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Unfinished Feticide Journal ofmedical ethics, 1990, 16, 61-65 J Med Ethics: first published as 10.1136/jme.16.2.61 on 1 June 1990. Downloaded from Unfinished feticide Robert P S Jansen Royal Prince Alfred Hospital, Sydney, Australia Author's abstract Thwarted abortion A fetus may survive an intentional interference with its A fetus may survive an attempt at abortion (1) if intrauterine environment (1) ifgestational age is mistaken gestational age is mistakenly underestimated and and the procedure ofinduced abortion does not kill the procurement of the abortion does not itself kill the fetus, (2) ifa change ofheart takesplace afterabortifacient fetus, or (2) if, after abortifacient drugs are taken that drugs are taken and the abortion does notproceed, and (3) fail themselves to complete the abortion, a change of ifa high-multiple pregnancy is reduced to a singleton or a heart takes place that stops attempts to complete the twin pregnancy to improve the likelihood that the abortion by surgically evacuating the uterus. Neither remainingfetuses will reach viability. In each case, circumstance is novel, but both have so far been rare. through cause or coincidence, an abnormal baby may be In the second trimester, for example, neonatal born. The well-intentioned to a survival has been reported after the operation of fetal physician, responding extraction by hysterotomy (technically similar to patient's medical orpsychological needs, risks a legal copyright. action in negligence or assault brought by a deformed caesarean section (5)) or when prostaglandins have surviving child. This hazard means that medical been used to stimulate uterine contractions and the termination ofpregnancy andselectivepregnancy reduction fetus is expelled vaginally (6). With hysterotomy the put thepractisingphysician atsubstantial risk in a way not dangers are just those of immaturity. With usually associated with induced abortion. prostaglandin-induced abortions, spasm of fetal and umbilical vessels occurs and fetuses that are born alive are damaged beyond the consequences of their http://jme.bmj.com/ Two developments have taken place that can change immaturity. Injured neonates have thus occasionally the nature of ethical medical practice in the area of survived attempts at abortion in the second trimester, induced abortion. The first is the availability of either because the procedure has been discontinued (7) effective drugs for non-operative termination of or because the delivered infant has been mature pregnancy (1). The second is the procedure ofselective enough to live (5). embryocide or feticide, in which a multiple pregnancy Second trimester methods ofinducing abortion that is reduce to a singleton or twin pregnancy by an both kill the fetus and ensure its expulsion are ultrasonographically or fetoscopically directed available. Intra-amniotic injections of hypertonic on September 26, 2021 by guest. Protected operation aimed at destroying some but not all of the saline are usually feticidal before uterine contractions fetuses present (24). In these practices the well- are induced by the hypertonic solution and the fetus is intentioned physician faces hazards greater than those expelled (8); dilatation of the cervix followed by that attend ordinary induced or therapeutic abortion, surgical evacuation of the uterus as a two-step in which the pregnant uterus is reliably and completely procedure is considered to be the safest method of evacuated. terminating pregnancy in the second timester (6,9). I do not mean to influence the wider debate on the The fetus cannot survive such surgical evacuation of morality or immorality of induced abortion. Those the uterus, but there have been reports of women who oppose abortion on moral grounds may find changing their minds and not proceeding with support for their cause in the arguments that follow. evacuation of the uterus after the initial step, in which But there will also be those who, despite the hazardous the cervix is softened and dilated by insertion of consequences of these newly popular procedures, will hygroscopic tents (10). In these cases the cervix may still perceive a duty to help individual patients in not always be firm enough to retain the gestation to immediate and desperate trouble. term without the need for a supporting suture; the risk of chorioamnionitis and premature delivery may thus be increased although the fetus itselfwill not have been Key words injured directly. Medical induction of abortion is possible with the Feticide; abortion. administration ofthe drug mifepristone (RU-486), the 62 Unfinishedfeticide J Med Ethics: first published as 10.1136/jme.16.2.61 on 1 June 1990. Downloaded from 'abortion pill'. Mifepristone antagonises the action multiple pregnancy to survive when the alternative is of progesterone, the ovarian and placental hormone for all to die from premature birth. that is essential for the endocrine maintenance of Observers who on moral grounds reject the feticide pregnancy. Administration ofmifepristone by mouth, inherent in all induced abortion will straightaway usually together with drugs that promote uterine reject selective feticide. For others, the ethicalness of contractions, is followed in most pregnant women selective feticide will vary according to the clinical within a few days by bleeding from the uterus and then circumstances. The legality of cases of selective expulsion of the fetus (1). feticide, however, may depend not so much on clinical Unintentional survival of iatrogenically damaged circumstances as on statutes and case law. fetuses will more commonly follow failed attempts at medical abortion. When induced abortion was a crime, EUGENIC SELECTIVE FETICIDE attempts to induce abortion with large doses of In 1978, Aberg et al described cardiac puncture and contraceptive steroids or oxytocics (drugs that exsanguination ofa fetus with Hurler's disease to avoid stimulate the uterus to contract) were often as aborting an unaffected twin (15). Since then, selective pharmacologically inappropriate as patients were feticide in the second trimester by ultrasound or desperate. In the 1970s, prostaglandin preparations fetoscopically directed procedures, or by hysterotomy, were administered in early pregnancy as intramuscular has avoided the birth of twins affected discordantly injections or intravaginal suppositories (11). Heavy with Trisomy 21 (8), Turner's syndrome (16), Tay- bleeding and incomplete abortion, as well as the Sachs's disease (17), haemophilia suspected on the possibility of the pregnancy continuing, often meant a grounds offetal sex (18), microcephaly (2), spina bifida need for curettage - which if used in the first place (2) and bicephaly (19). would have been the more certain procedure. Inadvertent damage to an otherwise normal Mifepristone's greater effectiveness as an surviving fetus during selective feticide for eugenic abortifacient drug in comparison with the mostly reasons can happen immediately during the feticidal abandoned first-trimester use of prostaglandins has operation or can occur afterwards, from the reintroduced the clinical promise of non-surgical development of a compromised intrauterine abortion in early pregnancy (12). The ethical hazards environment. copyright. are not new (13), but the historical reality is that the A formed, unexpelled, dead fetus becomes a 'fetus hazards were not, in the past, properly taken into papyraceous', a fetus shrunken and parchment-like. account. The natural event is known to obstetricians. The The main hazard that any medical abortifacient faces surviving twin may have its growth retarded before results from the fact that, unlike properly performed delivery, in some cases reflecting the continued hostile surgical evacuation ofthe uterus, there is an interval of intrauterine environment that led to the demise of the time between administration of the abortifacient and survivor's fetal sibling (20). There is also the risk that http://jme.bmj.com/ occurrence of the abortion. During this time the thromboplastins released from the degenerating fetal abortion may be blocked by pharmacological and placental tissues will cause coagulopathy in the inadequacy, by a change in the wishes of the woman remaining fetus or precipitate premature labour. The having the abortion, or by both. result of feticidal operations in the second trimester Clinical use ofmifepristone therefore means that the (other than hysterotomy and sectioparva) is to produce fetus may survive, despite the intention, at the time of such a fetus papyraceous. the drug's administration, for abortion to follow. In another era, eugenic infanticide of the abnormal on September 26, 2021 by guest. Protected Survival of the fetus may mean the birth of an neonate was, or might again be, a safer option - safer, iatrogenically damaged child. at least, for the normal sibling. Should a medical practitioner risk performing SELECTIVE FETICIDE AS AN ALTERNATIVE TO abortions with mifepristone? NATURAL FETAL DEATH Selective feticide for non-eugenic indications may be Selective feticide indicated when there is a major collective threat to In most Western countries it can be lawful for a fetus to survival ofthe fetuses that can be lessened by reducing be aborted for eugenic and other elective reasons (14) the number of candidates. The twin-to-twin (albeit through the ostensible purpose of safeguarding transfusion syndrome is an example. High multiple the mental health of the pregnant woman). With these pregnancy can also constitute such an intrauterine induced abortions
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