SPECIAL ARTICLE * ARTICLE SPECIAL

Eugenic abortion: an ethical critiqueMalcolm N. Beck, MD, CM, FRCPC

In 1967 the CMA officially approved abortionsby physicians when there was "a substantialchance that the child would be born with grave

mental or physical disability".' The stimulus for thatrevolution in the ethics of medical practice was thenewly demonstrated causal association between ma-ternal German measles in early pregnancy and se-vere physical and mental defects in the newborn.' Irecall that there was surprisingly little debate aboutthe resolution in the medical press or among mem-bers of the medical profession. Most of us thoughtthat such a procedure would rarely be used.

The policy still stands,2 but new technologicadvances in ultrasonography, intrauterine tech-niques, karyotyping, biochemical analysis of amniot-ic fluid and molecular genetics have resulted ineugenic abortions becoming a regular occurrence inmedical practice in Canada. Since 1967 few articleshave addressed the rationale and indications foreugenic abortion, and even fewer have questionedwhether eugenic abortion should be performed at all.The medical literature has betrayed a widespread,usually unstated assumption by the profession thatfetal life should be terminated whenever a seriouscongenital abnormality is strongly suspected.

It is now possible to diagnose relatively reliably200 or more handicapping disorders. In Canada asurge in the use of such prenatal diagnostic tech-niques occurred in 1976 after the publication ofthree reports of international collaborative studies3-5and one from the Medical Research Council ofCanada.6 As early as 1983 Allanson and associates7reported that 50% of older pregnant women in theVancouver area "took advantage of the availabilityof amniocentesis". The indications now accepted forthe prenatal investigation and diagnosis of geneticdisorders have been established by the Society ofObstetricians and Gynaecologists of Canada;8 themost common indication by far is high maternal age,usually defined as over 35 years, at the expected dateof delivery.

Physicians are not only accepting and some-times promoting such investigative procedures butalso are being increasingly pressed by older mothersand their partners to do them, mostly because of thefear of having a retarded child.

The 16th postmenstrual week is the preferredtime for amniocentesis. Since it takes 2 to 3 weeksfor the laboratory analysis and reporting, the mini-mum time for the termination of fetal life is the 18thgestational week. Several authors have reported amean gestational age of 20 weeks.6'9"'0

The issues raised by eugenic abortion should bedistinguished carefully from those raised by thecontinuing debate on abortion as a matter of repro-ductive choice, determined by the "mother's ownpriorities and aspirations", the terminology used bythe Supreme Court of Canada in the Morgentalerdecision." Eugenic abortion deals with neither thepathos of an unplanned, unwelcome or forced preg-nancy nor the personal matter of freedom of choiceabout what happens to one's body. Instead, it in-volves a deliberate, systematic search for those whomay be unfit in mind or body, the primary intentbeing to terminate fetal life if such is found. If thefetus is thought to be "normal" the pregnancy isallowed to continue. Therefore, I prefer the moredescriptive term "selective feticide", following Rob-erts and collaborators,'2 over the more commonterms such as eugenic abortion, selective abortionand genetic abortion. My preference is supported byan awareness of the infrequently used, yet widelyaccepted, practice of selectively terminating the lifeof an "abnormal" twin in utero by exsanguination orinjection of potassium chloride or a bolus of sterileair directly into its heart or umbilical vein andallowing the "normal" twin to develop to term. Thedead twin is not "aborted" but, rather, is deliveredat term as a fetus papyraceus.'3-'5

Selective feticide should not be equated with thereduction of multiple pregnancies associated withassisted ovulation and fertilization. Here the objec-

Dr. Beck practises child psychiatry in Charlottetown.

Reprint requests to: Dr. Malcolm N. Beck, 279 Richmond St., Charlottetown, PEI CIA IN8

CAN MED ASSOC J 1990; 143 (3)

tive is to create a maternal environment in whichone or more of the fetuses can survive to viabilityand normality - a goal compatible with the tradi-tional scope of medicine. 16,'7

Physicians should be concerned about the con-tinuing welfare of their patients and the attitude ofsociety toward them. Mentally handicapped peopleare not able to speak well for themselves; therefore,we who serve them must speak on their behalf,because it is unlikely that others will.

Selective feticide is fraught with technical prob-lems and clinical complications and may have severepsychologic effects on the mothers. It has ethicalimplications for physicians and some broader socialimplications. In addition, it may adversely affect thesocial identity of the medical profession.

Adverse effects of amniocentesison the fetus

Amniocentesis is not harmless. Early reportswere divided on whether it caused fetal loss, butother, larger studies have demonstrated that uncom-plicated amniocentesis in the second trimester hascaused an increase in the mortality rate of healthyfetuses of 0.5% to 1.0% because of an increased rateof spontaneous abortion and a small but significantincrease in the perinatal mortality rate.6,8- 10.1217-21Also, after amniocentesis an increase of 0.4% abovethe expected rate of prenatal hemorrhage from pla-centa previa and abruptio placentae has been report-ed,'8 as has a threefold increase in the incidence ofbreathing problems in the normal newborn and oforthopedic problems, especially club foot and con-genital dislocation of the hip.20,22

In a Canadian study Finnegan and colleagues23found "needle marks" 6 months after birth on 6 of91 infants whose mothers had undergone amnio-centesis. Although the marks were only cosmeticallyimportant, they reviewed reports of single or rareinstances of needle injury, such as exsanguination,cardiac puncture, puncture of the gut, ocular trauma,neurologic damage to a limb and gangrene of alimb.

False-positive and false-negative laboratory re-sults do occur.24 The error rate of 0.3% in cytogeneticdiagnosis reported in larger series is very low but ofcritical significance when the termination of life isinvolved.'0 Procedural mistakes by physicians,nurses, laboratory technicians and clerical staff occurdespite the utmost care.'0 Furthermore, the proce-dures are not very effective in decreasing the rate ofmental retardation. For example, the screening ofmothers over 35 years of age prevents the birth ofonly 25% of the children expected to be born withDown's syndrome.25 The human cost for this sup-posed gain is very high: the number of cases of

handicap prevented by these prenatal procedures isalmost identical to the number of "normal" childrensacrificed.26 27 Primum non nocere.

Adverse effects of selective feticideon the mother

The degree of psychiatric illness caused byinduced abortion of unwanted pregnancies may stillbe debatable.28 29 However, selective feticide and therelated experiences create unusually high levels ofstress for the mother30-32 and negatively affect thefather33 and the siblings of the aborted fetus.34 Themothers are usually mature in their thoughtfulnessand sensitivity, and their pregnancies are oftenplanned, wanted and sometimes treasured events.For 4 months they have anticipated the healthyoutcome of their pregnancy. Shortly after amnio-centesis they experience quickening, with its conse-quent enhancement of maternal attachment and anincreased awareness of the fetus as having a separateexistence.3536 The interval of 2 to 4 weeks betweenamniocentesis and receipt of the laboratory resultscauses much anxiety and even denial of the pregnan-cy by the parents;37 this anxiety is not alwaysrelieved by good genetic counselling, which mayeven increase the mother's anxiety.38 When unwant-ed results are received the parents must make verydifficult personal decisions based on conceptscouched in terms that are foreign and often dreadfulto them.

The termination of a pregnancy through amni-oinfusion techniques subjects the mother to distress-ing labour, which is often poorly attended by themedical and nursing caregivers.37 The stress is muchless on the mother and the nurses if the abortion isdone through dilatation and evacuation, which inskilled hands is the preferred procedure up to 20weeks' gestation; however, this procedure is muchmore distasteful and stressful to the physician.3940With the use of infusion techniques the dead fetus iseasily recognizable as a tiny human being and maybe seen by the mother after delivery.

Physical complications after a second-trimesterabortion for any reason are common4' and morefrequent than would be acceptable in regular electivesurgery. Castodot42 reported that in abortion after 16weeks' gestation the rate of hemorrhage is over 10%,endometritis 10%, cervical laceration 3% and re-tained products of conception 32% to 46%. Grimesand Schulz,43 who reported the results of a collabora-tive study of 84 000 late induced abortions, foundthat abortion at 20 to 21 weeks resulted in a 12.4%risk of hemorrhage and a 7.7% risk of cervicallaceration.

The psychologic complications after delivery arealso severe. Mothers who have undergone eugenic

182 CAN MED ASSOC J 1990; 143 (3)

abortion and have previously lost a child because ofstillbirth or neonatal death have reported that thelevel of bereavement is equal; too often the intensityof the grief is not eased by the usually healingprocess of mourning.44,45 Normal grieving is con-founded by the mother's mixed feelings of guilt andgrief, her sense of relief about and responsibility forthe abortion and the lack of awareness of the depthof her loss by the people close to her. There is nobaby, no name, no photograph, no funeral, nograve.46

These negative psychologic consequences arenot helped by the negative attitude of physicians toeugenic abortion, which is shown by the low rate oftheir attendance during the delivery39 and the lack offollow-up care given by physicians and public healthnurses as compared with that given the same moth-ers after previous stillbirths or neonatal deaths.46 47

The few reports of follow-up of eugenic abortionhave suggested that the rate of psychiatric complica-tions is high.44-49 Lloyd and Laurence46 followed up53 cases and, although the study was inadequatelycontrolled, found that 78% of the women had acutegrief reactions similar to those expected in anysituation of major bereavement; 46% continued tosuffer from clinically significant anxiety or depres-sive states up to 6 months after the abortion, and10% required psychiatric treatment.

Ethical issues

The central ethical issue in selective abortion iswhether physicians should become involved in pure-ly eugenic procedures that involve the termination ofa human life. A cogent understanding of the proclivi-ty of mankind to evil50 and the actions of the verysophisticated medical profession in Germany in the1930s5-153 suggest that we should be very leery ofsuch an involvement. The fears are not allayed byreports of the use of selective abortion techniques inIndia, administered on the basis of sex (WinnipegFree Press, Aug. 28, 1982, and Times of India[Bombay ed], Oct. 17, 1985),54,55 or by evidence of awidespread acceptance of this practice among med-ical geneticists in the United States and Canada56and the students of a supposedly conservative ruralUS college.57

Eugenic abortion is most often done at a gesta-tional age that nearly approaches the age of fetalviability, even with good sequencing of proceduresand reports. The dramatic advances in neonatologyhave resulted in the age of viability being changed to24 weeks or even lower.58'59 At its 1988 meeting theCMA General Council accepted 20 weeks as the ageof viability.2 However, in Britain the terminationover a period of 6 months of 26 fetuses after 24weeks' gestation was reported.606' Also, it has been

argued that the statutory age of viability not belowered from 28 weeks because to do so mightencourage legal infringement on the practice of lateabortion of defective fetuses.31'60'62'63

What is technologically possible is not alwaysright. Our ability to use these new techniques con-fronts us with the modem moral predicament posedby the Durants:64 Have we given ourselves morefreedom than our intelligence can digest?

Broader social implications

Vigorous public education efforts by the helpingprofessions and voluntary organizations such as theAssociation for Community Living, formerly theCanadian Association for the Mentally Retarded,have done much to reduce the stigma borne byhandicapped people. However, we should be con-cerned lest these gains be lost when most expectantmothers over 35 years of age and their husbandsdecide to have prenatal diagnostic studies done withthe intent of terminating the life of their unbornchild if a mental or physical defect is suspected. Sucha reversal in public attitude could lessen the resolveof governments to fund adequate medical and otherservice programs for handicapped people and coulddiminish the impetus for public institutions to fundresearch into the disorders underlying mental andphysical disability.65

It has been regularly argued in the medicalliterature that the economic burden of the lifelongcare of retarded people provides adequate justifica-tion for genetic abortions.66-69 The economic load isreal, but this argument is based on sociopolitical, notmedical, premises (Audrey D. Cole: personal com-munication, 1985).

Paradoxically, although the practice of eugenicabortion continues to grow, there is an increasingawareness that the fetus possesses an identity in-dependent from its mother.70 This is prompted byincreased public awareness of the success of prenatalfetal therapy71-73 and the procession of legal suits onbehalf of children for "prematernal liability","wrongful birth" and "wrongful life". Although aconsensus on such suits has not been reached in thecourts of the Commonwealth countries or the UnitedStates, physicians should be aware that a child cannow sue his or her parents for giving them birthand win.74-76

New techniques, such as chorionic villus sam-pling, may lower the fetal age at which life can beterminated after prenatal laboratory diagnosis, butthe risks of chorionic villus sampling are not yetconfirmed as being acceptably low. Studies haveshown the rate of fetal loss to be 0.7% to 2.7% higherthan that associated with amniocentesis.71-8' Whenthis is added to the increase of 0.5% to 1.0% in the

CAN MED ASSOC J 1990; 143 (3)

rate of fetal vulnerability from amniocentesis theupper side of these figures would be unacceptable.Even if the low side is confirmed in current studiesthe core arguments against medical involvement inthe procedures - the negative psychologic impacton mothers, their families and the handicapped andtheir questionable ethical, social and professionalimplications - remain unaffected and as convincingas ever.

Selective abortion and the social roleof medicine

The medical profession has earned respectthrough its persistent exercise of traditional ethicalvalues that lead physicians to abhor death and towork hard to maintain and restore health. If theprofession is to maintain credibility it must continueto demonstrate concern for the preservation of thelives of the sick and the weak. Eugenic abortion doesnot fit this ideal; its practice endorses a principle ofrejecting defect that gives a nonmedical (evenantimedical) priority to parental, familial andsocietal claims to well-being over those of the per-son yet to be born.82

In addition, eugenic abortion does not fallwithin the usual rigors of good medical practice.Ordinarily physicians demand more clinical valida-tion than that provided only through laboratoryinvestigation and ultrasonography before they per-form procedures of grave importance to life. Howev-er well conducted, karyotyping and biochemicalanalysis of amniotic fluid do not possess the diagnos-tic validity derived from the direct examination ofphysical and mental status corroborated by laborato-ry studies. Campbell83 argued persuasively thatpoints of view denying protection to the fetus at anystage are equally arguments for infanticide. If thepremises underlying the practice of searching out theunfit and terminating their lives before birth arejudged to be reasonable, then clearer logic and firmerresolve would lead to the conclusion that suchtermination should occur after the delivery, whenthe diagnosis can be more exact and no increasedrisk to the "normal" fetus is created.

The logical conclusion would be for the state tocreate a new bureaucratic position, filled by someonewith a high level of technical training, to performthis task adequately. In the early 1970s Dr. John H.Maloney, a widely respected senior colleague in myhome city, dubbed such an official "the provincialassassin". It is evident that our governments wouldnot undertake a program as repugnant to the sensi-bility of our citizenry as this. But, when physicianscondone and actively participate in eugenic abortionthe medical profession must recognize that it isachieving these very ends in the secrecy of its offices

and laboratories, in the silence of the womb and inthe sterility of the operating theatres. In so doing theprofession veils the awful reality of the means toattain such nonmedical, sociopolitical goals frompublic view and awareness.

Physicians should not assume this death-dealingrole. This great and historical, learned professionshould not have thus allowed itself to become eitherthe unwitting agent of public policy or the automaticservant of popular demand. Medicine must nowraise the level of its internal debate about eugenicabortion. This could launch us on a process wherebyour profession could return to its historical, distinc-tive, ethical foundations.

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Conferencescontinuedfrom page 180

Sept. 30-Oct. 3, 1990: International Health Policy andManagement Institute 7th Annual Conference -"World Health Care in Transition"

Hotel Berlin, Berlin, West GermanyDarwin W. Schlag, Jr., c/o Laventhol & Horwarth, Ste.

1100, One City Centre, St. Louis, MO 63101;(314) 421-1710

Le 30 sept.-le 3 oct. 1990: 4e Congres internationalfrancophone de gerontologie

Palais des congres, MontrealLes services de congres GEMS, 100-4260 Girouard,

Montreal, PQ H4A 3C9; (514) 485-0855,telecopieur (514) 487-6725

Oct. 1-5, 1990: Canadian Society of Forensic ScienceAnnual Conference

Skyline Hotel, OttawaCanadian Society of Forensic Science, 215-2660

Southvale Cres., Ottawa, Ont. Kl B 4W5;(613) 731-2096

Oct. 2-5, 1990: Canadian Association of PediatricHospitals Annual Conference

MontrealBarry Rabinovitch, chairman, Organizing Committee,CAPH Conference '90, Montreal Children's Hospital,2300 Tupper St., Montreal, PQ H3H 1P3;(514) 934-4400

Oct. 10-12, 1990: Colloquium on Violenceand the Elderly - Organizing Today for Tomorrow(cosponsored by Suirete du Quebec)

Universite du Quebec, MontrealTransition House Association of Nova Scotia, 310-169

Provost St., New Glasgow, NS B2H 2P9; (902) 755-4878

Oct. 10-13, 1990: 5th National Conference on PerinatalCare and Prevention of Handicap: Promotion of Health

Prevention of HandicapRamada Renaissance Hotel, SaskatoonSaskatchewan Institute on Prevention of Handicaps, Box

81, University Hospital, Saskatoon, Sask. S7N OXO;(306) 966-2512

Oct. 11 - 12, 1990: Histopathologic Diagnosis ofInflammatory and Neoplastic Skin Diseases: Assessmentof Patterns and Silhouettes

Halifax SheratonDr. Noreen Walsh, Department of Pathology, Victoria

General Hospital, Rm. 721, D.J. MacKenzie Building,1278 Tower Rd., Halifax, NS B3H 2Y9; (902) 428-3897

Oct. 11-14, 1990: Canadian Pain Society (IASP Chapter)Annual Meeting

London, Ont.Ms. Inese Kramins, Local Arrangements Committee,Department of Psychology, University of WesternOntario, London, Ont. N6A 5C2

Oct. 12-14, 1990: Freud and the History of PsychoanalysisTrinity College, University of TorontoDr. Andrew Brink or Herma Joel, 300 Larkin Building,

Trinity College, 6 Hoskin Ave., Toronto, Ont. M5S 1H8;(416) 978-8454

Oct. 13, 1990: Undersea and Hyperbaric Medical Society(Great Lakes chapter) 11th Annual Scientific Meeting

Toronto General HospitalDr. Rhonda Wilansky, Hyperbaric Department,CCRW G-821, 200 Elizabeth St., Toronto, Ont.M5G 2C4; (416) 340-4481, FAX (416) 340-3698

Oct. 14-18, 1990: Canadian Association of Radiologists53rd Annual Meeting

Pan Pacific and Vancouver Trade and Convention CentreSuzanne Charette, Canadian Association of Radiologists,510-5101 Buchan St., Montreal, PQ H4P 2R9;(514) 738-3111

Oct. 16-20, 1990: Annual Joint Meeting of the CanadianCardiovascular Society, the Canadian Council ofCardiovascular Nurses, the Heart and StrokeFoundation of Canada and the Canadian Society ofClinical Perfusionists

World Trade and Convention Centre, HalifaxBetty Fata, 645-375 Water St., Vancouver, BC V6B 5C6;

(604) 681-5226, FAX (604) 681-2503

continued on page 193

186 CAN MED ASSOC J 1990; 143 (3)