Academic journal article The Hastings Center Report

Risk and the Pregnant Body

Academic journal article The Hastings Center Report

Risk and the Pregnant Body

Article excerpt

Reasoning well about risk is most challenging when a woman is pregnant, for patient and doctor alike. During pregnancy, we tend to note the risks of medical interventions without adequately noting those of failing to intervene, yet when it's time to give birth, interventions are seldom questioned, even when they don't work. Meanwhile, outside the clinic, advice given to pregnant women on how to stay healthy in everyday life can seem capricious and overly cautious. This kind of reasoning reflects fear, not evidence.

The first trimester of pregnancy had not been an easy one for Andrea--mornings brought waves of nausea and vomiting, and afternoons, debilitating fatigue. (1) What got her through were two things: the hope that her symptoms would start to lift when she got past her first trimester, and, of course, the promise of a baby in December. Unfortunately, neither of these came to pass.

Andrea had just reached fifteen weeks' gestation when she arrived in the emergency room at a major academic medical center. After a short week of relief, her nausea had returned, accompanied by a low-grade, persistent, gnawing abdominal pain, and-perhaps of more concern--a conviction that something was badly wrong. Given the signs, her attending obstetrician ordered a CT scan, the gold standard for ruling out what would be inexcusable to miss: appendicitis.

Yet the medical imaging team, nervous about radiation exposure with a pregnant patient, resisted the CT scan. First they attempted to image without radiation, but an ultrasound and an MRI yielded no useful information. The team then requested extra layers of documentation verifying that risks of radiation exposure to the fetus were discussed with the patient--who, by this time, had been admitted to the hospital with signs of evolving sepsis. And when the CT was finally done eighteen hours after it had been requested by the attending obstetrician, it did, in fact, reveal not only appendicitis, but a ruptured appendix.

Andrea was right; something was wrong. Five days later she miscarried in her hospital bed.

As it turns out, Andrea's story was tragic in more ways than one, for the resistance to imaging that led to these layers of critical delay was unfounded. As the American College of Radiology emphasizes, the risks of a single CT scan even for fetuses are negligible, carrying a fraction of the radiation dose shown to cause fetal harm. (2) Acting out of concern for the fetus brought about what the physicians had feared all along--not in spite of, but because of their "caution."

Far from being an isolated incident, Andrea's story illustrates a widespread pattern of perceptions and reasoning about risk in pregnancy. Certainly, reasoning well about risk is among the most challenging tasks in the practice of medicine. A breadth of cognitive biases is well documented: absolute and relative risks are often confused; ranges of risk get falsely dichotomized into binary categories of "low risk" and "high risk"; information framing can alter risk perception. (3) But with the addition of a fetus, reasoning about risk becomes yet more problematic. (4)

In this article, we review certain specific patterns of distortion that shape the perception, communication, and management of risk around the pregnant body in a variety of settings. In the first two sections, we explore the dual nature of attitudes toward medical intervention during pregnancy and birth. When treating pregnant women's nonobstetrical medical needs, it turns out, there is a tendency to notice the risks of intervening without adequately noting the risks of failing to intervene. In contrast, when we turn from management of pregnancy to management of birth, we note a tendency to intervene without due regard for the burdens to both fetus and woman that such interventions may bring. If risk perception is often distorted, the nature of the distortion changes markedly de pending on the circumstance of a pregnant woman's health needs. …

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