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Yen & Jaffe’s Reproductive Endocrinology: Physiology, Pathophysiology, and Clinical Management, 8e Yen & Jaffe’s Reproductive Endocrinology: Physiology, Pathophysiology, and Clinical Management, 8e 2018 8th Edition 8E Yen & Jaffe’S Reproductive Endocrinology: Physiology
Ethics, Jurisprudence and Practice Management in Dental Hygiene (Kimbrough, Ethics, Juriprudence and Practice Management in Dental Hygiene) – Ebook PDF Version
Preventing, Initiating, and Managing Pregnancy and Delivery
Essays Inspired by the MacLean Center for Clinical Medical Ethics Lecture Series
Edited by
JULIE CHOR, MD, MPH
Assistant Professor, Obstetrics and Gynecology, Pritzker School of Medicine, The University of Chicago
Assistant Director, MacLean Center for Clinical Medical Ethics, The University of Chicago
KATIE WATSON, JD
Associate Professor, Medical Social Sciences, Medical Education, and Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University
3
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LC record available at https://lccn.loc.gov/2021008369
DOI: 10.1093/med/9780190873028.001.0001
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Deepest gratitude to the Charlie Boys for their constant love and support.
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For my grandmothers, both nurses, for modeling women at work and caring for others as a profession.
KW
Introduction 1
Julie Chor MD, MPH and Katie Watson JD
SECTION I CONTRACEPTION AND ABORTION
ETHICS: PREVENTING PREGNANCY AND BIRTH
Overview: Contraception and Abortion Ethics
Katie Watson JD and Julie Chor MD, MPH
9
1. Why Reproductive Justice Matters to Reproductive Ethics 17
Melissa Gilliam MD, MPH and Dorothy Roberts JD
2. Religiously Affiliated Healthcare Institutions: An Ethical Analysis of What They Mean for Patients, Clinicians, and Our Health System
Lori Freedman PhD and Debra Stulberg MD, MAPP
29
3. Contemporary Challenges to Providing Confidential Reproductive Healthcare to Minors 44
Amber Truehart MD, MSc, Lee Hasselbacher JD, and Julie Chor MD, MPH
4. Contraception and Abortion in the United States: A Brief Legal History 62
David A. Strauss JD
SECTION II ASSISTED REPRODUCTION
ETHICS: INITIATING PREGNANCY
Overview: Assisted Reproduction Ethics 79
Katie Watson JD and Julie Chor MD, MPH
5. The Reproduction of Stratified (Assisted) Reproduction: Epidemiology, History, and Ideology in Infertility Care 84
Lisa H. Harris MD, PhD
6. Preimplantation Genetics: Liabilities and Limitations 98
Valerie Gutmann Koch JD
7. Who Are Your Patients, and What Happens When They Disagree? Conflicts in Treating Multiple Parties Engaging in Third-Party Reproduction 110
Heather E. Ross JD
8. Ethical Issues in Oocyte Donation 123
Susan C. Klock PhD
9. Oncofertility: Ethics and Hope after Cancer 136
Bruno Ramalho de Carvalho MD, MSc, MBA, Jhenifer Kliemchen Rodrigues BSc, MSc, PhD, and Teresa K. Woodruff PhD
10. Accessing Reproductive Technology in France: Strengths and Limits of a Model that Privileges “Just Reproduction” above Respect for Autonomy 151
Laurence Brunet MLS and Véronique Fournier MD, PhD
SECTION III OBSTETRIC ETHICS: MANAGING PREGNANCY AND DELIVERY
Overview: Obstetric Ethics 165
Julie Chor MD, MPH and Katie Watson JD
11. Refusing to Force Treatment: Reconciling the Law and Ethics of Post-Viability Treatment Refusals and Post-Viability Abortion Prohibitions 170
Katie Watson JD
12. Professional Ethics in Obstetric Practice, Innovation, and Research 197
Frank A. Chervenak MD, MMM and Laurence B. McCullough PhD
13. Doing Harm: When Healthcare Providers Report Their Pregnant Patients to the Police and Other Authorities 212
Jeanne Flavin PhD and Lynn M. Paltrow JD
14. Prenatal Counseling for Maternal–Fetal Surgery: Potential Biases, Competing Interests, and Undue Practice Variation in the World of Fetal Care
Stephen D. Brown MD
15. Ethical Issues in Academic Global Reproductive Health
Kayte Spector-Bagdady JD, MBE and Timothy R. B. Johnson MD, AM
232
247
Acknowledgments
Julie Chor and Katie Watson thank the MacLean Center for Clinical Medical Ethics at the University of Chicago and Dr. Mark Siegler, Director of the MacLean Center, for their support of the production of this book, for the year-long lecture series that served as the foundation for this volume, and for the Fellowship training that first taught us to think deeply about the ethical complexity and impact of patient–healthcare professional interactions.
About the Authors
Stephen D. Brown, MD, is a pediatric radiologist at Boston Children’s Hospital and immediate past Director of the Hospital’s Institute for Professionalism and Ethical Practice. He is Associate Professor of Radiology at Harvard Medical School, where he serves on the core faculty in the medical student Medical Ethics and Professionalism curriculum and as a Capstone Seminar faculty member in the MBE program. Dr. Brown attended the University of Pennsylvania School of Medicine, completed a diagnostic radiology residency at Massachusetts General Hospital, and fellowships in pediatric radiology and pediatric interventional radiology at Boston Children’s Hospital. He also completed the 2003–2004 Harvard Medical School Fellowship in Bioethics, where the ideas for his book chapter were conceived, with empirical work subsequently funded through a Boston Children’s Hospital Faculty Career Development Award, the American Roentgen Ray Society Leonard Berlin Scholarship in Medical Professionalism, and grants from the Kornfeld Program in Bioethics and Patient Care, the Greenwall Foundation, and the Harvard University Milton Fund.
Laurence Brunet, MLS, is a legal scholar and research associate of the Institut des sciences juridique et philosophique de la Sorbonne (UMR 8103) at the Université de Paris I. While lecturing on Fundamental Rights and Personal Law at the Institut d'Etudes Judiciaires of the Université de Paris XI, she also is a legal counsel at the Centre de Référence des Maladies Rares du Développement Génital (DEVGEN) of the Kremlin Bicêtre Hospital. Her research focuses on the interactions between family law and advances in scientific and medical research, with special emphasis on new family configurations, children born of surrogacy, and the status of transgender individuals.
Frank A. Chervenak, MD, MMM, is Professor and Chair of Obstetrics and Gynecology, Lenox Hill Hospital and Chair and Associate Dean for International Medicine at the Zucker School of Medicine at Hofstra/ Northwell in New York. He is a member of the US National Academy of
Medicine and has received honorary doctorates at 11 medical universities throughout the world. He has collaborated for 38 years with Dr. Laurence B. McCullough on ethics in obstetrics and gynecology, resulting in 286 peerreviewed papers and three books. The most recent of these, co-authored with Dr. John H. Coverdale (Professor of Psychiatry and Medical Ethics, Baylor College of Medicine), Professional Ethics in Obstetrics and Gynecology, was published by Cambridge University Press in 2020.
Julie Chor, MD, MPH, is an Assistant Professor of Obstetrics and Gynecology and an Assistant Director of the MacLean Center for Clinical Medical Ethics at the University of Chicago. After completing medical school at the University of Chicago's Pritzker School of Medicine, Dr. Chor completed her Obstetrics and Gynecology residency, Fellowship in Complex Family Planning, and MPH at the University of Illinois at Chicago. Her academic and clinical work focus on understanding and addressing barriers that adolescents and young adults face in seeking and obtaining reproductive health care. Dr. Chor also serves as a member of the American College of Obstetricians and Gynecologists' Committee on Ethics.
Bruno Ramalho de Carvalho, MD, MSc, MBA, is a board-certified specialist in gynecology and human assisted reproduction. After completing medical school at the Federal University of Uberlândia, Minas Gerais, Brazil, Dr. Bruno completed his obstetrics and gynecology, and assisted reproduction residency and MSc at the University of São Paulo in Ribeirão Preto, São Paulo, Brazil. His work focuses on providing reproductive health assistance, with special interest on fertility preservation, either for medical or social reasons. He also serves as a member of the Brazilian Federation of Gynecology and Obstetrics Associations’ National Specialty Commission on Human Reproduction and as a member of the clinical staff of Hospital SírioLibanês in Brasília, Federal District, Brazil.
Jeanne Flavin, PhD, is Professor of Sociology at Fordham University in New York City. She received a 2013 Sociologists for Women in Society award for social action and a 2009 Fulbright research award to study women, family, and crime in South Africa. Her publications include the awardwinning Our Bodies, Our Crimes: Policing Women's Reproduction in America (New York University Press, 2009) and the co-edited volume, Race, Gender, and Punishment: From Colonialism to the War on Terror (Rutgers University
Press, 2007). Her current research, undertaken in partnership with National Advocates for Pregnant Women, documents the assaults on the personhood of pregnant people, including women whose poverty, race, and/or mental health make them vulnerable targets for arrest and prosecution on the basis of their actions or inactions during pregnancy, and other abuses of state power.
Véronique Fournier, MD, PhD, founded the first clinical ethics service support in France in 2002 and directed it for 18 years. She conceived this service after having been delegated by the French Minister of Health to investigate the field of clinical ethics in the United States and having spent 1 year in the MacLean Centre for Clinical Medical Ethics (Chicago) as a fellow in Mark Siegler’s intensive training clinical ethics program. Her position led her to work on, among others, the ethical issues raised by concrete access to reproductive technologies on the clinical ground and to confront the way they were faced in France as opposed to the United States. In 2009, she published Le bazar bioéthique (The Bioethics Bazaar; Editions Robert Laffont, Paris) to alert readers to the difficulties encountered by couples who are not perfectly compliant with the norms of public morality in accessing such technologies, difficulties partly due to the illiberalism of the legislative framework to which the bioethics field is subject in France.
Lori Freedman, PhD, is Associate Professor of Obstetrics, Gynecology, and Reproductive Sciences at the University of California, San Francisco. She conducts qualitative research within the Advancing New Standards in Reproductive Health (ANSIRH) program. Dr. Freedman completed her sociology doctorate at the University of California, Davis, in 2008. She became a Greenwall Faculty Scholar in Bioethics in 2014 and an Emerging Leader in Health and Medicine at the National Academy of Medicine in 2017. Dr. Freedman investigates how reproductive healthcare is shaped by our medical institutions and social structures.
Melissa Gilliam, MD, MPH, is the Ellen H. Block Distinguished Service Professor of Health Justice and Vice Provost at the University of Chicago. Dr. Gilliam is the founder and director of the Center for Interdisciplinary Inquiry and Innovation in Sexual and Reproductive Health (Ci3), an interdisciplinary research center at the University of Chicago addressing the health of adolescents using technology, design, and narrative. She is also a
member of the National Academy of Medicine. Her clinical focus is in pediatric and adolescent gynecology.
Valerie Gutmann Koch, JD, is Assistant Professor and Co-Director of the Health Law and Policy Institute at the University of Houston Law Center and Director of Law and Ethics at the MacLean Center for Clinical Medical Ethics at the University of Chicago. After receiving her law degree at Harvard Law School, Professor Koch was the Special Advisor and Senior Attorney to the New York State Task Force on Life and the Law, the state’s bioethics commission. She has served as the Chair of the ABA’s Special Committee on Bioethics and the Law and as Co-Chair of the Law Affinity Group for the American Society for Bioethics and the Humanities.
Lisa H. Harris, MD, PhD, is the F. Wallace and Janet Jeffries Collegiate Professor of Reproductive Health, Professor of Obstetrics and Gynecology, and Professor of Women’s Studies at University of Michigan. After completing college and medical school at Harvard University, Dr. Harris completed obstetrics and gynecology residency at the University of California, San Francisco, and a PhD in American culture and women’s studies at the University of Michigan. Her clinical work encompasses abortion, miscarriage, and birth care. She is known for interdisciplinary approaches to scholarship, including work on abortion stigma, experiences of abortion caregivers, conscience in reproductive healthcare, women’s preferences for miscarriage management, and the social construction of assisted reproductive technologies. She serves as Associate Chair of her department and directs the University of Michigan’s Fellowship in Complex Family Planning.
Lee Hasselbacher, JD, is Senior Policy Researcher at the Center for Interdisciplinary Inquiry and Innovation in Sexual and Reproductive Health (Ci3) at the University of Chicago. Lee leads Ci3’s reproductive health policy research, collecting data and translating research to inform policy debates and legislation. Her research covers topics such as access to contraception and abortion, health insurance, religious refusals in healthcare, and consent and confidentiality for young people. Lee is a graduate of Northwestern Pritzker School of Law, where she focused on law and social policy, and the University of Wisconsin-Madison.
Timothy R. B. Johnson, MD, AM, FACOG, is Arthur F. Thurnau Professor of Obstetrics and Gynecology and Gender and Women’s Studies and a member of the Center for Bioethics and Social Sciences in Medicine at the University of Michigan. His academic and clinical interests include fetal assessment, prenatal care, medical education and human resource capacity building, global women’s health, reproductive justice, global health ethics, and assessment and prevention of sexual harassment in academic medicine. He has long been involved in international medical education and research, notably in Ghana, and is honorary Fellow of the West African College of Surgeons, the Ghana College of Physicians and Surgeons, and the Royal College of Obstetricians and Gynaecologists (London). He has received the Distinguished Service Award of the American College of Obstetricians and Gynecologists (ACOG), the Distinguished Merit Award of FIGO (International Federation of Gynecology and Obstetrics), and is an elected member of the US National Academy of Medicine.
Jhenifer Kliemchen Rodrigues, BSc, MSc, PhD, is Technical and Administrative Director at In Vitro Embriologia Clínica e Consultoria and Professor/Researcher at the Federal University, Minas Gerais, Brazil. Dr. Rodriques received her MS and PhD in biology of reproduction at the University of São Paulo and subsequently completed a postdoctoral fellowship in oncofertility at Oregon Health and Science University and a postdoctoral degree in molecular medicine at Federal University of Minas Gerais. She was a doctoral thesis winner of the CAPES Thesis Award, 2015 Edition, in the area of Medicine III and has published several scientific articles in this area. Dr. Rodriques is also a founding member of the Latin America Oncofertility Network and is a member of several medical societies, including the Brazilian Society for Reproductive Assistance (SBRA), the Brazilian Society for Human Reproduction (SBRH), Pronucleo, American Society for Reproductive Medicine (ASRM), and the European Society of Human Reproduction and Embryology (ESRHE). She has more than 16 years of experience in clinical embryology, research, and technical consultancy in reproductive medicine, having received merit certification in laboratory directorship, clinical embryology, and andrology by the Latin American Network for Assisted Reproduction (REDLARA).
Susan C. Klock, PhD, is a clinical psychologist specializing in the psychological aspects of assisted reproduction. She is Professor of Obstetrics and Gynecology and Psychiatry at Northwestern University’s Feinberg School of Medicine. She provides consultation and counseling to individuals undergoing assisted reproduction treatment. She is past Chair of the Mental Health Professional Group of the American Society for Reproductive Medicine. Her program of research focuses on the psychosocial aspects of third-party reproduction. She has authored more than 50 peer-reviewed and invited publications regarding the psychological aspects of assisted reproduction and is current Specialty Editor for Mental Health, Ethics, and Sexuality for Fertility and Sterility
Laurence B. McCullough, PhD, is Professor of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell at Lenox Hill Hospital in New York City and Distinguished Emeritus Professor in the Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas. After completing his doctorate in philosophy at the University of Texas at Austin, he was a Post-Doctoral Fellow at the Hastings Center. He has collaborated for 38 years with Dr. Frank A. Chervenak on ethics in obstetrics and gynecology, resulting in 286 peer-reviewed papers and three books. The most recent of these, co-authored with Dr. John H. Coverdale (Professor of Psychiatry and Medical Ethics, Baylor College of Medicine), Professional Ethics in Obstetrics and Gynecology, was published by Cambridge University Press in 2020.
Lynn M. Paltrow, JD, is the Founder and Executive Director of National Advocates for Pregnant Women. She is a graduate of Cornell University and New York University School of Law. Ms. Paltrow combines legal advocacy with grassroots and national organizing and policy work to secure the human and civil rights, health, and welfare of all people, focusing particularly on pregnant and parenting women and those who are most likely to be targeted for arrest and state control: women of color, low-income white women, and drug-using women. She has worked on numerous cases challenging restrictions on the right to choose abortion as well as cases opposing the prosecution of pregnant women seeking to continue their pregnancies to term. She is a frequent guest lecturer and writer for popular press, law reviews, and peer-reviewed journals.
Dorothy Roberts, JD, is the fourteenth Penn Integrates Knowledge Professor and George A. Weiss University Professor at the University of Pennsylvania, with joint appointments in the departments of Africana Studies and Sociology and the Law School, where she is the inaugural Raymond Pace and Sadie Tanner Mossell Alexander Professor of Civil Rights. She is also Founding Director of the Penn Program on Race, Science, and Society. Roberts has written and lectured extensively on law, public policy, and social justice issues related to reproductive freedom, child welfare, and bioethics. She is author of Killing the Black Body: Race, Reproduction, and the Meaning of Liberty (Pantheon, 1997/2017), Shattered Bonds: The Color of Child Welfare (Civitas, 2001), and Fatal Invention: How Science, Politics, and Big Business Re-create Race in the Twenty-First Century (New Press, 2011), and more than 100 scholarly articles and book chapters, as well as being co-editor of six books. Recent recognitions of her work include a 2019 election as a College of Physicians of Philadelphia Fellow, a 2017 election to the National Academy of Medicine, a 2016 Society of Family Planning Lifetime Achievement Award, a 2015 American Psychiatric Association Solomon Carter Fuller Award, and a 2011 election as a Hastings Center Fellow.
Heather E. Ross, JD, co-founded the law firm of Ross & Zuckerman, LLP, in 2005 to focus solely on legal issues surrounding assisted reproductive technology. Ms. Ross is a past chair to the Legal Professional Group of the American Society of Reproductive Medicine. She is also a member of the Academy of Adoption and Assisted Reproduction Attorneys, a professional member of Resolve, Family Equality Council, the LGBT Bar, and a committee member of the American Bar Association’s Assisted Reproductive Technology Committee. Ms. Ross has represented thousands of clients in gamete donation, embryo donation, and gestational surrogacy arrangements. She is a frequent lecturer and writer in the area of assisted reproductive technology (ART) law and has presented numerous CLE courses to attorneys, medical professionals, and law students practicing in this field. Heather is also a Village Trustee in her hometown of Northbrook, Illinois, where she lives with her spouse, and 3 teenage girls—all of whom are the successful outcome of ART.
Kayte Spector-Bagdady, JD, MBe, is Associate Director at the Center for Bioethics and Social Sciences in Medicine and Assistant Professor of
Obstetrics and Gynecology at the University of Michigan Medical School. Professor Spector received her JD and master’s degree in bioethics from the University of Pennsylvania Law School and School of Medicine, respectively, after graduating from Middlebury College. She served as Associate Director for President Obama’s Presidential Commission for the Study of Bioethical Issues. She is currently on the Board of Directors for the American Society for Bioethics and Humanities.
David A. Strauss, BA, BPhil (Oxon), JD, is the Gerald Ratner Distinguished Service Professor of Law and Faculty Director of the Supreme Court and Appellate Clinic at the University of Chicago Law School, where he teaches and writes about constitutional law and related subjects. He has been a visiting professor at Harvard and Georgetown. He is the author of The Living Constitution (Oxford University Press, 2010), and he is an editor of the Supreme Court Review. He is a member of the American Academy of Arts and Sciences. He has been Assistant Solicitor General of the United States and Special Counsel to the US Senate Committee on the Judiciary.
Debra Stulberg, MD, MAPP, is Associate Professor and Chair of Family Medicine at the University of Chicago. She joined the University of Chicago faculty in 2007, with a primary appointment in Family Medicine and secondary appointments in the Obstetrics and Gynecology Section of Family Planning and Contraceptive Research, and the MacLean Center for Clinical Medical Ethics. Dr. Stulberg graduated from Harvard Medical School and completed her Family Medicine residency at West Suburban Hospital in Oak Park, Illinois. She received an MA in public policy from the University of Chicago, where she also completed fellowship training in primary care research and clinical medical ethics. Her research focuses on reproductive health service delivery in the United States. This includes studies on incorporating reproductive health in primary care, addressing racial and socioeconomic disparities in pregnancy outcomes, and understanding how religious healthcare institutions affect care delivery. She directs the Reproductive Health Outcomes and Disparities (RHOADs) Research Group and codirects the Research Consortium on Religious Healthcare Institutions with co-author Lori Freedman. Dr. Stulberg provides patient care at a federally qualified health center on Chicago’s south side.
Amber Truehart, MD, MSc, is Assistant Professor of Obstetrics and Gynecology at the University of Chicago. She completed her fellowship in family planning at the University of Chicago in 2015. She then completed specialized training in pediatric and adolescent gynecology and, in 2018, she received a Focused Practice Designation in Pediatric and Adolescent Gynecology from the American Board of Obstetrics and Gynecology (ABOG). Her clinical work focuses on hormonal counseling and management in adolescents with complex medical conditions. Dr. Truehart also serves as a member of the American College of Obstetricians and Gynecologists’ Committee on Clinical Practice Guidelines–Gynecology.
Katie Watson, JD, is Associate Professor of Medical Social Sciences, Medical Education, and Obstetrics & Gynecology, and a Core Faculty Member of the Medical Humanities and Bioethics Graduate Program at Northwestern University's Feinberg School of Medicine (NU-FSM). Professor Watson is a graduate of NYU School of Law who clerked in the federal judiciary and worked in public interest law before completing Fellowships in Clinical Medical Ethics at the MacLean Center at the University of Chicago, and in Medical Humanities at NU-FSM. Her academic work focuses on women's health and reproductive ethics, and she is the author of Scarlet A: The Ethics, Law, and Politics of Ordinary Abortion (Oxford University Press, 2018). Professor Watson is currently on the National Abortion Federation Board of Directors, the National Medical Council of Planned Parenthood Federation of America, the Editorial Board of the AMA Journal of Ethics, and is a former Board member of the American Society for Bioethics and Humanities.
Teresa K. Woodruff, PhD, is Provost and Executive Vice President for Academic Affairs at Michigan State University. Prior to Michigan State, she was Thomas J. Watkins Professor of Obstetrics and Gynecology at the Feinberg School of Medicine, Director of the Center for Reproductive Science, Dean of the Graduate School at Northwestern University, and Founder and Director of the Oncofertility Consortium. She is an elected member of the National Academy of Medicine, American Academy of Arts and Science, National Academy of Inventors, and a recipient of a Guggenheim Fellowship.
Introduction
Julie Chor MD, MPH and Katie Watson JD
Like all clinicians, reproductive healthcare providers face specialty-specific ethical questions. However, the first editor of this book, Dr. Julie Chor (JC), an obstetrician-gynecologist who also completed a Complex Family Planning Fellowship, has never found an ethics text that is tailored to the needs of practicing clinicians, students, and trainees in reproductive healthcare. This is an unfortunate gap in the literature because whether reproductive health providers come from obstetrics and gynecology, family medicine, pediatrics, or another field, they all must be able to identify and analyze complex ethical issues that lie at the crossroads of patient decision-making, scientific advancement, political controversy, government regulation, and profound moral considerations in the context of continually evolving medical, legal, and societal factors. To fill this gap, Dr. Chor invited co-editor Professor Katie Watson (KW), a bioethics professor and lawyer who focuses on reproductive ethics, to partner in creating the text that she has always longed to use but has never found while practicing and teaching in this complex milieu. This book is a carefully curated compilation of essays inspired by a lecture series at the University of Chicago’s MacLean Center for Medical Ethics, where both JC and KW are former fellows, and JC is currently a faculty member. The essays are written by leading experts in the fields of ethics, medicine, law, and the social sciences addressing key issues in reproductive ethics. The book is organized into three sections: Contraception and Abortion Ethics: Preventing Pregnancy and Birth, Assisted Reproduction Ethics: Initiating Pregnancy, and Obstetric Ethics: Managing Pregnancy and Delivery. Each section begins with an overview by the editors that includes questions meant to inspire discussion about that section’s essays. To maximize this book’s usefulness to both trainees (including medical and nursing students, medical residents, and fellows) and experienced clinicians (including clinical ethicists, physicians, advanced practice nurses, nurse midwives, physician assistants, and social workers), we’ve kept the essays concise
and we’ve ensured they avoid the trap of “neon light ethics”—ethical analysis of shocking or extraordinarily complex cases that almost never arise in actual practice. Instead they follow the model of the MacLean Center itself, analyzing the clinical ethics questions that routinely arise in the day-to-day practice of reproductive healthcare while also raising the “big picture” bioethics implications of our practice patterns and choices.
The contemporary lens of reproductive justice informs our bioethics approach throughout the book.1 Reproductive justice connects people’s right to sexuality without procreation (Section I), their right to have a baby (Sections II and III), and their right to parent the children they have (a topic often outside the scope of medical practice but implicated by essays like Flavin and Paltrow’s analysis of breaking confidentiality to report pregnant patients to law enforcement). The reproductive justice framework also encourages us to focus on the needs and rights of the most marginalized. This approach is deserved as a matter of justice and, as a practical matter, it will typically also protect the needs and rights of those with higher incomes or more social capital. Justice is one of the traditional four principles of medical ethics analysis, and an emphasis on reproductive justice can make traditional principlism more robust by expanding it beyond the individual clinician–patient dyad and the snapshot of the clinical moment to include a longitudinal picture of the patient’s lived experience in their intersectional identity and those groups’ historical experience.
There are many frameworks for medical ethics, and advanced practitioners often find themselves consciously or unconsciously moving between them or combining them as situations seem to require. One foundational framework that explicitly or implicitly appears in numerous essays in this book (and is referenced in the preceding paragraph) is a framework of moral norms commonly referred to as “principlism” or the “four principles” framework, which was first described by Beauchamp and Childress in 1977.2 Therefore, the four principles of autonomy, beneficence, nonmaleficence, and justice warrant brief definition here for readers who may be unfamiliar with them. The principle of autonomy refers to respect and support for individuals’ ability and right to make and act on free, informed medical decisions.2 The principle of nonmaleficence, the obligation to not cause harm, is frequently paired with the principle of beneficence, the obligation to act to help others.2 The concept of justice encompasses the attempt to distribute benefits and burdens in a manner that is fair and equitable.2,3 Principlism does not rank any of these principles as more important than another. Instead, it encourages clinicians
to attend to each value, recognizing when they are in tension and balancing as possible or choosing as needed. When clinicians face scenarios that feel uncomfortable or ethically questionable for reasons that they are unable to clearly articulate, they should consider whether that is because two or more of these principles are in tension. Framing issues, problems, or questions in reproductive ethics through these principles often gives clinicians a way to parse their “gut reactions” to challenging encounters and to identify the root of a potential ethical conflict.
Books are divided in a way life often is not. We encourage readers to remember that the lines this book draws between preventing pregnancy, initiating pregnancy, and managing pregnancy can be crossed by the same individual, and many patients will be in each area more than once, bouncing between them from adolescence to menopause. They may also be dynamic in any one pregnancy: for example, a person who was initially trying to prevent pregnancy may choose to continue an unintended pregnancy, moving them from the prevention issue of Section I to the management issues of Section III, and, when faced with a diagnosis of fetal anomalies, that person might move back to the questions of pregnancy termination in Section I. This illustrates the need for specialists to maintain flexible mindsets across these phases— in the case just described, a maternal-fetal medicine (MFM) specialist must also be able to counsel like (and in some places, practice like) a family planning specialist. When a reproductive endocrinology and infertility (REI) specialist counsels someone seeking assistance getting pregnant (addressed in Section II), consideration of multiple embryo transfer requires them to look forward to the pregnancy management phase and think like an MFM. Or imagine a patient delivering by caesarian who wants a tubal ligation and is upset to learn that the fact that she is insured through Medicaid means she cannot have one because she did not consent 30 days before delivery. If she has attended prenatal care, this bad outcome may be the result of an obstetrician focused on delivery failing to also think like a family planning specialist and ask about her reproductive plans after this pregnancy and/or failing to provide care that is sensitive to her social context. (Medicaid requires advance consent for this family planning choice, and, because Medicaid covers some patients’ medical costs during pregnancy and delivery but not afterward, delivery might be her only opportunity to have a wanted tubal.)
This book is meant to be illustrative, not comprehensive. It is not possible to cover every ethically challenging situation that can arise in reproductive healthcare provision. Similarly, we centered this book on reproduction
