Dr. Paul Burcher has responded to my post “Is This OB Ethical” with a comment.  I would like to thank Dr. Burcher, and before I go on, here is the entire (verbatim) text of his comment:

This is Paul Burcher. You reference me in your blog, and I think you have made some incorrect pre-judgments about who I am. I am a practicing Ob/Gyn (true) and a PhD ethicist (also true) but I am no fan of Frank Chervenak’s position on home birth (if you google me you will see that I have collaborated extensively with, and defended midwives and home birth. I quoted Chervenak on a completely separate topic where I am with him–that talking with woman before labor, about labor, can reduce or eliminate misunderstandings and conflict. The “maybe” category that I wrote about is not a bait and switch as you suggest. As I wrote about in the Journal of Medical Ethics, how would you respond to a birth plan where the woman insists that no matter what happens in labor, and even if she requests it, that I must refuse her an epidural? As you know labor (and life) are fluid, and sometimes we don’t know “till we get there.” So maybe is maybe, and it means just that. The “non-starter” category is for me both real and small. I value patient autonomy, but it isn’t the only value in the room, and physicians also have values that must be respected by patients. If I say I can’t participate in what a patient requests, that is also my right. I rarely just say no, and I bend a lot even pushing beyond comfort zones at times.But physicians must be also be able to make rational and value laden choices–they must also be autonomous. These words don’t really express how it has played out in my practice, but I have 18 years in practice with almost no conflict with my patients, because I am respectful (and because I worked with midwives I have had strong-willed, conscientious women with alternative values as patients for much of this time).

I am honestly touched that Dr. Burcher cared enough to read and comment on my post, which I think gives much credence to what he says here about his respect for women.  If he didn’t care very much about his integrity and that of his practice, I’m sure he would not have bothered.  His “full biography” on the Albany Medical Center website states, “Dr. Paul Burcher specializes in general obstetrics and gynecology and women’s health. As an ethicist, he has a particular interest in the doctor/patient relationship and physician empathy.”  My post might have been more fair minded had I spent some more time researching his background.

For instance, I tied Burcher to Frank Chervenak because he begins his column by citing Chervenak’s idea of preventive ethics.  Dr. Chervenak’s attitude toward homebirth and midwifery is uninformed and patronizing, and because of the citation, I tarred Burcher with the same brush.  Burcher is not anti-homebirth, as evidenced by this piece about a woman who had a stillbirth while attended by unlicensed midwives.  This piece was co-written with Colleen Forbes, a licensed midwife (who is not a CNM, the kind of midwife who usually practices in hospitals–you can read a description of the various kinds of midwives here) and does not condemn homebirth.  He was also quoted in this piece in the New York TImes about the risks associated with episiotomies and the importance of women making informed decisions.  I think Burcher and I probably agree about many–even most–aspects of obstetric care.

I think some of the issues I have with Burcher’s column have more to do with audience than anything else.  In writing for other obstetricians, Burcher certainly had to appeal to them.  And defending the right of women to have birth plans and encouraging obstetricians to take them seriously is an important and noble undertaking.  I should have been less glib in my introduction and offered him more respect for his efforts.  I, on the other hand, am writing as a passionate advocate for women’s autonomy and agency, and my audience is those who are interested in that perspective.  I do not wish to imply that Burcher does not value women’s agency and autonomy, but we may approach the concept differently.

I do have problems with preventive ethics, at least as they are conceived by Chervenak.  I mentioned in particular Chervenak et al’s  piece “Obstetric Ethics: An Essential Dimension of Planned Homebirth” in which he states strongly that it is an obstetrician’s duty to convince women not to birth at home and to birth at a hospital.  Chervenak carries his ideas about obstetrical judgement based in beneficence to the conclusion that the obstetrician must convince a woman to do what the obstetrician thinks is best.

However, a woman may have vastly different values that lead her assessment on a very different path.  Anne Faidman’s wonderful book The Spirit Catches You and You Fall Down offers numerous examples of this conflict between the values of doctors and those of their patients.  While the book is primarily about the care of an epileptic child in a Hmong family, there are also a number of examples given about childbirth.  One section noted that many of the Hmong women in the book preferred to give birth with a little-respected family physician because he did not “cut” (meaning episiotomies and other surgical procedures–cutting the body is anathema to traditional Hmong beliefs) and because he would hand over the placenta to the family (the placenta was used in important post-birth rituals).  The more highly respected obstetricians held their own clinical judgment in higher esteem than the beliefs and values of their Hmong patients, and the patients sought care elsewhere.

Burcher, it seems, has a different approach to the idea of “preventive ethics” than Chervenak, one that is a true exchange involving shared decision making.  He is right to be honest with women about what is not possible, either because of structural constraints (the hospital will not allow it) or ethical ones (the doctor believes s/he cannot in good conscience provide what the woman requests).  I said in my original post that I though he had a reasonable approach to “non starters.”  I might even go further than he did on the “refuse me an epidural no matter what” question.  I would not be willing to work with a woman who gave up her autonomy and made me the gatekeeper of her care.  That is not shared decision making.

My issue with the “maybes” had more to do with Burcher’s  concerns about his colleagues and their approaches to care.  I understand that “maybe” is circumstantial–my position was that really the maybes are either “of courses” or “non-starters,” depending on the emergent situation.  It’s impossible to go through every possibility in advance to know which would be which.  While Burcher himself might be working with his patients to make sound decisions in the moment on the “maybes,” I do worry that many practitioners view the “maybe” as a way to placate women, with the situations in which the “maybe” becomes an “of course” so limited that the “maybe” is more accurately categorized as a “non starter.”  In my original post, I gave the example of the way many practitioners approach VBAC requests.  Again, if there is an evidence-based reason to do something, what would be the justification for removing that possibility based on a practitioner’s “comfort zone”?  Is the practice evidence based or not?  Is it safe or not?  It seems there are very limited situations in which the practitioner herself/himself would be the determinant (for example, an exception would be vaginal breech birth, which many practitioners no longer know how to attend safely).

Albany Medical Center, where Burcher practices, has a cesarean rate over 40%, indicating that much of the time, Burcher’s colleagues are not adhering to evidence based practice.  I am concerned that many doctors are happy to follow women’s non-evidence based requests when it suits them — for instance, performing non-medically indicated cesareans or inductions — but are not willing to comply with requests that are evidence based, such as eating during labor, laboring in water, or freedom of movement during labor.  I am also concerned that many physicians use non-evidence-based practices routinely, such as continuous electronic fetal monitoring for low risk women, routine oxytocin (Pitocin) augmentation,  routine amniotomy (breaking the bag of waters), or prophylactic cesarean for suspected macrosomia (big baby). Some practitioners view these practices as non-negotiable, and some hospitals institute them as protocol even though a woman’s request to forgo them is based in science while the practices themselves are not.

Burcher says, “If I say I can’t participate in what a patient requests, that is also my right.”  I agree with Burcher that the conflict between the rights of the patient vs. the rights of the practitioner are real and ethically complex.  I have written about conflicts in these rights here and here, and I am sure I will have future posts exploring this fraught issue.  It sounds as if Burcher’s decisions are generally based in evidence and ethics, but I do not have confidence that all practitioners abide by Burcher’s standards.  Is it ethical for a physician to refuse to provide evidence-based care because for some reason the evidence does not coincide with the physician’s “comfort zone”? Is it ethical for the physician to insist on non-evidence-based care, or care that has substantial evidence of harm, because it does fall within the “comfort zone”?  While I believe that physicians, like their patients, are autonomous beings, I would not want them to answer yes to these questions.

And thus I still ask if it is ethical for a colleague to refuse to follow a birth plan that Burcher has negotiated with a woman, and for Burcher to present that as acceptable.  “Maybe” should depend on the evidence and a shared decision making process, not on a nebulous, one-sided “comfort zone.”