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SCIENCE POLICY: ABORTION, HEALTH, AND THE LAW

The following points are made by M.F. Greene, MD and J.L. Ecker, MD (New Engl. J. Med. 2004 350:184):

1) The signing into law of the Partial-Birth Abortion Ban Act of 2003 by President George W. Bush has brought to the surface, yet again, the bitterly divisive subject of abortion. Is this bill, as it states, simply an act intended to ban "a gruesome and inhumane procedure that is never medically necessary"?(1) Or is it a carefully calculated first step in a plan to ultimately eliminate virtually all legal abortions, either by outright ban or by intimidation of abortion services providers?

2) Although the 1973 Supreme Court decision in Roe v. Wade currently protects the privacy and availability of abortion procedures at less than 24 weeks of gestation, there is no clear protection in the Constitution for a woman's "right" to obtain an abortion. The Supreme Court has periodically revisited the issues involved in Roe v. Wade, and that decision may not stand indefinitely. Even people in our society who support a woman's right to sovereignty over her own body, in the abstract and at early gestational ages, may become uneasy with the subject of abortion when forced to consider the details of the procedures involved and the clash between maternal rights and the claim of a "right to life" for a fetus of advancing gestational age.

3) Although there is a provision in the bill to exempt procedures "necessary to save the life of a mother," there is no exemption for her health. How should physicians interpret this standard? Consider the case of a young married woman with mild but increasing dyspnea on exertion who stopped cigarette smoking and became pregnant with the desire to start a family. Her obstetrician notes her hematocrit to be 52 percent. Her subsequent evaluation demonstrates a large atrial septal defect, right ventricular hypertrophy, and suprasystemic pulmonary hypertension. Her Eisenmenger's syndrome gives her a 50 percent probability of death if she attempts to carry the pregnancy to term.(2) That risk is substantially decreased if she terminates the pregnancy.

4) Would a procedure that averts a 50 percent risk of death be adequate to qualify as "necessary to save the life of the mother"? Just exactly how high does the risk need to be to meet that criterion; how good do the data in the literature documenting the risk of continuing the pregnancy and the benefit of terminating it need to be? Most important, who should make those decisions? The Partial-Birth Abortion Ban Act provides the opportunity for a defendant accused of violating the law to "seek a hearing before the State Medical Board on whether the physician's conduct was necessary to save the life of the mother." How many physicians will be willing to take prompt action when apparently necessary and trust that review bodies will uphold their decisions after the fact, with a potential two-year prison sentence hanging in the balance?

5) In an ideal world, all women with chronic medical conditions such as renal insufficiency would consult with their obstetrical care providers before becoming pregnant. Such consultation frequently does not occur, however, because many patients do not appreciate the potential for complications associated with pregnancy and because 50 percent of all pregnancies in the United States are unplanned. A woman with severe chronic renal failure has a 5 percent risk of losing her remaining renal function entirely if she attempts to carry a pregnancy to term.(3) Should that be considered a risk only to her health and not ultimately to her life? Should a woman's preference to avoid, or at least delay, dialysis and renal transplantation be irrelevant to the decision to terminate or continue a pregnancy?

6) A diabetic woman with active proliferative retinopathy may risk blindness if a pregnancy is carried to term. If a woman conceives when her diabetes is stable and discovers that she has active proliferative retinopathy at the end of the first trimester, who should decide whether she continues her pregnancy?

7) Finally, consider the case of a woman who learns at 18 weeks of gestation that she has a fetus with holoprosencephaly and trisomy 13. The fetus she is carrying will never become a child able to smile or talk or go to school, but the woman is at risk for complications of carrying the pregnancy to term. The risk of maternal death due to a legal induced abortion in the United States is approximately 0.6 per 100,000,(4) whereas the risk of death for a woman 35 to 39 years of age who attempts to carry a pregnancy to term is 21 per 100,0005 -- 35 times as high. If a fetus with severe congenital anomalies has a "right" to be born, how should that right be weighed against its mother's right to minimize her risk of death by terminating a pregnancy that she knows will not produce a baby who is able to survive over the long term?(5)

References (abridged):

1. Partial-Birth Abortion Act of 2003, S.3-8, 108th Congress, 1st Session (2003)

2. Gleicher N, Midwall J, Hochberger D, Jaffin H. Eisenmenger's syndrome and pregnancy. Obstet Gynecol Surv 1979;34:721-741

3. Davison JM, Lindheimer MD. Renal disorders. In: Creasy RK, Resnik R, eds. Maternal fetal medicine. 4th ed. Philadelphia: W.B. Saunders, 1999:873-94

4. Elam-Evans LD, Strauss LT, Herndon J, et al. Abortion surveillance -- United States, 1999. MMWR Surveill Summ 2002;51:1-9, 11

5. Callaghan WM, Berg CJ. Pregnancy-related mortality among women aged 35 years and older, United States, 1991-1997. Obstet Gynecol 2003;102:1015-1021

New Engl. J. Med. http://www.nejm.org

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