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Medical Ethical dilemmas in caring for the mother and unborn child

Medical Ethical dilemmas in caring for the mother and unborn child. Sam Coulter-Smith Master Rotunda Hospital, Dublin . Focus on Maternity Service. Galway Maternal death - multiple investigations Recent Oireachtas Health committee- Abortion Current debate Forthcoming Draft legislation.

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Medical Ethical dilemmas in caring for the mother and unborn child

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  1. Medical Ethical dilemmas in caring for the mother and unborn child Sam Coulter-Smith Master Rotunda Hospital, Dublin

  2. Focus on Maternity Service • Galway Maternal death - multiple investigations • Recent Oireachtas Health committee- Abortion • Current debate • Forthcoming Draft legislation.

  3. Background to current situation Practice / Law / Guidelines • Existing statute • Case law • Medical Council guidelines • Current practice

  4. X Case 1992 • Chief Justice Thomas Finlay ‘‘ if it is established as a matter of probability that there is a real and substantial risk to the life , as distinct from the health of the mother, which can only be avoided by the termination of her pregnancy, such a termination is permissible’’ • This new case law contradicts what is on the statute books • Current medical council guidelines based on this case law

  5. European court of human rights 2010 • Found Ireland had failed to provide for abortion in circumstances where the mothers life was at risk. • Instruction to Ireland to legislate for suicide • BUT • Did they take all the facts into consideration?

  6. Risk of suicide in pregnancy • European Court ruling - we must legislate for suicide • but • Suicidal ideation Rare in pregnancy. Incidence in UK is 1:500,000 pregnancies. More common in post natal women. • Unpredictable and risk is difficult to assess. Usually associated with Pre-existing mental health issues or social circumstances. • ToP not a treatment for mental health issues, no suggestion its a treatment for suicidal ideation.

  7. Confusion • Medical council guidelines • Case law • Statue • Is there a need for new legislation? • This has led to much debate and disagreement within the profession and beyond

  8. Implications of legislation • Positive • Brings law to comfort the medical profession • Backs up medical council guidelines • Negative • Is it required ? • ? Need to mention any clinical entity • ? Open door to ToP – many crisis pregnancies travel to UK – they may want ToP here • Definite Resource issues – 3 sub spec obs psych services in the country. Maternity services already overstretched, understaffed and underfunded

  9. Difficult Clinical scenarios • Mothers life at risk - variable acuity- How urgent? • Soon -Pre existing condition- Cardiac disease e.g. Eisenmenger’s syndrome • Urgent- New diagnosis – Cancer requiring surgery or chemo/radio therapy asap. • Emergency -Complication of pregnancy- Haemorrhage or Infection, Hyper emesis, Eclampsia, HELLP.

  10. Gestation Dependant intervention • All efforts always made to save infant • Before 23 weeks – fetus won’t survive • After 25-26 weeks - 80-90% survival with good NICU • Grey area 24 weeks – management depends on severity of maternal condition.

  11. Issues in providing a ToP service to save a mothers life • Who decides ? • How many opinions required- • Multidisciplinary input? • What happens in an emergency? • Where? • Who performs the procedure? • Conscientious objection !!!! ?? • Appeal mechanism if refused – who? • Oversight of the area? • Impact on service? • Terminology

  12. Other Ethical issues related to current debate but not covered in current discussion or proposed legislation • Rape • Incest • Lethal congenital / Genetic anomalies

  13. Other Obstetric Medical / Ethical issues • Jehovah’s witness – refusal of blood – 2 patients- e.g pregnant with parvo infection fetal anaemia and hydrops requiring transfusion. Or Mother has placenta praevia life threatening APH • Refusal to accept medical intervention in labour- relatively common in African women strong Christian belief God will look after them. • HIV + refusal to accept LSCS • LSCS rate target of 20% - maternal request for LSCS • Demand for LSCS on request – Right to choose in UK (NICE) v illegal in Turkey.

  14. Fertility related ethical issues • IVF embryo transfer (Single v Multiple transfers) • IVF- Age availability ? Limit • Selective termination in cases of large multiple gestation.

  15. New Technology • Lack of regulation in fertility service- surrogacy, frozen sperm/eggs/embryo in cancer patients • Technology moving faster then regulation • Pre implantation Diagnosis (microarray) • New fetal medicine interventions e.g In utero surgery (spina bifida)

  16. Governance issues • Clinical Governance • Budget allocation, Staff to patient ratios, infrastructure. • 30% busier then 2006 • Are the funders taking their moral and ethical responsibility seriously? • Appropriate KPIs in SLA

  17. Thank you

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