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Bennett R, Frith L. Editorial - The ethical implications of treating a pregnant woman to benefit the fetus. J Cyst Fibros 2022; 21:558-559. [PMID: 35697649 DOI: 10.1016/j.jcf.2022.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 05/30/2022] [Indexed: 11/24/2022]
Affiliation(s)
- Rebecca Bennett
- Centre for Social Ethics & Policy, Department of Law School of Social Sciences, The University of Manchester, Oxford Road, Manchester, M13 9QQ, UK
| | - Lucy Frith
- Centre for Social Ethics & Policy, Department of Law School of Social Sciences, The University of Manchester, Oxford Road, Manchester, M13 9QQ, UK.
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Rousseau AC, Riggan KA, Schenone MH, Whitford KJ, Pittock ST, Allyse MA. Ethical considerations of maternal-fetal surgery. J Perinat Med 2022; 50:519-527. [PMID: 35092654 DOI: 10.1515/jpm-2021-0476] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 01/13/2022] [Indexed: 11/15/2022]
Abstract
The practice of maternal-fetal surgery (MFS) has expanded from lethal fetal conditions to conditions which are significantly disabling but not a lethal fetal abnormality. The inclusion of myelomeningocele within the scope of MFS in the 1990s sparked a renewed debate over the ethics of MFS. While demonstrating increasing efficacy and range of application, MFS continues to be ethically fraught due to the inherent tension between maternal and fetal interests. Ethical issues central to MFS include the patienthood of the fetus; the balance of risks and benefits between the woman and fetus; informed consent for experimental procedures; and determination of conditions that meet ethical qualifications for MFS intervention. These concerns are likely to persist and evolve as perinatal medicine continues to advance. Here we summarize the current state of MFS ethics, highlighting the major positions in the literature thus far as well as examine future directions. It is essential robust discussions of these important issues continue both to ensure ethical medical practice and to provide support to clinicians, pregnant women, and their families.
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Affiliation(s)
- Abigail C Rousseau
- Biomedical Ethics Research Program, Mayo Clinic Rochester, Rochester, MN, USA
| | - Kirsten A Riggan
- Biomedical Ethics Research Program, Mayo Clinic Rochester, Rochester, MN, USA
| | - Mauro H Schenone
- Department of Obstetrics & Gynecology, Division of Maternal and Fetal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kevin J Whitford
- Department of Internal Medicine, Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Siobhan T Pittock
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Endocrinology and Metabolism, Mayo Clinic, Rochester, MN, USA
| | - Megan A Allyse
- Biomedical Ethics Research Program, Mayo Clinic Rochester, Rochester, MN, USA.,Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA
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Antiel RM, Curlin FA, Lantos JD, Collura CA, Flake AW, Johnson MP, Rintoul NE, Brown SD, Feudtner C. Attitudes of paediatric and obstetric specialists towards prenatal surgery for lethal and non-lethal conditions. JOURNAL OF MEDICAL ETHICS 2018; 44:234-238. [PMID: 29018178 DOI: 10.1136/medethics-2017-104377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 07/14/2017] [Accepted: 09/24/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND While prenatal surgery historically was performed exclusively for lethal conditions, today intrauterine surgery is also performed to decrease postnatal disabilities for non-lethal conditions. We sought to describe physicians' attitudes about prenatal surgery for lethal and non-lethal conditions and to elucidate characteristics associated with these attitudes. METHODS Survey of 1200 paediatric surgeons, neonatologists and maternal-fetal medicine specialists (MFMs). RESULTS Of 1176 eligible physicians, 670 (57%) responded (range by specialty, 54%-60%). In the setting of a lethal condition for which prenatal surgery would likely result in the child surviving with a severe disability, most respondents either disagreed (59%) or strongly disagreed (19%) that they would recommend the surgery. Male physicians were twice as likely to recommend surgery for the lethal condition, as were physicians who believe that abortion is morally wrong (OR 1.75; 95%CI 1.0 to 3.05). Older physicians were less likely to recommend surgery (OR 0.57; 95%CI 0.36 to 0.88). For non-lethal conditions, most respondents agreed (66% somewhat, 4% strongly) that they would recommend prenatal surgery, even if the surgery increases the risk of prematurity or fetal death. Compared with MFMs, surgeons were less likely to recommend such surgery, as were physicians not affiliated with a fetal centre, and physicians who were religious (ORs range from 0.45 to 0.64). CONCLUSION Physician's attitudes about prenatal surgery relate to physicians' beliefs about disability as well as demographic, cultural and religious characteristics. Given the variety of views, parents are likely to receive different recommendations from their doctors about the preferable treatment choice.
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Affiliation(s)
- Ryan M Antiel
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of General Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Farr A Curlin
- Trent Center for Bioethics, Humanities and History of Medicine, Duke University, Durham, North Carolina, USA
| | - John D Lantos
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri, USA
| | | | - Alan W Flake
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Mark P Johnson
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Natalie E Rintoul
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Stephen D Brown
- Department of Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Chris Feudtner
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
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Antiel RM, Janvier A, Feudtner C, Blaine K, Fry J, Howell LJ, Houtrow AJ. The experience of parents with children with myelomeningocele who underwent prenatal surgery. J Pediatr Rehabil Med 2018; 11:217-225. [PMID: 30507587 DOI: 10.3233/prm-170483] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Prenatal surgery for myelomeningocele (MMC) has been demonstrated to have benefits over postnatal surgery. Nevertheless, prenatal surgery requires a significant emotional, physical, and financial commitment from the entire family. METHODS Mixed methods study of parents' perceptions regarding provider communication, treatment choices, and the family impact of having a child with MMC. RESULTS Parents of children with MMC (n= 109) completed questionnaires. Parents were well informed and reported gathering information about prenatal surgery from a wide range of sources. After a fetal diagnosis of MMC, most learned about their options from their obstetrician, although one-third were not told about the option of prenatal surgery. About one-fourth of these parents felt pressure to undergo one particular option. Half of parents said that having a child with MMC has had a positive impact on them and their family, while the other half indicated that having a child with MMC has had both positive and negative impacts. The most commonly noted positive impacts were changes in parental attitudes, as well as having new opportunities and relationships. The most frequently reported negative impacts concerned relational and financial strain. The vast majority of parents indicated that they would still undergo prenatal surgery if they could travel back in time with their present knowledge. CONCLUSIONS A better understanding of the parental experiences and perspectives following prenatal surgery will play an important role in providing overall support for parents and family members.
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Affiliation(s)
- Ryan M Antiel
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Annie Janvier
- Department of Pediatrics and Clinical Ethics, University of Montreal, Neonatology, Clinical Ethics, Palliative Care, Sainte-Justine Hospital, and Sainte-Justine Hospital Research Center, Montreal, QC, Canada
| | - Chris Feudtner
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Jessica Fry
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, and Division of Neonatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Lori J Howell
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Amy J Houtrow
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
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Abstract
This article explores some of the complex ethical challenges that exist in the field of fetal diagnosis and treatment, especially surrounding maternal-fetal surgery. The rise of these new treatments force us to reconsider who or what is the fetus, what are our obligations to the fetus, and what are the limits to those obligations. In addition, we will consider provider and professional biases, disability issues, and how maternal-fetal surgery has, for a select group of women, changed the very experience of motherhood.
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Affiliation(s)
- Ryan M Antiel
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, 423 Guardian Dr, FL 14 Market St, Suite 320, Philadelphia, PA 19104.
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Lyerly AD, Little MO, Faden RR. A critique of the 'fetus as patient'. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2008; 8:42-4; discussion W4-6. [PMID: 18759185 PMCID: PMC2553002 DOI: 10.1080/15265160802331678] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Affiliation(s)
- Anne Drapkin Lyerly
- Department of Obstetrics and Gynecology, Trent Center for Bioethics, Humanities, and History of Medicine, Duke University Medical Center, Box 3040, 108 Seeley G. Mudd Building, Durham, NC 27710, USA.
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Bliton MJ. Ethics: "life before birth" and moral complexity in maternal-fetal surgery for spina bifida. Clin Perinatol 2003; 30:449-64, v-vi. [PMID: 14533888 DOI: 10.1016/s0095-5108(03)00046-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This article considers the ethical significance of a moral belief common among pregnant women (and their partners) who seek open uterine repair for fetal spina, namely that their fetuses are already "babies." The need to recognize and interact sensitively with a pregnant woman's vulnerability to her own beliefs and concerns regarding potential disabilities, the fetal intervention, and its potential outcome is emphasized. Such recognition and explicit discussions are ethically important for informed consent and to safeguard against the judgments, enthusiasms, and biases of surgeons and other team members.
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Affiliation(s)
- Mark J Bliton
- Clinical Ethics Consultation Service, Center for Clinical and Research Ethics, 319 Oxford House, Vanderbilt University Medical Center, Nashville, TN 37232-4350, USA.
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Current awareness in prenatal diagnosis. Prenat Diagn 2003; 23:694-700. [PMID: 12938665 DOI: 10.1002/pd.532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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