During the last two years of clinical practice, I have worked with various healthcare practitioners. During this time I experienced how different healthcare practitioners, in particular doctors, dealt with patients. I’ve seen some go the extra mile for patients compared to others who stick to doing what is expected of them and nothing more. During this year on my ICU block, I found myself in a situation where I faced a few ethical problems.

During my block at Tygerberg hospital, I treated a 24 year old woman who had an abortion at 24 weeks. The reason for her late abortion was unknown and it was most probably done by a practitioner who was not fully qualified, as she presented with intrauterine scarring and sepsis which lead to her ICU admission. Abortion can be defined as the process where an embryo or fetus is removed from the uterus during pregnancy at a stage where it is incapable of independent survival (Martin, 2010). Unsafe abortions are a major problem in developing countries due to poverty and legal restrictions. It is believed that unsafe abortions account for the largest number of hospital admissions with regards to gynecological services, specifically in developing countries, and the World Health Organization has estimated that every 1 in 8 death (pregnancy related) is caused by unsafe abortions (Singh, 2006). An estimate has been given that every 8 out of a 1000 women in South Africa admitted to public hospitals are due to unsafe abortions (Singh, 2006).

From the first day I saw her up until our last treatment session she continuously deteriorated – not physically, but mentally. Her mood and mental state became worse and she became more reluctant and unwilling to partake in physiotherapy. I continued to regularly check her daily medical notes but no reference was made to her mental state. My initial thought related to her mental state and deterioration was that she possibly had postpartum depression. Postpartum depression is a medical term used to describe depression that occurs in women after pregnancy, specifically after childbirth or in the case of a miscarriage or abortion – after the child is removed from the uterus (The American Psychiatric Association, 2019). Bellieni & Buonocore (2013), found that abortion was considered more of a risk factor for postpartum depression, compared to miscarriage and childbirth. Literature has also proven that the prevalence of postpartum depression was higher in women who had abortions compared to women who gave birth (Bellieni & Buonocore, 2013).

I approached the doctor to raise my concern and politely queried whether further investigation regarding possible postpartum depression could be done.  The result of this conversation: a doctor on duty sitting at her desk, focused on the Facebook app on her phone, not looking up or raising an eyebrow as I was explaining my concern. Not only did she not look up or acknowledge that she was listening to me, her response left me at a loss for words: “There is nothing wrong with her and I’m not just going to give medication for depression. Force her to do the stuff if you have to.”

I was placed in a situation consisting of a few ethical dilemmas. Firstly my patient had an abortion, which I morally believe to be wrong and secondly, the primary health care practitioner was being unethical which lead to malpractice (the patient was diagnosed with postpartum depression by a different doctor later that week). This whole situation was very unsettling and unknown to me. Caught between a rock and a hard place, I was faced with treating a patient (who I believed knowingly did a very wrong thing) and at the same time standing up for her well-being to another health care practitioner.

This was the very first time I had to treat a patient, who I was aware of had an abortion. Up until 1996 abortion in South Africa was allowed in a few limited circumstances, but that changed in 1997 when Act no.92 of 1996 the Choice on Termination of Pregnancy act was accepted as part of the constitution. According to this act a pregnancy may be terminated on request during the first 12 weeks of gestation as well as 13 weeks or more, following a consultation with one or more medical practitioners. This act defined the circumstances of abortion, legal places where it may be done as well as persons legally allowed to perform the abortion. This act was developed to recognize the rights of females with regards to decisions regarding their bodies, to advance equality and achieve the freedoms described in the human rights, which our constitution is based on. Thus this act is clearly in favor of abortion and termination of the life of the fetus. On the other hand, apart from the freedoms described in the Universal decleration of Human Rights, one specific right also needs to be taken into consideration and that is that everyone has the right to life

Life can medically be defined as “an organismic state characterized by capacity for metabolism, growth, reaction to stimuli, and reproduction.” (Merriam-webster.com, 2019). The Bible provides us with various scriptures strengthening the fact that God views life as starting before birth. Galatians 1:15 says “But even before I was born, God chose me and called me by his marvelous grace” (NLT). If you look at the definition of life and take into account what Scripture says, it makes sense that a fetus/embryo can be classified as “life” and that their lives deserve preserving. I believe that taking a life is considered murder, thus abortion can be seen as equal to taking the life of another person, however I can understand why a woman would possibly be willing to go through with it. According to Lawrence et al., (2005) reasons why women get abortions include interference of their education and work (financial implication), being afraid of being a single parent, feeling too irresponsible to care for a child as well as relationship and social issues. In cases of rape or abusive relationships, women are often forced into situations of pregnancy and may not have the resources to raise the child. If the child was conceived in an act of violence the mother might not be able to adequately love the child and provide a caring environment for him/her. Thus I can see what could lead women to making these decisions in specific situations, but there are other non-violent routes that could be followed, for example adoption. This being said the Bible provides us with a basis of wrong and right, which includes how we should treat people regardless of who they are or what they have done. Matthews 22:39 states “Love your neighbor as yourself” and Luke 6:13 reads “Do to others as you would have them do to you.” According to the Bill of Human Rights everyone has the right to dignity and equality. So even though I might believe that what she did was not right, I still respected my patient and treated her with care and compassion to the best of my ability.

The ethical dilemma with the doctor was the fact that not only was she violating the Hippocratic oath she undertook (which qualified health professionals have to take ensuring that they exercise their profession to their upmost best of their ability for the well-fare of the patients in their care), and ignoring a multi-disciplinary team advisement, but she was also practicing in a contradictory manner to the policy set in place to ensure the best quality health care in South Africa. This is known as the policy on quality of health care developed by the National Health Department of South Africa in 2000/2001 (NHD annual report, Pretoria, 2000/2001). This policy was put in place to be followed by public and private health care practitioners and institutions to ensure that the best quality of health care is provided to patients in South Africa. According to Section 27 of the South African constitution a person has the right to have access to health care services and the responsibility of the government to fulfill this right includes providing health care services.

I reported the incident to my clinician, who assured me that she would take the necessary further steps to ensure that something like this would not happen again. I then consulted with a different doctor who was on call later that week, who confirmed her postpartum depression diagnosis and advised me how to address and work with the patient during treatment sessions.

We face multiple ethical dilemmas on a daily basis in most of the government institutions and I now better understand that it is my responsibility wherever I am placed to work, to change and address these situations.

References:

Bellieni, C., & Buonocore, G. (2013). Abortion and subsequent mental health: Review of the literature. Psychiatry and Clinical Neurosciences, 67(5), 301-310.

Lawrence et al.. (2005). Reasons US Women Have Abortions: Quantitative and Qualitative Perspectives. Perspectives on Sexual and Reproductive Health, 37(3), 110-118.

Martin, E. (2010). Oxford Concise Medical Dictionary. (8th ed.). United Kingdom: Oxford University Press.

Merriam-webstercom. (2019). Merriam-webstercom. Retrieved 3 March, 2019, from https://www.merriam-webster.com/dictionary/life

Singh, S. (2006). Hospital admissions resulting from unsafe abortion: estimates from 13 developing countries. The Lancet, 368(9550), 1887-1892.

The American Psychiatric Association. (2019). Psychiatry.org. Retrieved 17 March, 2019, from https://www.psychiatry.org/patients-families/postpartum-depression/what-is-postpartum-depression