Clinical Scenario:
A 37 y/o Orthodox Jewish woman G5P3104 at 12+1 weeks of gestation presents to her obstetrician for a routine prenatal visit. Her OB tells her that as she nears the end of her first trimester, Noninvasive prenatal testing (NIPT) is indicated. He explains that NIPT is antenatal screening based on bloodwork done after 10 weeks of gestation to identify any chromosomal abnormalities in the fetus. She declines due to her religious beliefs against prenatal testing.
Cultural factors that need to be considered:
-Although prenatal screening is routinely done for many women during their prenatal and antenatal care, there is controversy surrounding these tests for many orthodox Jews.
– Due to Jewish law (halacha), termination of pregnancy is either not allowed or discouraged in most situations, with certain specific exceptions such as risk to the mother’s health or life.
– Along with the different sects of Judaism, even within Orthodoxy there are many different opinions based on one’s mesorah (Jewish tradition) and personal Rabbi.
– Orthodox Jews believe in a concept called Emunah (belief) and Bitachaon (trust) in G-d. Therefore, while they believe in Hishtadlus (personal effort) by receiving prenatal care and following their doctor’s suggestions regarding safe practices while pregnant, they don’t necessarily rely on nature and statistics but on G-d instead.
– Prayer (tefillah) is a main tenet of Judaism and is engaged in by Orthodox Jews to pray for something they desire, to prevent something undesirable or as a plea to change an undesired reality or state.
– Prayer may be in addition to medical intervention but may also take the place of certain interventions which are believed to be too invasive and/or beyond their scope of Hishtadlus (personal effort).
– The Orthodox culture is trust in G-d as the Controller of events and not in ourselves or even healthcare providers. Prenatal/antenatal testing does not give us control over the situation, rather knowledge of a situation of which very little to nothing can be done.
Differing beliefs from Western medicine and unique considerations:
– Popular opinion that there are advantages to prenatal and genetic screening especially early on in pregnancy, namely in order to allow maximum time for potential decision-making regarding pregnancy termination as per the 1967 Abortion Act.
– In a survey of British public, 67% of individuals were in favor of terminating a pregnancy after 20 weeks of gestation due to suspected fetal abnormalities.
– Orthodox Jews believe that each child is created in the image of G-d, is a blessing and not lesser than a healthy child. Therefore, as long as the mother is not in real danger, physically or mentally, they would not believe in terminating that child’s life.
– Due to the Orthodox Jewish view on abortion, knowledge of chromosomal or structural abnormalities is not beneficial as pregnancy termination is not supported.
Areas where conflict may develop:
The provider may disagree with the woman’s decision to forgo antenatal testing for fetal abnormalities and try to convince her that it will provide her with important information on how her fetus’ development. If she has not already spoken to her Rabbi about his opinion on antenatal screening, she’ll likely want to discuss the topic with him and get his opinion on the matter.
Expectation of the student in demonstrating Cultural Competence:
-The student should demonstrate respect of the woman’s religious and cultural beliefs despite any personal opinions or views on the matter.
– A lack of understanding of the religious/cultural belief is irrelevant and the student should aim at providing for and supporting the patient as best as possible regardless.
– The student should verbalize that the patient has the right to decide whatever she feels is best.
– Pressuring the patient to change her mind should definitely be avoided by the student.
– The student could consider asking the patient if she would like if they would speak to the Rabbi to explain the potential medical repercussions and advantages.
Patient counseling or education:
The patient should be educated on the advantages of antenatal testing and screening for abnormalities:
-It may prepare her and her husband for the arrival of a child with special needs and allow them adequate time to prepare mentally, physically and emotionally.
– If antenatal screening uncovers a condition, it is possible that it can be managed prenatally to allow for a more favorable outcome for the fetus and mother.
– As termination of pregnancy may be allowed in very specific cases like if the mother’s health or life is in danger, it would be beneficial to know of an abnormality now and monitor the fetus’ and mother’s condition.
– The patient can counsel the mother that since she is 37 years old, she is high-risk and has a higher chance of carrying a baby with a chromosomal abnormality.
– Due to NIPT being a screening test and non-diagnostic, the patient can educate the mother that its results are not absolute.
https://jme.bmj.com/content/medethics/16/2/75.full.pdf
