Toward the ethical evaluation and use of maternal-fetal surgery.

BACKGROUND: Important clinical, social, and ethical questions are associated with the evaluation and use of surgical approaches aimed at correcting fetal anatomic abnormalities. In particular, the expansion of maternal-fetal surgery to ameliorate nonlethal fetal conditions has intensified the need to address issues about the adequacy of technology assessment and the safety of those who undergo these novel procedures. APPROACH: After discussions at a multidisciplinary conference, we reviewed the development and current practices of maternal-fetal surgery and analyzed the relevant ethical issues concerning the use of maternal-fetal surgery for nonlethal conditions, focusing on the correction of myelomeningocele. FINDINGS: Characterizing nonvalidated maternal-fetal surgery procedures as "innovative therapy" blurs the boundaries between research and therapy and creates uncertainty about the obligations of clinicians and researchers. Further, maternal-fetal surgery raises ethical issues related to maternal risks and benefits, informed consent, distinguishing lethal from nonlethal conditions, withholding unproven treatments, entrepreneurship, and prioritization. RECOMMENDATIONS: To help ensure that maternal-fetal surgery will be studied and eventually applied in a scientifically and ethically sound manner, we offer several recommendations. First, innovation in maternal-fetal surgery should be conducted and evaluated as research. Second, women must be considered research subjects in these trials. Third, the informed consent process must ensure adequate comprehension and genuine voluntariness in those considering participation. Fourth, discriminatory and fearful attitudes toward individuals with disabilities should be addressed explicitly prior to making a decision to proceed with maternal-fetal surgery in an attempt to correct such disabilities. Fifth, maternal-fetal surgery should not be performed for cosmetic indications unless and until there is reliable evidence that maternal-fetal surgery can be performed safely and that long-term side effects on women and their offspring are minimal. Sixth, centers of excellence should be established for conducting research and providing maternal-fetal surgery. Seventh, funding for research on maternal-fetal surgery should be considered in the context of societal needs.

Psychological and sexual functioning in women with vulvar vestibulitis.

OBJECTIVE: The purpose of the study was to compare psychological and sexual functioning in women with vestibulitis with healthy controls. It was hypothesized that women with vestibulitis would experience greater psychological stress and sexual dissatisfaction than controls. STUDY DESIGN: Fifty-two women with vestibulitis recruited from a vulvovaginal disease clinic and 46 healthy controls recruited from an outpatient gynecology clinic completed five standardized measures of psychological and sexual functioning. Multivariate analyses of variance and covariance were used to examine group differences. RESULTS: Women with vestibulitis reported significantly higher scores than controls on the measures of depression (p < or = 0.001), psychological distress (p < or = 0.001) and sexual depression (p < or = 0.001). They reported significantly lower scores on the measures of sexual satisfaction (p < or = 0.001), sexual behavior (p < or = 0.001) and sexual self-esteem (p < or = 0.01). CONCLUSION: The results of this study highlight the importance of addressing psychological distress and sexual dissatisfaction in women with vestibulitis.

Factors influencing obstetric and gynecologic patients' decisions toward medical student involvement in the outpatient setting.

OBJECTIVE: We sought to determine the reasons for obstetric and gynecologic patients' acceptance or refusal of medical student participation in their outpatient care. STUDY DESIGN: A descriptive and analytic cross-sectional study of 180 patients at the University of California, San Francisco, was done to identify factors involved in patient acceptance or refusal of medical student participation in their outpatient obstetric-gynecologic visit. Responses were analyzed by Cochran-Mantel-Haenszel tests for rank order tests of factors involved in the decision to accept or decline medical student participation and chi(2) or Fisher exact tests for comparison of data among different groups. RESULTS: Reasons for accepting medical student involvement included the desire to contribute to the training of future physicians and the desire for the highest standard of care. Reasons for refusing medical student involvement included the protection of patient privacy and the low comfort level with the examination. The acceptance rate for medical students during the obstetric visits was 89.1%, and that during the gynecologic visits was 81.4%. CONCLUSION: Private faculty patients, as well as Medicaid patients, have a high acceptance of both male and female medical students in the obstetric-gynecologic outpatient setting.

Reproductive health under managed care: expanding provider obligations.

The discussion of ethical issues in managed care can be focused on two general areas. The first of these is the impact of the shift toward managed care on the fiduciary relationship between health care professional and patient, including the issue of trust, the potential for conflict of interest, and the impact of cost-saving strategies on the clinician's ability to address a patient's health care needs. The second is the attention to justice that managed care demands. Health care professionals must take issues in both areas into account, attempting to balance obligations to individual patients with obligations to patients collectively. Strategies for doing so are discussed.

New surgical procedures: can our patients benefit while we learn?

Several forces have combined to encourage gynecologic surgeons to acquire the skills they need to perform new endoscopic procedures. Pressures from health care institutions, industry, and, most important, from patients lead to increased demand for less invasive approaches to the treatment of gynecologic conditions. This demand may outstrip the profession's ability to demonstrate the safety and effectiveness of new procedures through rigorous clinical trials. Early on, the benefits expected from laparoscopic surgery may be limited by harms resulting from surgical inexperience. Physicians will struggle to achieve a balance between their ethical obligation to benefit patients while avoiding harm to them and their professional expectation of continued learning. Acquisition of new techniques involves a learning curve, across which complications and operating time decrease while the potential for benefit rises. To minimize harm to patients during the surgeon's learning process, peer review should play an expanded role. Surgeons should discuss their own surgical experience and level of skill openly with their patients as part of the process of informed consent. A relationship of trust is vital when one engages patients in a cooperative educational venture.

Ethical considerations in prenatal diagnosis.

Prenatal diagnostic testing raises a number of important ethical issues, some related to diagnostic testing in general and others related to the special circumstances of pregnancy. These issues are most effectively addressed in the context of a broader understanding of the goals of prenatal diagnosis. Our dual obligations--to the pregnant woman and to the fetus--have an important influence on the goals of testing. Testing seldom leads to treatment beneficial to the fetus, but more often can be beneficial to the pregnant woman, particularly if the information provided enhances her ability to make sound decisions about reproductive matters. The process of prenatal diagnostic testing can, however, limit a woman's sense of control over the decisions made about her pregnancy. It can also provide an opportunity for third parties to become involved in what are usually considered private matters. It is therefore important that the process of testing include adequate counseling and follow-up and that the patient's confidence be respected. As prenatal diagnostic technology expands, both in terms of patients to be tested and diagnoses to be sought, society will face difficult questions concerning access to testing and the justification for its use.

The impact of prenatal genetic testing on quality of life in women.

The techniques of prenatal genetic diagnosis are being used with increasing frequency in the provision of prenatal care. One aim of such testing is to benefit pregnant women. Inadequate data exist, however, to indicate whether testing provides benefits for or imposes burdens upon the women involved. The influence of testing on anxiety during pregnancy, on a woman's sense of control over the progress and outcome of pregnancy, and on a woman's relationships with her partner and future child are all of concern. Investigation of these questions should be integral to studies undertaken to assess prenatal genetic testing.

Conservative treatment of paroxysmal ventricular tachycardia during pregnancy.

Paroxysmal ventricular tachycardia during pregnancy presents a therapeutic dilemma for the treating physician. The clinical course of two otherwise healthy pregnant patients with this arrhythmia in whom treatment was withheld is outlined. The indications and guidelines for treatment in relatively asymptomatic patients is discussed.

Maternal brain death during pregnancy. Medical and ethical issues.

We present in detail a case of a 27-year-old primigravida who was maintained in a brain-dead state for nine weeks. An apparently normal and healthy male infant weighing 1440 g was delivered. The newborn did well and was found to be growing and developing normally at 18 months of age. Although the technical aspects of prolonged life support are demanding and the economic costs are very high (+217,784), there are ample ethical arguments justifying the separation of brain death and somatic death and the maintenance of the brain-dead mother so that her unborn fetus can develop and mature.

KIE: Physicians and an ethicist at the University of California, San Francisco, present the details of the case of a pregnant, brain-dead woman whose vital functions were maintained for nine weeks until the delivery of a healthy infant at 31 weeks' gestation. Despite the technical difficulties involved and the economic costs incurred ($183,031 for maternal care and $34,703 for neonatal care), the authors conclude that ethical considerations support the decision on care. They argue that the woman was not injured; that nonmaleficence and beneficence toward the fetus require a rescue attempt if there is a reasonable chance of reaching fetal maturity; that maternal medical care may be more cost effective than prolonged neonatal support; and that the father's wishes were respected. Rather than proposing guidelines, they hold that decisions on prolonged maternal support should be based on the circumstances of each case.

Cytologic detection of recurrent vaginal melanoma.

A case of malignant melanoma of the vagina is described. Ultrastructural examination of tissue from the neoplasm showed a well-developed protein framework similar in appearance to that seen in the slowly progressive lentigo maligna form of malignant melanoma from the general body skin. The spectrum of malignancy known for most other neoplasms, from slowly and locally recurrent to highly aggressive, seems to be found similarly in vaginal malignant melanoma. The patient was treated with local excisions and followed by cytologic examination; she is without known deep or systemic spread after more than three years.