Confronting a Fetal Abnormality: Reflections by Sheik N. Hassan
and Hossam E. Fadel
The following points should be considered when addressing the
case involving Leyla Ansari
and her family.
- First, it is important to determine how much if any Mrs.
Ansari knows about her medical situation. For example, was
she made aware of the possible fetal abnormality based on
the preliminary scan? It would have been better to let her
know that there was a suspicion of an abnormality. Is she
still having "severe cramps" when Dr. Fox enters
- Dr. Fox should have ascertained from Mrs. Ansari herself
if she wanted her husband to handle any news rather than relying
on the husband to say so. Later in the case, when the husband
asks Dr. Fox not to talk to Mrs. Ansari, the doctor should
have listened but told the husband, " Be sure to tell
your wife the facts as I told you. Then I will have to talk
to her personally to be sure she was told all the facts and
discussion and that she understands all the important points."
- Dr. Fox demonstrates insensitivity to the patient's (and
her family's) religious values when he interrupts her prayers.
Prayers five times daily are essential for Muslims. All except
one prayer (the evening prayer) have a window of 90 or more
minutes during which they may be offered. The window for the
evening prayer is ten minutes. Some Muslims hold firm to the
tenet, "one should not delay one's prayer." Many
Muslims will therefore offer their prayers at the beginning
of the prayer time rather than at the end of the time. Thus,
it would have been better for Dr. Fox either to wait for a
few minutes for the husband to perform prayers or to schedule
a time that he could have returned to discuss the situation
with him-unless it was really inconvenient for him to do so.
If he had other commitments, he could have attended to those
and later returned to the patient. If the other commitments
were away from the hospital, he could have waited a few minutes,
since each prayer lasts only 3-5 minutes. Alternatively, Dr.
Fox could have explained to the family that he had other commitments
that made it difficult for him to wait.
- Dr. Fox should have started the conversation with Mrs. Ansari
by discussing her "severe cramps," thus showing
his concern for her. It is unclear how long she was in the
hospital before the diagnosis of encephalocele was made and
whether the cramping had resolved by the time Dr. Fox entered
her room to talk to her about the fetal malformation. The
doctor should have assessed the possibility of threatened
- While discussing the situation with the husband, Dr. Fox
should have stated that, while the diagnosis is certain, the
prognosis is less certain. It is difficult to predict with
absolute certainty if an infant with encephalocele will survive
and for how long (minutes, hours, days, etc.) Moreover, if
the infant survives, doctors must assess whether there is
any chance for surgical treatment and how severe the child's
developmental problems will be.
- Instead of recommending termination of the pregnancy, Dr.
Fox should have offered it as an option. He should then have
described what could happen if the pregnancy were to continue.
He should have offered counseling by a team consisting of
a maternal-fetal medicine specialist (if that is not his own
specialty), an ethicist, a religious leader (in this case
an imam), a pediatric neurologist, and a social worker.
- In response to the mother's skepticism about the diagnosis
and her desire to wait and see "what God intends,"
Dr. Fox should have assured her that, while he does not mean
to belittle her belief and trust in God, it is his responsibility
to give the medical facts/opinions as accurately as possible
and to let the family decide what to do.
to the case
to Culturally Competent Care
to Culturally Competent Care for Muslim Patients
Sheik N. Hassan, M.D. is associate dean for academic affairs,
Howard University College of Medicine. From 2006-2007 he served
as president of the Islamic Medical Association of North America
(IMANA). From 2004-2006 he served as chairperson of the Steering
Committee on Cultural Diversity in Medicine for the American
College of Chest Physicians.
Hossam E. Fadel, M.D. is a clinical professor of obstetrics
and gynecology at the Medical College of Georgia and specializes in maternal-fetal
medicine at University
Hospital, Augusta, Georgia. He is also the chairman of the Ethics
Committee of the Islamic Medical Association of North America
(IMANA) and the editor-in-chief of its journal (JIMA).