"All that is necessary for the triumph of evil is for good men to do nothing" Edmund Burke, 18th century Philospher.

"A long habit of not thinking a thing wrong gives it a superficial appearance of it being right." Thomas Paine

"The welfare of humanity is always the alibi of tyrants." Albert Camus

"Choice is the essence of ethics: if there were no choice there would be no ethics, no good, no evil; good and evil have meaning only insofar as man is free to choose." Margaret Thatcher, March 14, 1977

“It is difficult to get a man to understand something, when his salary depends on his not understanding it.” ― Upton Sinclair

Explaining the Cause

I am a practicing obstetrician who is a strong supporter of patients rights to informed consent and refusal. I believe a patient has the right to choose her own path given true and not skewed informed consent. Following that tenet, just as a woman should be able to choose to have an elective c/section she should be able to choose not to have one, as well. The American system of hospital based obstetric practice has been eroding those choices for women for quite some time. Due to concerns of economics, expediency and fears of litigation women are being coerced to make choices that may not be in their best interest.

I have had a long relationship collaborating with midwives and find the midwifery model of care to be evidenced based and successful. I was well trained at Cedars-Sinai Medical Center in the mid 80's to perform breech deliveries, twin deliveries, operative vaginal deliveries and VBACs, and despite evidence supporting their continued value, hospitals are "banning" these options. Organized medicine is also doing its best to restrict the availability of access to midwives.

Home birthing is not for everyone but informed choice is. Medical ethics dictates that doctors have a responsibility and a fiduciary duty to their patients to provide true, not skewed, informed consent and to respect patient autonomy in decision making. Countries with the best outcomes in birthing have collaboration between doctors and midwives. This is not what has been happening in the hospitals of America. Its time for a change and the return of common sense.

The midwifery model of care supports pregnancy as a normal function of the female body and gives a legitimate and reasonable alternative to the over-medicalized model of birth that dominates our culture. Through this blog I hope to do my part to illuminate what is wrong with our maternity care system and what is right with it. I do not expect all to agree and that is OK. We must all understand that given honest data it is not always reasonable to expect two people to come to the same conclusion. Our differences should be respected.

Friday, April 29, 2011

Ethics in the eyes of the beholder!

In this months Green Journal, the ACOG publication, were 3 articles concerning the ethics of home birth. If anyone is interested in reading them please send me your email and I can send them to you. They are proprietary and password protected and cannot be linked here. One nearly brought me to tears called "An Obstetrician's Lament". The writer eloquently painted a picture of a somewhat professionally self inflicted dilemma. One took an honest look at relative vs. absolute risk and true informed consent. The third, surprisingly, upset me more than I thought. Dogmatically labeling obstetricians who participate in home birth as lacking integrity and suggesting that educated patients who refuse hospital birth should be given "respectful persuasion". In response to this article I wrote the following letter to the president of ACOG.

Dear Dr. Waldman, I just was reading the articles in this months Green Journal and came across one in particular that I found very troubling. I think you know that I am an advocate for true, not skewed, informed consent and a supporter of midwives and the option of out of hospital birthing for well informed low risk women. Dr. Chervenak and colleagues in an article titled, "Obstetric Ethics" seems to continue the College's selective bias against home birth and those who support it.

In the abstract he says this," ...Obstetricians have an ethical obligation to disclose the increased risks of perinatal and neonatal mortality and morbidity from planned home birth in the context of American healthcare and should recommend against it. Obstetricians should recommend hospital-based delivery and respond to refusal of these recommendations with "respectful persuasion". As a matter of beneficence-based professional integrity, obstetricians should not participate in planned home birth."

As my president I have to ask you if you believe this statement to be true.

As for myself, I find so much wrong with this in the context of known hospital based risks which the college does not seem as eager to recommend disclosure of. Also, the restrictions on choice occuring because of ACOG opinions and the legal and economic climate in which hospital policies restricting those choices are made. I find it repulsive that the authors, and I suspect the editors of the journal, condone respectful persuasion which seems to be just another nicer name for skewing informed consent. Am I and other obstetricians who support patients who desire an out of hospital birth acting without integrity and unethically as Dr. Chervenak proposes?

The demand by a better educated populace for a say in how and where they give birth is coming. The current trend in c/section statistics and interventions do not speak well for the medical model in low risk birth when compared to the midwifery model of pregnancy as wellness not illness. The obstetric profession is not preparing its doctors in training in the art of medicine any longer. Skills of breech birth, forcep and vacuum deliveries and twin vaginal birthing have disappeared from the training programs under our watch. Fear has replaced trust in that most natural of life's events. The authors and ACOG are running with a strawman argument that home birth is unsafe and building upon that questionable foundation. There is far more evidence based medicine that supports the safety of selective home birth. Certainly enough that should give pause to reasonable people labeling those that have a different view as unethical or lacking in professional integrity.

I am very concerned that we now have articles endorsed by our college that dogmatically define ethics and integrity to fit their definitions of what normal pregnancy should look like. Personally, I resent the implication. Just as the authors seem certain they know what is better for individual patients and have taken it upon themselves to label those who differ unethical, I am certain their hubris and possibly well-meaning paternalistic views are a violation of our oath and mission statement.

Again, as my president, I need to know if you agree with the finality of Dr. Chervenak's definitive statement.

Sincerely, Stuart J. Fischbein, MD

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