Ethical considerations of maternal-fetal surgery

Abigail C. Rousseau; Kirsten A. Riggan; Mauro H. Schenone; Kevin J. Whitford; Siobhan T. Pittock; Megan A. Allyse

doi:10.1515/jpm-2021-0476

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Article

Ethical considerations of maternal-fetal surgery

Abigail C. Rousseau , Kirsten A. Riggan , Mauro H. Schenone , Kevin J. Whitford , Siobhan T. Pittock and Megan A. Allyse

Published/Copyright: January 31, 2022

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From the journal Journal of Perinatal Medicine Volume 50 Issue 5

Abstract

The practice of maternal-fetal surgery (MFS) has expanded from lethal fetal conditions to conditions which are significantly disabling but not a lethal fetal abnormality. The inclusion of myelomeningocele within the scope of MFS in the 1990s sparked a renewed debate over the ethics of MFS. While demonstrating increasing efficacy and range of application, MFS continues to be ethically fraught due to the inherent tension between maternal and fetal interests. Ethical issues central to MFS include the patienthood of the fetus; the balance of risks and benefits between the woman and fetus; informed consent for experimental procedures; and determination of conditions that meet ethical qualifications for MFS intervention. These concerns are likely to persist and evolve as perinatal medicine continues to advance. Here we summarize the current state of MFS ethics, highlighting the major positions in the literature thus far as well as examine future directions. It is essential robust discussions of these important issues continue both to ensure ethical medical practice and to provide support to clinicians, pregnant women, and their families.

Keywords: ethics; maternal-fetal surgery; prenatal intervention

Corresponding author: Megan A. Allyse, PhD, Biomedical Ethics Research Program, Mayo Clinic Rochester, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA; and Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA, Phone: 1 (904) 953-0368, E-mail: Allyse.megan@mayo.edu

Research funding: None declared.
Author contribution: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
Competing interests: Authors state no conflict of interest.
Informed consent: Not applicable.
Ethical approval: Not applicable.

References

1. Radic, JAE, Illes, J, Mcdonald, PJ. Fetal repair of open neural tube defects: ethical, legal, and social issues. Camb Q Healthc Ethics 2019;28:476–87. https://doi.org/10.1017/s0963180119000409.Search in Google Scholar

2. Senat, M-V, Deprest, J, Boulvain, M, Paupe, A, Winer, N, Ville, Y. Endoscopic laser surgery versus serial amnioreduction for severe twin-to-twin transfusion syndrome. N Engl J Med 2004;351:136–44. https://doi.org/10.1056/nejmoa032597.Search in Google Scholar

3. Adzick, NS, Thom, EA, Spong, CY, Brock, JW, Burrows, PK, Johnson, MP, et al.. A randomized trial of prenatal versus postnatal repair of myelomeningocele. N Engl J Med 2011;364:993–1004. https://doi.org/10.1056/nejmoa1014379.Search in Google Scholar

4. Moreira de Sá, RA, Nassar de Carvalho, PR, Kurjak, A, Adra, A, Dayyabu, AL, Ebrashy, A, et al.. Is intrauterine surgery justified? Report from the working group on ultrasound in obstetrics of the World Association of Perinatal Medicine (WAPM). J Perinat Med 2016;44:737–43. https://doi.org/10.1515/jpm-2015-0132.Search in Google Scholar

5. Van Calenbergh, F, Joyeux, L, Deprest, J. Maternal-fetal surgery for myelomeningocele: some thoughts on ethical, legal, and psychological issues in a Western European situation. Childs Nerv Syst 2017;33:1247–52. https://doi.org/10.1007/s00381-017-3446-6.Search in Google Scholar

6. Antiel, RM, Flake, AW. Responsible surgical innovation and research in maternal-fetal surgery. Semin Fetal Neonatal Med 2017;22:423–7. https://doi.org/10.1016/j.siny.2017.05.002.Search in Google Scholar

7. Bliton, MJ. Ethics: “life before birth” and moral complexity in maternal-fetal surgery for spina bifida. Clin Perinatol 2003;30:449–64. https://doi.org/10.1016/s0095-5108(03)00046-0.Search in Google Scholar

8. Caniano, DA. Ethical issues in the management of neonatal surgical anomalies. Semin Perinatol 2004;28:240–5. https://doi.org/10.1053/j.semperi.2004.03.004.Search in Google Scholar PubMed

9. Chervenak, FA, McCullough, LB, Birnbach, DJ. Ethical issues in fetal surgery research. Best Pract Res Clin Anaesthesiol 2004;18:221–30. https://doi.org/10.1016/j.bpa.2003.10.001.Search in Google Scholar PubMed

10. Chervenak, FA, McCullough, LB. A comprehensive ethical framework for fetal research and its application to fetal surgery for spina bifida. Am J Obstet Gynecol 2002;187:10–4. https://doi.org/10.1067/mob.2002.124274.Search in Google Scholar PubMed

11. Chervenak, FA, McCullough, LB. Ethics of maternal-fetal surgery. Semin Fetal Neonatal Med 2007;12:426–31. https://doi.org/10.1016/j.siny.2007.06.001.Search in Google Scholar

12. Chervenak, FA, McCullough, LB. Ethics of fetal surgery. Clin Perinatol 2009;36:237–46. https://doi.org/10.1016/j.clp.2009.03.002.Search in Google Scholar

13. Chervenak, FA, McCullough, LB. The ethics of maternal-fetal surgery. Semin Fetal Neonatal Med 2018;23:64–7. https://doi.org/10.1016/j.siny.2017.09.008.Search in Google Scholar

14. Moaddab, A, Nassr, AA, Belfort, MA, Shamshirsaz, AA. Ethical issues in fetal therapy. Clin Obstet Gynecol 2017;43:58–67. https://doi.org/10.1016/j.bpobgyn.2017.02.005.Search in Google Scholar

15. Noble, R, Rodeck, C. Ethical considerations of fetal therapy. Best Pract Res Clin Obstet Gynaecol 2008;22:219–31. https://doi.org/10.1016/j.bpobgyn.2007.07.008.Search in Google Scholar

16. Rodrigues, HCML, van den Berg, PP. Randomized controlled trials of maternal-fetal surgery: a challenge to clinical equipoise. Bioethics 2014;28:405–13. https://doi.org/10.1111/j.1467-8519.2012.02008.x.Search in Google Scholar

17. Rodrigues, HCML, van den Berg, PP, Düwell, M. Dotting the I’s and crossing the T’s: autonomy and/or beneficence? The “fetus as a patient” in maternal-fetal surgery. J Med Ethics 2013;39:219–23. https://doi.org/10.1136/medethics-2012-100781.Search in Google Scholar

18. Segers, S, Pennings, G, Mertes, H. The ethics of ectogenesis-aided foetal treatment. Bioethics 2020;34:364–70. https://doi.org/10.1111/bioe.12715.Search in Google Scholar

19. Lyerly, AD, Mahowald, MB. Maternal-fetal surgery for treatment of myelomeningocele. Clin Perinatol 2003;30:155–65. https://doi.org/10.1016/s0095-5108(02)00080-5.Search in Google Scholar

20. Dickens, BM, Cook, RJ. Legal and ethical issues in fetal surgery. Int J Gynecol Obstet 2011;115:80–3. https://doi.org/10.1016/j.ijgo.2011.07.007.Search in Google Scholar PubMed

21. Lyerly, AD, Gates, EA, Cefalo, RC, Sugarman, J. Toward the ethical evaluation and use of maternal-fetal surgery. Obstet Gynecol 2001;98:689–97. https://doi.org/10.1097/00006250-200110000-00029.Search in Google Scholar

22. Balint, M. Early developmental states of the ego. Primary object love. Int J Psychoanal 1949;30:265–73.10.4324/9780429475924-8Search in Google Scholar

23. Ville, Y. Fetal therapy: practical ethical considerations. Prenat Diagn 2011;31:621–7. https://doi.org/10.1002/pd.2808.Search in Google Scholar PubMed

24. Austin, MT, Cole, TR, McCullough, LB, Chervenak, FA. Ethical challenges in invasive maternal-fetal intervention. Semin Pediatr Surg 2019;28:150819. https://doi.org/10.1053/j.sempedsurg.2019.07.002.Search in Google Scholar PubMed

25. Silberberg, A, Robetto, J, Grillo, M. Ethical issues in intrauterine myelomeningocele surgery. New Bioeth Multidiscip J Biotechnol Body 2018;24:249–57. https://doi.org/10.1080/20502877.2018.1521499.Search in Google Scholar PubMed

26. Antiel, RM. Ethical challenges in the new world of maternal–fetal surgery. Semin Perinatol 2016;40:227–33. https://doi.org/10.1053/j.semperi.2015.12.012.Search in Google Scholar PubMed

27. Bruner, JP. Intrauterine surgery in myelomeningocele. Semin Fetal Neonatal Med 2007;12:471–6. https://doi.org/10.1016/j.siny.2007.06.011.Search in Google Scholar PubMed

28. Hii, L-Y, Sung, C-A, Shaw, SW. Fetal surgery and stem cell therapy for meningomyelocele. Curr Opin Obstet Gynecol 2020;32:147–51. https://doi.org/10.1097/gco.0000000000000614.Search in Google Scholar

29. Howe, EG. Ethical issues in fetal surgery. Semin Perinatol 2003;27:446–57. https://doi.org/10.1053/j.semperi.2003.10.004.Search in Google Scholar PubMed

30. Smajdor, A. Ethical challenges in fetal surgery. J Med Ethics 2011;37:88–91. https://doi.org/10.1136/jme.2010.039537.Search in Google Scholar PubMed PubMed Central

31. Mavroudis, CD. Foetal cardiac intervention: an ethical perspective. Cardiol Young 2011;21(2 Suppl):141–7. https://doi.org/10.1017/s1047951111001727.Search in Google Scholar PubMed

32. Bartlett, VL, Bliton, MJ. Retrieving the moral in the ethics of maternal-fetal surgery: a response to “fetal repair of open neural tube defects: ethical, legal, and social issues by Julia Radic, Judy Illes, Patrick McDonald” (CQ28(3)). Camb Q Healthc Ethics 2020;29:480–93. https://doi.org/10.1017/s0963180120000225.Search in Google Scholar

33. Bliton, MJ. Parental hope confronting scientific uncertainty: a test of ethics in maternal-fetal surgery for spina bifida. Clin Obstet Gynecol 2005;48:595–607. https://doi.org/10.1097/01.grf.0000169660.80698.a8.Search in Google Scholar PubMed

34. Antiel, RM, Flake, AW, Collura, CA, Johnson, MP, Rintoul, NE, Lantos, JD, et al.. Weighing the social and ethical considerations of maternal-fetal surgery. Pediatrics 2017;140:e20170608. https://doi.org/10.1542/peds.2017-0608.Search in Google Scholar PubMed

35. Paris, JJ, Harris, MC. Ethical issues in fetal surgery involving a twin pregnancy. J Womens Health Gend Based Med 2001;10:525–31. https://doi.org/10.1089/15246090152543102.Search in Google Scholar PubMed

36. Riggan, KA, Collura, CA, Pittock, ST, Ruano, R, Whitford, KJ, Allyse, M. Ethical considerations of maternal–fetal intervention in a twin pregnancy discordant for anomalies. J Matern Fetal Neonatal Med 2021;34:1312–7. https://doi.org/10.1080/14767058.2019.1631793.Search in Google Scholar PubMed

37. Kanaris, C. Foetal surgery and using in utero therapies to reduce the degree of disability after birth. Could it be morally defensible or even morally required? Med Health Care Philos 2017;20:131–46. https://doi.org/10.1007/s11019-016-9727-0.Search in Google Scholar PubMed

38. Caniano, DA, Baylis, F. Ethical considerations in prenatal surgical consultation. Pediatr Surg Int 1999;15:303–9. https://doi.org/10.1007/s003830050588.Search in Google Scholar PubMed

39. Lyerly, AD, Mahowald, MB. Maternal-fetal surgery: the fallacy of abstraction and the problem of equipoise. Health Care Anal 2001;9:151–65. https://doi.org/10.1023/a:1011326119701.10.1023/A:1011326119701Search in Google Scholar

Received: 2021-09-15

Accepted: 2022-01-13

Published Online: 2022-01-31

Published in Print: 2022-06-27

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Articles in the same Issue

https://doi.org/10.1515/jpm-2021-0476

Keywords for this article

ethics; maternal-fetal surgery; prenatal intervention