Bioethical Deliberation in Gestational Diabetes Management: Integrating Diego Gracia’s Model into Clinical Ethics Consultation and Institutional Policy

Gestational diabetes mellitus (GDM) sits at the intersection of maternal bodily integrity, fetal risk mitigation, and healthcare equity, and rigid guideline enforcement can trigger bedside conflicts and institutional friction. This article examines GDM management through the deliberative model of the Spanish physician and philosopher Diego Gracia, influential in Southern Europe and Latin America but less familiar in North America, which separates moral duties into Level I (Non-Maleficence and Justice) and Level II (Autonomy and Beneficence). We explain why we start from Gracia rather than from Beauchamp and Childress: his model couples a defeasible ordering of duties with an explicit deliberative procedure that institutions can teach and document. We then argue against a misreading of the model in perinatal care that places fetal protection at Level I and maternal decision-making at Level II. Maternal bodily integrity and informed refusal also engage Level I non-maleficence duties, so bedside conflicts are better understood as clashes between two Level I obligations. We extend this reframing by translating Gracia's deliberative steps into a consultation protocol for Healthcare Ethics Committees (HECs), by using international variation in metformin's regulatory standing to show that pharmacological choice involves value judgments, and by treating access to glucose self-monitoring supplies as a matter of distributive justice. A hypothetical, composite vignette illustrates the protocol. The proposals are conceptual and untested; we suggest that structured deliberation may help institutions honor maternal self-determination without abandoning fetal interests.