A sound model of obstetric ethics.
Obstetric ethics has too often been characterized by polarized assertions, claiming either that the rights of the fetus or the rights of the pregnant woman must take precedence. These ethical models - one favoring fetal rights and one favoring the pregnant woman's rights - are overly simplistic and highly flawed. Rather, obstetricians must embrace a "professional responsibility model" of ethics in which they care for and protect both the pregnant and the fetal patient.
The obstetrician-gynecologist's professional obligations originate in the same ethical concept of the profession of medicine, and physicians as professionals. This concept emanated in large part from the work of two remarkable physician-philosophers, John Gregory and Thomas Percival, who practiced in Great Britain in the 18th century.
At that time, there was rampant entre-preneurialism in medicine. It was treated primarily as a business and was characterized by an overriding drive to obtain money and compete effectively. Gregory and Percival were both troubled by this model and argued that the patient should always come first. The concept they put forth was that physicians should be scientifically, ethically, and clinically competent and should protect and promote the patient as their primary concern and motivation.
Each spoke of medicine as a "public trust," and maintained that self-interest is fine - as long as such interest is a secondary consideration. Their work was incorporated into the first code of ethics of the American Medical Association in 1847, and the views of both these physician-philosophers were translated throughout me world. Today, as we face ever-increasing fiscal pressures and attempt to reshape the construct of obstetric ethics and move away from rights-based extremes, their work is very much alive and relevant.
The Clashing of Rights
The ethical issues we face as obstetricians are especially challenging, as we frequently have two patients. We often are faced with two extreme positions in obstetrics - and two models of ethics based on these positions - that emphasize overwhelmingly fetal or exclusively maternal rights.
However, these rights-based models are overly simplistic, embracing what is known as "reductionism." George Engel made a landmark contribution to medicine when he argued against biological reductionism. He developed what's referred to as the biopsychosocial model of health and disease, which considers clinically relevant psychosocial aspects of medicine as well as anatomic and pathophysiologic factors.
Engel argued against clinical tunnel vision where only biologic factors are considered; he warned that a purely biomedical model is scientifically and clinically incomplete and, therefore, misleading. His proposed biopsychosocial model is an integral part of medicine today. It reminds the ob.gyn. that many factors can contribute toward reproductive failure, for instance, and that comprehensive clinical judgment during pregnancy requires attention to psychological and social dimensions as well as biological fundamentals.
Moreover, Engel's case against biologic reductionism in medicine is analogous to the challenge we face today in obstetric ethics, with frequent use of two rights-based reductionism models for ethical thinking. As my associates and I have detailed in a previously published article on the professional responsibility model of obstetric ethics, reductionism has an appealing simplicity in either extreme, but is ethically incomplete, clinically inadequate, and, therefore, unprofessional (Am. J. Obstet. Gynecol. 2011; 205:315.0-5).
Under the fetal rights reductionism model of obstetric ethics, fetal rights systematically override the pregnant woman's rights. This model emphasizes the fetal right to life, for instance, from the moment of conception; the option of abortion is prohibited regardless of gestational age or whether the pregnancy is voluntary or not.
At the other extreme, under the pregnant woman's rights model, pregnant women have an unconditional, systematic right to control their own bodies; their rights automatically override fetal rights. This model would support a woman's right for her obstetrician to attend her planned home birth, for instance, or her right to refuse cesarean delivery or to have a clinically nonindicated cesarean delivery
The Professional Responsibility Model of Obstetric Ethics
A third model - what my associates and I call the professional responsibility model of obstetric ethics - emphasizes the relationship of the physician to the patient and the physician's responsibility to and for his or her patients. As obstetricians, our professional obligations are owed to both the pregnant woman and the fetal patient. The two patients, and our obligations to them, are inexorably linked.
To the pregnant woman, we have both autonomy-based and beneficence-based obligations. We also have beneficence-based obligations to the fetus when there are linkages between the fetus and the child the fetus will become. One such linkage is viability. Another such linkage occurs when the pregnant women confers on her previable fetus the moral status of being a patient, based on her beliefs and values.
Our obligations to the fetal patient are not absolute obligations; they must in all cases be balanced with autonomy-and beneficence-based obligations to the pregnant woman. Conversely, obligations to the pregnant woman must be balanced in all cases with obligations to the fetal patient.
The view that the fetus has rights, such as an unconditional "right" to life, does not consider the fact that there are irreconcilable differences among and within the major religions of the world - and among cultures, philosophers, and other authoritative sources - on the status of a previable fetus and on fetal rights.
The woman's "right" to be attended by her obstetrician for her planned home birth as viewed through the pregnant woman's rights model, on the other hand, does not consider that there are obligations of the medical profession and also of the pregnant woman to the soon-to-be-born child (Obstet. Gynecol. 2011:117:1183-7). Neither does a woman's "right" to smoke during pregnancy, nor her "right" to have cesarean delivery that is not medically indicated. In the latter case, for example, the professional responsibility model of obstetric ethics tells us we have a strong ethical obligation to try to persuade the pregnant woman not to have a procedure that is medically disadvantageous - an obligation that rights-based models ignore.
A woman who does not avail herself of the option of abortion before fetal viability subsequently has obligations to the soon-to-be-born child. The pregnant woman, in other words, should not be viewed as a person who has absolute rights, but as one who also has obligations to her soon-to-be-born child (Am. J. Obstet. Gynecol. 2009;201:560.e1-6).
Rights-based approaches obscure professional obligations. A professional responsibility model, on the other hand, is professional; it emphasizes obligations we have to both the pregnant woman and the fetal patient, and enables us to avoid extremes that promote unprofessional behavior. The model creates a solid foundation for our care of both the pregnant and fetal patient.
FRANK A. CHERVENAK, M.D.
DR. CHERVENAK said he has no relevant financial disclosures.