Guest JS28 Posted February 22, 2003 Report Share Posted February 22, 2003 Ms. X is a pregnant woman in the early stages of pregnancy and is a cocaine addict. Her previous 2 children have been surrended to Children's Aid and they have both been born with physical and mental disabilities. If she refuses to stop her cocaine taking, are you justified in reporting her case to the Child and Family Services Agency to seek an injunction to force her to get treatment (against her will) because her unborn child is at risk? What takes precedence: patient autonomy or the fetus' right to life? What is the doctor's obligation here? (if any) If no amount of counselling on the doctor's part can convince Ms. X to change her behaviour, what is left for the doctor to do? Link to comment Share on other sites More sharing options...
Guest Sil Posted February 23, 2003 Report Share Posted February 23, 2003 You cannot force a pregnant woman to stop smoking, drinking or doing drugs. I know is tough but the law says you are treating one patient until she delivers her baby. At this point the child can be taken away if she has done drugs, etc. (at least that is what I was taught when I did my maternity rotation in nursing). Edited for spelling. I am so glad I will not have to make my living as a writer Link to comment Share on other sites More sharing options...
Guest UWOMED2005 Posted February 23, 2003 Report Share Posted February 23, 2003 I'm prettys sure Sil's right - but a case very similar to this was brought before the Supreme Court within the last two, three, maybe four years. It involved a mom who was abusing solvents (ie sniffing gas,) had two kids who'd already been affected in utero, and was pregnant with the third. Wish I could remember the details beyond that - but as it's a recent case that often comes in bioethics classes (like our own here at UWO!) it's a pretty hot topic and it might not be a bad idea to do research. Link to comment Share on other sites More sharing options...
Guest Sil Posted February 23, 2003 Report Share Posted February 23, 2003 As a nursing student I had a pregnant lady who was abusing heroine. Hard to deal with but nothing you can do other than talk to them and try to convince them otherwise. Link to comment Share on other sites More sharing options...
Guest shelleyrn Posted February 23, 2003 Report Share Posted February 23, 2003 This is more common than you think. I currently work with a Street Health program, and these are the women who we serve. As someone rightly pointed out, there are limitations in terms of what we can do from a legal perspective. Quite often what will happen is that CFS will be notified of the patient's illicit drug use while pregnant, and then a "birth alert" will be put out to the hospitals in said city. The child will be apprehended at birth, assessments done, etc. (very difficult if there are complications with babe). The physician is in a difficult position. the woman may not be ready to quit the drugs....they could encourage her to reduce her intake of illicit drugs(a la Harm Reduction, which is very pragmatic) until babe is born, but really, they cannot hold her against her will (The One Patient Theory)..... Again, my humble opinion....cheers,Shelley Link to comment Share on other sites More sharing options...
Guest Dannyboy Posted February 24, 2003 Report Share Posted February 24, 2003 Just some suggestions: The case a former commentor was referring to was Winnipeg Child and Family Services v D.F.G [1997] case. The issues raised were Charter related and very much were linked to the ongoing debate over women vs. fetal rights. An unfortunate situation but a decision (ie. forced treatment is unconstitutional) of value. I would attempt to avoid the legal arguments, myself but perhaps I can contribute somewhat to possible answers for the question: One: do what you can both prof. and ethically in the given situation. Your client is the women. Never assume that the woman is intentionally harming her unborn child. She is troubled and in need of compassionate, multidisciplinary care. Attempt to ***stablize the addiction***(crucial)---a drs place is not necessarily to make moral judgments. Harm reduction may be the only viable outcome. Attempt to provide her access to appropriate community resources--iie. most cities have programs in place to treat substance dependant pregnant women. Two: know you stuff about drugs and pregnancy. Such as cocaine and heroin consumption during pregancy is not as harmful as one would intuitively suspect. HOWEVER, the indirect effects of the addict lifestyle certainly are--attempt, in a supportive fashion, to provide the mother information on harm reduction strategies (e.g. the importance of diet, effect of exposure to violence and other high risk activities, etc.) and try, in an appropriate way, to educate her. Three: if you evaluate the situation and determine that you are unable to provide the care the mother needs--for whatever reasons--make an effort, to connect her to an individual or an agency that can. She has taken a HUGE step by seeking prenatal care--she's not stupid, she is fed a steady diet of "you are a bad person for what you are doing"; she cares enough about herself and her child to seek your help so do what you can to help her. Support her efforts. She may not do what you have indicated she needs to do--perhaps just focus on the positive steps she has made. Four: the status/rules regarding your obligation vary provincially. Ontario has moved towards the conservative side. In Manitoba, the state can intervene and remove the newborn *on suspicion alone* (scary) of neglect/abuse. If you do not know the rules---ASK. I would stress the importance of relying and seeking the advice of others on this one. The situation transcends medical boundaries; cooperative intervention is required. Obviously, under the provision that the client's confidentiality is respected and maintained where/when applicable. I think the key variables are respect and providing non-judgmental and appropriate care. Hope that helps. Link to comment Share on other sites More sharing options...
Guest Ian Wong Posted February 24, 2003 Report Share Posted February 24, 2003 Thanks for the info Dannyboy. Ian UBC, Med 4 Link to comment Share on other sites More sharing options...
Guest JS28 Posted February 24, 2003 Report Share Posted February 24, 2003 DannyBoy, Wow. That was really well thought out. In this situation, I would think that the doc doesn't have the right to call up an agency (or report her) without the patient's knowledge. Just for argument's sake, can the doc refuse to continue to see her as a patient, on the grounds that she is refusing to give up her high-risk behaviour? (This sort of bleeds into the ethical question of whether or not docs can refuse to treat smokers who refuse to quit or severely obese patients who refuse to lose weight). e.g. Docs in Melbourne can refuse to perform coronary surgery on smokers. (One patient who was a smoker ended up dying because the docs wouldn't treat him). Sorry...sorta off topic! Link to comment Share on other sites More sharing options...
Guest UWOMED2005 Posted February 24, 2003 Report Share Posted February 24, 2003 This question has come up a number of times in our PCL sessions. My understanding is that docs are fully allowed to "fire," or refuse any patient they want. That's not to say that means it's right, but it is possible. Link to comment Share on other sites More sharing options...
Guest Dannyboy Posted February 24, 2003 Report Share Posted February 24, 2003 My understanding is that a dr reserves the right to refuse to see an individual as long as it doesn't not involve any negation of his/her "duty of care" (that is the tricky part--any opinions on what situations other than emergency ones that would involve??). However just my *uninformed* opinion but even suggesting that you might do that equates to you walking into a med school interview landmine field. It's the whole slippery slope idea: where do you draw the line? Do you only see healthy people between the ages of 18 and 30? Only those you "like"? I think that would send you down the thorny ethical road of who is the "worthy" client. Just my opinion but I would stay a big bus ride away from that one. If the topic comes up I would think that it would be acceptable to admit that you don't know what exactly you would do but you, of course, would act within your personal and professional boundaries and that refusing to see such a client would probably be an extremely difficult decision that you would arrive at as a last resort and after both consultation with others and after considerable deliberation. I would stress the importance of connecting her with other individuals/agencies who can both accept her as a client (the options need to be viable ones) and can better serve her unique needs if it is decided that you are not the best person to care for her. Unless you feel otherwise, I would think it would be better to suggest that you would want to improve the situation and to help the mother--you don't want the mother to be denied crucial prenatal care. You can't fix her situation--the drugs are likely the outcome of a long series of events in her life--but you can work with her to improve her health status and that of her unborn. I have heard of drs refusing people for other reasons, most of them relating to the care and comfort of their other clients (e.g. a client was abusive to staff or clients) or for other reasons such as they are too busy to take more clients on--that one is tricky unless it is actually the case. You do NOT want to be accused of discriminating. FYI: The fetus gains legal status at 6 months of age (that is why theraputic aboriton is legal up until that date). This does not involve the fetus's rights "trumping" the rights of the mother--hers come first but once the baby is born, and only if the dr suspects ill tx, his/her duty to report would kick in. At that time, the state's rights to protect the infant trumps the parental rights of the mother. But again, the dr might be safest to phone the appropriate agency ahead of time---no name or contact info is necessary to get advice. The interviewers are looking for your thought processes, right? Link to comment Share on other sites More sharing options...
Guest tirisa Posted February 24, 2003 Report Share Posted February 24, 2003 Great thoughts Dannyboy. Thanks. I agree that anyone could be walking on very thin ice if you attempt to justify rejecting "high risk" patients, such as smokers or obese patients. What you define as high risk is quite relative, since a member of the raptors basketball team and other elite athletes consume large amounts of health care time and money, both in terms of rapid diagnoses of injuries and speedy surguries and rehab. Some may argue that elite athletes (and you can expand this group to parachuters, rock climbers, etc) are choosing to put themselves at "high risk" just as a smoker is, so if you are rejecting smokers, you need to be ready to justify rejecting a larger segment of the population. Anyway, just my little spin on the earlier debate. Cheers, T Link to comment Share on other sites More sharing options...
Guest Dannyboy Posted February 24, 2003 Report Share Posted February 24, 2003 You've certainly raised some interesting points Tirisa--those athletes do cost a lot don't they? I went through my boxes of old school books to locate a book that might be helpful as far as answering possible med school interview questions. The book is considered to be a "bible" of sorts for medical practitioners. It is called: Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. It's by Albert R. Jonsen, Mark Siegler & William J. Winslade. To be honest, I haven't looked at it in years by I remember that it presents a comprehensive assortment of case scenarios followed by advice on how to best respond to the situation. It also clearly stipulates what obligations/duties that medical staff must adhere to. It is an easy read too. I remember it was an expensive book (for such a tiny one) but it is so widely used that it should be in the university libraries. Another note concerning any ethical dilemnas: from my understanding, drs have access to advisors regarding most any professional/ethical situation they may come across. I don't think it is ever assumed that they must act in isolation to resolve difficult situations so I would hope that a student in an interview situation is not expected to come up with any firm answers---but I obviously do not know this for a fact (??). Later! Link to comment Share on other sites More sharing options...
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