A 28-year-old woman, gravida 2 para 1, comes to the emergency department for evaluation of vaginal bleeding. The patient has had bright red spotting for the past 24 hours but no contractions or leakage of fluid. She is at 31 weeks gestation by last menstrual period and has not had prenatal care this pregnancy. Her first pregnancy ended in an uncomplicated spontaneous vaginal delivery at term. Vital signs and fetal heart rate tracing are normal. Physical examination shows a nontender uterus consistent in size with 31 weeks gestation. A pelvic ultrasound reveals a complete placenta previa. The findings are discussed with the patient, and she states that she would still like to have a vaginal delivery. The physician says, "Unfortunately, the only safe option for delivery is a cesarean delivery." The physician's statement is an example of which of the following ethical principles?

Question

A 28-year-old woman, gravida 2 para 1, comes to the emergency department for evaluation of vaginal bleeding.  The patient has had bright red spotting for the past 24 hours but no contractions or leakage of fluid.  She is at 31 weeks gestation by last menstrual period and has not had prenatal care this pregnancy.  Her first pregnancy ended in an uncomplicated spontaneous vaginal delivery at term.  Vital signs and fetal heart rate tracing are normal.  Physical examination shows a nontender uterus consistent in size with 31 weeks gestation.  A pelvic ultrasound reveals a complete placenta previa.  The findings are discussed with the patient, and she states that she would still like to have a vaginal delivery.  The physician says, "Unfortunately, the only safe option for delivery is a cesarean delivery."  The physician's statement is an example of which of the following ethical principles?

Quizplus · Accepted Answer

Most medical decisions are made via shared decision-making, in which the patient's preferences and personal values are considered when discussing ≥2 medically reasonable treatment options (Choice D). However, when there is only 1 medically reasonable treatment option that has clearly superior evidence-based support, it is ethically appropriate for the physician to provide directive counseling, in which only a single treatment option is recommended to a patient. This patient has a complete placenta previa, a condition in which the entire placenta covers the cervix, which is associated with a high risk of maternal (eg, hemorrhage) and fetal (eg, intrauterine demise) morbidity and mortality with vaginal delivery. Due to these risks, the only safe option for delivery, as stated to this patient, is cesarean delivery. Although this patient prefers a vaginal delivery, it is inappropriate for the physician to discuss this choice as a safe and reasonable option. It is the physician's ethical responsibility to advise against it and provide directive counseling by explaining why a cesarean delivery is medically necessary. (Choice A) Assisted decision-making occurs when a family member or other caregiver helps the patient in making a medical decision (but does not make the decision for the patient). Common scenarios include when patients have intellectual disability or a potentially reversible impairment in decision-making capacity (eg, fluctuating mental illness [schizophrenia]). (Choice C) Informed refusal refers to the patient's refusal of a recommended medical treatment following an informed consent discussion (including full disclosure of the risks of refusing treatment). This would occur in this case if, after discussion of the need for cesarean delivery, the patient refuses the procedure. (Choice E) Substituted judgment occurs when a surrogate decision-maker makes a health care decision for an incapacitated patient based on the surrogate's knowledge of the patient's wishes and values. Educational objective: Directive counseling is ethically appropriate when only one treatment option is medically reasonable and has clearly superior evidence-based support. Patients with complete placenta previa should be counseled that cesarean delivery is medically necessary.

A 28-Year-Old Woman, Gravida 2 Para 1, Comes to the Emergency