The Physician's Moral Obligations to the Pregnant Woman, the Fetus, and the Child Alan R. Fleischman, Frank A. Chervenak, and Laurence B. McCullough The moral obligations and ethical duties of health care professionals responsible for the care of a pregnant woman, a fetus, and a child are complex and evolve with gestation and birth. Well-inten- tioned physicians and others concerned with the interests of pregnant women and their fetuses may disagree about the moral status of the fetus and the ethical duties owed to both the woman and fetus. This article lays out a framework for thinking about these issues from several perspectives. Copyright 9 1998 by W.B. Saunders Company M any physicians and other health care pro- fessionals participate in the care of a preg- nant woman, monitor the process of growth and development of her fetus, and facilitate the deliv- ery and early care of the newborn. What are the moral obligations of these health care providers to the pregnant woman, the fetus, and the child? Do these professional ethical duties change and evolve over the duration of the gestation and after birth? In addition, what are the moral obli- gations of the pregnant woman herself to the developing fetus, and do these duties change after the birth of her child? Many questions have been raised in the litera- ture on the ethics of maternal-fetal medicine and neonatology concerning the obligations of a phy- sician to a pregnant woman, obligations of a phy- sician and pregnant woman to a fetus, and obli- gations of a physician and new parents to a child. We will develop, in this introductory essay to this issue of Seminars in Perinatology on Ethical Issues in Perinatal Medicine, tentative answers to these questions in an attempt to help all providers of perinatal care to understand these complex is- sues and to reinforce the importance of thinking about the process of gestation and birth as hav- ing evolving moral obligations. The Physician's Moral Obligations to the Pregnant Woman The physician has two sorts of moral obligations to the pregnant woman. The first of these obliga- From the New York Academy of Medicine, the Department of Obstet- rics and Gynecology, New York Hospital-Cornell Medical Center, New York, NY, and the Center for Medical Ethics and Public Issues, Baylor College of Medicine, Houston, TX. Address reprint requests to Alan tL Fleischman, MD, the New York Academy of Medicine, 1216Fifth Ave, New York, N Y 10029-5293. Copyright 9 1998 by W.B. Saunders Company O146-0005/98/2203-0002508. 00/0 tions is based on the physician's duty to act in a way that protects and promotes the clinical or health-related interests of the pregnant woman. To identify these obligations, the physician should form rigorous clinical judgments about which clinical management strategies will result in the greatest balance of health-related good over health-related harm to the woman. In the language of ethics, these are known as benefi- cence-based obligations of the physician to the woman. 1 The second type of physician obligation to the pregnant woman, related to but distinct from the first type, is based on the physician's obliga- tion to act in a way that protects and promotes the woman's interests as she defines them in terms of what is important to her and what she values in her life, past, present, and future. The pregnant woman, like any other person, will de- fine her interests in terms of her health and life, but also on the basis of other domains of impor- tance, eg, the number of children she wishes to bear and rear, whether to be or remain married, and what she wishes to achieve in her occupa- tion. She is under no requirement to give the same weight to her health-related concerns as her physician does. Indeed, these may be the lesser or even the least important of her con- cerns. To fulfill this obligation, the physician should provide the pregnant woman with an adequate amount of information about her diagnosis and the reasonable medical alternatives that can be used to manage her clinical problems, as well as information about the alternative of noninter- vention; elicit her values and preferences; and, unless there are very compelling reasons to the contrary, implement her wishes. In the language of ethics, these are known as autonomy-based obligations. 1 184 Seminars in Perinatology, Vol 22, No 3 (June), 1998: pp 184-188