Ethical dilemmas in fetal echocardiography

Recent technology permits detection of congenital heart diseases as early as the 17th or 18th week of gestation. These detectable defects include hypoplastic left heart syndrome, Ebstein anomaly, and atrioventricular canal malformation. Surgical treatments for these problems raise ethical as well as medical questions regarding patients whose prenatal diagnosis reveals congenital heart disease. We report six cases of in utero diagnosis of hypoplastic left heart syndrome and other complex congenital heart anomalies. Empirical factors relevant to our management were gestational age, severity of the anomaly, degree of certainty of diagnosis and prognosis, possibilities for treatment, and parental wishes regarding the fetus or newborn. Each of these factors was examined in the context of the reported cases and correlated with ethical principles applicable to obstetrics and neonatology: 1) respect for parental autonomy, 2) promotion of the infant's welfare, and 3) fairness in distributing scarce medical resources. We maintain that the first two principles are paramount in ethical decisions regarding individual patients, while the third is foremost in policy decisions affecting others as well.