Often one reads about historical failures in medical ethics, such as the Tuskegee Syphilis Study or the forced sterilization of Carrie Buck, and one reflects with relief that health care has progressed in our society to the point where such abuses are no longer possible. Then one stumbles upon an occasional systemic failure so grievous, such as the amputation of a patient's wrong leg, that it nearly defies credibility, and reminds us that we are still vulnerable to medical exploitation and misconduct. If the facts as alleged in the media and court filings prove accurate, then the treatment of a pregnant Tallahassee mother, Samantha Burton, by her obstetrician, Jana Bures-Forsthoefel, may well rank among the most egregious abuses perpetrated against a patient by her caregiver since the triumph of the patients' rights movement in the 1970s.
The facts as reported are strikingly straightforward. Burton, a married mother of two toddlers, contacted her obstetrician in March 2009 -- during her twenty-fifth week of pregnancy -- when she became concerned that she might be going into premature labor. The obstetrician advised her to report to Tallahassee Memorial Hospital. While at the hospital, it became apparent that Burton was not going into labor. However, Dr. Bures-Forsthoefel recommended up to fifteen weeks of bedrest for her patient. When Burton explained that she had two children at home and a job, and that full bed rest was not a viable option for her, Bures-Forsthoefel ordered her confined to a hospital room to protect the health of her fetus. The hospital and Bures-Forsthoefel then obtained an order from the Circuit Court of Leon County that mandated Burton remain in bed for the duration of her pregnancy (eg. up to fifteen weeks) and to undergo "all medical treatments" that her physicians believed were in the fetal interest. Burton was denied any opportunity to obtain a second opinion at another hospital. She was effectively held prisoner in her room for three days, at which point an emergency C-section revealed a dead fetus.
Burton and the Florida ACLU are now appealing the Circuit Court's decision to Tallahassee's First District Court of Appeals, where oral arguments were heard last week, in the hope that future patients will not have to endure such mistreatment. Likely, she will prevail on Constitutional grounds -- although this case may work its way through the state and federal appeals courts before such a victory. Whatever the legal results of that case, the implications for medical ethics should not be given short shrift. Once Burton expressed her wish to decline further care and to exit the hospital, her physicians had an ethical duty to explain to her the risks of refusing treatment -- and to let her depart immediately. If Dr. Bures-Forsthoefel did knowingly force unwanted medical care upon a mentally-capable patient -- and there is no evidence that Burton was anything less than sane and rational when she expressed a desire to leave the hospital -- then doing so was a gross violation of the most basic tenets of her profession. Obtaining a court order may grant a physician a legal right to engage in certain conduct. It does not follow that such conduct meets the ethical standards of the medical community or that it is beyond formal censure. Both state medical authorities and national professional governing bodies, such as American College of Obstetricians and Gynecologists, have a duty to investigate this alleged breach of ethical norms.
One of the most essential principles of modern medical care -- possibly the fundamental underpinning -- is that competent patients have the right to make their own medical decisions. Pregnant women have as much authority to control their course of care as does anybody else. Philosophers and political activists can argue ad nauseam as to the precise moment when an embryo, fetus or baby achieves full personhood, but as long as this entity is physically part of the mother, longstanding medical practice is that its medical welfare is under the control of -- and subordinate to -- her wishes.
Our society may discourage pregnant women from drinking alcohol or smoking tobacco, but we do not jail them for doing so. Some future mothers may defer necessary medical care, such as chemotherapy, in order to bring pregnancies to term, but none are compelled to risk or sacrifice their lives in this manner. Moreover, women at their twenty-fifth week of pregnancy can choose termination legally in at least ten American states and Canada. While views on abortion may differ widely, nobody -- even those most strongly opposed to abortion -- argue that all pregnant women should be prohibited from traveling to those jurisdictions because opportunities for termination might then be available to them. By holding Samantha Burton a de facto prisoner, as alleged, Dr. Bures-Forsthoefel and Tallahassee Memorial Hospital effectively imposed their own moral values upon a relatively helpless patient at the moment when she was most vulnerable. The prospect of fifteen weeks' confinement -- and its consequences, such as the possible loss of one's job -- should not be viewed as anything less than horrific. When imposed by the same caregivers whom one has called upon for medical assistance, this trauma must surely be magnified. Preventing a competent pregnant woman from leaving the hospital under these circumstances is no less egregious than compelling her to have an abortion. Forcing additional intrusive care upon her, such as unwanted vaginal exams or cervical assessments, is legally-sanctioned digital rape.
As outrageous as was Burton's confinement, the damage done in this case transcends the particular horrors suffered by one patient. In order for prenatal care to be delivered effectively, pregnant women must be able to trust their physicians. Needless to say, if these allegations are indeed true, no sane mother or couple would ever choose Dr. Jana Bures-Forsthoefel to deliver a child. Nor would any rational woman seek obstetric care at Tallahassee Memorial Hospital--knowing that, if she wished to pursue a second opinion elsewhere, the hospital's attorneys might seek to lock her up. However, the very prospect of such involuntary confinement may well deter other women, both in Florida and elsewhere, from seeking necessary prenatal care. This danger is especially true with regard to poor and minority women who often already have reasons to distrust the medical profession.
Women who fear that they will be coerced into unwanted care will not seek any care at all -- and the inevitable result will be miscarriages, premature births, sick children and even maternal mortality. That is the greater, invisible tragedy in this case: Some expecting mother, somewhere, fearing fifteen weeks of unwanted hospitalization and forced bed rest, may die indirectly as a result of the aggressive and unwarranted actions of Dr. Bures-Forsthoefel and the Tallahassee Memorial Hospital's legal team, although nobody will actually trace that unfortunate woman's death to their doorstep.
Dr. Bures-Forsthoefel should be given an opportunity to explain her actions. If the allegations against her are true, she should immediately apologize, acknowledge her misconduct and have her license suspended for a reasonable period of time. Mrs. Burton is certainly entitled to an apology -- and appropriate compensation. At the same time, physicians are as capable as anyone else of grave lapses in judgment. If they acknowledge their mistakes, they ought to be forgiven. However, if Dr. Bures-Forsthoefel refuses to apologize and explain, and instead seeks to defend her conduct in court, she should have her license permanently revoked. The medical community has an obligation to police the actions of its members. One may argue for disciplinary restraint in gray areas, as one does not want to interfere unduly with the judgment of individual providers. This is not remotely such a case. Every third-year medical student knows that forcing unwanted care upon patients -- pregnant or not -- is fundamentally unacceptable.
Pregnant women and those planning pregnancies should also take away a lesson from the Samantha Burton tragedy. Ask your obstetrician directly: Is there any circumstance under which you will refuse to let me make my own medical decisions or will prevent me from leaving the hospital? That is a question no woman should ever have to ask her doctor. Unfortunately, as long as rogue OBGYNs continue to impose their values upon unsuspecting patients, it is a prudent question to ask.
"If the facts as alleged in the media and court filings prove accurate"
Without fair and balanced information, I don't think anyone should form an opinion on anything. You have not included any information from the doctor or the hospital. I'm perplexed as to how a hospital can force a patient to remain unless they are a danger to themselves or someone else. Was Ms. Burton physically shackled to a bed or something? I'm not being a wisecracker...I'm serious - how did they physically detain her?
I also am confused about how "it was determined she was not in labor" resulted in forced detainment and a dead baby delivered by C-Section three days later. I wish that your article provided more information.
My condolences to Ms. Burton and her family.
You are an advisor, not a god. You are a human and make mistakes -- am I willing to blindly follow you in the face of that? Absolutely not.
Further, you appear to be accusing the author of omitting facts from the record but without having any basis for doing so except your assumption that a doctor would NEVER do something so ridiculous--but, as a malpractice defence attorney I have seen doctors do some incredibly stupid things. They are people, too (again, you are not a god). Truth be told, if the patient had been incompetent that would have been a key point of defence for the doctor or hospital and Appel would be a pretty poor journalist to exclude that.
Even individuals with severe mental illness who are subject to potential civil confinement receive due process that this woman did not. Are you really saying that she should not have been allowed to get a second opinion? At the end of the day, the hospital should have handed her a AMA form, not chained her to a bed.
I will be watching this case closely. Maybe, Mr. Appel will be so kind as to write an up-date when the finial facts and subsequent ruling(s) are in. :)
okay..My first instinct WAS to write a scathing comment..I did read on however..and you wrote:
"Dr. Bures-Forsthoefel should be given an opportunity to explain her actions. If the allegations against her are true, she should immediately apologize, acknowledge her misconduct and have her license suspended for a reasonable period of time. Mrs. Burton is certainly entitled to an apology -- and appropriate compensation"
yes..we need to her the full story (I think..it may be even WORSE)..but..I'll wait.. MUST say..Just when I'm ready for Tort reform.."if" this ob/gyn is as horrid as it appears...the family deserves to sue her back to the stone age...and her license..taken away.. (again..IF the story is as scary as it seems)...I have a Medical Directive..and just last week asked my doctor if HE was a Catholic (nothing against catholics..).but I WANT no extraordinary measures..none..zero... I'd like the kool-aid.. We must be able to trust our doctors to carry out OUR wishes.. I can't imagine what this young woman mentally went through..(and frankly...her husband should have snuck in at night..and gotten her out...that's my opinion)
This is not a future scenario--it is happening now as increasing numbers of women are unable to find an attendant for a VBAC (vaginal birth after cesarean), whether in a hospital, birth center, or home. Often their disparate options are: 1. repeat cesarean birth or 2. unassisted home birth.
While the Big Push for Midwives does increase maternity care options in general, it is problematic because Licensed or Registered Midwives are only allowed to attend a VBAC birth in a handful of states. One-third of the population of childbearing women has a cesarean scar now. When midwives allow themselves to be in cahoots with the government, automatically one-third of their potential client base is wiped off the map.
Think of it this way: States that don't allow midwives to attend home birth after cesarean is just another example of the state (legislatures and courts) demonstrating profound disrespect for women's autonomy in childbearing decisions. If a woman is informed of the risks of both VBAC and repeat cesarean, she has the right to decide which risks she prefers to assume based on her own values.
Legalizing midwives isn't about 'cahoots'- its about empowering consumers, including those 30% of women with uterine scars, to demand that their legislatures enact laws that promote public health rather than make a legitimate choice (VBAC) less safe (by being unattended).
Yes, she should. I would love to hear her rationale.
Great post.
Yet, when the states released hundreds of thousands of incompetent patients from the state psychiatric hospitals over the past four decades, they did the exact opposite. The expected incompetent patients to make their own medical decisions, often to the detriment of themselves and those around them.
Yes, new drugs make it possible for many of these former patients to live productive lives in the community, but for the sickest of the sick, those who no drug or behavioral therapy could reach, their release turned into a living nightmare of recurring psychotic episodes, incidents with police and homelessness.
Yes, there were abuses, but would an Alzheimer's patient be expected to live in their own apartment, cook their own food, manage their own medical care, including taking a myriad of drugs everyday. No, so why did they expect that of my brother, who had been committed for over 20 years with severe schizophrenia?
There is only one real reason the states emptied their beds. Money. Call your representatives. Repeal the Medicaid law, called the IMD Exclusion (Institutes for Mental Disease).
Under this scenario the doctor would of had to file fraudulent paperwork with the courts... there is no compelling reason for the court order otherwise. And this doc should be given more than a slap on the wrist. She needs to be charged criminally.
Perhaps then, more doctors of this ilk will think twice before violating a pregnant woman's constitutional rights. Outrageous.
This woman needed compassionate support at the loss of her pregnancy, and competent medical care. Did it not occur to them to put a fetal monitor on and find out what was wrong?
I hope she is doing better now.
However, just as important and outrageous as the doctor's actions is the willingness of our courts to confine women- competent, adult individuals with full constitutional rights- to a hospital and force them to undergo unwanted treatment.
Informed consent is at the heart of care women receive from Certified Professional Midwives, trained experts in out-of-hospital birth. The Big Push for Midwives advocates for access to Certified Professional midwives across the US, so that no woman will ever have to wonder whether she can access a provider who will respect her right to informed consent.
That just bore repeating. Doctors like Bures-Forsthoefel may thankfully be in the minority, but they ARE out there, and it's worth doing everything possible to ensure you're in good hands.
Fantastic analysis of the whole wretched situation.
I've seen many doctors in my life, and there isn't one single other profession I can point to (that I've personally dealt with) where arrogance is fairly constant among it's practitioners.
I've had a very sick friend for years who sometimes ends up in the emergency room due to their difficulties.
There exists an agreement between all of us who know them that this person is never to be unattended for any length of time during such a stay, as historically, this person's life is put in serious jeopardy by gross mismanagement of their condition at least once per such visit.
A friend of my brother's is deathly allergic to a certain dye used in MRIs (I believe). During her last MRI, they had to argue with the tech who was about to shoot them up with the dye that WOULD HAVE KILLED THEM, just to get the tech to verify that he was about to use the correct dye - which he was not.
God bless surgeons, but so many (not all) doctors are not worth the paper their degrees are printed on. And the really bad ones will kill or maim you before they admit the capacity to make mistakes, or to be incorrect about anything at all.
I later learned they are known to cause kidney failure, which is what he had to begin with. I have put an allergy to them on my medical record, to be safe and have a chance to discuss the risks and benefits with my doctor.
Even with that on my record, I had to call a halt to a procedure once where the technician blithely wanted to inject me with the stuff without any previous notification or handout from the ordering doctor's office.
She did not believe I was serious until I told her I would run out the waiting room and out the door of the hospital with the robe flapping open in the back if she came near me with the stuff. She made a phone call (probably to the psych ward : ) and magically found a way to get the test done without it.
Makes you wonder how many tests are done with contrast dyes when it could be avoided.
- that also reads medical records before treatment and/or looks at a medical alert bracelets/dogtags before emergent treatment (though I could go on with so much more)
Sad to say that it is not only in Obstetric cases that we see such arrogance and poor treatment. Being a lifelong consumer of medical care, it took me many years to realize that doctors are not omnipotent and that patients do have a voice and a choice in their care. I have had far more horrible doctors than good, but I thank God for the handful of wonderful doctors I have had and credit them with saving my life.
With all this said, I do feel their is something very important missing from this article, and that is the doctor's side of the story. There is no information provided whatsoever that informs of us why a doctor would take such a drastic step with this patient. I hope that the author does follow up with that crucial information.
Meanwhile my condolences go out to Ms. brown for the loss of her child.