Clinical implications of respect for autonomy in the psychiatric treatment of pregnant patients with depression

Major depression, as well as depressive symptoms that do not meet the full diagnostic criteria for a diagnosis of depression, can chronically and variably affect a woman patient's decisions about the management of pregnancy, including the decision about whether to continue a pregnancy. Depression also has potential adverse consequences for the pregnant woman and her pregnancy. However, little attention has been given to the ethical challenges posed by the psychiatric management of depression during pregnancy. The psychiatrist should balance respect for the autonomy of the depressed woman with beneficence-based obligations to the pregnant woman, and also to the fetus, when the fetus is viable. The authors recommend strategies for assessing the decision-making abilities of pregnant patients with depression and for enhancing their autonomy. They suggest that nondirective counseling should generally be used with pregnant patients with depression when the fetus is previable and that directive counseling is ethically justifiable when the fetus is viable.