The Delicate Balance in Gynecology-Obstetrics and Anesthesiology
Where Life Begins and Responsibility is Maximum
Imagine a delivery room. On one side, the joy and expectation of a new life. On the other, a team of health professionals who must make critical decisions in seconds, where every choice has immense ethical weight. Medical practice in Gynecology-Obstetrics and Anesthesiology services represents one of the most complex fields of contemporary medical ethics. Here, it's not just about applying protocols, but navigating between moral principles, patient rights and clinical realities in situations where two lives are frequently at stake: the mother and her unborn child.
This article explores the ethical challenges faced by health professionals in these services, where patient vulnerability meets professional responsibility at its maximum expression. We will analyze from fundamental principles to concrete cases, unraveling the intricate world of ethical decision-making in environments where every action has profound consequences.
Medical practice in Gynecology-Obstetrics and Anesthesiology is guided by four fundamental ethical principles that, although simple in theory, present unique complexities in their application:
Respect for the patient's ability to make informed decisions about their care. In obstetrics, this acquires additional dimensions when we consider that decisions affect both the pregnant woman and the fetus 2 .
Obligation to act in the patient's best interest. The American College of Obstetricians and Gynecologists (ACOG) emphasizes that this obligation should never be subordinated to the desire to teach or learn new skills 1 .
The principle of "do no harm". Anesthesiologists, for example, have the special responsibility of protecting the anesthetized patient, who is in a state of maximum vulnerability 5 .
Treat all patients in an equitable and fair manner. Studies show that the most disadvantaged populations often receive care in teaching hospitals, which adds an additional layer of ethical responsibility for these centers 1 .
Obstetrics transcends the purely medical as it deals with fundamental human realities such as the transmission of life, the beginning of human existence and sexuality. These dimensions are "strongly configured with meaning," as explained by Dr. Sergio Valenzuela in his analysis of ethical aspects in obstetrics 2 . Philosopher Emmanuel Lévinas provides a crucial perspective: from the moment the "face of the other" looks at us, we become responsible for him. This idea takes special relevance with technological advances that allow visualizing the fetus with incredible detail, reinforcing its perception as a person 2 .
In teaching hospitals such as the Maternity Hospital "Babahoyo", care is provided within a "therapeutic triangle" composed of the patient, the trainee (student or resident) and the supervising physician. Each has ethical obligations to the others 1 .
Supervising Physician Responsibilities
Their role is "paramount to ensure safe, effective and equitable care" 1 . This includes providing adequate supervision at all training levels and not placing trainees in situations for which they are not prepared 1 .
Patient Rights
Respect for patient autonomy requires that they can choose not to be treated by trainees when this does not compromise their safety. These refusals should be handled with compassion and respect, especially when addressing sensitive issues or invasive examinations in patients with a history of trauma 1 .
Pelvic Exams Under Anesthesia
A practice that requires special ethical consideration. ACOG recommends that trainees participate in these exams only when: the patient has given explicit consent, the exam is relevant to the surgical procedure, the patient recognizes the trainee as a member of their team, and the exam is performed under direct supervision 1 .
In rare circumstances, and when it does not compromise patient safety, trainees should have the right to decline participation in a patient's care when this participation creates a conflict of conscience 1 . However, this right comes with responsibilities: objectors must refer patients to other colleagues who can provide the required care, ensuring continuity of care 4 .
A Greek study published in 2022 analyzed 184 judicial decisions related to obstetrician-gynecologists between 1988 and 2021 6 . The research, which excluded cases where the primary responsibility was of anesthesiologists, sought to identify patterns in malpractice lawsuits and their relationship with judicial outcomes 6 .
A team composed of an expert obstetrician and an anesthesiologist analyzed the causes of death and the validity of judicial decisions, collaborating with the investigation lawyers. It was evaluated whether patients had received a detailed medical history, continuous and urgent follow-up, and whether established treatment guidelines had been applied 6 .
The study revealed that of 600 judicial decisions analyzed, 184 (30.66%) concerned obstetrician-gynecologists, the most represented specialty 6 . The main causes of negligent homicide lawsuits included hemorrhages (18 cases), neonatal death (4 cases) and misdiagnoses (2 cases) 6 .
The analysis of negligent bodily harm cases (35 convictions) revealed significant financial compensation, including a case of obstetric hemorrhage with vegetative state that resulted in compensation of 850,000 euros, and a case of cystic fibrosis with inadequate parental information that generated compensation of 500,000 euros 6 .
The analysis showed that 81.16% of death and bodily injury cases could have been avoided 6 . The main factors that contributed to these tragedies were:
These findings reinforce the importance of maintaining high standards in daily practice with continuous training and use of international protocols, as well as the need for continuous monitoring of parturients and newborns and coordinated cooperation between all professionals involved 6 .
In the complex environment of Gynecology-Obstetrics and Anesthesiology, professionals have various ethical "tools" to navigate challenging situations:
More than a form, it is a continuous communication process that respects patient autonomy. Trust in the relationship is vital for its correct development 4 .
Anesthesiologists and other professionals have the responsibility to serve on hospital committees, reviewing colleagues' practices and helping to develop procedural guidelines 5 .
It is essential to have established processes for reporting unethical behaviors or incompetent conduct by supervisors and trainees, without risk of reprisals 1 .
Achieving and maintaining competence in the specialty is the primary professional duty of all anesthesiologists, a responsibility that does not end with residency or certification 5 .
Ethical practice in Gynecology-Obstetrics and Anesthesiology transcends mere compliance with rules and protocols. It represents a fundamental commitment to respectful, competent and compassionate care of some of the most vulnerable patients in the health system.
As we have seen through this analysis, the ethical challenges in these fields are numerous and complex: from ensuring adequate supervision of trainees to navigating situations of conscientious objection; from managing obstetric emergencies with implications for two lives to maintaining standards of excellence in high-pressure environments.
Studies demonstrate that most adverse events could be prevented with constant monitoring, timely treatment and adherence to established protocols 6 . The creation of safe learning environments and support for trainee well-being is equally essential to educate and supervise future professionals 1 .
Ultimately, medical ethics in these specialized services is about remembering that, behind each case, each procedure and each difficult decision, there are human beings whose trust has been placed in the hands and consciences of health professionals. Honoring that trust requires not only technical expertise, but also moral integrity, intellectual humility and an unwavering commitment to the fundamental value of all human life.