Ethical Issues in Maternal and Infant Care

Ethical Issues in Care

• Ethical considerations arise in the care of pregnant women and children
• This includes in the care of seriously ill infants

Objectives

• Become Conversant in ethical issues related to caring for pregnant women, children, and seriously ill infants
• Learn how to navigate related concerns in clinical practice
• Develop awareness of ethical issues in assisted reproduction
• Understand impact of technological advancements in reproduction

Introduction

• Multiple parties involved in care require a balancing act
• During pregnancy, benefits to the fetus are weighed against potential harm to the mother
• After birth, medical interests of child are weighed against the interests of the family or parents, including those of a spiritual or religious nature
• Technological advances in care for women and pregnant women bring about "preventing" and "promoting" ethical dilemmas
• Whether or not such advances are innately good or bad is a consideration

Ethical Dilemmas in the Care of Pregnant Women

• Conflicts which arise when a pregnant woman behaves in ways that endanger the health of the fetus
• Also includes refusal of diagnosis or lack of compliance to a medical intervention
• Previously termed maternal-fetal conflict

Core Considerations

• Balancing autonomy, beneficence to the woman vs non-maleficence to the fetus
• Pregnant women's rights don't override fetus' right to life
• Once a woman decides to keep a pregnancy, she automatically takes on responsibility to protect and promote health and well-being of fetus
• Intervention to save fetal lives compared to tolerable forced action to save non-fetal lives

Ethics of Assisted Reproduction

• This involves deliberate manipulation of the processes and materials of human reproduction

Pros

• Allows women or couples with infertility issues to become parents
• Promotes diversity in family types
• Can prevent the passing along of genetic conditions

Ethical Concerns

• "Commercialization" of the reproduction process
• Informed choice considerations
• Accessibility is inhibited by socioeconomic status
• Even when treatment is subsidized, issues arise when physicians make decisions about a person's ability to parent, using non-medical criteria

Genetic Implications

• Genetic determination promotes creation of 'designer babies'
• Involves enhancement rather than therapeutic benefits
• Can lead to the creation of savior siblings

Social Implications

• Unique parental situations such as virgin births
• Challenges or expands the idea of family

Children and Ethical Considerations

• "Triadic” relationship
• Children traditionally excluded on grounds of lacking capacity and being non-autonomous
• In most cases parents serve as stand-in decision makers

Evolution of Considerations

• Due to recognition that there are differing levels of capacity for decision making in children
• The need for clarity about children’s roles
• Attention to a child’s developing decision-making capacities
• Considering stage of cognitive development

Three Levels of Decisional Capacity

• Without decisional capacity means a need for parental consent
• Developing decisional capacity means a need for both parental consent and child assent
• Developed decisional capacity means a need for child’s consent

Important Considerations

• A physician’s first obligation is to the child, so preferences and insights should be considered
• Involving children doesn't mean excluding parents
• Requires involving children at a level commensurate with the child's development, experience, and desire to participating, while affirming parents' responsibility
• Decision-making should occur along a spectrum that considers decision making capacity with the complexity and significance of the decision
• Utilize a family-centered approach by which decisions are weighed on how they impact all members of the family

Basic Framework for Involving Children

• Share information, this is a basic requirement, not dependent on decisional authority
• Goal is to achieve awareness of the nature of their condition and convey full and accurate information regarding tests, treatment and expectations

Involving Children

• Ask for their views, as children who are able to communicate should at least be consulted
• Respect as primary consent giver, a child may grant or withhold consent

Conflict in Practice

• Disagreement between parent and child about medical decisions
• Disagreement between parent(s) and team about course of action, such as denying blood transfusions or vaccinations
• Parents who are not acting in best interest of child
• Munchausen by proxy
• Disagreement between parents, with the child as a pawn in parental disputes

Non-Therapeutic Pediatric Interventions

• "Medical interventions that are not intended to benefit medically the child upon whom they are perform"

Ethical Concerns

• Validity of consent
• Interests of substitute decision makers
• In cases of research, benefits are usually to other children
• In cases of transplantation, benefits to family members
• Should interventions be permissible, given lack of competency?
• Threshold risk of harm

In Practice

• Is the benefit to self or others greater than risk of harm?
• Is harm or risk excessive?
• Does the child support the intervention?

Impact of Technological Advancements

• Rise and availability of prenatal testing vs newborn screening programs
• Serve to promote informed reproductive decision making
• Still has limits
• Raises ethical concerns
• Termination of wanted pregnancies
• Potential for greater discrimination against people living with disabilities