Clinical decisions amid ethical issues of varying hues of grey

MEDICAL MATTERS:The tragic death of Savita Halappanavar, when she was 17 weeks pregnant, at University Hospital Galway, raises a myriad of issues. This column will attempt to deal with two aspects: the medical and the ethical.

Spontaneous miscarriage is the commonest complication of pregnancy, occurring in up to 20 per cent of cases. Miscarriages may be threatened, inevitable or incomplete: an inevitable miscarriage occurs when on medical examination the neck of the woman’s womb is found to be open. Even if there is still a sign of foetal life, there is no chance of the pregnancy continuing to term.

In many cases, the foetus will die and be evacuated naturally, which is why the initial management is often one of “watch carefully and wait”.

However, when there is evidence of an amniotic fluid leak and the neck of the womb is open, the possibility of infection arises. The next question is how far this infection will travel. Will it invade the wall of the womb? And will it spread to the blood stream giving rise to blood poisoning or septicaemia?

So the clinical situation is often an evolving one, with the potential for septicaemia and serious collapse in a minority of cases. But there is a significant risk of death if the woman goes into septic shock, a risk that persists no matter what range of timely treatment is given.

Usually septicaemia will respond to intravenous antibiotics; if it doesn’t then doctors must consider removing the source of the infection, which in a case like this is the womb, in other words, to carry out a hysterectomy.

Even when there is a firm protocol in place in a maternity unit for the management of septic miscarriage, the timing of each intervention requires experience and a finely tuned clinical judgment that may turn out to be different in every case. Included in the range of interventions is to bring the woman whose condition is deteriorating to theatre for either a surgical evacuation of her womb (an abortion) or to carry out a hysterectomy.

So much for the medical issues: as I have portrayed them there is a linear, albeit at times tricky decision-making process for doctors to undertake. But this is Ireland with its backdrop of ethical issues of varying hues of grey.

Starting with the X case of 1992, then chief justice Thomas Finlay stated that “ . . . if it is established as a matter of probability that there is a real and substantial risk to the life, as distinct from the health of the mother, which can only be avoided by the termination of her pregnancy, such termination is permissible . . .”

Two years ago, the European Court of Human Rights found Ireland had failed to provide for abortion in circumstances where the mother’s life is at risk. Yet as UCD law lecturer James Mc Dermott pointed out last week, “legislation is necessary because you cannot have a situation where a doctor standing over an operating theatre needs to consult over 50 pages of Supreme Court text spread out over five different judgments in order to work out what the law currently permits”.

Allowing for some hyperbolic licence, the vacuum he describes at the very least creates doubts in obstetricians’ minds. Add in a slightly ambiguous Medical Council guideline on the issue and any doctor faced with a woman like Savita who was deteriorating rapidly could be excused for feeling exposed, confused and even wary. And this sorry state of legislative limbo also makes it very difficult to have comprehensive clinical guidelines on the management of bacterial infection in pregnancy in place.

This means some women cannot be assured that they will receive a standard of care that maximises their safety when patients in Irish hospitals. Sadly, none of which will bring his lovely wife back to Praveen Halappanavar.

muirishouston.com; mhouston@irishtimes.com