“Electronic Fetal Monitoring, Cerebral Palsy, and Medical Ethics”

A Consultant Neurologist in private practice, Dr. James C Johnston holds an MD from the University of Texas Health Science Center, is a Diplomate of the American Board of Psychiatry and Neurology, and an Attorney and Counselor at Law. Dr. James C Johnston is also an accomplished clinical researcher and medical author.

Among Dr. James C Johnston’s numerous peer-reviewed articles on cerebral palsy and electronic fetal monitoring, he published “Electronic Fetal Monitoring, Cerebral Palsy, and Medical Ethics: Nonsense of a High Order” with coauthors Berna Arda and Thomas P Sartwelle. This article appeared on May 2, 1017 in the medical law, health governance, and bioethics journal Medical Law International.

Electronic fetal monitoring (EFM) is employed to monitor the heart activity of unborn babies during the labor process. The inventors of EFM saw great benefits for the prevention of cerebral palsy (CP), believing that the technology could predict CP and allow physicians the time to prevent CP by ordering immediate C-sections.

“Electronic Fetal Monitoring, Cerebral Palsy, and Medical Ethics” demonstrates that EFM has done nothing to combat CP since the technology became the standard of care almost half a century ago. Furthermore, the article describes how EFM harms mothers and babies alike and discusses how physicians relying on EFM violate the fundamental bioethical principles of autonomy, beneficence, and nonmaleficence.

James C. Johnston, MD, JD and his colleagues have also published an article in the 2018 Surgery Journal highlighting the failed arguments of a typical EFM advocate. This article, “Continuous Electronic Fetal Monitoring During Labor: A Critique and Reply to Contemporary Proponents” is freely available in the open access journal or through the following link on Researchgate.net:

https://www.researchgate.net/publication/323614188_Continuous_Electronic_Fetal_Monitoring_during_Labor_A_Critique_and_a_Reply_to_Contemporary_Proponents

The Medical Law International article is also open access and available through Researchgate.net under Dr. James C. Johnston: https://www.researchgate.net/publication/316693326_Electronic_fetal_monitoring_cerebral_palsy_medical_ethics_Nonsense_of_a_high_order.

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ELECTRONIC FETAL MONITORING:  A BLATANT DISREGARD OF MEDICAL ETHICS

Prominent medical malpractice attorney Thomas P. Sartwelle and neurologist James C. Johnston, MD, JD, published a new article on cerebral palsy and electronic fetal monitoring (EFM) in the journal Clinical Ethics, co-authored with renowned medical ethicist Professor Berna Arda, and neurologist Dr. Mehila Zebenigus.  

This article represents the latest in an ongoing series by these authors who have related publications in the Journal of Child Neurology; Neurologic Clinics; Surgery Journal; Maternal Health, Neonatology and Perinatology; Journal of Pediatric Care; Journal of Maternal, Fetal and Neonatal Medicine; Medical Law International; Journal of Childhood and Developmental Disorders; and several other journals and book chapters.  These articles may be accessed on ResearchGate.net. In this particular Clinical Ethics article, the authors discuss the use of EFM without informed consent which represents a blatant disregard of patient autonomy.

An abstract summary highlights the content:  A half century ago electronic fetal monitoring was rushed into clinical use with the promise that the secrets of fetal heart rate decelerations had been discovered and that the newly discovered knowledge would prevent cerebral palsy with just in time cesarean sections (C-sections) preventing babies from experiencing asphyxia, which was thought to be the primary cause of cerebral palsy. In the years since electronic fetal monitoring’s debut, it has been discovered that asphyxia is a rare cause of cerebral palsy. At the same time electronic fetal monitoring use increased to 85% of all labors, the C-section rate increased to 33% without an attributable decrease in the rate of cerebral palsy. What went wrong with electronic fetal monitoring?

The answer lies in a new analysis of the physiologic theories concerning fetal heart rate decelerations, demonstrating that the earlier electronic fetal monitoring theories were wrong. This revelation is only the latest evidence that electronic fetal monitoring use today is harming mothers and babies with useless C-sections. Yet electronic fetal monitoring use continues unabated. Why? This article explores the complex answers and bioethical concerns, through a review of the new evidence underlying fetal heart rate decelerations in labor.

UN High-Level Political Forum

With 30 years of experience as a neurologist, James C. Johnston, MD JD is the Founder and Director of Global NeuroCare® and serves as a Partner with GlobalNeurology®, organizations dedicated to advancing the field on a global scale. Dr. James C. Johnston is uniquely qualified through his medical and legal training and experience to address international medical law concerns that impact healthcare. Dr. Mehila Zebenigus is a board-certified internist and neurologist in Addis Ababa, Ethiopia, and Director of the largest private neurology clinic in eastern Africa.

Serving as Delegates for Global NeuroCare at the United Nations, they provide expert analysis on neurological care in developing nations and makes policy recommendations to intergovernmental organizations. Mehila Zebenigus, MD and James C. Johnston, MD JD, recently published statements for the UN Economic and Social Council on improving access to healthcare as a means of poverty reduction, and for the UN Commission for Social Development pointing out that equitable access to essential, affordable, quality healthcare is an absolute prerequisite for implementing more comprehensive social protection policies.

Drs. Zebenigus and Johnston will present recommendations to the upcoming High Level Political Forum (HLPF) explaining how improving healthcare underpins the ability to achieve the Sustainable Development Goals. This HLPF serves as the central platform for follow-up and review of the 2030 Agenda for Sustainable Development and the Sustainable Development Goals, providing for full and effective participation of all States Members of the UN and States members of specialized agencies. Forty-seven countries will present voluntary reviews including 17 in Africa.

Drs. Zebenigus and Johnston, both serving as Directors of Global NeuroCare®, will focus on how following their recommendations “will ensure government, private sector, non-government organizations and international and local communities effectively engage in an integrated, multi-faceted, cross-sector approach to implementing sustainable social protection policies, promulgated through cooperative alliances with a goal of attaining universal healthcare coverage including access to healthcare services and access to safe, effective, quality and affordable medicines and vaccines [SDG 3.8], particularly in developing regions [SDG 3(c)], which will play a critical role in poverty reduction [SDG 1], serve to advance overall health capacity and security [SDG 3(d)], reduce maternal and childhood morbidity and mortality [SDG 3.1, 3.2], decrease communicable and non-communicable diseases [SDG 3.3, 3.4], diminish deaths and injuries from accidents [SDG 3.6], promote social protection systems [SDG 1.3] to progressively achieve greater equality [SDG 10.4], eliminate harmful practices including gender inequality [SDG 5.4], and stimulate economic growth [SDG 8.5].” [Johnston JC and Zebenigus M. UN E/CN.5/2019/NGO/33].

NON-COMMUNICABLE DISEASES: A GLOBAL HEALTH THREAT

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World Association for Medical Law Congress in Tokyo on 6-8 August 2019.     

Non-communicable diseases (such as heart disease, stroke, cancer, diabetes) are collectively responsible for 7 out of 10 deaths in the world, 41 million people every year.  Many of these people die prematurely and the vast majority of these deaths are in the low income countries.  The World Health Organization considers non-communicable diseases to be one of the top ten global health threats.

The situation is even worse in the least developed nations that are facing a triple burden on ongoing infectious diseases, rapidly increasing non-communicable disease and the effects of globalization including accidents and injuries, compounded by a dearth of healthcare workers.

Neurologist and Attorney James C. Johnston, MD, JD and Neurologist Mehila Zebenigus, MD discussed these concerns at the 2018 United Nations (UN) High Level Political Forum in New York and provided specific recommendations for improving healthcare access in the least developed nations, particularly sub-Saharan Africa.

On behalf of Global NeuroCare® Drs. Johnston and Zebenigus published a written statement on improving healthcare as a strategy for poverty reduction at the UN 56th Commission for Social Development with specific recommendations for Member States to improve healthcare access.  Global NeuroCare® is a non-profit organization holding Special Consultative Status with the United Nations ECOSOC.  This allows Drs. Johnston and Zebenigus, as Directors of the NGO, to provide expert analysis on issues related to global health, make written and oral recommendation statements, and serve as UN Delegates at the United Nations sessions in New York, Geneva and Vienna.

Drs. James C. Johnston and Mehila Zebenigus reviewed their recommendations for improving healthcare in developing regions with leading international experts from over 40 countries at the 24th World Association for Medical Law Congress in Tel Aviv, Israel.  The WAML, in conjunction with the Israeli Ministry of Health and Tel Aviv University honored Dr. Johnston with the Inaugural Davies Award in Public Health.  Dr. Johnston dedicated the award to the Addis Ababa University Department of Neurology and donated the funds to Global NeuroCare.®

Drs. Johnston and Zebenigus have published another statement for the 57th Session of the UN Commission for Social Development addressing inequalities and challenges to social inclusion through advancing healthcare strategies.

They will also present these recommendations to the 25th  World Association for Medical Law Congress in Tokyo on 6-8 August 2019.

Medical Error: Third Leading Cause of Death in the United States

Medical Error Third Leading Cause of Death in the United States

Medical Error Third Leading Cause of Death in the United States

Role of Evidence-Based Guidelines in Medical Malpractice

Medical errors rank behind heart disease and cancer as the third leading cause of death in the United States (see BMJ 2016; 353:i2139), with over 250,000 deaths a year.  700 a day.  And despite tort reform, medical malpractice litigation will never entirely disappear.  It remains important for physicians to understand the elements of a malpractice claim not only to protect themselves but more importantly to improve patient care.

The most confusing aspect of a medical malpractice claim is the standard of care element, and this is further complicated by the increasing use of evidence-based guidelines (EBG) or practice guidelines.  In some countries, EBG provide the legal standard of care, while most common law countries such as UK, Australia and New Zealand place great reliance on guidelines but allow courts discretion in accepting them on a case by case basis.

In the United States, most courts allow testimony using EBG both for and against physicians.  Whether a particular guideline applies to a specific case is simply another argument for the expert witnesses with the jury deciding who to believe.  In most cases, the actual written EBG may not be admissible as an exhibit.  It would fall into the same category as learned treatises and medical journals – the witness can talk about it and be cross-examined, but the document itself is not admissible.  Some courts have adopted a more liberal approach by admitting EBG as demonstrative aids.  Regardless of which approach, a physician on trial for malpractice must recognize that although EBG are not sacrosanct, any deviation from the guideline represents a very powerful argument to the judge or jury.

Neurologist and Attorney James C. Johnston, MD, JD and renowned medical malpractice attorney Thomas P. Sartwelle published the seminal article on expert witnesses discussing guidelines in the Journal of Child Neurology (http://journals.sagepub.com/doi/abs/10.1177/0883073813479669).

Dr. James C. Johnston is one of the very few neurologists in the world that is also qualified in law, and licensed to practice both professions.  He wrote the comprehensive chapter on advancing a neurology malpractice claim in Preparing and Winning Medical Negligence Cases, Third Edition (http://www.jurispub.com/Neurology-Chapter-11-Preparing-And-Winning-Medical-Negligence-Cases-Third-Edition.html).

He has published a number of journal articles and book chapters on how neurologists can improve patient care and protect themselves from malpractice claims.  These publications include book chapters in multiple editions of the American College of Legal Medicine textbook Legal Medicine and Medical Ethics, the Medical Malpractice Survival Handbook, and the landmark three volume treatise Legal and Forensic Medicine.  Dr. Johnston has published peer-reviewed articles in Neurology Clinics, Journal of Child Neurology, Headache, Medical Law International, Journal of Legal Medicine, Medicine and Law, and a number of other journals.

In a recent Neurologic Clinics, Dr. Johnston published a case studies article highlighting specific neurology claims related to malpractice (https://www.neurologic.theclinics.com/article/S0733-8619(16)30011-1/abstract).  This was co-authored with Thomas P. Sartwelle and leading neurosurgeon Professor Dr. Knut Wester, with the purpose of providing recommendations to improve patient care and safety.