Maternal-fetal Conflict C3
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Maternal Fetal Conflict
James Abraham Malala
Maternal-Fetal Conflict • Physician must consider the health of two patients who are biologically linked, yet individually viable. • Mother seems likely to bring the fetus to term. – Fetus’s claim to health VS Mother’s autonomy
Maternal-Fetal Conflict • Types of difficulties: – Women’s behavior during pregnancy – Obligations if her fetus or the mother is diagnosed as requiring medical treatment. – Health care professional’s obligations to mother and fetus.
Limits on a Mother’s Behavior • Presumption of maternal goodwill • Women’s behavior during pregnancy – Religion • Blood Products
– Beliefs / Choices • Refusal of Diagnostic Testing • Delivery options
– Lifestyle • • •
Smoking Drinking Alcohol Drug Abuse
Case 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 The ethics pager goes off. It’s 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 csection 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.
When a mother refuses consent – Primary responsibility for the care of children rests in the parents. – No other person or group is likely to make better decisions for a child than the child’s parents. – Presumption of maternal goodwill.
When a mother refuses consent • Principle of Double Effect – Physicians must remember that the ethical injunction against harming one patient in order to benefit another is virtually absolute.
Case • 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 continued… • 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 transcriptasepolymerase chain reaction did not reveal evidence of Philadelphia chromosome (an adverse prognostic factor). Wallace, AACN Clinical Issues, 1997
Case continued… • After the consultation, a medical management plan was developed that postponed chemotherapy for the patient to allow fetal lung 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
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
Maternal-Fetal Conflict and Professional Obligations “Vigorously attempting to persuade the woman to accept the required restrictions or treatment.” or, if this fails, “A more coercive approach, e.g., threatening to seek or seeking a court order, may sometimes be morally justifiable.” Chervenak & McCullough, 1985
Maternal-Fetal Conflict and Professional Obligations • Physician: Beneficence-based obligations toward the fetus • Override the autonomy of the mother • Physician’s respect for the patient must remain at the heart of its ethics. – Even in the face of a conflict between the needs of two patients.
Maternal-Fetal Conflict and Professional Obligations • Autonomy-Beneficence conflict • Profession must be careful about imposing them on parents.
Maternal-Fetal Conflict • One Patient Model – Treat the mother and the fetus as a single patient
• Two Patient Model – Treat the mother and the fetus as two separate patients.
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
One Patient Model • Maternal and fetal burdens are relatively small and prospective benefits to the fetus are substantial recommend treatment • What matters is that the combined maternalfetal benefits outweigh the combined maternal-fetal burdens 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 recommendation Mattingly, Hasting Center Report, 1992
Mediating the Conflicts • 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 accumulate to one and the same patient Mattingly, Hasting Center Report, 1992
Maternal-Fetal Conflict • In conclusion… – Fetus has a serious right to life. – Neither the rights of the fetus nor the rights of the pregnant woman are absolute. – A settlement is to be sought in weighing the goods and evils to discover who has a superior claim.
Sources: • • • • • •
MEDICINE AND CHRISTIAN MORALITY 3rd revised and updated edition, Thomas J. O’Donnel, SJ LOVE/LIFE-MAKING, CONFIDENTIALITY, XENOTRANSPLANTS, AGING, Edited by Fausto B. Gomez, OP & Anniela Yu-Soliven, MD INTERVENTION AND REFLECTION Basic Issues in Medical Ethics Fifth Edition, Ronald Munson MEDICAL ETHICS AND LAW The Core Curriculum, Hope, Savulescu, and Hendrick HEALTH CARE ETHICS Principle and Problems, Thomas M. Garrett ETHICS OF HEALTH CARE An Introductory Textbook 3rd Edition, Benedict M. Ashley, OP
James Abraham Malala
Maternal-Fetal Conflict • Physician must consider the health of two patients who are biologically linked, yet individually viable. • Mother seems likely to bring the fetus to term. – Fetus’s claim to health VS Mother’s autonomy
Maternal-Fetal Conflict • Types of difficulties: – Women’s behavior during pregnancy – Obligations if her fetus or the mother is diagnosed as requiring medical treatment. – Health care professional’s obligations to mother and fetus.
Limits on a Mother’s Behavior • Presumption of maternal goodwill • Women’s behavior during pregnancy – Religion • Blood Products
– Beliefs / Choices • Refusal of Diagnostic Testing • Delivery options
– Lifestyle • • •
Smoking Drinking Alcohol Drug Abuse
Case 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 The ethics pager goes off. It’s 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 csection 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.
When a mother refuses consent – Primary responsibility for the care of children rests in the parents. – No other person or group is likely to make better decisions for a child than the child’s parents. – Presumption of maternal goodwill.
When a mother refuses consent • Principle of Double Effect – Physicians must remember that the ethical injunction against harming one patient in order to benefit another is virtually absolute.
Case • 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 continued… • 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 transcriptasepolymerase chain reaction did not reveal evidence of Philadelphia chromosome (an adverse prognostic factor). Wallace, AACN Clinical Issues, 1997
Case continued… • After the consultation, a medical management plan was developed that postponed chemotherapy for the patient to allow fetal lung 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
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
Maternal-Fetal Conflict and Professional Obligations “Vigorously attempting to persuade the woman to accept the required restrictions or treatment.” or, if this fails, “A more coercive approach, e.g., threatening to seek or seeking a court order, may sometimes be morally justifiable.” Chervenak & McCullough, 1985
Maternal-Fetal Conflict and Professional Obligations • Physician: Beneficence-based obligations toward the fetus • Override the autonomy of the mother • Physician’s respect for the patient must remain at the heart of its ethics. – Even in the face of a conflict between the needs of two patients.
Maternal-Fetal Conflict and Professional Obligations • Autonomy-Beneficence conflict • Profession must be careful about imposing them on parents.
Maternal-Fetal Conflict • One Patient Model – Treat the mother and the fetus as a single patient
• Two Patient Model – Treat the mother and the fetus as two separate patients.
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
One Patient Model • Maternal and fetal burdens are relatively small and prospective benefits to the fetus are substantial recommend treatment • What matters is that the combined maternalfetal benefits outweigh the combined maternal-fetal burdens 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 recommendation Mattingly, Hasting Center Report, 1992
Mediating the Conflicts • 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 accumulate to one and the same patient Mattingly, Hasting Center Report, 1992
Maternal-Fetal Conflict • In conclusion… – Fetus has a serious right to life. – Neither the rights of the fetus nor the rights of the pregnant woman are absolute. – A settlement is to be sought in weighing the goods and evils to discover who has a superior claim.
Sources: • • • • • •
MEDICINE AND CHRISTIAN MORALITY 3rd revised and updated edition, Thomas J. O’Donnel, SJ LOVE/LIFE-MAKING, CONFIDENTIALITY, XENOTRANSPLANTS, AGING, Edited by Fausto B. Gomez, OP & Anniela Yu-Soliven, MD INTERVENTION AND REFLECTION Basic Issues in Medical Ethics Fifth Edition, Ronald Munson MEDICAL ETHICS AND LAW The Core Curriculum, Hope, Savulescu, and Hendrick HEALTH CARE ETHICS Principle and Problems, Thomas M. Garrett ETHICS OF HEALTH CARE An Introductory Textbook 3rd Edition, Benedict M. Ashley, OP
