2 to the pregnant woman). If the fetus is also a patient, then the ethical situation becomes much more complex. What is best for the pregnant woman may diﬀer from what is best for the fetus (for example, where there are physical risks to the woman in continuing the pregnancy). In addition, the woman may make decisions which are contrary to the best interests of the fetus (for example to terminate a viable pregnancy). Diﬃcult choices may have to be made and are based on where ethical priorities lie. There are two possible approaches to dealing with the question of whether the fetus should be regarded as a patient. The ﬁrst approach is that the physician comes to his or her own moral decision about whether the fetus should be regarded as a patient. This approach would require the physician to have a clear and sound moral or philosophical basis on which to make this decision. The second approach is that the physician adopts no view and leaves it up to the pregnant woman (and her partner, if involved) to decide how they wish to regard their fetus. This approach need not involve any moral or philosophical reasoning by the physician about the fetus; simply giving primacy to the pregnant woman’s autonomy in relation to decisions relating to her fetus. Chervenak et al. [3] suggest a variation of the ﬁrst approach. They concede, as many others do [1, 5], that the fetus cannot meaningfully possess values and beliefs, and is therefore not a person to whom obligations can be owed. However, they maintain that the obligations of beneﬁcence to the fetus arise from the fact that obligations are owed to the infant which that fetus will become after birth. This makes the fetus a patient, regardless of whether it is a person. More speciﬁcally, Chervenak et al. argue that the fetus becomes a patient only after viability; the pre-viable fetus does not have the status of a patient, and should only be treated as a patient if the pregnant woman wants to regard it as such. Once a fetus is viable (a state related to the biological stage of development aided by the availability of medical technology) it is possible for the fetus to survive independently outside the womb. Hence, according to Chervenak et al., there are beneﬁcence obligations to the viable fetus, whenever it is presented to the physician and there exist medical interventions (whether diagnostic or therapeutic) that could. produce a greater balance of clinical good over clinical harm for it in the future that is, when it becomes an infant, a child or an adult. There is extensive data to support the possibility of clinical beneﬁt in cases of cardiac anomalies [6–8]. If this argument is accepted, it means that the physician may end up having an obligation to seek to change or override pregnant woman’s wishes, for the sake of the fetus. If the physician believes the fetus is a patient, owed the same obligations as any other patient, then his or her obligation is directed to the best interests of the fetus. If the pregnant woman’s decisions are contrary to the best interests of the child that the fetus will become, then the physician has an obligation to protect those interests, just as for any child put at risk by parental decisions about medical treatment. The logic of Chervenak and his co-authors’ position implies that if attempts at persuasion do not work, the physician may have to seek legal avenues to override the woman’s International Journal of Pediatrics decision, a course of action that could lead to court-enforced fetal surgery [9], immediate delivery of the fetus and, in theory, court-ordered continuation of pregnancy (although it should be noted that in situations where the local laws permit abortion, they do not generally allow for a third party to prevent a woman having an abortion). However, we caution against this approach, where the physician adopts an independent moral stance on the fetus, and seeks to act accordingly. Whilst the arguments of Chervenak et al. [3] are well reasoned, there are also well- reasoned arguments to the opposite eﬀect, namely that the fetus should not at any stage of gestation be regarded as a patient to whom the physician has direct obligations, unless the pregnant woman chooses to do so. The obligation to the fetus, as Chervenak et al. acknowledge, is based on the well- being of the child it will become. However, whether or not the fetus becomes a child depends on the woman continuing with her pregnancy. It could be argued that if she decides to terminate her pregnancy, at any stage and for whatever reason, there is no longer any obligation to the fetus, since there will not be any child. This conclusion is contrary to the view of Chervenak et al., yet draws on the same reasoning they do. The well-known diﬀerence in views about the status of the fetus and the morality of abortion, across diﬀerent cultures and religions also introduces a note of caution. A physician working in the multi-cultural setting of today’s increasingly globalised world is likely to encounter patients with quite varied views. In addition, laws relating to abortion vary considerably between jurisdictions. We suggest, then, that the second approach suggested above is preferable, namely for the physician to leave it to the pregnant woman (and partner) to decide if the fetus is to be regarded as a patient or not (providing that local laws permit abortion). Adopting that view does not mean that the physician should not have a personal position on the status of the fetus, only that he or she should not attempt to impose it on his or her patients. If the wishes of the pregnant woman in regards to termination of her pregnancy or intra- uterine therapy for her fetus are signiﬁcantly at odds with the physician’s moral views, the physician should exercise the right to conscientious objection, and hand over the care of the patient to another doctor [10]. This obligation to refer is a standardly accepted caveat on the right to conscientious objection [11]. The Australian Medical Association Code of Ethics [12], for example, states the following: When a personal moral judgement or religious belief alone prevents you from recommending some form of therapy, inform your patient so that they may seek care elsewhere, and recognise your right to refuse to carry out services which you consider to be professionally unethical, against your moral convictions, imposed on you for either administrative reasons or for ﬁnancial gain or which you consider are not in the best interest of the patient. This position is an attempt to negotiate between compet- ing moral values: the woman’s autonomy and the physician’s integrity. The physician is not forced to do something he or she believes morally wrong, but the woman is also able to exercise her own choice.