17
MEDICAL ETHICAL DILEMMAS IN CARING FOR THE MOTHER AND UNBORN CHILD Sam Coulter-Smith Master Rotunda Hospital, Dublin

Medical Ethical dilemmas in caring for the mother and unborn child

  • Upload
    bill

  • View
    31

  • Download
    2

Embed Size (px)

DESCRIPTION

Medical Ethical dilemmas in caring for the mother and unborn child. Sam Coulter-Smith Master Rotunda Hospital, Dublin . Focus on Maternity Service. Galway Maternal death - multiple investigations Recent Oireachtas Health committee- Abortion Current debate Forthcoming Draft legislation. - PowerPoint PPT Presentation

Citation preview

Page 1: Medical Ethical  dilemmas in caring for the mother and unborn child

MEDICAL ETHICAL DILEMMAS IN

CARING FOR THE MOTHER AND

UNBORN CHILD

Sam Coulter-SmithMaster Rotunda Hospital,

Dublin

Page 2: Medical Ethical  dilemmas in caring for the mother and unborn child

FOCUS ON MATERNITY SERVICE

Galway Maternal death - multiple investigations

Recent Oireachtas Health committee- Abortion

Current debate

Forthcoming Draft legislation.

Page 3: Medical Ethical  dilemmas in caring for the mother and unborn child

BACKGROUND TO CURRENT SITUATION PRACTICE / LAW / GUIDELINES

Existing statute Case law Medical Council guidelines Current practice

Page 4: Medical Ethical  dilemmas in caring for the mother and unborn child

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

Page 5: Medical Ethical  dilemmas in caring for the mother and unborn child

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?

Page 6: Medical Ethical  dilemmas in caring for the mother and unborn child

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.

Page 7: Medical Ethical  dilemmas in caring for the mother and unborn child

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

Page 8: Medical Ethical  dilemmas in caring for the mother and unborn child

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

Page 9: Medical Ethical  dilemmas in caring for the mother and unborn child

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.

Page 10: Medical Ethical  dilemmas in caring for the mother and unborn child

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.

Page 11: Medical Ethical  dilemmas in caring for the mother and unborn child

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

Page 12: Medical Ethical  dilemmas in caring for the mother and unborn child

OTHER ETHICAL ISSUES RELATED TO CURRENT DEBATE BUT NOT COVERED IN CURRENT DISCUSSION OR PROPOSED LEGISLATION

Rape

Incest

Lethal congenital / Genetic anomalies

Page 13: Medical Ethical  dilemmas in caring for the mother and unborn child

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.

Page 14: Medical Ethical  dilemmas in caring for the mother and unborn child

FERTILITY RELATED ETHICAL ISSUES

IVF embryo transfer (Single v Multiple transfers)

IVF- Age availability ? Limit

Selective termination in cases of large multiple gestation.

Page 15: Medical Ethical  dilemmas in caring for the mother and unborn child

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)

Page 16: Medical Ethical  dilemmas in caring for the mother and unborn child

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

Page 17: Medical Ethical  dilemmas in caring for the mother and unborn child

THANK YOU