The fetus as a patient: professional responsibility in contemporary Perinatal Medicine

Introduction

The ethical and clinical recognition of the fetus as a patient has evolved over decades, shaped by developments in fetal medicine, neonatology, and bioethics. The modern roots of this concept trace back to the mid-20th century with the pioneering work of Erich Saling, Ian Donald, William Liley, L. Stanley James, Roberto Caldeyro-Barcia, and others [1], [2], [3], [4]. Chervenak and McCullough developed a systematic model outlining clinicians’ ethical obligations to pregnant and fetal patients [5], 6]. Together, these contributions forged a path for contemporary perinatal ethics, in which maternal and fetal interests are viewed through a unified but ethically differentiated lens.

The Society of the fetus as a patient

The Society “The Fetus as a Patient” was inaugurated in the early 1990s under the visionary and inspirational leadership of Asim Kurjak, who recognized the need for a dedicated international forum to address the rapidly evolving clinical and ethical challenges in fetal medicine. Founded with the aim of advancing interdisciplinary collaboration, education, and research, the Society brought together obstetricians, neonatologists, ethicists, and basic scientists committed to understanding and treating the fetus as a patient. Through regular congresses, consensus statements, and scholarly publications, the Society has played a pivotal role in promoting the concept of the fetal patient globally. It has fostered dialogue around emerging technologies, ethical frameworks, and professional responsibilities, aligning clinical innovation with professional care. Over the decades, it has evolved into a leading voice in perinatal practice and ethics, reinforcing the importance of the fetus as a patient in modern obstetrics.

Defining the fetus as a patient

A patient is someone who receives or seeks medical care from healthcare providers, establishing a relationship grounded in the physician’s professional obligation to protect and promote health-related interests. The fetus becomes a patient when two clinical criteria are satisfied: the pregnant patient seeks medical care, and there exist viable medical interventions that can reasonably benefit the fetal condition, thereby establishing a therapeutic relationship based on clinical utility rather than philosophical debates about personhood or rights [5], 6]. This definition avoids contentious debates about fetal personhood or rights, instead focusing on actionable, clinical criteria. This framing respects the interdependence of the maternal-fetal dyad while introducing an ethically justifiable threshold for recognizing fetal interests.

Fetal viability is the point in pregnancy when a fetus has the potential to survive outside the uterus with or without medical support depending on the availability of specialized neonatal intensive care, advanced life support technologies, surfactant therapy, mechanical ventilation, and skilled perinatology teams, as well as individual fetal factors such as gestational age, birth weight, presence of congenital anomalies, and overall fetal health status. This typically occurs around 22–24 weeks of pregnancy in higher resource settings and later in lower resource settings. The fetus becomes a patient when the pregnant woman confers patient status on a previable fetus or when fetal viability is reached, a definition based on clinical utility rather than philosophical debates about personhood or rights. This dynamic understanding evolves with gestational age, technology, and clinical capability, requiring physicians to reassess obligations after fetal viability has been reached [6], 7].

Historical evolution of the fetal patient concept

The recognition of the fetus as a patient has deep roots in the clinical innovations of the mid-20th century, particularly through the foundational work of Erich Saling, Ian Donald, William Liley, L. Stanley James, Caldeyro-Barcia, and others. Saling was among the first to apply rigorous clinical methodology to the fetus, transforming it from a passive presence within the maternal body into an active subject of medical diagnosis and treatment [1], [2], [3], [4]. His development of fetal scalp blood sampling, intrauterine monitoring, and amniotic fluid diagnostics provided the technical means to observe and treat fetal conditions in utero – contributions that shifted obstetric care toward a dual-patient framework. Ian Donald introduced diagnostic ultrasound to obstetrics, and William Liley, developed intrauterine transfusion for Rh disease, further establishing the fetus as a patient. L. Stanley James pioneered neonatal resuscitation techniques and developed the modern approach to newborn intensive care, significantly improving survival rates for high-risk infants. Caldeyro-Barcia was instrumental through his development of Montevideo units to quantify uterine contractions and his foundational research in maternal-fetal physiology, which established key principles for modern perinatology and advanced the monitoring and care of both mother and fetus during labor. In parallel, advances in neonatology and the emergence of perinatology as a distinct discipline reinforced the concept of the fetus as a patient. The formal ethical grounding of this concept came later through the work of Frank A. Chervenak and Laurence B. McCullough, who articulated the professional responsibility model to define when and how the fetus should be considered a patient [5], 6]. Their framework provided ethical clarity to the growing clinical capacity to intervene on behalf of the fetus, helping establish fetal patienthood as both a scientific and moral category within modern medicine. This evolution, from technological innovation to ethical codification has helped define the trajectory of contemporary perinatal care.

The professional responsibility model

At the heart of this ethical framework is the professional responsibility model, which rejects simplistic deference to clinician or patient preferences in favor of principled, evidence-based advocacy for patients’ interests. This model distinguishes between what patients want and what benefits patients, a distinction critical when managing a fetal patient who cannot express preferences [5], [6], [7], [8].

Clinicians are ethically obligated to make recommendations based on scientific evidence and sound ethical reasoning, not merely to acquiesce to patient demands. For the fetal patient, this means advocating for interventions that improve outcomes, even when they pose challenges to maternal preferences, institutional policies, or cultural norms [5], [6], [7], [8]. The model also embeds a preventive ethics approach – anticipating and managing ethical conflicts before they escalate. By clearly delineating roles, expectations, and ethical boundaries, clinicians can preserve trust while upholding professional integrity [8], 9].

Beneficence-based obligations to the maternal and fetal patient

Beneficence-based obligations entail actively promoting maternal and fetal well-being, not merely avoiding harm. This includes recommending maternal behavioral changes, optimizing prenatal care, planning for delivery, and – when indicated – recommending performing direct fetal interventions [9], [10], [11]. Each recommendation must be grounded in an objective evidence-based clinical assessment of likely benefit, balanced against potential risks [11], 12].

The clinical efficacy of invasive procedures such as fetal surgery or transfusions support these obligations. Because they involve potential maternal risk, such interventions must meet an evidence-based threshold of fetal benefit. The clinician must ensure the proportionality of risk and advocate for alternatives when appropriate [13], [14], [15]. This model reinforces the clinician’s duty to remain an advocate for the maternal and fetal patient even when this position is ethically or emotionally challenging. Professional responsibility sometimes requires resisting institutional or cultural pressures that compromise maternal or fetal interests [5], 16].

Respect for maternal autonomy

Respect for autonomy remains a foundational principle in medical ethics. Pregnant patients retain the right to make healthcare decisions, including the refusal of interventions, even those that benefit the fetal patient. However, when fetal interests are strong – particularly post-viability – clinicians may intensify their advocacy [6], 14].

Ethical analysis should weigh fetal benefit, maternal risks, likelihood of intervention success, and availability of alternatives. A graduated model of advocacy, tailored to the strength of maternal and fetal interests and evidence quality, allows clinicians to respect autonomy while fulfilling obligations to both patients [5], 6], 17].

Informed consent in fetal medicine should address the dual-patient reality. Pregnant women should understand that their decisions affect two interconnected but ethically distinct entities. Transparent, non-coercive communication is key to ethically sound care [18], 19].

Viability and ethical decision-making

Viability marks an important inflection point in perinatal ethics, signifying the point at which a fetus has a realistic chance of survival outside the uterus with appropriate medical support. Viability is not fixed but depends on several factors, including gestational age, fetal weight, presence or absence of congenital anomalies, and the availability and quality of neonatal intensive care [11], 20]. In high-resource settings, viability typically begins between 22 and 24 weeks of gestation, though this range can vary based on technological capabilities and institutional practices [20], 21]. As such, viability serves as a clinical and ethical milestone, influencing decisions about resuscitation, maternal-fetal interventions, and obligations of care.

Once fetal viability has been reached, it imposes greater ethical obligations on clinicians to potentially intervene for fetal benefit. For previable fetuses, interventions can be generally offered or recommended only if the pregnant patient confers patient status on the fetus. After viability, clinicians should consider the fetus a patient with corresponding ethical status [11], 22], but consent of the pregnant patient is required for an intervention.

Decision-making in the “gray zone” of peri-viability requires individualized, evidence-based assessments. Uncertainty about survival and long-term outcomes necessitates nuanced counseling. Clinicians should aim to support pregnant patients while articulating clear recommendations when fetal interests are strong [23], [24], [25].

Emerging technologies in fetal medicine

Technological innovations – from in utero surgery to gene therapy and artificial uteri – have expanded the landscape of potential fetal interventions. These advances hold promise but also raise complex ethical questions about proportionality, informed consent, and equitable access [13], 15], 26].

Fetal surgery exemplifies the ethical tension between maternal risk and fetal benefit. Procedures such as repair of myelomeningocele require careful ethical analysis of outcomes, maternal burden, and future pregnancy implications. Only when fetal benefit outweighs maternal risk can such interventions be ethically justified [13], [14], [15].

Gene therapy introduces additional concerns, including enhancement vs. therapy, consent for future generations, and socio-economic disparities in access. Ethical deployment of these innovations requires regulatory oversight, outcome transparency, and professional self-regulation [16], 23].

The development of artificial uteri and advanced neonatal life support challenges traditional definitions of viability and patienthood. As technology progresses, ethical frameworks need to adapt without compromising maternal autonomy or public trust [20], [27], [28], [29], [30], [31].

Reproductive freedom and the fetal patient

Ethical care in fetal medicine must reflect a broader commitment to reproductive freedom, recognizing that decisions about contraception, pregnancy, and abortion belong to the woman – supported, but not directed, by her physician through shared, respectful, and evidence-based consultation [6], 32].

Prior to viability, termination of pregnancy is ethically grounded in the pregnant woman’s right to autonomy. After viability, ethical considerations become more complex, focusing on maternal life, health, and the presence of fetal anomalies. Clinicians must respect these distinctions while facilitating informed, nonjudgmental care [6], 32].

International approaches to reproductive freedom vary. In Europe, abortions are usually legal and broadly accessible, usually within the first 12 weeks of the pregnancy, often integrated into national healthcare systems with supportive legal frameworks. In contrast, U.S. policy is fragmented following the 2022 Dobbs v. Jackson Women’s Health Organization Supreme Court decision that overturned Roe v. Wade and returned abortion regulation to individual states, creating barriers to equitable care, with states establishing abortion restrictions ranging from complete bans to gestational limits as early as 6 weeks of pregnancy, often with limited exceptions for maternal life, rape, or incest. This patchwork of laws forces patients to navigate complex legal landscapes and often travel across state lines for care, creating disparities based on geography and socioeconomic status. Clinicians have a role in advocating for reproductive health policies based on evidence and ethical standards, including access to safe abortion services [32].

Clinical implementation and future directions

The 2009 International Academy of Perinatal Medicine New York declaration reaffirmed the commitment of participating nations to achieving internationally agreed development goals in global public health, emphasizing the right of everyone to the highest attainable standard of physical and mental health and recognizing the importance of international cooperation to address emerging health threats and reduce health inequities [33], 34]. The declaration also called for improved access to medications, respect for traditional medicine, and the strengthening of national health information systems and research capacity to better measure and address health inequities.

The International Academy of Perinatal Medicine (IAPM) declared abortion as a fundamental reproductive right at their June 28, 2024 meeting in New York City, advocating for legalization up to fetal viability and beyond for maternal health risks or severe fetal anomalies [35]. This position, grounded in professional responsibility and respecting autonomy-based and beneficence-based obligations to pregnant and fetal patients, emphasizes that safe, legal abortion access is essential for gender equality, public health, and reducing maternal mortality globally.

Healthcare systems should ensure equitable access to specialized maternal-fetal care, particularly in low-resource settings. Decisions about expensive or experimental fetal interventions should balance individual benefit with public health priorities [8], 16]. Clinicians should not only serve as caregivers but also be patient advocates. They must work with institutions, governments, and international organizations to ensure justice in perinatal care allocation, training, and infrastructure [6], 8], 32].

While ethical pregnancy care requires individual virtue it also requires institutional commitment. Hospitals and medical schools must develop ethics education, consultation services, and policy frameworks that support clinicians navigating complex dual-patient relationships [6], 8]. Training should encompass fetal physiology, risk-benefit analysis, conflict resolution, and cultural competence. Ongoing education is essential for aligning clinical practice with evolving ethical standards [8], 19].

Future developments will further challenge traditional frameworks. As maternal-fetal medicine advances, clinicians must remain grounded in principles of respect for autonomy, beneficence, and justice. Ethical reflection and professionalism are essential for maintaining trust, equity, and excellence in perinatal care [6], 8], 32].

Conclusions

The fetus as a patient is no longer a theoretical abstraction but a clinical and ethical reality that has reshaped perinatal care. The professional responsibility model offers a principled approach to navigating obligations to pregnant and fetal patients. By integrating respect for autonomy, beneficence, and justice, this framework guides ethical decision-making in an era of rapid technological advancement and shifting societal values. Clinicians must remain committed to ethical analysis, professionalism, evidence-based recommendations, and respect for the complex relational context of pregnancy. Through this commitment, the field of maternal-fetal medicine can continue to advance both clinical outcomes and ethical integrity in the care of its most vulnerable patients.