77. Case: Accommodating Requests: Which Differences Make a Difference?

 

Michelle Yoder is 8 months pregnant and a member of the Amish community.  She requests that only female health care providers and staff be involved in providing her care during labour and delivery.

Michelle Federov is 8 months pregnant.  She requests that only white health care providers and staff be involved in providing her care during labour and delivery.

 

Discussion:

  • What are the ethical concerns raised by these cases?
  • How are your responses different to these two scenarios?
  • How do you think health care organizations should respond to requests like these?

Resources:

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63. CASE: Breastfeeding Concerns

Natasha is 15 years old and you, an RN, are meeting her for the first time at a prenatal visit. Her boyfriend, Josh, is 17. Natasha is planning on feeding her baby breast milk substitute as she thinks it will be easier. She has heard that it is harder to lose “baby weight” while breastfeeding, and is worried about fitting into her bikini this summer. She also tells you that she has heard that breastfeeding makes breasts saggy and is worried that Josh won’t be attracted to her anymore. Her mother, on the other hand, is pressuring her to breastfeed.

  • What values are at play here and for whom?
  • Are there any ethics issues in this situation?
  • How would you continue the discussion with Natasha?

Some Values and Ethics Issues to Consider

  • Respect for autonomy
  • Patient-family relationships
  • Patient-centred care
  • Responsibility for health
  • Stigma and blame

62. CASE: Formula Feeding Resource Book

Andrew Godwin is a relatively new staff person working for Public Health. He is learning about the WHO Code of Marketing Breastmilk Substitutes and the importance of promoting breastfeeding as a norm in Nova Scotia, as part of the Healthy Eating Strategy.

He has received several phone calls from new parents asking him why the province’s formula feeding resource book is not online and requesting him to consider adding it to the electronic resources. What should Andrew do?

  • Identify the values that are relevant to this discussion and select the ones that you think should guide Andrew’s response. 
  • Would it be appropriate to post this booklet online? Why or why not?

Some Values and Ethics Issues to Consider

  • Duty to provide care
  • Honesty, trust and truth-telling
  • Respect for autonomy
  • Transparency
  • Community/ public health ethics
  • Compliance with policy
  • Patient-centred care

2. CASE: Treatment and/or Termination? Tough Choices

Melanie is a 21 year old who was recently involuntarily committed after she started a serious fight at a local shelter, thinking that one of the leaders was trying to steal her favourite T-shirt. Melanie has schizophrenia and is well-known to both the police and mental health care providers. She has been living on and off the streets since she left home when she was 16 years old, and has a rather strained relationship with her parents. They have been trying to support her and often provide money for her medications. When Melanie is taking her medications, she is able to find work and has talked about going back to school. However, Melanie finds the side effects of the medications awful and stops taking them, leading to being kicked out of apartments or friends’ places when she gets too aggressive.

In doing Melanie’s work-up upon admission, it was discovered that she is about 7-8 weeks pregnant. While trying to determine what to do with respect to the pregnancy, she is placed on medications that minimize teratogenic effects for the fetus, and that may have some success in stabilizing Melanie’s condition (although it is recognized that this is not the “gold standard” treatment). Melanie’s mother, Krystine, was named by Melanie as her substitute decision-maker (witnessed by her psychiatrist at the end of her previous admission), despite some of the challenges in their relationship, and she endeavours to do the best for her daughter. The team has been in discussion with Krystine about treating Melanie and about her pregnancy.

Melanie has indicated that she doesn’t know who the father is, as she has had several partners over the last few months. She also alternates between saying that she wants the baby to saying that the baby is cursed and she should be rid of it. Krystine indicates that Melanie has not talked to them about having children, only about trying to get well to go back to school.

Both Krystine and the health care team have some questions and concerns about how to move forward with Melanie’s treatment. The health care team calls for a clinical ethics consultation.

  • If the medication regime doesn’t stabilize Melanie, would it be ethical to move to a different treatment plan, knowing that this might cause substantial harm to the fetus?
  • Should the possibility of terminating the pregnancy be discussed further?
  • Should an attempt be made to find and notify the biological father?
  • How do the dynamics if Melanie’s family relationships factor into this case?
  • Can or should someone other than Melanie make these decisions?

Some Values and Ethics Issues to Consider

  • Capacity
  • Respect for patient autonomy
  • Living at risk
  • Vulnerability
  • Patient-family relationships
  • Substitute decision-makers
  • Beneficence and non-maleficence