I am one of eleven high risk pregnancy specialists in a busy practice in Minnesota that serves a complicated referral population. I teach obstetrics to medical students and residents at the University of Minnesota Medical School. I am also the co-chair of the Program in Human Rights in Medicine at the University of Minnesota. My testimony today reflects my own views.
The subspecialty of Maternal-Fetal Medicine is only two decades old and is unique in that we care for two patients in the mother and her unborn child. (As was the case recently in Iowa sometimes our colleagues involved in the treatment of infertility are so successful that we have even more than two patients). Only on very rare occasions are the medical interests of the mother and unborn baby in conflict.
During the last 25 years progress in the area of obstetrics and maternal-fetal medicine has been astonishing. By 1973 obstetrics had made great strides in making pregnancy and birth a relatively safe experience for women. Since the beginning of this century developments in antibiotics, transfusion and anesthesia caused the risk of maternal death to decrease by 50- to 100-fold. Attention was then turned to improving the outcome for the baby. Fetal monitoring was developed and some cases of fetal distress could be identified before and during labor. This was generally beneficial but also lead to many unnecessary cesarean sections-not the first or last time that the best of intentions has had negative consequences.
During the late 1960's and early 1970's progress was also being made in decreasing the number of pregnancies complicated by Rh problems. In those pregnancies where Rh incompatibility was present fetal treatment was first used. This was accomplished by prenatal transfusion of blood into the abdominal cavity of affected unborn babies. The new focus on the baby was achieved by development of fetal ultrasound imaging technology. Prior to 1973 the anatomic development and activities of the fetus were invisible.
Professor Ian Donald of Scotland served in the British Navy during World War II and became familiar with the use of sonar to detect German U-boats. By the 1960's he had developed exciting but unrefined methods of using sound waves to look into the uterus. At the time of the Roe v Wade decision, ultrasound during pregnancy was largely experimental. During the 70's and 80's the beneficial uses of ultrasound in pregnancy multiplied. Today the practice of modern obstetrics would be impossible without ultrasound and nearly every American has seen ultrasound images of unborn babies.
Current ultrasound imaging techniques reveal the marvelous complexity of prenatal growth and development. Just as parents of newborns mark their baby's developmental progress with activity milestones, thanks to modern technology we can see similar developmental milestones for unborn babies. However, the use of this wonderful window on the womb has become increasingly disconcerting for some who would rather view the fetus as pregnancy tissue or the products of conception.
Last week in preparation for this testimony I did a literature search covering the topic of treatment of babies before birth. There are legitimate criticisms of government programs but it is important to mention those times when those programs are an unqualified success. Internet access to the National Library of Medicine by way of the Grateful Med program is one of the benefits of practicing medicine in the United States. In only minutes one can do a comprehensive search of any combination of medical topics referencing thousands of medical journals published during the last thirty years.
In the last two and one half decades our ability to obtain clear images of the fetus has expanded the concept of the fetus as a patient. Over the last two and one half decades the number of studies describing the fetus as a patient has multiplied. Between 1966-74 there were none, from 1975-1979 there were a few dozen, between 1980-1984 there were a couple of hundred. Over the last 13 years there have been thousands of articles describing the various ways that prenatal diseases can be detected and often treated.
Unborn babies can be treated with medications for dangerously irregular heart rhythms and can receive blood transfusions if they are anemic. On rare occasions surgical procedures can be performed before birth. A frequent use of ultrasound is to evaluate the health of our unborn patients. In high risk situations we recommend frequent ultrasound checkups that look for prenatal breathing movements and other activities.
Fetal treatment centers at UCSF, Penn, Tufts, Brown, Harvard and elsewhere have done basic and applied research on fetal medical and surgical treatment. One of the most dangerous abnormalities of fetal development is absence of the diaphragm muscle that separates the abdomen from the chest and is necessary for normal breathing. This problem can be diagnosed by prenatal ultrasound and some of the pioneering groups are working on fetal surgery and other treatments that may improve the outcome for affected babies. An amazing fact found by these pioneers in prenatal surgery is that fetal skin wounds heal without scarring.
We are clearly in a new era of obstetrics because of ultrasound and the expanding concept of treatment of the fetus as a patient. Yet there is an inescapable schizophrenia when modern medicine works under ethical rules which say that a fetus is a patient only when the mother has conferred this status. The trouble is that this status can be withheld or withdrawn. The combination of current unrestricted legal abortion and our increasing abilities to diagnose fetal abnormalities and diseases prenatally is a very dangerous two-edged sword.
Future Concerns
In many ways modern obstetrics is becoming an impersonal techno specialty dedicated to the concept of the perfect baby. Prenatal diagnosis can benefit the mother and baby when treatment options are available but much of prenatal diagnosis is designed to detect fetal abnormalities so that the choice of abortion is available. The majority of these abnormalities, such as Down syndrome, are not usually fatal. Even abortion supporters are horrified by the possibility of abortions based only on the sex of the unborn child. But why is abortion for the most sexist of reasons any worse that abortion for any other reason?
So far we do not have an overtly eugenic social policy but we are certainly encouraging family-based eugenics. This use of abortion will gradually weaken society's commitment to the inclusion and care of the disabled in our human community.
In 1973, Roe v. Wade shattered the issue of abortion into sharp fragments. We are still dealing with the medical, social, and political fallout of the Supreme Court's willingness to go far beyond the traditional boundaries of medical ethics and practice. The tenets of Hippocratic medicine have served us well for more than 2,000 years. But our 25 year experiment with unrestricted abortion has caused the practice of medicine to become increasingly inconsistent. The tension between valuable ethical traditions and currently legal medical practice is untenable.