Nigerian Journal of Paediatrics

Ethics in Perinatal Medicine

Niger J Paediatr 2016; 43 (3): 221 – 228

ORIGINAL

Adinma JIB

Ethics in Perinatal Medicine

DOI:http://dx.doi.org/10.4314/njp.v43i3.12

Accepted: 16th March 2016

Abstract : Background: The cur-

casuistry, communitarian and vir-

rent trend in perinatal medicine

tue orientation), together with the

Adinma JIB

(

)

addresses the challenge posed to

guiding principles of modern bio-

Department of Obstetrics &

newborn survival by newborn

ethics and their levels of applica-

Gynaecology

Nnamdi Azikiwe University Teaching

prematurity and other morbidities

tion (micro-ethical, macro-ethical,

Hospital, Nnewi,

requiring neonatal newborn inten-

meso-ethical and mega-ethical

Anambra State, Nigeria.

sive care.

level).

Email: brainadinma@yahoo.com

These ethical

concerns

span

Research ethics developed tremen-

dously during the 20 century and

through the spectrum of educa-

tion, clinical practice and re-

it was boosted by a number of

search, domicile in obstetrics and

regulations such as Nuremberg

neonatology. Effective application

code, CIOMS, Helsinki declara-

of ethics to perinatal medicine

tion, Belmont Report and the Ni-

requires basic knowledge bio-

gerian National Code of Health

ethics in health care and medical

Research Ethics.

research.

Ethics in perinatal medicine focus

Objectives: The objective of the

on medical decision making and

article is to highlight the basic

foeto-maternal conflict as well as

aspects of ethics, review research

the concept of a foetus as a patient

ethics and practical ethical issues

and medical futility. It includes

in perinatal medicine and provide

prenatal diagnosis and interven-

an analytical application of the

tions for severe congenital malfor-

principles involved in bioethics.

mations of the foetus, safe mother

Methodology: A search for the

hood and cord blood collection and

relevant literature available on the

newborn care.

internet, journal publications,

Conclusion: Bioethics is an impor-

textbooks and monographs was

tant component of perinatal medi-

conducted

cine. The consideration and appli-

Result: The basics of ethics span

cation of bioethics in all aspect of

through the definition of medical

perinatal medicine will undoubt-

ethics, ethical codes and bioethics.

edly improve the quality of care

It also includes the various bio-

for obstetric patients and their

ethical orientations (historical,

newborn infants.

duty-based, utilitarian, feminist,

Introduction

perinatal care.^1,2

Over the past five decades, perinatal medicine and neo-

Ethical considerations have been recognized to arise

natology have developed tremendously to respond to the

over a wide area of obstetric issues ranging from pre-

challenges of newborn survival and well-being as related

conception genetics and embryo research through as-

to prematurity and morbidities requiring newborn inten-

sisted reproduction, pregnancy care and in particular,

sive care. Ethical concerns generated in response to this

issues related to abortion, multiple gestation, HIV infec-

development have continued to pose tremendous chal-

tion in pregnancy, caesarean section, surrogacy and oth-

ers.

3,4

lenges spanning the spectrum of education, clinical prac-

Ethics built into professionalism, initiated and

tice and research. Perinatal care is domicile in the spe-

nurtured during training has been recognized to be a sine

cialty of obstetrics and the sub-specialty of neonatology.

quanon towards professional specialty best-practices. In

The International Federation of Gynaecology and Ob-

the recent quarter of a century, McNealy and Singer

stetrics (FIGO) has played a leading role in the develop-

have highlighted the need to include ethics in the train-

ing of resident doctors. In the same vein, from the latter

ment of ethical guidelines in both obstetric and perinatal

practice through its committee on ethical aspects of hu-

part of the nineties, the Royal College of Physicians and

man reproduction and women’s health, which published

Surgeons of Canada, together with the Council on Resi-

periodically revise ethical guidelines for health profes-

dent Education in Obstetrics and Gynaecology, recom-

sionals practicing obstetrics and gynecology as well as

mended that the teaching of bioethics be made a require-

222

ment for the accreditation of residency training pro-

laration of the World Medical Association of 1964

grammes. In addition, “residents were expected to dem-

which was made in response to ethical breaches re-

corded in health care and research.

10,11

onstrate an understanding of the basic principles of eth-

The Hippocratic

Oath of the 4

ics together with the knowledge of the applications as

Century B.C, has been adapted, and

related to obstetric and gynaecological practice.

sworn to by graduating medical practitioners in various

countries as a guide towards the practice of ethics-based

Over the past 40 years and more, giant strides have been

medical care.

taken in the United States of America, in the develop-

ment of perinatal medicine through the improvement of

The term “Bioethics” was coined in the 1960s by the

technical capabilities of the healthcare providers to

American biochemist, Van Rensselaer Potter of the Uni-

promptly make accurate diagnoses and provide effective

versity of Wisconsin. However, the first institutional use

monitoring and specific treatments. Special Care New-

of the word was in 1971, by Kennedy Institute of Ethics,

Georgetown University – Washington DC.

born Units, equipped with the necessary technologies to

manage premature and sick infants have been estab-

Bioethics is a sub-division of ethics that regulates the

lished in all nooks and crannies of the United States.

relationship between the healthcare provider and the

The results of these efforts have been varied. The mor-

beneficiary of healthcare. It is generally regarded as a

tality rate among preterm infants has reduced tremen-

multi-disciplinary field of inquiry, which addresses ethi-

dously, although, the incidence rates of preterm and low

cal issues in clinical practice and healthcare, biomedical

birth weight babies have not shown any reduction. In

research involving humans and animals, health policies

and the environment.

12, 13

addition, the overall infant mortality rate has declined

It has its roots in the value

but the incidence rate of birth defects has remained con-

system developed by the ancient Greek Philosophers

stant. Perinatal ethics is encumbered with peculiarities.

earlier mentioned but over several years, it has been

Balancing the ethical issues between a foetus and the

modified by the thinking and presentations of ethicist of

mother could be as challenging to the health profes-

varied orientation in response to the challenges of novel

sional as it is with regards to the clinical management of

and expanding knowledge of the biomedical sciences.

the newborn in the neonatal intensive care unit (NICU).

In addressing some of the ethical issues in the NICU,

Bioethical Orientation

the goals of specific monitoring, diagnostic tests, treat-

ment, and patient-centered research protocols and the

Bioethical orientation refers to the thinking trends of the

situation of the family who will live with the long term

various bioethicists. Historically, bioethical orientation

consequences of the day to day decisions made in the

is related to the Greek Philosophy and value system

care of the infant should be put into consideration.

enunciated and propagated by the ancient Greek Phi-

losophers together with the pattern and thoughts that

Effective application of ethics to perinatal medicine re-

informed and guided the activities of various religions of

quires that the clinicians be vast in the fine details of

old - notably Islam and Christianity. Deontological or

bioethics as related to clinical practice. This review

duty-based bioethics is related to natural laws and rea-

highlights the basic aspects of ethics – the definition of

sons, distinguishing vice from virtue as an integral asso-

medical ethics, bioethical orientation and the guiding

ciation of any intentions or actions. It is the commonly

principles of modern bioethics together with analytical

accepted ethical orientation of the Catholic Church and

level of its applications. It also addresses research ethics

is very manifest in several of its doctrinal practices. For

and practical issues in perinatal medicine which requires

example the church’s approval of natural family plan-

ethical considerations.

ning method as its own acceptable birth control method,

for the adherents. In the same vein, the church abhors

Basics of Ethics

the use of condom as a means of protection whether

against unwanted pregnancy or sexually transmitted

infections. St. Thomas Aquinas in the 13 century incor-

The three Greek philosophers – Socrates, Aristotle and

Plato are regarded as the founding fathers of ethics. Eth-

porated the doctrine of a church as ethical issues that

ics is a term derived from the Greek word “Ethos,”

were patterned after the natural laws of Aristotle. Deon-

which means custom or habit. Medical ethics has been

tological bioethical orientation is usually inflexible with

defined as the principles or norms that regulate the con-

absolutism in contradistinction to the relativity that usu-

ally characterises ethical considerations.

duct of the relationships between medical practitioners

and other groups with whom they come in contact in the

course of their practice - professional colleagues, allied

Consequentialist or utilitarian bioethical orientation rec-

health

professionals,

patients,

governments/non-

ognizes the responsibility of an individual for his bio-

governmental organizations and other actors in health-

ethical choice. Whatsoever will cause or influence the

care delivery. Ethical codes are sets of principles or

happiness or overall well-being of an individual is con-

rough guides to practice, usually developed following

sidered to be good whereas whatever does the opposite

serious breach of ethical standards. An example of

is considered to be bad. Man is, therefore, considered as

ethical code is the Nuremberg code of 1947, which was

an end in himself rather than a means to an end.

developed following the revelations of inhuman experi-

Feminist bioethical orientation, also known as the ethics

mentations carried out during the second world war by

of care and connectivity seeks to achieve gender parity,

the German Nazi. Another example is the Helsinki Dec-

thus, incorporating women’s social experiences, think-

223

ing and behaviour into the value system of healthcare

The protection of persons incapable of autonomy consti-

and clinical practice. It is a consequence of, hitherto

tutes the second level of the principles of respect for

exclusion of women from the historical sources of moral

persons. Three categories of persons are considered to

authority such as clergy, high ranking military com-

be incapable of autonomy - the unconscious, the men-

mands and legislature.

tally sub-normal and the child. These three groups re-

Communitarianism refers to bioethical orientation that

quire the protection of their autonomy. The first consid-

advances the good of the community while casuistry

eration, particularly concerning the unconscious patient,

subscribes to the resolution of issues on the basis of their

is whether or not he or she has a living will. In the ab-

merit rather than on a resort to universal rules. Virtue

sence of this, the protection of the autonomy of the un-

represents the ethical orientation patterned after Hippo-

conscious patient, along with that of the mentally sub –

cratic ideals – the tenets of which required health practi-

normal and the child, lies in the consent of a surrogate.

tioners to pay stringent attention to kindness, trustwor-

Where there is no surrogate, the ethics committee of the

thiness, discernment and integrity in their practice.

health institution gives the consent, and where the latter

is not available, a clergy or Imam, and in the absence of

Guiding principles and the levels of application of mod-

any of these, as a last resort, the law court, shall give the

ern bioethics

consent.

The guiding principles of modern bioethics have been

developed as a consensus resolution of the various bio-

A surrogate decision maker is a person authorized to act

ethical orientations together with the recommendations

on behalf of the subject when the patient is mentally

made from the Belmont Report. This report was high-

incapacitated and lacks the ability to make decisions.

lighted basically through the work of two notable

The surrogate is an adult with the ability to comprehend

American Ethicists, Tom Beauchamp and James Chil-

information and make decisions on the basis of that in-

dress, together with British Raanan Gillon.

15 - 17

formation. Furthermore, the person is available and is

The Belmont Report, published in 1979, contains the

willing to make medical decisions on behalf of a patient

recommendations of the United States’ National Com-

who lacks decisional capacity. Most surrogates are natu-

mission for the Protection of Human Subjects of Bio-

rally drawn from family members. In recent times, the

medical and Behavioural Research. This commission

state enacted legislation which confers surrogacy for

was established following the passage of the National

medical decisions on family members in order of prior-

Research Act of 1974 by the American Congress, in

ity. Surrogate decision making is aimed at arriving at the

response to the complaints which accompanied the reve-

goal the patient would have reached if able to and not

lation of atrocious inhuman treatments meted out to four

really, the preferred goal of the surrogate.

hundred black American subjects during the syphilis

The over- riding of patient’s autonomy is known as

trial experiment in Tuskegee Alabama, USA between

medical paternalism. Strong paternalism is the over-

1932 and 1972. Three of the four key guiding princi-

riding of the autonomy of a capable person and it is not

ples of modern bioethics are contained in the Belmont

ethically permissible. On the other hand, weak paternal-

Report viz - the respect for persons, beneficence and

ism is the over-riding of the autonomy of an incapable

justice. Non-maleficence, which is the fourth item, is

person, which is permissible if performed in the overall

derived from beneficence. Three other principles – fidel-

interest of the person. The ethical principle of benefi-

ity, veracity and scientific validity- have been added to

cence enjoins practitioners to do and maximize good,

the latter.

emphasizing the practice of the optimal best for the pa-

tient in both preventive and curative healthcare.

There are two levels in the principle of respect for per-

The ethical principle of non-maleficence enjoins practi-

sons – the autonomy of persons who are capable and the

tioners to do no harm and cause no pain to their patients;

protection of persons incapable of autonomy. Autonomy

harm or pain, in this instance, could be physical or emo-

upholds the patient’s right to voluntary informed con-

tional trauma meted out to patients during the course of

sent and choice, on the basis of his or her comprehen-

medical care. The principle of justice connotes the ethi-

sion of available options. Respect for autonomy requires

cal responsibility to ensure equitable distribution of

that the physician respects the values and beliefs of the

health benefits and risks to patients without any consid-

patient, including the decisions made by the patient such

erations of sex, social status, ethnicity or religion. The

as the informed consent. The implication of this is that,

principle of veracity enjoins the health practitioners to

informed consent is a pre-requisite to the autonomy of

tell the truth all times.

the patient. There are three elements of informed con-

sent:

The principle of fidelity refers to the ethical responsibil-

ity of health practitioners to honour whatever promises

Disclosure - appropriate communication with the

has been made to the patients, at all times. In addition,

patient as to what he or she needs to know for good

the principle of scientific validity enjoins health practi-

understanding of the situation in question.

tioners to uphold the highest standards of professional

Comprehension - a clear understanding of the infor-

competence and scientific soundness in the care of their

mation received by the patient.

patients. Therefore, health practitioners should, at all

Free consent - the freedom of the patient to freely

times, desist from embarking on treatment which they

decide whether or not, to give consent.

are not competence to carry out.

There are four analytical levels of application of ethical

224

principles. Micro-ethical analytical level is individual-

while trying to develop anti-syphilis agent injected cell-

ized and refers to the relationship between the health

free serum from syphilitic patients to other patients –

practitioner and the patients. Much as the health practi-

most of whom were prostitutes – without their consent.

tioner has the ethical obligation to give the patient accu-

Some of the subjects consequently developed syphilis.

rate and concise clear information to enable the patient

Professor Neisser was tried and found guilty by the

make an informed decision, the patient, similarly has the

Royal Disciplinary Court and was fined an amount

ethical obligation to respect the health practitioner’s

equivalent to 25% of his annual income. The first true

conscientious objection to carry out certain treatments

National Research Ethics Regulation - involving new

that the patient may desire. Macro-ethical analytical

therapy and human experimentation, was enacted by

Germany on the 28 February 1931. Over the ensuing

level is more broad-based and refers to the relationship

seven decades of 20 century, a good number of scandal

between groups or communities – between members of

a community or between members of more than one

-targeted regulations were enacted the world over, in

community. A typical example of breach of ethical prin-

response to inhuman experimentation meted out to hu-

ciples at the macro-ethical level is the inequitable distri-

man subjects, notable among these were:

bution of medical doctors between the urban centers,

where they abound in greater numbers, and the rural

Nuremberg Code 1947 – enacted following the

areas, where there are very few medical doctors, in spite

revelations of atrocities and inhuman experiments

of a relatively higher population in the rural areas.

carried out during the Second World War by the

Meso-ethical analytical level refers to the disparity in

German Nazi and the following Nuremberg trial.

the allocation of resources between various groups,

The Helsinki declaration – enacted by the World

whether in the public or private sector. It is also known

Medical Association in 1964 in Helsinki, Finland.

as inter-generational justice; it falls between micro-

This declaration consists of guidelines to protect

ethical and macro-ethical analytical levels and violates

humans, animals and the environment with respect

the ethical principles of both beneficence and justice.

to biomedical research.

Mega-ethical analytical level refers to issues which trav-

National Research Act and the Belmont Report

erse national boundaries. Areas of concerns of this in-

1974/79 – this is the United State Congress’ re-

clude reproductive health issues and its related impact

sponse to the complaints raised following the reve-

areas such as, status of women and the environment.

lations from the inhuman syphilis trial experimenta-

tion which was out on four hundred black Ameri-

Ethics and research

cans at Macon County, Alabama, between 1932 and

1972. The US Congress enacted the National Re-

In the words of Sir William Osler, “Medicine arose out

search Act of 1974 and then, set up the commission

of the primal sympathy of man with man and out of the

on the protection of human subjects involving bio-

desire to help those in sorrow, need and sickness.”

medical and behavioral research in 1975. This com-

This is, apparently, the premise under which medical

mission produced the report of their finding in 1979

research arose in response to the suffering that accompa-

and this report is known as the Belmont Report in

1979.

nied several epidemics of old such as plaques and tuber-

culosis. Apart from aiming to alleviate the suffering, this

The Council for International Organizations of

principle also ensures that even when deaths occur, it

Medical Sciences (CIOMS) Guidelines (1993/2002)

has to be with an attendant dignity and the satisfaction

- This council was jointly established in 1949 by

of health practitioners and researchers that enough care

World Health Organization (WHO) and United Na-

has been given, within every reasonable human capabil-

tions Educational, Scientific and Cultural Organiza-

ity.

tion (UNESCO) to serve the scientific interests of

the international biomedical community through

Medical research has the noble goal of improving hu-

various activities such as the development of guide-

man well-being. However, the question arises as to how

lines for ethical conduct of research. In 1993,

the rights of an individual can be reconciled with the

CIOMS developed a set of guidelines entitled the

demands of scientific ventures. Is it possible to ensure

International Ethical Guidelines for Biomedical

Research Involving Human Subjects.

21, 22

the protection of the right of the individual while seek-

Periodic

ing to achieve the laudable end result of research? Most

revisions of these guidelines and others have gone

researchers of the 17 and 18 century were unmindful

off since 2002 including the revision of Helsinki

Declaration in 2013.

of the need to protect the rights of human beings in-

volved in biomedical research, and this continued even

Nigerian National Code of Health Research Ethics

into the second half of 20

century. The Surgeon-

(2007) - In 1996, Nigeria witnessed the worst ever

General of the United States of America, in 1900, em-

epidemic of cerebro-spinal meningitis (CSM)

ployed twenty-two Spanish immigrant workers in Cuba

involving 300,000 people and causing 30,000

to prove that mosquitoes transmit yellow fever, and con-

deaths. Pfizer drug company saw that epidemic as an

tract was substituted for informed consent. In the same

opportunity to embark on a second phase therapeutic

year 1900, what was seemingly the first “National

trial of their new antibiotic drug “trovafloxacine” (built

Guideline” on health research ethics was issued by the

for registration with the US FDA) for its efficacy in the

Prussian Ministry of Health as a ministerial directive in

treatment of paediatric CSM., This trial involved the

response to the work of Professor Neisser who, in 1898,

recruitment of 98 children who received the new drug

225

and another 100 patients who received an under-dose of

sidered necessary to optimize the safety of her life and

another antibiotic drug, ceftriaxone , with case fatality

that of her unborn child. For example, when a pregnant

rates of 5% and 6% respectively. It was discovered that

woman with Type 4 placenta praevia vehemently rejects

the subjects were neither adequately informed about this

an offer of caesarean section, or as does also, a woman

trial nor were their consents obtained. The result of this

with severe pre-eclampsia causing intra-uterine fetal

study was an increased awareness on the need to observe

growth restriction. The conflict in these cases lies be-

ethical standards in clinical research, the training of

tween the physician’s recommendation and the pregnant

health researchers, at the local and international levels,

woman’s autonomous decision to reject the recom-

on ethical aspects of clinical trials involving human sub-

mended intervention. In these cases, it is ethically expe-

jects. In furtherance to these, in the year 2005, the Fed-

dient that the physician examines the reasons for the

eral Ministry of Health of the Federal Republic of Nige-

patient’s refusal to accept his medical advice to guide

ria inaugurated the National Health Research Ethics

his next line of action. It is true that, for the pregnant

Committee for the strengthening of a mechanism that

woman, her duty of beneficence to the foetus may over-

will ensure the protection of Nigerians when they are

ride her right to autonomy. However, the resolution of

enrolled to participate in research. The terms of refer-

any associated conflict must be her choice. In materno-

ence of this committee included, the setting of standards

foetal conflicts, therefore, the pregnant woman’s auton-

and guidelines on health research including clinical tri-

omy takes the center stage. If the pregnant woman has

als, adjudicating on complaints involving breaches of

decisional capacity, ethics demands that her autonomy

ethical standards during research and reporting such

and choices, even ‘bad’ choices, be respected. A preg-

breaches to appropriate regulating bodies in addition to

nant woman’s autonomy and informed refusal should be

recommending appropriate disciplinary actions. The

respected. These viewpoints have become the standard

committee is also empowered to advice the Federal and

responses to the vexed issues of “court ordered caesarian

section”.

State Ministries of Health on any ethical issues con-

cerning health research.

“The foetus as a patient” concept

Ethical issues in perinatal medicine

Perinatal medicine has recently promoted the concept of

Perinatal medicine is replete with important issues that

a foetus as a patient. In their review of this subject mat-

elicit ethical concerns. The knowledge of this fact has

ter, Chervenak and McCullough posited that the foetus

heightened the inevitable need to develop and include

becomes a patient when the foetus has a problem requir-

ethics in the curriculum of undergraduate and postgradu-

ing medical intervention which will considerably deter-

ate medical education. Admittedly, this inclusion is be-

mine the well-being of the foetus and aid her develop-

ment into a healthy child.

lieved to be coming relatively late in the field of obstet-

rics and perinatal medicine compared to other specialties

Before the age of viability i.e. 24 weeks gestation, the

such as medicine, general pediatrics and psychiatry.

foetus is not considered to be a patient that is independ-

Nonetheless, a lot has been done in the sensitization of

ent of the mother’s autonomy in so far as it is incapable

practitioners of perinatal medicine as to the ethical im-

of independent survival ex-utero . The implication is that

peratives associated with their practice in the areas of

the pregnant woman can bring her values to bear on her

education, research and clinical practice. Some key areas

attitude towards the status of the foetus as a patient. She

and their ethical associations need to be highlighted.

may, therefore, decide to uphold or withdraw the patient

status of her pre-viable foetus. The situation is differ-

Perinatal medical research, because of its sensitive na-

ture, should be associated with protocols that conform

ent for the viable foetus (gestational age 24 weeks or

with laid down ethical guidelines in order to ensure that

more) which is considered to be capable of surviving

appropriate benefits, rather than harm, accrues to the

outside the womb of the mother; this independent sur-

fetus or neonate, the mother and indeed the society.

vival confers on it the autonomy status that is independ-

ent of the mother.

27,28

Medical decision making and materno-foetal conflict

The foetus, as a patient, can be understood in relation to

Medical decision was, over a long period of time, pater-

the two ethical principles of beneficence and respect for

nalistic, with decisions made solely by the medical prac-

person. The treatment given to the pre-viable foetus

titioners and handed down to the patient without ques-

must uphold the ethical principles of beneficence to the

tions. However, in recent times, decision-making is

foetus, albeit subsumed within the autonomy of the

shared between the patient and the doctor, with patient’s

mother, while the treatment given to the viable foetus

autonomy occupying a more prominent place, even if, it

upholds the two ethical principles of beneficence and

conflicts with the doctor’s recommendations. It has be-

autonomy of the viable foetus. Both ethical principles

should be upheld in the mother.

28-30

come the responsibility of the doctor to present informa-

tion, together with alternatives and options, to enable the

Therefore, it is clear that the physician has maternal

patient make informed decision as to what management

autonomy-based and maternal beneficence-based obliga-

option to accept.

tions as well as foetal beneficence-based obligations,

which must be balanced. The pregnant woman’s auton-

Materno-foetal conflict arises when a pregnant woman

omy has priority. If maternal autonomy is at variance

refuses to accept medical treatment or intervention con-

with the interests of the foetus, her interests, which in-

226

clude her autonomy, takes precedence over that of the

Safe motherhood

foetus irrespective of whether the foetus is at increased

risk or not.

The key indicators to safe motherhood are maternal and

perinatal mortality as aptly captured in the fourth and

Medical Futility

fifth goals of the United Nation Millennium Develop-

ments Goals.

32,33

Medical futility is a situation where medical interven-

Most causes of maternal and child deaths are prevent-

tions for the mother or foetus are considered to be of no

able and, therefore, constitute a violation of key ethical

benefit. It is commonly encountered in situations of ex-

principles in obstetric and perinatal care.

treme prematurity, severe congenital anomalies and

Lack of access to family planning services, abortion

other situations of severe newborn complications requir-

services, good antenatal care, emergency obstetric care,

ing resuscitation. It is a terminology presently consid-

safe and clean delivery by skilled birth attendant, post-

ered to be unpopular because of its semblance of hope-

natal care services and good neonatal care – all consti-

lessness which could discourage health practitioners

tute a violation of the ethical principles of respect for

from putting their best forward towards the salvage of

persons, beneficence, non – maleficence, and justice

the patient. Futility conflict arising from treatment op-

which may occur both at micro-ethical or macro-ethical

level.

tions should balance the values and feelings of the pa-

tient’s relatives who will care for the patient with that of

the default position of maintaining life in ordinary

Cord blood collection and newborn care

terms.

The umbilical cord blood is a good source of haemopoi-

Prenatal diagnosis and interventions for severe congeni-

etic stem cells which can be used in the treatment of

tal malformations in the foetus

certain blood-related disease conditions such as leukae-

mia. At the point of birth, the cord blood can be col-

Perinatal diagnosis is an essential procedure in modern

lected, pooled and stored in cord blood bank for dispens-

obstetric care. It provides information on foetal diseases

ing when required. The storage and collection of umbili-

which may require termination of pregnancy in countries

cal cord blood requires informed maternal consent.

where such is legally permissible. The procedure should

Early clamping of the umbilical cord at birth has been

be preceded by counseling and informed consent should

shown to cause a reduction in the circulatory volume of

be obtained. Ethical questions arise on what degree of

foetal blood by 30% which may tip the foetus in to cir-

abnormality warrants the termination of pregnancy. In

culatory collapse. Therefore, obtaining an informed con-

general, the decision on whether or not to terminate the

sent from the mother including an explanation of the

pregnancy should be made by the parents and relations

procedure and a promise to avoid early clamping of the

of the patient, who are appropriately guided and not co-

umbilical cord, should be a pre-requisite for the collec-

erced. Where abnormalities are compatible with life,

tion of cord blood for pooling and storage.

parents are discouraged from opting for pregnancy ter-

Newborn resuscitation is also an integral aspect of good

mination.

perinatal care. Newborn resuscitation requires that the

medical practitioner upholds the ethical principles of

It is ethically appropriate for a woman carrying a se-

respect for person and non-maleficence through a pains-

verely malformed foetus to seek pregnancy termination.

taking, careful and non-traumatic resuscitative practice.

Where termination of pregnancy is not possible on legal

The neonates undergoing resuscitation constitutes a per-

and religious grounds, such pregnancy should be sub-

son incapable of autonomy but whose autonomy, none-

jected to prenatal diagnosis procedures to ascertain the

theless, needs to be protected. It is therefore ethically

extent of abnormalities. The pregnant woman must be

appropriate that the parents of the newborn, serving as

appropriately counseled before and after the procedure

the surrogate, be appropriately informed on any resusci-

to allow informed decision with regards to pregnancy

tative measure or intervention that needs to be carried

process and termination of pregnancy should never be

out on the newborn and consent appropriately obtained.

carried out on the ground of foetal sex. Where a dis-

Counseling of the parent surrogate requires that the

agreement exists between couples on the fate of the ab-

medical practitioner be vast with the knowledge of the

normal foetus, the decision of the mother takes prece-

clinical condition and diagnosis, management and prog-

dence. Where the couple disagrees with the advice of the

nosis of the infant under care, to enable him give accu-

attending physician, the physician is ethically bound to

rate information to the parents otherwise, consultation

encourage them to seek the opinion of another physi-

with senior members of the team may be necessary.

cian. It is ethically appropriate for the physician to seek

Where the parents disagree with the advice of the medi-

consent to confirm and appropriately document the na-

cal practitioner, an independent adjudication may be

ture and extent of foetal malformation following termi-

sought and in extreme cases, the views and intervention

nation. In addition, the physician must inform and coun-

of the institution’s ethical committee.

sel the parents on the magnitude of the problem, and the

action required.

227

Conclusion

lenges involved in such care and the response necessary

to achieve success. Therefore, health professionals

The development of perinatal medicine over the years

should be aware of the ethical issues concerning foeto-

has been targeted at the improvement of newborn sur-

maternal questions arising pre-conception, during preg-

vival from prematurity and other morbidities associated

nancy, at delivery and during the post-partum period, in

with the newborn. Bioethics has inevitably developed

order to optimize positive outcome of care and interven-

alongside to address ethical issues associated with the

tions involving the mother and newborn during these

obstetric care, perinatal research and newborn intensive

period.

care necessary to ensure the survival and well-being of

newborn infants. The implication of this is that, health-

Conflict of interest: None

care professionals caring for the pregnant mother and

Funding: None

her newborn should be conversant with bioethical chal-

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