Medical Ethics in Gynecology and Perinatology
Catholic University of Croatia; Department of Medical Ethics, University of Zagreb, School of Medicine; Special Hospital AGRAM - Polyclinic Rijeka, Croatia
Corresponding Author: Morana Brkljacic, Catholic University of Croatia; Department of Medical Ethics, University of Zagreb, School of Medicine; Special Hospital AGRAM - Polyclinic Rijeka, Croatia, Phone: +385915478513, e-mail: firstname.lastname@example.org
Received on: 15 January 2023; Accepted on: 10 February 2023; Published on: 14 April 2023
Background: This paper aims to present medical ethics in perinatal medicine as application of some key ethical principles to the practice of perinatal medicine.
Methods: This is review of how medical science, combined with the progress of technology, has contributed in many ways to improving the maintenance of human health. Medical ethics acts as a functional interface between medicine, science, and ethics.
Results: Medical ethics links scientific endeavor and its application into adaptive forms of ethical consensus. Its major elements are an increased understanding of biological systems and the responsible use of technology in tune with new scientific insights. When does a human being become a person? When does personhood end? These critical questions are some of the most interesting and affecting in medical ethics; at the beginning and end of life rights of the mother versus rights of the fetus, abortion, assisted reproduction and surrogacy are the hot-button issues that can be addressed with medical ethics.
Conclusion: Bioethics should represent a new scientific ethics that connects humility, responsibility, and ability; a science that is interdisciplinary, cross-cultural and global, and that exalts the meaning of humanity. It perceives the man’s well-being in the context of respect for nature, and as such, should become a kind of a “science of survival”.
How to cite this article: Brkljacic M. Medical Ethics in Gynecology and Perinatology. Donald School J Ultrasound Obstet Gynecol 2023;17(1):47-53.
Source of support: Nil
Conflict of interest: None
Keywords: Bioethics, Gynecology, Human being, Medical ethics, Medicine, Science.
This paper was presented at the symposium Zagreb—New York ethical and perinatal dialogue (first International symposium when does human life begin? Ethics, law, and professionalism in reproductive medicine; and fetal neurology—from short to long-term follow-up—how to proceed? Multicenter results on the clinical use of Kurjak’s antenatal neurodevelopmental test), held on 8–9th October 2022 in Zagreb, Croatia.
Ethics, sometimes known as philosophical ethics, ethical theory, moral theory, and moral philosophy, is a branch of philosophy that involves systematizing, defending, and recommending concepts of right and wrong conduct, often addressing disputes of moral diversity. The term comes from the Greek word ηθικός ethikos from ἦθος ethos, which means “custom, habit.” Philosophical ethics investigates what the best way for humans to live is and what kinds of actions are right or wrong in particular circumstances.1
Ethics and morality mean the same thing to many people, and they are similar. Morals are used to describe personal character, whereas ethics defines behavior in different situations. Morality refers to personal character, beliefs, and behavior; ethics is about the reflection on morality and deciding how to act as a person or a professional. An ethical person and moral person are usually one and the same. We use medical ethics to refer to those guidelines and behaviors that we expect a medical professional with moral integrity to exhibit.
Medical ethics acts as a practical interface between medicine, science, and ethics. It links scientific endeavor and its application into adaptive forms of ethical consensus. Its major elements are an increased understanding of biological systems and the responsible use of technology in tune with new scientific insights.2
Medical science, combined with the progress of technology, has contributed in many ways to improving the maintenance of human health and, thus, inevitably extending the length of human life. Along with the growing application of various medical-technological aids with the aim of extending the length of life, medicine necessarily had to develop and has developed a set of new principles necessary to solve complex ethical problems.
FROM MEDICAL ETHICS TO CLINICAL ETHICS
In the past decades, medical ethics/bioethics has lived a very rich and complex history, and today clinical ethics represents its most prominent and dynamic segment. Taking into account clinical ethics’ most important characteristics (focus on questions of ethics in the continuous, daily care for the patient, discussions about different models of ethical decision-making in practice and the importance of education and research), Fletcher and Brody have identified three focal points of any clinical ethics program in a healthcare institution:
Services (models of ethical decision-making in clinical practice, such as consultations and policy formulation).
Medical ethics, which is now being practiced under the name of bioethics, is a short-term tactic; in fact, it is clinical ethics, which deals with dilemmas faced by doctors, their patients, and those who care for patients. Global bioethics, in turn, calls upon medical ethicists to consider the basic meaning of bioethics and to expand their thinking and actions to global public health problems. Medical ethicists are obliged to consider not only the everyday clinical decisions but also long-term consequences of actions they recommend or fail to consider. Medical ethics are simply some key ethical principles applied to the practice of medicine. These principles are the bedrock of good clinical practice and they are autonomy, nonmaleficence, beneficence and justice. Using these principles in each individual case, it can be easier to make difficult decisions with your patients as you guide them through their care.4
Medical ethics as professional ethics is the area of application of general ethical principles to the specific material of medical practice. Two important qualifications make it exclusively the area of activity of medics and other health professionals:5
Practice in solving professional ethical dilemmas.
Responsibility for one’s own moral practice.
Both medicine and its medical ethics should refer to an ethical attitude toward the patient, especially one suffering from a difficult or incurable disease, as well as an ethical approach to his pain and needs.
All of Hippocrates’ traditional medical thought emphasized beneficence. Its goal is to do the best possible for the patient, but at the same time, it is necessary to emphasize that in modern times when medical ethics is on the scene, it is important not only to do a good deed but also to have permission for that deed, which is emphasized through the notion of patient autonomy in making decisions.6 Patient autonomy is one of the most important ethical principles in medicine, including in oncology, and is based on the patient’s decision about treatment after being informed about it, that is, on informed consent. The doctor is obliged to adapt the information to the patient’s education and ability to understand, and he must give it not too late so that the patient can finish his work and fulfill his obligations on time.7 Ethical values, both in medicine and in patient care, are achieved through four fundamental ethical principles.8
Beneficence and nonmaleficence require from the person caring for the patient the obligation of maximum benefit and minimum harm to the patient. Perhaps, seemingly, it seems a very simple task to fulfill the above principles; however, what is the peak of well-being and harmlessness for one patient, should not be for another patient, or it does not seem to that patient that maximum benefit and minimum harm for him has been achieved. Huge diversity of cultures, religions, beliefs, and ways of life indicates the need of the one who cares for the patient not to hesitate to ask the patient what is best for him and in what way to do it best. It is precisely through this method of communication that we, as guardians, ensure the maximum of doing good, that is, not doing harm.
Autonomy is a principle based on the patient’s self-awareness and self-determination and his right to make a decision. The concept of integrity (integration) and informed consent are key to all discussions of patient autonomy. Also, as caregivers and members of an interdisciplinary team (either doctors, nurses, or other health personnel), we must be ready for “informed disagreement-refusal” as one of the possibilities of the patient’s choice and thus prove our ethical maturity in respecting the patient’s decision-making autonomy.
Fairness represents the principle that is the main way out in solving all discussions whose core problem lies in diversity. Diversity (inequality), especially of opinions and attitudes, is the most common problem of the patient not believing in the decisions of both the medical professional and the interdisciplinary team.
It is also necessary to mention truthfulness and trust as derived ethical principles whose role is precisely in the moments of telling the truth about the diagnosis (cancer and oncological disease), the basis of building a quality relationship between the patient and the members of the healthcare team and finds its foothold in telling the truth, keeping a secret and fulfilling promises.
MEDICINE IS AN ART AND SCIENCE
The practice of medicine is an art and a science. Art comes from dealing with human beings, which can be fragile and unpredictable when they are sick and need your help. Science comes from years of research and study.
Medical ethics puts the art and science together in practical applications to tricky problems. Everyone makes mistakes, but it’s possible to learn from medical errors and design your/our practice so they are caught and fixed before they become serious problems or affect patients. As physicians, we follow patients through their lives, from prenatal care and dealing with the ethical issues of pregnancy, abortion, and reproductive technology, to treating children and working with parents.9
Everyone is a patient at some point in their life, so understanding the philosophical/ethical side of medicine can only make the process smoother, and the more medical providers understand the ethics of their profession, the more satisfying their work lives will be.
WHEN DOES A HUMAN BEING BECOME A PERSON?
When does Personhood End?
These critical questions are some of the most interesting and affecting in medical ethics at the beginning and end of life rights of the mother vs the rights of the fetus, abortion assisted reproduction and surrogacy are the hot-button issues that can be addressed with medical ethics. Pregnant women are a special subject in medical ethics.
Technically, there is only one patient, but two/more lives are in the balance. Healthcare providers must weigh issues such as medication, treatments for disease, and the autonomy of both patients. Sometimes what is good for the mother is not good for the fetus, and vice versa. Because their rights may sometimes compete, doctors must understand the ethical and legal challenges of that balancing act. The rights of the mother may automatically be diminished if it’s decided that the fetus has the same rights as a full person.
Most women choose to be pregnant and consent to treatments offered to them. But in some circumstances, some women won’t consent to medical interventions that restrict their freedom or endanger their health during pregnancy, even if these treatments may be in the best interest of the fetus. A few women have even refused treatments that may save their fetus’s life with little risk or inconvenience to themselves.10
One of the very famous cases was the case of Samantha Burton. Burton v. Florida, 49 So.3d 263 (2010), was a Florida District Court of Appeals case ruling that the court cannot impose unwanted treatment on a pregnant woman “in the best interests of the fetus” without providing evidence of fetal viability. The case was decided in Ms Burton’s favor in August 2010 by the Florida District Court of Appeals.11
BALANCING TREATMENTS FOR A WOMAN AND FETUS
Given these ethical considerations, we, as healthcare providers, must balance the health of the mother and fetus during pregnancy.
There are medical treatments for the mother that can harm the fetus:
Treatments for maternal cancer.
Diagnostic tests such as X-rays or computed tomography scans.
Prescription medications such as accutane, tetracycline, valium, warfarin, some blood pressure medicaments, and antibiotics.
There are medical treatments for the fetus that have the potential to harm the mother:
Forced cesarean sections.
Keeping a terminally ill mother alive through medical intervention to keep the fetus alive until viability.
In utero operations on the fetus.
The advent of the birth control pill changed women’s lives forever. In fact, the advent of accessible and reliable birth control has changed society.
Birth control has given women a more reliable way to prevent both unwanted pregnancies and dependence on one particular man because of a shared biological child. There are two kinds of birth control—one prevents fertilization, such as the pill and barrier methods and the other prevents implantation, such as the intrauterine device (IUD) and the morning-after pill. Some people/providers feel that this second type of birth control is actually abortion because rather than preventing the egg from being fertilized, these forms of birth control prevent a fertilized egg from implanting in the uterine lining.12 Parental consent isn’t required to treat minors in certain situations, such as sex education and prescribing contraceptives. In some states, minors can seek an abortion without parental permission. Mature minors or minor children who are old enough to understand the consequences of sexual acts can get prescriptions for birth control and other treatment related to sexuality.
The ethical issues of autonomy and informed consent come into play here.13
Teenage girls and adult women should receive all the information necessary to make the best decision about their health.
When counseling a patient about birth control, you should tell her:
How to use the method and if there are any special precautions.
How reliable that method is.
Any risks of the method, including risk.
Side effects or other health concerns, including the circumstances under which it should not be used.
Any health risks involved in that method.
What to do if the birth control methods fails.
RELIGIOUS ETHICS AND BIRTH CONTROL
Religious ethics and edicts play a large part in the lives of many people. Devout members of some religions choose to forgo medical treatment. Some religions prohibit certain types of treatment. And religious ethics can play a large part in birth control. In any case, it is important for you, for the provider, to understand different religious points of view about this issue so you can treat your patient. And you must respect your patients’ decision about whether to use birth control and which type to use.14,15
The different religions and their views on birth control include:
Catholic church: Formally, the Catholic church opposes all forms of artificial birth control because they believe that human beings should not oppose or thwart the natural God-given end of human sexuality, which is the procreation of children. The Catholics support birth control through abstinence and natural family planning or the rhythm method, which follows the natural pattern of fertility in women to avoid pregnancy. Not all Catholics adhere to this standard.
Hindu: Hindu scholars do not ban birth control. They do believe that there is a duty for adults to have children at a certain stage of life.
Islam: The Islam faith does not oppose birth control, except to state that in a marriage, birth control should be used with the full knowledge and consent of both parties. Islam opposes permanent sterility.
Judaism: Jews have several views on birth control, depending on their branch. Orthodox Jews approve of birth control when a couple already has some children. Conservative Jews allow birth control in more situations and Reform Judaism lets its followers use their own judgment.
Protestantism: Most liberal Protestants, such as Presbyterians and Anglicans, hold that birth control is entirely acceptable and a matter of personal privacy and conscience between the individual and their god. Some evangelical Protestants disagree with this view. They condemn the type of birth control that works to prevent implantation of the blastocyst, such as the IUD–some consider that an abortion.
Sikhism: Sikhs do not object to birth control, considering it a private matter relevant only to the parties directly involved.
It is important to remember that religious beliefs about birth control are important to both patients and providers, but your personal beliefs should not interfere with your patient’s rights to the care they want and deserve.
DETECTING FETAL ABUSE: ETHICAL AND LEGAL OBLIGATIONS
Fetal abuse is a relatively new area of medicine. This concept goes hand in hand with fetal rights, the idea that fetuses should have the same legal rights and protections as children. In other words, under certain conditions, pregnant women could be arrested and charged with fetal abuse. Laws are based on the principle of nonmaleficence toward the fetus. But, in certain circumstances, the concept of “do not harm” to the fetus can infringe on the mother’s right or autonomy. Women’s rights advocates do not like trend toward charging mothers who may neglect or abuse their bodies, and therefore their fetuses.16
As long as a woman is competent, she has autonomy and can make decisions about her own body. But are there conditions where a mother’s competence is questioned? How about a severe drug addiction or mental illness? Nonpregnant patients can be committed based on these conditions if they pose significant harm to themselves or others. How about if they pose a significant risk to the fetus? This is a conflict between a mother’s autonomy and the concern for the principles of nonmaleficence and beneficence for both the mother and fetus.
Healthcare providers walk a fine line when they suspect fetal abuse and detecting fetal abuse can be difficult. A mother rarely admits to a behavior that can harm the fetus. Some clues to look for when seeing a pregnant patient—poor fetal growth on abdomen measurements or ultrasound, poor weight gain of the mother, fetal tachycardia suggesting stimulative use, history or signs of maternal alcohol or drug abuse, history of signs of anorexia or bulimia, worsening depression or apathy toward the pregnancy, and history or signs of domestic abuse.
Limiting the freedom of pregnant women for the well-being of the fetus is a last resort and should only be tried when there is a significant risk of harm to the fetus. The circumstances for this type of action should be very narrowly defined. Courts are more likely to restrict maternal freedom when the fetus is at or very near the point of viability. This issue of brain-dead pregnant women is also relevant here. If a woman’s body is going to be kept alive just so her fetus can develop to viability, certain conditions must be met. They are:
The family, preferably the father of the fetus, should agree. Providers should ask about what the mother would have wanted.
There should be a reasonable chance that the fetus will reach viability in a reasonable amount of time. Keeping a brain-dead woman on life support for months is usually inappropriate.
The dignity of women must be preserved.
Each case should be decided individually.
Ethical Aspects of Abortion
There is possibly no more divisive subject in medicine/medical ethics than abortion. Although abortion is one of the most ethically difficult issues, the role of the healthcare provider is relatively simple. As in all other cases, our responsibility is to the patient.
The ethical positions about abortion vary widely. Providers need to know the ethical stances of each side to provide the best care for their patients. Autonomy, informed consent, beneficence, nonmaleficence, and justice all play a part in this debate. How should doctors communicate with women who are wondering about abortion?17 The question of when personhood begins is crucial to the abortion debate. Abortion stops the development of an embryo into a fetus and a fetus into a baby. At what point does a person, with all their inherent rights and privileges, begin? Can we even decide on a point? The establishment of personhood is important for ethical reasons and because of legal status. A person is legally protected against harm and killing because of their status as a human being. The court chose the end of the first trimester as the point where abortion could be regulated.
There are several definitions of a person. Most include some type of interaction with the world.
A human being who has a conscious awareness of self.
A human being, regardless of age or mental capacity.
A being who can set personal values and goals.
A human being who has been born and will die.
Many people use the term potential person to describe the embryo and fetus.
They state that because all of the deoxyribonucleic acid (DNA) and material needed to produce a human being exist at the moment of conception, it is ethically wrong to stop this process.
After all, an embryo will likely become a person who can set values and goals.18 Some people believe that an embryo, a potential person, should have all the rights and moral status of a person who has been born. However, at this time, in some countries, a potential person doesn’t have the same legal rights as a full person. As soon as you qualify the term person, should the legal standing change? The question is—what rights and status, if any, should be offered to a potential person? According to those in the pro-life movement, human life—personhood—begins at conception. They believe that a zygote, an embryo, or a fetus is a tiny little person who has a short-term lease on womb with heat and hot water. This tiny little person has, or deserves, the same rights as every other living, breathing, independent person.
All of the ethical principles of medicine are relevant to the fetus’s status of personhood. Under the principle of autonomy, a woman has the right to determine what medical procedures she chooses and refuses.19
But does the embryo or fetus also have the right to autonomy?
Doctors must do what is best for the patient under the principle of beneficence. Doctors must do what is best for the patient under the principle of beneficence. But who is the patient—the pregnant woman, the fetus, or both? The principle of nonmaleficence is important, too. When an abortion would save the life or health of the mother, refusing to perform it causes harm. But performing an abortion ends fetal development and growth, harming the fetus. And justice, of course, is central to this issue.
Whose rights are more important—the women’s or the fetus’s? Many ethicists have debated the abortion issue on both sides. Some of these arguments are well-documented and have been discussed countless times over the years.
UNDERSTANDING THE PRO-LIFE STANCE
A person is classified as pro-life if they don’t believe abortion should be available on demand. This side focuses on the rights and moral status of the embryo and fetus. Pro-life individuals believe that human life should be valued from conception to natural death. In most pro-life arguments, personhood begins at conception, and this side believes that any deliberate destruction of human life is ethically wrong. Those on the pro-life side do not think that the destruction of life is ever mitigated by benefits to others. From the pro-life view, any action which destroys an embryo or fetus kills a person and that is always wrong.
One well-known ethical position that supports the pro-life view is proposed by federal judge John Noonan says that genetic criteria are all that is needed to assign rights to an embryo. In other words, when sperm and egg meet and merge genes, a genetically unique person is created. The embryo has all the potential in its DNA to become a full person; therefore, it has a right to life that is absolute. This argument rests on the presumption that if you are conceived by two human beings, you are a human being and have personhood, no matter your stage of development. In this scenario, abortion is argued to be wrong because it takes the life of a genetically unique person beginning at conception.
UNDERSTANDING THE PRO-CHOICE STANCE
The pro-choice stance is based on autonomy, privacy and self-determination. This side focuses on the rights and moral status of the mother. The pro-choice side believes that because she bears the burdens of pregnancy, birth and raising a child, a woman should be able to decide if she wants to let her pregnancy proceed. The pro-choice side argues that this decision belongs to the mother alone, and that government has no jurisdiction on this issue.
This side believes that an embryo or fetus gradually attains moral standing and legal rights as it develops but doesn’t have them from the moment of conception or during the first few months of gestational development. A famous ethical argument on the pro-choice side is made by Judith Jarvis Thomson, an American philosopher who studied and worked on ethics and metaphysics; compares pregnancy to one person being attached to another person for the purpose of survival. The existence of the first person depends on the second person giving up rights to keep the first person alive. Thompson argues that no one has the right to impose himself on another person for survival. She argues that you would have the right to choose to unplug yourself from this person and recover your freedom, even if it means the death of the other person. Thomson states, “I propose, then, that the fetus is a person from the moment of conception.” Now the ethical dilemma is this—if both mother and uterine child are both human and both have rights to life, can abortion be ethically permitted where the woman does not want to continue her pregnancy?
In ethics, there are two kinds of rights—positive and negative.
Positive rights are the right to some kind of benefit, such as the right to life.
A negative right is a right to be left alone or to not be forced to do something, such as the right to refuse medical treatment.
The pro-choice side argues that a woman’s right to be left alone to make her own decision about her own life (a negative right) outweighs the pro-life side’s right to force their opinion on her life (a positive right). And a woman’s right not to be burdened with pregnancy (a negative right) outweighs the embryo’s or fetus’s rights to life (positive rights).
UNDERSTANDING THE RIGHTS OF THE CHILD
If there are problems between the couple, who have contracted with the surrogate, all bets are off. There are cases where a couple has divorced while a surrogate is carrying their child and when surrogates have changed their minds and want to keep the baby. Not all surrogacy contracts cover all situations. Informed consent is crucial in this situation. All relevant medical information should be shared with the doctor managing the surrogacy before the pregnancy begins. The potential parents have primary responsibility for the baby after it is born. And the surrogate has primary responsibility for the fetus before it is born. You must tell all parties about all of the issues of this situation and all parties should agree to details.
Summarizing the above, let’s conclude with the thought of theologian Ramsey, who, in his book “The Patient as Person,” directs his attention to the question of respecting the patient as a person. He points to the fact that the knowledge and handling of the achievements of medical technology do not allow doctors and other medical professionals to ignore the personality of each patient, especially the seriously ill and especially the terminal, and to identify patients with the diseases they suffer from or the physical defects they have, insisting on the attitude that sees the patient as a person who has his own fundamental rights and freedom. The above is an old and new ethic of the relationship of medical and health professionals toward the patient, which realizes its full application and essence in the ethics of patient care.22
In 1998, Potter, the father of bioethics, said: “as I am entering the dusk of my life, I feel that bioethics has reached the threshold of a new time that goes beyond anything I could have imagined and developed. By entering the era of the third millennium, we are becoming increasingly aware of the dilemma that places before us, an exponential increase in knowledge without an increase in the wisdom required to manage it”.
Let us recall that Potter II always viewed bioethics as a new discipline, a “new medical ethics” which would combine knowledge and deliberation, a dynamic approach to the ongoing search of the human race for wisdom, that is, knowledge on how to use knowledge for human survival and improvement of the quality of life.
Medical ethics/bioethics is the science about the use of science.
It is the ethical supervisor of science. Without such a supervisor, science can escape human control and become “dangerous knowledge.” Bioethics should, therefore, represent a new scientific ethics that connects humility, responsibility, and ability; a science that is interdisciplinary, cross-cultural and global, and that exalts the meaning of humanity. It perceives the man’s well-being in the context of respect for nature, and as such, should become a kind of a “science of survival.”23
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