Background:
Many procedures requiring sedation in the pediatric emergency department are performed by consultants from outside the department. This team usually includes orthopedic surgeons and general surgeons. As sedation is now a standard of care in such cases, we evaluated consultants' views on sedation.
Objectives:
To evaluate consultants' views on sedation.
Methods:
A questionnaire with both open-ended questions and Likert-type scores was distributed to all orthopedic surgeons and general surgeons performing procedures during the study period. The questionnaire was presented at three medical centers.
Results:
The questionnaire was completed by 31 orthopedic surgeons and 16 general surgeons. Although the vast majority (93–100%) considered sedation important, a high percentage (64–75%) would still perform such procedures without sedation if not readily available.
Conclusions:
Sedation is very important for patients and although consultants understand its importance, the emergency department staff must be vigilant in both being available and not allowing procedures to "escape" the use of sedation.
After the recent overturning of "Roe v. Wade", widespread attention has been made to the philosophical, ethical, and legal aspects of elective abortions. Here I will address the detrimental effects of this matter from a practical standpoint, as abortion care is - and will always be - healthcare.
Background and History
During the 19th and early 20th centuries, legislative authorities in the U.S.A passed various abortion-restricting laws, mainly among the conservative states. This anti-abortion movement reasoned that pregnancy termination morally violates the fetus's right to life, psychologically harms mothers with unavoidable guilt, and medically may lead to irreversible infertility. Pregnancy termination quickly became a prosecutable offense - a felony - to practicing clinicians and patients alike, either by the common law or state-specific anti-abortion statutes. However, juries were often reluctant to convict women for undergoing an abortion, which led to an increasing focus of legal officials on abortion-performing physicians. [1]
By the early 1970s, elective abortions were effectively available in only 6 American territories: Alaska; California; Washington, D.C.; Washington state; Hawaii; and New York. This widespread abortion restraint was abolished in January 1973 by the supreme court ruling on the Roe v. Wade appeal. For 50 years, anti-abortion laws were deemed unconstitutional, encompassing unequivocal harm to women's autonomy and the right to privacy. Nonetheless, maternal autonomy was never considered absolute, and the court attempted to balance this right with the unborn children's right to live. The trimester division of pregnancy was applied as a legal landmark: during the first trimester, abortion was allowed entirely as long as a licensed physician performed it; from the second trimester, state legislation was allowed to limit abortions minimally, so long these regulations were "reasonable" and enacted to protect the mother's health; and during the third trimester, the unborn child is viable - as such, state legislation may outlaw abortion altogether, except for unique condition under which the mother's health or life is at jeopardy.
In the infamous Planned Parenthood v. Casey (1992) ruling, the original trimester division was replaced by a singular landmark of 24 weeks post-conception, as this developmental stage marks the fetus's viability. Accordingly, state legislation must refrain from statutes causing undue burden upon the maternal autonomy in the early pregnancy (i.e., partially allowing abortion restriction in the first trimester). Nonetheless, Roe v. Wade remained and has been regarded as a true beacon of human rights.
Today
On June 24, 2022, the supreme court ruled in the Dobbs v. Jackson case. The court's ruling determined that the Mississippi's Gestational Age Act - which effectively bans all abortions post 15 weeks of conception - is, in fact, constitutional, thus overruling both Roe v. Wade and Planned Parenthood v. Casey.
Most Republican-ruled states passed several abortion-restricting laws before Dobbs v. Jackson. 13 of which have already passed trigger laws that ban abortions in the first and second trimester. These laws - now uninhibited by Roe v. Wade - are enforceable and thus in place.
Ethics, Law, and the Healthcare in Between
Pregnancy termination is incredibly complex from an ethical standpoint: It includes both maternal and fetal (often conflicting) interests; incorporates questions regarding the timeframe of life itself; and retains the unavoidable tension between self-autonomy and societal intervention. When does life begin? What is the proper balance between the states' and the individuals' wills? Does the sanctity of one's life outweigh the quality of another?
As burning as these questions may seem, the issue at hand is not merely theoretical, as it has immediate real-life consequences. It is empirically validated that diminished access to healthcare does not impede abortions (i.e., a transition from regulated to clandestine, unsafe abortions will most likely occur).[2] Furthermore, mortality rates of physician-led abortions, overall maternal mortality, and unsafe-abortion case fatality rates are estimated at 0.41 per 100,000, 23.8 per 100,000 live births, and 220 per 100,000 abortion attempts, respectively.[3, 4, 5] The risk of death is approximately 60 times higher in pregnancy - and more than 500 times higher in unsafe abortions - than in abortions conducted by licensed practitioners. With almost 700,000 abortions performed annually in the United States, the infringement of abortion law will translate immediately to a tremendous loss of life. [3]
Under the suppositions that: a. personhood begins at fertilization, and that b. actions that directly lead to a person's demise are invariably immoral - special attention to in-vitro fertilization (IVF) treatments is warranted. Several oocytes are fertilized during each therapeutic session to increase their success chances. Some embryos are selected, yet the rest are neglected - either kept frozen or destroyed as biological waste. If waste disposal is now outlawed, what should be done with the vast banks of unwanted IVF embryos?
Finally, abortion outlaw is territorially differential. Abortion-seeking patients may attempt to travel to a more liberal state, thus suffering from increasing care costs. The growing costs will deepen the inaccessibility of healthcare among disadvantaged communities - the so-called socio-medical gap. This violation of equity is simply unjust, unfair, and morally condemnable - as abortion care is, and will always be, health care.
There are additional aspects to the current discussion, yet it is worth mentioning that the overturning of Roe v. Wade is more than an American legal saga: It signifies a major setback in human rights activism, effectively sending women's rights backward by almost 50 years; it questions where autonomy itself should be placed in our everyday lives and professional ethics; and it even provokes the absurd dilemma: if healthcare was outlawed, would you still practice your profession?
Corresponding Author
Stav Kislev
[email protected]
References
[1] Paltrow L. Roe v Wade and the New Jane Crow: Reproductive Rights in the Age of Mass Incarceration. American Journal of Public Health [Internet]. 2013 [cited 25 June 2022];103(1):17-21. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3518325/
[2] Bearak J, Popinchalk A, Ganatra B, Moller A, Tunçalp Ö, Beavin C et al. Unintended pregnancy and abortion by income, region, and the legal status of abortion: estimates from a comprehensive model for 1990–2019. The Lancet Global Health [Internet]. 2020 [cited 25 June 2022];8(9):e1152-e1161. Available from: https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30315-6/fulltext
[3] Kortsmit K, Jatlaoui T, Mandel M, Reeves J, Oduyebo T, Petersen E et al. Abortion Surveillance — United States, 2018. MMWR Surveillance Summaries [Internet]. 2020 [cited 25 June 2022];69(7):1-29. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7713711/
[4] Raymond E, Grimes D. The Comparative Safety of Legal Induced Abortion and Childbirth in the United States. Obstetrics & Gynecology [Internet]. 2012 [cited 25 June 2022];119(2, Part 1):215-219. Available from: https://pubmed.ncbi.nlm.nih.gov/22270271/
[5] Unsafe abortion incidence and mortality Global and regional levels in 2008 and trends during 1990–2008 [Internet]. WHO. 2012 [cited 25 June 2022]. Available from: https://apps.who.int/iris/bitstream/handle/10665/75173/WHO_RHR_12.01_eng.pdf;jsessionid=FB4AC2A2EAE0034ACE1AD8D3ED31848A?sequence=1