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A pregnant fellow.

Jane Kenny was thirty-two years old, married for five years, and had just completed her first year of a fellowship in high-risk obstetrics when she became pregnant for the first time. She and her husband John, a third-year graduate student in molecular genetics, looked forward to being parents.

In the third trimester of her pregnancy, Jane began to have premature labor. Her doctor advised bed rest and prescribed a medication intended to prevent further contractions. Four weeks later, when tests showed adequate fetal lung maturity, the medication was discontinued. Within a few days Jane delivered a healthy baby boy.

During the time that Jane was on bed rest, the other two fellows in the program split the "on call" time between them. One who had been married for seven years did not have children; the other had two small children at home. Jane indicated to her colleagues that she felt "guilty" for not "being there to do the work."

As a rule the department allowed six weeks' maternity leave for house staff and fellows. Although Jane asked to have her four weeks of vacation time added to this, her request was denied. She was advised to postpone her vacation until the summer, when an additional fellow would join the program. Her mentor told her: "You've already missed too much time in the fellowship. Pregnancy, after all, is elective."

Was this a fair way to respond to Jane's request? Would it be unfair to consider her experience of a high-risk pregnancy relevant to the training in a high-risk specialty? What are the moral implications of considering pregnancy elective?

As a woman in medicine who has had one child during her residency and is expecting another soon, I cannot help but feel emotionally drawn to criticize Jane's mentor for his seeming hardness of heart. But on a closer, more rational analysis I believe that Jane's mentor made the right call in denying her additional time off for maternity leave. However, the manner and tone in which the mentor communicated this decision were suboptimal.

In being denied the extra leave, is Jane's identity as a woman shoehorned into a masculine norm? Is she a victim of a false gender equality? Jane entered her fellowship and signed a contract that assured her a six-week maternity leave. When her male colleagues signed their contracts the maternity clause simply did not apply. If standard operating procedure at Jane's hospital is anything like the hospital where I practice, her male colleagues would be given minimal time off to bond with a new child. They would be back to the grind in a matter of days. Women parents get approximately ten times more leave to be with their newborn children than men parents do. This vastly unidentical treatment may or may not be appropriate (the question of extended paternity leave is not at issue in the case study) but it does demonstrate this point: women in medicine are not expected to "act identically" to their male counterparts.

Still, one might argue that Jane's needs as a woman and a new mother transcend contractual obligations. This "contract-be-dammed" attitude imposes what I would like to call a "false gender inequality." Instead of promoting the interests of women in the professions, such a devaluation of one of the most basic business institutions, the contract--and thereby one of the most basic ethical institutions, the promise--if promulgated generally would be devastating for women's long-term prospects in the professional community. Jane has professional responsibilities she entered into contractually, and the contract has been particularly formulated to take into account important gender differences. If Jane's contract specifies that she is to receive six weeks of maternity leave but she finds that ten weeks would make her happier, then Jane has made a mistake: she has signed the wrong contract.

Jane desires extra time off because she values family. She values active motherhood; she values parenting. Why dishonor this value by denying Jane's request? Here, I wish to bring into the picture the other two obstetrics fellows who have been waiting patiently in the background. The case specifies that one of the other two fellows "had two small children at home." I imagined myself in a fellowship next year, with two small children of my own "at home," confronted with the possibility that I would have to change from every third night call (very demanding) to every other night call (even worse) and accept the extensive consequent loss of time with my children. And for what reason would I be subjected to this change? So that another woman in my specialty should have extra time with her one child. Unless there is some good reason why one woman's valuing of family should have preeminence over another's (and there seems to be no such reason), there can be no ethical justification for giving Jane extra family time by taking the same away from any other fellow. This is simply robbing Peter to pay Paul.

Though I support the mentor's decision, the claim that "pregnancy is, after all, elective" is troublesome. It is true that with the incomparable access to birth control which Jane as a doctor possesses, her pregnancy was almost certainly elective. On the other hand, the extra time Jane took off due to complications was anything but elective. If I elect to take a ski vacation and fracture both femurs in a ski accident, thus missing a month of work, am I to be blamed for the misfortune? Did I "elect" to miss the weeks of work? No. The four weeks Jane missed due to complications in her third trimester were not missed "electively" either. The mentor, though justified in denying Jane's request, has muddied the issue of responsibility by glibly deeming all aspects of the pregnancy elective.

Clinical fellowship programs are designed to train subspecialists in a particular area of medicine. After completing their residencies, some physicians pursue fellowships to prepare themselves further for a specific focus within their specialty. To that end, if they enter a fellowship program, they postpone or forgo the more lucrative alternative of private practice. Because of the demands of training, women accepted into fellowships often postpone pregnancy also. In doing so, they recognize that problems of pregnancy and fetal abnormalities increase with maternal age. The American Medical Association endorses policies of parental leave for practicing physicians, and recommends that pregnant physicians be allowed the same sick leave or disability benefits as physicians who are ill or diabled.

Most fellows perform a substantial share of the scut work of modern medicine, for example, by taking night and weekend call on a regular basis. Fellows also serve as a resource for teaching medical students and residents. Most programs stipulate that the fellows be primarily committed to clinical service during some months and to research during other months. While she couldn't do the scut work, Dr. Kenny might have devoted her weeks of bedrest to research. Being at home does not imply that she was not working.

It is true not only in movies like The Doctor that physicians' attitudes toward patients are improved through their experience of being patients; studies of real doctors who become patients also support that expectation. That the experience of a high-risk pregnancy is relevant to training in high-risk obstetrics is hardly contestable. While it may not enhance the clinician's technical skills or knowledge base, the experience has the potential of contributing uniquely to the clinician's understanding of patients with whom she will interact throughout her professional life. Surely this is, or ought to be, a goal of high-risk obstetric training. It may even be argued that this experience is more conducive to promoting the goals of the program than activities in which individuals have already gained knowledge and experience--that is, the bulk of work that fellows do in their time on call. Apparently, Dr. Kenny's pregnancy was not regarded in this light by her mentor. He seems to have viewed her time away from the workplace as a complete loss of program time.

Nonetheless, it is not clear that Dr. Kenny's mentor--let's call him Dr. M--acted unfairly in denying her request to add her vacation time to her maternity leave. Fairness, after all, involves balancing harms and benefits among all those affected by a decision. While vacation is a benefit to which all of the fellows are entitled, its timing may infringe on the plans and needs of others, both patients and colleagues. Whether it is just for Dr. M to insist that Dr. Kenny postpone her vacation depends in part at least on how its timing affects them, as well as her own fulfillment of program requirements. In other words, a comparison of needs is called for in order to handle the request fairly. The case described does not provide enough data to determine whether Dr. M has based his decision on considerations of fairness. If instead his decision was based on judgment that Dr. Kenny had already had a holiday from work during the period before delivery, he acted mistakenly as well as unfairly.

Dr. M's concept of pregnancy as elective is the most troubling aspect of this case. Presumably, he considers pregnancy elective either because women are always free to avoid pregnancy, or because they may undergo abortions if they become pregnant. Yet on religious, ethical, and economic grounds, abortion is not an option to some women who unintentionally become pregnant. Some become pregnant despite consistent practice of contraception. Moreover, Dr. Kenny's decision to become pregnant or continue pregnancy might well have been guided by a conscious realization of the limits imposed by her own biological clock. An increasing number of women in medicine struggle with this issue, while their male colleagues confront no comparable dilemma. Even if Dr. Kenny's pregnancy was intentional, the complications she experienced during pregnancy were not.

Dr. Kenny's experience of a high-risk pregnancy should be treated as elective in the academic sense of the term, that is, as fulfillment of one of several optional requirements. Obviously this is a different meaning of elective than Dr. M had in mind. Like other pregnant women, Dr. Kenny had no desire to be a high-risk patient herself; in fact, she felt "guilty" for having to stay at home. (I don't think she should have felt guilty, but I won't elaborate on that point here.) When she did experience complications, this was not at all irrelevant to the subspeciality in which she was preparing to practice. Accordingly, Dr. M was wrong to consider Dr. Kenny's period of bedrest as time out from the program. Her weeks spent as a pregnant high-risk patient were as relevant to her training as time spent in the lab, in the library, in the birthing rooms, or in the clinics.
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Title Annotation:Case Study; includes commentaries; maternity leave from obstetrics fellowship
Author:Geilker, Joyce; Geilker, Eric; Mahowald, Mary B.
Publication:The Hastings Center Report
Date:Sep 1, 1992
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