The ethics of neurologically complicated pregnancies

Bioethical conflicts in pregnancy are distinguished from those in other areas of medicine due to competing interests between mother and fetus because of their shared biology. Historically, prior to the advent of fetal therapy and advances in medical technology, the maternal-fetal complex was considered to be a single entity. With advances in medicine, treatment options can now be directed at both the mother and the fetus, and a duality has evolved in the maternal-fetal unit. Thus at some point during pregnancy, two individuals rather than just one are the responsibility of the physician. In determining how to properly care for the pregnant woman with a neurologic condition, therapeutic choices must take into consideration the impact a treatment will have on both the mother and the fetus. Since what benefits one may harm the other, tension results from the need to choose. This chapter will highlight ethical conflicts arising at the interface of obstetrics and neurology. We will delve into situations where difficult reproductive and therapeutic decisions must be made in pregnant women with intellectual disabilities, stroke, brain tumors, and epilepsy. The complexity of brain death in pregnancy will be analyzed, acknowledging the influence of politics, law, and religion that bears on ethical decision-making. In approaching ethical dilemmas encountered in pregnancies complicated by neurologic conditions, frameworks based on principles, virtues, care, and feminist ethics, and case precedents will be applied to facilitate ethically appropriate shared decision-making. We hope that this chapter will provide valuable guidance for providers caring for this complex obstetric population.