Transcript of video
Ethics in medicine is a big subject. And you know, we already discussed the diagnosis and treatment, even endoscopic fetal surgery, congenital malformations, infections. Birth defects in a developing fetus are a very difficult news for parents, for a mother especially. You have those difficult conversations with your patients daily in your clinical practice. What are the psychological and ethical aspects of discussions about fetal surgery, congenital malformations that you have with your patients? Dr. Anton Titov, MD. How do you approach these conversations in your clinical practice? Dr. Anton Titov, MD. I see one of many books in your office, The ethics in obstetrics and gynecology. It’s a huge topic, but a very important topic. Well, we are not priests, and we are not philosophers. We are doctors. Our first duty is to the pregnant woman. Once you’ve said that, ethics has to follow the law. You’re a doctor. You practice in a legal environment, and you have to follow the rules. So ethics follows the law. Medical second opinion. If you’re a philosopher or a priest, it precedes the law. Medical second opinion. If you’re a doctor, you follow the law. So your ethics is very much based on your legal environment. In Europe at large, and in France, in particular, we are very privileged because the law leaves the decision to the medical discussion together with the pregnant woman. The embryo has no say, and the fetus lives through its mother. Medical second opinion. If you have those principles clear, then your job is, of course, difficult. It’s never easy to terminate a pregnancy. Dr. Yves Ville, MD. But at least you are acting in agreement with the law. And in a close relationship with the pregnant woman. She has the last say. And that’s, I think, very, very sensible. So if you have a severe fetal malformation, you can become in this job completely schizophrenic. Because some women in the same situation will ask you to struggle and fight up to the latest limits in technology and what is humanly possible. And others will ask you to terminate the pregnancy. Same problem, same gestational age, same profile. And you have to take that on. And both decisions are part of your job. You like it, and you don’t like it, you’re free not to do it. Dr. Yves Ville, MD. But you cannot oppose. As long as this is in accordance with the law. Your duty is to inform her extremely well. And to inform women in a way that they can understand what you’re saying, You’re not imposing your views. You’re trying through what you know of her by your conversation, history, or environment. You’re trying to let her see through the options that would be either best for her or to avoid the worst options. Very often, it’s called the principle of utility in ethics, where you avoid what is worse. Medical second opinion. If you can’t find something that is good, you can avoid what is worse. With this, you increase your scope of understanding your patient and answering your expectation. Dr. Yves Ville, MD. But your first duty is to the pregnant woman. And that works. Is there a patient story that you could discuss that would illustrate some of the topics and conversations today? Dr. Anton Titov, MD. Perhaps an example or an amalgam of clinical cases from your practice? Dr. Anton Titov, MD. I think if you are looking for those dilemmas, some are very abrupt and very schematic, a disease that is curable. One woman would ask for a termination still because she’s not willing to take whatever risk is, and the other woman would like to go ahead with the pregnancy, irrespective. For a disease that is easily treatable, like fetal anemia, you can encounter that. Dr. Yves Ville, MD. But if those people have to go over the shock of the announcement of the problem, you leave time, and you give information, you answer their questions. There’s no reason why those people would then go and be insensible. Most people are sensible, and you work for the majority of people. When people have a psychological or psychiatric problem, that’s different, but then it becomes a maternal problem, an indication potentially of terminating or not the pregnancy, okay? Dr. Anton Titov, MD. Medical second opinion. If you are dealing with sensible people, you shouldn’t encounter that much much of those stories at all. Dr. Yves Ville, MD. But if the treatment is uncertain, and I pick on another example, which is not fetoscopy, which is ultrasound-guided. Say, the aorta of the fetus, the aortic valve is sick. You got critical aortic stenosis. Critical aortic stenosis in early pregnancy, if this is severe, and the passage for the blood is minimal, the left ventricle will not develop. It will be hypoplastic, left heart, and the baby will be born with one ventricle only, which then leads to several surgeries and nothing really like a cure. It’s a life of surgeries and a life expectancy that is neither long nor comfortable. So when you make this diagnosis, the diagnosis of fetal aortic stenosis is completely amenable to ultrasound. The options are, leave nature to have its course, terminate the pregnancy, or try to treat in utero. What we do in utero, under ultrasound, is we put the needle in the heart, in the left ventricle. And we catheterize the stenosis of the aorta, of the valve. And we blow a balloon, the same balloons the cardiologists use for dilating coronary arteries. So you dilate the valve. And then you remove the needle. So one, this procedure is risky. The risk of death is about 15%, straightaway. Two, this is uncertain in results because if you succeed in dilating the cervix, you don’t know if the dilatation will be enough for the blood to pass through and the ventricle to grow. So you need to allow several weeks after the procedure. And with this, you can have the same clinical picture or ultrasound picture, different conversations, and completely different options. Some women would say, “Sorry, you told me that the success rate was 50%, the risk of the fetus to die from the procedure is 15%. So altogether, I’m left with a 35% of favorable outcome”. And the baby might need a dilatation after birth. And we hope that which will be enough. I’m not taking that. Another woman would say, you’ve told me that this ventricle was already fibrotic, that the risk of death is 15%. And the risk of success is 10 – 20%. Dr. Yves Ville, MD. But I want to do everything I can for this baby. And if the baby dies afterward, right? Dr. Anton Titov, MD. And some people would say, Oh 15% risk of death. I’d rather do nothing. Even if the probability that this heart can be put on its own feet, so to speak, with two ventricles is 5%. So again, this is a job for schizophrenic people. And you don’t have to be judgmental. Just explain. Make sure people have understood everything and just follow the woman; it’s her pregnancy. And that’s potentially her baby or not. Can you categorize the people, your patients, pregnant women who are more likely to take these very diverse potentially three decisions? Dr. Anton Titov, MD. Are there any trends? Dr. Anton Titov, MD. Is there any system that you see? Dr. Anton Titov, MD. Or could it be a complete surprise coming out from any type of person? Dr. Anton Titov, MD. Are there any patterns that you see? Dr. Anton Titov, MD. Patterns? Dr. Anton Titov, MD. I wouldn’t describe it as a pattern. Dr. Yves Ville, MD. But if you dig deep enough into their life, their history, their childhood, their relationship, you can find the origin of that decision. Sometimes it’s easy. You know, if you take, I don’t know, it’s a caricature again, but you have a fetus with a facial cleft. And this woman is a model. Why has she become a model? Dr. Anton Titov, MD. What was the pressure on her? Dr. Anton Titov, MD. Can she cope with a fetus with a facial cleft? Dr. Anton Titov, MD. Probably, generally. Dr. Yves Ville, MD. But it doesn’t mean individually. Dr. Yves Ville, MD. But generally, that will be more difficult for this woman than for a woman who has no outside influence on her behavior and appearance, no pressure, and for whom that baby will be the last chance to have a baby, for example. You can’t, and you can’t have a pattern. You have factors, always somewhere, deep enough, sometimes very, very easy to understand, sometimes very deep, that would build their decision. And that’s the definition of a human being. Professor Ives Ville, thank you very much for your time and thank you for sharing all the important information, also more than information about the ethics of decisions and the difficulties that you know physicians like yourself face everyday. Dr. Yves Ville, MD. But you help so many people in very difficult situations. We hope to revert to you in the future for more information. Thank you! Thank you.