Mednotes

L7 Ethics Ethical issues of pregnancy _ birth

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tagsethics, lecture
aliasesL7 Ethics Ethical issues of pregnancy _ birth

11 min read

Overview

This lecture (the third of a four-part RDA ethics block) covers three linked topics: the everyday ethical tension around lifestyle advice and risk during pregnancy, four conceptual models used to think about the moral status of the pregnant person and fetus (and the real-world legal cases that turn on them), and the application of the Code of Health and Disability Services Consumers’ Rights (specifically Rights 5, 6 and 7) to pregnancy and birth care.

Reproductive Ethics and Patient Rights

Reproductive ethics covers the ethical or moral issues that arise in contraception, sterilisation, abortion, assisted reproductive technologies, pregnancy and birth. Reproduction is biological, technological, deeply personal, sometimes spiritual, heavily socially regulated and interpersonal, and is an area where ethics, law, politics, science and religion interact and influence one another.

The historical evolution of reproductive rights concepts, in order:

  1. Right Not to Reproduce - challenging bans on contraception and abortion.
  2. Right to Reproduce - challenging forced sterilisation.
  3. Reproductive Autonomy - the right to decide whether to get pregnant, stay pregnant, be sterilised, and other birth/fertility decisions.
  4. Procreative Liberty - challenging legal/practice barriers to assisted reproductive technologies (ART), e.g. barriers based on sexual orientation, marital status, age, or the technology itself.
  5. Reproductive Justice - the right to have children, to not have children, to parent existing children, and to the enabling conditions for these rights; centres people marginalised by existing frameworks.

Reproductive Autonomy and Procreative Liberty are highlighted as the current focus of legal protections.

Risks and Lifestyle Changes During Pregnancy and Childbirth

  • Intention-behaviour gap: health-behaviour intentions (e.g. eating better, being more active) are frequently not enacted; research indicates intentions are translated into action only about half the time (Sheeran & Webb, 2016), which is directly relevant to pregnancy lifestyle-change advice.
  • Food safety: foods to avoid and why - raw seafood (parasites/bacteria), unpasteurised juice/cider/milk (E. coli, Listeria), soft cheese from unpasteurised milk (E. coli, Listeria), undercooked eggs (Salmonella), premade deli salads (Listeria), raw sprouts (E. coli, Salmonella, Campylobacter), cold hot dogs/luncheon meats (Listeria), undercooked meat/poultry (Toxoplasma gondii). Safe cooking temperatures: 145°F for beef/pork/veal/lamb steaks, roasts, chops (3 min rest) and fish; 160°F for egg dishes and ground beef/pork/veal/lamb; 165°F for whole/ground/pieces of chicken, turkey, duck. General rules: clean hands/surfaces, separate raw meat from ready-to-eat food, cook to safe temperature, refrigerate leftovers within 2 hours.
    • Pregnant people are 10x more likely to get listeriosis, which can cause miscarriage, premature labour, low birth weight or infant death.
    • About 50% of toxoplasmosis infections (US) are food-acquired; toxoplasmosis can cause hearing loss, blindness, intellectual disability and brain/eye problems in the child later in life.
  • Caffeine: recommended limit is under 200mg/day.
  • Official lifestyle guidance (NZ health websites) covers immunisations, antenatal classes, exercise, nutrition, morning sickness, medicines in pregnancy, multiple pregnancy, pre-eclampsia, supplements, perineal massage, fetal development, becoming smoke-free, alcohol and drug use, finding a midwife, mental health/self-care, antenatal depression, tests and appointments, relationships, and support for young or whānau-supporting pregnant people.
  • Smoking: raises risk of miscarriage/stillbirth, premature birth, low birth weight, infant pneumonia/asthma/glue ear, and sudden infant death after birth. Quitline: 0800 778 778.
  • Vaping: being nicotine-free is best; vaping is less harmful than smoking but not harmless.
  • Alcohol/drug support: Alcohol Drug Helpline 0800 787 797 (free text 8681), available 24 hours.
  • Smoking prevalence in pregnancy: 4.2%-18.9%, highest in Eastern European countries. Women with fewer resources are more likely to continue smoking during pregnancy: living alone, high school or less education, low health literacy, being a housewife, having previous children, having an unplanned pregnancy, and not using folic acid.

    Transcript flag: the "prevalence" and "implications for antenatal care" text boxes on this slide overlapped on the page and were reconstructed by cross-checking against the raw extracted text, not read cleanly off the image.

    • Implications for antenatal care: knowing which groups are high-risk is essential for designing prevention/intervention; providers should be aware of this group; effective cessation interventions exist, but the context of women’s lives makes quitting and staying quit difficult.
  • Maternal requests against medical advice (Dutch midwives study): most frequent requests were declining gestational diabetes testing (66.3%), opting for home birth despite a high-risk pregnancy (65.3%), and declining fetal monitoring in labour (39.6%). Most hospital staff receive at least one request for an elective caesarean section per year. Requests for more care and for less care than indicated are equally prevalent. Counselling a patient who disagrees with their care provider takes time; where a patient requests less care, “second best care” should be considered.

Conceptual Models of Pregnancy and Patient Rights

Four conceptual models describe the relationship between the pregnant person and the fetus:

  • Container Model: the pregnant body is treated as a vessel/container holding the fetus (historically illustrated by “homunculus” imagery).
  • Dual Patient Model: the pregnant patient and the fetus are treated as two separate patients (illustrated by ultrasound scanning of the fetus as a distinct subject).
  • Relational Model: the pregnant person and fetus are connected but distinct, like a person and something they carry with them (canoe-paddling analogy).
  • Parthood Model: asks whether the fetus is part of the pregnant person or a separate, contained entity (“bun or bump?”).

Real-world cases illustrating how these models cash out legally and clinically:

  • NZ newspaper case (1997): police considered applying to the courts to commit a pregnant teenager who abused solvents and alcohol to a safe house to protect her unborn child, under the Alcoholism and Drug Addiction Act 1966. Her first child had already been removed by CYFS at birth after severe withdrawal symptoms. A precedent existed from 1995, where a pregnant 15-year-old solvent abuser in a violent relationship was made a ward of the court with her own consent, enabling her to be moved to a safe environment until the birth.

    Transcript flag: a handwritten/printed vertical label beside the clipping (reading approximately "OOT.") is not legible and its meaning is not explained on the slide.

  • US Fetal Personhood and court-ordered caesareans: the link between fetal personhood and court-ordered C-sections dates to the 1980s, when courts began ruling hospitals could override a patient’s decision in favour of fetal health. In 1986 Minnesota became the first US state to recognise fetuses as victims in homicide cases. Some states have imprisoned pregnant women for exposing a fetus to drugs. Nearly 30 states allow hospitals to invalidate a pregnant patient’s advance directive. Alabama extended personhood to the earliest stages of fertilisation/conception, giving frozen embryos the same legal status as children, though this was later said to be unenforceable by the Legislature. (Case example: Cherise Doyley, whose hospital sought an emergency hearing in 2024 to force a C-section during her labour.)
  • A further case example, a stillbirth that was prosecuted as a crime (NYT opinion piece “How My Stillbirth Became a Crime”), illustrating criminalisation of a pregnancy outcome.

Code of Health and Disability Services Consumers’ Rights

Recap of three Rights (previously taught, applied here to pregnancy/birth):

  • Right 5 - right to effective communication.
  • Right 6 - right to be fully informed.
  • Right 7 - right to make an informed choice and give informed consent, including the right to refuse and to withdraw consent.

Worked HDC case: a patient had a traumatic emergency caesarean section 18 months prior. The caesarean had been planned because the baby was believed to be in a breech position; her partner was given leave from prison to attend the birth. The breech position was not re-checked before the caesarean was performed, and the baby was found to be head down at the time of surgery (i.e. not actually breech). Findings: breach of Right 6 (the breech position, the primary basis for the earlier consent to caesarean, was not checked) and breach of Right 7 (the necessary consent for the procedure actually performed was not obtained).

Self-test

  1. Give the four-part description of what reproductive ethics covers.
  2. Describe, in order, the five stages in the historical evolution of reproductive rights concepts.
  3. What does the intention-behaviour gap research say about the proportion of health-behaviour intentions that get enacted, and why is this relevant to pregnancy?
  4. List four foods pregnant people are advised to avoid and, for each, the pathogen of concern.
  5. Why are Listeria and Toxoplasma gondii singled out as particular risks in pregnancy? Give one specific harm caused by each.
  6. What is the recommended daily caffeine limit during pregnancy?
  7. Describe the specific health risks to the baby associated with smoking during pregnancy.
  8. Which groups of pregnant women were found to be more likely to continue smoking during pregnancy?
  9. In the Dutch midwives study, what were the three most frequent maternal requests that went against medical advice, and how common was each?
  10. Distinguish the container model of pregnancy from the dual patient model.
  11. Distinguish the relational model of pregnancy from the parthood model.
  12. Describe how the concept of fetal personhood has been used in US law since the 1980s to justify overriding pregnant patients’ decisions, with one specific legal example.
  13. In the HDC case discussed, which two Rights were breached, and what specifically was the failure in each?
  14. Integrative: a pregnant patient requests to decline fetal monitoring during labour, against her midwife’s advice. Using Right 7 and the “second best care” concept from the maternal-requests study, describe how her care team should approach this request.

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