Application of legal principles and medical ethics: multifetal pregnancy and fetal reduction

Cheong MA, Tay SK
Correspondence: A/Prof Catherine Tay Swee Kian, biztayc@nus.edu.sg

ABSTRACT
In the management of complex medical cases such as a multifetal pregnancy, knowledge of the ethical and legal implications is important, alongside having competent medical skills. This article reviews these principles and applies them to scenarios of multifetal pregnancy and fetal reduction. Such a discussion is not solely theoretical, but is also relevant to clinical practice. The importance of topics such as bioethical principles and informed consent are also herein addressed.

Keywords: assisted reproductive technology, fetal reduction, medical ethics, medicolegal, multifetal pregnancy
Singapore Med J 2014; 55(6): 298-301; http://dx.doi.org/10.11622/smedj.2014077

http://smj.org.sg/sites/default/files/5506/5506ra1.pdf

REFERENCES

1) Chia KS, Lee JJ, Cheung P, et al. Twin births in Singapore: a population-based study using the National Birth Registry. Ann Acad Med Singapore 2004; 33:195-9.

2) Benirschke K, Kim CK. Multiple pregnancy. N Engl J Med 1973; 288:1276-84. http://dx.doi.org/10.1056/NEJM197306142882406

3) Blondel B, Kaminski M. Trends in the occurrence, determinants, and consequences of multiple births. Semin Perinstol 2002; 26:239-49. http://dx.doi.org/10.1053/sper.2002.34775

4) World Health Organization. Current practices and controversies in assisted reproduction : report of a WHO meeting on "Medical, Ethical and Social Aspects of Assisted Reproduction". WHO; 2002.

5) Cunningham FG, Hankins GDV, et al. Multifetal Pregnancy. In: Cunningham FG, MacDonald PC, et al, eds. Williams Obstetrics. 20th ed. Connecticut: Appleton & Lange,1997: 861-94.

6) Jones HW, Schnorr JA. Multiple pregnancies: a call for action. Fertil Steril 2001; 75:11-3. http://dx.doi.org/10.1016/S0015-0282(00)01612-5

7) MacDorman MF, Martin JA, Mathews TJ, Hoyert DL, Ventura SJ. Explaining the 2001-02 infant mortality increase: data from the linked birth/infant death data set. Natl Vital Stat Rep 2005; 53:1-22.

8) Wen SW, Demissie K, Yang Q, Walker MC. Maternal morbidity and obstetric complications in triplet pregnancies and quadruplet and higher-order multiple pregnancies. Am J Obstet Gynecol 2004; 191:254-8. http://dx.doi.org/10.1016/j.ajog.2003.12.003

9) Ellison MA, Hall JE. Social stigma and compounded losses: quality-of-life issues for multiple-birth families. Fertil Steril 2003; 80:405-14. http://dx.doi.org/10.1016/S0015-0282(03)00659-9

10) Bryan EM. The consequences to the family of triplets or more. J Perinat Med 1991; 19 Suppl 1:24-8.

11) Howie PW. Selective reduction: medical aspects. In: Templeton AA, Cuisine DJ, eds. Reproductive Medicine and the Law. London: Churchill Livingstone, 1990: 25-32.

12) FIGO Committee for the Ethical Aspects of Human Reproduction and Women's Health. Ethical recommendations on multiple pregnancy and multifetal reduction. FIGO Committee for the Ethical Aspects of Human Reproduction and Women's Health. Int J Gynaecol Obstet 2006; 92:331-2. http://dx.doi.org/10.1016/j.ijgo.2005.12.019

13) Evans M, May M, Fletcher J. Multifetal pregnancy reduction and selective termination. In: Iff L, Apuzzio JJ, Vintzileos, eds. Textbook of Operative Obstetrics. 2nd ed. London: Pergamon Press; 1992: 67-76.

14) Stone J, Berkowitz RL. Multifetal pregnancy reduction and selective termination. In: Gall SA, ed. Multiple Pregnancy and Delivery. St Louis: Mosby-Year Book, 1996: 181-97.

15) Fasouliotis SJ, Schenker JG. Multifetal pregnancy reduction: a review of the world results for the period 1993-1996. Eur J Obstet Gynecol Reprod Biol 1997; 75:183-90. http://dx.doi.org/10.1016/S0301-2115(97)00132-2

16) Evans MI, Dommergues M, Wapner RJ, et al. International, collaborative experience of 1789 patients having multifetal pregnancy reduction: a plateauing of risks and outcomes. J Soc Gynecol Investig 1996; 3:23-6. http://dx.doi.org/10.1016/1071-5576(95)00037-2

17) Stone J, Eddleman K, Lynch L, Berkowitz RL. A single center experience with 1000 consecutive cases of multifetal pregnancy reduction. Am J Obstet Gynecol 2002; 187:116-7. http://dx.doi.org/10.1067/mob.2002.126988

18) Chester v. Afshar [2002] EWCA Civ 724; [2003] Queen's Bench Division 356.

19) Bolam v. Friern Hospital Management Committee [1957] 1 Weekly Law Reports 583.

20) Bolitho v. City and Hackney Health Authority [1997] 4 All England Reports 771.

21) Knopoff KA. Can a pregnant woman morally refuse fetal surgery? Calif Law Rev 1991; 79:499-540. http://dx.doi.org/10.2307/3480692

22) Singapore Statutes, Termination of Pregnancy Act (Cap. 324) – 1974.

23) Nisand I, Shenfield F. Multiple pregnancies and embryo reduction: ethical and legal issues. In: Shenfield F, Sureau C, eds. Ethical Dilemmas in Assisted Reproduction. New York: Parthenon Press, 1997: 67-76.

24) Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 6th ed. Oxford: Oxford University Press, 2009: xiii, 417.

25) Daar JF. Selective reduction of multiple pregnancy: lifeboat ethics in the womb. Univ Calif Davis Law Rev 1992; 25:773-843.

26) The Queen v. Dudley and Stephens, 14 Queen's Bench Division 273 (1884).

27) United States v. Holmes. Circuit Court, E. D. Pennsylvania. 26 F.Cas. 360 (1842).

28) Singapore Statutes, Private Hospitals and Medical Clinics Act (Cap. 248) – Revised Edition 1999.

29) FIGO Committee for the Ethical Aspects of Human Reproduction and Women's Health. Ethical recommendations on multiple pregnancy and multifetal reduction. FIGO Committee for the Ethical Aspects of Human Reproduction and Women's Health. Int J Gynaecol Obstet 2006; 92:331-2. http://dx.doi.org/10.1016/j.ijgo.2005.12.019

30) Evan MI. Selective first-trimester termination in octuplet and quadruplet pregnancies: clinical and ethical issues. Obstet Gynecol 1988; 72:821-2.

31) Britt DW, Risinger ST, Mans M, Evans MI. Anxiety among women who have undergone fertility therapy and who are considering multifetal pregnancy reduction: trends and implications. J Matern Fetal Neonatal Med 2003; 13:271-8. http://dx.doi.org/10.1080/jmf.13.4.271.278

32) Eller TR. Informed consent civil actions for post-abortion psychological trauma. Notre Dame Law Rev 1996; 71:639-70.

33) Purdy L. Women's reproductive autonomy: medicalisation and beyond. J Med Ethics 2006; 32:287-91. http://dx.doi.org/10.1136/jme.2004.013193

34) Tay CSK. Recent developments in informed consent: the basis of modern medical ethics. APLAR J Rheu 2005; 8:165-70. http://dx.doi.org/10.1111/j.1479-8077.2005.00143.x

35) Goffman, Erving. Frame Analysis: An Essay on the Organization of Experience. Cambridge, MA: Harvard University Press, 1974.

36) Britt DW, Evans WJ, Mehta SS, Evans MI. Framing the decision: determinants of how women considering multifetal pregnancy reduction as a pregnancy-management strategy frame their moral dilemma. Fetal Diagn Ther 2004; 19:232-40. http://dx.doi.org/10.1159/000076704

37) Directives for private healthcare institutions providing assisted reproduction services: Regulation 4 of the private hospitals and medical clinics regulations (CAP 248, REG 1).

38) Cohen MH. Toward a bioethics of compassion. Ind L Rev 1995; 28:667-8.