Minkoff Howard, Ecker Jeffrey
Department of Obstetrics and Gynecology at Maimonides Medical Center and Professor of Obstetrics and Gynecology, SUNY Downstate, in Brooklyn, New York, USA.
J Clin Ethics. 2013 Fall;24(3):207-14.
Home births continue to constitute only a small percentage of all deliveries in the United States, in part because of concerns about their safety. While the literature is decidedly mixed in regard to the degree of risk, there are several studies that report that home birth may at times entail a small absolute increase in perinatal risks in circumstances that cannot always be anticipated prior to the onset of labor. While the definition of "small" will vary between individuals, and publications vary in the level of risk they ascribe to birth at home, studies with the least methodological flaws and with adequate power often cite an excess death rate in the range of one per thousand. Home birth is, in that regard, but one example of patients' choices and plans that sometimes carry increased risk or include alternatives that individual physicians feel uncomfortable supporting or recommending. Our intention in this opinion piece is not to advocate for or against home birth. Rather, we recognize that home birth is but one example of a patient choice that might differ from what a provider feels is in a woman's best interests. In this article we will discuss ethical considerations in such circumstances using home birth as an example. We consider in this article how the ethical principles of respect for autonomy and non-maleficence can be balanced using, among other examples, the choice by some for a home birth. We discuss how absolute rather than relative risk should guide individuals' evaluation of patient choices. We also consider how in some circumstances, the value and safety added by a physician's participation may outweigh a potentially small increment in absolute risk that might result from a patient's decision to deliver at home because of a perceived physician endorsement. We recognize, however, that doctors and midwives participating in choices they have not recommended, or may even believe will lead to or increase risk for adverse outcomes, presents dilemmas and raises important questions. When does respect for patient choice and autonomy become support for poor decision making? When is participation not respectful but enabling? Finally we discuss the role and responsibility of organized medicine in making all births as safe as possible.
在家分娩在美国所有分娩中所占比例仍然很小，部分原因是人们担心其安全性。虽然关于风险程度的文献结论不一，但有几项研究报告称，在家分娩有时可能会在分娩开始前无法总是预见的情况下，使围产期风险绝对小幅增加。虽然“小”的定义因人而异，而且不同出版物对在家分娩所归因的风险水平也有所不同，但方法学缺陷最少且有足够说服力的研究通常提到每千例中有一例的额外死亡率。在这方面，在家分娩只是患者选择和计划的一个例子，这些选择和计划有时会带来更高风险，或者包含个别医生觉得难以支持或推荐的替代方案。我们撰写这篇观点文章的目的不是提倡或反对在家分娩。相反，我们认识到在家分娩只是患者选择的一个例子，这种选择可能与医疗服务提供者认为符合女性最佳利益的选择不同。在本文中，我们将以在家分娩为例，讨论这种情况下的伦理考量。在本文中，我们将探讨如何以在家分娩等为例，平衡尊重自主权和不伤害这两条伦理原则。我们讨论绝对风险而非相对风险应如何指导个人对患者选择的评估。我们还会考虑在某些情况下，医生参与所带来的价值和安全性可能会超过患者因认为医生认可而决定在家分娩可能导致的绝对风险的潜在小幅增加。然而，我们认识到，医生和助产士参与他们未推荐甚至可能认为会导致或增加不良后果风险的选择，会带来困境并引发重要问题。对患者选择和自主权的尊重何时会变成对糟糕决策的支持？参与何时不是尊重而是促成？最后，我们讨论有组织的医学在使所有分娩尽可能安全方面的作用和责任。
