Case Study #: Maternal-Fetal Conflict
Pregnancy is a unique circumstance in medical ethics because of the absolute requirement to access the fetus only through intervention on the pregnant woman. Increasingly, as medical advances have offered the promise of therapy to the fetus, fetal interests have been considered separately from maternal interests by clinicians, policy makers, and the bioethics community. This is a somewhat artificial distinction, as usually maternal and fetal interests are aligned, and care of the fetus is intertwined with and dependent on care of the pregnant woman.
When conflict arises between maternal and fetal interests (eg, treatment of cancer during pregnancy that may result in fetal demise), a variety of ethical frameworks may be useful to consider for conflict resolution and decision-making. Helpful theoretical approaches include case-based analysis, the ethics of care, feminist theory, and traditional ethical principlism that uses the framework of autonomy, beneficence and nonmaleficence, and justice. In addition, societal and practitioner values can elevate emotionally laden issues of obstetric conflict and benefit from a comprehensive, thoughtful analysis from a variety of perspectives.
Different theoretical approaches all agree with the importance of promoting the autonomy and bodily integrity of the pregnant woman, ensuring that she has the information to provide a fully informed consent that is consistent with her values regarding pregnancy outcome.
In cases in which her decision may harm her fetus, coercion to force treatment is never justified. In extraordinary cases, legal intervention has been attempted. Using the courts to enforce treatment compliance by pregnant women has frequently been unsuccessful or has activated processes that are hasty and incomplete, and such court rulings are frequently overturned on appeal. Evidence shows that continuing a trusting, compassionate, professional relationship with the pregnant woman generally results in greater success in improving maternal and child health. Feminist ethics perspectives can help detect subtle, gender-based biases in clinicians’ approaches to conflict resolution and support collaborative decision-making for the pregnant woman and her health care team.
Jesse is a 24-year-old who presents in active labor with no prenatal care. The fetus appears to be term, quite large, and at risk for dystocia. Jesse is told that a cesarean birth is the best route of delivery for the fetus’ well-being. She declines the operation and requests a natural childbirth. Although the fetus begins to have heart rate deceleration consistent with fetal distress, Jesse continues to decline the recommended cesarean delivery.
1. Does the provider have an ethical obligation to intervene on behalf of the fetus as a patient?
2. What are the best interests of the pregnant woman and how are they determined?
3. What are the best interests of the fetus and how are they determined?
4. What ethical considerations, other than best interests, can inform the decision-making process?
5. Can the pregnant woman refuse the recommended treatment, particularly if harm is expected to come to the fetus?
