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The clinicians who developed technologies for assisting human reproduction had a double motivation. Paternalistic concern to help women experiencing difficulties with reproduction was coupled with a utilitarian ethic that assumed that such innovations would result in more benefit than harm. Current techniques—donor insemination, the induction of ovulation, in-vitro fertilization, antenatal screening for fetal abnormality, antenatal diagnosis (with the option of abortion), and fetal treatment in utero—were accepted because of their obvious benefits. They became routine practice long before adverse effects were quantified, and before it became apparent that the clinicians' assumptions of the benefits to women and their children had been simplistic: in-vitro fertilization has resulted in the birth of children disabled by the prematurity associated with multiple pregnancy; after normal conception, the notion of pregnancy as a natural and rewarding process has been undermined by pressures to accept antenatal diagnosis and fetal monitoring.
Discussion of ethical issues and legal regulation has followed rather than led the developments in maternal—fetal medicine. The autonomy of the woman and the moral status of the fetus are central to the debate. Western secular ethics gives priority to personal autonomy, but in matters of sex and reproduction society persists in assigning more autonomy to men than to women. Men often coerce their partners into undesired sexual activity. Unintended pregnancy is disproportionately harmful to women yet their default behaviour is expected to be acceptance both of the pregnancy and of the obligation to care for the child. Full autonomy for women means equality in sexual behaviour and complete personal authority over the fetus.
But what is the moral status of the fetus? It is not ‘new life’—the intracellular biological processes of the fetus are in direct continuity with those of the women, with the man adding only his half of the chromosomal genes. The fetus acquires moral status progressively throughout pregnancy, a progress that is marked by developmental milestones such as formation of the neural tube, completion of macroscopic organogenesis, functional maturation of lungs, liver and kidneys, increasing electrical maturation of the cerebral cortex, and then birth itself. Increasing moral status is also marked by the bonding that results from the woman's growing awareness of the fetus, and which, as the pregnancy becomes increasingly obvious, extends to her partner, her family, and then everyone she meets. This bonding with the fetus is the foundation for the responsibility she feels for the welfare of the future child. Birth itself is a major moral event. By ‘giving birth’, the woman confers to her new baby status as a person. The baby, unlike the fetus, does not have an obligatory dependence on the woman, and adaptation to extra-uterine life has necessitated sudden, radical and irreversible changes in its circulation and respiration. British law supports the view that the fetus is not a person at any gestation, and recent case law has established that the consent of the woman is required for any intervention in pregnancy that is considered necessary to benefit or to reduce the risk of harm to the fetus. After birth, the baby is legally a person who, if not provided with adequate care, has special protection under the Children Act. In contrast to the fetus, the wellbeing of the child is the responsibility of both parents and of society as a whole.
There are practical difficulties in respecting the autonomy of the pregnant woman when providing the potential benefits of maternal—fetal medicine. The woman's view of pregnancy as a rewarding natural process differs from that of the health professionals who are primarily motivated to minimize the risks to her and her fetus. The offer of screening and antenatal diagnosis of fetal abnormality disturbs the woman's positive view of her pregnancy, but she may have difficulty in refusing what appears to her to be a routine part of antenatal care—something she does not fully understand, and that she cannot easily discuss in the crowded minutes she spends with the professionals in the antenatal clinic. She tends to accept the tests on offer and only later becomes truly aware of their positive and negative value for her. Techniques such as ultrasound imaging and fetal heart rate monitoring bond the clinicians to the fetus and create the illusion that the fetus is a person, a patient, for whom they are directly responsible. The clinicians' relationship with the woman can deteriorate and become adversarial when their view of what is good for the fetus differs from hers. Such disagreement has two causes: the first is correctable by effective education and results from lack of accurate knowledge and understanding by the woman; the second has to be accepted and is a consequence of deeply conditioned cultural differences between the woman and the healthcare providers. This may result in an adverse outcome that was potentially avoidable; but experienced obstetricians know that adverse prognoses are sometimes disproved—and that a woman who initially rejects necessary interventions will often accept the recommended management once time has passed and it has become clear that disaster looms. Ethical care should aim at ensuring that the woman remains responsible for herself and her fetus and that she retains her trust in the health professionals providing her care: it is not right to attempt to use the courts to force a competent woman to have treatment against her will.
Innovations in maternal—fetal medicine must not only respect the autonomy of the woman but must also be beneficial and unlikely to cause serious harm. The balance between benefit and harm can be estimated prospectively but, very importantly, can also be measured retrospectively by the methods of audit that are part of evidence-based medicine. The provision of audit should be a requirement before any new method is introduced experimentally: it is not enough to design follow-up studies after a method has passed into general use and unforeseen harm has been done.
Justice is a neglected principle in maternal—fetal medicine—as it is in the application of new techniques and drugs in medicine as a whole. This is particularly true for infertility techniques that are expensive and difficult to provide through the National Health Service. The lack of NHS services has led to the growth of independent providers whose rates are determined by the market. The regulation of the independent sector by the Human Fertilisation and Embryology Authority—inspection, registration and the monitoring of outcomes—is much more important than its duty to impose ethical limits for the use of gametes and embryos, formulated more than 10 years ago during heated debates in Parliament. These should be the responsibility of a non-political national ethical committee that could vet and authorize innovative research and, when the balance of outcomes is clearly beneficial, approve routine use.
The above paragraphs express my personal view after reading Ethical Issues in Maternal—Fetal Medicine1. The book itself is not so prescriptive and has a much wider scope. The editor, Donna Dickenson, has written a skilful overview that brings together chapters by individual authors from Britain (11), North America (8), and Scandinavia (2). The treatment of an issue often reflects the nationalities and the professional backgrounds of the writers—which include moral philosophy, political science, law, and clinical practice. The aim is to stimulate thought rather than to guide treatment in detail. The authors vary in their perspectives and often question established views: for example, reproductive cloning is not necessarily an insult to human dignity; there may be advantages in recruiting semen donors from mature men who are willing for their identity to be known by the resulting children; a woman should have some property rights in fetal or placental tissue when these result in commercially successful therapies; commercial surrogate pregnancy is rejected because the surrogate and her immediate family inevitably bond to the child that will be born; arguments are presented against the views of some politically active disabled people that negative attitudes towards them are encouraged by abortions for fetal abnormality. There is a well considered chapter by Carson Strong on the moral status of the fetus. The chapters by practising clinicians are particularly helpful to those who currently provide services for pregnant women: Paquita de Zulueta deals with HIV in pregnancy; Susan Bewley discusses the problems posed by women who reject medical advice in pregnancy; Wendy Savage analyses whether women should have the option of vaginal delivery or caesarean section; Neil McIntosh presents ethical issues in withdrawing life-sustaining treatment from handicapped neonates. An omission is any debate on the paradox that helping women to conceive desperately wanted children is seen by an influential minority of our society to need statutory regulation, whereas fertile couples have freedom to conceive just as they wish. This is not a textbook but a valuable contribution to a continuing discussion.