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Ethical Frameworks for Addressing MaternalFetal Conflicts


ACOG physical force against a pregnant woman if fundamentally inappropriate ... The patient was a 37-year-old pregnant woman at 30 weeks' gestation. ... – PowerPoint PPT presentation

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Title: Ethical Frameworks for Addressing MaternalFetal Conflicts

Ethical Frameworks for Addressing Maternal-Fetal
  • 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

  • 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.

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

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.

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

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

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
  • Mattingly, Hasting Center Report, 1992

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
  • Distribution between the two not ethically
  • Mattingly, Hasting Center Report, 1992

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
  • Mattingly, Hasting Center Report, 1992

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

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
  • Mattingly, Hasting Center Report, 1992

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
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
  • Mattingly, Hasting Center Report, 1992

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
  • Mattingly, Hasting Center Report, 1992

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
  • Mattingly, Hasting Center Report, 1992

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

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

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

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

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
  • 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

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

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

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

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

Balancing Oduncu, J Cancer Res Clin Oncol. 2003
(No Transcript)
  • Continue pregnancy and not treating woman harm
  • 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

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

  • See attached list