Ethical Principles of Prenatal Care

The autonomy of pregnant women should be given priority, no harm should be done, the welfare of pregnant women and fetuses should be taken into consideration, and fairness should be considered. However, all principles have no absolute priority and must be dynamically adjusted based on specific scenarios. There is no unified implementation standard that can cover all situations.

Last month, I encountered a typical contradiction when I was on duty at the obstetrics clinic: a 32-year-old first-time mother was diagnosed with complete placenta previa and placenta accreta at 27 weeks of pregnancy. The doctor assessed that continued pregnancy would have a high probability of uterine rupture, massive bleeding, and even life-threatening risks of hysterectomy. It was recommended that an immediate cesarean section be terminated. However, the survival rate of the fetus at this age is only 60%, and there may be neurological sequelae. The pregnant woman insisted on keeping the baby alive for another two weeks in order to ensure that the fetus's lungs would develop more maturely. Her husband was afraid that something might happen to her and insisted on having an autopsy now. The two parties had a heated argument in the clinic.

If this matter were left to the ethics community, decades of old scores could be revealed. One group of scholars insists that as long as the fetus has passed the survival threshold of 24 weeks, it has independent personality rights. Medical decision-making must put the interests of the fetus and the pregnant woman in the same position. If the pregnant woman's choice obviously endangers the life of the fetus, the hospital can even apply for judicial intervention. ； The other group insists that the bodily autonomy of pregnant women is absolutely paramount. After all, all medical risks are ultimately borne by the pregnant women themselves, let alone protecting the child. Even if she wants to induce labor due to personal reasons, no one has the right to stop her. These two views have been arguing and there is no conclusion yet. In clinical practice, we can only follow the current standards: first break down all the risks, benefits, and possible consequences and explain them thoroughly to the pregnant woman and her family members. Even if she has never gone to school, make sure she really understands it. As long as she is a person with full capacity for civil conduct and is conscious, her signature shall prevail in the end.

It sounds simple to say "do no harm", but in practice it is all details that are easily overlooked. I used to go to grassroots free clinics with the director, and found that many township health centers routinely prescribe a bunch of supplements to all pregnant women, such as DHA, multivitamins, and calcium tablets, regardless of whether their daily diet is balanced or whether they are really deficient. Some pregnant women have severe morning sickness, and the reaction to taking medicine is even greater, and they can't even eat. This actually violates the principle of do no harm-unnecessary medical intervention, even if there are no clear side effects, is also increasing the physiological and economic burden of pregnant women. There are also "frequent ultrasound screenings throughout pregnancy" advocated by many private institutions, and some even take "0-year-old photos" of the fetus. In fact, although the safety of ultrasound has been proven, frequent examinations without indications have no benefit except increasing the anxiety of pregnant women. This is something that our industry has been correcting.

When I first entered the industry, I thought these principles were rigid rules printed in a manual. It wasn’t until I hit a few snags that I realized that flexibility is what tests people the most. There was a pregnant woman who was born deaf and mute who came for a prenatal check-up. No one at home accompanied her. We specially found a sign language interpreter who cooperated with the hospital. We talked about it three times. We even showed her the thickness of the needle for painless delivery, what the process of antegrade autopsy was like, and the possible risks. We showed her the illustrated manual and model. In the end, she signed it herself during the anterotomy. The moment the baby came out, she made a thank you gesture to us. I still remember it. It was then that I realized that the so-called "principle of autonomy" does not mean asking pregnant women to just sign and everything is done, but to allow her to truly have the ability and conditions to make her own choices.

As for the principle of justice, it is more realistic. I went to a county in the west to help last year. The only prenatal screening available to pregnant women there was the ordinary Down syndrome screening, with an accuracy rate of only about 60%. If a high-risk pregnancy was detected, it would have to take a six-hour drive to the city for an amniocentesis. Many people found it troublesome and had no money, so they simply did not do it. In the end, the incidence of birth defects there was more than twice as high as in the eastern coastal areas. There are also differences in the industry on solutions to this problem: One group says that prenatal screening resources should be universalized. Even if the per capita investment is less, free basic screening should be covered to all pregnant women in remote areas. ； The other group said that it would be better to allocate limited resources to high-risk pregnant women over 35 years old, as the input-output ratio would be higher. Both statements are supported by data, and both are reasonable. Now each region is based on its own actual situation, and there is no unified standard answer.

I also encountered a particularly powerless moment: A pregnant woman was diagnosed with a severe neural tube defect in her fetus when she was 6 months pregnant. She would not live for more than a year after birth. She had already signed for induction of labor. However, her parents-in-law ran to the hospital door and held a banner, saying that we were murderers and forcing her husband to divorce her. In the end, she cried and tore up the consent form for induction of labor. There was another pregnant woman who insisted on staying up until 30 weeks in order to save her baby. In the end, she had massive bleeding during cesarean section, her uterus could not be saved, and she was admitted to the ICU. In the end, the baby survived. When she woke up, the first thing she said was to ask if the baby was okay. At this time, who do you think is right and who is wrong? There is simply no way to apply principles.

To put it bluntly, the ethics of prenatal care is never a black-and-white multiple-choice question. It is the answer that every medical nurse, every family, and every pregnant woman finds to be the most suitable answer to their specific dilemma. The ultimate purpose of the principles written in the guide is never to restrict anyone, but to try to ensure that every life, whether it is a woman about to become a mother or an unborn child, can receive the greatest respect.