Maternal–Fetal Surgery: Does Recognising Fetal Patienthood Pose a Threat to Pregnant Women’s Autonomy?

Abstract

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.

Beneficence on unborn patients treated in wombs vs. autonomy of pregnant women: A legal standpoint

“…This necessitates the doctors to balance the obligations towards each. In Chervenak & McCullough's ethical framework, it is explained that a human being becomes a patient, when it is presented to the physician for medical care and when there exist clinical benefits over clinical harms 14 . In this context, the recognition of fetus as a patient is dependent on the very competence of the physician to provide treatment and the choice of the pregnant woman to present it for medical care 14 .…”

Three‐dimensional real and virtual models in fetal surgery: a real vision

“…Now, once a congenital defect has been diagnosed, prompt action can be planned and undertaken. Although surgical intervention can jeopardize the pregnancy, it offers the possibility of a correction that could alleviate a fetal condition before delivery 56 . Its application in correcting severe but not life-threatening defects thus makes it a form of preventative medicine 57,58 .…”

The value and limitations of using predetermined criteria in decision making for maternal‐fetal interventions

“…Considering the impact of maternal-fetal interventions on the pregnant person is pivotal, as any intervention is performed through the pregnant person for the benefit of the fetus. 12,13,27 The maternal and fetal risks of particular procedures (e.g., bleeding, preterm birth, subsequent adverse reproductive health outcomes 5,6,28 ) must always be weighed against the potential future benefit of the offspring (e.g., improvement in motor function and neurocognitive outcomes for prenatal MMC repair [29][30][31][32] ). From a principle-based bioethical perspective, nonmaleficence must be weighed against maternal autonomy.…”

“…Decision making must balance preservation of maternal autonomy with beneficence and nonmaleficence, both for the pregnant person and the fetus. [9][10][11][12][13] This balance requires disclosure to the pregnant person of the uncertainty inherent in any intervention.…”

“…Any medical condition which raises the likelihood of preterm birth increases the potential risk of perinatal morbidity and mortality. Decision making must balance preservation of maternal autonomy with beneficence and nonmaleficence, both for the pregnant person and the fetus 9–13 . This balance requires disclosure to the pregnant person of the uncertainty inherent in any intervention.…”