International Journal of Pediatrics surgical incision in pregnant woman to facilitate needling of the ventricles. One important question to answer is whether the poten- tial beneﬁt to the fetus warrants the risks to the pregnant woman. Another important question is about the risks to the fetus: are they suﬃciently outweighed by potential gains that it is reasonable to expect overall beneﬁt to the fetus? One may argue that it is reasonable to oﬀer and recommend fetal therapy if there is a probability of saving the life of the fetus or to prevent serious or irreversible disease to fetus or child and yet carries a low mortality/morbidity risk to the fetus/child and low morbidity to mother [27]. But when the results of such an intervention are questionable and not without risks to the mother, it is not so straightforward. We suggest that in these situations, respect for the woman’s autonomy and her assessment of her own and her future child’s health-related interests be given priority. Arguably, such innovations as in utero fetal surgery need to be conducted and evaluated as research [29], preferably conducted in centres of excellence. In such cases, the women need be considered as research participants. Genuine volun- tariness and informed consent is a standard prerequisite for any such research. 5. Multiple Pregnancies with One Fetus with a Serious Cardiac Anomaly: Ethical Issues We have discussed this issue in detail in a separate paper [30]. To summarise, dealing with the management of a twin pregnancy where one fetus has a serious anomaly is one of the most challenging and confronting issues a clinician faces. The management depends on the wishes, values and preferences of the mother/parents once provided with detailed and accu- rate information about the condition of the twins. The risk to the unaﬀected fetus depends on chorionicity and becomes much more problematic in monochorionic pregnancies. Selective termination of an aﬀected twin with a serious con- genital heart disease is possible in some circumstances. Clini- cians need to provide detailed probability of the risks of selec- tive termination to pregnant woman and the risks to the nor- mal fetus, including the onset of premature labour, cerebral hypoxia and death to the unaﬀected twin. It is also important for expectant parents to understand that fetal death of the normal twin, especially in monochorionic twin pregnancies, may occur even if the twin pregnancy is continued, in cir- cumstances where the aﬀected twin becomes unwell or dies. 6. Conclusions The basic ethical principles of respect for autonomy and beneﬁcence play the major role in grounding physicians’ ethical responsibilities in pregnancies where there may be a fetal cardiac anomaly. The physician’s main ethical obligation is to provide adequate and correct information, in a way that takes account of the extremely distressing circumstances, so as to allow for informed decision making. The ethical principle of autonomy creates a responsibility for the physician to help the pregnant woman make informed decisions based on her values and aspirations. A decision to 5 terminate is partly a medical matter, relating to the procedure and its risks, and partly a personal moral decision bound by legal, cultural and religious constraints. Clinicians can advise regarding the former, but it is not within their realm to advise regarding the latter. The decision whether to continue or terminate in fetal cardiac anomalies is complicated by the fact that in the present era there are very few cardiac conditions which are not amenable to repair and with a reasonable future quality of life. Parents have to deal with shades of grey. 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