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Symphysiotomy for obstructed labour: a systematic review and meta-analysis

A Wilson, EG Truchanowicz, D Elmoghazy, C MacArthur, A Coomarasamy

British Journal of Obstetrics and Gynaecology

Abstract
Background: Obstructed labour is a major cause of maternal mortality. Caesarean section can be associated with risks, particularly in low- and middle-income countries, where it is not always readily available. Symphysiotomy can be an alternative treatment for obstructed labour and requires fewer resources. However, there is uncertainty about the safety and effectiveness of this procedure.

Objectives: To compare symphysiotomy and caesarean section for obstructed labour. Search strategy: MEDLINE, EMBASE, Cochrane library, CINAHL, African Index Medicus, Reproductive Health Library and Science Citation Index (from inception to November 2015) without language restriction.

Selection criteria: Studies comparing symphysiotomy and caesarean section in all settings, with maternal and perinatal mortality as key outcomes.

Data collection and analysis: Quality of the included studies was assessed using the STROBE checklist and the Newcastle Ottawa scale. Relative risks (RR) were pooled using the random effects model. Heterogeneity was assessed using I2 tests.

Main results: Seven studies (n = 1266 women), all of which were set in low- and middle-income countries (as per the World Bank definition) and compared symphysiotomy and caesarean section were identified. Meta-analyses showed no significant difference in maternal (RR 0.48, 95% CI 0.13–1.76; P = 0.27) or perinatal (RR 1.12, 95% CI 0.64–1.96; P = 0.69) mortality with symphysiotomy when compared with caesarean section. There was a reduction in infection (RR 0.30, 95% CI 0.14–0.62) but an increase in fistulae (RR 4.19, 95% CI 1.07–16.39) and stress incontinence with symphysiotomy (RR 10.04, 95% CI 3.23–31.21).

Conclusion: There was no difference in key outcomes of maternal and perinatal mortality with symphysiotomy when compared with caesarean section.

Tweetable abstract: Symphysiotomy could be an alternative to caesarean section when resources are limited.

Wilson A, Truchanowicz E, Elmoghazy D, MacArthur C, Coomarasamy A. Symphysiotomy for obstructed labour: a systematic review and meta-analysis. BJOG: An International Journal of Obstetrics and Gynaecology. 2016 Jul 20;1453-1461.

Nurses’ Participation in the Euthanasia Programs of Nazi Germany

Susan Benedict,Jochen Kuhla

Abstract
During the Nazi era, so-called euthanasia programs were established for handicapped and mentally ill children and adults. Organized killings of an estimated 70,000 German citizens took place at killing centers and in psychiatric institutions. Nurses were active participants; they intentionally killed more than 10,000 people in these involuntary euthanasia programs. After the war was over, most of the nurses were never punished for these crimes against humanity-although some nurses were tried along with the physicians they assisted. One such trial was of 14 nurses and was held in Munich in 1965. Although some of these nurses reported that they struggled with a guilty conscience, others did not see anything wrong with their actions, and they believed that they were releasing these patients from their suffering.

Benedict S, Kuhla J. Nurses’ Participation in the Euthanasia Programs of Nazi Germany. West J Nurs Res. 1999;21(2).

Conscientious Objection in Healthcare Provision: A New Dimension

Peter West-Oram, Alena Buyx

Abstract
The right to conscientious objection in the provision of healthcare is the subject of a lengthy, heated and controversial debate. Recently, a new dimension was added to this debate by the US Supreme Court’s decision in Burwell vs. Hobby Lobby et al. which effectively granted rights to freedom of conscience to private, for-profit corporations. In light of this paradigm shift, we examine one of the most contentious points within this debate, the impact of granting conscience exemptions to healthcare providers on the ability of women to enjoy their rights to reproductive autonomy. We argue that the exemptions demanded by objecting healthcare providers cannot be justified on the liberal, pluralist grounds on which they are based, and impose unjustifiable costs on both individual persons, and society as a whole. In doing so, we draw attention to a worrying trend in healthcare policy in Europe and the United States to undermine women’s rights to reproductive autonomy by prioritizing the rights of ideologically motivated service providers to an unjustifiably broad form of freedom of conscience.

West-Oram P, Buyx A. Conscientious Objection in Healthcare Provision: A New Dimension. Bioethics. 2016 Jun;30(5):336-343.

A Defence of Conscientious Objection in Medicine: A Reply to Schuklenk and Savulescu

Christopher Cowley

Abstract
In a recent (2015) Bioethics editorial, Udo Schuklenk argues against allowing Canadian doctors to conscientiously object to any new euthanasia procedures approved by Parliament. In this he follows Julian Savulescu’s 2006 BMJ paper which argued for the removal of the conscientious objection clause in the 1967 UK Abortion Act. Both authors advance powerful arguments based on the need for uniformity of service and on analogies with reprehensible kinds of personal exemption. In this article I want to defend the practice of conscientious objection in publicly-funded healthcare systems (such as those of Canada and the UK), at least in the area of abortion and end-of-life care, without entering either of the substantive moral debates about the permissibility of either. My main claim is that Schuklenk and Savulescu have misunderstood the special nature of medicine, and have misunderstood the motivations of the conscientious objectors. However, I acknowledge Schuklenk’s point about differential access to lawful services in remote rural areas, and I argue that the health service should expend more to protect conscientious objection while ensuring universal access.

Cowley C. A Defence of Conscientious Objection in Medicine: A Reply to Schuklenk and Savulescu. Bioethics. 2016 Jun;30(5):358-364.

The Limits of Conscientious and Religious Objection to Physician-Assisted Dying after the Supreme Court’s Decision in Carter v. Canada

Amir Attaran

Extract
[The Supreme Court of Canada decision to legalize euthanasia and assisted suicide “is in abeyance until June 2016.”]. . . Trouble is, not many physicians seem willing to assist. . . . overall, it is clear that a majority of Canadian doctors polled refuse to participate in physician assisted dying.

. . . This article argues that whether doctors do or do not have the right to refuse to treat patients on conscientious or religious grounds is neither a difficult nor a novel legal issue. Patients and doctors have clashed on this issue before, and when they have, tribunals and courts have overwhelmingly sided with the patients over the doctors. . .

Attaran A. The Limits of Conscientious and Religious Objectionto Physician-Assisted Dying after the Supreme Court’s Decision in Carter v. Canada. Health Law Can. 2016 Feb;36(3):86-98.

From women’s ‘irresponsibility’ to foetal ‘patienthood’: Obstetricians-gynaecologists’ perspectives on abortion and its stigmatisation in Italy and Cataluña

Silvia De Zordo

Abstract
This article explores obstetricians-gynaecologists’ experiences and attitudes towards abortion, based on two mixed-methods studies respectively undertaken in Italy in 2011–2012, and in Spain (Cataluña) in 2013–2015. Short questionnaires and in-depth interviews were conducted with 54 obstetricians-gynaecologists at 4 hospitals providing abortion care in Rome and Milan, and with 23 obstetricians-gynaecologists at 2 hospitals and one clinic providing abortion care in Barcelona. A medical/moral classification of abortions, from those considered ‘more acceptable’, both medically and morally – for severe foetal malformations – to the ‘least acceptable’ ones – repeated ‘voluntary abortions’, emerged in the discourse of most obstetricians-gynaecologists working in public hospitals, regardless of their religiosity. I argue that this is the result of the increasing medicalisation of contraception as well as of reproduction, which has reinforced the stigmatisation of ‘voluntary abortion’ (in case of unintended pregnancy) in a context of declining fertility rates. This contributes to explain why obstetricians-gynaecologists working in Catalan hospitals, which provide terminations only for medical reasons, unlike Italian hospitals, do not experience abortion stigma and do not object to abortion care as much as their Italian colleagues do.

Zordo SD. From women’s ‘irresponsibility’ to foetal ‘patienthood’: Obstetricians-gynaecologists’ perspectives on abortion and its stigmatisation in Italy and Cataluña. Glob Public Health. 2018 May 27;13(6).

Cross Cultural Perspectives on Dignity, Bioethics, and Human Rights

Maria Isabel Cornejo-Plaza, Darryl RJ Macer

Eubios Journal of Asian and International Bioethics

Abstract
The concept of dignity is the foundation of fundamental rights expressed in international declarations on human rights and bioethics. Sometimes there are collisions of rights, which must be weighed. However, more often dignity is invoked in order to argue for or against the same issue. Is it possible that a concept can be so broad that it becomes meaningless? What do we mean when we argue for moral decisions based on dignity? This paper aims at understanding dignity as a construct, in an analytical and evolutionary cross-cultural approach, from a Western and Eastern view, and then considers its impact on the teaching of human rights and biolaw.

Cornejo-Plaza MI, Macer DR. Cross Cultural Perspectives on Dignity, Bioethics, and Human Rights. Eubios J Asian & Int Bioethics. 2016 May;26(3):90-95.

Physician opinions concerning legal abortion in Bogotá, Colombia

Kaitlyn Stanhope, Roger Rochat, Lauren Fink, Kalie Richardson, Chelsey Brack, Dawn Comeau

Abstract
Since the decriminalisation of abortion in 2006, women in Colombia have continued to seek clandestine abortions, endangering their health and contributing to maternal mortality and morbidity. The goal of this study was to explore physicians’ opinions towards and knowledge about legal abortion in Bogotá, Colombia, and key barriers to the legal abortion access. We conducted 13 key informant interviews followed by a survey with a probability sample of 49 doctors working in public hospitals in Bogotá. Interview and survey data showed lack of technical experience in the provision of abortion and nuanced opinions towards its practice. Key informants described ignorance and lack of abortion training in medical schools as key barriers to provision. In the survey, 16/49 respondents had performed an abortion, 24/49 had referred a woman for an abortion and only 33/49 showed correct knowledge of the law.

Stanhope K, Rochat R, Fink L, Richardson K, Brack C, Comeau D. Physician opinions concerning legal abortion in Bogotá, Colombia. Culture, Health and Sexuality. 2017;19(8):873-887.

Why medical professionals have no moral claim to conscientious objection accommodation in liberal democracies

Udo Schuklenk, Ricardo Smalling

Abstract
We describe a number of conscientious objection cases in a liberal Western democracy. These cases strongly suggest that the typical conscientious objector does not object to unreasonable, controversial professional services—involving torture, for instance—but to the provision of professional services that are both uncontroversially legal and that patients are entitled to receive. We analyse the conflict between these patients’ access rights and the conscientious objection accommodation demanded by monopoly providers of such healthcare services. It is implausible that professionals who voluntarily join a profession should be endowed with a legal claim not to provide services that are within the scope of the profession’s practice and that society expects them to provide. We discuss common counterarguments to this view and reject all of them.

Schuklenk U, Smalling R. Why medical professionals have no moral claim to conscientious objection accommodation in liberal democracies. J Med Ethics. 2016 Apr 22; 43(4) (online)(1-7.

Emerging assault on freedom of conscience

Stephen J. Genuis

Extract
Discussion on physician autonomy at the 2014 and 2015 Canadian Medical Association (CMA) annual meetings highlighted an emerging issue of enormous importance: the contentious matter of freedom of conscience (FOC) within clinical practice. In 2014, a motion was passed by delegates to CMA’s General Council,and affirmed by the Board of Directors, supporting the right of all physicians, within the bounds of existing legislation, to follow their conscience with regard to providing medical aid in dying. The overwhelming sentiment among those in attendance was that physicians should retain the right to choose when it comes to matters of conscience related to end-of-life intervention. Support for doctors refusing to engage in care that clashes with their beliefs was reaffirmed in 2015. However, a registrar from a provincial college of physicians and surgeons is reported to have a differing perspective, stating “Patient rights trump our rights. Patient needs trump our needs.

Genuis SJ. Emerging assault on freedom of conscience. Canadian Family Physician April 2016 vol. 62 no. 4 293-296.