4 During the counselling, assuming a “neutral” tone on the part of the clinician—not overly pessimistic or optimistic— is vital [2] but may be extremely diﬃcult to achieve. The ultimate aim is to allow the expectant parents to form their own assessment of the impact the condition would have on their future child. As Shinebourne [5] notes: “It is the mother’s perception of the fetal cardiac anomaly and not the cardiologist’s that should determine outcome (continuation or termination)”. It is open to question, though, how achievable this is in a setting of acute emotional distress where the mother is in a state of shock and grieving the loss of a sought-after normal infant [4]. The ethical obligation is to do one’s best to achieve this aim. 3.3. Step 3. Discuss Options. The next stage is discussing the options with parents which is the most ethically contentious stage. There are diﬀerent views even about which matters are ethically appropriate to raise and discuss, let alone about the degree to which it is appropriate to recommend or favour a particular option, rather than being as neutral as possible. Most professionals advocate non-directive [4, 5, 21] counselling if possible. It is important to realize that the impact of counseling is aﬀected by the physician’s approach, speech, tone, and so forth [5]. In many counseling sessions, selective information is provided, whether deliberately and inadvertently, though some feel obligated to provide all the information available. There is also the question as to who is the best person to do the counseling. Cardiologists, genetic counsellors or obstetricians have counseled independently or together [4]. Making a decision may not be easy for the parents. They have to come to terms with the abnormality and grieve the loss of a normal infant, as well as grapple with the questions of what they think about abortion, disability, their personal capacity to care for such an infant/child and their ideas about parenthood and family life. They may wish to talk through the options. They may want their cardiologist’s opinion about what they should do. Simply giving such an opinion may not be the best option as the personal circumstances of the clinician diﬀer from that of the parents. It is preferable to discuss how one might decide, what factors one would take into account, in order to model to the expectant parents a way of thinking about the issue, rather than simply give them an answer. The reasons for considering termination may be very variable, complicated and as Shaﬀer et al. [22] acknowledge, may not necessarily be “rational” in the strictest sense. This can make the discussion of options diﬃcult, especially for those not speciﬁcally trained for these situations. The reasons for which women decide to terminate aﬀected pregnancies are not well documented or understood, though the few studies done in the area indicate it is the nature of condition rather than the stage of gestation that carries most weight [23]. A common understanding of physicians is that most terminations for fetal cardiac anomaly are done to minimize distress and grief to the parents of having a child with reduced physical activity who may die young. This allows mother time for other important aspects of her life, care of International Journal of Pediatrics the other children and to prevent hardship to others [5]. There may be also be other social reasons, or a medical condition of the pregnant woman. Note that in these discussions, the pregnant woman (and partner) is not necessarily thinking of the the fetus as a baby, or being with independent rights. Ethically speaking, a pregnant woman’s decision need not be based on what is best for the future child; she may legitimately considers her own and others’ interests [5]. For example, there is the perception that an anomaly may have a traumatic or deleterious eﬀect on the parents and the other children, as well as the future child [24]. Here, it is important to note the diﬀerences between expectant parents’ decisions regarding termination of pregnancy and actual parents’ decisions regarding the treatment of the newborn infant. The actual parents’ role is to decide on behalf of the infant, on the basis of what is in best interests of the infant [11]. Once delivered, the priority is on maintaining the life and health of the infant, aiming for the best outcomes. If the parent’s wishes are signiﬁcantly contrary to the infant’s well-being they can be legally overridden. In contrast, decisions regarding the termination of the pregnancy are not ethically required to be about the best interests of the future child. If the local laws permit termination of the pregnancy, prospective parents may decide for their own reasons. This may include what they perceive would be in best interests of the future child, but will not necessarily do so. Specialist prenatal genetic counsellors may be particu- larly helpful for the expectant parents in talking through these sorts of issues, though such counselors may not have the detailed cardiac knowledge to answer the relevant questions. What parents need most from the paediatric cardiologist is the best available understanding of what their child’s life would be like, what sort of interventions would be needed and the risks of these to the child in the local setting. 4. Intrauterine Intervention: Ethical Issues If intrauterine interventions are available the further impor- tant issue is the pregnant woman’s autonomy versus the potential beneﬁcence to the fetus and future child, where the pregnancy is going to continue and the fetus can reasonably be regarded as a patient. In this situation, the pregnant woman is in the ethical role of parent making decisions for the health of her future child—but she is also making decisions about herself and her own health. There is a conﬂict between American College of Obstetricians and Gynecologists and the American Academy of Pediatrics [25] regarding the issue of fetal interventions. The latter accords less weight to maternal decision making and is more tolerant of overriding maternal refusal of intervention which may be suggested for fetal beneﬁt. An intervention to the fetus may pose risks to pregnant woman which she may not be willing to take. One example is prescribing medication to the mother for treating fetal arrhythmias. Another example is surgical intervention for critical aortic or pulmonary stenosis [26– 28] which has been employed to improve fetal outcomes, though it may lead to premature labour and may require a