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Goldblatt Hyatt E, Wilpers A, Bahtiyar MO, Hu Y, Leon-Martinez D, Chervenak FA, McCoyd JLM. "I don't have a telephone to the fetus": Clinicians' conceptions of fetal patienthood in maternal-fetal surgery counseling. Soc Sci Med 2024; 342:116525. [PMID: 38199011 DOI: 10.1016/j.socscimed.2023.116525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 12/01/2023] [Accepted: 12/16/2023] [Indexed: 01/12/2024]
Abstract
RATIONALE Maternal fetal surgery (MFS) has developed rapidly since the 1960s and centers for fetal diagnosis and therapy (CFDT) have proliferated. As a result, CFDT clinicians have intervened with fetuses through pregnant bodies for decades, yet the patienthood status of the fetus and its implications for the pregnant person's autonomy have been relatively unexamined. OBJECTIVE Our overall research aims were threefold: (1) to explore how clinicians train for and provide counseling for MFS; (2) to examine how clinicians assess fetal patienthood and its implications; and (3) to understand clinicians' professed needs and their recommendations for education and training for the provision of MFS counseling. This focuses on aim two. METHOD In this qualitative study, conducted using in-depth interviews, we examined how 20 clinicians from 17 different sites understood fetal patienthood, how that affected their counseling of pregnant patients, and whether they drew on extant ethical frameworks for guidelines. RESULTS We identified three major themes: 1) Clinicians entered fetal surgery consultations with assumptions about fetal patienthood (frequently informed by beliefs about fetal viability, maternal attachment, and disciplinary perspectives); 2) they consciously assessed their pregnant patients' connections to their fetus to inform or re-calibrate their own understandings of fetal patienthood; and 3) they used a threshold -based conceptualization whereby the fetus achieved patienthood after crossing a symbolic boundary, often related to the clinician's ability to intervene. CONCLUSIONS Few clinicians invoked an extant ethical framework to determine fetal patienthood; most asserted that they did not view directive counseling toward MFS as appropriate, instead working diligently to protect pregnant patients' autonomy and rights to self-determination.
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Affiliation(s)
- E Goldblatt Hyatt
- School of Social Work, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA.
| | - Abigail Wilpers
- Department of Family and Community Health, University of Pennsylvania School of Nursing, 9 Philadelphia, PA, USA; Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mert Ozan Bahtiyar
- Fetal Care Center, Yale New Haven Hospital, New Haven, CT, USA; Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, And Reproductive 15 Sciences, New Haven, CT, USA
| | - Yunzhe Hu
- Columbia University, New York, NY, USA
| | | | - Frank A Chervenak
- Department of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell 20 and Lenox Hill Hospital, Hempstead, NY, USA
| | - Judith L M McCoyd
- School of Social Work, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
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Moehrlen U, Ochsenbein-Kölble N, Stricker S, Moehrlen T, Mazzone L, Krähenmann F, Vonzun L, Zimmermann R, Meuli M. Prenatal Spina Bifida Repair: Defendable Trespassing of MOMS Criteria Results in Commendable Personalized Medicine. Fetal Diagn Ther 2023; 50:454-463. [PMID: 37544297 DOI: 10.1159/000533181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 07/03/2023] [Indexed: 08/08/2023]
Abstract
INTRODUCTION We hypothesize that after publication of the quintessence of the MOMS trial, eligibility criteria for prenatal spina bifida (SB) repair may be modified if a tenable argumentation underlies this decision. METHODS Our first 154 fetal surgery patients were analyzed with particular focus on how many, which, and why the original eligibility criteria, set forth by the MOMS Trial Protocol, were disobeyed, and what the eventually detectable, negative and positive impacts of these deviations on outcomes were. RESULTS A total of 152 patients (2 missing consent) were included (100%). In 69 patients (45.4%), a total of 89 eligibility criteria were disobeyed. In 54 (35.6%) cases, the following maternal criteria were concerned: gestational age at operation of >25+6 weeks in 17 (11.2%), uterine pathologies in 13 (8.6%) women, preoperative BMI ≥35 kg/m2 in 12 (7.9%), previous hysterotomy in 7 (4.6%), previous prematurity in 3 (2%), HIV/hepatitis B in 2 (1.3%), psychosocial issues in 2 (1.3%), and placenta praevia in 1 (0.7%). In 32 (21.1%) cases, fetal criteria were disobeyed 34 times: Fetal anomaly unrelated to SB in 19 (12.5%), no/minimal evidence of hindbrain herniation in 13 (8.6%), and severe kyphosis in 2 (1.3%). We could not identify cases where non-observation of criteria led to clear-cut maternal and/or fetal disadvantages. CONCLUSION This study shows that MOMS trial eligibility criteria for prenatal SB repair should be modified or even abandoned with adequate medical and ethical argumentation, and with written parental informed consent after non-directive, full disclosure counseling. This clear-cut change of paradigm is a necessity as it leads toward personalized medicine, allowing more fetuses to benefit from fetal surgery than would have benefitted with the former, published, MOMS criteria in place.
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Affiliation(s)
- Ueli Moehrlen
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- Children's Research Center (CRC), University Children's Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
- Spina Bifida Academy, University Children's Hospital and University Hospital Zurich, Zurich, Switzerland
| | - Nicole Ochsenbein-Kölble
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
- Spina Bifida Academy, University Children's Hospital and University Hospital Zurich, Zurich, Switzerland
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
| | - Sarah Stricker
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland
- Children's Research Center (CRC), University Children's Hospital Zurich, Zurich, Switzerland
| | - Theres Moehrlen
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- Children's Research Center (CRC), University Children's Hospital Zurich, Zurich, Switzerland
- Spina Bifida Academy, University Children's Hospital and University Hospital Zurich, Zurich, Switzerland
| | - Luca Mazzone
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland,
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland,
- Children's Research Center (CRC), University Children's Hospital Zurich, Zurich, Switzerland,
- Spina Bifida Academy, University Children's Hospital and University Hospital Zurich, Zurich, Switzerland,
| | - Franziska Krähenmann
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- Spina Bifida Academy, University Children's Hospital and University Hospital Zurich, Zurich, Switzerland
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
| | - Ladina Vonzun
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- Spina Bifida Academy, University Children's Hospital and University Hospital Zurich, Zurich, Switzerland
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
| | - Roland Zimmermann
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- Spina Bifida Academy, University Children's Hospital and University Hospital Zurich, Zurich, Switzerland
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
| | - Martin Meuli
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
- Spina Bifida Academy, University Children's Hospital and University Hospital Zurich, Zurich, Switzerland
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