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The maternal-fetal dyad: exploring the two-patient obstetric model.

Developments in obstetric medicine during the past ten to twenty years have transformed the clinical status of the fetus. [2] Traditionally physicians have been trained to assess fetal condition by indirect methods: palpating the fetus through the maternal abdominal wall and uterus, measuring hormonal milieu through maternal urine and serum, estimating statistical risks from parental medical histories. While the skillful use of these methods could produce highly reliable clues to fetal health and development, the fetus itself eluded direct examination. Throughout pregnancy the fetus could not be known, but only approached inferentially and probabilistically. Until recently suspected fetal anomalies have been treated indirectly too, by therapeutically managing the maternal environment. Unable to interact with the fetus in clear distinction for its host, physicians conceptualized the maternal-fetal dyad as one complex patient, the gravid female, of which the fetus was an intergral part.

High-resolution ultrasonography and techniques for sampling fetal blood, urine, and other tissue have changed this conceptual scheme. These diagnostic tools penetrate the opaque environment and reveal the fetus to clinical observation in all its anatomical, physiological, and biochemical particularity. When anomalies are detected, in utero medical and surgical procedures are already beginning to offer alternatives to therapeutic delivery and neonatal treatment. The biological maternal-fetal relationship has not changed, of course, but the medical model of that relationship has shifted emphasis from unity to duality. Clinicians no longer look to the maternal host for diagnostic data and a therapeutic medium; they look through her to the fetal organism and regard it as a distinct patient in its own right.

What ethical implications flow from the fetus's transformation from inferred to observed entity? Unfortunately, legal developments have tended to preempt ethical exploration of the new two-patient obstetric model. Some physicians, assuming enhanced rights on the part of the fetal patient, have sought and obtained court orders to perform fetal therapies (notably cearean deliveries) without maternal consent. [3] Although few in number, these cases raise the possibility of a new standard of clinical practice with far-reaching implications for civil and criminal liabilities to physicians and pregnant women. With legal stakes so high, it is not surprising that ethical inquiry has been displaced. Yet in the absence of independent and thorough ethical analysis one cannot judge whether these developments are compatible with fundamental values of medicine and medical care, and so one cannot know whether physicians have responsibilities, individually or collectively, to promote or resist them.

Well-grounded in law and ethics or not, cases of court-ordered fetal therapy have set the agenda for debate, focusing attention on the question, What should the physician do when a pregnant woman refuses medical or surgical treatment recommended for the well-being of the newly individuated fetal patient? The two-patient problem for the physician is seen to begin at the point of maternal refusal and is framed as a conflict between values of fetal benefit and maternal autonomy. The medical recommendation precipitating refusal is, presumably, unproblematic. But that presumption requires examination. Inherent in any conceptual shift is the potential for equivocation between the old paradigm and the new. If the physician's recommendation of fetal therapy incorporates one-patient thinking about the maternal-fetal relationship, questions about maternal refusal of that recommendation may be spurious, resting on a logically illicit hybrid of one-patient and two-patient conceptual schemes.

We need, I think, to gain a fresh perspective on this issue by stepping back from the legal debate and considering in a systematic way how ethical guidelines for prenatal medical care are altered by transition to the two-patient obstetric model. How do the familiar principles of beneficence, justice, and autonomy operate within the new model in contrast to the old? Fetal rights and fiduciary responsibilities of professionals, parents, and the state may all be affected by the fetus's newly acquired identity as a second individual patient, but to avoid blurring distinctions among these roles may focus will rest on ethical implications for physicians. After all, elevation of the fetus to patient status has occurred not because of any change in the fetus or in the maternal-fetal relationship but because of a change in physicians--in how they think about and relate to their patients during pregnancy--so it is in the physician-patient relationship that we should expect the ethical repercussions to begin.

For the Patient's Own Good

The ethical principle guiding initial formulations of medical recommendations is beneficence. It directs physicians to recommend that course of therapy most likely to protect and promote patient health, based on estimates of medical benefits relative to burdens for the various treatment options. In making these complex comparisons, physicians are to ignore their own and third-party interests, responding compassionately to patient medical needs alone. For some purposes it is important to distinguish positive duties to offer benefits from negative duties not to inflict burdens. 'Beneficence' then refers more narrowly to the former duties, 'nonmaleficence' to the latter. Nonmaleficence requires that the risks, discomforts, and harms inherent in medical or surgical treatment be offset by proportionate therapeutic gains for the patient. Accordingly, treatment without therapeutic intent is categorically prohibited by the principle of nonmaleficence.

In cases where maternal and fetal burdens associated with fetal therapy are relatively small and prospective benefits to the fetus are substantial, the physician's duty of beneficence on the one-patient obstetric model is clearly to recommend treatment. This is true even if treatment offers no medical benefits, only burdens, to the woman in distinction from the fetus. When the maternal-fetal dyad is regarded as an organic whole, what matters is that combined maternal-fetal benefits outweigh combined maternal-fetal burdens. Distributions of benefits and burdens between fetal and maternal components of the one patient are not ethically relevant.

When fetus and pregnant woman are conceptualized as two individual patients, however, it is no longer appropriate to consider effects of treatment on the two combined. Physicians are to decide what is medically best for each patient considered separately. When fetal benefits outweigh fetal burdens of intervention, beneficence dictates recommending therapy for the fetal patient. But when anomalous fetal conditions pose no threat to maternal health, caring for the fetal patient imposes some degree of discomfort, harm, or risk on the maternal patient with no offsetting therapeutic benefits to her. [4] Maternal medical burdens outweigh maternal medical benefits, such maleficence requires recommending against treatment for the maternal patient.

Here is an ethical two-patient problem for the physician that arises well before the point of maternal refusal: treatment medically indicated for one patient is contraindicated for the other, yet both must be treated (or not treated) alike. It is difficult to see a favorable ratio of fetal gains to maternal losses as a problem and not a solution, of course, for we are accustomed to maternal-fetal balancing on the one-patient model. Also, we know that in most cases pregnant women expect to assume reasonable risks to improve the chances of delivering a healthy baby. Willingness to do so is ideally implicit in the choice of pregnancy, and indeed the argument that the pregnant woman increases her responsibility for the fetus's well-being by choosing not to have an abortion is often cited to support the medical duty to provide fetal therapy. [5] Given persistent economic and social obstacles to abortion, not to mention its precarious legality, the degree to which abortion rights increase maternal responsibilities is, I think, dubious, but that is a side issue. The real question is how maternal duties affect professional duties and exactly which duties are affected. Since beneficence considerations are restricted to medical benefits and burdens, it seems clear that maternal morality must be a factor to be weighed against beneficence at a later stage of ethical analysis.

On the two-patient model of the maternal-fetal dyad, a single treatment recommendation for both patients cannot be justified in terms of the beneficence principle alone, for it includes no provision for balancing burdens to one patient against benefits to another. Indeed, tradeoffs between patients are expressly prohibited by the exclusion of third-party interests. Beneficence, applying as it does to patients one by one, is logically unequipped to produce a single recommendation for two linked patients with conflicting medical needs.

Mediating the Conflict

Conflicts between duties of beneficence and nonmaleficence to multiple patients are rare in medicine but they do characteristically occur in two areas in addition to obstetrics: live-donor tissue transplantation and nontherapeutic research. In both fields physicians' unusual divided loyalties--to patients in need of medical help and to those put at medical risk to provide that help--have engendered considerable concern and an extensive ethical literature. [6] The resulting codes and practices resist any movement toward a utilitarian ethic whereby imperatives of medical rescue and medical progress would justify imposing relatively small harms and risks on donors and subjects. The rationale for rejecting an approach that trades off benefits against harms between patients hinges on the way medical moral authority is circumscribed. Professional ethical decisions are not generic judgments made from a neutral standpoint preferring always the lesser to the greater harm. They are choices made from the standpoint of the professional as moral agent, hence causal responsibility and motivation for harm are more significant variables than quantity of harm. If physicians do not intervene to help a patient in need of a kidney transplant, the patient suffers harm due to progress of the disease condition, and the physician's choice is at most a contributing factor; if physicians do intervene, the donor suffers harm directly and exclusively from medical intervention. The Hippocratic tradition is shaped by the presumption that moral liability for physician-caused harm to a patient is relieved only by therapeutic intent for that patient, whereas excusing conditions and motivations for failure to benefit a patient are many and varied. Nonmaleficence constrains beneficence and not vice versa.

In transplantation and research ethics, nonmaleficence constraints have been cautiously qualified to permit physicians under narrowly specified conditions to treat some patients nontherapeutically in order to benefit others. First, the medical burdens inflicted must be smaller in relation to anticipated benefits than they are when they accrue to one and the same patient. Second, patients treated nontherapeutically must be volunteers. Recommending nontherapeutic treatment remains unethical, although providing it is permissible at the subject's or donor's request.

On the one-patient model for obstetric care, conflicts between maternal and fetal needs occur within, not between, patients; they are balanced and resolved by physicians under the principle of beneficence in determining the medically indicated course of therapy. On the two-patient model, however, competing maternal and fetal needs must be settled at a different level, by applying standards of justice. According to these standards, physicians are not at liberty to benefit one patient by inflicting medical harms on another, except under stringently qualified conditions. In most cases, pregnant women, continuing to identify fetal needs and interests with their own, will request treatment to promote fetal health, thereby lifting constraints of nonmaleficence and authorizing physicians to proceed with proportionate fetal therapy. For physicians to recommend fetal therapy as if it were medically indicated for both patients, however, would be misleading and unethical.

The question is whether, having removed fetal needs from the calculus of maternal medical interests and having divided one compound professional-patient obligation into two discrete fiduciary commitments, physicians may discount protective duties owed to the woman as an individual patient in her own right. Is this the stage at which professional duties are altered by maternal duties? In other areas of medicine, the injunction against intentional medical harm is not thought to be affected by patient morality or social role: neither moral debts to society nor obligations of family relationship authroize physicians to take a stronger-than-invitational approach in recruiting research subjects or tissue donors. Indeed, incarcerated felons and other institutionalized populations are virtually off-limits to medical researchers, since distinctions between inviting, advising, and requiring are difficult to maintain in coercive contexts. More to the point, in transplantation ethics, family pressures on the donor are considered a form of moral coercion, increasing rather than decreasing professional obligations to emphasize the optional nature of the transaction. When alternate volunteers or procedures are unavailable or unlikely to yield successful results, this restrained approach on the part of physicians may result in the loss of significant prospective benefits, including lives that might have been saved. That is the price of role-based limits on professional moral agency. But a professional ethics that allowed treatment recommendations to be based on moral diagnosis of patients and therapeutic intent for others would also exact a price: it would erode the fiduciary character of the physician-patient relationship, undermining the basis for patients trust.

By separating the maternal-fetal dyad conceptually into two individual patients, the new obstetric model bifurcates the process of formulating medical recommendations: physicians should recommend beneficial fetal therapy for the fetal patient, but recommending treatment for the maternal patient contrary to her best medical interests is prohibited by standards for the just resolution of conflicting duties to multiple patients. In two-patient obstetrics, physicians may at most invite and encourage the pregnant woman to submit voluntarily to burdensome treatment for the sake of proportionate fetal benefits. Usually the invitation will be readily accepted, so the distinction between inviting treatment and recommending it will have little practical importance. It is of considerable theoretical importance, however, to the pregnant woman's autonomy.

Honoring the Patient

On the one-patient obstetric model, recommended fetal therapy offers net medical benefits to the pregnant woman, the refusal of which, here as in other medical contexts, should trigger discussion to determine whether her needs and values are in fact incompatible with treatment. Although efforts to encourage consent are appropriate, paternalistic treatment of a competent dissenting patient is unlikely to be justified. In particular, her autonomy cannot be restricted on the grounds that she is causing harm to others, as the pregnant woman on the one-patient model causes harm only to herself.

Rejecting treatment on the two-patient obstetric model is more complicated. The physician's two treatment proposals--the recommendation of therapy for the fetus and the invitation to nontherapeutic maternal treatment as a means to fetal therapy--call for two distinct maternal replies, neither of which is a standard exercise of patient autonomy. First, the recommendation of therapy for the fetus requires a maternal proxy decision on behalf of the incompetent fetal patient. Maternal responsibility for fetal well-being is certainly relevant at this point, and physicians are morally authrorized to challenge proxy decisions that are palinly contrary to the patient's best interests. Yet even if an alternate proxy (the father of the future child, for instance, or a court-appointed legal guardian) consents to therapy on behalf of the fetus, another ethical step remains. The physician's second proposal, the invitation to nontherapeutic maternal treatment, requires a maternal patient decision. This second step distinguishes fetal therapy from treatment of an infant or child. Treatment of an infant may impose substantial burdens of financial and personal care on parents, but physicians do not directly cause these harms through nontherapeutic practice of the medical art on parents qua patients. New technologies notwithstanding, diagnostic and therapeutic interventions on behalf of the fetus do entail medical invasion of the mother, and the proxy for the fetus has no ethical standing to consent to this invasion. What if the maternal patient declines treatment of herself?

When a proposed course of treatment is in a patient's medical best interests, refusal raises questions about the professional duty of respect for patient autonomy, because the harm caused by not treating her cannot be justified if the patient's refusal was not fully voluntary. When a patient requests treatment contrary to her medical best interests, the situation is the same: the request to donate a kidney, for instance, provokes questions about the duty of respect for patient autonomy because the harm caused by harvesting the kidney cannot be justified if the request was not fully voluntary.

In contrast to both of these cases, refusal of treatment contrary to a patient's medical best interests prompts no such questions about the duty to honor autonomy. When physicians disregard a patient's refusal of harmful treatment, the violation of patient autonomy is the least of their professional wrongs. Since ethical immunity against medical harm is independent of patient autonomy, it is uncompromised by limits on automomy--incompetence, coercion, harm to other--that sometimes justify paternalism. Harming a patient without consent is not medical paternalism but medical maleficence.

A woman's failure to volunteer for fetal therapy may seriously violate her fiduciary responsibilities to the fetus, thus disqualifying her as proxy, but the physician's duties to her as patient remain intact. It is not the woman's moral obligation to consent that authorizes physicians to subject her to harm or risk without therapeutic intent; consent itself is necessary--consent that is to the highest degree competent, informed, uncoerced, and harmless to third parties. These exacting standards rule out any attempt to substitute proxy or presumed consent for maternal dissent. As on the one-patient model, physicians would be remiss if they did not make every effort to elicit maternal consent to low-risk, high-gain fetal therapy by providing honest reassurance and encouragement, but in the principles and precedents of medical ethics as applied to the two-patient obstetric model we find no basis for overriding maternal refusals to volunteer for such procedures.

Two-Patient Ethics & the Maternal-Fetal Ecosystem

When the fetus is conceptualized in clinical obstetrics not as an integral part of the pregnant woman (her condition of pregnancy, as it were) but as a second individual patient, the physician's duties to promote fetal well-being are, prima facie, increased. Maternal harms no longer weigh against recommendations made for the sake of fetal benefit. Also, the pregnant woman no longer speaks inclusively as maternal-fetal patient; if her decisions are not sufficiently protective of fetal interests an alternate proxy may be sought. But this is only half of the story. The other half is that professional duties to the first patient--the maternal patient--are paradoxically increased as well. Detached conceptually from the fetus, the maternal patient suffers medical harms from fetal therapy that are no longer

offset by fetal benefits. Her physician may not recommend fetal therapy for her, and the injunction against harming one patient involuntarily to help another is virtually absolute.

Drawing selectively and equivocally from both models--treating the fetus as an independent patient but continuing to regard the pregnant woman as a compound patient incorporating the fetus--has, I think, caused the physician's ethical dilemma to be misconstrued as a conflict between the duty to benefit the fetus and the duty to respect the woman's autonomy. If maternal refusal of fetal therapy were a standard exercise of patient autonomy, it would be subject to paternalistic review to guard against harms to others. But fetal therapy is beneficial to the pregnant woman only on the old model, where she includes the fetus, while fetal harm is harm to another only on the new model, where the fetus is independent and exclusive of the woman. In fact, maternal autonomy plays a peripheral role on the two-patient model: maternal autonomy qua proxy may be challenged, and maternal autonomy qua patient is redundant, a secondary defense against treatment that may not ethically be recommended for her in the first place. From the standpoint of professional ethics, the obstacle to fetal benefit is not maternal autonomy but maternal nonmaleficence. Newly strengthened duties to help the fetal patient are constrained by stronger duties to do no harm to the individualized maternal patient.

Despite the fetus's new clinical status as a second distinct patient, then, physicians' prerogatives to intervene on its behalf are no greater than before. Whether the maternal-fetal dyad is regarded as one patient or two is less relevant to providing ethical prenatal care than the fact of that dyad's biological unity. Literally, if not conceptually, the pregnant woman incorporates the fetus, so direct medical access to the fetal patient is as remote as ever. Ironically, when the fetus is construed as a second independent patient, physicians' prerogatives to act as fetal advocates are actually diminished. This consequence flows not from any assumed superiority of maternal rights over fetal rights but from differential professional duties to donors and recipients of medical benefits. Two-patient benefit-burden transactions require of physicians a deferential approach to those asked to assume medical risks for others and a readiness to shield reluctant or indecisive patients from involuntary harm. If the example of transplantation ethics is followed in obstetrics, physicians have acquired obligations to neutralize moral pressures on pregnant women arising from family relationships and ensure that any maternal sacrifices to benefit the fetus are strictly voluntary.

But surely our argument has carried us too far. If status as an independent patient affords the fetus relatively less protection than its previous state of dependency, instead of revising ethical standards of obstetric care to fit that counterintuitive conclusion one might simply retract the two-patient hypothesis. Perhaps developments in fetal medicine do not require reconceptualizing the obstetric patient after all. Alternatively, since the concept of the fetus as a second patient is already well entrenched in perinantal medical philosophy, one might challenge the orthodox view of the professional-patient relationship, which suppresses dependency relations among patients and posits them as strangers to one another. [7] Deeply ingrained in the Western Hippocratic tradition and in Eastern medical traditions as well, the assumption that physicians should treat patients as generic individuals without regard to social role or status reflects an ideal of egalitarian, compassionate, patient-centered medical care. [8] Can professional obligations be made sensitive to relationships of dependency between patients without detriment to that ideal and without simply making an ad hoc exception for the case at hand?

Efforts to reinterpret professional ethical principles to accommodate just such relationships are in fact under way in family practice medicine. [9] Family medicine rejects the reductionist model of illness, which focuses narrowly on proximate causes within the patient as a biological organism, espousing instead a biopsychosocial model of health and disease. It looks beyond organic conditions, even beyond the presenting patient, to family relationships and circumstances that affect and are affected by patient health. For diagnostic and therapeutic purposes, the patient is conceptualized in relation to the family ecosystem. This environmental medical model is not entirely compatible with an individualistic patient-centered professional ethics. Responsibilities of family practice physicians to their patients must be understood expansively to include the family context--guiding patients toward choices that are responsive to their family situations and helping family members fulfill obligations of care to one another.

Adapting the contextual approach of family practice medicine to obstetrics, we might think of the maternal-fetal dyad as an integrated, two-patient ecosystem whose individual components are not conceptually independent. Caring for one implicates the other and the family context. An environmental medical model would remove the specter of dueling specialists vying for medical control of a complicated pregnancy--the reductio ad absurdum of the two-patient thesis. It would counteract any tendency of physicians to discount the impact of fetal treatment on the pregnant woman, now effaced by her clinical transparency, and at the same time legitimize looking beyond the maternal patient to her protective biological and social role. Helping the pregnant woman fulfill her fiduciary duties to the fetus would again, as on the one-patient model, become a primary professional goal.

Once family roles and circumstances are drawn into the purview of patient care decisions, they may not be selectively considered only when the weigh in favor of treatment. Maternal fiduciary duties, for instance, typically extend beyond the fetus to other family members, and standards of family ethics do not always assign highest priority to fetal needs and claims. If the practice of fetal medicine were informed by an environmental maternal-fetal model, family demands would be acknowledged, not dismissed as irrelevant or even illicit conflicts of interest. By assuming obligations to address a wide range of health-related but nonmedical family problems, physicians may make it possible for the woman to accept therapy recommended for the fetus, but sometimes physicians must help patients and proxies make tragic choices forced by limited family circumstances, when resources cannot be stretched to meet the basic needs of all. [10] also, family and medical values will sometimes diverge: increasing the chances for live delivery of a severely damaged fetus, for example, might be a medical value but a family disvalue. A context-sensitive perspective commits physicians to respect a family's well-considered value judgments unless basic family duties are violated.

Not surprisingly, ethical standards evolving in family practice medicine do not sanction doctors' enforcing a duty on the part of family members to sacrifice for each other, although reluctance to volunteer might be considered symptomatic of family dysfunction, to be treated through supportive intervention. In family practice, medical authority is exercised by negotiating medical goals and in collaborative decisionmaking. The physician's last resort in cases of severe and irremediable family problems--petitioning for the temporary or permanent removal to alternate caregivers of dependents at risk--is not available for the fetal dependent, of course, although planning for transfer of the neonate might be considered, but then the social meaning of the maternal-fetal relationship is changed. It reverts to the generic relationship of strangers, so the donor protections of two-person ethics apply: physicians should guard the woman from undue pressures to undergo medical harms for someone else's child.

Maternal-fetal conflicts are interesting out of proportion to their incidence in part because they raise in a compelling way questions about the integration of medical and family ethics, an important and underdeveloped topic. Conceptualizing the maternal-fetal dyad as two unrelated patients is bizarre whether the consequence is to tilt the ethical standard toward strongly weighted professional obligations to protect the maternal donor, as I have argued, or in the opposite direction. Yet the integration of family status into the patient role is not a simple or clearcut matter. Patients who voluntarily present assume prima facie duties to act in their own medical best interests, but neither medical ethics nor medical education addresses the task of helping patients combine these duties with the imperatives of their family roles. Family responsibilities are lumped together with patients' idiosyncratic preferences and masked by professional respect for individual patient autonomy. But while exclusion of family concerns from medical attention is often unsatisfactory, to select one familial duty that bolsters the case for medical intervention and graft it onto a medical model that otherwise suppresses family relationships clearly will not do.

To expand the medical gaze to encompass family status is to see patients as persons in social systems, and this in turn demands a broader view of professional care than is typical of modern scientific medicine. Family practice medicine is an exception, and a biopsychosocial perspective is implicit, as well, in the traditional medical and ethical values of obstetric care. Recent developments in obstetrics, however, particularly the emergence of a subspecialty in fetology, introduce a narrow focus that sees only the fetus as it survives the pathologies of pregnancy.

Constructing a model of the maternal-fetal dyad as a two-patient ecosystem would restore to medical relevance the relationship of dependence and protection characteristic of the dyad. The effect of such a model would be to join the professional-patient relationships to the two patients almost as closely as if they were a single compound commitment to one compound patient. Protections associated with dependence would be reinstated and the two-patient presumption against maternal medical sacrifice averted. Within a two-patient framework, it is possible, then, to approximate the one-patient standard of obstetric care, but there is no warrant for requiring or permitting physicians to move beyond it toward a stronger posture of fetal protection. One patient or two, independent or dependent, when the various possible models of the maternal-fetal dyad are consistently applied, they converge to reinforce the physician's customary ethical stance--working cooperatively with the pregnant woman for common, linked goals of infant, maternal, and family well-being.

References

[1] Fernand Daffos, "Access to the Other Patient," Seminars in Perinatology 13, no. 4 (1989):252.

[2] F.A. Manning, "Reflections on Future Directions of Perinatal Medicine," Seminars in Perinatology 13, no. 4 (1989):342-51. In the introductory paragraphs I have relied heavily on Manning's excellent account of the way in which technical innovations in perinatal medicine have brought about subtle but far-reaching changes in underlying philosophy.

[3] Veronika E. G. Kolder et al., "Court-Ordered Obstetrical Interventions," NEJM 316, no. 19 (1987):1192-96.

[4] Michael R. Harrison et al., "Management of the Fetus with a Correctable Congenital Defect," JAMA 246, no. 7 (1981):774-77.

[5] H. Tristram Engelhardt, Jr., "Current Controversies in Obstetrics: Wrongful Life and Forced Fetal Surgical Procedures," American Journal of Obstetrics and Gynecology 151 (1985):313-18. Engelhardt's argument is cited, for example, by Frank A. Chervenak and Laurence B. McCullough, "Ethical Challenges in Perinatal Medicine: The Intrapartum Management of PregnancyComplicated by Fetal Hydrocephalus with Macrocephaly," Seminars in Perinatology 11, no. 3 (1987):323-39.

[6] See, for instance, Gordon Wolstenholme and Maeve O'Connor, eds., Law & Ethics of Transplantation (formerly Ethics in Medical Progress: With Special Reference to Transplantation) (London: Churchill, 1966); Roberta G. Simmons et al., Gift of Life: The Social & Psychological Impact of Organ Transplantation (New York: John Wiley & Sons, 1977); Paul A. Freund, ed., Experimentation with Human Subjects (New York: George Braziller, 1970); Robert J. Levine, Ethics and Regulation of Clinical Research (Baltimore: Urban and Schwarzenberg, 1981).

[7] Informal practice varies widely, but theoretical medical ethics assigns no relevance to family responsibilities in arriving at patient care decisions except to the extent that family members are acknowledged as proxy decisionmakers, and then, perversely, they are to ignore responsibilities they or the patient may have aside from their duty to represent the wishes and interests of the patient. For a different view, see John Hardwig, "What About the Family?" Hastings Center Report 20, no. 2 (1990):5-10.

[8] Albert Jonsen, "Do No Harm," in Cross Cultural Perspectives in Medical Ethics: Readings, ed. Robert M. Veatch (Boston: Jones and Bartlett, 1989), pp. 199-210.

[9] See, for example, Ronald J. Christie and C. Barry Hoffmaster, Ethical Issues in Family Medicine (New York: Oxford University Press, 1986).

[11] Physicians and parents have distinct fiduciary responsibilities for the fetal patient, reflecting differences of scope between the professional and parental ethical standpoints. I have developed this point more fully in "Fetal Needs, Physicians' Duties," Midwest Medical Ethics 7, no. 1 (1991):8-11.

Susan S. Mattingly is associate professor of philosophy at Lincoln University, Jefferson City, Mo.
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Author:Mattingly, Susan S.
Publication:The Hastings Center Report
Date:Jan 1, 1992
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