TIGHTROPE ACT
Balancing maternal versus fetal rights
By Dong de los reyes, Contributing Editor
Physicians have been on a quest for nearly three millennium to find a Holy Grail of sorts-the balance on fetal rights and maternal rights. The arduous quest continues to this day.
Forgo with such a quest, leave fetal rights, and proceed as clinicians to start on something that every practitioner of the healing arts can agree upon, so counseled Dr. Frank Chervenak.
"The child is a patient and when there are links between the fetus and the child the fetus will become, we have obligations to the fetus as a patient," said the professor and director of maternal and fetal medicine of the department of obstetrics and gynecology at the New York Presbyterian Hospital, Weill Medical College of Cornell University. "What I'm suggesting is we need to get away from these endless disputes of fetal rights versus maternal rights. They get us nowhere. A better way for us to proceed as doctors throughout the world is how do we balance obligations in difference circumstances?"
Before fetal viability all the technology in combination means nothing without the woman's body as necessary condition. After fetal viability, there's much that modern DNA technology can do to help the fetus as a patient, he added.
But here's the rub on fetal viability: "There's no worldwide uniform gestational age to define viability."
Chervenak opts for a cutoff gestation period-24 weeks or six months-which may apply in some parts of the world. Still he cautioned "this is not a sharp red line and we shouldn't pretend it is."
Prior to fetal viability, aggressive management is the ethical standard of care. The decision to abort a fetus due to an anomaly is only in part governed by health-related issues. That decision is often a woman's.
"What goes into a woman's decision? Let's say here in Manila you diagnose spina bifida, hydrocephalus. The woman's values and beliefs whether she's willing to rear a handicapped child, whether she can afford the expense, whether abortion is consistent with any religious belief.
"We as doctors are not competent to decide for a patient whether to have an abortion or not. This is a personal decision for the patient. Our role is to provide the best information possible," he emphasized.
Religious beliefs often color a woman's decision and a doctor must be sensitive to the patient's religious beliefs whether he agrees with them or not: However, a fetus cannot decide for itself. This quandary brings into play a critical distinction, the distinction between professional ethics and private conscience.
"If we accept the person as a human being without decision-making capacity and a patient is a human being presented to the physician and there exist beneficial interventions. The fact that the viable fetus is not a person, it does not follow that a viable fetus is not a patient," Chervenak pointed out.
He pointed to a law in Great Britain that permits third-trimester abortion for any fetal anomaly, ruing that "a fetucide during the third trimester violates our obligations to the fetus as patient."
But there are fetal anomalies-Down's syndrome, spina bifida, many forms of hydrocephalus, achondroplasia, and most cardiac anomalies-in which death or absence of learning capacity is a likely outcome. Anomalies like these entail a burden on patients, parents, society, communities, institutions and health-care professionals. The concept of such burden is supported by the Royal College of Obstetricians and Gynecologists.
Amid these burdens, a doctor's obligations to the patient-fetus will hold and stand its ground.
Argued Chervenak: "Society has a justice-based obligation to look after its disabled and to maximize their potential. I'd suggest the seriousness of a fetal anomaly should be defined without reference to dependency or burden on another's especially in the developed countries such as Great Britain, United States. I'll leave it to your interpretation if that implies to the Philippines as well."
And there is the option of nonaggressive management, which often escapes attention.
"A very important clinical ethical point is that management in the third trimester is not a binomial-i.e. if the woman chooses not to have an abortion, it doesn't mean that everything must be done in all cases for the fetal patient. And when we deal with severe anomalies, there's an important place in obstetrics not to do a caesarean delivery for fetal distress, not to use intensive surveillance, not to do a full-court press."
But in modern obstetrics throughout the world, there will be less and less of fetucide, cephalocentesis, or nonaggressive management to be seen as "decisions are best made earlier in pregnancy rather than later.
"Even a simple word such as 'mother' is ethically charged as it implies that the pregnancy will continue to term. We don't use the term 'mother' when termination is on the table," he added.
In the ensuing open forum, a neonatologist from Philippine Children's Medical Center pointed out to him that in the Philippines pregnant women are known by the term nagdadalang-tao or literally "carrying a human": Tao is human. And to us it is simple. That life is inviolable and any form of intervention, action that would make that life at risk is certainly no way to go."
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