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Ethical dilemmas: Rights unborn

Chris Elfes, Juliette Mathie

This is the fifth piece in a short series looking at real-life ethical dilemmas concerning people with diabetes and their primary care health professionals.The authors’ objective is to raise awareness in this important and complex part of person-centred care, where the boundaries are grey and the answers are varied and depend on who you talk to. This can cause misunderstanding for all concerned; therefore, some important ethical principles that underlie clinical decision-making are outlined.The case scenarios have been anonymised so that they bear no resemblance to the original person with diabetes.

The authors recognise that there are wide-ranging opinions and possible ways forward in all of the ethical cases in this series. They are not trying to highlight expert clinical management, but instead wish to demonstrate the contrasting ethical viewpoints that contribute to decision-making processes.

by Juliette Mathie, Practice Nurse
Mrs X is a 31-year-old overweight, pregnant mother of two young children. She had gestational diabetes in her second pregnancy, which culminated in a very difficult delivery secondary to having a large for dates infant. She underwent an emergency Caesarean section because of fetal distress, and the baby had significant problems with neonatal hypoglycaemia.

She has developed gestational diabetes in her current pregnancy but has gained a lot of weight and is poorly concordant with taking her insulin. The diabetes specialist team is concerned, but she appears to be ignoring all the concerns. The other day, her husband attended with the children for their flu immunisations and said he was frightened something similar to last time will happen to their unborn baby.

Ethical discussion of the scenario
by Chris Elfes, GP
This situation clearly raises multiple, worrying issues. Many individuals from primary and secondary care are involved and all have their own autonomous rights and deontological responsibilities.

The two parents perceive the risks differently and yet it is the mother who, providing she demonstrates capacity, has the ultimate right to decide.

What is her level of understanding and what are her perceived barriers to recognising the healthcare team’s drive for good glycaemic and weight control? Does she really appreciate the wider potential ramifications of the possible harm to herself and her unborn infant?

By definition, to make a truly autonomous decision, an individual needs to have enough (balanced) information about the relative risks in order to make an informed choice – whether consent or dissent.

The most challenging moral dilemma in this situation concerns the rights, or rather lack of rights, of the unborn child. Intentional harm, if this were to be construed as such, risks the mother being reported to the local authority as putting her unborn child at significant risk on being born. It can be a thin line before some would justify invoking safeguarding procedures.

Consequentialism arguments need to be carefully framed to her without being perceived as accusatory or intimidating. At this stage in her pregnancy, it is crucial she regards the healthcare team as welcome partners in her pregnancy and delivery.

In the UK, unborn children have no legal recognition and this only irrevocably changes once delivery has occurred. Many authoritative opinions debate this issue around the world and remain divided.

On a local level, working at the coalface of primary care, our role is to keep her engaged, try and establish her ideas, concerns and expectations, as well as explore what her personal values are. Can we then achieve desirable behaviour change? 

This will require regular, co-ordinated review by non-judgemental health professionals – even in situations where we may disagree with the decision being taken. Care-based ethical arguments underline the need for us to remain compassionate, empathetic and caring.

Ethical principles covered

  • Autonomy
  • Deontology
  • Consequentialism
  • Virtue ethics
  • Care-based ethics

Care-based ethics is a subset of virtue ethics and, in essence, summarises what many would regard as the essential requirements of what make an ideal healthcare practitioner – compassion, confidence, conscience and commitment with a sympathetic understanding and response. Using this ethical framework we are required to pay moral attention to any individual we care for and to be consciously aware of the professional–patient relationships that we foster.

It is up to health professionals to ensure their own desires and obligations converge – this will require a deliberate choice to then act accordingly. 

To achieve all of the above, practitioners have to remain competent within their professional boundaries with the necessary knowledge, judgement, skill, energy, experience and motivation.

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