Maternal Fetal Conflicts

MATERNAL FETAL CONFLICTS

Maternal - Fetal Conflicts  Occur when a pregnant woman’s interests conflict with the interests of her fetus.  Requires dealing with 2 patients: the mother and the fetus

Such conflicts occur when…  A pregnant woman decides not to comply with recommendations that her physician considers to be in the best interest of the fetus  On the other end, when a pregnant woman refuses therapy or any intervention because it will endanger her baby

 What is the best method of

resolving this situation?  What are the moral obligations of the physician to the pregnant woman and to the fetus?

Moral status of the fetus  When does human life begin?  There are currently 3 ways of approaching this issue:  Full fetal rights  No rights  Increasing rights with advancing gestation

 Pope Pius XII has said, “Life, from the moment of its inception is sacred.”  Life is God’s gift and to be valued as such, a gift to be protected, cherished and upheld; so that as far as the moral status of the embryo is concerned, its status, rights and dignity are equal to that of the mother’s.

 As a rule, in maternal-fetal conflicts, what is beneficial to one is detrimental to the other and vice-versa.  There will be some instances where the benefit to one is negligible while to the other, it is maximal.  When we cannot hope to attain the best consequences for both, whose benefits do we give greater weight to?

 Both mother and fetus have the right not to be harmed, the right not to be killed, the right to be aided in times of need, to be treated as an end.  But in the face of conflicting rights, whose rights should prevail?  Basic issue is: We have two patients whose best interests conflict.

PRINCIPLE OF DOUBLE EFFECT - Serves as guiding principle in maternal-fetal conflict.

5 Conditions: 1. The action itself must be morally good or at least indifferent.  Action itself independent of its effect.  Action should be fair.

2. The intention of the agent should be directed towards the good effect.  Direct voluntary

1. The evil effect must never be directly intended.  Indirect voluntary.

1. There should be no relationship of causality.  Evil effect must not cause the good effect.

5. Proportionality.  The good must compensate for the evil.

Role of the health provider  It is the moral responsibility of the health professional to provide his patient with an accurate “risk assessment.”  Support a patient’s informed and free decision regarding a treatment process, as far as the physician’s personal values would allow.

 The health provider should not feel obliged to provide a service which conflicts with his values and he should openly communicate this information to his patient at the onset of the patient-physician relationship.

Case 1

Maternal-Fetal Conflict

Abruptio Placentae –premature separation, in part or wholly, from the uterine wall of the placenta at its normal site -results in hemorrhage at the site of detachment -the degree of separation may vary from being slight and harmless to complete separation; maternal mortality nearing 30%

Moral Aspects:  Abruptio Placentae occurs near term or at the onset of labor, when the fetus is viable – OB will do all that he can to save the lives of both the mother and child  If however, occurs before the fetus is viable, the following points are important: * When the maternal hemorrhage is mild and not endangering the mother’s life – no steps can be taken which would even indirectly expose the life of the fetus to any danger * Even if the hemorrhage becomes serious, the directly intended removal of a non-viable fetus from the uterus is direct abortion and is never permitted

* When the maternal life is in danger from hemorrhage it is morally permissible to try to control the bleeding by drug therapy or tamponade * The removal of a dead fetus at any stage of development is obviously not wrong

Case 2

Fetal anencephaly – prognosis of the fetus was extremely poor - lack a functioning cerebral cortex - majority are stillborn, and most that are born alive die within 24 hours of birth; death almost always occur within 2 weeks

*Other moralists approach…”Brain function is the criterion that would make man unique in the whole animal kingdom, the initial evidence of organic brain function would determine the point of personhood” - WRONG *Pope Pius XII…”Life from the moment of its inception is sacred” - CORRECT/ MORAL

 Under such circumstances, immediate steps may be taken to remove the fetus, even though some trace of fetal life remains. Such procedure puts the fetus in no worse an env’t, and is therefore permitted. - WRONG  The fetus will have a short non-sentient existence regardless of what is done, so a prompt death associated with abortion would not deprive it of any benefit, due to the absence of awareness. - WRONG # In the article, the Catechism entry 2270 “As the 5th commandment makes clear, human life fully begins as the moment of conception, when the egg is fertilized, and must be absolutely respected and protected as such from that moment onwards”

“CHILDREN are a BLESSING from the LORD, the FRUIT of the WOMB a REWARD” (Psalm 127:3) * Let the fetus die a natural death if that’s what the Lord intended.

Case 3  The patient was a 37-yr old pregnant woman at 30 weeks gestation…Bone marrow aspiration and biopsy revealed 100% cellularity with increased lymphoid infiltrates. It revealed B-cell acute lymphocytic leukemia (ALL).  After the consultation, medical management plan was developed that postponed chemotherapy for the patient to allow fetal lung maturity because platelet count were still within normal ranges  Within 1 week, however, the WBC ct. dropped from 5.7-2.9 x10 3/mm3 and her Hemoglobin decreased from from 8.9-7.9 g/dl. (Increased activity of leukemia in Bone Marrow) ETHICAL DILEMMA: *Begin chemo to treat ALL – harm the fetus *Not begin chemo – could lead to the death of mother *Continue pregnancy and not treating woman – harm both

Starting therapy: + in favor of maternal well-being - to the disadvantage of fetal well-being Delaying therapy: + in favor of fetal well-being - to the disadvantage of maternal well-being MCCB document, Ethical and Religious Directives for Catholic Health Services (1995)… ”Operations, treatments and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman (may result to her death) are permitted when they cannot be safely postponed until the unborn child is viable”