Informed Consent and Reproductive Choice

Informed Consent and Reproductive Choice

Description

This Symposium on Patient's Rights underscores the value of multinational approaches to issues of law, ethics and medicine. Thus, I regret that this chapter focuses on the United States. The question addressed here—how should doctors talk with pregnant women?—arises throughout the world. More cross cultural analysis would benefit everyone. The limits of my knowledge and information force me to emphasize issues of abortion practice and policy within the United States. In 1988, 6.4 million women became pregnant in the United States. Of these, 3.9 million, or 60.7 % gave birth and 1.59 million, or 24.7 %, had abortions. Some women confirm their pregnancies at home with a commercial test kit, consult with their own conscience, their partners, parents or friends, make a decision and find their way to a provider who can help them to continue or to end the pregnancy. But often it is a health care provider who informs a woman that she is pregnant. This article explores the ethical and medical principles that should guide physicians and other health care providers in conversations that follow the confirmation of pregnancy. At an abstract level, principles of medical malpractice and medical ethics require responsible physicians to facilitate choice for all patients. The first section demonstrates that legal principles developed in four contexts support the claim that physicians should facilitate informed patient choice: A) common law concepts of informed consent; B) medical malpractice cases recognizing a cause of action for wrongful birth; C) malpractice and professional standards defining physicians' obligations to make referrals for services a treating doctor is unable or unwilling to provide, and D) constitutional principles protecting patient choice. Despite this abstract commitment to patient choice the next section demonstrates that contemporary patterns of medical practice are systemically anti-choice and anti-abortion. This anti-choice bias is reflected in and reinforced by contemporary standards of medical ethics, licensing and accreditation standards, and patterns of medical education and practice. The following section defends a model of responsible professional behavior that requires the practitioner to help the patient to reach an informed decision and to find the medical services that meet her needs. It builds upon the ethical principles and practices of responsible abortion providers. These clinics offer a concrete model of informed consent to facilitate choice for pregnant women. This is followed by the considerations of objections that might be raised against applying these ethical and legal principles to counseling for pregnant women in settings other than abortion clinics. It concludes that the physician's own moral views about abortion cannot excuse the doctor from his or her ordinary ethical and legal obligations to facilitate choice for pregnant women through counseling and referrals. The section that follows demonstrates that in practice neither constitutional concepts, malpractice remedies, nor state legislative mandates are likely to provide effective legal incentives to encourage physicians to facilitate choice. A variety of factors, extrinsic to the core value of patient choice, make it inappropriate to look to these sources of law to protect the reproductive choices of pregnant women. The final section explores the questions of how actors, other than constitutional and common law courts, can encourage conversations between pregnant women and physicians to facilitate choice. It argues that professional associations and medical educators, working together with organized women, should take the initiative to address these issues. While focus here is on the conversations between individual pregnant women and physicians, the problem addressed has a broader social aspect. The individual physician does not act in a vacuum. Rather, he or she is influenced by medical education, ethical standards, economic factors, accreditation and licensing requirements for medical education and health care facilities, the law, the press, and the larger cultural environment. In the 1980s provision of abortion services became increasingly concentrated in specialized clinics, as general physicians and hospitals declined to provide the service. These clinics, their medical personnel, and their patients are subject to harassment and violence. Medical education, after initially creating programs to train physicians to perform abortions, abandoned this training in the 1980s. In 1991, only thirteen percent of US residency programs training specialists in obstetrics and gynecology required training in first trimester abortions, and only seven percent required training in second trimester abortions. In 1988, there were no abortion providers in 83 % of the counties in the United States. Further, the segregation and devaluation of abortion services is not confined to states in which anti-choice views are political dominant. These US patterns are quite different from those that prevail in other developed Western nations. As in the US abortion is legal—either on request or for a broad range of social or personal reasons—in every developed Western nation, except for Ireland. However, the US is the only developed Western nation in which abortion is not financed through general public health insurance programs. The lack of funding, and other legal and practical barriers to abortion, mean that in the US far more abortions are delayed to the second trimester than in other developed Western nations. Abortion, one of the most common surgical procedures in the United States, has been marginalized by the medical profession. This article explores the concrete mechanisms by which abortion can be brought into the mainstream of American medicine. It argues for ethical and legal norms to encourage ordinary physicians to engage in a dialogue with pregnant patients to facilitate choice and make appropriate referrals to help the woman act on her choice. Such norms would make explicit the values of self-determination and bodily integrity generally recognized by medical ethics and legal principles, yet ignored for pregnant women in mainstream medical practice. Recognition of such a norm would have an important effect on interactions between individual patients and providers and also would impact the larger political and social status of abortion. For example, to make an appropriate referral for a pregnant patient who seeks an abortion, the physician must be informed about the availability of such services. In many parts of the country, women seeking abortion confront large obstacles of travel, cost and delay, as well as risks of harassment and violence. Mainstream medicine's current failure to facilitate choice for pregnant women contributes to the invisibility, unavailability and vulnerability of abortion services.

Source Publication

Patient's Rights: Informed Consent, Access and Equality

Source Editors/Authors

Lotta Westerhäll, Charles Phillips

Publication Date

1994

Informed Consent and Reproductive Choice

Find @ NYU

Share

COinS