Ethical considerations of fetal urology: summary of the Twenty-Second Biannual Meeting of the Society for Fetal Urology

Abstract

T fundamental driving force in life is to do the right thing. Those who teach children or raise their own children know that children thrive on being told the right way to behave and how to excel in life. They become frustrated and lose attention if not given specific, logical instruction. Physicians, especially surgeons, know that when faced with uncertainty or incomplete information, we use principles of physiology, anatomy, biochemistry, and past experience to find a solution to a problem. But what about the case where there is little experience to guide us? How do we choose a path to follow, especially, in the words of Professor Clare Fekete, when there is only a “least worst” choice? What about our initial decision to act? What principles do we follow to guide patient care when faced with an uncertain outcome? Finally, who decides what constitutes the best outcome? Probably the most dramatic example we face as urologists is a woman carrying a fetus with bilateral hydronephrosis and megacystis and oligohydramnios. When facing that pregnant couple in the consultation room, what is our responsibility as physician to the fetal patient, to the family, to society? Is there is a decision tree to use? How do we guide ourselves and those involved through this decision tree? How do we start to prioritize our decisions? These were the questions posed before a panel of experts at the 22nd biannual meeting of the Society for Fetal Urology, in Dallas, Texas, who discussed the topic of ethics, with particular regard to fetal anomalies. Present were Bill Cromie, Professor of Surgery/Pediatrics at the University of Chicago, Clare Fekete, Professor of Pediatric Surgery at Necker-Enfants Malades in Paris, and Roy Martin, D.Min., Chaplain Emeritus, Cook Children’s Medical Center in Fort Worth, Texas. Presentations and discussions centered around practical dilemmas, and most present came to a better understanding of the problems and questions we face in the practice of fetal urology. First, we reviewed a very brief outline of how normative ethics might help to describe solutions. This was based on a number of sources and represents a conceptual line of reasoning concerning fetal ethics. Further ethical understanding and examination is needed to provide physicians with a paradigm for counseling and is beyond the scope of this paper.1 Physicians are familiar with the Hippocratic oath. The core of the oath is, of course, to do what is good for our patients, at least without harm. The ethics of the Hippocratic corpus were written over a period of time by various Greek schools of philosophy and contain obligations of beneficence, nonmaleficence, and confidentiality, as well as some prohibitions against abortion, euthanasia, surgery, and sexual relationships with patients. Throughout the years, these codes were modified with cultural, religious, and theological overtones in the Judeo-Christian society until Perceval attempted to solidify this into a written code in Britain in 1803. In 1847, the American Medical Association released its first written code of ethics. It was based on the Hippocratic method but also included information on etiquette for physicians such as proper dress, gossip, reputation, cleanliness, truth-telling, consultation with other physicians, and the physician’s education. With the 1960s came societal re-examination of traditions, including these Hippocratic principles. This came about because of a better-educated public and the spread of participatory democracy such as civil rights, feminism, and consumer action. The need to re-examine medical ethics also came about This paper was presented at the Society for Fetal Urology Conference in Dallas, Texas, May 1999. From the Division of Pediatric Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina Reprint requests: Timothy P. Bukowski, M.D., Division of Urology, University of North Carolina School of Medicine, 427 Burnett-Womack Building, Campus Box 7235, Chapel Hill, NC 27599-7235 Submitted: July 2, 1999, accepted (with revisions): August 2, 1999 SOCIETY FOR FETAL UROLOGY UPDATE