Are decisions made against the wishes of a person, but allegedly for that person’s best interest, the right or ethical thing to do? Are classic ethical dilemmas not those that involve multiple parties, each pursuing what they think is right to the detriment of all other parties involved?
Such ethical dilemmas came to light after I read about a litigation case where a woman came to the hospital in labor and allegedly was coerced into having a surgical procedure. In short, the details are as follows: Having had two prior cesarean sections, Rinat Dray desired to give birth vaginally, but when she arrived at the hospital, doctors quickly concluded that if she continued naturally, not only would she be in danger, but her unborn baby would be in trouble as well. The specific medical indications for the C-section remain confidential, but generally speaking, after a woman has had a C-section and heals, the scar left behind leaves the uterus (where the baby grows) weaker than before. As a result, when attempting a normal delivery after a C-section, the risk of the uterus rupturing—like a weakened balloon popping under excess pressure—is much higher. This is one possible reason to do a C-section after a woman has already had one, and the other possible indications are numerous. The point is a C-section is a surgical procedure that carries its own set of risks, and deciding to do one isn’t like having stitches put on your pinky finger.
Apparently, Mrs. Dray did try to deliver vaginally for a few hours before having the C-section. The medical chart contains a note from the attending physician at the time that documented that the operation was conducted against the will of Mrs. Dray.
In her lawsuit, Mrs. Dray is suing the doctors and the hospital for “improperly substituting their judgment for that of the mother” and “pressuring and threatening” her during the birth of her child.
A thought leader in the field of medical ethics, Dr. Howard Minkoff has written numerous articles on the issue of patient autonomy. He did not comment specifically on the case of Mrs. Dray but did say, “In my worldview, the right to refuse is uncircumscribed … I don’t have a right to put a knife in your belly ever.”
After reading the alleged facts of the case, I proceeded with extreme caution cognizant that in any medical dispute, it is impossible to calculate a fair, objective analysis without having the complete medical record and all other pertinent data. Especially when it comes to articles for newspapers, writers have a tendency to only present facts that persuade the readership in one particular direction.
The first question I would have to ask is this: are the child and mother doing well? Thankfully, both are quite healthy.
The second is this: how can any physician ever be held liable for acting in the best interests of a child, and adhering to the appropriate medical standards, when that child is at the mercy of someone who medically may not be acting in that child’s interests? (Notably, no doctor is infallible, and I can remember a case in training where, despite all the medical information available, everyone [except the patient’s mother] dismissed the unfortunate case of a child with a serious head injury as a “lost cause” and “destined for death” no matter what we did. The result? That child walked out of the hospital and is now doing just fine. Sometimes there’s more than medicine that can heal.)
Medical malpractice normally involves purposeful negligence or a departure from the standard of care on the part of the physician. Superficially, it would seem that neither applies in this case, and if we assume they don’t, should ethical violations ever be penalized? Based on the accusations of her lawyers, that’s what the case of Mrs. Dray essentially amounts to. If the only adult who observes an unattended child playing in the middle of a busy street fails to intervene and that child is subsequently hit by a car, would the adult need to be put on trial? Yes, the lack of action would be morally wrong, but would it also be punishable by force of the law or litigation for an ethical violation? This is a slippery slope to journey down since all of ethics is contextual and subjective. If this case only involved Mrs. Dray, then there would be no issue—if she said no, then that’s final. The problem here is that the unborn child cannot speak for himself, and thus, someone must advocate for the baby and give a voice to those who have none.
When physicians use their best judgment for a patient yet the patient chooses to act against their own interest, then I would have to assume there is something (however trivial to me) that the patient clings to that he or she thinks will bring them happiness by not following the advice. Part of the psychology of the doctor-patient relationship involves digging in to find that something and unpack it, hoping to find a mutually agreeable solution.
Working in the emergency department for almost a decade puts me in contact with patients who “want” certain things all the time, but medicine is not as simple as picking desired items off a menu. Hence, while I will always be a staunch advocate of free will and individual autonomy, I also am compelled to balance that conviction with the fact that people make decisions for themselves liberally, but often with biased conceptions of expected results, incomplete data, or lack of the appropriate wisdom. When free will competes against wisdom, the latter always wins in the end. The triumph of the former invariably leads to ruin.
In a rational world, what exactly would Mrs. Dray being suing for? Is being pressured and threatened punishable by law? If so, then we can criminalize the behavior of all bullies and anyone who is known for being “overbearing.” Mrs. Dray has her health and a healthy baby to match—in fact, she has three healthy children, with two from prior C-sections. The doctors aimed to “do no harm” as best they could, and yet, still, we are now left in the legal remains of a very tricky ethical conundrum. Even if the doctors did use “improper judgment,” the fact remains that judgment did yield positive outcomes (although I must note that Mrs. Dray did sustain a cut on her bladder from the surgery, a commonly recognized complication of all C-sections).
I believe the constant answer to the original question is this: there is no answer because it depends. It depends on who is deciding, what is being decided, why it’s being decided, and the consequences for deciding differently. Many divergent solutions may seem right contingent upon the lens of the person viewing it.
I can remember quite a few times this year “pressuring” a patient, who is a repeat offender to the ER, to stop his excessive smoking since he always comes into the hospital with breathing problems. If I said nothing, I would be “doing harm,” and if I did say something, I could be portrayed as an alleged “bully” and possibly penalized. It’s a delicate path to walk.
Dr. C. H. E. Sadaphal