10/2/2015

1

Obstetrical Ethics

The Right to Choose

The Right to Refuse

CONFLICT OF INTEREST DISCLOSURE STATEMENT

• I don’t have financial interest or other relationships with the industry relative to the topics being discussed.

Learning Objective

The illiterate of the 21st century will not be those who cannot read and write, but those who cannot learn, unlearn, and relearn.                                     

Alvin Toffler

unlearn

10/2/2015

2

Why Do/Don’t We Accept a Woman’s Choice?

• The Facts

• The Fetus

• The Physician

Why Do/Don’t We Accept a Woman’s Choice?

• The Facts

• The Fetus

• The Physician

10/2/2015

3

What Is Morality?

Morality

Rationalist v. Intuitivist

ReasonRationalize

Morality

Nature

Nurture

10/2/2015

4

Nature: Babies Have Morals

Nature: Babies Have Morals

Evolutionary Moral Adaptations

Me Us Them

10/2/2015

5

Morality: a set of psychologicaladaptions that allow otherwiseselfish individuals to reap the 

benefits of cooperation

Joshua Greene. Moral Tribes

Evolutionary Moral Adaptations

Me Us Them

Nurture: Neutral, Laudable, Appalling

• Masturbation

• Homosexuality

• Sexual abstinence 

• Polygamy

• Abortion

• Circumcision

• Corporal punishment

• Capital Punishment

• Women allowed/no allowed to work

• Islam, Christianity, Judaism

• Capitalism

• Democracy

• Flag burning

• Long hair

• No hair 

• Meat consumption

• Alcohol consumption

Richard Schweder

10/2/2015

6

•Is it how we value Sanctity?

•Is it how we value Community?

•Is it how we value Autonomy?

Nurture: What Makes Us Different? 

Autonomy Community Divinity

Shweder, R. A., Much, N. C., Mahapatra, M., & Park, L. [1997] 

Domains of Moral Discourse

N Grams (Family, Me)

Chinese

American

Me

Family

10/2/2015

7

Philippa Foot

“If you talk to a man in a language he understands, that goes to his head. If you talk to him in his language, that goes to his heart.”Nelson Mandela

Ventromedial prefrontal cortex

=

Dorsolateral prefrontal cortex

=

Would You Kill The Fat Man?

No

Yes

10/2/2015

8

Autonomy Beneficence

“Ethics needs principles—and respect for autonomy should be ‘first 

among equals’” R. Gillon

Ethics

N Gram (Autonomy, Beneficence, Do No harm)

Patient and Provider

10/2/2015

9

Child

Schrödinger's Fetus

Minkoff H, Marshall MF, Liaschenko J. The fetus, the "potential child," and the ethical obligations of obstetricians. Obstet Gynecol. 2014 May;123(5):1100‐3

Abortus

Potential

Hierarchy of Rights/Interests

• Pre-viable1. Mother’s Negative Autonomy

2. Mother’s affirmative Autonomy

3. Fetal

• Viable1. Mother’s Negative Autonomy

2. Fetal

3. Mother’s Affirmative

10/2/2015

10

Obstetrician's response to the abortion controversy can’t be based on accounts of the independentmoral status of the fetus, because all such accounts are irresolvablydisputable.

Chervenak F, McCullough LB Am J Ob Gyn 1990;163

An Obstetrician’s View

Survey at ACOG

Section Without Consent = 54.5%

Marrow Without Consent = 26.1%

Those who performed a C/S (p=.04) or a marrow (P=<.01) without consent

scored higher on the Sanctity Scale & were more likely to be Male (P =.03

and P=.01 for C/S and marrow respectively)

10/2/2015

11

Hierarchy of Rights/Interests

• Pre-viable– Mother’s Negative

Autonomy

– Mother’s affirmative Autonomy

– Fetal

• Viable– Mother’s Negative

Autonomy

– Fetal

– Mother’s Affirmative

“Potential Child”

Potential Child

Minkoff H, Marshall MF, Liaschenko J. The fetus, the "potential child," and the ethical obligations of obstetricians. Obstet Gynecol. 2014 May;123(5):1100‐3

Potential Abortus

Fetus

Interests

No InterestsRights

Mother’s Right To Refuse

Fetal Rights

Considerations of Potential Child

10/2/2015

12

Amniocentesis for Huntington's Chorea

Continue Pregnancy if PositiveAbort if positive

Autonomy

Mother Physician

Negative

NegativePositive

Positive

Potential Child

Morality

Rationalist v. Intuitivist

Reason Rationalize

Morality

1. Nature2. Nurture

10/2/2015

13

Motivated Reasoning

Can I believe this?

Must I believe this?

Party Over Policy

Cohen GL. Journal of Personality and Social Psychology 2003Vol. 85, No. 5, 808–822

Motivated Reasoning?

B]. Assume the risk of excess death or serious morbidity associated with TOLAC is 1/1,000. Is 1/1,000 an acceptable risk?

*P = <0.001 for A vs. B

A]. Assume the risk of excess death or serious morbidity associated with home birth is 1/1,000. Is 1/1,000 an acceptable risk?

No = 28.9%*

No = 63.9%*

10/2/2015

14

Eating toastBeating your wifeHaving sex with a Corpse

No Right to Put A Baby at Risk?

• Refused Cesarean Delivery

• Smoking

• Supersizing

• Overworking as a resident

• Left Turns

Morality

Rationalist v. Intuitivist

Reason Rationalization

1. Be aware of bias2. Be concerned about consequences

10/2/2015

15

Thank You