Biomedical Ethics and Fetal Therapy

6. Fetal Therapy: Ethical Considerations

6 FETAL THERAPY: ETHICAL CONSIDERATIONS David J. Roy My attention to fetal therapy, awakened several years ago, was recently sharply focused by a report of successful intrauterine treatment of fetal cardiac failure in a twin pregnancy. One twin was an acardiac, acephalic fetus. Ultrasound at twenty-eight weeks revealed notable edema of the trunk in the supporting viable twin, indicating fetal cardiac failure, possibly due to cardiac overload. Digitalization of the mother led to resolution of the edema in the viable twin and to its birth as a normal male infant with no evidence of edema or cardiac failure at birth. 1 Some of the earlier reports that awakened my attention were more dramatic, perhaps, and related to the first report, in 1963 by 2 Dr. A.W. Liley, of an infant saved by use of intrauterine transfusions . Externalizing the fetus by hysterotomy, transfusion, and replacement of the fetus in the uterus was mentioned as early as 3 4 1969 and again in 1977. Today, individual reports of attempted fetal therapies appear at rapidly increasing rates and cover an ever wider range of intrauterine treatments, including, as examples, administration of medication to the mother to correct fetal malfunctions , fetal transfusion by fetoscopy and other methods, ventriculoamniotic shunting for hydrocephalus, diversion or bladder-amniotic shunting for urinary tract obstruction, and aspiration of sacrococcygeal teratoma. Fetal Therapy and Prenatal Diagnosis Thirty years have passed since the first systematic attempts to diagnose a pathologic condition in the fetus by analyzing samples of the amniotic fluid surrounding the unborn in the mother's womb. In its earliest phase, prenatal diagnosis was linked to treatment of the fetus affected by severe anemia resulting from Rh incompatibility. Amniocentesis became a routine method in the management of the 60 Biomedical Ethics and Fetal Therapy Rh-immunized mother, and many fetuses who would have died in the womb were saved. If emphasis at the very beginning of prenatal diagnosis was on "late detection and treatment," attention, interest, and intentions shifted by the late 1960s to "early detection and abortion." 5 Selective abortion following prenatal diagnosis became socially possible after attitudes towards abortion became less restrictive in the early 1970s. Early tentative suggestions that prenatal diagnosis might permit selective abortion changed quite rapidly into the position "that abortion for genetic defects discovered by intrauterine diagnosis is here to stay for a long time."6 It is very difficult, of course, totally to ignore the in-built tendency of diagnosis towards treatment, care, and eventually the prevention of disease. Dr. R.J. Benzie emphasized this connection several years ago with the statement: "Prevention and treatment, not abortion, should be the aim of antenatal genetic diagnosis." 7 This connection between fetal therapy and prenatal diagnosis is acquiring new prominence. First, the increasing possibilities for effective fetal therapy give a new direction and a new meaning to prenatal diagnosis. The change appears in the following words: Until recently, the only question raised by the prenatal diagnosis of a fetal malformation was whether to abort the fetus, but other therapeutic alternatives are becoming available, such as changing the timing of delivery, changing the mode of delivery, and even treatment before birth. Since perinatal management may be altered, pr8enataldiagnosis now assumes practical clinical significance. It is essential to emphasize, secondly, that prenatal treatment of the fetus would never have reached even its present embryonic stage had it not been for the rapid development of a panoply of precise fetal diagnostic techniques. Of course, the demand for selective abortion of defective fetuses played a role, a major role, in the development of these diagnostic methods. With such a complex history, is it unreasonable to wonder whether this role of selective abortion will prove to be temporary, historically limited, and destined to pass? The fetus is now on the threshold of being seen, treated, and valued as a patient. Will this shift in perspective change societal and medical attitudes towards selective abortion and prenatal diagnosis? Fetal therapy may exert such an influence. Of course, in utero fetal therapy, particularly in Roy / Ethical Considerations 61 utero fetal surgery, turns the mother into a patient. She has to be operated on also. If this therapy does modify attitudes towards selective abortion, it will, as does every advance, also spawn a whole new generation of difficult medical, ethical, and legal dilemmas. The Goals of Medicine A woman golfer with rather large breasts once asked a doctor if...