4. Justice is the physician`s obligation to give the patient what is due or owed to him. This is the most complex of ethical principles, in part because of the physician`s role in allocating limited medical resources. Justice is the obligation to treat those who are identical or similar equally, according to the criteria chosen. Individuals should be treated equally, unless scientific and clinical evidence shows that they differ in a manner relevant to the treatments concerned. Ethical issues in modern obstetrics often refer to a conflict between the rights and possibilities of the fetus and those of the mother. After childbirth, if the fetus is by definition a child, this new person is granted all legal rights. Whether rights should be granted or offered to the fetus depends on the situation. General rules are difficult to give due to the rapid development of clinical medicine – overly strict rules given today may well be an obstacle in the near future. All cultures have established opinions on issues related to pregnancy and childbirth. Cultural and religious dogmas are often in conflict with modern medical technology and financial issues.
In many modern societies, state laws regulate legal abortion and other aspects of abortion. Current laws often determine not only decisions, but also the minds of physicians and patients. Advanced medical technology has created the possibility of a selective foeticide. Again, our experience with this new technique is limited, and several questions of ethical importance may arise from the use of such techniques. Indications for selective feticide depend on the benefits and risks of the procedure itself, as well as the process of selecting the fetus for abortion. Of course, no definitive rules could be established at this stage of development. The advice given to the woman by her doctor is crucial to the outcome of the pregnancy in question, whether it is a selective foeticide or a legal abortion. However, the existing social protection system and the support a woman can receive from her society are also factors. Should she give birth to a child with a congenital metabolic malformation or other chronic disease? Drug abuse, including alcohol and tobacco, is a particular problem. In Sweden, pregnant women who are addicted to drugs are hospitalized during their last trimester. This policy leads to a drug-free last trimester and a reduction in the number of newborns affected.
Should a similar approach be taken to address alcohol and tobacco abuse during pregnancy? Improvements in in vitro fertilization techniques have introduced a new concept, the surrogate mother. In some countries this is prohibited by law, in others it is a recognized medical practice, but some medico-legal and ethical issues require further clarification. What are the surrogacy`s legal rights? Should there be an age limit for surrogates? Who is responsible for problems during pregnancy? In cases of male infertility, ethical questions may arise. Should the child have the legal right to know the name of the biological father? Should there be a limit to the use of donor sperm in terms of the number of fertility attempts, as well as for potential patients who can use the same sperm donor? 4. Systematically evaluate these options. After eliminating all unethical options, the remaining options are reviewed and “best management” is selected. The patient`s values will usually be the most important consideration as the decision progresses. Patients and their physicians sometimes face a dilemma in choosing or implementing a clinical management decision, even when there is enough medical information to provide one or more logical management plans.
Such dilemmas may involve ethical, moral, economic or religious issues for the patient, his family or the physician. They may also result from conflicts between the law and the choice of management decision. Unfortunately, pressure from physicians and health systems caused by medical liability concerns often contributes to this dilemma. In some cases, these dilemmas may include issues of omission or commitment related to patient safety. In this chapter, we explore these three areas (ethics, medical liability, and patient safety) with the goal of helping the patient, physician, and others involved in such dilemmas find the best management options. Principles-based clinical management is based on a systematic review of the case against four ethical principles. However, the College believes that principles-based ethics should not dominate the other approaches described in Table 3.2 and is not sufficient on its own.