Critical care decisions in fetal and neonatal medicine: ethical issues
Fetal medicine
16 In fetal medicine, improvements in technology and greater understanding of how fetal development affects the future health of a child have changed the way in which pregnancies are managed. Screening will provide reassurance for most pregnant women, but a minority will find that their unborn baby may have a serious abnormality. Most commonly, the choices will be for the woman to continue with the pregnancy, agreeing to an early delivery if appropriate, or electing to terminate the pregnancy. The Working Party endorses the current position in the UK whereby decisions about the fetus, including the mode and timing of delivery, are made only with the consent of the pregnant woman, and that she should determine what happens in cases of dispute with her partner or her obstetrician.2 Women making such decisions must be provided with comprehensive, accessible information on the risks and benefits of what is proposed, and (where possible) enabled to make their decisions with the support of their partners, their wider family or others they would like to consult, should they so wish (see paragraphs 8.3–8.4 and 9.7).
17 Advances in fetal diagnosis have not been matched by prospects for effective treatment with medicine or surgery. We are aware of the development of open fetal surgery as a possible means of correcting or lessening the impact of abnormalities in a limited number of conditions although we believe that the value of such procedures remains unclear at this time. Such procedures carry a high risk to the pregnant woman. Our view is that in the UK, new procedures in fetal surgery should be offered only within a protocol approved by a research ethics committee (see paragraphs 4.11 and 9.8).
18 The Working Party does not take a position on whether the time limit for legal termination of pregnancy should be reduced since the kinds of decision making that we examine in this Report would not be affected, provided that termination on grounds of fetal abnormality continued to be permitted. In late termination of pregnancy, feticide is recommended before the initiation of labour in terminations after 21 weeks, six days of gestation to ensure that the fetus is not born alive. The procedure pre-empts the possibility of dilemmas about whether a baby born alive after a termination should be resuscitated. However, a minority of pregnant women do not wish to have feticide, whatever the diagnosis. The Working Party was advised that termination of pregnancy after 22 weeks without feticide was an issue of major concern for healthcare professionals in fetal medicine. In particular, they needed a greater understanding of the legal position. We recommend that there should be greater uniformity of practice and interpretation of the law, which does not require all possible measures to be taken to prolong the life of a baby born alive if it is not in his or her best interests. A code of practice should be developed for healthcare professionals to achieve clarity about what the law does and does not require doctors to do. Such a code would also help ensure that pregnant women are given sufficient information about possible outcomes if a baby is born alive following termination on grounds of fetal abnormality. The responsibility for developing the code should be taken by a broad group of professional organisations consulting as appropriate. Where relevant, it should be made available to a woman as part of her care pathway (paragraphs 4.14–4.16, 8.7–8.8 and 9.10).
Footnotes2 Unless her mental capacity is impaired.