Ethical issues in pre-eclampsia : hurry up and wait

[摘要] ENGLISH ABSTRACT: Pre-eclampsia is a common and dangerous condition of pregnancy. During clinical care the sensitive obstetrician will frequently recognise moral ambiguity and ethical conflicts. It is important to understand the pertinent issues and find ways of resolving them.Counselling is an important element of modern medicine. In deciding which counselling model to apply, clinicians must consider many variables including the particular clinical scenario, strength of evidence, and the justifiable limits of paternalism and autonomy in a position of shared responsibility. Couples have a moral right to procreate even when the pursuit of pregnancy involves significant risks. However, with their understanding of care ethics as well as rights ethics, informed women are well placed to negotiate the extremes of these positions when deciding whether to risk a pregnancy or not. The concept of the 'fetal patient is a helpful one. An autonomous woman may choose to confer or deny this status to her previable fetus, while obstetricians must balance autonomy- and beneficence-based obligations to the pregnant woman with beneficence-based obligations to her fetus.Maternal behaviour that harms the fetus and future child is categorised as maternal-fetal conflict. However, any pregnant woman is morally required to avoid harming the fetus, if this can be done without sacrificing her own important interests. The term non-compliance implies a hierarchical nature in the doctor-patient relationship. This reduces patient agency, erodes trust and conflicts with informed choice. Although sometimes justified, this 'label generally does more harm than good.Expectant management of early pre-eclampsia recognises that neonatal intensive care is an expensive and limited resource. The ultimate goal of expectant management remains the safety of the mother and the delivery of a live infant who will not require intensive and prolonged neonatal care. This judicious use of neonatal intensive care improves distributive justice but by consenting to expectant management as an inpatient, the pregnant woman voluntarily restricts her freedom. The decision is morally undergirded by the value accorded to the viable fetus and the scientific evidence informing the decision. When an extremely preterm, growth restricted fetus requires delivery, resuscitation may become an issue for consideration. The distinction between withholding resuscitation in such cases, or initiating but later withdrawing care is morally irrelevant. Categories of optional and obligatory treatments are more helpful, but perinatologists must determine treatment thresholds through understanding the relevant data and ethics issues.Finally, women do not lose their rights when they become terminally ill. When an undelivered woman is declared brain dead following complications of pre-eclampsia, her doctors and family must formulate clear plans for her and her living fetus. She must still be treated with respect and her right to die with dignity not forgotten. Extension of somatic support to optimise the outcome of her fetus can be supported ethically provided that the fetus is at the threshold of viability, the support is not prolonged (distributive justice), advanced level support is available with a successful outcome likely, and that doctors and family are in clear agreement.

[发布机构] Stellenbosch University