You are an obstetrician in Massachusetts. A pregnant woman comes to your clinic for a routine prenatal (before birth) exam. She is 21 weeks pregnant with her sixth child. The ultrasound reveals a worrisome picture: the woman's placenta has migrated to the wrong location--it covers the cervix (placenta previa) and is adhering to the uterine wall (placenta accreta). These conditions occur more often in patients like this one who have undergone a prior Caesarean section. The pregnancy will pose a substantial risk both to fetus and mother.The major question is: if the mother hemorrhages (bleeds uncontrollably) in the delivery room, can the medical team ethically overrule her wishes and infuse her with blood anyway, thus sparing her life? Do the doctors have an obligation to the woman's five children to keep her alive against her will? How does one even begin to untangle an emotionally-charged dilemma such as this?
The mother declines to consider an abortion. In 3 months, the baby will be at full term and can be delivered only via Caesarean section. Even if the procedure goes well, the mother will lose a worrisome amount of blood.
Now for the kicker: the mother belongs to the Jehovah's Witnesses and refuses any blood transfusions. Even more problematic is that she has anemia (a inadequate amount of functional red blood cells). She understands that her refusal to receive transfusions substantially increases her risk of death. Her husband disagrees with her decision.
The field of clinical ethics provides a framework for thinking through these types of thorny and emotionally-charged situations. It marries medicine with philosophy. Few doctors formally study clinical ethics, though. At my school, we received a total of two hours of formal lecture on the subject during our first year. This is typical of schools nationwide. This dearth of instruction in clinical ethics seems to be at odds with the profession's (and the public's) firm expectation that we act ethically, honorably, and in compliance with the law.
In subsequent posts, I discuss why I am grateful to have studied bioethics as undergraduate, as well as how the case I've described was ultimately resolved (mother and baby both lived).
