Abstract
When surgery is performed on pregnant women forthe sake of the fetus (MFS or maternal fetalsurgery), it is often discussed in terms of thefetus alone. This usage exemplifies whatphilosophers call the fallacy of abstraction: considering a concept as if it were separablefrom another concept whose meaning isessentially related to it. In light of theirpotential separability, research on pregnantwomen raises the possibility of conflictsbetween the interests of the woman and those ofthe fetus. Such research should meet therequirement of equipoise, i.e., a state ofgenuine uncertainty about the risks andbenefits of alternative interventions ornoninterventions. While illustrating thefallacy of abstraction in discussions of MFS,we review the rationale for explicitacknowledgment of the essential tie betweenfetus and pregnant woman. Next we examinewhether it is possible to meet the requirementof equipoise in research on MFS, focusing on afetal condition called myelomeningocele. Weshow how issues related to equipoise innonpregnant populations appear also in debatesregarding MFS. We also examine evidence insupport of claims that the requirement ofequipoise has been satisfied with respect to``the fetal patient'' while considering risks andbenefits to gestating women only marginally ornot at all. After delineating challenges andpossibilities for equipoise in MFS research, weconclude with a suggestion for avoiding thefallacy of abstraction and achieving equipoiseso that research on MFS may be ethicallyconducted.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Aguillera-Helweg, M. (1999) Born Twice. Life, December 1999.
Annas G.J. and Elias, S. (1984) Perspectives on Fetal Surgery. In: A. Milunsky and G. Annas (Eds.), Genetics and the Law (pp. 347-363). New York: Plenum Press.
American Academy of Pediatrics Committee on Bioethics (1999) Fetal Therapy — Ethical Considerations. Pediatrics 103, 1061-1062.
Bianchi, D.W., Crombleholme, T.M. and D'Alton, M.E. (2000) Fetology: Diagnosis and Management of the Fetal Patient. New York: McGraw-Hill.
Bruner, J., Tulipan, N., Paschall, R.L., Boehm, F., Walsh, W.F., Silva S.R., Hernanz-Schulman, M., Lowe, L. and Reed, G.W. (1999) Fetal Surgery for Myelomeningocele and the Incidence of Shunt-Dependent Hydrocephalus. JAMA 282, 1819-1825.
Carse, A. and Nelson, H.L. (1999) Rehabilitating Care. In: A. Donchin and L. Purdy (Eds.), Embodying Bioethics (pp. 17-31). Lanham, Maryland: Rowman and Littefield Publishers.
Casper, M.J. (1998) The Making of the Unborn Patient. New Brunswick: Rutgers University Press.
Farrell, J.A., Albanese, C.T., Jennings, R.W., Kilpatrick, S.J., Bratton, B.J. and Harrison M.R. (1999) Maternal Fertility Is not Affected by Fetal Surgery. Fetal Diagn Ther 14, 190-192.
Fletcher, J.C. and Jonsen, A.R. (1990) Ethical Considerations in Fetal Treatment. In: M.R. Harrison, M.S. Golbus and R.A. Filly (Eds.), The Unborn Patient (pp. 14-18). Philadelphia: W.B. Saunders.
Freedman, B. (1987) Equipoise and the Ethics of Clinical Research. N Engl J Med 317, 141-145.
Fried, C. (1974) Medical Experimentation: Personal Integrity and Social Policy. New York: American Elsevier.
Harrison, M.R., Golbus, M.S. and Berkowitz, R.S. (1982) Fetal Treatment. N. Engl J. Med. 307, 1651-1652.
Harrison, M., Golbus, M. and Filly R. (Eds.) (1991) The Unborn Patient. Philadelphia: W.B. Saunders.
Harrison, M. (1996) Fetal Surgery. Am J Obstet Gynecol 174, 1255-1264.
Jennings, R.W., Adzick, N.S. and Harrison, M.R. (1992) Fetal Surgery. In: M.I. Evans (Ed.), Reproductive Risks and Prenatal Diagnosis (pp. 311-320). Norwalk, CT: Appelton and Lange.
Johnson, N., Lilford, R.J. and Brazier, W. (1991) At What Level of Collective Equipoise Does a Clinical Trial Become Ethical? J. Med. Ethics 17, 30-34.
Jonsen, A.R. (1984) The Ethics of Fetal Surgery. In: A. Milunsky and G. Annas (Eds.), Genetics and the Law (pp. 365-368). New York: Plenum Press.
Karlawish, J.H. and Lantos, J. (1997) Community Equipoise and the Architecture of Clinical Research. Camb Q Health Ethics 6, 385-396.
Kitano, Y., Flake, A.W., Crombleholme T.M., Johnson, M.P. and Adzick N.S. (1999) Open Fetal Surgery for Life-Threatening Fetal malformations. Seminars in Perinatology 23, 448-461.
Little, M.O. (1999) Abortion, Intimacy and the Duty to Gestate. Ethical Theory and Moral Practice 2, 295-312.
Longaker, M.T., Golbus, M.S., Filly, R.A, Rosen, M.A, Chang, S.W. and Harrison, M.R. (1991) Maternal Outcome after Open Fetal Surgery: A Review of the First 17 Cases. JAMA 265, 737-741.
Mahowald, M. (1995) As If There Were Fetuses Without Women: A Remedial Essay. In: J. Callahan (Ed.), Reproduction, Ethics and the Law: Feminist Perspectives (pp. 199-218). Bloomington: Indiana University Press.
Okie, S. (2000) Over the Tiniest Patients, Big Ethical Questions. New York Times, April 12, A01.
Paek, B.W., Harrison, M., Albanese, C.T. and Farmer, D.L. (2000) Advances in Fetal Surgery: Prenatal Repair of Myelomenigocele. The Female Patient 25, 15-19.
Parens E. and Asch A. (1999) The Disability Rights Critique of Prenatal Genetic Testing: Reflections and Recommendations. Hastings Center Report, Sept-Oct, S1-S25.
Pickett, J.P. (Ed.) (2000) American Heritage Dictionary of English Language 4th edn Boston: Houghton Mifflin.
Rosen, M.G., Dickinson, J.C. and Westhoff, C.L. (1991) Vaginal Birth after Cesarean Section: A Meta-Analysis of Morbidity and Mortality. Obstet Gynecol 77, 465-470.
Simpson, J.L. (1999) Fetal Surgery for Myelomeningocele: Promise, Progress, Problems. 282, 1873-1874.
Singer, P.A., Lantos, J.D., Whittington, P.F., Broelsch, C.E. and Siegler, M. (1988) Equipoise and the Ethics of Segmental Liver Transplantation. Clin. Res. 36, 539-545.
Sutton, L.N., Adzick N.S., Bilaniuck, L.T., Johnson, M.P., Crombleholme, T.M. and Flake, A.W. (1999) Improvement in Hindbrain Herniation Demonstrated by Serial Fetal Magnetic Resonance Imaging Following Fetal Surgery for Myelomeningocele. JAMA 282, 1926-1831.
Taylor, K.M., Morgolese, R.G. and Soskolne, C.L. (1984) Physicians' Reasons for not Entering Eligible Patients in a Randomized Clinical Trial of Surgery for Breast Cancer. N. Engl. J. Med. 310, 1363-1367.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Lyerly, A.D., Mahowald, M.B. Maternal-Fetal Surgery: The Fallacy of Abstraction and the Problem of Equipoise. Health Care Analysis 9, 151–165 (2001). https://doi.org/10.1023/A:1011326119701
Issue Date:
DOI: https://doi.org/10.1023/A:1011326119701