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Caregivers’ Role in Maternal–Fetal Conflict
Abstract

The case, which occurred in a public hospital in Turkey in 2005, exhibits a striking dilemma between a mother’s and her fetus’ interests. For a number of reasons, the mother refused to cooperate with the midwives and obstetrician in the process of giving birth, and wanted to leave the hospital. The care providers evaluated the case as a matter of maternal autonomy and asked the mother to give her consent to be discharged from the hospital, which she did despite the fact that her cervix was fully open. She left the hospital and gave birth shortly thereafter. Subsequently, the baby died two days later. In light of the contemporary ethical principles, the mother’s competency could be debatable due to the physical and psychological conditions the mother confronted. Furthermore, protection of the fetus’ life should have been taken into account by the caregivers when making a decision concerning discharging of the mother.

Keywords

Ability to Consent, Autonomy, Beneficence, Decision Making Capacity, Ethical Dilemma, Fetal Beneficence, Fetal Rights, Maternal Autonomy, Maternal–Fetal Conflict, Pregnancy

The Case

The mother of two children was taken to a hospital for the birth of her third child at around 10:00 p.m., when only midwives were on duty and obstetricians were called to the hospital only in a case of emergency. A midwife examined the mother and said: Everything seems normal. I think it will be a natural vaginal birth, but you should help us to make the birth as quick as possible. However, due to strong contractions and labor pain, the mother, who was quite overweight, could not stay on the gynecological table, and she was constantly ending up on the floor.

The midwife realized that it would be difficult to deal with the situation, so she decided to call the obstetrician. It was about 1:00 a.m. when the obstetrician’s phone rang. The midwife explained the patient’s condition to the obstetrician who was not happy to be called at such a late hour. The obstetrician arrived at the hospital at 1:20 a.m. She examined the mother and listened to the fetus’ heart sounds. The examination showed that the cervix was almost fully open and the fetus was healthy. However, the mother was screaming, crying, and refusing to stay on the gynecological table and push the fetus.

The obstetrician: Your baby is healthy. If you push the baby, the birth will finish soon.

The mother: I do not want to stay here; I do not want to give birth here.

The obstetrician got angry, and without saying anything, she left the delivery room to talk with the husband who was waiting outside.

The obstetrician: Your wife is refusing to give birth and push the baby. [End Page 67]

The husband: Please do whatever you can, even Cesarean delivery.

The obstetrician did not respond to the husband and went back to the delivery room where the mother was still screaming and crying on the floor.

The obstetrician: You have to comply with my instructions; otherwise I will discharge you, so if you would like to be discharged, write down your consent as “I am voluntarily leaving the hospital” and sign it.

The midwife gave a piece of paper to the mother who was writhing on the floor, and the mother wrote, “I am voluntarily leaving the hospital” and signed it. The obstetrician instructed the midwife to notify the husband of the decision to discharge the mother. The midwife informed the husband about what happened. The husband was shocked and felt helpless and desperate. However, he had to take his wife—her cervix fully open—out of the hospital to another hospital, where she gave natural vaginal birth within 10 minutes of arriving.

Unfortunately, the newborn baby was not healthy, so it was decided to refer the baby to a children’s hospital for intensive care. Nevertheless, the baby died two days later. The cause of death was recorded as perinatal asphyxia, inadequate oxygen supply, and meconium aspiration syndrome, breathing a mixture of meconium and amniotic fluid.

Introduction

As a health inspector in the Ministry of Health in Turkey, I conducted an investigation of the aforementioned case. The mother claimed that she was humiliated by the midwives when she was in labor with unbearable pain, so she did not feel comfortable giving birth there. On the other hand, the midwives and obstetrician denied the mother’s allegations of humiliation and asserted that she did not cooperate in the delivery. The obstetrician defended the discharge by claiming that the mother’s signed declaration was an appropriate and valid informed refusal. The obstetrician said she could not continue the delivery without the mother’s permission; otherwise, she would have breached the mother’s autonomy.

Though at first blush this may appear to be a typical malpractice case, the obstetrician’s stated goal of respecting the mother’s autonomy resulted in a disregard for the well being of the fetus. From this perspective, the following discussion will examine the case in light of the conflict between maternal autonomy and fetal beneficence.

Investigation Process of the Case

While conducting the investigation, as an inspector, I focused on the legal aspects and looked for the answers to three main issues: whether the mother experienced verbal abuse from the caregivers, whether the discharge was medically appropriate, and whether there was any connection between the baby’s death and the discharge. I collected and examined all the relevant medical records, interviewed both the complainant and defendant parties, and appointed a panel of experts (as a compulsory procedure in medical investigations in Turkey) comprised of two obstetricians and one pediatrician, to evaluate the case in terms of medical propriety.

The husband claimed that the care providers’ mistreatment, negligence and inappropriate discharge caused the death of the baby. Furthermore, he asserted the midwives humiliated his wife by their remarks, such as “you know how to get pregnant, but you do not know how to give birth,” and “why did you get pregnant, seeing that you cannot give birth,” and this attitude drove the mother to depression during and after the birth. The husband also said his wife had been threatened by such comments as “sign the document to leave the hospital, or else you will die,” and although he had been present at the hospital, no one had sought his consent or permission for his wife’s discharge from the hospital (the mother did not give testimony during the investigation on the grounds of having psychological problems, but her original complaint letter matched the husband’s testimony).

However, the obstetrician and midwives did not admit to the plaintiffs’ allegations. They said the mother had been throwing herself on the floor without any reason, and they had not had any [End Page 68] option but to discharge the mother in accordance with her free will. The midwives said they tried to handle the situation, but failed, so they called the obstetrician, who made the decision regarding the discharge. According to the obstetrician, it was an explicit autonomy–related issue; as a physician, she did not have any authority to force the mother to stay in the hospital or impose any medical procedure on her without her consent. The obstetrician said that she had adequately informed the mother and the husband and got a signed document as a proof of the mother’s demand to be discharged.

The panel of experts reported to me that the obstetrician’s decision to discharge the patient was correct and that there were no medical errors or negligence in the obstetrician’s approach, except in discharging the patient without providing an ambulance. Moreover, they stated that it was not possible to determine whether or not the baby’s death was related to the discharge.

I conducted the investigation in light of the existing legal regulations, particularly “the Code of Medical Deontology” and “the Regulation on Rights of Patients” (1998). Even though I reported the case based on my personal judgment, I was restricted by the statutory rules and procedures. However, now I would like to study the same case solely from the perspective of medical ethics.

What is Autonomy?

In the Western world, autonomy is a leading principle of ethics (Pelto–Piri, K. Engstrom & I. Engstrom, 2013). It is believed that as a rational entity, a human being has the capacity to decide which preferences are best for her or him. However, the importance of autonomy does not depend upon its consequences. Patients with decision–making capacity have an absolute and fundamental right to make their own medical decisions, even if the decisions lead to bad outcomes including death. As Munson (1996) mentions, “autonomy is significant not only because it is a condition for moral responsibility, but because it is through the exercise of autonomy that individuals shape their lives” (p. 41).

Beauchamp and Childress (2009) outline a general framework for autonomy in light of self– governance as “independence from controlling influence” (liberty) and “capacity for intentional action” (agency) and distinguish an autonomous choice from a general capacity for self–governance. Moreover, according to them, “even autonomous persons who have self–governing capacities and are generally good managers of their health sometimes fail to govern themselves in particular choices because of temporary constrains caused by illnesses, depression, ignorance, coercion, or other conditions that restrict their option” (p. 100).

Furthermore, even under the circumstances of having capacity for self–governance and being free from all the types of restrictions, the patient’s decision–making capacity relies on the information given by caregivers. Incomplete and/or erroneous information might cause the patient to make an undesirable decision. Hence, a thorough informed consent procedure is crucial in the implementation of autonomy.

What is Beneficence?

The principle of beneficence, “stemming from the Hippocratic tradition” (Zeiler, 2012, p. 342), is “a moral obligation to act for the benefit of others” (Beauchamp & Childress, 1994, p. 260). By the Hippocratic oath, physicians pledge to apply their ability and judgment for the benefit of the sick (Teays & Purdy, 2001). However, as Munson (1996) states, the problem is about the extent of the duty. Wide interpretation of beneficence could result in paternalism, which would infringe upon autonomy. In a paternalistic approach, “the health care professional believes that he or she knows what is best for the patient and acts on this belief without the patient’s consent” (Anderson, 1987, p. 177). Although the intention behind paternalism is to protect patients from harm, in many cases it is difficult to justify this by its benefits because of overriding the patient’s autonomy.

On the other hand, ignoring beneficence might cause irreversible consequences for the patient’s [End Page 69] health. In the relationship between patients and caregivers, patients are the vulnerable party needing help and care. Proper communication in the physician–patient relationship might facilitate finding a balance between the principles of respect for autonomy and beneficence. The balance could be struck by informing the patient correctly for an autonomous choice. Therefore, providing complete and accurate information to patients is not only a matter of autonomy, but also an obligation resulting from the principle of beneficence.

The Role of Fetal Rights

The relationship between a mother and her fetus is special, delicate, and personal. However, it is also controversial in terms of ethical behavior. The mother’s behavior and actions sometimes may conflict with the interests of the fetus. For instance, substance abuse, such as drug, alcohol and tobacco might cause many serious implications like brain damage, intra–uterine stroke, and even fetal death (Isaacs, 2003). Should the mother be restricted in the interest of the fetus?

In the United States, the Unborn Victims of Violence Act of 2004 describes a fetus in utero as a legal victim, and in many states, child–protection laws give “authorities the power to confine pregnant women for substance abuse” (Eckholm, 2013, para. 7). Some scholars are concerned that this recognition “would make the woman a slave of the fetus” (Blank, 2001, p. 502). However, others think that “it is incumbent on the healthcare provider to make sure that the needful is done to ensure that the obligation of beneficence to the unborn is met, even if it entails overriding a pregnant woman’s autonomy” (Bogaert, 2006, p. 18).

According to McCullough and Chervenak (1994), the discussion on the moral status of the fetus is “ . . . one of the oldest ethical debates in Western culture” (p. 98). Isaacs (2003) analyzes the debate over fetal rights as the following three moral perspectives “a fetus has the same rights as a live child; that a fetus has no rights; or that a fetus has increasing moral status with advancing gestation” (p. 1).

The premise that a fetus has the same rights as a live child indicates that the mother and the fetus are two independent entities. The intention aiming to prevent a mother from harming her fetus stems from this approach. The second perspective Isaacs puts forth is that a fetus has no rights. In our case, the caregivers implicitly acknowledged this viewpoint. Even though the moral justification of abortion may be associated with this perspective, the period of gestation or an intentional act that ends up killing the fetus creates different arguments.

McCullough and Chervenak (1994) do not take a certain position on the moral status of the fetus, but they stress the importance of “the prevention of premature or unnecessary death” of the viable fetus in terms of the principle of beneficence (p. 113). Moreover, they highlight the necessity of physicians’ obligations to prevent a conflict between respect for the autonomy of the pregnant woman and beneficence of the viable fetus.

The stance on fetal rights also exposes the position on abortion. The pro–choice side claims that a fetus turns into a person after birth (English, 1983). Moreover, some liken a fetus to “a parasite or even a tumor” (Isaacs, 2003, p. 58). Even if it is assumed that a fetus is not a person, should killing or neglecting it be allowed? For example, animals are not persons, so can people overlook killing or torturing animals (English, 1983)?

The ideas in favor of abortion interpret the mother’s and fetus’ rights as inversely proportional. Warren (2001) claims “there is room for only one person with full and equal rights inside a single human skin” (p. 480). She asserts that accepting the fetus as a person means treating the mother as less than a person. On the other hand, anti–abortionists extol fetal rights and recognize the fetus as a person (Bolton, 1983). In addition to these two opposite views, there are some other opinions regarding the maternal and fetal relationship which suggest striking a balance between maternal and fetal interests through educating pregnant women about their actions which may be potentially hazardous to the fetus, providing adequate counseling and prenatal and preconception care, and in the event of any [End Page 70] legal intervention, focusing on protecting the fetus instead of punishing the mother (Blank, 2001).

Competency to Consent

Competence is the qualification to self–governance and “ . . . determined primarily by whether a person has the capacity to decide autonomously” (Beauchamp & Childress, 1994, p. 141). In this sense, consent is the means to carry out this self– governance. For an autonomous decision, the decision maker must have the capacity to make a free decision through the informed consent/informed refusal procedure. (The term “consent” is used to refer to “informed consent” accepting treatment as well as “informed refusal” declining treatment in this article.)

O’Brien, Callahan and Savaiano (1987) explain that a valid consent has to meet three criteria concurrently: sufficient information; capacity to understand the information; and voluntary decision. The first element requires caregivers to inform the patient adequately using the reasonable patient disclosure standard. The information has to include the patient’s existing conditions, suggested treatment plan, the reasons behind the plan, the benefits and risks of the plan, prospective implications of denying the plan, and alternative procedures. The second criterion is about the patient’s capacity, which necessitates being qualified to understand the given information and make a decision in light of the information. The last component for a valid consent is that the patient’s decision has to be voluntary and free from coercion and undue influences. It is essential to assure that “patients and others are neither deceived nor coerced” in their informed decisions (O’Neill, 2003, p. 4).

Grisso and Appelbaum (Appelbaum, 2007) elucidate four criteria for decision making capacity, including communicate a choice, understand the relevant information, appreciate the situation and its consequences, and reason about treatment options. Each criterion comprises certain patient’s tasks, such as “grasp the fundamental meaning of information communicated by physician” and physician’s assessment approaches, such as “encourage patient to paraphrase disclosed information regarding medical condition and treatment” (p. 1836).

Appelbaum (2007) underlines that “the determination of whether patients are competent is critical in striking a proper balance between respecting the autonomy of patients who are capable of making informed decisions and protecting those with cognitive impairment” (p. 1835). Thus, in a case of refusing treatment or reversing an informed consent, healthcare professionals need to be much more cautious about accepting or overriding the patient’s decision, digging out whether the patient is competent. The consequences of the patient’s decision can be irrational, but the decision must be based on rational reasons. The common example is Jehovah’s Witnesses’ refusal of blood transfusion on the grounds of their religious belief. Dying because of not accepting blood transfusion is not rational, but as an adult, believing that an obligation to refuse comes from religion is a rational reason needing to be respected. However, in such cases, caregivers should also ensure that the patient understands the given adequate information and makes the decision voluntarily (Chell, 1988).

Analysis of the Case

With regard to the case, an ethical dilemma between the mother’s and the fetus’ interests and rights may be reckoned. However, according to the caregivers, there was only one choice not involving any ethical dilemmas: the mother had the competency to express her consent; she refused the treatment as a result of her autonomous decision and declared her will by writing down “I am voluntarily leaving the hospital” and signing it.

The issue of whether the signed document was adequate to prove the mother’s competency and the legitimacy of the consent is significant in assessment of the case. McCullough and Chervenak (1994) describe informed consent as a process and say that “informed consent is not a form or a piece of paper and it is not the signature of the female patient or pregnant woman on a form or piece of paper” (p. 138). For this reason, it is difficult to ascribe too [End Page 71] much importance to the signed document without looking at other relevant considerations.

There was no evidence that the mother was forced to go to the hospital, so going to the hospital implicitly shows that the mother wanted to give birth in the hospital. Furthermore, we know that the mother was taken to another hospital after leaving the first hospital, and ten minutes after arriving at the second hospital, she gave birth without any medical intervention. All these facts indicate that the mother may have changed her preference after being admitted to the first hospital. Why did she change her preference? This situation can be explained by at least two possibilities: the mother was distressed due to labor pain or the mother was mistreated by the caregivers.

The U.S. Department of Health and Human Services (2010) declares that due to different social and individual reasons, a considerable number of women experience “a broad range of physical and emotional struggles,” such as stress, depression, and anxiety during and even after pregnancy (p. 3). Other researchers who described similar struggles include Schetter and Tanner (2012), and Hofberg and Ward (2003). Additionally, the mother was overweight and research studies show that obesity in pregnancy increases risks of pregnancy complications, such as gestational diabetes, preeclampsia, and Cesarean delivery (Baeten, Bukusi & Lambe, 2001). These indicate that the mother was in need of the health professionals’ care and kindness both physically (due to her unendurable pain and excess weight leading to the need for Cesarean delivery) and psychologically (due to stress, depression, and anxiety). The caregivers were legally and morally expected to know such information, sympathize with the mother, and be prepared for dealing with her suffering. Therefore, the vulnerability of the mother was supposed to be taken into account by the caregiver. On the contrary, the mother alleged that the midwives humiliated her in the delivery room.

Although the study conducted by Grisso and Appelbaum (1995) showed that the majority of patients with depression met all the measures of competency, it should not be interpreted to mean that patients’ temporary or permanent psychological disorders can be overlooked by caregivers in the assessment of competency. If we accept the premise that the caregivers told the truth that they did not mistreat and humiliate the mother, we have to wonder why the mother went to the first hospital, and then decided to leave there with the condition of an open cervix. This seemingly irrational behavior makes the mother’s competence questionable in terms of Chell’s (1988) “rational reasons based decision” and Grisso and Appelbaum’s “reason about treatment options” criteria (Appelbaum, 2007).

Additionally, the mother’s treatment refusal is debatable in terms of the criteria of adequate information, understanding the information, and voluntary decision. McCullough and Chervenak (1994) call these points as three steps of the law of malpractice in the law of informed consent and extend these obligations as nine steps of informed consent in an ethical assessment, which also entails physicians’ recommendations and creating moral common ground. Thus, this process necessitates a thorough understanding and communication in the relationship of patients and physicians, which can be implemented by physicians as a negotiation or respectful persuasion. As the case illustrates, almost none of the information and ethical obligations, specified by McCullough and Chervenak (1994), was provided to the mother. On the contrary, the obstetrician’s expression as “you have to comply with my instructions; otherwise I will discharge you,” might be perceived as dictation and coercion on the mother’s decision.

As a result, when we examine the case, in light of above–mentioned arguments, we can say that just the existence of the signed document does not demonstrate the mother’s competency or validate her consent.

Another critical point is that even if the mother was regarded as fully competent to give consent to leave the hospital, because of the current law in Turkey the mother’s preference should have been overridden. The Regulation on Rights of Patients (1998) stated:

Patients can demand to go to another healthcare institution while they are admitted by a healthcare facility. However, physicians have to inform [End Page 72] patients regarding prospective risks of going to another healthcare facility and it is essential that shifting the healthcare institution should not cause life threating conditions

(Article 8).

The relevant medical records and testimonies did not provide any clues that the mother and/ or father were informed about the risks of leaving the hospital. In other words, neither the obstetrician nor the midwives informed the mother and/ or father about the dangers the mother and fetus may have faced.

As a general requirement, in the United States as well as in Turkey, physicians should be aware of the criteria to assess patients’ competency; in case of any suspicion, they are expected to ask for a psychiatric consultation; in the event of determining lack of competency, they should seek a substitute decision maker (Appelbaum, 2007). However, without utilizing any competency assessment criteria or measurements, the obstetrician assumed that the mother was fully competent to refuse the treatment. Additionally, in Turkey, substitute consent from patients’ relatives, such as fathers, spouses, and children is common, even when patients are competent. However, the case indicates that although the husband was at the hospital, the caregivers did not take consent from him—instead of asking the mother to sign the document when she was suffering on the floor. Though the law did not require a specific format for consent, forcing a woman writhing in agony on the floor to sign a document should not be deemed morally appropriate.

As the case clearly demonstrates, the obstetrician discharged the mother without making an effort to protect the fetus’ wellness. Although patient–rights related discussions are still at a nascent stage and some flaws have arisen in ethical issues in Turkey, the Regulation on Rights of Patients draws a general framework whose provisions are supposed to accurately be implemented by healthcare professionals. For this reason, both the regulations and the ethical principles do not justify the caregivers’ defective evaluation and approach. The delivery in the other hospital indicates that there were no physical obstacles to the birth. If the caregivers had encouraged the mother to give birth through a compassionate approach and offered appropriate communication as “respectful persuasion” (McCullough & Chervenak, 1994), the birth could have finished at the first hospital, and the baby may have survived.

Does the Case Include a Conflict?

Suppose for a moment that the caregivers provided thorough medical care and completely implemented all preventive ethics strategies introduced by McCullough and Chervenak (1994), but still the mother insisted on leaving the hospital with a fully open cervix. In this case, can we talk about an ethical conflict or dilemma? Did the mother have the right to demand to leave? Did complying with this demand vitally endanger the fetus’ viability?

The panel of experts could not describe with certainty whether or not the discharge caused the death. Nevertheless, according to medical records the fetus was healthy before the mother’s discharge. Moreover, a study done by Berglund, Grunewald, Pettersson, & Cnattingiusb (2008) demonstrates that “neglecting to supervise fetal wellbeing” is the most common reason for asphyxia in childbirth (p. 316). Therefore, we can assume that the discharge put the fetus at risk.

In terms of McCullough’s and Chervenak’s (1994) criterion for viability of the fetus, the fetus was a patient and the mother’s decision to leave the hospital generated a conflict between autonomy–based obligation to the mother and beneficence–based obligation to the fetus. McCullough and Chervenak (1994) burden caregivers with the responsibility of preventing ethical conflict in clinical practices by employing certain strategies. Furthermore, they say that when a pregnant patient declines any longer to be a patient, if “the fetal patient’s social–role interests are vitally at stake,” the case should be referred to an ethical committee, and if the patient does not accept the committee’s decision, a court order should be sought (p. 244).

Thus, caregivers should be vigilant in cases in which the mother’s refusal endangers the fetus’ viability. However, this case shows that the obstetrician did little more than discharge the mother on the [End Page 73] grounds of the mother’s statement, “I do not want to stay here; I do not want to give birth here” which vitally put the fetus in jeopardy. For this reason, it is believed that the case involves a conflict between the mother’s autonomy and the fetus’ beneficence. However, this conflict is substantially stemmed from the caregivers’ misbehavior, not treating the mother with dignity and respect, and the obstetrician’s incorrect judgment regarding ethical issues rather than the mother’s individual decision. The misbehavior made the mother feel uncomfortable to stay in the hospital, and the incorrect judgment caused the obstetrician to overlook essential considerations of medical ethics.

Conclusion

The argument regarding a mother’s versus a fetus’ rights is a widespread issue in medical ethics. The debate is commonly surrounded by discussions concerning abortion. However, as the case illustrates, the conflict between maternal and fetal rights and interests is not just an abortion–related problem.

In light of the principle of autonomy, the competent patient’s decision, which can be either rational or irrational, must be respected regardless of the consequences. However, in the case of an ethical dilemma between two distinct persons or entities, such as a mother and her fetus, the rationality should concern care providers. The consequences of a free decision can be justified and respected as long as they solely affect the decision maker. On the contrary, when it comes to the rights of the other entity, the balance between two parties’ interests should be examined carefully.

The case exhibits that the caregivers discharged the mother based on the document signed by the mother when she was convulsed with pain on the floor of the delivery room, allegedly on the grounds of the respect to the mother’s autonomy. However, the competency of the mother and the validity of the consent for an autonomous decision are, in the above–discussed ways, questionable if not entirely invalid. The mother was neither appraised whether or not she was competent to give the consent, nor informed appropriately by the caregivers about the consequences, on her and her fetus, of leaving the hospital.

According to McCullough and Chervenak (1994), physicians should undertake the responsibility to prevent ethical conflict or crisis by using clinical strategies, such as informed consent, negotiation and respectful persuasion. Furthermore, as the Hippocratic Oath reveals, care providers are expected to apply their best efforts for the benefit of patients and keep them from harm and injustice (Teays & Purdy, 2001). Conversely, instead of implementing these conflict–preventing practices and also taking the fetus’ rights into account by striking a balance between the mother’s and the fetus’ interests, the caregivers’ medically apathetic and ethically inaccurate stance generated the conflict which ended with the baby’s death. Hopefully, this study will initiate discussions among academics and health authorities, particularly in Turkey, to raise awareness of such cases in medical ethics.

Discussion Questions

  1. 1). Did the mother have the right to demand to leave? Would your answer to this question change if discharging the mother endangered the fetus? Why or why not?

  2. 2). Was the mother in a position to make an autonomous choice? Other than autonomous patient decision-making, are there models of decision-making that might have been considered in this case? How might they be applied?

  3. 3). How could the care team have done better? Could a hospital have policies to help prevent or address such a situation? If so, what would these policies look like?

Ercan Avci
Graduate Student in Healthcare Administration, University of New Haven
Correspondence concerning this article should be addressed to Ercan Avci, Senior Health Auditor, the Ministry of Health of Turkey. Email: eavci1@unh.newhaven.edu

Conflicts of Interest

The author reports no conflicts of interest.

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Appendix. The Regulation on Rights of Patients (The Case–Related Provisions)

Article 8—Patients have the right to choose a healthcare facility. Patients can demand to go to another healthcare institution while they are admitted by a healthcare facility. However, physicians have to inform patients regarding prospective risks of going to another healthcare facility and it is essential that shifting the healthcare institution should not cause life threating conditions.

Article 14—Caregivers have to take care of patients’ conditions. Even though it is not feasible to save the patient’s life, caregivers have to endeavor to relieve the patient’s suffering.

Article 22—Excluding the exceptions shown by law (the exceptions are generally related to public health and individual vital health conditions), no one can be treated without her/his consent and against her/ his given consent.

Patient’s consent is required for medical interventions.

If the patient is a minor or incapacitated, the consent is provided by the patient’s parents or guardians. If the patient’s parents and guardians are not available, or the patient is unable to express her/his will, this condition is not required.

In the cases when the patient’s representative does not give consent for medical treatment, if the intervention is medically necessary, the intervention depends on the court order. However, the permit is not required if obtaining the permission from the guardian or court requires the time, and the patient’s life or vital organs are under threat unless an immediate action.

Article 24—Patients have the right to revoke the consent which means the patient refuses the treatment. Revoking the consent, after beginning of the treatment, must not endanger the patient’s health.

Article 25—Provided that patients are responsible for the potential negative consequences, patients have the right to decline a planned medical treatment or stop an ongoing medical process, except the situations required by law. In this case, the potential consequences and implications have to be explained to the patient or the patient’s legal representatives or relatives, and a written document indicating the patient’s will has to be obtained.

Article 28—Exceptions stipulated by the legislation, consent does not require any specific format (consent may be given either orally or in writing). Consent gained in violation of law and morality is void and such consent based interventions cannot be implemented.

Article 31—It is essential to inform and enlighten the patient or the patient’s legal representatives about the subject and results of the medical intervention. [End Page 76]