ETHICAL CONSIDERATIONS IN OBSTETRICS AND GYNECOLOGY
Issues surrounding maternal and fetal rights are uniquely central to obstetrics and gynecology. The primary con-cern of physicians is to provide the best care to their pa-tients. However, recent legal actions and policies aimed at protecting the fetus as an entity separate from the woman have challenged the rights of pregnant women to make decisions about medical interventions and have criminal-ized maternal behavior that is believed to be associated with fetal harm or adverse perinatal outcomes. Threats andincarceration have been proved to be ineffective in reducing the incidence of alcohol or drug abuse, and removing children from the home may only subject them to worse risks in the foster-care system. ACOG and medical ethicists have consistentlymaintained that the rights of the mother in considerations of medical care or the therapeutic alliance of physician and patient take precedence over those of the fetus.
Conflicts between maternal and fetal rights arise when a pregnant woman engages in behaviors, such as il-licit drug use, that may put her fetus at risk. According to theprinciple of autonomy, obstetrician–gynecologists are obligated to respect the mother’s prerogative to make choices and take action based on her beliefs or values, even if these choices and actions are harmful to herself and her child. However, thephysician is also obligated under the principle of benefi-cence to promote the well-being of others. In situations in which a pregnant woman is putting her fetus at risk through harmful behaviors, the obstetrician–gynecologist should provide accurate and clear information regarding the consequences of the harmful behaviors. The patient should also be referred to an appropriate treatment pro-gram. Treatment is both more effective and less expensive than restrictive policies.
The ethical principle of justice governs access to care and fair distribution of resources. Therefore, implementa-tion of universal screening for risky behaviors is an impor-tant step in equalizing access to care and in assessing the resources that are needed for particular patients. Psycho-social screening of all women seeking pregnancy evalu-ation or prenatal care should be performed regardless of social status, educational level, or race and ethnicity. Because risks may not be evident at the first prenatal visit, screen-ing should be repeated at least once a trimester. There is evidence that women who are screened for psychosocial is-sues once each trimester are half as likely as women who are not screened to have a low–birth-weight or preterm baby. Screening consists of questions designed to elicit in-formation regarding current and past alcohol and drug use, ability to access prenatal care, and safety at home. Screening questions are now included in the ACOG Obstetric Medical History form (Appendix C).
Another maternal–fetal conflict may arise if a pregnant woman rejects medical advice or interventions that are nec-essary to avert fetal complications or death. Again, the preg-nant woman’s autonomous decisions should be respected as long as she is competent to make informed medical deci-sions. The obstetrician’s response to a patient’s unwillingness tocooperate with medical advice should be to convey clearly the rea-sons for the recommendations to the pregnant woman, examine the barriers to change along with her, and encourage the develop-ment of health-promoting behavior. When conveying this in-formation, the obstetrician must keep in mind that medical knowledge has limitations and medical judgment is fallible. He or she should make every effort to present a balanced evaluation of expected outcomes for both the woman and the fetus. Even if a woman’s autonomous decision seems not to promote beneficence-based obligations (of the woman or the physician) to the fetus, the obstetrician must respect the patient’s autonomy, continue to care for the pregnant woman, and not intervene against the patient’s wishes, re-gardless of the consequences (Box 3.1).