where the difference seems to come in is on the question that comes up is whether there are situations where it is justified to take another human life. Most people would give examples such as self defense or perhaps in times of war for an infantryman. Closer to healthcare, many people believe in stopping "medically futile" care. Anyway, it's been an interesting discussion, and I appreciate your thoughts. It's not often that I get to chat with a future abortion provider about abortion. These threads on SDN may be my only chance.

 

[RokChalkJayhawk]

I think people have gotten way off track. Those ectopic pregnancies aren't going to become babies--they're going to kill Mom. While I'm not pro-life I don't see how it's possible that anyone would have a problem with removing a fetus that is going to kill a mother.

Now you have two dead bodies rather than one. That just seems irrational.

 

[hilseb]

How does the fetus get nutrition outside of the uterus anyway?

How does a fetus get nutrition when the mom has died from hemorrhage from the rupture?

 

[Keg]

*Jesuses* Consider the thread resurrected.

Today is day 6 of my OB/Gyn rotation - I'm on infertility (IVF clinic), so I thought I was safe from this topic for at least 3 more weeks before my benign surgical gyn rotation. But, alas, I was wrong. There was an emergent case where one of the attendings' patients had a ruptured tubal and was en route to the hospital via ambulance. My resident asked me if I wanted to assist, and I said, "no" - I could tell that she was confused/disappointed. An attending said, "if you have something else you have to do, it's ok," to which I replied, "no, it's not that, it's a moral thing," though I didn't get a chance to get deeper into my objections at this point because the team had to get across campus to the OR. An attending not actively involved with the case talked with me for about 20 minutes after the resident, the fellow, and the sub-I left to perform the removal, and I'm pretty much where I started. I'm pretty sure this is HIPAA safe, but if not, flag me and I'll fix it - the conceptus was 6.x wga with no heartbeat on U/S and the mother had received MTX over the weekend when the ectopic was diagnosed. I didn't feel that this was definitive enough for me to say that this was a non-living being, making me uncomfortable with assisting. In fact, when I was asked to assist and I quickly reviewed the information, realizing that this (to me) was still a living being, I had a gnawing pain in the hypogastric area of my morality eating its way out.

So, in essence, my stammered out "no," to the opportunity to scrub in on this wasn't exactly as eloquent as I had hoped when this issue came up. Per the recommendations of the attending with whom I spoke after the incidence, I'm going to meet with my Dean of Student Affairs to discuss my position and what I can do to assist my team while not compromising my morality, especially on my benign gyn rotation; however, that meeting won't be until next week. Which leaves me waffling over what I should say to my resident tomorrow morning - I want to be completely honest, but at the same time, I want to avoid as many adverse effects from this as possible. I'm just trying to figure out how to get my views across without sounding like a nutjob (even though that may be synonymous with Fundamentalist Christianity for some by definition, anyway). Help?

 

[AmoryBlaine]

*Jesuses* Consider the thread resurrected.

Today is day 6 of my OB/Gyn rotation - I'm on infertility (IVF clinic), so I thought I was safe from this topic for at least 3 more weeks before my benign surgical gyn rotation. But, alas, I was wrong. There was an emergent case where one of the attendings' patients had a ruptured tubal and was en route to the hospital via ambulance. My resident asked me if I wanted to assist, and I said, "no" - I could tell that she was confused/disappointed. An attending said, "if you have something else you have to do, it's ok," to which I replied, "no, it's not that, it's a moral thing," though I didn't get a chance to get deeper into my objections at this point because the team had to get across campus to the OR. An attending not actively involved with the case talked with me for about 20 minutes after the resident, the fellow, and the sub-I left to perform the removal, and I'm pretty much where I started. I'm pretty sure this is HIPAA safe, but if not, flag me and I'll fix it - the conceptus was 6.x wga with no heartbeat on U/S and the mother had received MTX over the weekend when the ectopic was diagnosed. I didn't feel that this was definitive enough for me to say that this was a non-living being, making me uncomfortable with assisting. In fact, when I was asked to assist and I quickly reviewed the information, realizing that this (to me) was still a living being, I had a gnawing pain in the hypogastric area of my morality eating its way out.

So, in essence, my stammered out "no," to the opportunity to scrub in on this wasn't exactly as eloquent as I had hoped when this issue came up. Per the recommendations of the attending with whom I spoke after the incidence, I'm going to meet with my Dean of Student Affairs to discuss my position and what I can do to assist my team while not compromising my morality, especially on my benign gyn rotation; however, that meeting won't be until next week. Which leaves me waffling over what I should say to my resident tomorrow morning - I want to be completely honest, but at the same time, I want to avoid as many adverse effects from this as possible. I'm just trying to figure out how to get my views across without sounding like a nutjob (even though that may be synonymous with Fundamentalist Christianity for some by definition, anyway). Help?

Probably should have started a new thread but I will bite.

The Catholic Church* is by far the most stringent in its definition of what is "abortion." Many otherwise strict Protestant sects** will allow contraception, not Rome.

When it comes to ectopics the Catholic Church does a little fancy hand-waving: surgery to remove the "diseased tissue" in which the conceptus is planted is ok b/c it is an act to preserve the life of the mother and the death of the conceptus is a secondary action. It's morally alot like killing an intruder in your home to protect your family -- you are presumably thinking, "I want to protect my children/spouse" and not "DIE PUNK!!!"

See the difference? I would check with a trusted pastor, it is very unlikely that your brand of Xianity is against ectopic surgery. If this is indeed the case you might want to think about your stance a little bit. I'm not trying to flame you but you probably have a mountain of theology and a chorus of religious leaders that disagree with you.


* views not necessarily shared by AB
** see above

 

[Keg]

Probably should have started a new thread but I will bite.

The Catholic Church* is by far the most stringent in its definition of what is "abortion." Many otherwise strict Protestant sects** will allow contraception, not Rome.

When it comes to ectopics the Catholic Church does a little fancy hand-waving: surgery to remove the "diseased tissue" in which the conceptus is planted is ok b/c it is an act to preserve the life of the mother and the death of the conceptus is a secondary action. It's morally alot like killing an intruder in your home to protect your family -- you are presumably thinking, "I want to protect my children/spouse" and not "DIE PUNK!!!"

See the difference? I would check with a trusted pastor, it is very unlikely that your brand of Xianity is against ectopic surgery. If this is indeed the case you might want to think about your stance a little bit. I'm not trying to flame you but you probably have a mountain of theology and a chorus of religious leaders that disagree with you.


* views not necessarily shared by AB
** see above

I'm not entirely sure that that invocation of double effect isn't smoke and mirrors... salpingostomy is bad, salpingectomy is OK. Both have the same effect, and it's not as if there's a chance that the child will survive removal. At least with other uses of this ethical structure, there's a chance that the harm will not come to fruition... not here. But I read a statement from the Catholic Church talking about this.

Using another website, it was advocated that unless the fetus has stopped showing signs of life (if once present) or never shows signs of life (once they would be expected in 100% of viable pregnancies), removal becomes an option. I tend to agree with this. But I don't know that the absence of fetal heart motion at 6 weeks says that this is not a viable life - by 9 weeks, from what I understand, heart motion will be seen if the pregnancy is viable. So this instance is in the grey area for me.

The statement of faith for my denomination says that life begins at conception and should be protected as an individual life. Ectopic pregnancies are not specifically mentioned. Regrettably, I don't have any way to contact a trusted pastor at this point, and probably won't until I go home for a visit (first chance will be at Thanksgiving, probably). Hence, I lay out my ethical dilemma to the faceless masses and hope for some sort of guidance.

 

[smq123]

Using another website, it was advocated that unless the fetus has stopped showing signs of life (if once present) or never shows signs of life (once they would be expected in 100% of viable pregnancies), removal becomes an option. But I don't know that the absence of fetal heart motion at 6 weeks says that this is not a viable life - by 9 weeks, from what I understand, heart motion will be seen if the pregnancy is viable. So this instance is in the grey area for me.

It doesn't matter whether the ectopic fetus has a heartbeat or not. It will almost never be viable, particularly if it's not located in the tube. The few exceptions that you mentioned in your very first post (over a year ago) are SUCH rare exceptions that you can't count on them happening to the patient that is right in front of you.

And, as a physician, it is unethical to have your patient keep that ectopic pregnancy in the wild hopes that it would lead to a full-grown baby. It violates the principle of "First, do no harm," since the mother would almost certainly die once that tube bursts.

 

[Keg]

It doesn't matter whether the ectopic fetus has a heartbeat or not. It will almost never be viable, particularly if it's not located in the tube. The few exceptions that you mentioned in your very first post (over a year ago) are SUCH rare exceptions that you can't count on them happening to the patient that is right in front of you.

And, as a physician, it is unethical to have your patient keep that ectopic pregnancy in the wild hopes that it would lead to a full-grown baby. It violates the principle of "First, do no harm," since the mother would almost certainly die once that tube bursts.

And expectant, in-house management until the fetus succumbs to the lack of blood flow or advances to the point of a medical emergency is reached is unethical, as well? And I'm not naive enough to think that my patients will all have spontaneous transfers of the fetus to the uterine cavity or the mesentery (where they may stand a chance of surviving until 24wga), but that doesn't change the fact that, to me, the fetus is a living creature with a unique, never-again-to-be-created genome/proteome that was the product of conception - again, in my mind, giving it a soul. As such, I don't feel comfortable terminating such a life, even in the name of preserving that of the mother.

Again, outside of these six weeks of this third year OB/Gyn rotation, I'm going to make an assumption that I shan't have to deal with this again - which may limit my moonlighting as a surgical resident (if I go that route) to well staffed hospitals where I don't have to be the one to perform an emergent salpingectomy, but if that's the price I have to pay to sleep at night, so be it.

 

[smq123]

And expectant, in-house management until the fetus succumbs to the lack of blood flow or advances to the point of a medical emergency is reached is unethical, as well?

There is a good chance that the fetus wouldn't succumb to the lack of blood flow first, without blowing up the Fallopian tube and taking it out, too.

Sitting around and waiting on an ectopic that may burst is poor management - you're increasing the possible morbidity and mortality of the maternal outcome...and for what? For a fetus that is definitely not going to survive?

Waiting around for a small problem to become a potentially REALLY big problem is pretty bad care. Take care of it now, and reduce the risks to the mother.

but that doesn't change the fact that, to me, the fetus is a living creature with a unique, never-again-to-be-created genome/proteome that was the product of conception - again, in my mind, giving it a soul. As such, I don't feel comfortable terminating such a life, even in the name of preserving that of the mother.

Look, I understand where you're coming from. I'm also quite pro-life (for many of the reasons that you've mentioned), and still want to go into OB/gyn. But as a physician (ANY kind of physician), the second you let your personal beliefs interfere with good patient care (or leads you to ignore the currently accepted standard of care), you've let your patients down.

 

[Keg]

The second you let your personal beliefs interfere with good patient care (or leads you to ignore the currently accepted standard of care), you've let your patients down.

Thank you for your response - I'm really not trying to be antagonistic, I'm just trying to think through my stance on this before I'm forced to vocalize it to several people tomorrow. I apologize if I come across as such. But I'm interested in the part that I pulled out in the quotes above - at what point are you obligated to put your mores above the patient's needs? For example, in my mind, for better or for worse, removing a living fetus from a mother - viable or not, salpingostomy or salpingectomy - is murder... am I obligated to doom myself to an eternity of punishment for participating in such an act to potentially extend the mother's life? I don't think it's as clear cut as that, but there has to be some point where one can say, "No, I'm not doing that because it's against my beliefs, even if the patient is asking me to do that." Defining what that, is, however, is another matter entirely.

 

[smq123]

Thank you for your response - I'm really not trying to be antagonistic, I'm just trying to think through my stance on this before I'm forced to vocalize it to several people tomorrow. I apologize if I come across as such.

I also apologize if I sounded antagonistic, too.

But I'm interested in the part that I pulled out in the quotes above - at what point are you obligated to put your mores above the patient's needs?

In my mind, there isn't such a point.

With the exception of turning off life support because a mentally sound patient requested that I do so, I can't imagine ever withholding lifesaving treatment because of my personal beliefs.

If it's not strictly life-saving treatment (i.e. an elective abortion or other elective procedure), then that's when I would start considering whether or not I'm morally comfortable with what the patient is suggesting. Otherwise - I don't think that my morals come into play.

For example, in my mind, for better or for worse, removing a living fetus from a mother - viable or not, salpingostomy or salpingectomy - is murder... am I obligated to doom myself to an eternity of punishment for participating in such an act to potentially extend the mother's life?

In this case, removing the ectopic fetus IS saving the mother's life. The ectopic fetus really didn't have a chance to survive - and letting it hang around the tube a little while longer, while putting the mother's life at increasing risk just for your personal beliefs is, in my mind, really really bad medical care.

As a physician (especially if you were an OB/gyn), your responsibility is NOT just to the ectopic fetus - it's to the mother as well. And you're risking the mother's life for what reason? Just to assuage your own guilt? That's indefensible. What if she bled out because the tube burst? What if she died? How is THAT not murder? Do you really think that God would be okay with letting that happen - you had the means of saving her life, but you didn't take advantage of those means, and she died as a result? What does that accomplish?

I know that's harsh, and I'm sorry. But I honestly think that, while your devotion to your moral beliefs and your religion is admirable, you're missing the bigger picture here. And I have a feeling that your OB/gyn resident is going to say something along the lines of what I said above.

As for what you should say....I'm honestly not sure. I guess....talking about how you feel that life begins at conception (although this is might lead to the dangerous topic of whether or not you can prescribe birth control), and how, to you, that fetus had a soul....maybe it will resonate with them. Maybe.

Good luck. Let us know how the meeting with your resident goes.

 

[Blade28]

Great discussion, you two.

Just to interject here for a sec since we're talking about medical ethics...

As a physician you're meant to serve and do everything you can do advocate for your patient - this means withdrawing care if they're of sound mind and wish to do so; or witholding blood transfusion products if a hemorrhaging patient happens to be a Jehovah's Witness; or refusing to operate (e.g. tumor debulking) on a terminally ill cancer patient because there is no medical/surgical indication.

These are the tenets of medical ethics. You should always strive to do what is ethically sound and should never go against this.

What your MORALS are, however, may be a whole 'nother matter. Does it bother me when I treat a man who has just beaten up his wife and thrown her down the stairs, a man who has a few superficial lacerations from her actions of self-defense? Of course. Do I sew up his lacs anyway? Yes, because it's the ethical thing to do.

Likewise, do I treat the prisoner who's in jail for rape or murder like I do every other patient? Do I offer him the same standard or care? Or do I purposely inflict more pain, give him less analgesia, deny him the same prn meds and basic comforts, refuse to see him when the nurses ask for my help because I feel that his crime is morally reprehensible? Nope. Can't do that. As a physician I took an oath to treat everyone equally, to the best of my ability.

It would be nice to succumb to my moral standards whenever I wanted to. There have been lots of alcoholic cirrhotics that I would have loved to have seen NOT take up a priority spot on the liver transplant list. Ditto with noncompliant renal transplant patients who stop taking their immunosuppressants, reject their kidney, and now automatically get bumped up to the top of the list while waiting for a replacement. Or how about the vasculopath who keeps clotting off his grafts because he won't stop smoking? The atherosclerotic who won't give up McDonald's? The DUI driver who killed an innocent pedestrian but now needs a trauma ex-lap?

Just some food for thought.

 

[OncoCaP]

Thank you for your response - I'm really not trying to be antagonistic, I'm just trying to think through my stance on this before I'm forced to vocalize it to several people tomorrow. I apologize if I come across as such. But I'm interested in the part that I pulled out in the quotes above - at what point are you obligated to put your mores above the patient's needs? For example, in my mind, for better or for worse, removing a living fetus from a mother - viable or not, salpingostomy or salpingectomy - is murder... am I obligated to doom myself to an eternity of punishment for participating in such an act to potentially extend the mother's life? I don't think it's as clear cut as that, but there has to be some point where one can say, "No, I'm not doing that because it's against my beliefs, even if the patient is asking me to do that." Defining what that, is, however, is another matter entirely.

This thread brings back memories . I do not have a problem with these procedures and would do what is necessary to save the mother.

If I was in your shoes (and did have a problem with these procedures, which, again, I don't), I would simplify the matter until I was more sure of my perspective. I would just tell the resident that you do not wish to participate in a procedure that ends another potential human life even if the mother's life is in danger because of personal moral and religious objections that you have. I would not get into all kinds of discussions about this (hold off until you have this all sorted out in your mind). I would listen and be polite and tell them that it's against your religion and that you are not a religious scholar and would be happy to look up any questions that the resident might have. I'm not sure if the resident would try to convince you that you are wrong. I get the impression they are busy creatures and don't want to spend time on stuff like this. If it's against your religion (again, keep it simple and understandable), your instructors aren't going to argue about that. Make it clear what procedures are ok for you to do (hysterectomies, vaginal births, etc.) and what isn't. If I had a doubt, I would just say that it was against my religion and be done with it. In your case, you don't remove human beings from a mother unless they are necrotic or can survive outside the mother; that's a pretty simple rule. I like simplicity when it comes to these things.

 

[Gut Shot]

But I don't know that the absence of fetal heart motion at 6 weeks says that this is not a viable life - by 9 weeks, from what I understand, heart motion will be seen if the pregnancy is viable. So this instance is in the grey area for me.

After a weekend of MTX I think you're pretty safe. Even God would let that one slide.

 

[AmoryBlaine]

And expectant, in-house management until the fetus succumbs to the lack of blood flow or advances to the point of a medical emergency is reached is unethical, as well? And I'm not naive enough to think that my patients will all have spontaneous transfers of the fetus to the uterine cavity or the mesentery (where they may stand a chance of surviving until 24wga), but that doesn't change the fact that, to me, the fetus is a living creature with a unique, never-again-to-be-created genome/proteome that was the product of conception - again, in my mind, giving it a soul. As such, I don't feel comfortable terminating such a life, even in the name of preserving that of the mother.

Again, outside of these six weeks of this third year OB/Gyn rotation, I'm going to make an assumption that I shan't have to deal with this again - which may limit my moonlighting as a surgical resident (if I go that route) to well staffed hospitals where I don't have to be the one to perform an emergent salpingectomy, but if that's the price I have to pay to sleep at night, so be it.

Well, yes. A ruptured ectopic is not a small deal that can be easily dealt with -- women die from these. The chance of viability from this sort of pregnancy is vanishingly rare. So in effect you as the physician would be keeping an otherwise (hopefully) healthy patient in house until a) a miracle happened or b) she had an acute surgical abdomen. That is shaky ethical ground at best.

Like I said, the problem you might encounter here is that no major religious group of which I am aware is behind you (please correct me if I'm wrong). I'm sure that every Ob/Gyn resident in the world has heard of/dealt with a student who didn't want to be involved in ABs but if you are morally opposed to salpingectomy for ectopic expect some raised eyebrows.

 

[aiLoveJuh]

I had an ectopic pregnancy, it's not the same as abortion because I didn't choose for this to happen.

 

[SoCuteMD]

I had an ectopic pregnancy, it's not the same as abortion because I didn't choose for this to happen.

So sorry that happened to you. Hope you are well now!

 

[Blesbok]

do no harm by action or inaction. So, who dies? Mom or the fetus?

In the case of an ectopic pregnancy? Both.

Which would you rather have? One life saved by your actions or both lives lost by your inactions. I think the choice is clear, regardless of religious and moral beliefs.

 

[Keg]

In the case of an ectopic pregnancy? Both.

Which would you rather have? One life saved by your actions or both lives lost by your inactions. I think the choice is clear, regardless of religious and moral beliefs.

Humor me - perhaps a bad analogy, but in my worldview, it's the same. Say you're in a call room with two friends, whom you value equally. A person comes in and hands you a gun, saying, in all seriousness, "Either you shoot and kill one of them, or I'll shoot and kill both of them." Would you kill one to save the other? I wouldn't. I don't want that hanging over my head.

 

[Gut Shot]

I don't want that hanging over my head.

You don't want saving a life hanging over your head? Damn, you're hardcore.

 

[Blesbok]

Humor me - perhaps a bad analogy, but in my worldview, it's the same. Say you're in a call room with two friends, whom you value equally. A person comes in and hands you a gun, saying, in all seriousness, "Either you shoot and kill one of them, or I'll shoot and kill both of them." Would you kill one to save the other? I wouldn't. I don't want that hanging over my head.

So you are really arguing that you would rather watch both a mother and child die from your inactivity rather than save the mother? You should probably avoid medicine.

 

[MrBurns10]

Keg, I hope your discussion with your residents went well. The point is that you're a medical student right now...you're here to learn and to help the team however you can. However, in no way is your presence in an abortion or ectopic pregnancy removal necessary. I think it's perfectly fine to tell your team what you cannot allow yourself to be involved with since you're really not impacting patient care. I think the ethical thing for you to do, however, is to stay away from specialties where you may have to be faced with this and similar dilemmas- OB/GYN, EM, maybe FM come to mind.

 

[smq123]

Humor me - perhaps a bad analogy, but in my worldview, it's the same. Say you're in a call room with two friends, whom you value equally. A person comes in and hands you a gun, saying, in all seriousness, "Either you shoot and kill one of them, or I'll shoot and kill both of them." Would you kill one to save the other? I wouldn't. I don't want that hanging over my head.

This is NOT a good analogy. Because this is NOT the same thing as an ectopic pregnancy.

An ectopic pregnancy is like being in a call room with two friends, whom you value equally. One friend has a terminal illness and is DEFINITELY (barring a major miracle) going to die in the next few days. This friend, however, is holding a knife to the throat of your other friend. If you don't do something, your crazed and dying friend is going to murder your other friend. And you're going to stand back and do nothing? :cry:

No one said that it's an easy decision to make. But, in medicine, you have to do make the hard choices, sometimes, to get good outcomes for your patients. This is one of those instances.

Finally, for at least the rest of this rotation, I'm really asking you to remember that your duty is not just to the fetus! The hard part about OB is that you have two patients, and you have an equal responsibility to both. In this case, that ectopic fetus is long gone - you can't save it. It's going to die in a matter of days, if it hasn't died from the MTX already. But you also have a responsibility to that woman...and you CAN save her life. And you have an obligation to do so, once you're a physician.

P.S. What did your resident say about it today?

 

[45408]

Humor me - perhaps a bad analogy, but in my worldview, it's the same. Say you're in a call room with two friends, whom you value equally. A person comes in and hands you a gun, saying, in all seriousness, "Either you shoot and kill one of them, or I'll shoot and kill both of them." Would you kill one to save the other? I wouldn't. I don't want that hanging over my head.

I also have very strong beliefs about abortion, but I view the removal of an ectopic as saving one life instead of watching two of them die. The fetus is not going to survive, and simply waiting for it to die would be gambling with the mother's life, IMO. It'd be more like the gunman coming in and handing you the gun and saying "If you don't kill me, I'll kill this innocent person and then shoot myself."

 

[bcat85]

I also have very strong beliefs about abortion, but I view the removal of an ectopic as saving one life instead of watching two of them die. The fetus is not going to survive, and simply waiting for it to die would be gambling with the mother's life, IMO. It'd be more like the gunman coming in and handing you the gun and saying "If you don't kill me, I'll kill this innocent person and then shoot myself."

I agree with you prowler. I am a strong opponent of abortion, but an ectopic pregnancy will kill both the mother and the fetus 99.9% of the time if it is not treated. As stated before, even the catholic church supports the ending of an ectopic pregnancy. Let me make this perfectly clear, IF YOU DO NOT TREAT THIS, THEY BOTH WILL DIE. If you treat it, one will live.