Ethical Issues in Maternal-Fetal Medicine

Edited by Donna L. Dickenson*

Reviewed by Barbara A. Elliott, Ph.D.**

*Cambridge University Press, 2002, 366 pages.

**School of Medicine Duluth Duluth, MN

Donna Dickenson has edited a remarkably broad and ground-extending book titled Ethical Issues in Maternal-Fetal Medicine. The authors represent eight disciplines with international perspective, including philosophy, political science, sociology, obstetrics, pediatrics, general practice, ethics and law. This diversity is edited to capture the interest of a wide-ranging audience, and the strength of the book is that each section and its chapters consider related concerns through the eyes of alternate disciplines.

The text is arranged to be clinically accessible. After a theoretical framework for approaching the ethics of reproductive health is described, the first section addresses over-reaching issues, including diversity concerns, HIV in pregnancy, genetic screening, and society's shaping of the roles of mother and father during pregnancy. The next section discusses issues related to the inception of pregnancy; the following one considers the first and second trimesters; the next one discusses issues of the third trimester; and the final section includes chapters about ethical issues in the neonatal period. The chapters in each section address separate issues, rather than presenting contrasting views to a specific topic.

In addition, there are themes that weave throughout the text and are enriched by the longitudinal clinical view established by the table of contents. The themes addressed in this way include power issues between physicians and mothers; the impact of new technologies and diseases on reproduction; the experience of disability; and the role of differences in gender and culture in reproduction. Each of these themes is also addressed in turn by the various disciplines. This arrangement highlights Professor Dickenson's scholarship, insight into the complexity of reproductive health, and her editing skill.

The theoretical framework put forward at the beginning of the book defines three components as basic in approaching ethical issues of reproductive health care. Carson Strong, the author of the chapter, proposes that these concerns include the importance of reproductive freedom, the moral status of offspring during various stages of development, and the level of generality to use when assigning priorities in resolution of values conflicts. This discussion distinguishes four approaches in the process: decision making based on a hierarchical ranking of values; based on ranking of values that is followed in all cases involving a specific issue; based on ranking of values in the context of the particular circumstances (e.g., strict casuistry); and based on ranking of values considering the context and the issues (modified casuistry). His preference is to use the final approach in considering ethical dilemmas in reproductive health. After describing the framework, he applies it to three cases to show its usefulness: a mother's refusal for a Caesarian section for the fetus' sake, development of pre-embryos (the products of conception during approximately the first 14 days following fertilization) for research purposes, and a 63 year-old woman requesting ovum donation to become pregnant. His framework is thoughtfully presented, and its components are relevant to the arguments raised by the other authors.

The first section's general approach introduces the reader to the range of issues that have been commonly identified as part of the ethics of reproductive health ethic. The perspectives are clinical, political, philosophical and cultural--all with clear policy implications. In her chapter on multicultural issues, Sirkku Hellsten provides many examples as to how women's reproductive health is constrained culturally and politically all over the world, and argues that there are moral rights that should be protected in all settings. Paquita de Zulueta adds to this observation in her discussion of HIV screening and therapeutic research around the world: despite the benefit to future generations, anonymous testing and placebo-controlled trials erode the trust relationship between women and health professionals. Rosemarie Tong considers genetic screening as a route to perfect future children. She concludes that this brings us back to eugenics and that the use of genetics screening will also further separate the haves and have-nots. Whether there is a duty not to reproduce when inadequate parenting or disabled children result is considered by Jean McHale; criteria have already been established as part of the Human Fertilisation and Embryology Authority Revised Code of Practice (1998) for people seeking reproductive assistance. Cynthia Daniels considers the socio-political role of a father in harming his fetus. Although science reflects that men's actions do affect fetal health, she points out that preventative measures--and media interest--focus on maternal harms. The final paper in this section reviews the restriction of freedoms for pregnant women. Susan Bewley considers the moral relationship between fetus and mother, and then analyzes how society works to protect the unborn by restricting mothers' freedoms. She uses examples of how society treats the drug-using pregnant woman, with offers (and threats), coercion, and punishments, in order to achieve the healthiest possible outcomes.

The second section's three chapters identify ethical issues raised by new reproductive technologies. Francoise Shenfield moves beyond the conventional concerns raised in assisting conception to issues raised by pre-implantation diagnosis, cryopreservation of tissues, and cloning, and concludes that although national and international think tanks have considered the respect owed to the embryo and human rights of the child and family, the important discussions of these issues will not occur until they become available to patients and families. The second chapter in this section relates again to the "duty not to reproduce" question introduced earlier: whether a woman at extremely high personal health risk for pregnancy should have access to in-vitro fertilization (IVF). Gillian Lockwood describes a woman who sought IVF after renal transplant (due to pre-eclampsia[i] in previous unsuccessful pregnancies), and then went on to deliver a living child. In the last chapter of the section, Heather Widdows argues that the impact of the secrecy of donor insemination parallels lying and should be replaced with openness.

The third section is the longest of the book, with six chapters that consider ethical issues related to the first and second trimesters of pregnancy. Again, each chapter builds on previous information but does not repeat any of the arguments or substantive material included earlier in the book. The first chapter discusses fetal screening with the intention of saving fetuses/infants and preventing disabilities. In this chapter, Elina Hemminiki recommends that new health technologies be only introduced when assessments about their social and ethical dimensions are also completed. Priscilla Alderson then discusses prenatal counseling and its implications for living with disabilities in the next chapter. The series of interviews with disabled adults documented their impression that prenatal counseling implies society does not want people with disabilities to be born or survive, and that able-body is both socially desirable and attainable. The next chapter considers the ethical and legal aspects of the abortion debate. Eileen McDonagh reframes the American debate and legal position from one of self-sacrifice to one of self-defense. She argues that the feminist agenda has been limited by its definition of the role of women in society, and that this has affected the abortion debates as well. The next chapter was written by the book's author, Donna Dickenson. In the chapter, Dickenson considers the ownership of embryonic and fetal tissues. Using Lockean and Marxist arguments, she establishes that the woman who produces embryonic or fetal tissue has property rights over the tissue, and that these rights should protect her from exploitation in their use. The final chapter in this section is written by Mary Mahowald, and considers the ethical issues related to the successful implantation of more than two embryos, resulting in higher order gestations (e.g., 3, 4, 5 or more fetuses). Her discussion concludes with the recommendation that women have the legal option of fetal termination with pregnancy preservation (FTPP) just as they have the option of abortion of singleton pregnancies.

The fourth section considers ethical issues related to the third trimester of pregnancy in two chapters: one on Caesarean section deliveries and the other on non-compliance in pregnancy. Wendy Savage's chapter on Caesarean sections (CS) considers who has the right to determine whether a CS is performed and if it can be forced on a mother to save a child. Ethical, medical and legal issues are reviewed with discussion of contrasting maternal and fetal rights; she concludes that patient autonomy and shared physician-patient decision-making are the important reasons the procedure cannot be forced on a woman. Issues of non-compliance during pregnancy are discussed by Fracoise Baylis and Susan Sherwin. They acknowledge that describing a patient as non-compliant confers a judgment about her behaviors, and should be changed to allow respectful and autonomous choices on the part of the patient.

The three chapters in the final section consider the role of reproductive ethics on the lives of the resulting children. The first chapter by Christine Overall, assesses whether these technologies benefit or harm children. After asserting that life itself can only considered a benefit if it is not heavily damaged, she concludes that surrogate and other contract pregnancy arrangements do harm resulting children, and that there are true risks from other reproductive technologies as well; the only true benefits are to the parents. Rebecca Bennett and John Harris then discuss diverging views of an issue encountered earlier: whether there are lives not worth living due to disability. They agree that there are lives with extreme suffering and that such lives should be avoided when possible; however they disagree as to whether there are moral reasons to avoid bringing children with disabilities into existence when the parents have the possibility of having able-bodied children. The final chapter, written by Neil McIntosh, considers the ethical issues of withdrawing life sustaining treatments from handicapped neonates. He reviews the three criteria established in 1997 by the Royal College of Pediatrics and Child Health for withdrawing treatments, which resemble those that have evolved in the United States since the 1980's as a consequence of the Baby Doe legislation and court actions. He concludes with clinical suggestions regarding how to negotiate the withdrawal of treatments and involvement of family in the decision-making.

These sections are woven together with strong themes that repeatedly present themselves. The role of the doctor-patient relationship in reproductive health is re-visited regularly. The power differential in that relationship and the position of women in social and cultural settings broaden the discussion to international and socio-political levels. The introduction of new technologies provides much of the currency for these discussions: who has access to them and what harms and costs do each entail. Their impact on creating imperfect offspring raises the discussions of able-bodied-ness and perfection that can result.

This book will be a valuable resource for individuals who work with issues related to reproduction and are concerned about the impact of our science, technologies and clinical practices on the lives of our children and families. The implications for policy development are especially important. Materials from the text have been included in my teaching, research, and clinical work.

[i] Pre-eclampsia is a condition of late pregnancy, with high blood pressure, kidney failure, and seizures, that can progress to stroke and death in the mother; it is also associated with growth retardation and early delivery of the fetus.

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