A physician goes to labor and delivery on Friday evening to check on the labor progression of her patient. The patient has had a protracted labor course throughout the day. Cervical dilation has increased 1 cm over the last 3 hours, and she is now at 8 cm dilation. Vital signs are normal, and the fetal heart rate tracing is category 1. The physician is leaving town for vacation in a few hours, but an on-call obstetrician will be available for later deliveries. The current physician recommends performing a cesarean delivery now because of the protracted labor course and this physician's inability to attend the delivery in a few hours. This situation demonstrates which of the following?
This patient's active phase of labor has been protracted. However, her vital signs and fetal heart rate tracing are reassuring, and vaginal delivery could still be possible if her contractions are optimized (eg, oxytocin augmentation). Although the current physician is leaving town for vacation in a few hours, there is still an on-call obstetrician available for later deliveries. Therefore, the most appropriate management is to continue labor for a possible vaginal delivery, even if the current physician cannot attend (and therefore charge for) the delivery.
Instead, this situation demonstrates a conflict of interest because the current physician's recommendation (cesarean delivery now) is out of self-interest and/or personal convenience (ie, expediting delivery prior to leaving for vacation), thereby influencing or biasing the process of informed consent. Physicians are obligated to inform the patient of all medically reasonable alternatives (eg, labor augmentation vs proceeding to cesarean delivery) and to provide medical care that is most likely to yield the greatest benefit to the patient, regardless of personal interest.
(Choice A) Vaginal delivery may still be achievable in this patient, and it has fewer maternal risks and shorter recovery times. Therefore, the current physician's recommendation for cesarean delivery does not demonstrate beneficence.
(Choice C) Directive counseling occurs when the physician assumes an active role in directing the patient toward a management option (eg, cesarean delivery for vasa previa, placenta previa) because it is the only medically reasonable option with clearly superior evidence-based support.
(Choice D) Justice is the ethical principle of fair and equitable treatment, such as equal distribution of scarce medical resources, lack of discrimination when providing medical care, and adherence to applicable laws.
(Choice E) Preventive ethics occurs when a consent process helps anticipate and prevent future ethical issues. An example is obtaining informed consent at a routine obstetric visit for cesarean delivery rather than intrapartum when emergency decisions may be required.
(Choice F) In this situation, veracity (ie, being truthful to patients) would occur if the physician acknowledged that vaginal delivery is still possible and safe for this patient and that a cesarean delivery is not required.
Educational objective:
Conflict of interest occurs when the process of informed consent is influenced or biased by a physician's self-interest. Physicians are obligated to inform patients of all medically reasonable alternatives and provide care that is most likely to yield the greatest benefit to the patient.