Clinical ethical topics in gynaecology

Contraception and sterilization

There are rarely in deliberative clinical judgement beneficence-based clinical indications for the prevention of pregnancy, secondary to se­vere medical illness, such as end-stage heart failure.

Much more commonly, women without such medical indications wish to prevent pregnancy. So long as there are no medical contra­indications, the doctor should engage in shared decision-making by presenting all medically reasonable options without making a rec­ommendation and supporting the patient or surrogate in making a well-informed decision. The doctor should emphasize the irreversi­bility of sterilization and the distinction between self-administered and implantable contraception. In some cases, counselling by a mental health professional may be needed, for example, when the doctor has clinical concern about impairments of the patient's decision-making capacity. In some cases, counselling should depart from shared decision-making and become directive, for example, when a 20-year-old nulliparous patient who wishes to prevent pregnancy asks for sterilization before all of the options to prevent pregnancy have been considered. Respect for autonomy calls for empowering such a patient with the information that she needs, to prevent an inadequately informed, precipitous decision, rather than simply acquiescing. The professional responsibility model supports the obligation to protect such a patient from herself by directive counselling aimed at the informed exercise of her positive right to request sterilization.

Assisted reproduction

The ethics of assisted reproduction has one of the most extensive literatures.

We therefore focus only on the obligations of doctors who provide primary gynaecological care for women with limitations on fertility. Professional integrity and beneficence both require the doctor to provide a comprehensive workup of the patient, including referral to fertility specialists when indicated. This workup should also aim to identify risks of assisted reproduction and pregnancy for the pa­tient, so that she can be provided with this clinically significant in­formation. Respect for patient autonomy then requires the doctor to present the results of this evaluation to the female patient and assist her in understanding and evaluating the medically reasonable al­ternatives for managing it. The doctor should also offer to assist the patient to think through fundamental, related questions: How im­portant is it to you to attempt to bear a child? How do you assess the biopsychosocial benefits and risks of assisted reproduction? Are you prepared for what could be considerable out-of-pocket (depending on scope of insurance, co-payments, and deductibles) financial costs? Are you prepared for the biopsychosocial benefits and risks of a multiple pregnancy that can result when more than one embryo is transferred? The doctor should offer to include the patient's partner or others, as the patient agrees, as she addresses these questions. Some women will accept limitations on their fertility and elect not to proceed with reproductive medical service. Some women will not accept such limitations. For such patients, the doctor should make a referral to a centre of excellence and prepare for the management of a subsequent pregnancy should one result.

Ectopic pregnancy

The standard of care for ectopic pregnancy may be so obvious that ethical justification is obvious. It is always good ethical practice in ethics to spell out the obvious. Ectopic pregnancy, with the very rare exception of some abdominal pregnancies, will not result in a livebirth. Clinical maintenance of such pregnancies is therefore physiologically futile. Provision of such clinical maintenance vio­lates both professional integrity and beneficence. Moreover, such pregnancies pose a threat to the woman's health and life, risks that are not offset by the benefit of livebirth. This reinforces the violation of professional integrity and beneficence. There is therefore only one medically reasonable alternative, ending the pregnancy promptly, and it should therefore be strongly recommended.

In very rare circumstance, a patient may refuse the recommen­dation on religious grounds. Including appropriately trained and experienced colleagues from pastoral care could be invaluable in persuading the woman to accept the physiologically futile nature of the pregnancy and that the risks to her will not have the benefit of a live-born child. The woman's right to a voluntary decision becomes unjustifiably violated when she is being subjected to potentially con­trolling influences, for example, insistence by a partner or family member that she refuse ending of the pregnancy. These individ­uals should be informed that their role is to respect and support the patient's exercise of her autonomy in the decision-making process and not usurp it.

Gynaecological cancers

There is a strict beneficence-based obligation of the primary doctor to make a timely and effective referral whenever gy­naecological cancer is detected. Doctors who specialize in the management of gynaecological cancers have distinctive ethical obligations to patients referred to them. As the clinical manage­ment of the various gynaecological cancers continues to evolve, the range of medically reasonable alternatives will expand.

Gynaecological oncologists have an indispensable role to play in preparing patients whose disease is not responding to treatment for decision-making about the management of end-stage disease. The oncologist should explain the concept that, while current treatment remains medically reasonable, it should be expected to become no longer medically reasonable in the end stages of disease. The oncolo­gist should add that, when deliberative clinical judgement supports this view, the oncologist will recommend cessation of treatment and redirection of the goals of care to comfort and a dignified dying pro­cess, including hospice care where it is available. The patient should be supported to achieve cognitive understanding, appreciation, and evaluation of the clinical reality of the limits of medicine to alter end­stage disease. Her preferences should be elicited and documented in the patient's record. She should be encouraged to communicate her preferences, to prevent provision of life-sustaining treatment by default (24).

Where supported by law and health policy, the patient should be encouraged to document her preferences in an advance directive. A directive to physicians, or living will, communicates preferences directly to the care team and takes effect when the patient has a ter­minal or irreversible condition as defined in applicable law and has lost decision-making capacity. A medical power of attorney, or dur­able power of attorney for healthcare, allows the patient to appoint an agent to act as her surrogate decision maker when the patient has lost decision-making capacity.

Decision-making with adolescent patients

There is ethically justified, practical guidance from the American Academy of Paediatrics regarding the professional responsibility of doctors to include paediatric patients, especially adolescents who are legal minors, in the decision-making process about their clinical care (25). The Academy invokes a concept based on respect for au­tonomy: paediatric assent. This concept calls for adolescent patients to be involved in a developmentally appropriate way in the decision­making process about their clinical care. Paediatric assent is to be implemented in clinical practice in four steps:

1. Helping the patient achieve a developmentally appropriate awareness of the nature of his or her condition.

2. Telling the patient what he or she can expect with tests and treatment(s).

3. Making a clinical assessment of the patient's understanding of the situation and the factors influencing how he or she is re­sponding (including whether there is inappropriate pressure to accept testing or therapy).

4. Soliciting an expression of the patient's willingness to accept the proposed care (25).

The ethical concept of paediatric assent requires the gynaecolo­gist to respond to parental requests not to inform the patient by explaining the concept of paediatric assent and its implication: the child should be informed and involved in a developmentally appro­priate way. The child and her parents should be supported as they adjust to this change.

Multicultural challenges

One of the distinctive features of life in modern nation-states is their cultural pluralism. Patients also travel from their home countries for obstetric or gynaecological care. Finally, some women are involuntarily displaced by conflict or famine or forced migration. As a consequence, a doctor's patients will present from backgrounds that are remarkably diverse in their values and be­liefs, including values and beliefs about the roles and prerogatives of women.

Managing the challenges of multiculturalism in a professionally responsible way should be guided by two ethical considerations: (a) adherence to the obligations generated by the professional virtues and ethical principles, and (b) respect for the values and traditions of the cultures from which patients come.

In some cultures, patients with serious diagnoses, such as gynae­cological cancers, are not to be told their diagnosis and others in the family are expected to make decisions for them. Freedman provides guidance for the management of such cultural practices (26). The professional virtue of integrity and the ethical principle of respect for autonomy are clear: patients who have decision-making cap­acity have the right to participate in the decision-making process about their clinical care. This includes the right to opt out of this role, if the patient wishes. Moreover, some women may not accept the passive role that is expected of them by their culture and respect for autonomy requires that the preferred role of such patients be identified and implemented. Freedman introduced the concept of ‘offering truth' to address culturally based requests that a patient with decision-making capacity not be told the diagnosis or make decisions about its clinical management. The family should be in­formed that the patient has the right to determine her decision­making role and that she will be informed by her doctor that her family is making decisions for her and asked if this is acceptable to her. This approach risks some psychosocial disruption in the family but this disruption should be assumed to be temporary and there­fore manageable.

There is an additional, practical reason why requests not to inform patients—adult and minor adolescent alike—about their diagnoses and treatment should not be implemented. In the modern hospital, care is delivered in multidisciplinary teams, the membership of which changes over time. It is inevitable that the patient will be in­formed, because some team members will fulfil their professional responsibility to inform patients, which the physician in charge will not be able to control. Patients talk to each other and overhear conversations. The promise not to inform the patient cannot as a practical reality be kept. The patient will learn her diagnosis. It is far better that she learn it in a way structured by the informed decision­making process or in the paediatric assent process.

In some cultures there is an expectation that women who marry for the first time are virgins. In some cultures there is also a practice of vaginal cutting. Vaginal cutting, that is, female genital mutilation, is illegal in many countries, including the United Kingdom and the United States. It also violates women's human rights. Ethically and legally, genital mutilation is completely incompatible with profes­sional integrity. It follows that there is no ethical justification in the professional responsibility model for these practices. Doctors are therefore ethically prohibited from performing a physical exam­ination to determine whether a female patient's hymen is intact or from surgically altering female genitalia (27). In cultural contexts in which non-adherence by the woman with the culture's expectations may put her life in danger, the doctor should report this danger to law enforcement.