The Case
A 27-year-old woman with seven years of rheumatoid arthritis presents for a return visit. She is taking hydroxychloroquine and methotrexate for the management of her disease. Although you have counseled her about using reliable birth control while taking methotrexate, she mentions to you that she thinks that she may be pregnant. A serum β-HCG test and pelvic ultrasound confirm that the patient is seven weeks pregnant. The patient asks your advice on what to do about the pregnancy. What do you tell her?
The Ethical Issues
Forty-nine percent of pregnancies in the United States are unplanned.1 While practicing rheumatologists may have more opportunities and impetus to discuss family planning with their patients than clinicians in other fields, inadvertent pregnancies in our patients can and do occur.3 Thus, the treating rheumatologist may be asked to weigh in on reproductive issues when a developing embryo/fetus is inadvertently exposed to an antirheumatic drug. Some of the medications we regularly prescribe, such as methotrexate, are absolutely contraindicated during pregnancy. This is based on both its known teratogenicity and abortogenic effects and, accordingly, the FDA considers methotrexate to be a category X for risk for use during pregnancy.2,3 As the prescribing clinician, you recognize that your patient’s developing embryo is at risk for congenital anomalies. How do you counsel your patient? Do you recommend termination? What if you and the patient have different religious, ethical, or philosophical beliefs regarding family planning? This presentation raises the additional challenges of decision making in cases of hypothetical versus certain risk of congenital anomaly.
Discussion
There is a large amount of literature on the ethics regarding family planning decisions. One of the many challenges in this area is determining who is the patient—the mother and/or the developing embryo/fetus—and whose rights take precedent in medical decision making. While these complex concepts are beyond the scope of this discussion, there are some constructs that are helpful in considering the above-mentioned case. Cervenak and McCullough argue that, “the previable fetus becomes a patient when the pregnant woman confers that status on it. The viable fetus becomes a patient when the pregnant woman is presented for obstetrical care.”4 They further maintain that, “when a fetal anomaly of any kind is diagnosed in pregnancy before viability, the physician should explain the nature and prognosis of the anomaly and offer both continuation of the pregnancy and induced abortion.” Presenting the full range of options to the pregnant woman fulfills the physician’s obligation of informed consent and enables the patient to make her own decision regarding their pregnancy. Wilkinson underscores this concept by asserting that physician counseling following prenatal diagnosis should be nondirective. This is only more so in the circumstances of uncertain prenatal diagnoses.5 However, a recent survey by Heusner et al indicated that, at least in the case of severe fetal anomalies, practitioners were somewhat directive in their counseling practices.6
