ABSTRACT
D medicine during the past ten to twenty years have transI I formed the clinical status of the fetus.2 Traditionally physicians have been trained to assess fetal condition by indirect methods: palpating the fetus through die maternal abdominal wall and uterus, measuring hormonal milieu through maternal urine and serum, estimating statistical risks from parental medical histories. While the skillful use of diese methods could produce highly reliable clues to fetal health and development, the fetus itself eluded direct examination. Throughout pregnancy the fetus could not be known, but only approached inferentially and probabilistically. Until recently suspected fetal anomalies have been treated indirecdy too, by therapeutically managing the maternal environment Unable to interact with the fetus in clear distinction from its host, physi-
cians conceptualized the maternal-fetal dyad as one complex patient, the gravid female, of which the fetus was an integral part
High-resolution ultrasonography and techniques for sampling fetal blood, urine, and other tissue have changed this conceptual scheme. These diagnostic tools penetrate the opaque environment and reveal the fetus to clinical observation in all its anatomical, physiological, and biochemical particularity. When anomalies are detected, in utero medical and surgical procedures are already beginning to offer alternatives to therapeutic delivery and neonatal treatment The biological maternal-fetal relationship has not changed, of course, but the medical model of that relationship has shifted emphasis from unity to duality. Clinicians no longer look to die maternal host for diagnostic data and a therapeutic medium; they look through her to die fetal organism and regard it as a distinct patient in its own right
What ediical implications flow from
the fetus's transformation from inferred to observed entity? Unfortunately, legal developments have tended to preempt ethical exploration of die new two-patient obstetric model. Some physicians, assuming enhanced rights on die part of die fetal patient, have sought and obtained court orders to perform fetal tiierapies (notably cesarean deliveries) widiout maternal consent3 Although few in number, these cases raise die possibility of a new standard of clinical practice widi far-reaching implications for civil and criminal liabilities to physicians and pregnant women. Witfi legal stakes so high, it is not surprising that educai inquiry has been displaced. Yet in the absence of independent and diorough ethical analysis one cannot judge whether these developments are compatible witii fundamental values of medicine and medical care, and so one cannot know whether physicians have responsibilities, individually or collectively, to promote or resist diem.
