 |
|
HEALTH ETHICS TODAY
Case Commentary Paul Byrne, MB, ChB, FRCPC Recent widespread media attention on attempts to force a pregnant woman to abstain from glue sniffing by incarceration included much legal commentary on the rights of the mother and the rights of the foetus. The case has been presented as a legal battle involving a maternal-foetal conflict of rights. Far less attention has been paid to ethical analysis of such cases. I wish to present a view of this case, which examines the basis of this perceived maternal-foetal conflict and the ethical duties of health care professionals (HCP) to pregnant women who are substance abusers. This view will attempt to resolve the much publicized conflicts in such cases within the framework of the doctor-patient relationship (and by inference, other HCPs also). The language of maternal-foetal conflict used in these cases presumes that the mother and foetus are distinct patients. In reality a pregnant woman is one person, and there is no internal conflict between her and her foetus. The foetus is living within and totally dependent on the mother, and as such, is truly part of her. The supposed conflict arises through the judgements of others who decide that the mother is causing the foetus harm in some way. This perception is associated with suggestions to force the pregnant woman to stop/cease harming the foetus and reveals a view of the pregnant woman as a vessel carrying the real patient, the foetus. To so view the pregnant woman depersonalizes her and reduces her to the status of a biological incubator. These assertions are usually presented as (1) accusations about the mother's behavior (as in alcohol or drug abuse) being directly harmful to the foetus with little attention given to the harms to the mother herself; (2) charges of maternal non-compliance with medical opinion during high risk pregnancy, resulting in serious risks to the foetus. The scene is now set for the foetal patient's right to be assessed in isolation from the mother. While the intimacy of the corded connection between mother and foetus would seem to make such a view nonsensical, the view fits well with the consideration of patients in general as machines to be fixed. The assumption behind this thinking is that the maternal foetal dyad is comprised of two distinct patients with distinguishable health needs and goals during pregnancy. How has this situation occurred? What is special about a pregnant woman which encourages others to interfere with her health care decisions? For non-pregnant patients who are judged to have decision making capacity about their own health, neither HCPs, society, nor the law forces them to accept treatments against their wishes. Individuals are not forced by the state to desist from such self-destructive behaviors as cigarette smoking, alcohol and drug abuse, race car driving, hang gliding, pot holing, etc. Based on the principle of respect for autonomy, the freedom to control one's own life, to live as we so choose within broad societal legal limits is protected. This is the basis of non-discrimination within our society and legal limits generally involve the prevention of harm to other persons by an individual's behavior. Why, then, is the pregnant woman portrayed as an exception to this very well established ethical and legal principle? Certainly the presence of a developing human being within her body makes the pregnant woman physically different. Traditionally she has been regarded as needing special care and protection to optimize her health and that of her foetus during pregnancy. The ability to "see" the foetus in early gestation by means of prenatal ultrasound has revolutionized the practice of perinatal medicine and obstetric care in general. Enormous benefits may be associated with the use of the technology in the diagnosis and subsequent management of maternal and foetal illness. But these "In the case of foetal treatment against the mother's wishes such actions either reduce the mother to non-competent status or to non-personhood. She becomes merely a means to support foetal needs." - Paul Byrne technological wonders alter our perception of the pregnant woman as one person and one patient. She is not viewed as one person but two patients. This development is understandable when one looks at a prenatal ultrasound being done and the screen displays the foetus as active, breathing, and as having clearly identifiable human features. The foetal physical characteristics, growth, movements, and even behaviour can be described in intimate detail on prenatal ultrasound. In the pre-ultrasound era the mother's perception of 'quickening' was the first evidence of foetal life that she experienced beyond the changes in her own body. The health care professional could confirm pregnancy, feel the foetal parts by examining the mother's abdomen, and listen to the foetal heart. There was no visual impression of prenatal life in the way ultrasound provides today. This technology has contributed a great deal to the view of the foetus as a separate patient. In this setting the foetus is clearly a patient, who is investigated and treated "independently of the mother" but with her consent and cooperation. Foetal treatment varies from early induction of labour to foetal surgery in utero for specific malformations1. Ethical analyses of perinatal decision making has concentrated on the two extremes of induced abortion and intensive care treatment of newborns. An area which has received less attention is that of foetal treatment which is not in the mother's interests and which may be detrimental to her. This issue of so-called maternal-foetal conflict has come about mainly as a result of technology. With the help of modern perinatal medicine women with serious medical conditions including diabetes, heart disease, kidney diseases, and even transplanted organs can carry a foetus to successful birth. The fact that these women often risk their own lives to do so has received little attention. It is widely expected that most pregnant women are willing to endure many risks and hardships to optimize the baby's outcome. There are notable exceptions; women who expose their foetus to toxins such as alcohol or drugs, women who refuse prenatal advice about diet, smoking, exercise, etc., women who participate in dangerous activities, women who reject specific treatments such as life saving blood transfusions or emergency surgery. In these situations the pregnant woman is exercising her autonomous choice to decide her own fate and that of her foetus. Respect for this principle is now established in all aspects of health care delivery to the extent that in North America autonomy is regarded as a "trumping principle." Despite individual cases of maternal coercion to accept treatment and court-ordered obstetrical interventions, the broad consensus of ethical and legal opinion is against such measures.1 There was a preponderance of single, poor, non-white, non-English speaking mothers in one report of forced Cesarean Sections, implying paternalistic discriminatory breaches of the process of informed consent.2 The duty of HCPs caring for mothers who indulge in practices which may be injurious to their foetus is to do everything possible to optimize the health of the mother. Prevention programs aimed highlighting maternal and foetal effects of substance abuse will have most benefit. The example of smoking in pregnancy illustrates how a public education program can positively influence the behaviour of pregnant women. Where the efforts of HCPs to help a pregnant woman are frustrated by her lack of cooperation, respect for her autonomy may limit any ability to help her. While the argument in favor of forced intervention can be made on the basis of preventing serious harm to the foetus that can only occur by trampling over the mother's autonomy. Even though the HCP's duty to do good is a basic ethical principle of clinical practice, it cannot be used to justify coerced treatment. In the case of foetal treatment against the mother's wishes such actions either reduce the mother to non-competent status or to non-personhood. She becomes merely a means to support foetal needs. Beneficial consequences to the foetus cannot justify this invasion of the mother's privacy and removal of her liberty. The consequence of such actions would reduce all pregnant women to objects whose health is primarily the concern of others. Such a situation is socially unacceptable and morally repugnant. I have avoided discussion of the lack of legal status of the foetus in terms of personhood because even if foetal status was altered legally it would still require disregarding maternal autonomy to pursue coercive foetal treatment. The solution to these cases rests on the ethical basis of the doctor-patient relationship. The relationship should be seen as based on mutual trust that the doctor will do everything possible to care for and optimize the patient's health. If these efforts are frustrated we must not abandon the patient but continue to attempt to provide whatever care we can. In pregnancy the mother is the patient and all attempts to help the foetus must be with her full understanding and cooperation. This is easier said than done in these cases, but difficulty does not invalidate the central importance of trust as the basis of this relationship. If HCPs understand truly the ethical nature of all interactions with patients, then trampling over any patient' autonomy will be seen as unacceptable. Difficult cases force us to examine the ethical basis of our practice. We must strive for workable solutions to help patients rather than blaming or punishing them. Dr. Paul Byrne is a Neonatalogist at the Stollery Children's Health Centre at the University of Alberta Hospital. He is an Associate Professor in the Department of Medicine at the University of Alberta and Co-Director of the John Dossetor Health Ethics Centre. References
Contents
|
|
Search our resources
(Books, articles, videos)
Updated September 10, 2010
Health Ethics Today
