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The use of ultrasound to screen pregnancies has led to earlier bonding of parents to their unborn children as they are able to observe the developing child and watch it move early in pregnancy. The alleged benefit to result from induction of labor under such circumstances is to relieve the mother of the psychological trauma of having to carry a grossly abnormal fetus throughout the full term of her pregnancy. Can such risks be justified using the principle of double effect with the intended good effect of the prevention of infection justifying the bad effect of possible death from premature birth? Early induction of labor in pregnancies complicated by premature rupture of the membranes could be justified if it could be shown that the child was being delivered into an environment where its chances of survival were actually enhanced over the chances of survival in utero. Could an analogous justification be constructed for the induction of labor between viability and full term of gestation where the mother is carrying an anencephalic child? The anencephalic is not truly brain absent of course, since brain stem function is present during the short survival period. Evaluations of the status of anencephalic infants in the medical literature are frequently pejorative. One standard proposed by the American Academy of Pediatrics for medical interventions involving infants is that what is done must be in the best interest of the child.(19) Protocols which recommend termination of pregnancy at any point where the diagnosis of anencephaly is established do not of course, address themselves to the best interest of the unborn anencephalic child. For those who accept abortion as a legitimate medical procedure there will be no conflict, of course. The diagnosis of anencephaly is being made more frequently as a result of routine ultrasound evaluation during pregnancy. The principles and polices of each agency are governed by the relevant decisions of each agency's governing body.
In addition, however, some defects previously only recognized at birth have been brought to the attention of parents prior to birth as a result of ultrasonic detection.
Presumably the closeness of the Mother-infant bond occasioned by the maintenance of pregnancy would intensify the mourning associated with being the parent of a child with defects.
This is so even though the survival of the viable anencephalic child would typically be only 1-7 days.
For example, the chances of survival for an infant delivered in high risk centers at 24 weeks gestation were approximately 45%. The benefit derived is the relief of the anxiety of the mother who is carrying the anencephalic child. The practice of arbitrary induction of labor will inevitably lead to a further erosion of society's dwindling respect for the status of the anencephalic infant.
Anencephaly has been listed among diagnoses justifying the performance of eugenic abortion in the third trimester.(20) Early induction of labor in anencephalics is best understood as a variety of late abortion. Some institutions have instituted protocols for the termination of pregnancy at the time the anencephalic child is ascertained.


The parents of anencephalic children will need to be provided with long term support and counseling regardless of when the baby is born.
Ethical and Religious Directives for Catholic Hospitals (The Catholic Hospital Association, St. Statistics for 1989, Neonatal Intensive Care Unit, Loyola University Medical Center, Maywood Ill. Peabody, J., Frank Admissions End Fetal Organ Harvesting, Los Angeles Times 8-19-88 Page33.
California Senate Bill #2018, Ohio Substitute House Bill #718, New Jersey Assembly Bill #3367. Gianelli, D., Pediatric Surgeon Back in the Spotlight with Controversial New Donor, AMA News 11-5-87. This is particularly true of abnormalities resulting in structural defects such as neural tube disorders. Since early induction of labor was not the standard management of such pregnancies prior to widespread use of ultrasound, there are very limited data as to the real therapeutic benefit of this method of care. What about the induction of labor after viability but prior to the end of the term of gestation?
The Principle of Double Effect would not apply since the good effect would result directly from the premature termination of gestation with its attendant risks related to prematurity itself. A recent in depth study(16) indicates that they are functionally closer to normal newborns than they are to adults in chronic vegetative states. It will, by extension, undermine the protection of infants with other severe abnormalities particularly those involving the central nervous system (e.g. Sympathetic and intensive programs of counseling are not precluded by the presence of and continuation of the pregnancy. H., The Religious Factor and the Role of Guilt in Parent Acceptance of a Retarded Child, Am.
C., et al Reactions of Mothers and Medical Professionals to a Film About Down's Syndrome, Am. With the ability to recognize anencephaly in-utero, there has developed pressure to induce early labor in order to terminate the pregnancy of the woman carrying the anencephalic child. The sporadic discovery of anencephalic infants through radiographs taken for another purpose or, more recently, through alpha-feto-protein screening has not provided for sufficient follow-up for evaluation.
The dilemma posed by this situation would be somewhat analogous to that of the pregnancy complicated by early rupture of the amniotic sac.
Are these risks relevant when we recognize that the anencephalic child will "die anyway" since its prognosis for prolonged survival after birth would be hopeless even if allowed to go to term?


Induction of labor after viability but prior to term would not be in the best interest of the anencephalic child.
Further clinical research and evaluation of such programs should be a high priority goal of obstetrical departments. The recognition of anencephaly either in-utero or in the nursery after birth is unquestionably traumatic for parents. Early rupture of the amniotic sac results in an increased risk of infection beginning as an amnionitis or infection of the membranes around the fetus but potentially spreading to result in infection of the unborn child and eventually the possibility of maternal sepsis as well.(4) Although there have recently been inventive strategies for the prevention of such infections by the introduction of sialastic catheters allowing for direct introduction of antibiotics into the uterine cavity,(5) there is substantial risk of infection to mother and child. Unlike the infant in the pregnancy complicated by premature rupture of the membranes, however, the chances for survival of the anencephalic infant in the short term are worsened rather than enhanced, The anencephalic infant will survive in utero as long as support is provided through the placental attachment.
The purpose of the induction of premature labor would be to relieve maternal anxiety and mourning. Although the period of time between recognition and the death of the child is usually brief when the diagnosis is made postnatally, the need for support and counseling is much more prolonged. Induction of labor has been proposed in such cases as the only alternative to potentially fatal sepsis. For the anencephalic infant, however, birth guarantees death (8) since sustained respiratory and cardiac function will be impossible on his own.(9) Induction of labor, in this type of case, guarantees that the anencephalic infant will die sooner rather than later. In such a rationale, the child in a Kantian (21) sense, is being used as a means to an end. Induction of labor also poses increased risk for the child related to the various complications of prematurity. It is the early death of the infant as well as the separation of the infant from his pregnant mother that is posed as a justification for ending the pregnancy prior to term. The end is the laudable goal of improving the mental state of the mother and the child's prognosis is hopeless for long term survival.
Whereas the principal support system for parents of children born with congenital anomalies will typically consist of neonatologist, pediatricians, social workers, geneticists and psychiatrists, the proposal for early induction of labor will usually originate from an obstetrician. The mother's knowledge that the anencephalic child is alive within her is alleged to be the principal cause of her anxiety and the delivery and subsequent inevitable death of the child is proposed as the source of relief from this anxiety.
Nevertheless, induction of labor irrespective of the unborn child's best interests will inevitably lead to further devaluation of the anencephalic child in particular and severely deformed children in general.



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