**16. Prenatal diagnosis and termination of pregnancy following the procedure**

Prenatal diagnosis is becoming an increasingly important component of obstetrics care, to identify in –utero, diseases of the foetus and their severity, that may require genetic engineering, future life style adjustment or termination of pregnancy. Prenatal diagnostic procedure requires prior counseling and informed consent of the woman. The woman is also required to state in advance any information that she would not want to be given following the procedure for example the sex of the foetus.

Prenatal diagnosis provides information as to foetal diseases that may permit termination of pregnancy in countries where the law permits. The ethical challenges raised however is related to how one determines the degree of the severity of the disease or abnormality and

Bioethics in Obstetrics 309

Angela carder's family and Reproductive Freedom Project (RFP) supported by several other bodies and human rights organizations filed an appeal at the D.C. court of Appeal for the vacation of the court order for that cesarean section and the legal precedents it had set, which was ultimately granted (ACLU, 1997). On no account therefore should a woman be forced or coerced into carrying out a procedure that she is unwilling to accept since this will amount to a violation of her autonomy. It is inappropriate to resort to judicial intervention when a woman has made an informed refusal of a medical or surgical procedure since this is considered to constitute an overriding of her autonomy (strong paternalism). The situation is noteworthy, different when the woman's competence to make decision is

The consent of a surrogate – the woman's spouse or any other member of her family is usually enlisted. It is important however to note that in general the mother should be of prime consideration and therefore decision on her well-being takes precedence over that of the foetus.

A woman carrying a severely malformed foetus has the ethical right of having the pregnancy terminated. In situations where termination of pregnancy is not considered as a management option, for example for legal, religious or other personal reasons, prenatal diagnostic procedures for severe foetal congenital malformations should be preceded by counseling of the woman on the possible findings and ascertaining from her the extent of the findings to be disclosed to her. Pregnancy termination on the basis of the sex of the foetus is un-ethical. In multiple pregnancies involving normal and malformed foetuses prime consideration should be given to survival of the normal foetuses provided the mother's life is not at risk. Where the couple disagrees on the management option in severe foetal malformations, the view of the woman should take precedence over that of spouse. The medical team has the ethical responsibility to encourage the parents, in the case of severe foetal malformation, to seek a second opinion, should they not be satisfied with the medical advice given to them. The decision on the termination of pregnancy for congenital malformation should be made by the parents free from coercion, financial inducement or demographic considerations whether from government or other bodies. Medical practitioner should seek appropriate consent to confirm and appropriately document the nature and extent of foetal malformation following termination and furthermore

Worldwide there has been and increasing incidence in the rate of caesarean section attributable to medical, legal, financial, social and psychological factors. Oftentimes physicians are confronted with request for caesarean section for personal reasons such as the convenience of the patient. Caesarean deliveries are associated with higher risks than vaginal deliveries. Furthermore complications, costs and duration of hospital stay are more following caesarean deliveries compared to vaginal deliveries. It is ethically wrong for medical practitioners to perform caesarean section for indications that are not medical. The health practitioners are therefore obligated to inform adequately and counsel woman

impaired as in the unconscious mother or in the mentally sub–normal.

appropriately inform and counsel parents.

**19. Caesaeran section for non-medical reason** 

against requests for caesarean section for non-medical reasons.

**18. Interventions for severe congenital malformation of the foetus** 

to what extent this will influence the quality of life of the infant following delivery to justify the termination of the pregnancy.

The decision to terminate a pregnancy following the discovery of foetal abnormality from prenatal diagnosis, is entirely that of the couple and on no account should the couple be coerced into choosing any of the available care option, in fact where abnormality discovered is treatable or compatible with life, termination of pregnancy is discouraged.

#### **17. Interventions for foetal well–being including court-order obstetrical interventions**

The majority of pregnant women act in a manner that protects the interest of their foetus. There are few occasions however where the habits or practices of a mother may impair the well-being of her foetus, for example, cigarette smoking, alcohol intake and the use of hard drugs. A mother may also refuse the advice of the health practitioner to carry out procedures such as cesarean section for foetal indication. The healthcare practitioner and indeed the medical team have a responsibility to empathically counsel and fully inform the patient, excising utmost patience in doing so, of the benefits or repercussions of the medical advice. Most of the time, the woman accepts to co-operate if she is adequately informed. Situations however may arise where the pregnant woman emphatically objects to the proposed obstetrics intervention to the extent that judicial mandate is sought for by the hospital authorities. Court order cesarean section, the most common of these interventions has been reviewed by Walden (2007). A 1987 New England Journal of Medicine report indicated that among 21 cases of cesarean sections for which court orders were sought, 86% were obtained; in addition a survey of heads of maternal-foetal medicine departments, revealed that 46% of the respondents supported court ordered cesarean section (Veronika et al, 1987). A more recent study of attendees at the annual meetings of the American College of Obstetricians and Gynecologists and the American Health Lawyers Association found that as high as 51% indicated the likelihood of their supporting forced cesarean section (Samuels et al 2007). The issue of court order (forced cesarean section) and what should constitute the health professionals' approach to it has been summarized in a 2004 American College of Obstetrics and Gynecology (ACOG) guidelines which states as follows:- "if an obstetrician disagrees with a patient's choice and is unable to arrange transfer of care, they must, continue to care for the pregnant woman and not intervene against the patient's wishes, regardless of the consequences." The guideline also states that the use of judicial authority to implement treatment regimens to protect the fetus violates the pregnant woman's autonomy and should be avoided. It further states, "Even in the presence of a court order authorizing intervention, the use of physical force against a resistant, competent woman is not justified. The use of force will substantially increase the risk to the woman, thereby diminishing the ethical justification for such therapy (ACOG, 2007). The position contained in the ACOG guideline concerning court order cesarean section is in tandem with the premise on which the first appellate court vacation of a court order cesarean section was made in 1990. Angela Carder a terminally ill cancer patient at 26 weeks pregnancy had a forced judicial mandate cesarean section at George Washington University Hospital in 1987 – against her wish and that of her doctor and relations. Angela and her child died shortly after the surgery and it was argued that the surgical procedure had accelerated the death.

to what extent this will influence the quality of life of the infant following delivery to justify

The decision to terminate a pregnancy following the discovery of foetal abnormality from prenatal diagnosis, is entirely that of the couple and on no account should the couple be coerced into choosing any of the available care option, in fact where abnormality discovered

The majority of pregnant women act in a manner that protects the interest of their foetus. There are few occasions however where the habits or practices of a mother may impair the well-being of her foetus, for example, cigarette smoking, alcohol intake and the use of hard drugs. A mother may also refuse the advice of the health practitioner to carry out procedures such as cesarean section for foetal indication. The healthcare practitioner and indeed the medical team have a responsibility to empathically counsel and fully inform the patient, excising utmost patience in doing so, of the benefits or repercussions of the medical advice. Most of the time, the woman accepts to co-operate if she is adequately informed. Situations however may arise where the pregnant woman emphatically objects to the proposed obstetrics intervention to the extent that judicial mandate is sought for by the hospital authorities. Court order cesarean section, the most common of these interventions has been reviewed by Walden (2007). A 1987 New England Journal of Medicine report indicated that among 21 cases of cesarean sections for which court orders were sought, 86% were obtained; in addition a survey of heads of maternal-foetal medicine departments, revealed that 46% of the respondents supported court ordered cesarean section (Veronika et al, 1987). A more recent study of attendees at the annual meetings of the American College of Obstetricians and Gynecologists and the American Health Lawyers Association found that as high as 51% indicated the likelihood of their supporting forced cesarean section (Samuels et al 2007). The issue of court order (forced cesarean section) and what should constitute the health professionals' approach to it has been summarized in a 2004 American College of Obstetrics and Gynecology (ACOG) guidelines which states as follows:- "if an obstetrician disagrees with a patient's choice and is unable to arrange transfer of care, they must, continue to care for the pregnant woman and not intervene against the patient's wishes, regardless of the consequences." The guideline also states that the use of judicial authority to implement treatment regimens to protect the fetus violates the pregnant woman's autonomy and should be avoided. It further states, "Even in the presence of a court order authorizing intervention, the use of physical force against a resistant, competent woman is not justified. The use of force will substantially increase the risk to the woman, thereby diminishing the ethical justification for such therapy (ACOG, 2007). The position contained in the ACOG guideline concerning court order cesarean section is in tandem with the premise on which the first appellate court vacation of a court order cesarean section was made in 1990. Angela Carder a terminally ill cancer patient at 26 weeks pregnancy had a forced judicial mandate cesarean section at George Washington University Hospital in 1987 – against her wish and that of her doctor and relations. Angela and her child died shortly after the surgery and it was argued that the surgical procedure had accelerated the death.

or

is treatable or compatible with life, termination of pregnancy is discouraged.

**17. Interventions for foetal well–being including court-order obstetrical** 

the termination of the pregnancy.

**interventions** 

Angela carder's family and Reproductive Freedom Project (RFP) supported by several other bodies and human rights organizations filed an appeal at the D.C. court of Appeal for the vacation of the court order for that cesarean section and the legal precedents it had set, which was ultimately granted (ACLU, 1997). On no account therefore should a woman be forced or coerced into carrying out a procedure that she is unwilling to accept since this will amount to a violation of her autonomy. It is inappropriate to resort to judicial intervention when a woman has made an informed refusal of a medical or surgical procedure since this is considered to constitute an overriding of her autonomy (strong paternalism). The situation is noteworthy, different when the woman's competence to make decision is impaired as in the unconscious mother or in the mentally sub–normal.

The consent of a surrogate – the woman's spouse or any other member of her family is usually enlisted. It is important however to note that in general the mother should be of prime consideration and therefore decision on her well-being takes precedence over that of the foetus.
