Maternal-Fetal Conflict

In this blog entry, I would like to address maternal-fetal conflict and personal beliefs, which many physicians encounter throughout their career. Respecting the patient’s beliefs and values is an important aspect of the medical profession. An effective therapeutic relationship between the patient and the physician is based on a bond of trust, known as fiduciary relationship.

We know that patients bring cultural, religious and ideological beliefs into their relationship with the physician. Failure to take the code of professional ethics seriously can undermine the patient’s ability to trust the physician. It may also encourage persons with non-mainstream cultural or religious beliefs to avoid seeking medical care.

In caring for pregnant women, the health of two patients, who are individually viable, must be considered. Most pregnant women will accept some risk to their own health in order to promote fetal health. However, ethical issues arise when women refuse medical therapy which could be life-saving for her fetus. Ethical principles of beneficence and nonmaleficence come into conflict when what is required to benefit one will cause harm to the other.

In general, the legal status of a fetus is determined by the pregnant woman or both parents. US courts have ruled that “a child has a legal right to begin life with a sound body and mind.” This creates a legal duty, on the part of a pregnant woman, to protect the health of her fetus. Refusals of hospitalization, intrauterine transfusion, or surgical delivery have been legally challenged on the grounds of an obligation to the fetus. Failure to fulfill that duty is subject to charges of abuse or liability for damage to the fetus.

As a physician, what would you do if maternal decisions are based on specific beliefs? Suppose your patient is a pregnant woman who presents with preterm labor, at 28 weeks gestation. Her contractions are successfully stopped with terbutaline (an asthma medication that is commonly used to treat preterm labor). However, she later states that she does not believe in medical interventions and will not follow treatment. She also tells you that God will not allow her, and that He had communicated this to her.