Bioethics
Maternal-Fetal Conflicts
Julius Ceazar Reyes MD
January 17, 2011
Who’s Life Should Be Saved?
No direct answer.
What if both have the same
chance of survival?
Save the mother and allow the
child to have a natural death.
But if you can save both, save
both the mother and fetus
GENERAL GUIDELINES
1. Maternal and fetal conflicts include complications,
surgical complications and invasive diagnostic
procedures during pregnancy. The conflict is between
the mother and fetus.
GENERAL GUIDELINES
2. Principle of double effect should be applied
GENERAL GUIDELINES
3. In assessing risk, the physician should provide the
patient with accurate objective observation of her
disorder and known data gathering.
GENERAL GUIDELINES
4. The physician should as accurately as possible,
quantify benefits and risks. This should be
communicated in a manner accepted to our Filipino
culture and appropriate to the particular patient.
GENERAL GUIDELINES
5. In risk acceptability, the physician must allow the
patient to make her own decision.
GENERAL GUIDELINES
6. Unless specifically requested by the patient, her family
should be given the same information and be involved
in the decision making process.
GENERAL GUIDELINES
7. A physician has the right to withdraw from the case if
what is decided by the patient conflicts with his own
personal values or the institution’s values
GENERAL GUIDELINES
8. In an emergency situation, the physician should serve
as the surrogate decision maker and exercise his
therapeutic privilege.
CASES
ECTOPIC PREGNANCY
1. When the tube is so damaged to constitute a
serious threat to the maternal life, the tube may
be removed as a traumatized pathological tissue.
The principle of double effect is applied
ECTOPIC PREGNANCY
Wrong Mentality – Remove the tube because the
fetus won’t live anyway
Right Mentality – The tissue of the tube is
traumatized pathological tissue, therefore should
be removed
ECTOPIC PREGNANCY
2. In a rare case when the pregnancy was
advanced to a stage approaching viability, the
element of proportion in the principle of
double effect has to be given special
consideration and attention.
ECTOPIC PREGNANCY
Proportion is between the risk of expectant
treatment for the mother and chance if soon
delivering a viable fetus.
ECTOPIC PREGNANCY
1. If no hemorrhage  Viability  Cesarian Section
ECTOPIC PREGNANCY
2. In actual crisis of dangerous hemorrhage, surgical
intervention to control the bleeding is morally
permissible under the principle of double effect,
provided no direct attack is made on the fetus
ECTOPIC PREGNANCY
As long as rupture has not occurred and as long as the
mother’s life is not in imminent danger from her
traumatized tissue, one could not justify surgical
intervention on the ovary while there remain some real
hope of delivering a viable fetus in the future.
ECTOPIC PREGNANCY
1. Direct attack is immoral
2. Surgical intervention upon dangerously pathological
tissue may be done under the principle of double
effect.
ECLAMPSIA
1. The principle of double effect can’t be applied
because the evil effect is necessarily directly willed,
since it is envisioned as a necessary means to
producing the good effect
ECLAMPSIA
2. What could be done if the patient is in eclamptic
crisis is to control the eclampsia MEDICALLY until
the fetus is viable and can be delivered.
CHORIOAMNIONITIS
1. The only morally accepted removal of the fetus
would be into an environment which would offer as
good or as better environment than it already is.
CHORIOAMNIONITIS
Wrong Mentality: Remove the fetus because it will going
to die anyway.
Correct Mentality: If we do empty the uterus, both
mother and baby will live longer.
H-MOLE
1. If the H-mole has advanced to such a stage that it is
incompatible with the presence of living fetus, dilatation
and curettage, hysterotomy or hysterectomy are morally
acceptable
H-MOLE
2. 1. If the uterus, even probably contains a living
fetus, expectant treatment must be maintained until
the positive diagnosis of H-mole is established and
the presence of a living fetus is ruled out.
ABRUPTIO PLACENTAE
1. When it occurs near term or at onset of labor, all
should be done to save both mother and child
2. It is morally acceptable to prematurely remove a
viable fetus
ABRUPTIO PLACENTAE
3. If fetus is not viable…
a. Hemorrhage is mild and doesn’t endanger the
mother’s life, no steps can be taken that would
considerably endangers the life of the fetus
ABRUPTIO PLACENTAE
3. If fetus is not viable…
b. Even if the hemorrhage becomes serious, the
direct removal of non-viable fetus is never
permitted
ABRUPTIO PLACENTAE
3. If fetus is not viable…
c. When the maternal life is in danger, it is morally
permissible to control the hemorrhage by drug
therapy, tamponade, even if it is foreseen that it
will result in premature labor or in fetal death
from some other cause (principle of double
effect)
ABRUPTIO PLACENTAE
3. If fetus is not viable…
d. Laparotomy and amputation of the uterus in the
presence of a fulminating placento-uterine
hemorrhage, even with a non-viable fetus in situ,
is morally permissible (double effect)
CANCER
rd
3
1. Before trimester, the Cancer is treated. Any
adverse effect on the baby is not intended but
merely permitted
CANCER
rd
3
2. In the trimester, as much as possible, the
pregnancy must be brought to term. If this is
adverse:
a. Remove the fetus if it is already viable
b. Treat the Cancer if it is not yet viable
CANCER
3. Viability is in bottom line, and the treatment is
necessary, the principle of double effect is applied
Bioethics
Sterilization
Julius Ceazar Reyes MD
January 17, 2011
Why is it unethical?
Because it stops pregnancy
What is allowed?
Indirect Sterilization
2 Types
1. Direct – the purpose of the procedure is to render
the patient infertile
2 Types
2. Indirect – one which results as a side effect of
medical therapy aimed at specific pathology
affecting a person (Principle of Double Effect)
PRINCIPLES
1. Sterilization may not be used as a means of
contraception.
PRINCIPLES
2. Every action which either in anticipation of the
conjugal act or in accomplishment or in the
development of its natural consequences proposes to
render procreation impossible IS NOT
PERMISSIBLE only when needed.
PRINCIPLES
3. Procedure that induces sterility are permitted when:
a. They are immediately directed to the cure,
diminution or prevention of serious pathological
condition, then the procedure may be done.
PRINCIPLES
3. Procedure that induces sterility are permitted when:
b. A simpler treatment is not reasonably available,
sterility, and is permitted
CASES (Morally Permissible)
1. Primary gonadal pathology – oophorectomy
2. Hysterectomy is permitted when it is sincerely judged
to be a necessary means of removing some serious
uterine pathological condition. In these cases, the
pathological condition of each patient must be
considered individually. Care must be taken that a
hysterectomy is not performed merely as a
contraceptive measure.
3. Hysterectomy in the presence of pregnancy and
even before viability is permitted when directed to
the removal of a dangerous pathological condition
of the uterus of such serious nature that the
operation cannot be safely postpone until the fetus
is viable.
4. Hysterectomy for prolapse of the uterus;
considerations:
a. a possible conservative repair (so that pregnancy is
possible)
b. The patient’s choice
c. The trauma and expense of conservative surgery,
with the likelihood of a less than fully satisfactory
result, and future need for more extensive surgery,
may not be proportionate to the temporary
preservation of fertility
4. Hysterectomy for prolapse of the uterus;
considerations:
d. Each case is an individual case and depends on:
1. Details of each case
2. Prudent judgment of the gynecologist
3. The reasonable wishes of the informed patient
5. Elective hysterectomy following bilateral oophorectomy;
reasons why it is morally justified:
a. to leave a “clean pelvis”;
b. uterus is functionless
c. principle of totality;
d. understood to involve no real additional surgical
risk;
e. does not in no way additionally impair the
functional integrity of the patient.
SPECIAL CASES
Uterine Damage in Multiple Cesarean Sections
Premises:
1. That the uterus is badly damaged
2. That the uterus cannot be repaired to support another pregnancy
safely
Morally permissible:
1. Hysterectomy – because of damaged and dangerous tissue within the
uterus itself
2. Tubal ligation – if the clinical condition of the patient contraindicates
the added trauma of total hysterectomy
Moral Bases:
1. No moral difference between uterine isolation and uterine
removal
2. Principle of totality – damage in the uterus
3. Principle of double effect – sterilization is not intended but a
moral “by-product”
4. Pregnancy is the occasion of the serious danger, the cause of
which is the damaged uterus itself.
Thank You