This chapter provides an ethical framework to guide decision making about periviable birth.

Viability in professional ethics in obstetrics and gynecology is a function of both fetal physiology and available resuscitation and life-sustaining treatment. Viability is therefore the biological capacity of a live-born infant to survive even if full technological support is needed. This is the concept of viability used by the United States Supreme Court in its landmark ruling, Roe v. Wade, in 1973.

This chapter provides an ethical framework for decision making about initiation of pregnancy.

Obstetrician-gynecologists play two important roles in the initiation of pregnancy. The first is the medically assisted initiation of pregnancy, usually to manage infertility in the female patient or her partner or both. The second is preconception counseling to anticipate and prevent ethical challenges in assisted initiation of pregnancy.

This chapter provides guidance on deliberative clinical judgment and decision making about preventing pregnancy in professional ethics in gynecology.

The biologic concept of sex is an essential component of the biologic concept of fertility. It is used to categorize human beings according to reproductive role: only the capacity to produce gametes, or the capacity to produce gametes and initiate a pregnancy. Sex was once thought to be dimorphic, but modern genomics of chromosomes has abandoned dimorphism for a concept of biologic sex as ranging along a continuum between these two productive roles. In other words, like all other human traits, biologic sex displays variation.

This chapter provides an introduction to professional ethics in obstetrics and gynecology based on the ethical concept of medicine as a profession and the ethical concepts of the female patient, pregnant patient, and fetal patient. There is also an introduction to professional ethics in perinatal medicine.

This chapter provides an ethical framework for offering, recommending, performing, and referring for induced abortion and feticide.

Counseling pregnant women about induced abortion and feticide presents the obstetrician with a distinct set of challenges., The American Medical Association and the American College of Obstetricians and Gynecologists have provided general guidance. Based on the ethical principles of beneficence and respect for autonomy in professional ethics in obstetrics and gynecology (see Chapter 2), this chapter provides practical, clinically comprehensive ethical guidance on when to offer, recommend, perform, and refer for abortion and feticide.

This chapter provides an ethical framework to guide decision making about fetal analysis.

The ethical principle of respect for autonomy in professional ethics in obstetrics creates the obstetrician’s prima facie ethical obligation to empower the pregnant patient to make informed and voluntary decisions about obstetric management. This ethical obligation has two components. The first is providing her with clinical information about options for fetal analysis using nomenclature that is precise.

This chapter provides an ethical framework for setting justified limits on life-sustaining treatment.

Sometimes a patient’s condition has deteriorated to such a degree that in deliberative clinical judgment the prediction of imminent death becomes reliable. When death is imminent patients are transferred to a critical care unit in which they receive life-sustaining treatment. Life-sustaining treatment deploys a range of interventions, including physical intervention such as cardiopulmonary resuscitation; intravenous administration of drugs, fluids, and nutrition; and mechanical devices such as circulation devices, extracorporeal membrane oxygenation, dialysis, and ventilators. These interventions are designed to support or replace organ functions in the absence of which the risk of mortality will rapidly approach 100%.

This chapter provides an ethical framework to guide decision making about intrapartum management.

Most women deliver their babies vaginally. Vaginal delivery is clearly safer for the pregnant patient because no invasive clinical management is involved, even when fetal monitoring takes place. This clinical reality makes assisting vaginal delivery the default in clinical judgment, placing the burden of proof on justifying cesarean delivery. As a consequence, in traditional obstetric thinking, cesarean delivery is either indicated – the burden of proof is met – or nonindicated – the burden of proof is not met. When cesarean delivery is indicated, it should be recommended. When cesarean delivery is not indicated, it should not be offered, much less recommended.

This chapter provides an ethical framework for the identification and responsible management of conflicts of interest and conflicts of commitment.

The professionally responsible management of conflicts of interest and conflicts of commitment is essential for sustaining the three commitments of the ethical concept of medicine as a profession (see Chapter 1) and therefore for professional integrity.

This chapter provides an ethical framework for responding to an expectation of having a perfect baby.

Patients sometimes present to their physicians requests for diagnostic tests and treatments, sometimes invasive tests and treatments. This is especially the case in obstetric practice. The prevalence with which pregnant women make requests of their obstetricians varies in different populations of pregnant women. However, obstetricians are familiar with – and are often challenged by – requests for diagnostic tests and for specific interventions, such as the detailed birth plans that some pregnant women present. These requests for clinical management reflect the values and priorities of pregnant patients and therefore should be taken seriously.

This chapter provides an ethical framework to guide clinical innovation and research in obstetrics and gynecology.

Improving the quality of obstetric and gynecologic care depends on clinical innovation and research. Innovation and research are both experimentation. An experiment occurs when in deliberative clinical judgment the outcomes of a clinical intervention cannot be reliably predicted.

This chapter provides a historical and philosophical introduction to professional ethics in medicine, based on the ethical concept of medicine as a profession.

In this book we provide an historical, philosophical, clinically comprehensive, and practical account of professional ethics in obstetrics and gynecology. The goal of professional ethics in obstetrics and gynecology is to identify what is ethically permissible, ethically obligatory, ethically impermissible, and ethically ideal in patient care, clinical innovation and research, organizational culture, and health policy and advocacy concerning female, pregnant, and fetal patients.