A recent statement of consensus held that the principle of double effect would allow the induction of a previable fetus in order to eliminate a grave and present danger to the life of a mother suffering from peripartum cardiomyopathy. The author responds to this declaration, points out some limitations preventing it from being a vehicle for broader agreement, and offers an alternative, namely, medical induction of labor in cases of maternal–fetal vital conflict can be justified if the (...) fetus has at least a fair chance of survival. This support of induction in cases of periviability considers the interests of both fetus and mother and, unlike the earlier consensus statement, can be defended by those who hold that one’s moral intention includes both the ultimate and proximate ends, or the immediate consequences of one’s act. (shrink)

We should not think of babies as having a right to be born healthy. We cannot say what such a right involves, and if we could, enforcing it would infringe on the mother's most basic rights. Most importantly, positing such a right casts the fetus and mother as adversaries, and so destroys the maternal‐fetal relationship.

The case, which occurred in a public hospital in Turkey in 2005, exhibits a striking dilemma between a mother’s and her fetus’ interests. For a number of reasons, the mother refused to cooperate with the midwives and obstetrician in the process of giving birth, and wanted to leave the hospital. The care providers evaluated the case as a matter of maternal autonomy and asked the mother to give her consent to be discharged from the hospital, which she did despite (...) the fact that her cervix was fully open. She left the hospital and gave birth shortly thereafter. Subsequently, the baby died two days later. In light of the contemporary ethical principles, the mother’s competency could be debatable due to the physical and psychological conditions the mother confronted. Furthermore, protection of the fetus’ life should have been taken into account by the caregivers when making a decision concerning discharging of the mother. (shrink)

Suppose a woman chooses to carry a pregnancy to term. What duties should she be understood to have with respect to the fetus? If she is informed that a vaginal delivery will pose significant risks to its life or health, for example, is she obligated to submit to a caesarean section procedure on its behalf?

In this essay, some of the signatories to “Medical Intervention in Cases of Maternal–Fetal Vital Conflicts: A Statement of Consensus” respond to “The Placenta as an Organ of the Fetus: A Response to the Statement of Consensus on Maternal–Fetal Conflict,” both recently published in this journal. The response examines Bringman and Shabanowitz’s claims and assumptions about the morally relevant pathologic condition in some cases of peripartum cardiomyopathy complicated by a subsequent pregnancy, the moral status of (...) a normally functioning placenta, and the use of the principle of double effect in these cases. The signatories’ response sets out to demonstrate how Bringman and Shabanowitz do not engage the essential points of the statement of consensus and how their argument is premised on false assumptions. National Catholic Bioethics Quarterly 15.2 : 241–250. (shrink)

The presence of fetal cells has been associated with both positive and negative effects on maternal health. These paradoxical effects may be due to the fact that maternal and offspring fitness interests are aligned in certain domains and conflicting in others, which may have led to the evolution of fetal microchimeric phenotypes that can manipulate maternal tissues. We use cooperation and conflict theory to generate testable predictions about domains in which fetal microchimerism may (...) enhance maternal health and those in which it may be detrimental. This framework suggests that fetal cells may function both to contribute to maternal somatic maintenance (e.g. wound healing) and to manipulate maternal physiology to enhance resource transmission to offspring (e.g. enhancing milk production). In this review, we use an evolutionary framework to make testable predictions about the role of fetal microchimerism in lactation, thyroid function, autoimmune disease, cancer and maternal emotional, and psychological health.Also watch the Video Abstract. (shrink)

in In Harm’s Way: Essays in Honor of Joel Feinberg, edited by Allen Buchanan and Jules Coleman (Cambridge: Cambridge University Press, 1994), pp. 324-343.

Is the “act itself” of separating a pregnant woman and her previable child neither good nor bad morally, considered in the abstract? Recently, Maureen Condic and Donna Harrison have argued that such separation is justified to protect the mother’s life and that it does not constitute an abortion as the aim is not to kill the child. In our article on maternal–fetal conflicts, we agree there need be no such aim to kill (supplementing aims such as to remove). (...) However, we argue that to understand “abortion” as performed only where the death of the child is intended is to define the term too narrowly. Respect for the mother, the fetus, and the bond between them goes well beyond avoiding any such aim. We distinguish between legitimate maternal treatments simply aimed at treating or removing a damaged part of the woman and illegitimate treatments that focus harmfully on the fetal body and its presence within the mother’s body. In obstetrics as elsewhere, not all side effects for one subject of intervention can be outweighed by intended benefits for another. Certain side effects of certain intended interventions are morally conclusive. (shrink)

Medea killed her children to take away the smile from her husband's face, according to Euripides, an offence against nature and morality. What if Medea had still been carrying her two children, perhaps due to give birth within a week or so, and had done the same? If this would also have been morally reprehensible, would that be a judgment based on her motives or on her action? We argue that the act has multiple and holistic moral features and that, (...) in fact, there is no absolute principle, such as the right of the fetus to life, which governs our moral judgments about fetal-maternal conflicts. We suggest that they illustrate a pervasive feature of human moral discourse and can only be addressed by attending to a range of negotiable moral considerations which depend on particular features of each situation. (shrink)

Obstetric ultrasound has become a significant tool in obstetric practice, however, it has been argued that its increasing use may have adverse implications for women’s reproductive freedom. This study aimed to explore Australian obstetricians’ experiences and views of the use of obstetric ultrasound both in relation to clinical management of complicated pregnancy, and in situations where maternal and fetal health interests conflict.

Why do humans menstruate while most mammals do not? Here, we present our answer to this long‐debated question, arguing that (i) menstruation occurs as a mechanistic consequence of hormone‐induced differentiation of the endometrium (referred to as spontaneous decidualization, or SD); (ii) SD evolved because of maternal–fetal conflict; and (iii) SD evolved by genetic assimilation of the decidualization reaction, which is induced by the fetus in non‐menstruating species. The idea that menstruation occurs as a consequence of SD has (...) been proposed in the past, but here we present a novel hypothesis on how SD evolved. We argue that decidualization became genetically stabilized in menstruating lineages, allowing females to prepare for pregnancy without any signal from the fetus. We present three models for the evolution of SD by genetic assimilation, based on recent advances in our understanding of the mechanisms of endometrial differentiation and implantation. Testing these models will ultimately shed light on the evolutionary significance of menstruation, as well as on the etiology of human reproductive disorders like endometriosis and recurrent pregnancy loss. (shrink)

There are limitations of obstetric estimation of neonatal outcome in extremely premature newborns. Predicting outcomes, survival, and morbidity are often uncertain, such as in cases of extreme prematurity, certain fetal anomalies, intrauterine growth restriction, and intrauterine infection. Informed consent, truth telling, the maternal–fetal conflict, decision making, and the fetus as a patient are the most important issues of obstetric and neonatal ethics. Because the boundary between utility and futility is not clear, the best interest of the (...) mother, the fetus, and the newborn will be subject of discussion every time. Here, we report a case of obstetric patient to discuss. (shrink)

This essay concerns what people should do in conflict situations when a doubt of fact bears on settling whether an alternative under consideration is legitimate or not. Its principal audience are those who believe that abortion can be legitimate when not having an abortion gives rise to serious harms that can be avoided by having one, but who are concerned that fetuses might feel pain when being aborted, and who believe that causing unnecessary pain should be avoided when doing (...) so would not pose an undue burden. The essay remains neutral on the substantive questions of the moral status of the unborn and the morality of abortion. The question of fetal pain has taken center stage in the last few years in the .. (shrink)

Assessing the risk-benefit ratio has always been considered key in designing clinical trials. These benefits can be diverse and may include social value and psychological benefits. When it comes to...

This paper aims to address how artificial gestation might affect equality of opportunity for the unborn and any resultant generation of “ectogenetic” babies. It will first explore the current legal obstacles preventing the development of ectogenesis, before looking at the benefits of allowing this technology to control fetal growth and development. This will open up a discussion of the treatment/enhancement divide regarding the use of reproductive technologies, a topic featured in various bioethical debates on the subject. Using current maternity (...) practices in Western society as a comparator, this paper will conclude that neither naturally nor artificially gestated fetuses have interests that can conflict with those of potential parents who might want to use this technology to control fetal development. Such control may include selective implantation of embryos of a desired gender, deliberate choice of genetic traits, or maintenance of an ideal incubation environment to avoid fetal damage. Objections on the basis of disability as well as concerns regarding eugenics will be addressed. The paper will conclude that none of these objections are compelling grounds to prevent the development and use of ectogenesis technologies for the purpose of achieving specific reproductive goals, particularly when compared to current practices in pre-implantation genetic diagnosis and selective abortion on the grounds of undesired traits. As such, when deciding whether to support ectogenesis research, the enduring interests of parents must be the primary consideration, with societal concerns regarding potential misuse the only valid secondary consideration. (shrink)

This chapter contains sections titled: Abortion and Mother‐Fetus Conflict Moral Obligations to the Unborn The Obstetrical Cases: Forced Cesareans Fetal Surgery Conclusion References Further reading.

For ages, medicine has had poor access to the fetus inside the mother's womb. But in relatively recent years, the human body has become transparent. The latest breakthroughs of technology have made it possible, from the very beginning of pregnancy, to consider the fetus as an individual who can be examined and sampled. His or her physician may now establish a diagnosis and prognosis and prescribe a treatment in the same way as in traditional medicine.

For ages, medicine has had poor access to the fetus inside the mother's womb. But in relatively recent years, the human body has become transparent. The latest breakthroughs of technology have made it possible, from the very beginning of pregnancy, to consider the fetus as an individual who can be examined and sampled. His or her physician may now establish a diagnosis and prognosis and prescribe a treatment in the same way as in traditional medicine.

What are the implications of microchimerism in sociocultural and ethico-legal contexts, particularly as they relate to the destabilization of genetic origins? Conventional biomedicine and related law have been reluctant to acknowledge microchimerism—the existence of unassimilated traces of genetic material that result in some cells in the body coding differently from the dominant DNA—despite it becoming increasingly evident that microchimerism is ubiquitous in the human population. One exception is maternal–fetal microchimerism which has long been recognized, albeit with little consideration (...) of the nonmedical implications. Most immediate issues concern the ongoing biomedical debate around whether microchimerism is beneficial in terms of enhancing the body’s range of immunological responses, harmful in provoking autoimmune diseases, or simply neutral with respect to subsequent health. That controversy remains unresolved, but whichever way it develops, I want to extend consideration by insisting that changing biological concerns cannot be separated from sociocultural and ethico-legal effects. Once the diversity of DNA coding in a singular body has been established, relations of kinship, the identification of legal parenthood, and the operation of surrogacy laws are of direct interest. The overriding problematic asks whether our ethical and legal apparatus is able to address such newly emerging questions. (shrink)

Maternal–fetal surgery (MFS) encompasses a range of innovative procedures aiming to treat fetal illnesses and anomalies during pregnancy. Their development and gradual introduction into healthcare raise important ethical issues concerning respect for pregnant women’s bodily integrity and autonomy. This paper asks what kind of ethical framework should be employed to best regulate the practice of MFS without eroding the hard-won rights of pregnant women. I examine some existing models conceptualising the relationship between a pregnant woman and the (...) fetus to determine what kind of framework is the most adequate for MFS, and conclude that an ecosystem or maternal–fetal dyad model is best suited for upholding women’s autonomy. However, I suggest that an appropriate framework needs to incorporate some notion of fetal patienthood, albeit a very limited one, in order to be consistent with the views of healthcare providers and their pregnant patients. I argue that such an ethical framework is both theoretically sound and fundamentally respectful of women’s autonomy, and is thus best suited to protect women from coercion or undue paternalism when deciding whether to undergo MFS. (shrink)

If the practice of maternal‐fetal medicine sometimes results in abortion, can a physician strongly opposed to abortion maintain his own integrity and still practice in this field?

When surgery is performed on pregnant women forthe sake of the fetus (MFS or maternal fetalsurgery), it is often discussed in terms of thefetus alone. This usage exemplifies whatphilosophers call the fallacy of abstraction: considering a concept as if it were separablefrom another concept whose meaning isessentially related to it. In light of theirpotential separability, research on pregnantwomen raises the possibility of conflictsbetween the interests of the woman and those ofthe fetus. Such research should meet therequirement of equipoise, i.e., (...) a state ofgenuine uncertainty about the risks andbenefits of alternative interventions ornoninterventions. While illustrating thefallacy of abstraction in discussions of MFS,we review the rationale for explicitacknowledgment of the essential tie betweenfetus and pregnant woman. Next we examinewhether it is possible to meet the requirementof equipoise in research on MFS, focusing on afetal condition called myelomeningocele. Weshow how issues related to equipoise innonpregnant populations appear also in debatesregarding MFS. We also examine evidence insupport of claims that the requirement ofequipoise has been satisfied with respect to``the fetal patient'' while considering risks andbenefits to gestating women only marginally ornot at all. After delineating challenges andpossibilities for equipoise in MFS research, weconclude with a suggestion for avoiding thefallacy of abstraction and achieving equipoiseso that research on MFS may be ethicallyconducted. (shrink)

This article focuses on maternal-fetal surgery (MFS) and on the concept of clinical equipoise that is a widely accepted requirement for conducting randomized controlled trials (RCT). There are at least three reasons why equipoise is unsuitable for MFS. First, the concept is based on a misconception about the nature of clinical research and the status of research subjects. Second, given that it is not clear who the research subject/s in MFS is/are, if clinical equipoise is to be used (...) as a criterion to test the ethical appropriateness of RCT, its meaning should be unambiguous. Third, because of the multidisciplinary character of MFS, it is not clear who should be in equipoise. As a result, we lack an adequate criterion for the ethical review of MFS protocols. In our account, which is based on Chervenak and McCullough's seminal work in the field of obstetric ethics, equipoise is abandoned. and RCT involving MFS can be ethically initiated when a multidisciplinary ethics review board (ERB), having an evidence-based assessment of the risks involved, is convinced that the value of answering the research hypothesis, for the sake of the health interests of future pregnant women carrying fetuses with certain congenital birth defects, justifies the actual risks research participants might suffer within a set limit of low/manageable. (shrink)

This book addresses the ethical problems in maternal-fetal medicine which impact directly on clinical practice.

Previously conducted research has determined that physiological and psychophysiological communications evident during pregnancy are vital to the bond formed prenatally. These innate biological responses are further enhanced through psychophysiological factors, such as maternal prenatal stress, which attest to the essential communication between a mother and child in maternal–fetal attachment. A consideration of these factors is necessary with the increase in assisted reproductive technology, such as in vitro fertilization, surrogacy, and elective cesarean section, as this may affect the (...) development of the maternal–fetal bond. It would be of benefit to the child, the mother, and every society to seek a more complete understanding of the intricate maternal–fetal bond, as the first friendship developed at the beginning of human life. (shrink)

Who has more rights-the mother or the fetus? Interdisciplinary in scope and character, this latest volume of Humana's classic series, Biomedical Ethics Reviews, focuses on the complex moral and legal problems involving human fetal life. Each article in Bioethics and the Fetus provides an up-to-date review of the literature and advances bioethical discussion in its field. The authors have avoided much of the technical jargon of philosophy and medicine in order to speak directly to a broad and general readership. (...) Topics include: • maternal-fetal conflict • the disposition of aborted fetuses • frozen embryos • creating children to save sibling's lives • fetal tissue transplantation • moral implications of fetal brain integration • the embryo as patient • prenatal diagnosis. Probing deeply into these thorny issues, Bioethics and the Fetus offers thought-provoking reading-and paves the ground for new insight-for a host of healthcare and other professionals, as well as concerned laypersons. (shrink)

The purpose of this commentary on James Nelson's article [1] is to advocate introducing the ethics of care into the arena of gestational conflict. Too often the debate gets stalled in a maternal versus fetal rights headlock. Interventionists stress fetal over maternal rights: they believe education, post-birth prosecution or pre-birth seizure of pregnant women may be permissible. In contrast to interventionists, other philosophers stress that favoring fetal rights treats women like fetal containers. I (...) question whether we should really consider issues of moral/parental obligations to children in terms of rights. Rather, the language of care should guide moral conduct vis-a-vis children/fetuses. The particularity of each woman's story — the particulars of her human relationships — inform her story. An individual's ability to care is largely a function of whether community cares for her. We must care for others to enable them to care for themselves and their loved ones — born or unborn. (shrink)

The history of maternal-fetal therapy is a complex and compelling one. It can be argued that the science and ethics underpinning this field evolved together, with emerging technology spurring on th...

To study Judicial determinants of the ordered obstetrical and fertility interventions. Nature, corresponding laws, decisions upon the 37 expounded holdings at the Probate, Trial, District, Appellate, and Supreme Courts are studied in 92 published materials identified through the ACOG, RCOG, SOCG portals, and Legal Scholarship Repository. Hearings are held in the US (83.8 %), Canada (10.8 %) and U.K (5.4 %). Of all the hearings reviewed, 27 % concern mentally impaired, 37.8 %-maternal incompetence, and 21.6 % cases are of (...) criminal nature. The Judicial determinants vary from country to country. In Canada, the ordered medical interventions are effected by the child protection legislation, whereas in the US, by court orders. In majority of cases, orders are obtained by dismissing the patriae petitions for involuntary sterilizations of mentally impaired sui juris adults (57 %); coerced obstetrical interventions (33.3 %), fetal custody (50 %); enforcement of surrogacy contracts (62.5 %) in favor of the Common Humanity Benefit clause; and recognizing the rights to inherit in posthumously conceived children (80 %) pursuant to the Social Security Act, Law of obviousness, Law of inherent anticipation, and Intestacy statute. Current study prioritizes two questions: (1) whether it is justified to override the wishes of a competent patient purportedly in her best interests; and (2) whether the patient’s autonomy and competence is an absolute concept. With the law unsettled as to a woman’s right to assent a treatment and contradict her fetus, parties concerned with fetal rights should consider exercising of screening tools on maternal judgmental fitness jointly developed by medical and legal practitioners. Further, given the advances in gamete conservations, states consider enacting legislation in order to safeguard the orderly administration of estates disrupted by claims from posthumously conceived children. A balance must be struck between the child’s right to inherit, the state’s interest, as well as the interests of prior born children. (shrink)

At no time in recent decades has more attention been paid to ethical issues in pregnancy. Particularly riveting—and alarming, to many—was the passage of Senate Bill 8, a Texas law banning abortion...

As members of the fetal surgery advisory board at a large tertiary care center, we read with great interest Hendriks’ et al. target article proposing a new ethical framework for fetal therap...

Pregnancy presents some interesting challenges for the philosophy of embodied cognition. Mother and fetus are generally considered to be passive during pregnancy, both individually and in their relation. In this paper, we use the enactive operational concepts of autonomy, agency, individuation, and participation to examine the relation between mother and fetus in utero. Based on biological, physiological, and phenomenological research, we explore the emergence of agentive capacities in embryo and fetus, as well as how maternal agency changes as pregnancy (...) advances. We show that qualitatively different kinds of agency have their beginnings already in utero, and to what extent fetal and maternal movement modulate affectivity and individuation in pregnancy. We thus propose that mother and fetus are both agents who participate in pregnancy. Pregnancy then emerges as a relational developmental organization that anchors and holds its developing participants. We end the paper with reflections on ethical implications of this proposal, and suggestions for future research. (shrink)