Capacity Evaluations in Late-Stage Pregnancy

Abstract

Consultation psychiatrists are often called upon to assess capacity for medical decision-making in the obstetrical setting. Although these assessments are similar to those in other clinical settings, there is one notable difference: the presence of a fetus who can suffer adverse outcomes due to decisions of the pregnant patient, particularly refusal of medical treatment. Specific questions of capacity vary with the stage of pregnancy. Evaluations in the first trimester (weeks 1–12) are often related to requests for elective termination, second trimester (weeks 13–28) assessments tend to focus onmanagement of nonviable pregnancies, including termination and delivery induction, and capacity evaluations in the third trimester (weeks 29–40) often center on consent for emergent or elective cesarean section. Assessments of medical decision-making capacity in the obstetrical setting have unique ethical and legal implications, both for the pregnant patient and for her treating physician. Questions of capacity during pregnancy are perhaps best approached using a framework that considers the ethically-based obligations that a pregnant woman potentially has toward her unborn child, the treatingphysician’s obligations to bothmother and child, and the conflicts that arise when these obligations go unfulfilled. In support of this, we present 2 obstetrical cases that involve questions of capacity during the third trimester of pregnancy, followed by a discussion of relevant bioethical and legal issues as well as recommendations for the consultation psychiatrist.