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 the room?
- 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 preterm labor.
- 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.
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).