This is a follow-up to my post yesterday about abortion.
I think almost everyone, no matter what their stance is on abortion, agrees that no physician should have to perform an abortion if they believe it's wrong. I certainly believe this.
However, consider this scenario:
There is a primary care physician named Dr. Green who believes abortion is wrong. Naturally, as a PCP, she does not ever have to perform this procedure.
However, Dr. Green has a patient named Mrs. Blue. Mrs. Blue has some serious medical issues, and recently became pregnant accidentally with her husband, despite believing she was sterile. She was told in the past that she would definitely not be able to carry a pregnancy to term; however, Mrs. Blue really wanted a child and initially was hopeful she could make it work. Unfortunately, about six weeks into the pregnancy, Mrs. Blue starts bleeding and feeling ill. She makes the difficult decision to terminate the pregnancy, as it is almost certain to miscarry or else result in significant morbidity to herself and/or the baby.
However, due to her significant medical issues, Mrs. Blue is told that she needs medical clearance prior to the abortion. She quickly makes an appointment with her PCP Dr. Green. Dr. Green knows Mrs. Blue's significant medical history, knows she is already bleeding, but at the appointment refuses to give her medical clearance because she feels abortion is wrong.
This appointment occurs on a Friday and now Mrs. Blue must wait through the entire weekend to see her specialist to get clearance. Unfortunately, she does not make it through the weekend, starts hemorrhaging on Sunday, and has to have a hysterectomy.
Should Dr. Green feel responsible for this turn of events? If there are complications involved, should Dr. Green be subject to lawsuit?
(Some variation on this happened to a woman I know.)
This falls under the "Dick Move" corollary of ethics: Patient wasn't asking the doctor to perform the abortion, but asking to be certified healthy enough to undergo a medical procedure. Its a dick move to not clear her if she is healthy enough for the sole reason that the doctor feels that abortion is wrong. This is especially true if the clearance was the sole reason for the visit...if the doctor knew that's why she was coming in and knew ahead of time that they wouldn't clear her no matter what, I would say that that also qualifies as an advance dick move and the doctor probably should have gotten her an appointment with the specialist to start off with instead of letting her come in under the impression that the doctor would be able to assess and clear her fairly.
ReplyDeleteCompletely unethical and Dr. Green deserves to be sued. As an example, I think doing drugs is wrong but would still give patients information regarding needle exchanges etc because I don't believe addicts deserve HIV/hepatitis etc.
ReplyDeleteFundamentally, people who are anti-choice believe that a pregnant woman does not deserve the same agency over her body as any other person has. If Fizzy needed a bone marrow transplant, for example, and my husband was the only match in the world no one would argue that my husband should be legally obligated to give her his, right? Even though Fizzy is alive and would likely die without a transplant my husband has rights over his body. I don't think an abortion is any different except that the woman deserves to be punished for daring to have sex and causing herself to become pregnant.
*off my soapbox*
Sophia
Easy to call it a dick move when abortion isn't something you consider immoral.
DeleteYour analogy of providing information regarding needle exchanges for drug addicts isn't entirely accurate either. You believe that using drugs is morally wrong. Okay. Fine. But providing information regarding needles isn't necessarily approving drug use. On the other hand, giving medical clearance is implicit approval. Not necessarily MORAL approval, but approval for the abortion, nonetheless. That's a non-starter for many people who might feel abortion is morally wrong.
Some solutions:
1. PCP should have made clear her position and should have provided information on specialists who can give clearance/do the procedure earlier on (this would be the same as your needle-drug example)
In this scenario, it seems like the PCP didn't do a good job of this--thus is AT LEAST partially responsible--because the patient made an appointment for clearance from the PCP.
2. The specialist should be sued. Doctors should work weekends. It's their duty to be overworked to death.
Just kidding. But there needs to be a way for patients to get access to care, not just emergency care, during weekends. I don't know what that might look like.
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By the way, I'm not pro-life. But many in my family and friends are...at least from a moral standpoint. I find it insulting that you think that my family and friends are pro-life because all they want to do is punish women for having sex without having met any of them once. Especially when they're more or less okay with abortion being legal; they just want no hand in the direct process of abortion and do not want to be forced to say that abortion is morally okay.
Regardless of your definition of what constitutes "life" and "a person," ultimately, abortion still involves ending a potential life. That might not mean anything to you and that's fine, but don't disrespect others who disagree. Otherwise, you're being just as bigoted those Republicans/social conservatives you hate so much for being intolerant of others.
The intolerance is only troublesome when it limits the rights of others. Dr. Green is entitled to think what she wants. But her actions limited Mrs. Blue's right to get a safe, timely abortion. That's the part I have a problem with. If she had refused to schedule an appt with Mrs. Blue in the first place, I would not find her as culpable.
DeleteI assume that you review all your appointments at the time they are made and know what the person is coming in for. And by that I do mean at the time they are made. Not the morning of. That is too late.
DeleteAs we all know, the answer to my question is no you don't and neither does any other doctor except possibly a micro-practice.
Recently I called to make an appointment with my PCP because I needed an IUD check. The scheduler was able to inform me over the phone that my PCP does not do IUD checks. How hard is that? Time wasted by me: one minute for the phone call. Time wasted by the doctor: none.
DeleteIf there's something that a doctor refuses to do, I think the responsible thing is to let the schedulers know, so patients don't waste their time and neither does the doctor.
I love your blog and your irreverent sense of humor. I was going to reply to your initial post yesterday, in which you made a sweeping statement about Republican views on abortion, but I talked myself of the ledge, as I didn’t feel the need to get into a slanging match.
ReplyDeleteI have found this in Medicine and Academia: when you don’t quite agree with the majority people are not content to disagree with you, they seek to go further and disparage you.
What happened to free speech?
I believe in creation (and also have a PhD from one of the top 5 institutions in the world, in addition to a medical degree). I have presented good research at top academic meetings; so if I choose to believe in God and creation, you might think I am crazy, but is there a need to insult me personally ? This is something I have recently experienced myself and seen others experience too.
Abortion, in my view, regardless of the circumstance leading up to the pregnancy is wrong, so you know where I stand.
Maybe there is something I am not understanding in the scenario you pose, but would the purpose of the primary care practitioner “clearing” the patient for surgery/abortion be the same as a preoperative assessment?
I think a PCP is quite justified to provide her patient notes/medical history to the abortion provider, but what qualifies PCP (any more than a psychiatrist, or physiatrist, for example) to say a patient is able to undergo a surgical procedure?
The person carrying out the procedure should, quite reasonably, get a full history and, if need be, get the patient’s notes sent over if it is an elective procedure. If a patient is bleeding, it becomes less of an elective procedure, and is now an emergent situation; when you go to the ED with a bleeding ulcer, in a hemodynamically unstable state, they don’t exactly wait for your PCP to clear you for the procedure, do they ?
First, I wasn't making a sweeping statement about all Republicans, as I certainly don't believe half the country all feels the same way about abortion. I was just talking about the official platform, and that was actually my error, because my husband pointed out to me that was simply the view of Romney in the election and NOT the official platform of the party. Regardless, it IS the viewpoint of many people in the party.
DeleteRegarding medical clearance: when a person with multiple medical issues has to undergo a surgical procedure that is not emergent, the surgeon general requires that the patient obtain medical clearance from their PCP or another qualified professional. This is standard practice in medicine. It may not make sense to you, but this is the way things are always done.
Thanks for your reply.
DeleteTo play out the scenario, if the PCP gave ‘clearance’ on a Friday, would the abortion have been done later that evening?
It would seem to me that the issue, in the present case, arose because the patient’s clinical situation changed, such that it became an emergent condition. If you agree with this simple premise, then my earlier analogy about the bleeding ulcer becomes pertinent and the issue about medical clearance, becomes more of a technicality.
If you need emergent care, and you are bleeding, then going to the ED is the *SAFE* course of action, and I would have strongly advised the woman to go to the ED. At that point, if she is bleeding in early pregnancy, there are myriad reasons why this might be, and it becomes much less of an elective procedure; she needs to be in a hospital where unexpected complications can be appropriately dealt with.
An example could be an ectopic pregnancy that is ruptured – the ED, and not the abortion clinic, is the safest place to be – and you certainly don’t need PCP clearance to go to the ED.
Taken directly from the official 2012 Republican platform: "we assert the sanctity of human life and affirm that the unborn child has a fundamental individual right to life which cannot be infringed. We support a human life amendment to the Constitution and endorse legislation to make clear that the Fourteenth Amendment's protections apply to unborn children." Don't know what Romney was saying by election time, as it was difficult to keep track.
DeleteThe receptionist or nurse setting up appointments could easily say "that's not something we handle" so the patient has the option to make other arrangements. Manipulating the system in order to take away a patient's choices is an egregious abuse of power and must be punished. Any physician who engages in behavior resulting in harm to a patient should be subject to loss of license to practice.
It's not quite the same situation, but I once refused to work on a large, lucrative project because I thought the company's products and business practices were harmful. My boss respected me for standing by my principles and also valued my ability, so I didn't lose my job and ended up being assigned to another project. Had I agreed to work on the project then produced a sub-par final report, I would have caused actual harm to the client. I suppose I could have sabotaged the client, but why ruin my professional reputation?
Of course, those who are vehemently anti-choice probably believe much more strongly that all abortion should be prevented than I believe that this company should go out of business, and the balance of power and potential for harm is much more lopsided between a patient and doctor than a company and consultant. I hope Mrs. Blue's doctor was punished, but I'm guessing nothing happened to her.
Can you elaborate on how the system is being manipulated ?
DeleteIn this case, Mrs. Blue made an appointment with her PCP specifically to obtain medical clearance for an immediate abortion. Mrs. Blue told the person who made the appointment the reason for the appointment. Had Dr. Green's office simply told Mrs. Blue she needed to see another provider, she could have done so. Instead, Mrs. Blue wasted precious hours waiting to see Dr. Green when she could have been on the phone making an appointment elsewhere. Dr. Green knows the less time she has, the more difficult it will be for Mrs. Blue to figure out how to obtain approval, especially on a Friday. That's manipulative.
DeleteDelay is a common nuisance tactic among the anti-abortion crowd, and that's exactly what Dr. Green did, passively or not. Laws requiring mandatory wait times have the same objective. The problem is that in Mrs. Blue's case, waiting resulted in permanent harm. Mrs. Blue wouldn't necessarily have realized she was risking losing her uterus. Dr. Green is a physician, and certainly should have been aware this was a possibility. If Dr. Green didn't know this, Dr. Green should be required to attend mandatory CE addressing deficiencies in knowledge, but that is a separate issue entirely.
Not to derail too much, but I have to respond to your question "What happened to free speech?"
DeleteAbsolutely nothing. Free speech does not mean, and has never meant, freedom to speak without consequence or disagreement. The theory underpinning our first amendment is the market place of ideas; we let all ideas into the marketplace to be freely discussed, examined, and debated. Those ideas with merit will find support, those without will be driven out. They are driven out by others using their own free speech to point out the deficiencies. Paraphrasing the Supreme Court, the answer to bad ideas or speech isn't to limit speech, it is more speech. So when one expresses an idiotic idea, free speech doesn't require us to stay silent, or respect that idea. If we are living up to our free speech ideals, it requires us to also speak up and say "that's a stupid idea."
Also, the first amendment limits the government, not citizens acting on their own authority (ie, not acting as government agents). Fizzy, you, me, bloggers, the media, etc., can disparage people voicing idiotic opinions all day long and twice on Sunday, and not violate a single person's right to free speech.
Jennifer, thank you for taking the time to reply.
DeleteAs you may, or may not, have realized, my question was rhetorical. Free speech works both ways - the point underlying the *rhetorical* question was the fact that people who express views that do not fit with the politically correct orthodoxy in medicine and academia are frequently subjected to person insults.
I am more than happy to have a debate/discussion from first principles about issues of politics or religion, but when people who identify themselves to be tolerant shuts down the debate by using personal slurs, then the question regarding free speech really is warranted. This happens a lot more than people may want to admit.
I point you to the recent treatment of Dr Ben Carson – who was brow beaten for expressing views that didn’t fit leitmotif of the metropolitan liberal elite regarding homosexual marriage.
I realize your question was rehtorical, but its premise was still faulty, which is what I was trying to point out.
DeletePersonal insults may not be desirable or the most mature way to engage in debate. (And I think there is an interesting debate to be had there, actually. Look at political cartoons going back to revolutionary times - they are often piercingly insulting, and undoubtedly important speech in their own right.) But the use of personal insults or not says nothing about free speech.
Unless Dr. Carson was being silenced by the government, his case is not a free speech matter. Only the government or its agents can violate speech rights.
Quite possibly my favorite quote relevant to the question of who can violate a person's constitutional rights: "There are two ways, and two ways only, in which an ordinary private citizen, acting under her own steam and under color of no law, can violate the United States Constitution. One is to enslave somebody . . . . The other is to bring a bottle of beer, wine, or bourbon into a State in violation of its beverage control laws.” Lawrence H. Tribe, How To Violate the Constitution Without Really Trying, 12 Const. Commentary 217, 220 (1995).
"An example could be an ectopic pregnancy that is ruptured – the ED, and not the abortion clinic, is the safest place to be – and you certainly don’t need PCP clearance to go to the ED."
DeleteYes, but if you know you have an ectopic, why wait for it to rupture? It's much safer to have the procedure done before it becomes emergent and life-threatening. She attempted to do this, but because of the refusal of her PCP, she had to wait through the weekend, and resulted in a serious urgent medical situation that could have cost her her life. How can you justify this when she was very likely not capable of carrying a fetus to term and giving clearance for a non-urgent termination was the safest option?
I sense a left wing lawyer seeking to get into a fight.
DeleteAs far as I recall, I made no mention of the US constitution; believe it or not, the concept of free speech extends beyond the boundaries of both the continental US and the US constitution, in fact, it pre-dates the latter.
Freedom of speech is is actually an ancient Athenian concept: [That Socrates was prosecuted because of his religious ideas and political associations indicates how easily an ideal held dear by his fellow Athenians—the ideal of open and frank speech among citizens—could be set aside when they felt insecure. This ideal and its importance in Athens are well illustrated by the remark of the orator Demosthenes]
http://www.britannica.com/EBchecked/topic/551948/Socrates/233637/The-Athenian-ideal-of-free-speech
If Mrs. Blue had been diagnosed with an early ectopic that had not ruptured, the specialist almost certainly would have treated her medically before proceeding to surgery. That's the safest protocol.
DeleteHow do I know? I was treated for a 5-week ectopic and never required surgery. It's what I'd do if it happened again. Who wants surgery if it can be treated safely, medically?
Fizzy at 9.50am
DeleteWhen I used the ectopic pregnancy example, I was using it as an illustration of one of the many causes of bleeding early in pregnancy.
You are unlikely to know at that stage that it is ectopic – as she would just have missed her period and have a positive B-HCG.
So, a woman who has a positive pregnancy test and is about six weeks along comes in with frank bleeding – that is a medical/surgical emergency.
They go to the ED and that gets taken care of, regardless of primary care physician opinion. At that stage, sending her to the ED for a full evaluation is the most responsible thing to do, whatever the opinions may be about abortion.
"If Mrs. Blue had been diagnosed with an early ectopic that had not ruptured, the specialist almost certainly would have treated her medically before proceeding to surgery."
DeleteShe was not diagnosed with an ectopic though, and it was decided that a procedure had to be performed. For whatever reason, they did not feel it was appropriate to treat her with medications only, and we have no other information about her medical history to believe this was an error. The PCP didn't not give clearance because she felt it was unsafe, only because she didn't believe in abortion.
"So, a woman who has a positive pregnancy test and is about six weeks along comes in with frank bleeding – that is a medical/surgical emergency.
They go to the ED and that gets taken care of, regardless of primary care physician opinion."
Bleeding is incredibly common in pregnancy and if every woman who bled during first trimester went to the ER, that would be a huge waste. I bled multiple times during my pregnancies in first trimester. At the point she saw her PCP, the bleeding wasn't severe enough to warrant an urgent evaluation in the ER. If she had gone to the ER on Friday, it's unlikely they would have performed an abortion unless it was urgent at that point, which is probably wasn't. It was only two days later that the situation escalated. And the situation wouldn't have escalated if she had gotten clearance and had the termination the next day, as she had planned. As I said in my original post, THIS ACTUALLY HAPPENED to someone I know. So it's not in any way far-fetched.
Let's not get lost in the details here. The ethical situation is pretty clear: Mrs. Blue asked for a termination for medical reasons (the pregnancy could not proceed). Dr. Green refused to give clearance even though she would not be performing the procedure herself, prolonging the amount of time Mrs. Blue would have to wait and increasing her risk of complications.
I like how you started out your post with the mention of your degrees. I understand why you did it, but it just reminded me strongly of Congressman-Doctor Paul Broun. Are you familiar with him? He's a member of our Committee on Science and Technology, received his MD back in the 1970's. This quote is his: "All that stuff I was taught about evolution and embryology and the Big Bang Theory, all that is lies straight from the pit of Hell." He believes the Earth is approximately 9,000 years old. While I worry that he may have developed a brain tumor some time between completing medical school and making those statements, the point is that you can still hold some very strange views of the world even with advanced degrees.
DeleteThe scenario presented by Fizzy is fairly clear. Abortion is currently a "choice of treatment." For better or for worse, we are no longer practicing paternalistic medicine. This was not the physician's call to make, it was the patient's. The physician's duty was to lay out the options, explain them to the patient with as accurate an assessment as possible in light of the patient's condition. The rest was up to the patient.
Regarding abortion and when life begins, I find it interesting that there's so much controversy over trying to pinpoint exactly when life begins. The fact is that we'll never know, as it's completely subjective. I was a bit torn over it, because I support a woman's right to have an abortion and don't feel that it's murder, yet I also feel that someone who kills a pregnant mother or intentionally kills the fetus within a mother against the mother's will would be guilty of murder against the unborn child.
What's the solution? Simple: it depends on the mother's views. Does the mother want the child? If so, then I have no problem recognizing what is within her as a human entity, regardless of the stage of development. If the mother does not want the child, then what is within her might as well as cancer. There is still a time limit to how long the developing embryo can't be considered a person - my personal bias is for when the nervous system develops - but I think this greatly simplifies things.
This is in response to Fizzy at 11.53
DeleteI think the case hinges on detail, but if you want to step away from the details (and thus the emergent nature of this case, which the details provide), Dr Green refused sign her undersign the medical clearance that facilitated an abortion.
We don’t know the nature of the conversation that took place when the appointment was being booked, and we don’t know if Dr Green offered to refer the woman in question to another physician who was more comfortable signing off a clearance. You are relying on second hand information from an aggrieved patient (who I would guess already shares your views).
Although it may be clear cut to you, Fizzy, the fact is if a doctor believes life begins at conception, as is their wont, you are asking this Dr to sign off on the death of another human being. No guesses as to what their decision in that situation would be. The action would thus depend on how emergent the case was, otherwise, it seems to me that you are intent on forcing the Dr to acquiesce to an abortion, regardless of the clinical condition of the patient.
The issue probably comes down to the conversation that was had when the appointment was made. If it is emergent, they belong in the ER (waste doesn’t come into it – that is a very subjective and weak point when a human life is at stake). If it is not emergent, then they need to see another physician. I don’t think you can decouple the details of the case from the risk profile.
If you are worried about putting her at risk, then we have to look at the details - with no details, what is she at risk of? Again, is your beef simply the fact that you can't force another physician to acquiesce to abortion ?
Victorinox: I was in a hurry when I replied to your first set of comments, so I want to address your statement "I was going to reply to your initial post yesterday, in which you made a sweeping statement about Republican views on abortion, but I talked myself of the ledge, as I didn’t feel the need to get into a slanging match."
DeleteI admit, I've engaged in comment-battles with people on here, but I genuinely always try to speak to commenters respectfully. I would never ever start slinging personal insults.... unless someone provoked me by doing it first. I think it's really unproductive and uninteresting, to be honest. I'd rather have an educated discussion than engage in namecalling. Furthermore, my post yesterday stated that I could completely sympathize with people like you, who believe abortion is wrong in all instances.
And I admit I made an error about the Republican party platform, and was actually reciting the view of the Republican Presidential ticket's platform in the most recent election.
Preoperative assessment takes about five minutes. We're not talking about an ASA IV or V patient here, and a PCP is perfectly capable of calling a specialist for advice and to communicate relevant past medical history. Dr Green's saying that she wasn't sure what to do so just delayed doing anything or asking for advice/help is NOT ethically or legally defensible.
DeleteVictorinox: In response to your most recent comment:
DeleteMrs. Blue did say why she was coming when she made the appointment and that she had a termination scheduled for the next day. In general, when you schedule an appointment, don't they always ask you why you're making it? If it was Dr. Green's practice not to give clearance for abortions, then Mrs. Blue should have been told this *immediately* rather than wasting precious time. Essentially, by allowing Mrs. Blue to come in for the appointment, she forced her own personal views on the patient, despite abortion being legal and within the patient's rights. It was manipulative, as someone said above.
Without knowing the details of the case, we can't say exactly how egregious Dr. Green's behavior was. Women *have* been allowed to nearly bleed to death in ERs by doctors who did not believe in abortion. I can't say if Dr. Green knew how serious Mrs. Blue's situation is and whether she was putting her patient's life in serious danger by denying her clearance. Maybe she didn't know and what happened was a fluke. Or maybe she did know and felt her personal beliefs were worth the risk to her patient's life.
Another point is that when you're not performing the procedure yourself, do you really have the right to deny someone clearance, which essentially just says, "Patient is healthy enough to have a procedure"? Especially when the patient is clearly not capable of carrying the pregnancy to term. It's similar to the argument someone else made about pharmacists having or not having the right to refuse to dispense Plan B.
Ledgem, I just noticed your reply.
DeleteIt is extremely unlike me to get involved with online slanging matches. I know what I believe, and if you are close to me, I don’t hide my views. As mentioned, I read the initial post yesterday and didn’t respond. But today, I felt I had to take a stand.
Generally the posts have been civil – and I have enjoyed the discourse, especially with our *friend* Jennifer, the Texan lawyer who thought she was going to school me on free speech. The point you make about starting with my degrees/background, is extremely unlike me, but in this discussion, there is clear justification – I am glad you could see that.
We may disagree about the case at hand and that is fine – you are free to hold your opinions, no matter how much I may disagree with them.
I had a situation where I work in which someone butted into my conversation and then thought they would corner me by asking me about evolution. I am a Christian, and I believe in the life, death and resurrection of Jesus, and our redemption because of Jesus’ death. I get that my views are not cool or popular, but for the person who asked me the question to then hurl a personal insult at me was eye opening.
I have, for a long time, been aware of the theory that many Liberals are only liberal as long as you agree with them, but when you come face to face with unprovoked hate for expressing your beliefs (in response to a question) then I guess I have to take a stand.
I don’t intend to offend anyone, but I will not be brow beaten into accepting things that contravene my beliefs just I can to fit in.
Fizzy at 1.39pm
DeleteFizzy, I note your efforts to be civil, and I appreciate this.
I would disagree with you about Dr Green brin egregious -we simply dont know enough.
You ask about a doctor just signing off and not participating in the procedure. I have a personal situation when I was an intern that addresses this very issue, which I wont go into now (I can later, but I am in a hurry); if you seriously want me to answer, I can give you an answer from the Bible, because that is where I take my frame of reference from.
Yes the Bible doesn’t talk about abortions and primary care providers, but it does say (King James Version)” Thou shalt not follow a multitude to do evil;” if I think the act is wrong, then I cannot, in all conscience, provide material support to the execution of that act. If the majority are going along with something, I cannot go along with it just becuase that is cool/the majority view.
@Victorinox:
DeleteA physician whose personal beliefs conflict with her ability to uphold the medical standard of care is welcome to seek employment in a different profession.
As Fizzy notes, first trimester bleeding is common. It does, however, require thorough evaluation, and the details of the scenario suggest spontaneous abortion was inevitable in this pregnancy. Dr Green failed to expedite a referral either to specialist care or to a willing abortion provider in a timely fashion and directly contributed to an unacceptably bad outcome. She may not have been upfront about her views with Mrs Blue ether.
Were there any legal consequences in the real scenario? (I understand if that's too specific to discuss here.)
JG
DeleteThis is not about medical standard of care, and you know it.
Refer to my earlier posts, and you will find specific reference to either go to the ED (if it is emergent) which falls in the same category as specialist referral or if it is not emergent, to refer to a physician willing to be part of the abortion process.
I mentioned something about liberals ceasing to be such once you disagree with them - your post, in a small way, proves my point; who are you to decide who should and who shouldn’t be a doctor ?
As long as they are safe in their practice of patient care, you can keep your faux liberal ideas to yourself. You can choose not to be part of an abortion and still be safe doing so
Victorinox:
DeleteI had a situation where I work in which someone butted into my conversation and then thought they would corner me by asking me about evolution. I am a Christian, and I believe in the life, death and resurrection of Jesus, and our redemption because of Jesus’ death. I get that my views are not cool or popular, but for the person who asked me the question to then hurl a personal insult at me was eye opening.
What that person did to you was wrong and offensive. As I'm discussing with you I certainly hope that I do not come off that way.
But there's something you said about your views, recognizing that they're not "cool" or popular at the moment. Understand that a lot of the frustration with the hard-core Christian views have less to do with the views themselves (regardless of their "coolness") and more to do with how many self-proclaimed Christians force their views on others. Fizzy's case with Dr. Green deals strictly with abortion and does not bring religion into the picture, but it is certainly the case that many who are against abortion espouse Christian views. This is a clear case of someone imposing their views on someone else, made even worse because it overstepped the boundaries of what is professionally correct. Another example of Christians imposing their beliefs is the "gay marriage" debate. It's not that all Christians do this (there are plenty of Christians who support a woman's right to choose abortion, gay marriage, and so on), but the "conservative opposition" often seems to be hardcore Christians. Their reasons for their opinions are their beliefs. While there's nothing outwardly wrong with that, it stirs up a lot of resentment from people who do not share those beliefs. It's understandable, isn't it?
(Although that said, I admit that I find the views of the "young Earth" creationists to be frustrating. How can you believe such a thing in light of all of our scientific advances and discoveries? How can that knowledge be dismissed so easily? What proof do they have that is so much more concrete and compelling?)
I understand why the abortion issue is a challenging one for those who believe life begins at or near conception, though. If you view it as the murder of an innocent, then who cares whether it's a legally permissible procedure? Shouldn't you do everything in your power to prevent it from occurring? It's quite a dilemma. Even if you're not performing the procedure yourself, you're still abetting it. How would it be different from handing someone with murderous intent a gun? And so, even though I think that what Dr. Green did is wrong, I can understand why it's a difficult scenario.
One thing I really do not understand is the idea that an abortion should never be performed, even in a case where the mother's life may be threatened and/or the fetus is going to be lost anyway. Is it simply because it is easier to make an absolute rule that has no exceptions? Why is the fetus seemingly prioritized over the mother, regardless of the mother's wishes? In that sort of emergent case there is the potential to prevent a total loss by saving at least one life; do nothing and you risk a total loss of one life (or two lives, depending on developmental stage and your beliefs). How can that possibly be considered OK? Even in religious terms (my approach is from the Jewish perspective), how can that possibly be sanctioned by God?
Ledgem, you make some very reasonable points, perhaps one day we can engage in a conversation similar to today's, to address the points you raise.
DeleteI have not found your tone at all offensive - God speed!
This is not about medical standard of care, and you know it.
DeleteRefer to my earlier posts, and you will find specific reference to either go to the ED (if it is emergent) which falls in the same category as specialist referral or if it is not emergent, to refer to a physician willing to be part of the abortion process.
It is ALWAYS about the standard of care. I find it disturbing that any self-described physician would consider that there are valid reasons to fail to provide the standard of care. Dr Green in this scenario wilfully obstructed access to a procedure based on her own values without any regard for ensuring appropriate care for her patient, for whom she is the PCP. There is no indication that Dr Green was upfront about her beliefs. Furthermore, it is not the role of the patient to self-triage or to be aware of the appropriate evaluation of first trimester bleeding. The supposed need for "medical clearance" was entirely spurious and it is the role of the operator and anesthesia staff to determine whether it is safe to proceed. For that matter, there is no indication that Dr Green made any attempt to ascertain the viability of the gestation - suppose it was a molar pregnancy, would it have been appropriate to without clearance for a D&C?
I mentioned something about liberals ceasing to be such once you disagree with them - your post, in a small way, proves my point; who are you to decide who should and who shouldn’t be a doctor ?
Medicine is a self-regulating profession; I have every right to question whether a colleague is exercising appropriate judgement. Being a physician is a privilege, and it comes with a responsibility to patients that transcends my personal values. If I were to find myself in an irreconcilable conflict between a patient's legal preferences and my own values, I would have to remove myself from that patient's care. I could not obstruct any indicated treatment or investigations, and if through such obstruction the patient experienced untoward morbidity (or mortality!) I could certainly be sued and potentially face disciplinary action.
As long as they are safe in their practice of patient care, you can keep your faux liberal ideas to yourself. You can choose not to be part of an abortion and still be safe doing so
No, this has nothing to do with the political straw man you are setting up. In fact, you are simply arguing that Dr Green's deontological ethics trumps the bad outcome because, maybe, the patient could've arbitrarily decided to go to the ED earlier even when she had presented with only a run-of-the-mill first trimester bleed. It has been made perfectly clear in this scenario that the physician was NOT safe in their practice of patient care. If through your negligent actions you cause patient harm, you will be successfully sued. I suppose some judges and juries might be more sympathetic to the physician's intent, but on balance the (1) inevitable abortion, (2) deliberately obstructive withholding of "medical clearance", and (3) consequent morbidity are pretty damn clear.
But, sure, dismiss this as a "faux liberal" argument. Physicians don't get the freedom to make any decisions they want in patient care.
Victorinox, you wrote "I have, for a long time, been aware of the theory that many Liberals are only liberal as long as you agree with them, but when you come face to face with unprovoked hate for expressing your beliefs (in response to a question) then I guess I have to take a stand."
DeleteWhat is your definition of liberal? Does "liberal" mean you have to agree with what everyone else says and be tolerant of everyone else's opinions?
To me, it doesn't mean that. To me, liberal means that you feel that everyone has the right to think, do, and believe whatever they want *as long as it doesn't interfere with another person's freedoms*. You can believe gay marriage is wrong, but if you try to take away the rights of a gay couple to marry, then I will fight with you. In the case of Dr. Green, it is perfectly within her right to believe abortion is wrong and never perform it. But in this particular case, she took away Mrs. Blue's right to have an abortion in a safe, non-urgent setting and nearly cost her her life--the ultimate betrayal of her rights. So in my opinion, that is wrong.
Victorinox, since you cite the bible to support your view about abortion I am curious what you think of this piece:
DeleteThe Biblical View That's Younger Than the Happy Meal
In my experience, conservatives are only conservative until it's their 13-year-old daughter who becomes pregnant, or it's their wife or sister whose life or reproductive health in danger after a failure of birth control results in an unwanted pregnancy.
DeleteThere are numerous other examples of this, both negative and positive (Dick Cheney's stance on gay marriage comes to mind).
It cuts both ways.
I read an article about this recently, about how there have been many conservative politicians who have changed their stance on certain key issues after having it affect them personally, such in the case of gay marriage (there was a recent example of this that escapes me). There's also the example of Sarah Palin and disability rights, and Marco Rubio and his stance on immigration.
DeleteWhile it's great that having this personal issue causes them to alter their views on that issue, the article I read pointed out that having this experience ought to make the politician more introspective about all their opinions and possibly learn to empathize with people who have different problems than their own. But somehow that never happens.
If Dr. Green refused to give medical clearance based on pt's medical history, that's being responsible. If Dr. Green refused because of her personal feeling about abortion, then she really let her patient down and shame on her.
ReplyDeleteI agree with you and how you phrased your comment. However, as a physician, Dr. Green should have realized that if the patient was not stable enough for elective surgery, she most certainly would be in more danger in the likely situation that emergency surgery would be necessary. We are not talking about medical clearance for a face lift; the patient needed medical clearance for a potentially life-saving procedure. Dr. Green was wrong, wrong, wrong. What happened to "First, do no harm"? I think it might be difficult to prove causation in a malpractice hearing (i.e., the delay in medical clearance was a direct cause of the hemorrhage and the resultant hysterectomy), but it might be worth pursuing a case with a suit or a complaint to the medical board, if for no other reason than to teach Dr. Green about his or her responsibility to the patient. TCG
DeleteIs this a realistic scenario though?
ReplyDeleteIt seems if a pregnant woman were actively hemorrhaging than she would go see her Ob/GYN and not her internist. The Ob/Gyn doc, I presume, could clear her medically for the procedure. Moreover, if she is actively hemorrhaging then it would no longer be a issue requiring prior medical clearance.
The only way I see this scenario being realistic is if the patient wasn't bleeding and wanted to terminate the pregnancy for other non-emergent reasons.
Davis
Mrs Blue wouldn't yet have an OB because she was not very far along, and I'm sure it was an OB/gyn that would be performing the procedure, but had probably never seen the patient before.
DeleteIt actually happened to someone I know, up until the part about the hysterectomy. She wasn't actively hemorrhage YET when she went to her PCP.
DeleteMany women see a family doc for their usual women's health things, not an OB-GYN. I worked with a family doctor who would see patients up until their third trimester of pregnancy before turning them over to the OBs, because she didn't do deliveries. If the patient suddenly became complicated or high risk, the patient would be sent to the OB faster.
DeleteSo it's not unreasonable for this woman to have gone first to her PCP, rather than an OB she hadn't established care with yet.
Also, many OB-GYNs don't want to be PCPs for patients with complicated medical histories. They're okay taking care of the healthy young women who just want OCPs or need a pap smear every few years, but they are not going to be the ones managing a complicated regimen of medical problems.
PCPs are not performing the procedure- they are providing a statement of general health. The PCP in your example was dead wrong. She imposed her morality on her patient. This conversation will eventually go there so I'll weigh in now: OBs should not be required to perform abortions if they are morally opposed because that is active participation. (Emergent D and C's would be different.). Pharmacists should be required to dispense OCPs and Plan B because while handing the patient the pills is not contributing to the patient's reproductive decision, refusing to hand them over is (again) imposing the pharmacist's personal morality on the patient. Next up for the soapbox?
ReplyDeleteIn Finland doctors actually have to perform abortions regardless of their beliefs and abortions are legal before the 12. week or the 20. if the fetus has significantly increased chance of premature morbidity or mortality or be otherwise disabled.
ReplyDeleteThere are some good reasons for this. Some large areas of Finland are very remote and only have one doctor/gynecologist available. If this doctor refused to do abortions (wich are legal!), considerably large numbers of people would be basically unable to get an abortion, even if it was for medical reasons.
Secondly, it is believed among doctors and other professionals, that if you could choose to not do any abortions, a lot of doctors would do so. Not necessarily because of their personal beliefs, but because they find the procedure taxing, emotionally or otherwise. This would lead to fewer and fewer people wanting to do basically nothing but abortions all day and eventually decreasing the availability of abortions radically.
Personally, I find that it's very good policy for such a small country as ours. :)
Being that it is such a small country, surely a woman in a rural area so desperate to rid herself of the life inside her body could drive to the willing abortionist.
DeleteAre physicians in the US actually allowed to apply their personal moral and religious beliefs to patient care? That's crazy.
ReplyDeleteYour scenario is a little similar to the case of the Indian woman who was left to die of septicaemia in Ireland during a protracted miscarriage, owing to laws against abortion in the country. However, that law seems to be implemented at the level of government. Not entirely down to personal beliefs of the physician.
Except that woman actually died. This woman already seemed unable to have children, so I don't blame Dr. Blue for the hysterectomy.
DeleteOy. Morals and Medicine. Personally, I am on the fence on this one. One hand - rural areas may only have one PCP or one Pharmacist and if they deny a patient an abortion/Plan B, then that patient is screwed. However, do we really have the right to force a person to commit what they believe to be murder? Similar to forcing a PCP to authorize/perform elective euthanasia - the patient wants it, qualifies for it, but the MD is against it because to them it is murder regardless.
ReplyDeleteIn this specific case, the PCP/receptionist screwed up by not being forward enough when the patient made the appointment, but I highly doubt that even IF the doctor signed the paperwork, that the procedure would have been performed so quickly. So the patient's medical condition deteriorated quickly, which could not be immediately foreseen and not the fault of the doctor, and had to go to the ER. So no, I don't think the doctor should be sued.
Them is my sentiments at 6.48 am
DeleteIn the actual situation that really happened, the procedure HAD been scheduled for the next day (Saturday), but then had to be postponed until after the weekend due to being unable to get clearance. So it was those extra days that made the difference.
DeleteJust to clarify, because as an Ob/Gyn, this drives me nuts: Plan B is NOT an abortifacient. Plan B is progesterone, which is used to suppress ovulation. If you have already ovulated, it does not impact conception/implantation in the slightest, and that pregnancy will continue unless otherwise interrupted.
DeleteSorry for the highjack of this thread.
I don't think drimera was necessarily saying that Plan B is an abortifacient. It IS an example of a medication that pharmacists have denied to women (along with regular birth control), even with a prescription. Luckily, it is now available OTC to all women of any age.
DeleteTo the Ob/Gyn above, as a pharmacist, progesterone can change the nature of the lining of the uterus, making implantation more likely to occur. While although you are right that it will suppress ovulation by blocking the LH surge, it will also help to prevent implantation of an already fertilized egg that has not yet been implanted.
DeleteOh She said it was her husbands child, it was actually my husbands child and I needed her to go full term so I could get a paternity test to be used during my divorce
ReplyDeleteYou're a monster.
DeleteDr Green was negligent, inasmuch as she failed to provide the standard of care, regardless of her motivations. The entire "medical clearance" idea is a red herring. Even though Mrs Blue had several comorbidities, her bleeding was not of any hemodynamic significance (initially), and there is no defensible reason why she had not already been referred to specialist care since she was evidently high risk regardless. (Should I infer that an ultrasound hadn't been done, so the ectopic issue had yet to be determined?) At 6 weeks she could even be managed medically, and as her PCP Dr Green should already have been aware of any contraindications to methotrexate.
ReplyDeleteEven granting that a D&C under general anesthesia would be indicated here, there is still no reason why she needs some sort of arbitrary medical clearance in advance of arranging a therapeutic abortion. With "serious medical problems", Mrs Blue could easily get some routine labs and an EKG done, and if she was otherwise well and presumably under 40 she wouldn't need any preop investigations. It's not the PCP's job to determine whether a stable, young patient with a few chronic health problems is fit for surgery; that's the anesthesiologist. Dr Green could have readily arranged any necessary tests which would have been complete in the space of an hour and called a specialist. Failing to do so was negligence, and even worse was the evident failure to manage first trimester bleeding - the absolute first step would be an ultrasound to confirm intrauterine gestation.
"Do no harm." Dr. Green was in the wrong.
ReplyDeleteIronically, though the original Hippocratic Oath forbade abortions.
DeleteDr. Green should feel responsible. I don't know about whether a lawsuit is right, although I am inclined to believe that it is.
ReplyDeleteWhen people go to medical school, they make an oath to put the patient first. In this case, Dr. Green put her personal beliefs first completely disregarding what it would do to the patient. She indirectly caused more harm to the patient that was unnecessary.
So Dr Green was pro-life even if an abortion would save the life/health of the mother? Because it would be one thing to not be involved if the pregnant woman was otherwise healthy, but quite another if she didn't care about the medical grounds for abortion. :(
ReplyDeleteThis comment is probably never going to get read, but for me the abortion issue is simple: the fetus is a human being that should have the same rights to life as other human beings. Abortion is akin to homicide. Homicide, however, is justifiable (by most standards) when it is in self defense. So, abortion in a case like Mrs. Blue's where the life of the mother is endangered is justified. In addition, if the fetus is already dead, or has encephalitis and is, for all intensive purposes, dead, abortion is justified because it is not murder or homicide to move a dead body from an inconvenient location (in this case, the uterus. Doctor Green should have provided clearance because the women's fetus was bound to die or be aborted no matter what; she only endangered Mrs. Blue's life and did nothing to prevent the homicide or death of an unborn infant.
ReplyDeleteYes, I agree. That's my big issue with the case. If Mrs. Blue had been totally healthy and the pregnancy was normal, I would not be posting this. Obviously, she was in quite bad medical condition if she was required to get medical clearance for the termination, and she was already bleeding. Dr. Green had no chance of saving the fetus's life, only risking her patient's life.
DeleteThat's the thing that gets me angry. Not people who are pro-life, but rather people who are "pro-death." When a situation arises where the mother's life is clearly in danger (which would end the pregnancy anyway), they STILL don't support termination. Or people who don't support abortion when the fetus has a medical condition that's completely incompatible with life, like anencephaly. What's the point of making a woman carry a fetus for months that has no brain???
It seems to me the question being asked of Dr. Green was not "is it morally or ethically ok for Mrs. Blue to get an abortion," but "is it medically safe for Mrs. Blue to get an abortion." If, in Dr. Green's opinion, it was medically safe, then the only ethically correct answer is "yes, it is safe." If Dr. Green refused to cooperate by clearing her for the procedure based on medically irrelevant moral or ethical grounds, she behaved unethically IMO and should be reprimanded by the board at the very least.
ReplyDeletean article on KevinMD nails is http://www.kevinmd.com/blog/2012/11/religion-patients-practice-medicine.html
ReplyDeleteHonestly, it probably happened like this: surgery scheduler calls Dr. Green office "mrs. blue needs pre-op clearance for a (place icd-9/cpt cde here)". Miss Nice office person puts it on the schedule. Dr. Green and Miss Nice office person don't know each other except to smile as they pass at the elevator. Dr Green doesn't look at her schedule until the patient is roomed. She refuses to do the exam and blames all of her office staff "they should have known".
ReplyDeleteYou opened up alot of fun with this one!I live in the South where there is a lot of people who are anti-almost everything. I worked in a retail pharmacy a few years ago,and a woman came in asking for plan B. She stated that my store was the 7th store in the area she had tried and all the pharmacists refused to sell it to her, many did not even stock it due to their beliefs. She had been raped, and yet no one would let her get the medication to prevent implantation. My pharmacist also refused her. I went into the lobby and told her to wait a moment. I convinced my pharmacist that I would take responsibility of selling it to her, and she left the pharmacy so she would not be present during my few moments of terrible sinning. I sold the woman the Plan B, and provided her with some information for support groups. My pharmacist returned a few minutes after the woman left and berrated me on my moral ethics. Love your blog
ReplyDeleteCindy
I'm a little late to this convo, but I am curious about something. I am 100% pro-choice pre-viability. However, post-viability abortions baffle me. I understand the necessity for one if fetal abnormalities are detected, but I don't understand for any other reason. The "life of the mother" argument is particularly baffling b/c - and I'm not a doctor, so it's QUITE possible that I just don't know - isn't it the case that any "life of the mother" problem could be solved by delivering the fetus preterm? It's not ideal, but isn't it better than having a post-viability abortion?
ReplyDeleteI have never heard an instance of that particular situation, in which a viable, normal fetus was aborted. Reference?
DeleteOh, I've never heard of such a thing, either. It's just the language that is used. Like this article where Kevin Drum specifically says "late-term abortions would be completely illegal unless the life of the mother were clearly and directly threatedened." He refers to late-term abortions as after 22 weeks. I think it's honestly political posturing more than anything medical, but people say it quite often. http://www.motherjones.com/kevin-drum/2013/04/quick-survey-abortion
ReplyDeleteI think my previous post may not go through b/c I included a link. Sorry about that! Basically, I haven't heard of it happening, either, but people use that language frequently when discussing it. I think it's more a political argument than a medical one. I'm just curious if there IS a medical reason.
ReplyDelete