I knocked softly. The room was dark as I slipped around the sage-green
door, save for light sifting through the metal blinds and the blue-gray glow
of the screen as it showed off its sandy sonographic images of the abdominal
wall, placenta, and fetus. The obstetrician moved the slickened transducer
across the woman's abdomen, pointing out landmarks and serving as guide to
this anatomical museum suspended in amnion. "This is baby's kidney. And over
here we have baby's stomach." Baby? Talking in the hallway out of the patient's
earshot, my attending remarked, "The fetus appears on exam to be healthy."
Although the proper use of "baby" vs "fetus" is generally not a part of formal
obstetric training for medical students, maternal-fetal ethics instruction
is a component of medical and resident education. A 1994 study found that
the top 2 issues of interest in obstetric ethics education were "abortion"
and "maternal-fetal conflict."1
Although obstetricians rarely encounter ethical dilemmas like court-ordered
cesarean deliveries or pregnant patients refusing life-sustaining blood transfusions,
unplanned pregnancy and drug and alcohol use during pregnancy are common occurrences.2,3 Thus it is not surprising that
the pregnant woman is a focus of complex cultural expectations, moral obligations,
and legal rights. This issue of MSJAMA addresses
some of the constructs and tensions in the maternal-fetal relationship.
The maternal-fetal relationship is the subject of intense public policy
debates. Lisa Harris and Lynn Paltrow report on courts' opinions regarding
the prosecution of pregnant women for potential fetal harm. Nathan Stormer
explores how contemporary biomedical images of the fetus are changing public
perception of the pregnant body and fetus. Amy Salisbury and colleagues describe
how researchers are attempting to measure maternal-fetal attachment and its
possible implications for fetal and maternal health during pregnancy.
Although fundamental and seemingly unalterable, the definition of the
maternal-fetal relationship is undergoing a rapid evolution of context, in
part due to advances in imaging, prenatal diagnostics, genetic screening,
and fetal surgery. While the formal principles of autonomy and beneficence
provide an initial point from which to analyze the sometimes conflicting needs
of the pregnant woman and her fetus, the maternal-fetal relationship is becoming
too complex to rely on simple algorithms. As medical technology and innovation
advance, and as cultural and political dialogues continue to influence the
patient-physician encounter, physicians' knowledge of and participation in
ethical dialogue on the maternal-fetal relationship will continue to be an
increasingly important part of obstetric care.
van Dis J. The Maternal-Fetal Relationship. JAMA. 2003;289(13):1696. doi:10.1001/jama.289.13.1696