Discussing motherhood when the oncological prognosis is dire: ethical considerations for physicians

Abstract

Physicians are increasingly open to discussing and supporting pregnancy after cancer treatment. However, counselling patients who are seeking pregnancy despite advanced oncological disease and/or uncertain prognosis is still challenging. Two paradigmatic cases are presented and analysed to illustrate the ethical uneasiness faced by treating physicians when seriously ill patients seek fertility preservation and/or pregnancy. Review of ethical issues is built around the four principles of biomedical ethics. Respect for patients autonomy in relation to managing realistic expectations and avoiding giving patients false hopes opens the analysis. It is followed by considering fair allocation of resources and meaningful distinction between protecting patients from harm and contributing to their welfare. Responsibilities towards the unborn child are discussed in a light of maternal and fetal interdependency. Respecting personal autonomy requires abstaining from controlling inferences to the individual patient’s choices, but it does not mean that patients should be left on their own to pick and choose their disease management approaches without advice and guidance from healthcare professionals. Physicians should reason evaluating the potential harms and checking if benefits will outweigh the risks and if costs will produce the best overall results. Responsibilities towards the unborn child can be managed by balancing the respect for maternal autonomy and beneficence for pregnant woman and her fetus. The oncologist cannot determine how patients should view their disease but with empathy and compassion can help them understand the logical rationale behind clinical advice.

Guidelines for Cancer Treatment during Pregnancy: Ethics-Related Content Evolution and Implications for Clinicians

“…Moreover, the patient is not left alone to make difficult moral choices and the most recent guidelines seem to support the maternalistic approach from the clinical teams by emphasizing the importance of available scientific evidence in patient counselling [ 14 ]. The content in clinical practice guidelines appears to support the ideas expressed elsewhere that clinicians cannot determine how the patients should view their disease, but when equipped with empathy and compassion clinicians can support their patients by explaining the logical rationale behind evidence-based clinical advice [ 13 ]. It also somewhat allows healthcare professionals to have an active, collaborative role in decision making.…”

“…Furthermore, the resource allocation theme corresponding to the biomedical ethics principle of justice [ 18 ], which takes into consideration equity and utility of the chosen treatment plan, emerged in 2015. It is not consistently mentioned in other guidelines, but its importance has been noted in the literature [ 13 ] and it would be reasonable to expect that more future guidelines will include resource allocation and treatment futility in their ethical guidance.…”

“…This, however, depends on the gestational age of the fetus at the time of treatment, tumor type and disease stage, as treatments may induce developmental teratogenicity [ 10 , 11 , 12 ]. There are a number of ethical questions involved, especially when oncological prognosis is dire and a patient’s desire for parenthood is strong; practical questions such as breastfeeding after breast cancer are also frequently triggered in this setting [ 13 , 14 ]. Nevertheless, knowledge regarding bioethical aspects arising during this unusual co-occurrence is scarce [ 15 ].…”

Caring for Pregnant Patients with Cancer: A Framework for Ethical and Patient-Centred Care

“…An extra layer of complexity stems from the idiosyncratic nature of this condition, as the patient herself is not the only player involved or affected (Figure 1). Ethical questions raised by the healthcare team, patients and/or their families are not always the same and might be conflicting, such as when one party does not feel comfortable with care decisions that are either taken or desired by another party involved [33,34]. For these reasons, taking care of pregnant cancer patients requires a multidisciplinary clinical team that should also include decisional counsellors [35,36], psychologists and ethicists [37], in addition to the oncological core medical team [1,[38][39][40].…”

“…Furthermore, the medical maternalism approach to patient treatment and care provides the groundwork for clinical decisions taken or recommended for a patient based on a reasonable understanding of that person's own preferences [50]. This is especially relevant in cases where a pregnant cancer patient lacks capacity, is seriously ill [33], is dying and/or being kept on life support for the benefit of the foetus [86] and is not able to participate in the medical decision-making process.…”