About 16.1 million adults in the U.S experience at least one major depressive episode in a year, and nearly 1 in 8 women experience depression in their lifetime. In the article “Weighing Risks and Benefits of Prescribing Antidepressants during Pregnancy”, a young woman, Rebecca, presents to her doctor after recently learning she is pregnant. While her pregnancy was unexpected, she decides to continue it, however an issue presents given her current medications. Her doctor, Dr. Krieger, has been prescribing Rebecca Paxil for the past 8 years to control her depression symptoms. Prior to the 8 years, Rebecca had tried a number of different antidepressants, including Prozac, Lexapro, and Effexor, but none seemed to work for her and it wasn’t until beginning Paxil that she was able to feel more like herself and enjoy life. During this visit, Dr. Krieger expresses concern for Rebecca’s continued use of Paxil through her pregnancy because while some studies have shown no harm with its use, others have shown evidence that Paxil may put the fetus at risk for a congenital heart defect. Dr Krieger recommends being on the safe side and discontinuing Rebecca’s Paxil use during the remainder of her pregnancy. Rebecca, however, is not a fan of this plan and although wants her baby to be healthy, she is worried about having a recurrence of her depression during her pregnancy. Since Rebecca is due for a refill on her prescription, a decision must be made on whether to renew that Paxil prescription. Despite Dr. Krieger’s desire to follow the ethical principle of nonmaleficence and do no harm to the fetus, Rebecca’s autonomy to continue her paxil prescription should outweigh this because ultimately, discontinuing the paxil is able to also cause harm to both the mother and baby if her depression once again returns and worsens. 

Under the principle of autonomy, a patient has the right to choose or refuse specific treatments. Rebecca possesses the competence to make her own decisions, thus her opinions toward her own health must be taken into consideration. After hearing about the potential risks, despite the evidence of potential congenital heart defects to the fetus, Rebecca believed that her symptoms and the possible effects that suffering from a depressive episode during her pregnancy can have on both her and the fetus. When making this decision, one must also take into consideration the effects that a return of the depressive episodes may have. It is possible that she can become a risk to not only herself, but also to the unborn baby if her medication prescription is changed and her symptoms regress. It can be argued that stopping Rebecca’s Paxil prescription, despite her disapproval of this plan, can be considered doing harm to the patient. After years of trying alternatives, a treatment that works for her and helped her out of a dark place was found. By removing this treatment, it can be considered doing harm because of the possible implications that her symptoms may regress since other treatments have not worked for her in the past. 

On the other side of this issue, some may believe that it is Dr. Krieger’s ethical duty of nonmaleficence to not to renew the Paxil prescription because of the potential harm on the fetus. In this situation, they may argue that non-maleficence toward the fetus should trump the patient’s autonomy. In an optimal situation, Rebecca would switch over to a different SSRI to ensure the fetus is not exposed to anything that may harm its development; however, optimal situations are not always possible or the best option. While it can be said that continuing Paxil is not in the best interest of the fetus, the same can not be said for Rebecca’s interests. When considering nonmaleficence vs. beneficence it must be considered, who exactly is the patient here. Is it the fetus, the mother, or both? Arguably, if we answer with the fetus, then Dr. Krieger’s duty of nonmaleficence would point her towards not renewing the prescription, however if we answer saying it is Rebecca, Dr. Krieger’s duty of beneficence may point her towards renewing it. It is important to acknowledge these potential risks and even more important that the mother, Rebecca, fully understands these risks, benefits, implications and alternatives to treatment. 

Considering that the fetus is not yet viable, the mother’s rights should be prioritized. While some will consider the previable fetus a patient, it is true that the fetus is not able to be treated independent of the mother. I urge you to consider this – if Rebecca were not pregnant and presented for the renewal of prescription there most likely would have been no debate as to whether or not to renew the prescription. However, her pregnancy raises an issue and despite her strong desire and right to continue her treatment with the only medication that has provided her symptomatic relief, Dr. Krieger still faces an ethical decision. If the pregnant patient’s autonomy is not taken as precedent in this situation, does this mean that a pregnant woman has less rights to autonomy than a non-pregnant woman? Patient autonomy should be prioritized in this situation and Rebecca’s prescription should be renewed so that her depression does not recur and put both her and the fetus at further risk. 

References

Mahowald M. B. (1992). Maternal-fetal conflict: positions and principles. Clinical obstetrics and gynecology, 35(4), 729–737.

Silverman, B. C., & Gross, A. F. (2013, September 1). Weighing risks and benefits of prescribing antidepressants during pregnancy. Journal of Ethics | American Medical Association. Retrieved June 20, 2022, from https://journalofethics.ama-assn.org/article/weighing-risks-and-benefits-prescribing-antidepressants-during-pregnancy/2013-09 

Women and depression. Women and Depression | Anxiety and Depression Association of America, ADAA. (n.d.). Retrieved June 20, 2022, from https://adaa.org/find-help-for/women/depression