PERSPECTIVE n engl j med 366;24 nejm.org june 14, 2012 2240 What is an exceptional case? Is it the same in all states? Should it be? Although the Committee on Ethics of the American Col- lege of Obstetricians and Gyne- cologists endorses the “extraor- dinary circumstances” approach, even it “cannot currently imagine” what that scenario could be. 5 The Illinois approach — to re- spect informed refusals — should be the rule for courts, hospitals, and physicians. Physicians should discuss and revisit the risks, ben- efits, and alternatives of recom- mended care, and they should ad- equately document an informed refusal. But they should not in- volve courts. These cases begin at the bedside, and that is where they should end. Physicians who seek judicial intervention should disclose that practice so patients can seek care elsewhere. For many, though, al- ternatives are illusory. In Talla- hassee, there may be no safe har- bor. In 1996, after laboring at home and becoming dehydrated, Laura Pemberton sought intrave- nous fluids at TMH, but physi- cians conditioned her medical care on agreement to a cesarean sec- tion. She declined and left. TMH then obtained a court order to re- trieve her from her home (she was found laboring in her bedroom) and bring her to TMH by ambu- lance, where she was forced to undergo an apparently unneces- sary cesarean section. In 1976, a man dying of aplas- tic anemia sued his cousin, ask- ing a court to order the forcible extraction of his potentially match- ing — and lifesaving — bone marrow. The court refused and explained, “For our law to compel defendant to submit to an intru- sion of his body would change every concept and principle upon which our society is founded. To do so would defeat the sanctity of the individual” and “raise the spectre of the swastika and the Inquisition, reminiscent of the horrors this portends” (McFall v. Shimp). Those horrors are no less sa- lient here. Forced interventions undermine the liberty, privacy, and equality of pregnant women. But they are far more insidious. Because they betray foundational legal principles of our free soci- ety, they endanger the liberty of us all. Disclosure forms provided by the author are available with the full text of this arti- cle at NEJM.org. From the UCLA School of Law, Los Angeles. 1. In re: unborn child of Samantha Burton, Case No. 2009 CA 1167 (March 27, 2009). 2. Roth R. Making women pay: the hidden costs of fetal rights. Ithaca, NY: Cornell Uni- versity Press, 2000. 3. Adams SF, Mahowald MB, Gallagher J. Refusal of treatment during pregnancy. Clin Perinatol 2003;30:127-40. 4. Samuels TA, Minkoff H, Feldman J, Awonuga A, Wilson TE. Obstetricians, health attorneys, and court-ordered cesarean sec- tions. Womens Health Issues 2007;17:107- 14. 5. ACOG Committee Opinion #321: mater- nal decision making, ethics, and the law. Ob- stet Gynecol 2005;106:1127-37. Copyright © 2012 Massachusetts Medical Society. Court-Ordered Care during Pregnancy Escaping the EHR Trap — The Future of Health IT Kenneth D. Mandl, M.D., M.P.H., and Isaac S. Kohane, M.D., Ph.D. I t is a widely accepted myth that medicine requires complex, highly specialized information- technology (IT) systems. This myth continues to justify soaring IT costs, burdensome physician workloads, and stagnation in in- novation — while doctors be- come increasingly bound to doc- umentation and communication products that are functionally decades behind those they use in their “civilian” life. Even as consumer IT — word- processing programs, search en- gines, social networks, e-mail sys- tems, mobile phones and apps, music players, gaming platforms — has become deeply integrated into the fabric of modern life, physicians find themselves locked into pre–Internet-era electronic health records (EHRs) that aspire to provide complete and special- ized environments for diverse tasks. The federal push for health IT, spearheaded by the Office of the National Coordinator for Health Information Technology (ONC), establishes an information backbone for accountable care, patient safety, and health care re- form. But we now need to take the next step: fitting EHRs into a dynamic, state-of-the-art, rapidly evolving information infrastruc- ture — rather than jamming all health care processes and work- flows into constrained EHR op- erating environments. We believe that EHR vendors propagate the myth that health The New England Journal of Medicine Downloaded from nejm.org at UNIVERSITY OF AUCKLAND on June 29, 2012. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved.