The case for a middle ground

Abstract

M aternal-fetal conflict is a relatively new and mysterious phrase that is being applied to more and more medical-ethical-legal dilemmas in obstetric care. It describes such situations as legally mandated treatment programs for alcohol abuse in pregnancy, punitive legal action for cocaine abuse in pregnancy, decisions to perform (at significant maternal risk) in utero surgery for fetal anomalies, and even court-ordered cesarean sections to benefit the viable fetus. Not unrelated are the numerous issues surrounding abortion and prenatal genetic counseling. Rather than the traditional (mis)conception of a passive woman willing to give birth to a healthy child at any cost, the contemporary American woman occasionally resists health care that appears overly restrictive, intrusive, invasive, or threatening to her when fetal well-being is in question. Such situations seem to amplify an increasingly common conflict between mother and fetus. A brief look at the court-ordered cesarean section issue highlights these situations and gives a basis for the emotion and distress they foster. 1. Prominent ethical and legal concerns about privacy, bodily integrity, and autonomy are held to be near absolutes in a free society. 1 In health care, this has been translated into a strong doctrine of informed consent and an emphasis on each competent person's right to refuse medical treatment. 2 An extreme autonomy stance places the physician in the role of an obstetric technician whose only task is to assess patient competency and whose duty is to perform the competent patient's wishes or refer her to someone who will. 2. Retrospective reviews have revealed errors in diagnostic accuracy that have led to forced cesarean section. 3 Some claim that in utero assessment is simply not exact enough ever to allow using such parameters to force treatment against someone's will. 3. The dominant place of the mother in comparison with the fetus in obstetric decision making is also championed by many, even at near-term gestation. Rights theorists give little philosophic justification to any concept of fetal rights. 4 The most extreme position sees only one patient (the mother) to whom the fetus belongs as property, s 4. Finally, arguments are made that incorporate broader concerns than simply a single situation. Authors have tried to make settings where forced cesarean sections were considered analogous to other settings of interdependence (such as a sibling's need for a bone transplant) in which no court has ever forced organ donation or surgery on one person for the benefit of an© 1990 by The Jacobs Institute of Women's Health 1049-3867/90/$3.50