Court-ordered treatment in obstetrics: the ethical views and legal framework

Four main ethical views have been put forward concerning court-ordered treatment of mentally competent pregnant women for fetal indications: 1) Such treatment is never justifiable; 2) it is justifiable provided it poses no health risks for the woman, minimally invades her bodily integrity, and would clearly prevent substantial harm to the fetus; 3) it is justifiable provided the maternal risks are low, there is a substantial likelihood that the fetus will suffer irrevocable harm without the intervention, and the treatment will likely be effective; and 4) it is justifiable provided the risks to the woman are ones she should reasonably accept, the fetal risks of treatment are minimal, and the potential fetal benefit is substantial. However, the first two views are too rigid to adequately handle the variety of clinical situations in which maternal treatment refusal can occur, and recent legal decisions have ruled out the other views. The ethics of court-ordered treatment are often discussed as though the only interests involved are those of the pregnant woman and fetus, but other important interests may be relevant. An ethical view that avoids these difficulties and takes better account of the complexity of the issues is as follows: Such treatment is justifiable in rare, exceptional circumstances provided it poses insignificant or no health risks to the woman or would promote her interests in life or health and there are compelling reasons to override her autonomy.