Directive 45 of the Ethical and Religious Directives for Catholic Health Services [NCCB 1995] states “Abortion, that is, the directly intended termination of pregnancy before viability is never permitted.” Directive 49 states “For a proportionate reason, labor may be induced after the fetus is viable.” A question has arisen as to whether these two directives are consistent with the deliberate induction of labor, after viability, in the instance where a mother is carrying a baby with a prognosis for only a short-term survival (such as anencephaly, renal agenesis) or multiple congenital anomalies with a prognosis for survival of approximately one year (e.g. Trisomy 13, Trisomy 18). Some institutions have included congenital anomalies with a prognosis for long-term survival, such as Down syndrome and meningomyelocele, in this type of management.
Induction as Direct Killing
The paradigmatic case involves the question of early delivery of an infant with anencephaly (1). Since the anencephalic infant has such a uniformly brief prognosis and should receive only comfort care after birth, it lends itself more readily to an illustration of the moral principles involved.
The ultimate intention of those recommending early delivery would be the morally good intention of eliminating anxiety on the part of the parents of the deformed and/or handicapped child (1). The justification proposed is that early delivery constitutes an indirect rather than a direct abortion. An indirect abortion occurs when the goal of the act is to produce a therapeutic benefit for the pregnant woman and the death of the fetus is a necessary but unintended side-effect of the therapeutic procedure. The distinction between direct and indirect abortion is an application of the principle of double effect.
The early delivery of a viable infant, however, can only be justified if the infant can no longer safely live in the womb. For example, in the case of amnionitis resulting from premature rupture of the membranes after viability, the prognosis for survival of the infant may actually be enhanced by premature delivery if the infant is immediately introduced into the supporting environment of a neonatal intensive care unit.
In the case where a viable human being with a uniformly fatal prognosis is deliberately delivered early (e.g. anencephaly, renal agenesis) the institution of useless neonatal intensive care support would be contra-indicated, if not unethical. It is clear, therefore, that the intention of early induction of delivery in these cases is not to enhance the possibility of survival but rather to guarantee the death of an innocent human being. The principle of double effect does not apply since the good intention of improving the psychological reaction of the parents is achieved through the immoral action of directly killing the infant.
The legitimate application of the principle of double effect would require that the death of the infant be an indirect effect of the morally licit intention of reducing or eliminating parental anxiety (2). Since the goal of the action of early delivery is the direct killing of an innocent human being, the principle of double effect would not apply (3). If early induction of labor cannot be justified in the case of an anencephalic infant who will “die anyway” usually in a week or less, it cannot be accepted where the infant has a longer expectation of survival such as Trisomy 13 or Trisomy 18.
Deliberate induction of prematurity in the case of Down syndrome or meningomyelocele is obviously a form of fetal euthanasia and is mentioned only to be condemned. The child with low-meningomyelocele who is operated upon early will have a likely prognosis of normal intelligence and community ambulation with braces. Recent advances in the mainstreaming of children with Down syndrome are well known. Extraordinary surgical and medical procedures (such as closure of the defect and shunting that would be indicated in most neural tube defects), complicated cardiac surgery, and other high-technology management, would not be indicated in uniformly fatal syndromes such as Trisomy 13 and Trisomy 18.
Grief and Perinatal Loss
Several recent studies have pointed out the necessity of adequate informed consent before ultrasonic screening is undertaken (4, 5, 6). Many women are not aware of the scan’s potential to detect abnormalities. Women whose pregnancies would have ended in spontaneous perinatal loss are thus faced with having to make a decision about whether to continue their pregnancy. Without full explanation of the technology, patients may be unprepared for bad news or a period of uncertainty. Unlike patients at high risk who have amniocentesis, these women have not had the advantage of contemplating the early induction of labor in a planned and wanted pregnancy. Not all women will want to know their baby is abnormal and not all women will choose to terminate their pregnancy if it is.
Psychological support has been defined as one objective of scanning for abnormality (7), but evidence indicates that psychological morbidity after early induction may be as high as that of spontaneous perinatal loss. Acute grief reactions were observed in 78% of women who had termination for fetal malformations (8). This was equal to that of stillbirth and neonatal death and much higher than that associated with miscarriage (6%).
Health professionals may not associate the classic grief reaction with losses in the perinatal period because they believe the family has not had a chance to become “attached” to the baby or fetus. There is strong evidence to the contrary. Kennell (9) points out that “strong affective bonding appears to begin before physical contact and caretaking.” It is important in the management of this grief reaction that the parents be encouraged to mourn actively. Phrases such as “it’s for the best” or “You can always have another child” tend to evoke anger because they deny the parent’s right to grieve (10). Gulber (11) reported pathologic mourning in 34% of mothers studied. The facilitation of normal grief reactions may minimize the occurrence of abnormal grief.
Before parents can accept the death of their baby, they must perceive that it has actually existed. This requires that the mothers and fathers see and touch and hold their baby in a private surrounding (12). It is probably advisable that the child be given a name. Baptism or other religious rites desired by the family are in order. Parents who wish to have a funeral should not be discouraged. Psychological support should continue after the mother is discharged from the hospital and plans her future pregnancies.
Although the management of the pregnancy of a mother carrying an abnormal baby by early induction of labor is frequently proposed as a way of minimizing suffering of parents and child, it is best evaluated against alternative options. Semantic manipulations notwithstanding, it is most appropriately evaluated as a form of third trimester abortion (13).
The justification of third trimester abortion by an appeal to the expected opportunity to conceive a subsequent child contradicts proper management of perinatal death, and the principle of beneficence. It not only fails to benefit or relieve suffering but it also is a source of suffering because it contributes to the likelihood that mourning will be incomplete (14). There is almost invariably an inadequate appreci-ation of the importance of prenatal bonding. The mourning reaction after perinatal death occurs in all parents regardless of term of gestation or birth weight. Proper management of perinatal death must facilitate normal grief.
Eugene F. Diamond, M.D.
American Academy of Pediatrics
Executive Committee, Section on Bioethics Chicago, Illinois
1.Diamond, E. “Management of a Pregnancy with an Anencephalic Baby,” Linacre Quarterly (59:19), 1992.
2. O’Rourke, K. E., O.P. “Ethical Opinions in Regard to the Question of Early Delivery of Anencephalic Infants.” Linacre Quarterly (63: 55), 1996.
3. “Anencephalic Infants and Their Care,” USCC,L’Osservatore Romano [Eng.] 38 (September 1998), 7.
4. McFadyen, A. and J. Gledhill, “First Trimester Ultrasound Screening,” BMJ (317: 694), 1998.
5. Venn-Treloar, J. “Screening Without Consent,” BMJ (316:1022–7), 1998.
6. Proud, J. et al., “How Much Information Do Women Receive Before Ultrasound? Br. J. Midwifery (5: 144), 1997.
7. Leanah, C. H., et al. “Do Women Grieve after Terminating Pregnancies For Fetal Abnormalities?” Obstet. Gynec. (82: 270), 1993.
8. Lloyd, J. and K. M. Laurence. “Sequelae after Termination of Pregnancy for Fetal Malformations,” BMJ (290: 907), 1985.
9. Kennell, J. et al., “The Mourning Response of Parents at the Death of a Newborn Infant,” N. Eng. J. Med. (283: 344), 1970.
10. Furlong, R. and J. Habbins. “Grief in the Perinatal Period,” Obstet. Gynec.(61: 497), 1983.
11. Gulber, J. Psychosomatic Medicine in Obstetrics and Gynecology (Basel S. Karger, 1972).
12. Speck, W. and J. Kennell. “Management of Perinatal Death,” Pediatrics in Review (), 1980.
13. Chervanek, F. et al., “When Is Termination of Pregnancy in the Third Trimester Justified?” N. Eng. J. Med. (310: 501), 1984.
14. Fries, P. “Correspondence,” N. Eng. J. Med. (311: 265).