Clinical ethical topics in obstetrics

The professional responsibility model of obstetric ethics is based on the ethical concept of the fetus as a patient and respect for the preg­nant patients autonomy. The concept of being a patient is beneficence based, creating an obligation to protect the health and life of the fetus.

In this respect, the professional responsibility model differs from two other approaches in the literature. Both appeal to rights and treat rights as absolute, that is, admitting of no exceptions. One approach we call maternal rights-based reductionism and the other, fetal rights-based reductionism (1, 3). Both are ethically and clinically simplistic but inadequate for the complexities of obstetric practice.

Offering induced abortion or feticide

The ethical justification for offering feticide after viability requires the reliable diagnosis of a severe fetal anomaly: a certain or near­certain diagnosis of an anomaly that is reliably expected either to result in death, even with aggressive obstetric and neonatal inter­vention, or short-term survival with severe and irreversible deficit of cognitive developmental capacity (28, 29).

There are ethical justifications for offering induced abortion be­fore viability. The first is based on a deliberative clinical judgement that continuing pregnancy poses a threat to the health or life of the pregnant woman. When deliberative clinical judgement is that con­tinuing pregnancy poses a risk to the pregnant woman's health or life, she should be informed about this matter and offered the alter­native of induced abortion. Some women, because of moral convic­tions about the general moral status of the fetus, will refuse this offer. They should be informed that their refusal increases the risk that their health could be severely compromised and that they could die. The final decision to remain pregnant or to elect induced abortion is ultimately a function of the pregnant woman's autonomy and should be respected by the physician.

The second justification for offering feticide before viability is based on the deliberative clinical judgement that continuing preg­nancy poses a threat to the life or health of coexistent fetuses. This can occur in higher-order pregnancies and twin pregnancies in which the continued existence of the anomalous fetus that is causing hydramnios poses a threat to the health or life of the other fetus.

When deliberative clinical judgement is that continuing a previable pregnancy does not pose an increased risk to the health or life of the pregnant woman or fetuses, the only remaining jus­tification for offering induced abortion or feticide is autonomy based. Some pregnant women will request an induced abortion. For others, a previable pregnancy will be diagnosed with an anomaly or a viable pregnancy will be diagnosed with a severe anomaly. For some women, a complication occurs that threatens the successful continuation of a previable pregnancy, such as preterm premature rupture of membranes. Some pregnant women will directly or in­directly express concern about remaining pregnant or will be con­cerned about a multiple birth and will prefer for economic or other personal reasons to have a singleton pregnancy. Physicians should respond to these women by discussing the option of induced abor­tion and, when appropriate, explaining time limitations created by applicable law.

In response to the offer of induced abortion, physicians should plan for pregnant women to sort themselves into three subgroups (31).

Shared decision-making should guide physicians in discussing induced abortion with women with previable pregnancies who re­main uncertain. Physicians should refrain from making, suggesting, or implying a recommendation about continuation or termination of a previable pregnancy. Directive counselling towards continu­ation of a previable pregnancy based on alleged benefit to the preg­nant woman of providing information about fetal development or showing images of fetal development, to prevent remorse or re­gret, lacks an evidence base. Such directive counselling is an ethic­ally impermissible distortion of the physician's professional role in the informed consent process (3). All women should be informed that their decision about termination is time-limited, given the legal availability of induced abortion. In addition, in order to re­spect autonomy, the doctor should provide frank, evidence-based information about maternal or fetal conditions, even if it is emo­tionally distressing. Doctors need to make the time available for the sometimes extensive discussions required to disclose the medical facts and assist the woman to assimilate those medical facts into her decision-making process.

Individual conscience concerns the values and beliefs of a doctor that arise from sources outside the ethical concept of medicine as a profession, such as upbringing and religion. Individual conscience does not justifiably place limits on the ethics ofoffering induced abor­tion or feticide after and before viability, when the earlier mentioned ethical justifications apply.

Performing induced abortion and feticide

Before viability, it is ethically permissible in the professional respon­sibility model to perform an induced abortion. This is because the pregnant woman is free to withhold or withdraw the moral status of being a patient from the previable fetus at her discretion. Induced abortion of the previable fetus in such circumstances therefore does not involve the killing of a patient (2, 3). For the same reason, per­forming feticide in a previable pregnancy is ethically permissible.

Pregnant women should not be presumed to understand that ex­pelling the near-viable fetus with a severe anomaly from the uterus could result in a live birth and that feticide can prevent this out­come. In such circumstances, live birth creates an increased risk of preventable neonatal morbidity. There is a beneficence-based obli­gation to prevent this risk. Refusal of feticide can also be seen as contradictory because election of termination of pregnancy means that the pregnant woman does not wish to have a live-born child issue from her current pregnancy. Such contradictory thinking is evidence of significant impairment of the capacity for autonomous decision-making. It is therefore reasonable for the doctor to require that the pregnant woman accept feticide as a condition for per­forming termination of her pregnancy.

Some doctors may have objections in individual conscience to participation in induced abortion or feticide. Respecting individual conscience means that such doctors should be free to refuse to per­form induced abortion or feticide. An important implication of this analysis of individual conscience is that a requirement of residents or fellows to participate in induced abortion or feticide is ethically impermissible. However, a requirement that trainees have an appro­priate fund of knowledge about these procedures and an appropriate fund of knowledge and clinical skills in managing their complica­tions is consistent with individual conscience and a matter of profes­sional obligation (2, 3).

Doctors with individual conscience-based objections to induced abortion or feticide must keep in mind, when they refuse to per­form the procedure, that individual conscience does not govern the doctor's professional role. It is therefore impermissible for the doctor to invoke individual conscience to justify expression of judgements about the morality of a woman's election of induced abortion or feti­cide or of colleagues who perform these procedures (2, 3).

Referring for induced abortion or feticide

The ethics of referral for induced abortion or feticide is straightfor­ward for physicians who do not have conscience-based objections to induced abortion. They can make what we call direct referrals (33). The referring physician sees to it that the patient will be seen by a colleague competent and willing to perform the procedure with the patient's informed consent.

Direct referral appears not to be an option for doctors with a conscience-based objection to induced abortion or feticide, because of the explicit involvement of the physician in the subsequent ter­mination of a pregnancy. To concomitantly respect the pregnant woman's autonomy and the individual conscience of doctors, an in­direct referral for termination of pregnancy should be made. Indirect referral is both autonomy based and beneficence based. When it is obligatory to offer induced abortion or feticide, respect for the pregnant woman's autonomy in previable pregnancies requires the doctor to inform her that induced abortion or feticide is an op­tion. Beneficence requires the doctor to provide information about clinics or agencies, such as Planned Parenthood in the United States, that provide competent and safe induced abortion or feticide. The doctor's individual conscience is not violated, because whether an induced abortion or feticide subsequently occurs is solely a function of the pregnant woman's subsequent exercise of her autonomy. The referring doctor is therefore not responsible for her subsequent deci­sion: the woman is. Direct referral for induced abortion or feticide is not ethically required but is ethically permissible. Conscience-based objections to direct referral for induced abortion or feticide have merit; conscience-based objections to indirect referral do not (33).

Intrapartum management

Sometimes, caesarean delivery is well supported and vaginal de­livery is not supported in beneficence-based deliberative clinical judgement. For example, when there is a previous classical incision on the uterus, caesarean delivery is clearly preferable to vaginal de­livery because caesarean delivery prevents the fetal and maternal risk of a ruptured classical incision in the uterus (34). Vaginal de­livery in these circumstances would result in a substantial increase in preventable maternal-fetal morbidity and mortality. No well- founded beneficence-based clinical judgement could support of­fering vaginal delivery to women with a previous classical uterine incision. The professional responsibility model therefore requires that caesarean delivery should be recommended to such patients. With the patient's consent, it should then be performed.

Sometimes, caesarean delivery and vaginal delivery are both well supported in beneficence-based deliberative clinical judge­ment. In some clinical circumstances there is scientific contro­versy as to whether caesarean delivery or vaginal delivery is the better alternative. Competing well-founded, beneficence-based, deliberative clinical judgements regarding how to balance the fetal benefit of preventing harm against the maternal risk of caesarean delivery generate these controversies. Whenever two management strategies are well supported in beneficence-based, deliberative clinical judgement, both should be offered to the pregnant woman so that she can exercise her autonomy in a shared decision-making process.

Trial of labour after a low transverse caesarean delivery (TOLAC), or vaginal birth after caesarean delivery (VBAC), illustrates this cat­egory. In 2010, both the United States National Institutes of Health (NIH) Consensus Panel (35) and American College of Obstetricians and Gynecologists (ACOG) (36) issued updated statements on VBAC. In the United Kingdom, the National Institute for Health and Care Excellence (NICE) report provides a thorough review of the clinical benefits and risks to both pregnant and fetal patients and calls for an evidence-based approach to the informed consent process (37). Both agree that there should be an evidence-based informed consent process in which pregnant women with a prior caesarean delivery be counselled concerning VBAC. Here we pro­vide an ethically justified, practical to the informed consent process for TOLAC.

When both repeat caesarean and TOLAC are supported in evidence-based, beneficence-based, deliberative clinical judgement, both should be offered in clinical settings where TOLAC can be performed safely. The NIH Consensus Panel (35) and ACOG (36) statements are in consensus that TOLAC after a previous single low transverse uterine incision is medically reasonable and should be offered when there has been one previous low transverse incision. Current evidence supports the beneficence-based clinical judgement that the clinical risks of TOLAC to both pregnant and fetal patients are acceptable when there has been one previous low transverse in­cision. Planned repeat caesarean delivery also has acceptable risks to both pregnant and fetal patients. Both therefore should be offered in the decision-making consent process to the pregnant woman with one previous low transverse incision, because both are medically reasonable in this clinical circumstance. Counselling about these alternatives should be non-directive in a shared decision-making process.

There is controversy concerning TOLAC after two low transverse incisions. The ACOG statement, on the basis of level B evidence, states: ‘Women with two previous low transverse incisions may be considered candidates for TOLAC' (36). The NIH Consensus Panel was silent on this topic (35). Level B evidence is inherently contro­versial in beneficence-based clinical judgement. As a result, doctors should responsibly manage competing evidence-based, beneficence clinical judgement about the safety for pregnant and fetal patients of TOLAC when the pregnant woman has had two previous low trans­verse incisions. In the informed consent process, responsible man­agement is achieved by offering TOLAC but only when the doctor explains the uncertainties of the current state of the evidence in this clinical circumstance.

For women with one previous low transverse incision, both TOLAC and planned repeat caesarean delivery should be offered. TOLAC should be offered only in clinical settings properly equipped and staffed to do so. Doctors should recommend against TOLAC when the pregnant woman has had a previous classical incision. TOLAC after two previous low transverse incisions may be offered provided that the informed consent process presents the uncertain­ties of the evidence.

Sometimes vaginal delivery is well supported in beneficence­based clinical judgement and caesarean delivery is not supported in beneficence-based deliberative clinical judgement. When delib­erative beneficence-based clinical judgement concludes that vaginal delivery is the only medically reasonable alternative, it should be recommended. Caesarean delivery involves a clinically significant increased risk of unnecessary and preventable maternal morbidity and mortality (38). The unnecessary and preventable nature of the risks of caesarean delivery loom large in this beneficence-based de­liberative clinical judgement. As a consequence, the professional re­sponsibility model prohibits the offering of caesarean delivery; only vaginal delivery should be recommended.

Some women will, unprompted, request non-indicated cae­sarean delivery. This is known as patient-choice caesarean delivery, maternal-choice caesarean delivery, or caesarean delivery on de­mand. One review reported a range from 2% of patient-choice cae­sarean deliveries in Canada to 17% in Australia and perhaps as high as 80% in Brazil (39).

How to respond to such requests has become controversial throughout the world. In the United States, for example, the ACOG stated in a committee opinion in 2003 that, while the right of pa­tients to refuse unwanted surgery is well known, less clear is the right of patients to have a surgical procedure when scientific evidence supporting it is incomplete, of poor quality, or totally lacking (40). The Committee concluded that the evidence to support the benefit of caesarean delivery remains incomplete and that there are insuffi­cient morbidity and mortality data to compare caesarean delivery with planned vaginal delivery. In addition, the United States NIH convened a 2006 conference regarding this issue that concluded that there is insufficient evidence to evaluate fully the benefits and risks of primary caesarean delivery as compared to vaginal delivery, and that more research is needed (41). The NIH conference concluded: ‘The magnitude of caesarean delivery on maternal request is difficult to quantify. There is insufficient evidence to evaluate fully the benefits and risks of caesarean delivery on maternal request compared with planned vaginal delivery. Any decision to perform a caesarean de­livery on maternal request should be carefully individualized and consistent with ethical principles' (20).

In the United Kingdom, the NICE 2011 report notes the increasing rates of ‘maternal request for caesarean delivery' and that a common reason for such requests is the pregnant woman's concern for the safety of her baby. The report also notes that ob­stetricians implement as much as half of the requests that they re­ceive. The report provides guidance for obstetricians in response to maternal request for caesarean delivery: ‘When a woman requests a CS [caesarean section] the first response should be to determine the reason for the request and the factors that are contributing to the request. This can then be followed by the provision of informa­tion that compares the risks and benefits of planned CS and vaginal birth' (37). The report makes the following recommendation: ‘For women requesting a CS, if after discussion and offer of support (in­cluding perinatal mental health support for women with anxiety about childbirth), a vaginal birth is still not an acceptable option, offer a planned CS' (37). Obstetricians unwilling to perform cae­sarean delivery on maternal request ‘should refer the woman to an obstetrician who will perform CS' (37).

Currently, beneficence-b ased deliberative clinical judgement favours vaginal delivery (2). Hence, counselling should be directive, as opposed to non-directive counselling, in response to requests for non-indicated caesarean delivery: the obstetrician should clearly recommend vaginal delivery. We therefore disagree with the NICE report's purely non-directive approach (37).

The obstetrician is expected to exercise professional, beneficence­based clinical judgement when making clinical recommendations and present the medically reasonable alternatives as well as the alter­native of non-intervention. The patient can then exercise her rights to accept or refuse intervention. Respect for autonomy in informed decision-making does not warrant routine offering of caesarean delivery, because doing so is not supported in beneficence-based clinical judgement. Routinely offering caesarean delivery does not empower pregnant women.

Considering beneficence-b ased and autonomy-b ased obliga­tions to the pregnant woman together, there is no ethical obligation to offer non-indicated caesarean delivery to all pregnant women. Offering caesarean delivery to all patients does not promote their health-related interests. Obstetricians must rigorously adhere to the requirements of professional integrity, to prevent potential bias from influencing the physician's discussion with the patient introduced by economic gain or other forms of self-interest. The NICE report's indications for offering planned caesarean delivery do not include routine offering of caesarean delivery (37) and therefore reflect this ethical position.