In this issue...
Reprinted with permission from "The New England Journal of Medicine"
Originally published February 17, 1983
We have recently seen two cases in which women in the late first or early second trimester of pregnancy reported feelings and thoughts clearly indicating a bond of loyalty toward the fetus that we and others (1) had associated with a later stage of fetal development.
We were impressed with the potential importance of many other similar events. We report these cases and our reflections to encourage more systematic study of two questions: Does parental viewing of the early fetus (before "quickening") by means of ultrasound imaging accelerate bonding with the fetus? If so, what are the medical, emotional, and ethical implications of this phenomenon?
In the obstetrics-gynecology department of a large, inner-city hospital we had the opportunity to observe an ultrasound examination and talk with the patient during the procedure. The woman was approximately 30 years old. Her physician explained why the procedure was being done. Ten weeks earlier she had been beaten in the abdominal area by the father of the fetus. She had been brought to the emergency room, and x-ray films had been taken before she was treated for the injuries. Subsequently, it was discovered that the woman was pregnant. The ultrasound examination was being done to establish the date of conception and the size of the fetus and to gather information about possible fetal damage inflicted by the beating or the radiation or both.
One of us asked the patient whether she would agree to talk about her experience during the examination. We briefly explained our interest in determining how patients and their families respond to new techniques for prenatal care. She agreed without hesitation, indeed, with a spark of interest in her eyes. One of us pointed to the small, visibly moving fetal form on the screen and asked, "How do you feel about seeing what is inside you?" She answered crisply, "It certainly makes you think twice about abortion!" When asked to say more, she told of the surprise she felt on viewing the fetal form, especially on seeing it move: "I feel that it is human. It belongs to me. I couldn't have an abortion now."
In the second case one of us was involved as a physician, and the other as an ethics consultant in a one-time trial of innovative steroid therapy to suppress fetal androgens in a suspected but undiagnosed case of congenital adrenal hyperplasia (2). A 32-year-old woman was referred to the genetics clinic at the National Institutes of Health, along with an affected 4-year-old daughter, whose ambiguous genitalia had been successfully treated with surgery. The mother, who was probably mildly affected by the adrenal disorder, was 10 weeks pregnant, according to the date of her last menstruation. The geneticists at the clinic calculated that the risks of recurrence were between one in four and one in eight if the fetus was female. While the physicians devised an approach to experimental fetal therapy by means of daily doses of desamethasone, the mother had an ultrasound examination to establish the date of conception and the size of the fetus. Family members, the primary physicians, a genetics counselor, endocrinologists, a social worker, and an ethics consultant then met to discuss the medical and moral aspects of the choice to be made. The parents clearly preferred the early trial of innovative therapy to deferred action, mid-trimester amniocentesis, and possible abortion of an affected female fetus. In the course of the meeting, after the parents had chosen the experimental trial, the mother was asked about her experience with ultrasound. She said, "It really made a difference to see that it was alive." Asked about her position on the moral choice she had to make, she said, "I am going all the way with the baby. I believe it is human."
For the sake of discussion, let us suppose that it is true that maternal viewing of the fetus by means of ultrasound results in an earlier initiation of parental bonding, the oldest form of human and animal loyalty. (3) Mid-trimester ultrasound examinations are gradually becoming routine in prenatal care, and even earlier examinations are indicated for diagnosis and monitoring of high-risk pregnancies. There is good reason to expect that on such occasions, parents probably will experience a shock of recognition that the fetus belongs to them. One of the oldest and most important emotional and ethical experiences thus occurs much earlier than usual in the process of gestation. Some have wondered about the unintended physical risks of ultrasound (4), but no harm has yet been identified. What about the immediate or long-term social and ethical consequences of ultrasound?
Several thoughts have occurred to us. First of all, the effect of this new prenatal technology on the emotional and moral component underlying parental acceptance or rejection of the fetus constitutes a natural social experiment. Parental recognition of the fetal form is a fundamental element in the later parent-child bond. Therefore, a social change with potentially important but perhaps largely unrecognized consequences will gradually unfold from beneath the medical canopy.
Secondly, contrary to the popular fear that medical intervention may dehumanize the fetal-maternal bond, ultrasound examination is likely to increase the value of the early fetus for parents who already strongly desire a child. Viewing the fetal form in the late first or early mid-trimester of pregnancy, before movement is felt by the mother, may also influence the resolution of any ambivalence toward the pregnancy itself in favor of the fetus. Ultrasound examination may thus result in fewer abortions and more desired pregnancies.
Thirdly, ultrasound imagery will probably change the way in which we view the fetus with a diagnosed and treatable disorder. In the future there will doubtless be many established fetal therapies, unlike the experimental situation described in the second case, and a strong moral argument will exist to treat the affected fetus. Indeed, surgeons already regard the fetus with a correctable congenital defect as a "patient." (5) On rare occasions, a woman with conflicting desires concerning her pregnancy may face a moral dilemma in choosing between her own interests and those of the treatable but previable fetus. The ethics of fetal therapy and the ethics of abortion will collide if such cases occur. Could ultrasound become a weapon in the moral struggle? Some communities and even one state have debated proposed legislation requiring that a picture of a human fetus be shown to a woman who requests an abortion. A court-ordered ultrasound viewing would be a potent (and unfair?) maneuver in the hands of those who represented the interests of the fetus in a dispute over proposed fetal therapy. Of course, ultrasound could be used to the same end by those who oppose abortion itself.
Finally, just as many centuries of cultural and biologic evolution were required before childhood was viewed as a differentiated stage of life (6), with its own requirements and authenticity, ultrasound and a host of other fetal technologies could become part of a more complex evolutionary story. Perhaps a new stage of human existence, "prenatality," previously only mirrored in poets' and mothers' dreams about the fetus, will be as real to our descendants as childhood is to us. Liley, the father of fetal therapy and a pioneer in ultrasonography, wondered as long ago as 1972 if the human fetus had a personality (7). For these and other reasons, physicians and their colleagues in obstetrics and reproductive and fetal medicine should not be surprised to find themselves attracting the most careful human scrutiny and imagination. Of such stuff are many human dreams made.
- John C. Fletcher, Ph.D., National Institutes of Health, Bethesda, MD 20205
- Mark I. Evans, M.D., George Washington University Medical School, Washington, DC 2037
- Klaus MH, Kennell JH. Maternal-infant bonding. St. Louis: CV Mosby, 1976.
- Fletcher JC. Emerging ethical issues in fetal therapy. Proc Norw Acad Sci. (in press).
- Baker ML. Dalrymple GV. Biological effects of diagnostic ultrasound: a review. Radiology. 1978; 126: 479-83.
- Harrison MR. Golbus MS, Filly RA. Management of the fetus with a correctable congenital defect. JAMA. 1981; 246:774-7.
- Ariès P. Centuries of childhood: a social history of family life. New York: Vintage, 1962.
- Liley AW. The foetus as a personality. Aust NZ J Psychiatry. 1972; 6:99-105.