Overview of the Maternal-Fetal Relationship • in general, maternal and fetal interests align • in some situations, a conflict between maternal autonomy and the best interests of the fetus may arise Ethical Issues and Arguments • principle of reproductive freedom: women have the right to make their own reproductive choices • coercion of a woman to accept efforts to promote fetal well-being is an unacceptable infringement of her personal autonomy Legal Issues and Arguments • the law upholds a woman’s right to life, liberty, and security of person, and does not recognize fetal rights; key aspects of the mother’s rights include: ■ if a woman is competent and refuses medical advice, her decision must be respected even if the fetus will suffer ■ the fetus does not have legal rights until it is born alive and with complete delivery from the body of the woman Royal Commission on New Reproductive Technologies (1993) recommendations: 1. medical treatment must never be imposed upon a competent pregnant woman against her wishes 2. no law should be used to confine a pregnant woman in the interest of her fetus 3. the conduct of a pregnant woman in relation to her fetus should not be criminalized 4. child welfare should never be used to control a woman’s behaviour during pregnancy 5. civil liability should never be imposed upon a woman for harm done to her fetus during pregnancy Examples involving the use of established guidelines • a woman is permitted to refuse HIV testing during pregnancy, even if vertical transmission to fetus results • a woman is permitted to refuse Caesarean section in labour that is not progressing, despite evidence of fetal distress Advanced Reproductive Therapies • includes non-coital insemination, hormonal ovarian stimulation, and IVF • topics with ethical concerns: ■ donor anonymity vs. child-centred reproduction (i.e. knowledge about genetic medical history) ■ preimplantation genetic testing for diagnosis before pregnancy ■ use of new techniques without patients appreciating their experimental nature ■ embryo status – the Supreme Court of Canada maintains that fetuses are “unique” but not persons under law; this view would likely apply to embryos as well ■ access to ART ■ private vs. public funding of ART ■ social factors limiting access to ART (e.g. same-sex couples) ■ the ‘commercialization’ of reproduction
Advanced Reproductive Technologies: Ethically Appropriate Actions • Educate patients and address contributors to infertility (e.g. stress, alcohol, medications, etc.) • Investigate and treat underlying health problems causing infertility • Wait at least 1 yr before initiating treatment with ART (exceptions – advanced age or specific indicators of infertility) • Educate and prepare patients for potential negative outcomes of ART
Payment of gamete donors is currently illegal in Canada. The ART Act is, however, not being enforced currently as it does not clarify whether ART falls under the jurisdiction of the federal or provincial government
The fetus does not have legal rights until it is born alive and with complete delivery from the body of the woman
Neonate as Member of Society Paediatr Child Health 2012;17(8):443-444 • Once outside the mother’s body, the neonate becomes a member of society with all the rights and protections other vulnerable persons receive. • Non-treatment of a neonate born alive is only acceptable if <22 wk GA • 23-25 wk GA: treatment should be a consensual decision between physician and parents • 25 wk GA and more: neonate should receive full treatment unless major anomalies or conditions incompatible with life are present
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Ethical and Legal Issues in Canadian Medicine Toronto Notes 2018 ELOM13 Ethical, Legal, and Organizational Medicine
Fetal Tissue • pluripotent stem cells can currently be derived from human embryonic and fetal tissue • potential uses of stem cells in research ■ studying human development and factors that direct cell specialization ■ evaluating drugs for efficacy and safety in human models ■ cell therapy: using stem cells grown in vitro to repair or replace degenerated/destroyed/malignant tissues (e.g. Parkinson’s disease) ■ genetic treatment aimed at altering somatic cells (e.g. myocardial or immunological cells) is acceptable and ongoing Induced Abortion • CMA definition of induced abortion: the active termination of a pregnancy before fetal viability (fetus >500 g or >20 wk GA) • CMA policy on induced abortion 1. induced abortion should not be used as an alternative to contraception 2. counselling on contraception must be readily available 3. full and immediate counselling services must be provided in the event of unwanted pregnancy 4. there should be no delay in the provision of abortion services 5. no patient should be compelled to have a pregnancy terminated 6. physicians should not be compelled to participate in abortion – if morally opposed, the physician should inform the patient so she may consult another physician 7. no discrimination should be directed towards either physicians who do not perform or assist at induced abortions or physicians who do 8. induced abortion should be uniformly available to all women in Canada and health care insurance should cover all the costs (note: the upper limit of GA for which coverage is provided varies between provinces) 9. elective termination of pregnancy after fetal viability may be indicated under exceptional circumstances Ethical and Legal Concerns and Arguments • no law currently regulates abortion in Canada • it is a woman’s medical decision to be made in consultation with whom she wishes; there is no mandatory role for spouse/family • 2nd and even 3rd trimester abortions are not illegal in Canada, but are usually only carried out when there are serious risks to the woman’s health, or if the fetus has died in utero or has major malformations (e.g. anencephaly) Prenatal/Antenatal Genetic Testing • uses 1. to confirm a clinical diagnosis 2. to detect genetic predisposition to a disease 3. allows preventative steps to be taken and helps patient prepare for the future 4. gives parents the option to terminate a pregnancy or begin early treatment • ethical dilemmas arise because of the sensitive nature of genetic information; important considerations of genetic testing include: ■ the individual and familial implications ■ its pertinence to future disease ■ its ability to identify disorders for which there are no effective treatments or preventive steps ■ its ability to identify the sex of the fetus ■ ethical issues and arguments regarding the use of prenatal/antenatal genetic testing include: ■ obtaining informed consent is difficult due to the complexity of genetic information ■ doctor’s duty to maintain confidentiality vs. duty to warn family members ■ risk of social discrimination (e.g. insurance) and psychological harm Legal Aspects • no current specific legislation exists • testing requires informed consent • no standard of care exists for clinical genetics, but physicians are legally obligated to inform patients that prenatal testing exists and is available • a physician can breach confidentiality terms in order to warn family members about a condition if harm can possibly be prevented via treatment or prevention (e.g. familial adenomatous polyposis) Genetic Testing: Ethically Appropriate Actions • thorough discussion and realistic planning with patient before testing is done • genetic counselling for delivery of complex information