BIOETHICAL ISSUES

IN
GYNECOLOGICAL CASES

Djamhoer Martaadisoebrata
Department of Obstetrics and Gynecology
Faculty of Medicine, Hasan Sadikin Hospital
 BIOETHICS
 MC Cullough & Laurence
Is the disciplined study of the
morality of health care, including
the morality of the physicians,
patients, the institution of health
care that organize, deliver or pay
of health care, and heath care
policy
 Hans-Martin Sass
Bioethics encompasses a field that is
wider than just the relationship
between individual physician and the
patient, one that includes a
professional responsibility toward all
form of life as well as the specific ethos
that much prevail in modern of
institutionalized and organized
medicine.
 Abel
Bioethics is the interdisciplinary
study of problems, caused by the
development of biology and
medicine, in micro as well as
macro scale, and its impact on the
community values systems, at
present, as well as in the future.
 BIOETHICS
1. Macro Bioethics
Other parties involved

1. Micro Bioethics = Clinical Ethics

Physician - Patient
 CLINICAL ETHICS

BEAUCHAMP & CHILDRESS

Moral philosophy of Clinical Ethics
1. Beneficence
2. Non Malficence
3. Autonomy
4. Justice
 Medicine
Medicine is the Art and Science of the
Diagnosis and Treatment of the
Disease and the Maintenance of
Health.
(Dorland’s Medical Dictionary)
SCIENCE = Clinical Competence = CURE.
ART = Ethical Competence = CARE.

Perfect health service should be a

combination of CURE and CARE, given
proportionally
 WHAT IS GYNECOLOGY ???

DEFINITION
Gynecology is a Science that study
deviation of anatomy and
physiology of woman
reproductive organ, outside
pregnancy
WOMAN REPRODUCTIVE ORGAN

ANATOMY :
PHYSIOLOGY
The main functions are :
 MENSTRUATION

 SEXUAL

 REPRODUCTION (PREGNANCY)
GYNECOLOGICAL CASES
 Infections : RTI, STD, HIV/AIDS

 Tumors : Benign, Malignant

 Congenital anomaly : Ambiguous

Genitalia, Uterus didelphus
BENIGN TUMOR
Ovarial Cyst

Ovarial cyst
Multiple and single myoma
MALIGNANT TUMOR (CANCER)
Choriocarcinoma Endometrial Carcinoma
Cervix Carcinoma

z
CONGETINAL ANOMALY
Uterus Didelphus
Female Pseudo Hermaphrodite
MEDICAL ASPECTS
 Pain

 Bleeding

 Foul and smelly discharge

 Dispareunea

 Death
PSYCHOSOCIAL ASPECTS
In General
 Discomfort

 Dissatisfaction

 Anger

 Depression

 Sexual problems

 Decrease in QOL
In Cancer
 Denial

 Isolation

 Anger

 Bargaining

 Depression

 Acceptance
 PHYSICIAN - PATIENT
COMMUNICATION

ANAMNESIS
 Objectives : to obtain

information’s on gynecological
complaints, risk factors and
underlying diseases.
 Patients may reluctant because of

personal and sensitive questions.

 Physicians should be careful with
interview, respect their integrity
and confidentiality.
 The present of her husband is
preferable.
GYNECOLOGICAL EXAMINATION (GE)
Lithotomy position
BIMANUAL PELVIC EXAMINATION
Speculum examination
Colposcopy Examination
Objectives of GE : to detect :
 The present or absent of any

deviation.
 The location and characteristics

of the deviation.
Patient’s feeling in Lithotomy :
 Awkward

 Vulnerable

 Discomfort

 Painful
 Privacy is very important
 Only doctor and nurse
 Patient should be prepared of all
procedures
 Conversation during GE should
be limited.
 Data obtained from anamnesis
and GE = CLINICAL DATA
 Clinical data can be used as
Tentative D/, but should be
completed with other supporting
data, such as laboratory and
imaging.
LABORATORY EXAMINATION (LE)
 Objectives : to support clinical

data.
 Has diagnostic, prognostic and

confirmative values.
 Could be painful and expensive.
IMAGING
 USG, Rontgen, CAT , MIR.

 Objectives : to detect local as well

as distant metastasis.
 Expensive.

 The indication should be tight

and selective.
INFORMED CONSENT (IC) - Beauchamp
A person gives IC to an intervention if
and only if the person receives a
thorough disclosure about the
procedure, comprehends the disclose
information, and acts voluntary, is
competent to act, and consent.
 What information’s should the
disclosed ?
 Medical situation (Complete or
Selected ?)
 Alternative of Interventions.
 Predictive QOL after Th/.
 Expenditure.
 BEHOLD !!!
 IC should be a dialogue, and
performed in stages.

 It is up to the patient to accept,

refuse or ask for second opinion.
 THERAPY
 Must be comprehensive with a

BIOPSYCHOSOCIAL approach.

 A combination of CURE and CARE

given proportionally.
OBJECTIVES :

 CURE : To make the patients get better,

IF POSSIBLE.

 CARE : To make the patients feel

better, ALWAYS.
 FOLLOW UP
Objectives :
 To evaluate the results.

 To rehabilitate physic, mental

and social, with CARE as a

dominant factor.
When should follow up be ended ??

WHEN THE PATIENT IS

PHYSICALLY, MENTALLY AND
SOCIALLY SATISFIED.
 BIOETHICAL ISSUES
IN
GYNECOLOGY

WHEN CAN BIOETHICAL ISSUES OCCUR IN

GYNECOLOGICAL CASES ???

It can happen in every stages, from

anamnesis through follow up.
HOW CAN BIOETHICAL ISSUES OCCUR
DURING ANAMNESIS ???
Lack of privacy
 More than one patients

simultaneously interviewed.
 Too many persons participate

(Doctor, Residents, Students etc.)

Misbehavior
 Arrogance

 Inappropriate questioning

 Paternalistic
 HOW DO WE PREVENT BIOETHICAL
ISSUES ???
DURING ANAMNESIS
 Privacy is very important with
only one interviewer.
 Make the patient comfortable and
start with general questions.
 Avoid misbehavior, such as
arrogance, paternalistic or
insinuating questions.
 Let she explain in her own word.
 Don’t contradict.
 If clarification is needed, do it
wisely with leading questions.
DURING GE
 Explain the benefit and drawback

of Lithotomy, Speculum and

Colposcopy Examination and do
it gently.
 Conversation should be limited.

 Unauthorized persons:

prohibited.
IN LAB. & IMAGING.
 Explain the benefit, discomfort
and cost of each procedures.
 Examination should be limited to
those which have diagnostic and
prognostic values.
IN THERAPY AND FOLLOW UP.
Patients should be informed about :
 Technical procedures and risks of Th/.

 Duration intervention and

hospitalization.
 Predictive prognosis, especially the

QOL.
 Abiding all doctor’s instructions.
Proper IC should be conducted, and
the patients have the right to
refuse, ask for second opinion or
accept doctor’s suggestion.
In case of acceptance, she and her
husband must give a Written
Consent.
 EXAMPLES
What is the bioethical aspects/issues in
these following cases :
1. A man came to a doctor with a chief
complain HIV (+). He want to be
treated with one condition that the
doctor must not inform his wife or
sexual partner.
(Confidentiality)
2. A woman, 45 years with 3 living
children, the youngest 5 years old,
came to a gynecologist complaining
of having irregular menstruation,
contact bleeding and painful coitus.
After rigorous examination, the
doctor concluded that she has
cervical carcinoma, terminal stage.
(Informed Consent + CARE)
3. A female baby was born. The mother
was anxious to see her first child, but
the doctor and the nurse did not
permit her, due to abnormal findings
of her external genitalia. No vagina,
clitoris like a penis and hypospadia .
Tentative D/ Ambiguous Genitalia.
(Informed Consent + Therapy)