Ethical Decision Making in Obstetrics and Gynecology*

Physicians vary widely in their familiarity with ethical theories and methods and their sensitivity toward ethical issues. It is important for physicians to improve their skills in addressing ethical questions. Obstetrician–gynecologists who are familiar with the concepts of medical ethics will be better able to approach complex ethical situations in a clear and structured way. By considering the ethical frameworks involving principles, virtues, care and feminist perspectives, concern for community, and case precedents, they can enhance their ability to make ethically justifiable clinical decisions. Guidelines, consisting of several logical steps, are offered to aid the practitioner in analyzing and resolving ethical problems. Committee on Ethics Reaffirmed 2016 Number 390 • December 2007 ACOG COMMITTEE OPINION The American College of Obstetricians and Gynecologists Women’s Health Care Physicians The importance of ethics in the practice of medicine was manifested at least 2,500 years ago in the Hippocratic tradition, which emphasized the virtues that were expected to characterize and guide the behavior of physicians. Over the past 50 years, medical technology expanded exponentially, so that obstetrician–gynecologists have had to face complex ethical questions regarding assisted reproductive technologies, prenatal diagnosis and selective abortion, medical care at the beginning and end of life, the use of genetic information, and the like. Medical knowledge alone is not sufficient to solve these problems. Instead, responsible decisions in these areas depend on a thoughtful consideration of the values, interests, goals, rights, and obligations of those involved. All of these are the concern of medical ethics. The formal discipline of biomedical ethics and structured ethical analysis can help physicians resolve ethical dilemmas. Physicians vary widely in their familiarity with ethical theories and methods and their sensitivity toward ethical issues. It is important for physicians to improve their skills in addressing ethical questions through formal undergraduate and graduate medical education, organized continuing education, or personal experience and reading as well as discussion with others. Ethical Frameworks and Perspectives Principle-Based Ethics In recent decades, medical ethics has been dominated by principle-based ethics (1–3). In this approach, four principles offer a systematic and relatively objective way to identify, analyze, and address ethical issues, problems, and dilemmas: 1) respect for patient autonomy, 2) beneficence, 3) nonmaleficence, and 4) justice. (These four principles will be discussed in some detail in subsequent sections.) However, critics claim that a principlebased approach cannot adequately resolve or even helpfully evaluate many difficult clinical problems. As a result, several other perspectives and frameworks have emerged: virtuebased ethics, an ethic of care, feminist ethics, communitarian ethics, and case-based reasoning, all of which have merit as well as limitations (2–8). As this discussion will stress, these different perspectives and frameworks are not necessarily mutually exclusive. They often are complementary because each emphasizes some important features of moral reasoning, agents, situations, actions, or relationships. Perspectives such as an ethic of care or feminist ethics also may change the lens through which to view both principles *Update of “Ethical Decision Making in Obstetrics and Gynecology” in Ethics in Obstetrics and Gynecology, Second Edition, 2004. and particular situations in which decisions have to be made.