Bioethics

1. Bioethics Maternal-Fetal Conflicts Julius Ceazar Reyes MD January 17, 2011

2. Who’s Life Should Be Saved?

3. No direct answer.

4. What if both have the same chance of survival?

5. Save the mother and allow the child to have a natural death.

6. But if you can save both, save both the mother and fetus

7. GENERAL GUIDELINES Maternal and fetal conflicts include complications, surgical complications and invasive diagnostic procedures during pregnancy. The conflict is between the mother and fetus.

8. GENERAL GUIDELINES Principle of double effect should be applied

9. GENERAL GUIDELINES In assessing risk, the physician should provide the patient with accurate objective observation of her disorder and known data gathering.

10. GENERAL GUIDELINES The physician should as accurately as possible, quantify benefits and risks. This should be communicated in a manner accepted to our Filipino culture and appropriate to the particular patient.

11. GENERAL GUIDELINES In risk acceptability, the physician must allow the patient to make her own decision.

12. GENERAL GUIDELINES Unless specifically requested by the patient, her family should be given the same information and be involved in the decision making process.

13. GENERAL GUIDELINES A physician has the right to withdraw from the case if what is decided by the patient conflicts with his own personal values or the institution’s values

14. GENERAL GUIDELINES In an emergency situation, the physician should serve as the surrogate decision maker and exercise his therapeutic privilege.

15. CASES

16. ECTOPIC PREGNANCY Tubal Pregnancy 1. When the tube is so damaged to constitute a serious threat to the maternal life, the tube may be removed as a traumatized pathological tissue. The principle of double effect is applied

17. ECTOPIC PREGNANCY Tubal Pregnancy Wrong Mentality – Remove the tube because the fetus won’t live anyway Right Mentality – The tissue of the tube is traumatized pathological tissue, therefore should be removed

18. ECTOPIC PREGNANCY Tubal Pregnancy In a rare case when the pregnancy was advanced to a stage approaching viability, the element of proportion in the principle of double effect has to be given special consideration and attention.

19. ECTOPIC PREGNANCY Tubal Pregnancy Proportion is between the risk of expectant treatment for the mother and chance if soon delivering a viable fetus.

20. ECTOPIC PREGNANCY Abdominal Pregnancy If no hemorrhage  Viability  Cesarian Section

21. ECTOPIC PREGNANCY Abdominal Pregnancy In actual crisis of dangerous hemorrhage, surgical intervention to control the bleeding is morally permissible under the principle of double effect, provided no direct attack is made on the fetus

22. ECTOPIC PREGNANCY Ovarian Pregnancy As long as rupture has not occurred and as long as the mother’s life is not in imminent danger from her traumatized tissue, one could not justify surgical intervention on the ovary while there remain some real hope of delivering a viable fetus in the future.

23. ECTOPIC PREGNANCY Cervical Pregnancy Direct attack is immoral Surgical intervention upon dangerously pathological tissue may be done under the principle of double effect.

24. ECLAMPSIA The principle of double effect can’t be applied because the evil effect is necessarily directly willed, since it is envisioned as a necessary means to producing the good effect

25. ECLAMPSIA What could be done if the patient is in eclamptic crisis is to control the eclampsia MEDICALLY until the fetus is viable and can be delivered.

26. CHORIOAMNIONITIS The only morally accepted removal of the fetus would be into an environment which would offer as good or as better environment than it already is.

27. CHORIOAMNIONITIS Wrong Mentality: Remove the fetus because it will going to die anyway. Correct Mentality: If we do empty the uterus, both mother and baby will live longer.

28. H-MOLE 1. If the H-mole has advanced to such a stage that it is incompatible with the presence of living fetus, dilatation and curettage, hysterotomy or hysterectomy are morally acceptable

29. H-MOLE 1. If the uterus, even probably contains a living fetus, expectant treatment must be maintained until the positive diagnosis of H-mole is established and the presence of a living fetus is ruled out.

30. ABRUPTIO PLACENTAE When it occurs near term or at onset of labor, all should be done to save both mother and child It is morally acceptable to prematurely remove a viable fetus

31. ABRUPTIO PLACENTAE • If fetus is not viable… • Hemorrhage is mild and doesn’t endanger the mother’s life, no steps can be taken that would considerably endangers the life of the fetus

32. ABRUPTIO PLACENTAE • If fetus is not viable… • Even if the hemorrhage becomes serious, the direct removal of non-viable fetus is never permitted

33. ABRUPTIO PLACENTAE • If fetus is not viable… • When the maternal life is in danger, it is morally permissible to control the hemorrhage by drug therapy, tamponade, even if it is foreseen that it will result in premature labor or in fetal death from some other cause (principle of double effect)

34. ABRUPTIO PLACENTAE • If fetus is not viable… • Laparotomy and amputation of the uterus in the presence of a fulminating placento-uterine hemorrhage, even with a non-viable fetus in situ, is morally permissible (double effect)

35. CANCER Before 3rd trimester, the Cancer is treated. Any adverse effect on the baby is not intended but merely permitted

36. CANCER • In the 3rd trimester, as much as possible, the pregnancy must be brought to term. If this is adverse: • Remove the fetus if it is already viable • Treat the Cancer if it is not yet viable

37. CANCER Viability is in bottom line, and the treatment is necessary, the principle of double effect is applied

38. Bioethics Sterilization Julius Ceazar Reyes MD January 17, 2011

39. Why is it unethical?

40. Because it stops pregnancy

41. What is allowed?

42. Indirect Sterilization

43. 2 Types Direct – the purpose of the procedure is to render the patient infertile

44. 2 Types Indirect – one which results as a side effect of medical therapy aimed at specific pathology affecting a person (Principle of Double Effect)

45. PRINCIPLES Sterilization may not be used as a means of contraception.

46. PRINCIPLES Every action which either in anticipation of the conjugal act or in accomplishment or in the development of its natural consequences proposes to render procreation impossible IS NOT PERMISSIBLE only when needed.

47. PRINCIPLES • Procedure that induces sterility are permitted when: • They are immediately directed to the cure, diminution or prevention of serious pathological condition, then the procedure may be done.

48. PRINCIPLES • Procedure that induces sterility are permitted when: • A simpler treatment is not reasonably available, sterility, and is permitted

49. CASES (Morally Permissible)

50. Primary gonadal pathology – oophorectomy Hysterectomy is permitted when it is sincerely judged to be a necessary means of removing some serious uterine pathological condition. In these cases, the pathological condition of each patient must be considered individually. Care must be taken that a hysterectomy is not performed merely as a contraceptive measure.