Authors' Reply


We thank Dr Paintin for his letter on the professional responsibility model of obstetric ethics.[1, 2] He is correct that we argue that abortion is not ethically permitted, and therefore is unprofessional when performed for such anomalies as achondroplasia or trisomy 21 late in pregnancy. He is not correct, however, when he infers that the law is determinative of appropriate professional judgment and behaviour regarding termination of pregnancy. The law stipulates what is permissible, but, within the bounds of the legally permissible, the law is silent. Responsible clinical judgment should fill the silence and guide obstetricians, based on professional obstetric ethics and one of its core concepts, the fetus as a patient.[3] The logic of this concept is that both the obstetrician and the pregnant woman have beneficence-based obligations to protect the health and life of the fetal patient. The obstetrician's beneficence-based obligations to the fetal patient in all cases must be balanced against beneficence-based and autonomy-based obligations to the pregnant patient. The pregnant patient is ethically obligated to take reasonable risks to herself in order to fulfill her beneficence-based obligations to the fetal patient. By contrast, for Dr Paintin the only thing that matters is implementing the preferences of the pregnant woman about the management of her pregnancy, no matter how well or poorly informed, or how clinically detrimental, her preferred management is for her health or life, or for the health or life of the fetal patient. Dr Paintin's avowed rights-based reductionism simply sweeps aside these ethically crucial considerations, and with them professional integrity in obstetric practice. The result of rights-based reductionism is not benign: obstetricians are deprofessionalised and become enablers of collateral damage to fetal patients from a blind adherence to patients' preferences. If this is what current law is interpreted to require in the UK, then we join with Dickens’ Mr Bumble to declare that ‘the law is a ass’ and should be changed to support professionalism in obstetric practice and not undermine it. The great English physician-ethicist, Thomas Percival (1740–1804), emphasised that professional medical ethics should be autonomous from the law and state power.[4] An autonomous professional obstetric ethics, unlike Dr Paintin's rights-based reductionism, does not give unquestioning acquiescence to the law.


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  2. References
  • 1
    Paintin D. Fatally flawed?. BJOG 2013;120:371.
  • 2
    Chervenak FA, McCullough LB, Brent RL. The professional responsibility model of obstetric ethics: avoiding the perils of clashing rights. Am J Obstet Gynecol 2011;205:315.e15.
  • 3
    McCullough LB, Chervenak FA. Ethics in Obstetrics and Gynecology. New York: Oxford University Press, 1994.
  • 4
    Percival T. Medical Ethics, or a Code of Institutes and Precepts, Adapted to the Professional Conduct of Physicians and Surgeons. London: Russell and Johnson, 1803. In: Pellegrino ED, editor. The Classics of Medicine Library. Birmingham, AL: Gryphon Editions; 1985.