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?:abstract
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Challenges arise when treatment to improve maternal health brings the possibility of risk to fetal health. COVID-19 vaccine is the most recent, but hardly the only example. Because pregnant patients are often specifically excluded from trials of new therapies, this is often the landscape facing patients and providers considering new treatments. In this piece we use COVID-19 vaccine as an exemplar to interrogate the broader issue of how society in general, and obstetricians in particular, should balance obligations to pregnant women\'s right of access to new therapeutics with the physician\'s desire to protect the fetus from potential risks. We will argue that in almost all circumstances (with few exceptions, as will also be discussed) maternal benefit and respect for the autonomy trump the uncertainty that absent safety data bring. Consequently, we believe that pregnant patients should be offered and supported if they choose interventions and treatments such as COVID-19 vaccination. Finally we will also argue that the right solution to avoid the dilemma of absent data is to include pregnant individuals in clinical trials studying new treatments, drugs and other therapies. We will also discuss the basis for our opinion, which are mainstream obstetrical ethics, precedents in law (Supreme Court ruling that forbids companies from excluding women from job site even if it poses a risk to the fetus), and historical events (Thalidomide). The ethical framework includes that supposition that sacrifice to improve fetal outcome is a virtue but not a mandate. Denying a pregnant patient treatment for threats to their life can create absurd and paradoxical choices. Either requiring abortion or premature delivery before proceeding with treatments to optimize maternal health, or risking a patient\'s own life and ability to parent a child by delaying treatment, bring clear and significant risks to fetal and/or neonatal outcome. With only rare exceptions, balancing such consequential choices cannot properly and ethically be undertaken but by the pregnant patient in the context of their own values and goals with active participation of their physician in shared decision-making.
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