PHI 413 V Moral Positions on a Fetal Abnormality
PHI 413 V Moral Positions on a Fetal Abnormality
PHI 413 V Moral Positions on a Fetal Abnormality
The case study, “Fetal Abnormality,” presents ethical challenges that individuals face in dilemma situations concerning the sanctity of life-based on different worldviews or perspectives. In this case, four individuals make decisions and feelings about an unborn deformed fetus who has a 25% chance of being born with Down Syndrome. The fetus is yet to develop limbs, and medical scans show that the probability of growing them is less. The four people include Jessica, the expectant mother, her spouse, Marco, Maria, their religious aunt, and Dr. Wilson, the physician, with the fetus’s medical opinion. Marco is willing to support his wife based on any decision that she will make. Maria believes that Jessica has obligations as a mother before God and should carry the baby to its full term irrespective of the condition. Based on medical and scientific evidence, Dr. Wilson endorses the decision to terminate the fetus because of the possible abnormality that it carries. As such, these individuals have different ethical perspectives in determining the moral status of the unborn baby. The paper evaluates the ethical options by these people and shows the moral status of the fetus.
Christian View on Nature of Persons and Compatible Moral Status Model
Life is sacred and given free by God and begins at conception. According to the Christian perspective, human life is superior and above all creatures because human persons are created in God’s image. Human beings’ exceptional nature is due to their ability to reason and have a sense of awareness that other creations lack. Humans have a clear language and are born as freed agents in God’s image (Stahl & Kilner, 2017). Christian perspective advances that human beings have intrinsic value and dignity, which form the basis of their existence in this world. They should act rationally and protect their moral status as conferred to them by God. They can make decisions about other creations, but taking any life belongs to God, the giver of that very life.
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Moral status is concerned with what individuals believe is valuable and what is not in one’s life, and how individuals conceive their decisions. Moral status determines the value linked to an individual, either born or not, but as long as they are alive. Imperatively, the most compatible theory with the Christian view on persons’ nature is the moral agency theory. The model agency perspective asserts that individuals have the ability, power, and freedom to select what they believe is acceptable and what is not. As such, relationships and interactions among human beings and other creations are based on the value based on life and protection and respect of human dignity. As free moral agents, human beings make decisions based on these aspects, and dignity depends on the degree of morality accepted by individuals and society (Stahl & Kilner, 2017). The implication is that righteousness comes based on free will, and humans should seek to protect all creatures, including fellow persons. The first obligation is this aspect is the protection of human life and its intrinsic value and dignity.
Determining the Fetus’s Moral Status
Jessica, Marco, Maria, and Dr. Wilson use various moral theories to determine the fetus’s moral status. Jessica understands that the baby will encounter hardships and place increased socioeconomic challenges on their resources and family. The baby will require specialized care based on its condition. On the other hand, as a Christian, Jessica understands that life is sacred and does not want to interfere with its sanctity. The baby has moral status, and she uses ethical agency theory by acting as a moral agent with free will to make choices that impact her life (Case, 2019). Jessica has considered all the alternatives, and while in a dilemma, believes that she should protect the unborn baby. She knows that the final decision on the fetus’s moral status rests with her perspective, and any decision that she takes will prevail. According to the ethical agency theory, the moral situation arises based on an individual’s ability to make choices as a moral agent based on free judgment concerning what is perceived as right or wrong. However, the baby cannot make decisions and thus lacks moral status or agency.
Marco has concerns about the potential socioeconomic burden of having a child with the medical team’s conditions. He understands that bringing up a child with Down Syndrome will constitute an increased financial obligation but is emphatic that he will support Jessica regardless of her decision (Simkulet, 2020). Therefore, based on these interactions and relationships, Marco uses the relational theory as he believes that his wife’s decision will be okay to him. Maria reminds Jessica of her obligations and roles as a mother and Christian and the need to respect God’s will. As a Christian, Maria emphasizes Jessica’s essential to seek God’s intentions and base her final decision on biblical and religious teachings. Maria is against the fetus’s termination and thus uses the divine command theory and the relational theory to advance that having a relationship with both God and the unborn child, Jessica should not terminate the fetus. Maria cannot demonstrate the baby’s moral status but applies divine logic to confer moral status to the fetus.
Dr. Wilson gives the family all information about the fetus’s status and its possible deformations and implications once it is born. The doctor believes that in his best opinion, the fetus should be terminated due to its deformity. His advice and opinion are based on medical information, knowledge, and experience. As such, the physician uses cognitive theory, which advances that an individual’s moral status begins when they have the rational ability and awareness (Andal, 2018). Based on medical facts, the doctor believes that the fetus has no rationality or attention. It would be difficult for it to attain these cognitive elements even after its birth. The implication is that the doctor believes that the fetus does not have moral status and does not sentience.
Impacts of Each Theory
The theories used by every person in the case study impacts their decision and opinions in the case. For instance, based on the cognitive model, Dr. Wilson is categorical that termination of the fetus is the best alternative because of the potential disabilities it shall have, which will impact the child’s quality of life. Jessica’s dilemma emanates from her utilization of the moral agency model and relational theory because she has a relationship with the fetus as its mother and God as a Christian and wife to Marco. She decides with knowledge about its potential impacts (Andal, 2018). The relationship between Jessica and Marco influences his decision about the fetus as he asserts that he shall support her irrespective of what action she takes. Maria’s opinion is influenced by Christian beliefs based on divine command theory. She encourages Jessica to consider the whole aspect of motherhood and her relationship with both the fetus and God, and the sanctity of life.
Theory Most Effective
Every person in the case expresses their opinion and uses the relative model to base the merits of their decisions. I believe that the moral agency theory and relational model are critical in this case. The moral agency determines the moral status of the fetus based on the existing relationship. This model transcends egocentrism and challenges one to consider the impact of their choices on another person’s life. Life is sacred and begins at conception. Therefore, Jessica, Marco, and Maria must consider their obligation before God and each other based on these theoretical perspectives. As moral agents with free will, they must make better decisions to benefit their family and relationship with God.
Conclusion
Individuals presented with critical challenges demonstrate and use different ethical perspectives in making significant decisions. People must consider the long-term implications of their choices and their consequences irrespective of how dire the situation may present. The unborn child’s moral status remains and should be founded on one’s rational thinking and cultural beliefs.
References
Andal, A. G. (2018). Revisiting International Law’s Discussion on the Moral Status of the Fetus.
In Proceedings of Topical Issues in International Political Geography (pp. 327-338). Springer, Cham.
Case, M. A. (2019). Abortion, the Disabilities of Pregnancy, and the Dignity of Risk.
The University of Chicago, Public Law Working Paper, (705).
Stahl, D. & Kilner, J. F. (2017). The Image of God, Bioethics, and Persons with Profound
Intellectual Disabilities. The Journal of the Christian Institute on Disability, 6(1-2), 19-40. https://journal.joniandfriends.org/index.php/jcid/article/view/143
Simkulet, W. (2020). Abortion and Ectogenesis: Moral Compromise. Journal of Medical Ethics,
46(2), 93-98. http://dx.doi.org/10.1136/medethics-2019-105676
Write a 750-1000 word analysis of “Case Study: Fetal Abnormality.” Be sure to address the following questions:
Which theory or theories are being used by Jessica, Marco, Maria, and Dr. Wilson to determine the moral status of the fetus? Explain.
How does the theory determine or influence each of their recommendation for action?
What theory do you agree with? How would that theory determine or influence the recommendation for action?
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
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The ethical issues behind the management of a fetus with a serious abnormality and the decisions made in relation to the outcome of the pregnancy are complex. This reflective paper deals with the ethical principles of managing a pregnancy with a congenital anomaly, with particular emphasis on the fetus with a serious cardiac abnormality. One major ethical concern is whether the fetus is or is not independent being to whom obligations of beneficence are owed. We review the debate on this matter, and suggest that it is ethically more appropriate for physicians who are involved in management of fetal abnormality not to adopt and insist on their own position on this matter. Rather, the appropriate course is to respect the pregnant woman’s own view of her fetus and how it should be regarded. This is an application of the principle of respect for autonomy. Within this framework, we discuss the difficulties in counselling a pregnant woman or expectant couple in this situation, and recommend three key steps in ethically sound counselling.
1. Introduction
Prenatal diagnostic ultrasound is widely performed especially in the western world. Parents attending a scan expect to be told that their baby is normal. They want to be reassured regarding the size and well-being of the infant, and may wish to know its sex [1]. When a possible anomaly is identified, it comes as a shock to the parents, who were not expecting such an outcome. If the anomaly is subsequently confirmed, there may be an assumption that as the parents sought screening in the first place; they intended to proceed to an abortion [2]. However, this is not always the case, given their expectations at the outset. Counseling the parents in such situations is complex and requires much sensitivity. This paper reviews the ethical issues involved and makes recommendations for practice.
2. Basic Ethical Principles
Chervenak et al. have very eloquently described the basic ethical principles in the management of pregnancies complicated by fetal anomalies [3]. The first ethical concept is that of beneficence. Health related interests of the patient obligate the physician to seek clinical benefits over clinical harms for the patient. The second basic ethical principle is respect for the patient’s autonomy. This principle means that the patient’s perspective on health-related and other interests is paramount. The physician needs to respect the patient’s own set of values, beliefs and decision-making capacity. The physician’s role is to provide adequate information and a recommended management plan, or range of possible plans, for the condition in question. It is vital that the information is provided in a manner that allows the patient to understand it, so as to be able to reach an informed and voluntary decision. We will discuss the physician’s ethical obligations in relation to informed consent in more detail below. However, it is important to note that the expectant parents’ great state of distress, grief or shock may make it very difficult for them to take in, understand and assimilate what is provided [4], even with very careful presentation of information
The crucial ethical question in pregnancies complicated by fetal anomalies, according to Chervenak et al. [3], is whether the fetus counts independently as a patient to whom the obligations of beneficence are also owed (in addition to the pregnant woman). If the fetus is also a patient, then the ethical situation becomes much more complex. What is best for the pregnant woman may differ from what is best for the fetus (for example, where there are physical risks to the woman in continuing the pregnancy). In addition, the woman may make decisions which are contrary to the best interests of the fetus (for example to terminate a viable pregnancy). Difficult choices may have to be made and are based on where ethical priorities lie.
There are two possible approaches to dealing with the question of whether the fetus should be regarded as a patient. The first approach is that the physician comes to his or her own moral decision about whether the fetus should be regarded as a patient. This approach would require the physician to have a clear and sound moral or philosophical basis on which to make this decision. The second approach is that the physician adopts no view and leaves it up to the pregnant woman (and her partner, if involved) to decide how they wish to regard their fetus. This approach need not involve any moral or philosophical reasoning by the physician about the fetus; simply giving primacy to the pregnant woman’s autonomy in relation to decisions relating to her fetus.
Chervenak et al. [3] suggest a variation of the first approach. They concede, as many others do [1, 5], that the fetus cannot meaningfully possess values and beliefs, and is therefore not a person to whom obligations can be owed. However, they maintain that the obligations of beneficence to the fetus arise from the fact that obligations are owed to the infant which that fetus will become after birth. This makes the fetus a patient, regardless of whether it is a person. More specifically, Chervenak et al. argue that the fetus becomes a patient only after viability; the pre-viable fetus does not have the status of a patient, and should only be treated as a patient if the pregnant woman wants to regard it as such. Once a fetus is viable (a state related to the biological stage of development aided by the availability of medical technology) it is possible for the fetus to survive independently outside the womb. Hence, according to Chervenak et al., there are beneficence obligations to the viable fetus, whenever it is presented to the physician and there exist medical interventions (whether diagnostic or therapeutic) that could. produce a greater balance of clinical good over clinical harm for it in the future that is, when it becomes an infant, a child or an adult. There is extensive data to support the possibility of clinical benefit in cases of cardiac anomalies [6–8].
If this argument is accepted, it means that the physician may end up having an obligation to seek to change or override pregnant woman’s wishes, for the sake of the fetus. If the physician believes the fetus is a patient, owed the same obligations as any other patient, then his or her obligation is directed to the best interests of the fetus. If the pregnant woman’s decisions are contrary to the best interests of the child that the fetus will become, then the physician has an obligation to protect those interests, just as for any child put at risk by parental decisions about medical treatment. The logic of Chervenak and his co-authors’ position implies that if attempts at persuasion do not work, the physician may have to seek legal avenues to override the woman’s decision, a course of action that could lead to court-enforced fetal surgery [9], immediate delivery of the fetus and, in theory, court-ordered continuation of pregnancy (although it should be noted that in situations where the local laws permit abortion, they do not generally allow for a third party to prevent a woman having an abortion).
However, we caution against this approach, where the physician adopts an independent moral stance on the fetus, and seeks to act accordingly. Whilst the arguments of Chervenak et al. [3] are well reasoned, there are also well-reasoned arguments to the opposite effect, namely that the fetus should not at any stage of gestation be regarded as a patient to whom the physician has direct obligations, unless the pregnant woman chooses to do so. The obligation to the fetus, as Chervenak et al. acknowledge, is based on the well-being of the child it will become. However, whether or not the fetus becomes a child depends on the woman continuing with her pregnancy. It could be argued that if she decides to terminate her pregnancy, at any stage and for whatever reason, there is no longer any obligation to the fetus, since there will not be any child. This conclusion is contrary to the view of Chervenak et al., yet draws on the same reasoning they do.
The well-known difference in views about the status of the fetus and the morality of abortion, across different cultures and religions also introduces a note of caution. A physician working in the multi-cultural setting of today’s increasingly globalised world is likely to encounter patients with quite varied views. In addition, laws relating to abortion vary considerably between jurisdictions. We suggest, then, that the second approach suggested above is preferable, namely for the physician to leave it to the pregnant woman (and partner) to decide if the fetus is to be regarded as a patient or not (providing that local laws permit abortion).
Adopting that view does not mean that the physician should not have a personal position on the status of the fetus, only that he or she should not attempt to impose it on his or her patients. If the wishes of the pregnant woman in regards to termination of her pregnancy or intra-uterine therapy for her fetus are significantly at odds with the physician’s moral views, the physician should exercise the right to conscientious objection, and hand over the care of the patient to another doctor [10]. This obligation to refer is a standardly accepted caveat on the right to conscientious objection [11]. The Australian Medical Association Code of Ethics [12], for example, states the following:
When a personal moral judgement or religious belief alone prevents you from recommending some form of therapy, inform your patient so that they may seek care elsewhere, and recognise your right to refuse to carry out services which you consider to be professionally unethical, against your moral convictions, imposed on you for either administrative reasons or for financial gain or which you consider are not in the best interest of the patient.
This position is an attempt to negotiate between competing moral values: the woman’s autonomy and the physician’s integrity. The physician is not forced to do something he or she believes morally wrong, but the woman is also able to exercise her own choice.
3. Ethical Responsibility of Cardiologists When a Serious Fetal Cardiac Anomaly Is Found
Physicians working in obstetrics and gynaecology are presumably aware of the need to work through these issues of the status of the fetus, and to develop their position on abortion, as these issues form a major aspect of their practice. Paediatric cardiologists, on the other hand, have had little cause to consider such issues when working in their discipline, and may never need to do so. However, since it is now possible to detect fetal cardiac anomalies prenatally, cardiologists are coming face to face with these issues. There is usually (in most jurisdictions) an option to terminate an affected pregnancy and increasingly intrauterine interventions may be possible. Cardiologists must consider how they will counsel women in these situations, how directive they will be about which option should be chosen, and what they will do if the woman’s choice is not the one that optimizes life and health for the fetus.
PHI 413 V Moral Positions on a Fetal AbnormalityHere, we set out the key steps in the counseling process from an ethical perspective, and make recommendations about ethically appropriate practice. These steps may take place over more than one consultation, and may need to be re-visited on each occasion, due to the emotional nature of the situation and the complexity of the information to be conveyed.
3.1. Step 1. Give Accurate Information about the Diagnosis and Prognosis of the Cardiac Abnormality
The first stage is providing accurate information about the diagnosis and prognosis in a manner and at a timing that the expectant parents are able to understand. Fetal cardiac anomalies like any congenital anomaly necessitate that physicians provide the parent adequate information. For any counselling to be credible the diagnosis must be accurate. This is even more relevant in the case of antenatally diagnosed cardiac anomalies. The general screening detection rates for congenital heart disease (CHD) vary between 14%–45% [13]. A standard 4 chamber view can detect 40%–50% of major CHD [14], while a 4 chamber view and outflow tract detects 70%–80% of major CHD [15]. In dedicated fetal cardiac centres the diagnostic accuracy is close to 100% [4, 16]. Fetal cardiac malformations are compounded by the fact that other malformations may be present, as is the possibility of chromosomal abnormalities. The most accurate information possible should be given to the expectant parents, along with a clear explanation of what is still uncertain, unclear or subject to change as the pregnancy progresses. The physician should keep in mind the possibility of evolving lesions [10] (e.g., a developing left and right hypoplastic heart syndrome) and inform the parents accordingly. For such condition, there is inadequate or incomplete data as far as their outcome and natural history, and this also must be conveyed to the parents.
Shinebourne argues that most CHD are treatable with a resultant reasonable quality of life [5]. Even in serious cardiac conditions, one is not always able to clearly define the possible outcomes. Few cardiac conditions are not amenable to at least palliative surgery, if not complete repair. In most cases the neurological development is normal or close to normal [17]. When dealing with fetal anomalies detected on ultrasound, the questions and concerns raised by parents relate to the quality of life issues starting from infancy right up to adulthood [18]. Generally the details of the abnormality, while important, are not the paramount issue for the parents [19]. Complications of the abnormality and the results of surgery or any intervention also figure in the considerations. There is the need to describe possible poor outcomes, especially if they are severe even though unlikely to happen. This information allows the parents to decide how to proceed with knowledge of the worst case scenario [10].
The physician needs to ensure the expectant parents understand the information about the nature of abnormality, the implications for the life of the future child, the possibility of intervention, and the risk for each intervention prenatally or postnatally. Parents also need to know the figures for local practice, for short, medium and long term outcomes, especially with respect to quality of life issues. The physician must be ready to discuss all of these issues with parents, providing the best available information, but also indicating the limits and uncertainties in this information and at a time when the parents are able to take in the information.
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3.2. Step 2. Identify Options
The next stage is to identify and present the options available. In brief, there are three main options: to continue with the pregnancy, to terminate the pregnancy (if legally permitted), or to consider prenatal intervention (if it is possible for the condition and available). If the decision is to continue with the pregnancy, there will perhaps be further decisions to make as to where the infant is to be delivered, the need for in utero transfer, and the mode of delivery [19]. There will also need to be an anticipatory management plan for the infant after birth. Parents will generally accept what is recommended to them on these matters, but still require them to be explicitly stated. If the decision is to terminate, there may be a need to shift hospitals (from example from a Catholic hospital), or change the obstetrician if termination is not personally acceptable to him or her. The parents should be made aware of these implications, not in an attempt to change their mind, but to inform and prepare them for the process.
Local laws and practices play an important role in the decision making. For example in some places it may be legal to terminate a pregnancy for maternal psychosocial reasons [17]; in other places, fetal indications may be specified in the law. There may or may not be restrictions on termination related to the stage of gestation. Broadly speaking, obstetricians are able to carry out a termination before 12 weeks [20], but the risk of legal complications increases after 12 weeks and especially after 20 weeks (which is about the stage at which antenatal diagnoses of cardiac anomalies are more commonly made.) In our state of Victoria, in Australia, the law has recently changed to allow termination for any reason up until 24 weeks, and after that there is the need for two doctors to agree that it is reasonable. Physicians must develop an accurate understanding of their local laws and seek legal clarification if necessary.
PHI 413 V Moral Positions on a Fetal AbnormalityDuring the counselling, assuming a “neutral” tone on the part of the clinician—not overly pessimistic or optimistic—is vital [2] but may be extremely difficult to achieve. The ultimate aim is to allow the expectant parents to form their own assessment of the impact the condition would have on their future child. As Shinebourne [5] notes: “It is the mother’s perception of the fetal cardiac anomaly and not the cardiologist’s that should determine outcome (continuation or termination)”. It is open to question, though, how achievable this is in a setting of acute emotional distress where the mother is in a state of shock and grieving the loss of a sought-after normal infant [4]. The ethical obligation is to do one’s best to achieve this aim.
3.3. Step 3. Discuss Options
The next stage is discussing the options with parents which is the most ethically contentious stage. There are different views even about which matters are ethically appropriate to raise and discuss, let alone about the degree to which it is appropriate to recommend or favour a particular option, rather than being as neutral as possible. Most professionals advocate non-directive [4, 5, 21] counselling if possible. It is important to realize that the impact of counseling is affected by the physician’s approach, speech, tone, and so forth [5]. In many counseling sessions, selective information is provided, whether deliberately and inadvertently, though some feel obligated to provide all the information available. There is also the question as to who is the best person to do the counseling. Cardiologists, genetic counsellors or obstetricians have counseled independently or together [4].
Making a decision may not be easy for the parents. They have to come to terms with the abnormality and grieve the loss of a normal infant, as well as grapple with the questions of what they think about abortion, disability, their personal capacity to care for such an infant/child and their ideas about parenthood and family life. They may wish to talk through the options. They may want their cardiologist’s opinion about what they should do. Simply giving such an opinion may not be the best option as the personal circumstances of the clinician differ from that of the parents. It is preferable to discuss how one might decide, what factors one would take into account, in order to model to the expectant parents a way of thinking about the issue, rather than simply give them an answer.
The reasons for considering termination may be very variable, complicated and as Shaffer et al. [22] acknowledge, may not necessarily be “rational” in the strictest sense. This can make the discussion of options difficult, especially for those not specifically trained for these situations. The reasons for which women decide to terminate affected pregnancies are not well documented or understood, though the few studies done in the area indicate it is the nature of condition rather than the stage of gestation that carries most weight [23]. A common understanding of physicians is that most terminations for fetal cardiac
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