Ethical and Legal Issues in Obstetrics and Gynecology

When confronted by a
complex situation in which there are conflicting values and rights, getting
the most people involved is the best approach to reduce risk and to come
up with the best, most defensible answer under the current circumstances.
The obstetrician should employ whatever departmental or hospital
resources are available. A standing ethics committee or an ad hoc committee
to deal with such complex situations is often available and will minimize
the ultimate medicolegal problems that can ensue when bad
outcomes seem likely. The obstetrician must further recognize that he or
she has two patients, but that it is not clear, nor is it legislated, whose interests
take priority. However, general ethical opinion is that the mother generally
should come first. Most court-ordered cesarean sections have been
performed on patients who were estranged from the medical system, and
this sets a very bad precedent for further state intervention in doctorpatient
relationships and maternal rights. Child abuse statutes do not at
this point require a court order to force a cesarean section even for a
healthy fetus, and a court order would almost never be appropriate.

unless relatively expeditious

Living wills represent the
chance for patients to declare their wishes in advance of situations in which
they become no longer competent to do so. They are revocable by the
patient at any time and are automatically invalid if the patient is pregnant,
as another being is involved. Living wills can be set aside if a long period
has elapsed since their drafting and the wishes are not known to be current.
Also, there is the potential for conflict if the patient has signed a donor card and prolongation of life would be needed to carry out those wishes. Generally,
such action would not be honored unless relatively expeditious
arrangements were possible.

working through ethical dilemmas.

Patient preferences,
quality of life issues, and medical indications are all examples of ethical
concerns that must be taken into account when working through ethical
dilemmas. Consideration of legal issues is not a factor in ethical decision
making. If the patient’s insurance company refuses to pay for the indicated
procedure (in this case, hysterectomy), the ethical principle of justice (the
patient should be given her due) is being challenged. Autonomy is the ethical
principle whereby the patient has the right to self-determination.
Therefore, the needs of society (a contextual issue) are not considered as a
factor of autonomy. Informed consent requires that the patient be able to
understand the risks, benefits, and alternatives of a particular medical procedure.
If the patient is unable to understand the medical information, a
legal guardian can be assigned to make those decisions for him or her. A
patient’s desire not to have his or her medical history discussed with anyone
else involves the ethical concept of confidentiality.

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Hyperlipidaemias :

Hyperlipidaemias can present with xanthomas, which are abnormal collections of lipid in the skin. All patients with xanthomas should be investigated for hyperlipidaemia although the most common type called xanthelasma (yellow plaques around the eyes) are usually associated with normal lipids. There are a number of other clinical variants of xanthomas such as (i) tuberous xanthoma (firm orange-yellow nodules and plaques on extensor surfaces), (ii) tendon xanthoma (firm subcutaneous swellings attached to tendons), (iii) plane xanthoma (orange-yellow macules often affecting palmar creases), (iv) eruptive xanthoma (numerous small yellowish papules commonly on the buttocks).

Chronic renal failure :

Chronic renal failure is commonly associated with intractable pruritus. Pallor, hyperpigmentation and ecchymoses are commonly seen. Rarely it is associated with non-inflammatory blisters, pseudo-porphyria cutanea tarda and cutaneous calcification. Long-standing renal transplant patients often suffer with recurrent viral warts and squamous cell carcinomas due to the immunosuppression.

Thyroid disease :

Hypothyroidism may cause dry firm gelatinous (myxoedematous) skin with diffuse hair thinning and a loss of the outer third of the eyebrows. Hyperthyroidism may be associated with warm sweaty skin and a diffuse alopecia. Graves' disease is rarely associated with thyroid acropachy ('clubbing' with underlying bone changes) and pretibial myxoedema (a red-brown mucinous infiltration of the shins which can become lumpy and tender).