Catholic Health Care Advocates Papers
The Counseling Of Patients Maternal Disorders
Paddy Jim Baggot, M.D. And M. G. Baggot M.D.
The accompanying paper on Marfan syndrome discusses from a pro-life perspective data which is already in the literature. The pro-choice justification for abortion in Marfan pregnancies is based on this literature. From the pro-choice perspective, it is axiomatic that concern for fetal welfare has no place in considerations of maternally indicated abortion. For pro-life patients, this may result in medical advice which is harmful to their baby.
A disorder such as Marfan syndrome crystallizes some of these issues. Many patients with Marfan syndrome are counseled to abort. Would it be reasonable to undertake a 1% risk of maternal death in order to save one’s child? From a pro-life perspective, this could be just as reasonable as running out into the street to rescue one’s small child. In many dire maternal situations, the most likely outcome from non-abortive management is still a healthy mother.
A pro-choice doctor who cares deeply about his/her patient (as they all do), but feels strongly that abortion is in her best interest, may feel an obligation to convince the patient to do what the pro-choice doctor feels is best for her. From their perspective, a dutiful, devoted, and conscientious doctor could hardly do otherwise. ‘Pro-choice’ doctors try to straddle both sides of the great divide, which is impossible. They cannot care deeply for their patients, and yet care not at all about what those patients decide.
The pro-choice doctors do not misinform their patients. They are very respectful of patient autonomy. But they may look at the same data and see different conclusions. They might focus on the risk of maternal death, even if it is low. They may not feel the unlimited potential of the child in the same way that the mother would. Their vocation is to prevent maternal death, not have a baby.
Doctors are by nature cautious and conservative, as they should be. They often see medical management as a matter of identifying the risks and then avoiding them. This thought process is usually helpful. It breaks down when competing risks are not identified. Pro-choice doctors often don’t see poorly justified abortions as major adverse outcomes.
Many have been sued for failing to perform or recommend an abortion, or for failure to make a diagnosis which would have led to an abortion. This author is not aware of anyone one being sued for performing or recommending an unjustified abortion. As a result, doctors tend to err on the side of offering abortion. It is unfair to advise abortion for fear of lawsuits, without disclosing the conflict of interest. Lawsuits are best avoided in the usual way: a comprehensive note documenting discussion of all the major risks, and that the patient made her own informed choice.
Medical recommendations regarding abortion should not be given without specifying their ethical frame of reference. The recommendations would often change significantly if the ethical frame of reference were changed. Failing to provide medical recommendations from an alternative ethical frame of implies that there is no medically reasonable alternative. This raises the possibility that the patient’s ‘choice’ could be skewed by one-sided advice.
The management of serious maternal disorders in pregnancy often involves interdisciplinary situations. Physicians are often comfortable with all the risks in their own specialty, because they have abundant experience and know alternate remedies for each problem. For situations outside their specialty, they may be uncomfortable due to lack of knowledge and experience.
For example, the OB might recommend abortion because while he is comfortable with high-risk pregnancy, (including beta-blockers or anesthesia in pregnancy), he is uncomfortable with an expanding aorta. The cardiologist may feel that he can deal with expanding aortas (beta-blockers) but he is uncomfortable with the unknown risks of beta-blockers to fetus. The cardiothoracic surgeon may feel that he is comfortable operating on aortas, but is not used to doing so in pregnancy (will anesthesia hurt the fetus?). Each might be in favor of abortion, but for different reasons, all motivated by fear of the unknown.
For the pro-life patient, this can all be very unfair. Unbeknownst to the patient, she is often being counseled by a doctor who may have a different agenda from her own. The doctor may tend to err on the side of recommending abortion. The doctor may not think of unjustified abortions as a major adverse outcome. The doctor does not question supposed indications for abortion with the same skepticism the doctor would apply to arguments to continue the pregnancy. Aborting any ‘high risk pregnancies’ may be thought to limit malpractice exposure. The doctor does not admit his ethical frame of reference before beginning counseling. The doctor does not qualify his medical recommendation with an ethical frame of reference. The physician feels that since he/she is ‘pro-choice’, he can accommodate the ethical wishes of any patient, whether ‘pro-life’ or ‘pro-choice’. The doctor may not disclose fear of lawsuits as a conflict of interest. How can a patient with no medical training defend herself from unjustified abortion?
Many pregnant patients are pro-life, especially as regards the particular baby moves within their womb. These patients are not well served when they are counseled according to a ‘pro-choice’ agenda. Pro-life patients who are counseled by ‘pro-choice’ doctors need the option of a second opinion from a pro-life perinatologist or obstetrician. Many pro-choice patients might even benefit from hearing a perspective which is incongruous to their own.
There is an established precedent which offers guidance. In work-related injuries, the patient may see both a company doctor and a union doctor. Both the company and the employee feel they can’t entirely trust the counseling which originates from an incongruous perspective. Doctors should be forthright and admit their orientation prior to counseling. Patients who are pro-life should have the option of management by pro-life obstetricians.
The perception of abortion as limiting malpractice risks is probably overestimated and may be an artifact of a pro-choice orientation. For a pro-life patient, discussion of abortion as an ‘option’ often poisons the physician-patient relationship. It may cause the patient to mistrust the doctor’s other recommendations. It often occasions a change of doctors. Abortions, especially late term surgical abortions, are notorious for complications.
Malpractice is almost always caused by risks which were unforeseen, by lack of attention to detail, poor communication, and poor execution. In this regard, malpractice is like poor performance in many other fields of human endeavor. Even in the most difficult situations, cases almost always have good outcomes when there is careful planning, good communication, attention to detail and good execution. In this regard, high-risk obstetrics is like any other form of human endeavor. The management of these cases is quite challenging and they must never be underestimated.
If the different specialists would pool their talents rather than their fears, they would often realize that ‘we can work this out’. The OB might say that ‘we use beta-blockers in pregnancy often, and their risks to the fetus are mild although not zero’. The OB could say ‘there might be some fetal risk from general anesthesia, but if there is it must be very low. General anesthesia is often used in pregnancy for appendicitis, cholecystitis, etc.’ Vague, mild or subtle fetal risks should not be allowed to trump the real needs of the mother. The fetus needs a living mother. The cardiologist might say that ‘as long as the beta-blockers are not a major teratologic problem, Marfan patients can often be managed medically.’ The cardiothoracic surgeon might say that ‘if anesthesia is a manageable concern, major chest surgery is no problem for me’. The surgeon might suggest operating on the aorta early if there is significant dilation, so as to avoid a crisis. A literature search would reveal that this type of surgery has been done in pregnancy. The OB might say that ‘no option is as risky to the fetus as abortion’. The cardiothoracic surgeon might say that ‘abortion will not treat maternal vascular disease.’ The group could then present the patient with a plan wherein the most likely outcome is a healthy mother and a healthy baby. They could say that ‘this plan does not guarantee a good outcome, but these odds may seem reasonable to you.’ The mother might say that ‘if the odds are in my favor, it would be a terrible mistake to lose my precious baby.’ She might say that ‘abortion will not guarantee that I won’t die from this disease.’ They might finally agree that they have many reasonable options, including surveillance options to warn of impending trouble (frequent ultrasound evaluation of the aorta), options that prevent adverse outcomes (beta-blockers and early surgery), as well as other options which can serve as fail-safe options (emergency surgery) that can back up the primary options. When the doctors hold the baby, they will know they did the right thing.
The assistance of Suzanne and M.G. Baggot, M.D. is gratefully recognized. Discussions with T. Murphy Goodwin concerning malpractice issues are gratefully acknowledged.
