Questions abound on global inequities in reproductive health care

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Inequalities in health status and access to reproductive health care services have consistently been critical areas of inquiry in bioethics. Questions persist about access to—and the utility of—reproductive technologies and differential treatment on the basis of race, ethnicity, and gender. The roles of a rich country’s clinical education and training programs among poor patient populations, and the changing nature of national and international reproductive health law and policy also pose dilemmas.

This month’s issue of the AMA Journal of Ethics® (@journalofethics) explores the ethical, social and cultural stakes of reproductive health care as a global clinical and educational enterprise.

Take a moment to consider this question: A medical student on an international rotation in obstetrics witnesses physicians and nurses engaging in violent and insulting behavior toward patients. How should he respond?

  • Intervene in the moment and tell the clinicians he will report them if they don’t stop.
  • Report the abuse to hospital authorities later.
  • Ask the patient if he wants her to remain and provide supportive care.
  • Only the latter two answers.

Give your answer and find responses to this question in the March issue of the AMA Journal of Ethics. Here are some of the articles included in this issue of the journal.

Is Lower Quality Clinical Care Ethically Justifiable for Patients Residing in Areas with Infrastructure Deficits?” Reproductive health services, including infertility care, are important in countries with infrastructure deficits, such as Lebanon. Islamic prohibitions on adoption and other alternatives mean most Muslim couples struggling with childlessness must turn to in vitro fertilization and intracytoplasmic sperm injection. Attempts to bring such procedures to those areas at a low cost might help infertile couples, but a low-cost protocol for male infertility remains technically challenging and could result in two standards of clinical care.

Balancing Demand for Universally Improved Health Outcomes with Need for a Local Standard of Care.” The U.S. leads global health care by advancing care through randomized controlled trials (RCTs), typically conducted in rich places. However, RCTs, including replications of previous trials, are also carried out in low- and middle-income locations. It is neither clinically appropriate nor ethically acceptable to extrapolate findings from one region to another without accounting for a number of factors.

Why Crisis Pregnancy Centers Are Legal but Unethical.” Crisis pregnancy centers are organizations that seek to intercept women with unintended pregnancies who might be considering abortion and persuade them to consider other options. Although such venues have First Amendment rights protections, propagating misinformation should be regarded as an ethical violation that undermines women’s health.

Linking Global Health to Local Health within an Ob/Gyn Residency Program.” Training programs that focus on global health have been criticized by some who suggest there is ample work to be done domesticlally. Also, such programs can become learner-centric, which makes it difficult to maintain and potentially burdensome for the host site. This article discusses a curriculum and training program that prepares learners to work responsibly and collaboratively in resource-poor settings, both nationally and globally.

Guests on the journal’s March podcast outline the history of a now alarmingly high rate of maternal mortality among black American women, and present potential areas of improvement for reproductive health practitioners. Guests include: Dorothy Roberts, JD, a scholar of race, gender and law at the University of Pennsylvania Law School; Nadia Sawicki, JD, academic director of Loyola University Chicago’s Beazley Institute for Health Law & Policy; and Stacie Geller, PhD, a professor of obstetrics and gynecology at the University of Illinois College Of Medicine. 

Subscribe to the podcast in iTunes.

Submit manuscripts and artwork

The journal’s editorial focus is on commentaries and articles that offer practical advice and insights for medical students and physicians. Submit a manuscript for publication. The journal also invites original photographs, graphics, cartoons, drawings and paintings that explore the ethical dimensions of health or health care.

A look ahead

In April, the AMA Journal of Ethics will examine ethical considerations in plastic and reproductive surgery. May’s issue will focus on trauma surgery ethics. Sign up to receive email alerts when new issues are published.

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May 17, 2018
In trauma settings, physicians often make urgent decisions without knowledge of the patient’s identity, values or history, which can leave a lasting impression on patients and their loved ones.