As physicians grow increasingly adept at assisted reproduction, perinatal care and prenatal genetic screening, the inherent ethical issues grow increasingly complex. Bioethics Department staff helped address these issues at Cleveland Clinic’s continuing medical education course “Ethical Dilemmas in the Practice of Obstetrics, Gynecology & Reproductive Medicine” on April 23, 2014.
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Deliveries at the threshold of viability are ethically complex, noted Ruth Farrell, MD, the course director and an ob/gyn specialist and bioethicist. Survival rates and neurodevelopmental disability for newborns of 20 to 25-6/7 weeks’ gestation are highly variable, and outcomes are vastly uncertain. The short time frame for key obstetric management and delivery decisions and the need for multidisciplinary care discussions further complicate matters.
“If intensive treatment uniformly led to survival and an acceptable quality of life, that would be the obvious choice,” said maternal-fetal medicine specialist Amanda Kalan, MD. Yet intensive treatment may cause pain and prolong time until death, and withholding treatment may increase newborn morbidity and mortality.
Paul J. Ford, PhD, Director of the NeuroEthics Program, noted that when pregnant women with a periviable fetus ask caregivers to “do everything” at delivery, the phrase is ambiguous. “We’re going to do everything to reach the goal we jointly agree to,” he said. “That may mean doing everything to preserve life or doing everything to provide comfort care after birth.”
Communication must be clear and direct among providers, pregnant women and family, and consider values, needs, gestational changes, laws and regulations, and caregivers’ ethical obligations.
Prenatal genetic screening
New advances in prenatal genetic screening and testing increase the type and amount of information available to pregnant women, yet they raise important clinical and ethical concerns. One example is noninvasive prenatal testing, which screens for fetal aneuploidy risk more accurately than conventional screening does.
Another example, chromosomal microarray analysis (CMA), is a prenatal genetic test so sensitive and specific that it reveals submicroscopic chromosomal abnormalities. Yet some genetic variants may cause no disease and others may cause adult-onset diseases of unknown severity, noted Marissa Smith, CGC. CMA may also reveal unexpected or new information, including consanguinity and non-paternity. These significant clinical and ethical implications call for clear, thorough counseling and informed consent for invasive and noninvasive tests that reveal fetal genetic information.
“We are ethically obliged to discuss available prenatal screening and diagnostic options so that patients can make the best choices — including potential decisions to continue or end the pregnancy,” said Dr. Farrell. “Regardless of how accurate and noninvasive new prenatal genetic tests may be or may become, we will continue to help pregnant women navigate the uncertainty that can come with such decisions.”
Conscientious objection holds special relevance in reproductive medicine. Hospitals must balance respecting caregiver objections with patient-care obligations, said bioethicist Cristie Cole, JD.
Key issues include the scope of the objections, the practical impact accommodations have on scheduling and staffing decisions (including the increased burden on other caregivers), and the hospital’s responsibilities to meet treatment expectations and provide access to care.
Ethics consults do not render decisions in these cases. Yet when conducted with appropriate goals by the right parties, they can resolve uncertainty and clarify ethically supportable actions.