We thank Dr Derham for his comments on rights-based reductionism, to which we have offered the antidote of professional responsibility as the basis for ethics in obstetrics and gynaecology and its clinical application to ‘lethal’ fetal anomalies. The professional responsibility model takes as fundamental the obstetrician–gynaecologist's fiduciary obligation to protect and promote the health-related interests of female patients in gynaecological practice and of pregnant, fetal, and neonatal patients in obstetrics. In the technical language of bioethics, in the professional responsibility model the physician's fundamental obligations to patients are beneficence-based.
The professional responsibility model does not exclude rights, as Dr Derham appears to suggest. Rights are justified claims that an individual makes against another individual, organisation, or the state to be treated in specified ways. People with the capacity to make their own healthcare decisions have the right to be informed about the medically reasonable alternatives (those supported in beneficence-based clinical judgement) for the management of their condition, disease, or injury, along with the benefits and risks of each. Empowering the exercise of decision-making rights is one of the components of the professional responsibility model. The rights of patients with decision-making capacity are not in question in the professional responsibility model. The problem is that not all patients have rights, severely limiting the clinical utility of rights-based reductionism. The ethical concept of being a patient is clinically comprehensive: when a human being presented to a physician or other healthcare professional and there exist clinical interventions that are reliably expected to benefit from such interventions (a beneficence-based concept), that human being becomes a patient.
Dr Derham invokes the discourse of human rights, which was invented in the middle of the twentieth century. Advocates of human rights understood that at that time—and still today—basing rights on the capacity to originate rights is controversial and therefore more likely to divide than to unite people in a global effort to assert and expand the scope of human rights. That Dr Derham is able to take for granted the moral and political force of the discourse of human rights is testimony to the success of the visionary pioneers of the last century. However, it is crucial to understand that human rights are justified claims against predatory state power, of which torture is among the most heinous forms. As fiduciaries of patients, physicians have the professional responsibility to protect patients. Physicians committed to the professional responsibility model are not predators on their patients, a profound difference between the ethics of state power and professional medical ethics that Dr Derham does not acknowledge. As a consequence, while rights-based reductionism—much better cast as advocacy for human rights—is entirely appropriate as a check on predatory state power, it has no place in the professional ethics and practice of obstetrics and gynaecology.