Regulating medical decision-making: a qualitative study of fetal reduction in multiple pregnancy.

Abstract

This thesis examines and critically evaluates the regulation and practice of medical decision-making where the context is that of a multiple pregnancy and where the question is whether or not to carry out a fetal reduction procedure. Three principal lines of inquiry are pursued: first, to understand more about the nature of fetal reduction, its frequency, and the legal ground(s) for termination on which doctors typically rely; secondly, to assess the extent to which legal, ethical and professional norms guide and constrain this particular kind of decision-making; and, thirdly, to evaluate the adequacy of these norms. We use a critical realist lens to pursue our inquiries and to develop our analysis. With regard to the first line of inquiry, the evidence suggests that fetal reduction (however defined) is a relatively rare event (fewer than 150 such reductions being undertaken each year) and that, by way of contrast with everyday terminations where the justifying ground is usually descriptively medical, it is fetal abnormality that is often given as the justifying ground. In relation to the second line of inquiry, analysis shows that the legal, ethical, and professional norms offer little explicit guidance in relation to fetal reduction. In relation to the general question of termination, ethical norms suffer from a high level of contestation and a plurality of views, the key norms in the abortion legislation are both unclear and no longer properly connected to the practice of terminations, and professional norms are only marginally more adequate. Given the indeterminacy of these norms, it is no surprise that the empirical evidence indicates that doctors are only weakly guided by them in making their decisions about fetal reduction. In practice, doctors are guided by the views of their peers and by the sense that, in the final analysis, they will be held accountable and will need to be able to justify their actions. Responding to the third line of inquiry, a number of recommendations are made. In particular, it is recommended that the fetal abnormality ground is so problematic that it should be removed from the abortion legislation; and that professional and ethical norms, while recognising that there is a legitimate place for professional medical discretion, should emphasise the importance of shared decision-making and patient- centred care.