"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, November 2, 2012

Ethics Under Assault

It’s a story that seems all too common; the recurring harassment of supportive and optimistic doctors willing to collaborate with midwives. Honest and brave doctors who want to provide evidenced based options to women are forced into a choice of business survival vs. professional morality. The power of the big over the small, the bully over the weakling, it’s a story of sham peer review to maintain the status quo. Somewhere along the line the ethical and moral code we swore to uphold gets pushed aside for expediency, economics and fears of liability. The story plays out as good people who remember their fiduciary duty to their patients are harassed and eventually squashed by the behemoth that is conveniently called the “standard of care”......... Because the established medical machine says that something is outside their rigid community standard then the supportive doctor cannot be allowed to individualize his care and support other reasonable options. They believe that “consensus” equates with truth. It does not. And if you are not in their fold then you are a danger to them, their liability and their livelihood and must be coerced into conforming or risk the isolation from colleagues and the threat from hospital committees and administrators. This is happening all over the country and recently to some wonderful local doctors. Having been through this I would not wish it on anybody......... The modern doctor-patient relationship is not the one we grew up with. Although doctors are still expected to treat their patients with the same measure of duty, skill and care that has always existed there are new and powerful outside forces pressuring that relationship. There has always been a duty owed to the patient that remains a “fiduciary” wherein the patient’s interests must be paramount to those of the doctor. This faith and trust placed in the doctor by the patient all too often comes in conflict with the doctor’s own interests. Doctors have many pressures put on them by third parties such as government agencies, malpractice insurance companies, hospital administrations and third party payers. Often these interests directly conflict with the fiduciary duty to the patient.......... As I see it, too many of my colleagues have succumbed to these pressures and thus prioritize not on what is best for the individual patient but what is going to help them survive financially. There is no doubt of the reality of the difficult choice they must make for themselves. If they truly thought about this it would be very painful. But in the mode of groupthink that has overwhelmed my profession the pressuring of the rare nonconformist is understandable. So as to remove themselves from responsibility the majority go along with policies that violate their fiduciary duty but protect them from direct culpability. They use the, “I wish I could honor that choice if only the hospital would allow it”, excuse rather than stand with the few who think decisions should still belong to the informed patient. On the simplest level these brave few who choose to honor Hippocrates make the tyrannical majority look bad and, so, they must be vilified.......... Furthermore, under the American Medical Association’s Code of Ethics there exists the beneficence model to which we are all supposed to adhere. According to Sonya Charles in her recent Medscape article on The Ethics of VBAC, 2012 The Hastings Center the beneficence model makes a peculiar claim: “To interpret reliably the interests of any particular patient from medicine’s perspective. This perspective is provided by accumulated scientific research, clinical experience and reasoned responses to uncertainty. It is thus not a perspective peculiar or idiosyncratic to any particular physician. Based on this model, the physician cannot refuse to accommodate any request for alternative treatment that is supported by scientific research and clinical experience."......... My point is this: Hospitals, medical staffs and groups of physicians that wield power over individual physicians and smaller groups and threaten their livelihood if they do not conform to whatever standard they deem appropriate are violating both their fiduciary duty and their ethical obligation to the people of their community. Doctors who support patients who choose a midwife are honoring their ethical obligation. Doctors who allow for selected breech delivery, VBACs and twins are honoring their fiduciary duty and their ethical obligation to put their patient’s reasonable choice ahead of their own self interest. It would be just as ethical for a doctor to say to a woman that he cannot support that choice but refer her to someone who can. It is also the ethical and, I would say, moral responsibility of those doctors to aggressively advocate for those reasonable choices in the facilities in which they practice and with the insurers who restrict the rights of patients to choose. It is too easy to throw up ones hands and do nothing but it is not right, it is not moral......... What is also not acceptable is for doctors to skew their consenting to funnel patients into choices they prefer. It is a violation of their ethical code to punish doctors who put the fiduciary interests of reasonable patients before their own. Worse, it is immoral to do these things for financial gain or for expediency in lifestyle. Yet, sadly, this goes on every day and has become the accepted norm. I encourage every patient to educate themselves on reasonable choices for their health. Go discuss them with your practitioner. If you are met with skepticism or disdain present the ethical and fiduciary argument and see what response you get. Many doctors have lost sight of these simple tenets and seek retribution when confronted by a colleague who tries to point this out. The power for change lies with the consumer and those of us who honor the doctor-patient relationship as it was once intended are counting on you for help.

1 comment:

  1. Thank you Dr. Fischbein for all you do.
    When we moved to Simi from Humboldt pregnant I was so resistant to the idea that there could really be anything here besides my family that could justify our move back from the beauty of the redwoods but then we found you. We were blessed to not only have you at the birth of our second bundle of love but also our third following close behind.
    You are amazing, and an inspiration to us all to stand up for what we believe in.. You gave me a voice when I didn't think I had one and the opportunity to bring my babies into this world the way I wanted. I felt safe with you and the trust I felt with you helped me to be the person in labor I knew I could be. A true shining star!!!
    Thanks again.