key: cord-0798050-lkb40ioo authors: Habiba, Marwan; Akkad, Andrea title: Ethical considerations relevant to infections in pregnancy: application to Covid-19 date: 2020-07-12 journal: Eur J Obstet Gynecol Reprod Biol DOI: 10.1016/j.ejogrb.2020.07.013 sha: db8f92be62559756eca3221cd0a33bfea52e144f doc_id: 798050 cord_uid: lkb40ioo Despite wide diversity and scope, the ethical dimensions relevant to infections in pregnancy remain little explored. Important questions span topics with personal or wider societal and public health impact. The conceptualization of the status and responsibilities of the pregnant woman and the legitimate limits of third-party interests are key determinants of our appreciation of applicable ethical obligations. Pathogens and infections will continue to influence if not threaten human existence and a large part of medical effort is directed to combating their aftermath. Yet, infectious diseases have not attracted proportionate attention in ethical debate. This perhaps conforms to the observation referred to as the 10/90 divide, whereby less than 10% of resource is directed at 90% of the disease burden (1) . J o u r n a l P r e -p r o o f Prevention Many infections have limited, or short-term effects and medicine has achieved big success in relation to others. But some, including otherwise mild infections, can have serious and longlasting impact during pregnancy. The notion that prevention is better than cure is deeply embedded in modern discourse and in health policy (2) . Prevention has inherent appeal but is necessarily constrained by the balance of burdens and benefits. Efforts aimed at prevention can entail significant sacrifice when patients constitute the disease reservoir at the centre of the infection cycle (3). Patient behaviour, their willingness to be tested and to comply with stipulates are important determinants of their outcome, the infection cycle and the emergence of drug resistance. The boundaries between doctors' commitment to the care of the individual and the desire to achieve public good can become blurred when it comes to testing and prescribing. When faced with public anxiety, confidentiality and autonomy can give way to notification and enforcement. Vaccinations can be central to prevention but their availably and efficacy vary. Achieving optimal levels of uptake requires trust, persuasion and motivation. The endeavour may entail measures designed to facilitate or encourage compliance, or more proactive measures targeting hard to reach groups. Despite their potential benefits, there are legitimate questions surrounding the framework and safeguards that need to be in place. Tension can arise at the interface with liberty, free choice and consent. Pregnancy could be linked to particular uncertainty, vulnerability and intense surveillance, which can strain the notion of autonomy. On the other hand, strong advocates of autonomy need to consider situations which threaten fetal welfare (4) . Efforts that aim to influence women's behaviour can be contentious especially if they go beyond persuasion. Yet, there are advocates who support punitive measures including exclusion from access to services, compulsory treatment, directly observed therapy, or quarantine if optimal compliance is not realised or if the risk of contagion is high (5, 6) . This calls for ethical scrutiny of policy, the role of clinicians, and of the locus of decision making and oversight. The Harm Principle and safeguarding the community or the baby rather than benefit to the individual woman may be advanced as justification for intervention. There are echoes to Mill's argument that '…the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant' (7). But the justification or possible explanation articulated by Mill ought not be confused with a motivation for action. A 'rightful' act is one that can be justified, not one that ought to be undertaken. Much remains contingent on circumstances including the degree of harm, the nature of the disease, the degree of risk and importantly, the range of available options. Still, a more accommodating stance may favour actions or intrusions by society if done to enhance public welfare or the welfare of the child. The spectrum of opinion includes those who view such interventions as legitimate, desirable or even necessary. Green argued that '...it is the business of the state to take the best security it can for the young citizens' growing up in such health' (8) . Intervention may be placed in the context of 'society's effort to prolong life and promote health' (9) . Some may place a responsibility on individuals to take part in collective efforts (10) . Article 25 of The Universal Declaration of Human Rights (1998) states that: 'Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family' (11) . This was also used as a basis for arguments in favour state intervention and corresponding obligations on citizens to enable achieving the aspired goal. Citizens' obligations can be understood with reference to the correlativity thesis, which envisages reciprocity between the existence of rights and obligation (12) . This however raises wider questions related to the notion of rational assent and the responsibility of citizens on the one hand and the ethical principles needed to guide or delimit the extent by which health agencies can be part in any endeavour towards concordance. Whilst effective against certain infections e.g. measles, tuberculosis and poliomyelitis, vaccines are not available against others e.g. malaria, or group B Streptococcus. Some vaccines are used for at-risk individuals e.g. hepatitis B, others are recommended for the entire population. High uptake of population-oriented vaccines creates 'herd' immunity, J o u r n a l P r e -p r o o f which requires 90-95% uptake for high, and 80-85% uptake for moderate contagion disease. Herd immunity benefits the small percentage who may have a contraindication to vaccination or those who have not otherwise been vaccinated. Overall, contraindications to any specific vaccine are rare, and lack of uptake is more likely to stem from passivity or deliberate choice. This creates inequity in the burden of risk and benefit. Minimizing own burden or risk in situations of high herd immunity becomes a tempting but, arguably, a self-centred choice. This can also create a dilemma for health care personnel when providing advice and brings into focus the tension between the desire to enable the exercise of individual choice and maintaining near universal uptake. Measures advocated to maximise uptake vary by the extent they employed persuasion, inducements or enforcement. Recently, the question of compulsory vaccination has come to the fore in relation to measles (in response to outbreaks) and influenza (vaccination of health care workers) (13, 14) . Relevant here is that population vaccination campaigns are typically designed to deliver high-volume at low cost, with little Women who are unable or unwilling to follow clinical advice may place themselves and, inturn, their babies at some risk. Whether non-concordance is voluntary can influence perception of moral agency. The status of pregnant women and unborn babies and the concern, interest or support afforded to them by society has changed over time and will necessarily continue to evolve in response to cultural and economic factors. Much of the infection burden is preventable. This begs the question of moral responsibility and the duties of the woman herself and of society at large to the welfare of the baby or to future generation. This is a contentious area that has been valued differently by different cultures and jurisdictions. Mill's standpoint referred to above views intervention as justifiable only if for preventing harm to others. But whether and how this may be applicable in pregnancy is debatable. First, the place of the unborn within this framework is contentious and second, because the exercise of power against a person's will is a threshold that is unlikely to be relevant to situations where failure to comply with recommendations is the product of apathy or competing priorities, rather than it being a considered expression of autonomous choice. It is arguable whether the prohibition contained in Mill's argument applies to interventions or intrusions short of coercive enforcement. Relevant to the question of prevention of infections in pregnancy is the role and duty of pregnant health care workers who can be at risk of catching infection whilst caring from affected patients. A certain risk of contagion can be seen as inherent in providing health care. However, the level of acceptable risk is relevant to its degree, severity of consequence and the degree by which this may be mitigated. Thus, the level of acceptable risk it is a matter for debate. One recommendation put forwards is for universal screening for HIV, hepatitis B and syphilis early in pregnancy and for selective prenatal screening targeting higher risk women for hepatitis C, chlamydia, gonorrhoea and tuberculosis (15). The critique of health screening at the interface with personal liberty and self-determination is relevant here. In addition, there is a need to consider whether efforts directed at detecting infections is primarily focussed or motivated by concerns for the woman herself, her unborn baby or by other societal concerns such risk of contagion or cost. Whilst many of these issues are interlinked and can be relevant, it is important to analyse underpinning assumptions in order to appreciate their relevance or relative contribution to ethics deliberation. Targeted screening requires judgements that blur boundaries as it confers advantage (and burden) selectively. Those not included within the programme may benefit from a universal service. Determinations around cut-off points or other selection criteria involve value judgements. The method of payment for services and the locus and mechanism for decisionmaking are relevant to deliberations. Women may be asymptomatic whilst harbouring infections with significant implications. Hepatitis C infection for example is associated with preterm labour and delivery, intrahepatic cholestasis, gestational diabetes, and postdelivery neonatal abstinence syndrome. There is a risk of in-utero-and intrapartum transmission. Until recently, hepatitis C had no effective treatment without a significant risk of teratogenicity. This, together with cost implications were used to argue against universal screening and in favour of selective testing for high risk women (16) . The more recent availability of protease and polymerase inhibitors raised the prospect of effective treatment during pregnancy (17) and generated calls for universal screening. The remaining uncertainties about safety in pregnancy and the fact that these drugs are not licensed for use during pregnancy, raise question of ethical and medico-legal import. Relevant here is the way antenatal tests come to be administered as 'routine'. Women often do not know the value or rationale for antenatal tests and rarely question them. The resource intensive provisions for opt-in HIV/AIDS testing introduced in the UK prior to the discovery of effective treatment have now been incorporated into routine care, with women able to optout. The distinction between opt-in and opt-out testing is rarely considered except for high profile illnesses. The effect of infections ranges from asymptomatic to severe or life threatening. The severity of fetal and maternal affection may not correlate. The fetus may remain unharmed -provided This status varies in different societies and over time. Pregnant women often receive support or unique entitlements that facilitate their access to health care. Whether health care structure reflects societal values and how these structures ought to interface with individual choices are matters for debate, but understanding these points clarifies the framework in which healthcare professionals' practice. Infections may be regarded as a matter for collective responsibility and endeavour or be consigned to individual resourcefulness or motivation. Whether societal interest is rooted in compassion, concern for the inescapable monetary or human cost, or in third party interest can have a strong influence. The approach adopted by different societies or healthcare systems will inevitably vary, but there will remain an inescapable need for collaboration in the face of outbreaks, epidemics or pandemics. J o u r n a l P r e -p r o o f given the reports of survival amongst those judged to be extremely ill. The degree of priority given to pregnant or postpartum women is rarely made explicit. Still, there is evidence of racial and age-related differences in outcome amongst peripartum women. In emergencies such as acute fetal distress the time required to don personal protection equipment or to allow for ventilation air exchange can significantly impact outcomes which places considerable burden on health care personnel when faced with choices that can put their own safety at risk. Ethics and infectious disease Prevention is better than cure. Our vision to help you live well for longer Compelled Medical Treatment of Pregnant Women. Life, Liberty, and Law in Conflict The use of legal action in New York City to ensure treatment of tuberculosis Compulsory vaccination and growing measles threat Liberal legislation and freedom of contract Public Health in England. The report of the committee of inquiry into the future development of the public health function Health promotion, models and values United Nations Department of Public Information Principles of Biomedical Ethics Should measles vaccination be compulsory? Mandatory flu vaccination won't fix the NHS Hepatitis B and C in pregnancy: a review and recommendations for care Hepatitis C in pregnancy in the era of directacting antiviral treatment: potential benefits of universal screening and antepartum therapy Woman who was refused an abortion died as result of "medical misadventure This article highlights questions of the moral responsibilities of the pregnant woman, the legitimate limits of her autonomous choice and whether society has a right or duty to interfere in the name of welfare or public good in contentious issues that are relevant to prevention, diagnosis and management of infections in pregnancy. The impact of infections varies, and the severity of maternal affection may be at variance with the effect on the baby. The author declare that he has no conflicts of interest. None received.