ethical and legal issues

1. ETHICAL AND
LEGAL ISSUES IN
MIDWIFERY AND
OBSTETRICS

2. ETHICAL AND LEGAL ISSUES IN
MIDWIFERY AND OBSTETRICS
• Maternal issues
• Foetal issues
• Other issues

3. Maternal issues Fetal issues Other issues
Surrogacy Sex determination Men in labour
Egg donation Female foeticide Family planning
ART Foetal tissue research Colostrum feeding
Abortion Eugenics and gene
manipulation
Trans sexualism
Informed consent Preterm and high-risk
neonate treatment
Hymen reconstruction
Prenatal screening Cord blood banking Mutilation
IVF Embryonic stem cell
research
Eugenics and gene
manipulation

4. Maternal issues

5. Surrogacy
• A surrogate mother is someone who
gestates (conceives and carries within
the uterus) and then gives birth to a child
for another person, with the full intention
of handing the child over to that person
after the birth.

6. Need of surrogacy
• A woman is unable to become pregnant as she has had a
hysterectomy or is missing part of her uterus, uterine lining,
ovaries or other parts of the genital tract.
• A woman may have a health condition which makes pregnancy
dangerous or she may not be able to carry a baby to term.
• A couple in a male same-sex relationship may wish to have a
child using their sperm.
• A man may wish to have a child but have no partner.
• A woman, who has embryos in storage with her male partner,
dies and the male wishes to use the embryos to have a child.

7. The argument against surrogacy
• What happens if the surrogate mother or commissioning person
or couple changes their mind?
• What happens in the case of miscarriage or multiple births?
• What happens if the child has serious disabilities?
• What are the rights of the child?
• Should payment be involved?

8. Other key issues
• Paternity and maternity rights
• Guardianship
• Custody and access
• Maintenance and financial support.

9. Ethical issues
1. What are the pros and cons of using unused embryos for
medical research?
2. Is there anything wrong with disposal of unused embryos
leaving them on the counter to unthaw and degenerate?
3. What if the surrogate decides to maintain her privacy?
4. What if the surrogate and the spouse violate the abstention
clause?
5. What if the surrogate decides to keep the baby?
6. What if the surrogate with genetic ties demands to visit her
child?

10. Cont…
7. Is there anything wrong with a surrogate giving her unused
embryos to someone else?
8. Who should make a decision to unthaw frozen embryos
9. Is handing over a child after delivery for a fee "baby selling"?
10.Do women participate in surrogacy to save the marriage?
11. Is it wrong for a surrogate to abort?

11. Egg donation
• Egg donation may be used
successfully in treatment of
multiple causes of infertility,
as well as some genet
diseases

12. Egg donation is usually used in the
following clinical situations:
• Patient is either in menopause or early menopause and is
unable to produce her own eggs.
• Patient with absent ovaries.
• Patient at risk of passing on a genetic disease which may not
be prevented through pre-implantation genetic diagnosis.
• Patient who has had multiple prior in vitro fertilization failures.
• Same gender couples who wish to become parent

13. Points about egg donation
• An egg donor may be anonymous or known
• Anonymous egg donors a typically women younger than age 30.
• They would agree to undergo a cycle of hormonal ovarian stimulation and
egg retrieval.
• Known donors are either family members or friends of the prospective
parents.
• The expert team at Reproductive Fertility Centre is dedicated to help
patients find and match an egg donor of the process, providing medical
advice, emotional legal guidance and financial assistance.

14. Artificial
Reproductive
Techniques
(ART)

15. 3. Artificial Reproductive Techniques
(ART)
• Artificial Insemination
• Insemination of the wife with her husband's sperm
• Artificial inseminations of the women with a donor's sperm.

16. AID (Artificial insemination of the donors)
In male infertility and genetic problems
• Is the child conceived illegitimate?
• Does AID constitute criminal adultery that could lead to divorce
on those grounds?
• Could the donor be held liable for rape if the women devices
she gave consent?

17. Invitro fertilisation
• In 1978 step toe's work resulted in the first successful live births
in which this method of conception was employed.

18. Invitro fertilisation
• The developing eggs could be discarded at 14 days or less after
fertilization, since normal uterine implantation would have occurred
by that time.
• If the child conceived by this method is born with physical or mental
handicap.
• The issue of IVF is certainly legally, morally and ethically significant.

19. CONT…
As the use of this technique proliferates questions will probably
increase
• 1. With IVF the ovum is fertilized outside the body and then
implanted into the uterus.
• 2. Between 15 and 20 embryos may results from a single
fertilisation effort
• 3.Only 3 to 5 of these are implanted in the woman's uterus.
• 4. Ethical questions may arise what to do with the remaining
embryos.
• 5. Although the procedure has allowed infertile couples to have
children some are concerned that it is unnatural.

20. ABORTION

21. Abortion
• Ethical consideration
From an ethical perspective, abortion is essentially the
removal of woman's support from the fetus, leading to the fetal
death.
• Camenish (1976) point of view that one does not have the right
to inflict the pain and tragic consequences of certain detectable
serious disease on an innocent infant

22. Social issues
Sex-selective abortion and female infanticide
• Targeted termination of female fetuses.
• 1970s and '80s, led to advertisements for services which read, "Invest
500 rupees [for a sex test] now, save 50,000 rupees [for a dowry]
later." In 1991, the male-to-female sex ratio in India was skewed from
its biological norm of 105 to 100, to an average of 108 to 100.
• Researchers have asserted that between 1985 and 2005 as many as
10 million female fetuses may have been selectively aborted.
• The Indian government passed an official ban of pre-natal sex
screening in 1994 and moved to pass a complete ban of sex-selective
abortion in 2002.

23. Ethical issues
• During the first trimester, the state cannot bar anywhere women from obtaining
an abortion from a licensed physician
• In the second trimester, the state can regulate the performance of an
abortion if such regulation relates to protection of the women's health.
• In 3rd trimester, the state can regulate and even prohibit abortions, except
those deemed necessary to protect the woman's life and health and the
state may impose safeguards for the fetus

24. Ethics and medico-legal aspects of obstetric
anaesthesia and informed consent
• Before treatment, diagnostic procedures or experimental therapy a
patient must be informed of the reasons of the treatment as well as
the possible adverse effects and alternative treatments.
• The physician must obtain signed consent.
• The nurse must ensure that signed consent is in the patients chart
before the procedure is performed

25. Prenatal screening

26. Prenatal screening
• Can detect the inherited and congenital abnormalities long
before birth.
• Early diagnosis may allow repair of an anomaly in the utero.
• May force a patient to choose between having an abortion and
assuming the emotional and financial burden of the raising a
severely disabled child.
• Some feel that the risk it poses to the fetus creates a conflict
between the rights of fetus and the right of the parent to know
the foetal health status.

27. Amniocentesis
• The mother must be informed of the risk and benefits of the
procedure when she is asked to sign the consent form.
• Physicians are accountable for the reports of amniocentesis.

28. Other prenatal diagnosis
• b. Other developing techniques to help obtain information about
the fetus include fetoscopy, amnioscopy and chorionic villi
sampling.
• PROBLEMS ARE ,
Accuracy in performing tests
Appropriate actions after the results are known and
confidentiality regarding the results are important legal precepts
relating to prenatal diagnosis.

29. Sexual counselling
• Should be done by trained sexuality: counsellors who are skilled
in helping people with sexual problems.
• Sexual matters have the right to privacy and confidentiality

30. Sterilization
• Most sterilizations operations are elective.
• Informed consent: - the expectations given to obtain this
consent explain the major alternatives to sterilization including
the must principal benefits and risks involved.

31. Genetic counselling
• Before genetic counseling accurate diagnosis must be done.
• Complete accuracy in genetic counselling is of paramount
importance, and therefore nurses who are not trained in genetic
counselling risk legal consequences if they choose to do
genetic counselling without appropriate training.
• Patients who receive genetic counselling have a right to privacy
concerning their matters.
• The parents may be unwilling to inform their relatives because
of guilt or embarrassment

32. Home births
• Many health professionals are reluctant to attend home births
because they fear a malpractice action if problem arises.

33. Ethical and legal issues in prenatal and labour care

34. Fetal monitors
• Fetal monitors – during labour
• The nurse is responsible for applying the monitoring equipments,
assessing and tracing for signs of possible complications.
• If an alarm system – if any changes

35. During labour and delivery
• Anaesthetics
General anaesthetic risks -promptly cross the placenta.
General anaesthesia depressant effects on the infants.

36. Maternal complication
• A women should not be left unattended during labor and frequent
physical assessment of her condition should be made and recorded
by the nurse.
• If any signs are detected informed to physician.

37. Still born infants
• When the infant is born dead, the events surrounding the delivery
must be carefully documented.
• Legal problems may arise when proper procedures are not followed.
when an infant is born dead there must be careful documentation of
the events surrounding the delivery.
• Examined for congenital anomalies by means of x-ray and laboratory
studies.
• Chromosomal anomalies studies.
• Genetic counselling.

38. Neonatal complications
• Careful identification of infant is required.
• For legal purposes, it is important that the infant be identified as
quickly as possible preferably in the presence of mother.

39. Ethical issues in neonatal care and
resuscitation
• Questions about the ethical issues in neonatal care are as follows:
1. "Who deserves access to prenatal and neonatal specialty care?"
2. "Who pays for this care?“
3. "Are the costs of neonatal intensive care acceptable?“
4. "How can this care be assured and equitably distributed?"
5. "Are some babies too sick or too premature for newborn intensive
care?“
6. "What outcomes of neonatal intensive care are too burdensome?"
7. "Who decides whether an infant receives care?"
8. "How are these decisions made?"

40. FETAL ISSUES

41. Fetal research
• Fetal research is a criminal offense and states that fetal research have
placed many constraints on this activity.
• Right to get consent. It should be the health needs of the fetus.
• Fetal therapy: Women refuses to do fetal therapy because of moral
obligations fetus abuse, rejection of the therapy.

42. Fetal tissue research
• Fetal tissue has facilitated the scientific research for Parkinson's
disease, Alzheimer's disease, diabetes and other degenerative
disorders.
• Transplanted fetal nerve cells helps to generate new cells in a patient
that somehow reduces the symptoms.
• Immaturity of the fetal immune system reduces the chances of
recipient rejecting the tissue.

43. Eugenics and gene manipulation
• Gene therapy can prevent and manage different disorders.
• Researchers can learn the sex of the fetus and whether it suffers from
certain serious medical conditions.
• Questions arise surrounding the ability to create designer babies leading to
perfect population.
• Genetic testing facilities the identification of fetus with such disorders as
Down syndrome and Tay Sachs disease.
• The screening of the neonates for the phenylketonuria is legally required in
most states.
• Gene therapy using DNA can be used to increase or decrease the activity of
a gene in the body or to introduce a new gene into the body.

44. Preterm and high risk neonate treatment
• Medical advances have improved the survival rates for high risk
neonates.
• Some are concerned about the physical, psychosocial and
economic costs.

45. Cord blood banking
• Leukemia, certain other cancers and immune and blood system
disorders.
• cord blood is like bone marrow and embryonic tissue contains
regenerative stem cells which can replace the diseased cells in the
affected individual.
• Cord blood has numerous advantages over bone marrow:
Collecting involves no risk to the mother or new born.
Cord blood is less likely than bone marrow to trigger potentially
fetal rejection response.
Cord blood works with a less than perfect match. Cord blood is
available for use more rapidly than bone marrow.

46. Ethical issues
1. Who owns the blood? The donor? The parents? Private blood
bank society?
2. How will informed consent be obtained and by whom?
3. How will the confidentiality be ensured?
4. How will the obligations to notify the family and donor be
addressed if testing of blood reveals infectious disease or genetic
disorders?
5. How will the harvested blood be allocated to ensure fairness
and availability to individuals from all races, ethnic groups, and
income levels?

47. Female foeticide
• In India, the available legislation for prevention of sex determination needs
strict implementation, alongside the launching of programmes aimed at
altering attitudes, including those prevalent in the medical profession.
• between 35 and 40 million girls and women are missing from the Indian
population. In some parts of the country, the sex ratio of girls to boys has
dropped to less than 800:1,000. The United Nations has expressed serious
concern about the situation

48. The Human Genome Project
• It is an international multi disciplinary effort to explore and map all
human genetic material.
• Mapping the human genome is the first step in the process o
attempting to understand the nature of hereditary diseases and finding
the ways to identify the individual who are risk of transmitting the given
disease.
• ISSUES
Payment for genetic testing
Appropriate counseling following testing
Confidentiality
Qualification of individuals engaged in testing and counselling

49. OTHER ISSUES

50. Colustrum feeding
• Shortly after birth and preferably before the first feeding, a small
piece of softened date is rubbed on the newborn's palate. The
infant's parent or a respected family member usually performs
this ritual
• An important aspect in breastfeeding in some cultures is the
mother's emphasis on privacy and modesty when
breastfeeding.
• Someone belief that there are parts of the body of men and
women that must be covered at all times in front of those who
are not close family members.

51. OTHER ISSUES
• Hymen reconstruction
• Men in labour
• Trans sexualism

52. Female genital mutilation
• Female genital mutilation (FGM) includes procedures that
intentionally alter or cause injury to the female genital organs for
non-medical reasons.

53. Female genital mutilation-TYPES
• Clitoridectomy: partial or total removal of the clitoris (a small, sensitive
and erectile part of the female genitals) and, in very rare cases, only the
prepuce (the fold of skin surrounding the clitoris).
• Excision: partial or total removal of the clitoris and the labia minora, with
or without excision of the labia majora (the labia are "the lips" that
surround the vagina).
• Infibulation: narrowing of the vaginal opening through the creation of a
covering seal. The seal is formed by cutting and repositioning the inner, or
outer, labia, with or without removal of the clitoris.
• Other: all other harmful procedures to the female genitalia for non-medical
purposes, e.g. pricking, piercing, incising, scraping and cauterizing the
genital area.

54. THANK YOU