Ethical Frameworks for Addressing MaternalFetal Conflicts

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Ethical Frameworks for Addressing Maternal-Fetal
Conflicts

• Jacqueline J. Glover, Ph.D.
• Associate Professor
• Department of Pediatrics and
• Center for Bioethics and Humanities
• University of Colorado at Denver and Health
  Sciences Center

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Objectives

• Identify typical maternal/fetal conflict cases
  that may be brought to ethics committees
• Describe the implications of the language used in
  this complex dialogue
• Describe 3 different ethical frameworks for the
  analysis of maternal/fetal conflicts and
• Apply a process of ethical decision making to
  cases of maternal/fetal conflict.

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Typical Cases

• Religious refusal of blood products during
  pregnancy and delivery
• Refusal of diagnostic testing blood draws
• Refusal of delivery options like C-sections
• Drug / alcohol use / abuse during pregnancy
• Treatment of cancer during pregnancy

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Case I

• You receive a call from a nurse in the Delivery
  Room about a 26 year old woman who is in labor
  and her physician believes she needs a unit of
  blood. The patient and her family are Jehovah
  Witnesses and refuse blood products. Her husband
  is with her. They have two other small children.

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Case II

• The ethics pager goes off. Its a call from
  Labor and Delivery. They have a woman in labor,
  progressing very slowly, breech presentation,
  large baby.  The patient was told this
  information and that a c section would need to be
  performed.  The patient refused the c-section
  explaining that she and her family wanted a
  natural birth.   A psych evaluation to look at
  capacity was done while the patient was in
  advanced labor.  CPS was also contacted and they
  informed the team that they would follow the case
  but were unable to intervene until the child was
  born. 

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The Power of Language

• Baby / embryo / fetus / pregnancy / product of
  conception / human life at all stages of
  development /fetal patient
• Mother / Pregnant Woman / patient
• Father / Husband / Partner / Sperm Donor

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One Patient Model

• Beneficence requires professionals to recommend
  therapy most likely to protect and promote
  patient health based on estimates of medical
  benefits relative to burdens
• Nonmaleficence requires that risks,
  discomforts, and harms inherent in medical or
  surgical treatment be offset by proportionate
  therapeutic gains for the patient
• Treatment without therapeutic intent is
  categorically prohibited by the principle of
  nonmaleficence
• Mattingly, Hasting Center Report, 1992

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One Patient Model Contd

• Maternal and fetal burdens are relatively small
  and prospective benefits to the fetus are
  substantial recommend treatment
• True even if NO medical benefits, only burdens to
  the woman
• What matters is that the combined maternal-fetal
  benefits outweigh the combined maternal-fetal
  burdens
• Distribution between the two not ethically
  relevant
• Mattingly, Hasting Center Report, 1992

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Two Patient Model

• What is medically best for each patient
  considered separately
• A single treatment recommendation for both fetus
  and mother cannot be justified by beneficence
  alone logically unequipped to produce a single
  recommendation
• Mattingly, Hasting Center Report, 1992

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Mediating the Conflicts

• Conflicts between duties of beneficence and
  nonmaleficence to multiple patients rare
• Living related donors for transplantation
• Nontherapeutic research
• Conjoined twins?
• Mattingly, Hasting Center Report, 1992

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Mediating the Conflicts Contd

• One patient model conflicts resolved by
  balancing under the principle of beneficence
• Two patient model cannot use beneficence
  appeal to justice - two steps
• (1) recommend beneficial fetal therapy
• (2) The medical burdens on the pregnant woman
  must be smaller in relation to anticipated
  benefits than they are when they accrue to one
  and the same patient
• Patients treated nontherapeutically must be
  volunteers
• Mattingly, Hasting Center Report, 1992

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Honoring the Patient

• One Patient Model refusal like other medical
  contexts should trigger further discussion of
  needs and values
• Autonomy cannot be restricted on the grounds of
  harms to others only one patient

Mattingly, Hasting Center Report, 1992
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Honoring the Patient Contd

• Two Patient Model more complicated
• Decision for the Fetus Maternal Proxy not valid
  even so must have next ethical step
• Maternal patient decision
• Not violation of autonomy (paternalism)
• Medical maleficence causing harm without
  consent
• Mattingly, Hasting Center Report, 1992

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Two Patient Ethics

• Duty to promote fetal well-being increased
• Only half the story
• Duty to maternal patient also increased
• Detached conceptually from the fetus (as two
  patients) the maternal patient suffers medical
  harms from fetal therapy that are no longer
  offset by fetal benefits
• Injunction against harming one patient
  involuntarily to help another is virtually
  absolute
• Mattingly, Hasting Center Report, 1992

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Two Patient Ethics Contd

• Drawing selectively from both models fetus as
  independent patient and woman as a compound
  patient has resulted in the mistaken
  characterization of the conflict as one between
  the duty to benefit the fetus and the duty to
  respect the womans autonomy
• The obstacle to fetal benefit is not maternal
  autonomy, but maternal nonmaleficence
• Ironically as a second independent patient
  prerogatives to act as fetal advocates actually
  diminished
• Mattingly, Hasting Center Report, 1992

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Third Alternative?

• Maternal-fetal dyad as integrated, two-patient
  ecosystem whose individual components are not
  conceptually independent
• Caring for one implicates the other and the
  family context
• Mattingly, Hasting Center Report, 1992

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Why Build An Alternative Model?

• Principle-based schemes are clumsy at best when
  it comes to illuminating the moral contours of
  intimate relationships
• Life particularities of parties adjudicating a
  moral dilemma are important all human subjects
  are situated
• Principle-based ethics neglects broad social and
  political arrangements inequalities associated
  with sex, race and class
• Harris, Obstet Gynecol, 2000

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Case III

• Prenatal Drug Use as a conflict addiction
  becomes a case of disregard for the fetus by a
  pregnant woman goal is to protect the fetus
  from the pregnant woman criminalizing behavior
  sex, race class issues
• Alternative model single unit within a social
  network fetal well-being is achieved by making
  maternal and family well-being the primary goal
• Harris, Obstet Gynecol, 2000
• ACOG Committee on Ethics, 2005

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Differences Between OBs and Pediatricians?

• AAP and ACOG policies share a common purpose
• 3 important areas of difference between the
  position papers
• Permissibility of using judicial intervention to
  force treatment on a pregnant woman
• The degree of recognition of psychosocial aspects
  of pregnancy and maternal vulnerability
• The approach to resolving conflict before
  considering judicial review
• Brown et al. Pediatrics 2006

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AAP/ACOG Differences Contd

• ACOG premised firmly on the principle of
  maternal autonomy and finds no circumstance in
  which such autonomy should be trumped by fetal
  concerns
• Although both statements reserve court action for
  rare and exceptional cases, the AAP would allow
  judicial authorization of physical interventions
  against maternal wishes
• Brown et al. Pediatrics 2006

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AAP/ACOG Differences Contd

• ACOG physical force against a pregnant woman if
  fundamentally inappropriate
• AAP seems predicated on the assumption that a
  woman is obliged to assume some degree of risk
  for the sake of the fetus
• ACOG woman should be treated deferentially and
  given the benefit of the doubt
• Brown et al. Pediatrics 2006

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Case IV

• The patient was a 37-year-old pregnant woman at
  30 weeks' gestation. She was receiving prenatal
  care and had no significant medical history. She
  was married with a 2-year-old daughter. The
  patient came to an emergency room with complaints
  of bilateral lower rib pain. A routine complete
  blood count revealed a leukocyte count of 5.7
  103/mm3 with increased lymphocytes and blasts
  seen in the differential cell count. Hemoglobin
  was 8.9 g/dL, and platelets were within normal
  limits. The patient had experienced an increase
  in gingival bleeding and mild, increased
  ecchymosis on the upper extremities. She was
  referred by her obstetrician to an oncologist for
  evaluation of her abnormal differential count.
• Wallace, AACN Clinical Issues, 1997

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Case IV Contd

• The oncologist's evaluation revealed no abnormal
  bleeding however, a bone marrow aspiration and
  biopsy revealed 100 cellularity with increased
  lymphoid infiltrates. Flow cytometry studies on
  the peripheral blood and bone marrow blood
  revealed B-cell acute lymphocytic leukemia (ALL).
  A reverse transcriptase-polymerase chain reaction
  did not reveal evidence of Philadelphia
  chromosome (an adverse prognostic factor).
• Wallace, AACN Clinical Issues, 1997

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Case IV Contd

• After the consultation, a medical management plan
  was developed that postponed chemotherapy for the
  patient to allow fetal lung maturation, because
  the patient's platelet count and leukocyte count
  were still within normal ranges. Within 1 week,
  however, the patient's leukocyte count dropped
  from 5.7 to 2.9 103/mm3 and her hemoglobin had
  decreased from 8.9 to 7.9 g/dL. The conclusion of
  the oncologist was that the drop could be
  attributed to the increased activity of the
  leukemia in her bone marrow. The patient was
  faced with an ethical dilemma Beginning
  chemotherapy to treat the ALL could harm the
  fetus, and not beginning chemotherapy could lead
  to the death of the mother.
• Wallace, AACN Clinical Issues, 1997

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Balancing Oduncu, J Cancer Res Clin Oncol. 2003
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Options

• Continue pregnancy and not treating woman harm
  both
• Continue pregnancy treat woman with cytotoxic
  drugs benefit woman/harm fetus
• Inducing labor and treating woman benefit
  woman/harm fetus
• Delaying birth by one week for betamethasone to
  the fetus delay treating woman only a little /
  reduce harms to fetus
• Wallace, AACN Clinical Issues, 1997

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Tips for Ethics Consultation

• Have OB/GYN and Pediatric MD/RNs on ethics
  committee
• Familiarize yourself with various policies
• Have dialogue / education NOW
• Review cases
• Include legal / administration

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Resources

• See attached list

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THANK YOU