Medical ethical questions arising from political bans on abortion

Post by Rebecca Solnit
July 5 at 10:06 PM

*Reality based questions from daily medical practice, from Dr Natalie Gregory

“I am a Fellow of the American College of OBGYN and a graduate of MUSC School of Medicine. I was trained to practice evidence-based medicine. As a Board Certified OBGYN, I am tested with oral and written exams, reviewed by peers, and expected to maintain Continuing Medical Education (CME) in my field of study. I am to use my training to uphold the Hippocratic Oath and obey the laws of our state and our nation while keeping the best interest of the patient as the priority.

I believe the following are not political decisions but rather are private matters between a patient and her physician. Because I have been trained to be prepared for any situation, please consider the following situations and help me to make most appropriate decisions. I have many questions.

1) Ectopic or tubal pregnancy with a fetal heartbeat seen. In this situation, without the possibility of fetal survival, there are 2 options: surgery to remove the pregnancy or medications to stop the growth and thus abort the abnormal gestation. With Senate Bill 1, the standard of care would not be options, however, withholding treatment would be considered malpractice and would be expected to end with hemorrhage, transfusion, loss of fertility or hysterectomy, and possibly death. What should I say to the family? What is the route to obtain permission if she is has internal bleeding and is unstable or unconscious? Can a judge allow it? Is her consent not enough? Will my malpractice insurance company defend me if I disobey the law and remove the tube? What about if I disobey the evidence I have been tested on and the standard of care? Will they continue to insure me? Without malpractice insurance I cannot practice.

2) Molar pregnancy at 9 weeks with fetal heartbeat. This is a genetically abnormal pregnancy with proliferation of placental-type tissue but can be associated with an abnormal fetus, sometimes with a heartbeat. It cannot end with a viable fetus and is genetically abnormal. The standard of care, treatment with a dilation and curettage, would be illegal under Senate Bill 1 and the patient would eventually hemorrhage, require transfusions, lose her uterus and potential for childbearing, and she would die. This is a condition that is curable but not without proper treatment. This bill sets the medical field back decades if not centuries. Do I wait until she hemorrhages, knowing there is no chance of survival of the fetus? Is her life worth less than this pregnancy? Does she not get another chance for a healthy child? Whom shall I contact to obtain approval for this patient’s survival? What if no one answers or the contact is unavailable? I ask because these things happen in the middle of the night.

3) Fetal Anencephaly. This is a condition in which the fetal brain does not form correctly or at all. At times brainstem function can allow a live birth but typically death follows soon after delivery. What do I tell the parents who see the concern on my face when I see the ultrasound? Do I tell them there are no options except waiting for the baby to be born and die? What if she requires a cesarean and suffers complications impairing her fertility? What if she suffers a pulmonary embolism during pregnancy, a known risk? What if she is nearing the end of her reproductive years and wants to try again for a healthy baby but her “clock is running out”? May I offer the standard of care? Is it more humane to end the pregnancy early in the gestation or to experience a neonatal loss? Who gets to make this decision and what are their priorities? Who do I call in the middle of the night? What if she is hemorrhaging and a decision must be made quickly? I take call shifts of 24 hours and my partners and I always have a physician available for our patients. Will there be someone is the legislature available like I am, at any time of day or night? What about Christmas morning? Will there be a hotline or a pager system?

4) Preterm Premature Rupture of Membranes. When this occurs prior to viability or around 23 weeks, the standard of care is to deliver with surgery or induction of labor. Both would be illegal under Senate Bill 1. The alternative is to manage expectantly, the fancy way of saying we let nature take its course. If some fluid reaccumulates, then there is the possibility of staying pregnant long enough for development to continue to viability. If the fluid continues to leak, the fetal lungs will not develop and there is no chance of survival after birth. More likely, an infection will develop that can rapidly spread into the maternal circulation. Treatment with antibiotics is insufficient without delivery as there is poor penetration across the placental barrier. Without delivery, mothers can die of systemic infection. Delivery, however, risks my career. Do I offer delivery, which is the standard of care? What if the fetus still has a heartbeat but the mother is unable to consent? Is the fetal life more precious than maternal life? Do I wait until her blood pressure drops and she can’t respond to me? Whom shall I call to get approval? What are the patient’s rights concerning the confidentiality of her situation? Does HIPAA apply?

5) Cervical cancer diagnosed in a woman with a pre-viable pregnancy. Termination with subsequent treatment of the cancer with surgical removal, chemotherapy and/or radiation provides the best chance of maternal survival. Morbidity and mortality are increased without immediate treatment. Should I tell her she has a better chance of survival if she moved to another state where evidence-based medical decisions are possible? What if she has other children and she is the primary care provider? What is the process for her to secure childcare if she is unable to care for the children while she undergoes palliative therapy? Can her family weigh in on their desire for their loved one to be valued for more than her womb? Who do I call if she has legal questions? Will there be a hotline?

6) Pregnancies that are the result of rape and/or incest. This bill requires the woman to file a police report and allows the hospital to violate HIPAA laws and file a report for her. Her options would be to carry the pregnancy or file a report. What if filing a report means her ex would get arrested and she needs his child support for the other children? What if filing a report means getting taken from your home and placed in foster care at age 17? Many women choose not to file reports and I do not know their reasons. It does not concern me caring for their medical needs. Again, who is on this rape and incest approval committee and how do I reach them 24/7?

I ask that you help guide me to provide the care that you would want for yourself or your wife, your daughter, your granddaughter. Please remember that pregnancy, for women, is a risky endeavor. We risk our lives for this. Respect us enough to know how to navigate our healthcare decisions with our doctors and families. And respect me and my profession enough to allow us to care for our patients without having our hands tied by these laws.”

Sincerely,
Natalie Gregory, MD, FACOG
Mount Pleasant, SC

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