Running head: PREGNANCY TERMINATION AT WEEK 27 GESTATION

Ethical Dilemma: Pregnancy Termination at week 27 Gestation

Ethics: Case study week Ana Alberto

Pacific College

November 9, 2012

Professional Code of Ethics and client advocacy:

The ethical dilemma regarding these two parents pertains to whether or not to terminate this pregnancy at 27 weeks, which is after the 24 weeks fetal viability period. Finding out a child carried to term is harmed is nothing less than jarring, to the parents, family, and physician. In this scenario we have a couple who’ve worked hard to conceive and carry a child to that point; any choices made will be very emotional. They now have to make a very big decision that can be very devastating to the family’s future. This can also be hard for the clinicians working with this family as we also have beliefs and values that can impact our ability to care for the family if the decision being made impacts our belief system. As clinicians, we have a choice to continue caring for the family or ask another clinician to help if it has a possibility to impact the care given to the family.
It is the clinicians’ responsibility to assess the mother’s/father’s values and beliefs and their reaction to the situation. If the pregnancy poses no harm to the mother, than it is the mother/father’s choice to continue the pregnancy until term if they wish. The clinician can provide all of the pros and cons of carrying fetus to term or terminating the pregnancy now. The mother should also be aware of the outcomes of the fetus in both choices as well. When the fetus is diagnosed with a severe anomaly then the focus should not be on aggressive management but that of the parents’ wishes, in particular, the mother’s choice, which may raise a second dilemma of the parent’s possibly viewing the fetus as a person.

Professional code of conduct: To provide guidance, societies or professions have formal written codes of conduct that outline the values of the group and expectations of those that to the group. The American Nurses Association code of Ethics (2001) is the code of conduct that guides nursing practice with in the United States. In essence, the code of Ethics (American Nurses Association, 2001) defines the ethical obligation and duties for individuals who have entered into and practice within the profession of nursing. The Code is based on the shared belief that “nursing encompasses the prevention of illness, the alleviation of suffering, and the protection, promotion, and restoration of health in the care of individuals, families, groups and communities”(American Nursing Association, 2001,p.5). In our society there are values outlined in the United States constitution that provides the foundation for our society. The guiding principles of ethical decision making are autonomy, beneficence, justice, nonmaleficence and veracity.(Guido,5th ed).

Client advocacy:

Clinicians have an obligation to follow the mother’s decision based on respect for autonomy. Both parents should be provided with time to discuss amongst themselves in private in order to come up with the decision as a couple/family. Counseling should be provided if the couple is not ready to make the decision at that time or if they are not in agreement with the treatment plan.

Medical Ethical and Ethical Principles:

The traditions and practices of medicine constitute an important source of morality for clinicians and health care providers because they are based on the obligation to protect and promote the health-related interest of the patient. This obligation tells the clinicians and health care providers, in general what morality in medicine ought to be. Medical ethics is disciplined study of morality in medicine and concerns the obligations of clinicians and health care organizations to parents as well as the obligations of the parents. (McCullough & Chervenak, 1994).

The Ethical Principal of Beneficence:

The ethical principal of beneficence requires one to act in a way that is expected reliably to produce the greater balance of benefits over harms in the lives of others. (Beauchamp & Childress, 2011). To put this principle into clinical practice requires account of the benefits and harms relevant to the case of the patients and of how those goods and harms should be reasonable balanced against each other and a possibly that not all of them can be achieved. In medicine the principle requires clinicians to act in a way that is reliably expected to produce the greater balance of clinical benefits over harms for the patient. (McCullough & Chervenak, 1994). Beneficence-based clinical judgment identifies the benefits that can be achieved for the patient in clinical practice based on the competencies of medicine. The benefits that medicine is competent to seek for patients are the prevention and management of disease, injury, handicap, and unnecessary pain and suffering and the prevention of premature or unnecessary death.
Non-maleficence means that the clinician should prevent, causing harm and are best understood as expressing the limits of beneficence. This is also known as “first do no harm”. In the beneficence- based clinical judgment there is a risk that it might be taken as the sole source of moral responsibility and therefore moral authority in medical care that may cause the clinicians to violate the mother’s autonomy. One way to prevent the ethics response to the inherent paternalism is that the clinicians must explain the diagnosis, therapeutic, and prognostic reasoning that leads to her or his clinical judgment about what is in the interest of the patient so that the patient can assess that judgment for herself. The clinician should disclose and explain to the patient/spouse the major factors of this reasoning process, including matters of uncertainty. It should be apparent that beneficence-based clinical judgment will frequently result in the identification of continuum of clinical strategies that protect and promote the patient’s health related interests, such as the choice of preventing and managing the complications of high risk pregnancy.
The Ethical Principal of Respect for Autonomy: In contrast to the principal of beneficence, the ethic principal of respect for autonomy is that this principal requires that one should always acknowledge and carry out the value-based preferences of the adult, based on the each patient’s perspective on her interests is a function of her values and beliefs. Therefore it is impossible to specify the benefits and harms of autonomy-based on clinical judgment in advance, because the definition of her benefits and harms and their balancing are the prerogatives of the patient. To accomplish the moral demands of this principle, we need a concept of autonomy. We would need to identify three autonomy-based behaviors on the patient; 1) Absorbing and retaining information about her condition and alternative diagnosis and therapeutic responses to it; 2) Understanding the information, by evaluating and rank-ordering those responses and appreciating that she could experience the risk of treatment; 3) expressing a value-based preference. The clinicians role in this case is, 1) to recognize the capacity of each patient to deal with medical information (and not understand that capacity), provide information, (disclosed and explain all medical reasonable alternatives, supported in beneficence-based clinical judgment) and recognize the validity of the values and beliefs of the patient; 2) Not to interfere with but her choice, but when necessary, to assist the patient in her evaluation and ranking of diagnostic and therapeutic alternatives for managing her condition; and 3) to elicit and implement the patient’s value-based preference.( McCullough & Chervenak,1994). “The obligations in United States Law of the clinicians regarding informed consent were established in a series of cases during the twentieth century. In 1914, Schloendorff v. The Society of The New York Hospital established the concept of simple consent, ie, whether the patient says “yes” or “no” to medical intervention. (Feden & Beauchamp,1986). To this date this decision is quoted: “Every human being of adult years and sound mind has the right to determine what shall be done with his body, and a surgeon, who performs an operation without his patient’s consent commits an assault for which he is liable in damages”.( Schoendorff v.the society of New York Hospital, 1914).” There are two standards in the United States law for consent disclosure, the professional community standard and the reasonable person standard. The professional community standard, defines adequate disclosure in the context of what the relevantly trained and experienced clinician tells the patients. The reasonable person standard, the clinician should disclose to the patient her and the fetus’s diagnosis (including differential diagnosis when that is all that is known), the medical alternatives to diagnose and manage the patient’s condition, the short-term and long-term benefits and risk of each alternative.
The Ethic Concept of the Fetus as a Patient: There are obviously beneficence-based and autonomy-based obligations to the pregnant patient: the clinician’s perspective on the pregnant woman’s health-related interests provides the basis for the clinician’s beneficence-based obligations to her, whereas her own perspective on those interests provides the basis for the clinician’s autonomy-based obligations to her. Because of an insufficiently developed in the central nervous system, the fetus cannot meaningfully be said to possess values and beliefs. Thus, one might say that there is no basis on the perspective of interests by the fetus. However, there can be uncertainty about when the fetus is a patient. One approach to resolving this uncertainty would be to argue that the fetus is or is not a patient in virtue of personhood, or some other form of independent moral status.
The Viable Fetal Patient: Viability exists as a function of biomedical and technological capacities, which are different in different parts of the worlds. As a consequence, there is, at the present time, no worldwide, uniform gestational age to define viability. In the United States, we believe, viability presently occurs at approximately 24 weeks of gestation age.( Chervenak& McCullough,1997).
When the fetus is a patient, the directive would be counseling for fetal benefit as it is ethically justified. Directive counseling for the fetus would involve the recommendation against termination of pregnancy, recommending against non-aggressive management; or recommending aggressive management. The aggressive obstetric management includes intervention such as fetal surveillance, tocolysis, and cesarean delivery. The non-aggressive obstetric management includes; directive counseling for fetal benefit, however, we must take into account the presence and severity of fetal anomalies, extreme prematurity, and obligation to the pregnant woman. Such conflicts is best managed preventively through the informed consent process as an ongoing dialogue, throughout the woman’s pregnancy, augmented as necessary by negotiation and respectful persuasion. ( Chervenak & McCullough,1990). Ones identifying the ethical dilemma for obstetric clinical judgment and practice, with particular emphasis on the ethical concept of the fetus as a patient; then we can move on to the next steps in how to handle the ethical dilemma whether the couple should or should not terminate the pregnancy at 27 weeks gestation by utilizing the MORAL model.
The MORAL model :( Guido, 5th ed).
Consisting of constructs similar to the nursing process, the MORAL model has five steps: *M= Massage the Dilemma: The dilemma is to terminate the pregnancy verses carrying to full term. The mother is important in making the decision, one that might cause strain in the relationship with her husband, as he might views the pregnancy different than her, since he is not the one that is pregnant /carrying the child. Determent, what is their religious belief? Are they pro-life? And how would they feel knowing their child most likely will die?

*O= Outline the options:
The options are as follows: 1. Terminate the pregnancy now, vaginal birth versus caesarian-section. Depending on the mother’s views and beliefs, it may be less emotional and less painful if the pregnancy was terminated now verses full term. It may also be traumatic emotionally to carry the fetus for 10-13 more weeks knowing the outcome as well as increasing the physical changes to the mother’s body that may cause discomfort. 2. Carrying the infant to term, obligated to provide aggressive treatment to the baby. If the mother wants to do everything possible for the fetus, then this might be the option she is more likely to go with. 3. C-section verses vaginal birth of a full term infant. Then the mother will need birthing plan, pain management during birth and after.

*R=Review criteria and resolve dilemma: Utilizing the Beneficence-based, then which option would promote the most good and do the least harm for the mother’s point of view.
The Autonomy- based, which option respects the rights and dignity of all the stakeholders based on mother and father’s wishes. *A= Affirm position and act by applying the chosen option: Which option is best for the parents/mother? Develop a plan that she /both parents approve and has the least emotional stress.
Talk through the plan and get a confirmation that it is ok and take the needed steps to either terminate the pregnancy now or at full term, delivery options, provide informed consent. *L= Look back and evaluate: How did the parents feel after the decision was made? Was help provided and taken by the parents. Counseling, support groups, grief classes. Did the baby have a struggle and cause more emotional pain if carry to full term.

Conclusion

Advocacy concerns the active support of a cause or issue, and is both ethical and legal, the responsibility for nurses to be able to provide the guidance through these difficult dilemmas. When confronted with an ethical dilemma, rarely does one principle alone provide adequate guidance for decision making. The best decisions occur when all the principles are considered and applied to the thought process. The role of the nurse is to support the patient’s decision making, whatever that might be, provide all the possible options, remain a neutral-party so the family involve may come to their own conclusion of what is best for the mother, child and father as this will affect the entire family.

References

-American Nurses Association. (2001): Code of ethics for nurses with interpretive statements. Washington DC: Author
-Guido, G. (2010). Legal and ethical issues in nursing (5th ed). Upper saddle River, N.J.: Pearson education, Incorporated.
-McCullough, L.B. & Chervenak, F.A. : Ethics in obstetrics and gynecology, New York: Oxford University Press, 1994.
-Beauchamp T.L. & Childress J.F.: Principals of biomedical ethics, 5th ed. New York: Oxford University Press, 2001.
-Schloendorff v. The Society of The New York Hospital: 211 N.Y.,125, 126, 105 N.E., 92.93 (1914).
-Chervenak F.A. & Mc Cullough, L.B.: the limits of viability. J. Perinat Med. 1997; 25,418-20.
-Chervenak, F.A & McCullough, L.B.: An ethical justiced, clinically comprehensive management strategy for third-trimester pregnancies complicated by fetal anomalies. Obstet Gynecol. 1990; 75:311-6.