Knowledge and risk

The increased presence of obstetricians and the introduction of technology to prenatal care altered the management of pregnancies and in turn, the relationship between doctors and pregnant women. Prior to ultrasounds and prenatal tests, information regarding fetal health was gained from a description of bodily symptoms provided by the pregnant woman.5 However, as technology has provided obstetricians with access to the fetus, the information exchange between doctors and pregnant women has changed. While women could retain some authority regarding bodily symptoms, many pregnant women now seek out the technologies for assurance of fetal health.7 8 They rely on obstetricians and other healthcare professionals to interpret and relay the results of scans and tests in order to provide them with knowledge of their fetus. Therefore, any authority that the pregnant woman has in the doctor–patient relationship is undermined by the technology, which can alienate women from the management of their pregnancies. With the expanded knowledge that prenatal technologies provide, the expertise regarding the fetus has shifted from the pregnant woman to the doctor, making women more dependent on doctors to confirm the status of changes occurring within their own bodies.

The increased presence of obstetricians is also claimed to have resulted in more pregnancies being deemed as a risk and consequently pregnancy has become more monitored and controlled.9 As a result, fixed medical time frames have been applied to pregnancies, allowing doctors to dictate when pregnancy begins and ends.10 These time frames are used to justify further technological interventions when the medical timings are not being conformed to.10 A standard pregnancy and childbirth ‘norm’ has thus been created,11 which ignores the variability of the experience for different women and has again made women reliant on doctors to confirm if their pregnancy is developing ‘normally’. Empirical studies have found that women feel pressured to comply with both medical and social expectations of accepting an induction when becoming overdue.12 They feel they have little choice in the management of the prolonged pregnancy with induction assumed to be inevitable.12 A study by Ross further indicated that women question bodily sensations in the early stages of pregnancy if they do not align with medical timelines, as well as the experiences of family and friends.13 Therefore, women are further reliant on doctors as they become influenced by a medical model of pregnancy.

The introduction of ectogenesis could exacerbate these issues and cause women and other intended parents to feel like they have even less authority in the doctor–patient relationship. In cases of partial ectogenesis, the information exchange between doctors and pregnant women is unlikely to be much different during human gestation. However, once the fetus is transferred to an artificial womb, the woman is likely to become more reliant on the doctor for information regarding fetal health as she will no longer have any physical connection to it.

Similarly, in cases where the fetus is fully gestated externally, there is little information that the woman can provide to the doctor, since her body is no longer engaged. In both full and partial ectogenesis, an artificial womb is likely to be a medical and technological minefield to lay people.² While it is expected that doctors would have more expertise in medical technology, the lack of understanding, in addition to no physical connection to the fetus, may exacerbate feelings of alienation from the reproductive process. With the balance of expertise shifted in this way, doctors may feel they have more authority in the relationship. Ectogenesis may also provide doctors with more control regarding timeframes as the development of the fetus will no longer be restricted by a human body. Again, more expertise will be placed with doctors as they become increasingly familiar with the development of the fetus and intended parents once again rely on their expertise.³

Prenatal testing

A further issue resulting from medicalisation has been raised by Jackson, who argues that the development of more accurate diagnostic tests have led to a trend towards routine prenatal testing.9 The routine nature of such testing raises concern over whether women are in fact consenting to the tests and if so whether they know what it is they are consenting to.14 The amount of information that can be collected through prenatal tests has expanded and the tests themselves have become less intrusive. For example, detecting genetic or chromosomal conditions in a fetus through amniocentesis involved inserting a needle into the abdominal wall of the pregnant woman in order to extract amniotic fluid. Such a procedure carries a small risk of miscarriage and can be uncomfortable for the pregnant woman.15 However, non-invasive prenatal testing can now detect the same conditions, and potentially many more,16 in the maternal blood stream, with a blood test being taken at an earlier stage in the pregnancy. While the discomfort is reduced for pregnant women and the earlier results can provide more options for women in relation to termination decisions,16 there is concern that the ease of the test can result in an assumption being drawn that all women will consent to it.16 This further alters the dynamics between doctors and pregnant women, as all women come to be treated the same as opposed to individuals with variable needs and desires.

While the type of testing and procedures available with ectogenesis are not yet clear, full ectogenesis, in particular, may eliminate some of the physical concerns regarding consent as a woman would not need to subject herself to treatment or tests for the sake of the fetus. However, if there is no longer any discomfort to a third party, and the risks are proven to be relatively small for the fetus, any refusal of testing from the intended parents may be harder to defend. They may, therefore, feel pressured into proceeding with recommended testing. This could also apply to cases involving partial ectogenesis, as some testing may become available that was not possible during human gestation.

Consent issues may also still arise when it comes to the intended parents understanding information being presented. Having intended parents fully understand the intricacies of an artificial womb and the treatment and testing options available through this technology could be difficult and as a result they may not understand if and what options are available. This, along with the potential pressure to comply, may result in intended parents, much like pregnant women, feeling in a weaker position to the doctors, resulting in them consenting to testing and procedures presented as routine.⁴

Expectations

Technology may have further impacted the relationship between women and doctors by increasing the expectations of medicine. Johanson et al suggest that as science advances, the belief that the medical profession can solve all ills or prevent all disasters increases.2 As a result, they claim that the increased medicalisation of pregnancy and childbirth is a result of defensive practice by the doctors.2 Due to the elevated expectations of pregnant women, doctors may be exercising excess caution and overusing available technologies. Cahill has further suggested that the visibility of these technologies provides ‘proof’ of the maternal and fetal care being delivered and as such both the public and politicians are reassured as to the use and allocation of resources.17

If ectogenesis is promoted as a healthier alternative to natural gestation for some women, which in itself has wider political implications,18–21 a belief that more medical difficulties can be overcome may be encouraged. As a result more disputes may arise between doctors and intended parents when it comes to treatment decisions, as parents try to insist that more can be done.4 For full ectogenesis, parents may have higher expectations for the health of the fetus if it was presented as safer than human gestation and with partial ectogenesis, women may try to demand that their fetuses be transferred to an artificial womb to improve prognosis for identified medical conditions. The breakdown in relationship between doctors and families has previously been evidenced in court proceedings,22 and a recent briefing note from the Nuffield Council on Bioethics has indicated that a feeling of powerlessness by parents can contribute to the strained relationships.23 Feelings of powerlessness may be exacerbated by a lack of understanding of the functioning of the artificial womb and therefore relationship breakdowns may increase between intended parents and healthcare professionals.

Information provision

The provision of information to the intended parents prior to any engagement with ectogenesis will be essential to limit the concerns outlined above. This may take the shape of preparation classes, much like antenatal classes, and if ectogenesis becomes a mainstream option for gestation, the function of artificial wombs may also form part of sex education classes in schools.⁵ Providing the information prior to any use of the technology reduces the occurrence of situations whereby intended parents need to digest complex information in a time-pressured and stressful situation. In order to manage expectations, discussions should also focus on the limitations of ectogenesis. This will be particularly pertinent for early users of ectogenesis, during which the limitations may still be under review.

The next part of this paper considers the impact of medicalisation on the treatment of a fetus in a clinical setting and how this may be influenced by ectogenesis.

Fetus as a second patient

As well as a change in the relationship between doctors and pregnant women, the observational technologies have altered the doctor’s relationship with the fetus. The ability to look inside the womb has been said to have encouraged the fetus to be viewed as a separate entity, disassociated from the pregnant woman.5 24 As a result the fetus has come to be treated as a second patient during pregnancy and childbirth.5 The range of fetal surgery that can now be carried out further encourages doctors to view themselves as providing treatment directly to the fetus as opposed to the pregnant woman.5 Treating the fetus as a patient is also likely to be driven by a doctor’s knowledge that should they injure the fetus as a result of negligence and the fetus goes on to be born alive, the doctor can be sued for the injuries.25 This may further account for the defensive use of prenatal technologies discussed above. This medicalisation of the status of the fetus could potentially be damaging to the autonomy of pregnant women, as their desires may be overshadowed by the needs of the fetus.

Tensions relating to a fetus being treated as a patient by doctors are driven by the fetus’ position within a pregnant woman. As ectogenesis presents an opportunity for the fetus and woman to be separated, it may be argued that treating an externally gestated fetus as a patient would not be controversial.⁶ Any treatment provided to the fetus would not physically impact the woman and there would be no need to balance the fetus’ needs with the bodily integrity of another. It, therefore, appears that ectogenesis could provide a solution to fetal status in the medical setting as a doctor can pursue their duty of care towards the fetus as a patient.⁷

Legal status of the fetus

Guidance

While ectogenesis appears to lighten the conflict of duties to mother and fetus, the existence of both natural pregnancy and ectogenesis raises new challenges for doctors in their treatment of a fetus. Should ectogenesis, in any form, translate to clinical practice, clear legislation and guidance will be necessary for doctors to ensure that they uphold a fair and appropriate standard of care for all patients.