Ethics - Tubal ligation

[Zzmed]

Guys, i 've come across two controversial statements about tubal ligation in a married patient:

Kaplan Qbook: When a married person seeks sterilization, spouse's consent is also needed, because if you don't seek for spouse's consent you violate his or her autonomy to have childern in the future.

Fischer's Ethics (also in Kaplan right?!?): Although it is preferable to have consensus, there is absolutely no spousal consent required! The fallopian tubes are located within the body of the woman etc etc

Which one is true?

---

Members don't see this ad.

 

[Stellar Clouds]

Guys, i 've come across two controversial statements about tubal ligation in a married patient:

Kaplan Qbook: When a married person seeks sterilization, spouse's consent is also needed, because if you don't seek for spouse's consent you violate his or her autonomy to have childern in the future.

Fischer's Ethics (also in Kaplan right?!?): Although it is preferable to have consensus, there is absolutely no spousal consent required! The fallopian tubes are located within the body of the woman etc etc

Which one is true?

Holy cow. Was that Kaplan Qbook written before the 19th amendment was passed? I can't even begin to think that is correct. Don't get me wrong, you should make sure that the woman has talked to her spouse about this, but you certainly don't need any formal consent from the spouse.

 

[Jonari]

these ethics questions are starting to get more difficult than they need to be, because of the discrepancy in answers between qbanks...if a patient doesn't want to know the diagnosis what do you do?

UWorld says: you have to tell them
Kaplan says: if they don't want to know, don't tell them

😡😡

Zz, are you using the pdf of the kaplan ethics book, the one located online @ slideshare?

 

[Zzmed]

these ethics questions are starting to get more difficult than they need to be, because of the discrepancy in answers between qbanks...if a patient doesn't want to know the diagnosis what do you do?

UWorld says: you have to tell them
Kaplan says: if they don't want to know, don't tell them

😡😡

Zz, are you using the pdf of the kaplan ethics book, the one located online @ slideshare?

Actually i've bought the new edition (Master the boards). But I've heard that there is no difference between them.

 

[ijn]

UWorld is completely wrong. WTF? Should women have to tell their man they got a depo-provera shot, an IUD placed, or a nexplanon? **** no. It's 2013 for christ's sake.

I think the valid ethical question for tubal ligation should be in the context of a young women, say less than 25 who has had 1-2 children and seeks permanent sterilization. I think a proper course for the doctor is to offer and non-permanent long term birth control like Mirena or the copper IUD. Lots of women who get ligations that young end up regretting it. But if you give her 1+ month to think it over then you're obligated to do it.

 

[Greenbayslacker]

Guys, i 've come across two controversial statements about tubal ligation in a married patient:

Kaplan Qbook: When a married person seeks sterilization, spouse's consent is also needed, because if you don't seek for spouse's consent you violate his or her autonomy to have childern in the future.

Fischer's Ethics (also in Kaplan right?!?): Although it is preferable to have consensus, there is absolutely no spousal consent required! The fallopian tubes are located within the body of the woman etc etc

Which one is true?

100% without a doubt, you do NOT have to get the spouse's consent. if there is an option to discuss with the patient about talking to the spouse though, it may be appropriate to SUGGEST it. not required.

these ethics questions are starting to get more difficult than they need to be, because of the discrepancy in answers between qbanks...if a patient doesn't want to know the diagnosis what do you do?

UWorld says: you have to tell them
Kaplan says: if they don't want to know, don't tell them

😡😡

Zz, are you using the pdf of the kaplan ethics book, the one located online @ slideshare?

100% without a doubt, if they don't want to know AND it's not a public safety hazard (i.e. TB) you do not have to tell them

 

[redpanda]

UWorld is completely wrong. WTF? Should women have to tell their man they got a depo-provera shot, an IUD placed, or a nexplanon? **** no. It's 2013 for christ's sake.

I think the valid ethical question for tubal ligation should be in the context of a young women, say less than 25 who has had 1-2 children and seeks permanent sterilization. I think a proper course for the doctor is to offer and non-permanent long term birth control like Mirena or the copper IUD. Lots of women who get ligations that young end up regretting it. But if you give her 1+ month to think it over then you're obligated to do it.

I'm just going to point out that it is generally a major point that you are not supposed to insert your own speculation about what a patient might want 10 yrs from now (i.e. would a 25 year old woman want children in the future?) and it is paternalistic to unilaterally decide what a patient might regret and drive their medical care that way. Obviously, you need to counsel about what the reversibility of any sterilization procedure is, but if the patient decides that she/he still wants it and is competent, it is probably not ok to force them into some 30 day waiting period or route the person into a long-acting form of birth control without offering sterilization/offering a referral to someone who will do the sterilization.

 

[hrain]

these ethics questions are starting to get more difficult than they need to be, because of the discrepancy in answers between qbanks...if a patient doesn't want to know the diagnosis what do you do?

UWorld says: you have to tell them
Kaplan says: if they don't want to know, don't tell them

😡😡

Zz, are you using the pdf of the kaplan ethics book, the one located online @ slideshare?

UW definitely says you DON'T have to tell them on this one. 'Just as competent patients have the right to refuse medical care, they also haw the right to refuse knowledge of their own medical information and diagnoses...' As
Long as they're informed.

Also, UW definitely said to 'ask whether or not the woman had talked to her SO,' in their similar question, but pointed out that it is NOT the SO's decision.

Edit: I can't believe Kaplan actually has that written somewhere. Crazy.

 

[stormchao]

UW definitely says you DON'T have to tell them on this one. 'Just as competent patients have the right to refuse medical care, they also haw the right to refuse knowledge of their own medical information and diagnoses...' As
Long as they're informed.

Also, UW definitely said to 'ask whether or not the woman had talked to her SO,' in their similar question, but pointed out that it is NOT the SO's decision.

Edit: I can't believe Kaplan actually has that written somewhere. Crazy.

Kaplan is correct about telling patients the diagnosis, there are situations where if a patient doesn't want to know the diagnosis then they shouldn't be told, however in that case they should appoint a surrogate decision maker. You should not order tests on a patient who does not want to know the diagnosis and has not appointed a surrogate decision maker since then the test results would be useless.

In a rarer and more complicated situation, where telling someone their diagnosis could cause serious acute harm, physicians can invoke therapeutic privilege.

 

[hrain]

Kaplan is correct about telling patients the diagnosis, there are situations where if a patient doesn't want to know the diagnosis then they shouldn't be told, however in that case they should appoint a surrogate decision maker. You should not order tests on a patient who does not want to know the diagnosis and has not appointed a surrogate decision maker since then the test results would be useless.

In a rarer and more complicated situation, where telling someone their diagnosis could cause serious acute harm, physicians can invoke therapeutic privilege.

Yeah UW goes on to say that they need to appoint a decision maker.

 

[survivordo]

If faced with this question on the boards I would without a doubt go with the answer that upheld the woman's autonomy. Ideally there would be an answer stem similar to "encourage the woman to talk to her husband but ultimately agree to perform the procedure as she desires"

Survivor DO

 

[bangarang]

these ethics questions are starting to get more difficult than they need to be, because of the discrepancy in answers between qbanks...if a patient doesn't want to know the diagnosis what do you do?

UWorld says: you have to tell them
Kaplan says: if they don't want to know, don't tell them

i ran across that question on uworld, and it specifically said, "healthcare information should be fully disclosed, unless the patient has expressedly asked not to be informed."

 

[ijn]

I'm just going to point out that it is generally a major point that you are not supposed to insert your own speculation about what a patient might want 10 yrs from now (i.e. would a 25 year old woman want children in the future?) and it is paternalistic to unilaterally decide what a patient might regret and drive their medical care that way. Obviously, you need to counsel about what the reversibility of any sterilization procedure is, but if the patient decides that she/he still wants it and is competent, it is probably not ok to force them into some 30 day waiting period or route the person into a long-acting form of birth control without offering sterilization/offering a referral to someone who will do the sterilization.

This is what is done in real life. Women who want BTLs immediately postpartum or while they're doing a c-section ideally have to give written consent far in advance of delivery. You can't really get informed consent for irreversible sterilization right before the woman is going under for anesthesia/getting the epidural. It most certainly is okay to force a waiting period. However it's the OB's job to make sure the woman has that opportunity to consent w/ a proper waiting period before the pregnancy gets to that point.

Medicaid already doesn't reimburse for BTLs for women below the age of 21. In effect that means most of them do not get it since none can/want to pay any healthcare expenses. Even if they're G4P4s and done having babies. Like it or not we're a paternalistic society. Copper IUDs are approved for 10 years use (and really they probably last forever). That's a far more ideal form of long term birth control for a parous female in the young 20s who is highly likely to regret the decision and later seek tubal ligation reversal or IVF when that fails.

 

[redpanda]

This is what is done in real life. Women who want BTLs postpartum or while they're doing a c-section ideally have to give written consent far in advance of delivery. You can't really get informed consent for irreversible sterilization right before the woman is going under for anesthesia/getting the epidural.

Medicaid already doesn't reimburse for BTLs for women below the age of 21. In effect that means most of them do not get it since none can/want to pay any healthcare expenses. Even if they're G4P4s and done having babies. Like it or not we're a paternalistic society.

We may be a paternalistic society, but it doesn't mean that you as a professional must (or should) act in a paternalistic way. I don't think anyone has suggested that one should consent the patient in a possibly drug-addled state, but if the patient would be allowed to consent for any other procedure at that point, you should lay out the risks/benefits of sterilization/other contraception procedures (including possible individual costs incurred) and what can be done in what time frame, not what only the options of what you have decided will apparently save the patient from regret.

 

[ijn]

We may be a paternalistic society, but it doesn't mean that you as a professional must (or should) act in a paternalistic way. I don't think anyone has suggested that one should consent the patient in a possibly drug-addled state, but if the patient would be allowed to consent for any other procedure at that point, you should lay out the risks/benefits of sterilization/other contraception procedures (including possible individual costs incurred) and what can be done in what time frame, not what only the options of what you have decided will apparently save the patient from regret.

This has nothing to do with being drug addled. A perfectly competent woman G1P0 twenty-something who all of the sudden decides she wants to get a BTL while she's in labor will get turned down and offered other forms of long term birth control. You'll see it once you start third year.

Likewise an early twenty-something male with no children is going to face an uphill climb to get a physician to consent him for a vasectomy. Any sane physician would make that kind of patient wait at least a few weeks before performing it rather than directly referring the patient to a vasectomy factory where they don't ask why.

 

[calvnandhobbs68]

UW definitely says you DON'T have to tell them on this one. 'Just as competent patients have the right to refuse medical care, they also haw the right to refuse knowledge of their own medical information and diagnoses...' As
Long as they're informed.

Also, UW definitely said to 'ask whether or not the woman had talked to her SO,' in their similar question, but pointed out that it is NOT the SO's decision.

Edit: I can't believe Kaplan actually has that written somewhere. Crazy.

Yeah I remember this specific UWorld question. It doesn't say you have to tell the patient but it does say you should ask about a surrogate decision maker who can make decisions for the patient with the information you have.

In that case it was the guy who was getting biopsied lung cancer who didn't want to know if he had it. Presumably (if he didn't want the information) you'd need to get a surrogate decision maker who can consent for the patient as you can't get informed consent from the patient for any procedures without him knowing all the information. The question wasn't saying you should tell the patient if he has lung cancer. I guess you could get him to waive informed consent in future procedures but certainly the ideal situation is that there is someone who has all the information available and who can make a decision.

In all cases, just pick the one that seems the most "caring" and "open ended". They're trying to emphasize that you should be asking these questions in the first place (and since, for instance, 35% of people got that lung cancer question wrong it looks like they need to be emphasizing it).

 

[Akr]

Yeah UW goes on to say that they need to appoint a decision maker.

BUT I just had another UWorld question about that, basically saying that appointing a surrogate decision maker is ideal but not required (e.g. a competent adult who does not want to know or for family/friends to know that patient has cancer). I would not have known or thought that before - confusing stuff sometimes!!

 

[wee eng]

Guys, i 've come across two controversial statements about tubal ligation in a married patient:

Kaplan Qbook: When a married person seeks sterilization, spouse's consent is also needed, because if you don't seek for spouse's consent you violate his or her autonomy to have childern in the future.

Fischer's Ethics (also in Kaplan right?!?): Although it is preferable to have consensus, there is absolutely no spousal consent required! The fallopian tubes are located within the body of the woman etc etc

Which one is true?

There is a difference between ethics and law. Consent is a legal document. As long as the woman is able to give her consent legally, that is all that is needed to proceed. Be sure to always differentiate between the ETHICAL and the LEGAL ramifications in these questions.

 

[YeahNoMind]

QID:2059 in UWorld: Patient says that he wishes to live the rest of his life at home, even though you know that he has a terminal illness, you may withhold the diagnosis if the patient requests you to do so.