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Addressing Refusal of Treatment During Pregnancy

Obstet Gynecol; ePub 2016 Jun; Marshall, Edmonds, et al

The American College of Obstetricians and Gynecologists’ Committee on Ethics has issued a committee opinion to provide obstetrician-gynecologists with an ethical approach to addressing a pregnant woman’s decision to refuse recommended medical treatment that recognizes the centrality of the pregnant woman’s decisional authority and the interconnection between the pregnant woman and the fetus. Among the ACOG recommendations:

• Pregnancy is not an exception to the principle that a decisionally capable patient has the right to refuse treatment, even treatment needed to maintain life.

• The use of coercion is not only ethically impermissible but also medically inadvisable because of the realities of prognostic uncertainty and the limitations of medical knowledge.

• Eliciting the patient’s reasoning, lived experience, and values is critically important when engaging with a pregnant woman who refuses an intervention that the obstetrician–gynecologist judges to be medically indicated for her well-being, her fetus’s well-being, or both.

• When working to reach a resolution with a patient who has refused medically recommended treatment, consideration should be given to the following factors: the reliability and validity of the evidence base, the severity of the prospective outcome, the degree of burden or risk placed on the patient, the extent to which the pregnant woman understands the potential gravity of the situation or the risk involved, and the degree of urgency that the case presents.

• Obstetrician–gynecologists are encouraged to resolve differences by using a team approach that recognizes the patient in the context of her life and beliefs and to consider seeking advice from ethics consultants when the clinician or the patient feels that this would help in conflict resolution.

• The College opposes the use of coerced medical interventions for pregnant women, including the use of the courts to mandate medical interventions for unwilling patients.

• It is not ethically defensible to evoke conscience as a justification to attempt to coerce a patient into accepting care that she does not desire.

• The College strongly discourages medical institutions from pursuing court-ordered interventions or taking action against obstetrician–gynecologists who refuse to perform them.

Citation:

Refusal of medically recommended treatment during pregnancy. Committee Opinion No. 664. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2016;127:e175–82.