MEDICAL ETHICAL DILEMMAS IN
CARING FOR THE MOTHER AND
UNBORN CHILD
Sam Coulter-SmithMaster Rotunda Hospital,
Dublin
FOCUS ON MATERNITY SERVICE
Galway Maternal death - multiple investigations
Recent Oireachtas Health committee- Abortion
Current debate
Forthcoming Draft legislation.
BACKGROUND TO CURRENT SITUATION PRACTICE / LAW / GUIDELINES
Existing statute Case law Medical Council guidelines Current practice
X CASE 1992 Chief Justice Thomas Finlay ‘‘ if it is
established as a matter of probability that there is a real and substantial risk to the life , as distinct from the health of the mother, which can only be avoided by the termination of her pregnancy, such a termination is permissible’’
This new case law contradicts what is on the statute books
Current medical council guidelines based on this case law
EUROPEAN COURT OF HUMAN RIGHTS 2010 Found Ireland had failed to provide for
abortion in circumstances where the mothers life was at risk.
Instruction to Ireland to legislate for suicide
BUT
Did they take all the facts into consideration?
RISK OF SUICIDE IN PREGNANCY European Court ruling - we must legislate for suicide
but Suicidal ideation Rare in pregnancy. Incidence in UK is
1:500,000 pregnancies. More common in post natal women.
Unpredictable and risk is difficult to assess. Usually associated with Pre-existing mental health issues or social circumstances.
ToP not a treatment for mental health issues, no suggestion its a treatment for suicidal ideation.
CONFUSION Medical council guidelines Case law
Statue
Is there a need for new legislation?
This has led to much debate and disagreement within the profession and beyond
IMPLICATIONS OF LEGISLATION Positive Brings law to comfort the medical profession Backs up medical council guidelines
Negative Is it required ? ? Need to mention any clinical entity ? Open door to ToP – many crisis pregnancies
travel to UK – they may want ToP here Definite Resource issues – 3 sub spec obs
psych services in the country. Maternity services already overstretched, understaffed and underfunded
DIFFICULT CLINICAL SCENARIOS
Mothers life at risk - variable acuity- How urgent?
Soon -Pre existing condition- Cardiac disease e.g. Eisenmenger’s syndrome
Urgent- New diagnosis – Cancer requiring surgery or chemo/radio therapy asap.
Emergency -Complication of pregnancy- Haemorrhage or Infection, Hyper emesis, Eclampsia, HELLP.
GESTATION DEPENDANT INTERVENTION All efforts always made to save infant
Before 23 weeks – fetus won’t survive After 25-26 weeks - 80-90% survival
with good NICU
Grey area 24 weeks – management depends on severity of maternal condition.
ISSUES IN PROVIDING A TOP SERVICE TO SAVE A MOTHERS LIFE Who decides ? How many opinions required- Multidisciplinary input? What happens in an emergency? Where? Who performs the procedure? Conscientious objection !!!! ?? Appeal mechanism if refused – who? Oversight of the area? Impact on service? Terminology
OTHER ETHICAL ISSUES RELATED TO CURRENT DEBATE BUT NOT COVERED IN CURRENT DISCUSSION OR PROPOSED LEGISLATION
Rape
Incest
Lethal congenital / Genetic anomalies
OTHER OBSTETRIC MEDICAL / ETHICAL ISSUES
Jehovah’s witness – refusal of blood – 2 patients- e.g pregnant with parvo infection fetal anaemia and hydrops requiring transfusion. Or Mother has placenta praevia life threatening APH
Refusal to accept medical intervention in labour- relatively common in African women strong Christian belief God will look after them.
HIV + refusal to accept LSCS
LSCS rate target of 20% - maternal request for LSCS
Demand for LSCS on request – Right to choose in UK (NICE) v illegal in Turkey.
FERTILITY RELATED ETHICAL ISSUES
IVF embryo transfer (Single v Multiple transfers)
IVF- Age availability ? Limit
Selective termination in cases of large multiple gestation.
NEW TECHNOLOGY Lack of regulation in fertility service-
surrogacy, frozen sperm/eggs/embryo in cancer patients
Technology moving faster then regulation
Pre implantation Diagnosis (microarray)
New fetal medicine interventions e.g In utero surgery (spina bifida)
GOVERNANCE ISSUES Clinical Governance
Budget allocation, Staff to patient ratios, infrastructure.
30% busier then 2006
Are the funders taking their moral and ethical responsibility seriously?
Appropriate KPIs in SLA
THANK YOU