Brown and colleagues have done an important service for the perinatal medical community by documenting significant differences of approach to counseling pregnant women regarding the management of a pregnancy complicated by a fetal anomaly. These descriptive ethics data do not establish professional responsibility.

Professional responsibility in such counseling, no matter who provides it, should be guided by the ethical principle of respect for autonomy. This ethical principle obligates the perinatal physician to empower the pregnant woman to make decisions about the management of a previable pregnancy when a fetal anomaly has been reliably diagnosed. We emphasize that the decision is the woman’s to make and that counseling should be assiduously nondirective. The alternatives of continuing pregnancy and termination should both be offered. When there is well-established intervention for fetal benefit, this alternative should also be presented. No recommendations should be made, especially about fetal intervention, given its maternal risks for the current and future pregnancies. This nondirective approach should not change for women who reject termination of pregnancy on religious or other moral grounds.

Conscientious counseling about the management of pregnancies complicated by fetal anomalies has been a shared responsibility, with the obstetrician seeking consultation and involvement from other specialties, such as genetics, neonatology, and pediatric surgical and neurologic subspecialties as needed. Progress in improving fetal intervention does not mitigate the obstetrician’s role as the primary counselor.

This primary role has an important new dimension when fetal care pediatric specialists are involved. The latter need to accept that pediatric ethics, which is based primarily on the best interests of the child standard, is not adequate to obstetric ethics, in which beneficence-based obligations to the fetus, when it is a patient (ie, the woman elects to continue her pregnancy), must in all cases be balanced against beneficence-based and autonomy-based obligations to the pregnant patient.