The rights of both mother and fetus must be considered when managing pregnancy because unilateral clinical decisions breach clinical ethical standards, said Dr. Frank Chervenak, Weill Cornell Medical College, New York, New York, US.
Perinatal ethics span a wide variety of situations, including abortion, stem cell research, mental health and pregnancy, and caesarean delivery.
Clinicians’ professional responsibility to the mother and fetus can seem conflicted, requiring unacceptable compromises.
However, considering the rights of only the mother or the fetus (at all gestational ages) is simplistic and, Chervenak said, will result in conceptual and clinical failure.
Instead of this kind of counterproductive reductionism, the professional responsibility model of obstetric ethics should gird clinical decisions, he added, and be comprised of medical science and compassionate clinical care for both the pregnant and fetal patients. [Am J Obstet Gynecol 2011;205:315.e1-5]
“Incorporating the psychological and social dimensions is required to have a clinically adequate model to guide obstetric care and avoid clinical tunnel vision,” Chervenak said.
The professional responsibility model also hinges on high quality informed consent of the pregnant patient to encourage autonomy.
According to the American College of Obstetricians and Gynecologists, “screening and invasive diagnostic testing for aneuploidy should be available to all women who present for prenatal care before 20 weeks of gestation regardless of maternal age.” [Obstet Gynecol 2007;109:217-227]
In a study to evaluate how pregnant women use risk assessment information for trisomy 21, 30,564 consecutive, singleton pregnancies were assessed based on maternal age, fetal nuchal translucency thickness and maternal proteins during the first trimester. [Am J Obstet Gynecol 2005;193:322-326]
Patients were counselled about estimated risk and informed that invasive testing, which has miscarriage risks of about 1 percent, were necessary to determine whether the fetus had chromosomal abnormalities.
Women were informed of the possiblity of a 1 in 300 risk of fetal trisomy 21 but that the choice of whether or not to test was theirs. Median maternal age was 34 years.
The rate of invasive testing increased exponentially with increasing estimated risk (P<0 .0001=".0001" 1="1" 21="21" 300="300" 4.6="4.6" 77.6="77.6" 8.4="8.4" 91.6="91.6" among="among" at="at" br="br" estimated="estimated" for="for" had="had" in="in" invasive="invasive" least="least" less="less" of="of" patients="patients" percent="percent" risk="risk" testing.="testing." than="than" the="the" trisomy="trisomy" was="was" which="which" whose="whose" women="women">
“These empiric data compliment the arguments of normative ethics to create evidence-based ethical standards for informed consent regarding invasive testing,” the researchers said.
Chervenak noted that women were able to use sophisticated risk assessment data to make informed, rational decisions about invasive fetal testing. Given that high quality informed consent on behalf of the mother and fetus requires adequate time, he suggested that clinicians who cannot meet this ethical standard should refer patients to centers that can. |
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