foetal medicine and prenatal diagnosis viewed individually or through the wider sphere of perinatal medicine , carries a rich spectrum of ethical issues , from either research or practice . the amazing progresses really impressive made in areas such as genetics , foetal ultrasonography ( echocardiography and foetal neurosonography ) or perinatal medicine have brought many benefits for both patients and practitioners , but also generated numerous controversies and bioethical issues . one of the most controversial discussion topics in modern bioethics , science or philosophy is represented by the beginning of the individual human life . the principles of modern bioethics on the various aspects of human reproductive biology involve the perception of the human conception product , as a patient , in embryo stage [ 1 - 3 ] . accepting human embryo or foetus as a person opens an extremely wide perspective through the questions that can be made on human personality and rights . it should be noted since the beginning , that in the context of foetal medicine on the one hand , the prenatal diagnosis on the other , and not least in the perinatal medicine in general , the concept of embryo or foetus as a patient is fully justified . it is ethically , medically and scientifically correct that the human conception product to be born , so to gain personality and individuality , to be treated as a patient since the intrauterine life . the clinical and ethical concept of the foetus as a patient does not imply that it has an individual status and own morals . more specifically , the status of the patient implies that the foetus may benefit from professional , clinical and technical possibilities of the medical practitioner . the clinical concept of foetus as a patient is essential for the perinatal medicine practice reasoning . new scientific acquisitions regarding foetal diagnosis and perinatal management have become almost universally accepted , encouraging the development of this concept . beyond the many religious , philosophical , moral or political controversies , on the award of an own personal and moral status to the human conception product , it is obvious that through the principles of perinatal medicine , it must certainly be looked as a patient . thus , the foetus becomes a patient when manoeuvres and medical techniques , whether diagnostic or therapeutic , are made on it , aiming at identifying , preventing or treating certain elements that could adversely interfere with the quality of life of the foetus to be born . the concept of the foetus as a patient is ethically strongly correlated with the quality of life that the human conception product will have when it will be born , so when it acquires a moral status and its own personality [ 3 - 6 ] . another important aspect in the concept of the foetus as a patient is the foetal viability . the limits of foetal viability , meaning the point at which the foetus would be potentially capable of extrauterine life , differ depending on the experience of different schools , both in europe and the usa . in the usa , it is somewhere around the age limits of 24 weeks and in europe varies between 24 and 28 weeks of gestation . intrauterine foetal interventions , performed in various therapeutic purposes are still in the experimental stage even in centres with rich experience in perinatal medicine . the multi - foetal gestation and the concept of the foetus as a patient  multi - foetal gestation , either spontaneous or through assisted human reproductive techniques , is an important factor for the prognosis of the pregnancy . the most important issue influencing most obviously the prognosis of the pregnancy is the chorionicity . ttts is the result of a blood transfer from the donor foetus , the small twin to the receiver foetus , the big twin through vascular anastomoses existing in monochorionic placentas . placental vascular anastomoses are present in all twin monochoriaal pregnancies and very rarely in those [ 7 - 9 ] . the protocol of tracking multiple monochorionic pregnancies , between 12 weeks and 22 weeks , respectively the diagnosis moment and foetal morphology moment is completely different from a single pregnancy . multiple monochorionic gestation must be reassessed weekly in order to observe as early as possible the signs of ttts . in the absence of a treatment , almost all cases of severe ttts die in the second trimester of pregnancy , and the outcome of other cases is reserved . it is also possible the situation in which one of the foetuses dies , the blood transfer stops and the other foetus survives and reaches the term . ttts treatment consists of several steps , some of them having a powerful ethical component [ 9 - 11 ] . laser coagulation of placental anastomoses - is the method of choice in the current treatment of severe ttts . the method is indicated when vascular anastomoses anatomy of the placenta produce a progressive and inevitable ttts . selective foeto - reduction is the most controversial method of treatment in the ttts , at least ethically . this method is based on the argument that the death of one of the foetuses stops the transfer of blood and maximizes the chances of survival of the other foetus . this method is exclusively reserved for cases in which one of the foetuses is severely compromised , and its death is imminent , especially in the presence of foetal hydrops . only in this context the method is justified by the purpose of saving one of the foetuses , given that the other is irreversibly damaged and thus imperils the evolution of the other . the most rational therapeutic approach in ttts remains the laser coagulation of placental anastomoses [ 7,11 - 14 ] . assisted human reproduction and selective foeto - reduction - millions of children are due to in vitro fertilization ( ivf ) . besides the immense benefits of this technique , naturally also complications or unwanted side effects exist . with ivf implementation , the number of multiple pregnancies has increased steadily and almost doubled the number of twin pregnancies . multiple therapies for infertility , including the assisted human reproductive techniques , generate nearly 70 % of twin pregnancies and almost 99 % of multiple pregnancies . the introduction of egg donation or donation of human zygotes opened a new perspective in terms of women over physiological reproductive age , bringing also a number of moral and ethical controversies . over 10% of patients requiring selective foeto - reduction are over 40 years old , and half of them received the zygote from the donor . also foeto - reduction is correlated with the existence of previous relationships , with children so that at that time the patient wishes existence of a single foetus . also another reason for foeto - reduction is the documented genetics affection of one of the conception products . the diagnosis is possible by amniocentesis or chorionic villus sampling , analyzing 13 , 18 , 21 , x and y chromosomes . assisted human reproductive aggressive techniques , which involve implanting multiple embryos in the idea that foeto - reduction will occur naturally generates multi - foetal pregnancy with triplets , quadruplets , quintuplets , going even to octuplets . multi - foetal gestation represents a special obstetric problem and under physiological conditions , but more so in terms of assisted human reproduction . in this context , obstetrical management can impose many times the selective foeto - reduction in therapeutic purposes , in view of a favourable prognosis for at least one of the foetuses . from a technical standpoint , foeto - reduction assumes in the current acceptance the placing of a needle through the abdomen or injecting various substances having feticide or foeto - reduction is done mechanically . ethically , the problem is extremely complex , with many similarities to the bioethics of abortion . the idea of implanting multiple embryos , resulting in the appearance of multi - foetal gestation , with all the subsequent consequences and complications is heavily countered by many names in foetal or perinatal medicine [ 7 - 9 ] . the problem of implanting more embryos or ova harvesting more than is necessary in order to make use of their material terms , is a serious ethical , moral and legal problem , not least , to be intensely combated in all respects . screening and prenatal diagnosis - the management of pregnancy in terms of prenatal diagnosis include both screening and prenatal genetic diagnosis itself . screening for chromosomal defects - one of the roles of this screening is to identify with a non- invasive method the duties to perform invasive diagnostic tests such as amniocentesis or chorionic villus biopsy [ 19,20 - 25 ] . 1st quarter combined screening - includes the determination of - hcg serum values ( human chorionic gonadotropin ) and papp - a ( pregnancy - associated plasma protein ) and the identification and measurement of some essential ultrasonographic markers : nuchal translucency , nasal bone , facial angle , intracranial translucency , venous ductus velocimetry , tricuspid flow ( regurgitation ) . even more , the current technology allows access to many more ultrasound foetal anatomic entities , outlining practically a genuine foetal morphological examination in the first trimester [ 26 - 33 ] . 2nd quarter screening - includes the ultrasound screening , serological screening or 2nd quarter combined screening ( triple and quadruple serological test ) . triple serological test - involves determining the serum values of the following parameters fp ( alpha foetal protein ) , - hcg and unconjugated estriol ( ue3 ) . quadruple serological test - adds to the three parameters of the triple test a fourth one : dimeric a inhibin [ 1,7,26 , 34 - 39 ] . non invasive prenatal test ( nipt ) - a dna test from maternal blood for screening of the most common foetal aneuploidies ( 21 , 18 , 13 , x or y chromosomes ) . this test is conducted on a sample of maternal blood containing foetal dna and determines more than 99 % of foetal aneuploidies of 21 , 18 , 13 , x and y chromosomes . to perform the nipt at least 20 ml of blood has to be harvested from the mother , between weeks 10 - 20th of pregnancy . from the dad it may be taken a sample of mouth scrapings . the foetal dna isolated from maternal blood if the sample was collected also from the father , the dna is similarly amplified and sequenced . the data obtained are analyzed for proper identification of aneuploidies of 21 , 18 , 13 , x , y chromosomes pairs [ 40 - 44 ] . this test represents without a doubt a great progress in prenatal diagnosis , but considering that it can be performed between weeks 10 - 20th of gestation , ethically and legally implies a series of controversies . as long as the test detects the conception product s sex and the result is communicated to the parents within the legal interval for pregnancy interruption on request , bioethics aspect , but also spiritual and especially moral one becomes spectacular .   from this point of view the role of practitioners in the field of perinatal medicine , on counselling and addressing the indication of this test becomes essential . risk estimation and management of positive screening - prenatal screening for aneuploidies has to be done to all pregnant women that agree knowingly with this type of investigation . therefore , they need to understand that after the test , its result is an estimate , a figure with statistical character , based on which they will have to agree with their partner and with the advice from the doctor , some decision about their pregnancy . the negative screening test does not guarantee that the patient will not give birth to a child with down syndrome as a positive screening test does not mean the child has certainly down syndrome . management of positive screening - in terms of a positive screening test , the obstetrician has a duty to inform the patient of the possible risks and the consequences thereof on the one hand , and of the options that he has for continuing or not the pregnancy , on the other hand . thus , the obstetrician practitioner will never suggest to the patient to terminate the pregnancy from his own initiative . there are genetic defects which represent absolute indication for pregnancy interruption or defects which are relative indication of pregnancy interruption , but the doctor has strictly the duty to present the options to both genitors , without influencing their decision in any way . the positive test or screening tests result currently represent the most important and most justified indication to switch to the second level of prenatal diagnosis , invasive testing , as diagnosis procedures . the invasive testing in prenatal diagnosis at this time includes two well stated elements : chorionic villus biopsy ( cvs - chorionic villus sampling ) and amniocentesis . both methods are based on the same principle - taking placental or foetal cells that can be genetically analyzed . the doctor is by definition a professional and as such has all the reasons to perform elective abortion , respecting the conditions imposed by the law in carrying out their medical profession . refusing this medical manoeuvre different theories and controversies that converge towards the idea that the doctor 's duty is to defend both mother s live and the child s , and to provide all therapeutic means to save both , or innocent live may not be suppressed directly under any reason , do not do nothing but mixing the medical professional act with the religious or philosophical scope . exercising the medical profession fairly and legally under no circumstances it is also ethically correct as failure to comply to any condition , either medical or legal regarding the elective abortion , implies all legislative , moral or personal consequences . the controversies about possible rights which human conception product would have either from the conception moment or from pre - embryonic or embryonic stage or during foetal period will be perpetual . but also the speculative side of this issue must be considered , of those who advocate for elective abortion ban on the one hand , and the religious aspect of the problem , which means by definition , persuasively to avoid any circumstance abortion , on the other hand . basically , giving human rights to the human conception product since the foetal life means necessarily restricting the freedom to choose and to express at least of one of the genitors , namely the mother , which is an obvious nonsense [ 1,2 , 4 , 7,50 ] in the framework of the 21st european congress of perinatal medicine , from istanbul in september 2008 , the joint committee of the european association of perinatal medical and world association of perinatal medicine have adopted this statement as the guide to ethical practice in perinatal medicine [ 51 - 58 ] . general ethical considerations - medicine seen as art and science , assumes as essential element the adequate and continuous communication between doctor and patient . beyond cultural , national , social or related differences , in perinatal medicine practice bioethics , even having philosophical dimension is an essential component of perinatal medicine and must provide answers to the questions what we should do ? or what to do ? in certain clinical circumstance . ethical reasoning is based on evidence or good reasons to come to the support of certain diagnosis or therapeutic conduct in different clinical situations . the main ethical concepts into practice clinics are : - optimal benefit to the patient , in all medical aspects is the ethical principle that requires the practitioner to seek maximum balance of benefits and risks in the benefit of the patient . - the physician must defend and promote with good will the interest of the patient . - justice as fairness principle of ethics requires unfold correctness in all aspects of diagnosis or therapy , without deviation from standard conditions that each diagnostic or therapeutic procedure entails . - the practitioner must respect as ethical principle the personality , autonomy and human dignity through dissemination of accurate and complete information on the medical act , with all the benefits and risks that it implies . - thus , the human rights are not dependent on any political system and all political systems must respect the human rights . if this principle is not respected , any system becomes practically unfair . application of ethical reasoning in perinatal medicine  from the medical point pf view , the notion of patient assumes that a human being is seeking a doctor who has the necessary elements to give him a net benefit of his health . the relationship between the pregnant woman and the foetus is the most intimate of all human experiences . thus , both our interests are to be taken into account by applying ethical reasoning in perinatal medicine . in perinatal medicine there are three potential patients : pregnant woman , foetus and newborn . the perinatal medicine practitioners have an ethical obligation to promote and protect the interests of health , but also other interests related to mother , newborn or foetus . first , it refers to the clinical perspective of a physician that exercises his job with responsibility , fairness and conscience , through the evidence - based medicine , the aim being the patient 's interest . the second , it refers to the pregnant woman 's perspective on her interests , based on her own values and beliefs being the expression of the ethical principle of respect for human individuality . the justice is a global ethical principle that requires that each individual to be given what is due when resources are limited . a fair policy in health field and by default in perinatal medicine prevents the exploitation of foetus , newborn or pregnant women by providing easy access to the resources of perinatal medicine . pregnant woman , foetus and newborn as patients in perinatal medicine ethics   pregnant woman - has the right to act according to her own beliefs and value systems in terms of both pregnancy and own person . the practitioner has a duty to expose to the patient all aspects of perinatal medicine practice , screening and prenatal diagnosis without trying to interfere in any way with her beliefs ( religious , social , philosophical , political , etc . ) and without trying to route in any way her decisions . the difference between the notions of human existence and human being is manifested mostly in the perinatal medicine . the foetus is deprived of both individuality and personality , but even more of beliefs and value systems . thus it becomes the patient only when the pregnant woman wishes to confer this status , in the interest of performing prenatal diagnosis or in the event of certain therapeutic manoeuvres in the uterus . the foetus is viable only in virtue of the fact that the patient is potentially capable of extrauterine life , otherwise has exactly the same status as the viable one . because the foetus s approach as a patient is always through the maternal organism , its options as the patient must each time be seriously considered . newborn  has from the moment of the transition to extrauterine life the status of human being . even if , he is unable to have evolutionary beliefs or value systems , the nerborn begins to develop personality and behaviour . the main purpose of the medical practitioner is to supervise and intervene when needed on the healthy growth and harmonious development of the child . there are situations where the physician is forced to defend the newborn from certain attitudes of the family members . in this case , the practitioner is obliged to protect , promote and foster the interests of the newborn patient . iv . genetic diagnosis , counselling and research   genetic research is rapidly evolving . genetic information obtained by prenatal diagnosis methods does not involve only the product of conception from which it was been obtained , but it can have negative effects on families and communities involved . genetic diagnosis , counselling and research in perinatal medicine the doctor must explain to the patient the risks , benefits , limitations of methods , alternatives , their possible consequences , but most importantly , the patient must receive assurances that her decision is exclusive to accept or to refuse prenatal diagnosis of their pregnancy . these statements are valid for the current invasive methods of diagnosis and for those non- invasive it may become available in the future . in the case of a genetic abnormality diagnosis , it is the patient s exclusively decision on continuing the pregnancy . both alternatives , continuation or interruption of pregnancy should be offered to patients , without the doctor to make a recommendation on any of the options . if the patient opts for an abortion , it must be performed in a centre able to provide safe termination of pregnancy . if the pregnant woman chooses to continue the pregnancy , counselling on issues of maternal management , foetal or neonatal , in the context of a specific genetic syndrome is recommended . counselling should be non - directive regarding the patient s participation in research projects in foetal or neonatal field , including various aspects and possible therapeutic that genetics might offer in the future .   any genetic information maternal , foetal or neonatal must receive strict protection , the doctor having the professional liability to keep the confidentiality . v. social issues in perinatal medicine   universal access to health care is a fundamental human right . this must be true also in the practice of perinatal medicine so that every pregnant woman can benefit from screening programs for foetal anomalies and prenatal genetic diagnostic techniques . regardless of the social , economic , geographical or political differences between nations or cultures , the access to a health service is a global ethical problem [ 51 - 58 ] . our paper is targeting to spotlight the essential principles and practice of ethics and law in perinatal medicine nowadays on one hand , and to bring an update review on a controversial topic on the other hand .
one of the most controversial discussion topics in modern bioethics , science or philosophy is represented by the beginning of the individual human life . 
 it is ethically , medically and scientifically correct that the human conception product to be born , so to gain personality and individuality , to be treated as a patient since the intrauterine life . 
 intrauterine foetal interventions , performed in various therapeutic purposes are still in the experimental stage even in centres with rich experience in perinatal medicine . 
 progresses truly outstanding are present especially in the prenatal diagnostic methods . 
 non invasive prenatal testing represents without a doubt a great progress in prenatal diagnosis , but from this point of view , the role of practitioners in the field of perinatal medicine , on counselling and addressing the indication of this test becomes essential . beyond cultural , national , social or related differences , in perinatal medicine practice 
 is particularly important to respect and permanently reassess the ethical codes . 
 our paper is targeting to spotlight the essential principles and practice of ethics and law in perinatal medicine nowadays on one hand , and to bring an update review on a controversial topic on the other hand .