The field of obstetrics and gynecology (OB/GYN) presents some of the most challenging and poignant ethical dilemmas for healthcare providers, healthcare systems, and their patients. At the foundation of these dilemmas lie profound questions about the beginnings of human life, reproductive justice, and the nature and obligations of impending motherhood. For healthcare providers, these issues often translate into the practical questions of who is the patient (i.e. the pregnant woman, the fetus, or both) and how to balance our ethical obligations to the pregnant woman and fetus. These are difficult questions in the setting of routine prenatal care, often intensified in the acute setting of the labor floor.

Pregnancy is also not a static condition: the progression of the pregnancy from trimester to trimester alters both what medical options are reasonable to offer patients and the counterbalancing risks that a pregnant woman may have to sustain. For example, it may be reasonable to offer a chorionic villus sample to a woman at 10 weeks gestation, with an associated risk of miscarriage of 1%. That same risk of fetal loss, however, may seem unacceptable at a later gestational age, especially after a fetus approaches or has reached viability. As pregnancies approach term, the benefits to the fetus of remaining in utero and the risks to the woman of remaining pregnant run in opposite directions.

The growth of the hospitalist model of care has added to some of these challenges as the delivering or inpatient healthcare provider may not be the one with whom the patient has an established relationship. Concomitantly, women with more severe morbidities are now able to achieve pregnancy. Thus patients who are more likely to have complicated medical courses—and therefore more likely to engender ethical dilemmas—are being cared for more and more frequently by providers to whom they have less of an established physician-patient relationship (or none at all). The goal of this chapter is to provide a framework to help resolve some of the ethical dilemmas that might arise on the labor floor and to demonstrate ethical analysis using this framework with a series of illustrative cases.

One of the first steps in approaching ethical issues in obstetrics is to establish a framework for understanding and describing the state of pregnancy. One such concept is the maternal-fetal dyad, which describes the interconnected state and changing relationship between the pregnant woman and the fetus over the course of the pregnancy.⁶ This framework not only provides guidance in understanding the complex relationship between the pregnant woman and the fetus but can also shed light on the source of many of the ethical dilemmas that can arise when dealing with complex obstetric cases.

Although the maternal-fetal dyad characterizes the woman and fetus as distinct entities, they are necessarily biologically connected in a way that dictates the health and well-being of both. Up to the time of viability, the fetus is absolutely dependent on the pregnant woman for survival; after viability, the fetus continues to rely on the pregnant woman for continued maturation and growth. The health of the pregnant woman and the decisions that she makes during pregnancy will affect fetal outcomes. At the same time, the continuation of a pregnancy will affect her health and well-being, sometimes adversely.

This construct of pregnancy, with its emphasis on interconnectedness, stands in sharp contrast to the framework of the maternal-fetal conflict, which depicts an adversarial relationship between the pregnant woman and her fetus.⁴ For many years, this was a predominant feature of analyses of ethical dilemmas in obstetrics. There was an underlying assumption that the pregnant woman and her fetus have irreconcilable interests that cannot be easily balanced when difficult medical decisions must be made. The concept of the maternal-fetal dyad helped to reframe this relationship as one that is marked by generally aligned rather than opposing interests.

The emphasis on patient autonomy and respect for persons is well established as the preeminent ethical principle in clinical medicine.^1,3,7 Simply put, this principle states that adult patients with decision-making capacity should be able to determine for themselves, without coercion or manipulation, which recommended tests or treatments they will accept or decline. This principle undergirds the process of informed consent that clinicians practice daily, and it is grounded in philosophical constructs of liberty and freedom that have been further codified in American jurisprudence.

Many ethical quandaries in obstetrics question whether the pregnant state should infringe upon the autonomy principle: that is, should pregnant women be given less autonomy and less control over their medical decisions, because they are pregnant and someone else (e.g. the state, courts, or the medical establishment) should be able to override her wishes and force upon her care that she does not want, when such care is thought to benefit the fetus.⁸ And while this debate continues in both the literature⁵ and the political arena, the authors, the American Congress of Obstetricians and Gynecologists (ACOG), and the American Medical Association (AMA) have not wavered in their conclusion that respect for the autonomy of pregnant women should remain the main guiding principle in analyzing and dissecting ethical problems that arise during pregnancy. However, other related disciplines and professional organizations may differ in the weight that they place on maternal autonomy. For instance, the professional guidelines of the ACOG and the American Academy of Pediatrics differ in the degree to which maternal autonomy should be safeguarded in pregnancy. As obstetric and pediatric providers must collaborate in the care of medically complicated pregnancies, it is important to recognize disciplinary perspectives and the role that they may play in ethical dilemmas in the care of these patients.

While respect for patient autonomy is crucial, it cannot function independently in our clinical decision-making. In order for women to make good choices about their care, clinicians need to provide them with accurate and evidence-based recommendations. This is the essence of beneficence, or doing good (and its opposite, nonmaleficence, or doing no harm). We cannot help women make good medical choices unless we ourselves are aware of what care has been proven to be best in any given clinical scenario. Now, of course, in clinical obstetrics, there may be many times where reliable evidence is lacking, but even that lack of data should inform our counseling. However, when there is strong medical evidence for (or against) a course of action, it is incumbent upon the practicing clinician to be aware of this data and the conclusions drawn from it so as to best counsel a patient.