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Gac Méd Caracas S289
Coronavirus, maternal fetal care and bioethics
Drs. Carlos Cabrera Lozada1
, Jeiv Gómez2
, Pedro Faneite Antequi3
Gac Méd Caracas 2020;128(Supl 2):S289-S300 ARTÍCULO ORIGINAL DOI: 10.47307/GMC.2020.128.s2.16
RESUMEN
La pandemia por la infección por el nuevo coronavirus
(SARS-CoV-2) durante el embarazo conlleva
problemas bioéticos potenciales en obstetricia crítica,
asesoría prenatal y decisiones sobre la interrupción
de la gestación y vía de resolución obstétrica. La
atención materno fetal utilizando la medicina
basada en evidencias del equipo de salud en MMF,
en conjunto con disciplinas asociadas como la
epigenética y la inmunología perinatal, debe utilizar
valores bioéticos, guía y protocolos productos de
consensos multidisciplinarios junto con la asesoría
de comités de bioética, donde es indispensable
manejar los principios de beneficencia y respeto por
la autonomía además de la consideración del feto
como paciente particularmente cuando hay viabilidad.
El uso del diálogo esclarecedor y el juicio clínico
deliberativo reflexivo tomando en cuenta los hechos,
valores y deberes para tomar decisiones es la pauta
ética y humana a seguir ante el tremendo desafío
que representa la pandemia durante el embarazo en
América Latina.
Palabras clave: Bioética, coronavirus, SARS-CoV-2,
atención maternofetal.
SUMMARY
The novel coronavirus (SARS-CoV-2) pandemic
infection during pregnancy brings potential bioethical
issues in critical obstetrics, prenatal counseling,
and making decisions over pregnancy termination
and delivery. Maternal-fetal care using evidence- based medicine from the MFM health team, along
with disciplines such as epigenetics and perinatal
immunology, should use ethical values, guidelines, and
protocols born of multidisciplinary consensus provided
along with ethical committees assistance, where it is
essential to apply the principles of beneficence and
respect of autonomy, in addition to fetal consideration
as a patient, particularly in presence of viability. Using
enlightening discussion and reflexive prudent clinical
judgment taking into consideration facts, values, and
duties to make decisions is the ethical and human
guideline to face the tremendous challenge represented
by the pandemic during pregnancy in Latin America.
Key words: Bioethics, coronavirus, SARS-CoV-2,
maternal-fetal care.
INTRODUCTION
The pandemic occasioned by the disease
known as COVID-19, disease originated from a
coronavirus that appeared in 2019 (SARS-CoV-2),
related to the reports of cases from November
of that year in the city of Wuhan, province of
DOI: https://doi.org/10.47307/GMC.2020.128.s2.16
1
PhD. Ms.Sc. En Bioética. Director del Programa de
Especialización en Medicina Materno Fetal. Universidad
Central de Venezuela. Caracas, Venezuela. 2
Médico Especialista en Obstetricia y Ginecología, Medicina
Materno Fetal. Coordinador del Programa de Especialización
en Medicina Materno Fetal, Universidad Central de Venezuela.
Sociedad de Medicina Materno Fetal. Caracas, Venezuela 3
MD. PhD. Especialista en Obstetricia, Ginecología y Perinatología.
Individuo de Número de la Academia Nacional de Medicina
de Venezuela.
Correspondence: Carlos Cabrera Lozada. ORCID: 2-3133-5183
E-mail: carloscabreralozada@gmail.com
Recibido: 24 de julio de 2020
Aceptado: 16 de octubre de 2020
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CORONAVIRUS, MATERNAL FETAL CARE AND BIOETHICS
S290 Vol. 128, Supl 2, diciembre 2020
Hubei, China, and people that visited the city’s
market (1-5), is the first topic of discussion of
professionals related to biomedicine. Such a
situation was formally notified by the People’s
Republic of China’s health authorities to the
World Health Organization (WHO) in late
December of 2019. One of the most unsettling
questions for any professional or participant in the
disciplines dedicated to health care in maternal- fetal medicine (MFM) in Latin America has
the following formulation: Is the maternal-fetal
health care team prepared for the big challenge
of the attention of patients with COVID-19?
To paraphrase Kant (6), the previous
conundrum is related to the illustrious three
questions formulated in relation with the interests
of reason: What can I know?, What should I do?,
What am I allowed to expect?
To start with the answers to these questions
we first need to remember the conception of
contemporary medicine and in particular, the
conception of MFM. According to León (7),
medicine is a practice endowed with a necessary
humanistic and moral orientation. The science
and technique progress, just as the art state, that
amplifies the capacity of attention and health care,
raise proportionally the necessity of subordinate
its use to increasingly ethical demands.
MFM by Cabrera et al. (8), is born from the
need for prepartum vigilance, even from the
preconception period of the mother-fetus pairing.
For this, diverse clinical and paraclinical resources
must be available, including biochemical,
hormonal, radiologic, ecographic (with doppler
and volumetrics), electronics, amniotic fluid
parameters, in such a way that they allow
to considerably decrease the maternal-fetal
morbimortality.
In these times of pandemic for the COVID-19,
that represents a public health crisis, experts
in bioethics such as Seoane (9), highlight the
multiplicity of languages such as the warlike
language that occupies a large part of the
governmental speeches and predominates in
areas such as the communicational (“the war
against the coronavirus”, “the invisible threat”);
the scientific language, closer to MFM, used to
inform the evolution of the population’s health in
statistic terms; or political language, to transmit
the social, economic and organizational measures
adopted.
The bioethical approaches can contribute
to solving the mistakes arisen from a warlike
conception of SARS-CoV-2. “Crisis” comes
from the Latin crisis, that comes from the greek
krísis, which means decision, what the deduction
entails is that this situation doesn’t require to
combat an enemy but to have a deliberative and
reflexive sense to make good decisions that direct
to an accurate intervention with a scientific and
clinical component against the virus, as well as
personal, social and economic measures (9).
War is not apart from civilization; not
everything counts and not even the final goal
(saving lives) justifies any means chosen to
accomplish it. Even in war, we act in a moral
world, and even though concrete decisions are
hard, problematic, or atrocious, our language
mirrors our moral world and allows us to formulate
shared judgment (9). In particular, every medical
decision derives in an ethical decision that requires
the elaboration of value’s judgment as well as
rational judgment consequently the bioethical
considerations in every scenario related to MFM
must come together with medical professionalism
with its four components (specialized knowledge,
autonomy in the making of decisions, social
service commitment and autoregulation).
Seoane (9), analyzes that for the construction of
the decisions that the deliberation is the language
of Bioethics and the method of the clinical ethic.
Reflected if acting and deciding prudently, in a
flexible manner going from concrete to single.
Consequently, a health care professional in MFM
should not rest on intuition, experience, theoric
knowledge, imitation, or common sense so that the
decisions during the pandemic in MFM reach the
range of science. The method to make decisions
must be structured in three levels: facts, values,
and duties (10-12). As such, deliberative prudence
in MFM would opt for the intermediate ways that
harmonize every valor involved, rejecting the
extreme courses of action, born from the belic
approach and language.
In this line, Seoane refers that “saying
something is doing something”, because language
determines the behavior of the person, configuring
the social reality. Thus, the language of
deliberation receives the minorities or discordant
voices and fosters constructive dialogue in the
decision (9,13-17).
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CABRERA LOZADA C, ET AL
Gac Méd Caracas S291
The situation for MFM in Latin America
could be resumed in what was announced by
Esparza (1), “The pandemic of COVID-19 is
only starting and probably the worst has yet to
come. Although we should wait for the better,
we have the duty to prepare for the worst. Which
makes necessary to answer with energy to the
epidemic of COVID-19 is not what we know about
it, but what we don’t know” The epidemiologic
behavior of COVID-19 is different in its attack
and lethal rate according to the country and region
affected; because of this, the planned scenario
for the preparation of the sanitary system in its
different attention levels are diverse, as happens
for instance in China, where the province of
Hubei differs considerably from the rest of the
country (18).
Although it is the initial stage of knowing the
implications of COVID-19 during pregnancy,
partum and postpartum, there are reports
about pregnant women with COVID-19
infection with repercussions in their pregnancy
and clinical, radiologic and paraclinical
characterization in comparison with patients
without pregnancy (19-21). Even if there are
international clinic protocols, of organizations
like the ones from the International Federation of
Gynaecology and Obstetrics (FIGO as the acronym
for its French name), or the International Society
of Ultrasound in Obstetrics and Gynecology
(ISUOG) or Society for Maternal-Fetal Medicine
(SMFM) with varying grades of standardization,
addressing the initial approach for the health
care professionals in MFM, there is still much
to know and uncertainty predominates around
the therapeutic and prognosis in the mother- fetus pairing, vertical transmission possibility,
congenital abnormalities or other disorders in
medium and large term (22-24). In the same
way, WHO recommends prioritizing maintaining
the services of sexual and reproductive health,
including the attention during pregnancy and
partum using design mechanisms and simple
goals in the coordination and governance of
the answering protocols, identifying relevant
services, optimizing the health attention centers,
establishing the effective flow of patients in
every level, quick redistribution of the capacities
in the health care team, keeping the availability
of health supplies, equipment and essential
consumables (25).
Latin America can follow orientations from
the Pan-American Organization of Health
(Organización Panamericana de la Salud, OPS)
and the bioethics network from the United Nations
Educational, Scientific and Cultural Organization
(UNESCO) about the ethical duty of the health
care providers in MFM in giving the best attention
possible and doing so in an equitable form; of
each State in having systems with universal
access and coverage to fulfill the right of health,
without resources restrictions, with advice from
bioethics commissions and civil societies in
the attention of vulnerable populations such
as pregnant women, eliminating individualist
behavior, fostering the use of ethical and clinical- scientific criteria, based in equity, cooperation,
solidarity and no discrimination (26,27). The
magnitude of the situation is as the grave that,
for April 10th, 5 months after the first cases in
China, the situational report from WHO refers
to 1 521 252 cases confirmed with 92 728 deaths
globally, which 493 173 confirmed cases and
17 038 deaths are from America (28). Potential
problematic situations exist that urgently need
a bioethical approach in the attention of MFM
during the pandemic of COVID-19 in Latin
America such as the admission criteria in critical
obstetrics, prenatal counseling of the infection of
SARS-COV-2, and the decision of interruption
of pregnancy and obstetric resolution.
DISCUSSION
Bioethics y Critical Obstetrics
Even though it is complicated doing estimations
of the proportions of COVID-19 in pregnancy
and its impact on the capacity of the sanitary
systems in Latin America, specifically in the
availability of critical obstetrics or intermediate
care beds in MFM, experts in bioethics such as
Emanuel et al. (29) refer that it can be predicted
in statistic models, that the infection of SARS- CoV-2 is in 80 % of the cases asymptomatic or
mild symptoms, of the 20 % left, 15 % have a
serious illness and 5 % critical disease in the
general public. Including conservative models,
even the 5 % of the population in a country like
the United States of America infected in the
following 3 months after the first case in that
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CORONAVIRUS, MATERNAL FETAL CARE AND BIOETHICS
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country take for granted (except in the flattening
of the epidemiologic curve of infected individuals
for a long period scenario) shortage of hospital
beds, intensivists, beds in intensive care and
ventilators.
This scenario of a shortage of sanitary
resources for the pandemic is given in a country
with 5 918 community hospitals and 209 federal
hospitals with 96 500 beds in intensive care, which
23 000 are for neonatal and 5 100 pediatrics with
62 000 ventilators with a range between 10 000
to 20 000 are permanently in use. By the end
of March 2020, with the Johns Hopkins CSSE
data contributed and updated every 24 hours it
was estimated that such numbers could increase
in new cases up to 35 % each day after a country
reaches 100 confirmed cases, although the use
of the logarithmic scale can compare more the
growth of the pandemic between countries, the
use of the lineal scale allows to evaluate the
real human impact (30). The reflection of the
Hastings Center remains valid: “The traditional
approach of analysis of cost-benefit excludes
formal considerations of distributive effect, of the
type of equity and justice. Although discrepancies
exist between the economists on how to resolve
this problem, the equity considerations probably
keep being underestimated in practice” In other
words, in the topics related to sanitary justice,
ethic neglects economy and politics, and these,
separate from ethic when they don’t opt to replace
it (31,32).
Thus, it is imperative to have certain
preconceptions of the ethical considerations
for a just distribution (equitable) of limited
resources during the pandemic of COVID-19 to
the obstetric population, to make conciliatory
multidisciplinary approaches with politics and
economic approaches. Emanuel et al. (29), refers
that bioethical values for the assignation of limited
sanitary resources in the middle of the pandemic,
even though the different sanitary models in Latin
America, can’t be bypassed because they lead
to better results without leaving the justice that
influences the Latin American macro bioethic :
a) Maximize benefits: Save most lives, maximize
the prognosis (save the most life years
possible) have a higher priority.
b) Treat people equally: The first come first
served guideline should not be used but instead
the selection prioritizing the pregnant patient
with a similar prognosis.
c) Promote and reward the instrumental value
(benefit to others): In retrospective, give
priority to those that have made relevant
contributions in prospective form, give
priority to those to those that most probably
will make relevant contributions; for example,
expectant mothers from sectors that maintain
operative infrastructure during the pandemic
such as civil or military security personal,
health care sector and others. Under this
consideration, give priority to the participants
in investigations, when other factors such as
maximizing benefits are equal.
d) Give priority to the worst: The guidelines
that prioritize the sicker and younger are used
when they are aligned with higher benefits,
in particular, the polemic point of younger
expectant mothers first if it can prevent the
dissemination of the virus.
They realize six recommendations in
consonance with these four value considerations,
which is deeply important for critical obstetrics
the following recommendations, that the authors
consider important to highlight: a) give priority
to health care workers and those sectors that
maintain critical infrastructure operative for
pregnant women, in centers with MFM about
the use of personal protection equipment (PPE),
diagnostic tests, prophylaxis and treatment,
availability of beds in intensive care, potential
vaccination; b) It should not be a difference in
the disposition of limited resources (like the
beds in intensive care and ventilators) between
patients with COVID-19 and others with other
conditions that require urgently availability of
resources in critical obstetrics, such as patients
with postpartum hemorrhage, hypertensive
disorders of pregnancy or sepsis.
To give shape in clinical scenarios closer to
our experience during the pandemic, about the
making of ethical decisions regarding critical
obstetrics, it is better to follow the criteria of
classification of priority established by the
Sociedad Española de Medicina Intensiva,
Crítica y Unidades Coronarias in the context
for the crisis of COVID-19 (33):