Whose Health Matters Most? Ethicality of Prescribing Teratogenic Medications During Pregnancy

Abstract

In cases where teratogenic medications are necessary for pregnant individuals, whose health matters most: the mother or the fetus? This paper will be looking at the ethical dilemma that arises as a result of this question, examining how pregnant individuals with chronic conditions such as bipolar disorder must weigh the risks of continuing a life-stabilizing medication such as lithium, which is known to have adverse effects on fetal development, against the consequences of discontinuing it on both the mother and child. The paper argues that women have the right to make informed decisions about their own health, even if those choices could affect their baby. By going off the medication, the mother is putting her own health at risk,k which can still lead to consequences for the fetus. It also looks at how different countries regulate the use of teratogens and whether governments should have the power to limit access based on the fetal risks. By examining a variety of situations and exploring principles such as autonomy, nonmaleficence, and justice, this paper shows the importance of respecting patient choice. The final question that guided my research was: How can maternal autonomy be ethically balanced with fetal well-being when treating chronic conditions with teratogenic medications during pregnancy, and what role, if at all, should the government play in these decisions?

Introduction and Historical Context 

The definition of a mother according to the United Nations is to be “the primary caregiver responsible for the health, nutrition, and early development of her child” (WHO). What happens when the health of the child conflicts with the well-being of the mother carrying them? This is a dilemma that has been faced by nearly 3.4 million women between 2006 and 2017 (Splett, 2022), due to the risks that have arisen from teratogenic medications. Teratogens are substances that could potentially produce physical defections in the human fetus if a pregnant woman is exposed to the substance (Chanapa, 2014). Many women, though, who take these medications are doing it out of necessity for their own health. Common teratogens include sodium valproate for lupus and acne, Topiramate for the treatment of epilepsy, migraines, and weight loss, and lithium for Bipolar Disorder (Valeii, 2024). These medications are highly effective in treating many of these chronic disorders, but if a woman taking them wants to become pregnant, they must also consider the possible risk to the fetus. Those who are pregnant with amentald disorder, such as bipolar disorder, must navigate the dilemma of continuing lithium to maintain their own mental health and stability versus suspending it to reduce fetal risks, potentially worsening their condition. The impact of teratogens can vary depending on several factors, such as how much is being taken, the duration, and when during the pregnancy the medication is being taken. Teratogenic influences during organogenesis, or the first trimester of pregnancy, can produce congenital effects as well as developmental effects. For example, while lithium is highly effective in preventing manic and depressive episodes, it has been associated with an increased risk of congenital heart defects in the fetus (Albertini et al., 2019; Patorno et al., 2017). The impact of teratogens cannot be overlooked, since history has proven that if left unchecked, they can have devastating consequences. 

Historically, teratogens such as thalidomide have led to severe impacts on the fetus with the thalidomide crisis, between 1957 and 1962, leading to birth defects in over 10,000 children around the world (Vargesson, 2015). Thalidomide was first introduced to the market as a sedative due to its effective nature in creating a calming environment for sleep. After testing, thalidomide was found to be very safe and nearly impossible, meaning that risks of death due to overdosing were not at all likely. So,n thalidomide became a very popular treatment as both a sedative and for morning sickness specifically during pregnancy (Rajkumar, 2004). Four years after the medication entered the market, a doctor named Widukind Lenz began believing that the medication was leading to defects in the fetus (Lenz, 1962); he had observed over 50 malformations in infants whose mothers stated they had been taking the drug during pregnancy. They finally took thalidomide off the market in most countries, but this was after thousands of children had already been born with defects such as absence of thumbs, phocomelia, defects in ear and eye development, and congenital heart disease (Donovan, 2018). In addition to these effects, thalidomide even proved to cause nearly 40% of affected infants to die within their first year of life. The impact of this teratogen cannot be understated, since it was later found that even a single pill was sufficient to produce teratogenic effects (Lenz, 1962). The impact of this drug was extremely detrimental, but in no way was the fault of the mothers, since they were unaware of the risk that taking the medication to help them would cause to their child. This crisis, though, led to the implementation of regulations of differing strength around the world. 

In the United States, thalidomide was never given FDA approval to be marketed due to the lack of safety data, even after applying for recognition (Kelsey, 2001). Once the teratogenic properties were made evident, the FDA approval was withdrawn. The significance of this event cannot be stressed enough due to its impact in altering the structure of the FDA to be clearer in its power. It was this incident that created the Kefauver-Harris amendments requiring the FDA to be responsible for approving drug safety and efficacy. Thalidomide did not end there, though; soon thalidomide’s impact on HIV-related wasting and aphthous ulcers became known, which resulted in the reevaluation of the drug's presence in the United States (Kim, 2011). Many people resorted to procuring thalidomide through “buyers clubs” and other illegal means,s resulting in efforts initiated by the FDA to make thalidomide legally available on a restricted basis in the United States (Lenz, 1962). Access to thalidomide through restricted FDA approval requires prescribing physicians to be enrolled in a program called the System for Thalidomide Education and Prescribing Safety (STEPS) program (Zeldis et al., 1999; Lary et al., 2012). The regulations, though, are even more strict for women of childbearing age who are required to undergo pregnancy testing every two to four weeks during treatment. In addition to this, women are asked to abstain from any sexual intercourse as well as use two contraceptive methods throughout treatment. They are asked to adhere to these rules for a month following their last dose of the treatment as well to prevent teratogenicity at all costs (Lenz, 1962). In this situation, it can be questioned whether or not the government's strict regulations limit the autonomy for a woman to choose to stay on a medication that benefits her during pregnancy or whether the government is potentially justified in doing so due to the proven risks to the fetus. 

While not necessarily on the same scale as the thalidomide crisis, women around the world continue to face the impacts of teratogens on their pregnancy, and many face the complex decision of choosing whether or not to continue their medication. The thalidomide crisis did not give these women the ability to choose since they were not informed of the risks,s nor were the companies distributing the medicine, potentially due to a lack of safety testing (Kelsey, 2001). Throughout the remainder of my project, it must be acknowledged that there are many circumstances, similar to the thalidomide crisis, in which we do not know if a drug is a teratogen. This is a result of pregnancy typically being an exclusion factor in clinical trials. For the sake of this paper, the research revolves around known teratogens and regulations that countries have already implemented as a result. Overall, this paper will investigate whether pregnant individuals should be held responsible for minimizing teratogenic risks at the cost of their autonomy. My final ethical analysis of this problem will be derived from specific cases focusing on Bipolar Disorder (I and II), with consideration to how the situation can change based on the chronic disorder or use of medication. Other medications that will be explored in terms of the global regulations throughout the world are Topiramate and Sodium Vaporate. I will explore the tensions that arise between religion, global regulations, the safety of both mother and fetus, and the influence of society in determining whether a mother has an ethical responsibility to stop using a known teratogen in order to protect her child's health, or whether she should prioritize her own well-being and autonomy. I will also consider what role, if any, the government should play in this decision.

The Case of Bipolar Disorder

Bipolar Disorder is, in many cases, a severe as well as chronic mental illness that uses medication to manage the symptoms by preventing mood episodes, including mania, hypomania, and depression. While off the medication, some bipolar disorder patients can face extreme risks of having a psychotic episode, suicidal ideation, and hospitalization (Grande et al., 2016). In addition to this, data have proven that bipolar disorders in women peak from ages 12-30 during the primary reproductive years (Epstein et al., 2014). There are different categorizations of Bipolar Disorder, which will be analyzed to ethically determine the various choices a mother might make and how they are potentially impacted by the severity of their specific bipolar disorder. Bipolar Disorder type I is categorized by depressive and manic episodes, whereas bipolar disorder type II is recognized for depressive and hypomanic episodes (Phillips, 2013). Bipolar disorder type II is typically considered to be more severe than type I due to various factors such as a more prominent history of comorbid anxiety disorder and personality disorder (Dell’Osso et al., 2015). In a study, it was found that while Bipolar Disorder II does present more severe symptoms in many cases, there are a few places where Bipolar Disorder I exceeds its counterpart. Bipolar Disorder I results in two main ways: firstly, through psychiatric hospitalizations and secondly through the prescription of psychotropic medications. Patients with Bipolar Disorder I were nearly 20% more likely to be taking antipsychotic or mood stabilizers such as lithium and sodium valproate (Dell’Osso et al., 2015). While the symptoms of Bipolar Disorder are considered to be more severe, it must also be considered which medications are necessary for Bipolar Disorder I versus II since they do have varying symptoms. 

Two medications that are highly effective and typically used to treat bipolar disorder are lithium and sodium valproate. They are both effective mood stabilizers that have high teratogenic risks. Lithium has been shown to have an association with Ebstein’s anomaly, which is a rare congenital heart defect. Sodium valproate is even more dangerous due to the increased risk of neural tube defects such as spina bifida, along with cognitive impairments, all being likely if taken during pregnancy (Iqbal et al., 2001). In this section, we will continue to discuss the potential implications of using lithium or sodium valproate during pregnancy and how this could change depending on the type of bipolar disorder the individual experiences.

Bipolar Disorder I (Lithium)

Research has shown that women with Bipolar Disorder I who discontinue their medication during pregnancy will face a high risk of relapse into a cycle of manic and depressive episodes, which would ultimately affect both the mother's health as well as the fetus. The relapse rate in Bipolar Disorder I during pregnancy approached nearly 50%, and the manic episodes also led to poor self-care, bad nutrition, and reduced prenatal care, which has led to preterm birth and low birth weight (Epstein et al, 2014). Untreated mania also increases the amount of risky behaviors a mother may have, such as substance abuse and sleep deprivation, which can also unintentionally bring harm to the fetus (Freeman, 2007). To stop taking medication if you have Bipolar Disorder can be detrimental to both your health and the fetuses' health. In reality, when considering the risk of taking lithium during pregnancy, it is significantly smaller (Rusner et al, 2016). Lithium is associated with an increase in cardiac deformities, but the chance of having a case of Ebstein's anomaly is very small, with the effect being around 1.5 cases for every 1,000 first-trimester exposure. This is a lot lower than the significant effects discontinuing the medication would have for both the mother and the child. For many women with this severe mania, continuing lithium may provide more benefits than the risks that would come with discontinuing the medication (Rusner et al, 2016). 

By looking at this situation through the view of utilitarianism, we begin to recognize that in this situation by the mother continuing her medication and technically choosing to prioritize her own healt,h she would also ultimately be helping her fetus as well. Due to the specific nature of Bipolar Disorder I, going off the medication would lead to more adverse effects for both of them. If the mother is not healthy that can also have effects on the baby, but we can weigh the differences of effects on the paper.  Therefore in the nature of helping the most people, utilitarianism would argue that this is the right decision. Considering deontology though we can once again consider what the definition of a mother is and wonder whether she has a responsibility to protect her child by using an “unnatural” means which could hurt the fetus. A deontological stance might argue it is inherently wrong to expose a fetus to known teratogens; simultaneously, it can be said that she has a duty not to abandon self-care. 

From a utilitarian perspective, one might argue that the primary goal should be to minimize harm to both mother and fetus, which would involve strict prescribing guidelines and clear communication of the risks. However, when considering the principle of autonomy, the situation becomes more complex. The right of individuals to make informed decisions about their own healthcare, especially regarding medications that may affect their reproductive health, is a cornerstone of medical ethics. Removing or limiting a person's autonomy in such a case could result in the erosion of their rights and dignity. Furthermore, making decisions about maternal health should not be done in a vacuum, considering only fetal well-being, as the health of the mother is integral to the success of the pregnancy itself. The notion of informed consent plays a critical role in these decisions. Ideally, pregnant individuals should be fully educated about the potential risks associated with any medication they take, including the possibility of birth defects or developmental issues. This enables them to make an informed choice about whether the benefits of a particular medication outweigh the risks.

Bipolar Disorder II

As previously mentioned, Bipolar Disorder II is characterized by depressive and hypomanic episodes. While these hypomanic episodes are considered less severe than mania and often require less medication, they are still vulnerable without it. Bipolar Disorder II, when not medicated, is often accompanied by poor self-care of the mother, poor nutrition, and increased suicide risk (“Bipolar disorder Information”). In comparison to lithium the sodium valproate has a significantly higher teratogenic risk of the fetus developing neural tube defects (Bodén, 2012). Unfortunately for Bipolar Disorder II it is difficult to even consider an alternative medication since medication such as lamotrigine is a lot more ineffective for depression prophylaxis in Bipolar Disorder II exposing women to relapse risks.

Understanding this may make it more necessary for the mother to choose to not continue her medication during pregnancy. It can be argued that nonmaleficence may favor the alternative therapies or no medication over the high risk medications that do the effort of balancing not doing harm to the fetus and not doing harm to the mother carrying the fetus. 

Another value when considering alternative medications is autonomy. In most medical situations, patients are allowed to make decisions about their treatment. But when someone is pregnant, people often forget about their autonomy. Doctors, family members, or even strangers may try to tell them what to do because they are also thinking about the baby. This can make it hard for pregnant people to make their own choices. For example, someone with bipolar disorder may take a medicine like lithium, which helps keep their moods stable, but due to the fact that lithium has been linked to birth defects (Rusner et al, 2016) their doctor might suggest switching to a different medicine that isn’t as strong. However, that new medicine might not work well for the person, and they might continue to experience symptoms. In this case, telling the person they must switch to a weaker medicine takes away their ability to choose what’s best for themselves.

Global regulations

The Bipolar Disorder dilemmas that have been presented so far have given full discretion of the mother, but in many countries there are regulations in place which dictate what a woman is expected to do. To further understand the varying countries, we will compare the regulation for Topiramate, a treatment for epilepsy, migraines, and weight loss, as well as sodium valproate which has been previously discussed as a way to treat Bipolar Disorder. This information is being presented in the hopes of determining ethically what values should contribute to a mother's decision and whether the government should be able to have power in the decision. 

Topiramate

Topiramate is used for the treatment of epilepsy, prevention of migraines, and in some cases–when used in combination with phentermine–for weight loss. It has been shown to cause serious birth defects if used while pregnant (Blotière et al,. 2020; Bromley et al,. 2016). Children who were born to mothers with epilepsy and were exposed to topiramate while in the womb had nearly a two to three times greater risk of having neurodevelopmental disorders such as autism spectrum disorder and other intellectual disabilities (Bjørk, 2022). An additional study was also conducted where they looked at whether a mother who had ever used topiramate in the past would affect the risks, but they found there was no increased risk if you had taken in before but not during pregnancy. The European Medicines Agency Safety Committee (PRAC) has taken measures to create a pregnancy prevention program aiming to keep women from being exposed to topiramate during pregnancy.  It is the opinion of the EU that women should avoid becoming pregnant while taking topiramate (PRAC, 2023). 

PRAC has stated that topiramate should not be used to prevent migraines or manage body weight during pregnancy. It even says that women taking topiramate for these reasons must be on birth control when using topiramate to prevent unplanned pregnancy as the child would have an increased risk of experiencing neurodevelopmental issues. In the case of women who are taking topiramate for epilepsy, PRAC also recommends that all use of topiramate be discontinued during pregnancy unless there is no other medication that could be taken in substitute during that period. Women must be fully informed of all risks if they should become/be pregnant while on topiramate. For all of the risks previously stated alternative treatment should consistently be considered and the need for topiramate must be reassessed at least annually. Healthcare professionals also go on to state that patients using the medication for prevention of migraine or for weight loss or regulation must continue to use a strong and reliable contraceptive throughout the entirety of treatments and for a minimum 4 weeks after stopping the treatment.  Doctors are not allowed to begin the topiramate treatment until a woman has taken a pregnancy test (Famhp, 2023; PRAC, 2023). 

Sodium Valproate

Sodium valproate is another known teratogen which can affect the development of a child if taken while the mother is pregnant. It is mainly used to control epilepsy, but it can also help those with bipolar disorder (Smith et al,. 2009). About 10% of babies exposed to valproate during pregnancy are born with birth defects and up to 40% are at risk for permanent developmental disorders according to the therapeutic guidelines of UK and Australia (Tomson et al,. 2015). The UK began to introduce regulations in January 2024 which require the review and signoff of two medical specialists before prescribing valproate to anyone under the age of 55. The UK has also implemented an acknowledgment form which required written informed consent from patients. However, Australia's Advisory Committee on Medicines met in April to consider changing the prescribing requirements for the drug to match the UK’s, but chose to maintain their current system of counselling for women under 55 and having warning labels. Australia felt it would be a burden to require doctors to get a second specialist to sign off on the request. Previously in Australia they determined that the restriction of the medication would be unjust, since their other regulation states that gender-based prescribing restrictions can affect equality of access to medications. It has been argued by other experts that regardless of gender-based restrictions it is necessary to address gaps and safeguard women and their pregnancy through stricter regulations (Macfarlane et al,. 2018). The concern also lies in that women in Australia who were affected by using sodium valproate feels like they were not sufficiently informed on all of the risks. It needs to be considered that for some people sodium valproate is the only medication that can control their seizures well, since it is easily the most effective drug for seizure control, specifically genetic epilepsy. In the UK they have also found that the tighter UK prescription regulations have, in some cases, led to injuries and deaths among women who stopped taking valproate and then as a consequence had seizures. In the UK, there is also the fear that increased regulations would make it harder to access sodium valproate (Gov.uk, 2015; Ornoy, 2009).

Utilitarian versus Deontological

In considering these different global regulations of the UK's dual-specialist sign off against the lighter approach of Australia we can now go into more depth and ethically analyze their topics. Utilitarianism will cause people to look at consequences and ask what choice brings about the least overall suffering. The United Kingdom’s rule that women under 55 must obtain two specialist approvals before receiving sodium valproate has cut the number of exposed pregnancies and the tragic birth defects that follow (Lovell, 2023). On the other hand, some women abruptly stopped the drug to meet these rules, as many as 15 percent suffer seizures that send them to hospitals and can endanger both mother and the fetus (Varkey, 2020). These seizures carry risks not only to the mother’s life but also to the health of the placenta which if harmed can lead to oxygen deprivation for the fetus. When weighing these competing harms, strict utilitarian reasoning would argue for a more flexible rule that continues to protect the fetus from teratogenic exposure while allowing valproate to be used when no safer substitute can maintain control of the chronic illness being considered.

The utilitarian would emphasize that it is okay to use the mother simply as a means to an end and would only truly be concerned with consequences of the medications and the risks of not taking the medication. To contrast that, deontological ethics emphasizes that every person must be treated as an end in themselves and never merely as a means to another’s well being, so forcing a woman off a medication only to shield the fetus emphasizes the idea that her body is only being seen as a vessel and would not be accepted when talking about deontology. This also violates the physician’s duty to preserve life and prevent harm (Fietz, 2024). 

Women's Choice in Using Medication During Pregnancy

A study conducted across multiple European countries looked at what types of medications mothers take depending on whether they are labeled safe, risky, or not given any classification. Out of the 587 medications that were reported to be used during pregnancy, 69% were considered safe, 28% were classified as risky, and the other 3% were not given any classification. This is significant to acknowledge, since nearly 30% of the medications were being classified as risky. In the study it was also found that there were sociodemographic factors that were associated with the continuation of risky medication during pregnancy.

95% of women who continued to use risky medication were due to a chronic disorder. The system which is used in Sweden, Australia, and the U.S. among other countries rank safety of medications in risk groups depending on fetal safety. Within the study it was found that there were extreme differences in the use of risky medications during pregnancy; in Italy only 2% consistently reported the use of potentially risky medications during pregnancy versus in France 59% had (Trønnes et al., 2017). It is interesting to note that there were several factors that ended up having an association to the use of risky medications during pregnancy; “being a student, a housewife, or working as healthcare personnel, having previous children, not using folic acid, consuming alcohol, and smoking were associated with the use of potentially risky medications during pregnancy, and the magnitude of the associations ranged between 10% and 30% increased odds”(Trønnes et al., 2017). Some women also decided to continue their medication depending on the benefit-risk that would occur for them. For some chronic conditions it might not even be possible to switch to a safer medication before pregnancy. Even if a safer option is available doctors may not recommend switching, since it can lead to relapse which could also increase the risk to the fetus (Trønnes et al., 2017). This could potentially create a feeling of guilt for mothers or even a lack of autonomy if they feel like they couldn’t possibly have done anything else. 

Society’s Views on Prioritizing Fetal Health

The fetus has in many cases been prioritized over the pregnant individual in medicine and society. In many societies, including ours, there is a strong belief that pregnant individuals have a responsibility to protect their unborn children. This responsibility often includes avoiding things like alcohol, drugs, harmful medications, and even too much stress. The idea is that since the fetus cannot make choices or protect itself, the pregnant person must act in its best interest (Trønnes et al., 2017). However, this can become complicated when protecting the fetus means putting the pregnant person at risk or taking away their ability to make decisions about their own body. For example, if someone needs to take medication for a mental illness that may affect the fetus, are they being irresponsible by taking it or by stopping it? These questions show how difficult it is to define what “responsibility” really means during pregnancy. In both medicine and culture, the health of the fetus is often treated as more important than the health of the pregnant person. For example, doctors may focus more on the baby's growth and health during checkups, sometimes ignoring the emotional or mental health of the mother. In some extreme cases, people have been forced to undergo surgeries or treatments while pregnant, even if they didn’t agree with them, just because it might help the fetus (ACOG, 2016). This creates a situation where the pregnant person’s voice is no longer the most important one in decisions about their own body. Does society pressure women to prioritize fetal health? 

Some women actually overestimate the risk to the fetus and feel high amounts of pressure from society. Is there a culture for an "overbearing" society towards mothers and telling them what to do with their bodies during pregnancy? Society often puts a lot of pressure on pregnant women to always put their baby’s health first, even if it means ignoring their own needs. This pressure can make some women feel like every choice they make, what they eat, what medicine they take, and even how much they rest or move, has to be perfect, or else they’re failing as a mother. Because of this, many women worry too much about harming their baby and feel guilty even when the risk is very small or not real. A good example of how society can be too controlling is the case of Alysia Montaño, a professional runner in the United States. In 2014, she ran in a race while she was five months pregnant. She had talked to her doctor beforehand and made sure it was safe. But people still criticized her harshly, saying she was a bad mother for taking that risk. Even though she was healthy and capable, many people believed she should have stayed on the sidelines just because she was pregnant (Graham, 2014). This shows how society often treats pregnant women like they don’t have the right to make decisions about their own bodies. Because of this pressure, some women may avoid important treatments or feel ashamed for making choices that are right for them (Trønnes et al., 2017). It’s important to remember that pregnant women are still people with rights, and their health matters too. 

This kind of pressure becomes even more intense when a pregnant person has to take a medication that might be harmful to the fetus, like a teratogen. Even if a woman really needs these drugs to stay healthy, society often expects her to stop taking them just to protect the baby. This can make her feel ashamed or scared to keep using the medicine, even if not taking it would put her own life or mental health at serious risk. For example, a woman with bipolar disorder might need lithium to stay stable, but lithium has some risks for the baby. If she chooses to take the medication, people might judge her harshly, even if it’s the safest choice for her overall health (Trønnes et al., 2017). The fear of being judged or blamed can lead women to stop taking necessary medication, which can make their conditions worse. This shows how society’s focus on the fetus can make it harder for pregnant people to make safe, balanced choices about their own health.

While it’s important to care for the health of unborn children, there is a real danger in going too far. If medical systems or society push too hard, it can take away a person’s ability to make choices for themselves. Pressure can turn into guilt, fear, or even force. Medical decisions should be made with the pregnant person’s full understanding and agreement not because they were scared into it (ACOG, 2016). Society needs to find a better balance: one that supports healthy pregnancies without treating pregnant people like they don’t matter. Some people believe that pregnant individuals have a moral responsibility to take care of their fetus by avoiding harmful things like smoking, drinking, or certain medications. These actions could lead to birth defects or long-term problems for the child. But at the same time, pregnant people have a responsibility to care for themselves. Ignoring their mental health, stopping needed medications, or staying in unsafe situations could also lead to harm for both them and the baby. So, it’s not always clear what the “right” choice is. What seems like the moral thing to do for the fetus might actually harm the pregnant person.

Further Ethical Considerations

Nonmaleficence and Justice

Pregnant individuals are expected to avoid causing harm to the fetus through avoidable behaviors. The principle of nonmaleficence means “do no harm.” In pregnancy, this often means trying not to hurt the fetus. Doctors and society expect pregnant people to avoid anything risky, like certain foods, drugs, or behaviors. But this idea can clash with autonomy, or the right to make your own choices. As my core analysis exemplifies, what protects the fetus has the potential to harm the mother, which makes respecting both nonmaleficence and autonomy at the same time hard, but it’s necessary to make ethical decisions in pregnancy. Nonmaleficence pushes people to avoid risk to the fetus, while autonomy supports a person’s right to choose what’s best for themselves. These ideas can fight against each other during pregnancy. Some people say the mother should decide because it’s her body. Others say the fetus must be protected no matter what.. How can society facilitate a pregnant person's autonomous decision-making, especially when fetal and parental health stand in conflict? To make the best decisions, pregnant people need full, clear, and honest information from healthcare providers. They need to understand both the risks and the benefits of their choices. Doctors should talk with them in a way that supports, not pressures, them. When people feel safe and informed, they can think about what’s best for themselves and their babies. Education, support systems, and good communication all help pregnant individuals make balanced, ethical decisions.

It is not fair to blame someone for things they couldn’t control. Many people face barriers like poverty, racism, lack of healthcare, or unsafe living conditions. These systemic issues affect what choices a person can make during pregnancy. If someone can’t afford medication or doesn't have access to a doctor, how can they be expected to follow perfect health guidelines? Justice means recognizing these challenges and working to fix them, not punishing people for them. We should support, not judge, those trying to do their best in difficult situations. Another aspect of justice that should be considered is that depending on one's socioeconomic status it may be more or less risky taking a teratogen such as lithium. If the mother can afford monthly blood tests to make sure the concentration of lithium in her blood is not toxic and doesn’t pose risks to her child then there is far less risk of mediation to use. Whereas for a mother that does not have those same financial means having monthly blood tests may not be possible. In this way it is the healthcare system which is not making its resources accessible enough, but this is not a challenge that can be solved by a single mother. 

This is outside the main scope of my paper but I still believe it is important to consider justice in terms of the unrealistic expectations that are put onto women in our current world. Specifically for pregnancy justice is evident within demographic disadvantages, access to healthcare, education, and social support–affect a person’s ability to make healthy choices. While there is now this unrealistic expectation of  If someone doesn’t have a doctor to talk to or can’t afford healthy food, is it fair to blame them for poor outcomes? Justice means looking at the full picture and understanding that not everyone starts from the same place. Holding people to the same standard without the same resources is unfair.

Conclusion

While protecting the fetus is an important ethical consideration, it cannot come at the expense of the pregnant person's mental health, physical safety, or fundamental rights. A fetus depends entirely on the health and well-being of the person carrying it. If the pregnant individual is not mentally or physically stable, especially in cases involving chronic conditions like bipolar disorder, then fetal outcomes may be compromised regardless. Prioritizing maternal autonomy ensures that care is person-centered, holistic, and compassionate. Additionally, when we take away a pregnant individual’s ability to make informed decisions about their own body, we reinforce dangerous ideas that pregnancy diminishes someone’s moral agency, or that their only role is to protect a fetus at all costs. That’s a slippery slope toward eroding reproductive rights. That said, this doesn’t mean fetal health should be disregarded. Ideally, medical guidance should support individuals in understanding all risks and helping them make the most balanced, evidence-based decision possible. But ultimately, the choice should lie with the individual most directly affected, the one carrying the pregnancy.

Overemphasizing maternal responsibility in managing teratogenic risk contributes to stigmatization, guilt, and a distorted sense of blame when outcomes are unfavorable. This kind of framing not only undermines maternal autonomy but also creates a public narrative that punishes individuals, who are often women, for complex medical decisions. It can lead to a chilling effect, where pregnant individuals may avoid seeking necessary treatments or even prenatal care out of fear of judgment or legal consequences. In cases of mental illness such as bipolar disorder, untreated symptoms due to fear of medication-related stigma can result in life-threatening conditions for both the mother and the fetus. Furthermore, this focus risks turning pregnant people into passive vessels for fetal development, reducing their dignity and humanity. This perspective also disproportionately affects those in marginalized communities who may already face barriers to healthcare, compounding inequalities. Ethically, the prioritization of fetal health should not come at the cost of parental mental health, access to care, and self-determination. Medicine must strive to support, not police, the choices of pregnant individuals navigating these difficult scenarios. The real harm lies not in a mother’s decision to medicate, but in a society that demands perfection without offering adequate support or understanding.

Sadly, pregnant people are often judged for the choices they make. If they continue taking strong medication, some people might say they are being selfish. This can lead to shame, fear, and guilt. In some places, pregnant people have even been arrested or punished for taking certain medications, even if they needed them to survive. This kind of judgment makes it harder for people to be honest with their doctors. Some might stop taking medicine without telling anyone, which can be very dangerous. Instead of blaming or judging pregnant people, we should support them. They are often doing their best in a difficult situation. Pregnancy is already stressful enough without the added pressure of being criticized for making hard health choices.

When someone is pregnant, they may have to make hard choices about their health and the health of their baby. One of the hardest decisions is whether to continue taking a strong medication that helps them stay healthy or switch to a different, “safer” medicine that might not work as well. Some people believe that pregnant individuals should always choose the safer option to protect the baby. But others believe the person should be able to choose what’s best for their own health, even if it carries some risk. This is a complicated issue, but pregnant people should not be forced or pressured to take a less effective medicine. They should be able to make the choice that is best for their body, their mental health, and their life. Doctors and patients are supposed to avoid making choices that cause harm. The pregnant person’s health matters just as much as the baby’s. If they are suffering, in pain, or at risk of serious illness, that’s also a kind of harm to the fetus. So choosing the “safer” medicine is not always the kindest or most ethical decision. Both the pregnant person and the baby matter, and we need to find a balance between protecting both.

Instead of saying a pregnant person has to take a less effective medicine, doctors should explain all the options and make sure the patient has informed consent. For example, they might learn that staying on their current medicine could slightly increase the baby’s risk of birth defects, but switching could cause their condition to get worse. With this information, they can make the best decision for themselves and their family. Some people might decide to stay on their regular medicine because their health depends on it. Others might choose to switch to something less risky for the baby. Both decisions are valid, as long as the person is given the chance to decide for themselves. There is no one-size-fits-all answer. Everyone’s situation is different. Pregnant individuals should not feel forced to accept less effective treatments just because they are pregnant. Their health and well-being matter just as much as the baby’s. Every person has the right to make their own medical choices, especially when it comes to serious conditions. Doctors and society should focus on giving people the information, support, and options they need to make the best decision for themselves. When pregnant people are trusted and supported, they are more likely to make choices that are safe and thoughtful for both themselves and their baby.

Looking forward, the ethical questions explored in this paper extend beyond traditional pregnancies into situations like surrogacy and pregnancies resulting from sexual abuse. In surrogacy, there is a tendency to assign elevated responsibility to the surrogate, as if the choice to carry a child equates to forfeiting full autonomy. While a surrogate does voluntarily accept the physical role of gestation, this should not negate her right to make informed decisions about her own health. Ethical frameworks must avoid holding surrogates to higher standards than biological parents, especially when medical issues like teratogenic medication arise. In contrast, pregnancies resulting from trauma, such as sexual abuse, highlight the moral danger of imposing rigid maternal responsibilities on someone who did not choose to be pregnant in the first place. These cases challenge the assumption that choosing to carry implies blanket acceptance of fetal prioritization. Future research should explore how varying contexts of pregnancy (chosen vs. unchosen, surrogate vs. biological) shape perceptions of responsibility and access to ethical care. Additionally, looking at more long-term effects of stigma, such as those between the UK and Australia on sodium valproate, can offer insight into developing more equitable global regulations. Ethics must evolve to include nuanced, intersectional perspectives that recognize the complexity of pregnancy in the modern world.

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