Patient Relations:
Professionalism, informed consent, and abortion
MS-3 Case Based Series
Gretchen S. Stuart, MD, MPHTM
Jennifer H. Tang, MD
Amy G. Bryant, MD
Family Planning Program, UNC-Chapel Hill
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Objectives
• To meet the UNC School of Medicine Core competencies
• Review the principles of informed consent
• Review the cases from opinions of those who oppose and those
who support abortion availability
• Increase self-awareness about specific patient situations that make
you feel uncomfortable
• To understand the potential for a judgmental reaction or tone to
interfere with the patient-doctor relationship and to develop
strategies for preventing this interference
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UNC School of Medicine Objectives
• Professionalism
– adherence to ethical principles
– sensitivity to patients
– maintenance personal health and well-being,
specifically:
• Demonstrate balance between priorities of patient care and
personal and professional development
• Identify and apply theories and principles that govern
ethical decision-making to the practice of medicine
• Advocate for access to health care for members of
underserved populations
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UNC School of Medicine Objectives
• Interpersonal and Communication Skills
– Students must demonstrate interpersonal and communication
skills that facilitate effective interactions with patients and
their families and other health professionals, specifically:
• Develop empathetic, caring relationships with patients
• Communicate effectively with patients, patients’ families,
colleagues, and other health care professionals.
• Demonstrate gender and cultural sensitivity in educational and
clinical care settings
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Patient interactions to consider
• Caring for a patient who is:
 An alleged crime suspect; an alleged or known abuser of children
or women
• Caring for patients who you don’t feel help themselves:
 Alcoholics; non-compliant patients with chronic disease
• Caring for pregnant patients who you don’t feel care about
the wellbeing of their fetus
• Caring for pregnant patients who want an abortion
• Working with other physicians who you feel behave
unethically
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Autonomy
• The mother’s prerogorative to make
choices or take actions based on her
beliefs and values even if these actions
are harmful to herself or her fetus
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Conscience
• The private, constant, ethically attuned
part of the human character. It operates
as an internal sanction that comes into
play through critical reflection about a
certain action or inaction.
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Beneficence
• To promote the wellbeing of others
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Non-Malifecence
• To do no harm
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Justice
• Access to care
• Distribution of resources
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Informed Consent
Informed consent is based on ethical and legal
requirements.
Ethical foundation of informed consent process is the
physician obligations of beneficence, nonmaleficence,
autonomy and justice.
Legal foundations of informed consent are spelled out in
statutes and case laws in all 50 states and can often be
found through state medical board websites.
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Informed Consent
Not just a signed piece of paper to signify “preoperative release”.
Aim is for patients to meaningfully participate in the decision making
process
Medical education of the patient is fundamental to the process.
The basis of the informed consent process is to respect and promote
the participant’s or patient’s autonomy, and to protect him or her from
potential harm.
The collaborative physician-patient relationship forms the foundation of
the informed consent process.
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Informed Consent
Risks and benefits of the intervention and alternative treatments or
procedures, as well as risks and benefits of not receiving or undergoing
a treatment, should be explained in language that will facilitate patient
comprehension.
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Informed Consent
A well designed ICF should promote the patient’s understanding and
the voluntary nature of their participation in the treatment.
Readability and comprehension of the informed consent form must be
appropriate.
Almost half of all U.S. adults read at or below 8th grade level but
consent forms should be written at least three grade levels lower than
the average educational level of the target population.
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Application to reproductive medicine
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Assisted reproductive technology
Contraception
Emergency Contraception
Abortion
Sterilization of mentally challenged
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Some background on abortion
• In 2005 1.21 million women chose to have an
abortion
• 1/3 of all women will have had an abortion by
age 45
• More than half (54%) or women who have an
abortion report using contraception when they
got pregnant
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More abortion information
• 58% of women say they would have liked to
have had their abortion sooner
• 53% of women having an abortion never had a
previous one
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Conscientious refusal and reproductive
medicine
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Sterilization for mentally challenged
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Sterilization for mentally challenged
• At UNC Hospitals requires involvement of
Legal Department and usually an ethics
consult
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Emergency contraception
• Example:
• A pharmacist rejected a rape victim’s
prescription for emergency contraception
arguing that dispensing the medication was a
“violation of morals”
ACOG Committee Opinion Number 385, November 2007
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Emergency contraception
• Example
– In Virginia a 42-year old mother of two was
refused a prescription for emergency
contraception, became pregnant and
ultimately underwent an abortion she had
tried to prevent by requesting the EC.
ACOG Committee Opinion Number 385, November 2007
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Assisted reproductive technology
• Example
– In California a physician refused to perform
intrauterine insemination for a lesbian couple,
prompted by religious beliefs and disapproval
of lesbians having children
ACOG Committee Opinion Number 385, November 2007
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Case Discussions
• Respond agree/disagree
• I’ll collect and redistribute
• Divide into two groups – agree and
disagree for each question and defend the
card you received.
• Maintains anonymity
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Discussion
• Statement completions regarding provision
of abortion services
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Case 1
• Jane is 17 years old and is 10 weeks pregnant. She
comes from a supportive working class family with strong
ties to the anti-abortion movement. She has been
accepted on an athletic scholarship to UNC and is due to
start her first semester in two months. Her boyfriend
wants them to get married and have the baby. She
doesn’t know what to do and she is in your office crying.
MS-3 students will be asked to agree or disagree to this statement,
then the answers will be mixed up and redistributed and you will be
asked to defend the answer you receive.
The abortion option: a values clarification guide for health care professionals, NAF
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Conclusion
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