Ethics in Pregnancy & Pediatrics

• The study material focuses on ethical issues in the care of pregnant women and children.
• It also explores how technological advancements impact reproduction.

Objectives

• The goals are to be conversant in ethical issues related to these populations: pregnant women, children, seriously ill infants.
• Another aim is to know how to navigate ethical concerns in clinical practice and also to be aware of ethical issues related to assisted reproduction.
• A final aim is to understand the impact of technological advancements related to reproduction.

Introduction

• Managing ethical issues with pregnant women and children requires balancing the interests of multiple parties.
• During pregnancy, the task involves balancing harm to the mother versus benefits to the fetus.
• After birth, balancing the child’s medical interests and the family's or parents' interests, whether spiritual or religious, is needed.
• Technological advances in women’s and pregnant women’s care present ethical dilemmas, especially around prevention and promotion.
• It is important to consider whether these advances are inherently good or bad.

Ethical Dilemmas in the Care of Pregnant Women

• Ethical dilemmas are defined as conflicts arising from a pregnant woman's behaviors that endanger the fetus's health.
• Ethical dilemmas also include refusal of diagnosis or lack of compliance with a medical intervention.
• These situations were previously known as maternal-fetal conflicts.

Key Considerations

• It is important to consider autonomy and beneficence for the woman versus non-maleficence for the fetus.
• The "pregnant women's rights do not override the fetus' right to life".
• Keeping a pregnancy means a woman takes on the responsibility to protect and promote the health and well-being of the fetus.
• Interventions to save fetal lives are compared to the level of forced action deemed tolerable to save non-fetal lives.

Ethics of Assisted Reproduction

• Assisted reproduction involves the deliberate manipulation of the processes and materials of human reproduction.

Pros of Assisted Reproduction

• Allows women/couples with infertility issues to become parents.
• Promotes diversity in family types.
• Prevents the passing along of genetic conditions in families.

Ethical Concerns of Assisted Reproduction

• "Commercialization" of the reproduction process is an ethical concern.
• Informed choice may be a concern.
• Accessibility may be limited by socioeconomic status.
• Subsidized treatment may cause physicians to make decisions about a person’s ability to parent using non-medical criteria.
• Genetic determination promotes the creation of 'designer babies'.
• This can lead to enhancement rather than therapeutic benefits and creation of savior siblings.
• Challenges/expands the idea of family is a social implication.
• Unique and novel parental situations, i.e., virgin births are also possible.

Ethical Considerations with Children

• Children are traditionally excluded from decision-making due to their non-autonomous status and lack of capacity.
• Parents usually serve as substitute decision-makers in most cases.
• Now there is evolution underway due to recognition that there are differing capacity levels for decision-making, even among children.
• With no decisional capacity, parental consent is needed.
• Parental consent and child assent are required with developing decisional capacity.
• Child consent is needed with developed decisional capacity.
• There needs to be clarity regarding a child's role, with cognitive development stages factored in.
• Attention should be paid to a child’s developing decision-making capacities.

Notes on Including Children

• A physician’s primary obligation lies with the child, so the child’s preferences and insights should be considered.
• Involving children does not exclude parents.
• Children should be involved at a level commensurate with their development, experience, and desire to participate, while affirming parental responsibility.
• Decision-making should occur along a spectrum, accounting for decision-making capacity, complexity, and significance.
• A family-centered approach should be followed, where decisions take into account how they might impact all members of the family.

Framework for Involving Children

• As a basic requirement, healthcare providers must share information to achieve awareness of their condition.
• They must convey full and accurate information regarding tests, treatment, and expectations.
• All children who are able to communicate should be asked for their views.
• Children may grant or withhold consent (assent); they should be respected as the primary consent giver.

Conflict in Practice

• Conflicts in practice occur when there is disagreements between a parent and child regarding medical decisions.
• Disagreements may also arise between parents and the medical team about the course of action.
• This can include denying blood transfusions or vaccinations or parents who are not acting in the child's best interest.
• There is also the issue of Munchausen by proxy.
• A child can also be used as a pawn in parental disputes where there is disagreement between parents.

Non-Therapeutic Pediatric Interventions

• This is defined as "medical interventions that are not intended to benefit medically the child upon whom they are performed".
• Ethical concerns include the validity of consent and the interests of substitute decision-makers.
• The benefits are typically for other children in cases of research.
• The benefits are to family members in cases of transplantation.
• Consider whether these interventions should be permissible given a “lack of competency."
• Account for how low the threshold risk of harm is.

In Practice Considerations

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

Impact of Technological Advancements

• The rise and availability of prenatal testing and newborn screening programs have an impact.
• This serves to promote informed reproductive decision-making, but it still has limitations, and raises ethical concerns.
• It can lead to the termination of wanted pregnancies and potential for greater discrimination against people living with disabilities.