What is the appropriate action for a pregnant woman with metastatic cancer and a history of multiple pregnancies (high gravida) and previous cesarean sections (C-sections), whose healthcare provider advises termination of pregnancy, but her relative refuses to consent?

Consent for Pregnancy Termination in Metastatic Cancer

Only the pregnant woman's consent is required for termination of pregnancy, regardless of her relative's objection (Answer B). The patient is the sole decision-maker for her medical care, including decisions about pregnancy continuation or termination.

Legal and Ethical Framework

The pregnant woman has complete autonomy over her medical decisions, and no consent from relatives is required. 1 This principle applies even in complex situations involving cancer during pregnancy where family members may disagree with the recommended treatment plan.

• The patient's right to autonomous medical decision-making is absolute when she is competent to make decisions 1
• Family members, including spouses or partners, have no legal authority to consent to or refuse medical treatment on behalf of a competent adult patient 1
• While family consultation and support is encouraged, the final decision rests solely with the patient 1

Clinical Context: Metastatic Cancer in Pregnancy

In this high-risk scenario with metastatic cancer, multiple prior cesarean sections, and high gravidity, the medical recommendation for termination is based on serious maternal mortality concerns. 1

• For metastatic cancer diagnosed during pregnancy, treatment decisions must balance maternal survival against pregnancy continuation 1
• The individualized treatment plan should be determined in consultation with the patient and a multidisciplinary team, but the patient retains final decision-making authority 1
• Women with metastatic disease during early pregnancy (weeks 1-20) may be advised that standard cancer treatment (which could include pregnancy termination) offers the best chance for maternal survival 1

Appropriate Clinical Approach

The healthcare provider should:

1. Ensure the patient has decision-making capacity through direct assessment, not through family intermediaries 1

2. Provide comprehensive counseling directly to the patient about:

   • Her cancer prognosis with and without immediate treatment 1
   • Risks of delaying cancer treatment to continue pregnancy 1
   • Maternal mortality risks given her metastatic cancer and obstetric history 1
   • Available treatment options and their implications 1

3. Obtain informed consent directly from the patient alone for whichever option she chooses after counseling 1

4. Document the patient's autonomous decision regardless of family agreement 1

Critical Pitfalls to Avoid

Do not require or seek consent from family members, as this violates patient autonomy and may constitute medical battery if treatment proceeds based on family rather than patient consent. 1

• Avoid deferring to family wishes when they conflict with the patient's expressed preferences 1
• Do not withhold treatment information from the patient because family members request it 1
• Recognize that significant psychological distress occurs when patients are advised to terminate pregnancy for cancer, requiring appropriate support services 1
• Understand that while family involvement in discussions is beneficial, it does not replace the patient's sole authority to consent 1

The correct answer is B: Only the patient's consent is required. No consent from relatives is legally or ethically necessary, though informing family members may be advisable for psychosocial support purposes if the patient wishes. 1