Ethical Principles of Prenatal Care

Prioritizing the autonomy of pregnant women, weighing the interests of minimizing harm, equitable access to the whole population, and substantial informed consent. However, when it comes to determining the priority of specific clinical scenarios, there are still obvious differences in the practical standards of different ethical schools and different regions, and there is no absolutely unified standard answer.

I came across a particularly impressive case when I was assisting in the county hospital two years ago: a 28-year-old first-time mother was diagnosed with severe preeclampsia at 32 weeks of pregnancy, her blood pressure soared to 170/110, and her urine protein was three plus signs. After our evaluation, we recommended an immediate cesarean section, otherwise the adult would most likely suffer from eclamptic convulsions and cerebral hemorrhage, and the fetus would also be at risk of intrauterine distress. But the pregnant woman gritted her teeth and wanted to stay in the hospital for another two weeks. She said that if the baby was born before 34 weeks, she would need to live in an incubator. Her family really couldn't afford the money. Her husband and mother-in-law were crying beside her and persuaded her to take care of herself first. They were in a stalemate in the ward. Speaking of which, we cannot avoid the core point of controversy: Who is qualified to make the final decision? The traditional medical patriarchal school tends to "doctors and family members jointly determine the best plan". It is believed that pregnant women are emotionally unstable at this time and their judgments will be biased. ； However, the mainstream view of modern bioethics is that as long as a pregnant woman is a person with clear consciousness and full capacity for civil conduct, her decision-making power is higher than that of everyone else - even if her choice does not meet the "optimal solution" in everyone's eyes. Finally, we applied for the Newborn Relief Fund for her, and she agreed to have the surgery at 33 weeks. Mother and daughter were safe, and she often sends us videos of the baby.

When it comes to autonomy, we cannot avoid another topic that has been quarreling for decades: where should the interests of the fetus be placed? Some ethical schools with religious backgrounds believe that the fetus is an independent life subject from conception, and pregnant women cannot make any choices that harm the fetus. For example, some states in the United States will even prosecute pregnant women who refuse cesarean section for "manslaughter."” ； However, my country's Civil Code and clinical consensus make it clear that a fetus can only have civil rights if it is alive when delivered. Therefore, the first priority in weighing interests is always the mother's right to life and health, and the fetus's survival interests are second. I have met a pregnant woman who had congenital heart disease and was pregnant. Her heart function had reached level 4. We repeatedly told her that if she continued the pregnancy, she would have a high probability of sudden death from heart failure in the third trimester. She insisted on giving birth to the child, saying that she wanted to be a mother in her life. The ethics committee held three meetings. One group said that the pregnancy must be forcibly terminated to avoid the worst outcome of one death and two lives. The other group said that she had clearly understood all the risks and we had no right to deprive her of her choice. In the end, we formulated a strict monitoring plan for her. She survived the cesarean section at 36 weeks, and both mother and daughter were safe. Of course, not all similar cases have such good results. Last year, colleagues from other places encountered a similar situation. The pregnant woman died of heart failure after resuscitation failed, and the child was born prematurely and lived in an incubator for two months. At this time, no one can say which choice is absolutely right.

To be honest, what we discussed above are all ethical controversies that only pregnant women who can go to regular hospitals will encounter. There are many more people who do not even have access to the most basic prenatal care. When I went to a free clinic in Nujiang, Yunnan Province last year, I met a 19-year-old pregnant woman. She was 32 weeks pregnant when she came for her first prenatal check-up. Her blood pressure had not been measured before. When she came, her lower limbs were swollen like steamed buns. She was found to have severe preeclampsia. We transferred her to the prefectural hospital overnight to avoid more serious consequences. This involves the third core principle: fairness and accessibility. There is now a lot of controversy in the academic circles on this topic. The public health school believes that limited medical resources should be invested in full coverage of basic prenatal check-ups. First, all pregnant women can have free screening, blood pressure testing, and routine B-ultrasounds, and then talk about high-end screening. ； The eugenics ethics school believes that priority should be given to including non-invasive DNA, single-gene disease screening and other more accurate items into medical insurance to reduce the incidence of rare diseases and birth defects, which will save social resources in the long run. Both statements are reasonable, and they are nothing more than priority choices under limited resources.

Finally, let’s talk about the informed consent that everyone is most familiar with. Don’t think that just signing it is done. I have dealt with a dispute before. A pregnant woman got an infection and had a miscarriage after undergoing amniocentesis. She came and complained that she was not aware of the risk of miscarriage. We pulled out the consent form, and she pointed to the dense technical jargon on it and said, "I am a junior high school student and can't even read the words. The doctor pointed out a place for me to sign. How could I know what was written on it?" Do you think this counts as informed consent? Definitely not. Our department later changed the rules. Before performing invasive operations, pregnant women should first watch a 3-minute animated science popularization. The risks, benefits, and alternatives are clearly explained in plain language. After the explanation, three questions are asked: Do you know what this operation is for? Know what the biggest risks are? Did you know you can choose not to do it? All three can answer the questions before signing. After doing this, the disputes will be reduced by more than half. Of course, some colleagues complained that taking dozens of calls a day was too inefficient and too busy. This is also a very real contradiction. Ethical principles are never castles in the air that are divorced from reality and must always be balanced with the actual situation.

I have been practicing obstetrics for almost ten years, and I feel more and more that these ethical principles are not slogans hanging on the walls of the hospital, nor are they rules and regulations used to block people. They are more like traffic rules for driving: you must abide by them at ordinary times, but when someone has a sudden illness and needs to run a red light and be sent to the hospital, you cannot cling to the rules. After all, what we are facing are never the two abstract concepts of "pregnant woman" and "fetus", but living people with their own difficulties and thoughts. The so-called ethics, to put it bluntly, is to always put people first.