Phase II Home Page
The
Language of Bioethics (Glossary)
Objectives
Goals
Required
Reading
Discussion
Questions
Clinical
Vignettes
Maternal–Fetal
Conflicts
Principles
of Reproductive Freedom
Ethical
Issues Related to Assisted Reproduction Techniques
Major
Contributors to the Discussion of Reproductive Health & Technology Issues
Guiding
Legal Principles
Suggested
Reading/References
References
& Resources
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Reproductive Health
Issues
Objectives
To explore the interaction of
physician and patient in the arena of reproduction, within a pluralistic
society, with consideration of increasing technologies requiring a host of moral
and ethical decisions, and involving interaction of women, their partners,
health care providers and government.
Goals
- To understand the physician's ethical
obligation to discuss all reproductive health options with his/her patient
(i.e., full informed consent)
- To understand the issues of maternal and fetal
rights and when there may be a conflict.
Required
Reading
- Ethics
Manual, Fourth Edition, American College of Physicians
"Decisions about Reproduction"
- Code of Medical Ethics, American
Medical Association,
"Abortion," 2.01
"Mandatory Parental Consent to Abortion," 2.015
"Artificial Insemination by Anonymous Donor," 2.05
"In Vitro Fertilization," 2.14
"Frozen Pre-Embryos," 2.141
"Pre-Embryo Splitting," 2.145
"Surrogate Mothers," 2.18
Note: Many of these AMA statements are in Doctor's Dilemma
- Introduction to Clinical Ethics by
Fletcher, Miller, Lombardo, and Marshall. Second Edition.
"Reproductive Issues," p 205-225
Discussion
Questions
- Does a pregnant woman have the right to make
reproductive choices including termination of the pregnancy?
- Is the fetus "a person" with
interests and rights that must be protected?
- Do the rights of the pregnant woman override
the fetus' "right to life?"
- Can the state intervene to protect the fetus
from "irresponsible" harm by actions of the pregnant woman?
- Who bears the responsibility for
contraception? Have reversible contraceptive techniques for men kept pace
with that for women?
- What obligations exist for physicians to offer
all available assisted reproductive technologies to infertile couples?
Clinical
Vignettes
Why Not Two to One? Introduction
to Clinical Ethics by Fletcher, Hite, Lombardo, & Marshall (2nd
Ed.), p 210.
The Case of Angela Carder
Adapted from the Journal of
Medical Ethics . 1996; 22: 327-333.
In 1987, Angela Carder was diagnosed
as having terminal cancer of the lung. She was twenty-five weeks pregnant and it
was expected that she would only survive for a week. Angela had lived under the
shadow of cancer since she was thirteen, but had thought herself to be in
remission when she planned her pregnancy. Whilst insisting that her own comfort
must be the primary consideration, she agreed in principle to consent to any
treatment which might enhance the survival prospects for her baby. Her husband,
parents and physician were in full agreement with these wishes. Almost a week
later, she refused her consent for a caesarean section and the hospital decided
to seek legal advice. Angela believed that it was unlikely that such an immature
fetus would survive, and that if it did, it would be likely to suffer multiple
disabilities. Emmett Sullivan, the judge appointed to the case, decided that the
pivotal issue was the fetus's chances of survival and what was in it's best
interest granted it's mother's terminal condition. He ordered the caesarean
section to take place. Angela still refused to consent so Sullivan again
listened to both counsels but reaffirmed his original decision. Less than one
hour later and with the c-section planned to occur within fifteen minutes,
Angela's counsel argued that the operation would shorten her life and was not
therefore in her best interest. Against this it was argued that she had no
interest as she was dying. Sullivan cut across the ensuing argument by asking
who had the best chances of surviving, the mother or the child. The answer was
that the baby did and so he again ordered the operation to take place. The
non-viable fetus died two hours after the caesarean was performed. Angela died
two days later. At no point in the proceedings did Sullivan speak to Angela
personally. In 1990, two appeal hearings later, the District of Columbia Court
of Appeal reversed Sullivan's decision, not for the benefit of Angela, but to
avoid setting a precedent for future cases.
HIV and Pregnancy
Ms C is a 25 year-old HIV-positive
mother of a two-year old child. When she presented to her primary care physician
at 20 weeks' gestation for her first prenatal visit, she encouraged her to start
taking AZT to prevent or minimize the risk of HIV transmission to the fetus in
utero or at the time of delivery. She refused to take AZT, and had only one
additional prenatal visit at 28 weeks. Ms C, pregnant in her 34th week,
presented today in preterm labor; her membranes rupture 8 hours before she came
to the clinic. She is admitted and delivers her preterm infant who weighs 2,000
grams. The baby has respiratory distress, hypotension, and cyanosis. Management
for respiratory distress, hypotension, and presumed sepsis are only marginally
effective in improving the baby's status. An echocardiogram is performed and
reveals an underlying cyanotic congenital heart lesion requiring urgent
palliative surgery and possible transplantation in the long term in order to
offer any hope of continued survival. Any heart surgery will have to be
performed at another institution, located some 500 miles away and out-of-state.
Ms C's primary care physician, her baby's Pediatrician and her baby's
Cardiologist are not in agreement about what the best course of action is at
this point.
Fetal Distress at Term
Mrs. D is a 30 year old mother of
twins who is pregnant with a singleton at 39 weeks' gestation. She presented
with regular contractions last night; her cervix, however, has failed to dilate
beyond 3cm. She desires a "natural childbirth" without analgesics,
episiotomy, or any operative assistance (to include forceps delivery or cesarean
section). Her physician has gone along with this plan but always maintained
during prenatal visits that she must consider the "second"
patient...Mrs. D's unborn infant...should any problems develop. Mrs. D never
understood what "problems" her physician might be alluding to, but
reiterated "No medication, no surgery."
Late in the evening, after laboring
for more than 20 hours there fetal heart rate tracing became concerning. Mrs.
D's physician informed her that the baby may be in jeopardy and could encounter
a problem with its circulation or oxygen delivery if the monitoring strip did
not change. She performs a pelvic exam, still finding the cervix at less than
4cm. She initiates some "non-invasive" conservative measures for Mrs.
D and then witnesses a sharp decline in fetal heart rate. Concerned about
placental abruption and bad outcome for the fetus/newborn, she recommends a STAT
cesarean section in view fetal distress. Mrs. D insists "No surgery."
Maternal–Fetal
Conflicts
A moral dilemma exists when a
physician believes he has a moral obligation to follow two conflicting courses
of action, such as when the physician believes he must respect a pregnant
woman's decision (autonomy) when the decision conflicts with the physician's
obligation to protect the fetus. (non-maleficence and perceived best interest)
Principle
of Reproductive Freedom
A woman has the right to make her
own reproductive choices, including termination of pregnancy. Conflict arises as
some feel this principle is morally objectionable, and overrides any "right
to life" of the fetus. This view, rests on the controversial presumption
that the fetus is a person. Finally, if a pregnant woman does decide to carry
her pregnancy to term, she has by this act implied obligations to the fetus.
Ethical
Issues Related to Assisted Reproduction Techniques
- What is the role of the government in
intervening in any of the following situations?
Refusal of HIV testing
Substance abuse
Voluntary v. non-voluntary intervention
Infringement of personal autonomy to promote fetal well-being.
- What is the role of third-party payors in
assisted reproductive processes such as genetic material donation,
surrogacy, genetic manipulation, pre-embryo research and splitting, cryo
preservation of occytes, sperm, pre-embryos.
- Does a woman have absolute autonomy over body?
- Provision of abortion services by trained OB/GYN
physicians in the United States (many training programs don't teach this
procedure).
Major
Contributors to the Discussion of Reproductive Health and Technology Issues
- Pregnant woman
- Infertile woman
- Prospective father
- Pre-embryo/fetus
- Physicians
- State/society
Guiding
Legal Principles
Roe v. Wade Balancing test
- Should respect for the pregnant woman's
autonomy when she refuses a medical intervention preclude any approach other
than to accept her decision?
- Should caregivers have recourse to coercive
techniques of persuasion?
- When is there justification for court-ordered
intervention?
Suggested
Reading/References
- Flagler
E, Baylis F, Rogers S. Bioethics for Clinicians: 12. Ethical dilemmas
that arise in the care of pregnant women: rethinking maternal-fetal
conflicts. Can Med Assoc J, June 15, 1997; 156(12): 1729-1732.
Note: This article can be found through Ovid and will require an ID and
password.
- The Doctor's Dilemma
"Roe v. Wade"
"Bowser Case"
"Juarez Case"
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