Medical errors: legal and ethical responses.

Liability to err is a human, often unavoidable, characteristic. Errors can be classified as skill-based, rule-based, knowledge-based and other errors, such as of judgment. In law, a key distinction is between negligent and non-negligent errors. To describe a mistake as an error of clinical judgment is legally ambiguous, since an error that a physician might have made when acting with ordinary care and the professional skill the physician claims, is not deemed negligent in law. If errors prejudice patients' recovery from treatment and/or future care, in physical or psychological ways, it is legally and ethically required that they be informed of them in appropriate time. Senior colleagues, facility administrators and others such as medical licensing authorities should be informed of serious forms of error, so that preventive education and strategies can be designed. Errors for which clinicians may be legally liable may originate in systemically defective institutional administration.     

Court-ordered cesarean section: an analysis of ethical concerns in compelling cases

Two previously unreported cases are presented in which court-ordered cesarean sections were considered appropriate by physicians. An analysis of the factors that compel physicians to deem court-ordered intervention appropriate is presented. When the significance of a third-trimester fetal death or a lifetime physical or mental disability is balanced against the demand to uphold maternal autonomy at all costs, the recognized ethical principles of beneficence, nonmaleficence, justice, obstetric contract keeping, and acting in the patients' best interests combine, in rare situations, to override concerns for individual maternal autonomy and justify court-ordered intervention.     

Conflict of interest: legal and ethical aspects.

Conflicts of interest arise when those who owe conscientious duties to others appear to have personal interests that might tempt them to subordinate those duties to their self-interest. Conflicts of interest are distinguishable from conflicts of commitment, which arise when individuals bear two or more mutually exclusive duties to others. If persons in conflicts of interest favor their self-interest, they may violate binding legal duties such as fiduciary duties. Conflicts arise when, for instance, medical practitioners refer their patients to other practitioners in exchange for payments (fee splitting), and when they gain secondary incomes such as from testing patients' samples in laboratories in which they hold ownership or investment interests. Financial dealings with commercial sponsors may place researchers in apparent conflicts of interest with research subjects. When conflicts of interest are unavoidable, they may be resolved by appropriate disclosure.     

International aspects of ethical problems in obstetrics and gynaecology.

Until the middle of the twentieth century, family planning was commonly condemned as an immoral enterprise. This chapter argues that ethical disapproval made access to fertility regulation difficult, and that while the rich and educated were often able to access the services they needed, typically the poor could not. Thus, ethical interpretations caused much of the differential fertility observed between social classes, ethnic groups and ultimately much of the explosion in population that has characterized the last 50 years. Since the 1960s human rights have been interpreted to encompass the right to decide the number and spacing of children and as a result access to contraception has improved. Where several methods of contraception (backed up by safe abortion) are available, fertility always falls. But, unfortunately, consensus has not been reached on how to specify particular sets of rights (e.g. decision-making for adolescents), and no consensus exists on how to balance the opposing rights of the mother and fetus in the case of abortion. The ethics of the one-child family in China is also noted.     

Multiple pregnancy: legal and ethical issues

Multiple pregnancy is increasingly considered a complication of in vitro fertilization (IVF) and ovarian stimulation for natural fertilization. Harms to fetuses, newborn and older children, mothers, families, and healthcare systems are encouraging single embryo transfer. When patients knowingly accept multiple pregnancy risks from IVF or ovarian stimulation, they are unlikely to succeed in litigation against healthcare providers for wrongful pregnancy or wrongful birth. More challenging are impaired children's claims for "wrongful life." These are unlikely to succeed against parents, but courts are ambivalent to claims against healthcare providers. Historically, courts rejected these claims, under the principle that live birth is not a legal injury. European and other courts, however, have been more sympathetic to these claims. Multiple pregnancy treated by fetal reduction is not usually found to offend abortion laws. This poses ethical concerns, however, of "lifeboat ethics," involving how fetal reduction choices are made.     

Ectopic pregnancy and emergency care: ethical and legal issues.

Ectopic or tubal pregnancy presents a medical emergency that requires prompt treatment in order to contain risks of maternal death and morbidity, including loss of future fertility. Medical circumstances involving individual patients and resources of the prevailing health care system will determine the options and means of treatment. Termination of ectopic pregnancy does not constitute or directly implicate abortion. Any practice of deliberately delaying treatment of reliably diagnosed ectopic pregnancy, on non-clinical grounds, until rupture of the fallopian tube has occurred or is imminent, in order to justify termination of the ectopic pregnancy on grounds of saving the patient's life, is unethical and illegal. Those who undertake or counsel deliberate delay of medically-indicated treatment can be charged with criminal offences and civil (non-criminal) liability, and medical professional misconduct. On reliable diagnosis, prompt treatment to remove ectopic pregnancy is legally justified, and ethically and legally required.     

Some ethical and legal issues in assisted reproductive technology.

The potential and actual applications of reproductive technologies have been reviewed by many governmental committees, and laws have been enacted in several countries to accommodate, limit and regulate their use. Regulatory systems have nevertheless left some legal and ethical issues unresolved, and have caused other issues to arise. Issues that regulatory systems leave unresolved, or that systems have created, include disposal of embryos that remain after patients' treatments are concluded, and multiple implantation and pregnancy. This may result in risks to maternal, embryonic and neonatal life and health, and the contentious relief that may be achieved by selective reduction of multiple pregnancies. A further concern arises when clinics must (or choose to) publicize their success rates, and they compete for favorable statistics by questionable patient selection criteria and treatment priorities.     

Women's access to health care: the legal framework.

The Millennium Development Goals set ambitious targets for women's health, including reductions in maternal and child mortality and combating the spread of HIV/AIDS. The law, which historically has often obstructed women's access to the health care they require, has a dynamic potential to ensure women's access that is being progressively realized. This paper identifies three legal principles that are key to advancing women's reproductive and sexual health. First, law should require that care be evidence-based, reflecting medical and social science rather than, for instance, religious ideology or morality. Second, legal guidance should be clear and transparent, so that service providers and patients know their responsibilities and entitlements without litigation to resolve uncertainties. Third, law should provide applicable measures to ensure fairness in women's access to services, both general services and those only women require. Legal developments are addressed that illustrate how law can advance women's equality, and social justice.     

Obstetrical delivery of the HIV-positive woman: legal and ethical considerations

Every year, thousands of perinatally HIV-infected children are born, resulting in debate about appropriate HIV treatment and interventions for pregnant women. Recent medical studies endorse the use of the cesarean delivery to reduce vertical (mother to infant) transmission of HIV. In addition to medical questions, this practice raises legal and ethical considerations for the attending physician. In the context of AIDS prevention, the potential exists for reasoned and well-informed decision making to give way to encouragement, and even duress, in cases where a woman refuses recommended surgical delivery. However, in such cases, the role of the physician should remain as that of an informed educator and counselor, enabling the patient to exercise her autonomy and personal choice within her social and cultural context.     

Crossing the line: the legal and ethical problems of foreign surrogacy

UK law has for many years taken a careful approach to surrogacy, neither banning it nor allowing it to develop unrestrictedly. This careful middle approach seeks to balance permitting what may be a last hope for infertile couples against a wider public policy that bars commercialized reproduction: surrogacy is allowed in the UK, provided it is consensual and involves the payment of no more than reasonable expenses. But in an increasingly globalized world, patients are crossing borders for treatment, often to places where such restrictions on the commerciality or enforceability of surrogacy arrangements do not apply. The resulting conflicts of law can be a minefield, and this makes the maintenance of the UK's careful legal balance increasingly untenable.     

Voluntary and involuntary sterilization: medical, ethical, legal and religious aspects.

Surgical voluntary sterilization has become one of the most widely used methods of contraception, with vasectomy and tubal sterilization being the most commonly employed techniques, associated with a low failure, morbidity, mortality, and long-term sequelae rate. As sterilization is related with the elimination of the possibility for procreation, a number of ethical, legal and religious issues have arisen, leading often to personal misjudgements, legal disputes, and failures in applying family planning. Involuntary sterilization is currently not practiced, except in cases of severely mentally retarded people, who are unable to appreciate the consequences of their acts or care for their children and who may have a high likelihood of propagating hereditary disease.     

The genetic revolution: new ethical issues for obstetrics and gynaecology

The genomic revolution inherently changes the paradigms that have informed the interactions between patient and physician. These changes obligate physicians both to continually learn about the advances occurring in genetic testing and to review their interactions in light of the changing ethical issues these advances uncover. Particular areas for concern are the use of genetic testing for predisposition genes. The issues differ between uses for adults, for children and for pre-implantation genetics. Furthermore, there are issues of justice raised by limited access to these technologies, research confidentiality, potential discrimination and the meaning of individuality in an era of potential genetic cloning. These changes require obstetrician/gynaecologists to advocate for the best interests of both their patients and those who may not be able to voice their interests, for example children-to-be and research subjects in developing countries.     

Ventriculoamniotic shunt for treatment of hydrocephalus in one of twins: medical, ethical and legal considerations

One of a pair of preterm twin fetuses was identified as having progressive hydrocephalus. After an extensive evaluation of the parents and both fetuses, a ventriculoamniotic shunt was placed. The affected twin, despite multiple additional neonatal procedures, has done well as matched against her normal twin sister. Both children are well 4 years after the surgery. The case presented a remarkable complexity of medical, ethical and legal issues which are presented.