Best Practice & Research Clinical Obstetrics and Gynaecology 28 (2014) 443–451

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Ethics of prenatal ultrasound David Howe, DM, FRCOG, FRCS(ed), Consultant and Honorary Senior Lecturer in Feto-Maternal Medicine * Wessex Fetal Medicine Unit, Princess Anne Hospital, Southampton SO16 5YA, UK

Keywords: ethics ultrasonography prenatal termination of pregnancy

Prenatal ultrasound has opened new opportunities to examine, diagnose and treat the fetus, but these advances bring with them ethical dilemmas. In this chapter, I address the ethical principles that need to be considered when treating both mother and fetus as patients, and how these can be applied in practice. In particular, ultrasound practitioners have an ethical duty to maintain their theoretical knowledge and practical skills to ensure they advise parents correctly. I also discuss the ethical issues in carrying out intrauterine therapy, ultrasound-related research, and termination of pregnancy for fetal abnormality. Ó 2013 Elsevier Ltd. All rights reserved.

Introduction Until the last century, the fetus was hidden from view until birth and inaccessible for diagnosis or treatment. The discovery of X-rays in 1895 allowed the first possibility of prenatal diagnosis of fetal problems, including multiple pregnancy (1911), neural-tube defects, Spalding’s sign indicating fetal death (1922), and assessment of fetal maturity from 1935 [1]. The earliest intrauterine treatment in regular use was intraperitoneal transfusion of blood in rhesus disease, first reported in 1963, again using X-ray guidance [2]. In 1958, Ian Donald described the use of ultrasound to examine intraabdominal masses, including the fetus [3], and by 1970 fetal polycystic kidney disease had been recognised [4]. Further developments, particularly the introduction of real-time ultrasound in the late 1970s, led to a rapid increase in the number of abnormalities that could be recognised antenatally so that, by the early 1980s, even fetal cardiac abnormalities were being identified. Ultrasound also supported invasive procedures. By 1982, chorionic villus sampling, amniocentesis, and the safe placement of fetoscopes had been described to guide intravenous transfusion [5].

* Tel.: þ44 23 8079 4228; Fax: þ44 23 8079 6207. E-mail addresses: [email protected], [email protected]. 1521-6934/$ – see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bpobgyn.2013.10.005

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As a result, the fetus is no longer hidden until birth but potentially a patient, who can be examined, subjected to additional diagnostic investigations, and treated, either by modifying the place, equipment and staff available at delivery or even by intrauterine treatment. This potential brings with it new ethical dilemmas for parents and clinicians. Ethical principles Ethics deal with the moral principles governing a person’s behaviour or conduct of an activity. It addresses what our behaviour ought to be and what virtues should be cultivated in our moral lives [6]. A number of approaches may be chosen when considering ethical decisions and behaviour in the use of prenatal ultrasound, including consideration of religious, secular and legal guidance. Most societies are now multicultural so not dependent on a single religious code to provide guidance, although laws will often by influenced by religion. In such a multicultural society, a secular framework is required to allow patients to be treated in accordance with their wishes, within the legal constraints of the country in which they live, even if these conflict with the religious views of the clinician. Gillon [7] proposed an approach using four principles plus scope as a ‘simple, accessible, and culturally neutral approach to thinking about ethical issues in health care’. These are respect for autonomy, beneficence, non-maleficence and justice. Using these can provide a common set of moral commitments and a shared moral language that help achieve a decision in difficult ethical situations. Respect for autonomy places a number of duties on the clinician. It requires that the patient be consulted and their informed consent obtained before anything is done to them; it requires their active involvement in decisions; and requires respect and support for their decisions even if these differ from those the clinician would have made. It requires that information is treated confidentially, and places a duty to communicate clearly and effectively so patients are fully informed to enable them to make their choices. Respect for autonomy requires the clinician to recognise that the patients’ values and beliefs will affect their decisions about what is in their best interests. Many of the decisions relating to obstetric ultrasound are complex, especially when fetal anomalies or life-threatening problems are found, yet the patient, in this case the mother, is assumed to be competent to consider the issues and decide the best option for her and her family [6]. The principle of beneficence requires that we aim to help the patient. Most health interventions, including prenatal ultrasound alone or as part of an invasive procedure, also have the potential to cause harm, and the principle of non-maleficence places the duty to avoid or minimise such harm. These two principles can be summarised as the clinician having the duty to act in the best interests of the patient. The ‘best interests’ should be decided by a careful, unbiased evaluation of the patient, making use of scientific knowledge and clinical experience [6]. The best health interests include avoiding premature death and minimising, curing or managing morbidity, while minimising the harm caused by any interventions or actions. We should seek to achieve the greatest balance of good over harm in the consequences of our behaviour. The principle of justice requires that fairness is applied when judging between competing claims. This may mean fair distribution of limited resources, respect for people’s rights, or respect for morally acceptable laws [7]. Gillon argues that these principles can be applied by distributing healthcare resources in proportion to the extent of people’s needs for health care; allowing healthcare workers to give priority to the needs of ‘their’ patients; providing equal access to health care; allowing people as much choice as possible in selecting their health care; and maximising the benefit produced by the available resources and respecting the autonomy of the people who provide those resources and thus to limit the cost to taxpayers [7]. These aims may not be simultaneously achievable. These principles underpin many codes of practice outlining the duties of doctors in relation to their patients. Within the UK, the General Medical Council provides guidance on Good Medical Practice [8], emphasising the need to respect the autonomy of patients by maintaining personal honesty and integrity, and treating patients as individuals and respecting their dignity and confidentiality. The principles of beneficence and non-maleficence are supported by the requirements to keep professional knowledge and skill up to date and to work within the limits of competence. Many other medical licensing authorities internationally have issued similar guidance.

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For this chapter, the scope to be considered is the application of these principles in the use of prenatal ultrasound in its various roles. These include identification of fetal anomalies, assessment of fetal growth, and as an adjunct to invasive testing or therapies. One of the most ethically contentious areas arising from prenatal ultrasound is the provision of termination of pregnancy, particularly in late pregnancy. When is the fetus a patient? Most clinicians have only one patient to consider during a consultation yet, in the practice of obstetric ultrasound, there are potentially two. Usually the mother shares the interests of her fetus but, on occasion, her interests may conflict with those of her baby, and this can cause ethical dilemmas for her clinician. Fundamental to considering and deciding on these issues is the moral status of the fetus, as the autonomy of the mother may need to be balanced against the rights or potential rights of the fetus. The moral status of the fetus has been debated for centuries, with no consensus achieved and with views ranging across wide extremes. The Catholic Church recognises the moral status of the fetus from the moment of conception, but other religions and cultures take very different views. Both secular and religious communities have a concept of ‘personhood’ separate from simply being alive, with most recognising the onset of personhood as gradual as pregnancy advances. Rimon-Zafarty et al. [9] found that this concept seemed to develop later in an Israeli population compared with others: in their study, only 36% of respondents considered the fetus alive at implantation, with most (71%) considering it alive once a heart beat could be detected. By contrast, it was not until fetal movements were apparent to the mother that most (63%) considered the fetus had ‘personhood’ status. They compared their findings with others from Australia and the USA, and found that the concept of personhood developed later in the Israeli population. In ancient times, personhood was also deemed to develop at different times. During the Middle Ages ‘quickening’ was considered to be the moment that the fetus developed its own moral status. In earlier societies, personhood was not felt to develop until later in infancy, and it was common for children with deformities or who were otherwise unwanted to be left, like the legendary Romulus and Remus, to die by exposure. A similar view was recently advanced by Giubilini and Minerva [10], who argued that ‘after birth abortion’ was justified for both babies with severe abnormalities and those who were unwanted by their parents. They argue that personhood does not develop until an individual is capable of attributing some value to their own existence, as before then loss of such an existence cannot represent a loss to the child. As the baby is only a ‘potential person’, the interests of actual people (parents and society) override the interests of those who are ‘merely potential’. Unsurprisingly, their view received considerable critical comment. In parallel with the spectrum of opinion about the onset of personhood, the legal status of the fetus varies in different countries and states, and the concept of developing personhood with advancing pregnancy is mirrored by laws relating to abortion. In English law, the fetus has no legal status separate from its mother until it is born [11]. Thus, although it might have moral status and claims, it has no legal rights or status in law before birth. Despite this, the fetus has ‘latent rights’ that crystallise upon delivery. Hence, obstetricians and midwives owe it a duty of care and, if an injury occurs before birth due to negligent treatment, the former fetus can now exercise its rights as a person to bring a claim for damages. Despite its lack of legal status, the fetus retains some protection in English law, as termination of pregnancy remains illegal except within the provisions of the Abortion Act, 1967 as amended by the Human Fertilisation and Embryology Act, 1990. For two of the five provisions under which termination is allowed, the upper gestation is limited to 24 weeks, considered to be the time of viability. Where the pregnancy could cause grave injury or risk to the life of the mother, her interests are considered paramount, and termination can be performed at any gestation. It is also allowable at any gestation for fetal abnormalities where there is ‘substantial risk’ that the child may suffer ‘serious physical or mental handicap’. In Israel, termination is permissible for fetal abnormality at any gestation but with greater restrictions after 24 weeks; in New Zealand, termination is more restricted after 20 weeks and only allowable if there is serious risk to the physical or mental health of the mother, so late termination for fetal anomaly may be carried out to avoid psychological injury; in Germany, no gestational limit exists

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on termination, but there are similar requirements to demonstrate a risk of psychological harm if a late termination is contemplated; and, in the USA, the law varies from state to state, with many allowing termination only up to the point of ‘viability’, although the legal definition of this varies. Legal restrictions on late termination in other European countries were summarised by Habiba et al. [12] Even where the law is clear, there is little case-law to clarify some of the terms used. Within the UK, for example, the interpretation of ‘substantial risk’ and ‘serious physical or mental handicap’ remain uncertain, and some clinicians have found themselves reported to the Crown Prosecution Service after carrying out a termination at 28 weeks in a fetus with cleft lip and palate, although they were not ultimately prosecuted [13]. It is also clear that, despite its lack of legal status, both parents and clinicians frequently consider the fetus as a patient, to whom they owe ethical duties of care. This differs from any other branches of medicine, as the clinician may have to consider his or her simultaneous ethical responsibilities to two patients, the mother and the fetus, and may also be a source of conflict. The fetus is incapable of assessing its own best interests so the obligations to it are based on beneficence rather than autonomy [11], and these obligations are shared by both the mother and clinician. In most cases, the interests of the mother are in harmony with the fetus, but Chervenak et al. [14] consider the relationship between the mother, fetus and clinician in cases where their interests may not be fully aligned, and highlight a potential for conflict. They consider three ethical models, one where the rights of the fetus are paramount, one where the mother takes full precedence, and a third which they describe as exercising professional responsibility to balance the two. In the first model, the rights of the fetus systematically override those of the mother. This would prevent termination of pregnancy in any circumstances, even where the life of the mother may be threatened, overriding all her choice in the matter. This is the position taken in Irish law, and this was recently suggested to have contributed to the death of a pregnant mother with a septic abortion [15]. In the second model, the mother’s autonomy is maintained throughout pregnancy, systematically overriding the rights of the fetus. Taken to its logical extreme, this would allow the mother to opt for termination of pregnancy at any stage and for any reason. It also allows her to refuse intervention, such as caesarean section, even where the life of the fetus is in jeopardy if not managed this way. In the USA and UK, courts have, on occasion, overridden the wishes of the mother and ordered delivery by caesarean against her wishes, but the current position in UK law is that the Court will not override the right of a mother to refuse operative delivery unless she lacks mental capacity to make the decision. The Royal College of Obstetricians and Gynaecologists has summarised the relevant case law and provides guidance in case such conflicts arise [16]. The third option requires the clinician to exercise his clinical judgement to maximise the benefit to both mother and baby, making use of the principles of beneficence and autonomy. The fetus has no ability for autonomous decisions so only beneficence can be applied, but the mother’s values and beliefs must be respected. McCullough and Chervenak [17] argue that the pregnant mother becomes a patient when she presents for care, so this is easy to define and recognise. The fetus becomes a patient in a more complex fashion. The fetus’ moral status is dependent on its mother, but an important step on its path to independent status is achieving viability, when it can exist separately. Viability is not a fixed point, but will depend on the biological capacity of the fetus, including its gestation and the presence of additional anomalies, and the technological support available. In countries with access to complex neonatal care, viability in a normally formed fetus is usually considered to occur at around 24 weeks of age. A fetus with trisomy 18 or with pulmonary hypoplasia secondary to renal agenesis, however, may never achieve viability, as no technical support can overcome its inherent problems. They contend that the ethical significance of viability is that ‘there are clinical interventions that can reasonably be expected to protect and promote the interests of the fetus’ that can prevent death, reduce suffering or limit or cure disease. Two features inherent in being a patient are (1) the individual presents to a clinician, and (2) it is for the purpose of applying clinical interventions that are reliably expected to promote the interests of that individual. Once the fetus reaches viability, the second condition applies and both the mother and the clinician then have an ethical obligation to promote the wellbeing of the fetus. The situation is arguably different for the pre-viable fetus. No technological interventions can enable the fetus to survive to achieve independent moral status, so ‘it has no claim on the pregnant

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woman or any physician to remain in utero’. Its status as patient can only be conferred by the mother’s autonomous decision to do so and to present the fetus to a clinician. The ethical implication of this is that the mother can choose to confer or withhold the status of patient on her fetus, or having conferred that status, later choose to remove it. McCullough and Chervenak [17] summarise their argument by stating that the fetus is sometimes a patient depending on (1) whether it is viable, which confers a responsibility on the mother to present it for care; or (2) if she confers the status of patient on a previable fetus. This has important implications for the practice of obstetric ultrasound. Applying ethics to clinical practice Antenatal ultrasound is used in four main ways in relation to the fetus: (1) as a method of examining the fetus to diagnose structural anomalies; (2) as a method to diagnose or monitor functional problems, such as growth restriction or wellbeing that might be affected by structural anomalies; (3) as an adjunct to invasive procedures or in-utero treatments; and (4) as a research tool. In all these areas, the clinician needs to ensure that appropriate ethical standards are maintained. Otherwise, instead of benefitting the mother or fetus, ultrasound may cause significant harm. Finally, the findings from prenatal ultrasound may result in mother’s requesting termination of pregnancy, and a clear ethical basis to support or refuse this is needed. Perhaps the most important requirement is that all practitioners of antenatal ultrasound ensure they have appropriate training and continue to maintain and develop their skills. The ethical principles of both beneficence and respect for autonomy require this. Inadequately skilled ultrasound practitioners may cause inadvertent harm in many ways. They may miss important diagnoses because they lack the ability to recognise the signs on scan or, just as damagingly, may cause unnecessary anxiety by incorrectly indicating to parents that there is a problem. As one of the choices made by parents may include termination of pregnancy, false-positive diagnoses may have serious consequences. Even apparently simple aspects of scanning may prove harmful if inadequately carried out (e.g. poor measurements of fetal size may suggest a fetus is growth restricted when not, possibly leading to inappropriate additional monitoring and intervention, or over-measurement might miss the diagnosis). Guibaud [18] pointed out the need for standardisation of a measurement as apparently simple as posterior ventricular horn diameter: conventionally, a diameter of greater than 10 mm is considered abnormal and in fetuses with measurements close to this threshold there are major consequences for slight over- or under-measurements. If over-estimated, the parents may be incorrectly informed that their fetus has a ‘brain abnormality’, and may have subsequent handicap, an anxiety that can persist into childhood even if later ultrasound examinations are apparently normal or reassuring. A falsepositive result may lead to unnecessary invasive testing, which may in turn lead to procedurerelated loss, or the anxiety about outcome may lead to parents terminating a pregnancy when their child would have developed normally. If the measurement is underestimated, the parents may be inappropriately reassured, may not be offered appropriate further investigations, and may have a child with serious handicap. The incidence of ventriculomegaly differs widely in different studies [19], and Levine et al. [20] showed high levels of disagreement between expert assessors for the presence or absence of ventriculomegaly, suggesting that some of this variation may be caused by different measurement techniques. Where international standards exist for a measurement, it is essential that practitioners try to adhere to these and, if possible, audit their compliance. Respect for autonomy requires that parents are given accurate information about their ultrasound findings and their implications, so they can make a properly informed choice. Obstetric ultrasound is a changing field, so that new research may quickly change the advice parents should receive. For instance, in 1990, an early description of choroid plexuses cysts suggested that chromosome anomalies occurred in as many as 25% of affected fetuses [21], yet by 1998 a multicentre study in a low-risk population found that, in fetuses with choroid plexuses cysts, the incidence of karyotype abnormality was only 2% overall, and only 0.5% where the cysts were isolated [22]. The importance of adequate up-to-date knowledge was demonstrated by Favre et al. [23] who showed that poor knowledge among professionals advising women before first-trimester ultrasound and nuchal translucency measurements, unethically undermined their autonomy [23]. Similar problems were demonstrated previously with serum screening [24]. There is the same duty to advise women about the implications and

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limitations of any scan in pregnancy, but particularly anomaly scans, ensuring women understand both the limitations and the potential for false positives and uncertain findings causing inappropriate worry. The provision of routine screening ultrasound scans varies in different health systems: within the UK and many other countries, most screening anomaly scans are carried out by sonographers without the skills to counsel in detail about anomalies found. Much of the initial counselling may be carried out by generalist obstetricians with limited scanning experience themselves, and with limited knowledge of the implications and management of anomalies. They have an ethical duty to establish links with a fetal medicine centre to ensure women have access to multidisciplinary counselling as required [25]. The ethical dilemmas are increased in relation to fetal therapy, which usually depends on ultrasound to guide treatment or at least diagnose the condition and assess the response to intervention. Fetal therapy may be appropriate where the natural history of a condition leads to death or severe morbidity or handicap in spite of optimal postnatal treatment [25]. It may provide an alternative to termination of pregnancy. Although treatment has been described in a large number of conditions, its effectiveness has been demonstrated in only a few. The International Fetal Medicine and Surgical Society suggests that intrauterine treatment should be considered if the natural history of the disease is understood, the condition is lethal or causes severe morbidity if not treated in utero, and if fetal intervention may be at least partially corrective, with results as good as, or better than, postnatal treatment. In addition, the duty of beneficence requires that, among the possible interventions, the one causing least risk of mortality or morbidity to the fetus should be chosen, and there should be only a low risk of harm to the mother [26]. Fetoscopic treatment for twin–twin transfusion syndrome [27] and open fetal surgery for spina bifida [28] have both been the subject of randomised-controlled trials but no ultrasound-dependent treatments have yet been subjected to the same rigour, although a randomised-controlled trial of vesicoamniotic shunt insertion for bladder outflow obstruction is due to be published shortly (www.pluto.bham.ac.uk). A key ethical component of any trial of intrauterine treatment is long-term follow up to assess potential late morbidity. Vesico-amniotic shunting may convert intrauterine or early perinatal death into late death or prolonged disability caused by renal failure; so pioneers of any new treatment need to be cautious and realistic in counselling parents about these problems, and to avoid publication bias where only successful outcomes are described. The uncertainties of intrauterine treatments raise several ethical imperatives. First, mothers offered these interventions need to be aware of the limited state of knowledge about their benefits. Ideally, where uncertainty persists about the indications for intervention or the outcomes, whether short or long-term, parents should be offered the opportunity to take part in well-conducted trials of treatment. As with all other aspects of antenatal ultrasound, there is also an imperative on the treating clinician to be competent at the procedure: for laser treatment of twin–twin transfusion, a significant learning curve and need for ongoing experience has been demonstrated [29], and this may conflict with the desire of some units to provide treatments for conditions that occur only infrequently: instead it may be better to focus such treatments in a smaller number of more specialised centres. A similar argument has been advanced even for much simpler and more common procedures such as chorionic villus sampling and amniocentesis, as loss rates before 24 weeks after these investigations were higher in Denmark in departments carrying out fewer procedures [30]. The argument for centralisation has to be balanced against the desire by patients for easily accessible local services [31]. Advancing our knowledge of prenatal ultrasound cannot be achieved without ongoing research, but this also needs to be carried out ethically to avoid unintended harm to pregnant women or their fetuses. Some of the most important research for prenatal ultrasound may be follow-up studies in children, as one of the weaknesses of fetal medicine is our limited ability to counsel parents accurately about the postnatal implications of many antenatally ultrasound diagnosed anomalies. For instance, even one of the largest reports of the outcome of agenesis of the corpus callosum could only identify 35 cases where the abnormality was isolated [32]. Of these, 19 were terminated and four lost to follow up before the end of pregnancy, leaving 11 followed as far as birth. Four of these were not followed up after delivery, leaving outcomes known for only seven and these were not followed up or assessed in any formal way or at a specified and comparable age. Despite such limited information, parents are being offered and accepting termination of pregnancy. Long-term outcome data are as limited for many other conditions and there is a pressing ethical need to develop more consistent follow up of all prenatally diagnosed anomalies. Arguably, this is a more important area for research than formal studies of

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intrauterine treatments, as it affects a much larger number of fetuses and mothers, but it is difficult to achieve because of the need for cross-specialty collaboration with those involved in paediatric follow up. Where treatments are being investigated, those organising the trial must ensure that there is a reasonable body of evidence that the intervention may be beneficial, usually from prior animal work or small uncontrolled case series. Once there is equipoise about the benefits of an intervention, it is appropriate to carry out randomised studies but within a clear ethical framework. There should be data monitoring to ensure that the trial is not continued longer than necessary if it demonstrates clear benefit or harm. The mother needs to be informed about the trial in a non-directive way, avoiding language that implies the intervention may be beneficial or terms that imply moral relationships [26]; the procedure should be described as an experimental intervention, rather than as a treatment to avoid ascribing it undue success and terms such as ‘mother’ and ‘baby’ should be replaced by ‘pregnant woman’ and ‘fetus’. She must be informed that she does not need to take part and that other options, such as termination of pregnancy are still open to her. Clinicians not directly involved in the research also have an ethical duty to inform women meeting the criteria that a trial is under way because, although this may not directly benefit this mother or her fetus, it has the potential to benefit others in the future when the outcome of the trial is known. The most difficult ethical issues in relation to antenatal ultrasound and prenatal diagnosis surround the provision of termination of pregnancy. In most developed countries, this is an option for parents after the diagnosis of serious fetal abnormalities. In Italy, termination is carried out for fetal abnormality, but this is allowed only to prevent psychological harm to the mother. There are no grounds for termination to prevent fetal disability [12]. Even where termination is allowed for fetal anomalies, debate continues about how severe the abnormality has to be, to justify termination. In the Netherlands, six criteria are considered when deciding how an abnormality will affect a child after birth: ability to communicate, self awareness, dependence on medical support, future self-sufficiency, and the likelihood of suffering [33]. Similar criteria were suggested by the Royal College of Obstetricians and Gynaecologists in their updated report on termination of pregnancy for fetal abnormality [34]. Dommergues et al. [35] showed that, in France, most terminations for abnormality were carried out where the anomaly would be lethal or clearly associated with severe physical or mental handicap, and only a minority for conditions that result in late onset problems or where the degree of disability might be disputed [35]. The difficulties and controversy surrounding termination are even greater later in pregnancy. In some countries, the law prevents termination for fetal abnormality after 22 weeks, releasing the clinicians from the dilemma of deciding when this is ethically justifiable [12]. The imposition of an upper gestational age limit on termination, however, may have the unintended effect of causing parents to end the pregnancy where they might not if they could wait for reassuring developments later. For instance, where mild ventriculomegaly is diagnosed in mid-pregnancy, the likelihood of later handicap is influenced by whether this progresses later in pregnancy or the finding of additional anomalies on subsequent scans or magnetic resonance imaging. Where late termination is not allowed, parents may opt for immediate termination rather than risk the chance that later investigations will find evidence of progression. Where late termination is allowed, clinicians find themselves as moral and legal arbiters of whether it is justified or indicated, and this may bring them into conflict with the mother or the state. De Crepisgny et al. [36] described several controversial legal decisions relating to termination, demonstrating that clinicians may find themselves prosecuted for providing late termination, but also sued for wrongful life claims if this is refused [36]. Statham et al. interviewed clinicians in the UK about their practice in relation to termination after 28 weeks, illustrating some of the ethical difficulties for those involved [37]. One set of ethical principles that may be used to guide decisions about termination in late pregnancy, particularly where there is disagreement between the parents and the attending clinician, was suggested by Chervenak et al. [38] in 1995. They proposed that the decision should be based on whether the fetus can be considered a patient, as discussed above. Before viability, the mother can withhold or confer the status of patient upon her fetus, so the clinician’s moral duty is to her alone, respecting the autonomy of her decisions. After viability, the fetus has its own dependent moral status, and the clinician has a beneficence-based duty to it as well as the mother, so has to balance these duties. They argue that,

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whatever the law, aborting a third-trimester fetus breaches the ethical obligations to it, except where an abnormality invariably results in early death or absence of cognitive developmental capacity. Viability is usually taken to be 24 weeks, but may be later in fetuses with structural abnormalities or severe growth restriction. Although the principles set out by Chervenak et al. [38] may be helpful to some, others argue that, where there is disagreement about termination for abnormality between the clinician and the mother, her autonomy remains paramount [39]. With such an ethically contentious issue, there will be no single solution acceptable to all. Conclusion Prenatal ultrasound has many benefits for both mothers and babies, whether used for simple purposes, such as confirming dates, identifying multiple pregnancies, diagnosing malpresentation or placenta praevia, or in more complex situations such as diagnosis and management of fetal anomalies. For parents, it is a marvel to see and relate to their child early in pregnancy, and it transforms the relation between clinician and the fetus who may now be a patient amenable to diagnosis and treatment. This new relationship brings with it ethical responsibilities and dilemmas. Working to a defined ethical framework may help to resolve or avoid some of the difficulties that may be encountered particularly where the interests of the mother and her fetus do not coincide. Ultrasound practitioners should be aware of their ethical duties to show respect for their patient’s autonomy, and to maximise the benefit and minimise the harm of their interventions. It is helpful to recognise when the fetus should be considered as a patient to determine the ethical duty owed and will help when considering interventions, including termination of pregnancy, especially at late gestations.

Practice points  Respect for parental autonomy, ensuring maximum benefit and minimum harm, all place a duty on the ultrasound practitioner to ensure their theoretical knowledge is up to date in a rapidly developing specialty. The practitioner must also develop and maintain competency in practical procedures.  Prenatal ultrasound will often involve a duty of care to two patients, the mother and the fetus.  No single definition has been agreed of when the fetus acquires moral or legal rights independent of its mother, with practice varying by culture, religion and local law.  The fetus may be considered a patient before viability if the mother presents it for diagnosis and treatment, but this status is dependent on the mother’s wishes and may be withdrawn.  After viability, when the fetus has the potential for life independent of its mother, the fetus has a moral status of its own, and this may alter decisions about management, particularly termination of pregnancy.

Research agenda  Societal attitudes to late termination for fetal anomaly so clinicians can practice both within the law and within the bounds of practice considered ethical in the locale.  Late postnatal outcomes of antenatally diagnosed conditions. For many anomalies identified by prenatal ultrasound, data are limited on late outcomes with no systematic follow up or formal neurodevelopmental assessment, limiting the accuracy of information given to parents.  Formal assessment of intrauterine treatments, including systematic late follow up.

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Ethics of prenatal ultrasound.

Prenatal ultrasound has opened new opportunities to examine, diagnose and treat the fetus, but these advances bring with them ethical dilemmas. In thi...
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