The parents tried to give birth to their baby at home and when complications developed they went to hospital. It was decided that a caesarean section was necessary and following delivery the baby also required some tests. The parents, most especially, it seemed, the father, raised a considerable amount of objection and refused to leave hospital, asking also for hospital regulations and protocols. Of course such things take professionals by surprise as they are taken out of heir run-of-the-mill routines.
Just because a person decides to make use of hospital services does not of course automatically translate into not having any say in his or her care. That is what the principle of respect for autonomy and informed consent procedures are all about. People have a right to participate in their care and also to refuse treatment.
The issue here was complicated on two counts. First, the father was not a patient. Secondly, where minors are concerned doctors are obliged to follow a standard of care and if this is refused by the parents then legal authorities are called in. Of course the behaviour of the parents will certainly have some weight. Even though one should not judge people by appearances – on whether higher authorities are called in for example – these can influence professionals to question the ability to make a decision in the best interests of the child. This happens with Jehova witnesses when they refuse transfusion for their children and it was likely to happen here where medical care was being refused notwithstanding that the parents came to hospital for help.
When treatment is not life threatening parents do have a moral right to participate. To what extent this is recognised varies from place to place. Many of us witnessed the Siamese Twins saga a few years ago. Are parents always wrong? I think not and perhaps the lesson we should learn here is one on customer care. Parents may need someone to sit down with them and explain what we mean by standards of care and also what patient responsibilities are. Abroad this is usually the job of a clinical ethicist. Unfortunately we often associate ethical issues with moral issues of a religious nature locally and therefore the hospital cannot offer anyone other than a chaplain – who of course, in a case like this would not have been competent, other than perhaps to offer empathy.
Was the mother able to give consent? Clearly she was agreeing with the husband. Legally she was of age. Morally doctors have to make a clear call. This is not being judgemental but being responsible. There is absolutely nothing wrong with a 20-year difference between spouses. Had it been 30 and 50 it would have been different. But 20 is too close to 18 for clinical comfort in such a situation; when combined with the stress the mother had just been through and with the emergency nature of the operation, one cannot rule out that the husband was not having any influence on her – even persuasion can influence a voluntary choice.
Perhaps one cannot judge this particular case but good clinical practice will certainly have called this into question. Pregnancy and delivery renders people vulnerable. I would say that as a husband I would have been vulnerable as well in that situation, especially had I tried to give birth at home and it failed – and there are many professionals who are in favour of home births, once they are supervised and there is access to help. Clearly someone watching over a mother, be it the husband or midwife, has a duty to recognise their limits.
We need to give patients and hospital staff a break. Clashes do occur. They occur at the beginning of life – as happened here; they occur at the end of life – some relatives protest when you want to switch off a respiratory machine when the body is still warm and breathing. No explanation of brain-death will do, especially if they read somewhere that a brain dead person on a life support can even be impregnated and give birth!
Clinical ethics is about conflict resolution. One is trained to have both sides agree on common principles first. In this case it could have been the principle of a safe delivery of the baby and quick return home of a healthy mother and child. Alas we do not see the importance of having a consultant ethicist. I empathised considerably with the hospital staff in this story.
Upon further reflection I could not but empathise even more with the parents. It is not about sitting down with them and making them see the light. Perhaps in the future we would have a case where indeed the patient is right. It is about offering professional clinical-ethical conflict management. Clearly this should come before people search your bag to find a liquor and a judge is called in. And whilst one cannot have plenty of fathers walking around the labour ward and post-partum, it may have been a case where an exception could have been offered had we had this mechanism in place.
Pierre Mallia is Associate Professor in Family Medicine, Patients’ Rights and Bioethics at the University of Malta; he is also Ethics Advisor to the Medical Council of Malta. He is also former president of the Malta College of Family Doctors.