ETHICAL ISSUES

IN ABNORMAL
PREGNANCIES
A. Ethical Considerations in Early
Induction of Labor
B. Ethics in treating Ectopic
Pregnancy
C. Maternal-fetal Conflict

Ethical
Considerations
in Early Induction
of Labor
Reporter: ABRIGO, Veronica Rosa
Acop, Karla Marie
Researchers:
Antonio Abello, Maria Rose Aceron, Karla Marie Acop, Andre Acosta

Labor induction
Labor is induced to cause a pregnant
woman's cervix to open (dilate) and
thin out (efface) to prepare for the
vaginal birth of her baby.
Use of medicines or with surgical
methods

What are the risks of inducing

labor?
Induction itself carries serious risks to
both mother and infant
Longer and stronger contractions
may lead to a more painful labor
increases the chance that pain medication
will be used, with the possibility of risks
related to the pain medication
interrupt blood flow and oxygen to the fetus
Decrease in heart rate

 Poor positioning of the fetus

Increase the risk of cesarean if
induction fails
Postpartum hemorrhage
Emotional distress
With all of these risk factors, what would be
a good and morally upright reason for
inducing labor? Induction should be
avoided if possible.

Did you kick me out of my warm,

cozy home early?

EARLY INDUCTION OF LABOR

early induction for fetuses with
anomalies incompatible with life"
This procedure induces a woman into
labor after her unborn child reaches
viability around 23 to 26 weeks in
cases when the child is known to have
a condition that makes death
inevitable soon after even a full-term
birth.

Indications
Timing
At least 1 to 2 weeks past the due date

Mother's health
Pre-eclampsia
Gestational diabetes

Pregnancy itself
Problems in the sac that holds the baby
Early breaking of the membrane that holds the sac
without the start of labor
abnormal fetal heart rate
the placenta is pulling away from the wall of the
uterus (abruption)
death of the baby before birth
University of Michigan Health Systems

Whats at stake?
Why women consider?
They are overwhelmed by emotional and
mental stress.
They are convinced that going to full
term will not improve the child's chances
of survival.
In cases of renal agenesis, fetal death
could result in release of toxins
dangerous to the mother.

Whats at stake?
Objections
Early induction is only permissible when the
physical life of the mother is gravely
endangered a very rare situation.
Prenatal diagnosis can be wrong, and a healthy
child could die as a result.
The procedure presents increased risk to the
mother of conditions including incompetent
cervix, impaired mental health and breast
cancer.
Prematurity reduces the chances of survival for
a child already diagnosed as unable to survive.

What is right?
Early induction is done
Operations, treatments, and
medications that have as their direct
purpose the cure of a proportionately
serious pathological condition of a
pregnant woman are permitted when
they cannot be safely postponed until
the unborn child is viable, even if they
will result in the death of the unborn
child.

Directive 47 (Ethical and Religious Directives)

Early induction is done

For a proportionate reason, labor
may be induced after the fetus is
viable.
proportionate
From the teaching of St. Alphonsus Ligouri,
who used the term for situations in which
some grave risk would be incurred if an
action were not taken to avoid it.

Ethical issues
Specific Ends of Early Induction of Labor
complete avoidance of direct abortion
preservation of the lives of both mother
and child to the extent possible under the
circumstances
NCBC STATEMENT ON EARLY INDUCTION OF LABOR
March 11, 2004

Principle of Double Effect

Actions that might result in the death of
a child are morally permitted ONLY IF
ALL of the following conditions are met:
treatment is directly therapeutic in
response to a serious pathology of the
mother or child
the good effect of curing the disease is
intended and the bad effect foreseen but
unintended

 the death of the child is not the means by

which the good effect is achieved
the good of curing the disease is
proportionate to the risk of the bad effect.
Fulfillment of all four conditions precludes
any act that directly hastens the death of
a child.

Example
Chorioamnionitis
Preeclampsia
H.E.L.L.P. syndrome.
-- it directly cures a pathology by evacuating
the infected membranes in the case of
chorioamnionitis, or the diseased placenta
in the other cases, and cannot be safely
postponed.

Anencephaly
Defect in the closure of the neural
tube during fetal development
resulting in the absence of a major
portion of brain, skull and scalp.
Remaining brain tissue often exposed
Usually without a forebrain and
cerebrum (thinking parts)
University of Michigan Health Systems

Anencephaly
Usually blind, deaf, unconscious, and
unable to feel pain
Lack of a functioning cerebrum
permanently rules out the possibility of
ever gaining consciousness
Reflex actions such as breathing and
responses to sound or touch may occur

University of Michigan Health Systems

Anencephaly
Cause is unknown
Mother's diet and vitamin intake may
play a role, but is not the sole factor
Addition of folic acid to the diet of
women of childbearing age may
significantly reduce the incidence of
neural tube defects

University of Michigan Health Systems

Anencephaly
No cure
Treatment is mainly supportive
Prognosis is extremely poor
If the infant is not stillborn, then he or
she will usually die within a few hours or
days after birth
Early induction for fetuses with
anomalies
incompatible with lifeUniversity
(EIFWAIL)
of Michigan Health Systems

Issue at hand
Anencephaly was regarded as a
special case from other lethal birth
defects because of the presumed
lack of mental function.

Women for Faith and Family

Organization

Sister Jean deBlois, CSJ

1993, then-senior associate for clinical ethics at The
Catholic Health Association
Anencephaly as a case where the pregnancy may
be terminated at any time although there is no
life-threatening maternal pathology she cited the
increased physical risks during labor and delivery,
the emotional trauma suffered by a couple upon
diagnosis of anencephaly, and the lack of mental
development in the baby as justification for
"inducing labor to end the pregnancy".
Acknowledged that "there is NO lifethreatening maternal pathology"

Sister Jean deBlois, CSJ

Principles of proportionality and "double effect
The resulting fetal death is indirect" and thus
NOT an abortion.
Human life involves more than simply
biologic life. Infants with anencephaly lack
"psychological, social, and creative capacities and
can never acquire the quality of viability, properly
understood".
Once the diagnosis is made, there seems to be
no purpose in maintaining the pregnancy".

If that is so
Catholic hospitals would then be
ethically allowed to perform early
induction delivery -- an
acknowledged abortion procedure
used for terminating babies with
birth defects -- as a kind of
termination of life support rather
than abortion.

What is right
"Moral Principles Concerning Infants with
Anencephaly - statement by US bishops
in 1996
It is clear that before 'viability' it is
never permitted to terminate the
gestation of an anencephalic child as
the means of avoiding psychological or
physical risks to the mother. Nor is such
termination permitted after 'viability' if
early delivery endangers the child's life
due to complications of prematurity.

What is right
Terminating her pregnancy cannot be a
treatment to a pathology she does not have.
Only if the complications of the pregnancy
result in a life-threatening pathology of the
mother, may the treatment of this pathology
be permitted even at a risk to the child, and
then only if the child's death is not a means
to treating the mother".
--Bishops Doctrinal Committee
"Moral Principles Concerning
Infants with Anencephaly

Change of heart
A Primer for Health Care Ethics - by Father
Kevin ORourke, 2000.
The application of the principle of double
effect does not seem to justify the early
delivery of anencephalic infants.
(Reversal of opinion: A Primer for Health
Care Ethics-Essays for a Pluralistic Society.
co-authored with Father Patrick Norris, OP
and Sister deBlois.

Another blow
"Early Delivery of a Fetus with Anencephaly - article
by Father Norman Ford, 2003.
Theorized that waiting until 33 weeks (almost two months
before term) to induce delivery of anencephalic infants
meets ethical standards.
Pre-maturity is considered as delivery before 37 weeks.
Cause of death would then be anencephaly instead of prematurity since most normal babies survive when delivered
at that stage
Deaths of anencephalic infants are anticipated.
Motivated by "a compassionate desire to alleviate the
mother's distress and minimize potential health risks for
the mother"
"by this stage the mother's duty of reasonable care for her
fetus would have been satisfied".

When it rains, it pours

Two October 2003 articles -- one in the Catholic Anchor,
Anchorage's archdiocesan newspaper, and one in the
National Catholic Register
Reported early induction deliveries of infants with other
"anomalies incompatible with life" in Catholic hospitals
as early as 24 weeks into pregnancy, which is the
commonly accepted limit of viability even with
treatment.
The ethicists involved defend the early inductions as
consistent with Directive number 49 of the US Bishops'
Ethical and Religious Directives for Catholic Health Care
Services (ERD), which says: "For a proportionate
reason, labor may be induced after the fetus is viable".

When it rains, it pours

Dr. Maria Wallington, director of ethics at
Providence Alaska Medical Center.
"The ERDs talk about proportioned good and then
they don't talk about how you decide that".
In a later article in the January 23, 2004 edition
of the Anchorage Daily News, Dr. Wallington
continued to defend the early inductions: "The
practice relieves suffering, Wallington said.
Imagine how hard it would be for a pregnant
woman to face constant questions about a baby
she knows will die."

Proportionality
Definition
Debunk

Risks of Early Induction of

Labor
Not uncommon practice and can even be life-saving for the
mother or baby
Inducing delivery two to four months early is a situation
that would certainly not be contemplated for a healthy baby
and a healthy mother.
The process itself carries serious risks to both mother
and infant.
May 2003 editorial in the American Family Physician journal
states, even elective induction delivery near- or post-term
"is not without potential risks, including iatrogenic
prematurity, uterine hyperstimulation, nonreassuring
fetal heart rate tracing, and greater likelihood of
operative delivery, shoulder dystocia, and
postpartum hemorrhage".

Other risks
Abnormal fetal heart rate from contractions that are

too strong or frequent, or from a squeezing

(compression) of the umbilical cord
Separation of the placenta from the uterus
(abruption) if contractions are too strong
Prolapsed umbilical cord (the umbilical cord falls into
the birth canal ahead of the baby's head or other parts
of the baby's body) or infection as a result of amniotomy
Damage to the uterus
Cesarean delivery if induction of labor does not work.
Infection from the breaking of the bag of waters with
amniotomy.

Choose LIFE
Despite the advances in prenatal diagnostics,
prenatal testing is still not 100% accurate
and there exists a risk of misdiagnosis that can
and often does result in the loss of a less
impaired or even healthy baby by early
termination of pregnancy.
Even when induction is considered necessary
in medically emergent situations, such as
severe pre-eclampsia, every effort is made to
give the baby as much time in the womb as
possible to lessen the usual risks of
prematurity.

Parents
Diagnosis of a lethal or other serious anomaly in
an infant is a distressing moment, whether this
occurs before or after birth.
There is a normal grieving process as the parents
face the reality of the loss of the "perfect" baby
they had imagined and must eventually prepare
for the death of that child.
In utero, there is a natural tendency to want to
"get it over with" rather than endure wellmeaning comments from strangers and imagine a
sadly different labor and delivery weeks or
months in advance.

Parents
The natural grief of losing a child cannot
be avoided.
Will waiting an additional two to four
months before the pregnancy is
terminated decrease maternal distress?
We have not found cited studies
supporting the contention that early
induction can be psychologically
beneficial.

Parents
Which would be more distressing?
Knowing that your child will die.
Living the rest of your life knowing that
you had a hand in killing your own baby.

What we learned
Bioethics is an unforgiving area of
medicine.
Lives can be unnecessarily and unjustly
lost because of a redefinition of terms or a
subjective interpretation of principles.
As in the argument on when life starts

Issues once considered settled can then

become open to even radical change with
unexpected consequences.

What we are facing

Presumed lack of mental function is a lethal
pathology that can override the obligation to
provide for the basic needs of a person.
Unborn baby with anencephaly (presumed to lack
mental function and with a lethal pathology),
similar override of the obligation to provide for
the basic needs of the baby by justifying
abortion.
Thus, pregnancy itself can then be viewed as a
form of 'life support" that can be ethically
withdrawn at some stage where, as Father Ford
states, "the mother's duty of reasonable care for
her fetus would have been satisfied".

The answer?
Pregnancy is NOT a form of life support.
God given gift
Specially given to women to take a part in the
wonder of creation
Women are not machines
Machines cannot feel and nurture and love

What we are facing

Arguments about the perceived
burdens of continuing an unborn life
that may be short.
Psychological
Mental
Financial

The answer?
A person's life is to be valued at all
stages and conditions until natural
death.
preclude attempts to justify
causing or even hastening death by
early induction of labor.

Conclusion
Elective early induction delivery of babies
with anencephaly or other lethal defects is
unfortunately motivated by a misplaced
compassion that not only deprives the
baby of his or her natural lifespan, but
also deprives the mother of the chance to
truly bond with and nurture her afflicted
child until death intervenes.

Conclusion
We should set a standard of integrity by
offering grieving families continuing
support and encouragement rather than a
premature termination of pregnancy.
Become much-needed and powerful witness to
the value of all human life, regardless of age or
condition.

There is no if-clause to our

parenthood: I will love you if you
are perfect.
The first thing a parent can do is
love his or her child. In some
cases, it's the only thing we can
do, and so we love them all the
harder. - Carrying to Term Pages

We didnt put any

pictures of
anencephalic babies
in the report. We all
know how babies with
the condition look
like.
Rather we would like you
to see them as part
of families, as the
human beings that
they are.

ECTOPIC PREGNANCY

Topic Outline
Introduction
Anatomy
Normal implantation

Ectopic pregnancy
Sites of ectopic pregnancy

Current Medical Procedures

Moral Considerations
Conclusion

Female
Reproductive
System

Ectopic Pregnancy
leading cause of pregnancy-related
death during the first trimester in the
United States
9% of all pregnancy-related deaths
the woman's future ability to
reproduce may be adversely affected

Ectopic Pregnancy
from the Greek word ektopos, meaning out
of place
implantation of a fertilized egg in a location
outside of the uterine cavity
grows and draws its blood supply from the
site of abnormal implantation
creates the potential for organ rupture
because only the uterine cavity is designed
to expand and accommodate fetal
development
lead to massive hemorrhage, infertility, or
death

Common Sites of Ectopic

Pregnancy

Normal course of an egg down through the

fallopian tube and into the wall of the uterus.

In Ectopic pregnancy the embryo is

implanted in the fallopian tube before it
reaches the uterus.

The embryo grows causing the

fallopian tube to bulge.

As the embryo grows larger, the fallopian

tube ruptures and hemorrhages.

Current Procedures for Managing

Ectopic Pregnancy

Medical Intervention
Methotrexate
an antimetabolite chemotherapeutic agent
binds to the enzyme dihydrofolate
reductase
interferes with DNA synthesis and disrupts
cell multiplication
destroys the placental (trophoblast)
cells/tissue

Medical Intervention
Methotrexate
option when the pregnancy is located on
the cervix, ovary, or in the interstitial or
the cornual portion of the tube
Surgical treatment in these cases is often
associated with increased risk of
hemorrhage
resulting in hysterectomy or
oophorectomy
good subsequent reproductive outcomes
risk of tubal injury is reduced

Surgical Methods
1. Laparotomy
surgical procedure involving an incision
through the abdominal wall to gain
access into the abdominal cavity
also known as coeliotomy

2. Laparoscopy
surgical procedure in which a small
incision is made, usually in the navel,
through which a viewing tube
(laparoscope) is inserted

Types of Surgery
Salpingectomy
surgical removal of a Fallopian tube
Salpingostomy
surgical incision into a fallopian tube
Fimbrial Expression Procedure
some ampullary pregnancies can be
teased out and expressed through the
fimbrial end (milking of the tube) by using
digital expression, suction, or aquadissection

Surgical Intervention

Moral Considerations for Managing

Ectopic Pregnancy

 all actions must be analyzed according

to
Intention (motive) of the acting subject
Means (the circumstances and
consequences)
End (the (moral) object itself of his act)

If any of these three are immoral, the

act itself is immoral.

Principle of Totality
holds that we may sacrifice even a
basic bodily function or organ to
preserve the whole of the bodily life
provided there is no less invasive way
of achieving this goal.

Principle of Double Effect

action to produce both a desired
good effect and at the same time
allow for certain evil
consequences

Four Conditions
for Considering the Principle of
Double Effect
1. The moral object may not be evil in itself;
the moral act must itself be good or morally
indifferent.
2. The good and evil effect must proceed at
least equally directly from the act (the
immediate effect must not be solely evil and
the good effect should not physically result
from the evil effect).
3. The agent may not intend or approve the
evil effect.
4. There must be a proportionate grave reason
in order to allow the evil effect.

Evangelium Vitae
(The Gospel of Life)
The evil of direct or induced abortion, for
whatever reason, is a moral absolute.
Procured abortion, according to John Paul
II is the deliberate and direct killing, by
whatever means it is carried out, of a human
being in the initial phase of his or her
existence, extending from conception to
birth and this direct and voluntary killing of
an innocent human being is always gravely
immoral.

Evangelium Vitae
(The Gospel of Life)
The killing of innocent human creatures
(an ectopic), even if carried out to help
others (e.g., the mother), constitutes an
absolutely unacceptable act.
Therefore, any attempt to directly remove the
living fetus, even if it is deemed nonviable, as
is eventually the case currently with tubal
pregnancies, has always been recognized by
Catholic moral teaching as gravely immoral
and essentially similar to abortion.

Salpingectomy
In extrauterine pregnancy the affected part
of the mother (e.g., cervix, ovary, or
fallopian tube) may be removed, even
though fetal death is foreseen, provided that
(a) the affected part is presumed already to
be so damaged and dangerously affected
as to warrant its removal, and that (b) the
operation is not just a separation of the
embryo or fetus from its site within the part
(which would be a direct abortion from a
uterine appendage) and that (c) the
operation cannot be postponed without
notably increasing the danger to the mother.

Salpingectomy
In the case of extrauterine pregnancy, no
intervention is morally licit which constitutes a direct
abortion.
Operations, treatments and medications that have
as their direct purpose the cure of a proportionately
serious pathological condition of a pregnant woman
(i.e., a salpingectomy) are permitted when they
cannot be safely postponed until the unborn child is
viable, even if they will result in the death of the
unborn child
It is not permissible, however, to initiate or to
recommend treatments that have as their purpose
or direct effect the removal, destruction, or
interference with the implantation of a fertilized
ovum

Salpingostomy
Fimbrial Expression Procedure
Methotrexate
directly attack an innocent human life
intrinsically immoral and never can be
justified
violate the Sixth Commandment
"means" used to accomplish the "end"
are not the same

Reporter: Joanabeth Aguirre

Before you were conceived I wanted you

Before you were born I loved you
Before you were here an hour I would die
for you
This is the miracle of Mother's Love.
-- Maureen Hawkins

Roe vs. Wade (1973)

controversial United States Supreme
Court case that resulted in a
landmark decision regarding abortion
decision overturned all state and
federal laws outlawing or restricting
abortion

 central holding of Roe v. Wade was that

abortions are permissible for any reason a
woman chooses, up until the "point at which
the fetus becomes viable, that is,
potentially able to live outside the mother's
womb, albeit with artificial aid
court accepted the conventional medical
wisdom that a fetus becomes viable at the
start of the last third of a pregnancy, the third
trimester, sometime between the 24 th and 28th
week

 because the point of viability varies,

the court ruled, it could only be
determined case by case and by the
woman's own doctor

Doe vs. Dalton (1973)

US Supreme Court supported abortion rights
after the point of fetal viability in order to
preserve womens lives and continuing health
concept of health, as defined by the Supreme
Court in Doe v. Bolton, includes all
medical, psychological, social, familial
and economic factors that may
potentially encourage a decision to
obtain an abortion

R. vs. Morgentaler (1988)

the court ruled that the Criminal Code
violated womens rights because forcing
a woman, by threat of criminal
sanction, to carry a fetus to term
unless she meets certain criteria
unrelated to her own priorities and
aspirations, is a profound interference
with a womans body and thus a
violation of security of the person

 Maternal-fetal conflict occurs when a

pregnant womans interests, as she defines
them, conflict with the interests of her
fetus, as defined by the womans physician.
A conflict of this nature may occur when a
pregnant woman decides not to comply
with recommendations that her physician
considers to be in the best interest of the
fetus.

 Fertilization, at which point fetus

receives genetic blueprint from
parents.
Implantation, embryonic attachment
to uterine wall.
At birth
28 days after birth.

 Life begins upon the creation of a

genetically
unique
individualfertilization.
Most popular public stance.
Scientists- process of 12-24 hours.
Twinning argument
Ability of zygote to split into 2 or more
zygotes.
Genetic uniqueness not prerequisite.

 Beginning of life at gastrulation

Establishing all three germ layers.
Third week of gestation.
Results in development of separate
individuals, unique personalities
and souls.
Human individual vs. human
person.

I will prescribe regimens for the good of my

patients according to my ability and my
judgment and never do harm to anyone...
To please no one will I prescribe a deadly
drug nor give advice which may cause his
death.
Nor will I give a woman a pessary to
procure abortion...
In every house where I come I will enter
only for the good of my patients, keeping
myself far from all intentional ill-doing

 The United Kingdom

Official view: embryonic view (Gilbert,
2006).
British Abortion Act of 1967

The United States

No official view on beginning of life.
Unborn Victims of Violence Act of 2004.
Argument for/against embryonic stem
cell research

 Male fetus- animated with a soul 40

days after conception.
Female fetus- 80 days after
conception.
Fetus condemned if died without
being baptized

 Life begins at conception

 If the fetus is considered to have the full

rights of a person, then it should be treated
as a separate entity from the mother.
Thus, the pregnant woman and the fetus
should be treated as two individual patients.
The medical model for the biological
maternal- fetal relationship has shifted
emphasis from unity to duality, and the fetal
organism is considered a distinct patient.

 CONFLICT: fetal dependence on

mother
Fetal diagnosis and therapy
optimize fetal outcome, however
any procedure performed must
include the involvement of the
pregnant woman.

 The concept of a persons autonomy is

their right to choose how to live their own
life.
The right to be free from unwanted bodily
invasions and to control ones own life.
The pregnant woman should be allowed
the freedom to decide upon alternative
courses of therapeutic action based on her
values and beliefs.

 The principle of beneficence requires an

individual to act in such a way as to reliably
produce more good than harm in the lives of
others.
With respect to maternal-fetal relationships,
the physician should assess objectively the
various therapeutic options that may exist.
The physician should implement those that
will most likely offer the patient and fetus
greater benefit over risk.

 Human life begins long before

conception
What we really want to know is
whether the living human fetus
should be recognized as a bearer of
the same range of fundamental moral
rights that you and I have, among
them the right not to be killed
without very good reason.

 Human life begins long before conception

(Scientific claim)
Distinct person emerges at conception
(Moral claim)
To call something a person is to already
assert that it is a bearer of the strongest
moral rightsfundamental rights
comparable to yours and mine, among
them the right not to be killed except for
the most compelling of moral reasons

 Recognizing a person as a person if

he has certain characteristics
A conceptus, however, has none of
these
characteristics.
What
is
amazing is that such radically
different beings emerge from such
beginnings.

 Personhood at birth
Personhood at conception
whether we should recognize the fetus as a
person now (full range of fundamental moral
rights attaches to the fetus ) or whether we
should recognize the fetus as a potential
personas a person-not-yet (remains an
open question what moral duties we might
have toward the fetus ).
Doubt of the personhood of fetus
(if there is any possibility that the fetus is a
person, we have a duty to act as if it were a
person -- a duty to avoid acting recklessly )

 Abortion in cases of rape or incest

must be ruled out
If fetuses are to be recognized as fullfledged persons, then justice requires
that those who abort them for
reasons less than self-defense must
be
recognized
as
full-fledged
murderers and treated as such.

CASES OF
MATERNALFETAL
CONFLICT
Reporter: Albert Alcaraz

 Religious refusal of blood products during

pregnancy and delivery
Refusal of diagnostic testing blood draws
Refusal of delivery options like C-sections
Drug / alcohol use / abuse during
pregnancy
Treatment of cancer during pregnancy

Angela Carder
the 27-year-old woman was hospitalized at the
25th week of gestation with metastatic terminal
sarcoma
she agreed to a medical plan which consisted of
palliative therapy, attempting to extend her life to
the 28th week of gestation
it was thought that if the baby was delivered at
28 weeks of gestation, there would be reasonable
expectation for survival

 Angelas condition deteriorated and she required

intubation and sedation
she was judged to be terminally ill and near
death
hospital administration became concerned about
the well-being of the fetus and despite the
opposition of her attending physicians and family,
obtained a court order authorizing a forced
cesarean section
judge ruled in favour of the cesarean section

 Angela unexpectedly regained

consciousness and was informed about
the judges order.
although she expressed her disapproval
with the decision, a cesarean section
was performed
several hours following the operation,
the baby died and two days later, so
did the mother

 case was reviewed by the Appeals Court,

District of Columbia, which was critical of the
trial judges decision
judge had based his decision on balancing the
rights of the mother against the interests of
the state in the life and well-being of the fetus
he reached his decision by assessing that the
States interest in protecting the fetus
outweighed whatever rights or interests the
dying woman had

A 29 year old woman in labor, progressing

very slowly, breech presentation, large
baby. The patient was told this
information and that a c section would
need to be performed. The patient
refused the c-section explaining that she
and her family wanted a natural birth.
A psych evaluation to look at capacity
was done while the patient was in
advanced labor. CPS was also contacted
and they informed the team that they
would follow the case but were unable to
intervene until the child was born.

 Position 1: The Pregnant Woman's Autonomy

Has Priority.
- consistent with other health care practices
Position 2: Beneficence Toward the Fetus has
Priority.
- arguably, beneficence toward the patient,
or at least nonmaleficence, always overrides
respect for autonomy, just as moral
obligations are greatest toward those who
are most in need.

 Position 3: Beneficence Toward Both

Patients Trumps Respect for the
Pregnant Woman's Autonomy.
- Coercive intervention is permissible
in cases of well documented
complete placenta previa

 Acting on a refusal of treatment would

amount to acting on unreliable clinical
judgment
This justifies the physician's resisting
the patient's exercising a positive right
- Since fulfilling the positive right contradicts the

most highly reliable clinical judgment, dooms the

beneficence-based interests of the fetus, and
virtually dooms the beneficence-based interests
of the pregnant woman.

 Background.
Malaria is one of the world's most serious health problems. It causes about 1
million deaths every year, and most of these deaths are in children. Several
different parasites can cause malaria; the most serious is Plasmodium
falciparum. One of the most serious consequences of infection is that this
parasite can multiply in the placenta of a pregnant woman. This placental
malaria is very harmful to the mother and to the fetus; it leads to low birth
weight and is estimated to be responsible for the deaths every year of about
200,000 babies within their first year of life. A woman who is pregnant for
the first time is most likely to suffer from placental malaria, and to have her
placenta become highly infected and extremely inflamed. If she later
becomes pregnant again, she will be protected to some extent by antibodies
she has developed against the parasite.
Another problem that is common in tropical countries and also causes many
deaths during pregnancy is preeclampsiahigh blood pressure
(hypertension) and protein loss in the urine. This is also a condition that is
most common in first-time mothers. The causes of preeclampsia are not
clear, but many factors are probably involved. Among the theories that have
been proposed are that inflammation in the placenta might play a part, and
that there may be a conflict between the needs of the mother and those of
the fetus.

Why Was This Study Done?

The researchers wanted to see whether placental malaria might be a factor in the
development of preeclampsia. This association has been suggested before, but there has
been no clear evidence.
What Did the Researchers Do and Find?
Working with pregnant women in Tanzania, they found that, overall, women with placental
malaria were no more likely than other women to develop hypertension. However, for
those women who were aged 1820 and pregnant for the first time, having placental
malaria was associated with hypertension. The researchers also measured levels of a
substance called sVEGFR1 (also called sFlt1), which is known to increase before and during
preeclampsia and is thus considered to be a biomarker for the condition. sVEGFR1 levels
were high in first-time mothers with either placental malaria or hypertension, or both, but
levels were not raised in other mothers with these conditions. A related substance, VEGF,
which is known to be involved with the process that causes inflammation, was high in firsttime mothers with placental malaria, but not in those who had preeclampsia alone.
What Do These Findings Mean?
The researchers believe that their findings support the view that, in younger first-time
mothers only, placental malaria can cause preeclampsia and that this results from a
conflict between the mother and her fetus. Action to reduce the chance of such women
getting malaria would have the additional benefit of lowering their chance of developing
preeclampsia. The findings have also led the researchers to propose possible mechanisms
as to how placental malaria leads to preeclampsia. They have made suggestions regarding
the further research that is now needed.
Source: http://dx.doi.org/10.1371/journal.pmed.0030446

 A medical condition where hypertension arises in pregnancy

(pregnancy-induced hypertension) in association with significant
amounts of protein in the urine.
While blood pressure elevation is the most visible sign of the
disease, it involves generalized damage to the maternal
endothelium and kidneys and liver.
It may develop from 20 weeks gestation (it is considered early
onset before 32 weeks, which is associated with increased
morbidity) and its progress differs among patients; most cases
are diagnosed pre-term.
Apart from abortion, Caesarean section, or induction of labor, and
therefore delivery of the placenta, there is no known cure. It may
also occur up to six weeks post-partum. It is the most common of
the dangerous pregnancy complications; it may affect both the
mother and the fetus.

 Cancer is the second most common cause of

death among women during the reproductive
years, complicating approximately 1/1000
pregnancies.
The most common cancers that occur during
pregnancy are cervical, breast, melanoma,
thyroid, leukemia, lymphoma and colorectal
(Sorosky et al., 1997).
In part, the recent increase in cancercomplicated pregnancies may be due to the
increased frequency of delayed childbearing.

 A diagnosis of cancer during

pregnancy causes significant conflict
for both the physician and the
patient when attempting to optimize
maternal theraoy and fetal well
being.

 Cancer patients have an increased tendency to

undergo febrile illnesses due to infections and/or
as a result of the tumor itself
Human studies do support the hypothesis that
maternal fever in early pregnancy may be
associated with neural tube defects and
microphthalmia.
Children's long-term cognitive outcome could also
be affected by maternal malnutrition, which may
be linked to malignancy

 All chemotherapeutic agents are potentially

teratogenic and mutagenic because they act on
rapidly dividing cells.
The potential exists for fetal malformations,
intrauterine growth restriction, spontaneous
abortion, stillbirth or premature delivery when a
woman is exposed to chemotherapeutic agents
prior to, or during, pregnancy.
Possible outcomes depend on the particular
treatment, its timing and duration, and the ability
of the drug to cross the placenta.

 The risk for birth defects to occur is greatest when

the fetus is exposed to chemotherapy during the
first trimester of pregnancy. This is because the
first
First trimester organogenesis, period of rapid cell
growth
Since chemotherapeutic drugs interfere with cell
growth and division, the fetus is most vulnerable
during this period of time.
Exposure to chemotherapeutic drugs during the first
trimester may also increase the risk for miscarriage.
Therefore, whenever possible, chemotherapy is
avoided during the first trimester of pregnancy.

 The risk for birth defects is less when chemotherapy

is administered in the second or third trimester.
With a few exceptions (such as the brain and the
reproductive system), most fetal organ system
development is completed by the beginning of the
second trimester.
However, exposure to chemotherapeutic drugs in
the second and third trimester has been associated
with a greater risk for premature birth, low birth
weight, and a temporary reduction in some of the
babys blood cells.

Source: http://www.motherisk.org/women/commonDetail.jsp?content_id=231

 Hence in cancer treatment, physician

must consider the gestational age of
the pregnancy, the stage of the
cancer, and the emotional, religious,
social and moral concerns of the
individual prospective parents.

 Vast majority of pregnant women are

willing to assume significant risks for the
welfare of their fetuses. Problems arise
when potencially beneficial advice is
rejected.
The role of the physician is to be an
informed educator and counselor, weighing
the risks and benefits to both patients, and
consider the social and cultural context in
which these decisions are made.

 The use of judicial authority to

implement treatment regimens to
protect the fetus violates the
pregnant womans autonomy and
must be avoided

Sources
National Institute for Neurological Disorders and Stroke
Women for Faith and Family
Voices Online Edition Vol. XIX No. 2, Pentecost 2004
http://www.anencephaly.net/
http://www.ewtn.com/library/PROLIFE/bcdanen1.htm
http://www.geocities.com/tabris02/index.html
http://www.anencephalie-info.org/e/pictures.php
http://www.lifeissues.net/writers/val/val_24prematureinduction.h
tml
http://www.lifeissues.net/writers/szy/szy_01prenatalethics.html
http://www.ncbcenter.org/04-03-11-EarlyInduction.asp
http://www.wf-f.org/04-2-PrematureInduction.html
http://www.che.org/ethics/topics.php?id=161
http://www.aafp.org/afp/990800ap/477.html