Don’t throw out the baby with the antenatal consultation!

While respecting autonomy: don’t throw out the baby with the antenatal consultation!
Michael van Manen

Antenatal consultation is recognised as a core activity of specialists in neonatal–perinatal medicine. Fundamentally, the intent is for practitioner and parent to meet prior to the birth of a child to contribute to the care of the mother and also the newborn. Antenatal consults may therefore serve a multitude of purposes such as obtaining informed consent, relieving parental anxiety, elaborating medical treatment plans and supporting parenting practices depending on the various situational and contextual factors underlying the consult.

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Gaucher and Payot propose a model for antenatal consultation, ‘relational autonomy’, whereby they encourage clinicians to explore and support patient experiences through trusting and empowering relationships [1]. Relational autonomy is presented in opposition to past individualistic models of autonomy that are historically rooted in the philosophy of Immanuel Kant. Of course, it has always been questionable whether people can truly be autonomous in their moral actions and ethical decisions in practical circumstances. Moral principles at times are too abstract to give practical guidance in everyday life, especially in the context of health care. And yet, however limited the concept of self-responsible autonomy must be, we cannot do without it. Therefore, a relational autonomy model has merit as Gaucher and Payot rightly argue that an individualistic model risks compromising ‘the ethical imperative to care, support, or engage with patients in more meaningful relationships [1]’.

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What remains absent, however, from the model of Gaucher and Payot is that the relational ethics of antenatal consultation are complicated by the fact that an antenatal consultation needs to anticipate how the presence of the newborn may profoundly change the perinatal decision-making reality of all partners and players in the health-care setting. Health-care professionals know that the experience of making decisions for a baby may be quite different prior to and following birth. Decision-making is subject to contingencies, uncertainties and unsuspected sensibilities [2]. For many parents, discussing the withholding of medical treatments is a fundamentally different relational experience when a baby has been held and touched compared to prior to birth. The corporeality of the birth experience may change the parent’s emotional self and moral being. Health-care professionals too may be stirred by changed relational responsibilities to infants before and after birth. In other words, the birth of the newborn may alter everything (including the sense of autonomy). So, I would urge readers of Gaucher and Payot to consider that a ‘good’ antenatal consultation is not necessarily simply a consult that supports the relational autonomy of parent decision-makers. Rather, a ‘good’ antenatal consult anticipates and considers the increased relational complexities of parent, health-care professional and pointedly the newborn child.

1 Gaucher N, Payot A. Focusing on relationships, not information, respects autonomy during antenatal consultations. Acta Paediatr 2017; 106: 14–20.Wiley Online Library |
2 van Manen M. On ethical (in)decisions experienced by parents of infants in neonatal intensive care. Qual Health Res 2014; 24: 279–87.

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