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  • Title: Maternal-fetal conflict: positions and principles.
    Author: Mahowald MB.
    Journal: Clin Obstet Gynecol; 1992 Dec; 35(4):729-37. PubMed ID: 1451356.
    Abstract:
    While maternal-fetal conflict includes a broad range of possible interventions, noninterventions, and coercive influences ranging from refusal to serve alcohol to a pregnant woman to unwanted medical involvement (Caesarean sections),and a refusal to follow medical instructions: bed rest, hospitalization. Where fetal distress indicates a need for a Caesarean section, but the 38-weeks-pregnant woman refuses to give her consent for the operation, how does the practitioner evaluate the ethically significant features of the situation? First a review of viability and the right to privacy: presumably a viable fetus can survive without the woman's body; privacy has provided grounds for terminating a pregnancy, of being left alone, and patient autonomy is a cornerstone of medical ethics, balanced with beneficence, the duty to protect or promote the welfare of the patient; where a pregnant woman and viable fetus are viewed as patients, conflict ensues. Position 1: The Pregnant Woman's Autonomy Has Priority. A position consistent with other health care practices. Position 2: Beneficence Toward the Fetus has Priority. Arguably, beneficence toward the patient, or at least nonmaleficence, always overrides respect for autonomy, just as moral obligations are greatest toward those who are most in need. Position 3: Beneficence Toward Both Patients Trumps Respect for the Pregnant Woman's Autonomy. Coercive intervention is permissible in cases of well documented complete placenta previa. Then, acting on a refusal of treatment would amount to acting on unreliable clinical judgment, justifying the physician's resisting the patient's exercising a positive right when fulfilling that positive right contradicts the most highly reliable clinical judgment, dooms the beneficence-based interests of the fetus, and virtually dooms the beneficence-based interests of the pregnant woman. Race and class must never provide the basis for complex clinical judgments, yet statistics show they do. Justice requires that equals be treated as equals.
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