Theory and Consequences
"The Case against Premature Induction Deliveries of Babies with Anencephaly and Other "Anomalies Incompatible with Life"
by Nancy Valko, RN
It is a soul-searing moment when parents are told that their child will die. Whether this occurs before or after birth, the anguish of the parents is very real and there is a natural desire on the part of everyone involved to alleviate this suffering in any way possible.
While a whole arsenal of emotional and physical help can be mobilized to support both parents and child during the dying process of a child who is already born, such options are more limited when a lethal condition is discovered before birth.
Anencephaly has long been considered one of the most tragic of such lethal conditions. The lack of major portions of the brain and skull usually results in the death of such an infant either before birth or shortly afterward, and there is no treatment to cure such a condition. Although prenatal testing is sometimes erroneous, the diagnosis is usually made in the second trimester of pregnancy and abortion is the typical recommendation to supposedly help such wounded parents.
In 1982, I had a friend who faced such a situation.
"Mary" (not her real name) had an ultrasound suggesting anencephaly when her unborn child was at 21 weeks gestation and she endured 28 hours of hard labor with a prostaglandin-induced abortion before her baby was delivered and died. Mary tried hard to put the tragedy behind her and decided to tell most of her friends that she had a miscarriage rather than an abortion. However, as she confided later, she half-expected to be somehow punished when she later had a son and it took several months after his birth before she could truly believe that her son was healthy. And every Christmas she secretly hangs an ornament for her dead first child.
Catholic Ethics and Anencephaly
In a 1993 article, "Anencephaly and the Management of Pregnancy",1 Sister Jean deBlois, CSJ, then-senior associate for clinical ethics at The Catholic Health Association, proposed anencephaly as a case where "the pregnancy may be terminated at any time". Although Sister deBlois acknowledged that "there is no life-threatening maternal pathology", she cited the increased physical risks during labor and delivery, the "emotional trauma suffered by a couple upon diagnosis of anencephaly", and the lack of mental development in the baby as justification for "inducing labor to end the pregnancy".
Employing the principles of proportionality and "double effect", she maintained that "the resulting fetal death is indirect" and thus not an abortion. Sister deBlois further stated that because "human life involves more than simply biologic life", and infants with anencephaly lack "psychological, social, and creative capacities", such babies "can never acquire the quality of viability, properly understood". Thus, she maintained, "once the diagnosis is made, there seems to be no purpose in maintaining the pregnancy".
Anencephaly was thus singled out as a special case from other lethal birth defects because of the presumed lack of mental function. According to Sister deBlois's rationale, Catholic hospitals would then be ethically allowed to perform early induction delivery -- an acknowledged abortion procedure used for terminating babies with birth defects2 -- as a kind of termination of life support rather than abortion.
Whatever the semantics, Sister deBlois's position was a radical departure from the Church's condemnation of direct termination of pregnancy based on the condition of the unborn baby. Especially because some ethicists consider anencephaly as analogous to the controversial "vegetative state", this position unfortunately also furthered the contention that a presumed lack of mental function overrides the obligation to provide for the basic needs of a person by justifying even the interruption of a process as natural as pregnancy.
Sister deBlois's article was later included in the 1994 book A Primer for Health Care Ethics-Essays for a Pluralistic Society. co-authored with Fathers Kevin O'Rourke, OP, and Patrick Norris, OP.
However, in 1996, the US bishops issued a statement titled "Moral Principles Concerning Infants with Anencephaly"3 that declared, "it is clear that before 'viability' it is never permitted to terminate the gestation of an anencephalic child as the means of avoiding psychological or physical risks to the mother. Nor is such termination permitted after 'viability' if early delivery endangers the child's life due to complications of prematurity. Only if the complications of the pregnancy result in a life-threatening pathology of the mother, may the treatment of this pathology be permitted even at a risk to the child, and then only if the child's death is not a means to treating the mother".
In the second edition of A Primer for Health Care Ethics, published in 2000, Father Kevin O'Rourke points out that he changed his earlier position described in the co-authored book above. He writes, "the application of the principle of double effect does not seem to justify the early delivery of anencephalic infants. (This conclusion is a reversal of the opinion of O'Rourke and DeBlois cited above.)" 4
Theory and Consequences
Despite an apparent emerging consensus on the issue, the matter of early-induction deliveries of anencephalic infants is not considered closed by some ethicists.
In a July 2003 article titled "Early Delivery of a Fetus with Anencephaly",5 Father Norman Ford theorizes that waiting until 33 weeks (almost two months before term) to induce delivery of anencephalic infants meets ethical standards. While prematurity is considered as delivery before 37 weeks, Father Ford maintains that the cause of these infants' deaths would then be anencephaly instead of prematurity since most normal babies survive when delivered at that stage even though the deaths of anencephalic infants are anticipated. He stated that these early inductions are motivated by "a compassionate desire to alleviate her [the mother's] distress and minimize potential health risks for the mother" and that "by this stage the mother's duty of reasonable care for her fetus would have been satisfied".
Some ethicists in Catholic hospitals would go even further.
Two October 2003 articles -- one in the Catholic Anchor, Anchorage's archdiocesan newspaper,6 and one in the National Catholic Register7 -- report early induction deliveries of infants with other "anomalies incompatible with life" in Catholic hospitals as early as 24 weeks into pregnancy, the commonly accepted limit of viability even with treatment. The ethicists involved defend the early inductions as consistent with Directive number 49 of the US Bishops' Ethical and Religious Directives for Catholic Health Care Services (ERD), which says: "For a proportionate reason, labor may be induced after the fetus is viable". However, as Dr. Maria Wallington, director of ethics at Providence Alaska Medical Center, told the Catholic Anchor, "The ERDs talk about proportioned good and then they don't talk about how you decide that".
In a later article in the January 23, 2004 edition of the Anchorage Daily News, Dr. Wallington continued to defend the early inductions: "The practice relieves suffering, Wallington said. Imagine how hard it would be for a pregnant woman to face constant questions about a baby she knows will die."8
The development of policies to allow early induction deliveries of babies with presumed lethal defects was a shock to many, especially those in the pro-life movement. In January 2004, Alaska Right to Life held a press conference to protest these early inductions as abortions and featured a mother of a child with such lethal defects who said she had no regrets about rejecting the option of early termination of pregnancy. Her baby lived for 32 days.9
Risks of Early Induction of Labor
While induction deliveries are not uncommon and can even be life-saving for the mother or baby, inducing delivery two to four months early is a situation that would certainly not be contemplated for a healthy baby and a healthy mother.
Induction itself carries serious risks to both mother and infant. As a May 2003 editorial in the American Family Physician journal states, even elective induction delivery near- or post-term "is not without potential risks, including iatrogenic prematurity, uterine hyperstimulation, nonreassuring fetal heart rate tracing, and greater likelihood of operative delivery [C-section], shoulder dystocia, and postpartum hemorrhage".10
Despite the advances in prenatal diagnostics, prenatal testing is still not 100% accurate and there exists a risk of misdiagnosis that can and often does result in the loss of a less impaired or even healthy baby by early termination of pregnancy.11
Even when induction is considered necessary in medically emergent situations, such as severe preeclampsia in the mother, every effort is made to give the baby as much time in the womb as possible to lessen the usual risks of prematurity.
Emotionally, the diagnosis of a lethal or other serious anomaly in an infant is a distressing moment for parents, whether this occurs before or after birth. There is a normal grieving process as the parents face the reality of the loss of the "perfect" baby they had imagined.
When a birth defect is deemed lethal, parents must also eventually prepare for the death of that child. When such a baby is still in utero, there is a natural tendency to want to "get it over with" rather than endure well-meaning comments from strangers and imagine a sadly different labor and delivery weeks or months in advance. However, the natural grief of losing a child cannot be avoided and it is by no means clear that waiting an additional two to four months before the pregnancy is terminated rather than waiting for natural delivery will substantially decrease maternal distress. To my knowledge, supporters of early induction have not cited studies supporting their contention that early induction can be psychologically beneficial.
As with any bereavement, the emotional distress of the parents does not end with the death of their infant and, as my friend Mary's situation illustrates, the intentional early delivery can add even more emotional trauma to an already tragic situation.
Unlike other areas of medicine, innovations in bioethics frequently involve philosophical or theological considerations rather than new medical information or research. Too often, bioethical theories are put into practice before such theories are adequately discussed with the public and Church authorities.
Bioethics is an unforgiving area of medicine, where lives can be unnecessarily and unjustly lost because of a redefinition of terms or a subjective interpretation of principles. Issues once considered settled can then become open to even radical change with unexpected consequences. Early induction is such an issue.
Unfortunately, the initial error appears to be the theory that a presumed lack of mental function is a lethal pathology that can override the obligation to provide for the basic needs of a person. When applied to the case of an unborn baby with anencephaly (who is also presumed to lack mental function and who indeed does have a lethal pathology), this theory allows a similar override of the obligation to provide for the basic needs of the baby by justifying abortion. Following that logic, pregnancy itself can then be viewed as a form of 'life support" that can be ethically withdrawn at some stage where, as Father Ford states, "the mother's duty of reasonable care for her fetus would have been satisfied".12 Now, other ethicists focus on the ERD's Directive 49, which allows for induction delivery after viability for "a proportionate reason" to justify early induction deliveries of infants with even other lethal anomalies at any time after 24 weeks.
Before the latest ethical reevaluation of early induction delivery, the accepted Catholic norm was that even in the most tragic of cases, the life of the unborn child must be protected. That meant that labor would be allowed to occur on its own or to be induced when the infant was overdue or when a life-threatening condition developed.
While secular bioethics focuses on the perceived burdens of continuing an unborn life that may be short, the Church has always maintained that a person's life is to be valued at all stages and conditions until natural death. The wisdom of this position should preclude attempts to justify causing or even hastening death by early induction of labor.
Elective early induction delivery of babies with anencephaly or other lethal defects is unfortunately motivated by a misplaced compassion that not only deprives the baby of his or her natural lifespan, but also deprives the mother of the chance to truly bond with and nurture her afflicted child until death intervenes.
Catholic hospitals can set a standard of integrity by offering grieving families continuing support and encouragement rather than a premature termination of pregnancy. In doing so, Catholic hospitals will also provide a much-needed and powerful witness to the value of all human life, regardless of age or condition.
1 "Anencephaly and the Management of Pregnancy" by Sister Jean deBlois, CSJ, Health Care Ethics USA (Fall 1993), reprinted in A Primer for Health Care Ethics - Essays for a Pluralistic Society by Sister Jean deBlois, CSJ; Reverend Patrick Norris, OP; and Reverend Kevin D. O'Rourke, OP, Georgetown University Press, 1994
2 "Induction Abortion" from the Health Library of Northwestern Memorial Hospital, Chicago, Illinois. Available online at: http://health_info.nmh.org/Library/HealthGuide/IllnessConditions/topic.asp?hwid=tw2562 broken link 6/27/2005
3 "Moral Principles Concerning Infants with Anencephaly" by the Committee on Doctrine, US Conference of Catholic Bishops. Available online at: www.ewtn.com/library/PROLIFE/bcdanen1.htm
4 "Early Delivery of Anencephalic Infants: Ethical Opinions" by Reverend Kevin D. O'Rourke, OP, A Primer for Health Care Ethics, Georgetown University Press, 2000, pp. 311-315
5 "Early Delivery of a Fetus with Anencephaly" by Father Norman M. Ford, S.D.B., Ethics and Medics, July 2003, Vol. 28 No. 7. Available online at www.ethicsandmedics.com/0307-1.html
6 "Providence is refining its policies on induced labor" by John Roscoe, Catholic Anchor (Anchorage, Alaska), Oct. 10, 2003. Available online:
www.archdioceseofanchorage.org/Anchor/vol5is21/vol5is21.htm##%20article%201broken link 6/27/2005
7 "Induction Procedures Raise Moral Dilemma" by Thomas Szyszkiewicz, The National Catholic Register, Oct. 13, 2003. Available online at: http://ncregister.com/Register_News/101903_3.htm
8 "Right-to-lifers target Providence" by Lisa Demer, Anchorage Daily News, January 23, 2004. Available online at: http://adn.com/alaska/story/4659382p-4614927c.html broken link 6/27/2005
10 "Labor Induction: A Decade of Change" by Elizabeth G. Baxley, M.D., American Family Physician, May 15, 2003. Available online at: www.aafp.org/afp/20030515/editorials.html
11 "Prenatal testing and informed consent: base your choices on the evidence" by Peggy O'Mara, Mothering magazine, Sept-Oct, 2003. Available online at: www.mothering.com/11-0-0/html/11-2-0/prenatal-testing.shtml
12 "Early Delivery of a Fetus with Anencephaly" by Father Norman M. Ford, S.D.B., Ethics and Medics, July 2003, vol. 28 no. 7. Available online at www.ethicsandmedics.com/0307-1.html
Nancy Valko, a registered nurse, is president of Missouri Nurses for Life and a spokesperson for the National Association of Pro-life Nurses. She speaks and writes frequently on bioethics issues, and is a Voices contributing editor. An edited version of this article appeared in Ethics and Medics, a publication of the National Catholic Bioethics Center (NCBC), and can be read online at www.lifeissues.net/writers/val/val_24prematureinduction.html. The NCBC's Statement on Early Induction of Labor can be read on their web site by clicking on the following link: http://www.ncbcenter.org/press/04-03-11-EarlyInduction.html
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