Ethical issues in fetal therapies of life-threatening malformations

Unlike any other medical field, fetal medicine addresses two patients: the fetus and the mother. Its primary goal is to improve neonatal outcomes, specifically by reducing mortality and morbidity, including long-term impacts, while minimizing risks to the mother. The aim of fetal interventions for life-threatening malformations is to decrease morbidity and mortality by mitigating the impact of the malformation on fetal growth and development. Although some randomized controlled trials have evaluated fetal medicine procedures, they have faced challenges such as the rarity of most conditions and ethical concerns related to clinical equipoise. Prematurity, an intrinsic risk of membrane puncture, remains a significant burden of fetal surgery, and maternal safety must always be prioritized when considering such procedures. Despite 50 years of research in fetal medicine, many questions remain, due to advancements in ultrasound technology and genetics, the inherent risks associated with fetal procedures, the lack of appropriate medical device for rare diseases and the cost associated with conditions that require complex multidisciplinary neonatal care. Justice and parental autonomy must be respected but the principle of non-maleficence should prevail.