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Schneider K, Müller J, Tissen-Diabaté T, Schleußner E. [Ethical Attitudes and Handling in Prenatal Conflict Situations - A Survey among Obstetricians and Prenatal Diagnosticians in Germany]. Z Geburtshilfe Neonatol 2024. [PMID: 38253330 DOI: 10.1055/a-2217-9635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
OBJECTIVE Various studies have shown that belonging to a professional group has an influence on ethical attitudes. The aim of this study was to assess and compare the attitudes and approaches of obstetrical specialists and prenatal diagnosticians in prenatal conflict situations. METHODS Explorative cross-sectional online survey among tertiary perinatal care centers and prenatal diagnosticians with DEGUM Level II/III in Germany. The questionnaire included questions on ethical attitudes in the perinatal context and a case presentation of a fetal hypoplastic left heart syndrome. RESULTS The response rate was 57.1% (310/543). 55.5% of the respondents practiced both obstetrics and prenatal diagnostics, 24.5% exclusively prenatal diagnostics, and 14.2% purely obstetrics. 27% agreed with the statement "An uncertain prognosis justifies pregnancy termination". For complex fetal malformations joint interdisciplinary counseling was advocated by 98.3%. Addressing the option of postnatal palliative treatment in a case of a hypoplastic left heart syndrome was accepted by 84.3% across all professional groups, while mentioning fetocide was more frequently cited as an option by prenatal diagnosticians than by obstetricians (57.7% vs. 34.1%). CONCLUSION Interdisciplinary prenatal parental counseling in complex fetal malformations is uniformly advocated by prenatal diagnosticians and obstetricians in Germany. However, different ethical attitudes appear among specialists groups with regard to the option of termination of pregnancy.
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Affiliation(s)
- Katja Schneider
- Klinik für Neonatologie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Johanna Müller
- Klinik für Geburtsmedizin, Universitätsklinikum Jena, Jena, Germany
| | - Tatjana Tissen-Diabaté
- Institut für Sozialmedizin, Epidemiologie und Gesundheitsökonomie, Charité Universitätsmedizin Berlin, Berlin, Germany
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Schneider K, Müller J, Schleußner E. German obstetrician's self-reported attitudes and handling in threatening preterm birth at the limits of viability. J Perinat Med 2023; 51:1097-1103. [PMID: 37256371 DOI: 10.1515/jpm-2022-0547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 05/04/2023] [Indexed: 06/01/2023]
Abstract
OBJECTIVES Antenatal treatment and information influences the course of pregnancy and parental decision-making in cases of threatened prematurity on the borderline of viability. Numerous studies have shown significant interprofessional differences in assessing ethical boundary decisions; hence, this study aimed to evaluate obstetricians attitudes, practices and antenatal parental counseling regarding threatened preterm birth in Germany. METHODS An anonymous online questionnaire was administered to 543 obstetricians at tertiary perinatal centers and prenatal diagnostic centers in Germany. The survey contained questions on basic ethical issues assessed using the Likert scale and a case vignette regarding the practical procedures of an imminent extreme premature birth at 23 1/7 gestational weeks. RESULTS In the case of unstoppable preterm birth, 15 % of clinicians said they would carry out a cesarean section; however, specialists from centers with a high number of very low birth weight infants would do so significantly more often. Among respondents, 29.8 % did not take any therapeutic measures without discussing the child's treatment options with their parents, 19.9 % refused to offer actionable advice to the parents, and 57 % said they would advise parents to seek intensive care treatment for the child with the option of changing treatment destination in the event of serious complications. Moreover, 84 % said they would provide information together with neonatologists. CONCLUSIONS Joint counseling with neonatologists is widely accepted. The size of the perinatal center significantly influences the practical approach to threatened preterm births. Respect for parents' decision-making autonomy regarding the child's treatment options is central and influences therapy initiation.
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Affiliation(s)
- Katja Schneider
- Department of Neonatology, Charité University Medicine Berlin, Berlin, Germany
| | - Johanna Müller
- Department of Obstetrics, University Hospital Jena, Jena, Germany
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Madrigal VN, Feltman DM, Leuthner SR, Kirsch R, Hamilton R, Dokken D, Needle J, Boss R, Lelkes E, Carter B, Macias E, Bhombal S. Bioethics for Neonatal Cardiac Care. Pediatrics 2022; 150:189885. [PMID: 36317974 DOI: 10.1542/peds.2022-056415n] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Clinicians caring for neonates with congenital heart disease encounter challenges with ethical implications in daily practice and must have some basic fluency in ethical principles and practical applications. METHODS Good ethical practice begins with a thorough understanding of the details and narrative of each individual case, examination via classic principles of bioethics, and further framing of that translation into practice. RESULTS We explore some of these issues and expand awareness through the lens of a case presentation beginning with fetal considerations through end-of-life discussions. CONCLUSIONS We include specific sections that bring attention to shared decision-making, research ethics, and outcomes reporting. We review empirical evidence and highlight recommendations.
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Affiliation(s)
- Vanessa N Madrigal
- Department of Pediatrics, Division of Critical Care Medicine and Pediatric Ethics Program, Children's National Hospital, George Washington University, Washington, District of Columbia
| | - Dalia M Feltman
- NorthShore University HealthSystem Evanston Hospital, University of Chicago, Pritzker School of Medicine, Chicago, Illinois
| | - Steven R Leuthner
- Departments of Pediatrics and Bioethics, Division of Neonatology, Children's Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Roxanne Kirsch
- Department of Critical Care, Division Cardiac Critical Care Medicine; Department of Bioethics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Rekha Hamilton
- Mednax Inc. Cook Children's Medical Center, Fort Worth, Texas
| | - Deborah Dokken
- Family Leader and Staff Member, Institute for Patient and Family-Centered Care, Bethesda, Maryland
| | - Jennifer Needle
- Department of Pediatrics and the Center for Bioethics, University of Minnesota, Minneapolis, Minnesota
| | - Renee Boss
- Department of Pediatrics, Johns Hopkins School of Medicine and Berman Institute of Bioethics, Baltimore, Maryland
| | - Efrat Lelkes
- Department of Pediatrics, Divisions of Critical Care Medicine and Palliative Medicine, Bioethics, University of California San Francisco, San Francisco, California
| | - Brian Carter
- Departments of Humanities and Pediatrics, Division of Neonatology and Bioethics Center, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Eduardo Macias
- Department of Pediatrics, Division of Pediatric Cardiology. University Hospital, University of Texas, San Antonio, Texas
| | - Shazia Bhombal
- Department of Pediatrics, Lucile Packard Children's Hospital. Stanford, Palo Alto, California
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The key role of the pediatric radiologist in developing a multidisciplinary fetal center. Pediatr Radiol 2020; 50:1801-1809. [PMID: 33252750 DOI: 10.1007/s00247-020-04702-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 04/10/2020] [Accepted: 05/05/2020] [Indexed: 12/25/2022]
Abstract
With the demand for fetal imaging and fetal care programs on the rise, the authors of this manuscript review the components of building a successful fetal imaging center. Creating an environment that engages a multidisciplinary team, utilizing a central coordinator to review clinical and psychosocial aspects of each patient, and ensuring ongoing research and quality control are essential components to the success of growing a program.
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Bührer C, Felderhoff-Müser U, Gembruch U, Hecher K, Kainer F, Kehl S, Kidszun A, Kribs A, Krones T, Lipp V, Maier RF, Mitschdörfer B, Nicin T, Roll C, Schindler M. Frühgeborene an der Grenze der Lebensfähigkeit
(Entwicklungsstufe S2k, AWMF-Leitlinien-Register Nr. 024/019, Juni
2020). Z Geburtshilfe Neonatol 2020; 224:244-254. [PMID: 33075837 DOI: 10.1055/a-1230-0810] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Redaktionskomitee
Federführende Fachgesellschaft
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Affiliation(s)
- Christoph Bührer
- Klinik für Neonatologie, Charité - Universitätsmedizin Berlin, Berlin
| | | | - Ulrich Gembruch
- Zentrum für Geburtshilfe und Frauenheilkunde, Universitätsklinikum Bonn, Bonn
| | - Kurt Hecher
- Klinik für Geburtshilfe und Pränatalmedizin, Universitätskrankenhaus Eppendorf, Hamburg
| | - Franz Kainer
- Abteilung für Geburtshilfe und Pränatalmedizin, Klinik Hallerwiese, Nürnberg
| | - Sven Kehl
- Frauenklinik, Universitätsklinikum Erlangen, Erlangen
| | - André Kidszun
- Zentrum für Kinder- und Jugendmedizin, Universitätsmedizin Mainz, Mainz
| | | | - Tanja Krones
- Klinische Ethik, Universitätsspital Zürich, Zürich
| | - Volker Lipp
- Lehrstuhl für Bürgerliches Recht, Zivilprozessrecht, Medizinrecht und Rechtsvergleichung, Juristische Fakultät / Institut für Notarrecht / Zentrum für Medizinrecht, Universität Göttingen, Göttingen
| | - Rolf F Maier
- Zentrum für Kinder- und Jugendmedizin, Universitätsklinikum Marburg, Marburg
| | | | - Tatjana Nicin
- Klinik für Gynäkologie und Geburtshilfe, Klinikum Hanau, Hanau
| | - Claudia Roll
- Abteilung Neonatologie, Pädiatrische Intensivmedizin, Schlafmedizin, Vestische Kinder- und Jugendklinik Datteln, Universität Witten/Herdecke, Datteln
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Scher MS. Fetal neurology: Principles and practice with a life-course perspective. HANDBOOK OF CLINICAL NEUROLOGY 2019; 162:1-29. [PMID: 31324306 DOI: 10.1016/b978-0-444-64029-1.00001-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Clinical service, educational, and research components of a fetal/neonatal neurology program are anchored by the disciplines of developmental origins of health and disease and life-course science as programmatic principles. Prenatal participation provides perspectives on maternal, fetal, and placental contributions to health or disease for fetal and subsequent neonatal neurology consultations. This program also provides an early-life diagnostic perspective for neurologic specialties concerned with brain health and disease throughout childhood and adulthood. Animal models and birth cohort studies have demonstrated how the science of epigenetics helps to understand gene-environment interactions to better predict brain health or disease. Fetal neurology consultations provide important diagnostic contributions during critical or sensitive periods of brain development when future neurotherapeutic interventions will maximize adaptive neuroplasticity. Age-specific normative neuroinformatics databases that employ computer-based strategies to integrate clinical/demographic, neuroimaging, neurophysiologic, and genetic datasets will more accurately identify either symptomatic patients or those at risk for brain disorders who would benefit from preventive, rescue, or reparative treatment choices throughout the life span.
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Affiliation(s)
- Mark S Scher
- Division of Pediatric Neurology, Case Western Reserve University, Cleveland, OH, United States.
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Levin-Decanini T, Houtrow A, Katz A. The Evolution of Spina Bifida Treatment Through a Biomedical Ethics Lens. HEC Forum 2018; 29:197-211. [PMID: 28555303 DOI: 10.1007/s10730-017-9327-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Spina bifida is a neurodevelopmental disorder that results in a broad range of disability. Over the last few decades, there have been significant advances in diagnosis and treatment of this condition, which have raised concerns regarding how clinicians prognosticate the extent of disability, determine quality of life, and use that information to make treatment recommendations. From the selective treatment of neonates in the 1970s, to the advent of maternal-fetal surgery today, the issues that have been raised surrounding spina bifida intervention invoke principles of medical bioethics such as beneficence and nonmaleficence, while also highlighting how quality of life judgments may drive care decisions. Such changes in treatment norms are also illustrative of how disability is viewed both within the medical community and by society at large. An examination of the changes in spina bifida treatment provides a model through which to understand how ethically complex decisions regarding care for children with disabilities has evolved, and the challenges faced when medical information is combined with value-based judgments to guide medical decision making.
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Affiliation(s)
- Tal Levin-Decanini
- Children's Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA. .,University of Pittsburgh School of Nursing, 3500 Victoria Street, Pittsburgh, PA, 15213, USA.
| | - Amy Houtrow
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh, PA, 15261, USA
| | - Aviva Katz
- Division of General and Thoracic Surgery, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
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Abstract
Prenatal diagnosis has changed perinatal medicine dramatically, allowing for additional fetal monitoring, referral and counseling, delivery planning, the option of fetal intervention, and targeted postnatal management. Teams participating in the delivery room care of infants with known anomalies should be knowledgeable about specific needs and expectations but also ready for unexpected complications. A small number of neonates will need rapid access to postnatal interventions, such as surgery, but most can be stabilized with appropriate neonatal care. These targeted perinatal interventions have been shown to improve outcome in selected diagnoses.
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Affiliation(s)
- Elizabeth K Sewell
- Emory Children's Center Neonatalogy Offices, 2015 Uppergate Drive-3(rd) floor, Atlanta, GA 30322, USA
| | - Sarah Keene
- Emory Children's Center Neonatalogy Offices, 2015 Uppergate Drive-3(rd) floor, Atlanta, GA 30322, USA.
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Moaddab A, Nassr AA, Belfort MA, Shamshirsaz AA. Ethical issues in fetal therapy. Best Pract Res Clin Obstet Gynaecol 2017; 43:58-67. [PMID: 28268059 DOI: 10.1016/j.bpobgyn.2017.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 02/05/2017] [Accepted: 02/06/2017] [Indexed: 02/03/2023]
Abstract
The introduction of routine fetal ultrasound and the technical improvements in ultrasound equipment have greatly increased our ability to diagnose fetal anomalies. As a consequence, congenital anomalies are diagnosed today earlier and in a greater number of patients than ever before. The development of fetal intervention and fetal surgery techniques, improved anesthesia methodology, and sophisticated perinatal care at the limits of viability, have now made prenatal management of some birth defects or fetal malformations a reality. The increasing number of indications for fetal therapy and the apparent desire of parents to seek out these procedures have raised concern regarding the ethical issues related to the therapy. While fetal therapy may have a huge impact on the prenatal management of some congenital birth defects and/or fetal malformations, because of the invasive nature of these procedures, the lack of sufficient data regarding long-term outcomes, and the medical/ethical uncertainties associated with some of these interventions there is cause for concern. This chapter aims to highlight some of the most important ethical considerations pertaining to fetal therapy, and to provide a conceptual ethical framework for a decision-making process to help in the choice of management options.
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Affiliation(s)
- Amirhossein Moaddab
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, United States
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, United States; Department of Obstetrics and Gynecology, Women's Health Hospital, Assiut University, Assiut, Egypt
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, United States
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, United States.
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Kukora S, Gollehon N, Weiner G, Laventhal N. Prognostic accuracy of antenatal neonatology consultation. J Perinatol 2017; 37:27-31. [PMID: 27684414 DOI: 10.1038/jp.2016.171] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/30/2016] [Accepted: 08/31/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Neonatologists provide antenatal counseling to support shared decision-making for complicated pregnancies. Poor or ambiguous prognostication can lead to inappropriate treatment and parental distress. We sought to evaluate the accuracy of antenatal prognosticaltion. STUDY DESIGN A retrospective cohort was assembled from a prospectively populated database of all outpatient neonatology consultations. On the basis of the written consultation, fetuses were characterized by diagnosis groups (multiple anomalies or genetic disorders, single major anomaly and obstetric complications), assigned to five prognostic categories (I=survivable, IIA=uncertain but likely survivable, II=uncertain, IIB=uncertain but likely non-survivable, III non-survivable) and two final outcome categories (fetal demise/in-hospital neonatal death or survival to hospital discharge). When possible, status at last follow-up was recorded for those discharged from the hospital. Prognostic accuracy was assessed using unweighted, multi-level likelihood ratios (LRs). RESULTS The final cohort included 143 fetuses/infants distributed nearly evenly among the three diagnosis groups. Over half (64%) were assigned an uncertain prognosis, but most of these could be divided into 'likely survivable' or 'likely non-survivable' subgroups. Overall survival for the entire cohort was 62% (89/143). All but one of the fetuses assigned a non-survivable prognosis suffered fetal demise or died before hospital discharge. The neonatologist's antenatal prognosis accurately predicted the probability of survival by prognosis group (LR I=4.56, LR IIA=10.53, LR II=4.71, LR IIB=0.099, LR III=0.040). The LRs clearly differentiated between fetuses with high and low probability of survival. Eleven fetuses (7.7%) had misalignment between the predicted prognosis and outcome. Five died before discharge despite being given category I or IIA prognoses, whereas six infants with category IIB or III prognoses survived to discharge, though some of these were discharged to hospice care. CONCLUSIONS The neonatologist's antenatal prognosis accurately predicted fetal-neonatal outcome. Infants with non-survivable or uncertain but likely poor prognoses had a very low probability of survival, whereas those with good or uncertain prognoses had a high probability of survival. There were few cases of prognostic failure with most occurring in fetuses with one major or multiple anomalies. The few cases of prognostic failure suggest a need for caution. Honest disclosure of prognostic uncertainty and shared decision-making with families utilizing their personal values is critical in the antenatal encounter.
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Affiliation(s)
- S Kukora
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA.,Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
| | - N Gollehon
- Division of Neonatology, Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA
| | - G Weiner
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
| | - N Laventhal
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA.,Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
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Zalles-Vidal C, Vega González MG, Valadez Reyes MT, Cabrera-Muñoz MDL. [Late prematurity with gastroschisis and severe hypoalbuminemia]. BOLETIN MEDICO DEL HOSPITAL INFANTIL DE MEXICO 2015; 72:339-345. [PMID: 29421533 DOI: 10.1016/j.bmhimx.2015.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 08/24/2015] [Indexed: 06/08/2023] Open
Affiliation(s)
- Cristian Zalles-Vidal
- Departamento de Cirugía, Hospital Infantil de México Federico Gómez, México D.F., México
| | - María Guadalupe Vega González
- Departamento de Neonatología, residente de quinto año, Hospital Infantil de México Federico Gómez, México D.F., México
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12
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The antecedents and consequences of a strong professional identity among medical specialists. SOCIAL THEORY & HEALTH 2014. [DOI: 10.1057/sth.2014.16] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Brown SD, Donelan K, Martins Y, Sayeed SA, Mitchell C, Buchmiller TL, Burmeister K, Ecker JL. Does professional orientation predict ethical sensitivities? Attitudes of paediatric and obstetric specialists toward fetuses, pregnant women and pregnancy termination. JOURNAL OF MEDICAL ETHICS 2014; 40:117-122. [PMID: 23572566 DOI: 10.1136/medethics-2012-101126] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND To determine (1) whether fetal care paediatric (FCP) and maternal-fetal medicine (MFM) specialists harbour differing attitudes about pregnancy termination for congenital fetal conditions, their perceived responsibilities to pregnant women and fetuses, and the fetus as a patient and (2) whether self-perceived primary responsibilities to fetuses and women and views about the fetus as a patient are associated with attitudes about clinical care. METHODS Mail survey of 434 MFM and FCP specialists (response rates 60.9% and 54.2%, respectively). RESULTS MFMs were more likely than FCPs to disagree with these statements (all p values<0.005): (1) 'the presence of a fetal abnormality is not an appropriate reason for a couple to consider pregnancy termination' (MFM : FCP-78.4% vs 63.5%); (2) 'the effects that a child born with disabilities might have on marital and family relationships is not an appropriate reason for a couple to consider pregnancy termination' (MFM : FCP-80.5% vs 70.2%); and (3) 'the cost of healthcare for the future child is not an appropriate reason for a couple to consider pregnancy termination' (MFM : FCP-73.5% vs 55.9%). 65% MFMs versus 47% FCPs disagreed that their professional responsibility is to focus primarily on fetal well-being (p<0.01). Specialists did not differ regarding the fetus as a separate patient. Responses about self-perceived responsibility to focus on fetal well-being were associated with clinical practice attitudes. CONCLUSIONS Independent of demographic and sociopolitical characteristics, FCPs and MFMs possess divergent ethical sensitivities regarding pregnancy termination, pregnant women and fetuses, which may influence clinical care.
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Affiliation(s)
- Stephen D Brown
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, , Boston, Massachusetts, USA
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