Moral Decisions 2

Article #14

MORAL DECISIONS One Thing After Another

by Reverend Monsignor James J. Mulligan

On the way home one evening, I stopped to take care of an errand. When I got back into the car, it wouldn't start. A mechanic informed me that I needed a new battery. In replacing it, he noticed that I needed a new tire. That led to alignment. The man who aligned it said that I needed work on the exhaust system. I'm afraid to find out where that will lead. This is life. One thing leads to another. Sometimes it leads to a blessing, sometimes to a problem. This is also true in science and medicine. The internal combustion engine led to a revolution in transportation, and then to a crisis in pollution. Advances in the study of human fertility have led to real blessings for couples unable to have children. They have also led to serious and complex moral issues. It is now possible to intervene in the life of the child in the womb in a bewildering variety of ways, and for a sometimes equally bewildering variety of reasons. Let's begin by looking at the reasons. The Vatican's Instruction on Procreation suggests four general purposes for these interventions. Diagnostic; therapeutic, scientific and commercial. Diagnosis is the art of determining if anything is wrong with a patient's health and, if so, then exactly what that condition is. It may also make use of techniques and tools that can cause pain or serious side effects. How free are we to use them on the unborn? Therapy is the treatment of diseases or disorders. Its intention is good, but its drugs or techniques may have undesirable side effects. When are we justified or not in the use of certain therapies? Well informed adults may often experience anguish in making such decisions for themselves. How do we know what decisions to make on behalf of the unborn? The scientific purpose of intervention is to acquire knowledge, which may indeed be quite useful. There are certainly moral limits as to how far one can go in involving adults in an experiment -- even when those adults are well informed of all aspects of what will take place. There are risks that one may accept for diagnosis or therapy which one would never accept merely for the sake of experiment. How are such decisions to be made for the unborn? Commercial goals refer to the intention of making a profit. We should not reduce adults to mere means of financial gain, even when they seem willing to be so used. It is unthinkable that we would use the unborn in such a way. Yet they are and have been so used, as we shall see in future articles. In each of the areas mentioned above, one thing leads to another. In each we must make serious moral and medical decisions. We must understand not only what we do, but also the implications and results of what we do. Our moral responsibility extends through a whole process, and it is never sufficient to claim that our intentions were good, if in fact we initiate a process that ends up causing moral wrong.

Article #15

MORAL DECISIONS Tell Me Where It Hurts

by Reverend Monsignor James J. Mulligan

The first step in diagnosis is simple: Just tell me where it hurts. That, of course, is rarely ever enough. The description of symptoms is usually followed by examination, which may become quite complex and demand some very elaborate devices. In the case of the unborn, the initial question may not even be possible. The child cannot answer and the mother may be unaware of any symptoms. Diagnosis will almost always involve some sort of intervention. This may take various forms, including such techniques as amniocentesis or ultrasonography. Before we look at particular procedures, it would be well to consider moral principles of intrauterine diagnosis in general. Ultrasound seems to be quite safe and has no currently recognized harmful side effects. It supplies a good deal of information about the developing child and helps to prepare for a safer delivery. This technique is now used, in many instances, just as a matter of course. None of this creates a moral problem. It is directed to the good of both child and mother. Other forms of diagnosis (such as amniocentesis or Chorionic Villus Sampling) are more invasive, with recognized degrees of risk. These should not be used without some serious reason to do so. The general principle is that methods which have risks attached should not be used simply as a matter of course, but only when there are serious reasons. This is good moral thinking and good medical thinking. In fact, good medicine and good morality generally tend to coincide. Another principle is that the parents should give informed consent for any procedure. This means a consent based on a good explanation and understanding of what will be done and why it is to be done. This also is good practice morally, medically and legally. We can put this all together and say, as a general principle that diagnostic techniques are allowed, with informed consent of the parents, (1) if they are necessary, (2) if they safeguard the life and integrity of mother and child and (3) if they do not cause undue risks. There still remains the question of motive. Diagnostic actions are seriously immoral when purpose is to make possible a decision for abortion. Sometimes the diagnosis looks for such things as Tay-Sachs disease, or sickle cell anemia, or Downs Syndrome, with the intention to abort the afflicted child. This is bad moral practice, since we have no right to destroy innocent life. It is bad medical practice, since the doctor should not get rid of disease by murdering his patients. Legally, it is perfectly acceptable -- and that is a disgrace for our whole society. There are groups and programs advocating removal of defects by removing those who are defective. They promote prenatal diagnosis to encourage the abortion of those with hereditary defects. Diagnosis -- which should be directed to health and life -- becomes a death sentence. Tell them where it hurts, and they'll get rid of all your pain.

Article #16

MORAL DECISIONS The Seeing-Ear Test

by Reverend Monsignor James J. Mulligan

Sometimes diagnosis demands seeing into places that cannot ordinarily be seen. We are all familiar with X-rays, which pass through a body to create a photographic image. A CAT scan is a more sophisticated use of X-ray and computers. Magnetic Resonance Imaging (MRI) uses radio waves and a magnetic field. Radioactive substances can be introduced into the body and traced for still further information. During pregnancy all of those techniques carry risks of harm or death to the fetus. However, sound can also penetrate tissue and seems not to have the same harmful effects. That is why ultrasound is often used for examination of the unborn child. Ultrasound uses sound beyond the range of human hearing to penetrate tissue. This is reflected back and a computer turns it into a video image (called a sonogram) visible on a screen. This also allows movement to be seen -- even the beating heart of the fetus. The sonogram can be of considerable help in the whole process of pregnancy and birth. The technique is non-invasive and allows the physician to be of more help to both mother and child. In making moral judgments about it, we ought to understand its uses. It can help with infertility. Being sensitive to soft tissue, it can reveal whether ovulation has occurred or detect the presence of ovarian cysts, which can impede fertility. During pregnancy the information gained through ultrasonography can be invaluable. The growing fetus can be seen as early as the fourth or fifth week, and its growth and position can be monitored. Where there is threat of premature birth, or when the health of the mother or child demands early delivery, some of the risks are overcome through sonography. Visualization of fetal body size and head circumference give evidence of sufficient development for viability (the capacity of the infant to survive outside the uterus). If there is a need for amniocentesis or Chorionic Villus Sampling, ultrasound is used to determine the precise location for the insertion of the needle. It also guides the doctor in the performance of intrauterine transfusion or surgery. Sonograms reveal the position of the child and the size and position of the placenta (that portion of the fetal organs which attach to the wall of the uterus). The position of the child is quite important at the time of delivery. Placenta previa is a condition in which the placenta is positioned in the uterus so as to block the normal exit. It impedes normal birth and can cause severe bleeding. Ultrasound can alert the delivery team to this before a state of emergency arises. There are, then, many morally acceptable reasons for using ultrasound. At present it seems quite safe, and no undesirable side effects have been seen. (It should be noted, however, that serious side effects have not been totally disproven either -- and it took decades to see the harmful effects of X-ray.) In terms of moral judgement, ultrasound seems quite acceptable. Right now it's the best way to hear a picture.

Article #17

MORAL DECISIONS What Is He Talking About?

by Reverend Monsignor James J. Mulligan

For almost half of my life I was a teacher. In the beginning, when everyone looked attentive and there were few questions, I congratulated myself on my clarity. It took me a while to realize that sometimes there were no questions because no one knew what I was talking about. And sometimes it was as simple a matter as using words with which people were not yet familiar. It is for this reason that today's column will consist of an explanation of some words. They are words that I used in preceding weeks, and will be using in the future as we continue our discussions on morality. Amniocentesis (am-knee-oh-sen-TEA-sis): The word means a puncturing of the amnion, which is the sac of fluid in which the fetus is contained in the uterus. In this process a needle is inserted through the abdominal wall of a pregnant woman and then into the amnion. Some of the fluid is drawn out for examination. This fluid is produced by the fetus and not by the mother. From the fetal cells contained in the fluid, a culture is prepared (which takes a few weeks). It serves as a basis for diagnosis of a number of fetal conditions. Amniocentesis is done in the fifteenth or sixteenth week of pregnancy. The procedure is delicate and can carry some serious risks to the fetus, causing miscarriage at a rate of about 1 per 200. Chorionic Villus Sampling (CVS): The chorion is the membrane around the embryo. It has villi (hairlike structures) which embed in the wall of the uterus, although both chorion and villi are part of the organs of the child rather than of the mother. CVS consists in inserting a needle through the mouth of the uterus or through the abdominal wall, to remove some of the chorionic cells. These can then be examined for genetic defects. CVS is more risky than amniocentesis, and anywhere from 2 to 6 miscarriages occur per 100. It is done in the eighth to tenth week of pregnancy. It offers more cells for examination than does amniocentesis, so the results are available in a matter of days rather than weeks. It is sad to report that the advantage of CVS over amniocentesis is described primarily in terms of making abortion decisions available at an earlier date. Fetoscopy: This is a process for directly viewing the fetus. An incision is made in the abdominal wall of the mother. A needle is inserted into the uterus and right into the amniotic sac. The needle contains a light and a lens. The fetus can be examined visually in order to detect any visible abnormalities. Fetoscopy can be done at about the fifteenth week of pregnancy. It carries a high risk of miscarriage. None of the procedures described above should be done simply as a matter of course. They are too dangerous to the life of the child. Moral judgments should take this into account. Such techniques should not be used unless the fetus is already at some risk and the potential benefit to the child is at least as important as the risk being taken. The purpose of the tests is also essential in making a moral judgement. If they are carried out in order to diagnose a serious fetal problem for which some treatment can be started, then they may be justified. If they are being done with the intention of deciding to abort a "defective" child, then their use is morally wrong.

Article #18

MORAL DECISIONS -- Lies, Damned Lies and Statistics

by Reverend Monsignor James J. Mulligan

Pythagoras, simply in order to make life difficult for all future generations of high school students, developed the theorem that the square upon the hypotenuse of a right triangle is equal to the sum of the squares upon the other two sides. What, you may ask, has that got to do with moral decisions or medical ethics? Nothing at all, so far as I know. But Pythagoras was enamoured of numbers. He saw in them a magical quality and thought that they ruled the world and human lives as well. We tend to do the same -- but, of course, we would never call that magic. We call it statistics! In the previous article of this series, I spoke of amniocentesis. It is frequently used to diagnose possible abnormalities in the developing child before its birth. All too often it is used in order to decide upon abortion. The decision as to whether to use it is, to a large extent, based on statistics. A good example of this is the occurrence of Down's Syndrome (also called Trisomy 21 or Mongolism). Children born, with this condition have some physical deformities and varying degrees of mental retardation. The condition can occur in any pregnancy, but it becomes more common as the age of the mother increases. In fact, when a woman is 40 years of age or older, she is 50 times more likely to have a Down's Syndrome Child. That sounds like a shocking increase -- but read on. Many -- doctors and others -- take this statistic as a sign that every pregnant woman over 40, and perhaps over 35, should undergo amniocentesis, with the option of aborting the afflicted child. Clearly, the fact of physical affliction or mental retardation is not and never should be an excuse for killing. But what are the real numbers which lead to the fear? Young mothers (in their twenties) have a chance of 1 in 2000 of having a Down's Syndrome child. That is 0.05%, which means that there is a 99.95% possibility of having a child without Down's Syndrome. By the time a woman reaches the age of 35, the chances go up to 1 in 200. That is a 0.5% chance of Down's -- which is ten times higher than it is for the younger woman. Of course, that still means that there is a 99.5% chance of a baby without Down's. At the ripe old age of 40, the woman's chances of a Down's baby will be 1 in 40, which is 2.5%. What then are her chances of having a child without Down's? A resounding 97.5%! Even though the risk of Down's is now 50 times higher, it is still less than 3%! Yet there are women over 40 who become pregnant and abort the child through fear that it will be afflicted with Down's. In fact, they are often enough encouraged to do so even without amniocentesis, since that cannot be done until after the fifteenth week of pregnancy, and earlier abortions are easier to perform. Should every woman after the age of 35 have amniocentesis routinely done in order to see if Down's Syndrome is present? My response would be a clear, "No." The chances of a child without Down's are overwhelming. And, in any case, abortion would still be murder. My point is not to deny that Down's Syndrome is a sad and serious condition. The real point is this: Numbers can convey a great deal of information, but they can be easily misread. There are also those who -- out of ignorance, avarice, malice or stupidity -- will misuse them for their own ends. Always check carefully when you are being overwhelmed by statistics. They are not magic.

Article #19

MORAL DECISIONS -- Something Stupid?

by Reverend Monsignor James J. Mulligan

Did I say something stupid or irresponsible in the last issue of this column? There is a general tendency to suggest that pregnant women over the age of 35 should undergo amniocentesis in order to determine if the child they are carrying has Down's Syndrome. If the test is positive, they are then offered the alternative of abortion. I offered it as my opinion that amniocentesis should not be performed simply in order to diagnose Down's Syndrome. My reasoning was neither stupid nor irresponsible. Even at the highest level of risks, in the group of women over the age of 40, the chances that the child will not have Down's is 97.5%. The risk of miscarriage due to amniocentesis is 1 in 200 -- a risk of 0.5%. That is a relatively small risk, but I would still consider it unwarranted. If it were possible to use that knowledge to cure or prevent Down's, then it might be worth the risk. But that is not the case. The knowledge is sought simply so that the child can be killed, because it is imperfect. And if perfection is our criterion, then we are all in trouble -- yea, even I, your humble servant! Indeed, what is Down's Syndrome, and why is there such fear of it? It is a genetic defect. The normal human cell has 46 chromosomes (the cell structures which contain the genes). These have been grouped and numbered and can be observed in cell studies. The Down's Syndrome child characteristically (95% of the time) has 47 chromosomes rather than the usual 46. There is an extra chromosome 21. This is what is detected in the cells cultured from amniocentesis. It is why the syndrome is also called Trisomy 21 (meaning the presence of three rather than two chromosomes in that group). It is referred to as Mongolism because of physical characteristic (shape of nose, eyes, etc.). Not very long ago it was assumed that the Down's Syndrome child was severely retarded and was best institutionalized for life. That, of course, was a self-fulfilling prophecy. A child put into an institution, taught nothing, removed from family, and given little environmental stimulation will match our lowest expectations. In those circumstances a normal child would show signs of serious retardation. What are the facts? About one-third of these children may have heart problems and could die at an early age. The others live to adulthood, but age a bit more quickly and have a life expectancy of 40 to 60 years of age. The average IQ is about 50 (50 to 70 is considered mild retardation). This means, of course, that some are over 50 and some below. It also means that the former assumption of inevitable severe retardation is totally inaccurate. Yet there are still many -- some doctors included -- who continue to propagate this error. Given early stimulation and attention, and with continued education, Down's Syndrome children can cope quite well. Some may continue to need a good bit of help, while others can become capable of holding responsible jobs. The common qualities I have observed in those I have known were gentleness, trust and a beautiful desire to love and be loved. What is stupid and irresponsible? Is it the desire to see these children have a chance to live? Or is it the compulsion to kill them before they can draw their first breath?

Article #20

MORAL DECISIONS -- Are We Winning The War?

by Reverend Monsignor James J. Mulligan

Do you recall, not so many years ago, when one of the political slogans was the "War on Poverty"? I don't know what stage we have reached in that war. Perhaps, indeed, the poor we shall have always with us... at least so long as we have selfishness. In any case, would you consider it a benefit to humanity and to human dignity, if you were told that the war was being won because we had succeeded at last in killing almost all of the poor? Would you consider it moral -- or even sane -- if you were told that you ought to seek out and kill a poor person for the benefit of society? What about the war on hereditary diseases? Should it be fought by seeking out and killing those who are its victims? Or should we be looking for a better way to counteract the disease itself? Two of the hereditary diseases which have been most publicized are Tay-Sachs Disease and Sickle Cell Anemia. Another, which is, perhaps, less widely known, is Thalassemia. All have been addressed in similar ways. One method is to screen carriers and encourage them to submit to sterilization or use birth control. The other method is to abort the children who have the diseases. Tay-Sacks Disease is most common among those who are of Eastern European Jewish origin, although only about 4% of them carry the disease. The carriers, of course, do not have the disease itself but they do have the genes which lead to it. When the disease itself is inherited, its effects occur early in life. These may include paralysis and blindness. The victim will die by the age of 4. Sickle Cell Anemia is found almost always in those of African origin. It, too, is a serious disease. Its name comes from the fact that the red blood cells, which should be round in shape, are instead sickle shaped. It has an effect on bodily development. It has periods when it causes pain. It can have adverse effects on lungs and kidneys. It causes heart problems and it shortens the lifespan to just beyond 40 years. There is no cure and treatment consists in whatever can be done to relieve symptoms. Thalassemia also affects people of particular ethnic backgrounds. One type is found among those of Mediterranean origin. Another is found among Orientals. Some forms of it are mild and require no treatment. Others are far more severe. The symptoms may be severe and include anemia, jaundice, impaired growth, liver disease and heart failure. Life expectancy varies. For some forms it is normal, for others it is in the early teens. I have described these diseases, not because they are common or because we are all in danger of contracting them, but simply to indicate that they are indeed severe and to show that those who suffer from them deserve our real concern and compassion. On the other hand, I want also to state clearly that killing those who have them still remains a totally false kind of compassion. We should address the disease and search for a cure, but it is wrong and dehumanizing simply to wipe out the afflicted. Diagnosis by amniocentesis serves no morally good purpose if its only result is one more casualty in a poorly fought war on disease.

Article #21

MORAL DECISIONS -- Back in the Saddle

by Reverend Monsignor James J. Mulligan

Early in the American Civil War it became clear that all the best generals seemed to have gone South. The Union army lacked leadership and one general replaced another with amazing rapidity. At one point, General John Pope was given command of the forces around Washington -- a choice which did not prove happy. He began with a flurry of activity and went off into the field with his troops, right into defeat at Second Bull Run. The story (perhaps apocryphal) is told that he sent a report to President Lincoln, signed, rather dramatically, "from my headquarters in the saddle." Lincoln's comment was along the lines of, "Things weren't bad enough. Now we have a general who has his headquarters where his hindquarters ought to be." In some ways our enthusiasm over new scientific achievements is as misplaced as was the general's burst of activity. We leap into new areas, wanting to use a new technology and end up getting a lot of things backwards. In the last few columns I have looked at a variety of conditions which can be diagnosed in the uterus by means of amniocentesis. For none of them do we have a cure. In fact, while the child is still in the womb there is little or nothing we can even do to help in those particular areas. Many, however, like that same general, seem to put their headquarters where their hindquarters ought to be. Seeing a disease, and having no cure, they decide simply to get rid of it by doing away with the person who has it. It seems, perhaps, to be the easy way out. It is also the most inhuman way. Obviously, I would in no way condone the taking of innocent life. That I reject completely. But I am certainly not opposed to amniocentesis in itself. It has good and proper uses, and it may have even more in the future. It may come about that we will develop the capacity to treat or even cure some of the genetic disorders that I have spoken of in preceding weeks. We may even be able to do so while the child is still in the womb. Amniocentesis will then be a valuable and life saving tool. Its relatively small risks will be far outweighed by its potential advantage to the unborn child. But its use now as a means of helping people to decide on abortion is a dreadful misuse of a potential good. In fact, during the second trimester of uterine life, when amniocentesis is first possible, it now serves no useful purpose since what it can diagnose cannot at that stage be treated. There are, however, some quite legitimate and life saving purposes that it has even now in the last three months of pregnancy. One of those functions, in the case of a condition known as erythroblastosis fetalis, is also a perfect example of what happens when we stop trying to solve problems by abortion. Once we stop sitting on our heads and get back to thinking with them, it is amazing what can be accomplished. But for now I am at the end of my allotted space, so I shall explain further in coming columns.

Article #22

MORAL DECISIONS -- Honest Therapy

by Reverend Monsignor James J. Mulligan

There is a condition which can occur in the unborn child, a life threatening condition called erythroblastosis fetalis. It is a problem which affects the blood of the child. It comes about only under certain specific conditions, and happens only to certain couples. When a mother has Rh-negative blood and the father has Rh-positive, the child may inherit either one. If the child has Rh-negative, the same as the mother, there is no problem. Even if the child has Rh-positive, there still may be no problem -- unless a certain series of events takes place. If a person with Rh-negative blood receives a transfusion of Rh-positive, the body recognizes this blood as foreign and tries to protect itself against it. It forms anti-bodies to fight off the invasion. Even after the threat is over, the anti-bodies remain. This is, in fact, similar to what happens in a vaccination. The body forms anti-bodies capable of fighting off that same infection, should it ever return. Under normal conditions, as I have said in earlier columns, there is no mixing of blood between mother and child. The two systems are in close proximity through the placenta. Nourishment and waste can be passed back and forth, but the blood cells do not make direct contact. It is also possible, however, for anti-bodies to pass back and forth. This is when the problem begins. Anti-bodies from the mother may see Rh-positive blood cells as an enemy to be destroyed. When they enter the blood of the Rh-positive baby, they begin attacking the red blood cells (erythrocytes). The result is anemia in the child, and its system fights back by producing more red cells in its bone marrow. It if can't keep up with the attack, it will begin sending immature red blood cells (erythroblasts) into the blood stream. The anemia may be severe enough to kill the unborn child. How does the mother become sensitized and begin producing these anti-bodies? I already mentioned one way -- transfusion. It can also occur if there is some accident in the placenta and blood of mother and child are allowed to mix. It may easily happen at the time of delivery, when the placenta pulls away from the uterine wall and bleeding occurs. Usually there is no problem with the first child, provided that the mother has not previously had a transfusion of Rh-positive blood. Once the condition begins, however, each succeeding pregnancy may have more and more serious problems. In fact, there was a time when, by the third or fourth child, the chances were relatively high that it would die before birth. This is no longer the case, as I shall explain in the next column. There was a time, as recently as fifteen or twenty years ago, when the medical literature often recommended performing an abortion when blood tests of the mother showed a rise in antibodies. The literature also recommended contraceptive sterilization to prevent future problems. It was the same "easy way out" that we find recommended so often and is no therapy at all, since it merely kills the one who is ill, or destroys the power to procreate. A more honest therapeutic approach has since been developed, an approach which seeks to save life and not to destroy it. That will be our topic the next time. Article #23

MORAL DECISIONS -- Amniocentesis Finds A Home

by Reverend Monsignor James J. Mulligan

In the last article I spoke of a condition called erythroblastosis fetalis. If you have not seen that article, it would be a good idea to find a copy, since what I say today will be clearer if you know what I said then. When a woman with Rh-negative blood has a child with Rh-positive blood, she may have anti-bodies in her system which pass over into the child and begin to attack its red blood cells. This causes an anemia which the unborn child may not be able to fight off. It may even lead to death in the uterus. There is, however, tremendously good news in this case. A situation which used to be frequently fatal can now be diagnosed and treated successfully. In fact, not so long ago, medical texts suggested abortion in these cases, as well as sterilization of the mother. This is one area in which amniocentesis has found a positive application. Amniocentesis for diagnosis carries with it some small degree of risk even in the third trimester. It is an acceptable risk morally, since its purpose is to offset the far greater risk to the fetus from disease. As the anti-bodies from the mother cause breakdown of the baby's red blood cells, they produce a red pigment called bilirubin. This is, for the most part, carried off as waste transfer through the placenta. Some of it, however, will also be found in the amniotic fluid. The rise in this, as well as a rise in anti-bodies in the mother's blood, are a sign of problems. If the mother's anti-bodies rise too high, then it is time to make use of amniocentesis in order to examine the bilirubin level in the amniotic fluid. This would usually begin at about the twenty-sixth to twenty-eighth week of pregnancy. It will probably be repeated about every two weeks. If the levels of bilirubin remain in a normal range, nothing more need be done. Monitoring will continue and pregnancy can go on to term. If the levels of bilirubin continue to rise, it may be necessary to perform a transfusion while the child is still in the uterus. This may be done at intervals until the child is more safely viable. At that time labor may be induced. Even after birth, there may be more which needs to be done. The bilirubin, which was being carried off through the placenta, may now begin to rise in the child. If allowed to continue, this could result in brain damage leading to death or to other complications, such as hearing problems or mental retardation. This, however, can also be prevented. The doctor delivering the baby will also be prepared to do an exchange blood transfusion, which will clear the child's blood and bring it back to normal. In other words, there are now methods of diagnosis and treatment which will head off and correct a situation which at one time would probably have been fatal. These methods, of course, will demand more than the usual care and will probably be done in specially equipped hospitals or medical centers. It is also good to know that the whole problem can often be prevented by the use of gamma-globulin injections for the mother just after the birth of an Rh-positive baby. Statistics also indicate that only about 13% of marriages are between Rh-negative women and Rh-positive men. And even in those marriages only about 4% will have problems. Here we have a fine example of a good and moral use of amniocentesis and an excellent example of how medical science operates when it focuses on the saving of the great gift of life.

Article #24

MORAL DECISIONS -- Accentuate the Positive

by Reverend Monsignor James J. Mulligan

Having said so much in earlier columns about the misuse of amniocentesis for promoting abortion, I then spent some time in the last few weeks talking about a very positive use. That was in the diagnosis and management of erythroblastosis fetalis (Rh incompatibility). This time I would like to continue to accentuate the positive by pointing to still another morally acceptable and medically desirable use of amniocentesis in the last trimester of pregnancy. When pregnancy reaches the twenty-third or twenty-fourth week, the child is viable. This means that it will be able to live outside the uterus, but it will still need some considerable and very special help to do so. The more premature the infant is, the more problems there may be. There was a time, of course, when a baby born before the twenty-sixth week would probably have died. It would not have been viable, because there were no medical procedures to help it sufficiently. As techniques have developed, the age of viability has been pushed back to an earlier date. When you consider how much growth and maturity takes place in each week of pregnancy -- especially in the first six months -- the change in the time of viability has been significant indeed. Earlier delivery means difficulties in a variety of areas. The central nervous system continues to develop up to and after the time of birth. A child born more than six weeks before term may therefore have problems with sucking and swallowing. This is treated by supplying nourishment intravenously or by use of a stomach tube. The premature newborn also has a less developed gastro-intestinal tract. In addition to the sucking problem, it also has a small stomach. This can be helped by using human milk or special formulas, fed through the tube. There may also be problems due to immature kidneys or high bilirubin levels. These also can be handled through ordinary and readily available procedures. One area, however, in which little help can be given at present, is lung immaturity. While in the uterus the fetus "breathed" the amniotic fluid. Oxygen and carbon dioxide pass back and forth through the placenta. Before the twenty-third week of pregnancy the inner surface of the lungs is not sufficiently developed to allow gases to pass into the blood system. Breathing air is, therefore, impossible. If it becomes necessary for the welfare of child and mother to induce labor at a very early stage, one serious concern will be whether the lungs are sufficiently developed. Sonograms can show the size of the child, and this may sometimes be sufficient to ensure that the lungs are developed enough for viability. There are, however, cases in which the size of the fetus may not be enough to guarantee lung maturity. When the exact week of pregnancy is not known (and it is not unusual for estimates to be off by a few weeks), a fetus which happens to be large for its age may still have immature lungs. This is especially the case when the mother suffers from diabetes mellitus. Her fetus will tend to be large for its age. What can show if the lungs are sufficiently mature? Amniocentesis can. The amniotic fluid contains substances from the lungs which will only be there when they are properly matured. Here again is a perfectly moral use of the procedure in order to ensure survival of the unborn child.

Article #25

MORAL DECISIONS -- Brought to You by...

by Reverend Monsignor James J. Mulligan

On Wednesday, April 26, 1989, the Supreme Court of the United States heard the case of Webster vs. Reproductive Health Services. This case had arisen from a Missouri law intended to place limits on abortion and abortion funding. The state of Missouri was attempting by law to assert its right to protect human life in the womb. Even the dreadful Roe vs. Wade decision of 1973 had recognized the rights of states to set some limit. It held that after viability, when the state's interest in "potential" human life becomes compelling, the state "may, if it chooses, regulate and even proscribe [i.e., forbid], abortion except where it is necessary, in appropriate medical judgment, for the preservation of the life or health of the mother." The Missouri law stated that, "No abortion of a viable unborn child shall be performed unless necessary to preserve the life or health of the mother." It is saying, quite simply, that a child capable of life outside the womb should not be killed as a matter of "choice." Surely a rather modest objective in the protection of human life. (In fact, there should never be a reason to kill such a child. Even if the mother's health is in danger the child can be delivered rather than murdered.) The Missouri law also stated: "Before a physician performs an abortion on a woman he has reason to believe is carrying an unborn child of 20 or more weeks gestational age, the physician shall first determine if the unborn child is viable." That seems quite reasonable. How is he to do this? The law required that he perform the tests necessary to determine gestational age, weight and lung maturity. He is required to record his findings and the determination of viability in the mother's medical record. The District Court stopped enforcement of the law and then the Eighth Circuit Court of Appeals struck down the law. In reference to the tests for viability it said they were an unconstitutional legislative intrusion on a matter of medical skill and judgment! The same court also said that tests for fetal weight at 20 weeks are inaccurate and would add $125 to $250 to the cost of an abortion. It also felt that amniocentesis was expensive and would impose "significant health risks for both the pregnant woman and the fetus." Would I be far wrong if I said that only an idiot would advocate killing a child without tests, on the ground that tests would be hazardous to its health? The law said viability must be tested at 20 weeks. Of course, a fetus is not viable until between 23 and 24 weeks. Why, then, the early test? Two reasons, I would say. The first is that mistakes of four weeks are not uncommon without testing. The second is that the doctor doing the judging would most likely be your local, friendly abortionist. The law at least required him to take an honest look at reality. And, of course, he has a monetary interest in doing the abortion, so a legal requirement is at least some check on greed. The Supreme Court, on July 3, 1989, rendered its decision and upheld the law. A small but significant victory for the value of human life. Who told the Court of Appeals about the rise in the cost of abortion and the risk of amniocentesis to a 20 week fetus? It was brought to you, I am sure, by those same wonderful people who brought you abortion on demand and the total safety of amniocentesis when it promotes abortion.

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