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.