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The Healthcare industry is the dimension in which people frequently face moral challenges with which they have to deal within short periods of time. Quite often, doctors do not have an opportunity to wait for the patient’s decisions on his or her health situation. In other cases, a patient may be unconscious, and the resolution lies on the healthcare workers’ shoulders. Sometimes, the opinions expressed by patients are considered by doctors as wrong, and they prefer not to fulfill the will of their customers.
In each of these cases, different ethical theories may be employed. Whatever decision healthcare workers make, they should think about their patient’s life in the first place. However, there are cases when people disagree with their doctors’ choices and decide to prove that the situation could have been resolved in a different way. The case of Rinat Dray, who is suing the Staten Island University Hospital of New York, is a demonstration of such a dispute.
Identification of the Ethical Issue
The issue that aggravates Dray occurred in 2011, but she has not yet received a final answer to her questions. The woman says that a doctor at the Staten Island University Hospital (SIUH) made her undergo a C-section against her will (Redden). It was Dray’s third pregnancy, and the first two times, she had been given a C-section, so she wanted to deliver the third baby vaginally. However, she claims that she was not deprived of such an opportunity.
The internal policy of the hospital gives detailed instructions to doctors that explain how to perform surgeries and other procedures without the patient’s consent. According to the policy, in some cases, a doctor can do surgery without a pregnant woman’s permission if he or she has not been able to obtain the patient’s consent. Such cases include situations when several doctors recognize the risk of vaginal delivery and consider that a C-section will benefit the fetus as well as will eliminate the risk for the woman (Redden). When there is a threat to the fetus, doctors become even more empowered to make decisions without the woman’s consent.
On such occasions, the doctor is allowed to neglect the woman’s decision and not consult other specialists. This policy is contradictory to ethical recommendations issued by the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) that disapprove of performing any procedures without obtaining the mother’s consent for the advantage of her fetus (Redden). According to the guidelines issued by the ACOG’s ethics committee, pregnancy is not an exception to the regulation that a “decisional capable” patient can deny treatment, even the one that is necessary to maintain life (Redden).
The ACOG and the AAP made a statement that even the most substantial evidence for the benefit of a fetus could not be considered as an ethical presumption to neglect the decision of a pregnant woman.
The SIUH manual of administrative policies and procedures states the following:
- every possible attempt should be made in order to adhere to the woman’s rights and decisions, but also to secure the fetus’s welfare;
- since the fetus is physiologically contingent on the pregnant woman, the burden of the outcome of her decisions on the fetus needs to be taken into consideration by the healthcare workers;
- in some cases, the importance of the possible benefits of medically specified treatment to the fetus “may justify” using the methods required to “override a maternal refusal of the treatment” (Redden).
The policy helps to clarify why doctors forced Dray to have a C-section without her agreement. However, according to the lawsuit filed by the woman, she “was begging” the doctors to give her more time and deliver in a natural way, but they refused to do so (Redden). The hospital does not reject the fact that they forced the woman to have the surgery she did not want. However, the SIUH doctors claim that they “likely saved” the life of her newborn son (Redden).
Before the operation, the head of obstetrics entered the following note in Dray’s chart, “The probable benefits of C-section significantly outweigh the possible risk to the woman… I have decided to override her refusal to have a C-section” (Redden). The hospital’s policy concerning the issues of performing procedures without patients’ consent had never been revealed prior to that issue. It became known in the process of a lawsuit and explained the reasons why some doctors overrule their pregnant patients’ medical decisions.
The Guardian wanted to compare the SIUH’s policies to those of other hospitals, so it requested the administration of some of the largest hospitals to share their protocols (Redden). Some of the healthcare facilities admitted having no policy for the situation when a pregnant woman resists her doctor’s advice. However, a few hospitals did have such a protocol. None of the facilities that shared their policies empowered doctors to make the final decision in a conflict situation (Redden). Thus, out of the hospitals, the policies of which had been checked, the SIUH was the only one empowering doctors to override pregnant women’s decisions in case of an emergency.
Dray is not the first woman to declare that doctors employed pressure and threats, trying to make her undergo a C-section. In 2003, a research study on maternal-fetal medicine was performed. Out of all the cases collected in forty-two hospitals, there were nine occasions when a pregnant woman was forced to have a C-section by the hospital with the help of a court order (Redden). In 2004, there was a case at a Pennsylvania hospital when by the court order, doctors were allowed to perform a C-section despite a woman’s objections.
The woman went to another hospital where she had a natural delivery with no complications (Redden). As it becomes clear from this example, the hospitals do make mistakes when making decisions concerning the C-section, and women do not feel worried without any reason.
While C-sections are considered to be life-saving in many cases, in the US, many of them may be avoided. In the majority of countries, the rates of C-section take up from 10% to 19% of all the cases. Meanwhile, in the US, more than one-third of all babies are delivered through C-section (Redden). According to the director of the Kennedy Institute of Ethics, Maggie Little, there are frequent disagreements about the necessity of a C-section.
In many cases, women’s refusal to have surgery is justified, and the doctors’ insistence on a C-section is not reasonable. The policy of the SIUH acknowledges that some hospitals have the power to decide “morally fraught” issues without taking into consideration the will of women who will be impacted by the decision (Redden). Dray’s lawyer Michael Bast says that he considers the SIUH’s policy unethical and illegal. The director of the National Advocates for Pregnant Women, Lynn Paltrow, mentions that the SIUH’s protocol is a “secret” policy, and no one informs pregnant women about it (Redden).
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According to the policy, when there is a serious risk to the fetus’s welfare without surgery, and when there is little risk to the woman, the doctor should endeavor to convince the woman to change her opinion. If she does not want to do so, the physician and the director of obstetrics, together with the department of legal affairs of the hospital, may choose to perform a surgery without her permission. Apparently, Dray does not agree with the doctor’s definition of risk and claims that there was none.
It is not a common situation when a woman who has previously had a C-section delivers the next baby vaginally. Dray decided to give birth to her third child at the SIUH because this hospital supports vaginal birth after Cesarean (VBAS). Also, the C-section rate of the hospital was comparatively low when the woman was making her choice. In contrast to the New York average rate of 34.4%, the SIUH rate was 18.7% (Redden). However, when the woman was in labor, the doctor insisted on a C-section. Dray claims that she begged for more time, whereas the doctor says that the thirty-four hours given to her were enough to resort to surgery.
There is no final decision on this situation yet. While Dray has filed a lawsuit against the hospital in a legal dimension, there are some highly important ethical issues to take into consideration. Apart from saving people’s lives, doctors have to think about satisfying moral principles. However, pregnant women also have an ethical responsibility to their fetuses.
Analysis and Evaluation of the Ethical Issue
In order to analyze and evaluate the issue, Kant’s ethical theory of deontology may be applied. According to Kant’s theory, actions are morally right when they are done out of duty. He remarks that a “goodwill” is not good because of what it achieves or impacts and not because of its ability to reach the set goal but merely because of its volition to do something well (Kant 485). Thus, the doctor’s decision to do what is best for the fetus may be regarded as consistent with deontological ethics.
He wanted to eliminate the harm to the fetus, so he decided to do a C-section even though the woman did not want it. In Kant’s works, it is emphasized that it is everyone’s duty to “be beneficent where one can” (Kant 487). In the situation with Dray, the doctor was trying to be beneficent to the unborn baby. Even though his decisions and actions contradicted the pregnant woman’s desire, he wanted to make sure that there was no risk to the baby. Meanwhile, the woman did not face any risks, so the only way to demonstrate goodwill was associated with the attitude towards the baby.
According to Kantian ethics, the doctor did everything well. He made sure that he fulfilled his duties in the best way. He eliminated the risk to the infant and did not put the woman’s life in danger. Thus, his actions may be justified by the assumptions of deontological ethics (Kant 485-489). Moreover, his decision was supported by the hospital’s policy. The woman was anesthetized, so she could no longer resist a C-section. Taking into consideration the circumstances, the doctor did the right thing.
A professor of medical ethics at Baylor College of Medicine, Janet Malek, emphasizes that the situation with Dray involves a big “emotional component” (Redden). She mentions that doctors should not override pregnant women’s decisions. However, when choosing between the mother’s wishes and the baby’s life, Malek admits that she considers life more significant (Redden). Even when the mother does not agree to have surgery, the doctor should fulfill his duty in the first place.
There are hospitals the policies of which are contradictory to that of the SIUH. George Washington University hospital allows their patients to “determine the course of medical treatment for yourself and, if you are a pregnant woman, for your fetus” (Redden). This regulation was issued after a patient forced to have a C-section died in 1987. A policy of the Memorial Healthcare System of southern Florida states that any adult patient who has no dependents can “refuse medical treatment… regardless of the reason” (Redden).
Thus, not all hospitals empower their doctors to accomplish their duties to the full extent. Meanwhile, the doctor at the SIUH acted in accordance with deontological ethics and wanted to do what was best for the fetus, taking into consideration that there was no risk for the woman.
In the current situation, the most probable resolution is the one that incorporates the ethical theory of utilitarianism. According to its principles, it is necessary to strive for the happiness of all people (Mill, 417-418). Taking into consideration the issue between Dray and the hospital, not everyone’s happiness was reached. The doctor cared about fetus’s welfare in the first place. What concerns the mother, the doctor did not pay sufficient attention to making her happy by satisfying her desires.
However, if he had allowed her to have some more time and had given her a possibility to deliver vaginally, he would have acted by utilitarian ethics and have reached the “happiness which forms the utilitarian standard of what is right in conduct” (Mill 417). The solution would have reached the highest point of utility, which was impossible due to the decision made by the doctor.
Utilitarians tend to put the greatest emphasis on the morality of actions and do not pay sufficient attention to other “beauties of character” that people apply when reaching their aims (Mill 419). When cultivating their moral feelings, utilitarians sometimes neglect artistic perceptions and sympathies, which may lead to adverse outcomes. Utilitarian ethics leaves space for rigidity and laxity in the implementation of their standards. Some of their principles are “puritanically rigorous,” whereas others are extremely “indulgent” (Mill 419). On the whole, the concept of utilitarianism presupposes thinking about each participant of the case rather than only of the one that requires the most attention.
Therefore, the situation with Dray could have been averted if the doctor and the hospital employed utilitarianism ethics when making their actions. First of all, they should have thought not only about the fetus’s welfare but also about the mother’s desires. Her two previous experiences with a C-section were painful and unpleasant, so her third delivery could have become the first positive experience of childbirth in her life.
Unfortunately, the SIUH policy deprived Dray of such an opportunity (Redden). Secondly, there was no obvious risk to the mother. The doctor’s statement that he was caring for the pregnant woman has not been proved by any facts or patient’s files. As such, it is another proof of the insufficient consideration of the woman’s rights and wishes. If the doctor had not neglected Dray’s request, nothing wrong would have probably happened either to her or her baby. However, there was no chance to check this theory since the decision taken by the healthcare provider-led to surgery.
Utilitarian ethics would have been the best solution to the analyzed situation because it would have reached the state of happiness for each of the parties. However, there was a pressure of time that made some impact on the doctor, which should not be disregarded. According to Smart, in the circumstances when there is not enough time to consider the situation thoroughly, utilitarians may trust the “rules of common-sense morality” (424).
In some situations, when the person’s interests are involved in the decision-making process, he or she may be prejudiced, and the drivers of the decisions may be not objective (Smart 424). It was exactly the case that occurred at the SIUH. The woman had been in labor for a day and a half, and the doctor considered a C-section the only possible variant under the circumstances. Viewing the situation from the angle of utilitarian principles, it is possible to suggest that the doctor exaggerated his own unhappiness and diminished the woman’s unhappiness.
He thought that in case of any problems with the baby, he would have faced serious consequences that might have led to losing his position, a lawsuit, or even losing practice. What concerns his consideration of the patient’s happiness, he thought that she would be glad to see that her baby was healthy, and there were no risks to its life. As for the fetus’s happiness, the doctor seems to have thought if it in the first place: he knew that while vaginal delivery might have posed some danger to the fetus, a C-section would have eliminated the risks. However, it seems that the doctor had enough time to analyze the situation, and if he had made a choice in favor of utilitarianism, everyone would have been satisfied.
Medical ethics is one of the most complicated dimensions of ethical theory. Doctors face challenges daily, and sometimes they make decisions that their patients do not like. While in the majority of the situations, there are policies that help to resolve conflicts, the current issue did not undergo sufficient analysis and led to the extreme dissatisfaction of a patient. The hospital acted I accordance with deontological ethics whereas the best possible solution was utilitarian ethics.
Rather than putting emphasis on the welfare of the fetus, the doctor should have given the pregnant woman an opportunity to have a natural delivery. Had he done that, she would not have filed a lawsuit against the hospital. Utilitarian ethics that puts the happiness of all in the first place would have been the best solution in this situation.
Kant, Immanuel. “Groundwork of the Metaphysics of Morals.” Ethical Theory: An Anthology, edited by Russ Shafer-Landau. 2nd ed., Wiley-Blackwell, 2013, pp. 485-498.
Mill, John Stuart. “Utilitarianism.” Ethical Theory: An Anthology, edited by Russ Shafer-Landau. 2nd ed., Wiley-Blackwell, 2013, pp. 417-422.
Redden, Molly. “New York Hospital’s Secret Policy Led to Woman Being Given C-Section Against Her Will.” The Guardian. 2017. Web.
Smart, J. J. C. “Extreme and Restricted Utilitarianism.” Ethical Theory: An Anthology, edited by Russ Shafer-Landau. 2nd ed., Wiley-Blackwell, 2013, pp. 423-427.