International Journal of Pediatrics 3. Ethical Responsibility of Cardiologists When a Serious Fetal Cardiac Anomaly Is Found Physicians working in obstetrics and gynaecology are pre- sumably aware of the need to work through these issues of the status of the fetus, and to develop their position on abortion, as these issues form a major aspect of their practice. Paediatric cardiologists, on the other hand, have had little cause to consider such issues when working in their discipline, and may never need to do so. However, since it is now possible to detect fetal cardiac anomalies prenatally, cardiologists are coming face to face with these issues. There is usually (in most jurisdictions) an option to terminate an aﬀected pregnancy and increasingly intrauterine interven- tions may be possible. Cardiologists must consider how they will counsel women in these situations, how directive they will be about which option should be chosen, and what they will do if the woman’s choice is not the one that optimizes life and health for the fetus. Here, we set out the key steps in the counseling process from an ethical perspective, and make recommendations about ethically appropriate practice. These steps may take place over more than one consultation, and may need to be re-visited on each occasion, due to the emotional nature of the situation and the complexity of the information to be conveyed. 3.1. Step 1. Give Accurate Information about the Diagnosis and Prognosis of the Cardiac Abnormality. The ﬁrst stage is providing accurate information about the diagnosis and prognosis in a manner and at a timing that the expectant parents are able to understand. Fetal cardiac anomalies like any congenital anomaly necessitate that physicians provide the parent adequate information. For any counselling to be credible the diagnosis must be accurate. This is even more relevant in the case of antenatally diagnosed cardiac anomalies. The general screening detection rates for con- genital heart disease (CHD) vary between 14%–45% [13]. A standard 4 chamber view can detect 40%–50% of major CHD [14], while a 4 chamber view and outﬂow tract detects 70%–80% of major CHD [15]. In dedicated fetal cardiac centres the diagnostic accuracy is close to 100% [4, 16]. Fetal cardiac malformations are compounded by the fact that other malformations may be present, as is the possibility of chromosomal abnormalities. The most accurate information possible should be given to the expectant parents, along with a clear explanation of what is still uncertain, unclear or subject to change as the pregnancy progresses. The physician should keep in mind the possibility of evolving lesions [10] (e.g., a developing left and right hypoplastic heart syndrome) and inform the parents accordingly. For such condition, there is inadequate or incomplete data as far as their outcome and natural history, and this also must be conveyed to the parents. Shinebourne argues that most CHD are treatable with a resultant reasonable quality of life [5]. Even in serious cardiac conditions, one is not always able to clearly deﬁne the possible outcomes. Few cardiac conditions are not amenable to at least palliative surgery, if not complete repair. In most 3 cases the neurological development is normal or close to normal [17]. When dealing with fetal anomalies detected on ultrasound, the questions and concerns raised by parents relate to the quality of life issues starting from infancy right up to adulthood [18]. Generally the details of the abnormality, while important, are not the paramount issue for the parents [19]. Complications of the abnormality and the results of surgery or any intervention also ﬁgure in the considerations. There is the need to describe possible poor outcomes, especially if they are severe even though unlikely to happen. This information allows the parents to decide how to proceed with knowledge of the worst case scenario [10]. The physician needs to ensure the expectant parents understand the information about the nature of abnormality, the implications for the life of the future child, the possibility of intervention, and the risk for each intervention prenatally or postnatally. Parents also need to know the ﬁgures for local practice, for short, medium and long term outcomes, especially with respect to quality of life issues. The physician must be ready to discuss all of these issues with parents, providing the best available information, but also indicating the limits and uncertainties in this information and at a time when the parents are able to take in the information. 3.2. Step 2. Identify Options. The next stage is to identify and present the options available. In brief, there are three main options: to continue with the pregnancy, to terminate the pregnancy (if legally permitted), or to consider prenatal intervention (if it is possible for the condition and available). If the decision is to continue with the pregnancy, there will perhaps be further decisions to make as to where the infant is to be delivered, the need for in utero transfer, and the mode of delivery [19]. There will also need to be an anticipatory management plan for the infant after birth. Parents will generally accept what is recommended to them on these matters, but still require them to be explicitly stated. If the decision is to terminate, there may be a need to shift hospitals (from example from a Catholic hospital), or change the obstetrician if termination is not personally acceptable to him or her. The parents should be made aware of these implications, not in an attempt to change their mind, but to inform and prepare them for the process. Local laws and practices play an important role in the decision making. For example in some places it may be legal to terminate a pregnancy for maternal psychosocial reasons [17]; in other places, fetal indications may be speciﬁed in the law. There may or may not be restrictions on termination related to the stage of gestation. Broadly speaking, obstetricians are able to carry out a termination before 12 weeks [20], but the risk of legal complications increases after 12 weeks and especially after 20 weeks (which is about the stage at which antenatal diagnoses of cardiac anomalies are more commonly made.) In our state of Victoria, in Australia, the law has recently changed to allow termination for any reason up until 24 weeks, and after that there is the need for two doctors to agree that it is reasonable. Physicians must develop an accurate understanding of their local laws and seek legal clariﬁcation if necessary.