A 30-year-old Catholic woman, in a civil partnership, originally from and resident of Mexico City, whose family nucleus was in vulnerable conditions due to her socioeconomic level and schooling.

The patient had been diagnosed with systemic lupus erythematosus according to SLICC 2012 classification criteria since 2019. At diagnosis, a remission induction scheme was started due to renal activity (lupus nephritis class III + V): methylprednisolone and cyclophosphamide from March to September 2019. In December 2019, cyclophosphamide was started every two months. Due to increased proteinuria, mycophenolate mofetil (2 g/d) was started in February 2020. Treatment was suspended from February to July 2020 due to the covid-19 pandemic. On resuming follow-up, an increase in proteinuria to 5720 mg in 24 h was documented, resulting in cyclophosphamide, mycophenolate mofetil (2 g/d) and prednisone (25 mg/d) being restarted every two months until April 2021, without achieving complete remission criteria. In April 2021, multi-target therapy (3 g/d of mycophenolate mofetil and 3 g/d of tacrolimus) was started due to poor response; however, the patient did not adhere to treatment for financial reasons.

The patient attended a prenatal check-up appointment on 17 October 2022 for pregnancy at 20 weeks' gestation. Oedema in the lower extremities and arterial hypertension were identified, for which she was referred and hospitalised in gynaecology and obstetrics at a tertiary level hospital in Mexico, where her evolution was documented (Table 1).

Bioethical deliberation occurred at 23 weeks gestation: this was a non-viable pregnancy considering the infrastructure and resources available. By this time no favourable response was achieved, as the patient persisted with hypertension and required renal replacement therapy. The patient was informed on multiple occasions about the maternal and foetal risk of continuing with the pregnancy; she reported being aware and understanding the risk. Despite medical advice, she expressed her desire to continue with the pregnancy.

Four main actors in the dilemma were identified: the patient, her family, the health personnel and the institution. The family includes a 10-year-old daughter for whom the patient is the primary caregiver, as well as her mother and her husband as the primary economic provider. The health personnel involved included health professionals from different services, including psychology, social work and nursing. The hospital’s Legal Department and Bioethics Committee were involved as institutional representatives.

The possible costs in this case included clinical, family and economic costs. In addition, the socio-cultural context of the patient who, knowing the male sex of the product of her pregnancy, expressed the desire to give her husband a male child, became relevant. This is due to the burden given to motherhood in the social/cultural construction and the gender condition of women and pregnant women, placing reproduction at the centre of "duty" and personal fulfilment.4 In addition to this, there is the preference, especially of men, to have sons, whether for the preservation of the family name in a patrilineal system such as the Mexican one or due to other gender stereotypes.5 Therefore, even recognising the context, termination of pregnancy represented a cost to the patient's life plan.

The following central moral dilemma was established: How should one proceed, considering the risk to the patient's life and her desire to continue the pregnancy? Various normative systems can be applied to such a question.

Utilitarism. The consequences of the action represent the central component, which is why the greatest benefit must be sought at the lowest cost for the greatest number of people.6

In this case, termination of pregnancy seeks to safeguard the life of the mother and, considering only the consequence, saving one life represents a greater benefit than losing two. Taking into account the characteristics of the family nucleus, taking care of a premature newborn and a patient on renal replacement therapy would be complex and very costly. For the institution, safeguarding the mother would imply a more efficient use of human and material resources. From a utilitarian perspective, termination of pregnancy is justifiable.

Deontology. It focuses the importance of the decision on the action itself, which must be regulated by respect for autonomy.7 It is based on duty and the values of law and justice. In medicine, professional deontology focuses on the preservation of health, and therefore actions must be established in medical professional practice to guarantee this premise. In this case, it implies seeking all available therapeutic alternatives.

Termination of pregnancy would be justifiable, as such an action would preserve the patient's health. However, considering respect for the patient as an autonomous and dignified person, her expressed wish to continue with the pregnancy must be taken into account. If the actions are centred on autonomy, deontology would justify continuing the pregnancy even if the consequence is the death of the patient. It is concluded that, through the deontological system, both actions would be justifiable: to continue or not to continue with the pregnancy.

Virtue ethics. The focus of decisions lies with the person doing the action. The core values revolve around enhancing the human flourishing of the people involved.8

The flourishing of the patient and her family lies in preserving her life. In the case of the institution and the medical staff, it is about fulfilling their vocation in the service of life, so preserving the life of the patient would be appropriate, by ensuring her well-being on an individual level and decreasing maternal mortality on a more general level. In conclusion, virtue ethics would consider termination of pregnancy justifiable.

The experience of the treating staff in this case refers to the importance of assessing the patient's environment, her emotional, socio-economic and work status, her family and her values. The reflection also indicates a questioning of the ingrained idea among medical personnel that “the less we get involved, the better” or that medical knowledge is sufficient to acquire a position of authority in making decisions that are, in reality, ethically complex.