Ethics & Jurisprudence

1. Ethics & Jurisprudence • Group names: • Faeeza Abdullatief • Mujeeb Hoosen • Ferial de Jongh • Aqeelah Mukadam • Raeesah Hassen • Faranaaz Vahed Case Presentation: A.C Caesarean Section

2. Sokol’s Four Quadrant Analysis

3. Quadrant 1: Medical Indications • Medical problem • Cancer (Tumor) that spread throughout her right lung= bad prognosis • Terminally ill patient Mrs. AC that required a premature C-Section at 26 weeks gestation due to maternal medical conditions and the health of the baby (baby’s condition was worsening)

4. C-Section birth Definition: In a cesarean birth (C-section), the baby is delivered through an incision in the mother's abdomen and uterus (womb) • Risks involved • For mother: Caesarean birth is major surgery and risks are involved. The estimated risk of a woman dying after a caesarean birth is less than one in 2,500 (the risk of death after a vaginal birth is less than one in 10,000) • For baby: Caesarean birth also carries risk for babies, especially those who are born premature. The risk of death for premature babies delivered by elective C-section is 54 out of 10,000, while the risk of death for premature babies born vaginally is 14 out of 10,000.

5. History of A.c. C-Section • Mrs. AC • 13 years old- diagnosed with cancer – treatment: chemo, radiation, surgery • 27 years old- married (remission) and soon after became pregnant. She wanted the baby • Tuesday, 9 June: 25 wks pregnant checkup: Also complained of S.O.B and pain in her back. An X-ray confirmed an inoperable tumor in her right lung. Admitted to hospital as a high risk pregnancy. • Friday, 12 June: Condition had temporarily improved. When doctors asked if she wanted the baby, she replied that she had. • Monday, 15 June: Conditioned had worsened over the weekend. Doctors told her that she was terminally ill and had agreed to palliative care. • Prolonging her life for the birth of the baby at 28 wks- better chance to life than 26 wks. • Ms. Carter was aware of harm to baby by being on palliative care. Her condition made her indecisive of whether she wanted the baby or not. That night she also consented to intubation to facilitate her breathing

6. History (cont.) • The next morning, June 16, the trial court convened: A neonatologist testified- chances of survival for baby at 26 weeks- 80% but due to mother's medical history- only 50% to 60% survival. • Risk of substantial impairment for the fetus, if it were delivered promptly, would be less than 20%. • The fetus' condition was worsening appreciably at a rapid rate. Any delay in delivering the child by caesarean section lessened its chances of survival." • The Court authorized the hospital to perform a caesarean section- to save the life of the fetus over the objection of the pregnant woman, her husband and parents. Operation was performed, but both the mother and the child died.

7. Quadrant 2: Patient preferences • Is the patient mentally capable and legally competent? Competence In order to give informed consent for a medical procedure, a patient must be legally competent to do so. • Every adult is presumed to be legally competent, unless and until determined otherwise by a court of law.

8. Principle of Informed Consent The ability to give informed consent depends on: •  adequate disclosure of information • patient freedom of choice • patient comprehension of information • patient capacity for decision making. By meeting these four requirements, three necessary conditions are satisfied the individual’s decision is voluntary as long as there is: • An appropriate understanding of the circumstances • Careful consideration of all of the expected benefits, burdens, risks and reasonable alternatives.

9. Presumed Consent- when treatment cannot be delayed consent should be given by: • his or her parent, spouse, • Physicians base such treatment decisions on what the reasonable person would want in such circumstances, and on what treatment is in accord with the current medical standard of care. Implied Consent • Implied consent exists when a person has actually consented to a certain treatment, but not to every detail of that treatment.

10. What are the patient’s wishes if competent and presumed wishes if not? • For the baby to be delivered at 28 weeks of gestation and not at 26 weeks as the baby’s chance of survival would be higher.

11. Quadrant 3: Quality of life • Is there good to be gained saving the life of the unborn child equal or greater than the harms involved for the mother’s personal autonomy and cutting into her body against her will thus putting her life at risk? • Is the possible harm to the mother only risked in order to achieve the greater good of saving the life of the unborn child

12. Quadrant 4: Contextual features • Economic factors: palliative care and C-Section very costly • Religious & Cultural factors: catholic tradition- the right to life is presumed from the moment of conception. • Section 15 of the constitution gives each individual a right to freedom of religion, belief, opinion and conscience.

13. The LawThe Constitution of the Republic of South Africa (1996): The Bill of Rights • The right to life (Section 11) Section 11 provides that everyone has the right to life. This right is also protected by common law. • The right to freedom and security of the person (section 12) Provides the following in subsection (2): Everyone has the right to bodily and psychological integerit, which includes the right: (a) to make decisions concerning reproduction; (b) to security in and control over their body; and (c) not to be subjected to medical or scientific experiments without their informed consent.

14. The prohibition of unfair discrimination (Section 9) Prohibits discrimination on the ground of disability Schedule to Act 4 of 2000: • subjecting persons to medical experiments without their informed consent

15. Ethical considerations • Beneficence of baby vs. Autonomy of mother • Beneficence: duty of health care providers to be of benefit to the patient, as well as to take active steps to prevent harm from happening to the patient • Autonomy: a competent person should make informed and voluntary decisions, translated it means all people should give their "informed consent". In health care decisions, respect for the autonomy of a patient implies that the patient has the capacity to act intentionally, with understanding, and without controlling influences which would be contra to a free and voluntary act. *Ethical Dilemma: Is a pregnant woman a person who carries within her body a human with fewer rights than she, or is she carrying a person with the same rights as human dignity that she herself posses? • C-section only chance of survival for fetus but would hasten the end of Angela’s grasp on life • Performing a C-section knowing that Angela objected and her legal medical proxy (Husband and parents) objected to it

16. Nonmaleficence: “first do no harm” – not to intentionally do harm. • The double effect: intended effects and merely foreseen effects. Conditions that must be adhered to: • the act itself must not be fundamentally immoral, but must be a good or neutral act; • only the good effect must be anticipated by the researcher, not the bad effect, even though it is foreseen; • the negative effect must not be the means of the good effect; and • the good effect must prevail over the bad that is permitted. • Intention: performing a C-section to better the chance of survival of the foetus • Foreseen circumstances: foetus has 50-60% survival chance after c-section. Mother is terminally ill and therefore has a slim chance for survival • Outcome: both the baby and the mother died

17. The right to life • The first right of every human individual, and the foundation and condition for the exercise of all other rights (and thus a human right). In the Catholic Tradition, the right to life is presumed from the moment of human generation • Personhood: when a person an actual person is debatable • Duty of healthcare practitioner to preserve and protect life • The means used to protect and preserve a particular life must take account of concrete circumstances and be "objectively proportionate to the prospect of improvement"

18. Respect for Human dignity • Intrinsic worth and dignity of every human person - a dignity that stems from our creation in the image and likeness of God - medical context, these rights, and our human dignity, exist and must be respected despite any physical imperfection: deformity, disability, disease, etc.

19. Recommendations • Finding a balance between the beneficence of the baby and the autonomy of the mother • Proxy protocol vs. Vicarious consent • The appellate court later ruled that the wishes of the pregnant woman should have been determinative in such a situation except in very unusual circumstances.

20. References • Ascension Health, Healthcare ethics- for the public- cases available at: http://www.ascensionhealth.org/default.asp • Nortjé N, 2009. Ethics & Jurisprudence class notes. University of the Western Cape, School of Natural Medicine • Wikipedia- the free encyclopedia http://www.wikipedia.com

21. Thank You… Any Questions???