When Good Intentions Lead to Unethical Prescriptions: A Case Against Bed Rest

I went to graduate school in philosophy after I had practiced Ob/Gyn for 10 years. One of my philosophy professors said that I was too much of an empiricist to ever be a good philosopher. (So naturally, I didn’t ask her to be part of my dissertation committee.)

However, in one sense she was right; I remain an unapologetic empiricist, particularly when it comes to questions of medical ethics. The facts matter, and you need more than philosophical theories to determine the rightness and wrongness of our behaviors and actions in medicine.

It is the empirical facts, much more than ethical theory, that lead to the conclusion I wish to draw in this ethics-based blog: Prescribing bed rest to a pregnant patient with a threatened abortion is always unethical. The empirical facts drive this conclusion far more than any complex ethical reasoning, and we should constantly be on guard for analogous circumstances and for the faulty reasoning that allows us to harm patients with our good intentions.

I’ll begin with the theory, and then examine the facts. I think physicians and ethicists can all readily agree that doctors should never prescribe a treatment with proven harm and no proven benefit. If we wish to couch this in philosophical language (and frankly it feels a bit superfluous here), we can say that a treatment violates the principle of nonmaleficence any time the risks outweigh the benefits or when there is no proven benefit.

The facts are equally clear. No study has ever shown a reduction in miscarriage for women prescribed bed rest after cramping or spotting.¹ There never was evidence. Bed rest is a historical medical practice that was adopted to treat everything from myocardial infarction to a sore back, even though no study had validated its utility.² It would be ethically suspect to prescribe a harmless treatment with no proven benefit, but bed rest is anything but harmless.

The risk of venous thromboembolism alone justifies abandoning bed rest as a treatment for anything unless the evidence for benefit was exceptionally compelling, but the social harms of lost wages, lost jobs, children put in child care, and the mental stress of enforced rest are important but probably unquantifiable. Bed rest is a significant intervention, and as such can only be justified by clear evidence of benefit-evidence that simply doesn’t exist.

A recent Current Commentary in Obstetrics and Gynecology reached the same conclusion with a more in depth discussion of the empirical evidence.³ What I wish to add to this excellent review is the plea that we must take this example as a paradigm of the kind of thinking that leads to both bad medicine and ethical lapses in our treatment recommendations to patients.

It is unfortunately not an isolated case.

I am still surprised and disappointed when I see colleagues placing pregnant patients on bed rest, so I would like to examine briefly the psychology that seems to impel this decision. I say psychology, because the reasoning is patently faulty; I think the decision arises from emotion, not reasoning.

Physicians hate to have nothing to recommend to patients, no treatment, no helpful advice. The previously mentioned Commentary described as “therapeutic imperative” the inertia that prevents physicians from abandoning ineffective therapies because no better alternative yet exists.³ Tocolysis in preterm labor is another example that supports this claim. Studies over a 30-year period showed little, if any, benefit and substantial risk to tocolytics, but it was not until an alternative therapy for preterm labor was validated (progesterone treatment as prophylaxis for high-risk women) that many labor units actually reduced their tocolytic use.

Rather than admitting that in most cases there is nothing we can do, we reach for a historical treatment, even though we know it accomplishes nothing. Somehow, we push aside our awareness of the risks in order to have something to recommend. The problem is that we are violating a basic principle of medicine to appear helpful (or worse, to avoid admitting our powerlessness).

It takes courage to do nothing, but when we have nothing of benefit to offer we must refrain from deluding ourselves and harming our patients. We discredit our profession when all we offer is snake oil.

References:

1. Aleman A, Althabe F, Belizan J, Bergel E. Bed rest during pregnancy for preventing miscarriage. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD003576.
2. Allen C, Glasziou P, Del Mar C. Bed rest: a potentially harmful treatment needing more careful evaluation. Lancet. 1999;354:1229-1233.
3. McCall CA, Grimes DA, Lyerly AD. Therapeutic bed rest in pregnancy: unethical and unsupported by data. Obstet Gynecol. 2013;121:1305-1308. doi: 10.1097/AOG.0b013e318293f12f.