Obstetric ethics is sometimes represented by polarized views. One extreme asserts the rights of the fetus as the overwhelming ethical consideration. Another extreme asserts the pregnant woman as the overwhelming ethical consideration. Both assertions are overly simplistic. Such oversimplification is called reductionism. This article explains the fallacy of rights-based reductionism and 2 models of obstetric ethics based on it and explains why the fetal rights reductionism model and the pregnant woman’s rights reductionism model result in conceptual and clinical failure and therefore should be abandoned. The article argues for the professional responsibility model of obstetric ethics, which emphasizes the importance of medical science and compassionate clinical care of both the pregnant and fetal patient. The result is that responsible medical care overrides the extremes of clashing rights.
Every obstetrician is challenged by the clashing demands of fetal rights vs maternal rights. Their resulting polarization forces the obstetrician into the unwelcome role of Odysseus struggling to avoid the mythical sea monsters of Scylla and Charybdis, either of which could devour his ship and crew if he sailed too close. To starboard, stand, like Scylla, the exclusive assertions of the rights of the fetus. To port, stand, just as unyielding as Charybdis, the exclusive assertions of the rights of the pregnant woman. Ethical peril awaits the obstetrician who sails too close to either extreme of rights, just as deadly peril did for Odysseus and his crew.
Models of obstetric ethics based on rights-based extremes commit the fallacy of rights-based reductionism. The purposes of this article are to explain the fallacy of rights-based ethical reductionism and 2 models of obstetric ethics based on it, explain why these models of rights-based reductionism are not acceptable, and put forward an ethically justified and clinically applicable alternative, the professional responsibility model. The professional responsibility model equips the obstetrician to successfully navigate the perils of rights-based Scylla and Charybdis by focusing on professional responsibility to and for patients. Just as Odysseus bore the responsibility to protect his crew, the obstetrician bears the responsibility to protect both the pregnant and fetal patient.
Fallacy of rights-based reductionism
The fallacy of rights-based reductionism can be understood by analogy to the fallacy of biologic reductionism or oversimplification of scientific models of disease and health. As an antidote to biologic reductionism in medicine, George Engel made a sentinel contribution with his introduction of the biopsychosocial concept of health and disease. In his classic paper in Science , Engel summarized the biomedical model:
The dominant model of disease is biomedical, with molecular biology its basic scientific discipline. It assumes disease to be fully accounted for by deviations from the norm of measurable biological (somatic) variables. It leaves no room within its framework for the social, psychological, and behavioral dimensions of illness. … the biomedical model embraces both reductionism, the philosophic view that complex phenomena are ultimately derived from a single primary principle, and mind-body dualism, the doctrine that separates the mental from the somatic. Here the reductionist primary principle is physicalistic; that is, it assumes that the language of chemistry and physics will ultimately suffice to explain biologic phenomena. , pp. 39-40
The history of biologic reductionism stands in contrast to traditional Chinese medicine, based on the concept of qi , which was understood to have both physical and spiritual components in an “incessant process of transformation.” This history also stands in contrast to more holistic strands in the history of Western medicine, eg, naturopathy and homeopathy. In this study, we sketch a complicated history.
Ancient Hippocratic physicians understood all diseases to be an interaction of the 4 humors. According to the Hippocratic or Coan school of medicine, diseases resulted from imbalances among blood, phlegm, black bile, and yellow bile. This theory recognized the existence of environmental factors, such as prevailing wind direction, but the explanation of the direct causes of disease and of their subsequent clinical management, mainly by modest changes in diet and exercise and the use of mild medications, appealed to what they took to be the biologically fundamental realities, the humors. Later anatomy became fundamental and the focus shifted to the skeleton and organs as the seat of diseases. Debates arose about more aggressive or “heroic” treatment, especially surgery, to correct abnormal anatomy. Physiology, the science of the functions of organs and then organ systems, then displaced anatomy as fundamental. Medications and potions to correct symptoms of abnormal function became increasingly important. The discovery of microbes led to a dramatic conceptual shift. The seat of disease was now understood to be microscopic, which led to an increased understanding of the pathophysiology and treatment of infections. We are now well into the era of genomic medicine, in which the genome supersedes the microbe as a senior partner in explaining the biologic basis of health and disease.
Engel’s concern was that equating health and disease with biologic fundamentals commits physicians to a clinically inadequate model of health and disease that results in inadequate diagnosis, prevention, and treatment. For example, a married woman of child-bearing years presents with a complaint of infertility. The biomedical model focuses on the mechanisms of ovarian, tubal, uterine, and sperm function. The biopsychosocial model includes this focus but rejects it as the exclusive focus, because it is clinically incomplete and could result in unneeded, invasive, and expensive workup and assisted reproduction. A psychosocial assessment goes on to identify psychologic and social factors such as stress in the workplace or household, which would be elicited only by a more complete history and would be missed by a workup for impaired anatomy of reproduction. The biopsychosocial model is clinically crucial because it reminds the obstetrician that psychosocial, as well as anatomic and pathophysiologic factors can result in reproductive failure.
As this example illustrates, Engel’s concern was not the limitations of our scientific knowledge at any given time about what is assumed biologically fundamental in obstetrics. His point was that even a very sophisticated scientific fund of knowledge about, for example, human reproduction, will be scientifically and therefore clinically fallacious if it focuses only on the biologic aspects of health and disease, eg, the basic science mechanisms of reproduction, mistaking these mechanisms of disease for an adequate model of the totality of the disease. Incorporating the psychologic and social dimensions is required to have a clinically adequate model to guide obstetric care and thereby avoid clinical tunnel vision. Fulfilling the requirements of the biomedical model by finding an anatomic cause for infertility, may be very fulfilling for the physician on a narrowly scientific basis, but not for the patient, whose complaint will remain inadequately addressed if her infertility is also a function of unidentified and therefore unmanaged psychosocial factors.
Engel’s main point remains germane: the biomedical model becomes a fallacy when it is assumed to be complete. The remedy is to recognize that it is scientifically and clinically incomplete and misleading. Comprehensive clinical judgment requires attention to the clinically relevant biomedical and the clinically relevant psychosocial aspects of pregnancy.
There is an analogous fallacious reductionism in obstetric ethics. The phrase, “ethical reductionism,” has been used, but not in a way that makes this analogy explicit. The fallacy of ethical reductionism occurs when a model for ethics appeals to one ethical concept in complex clinical circumstances that by their very nature require consideration of complementary concepts. Rights-based reductionism in obstetric ethics bases it exclusively on the rights of either the pregnant woman or the fetus and ignores other clinically relevant ethical concepts ( Table ).
