Friday, 6:00 p.m., September 30th. Three deliveries and two hours of sleep in the past 36 hours. I run to escape the weariness of a solo obstetric practice.
Ascending out of town on a dirt road, the majesty of fall in Montana envelopes me. Ahead are groves of golden quaking aspen. In each direction are mountain ranges freshly dusted with snow. The sun streaks through the clouds, casting long shadows across the foothills.
I click my beeper off. Being alive is a damn sight better than the alternative.
Four hours ago, I received a panicked call from the hospital labor and delivery staff. A laboring patient had the sudden onset of fetal bradycardia. For 6 minutes the heart rate had plunged down. I arrived immediately and, with oxygen and a medication to relax the uterus, the fetus recovered nicely. We proceeded to a prompt Cesarean-section and out came a healthy, vigorous baby boy.
Would I have driven through two red lights if I had known the baby had Down’s syndrome? What if the baby had spina bifida? Would I plunge a knife into the mother’s uterus to save a child whose quality of life could be compromised?
What about the woman I saw yesterday with an elevated alphafetal protein? The ultrasound we did looked normal, yet she wants to keep her options open. She has scheduled an amniocentesis out-of-town for the following week. If the chromosomes are abnormal, then what?
Then what?—the question haunts me daily. Delivering babies seems to be the easy part now. With modern perinatal and neonatal care, we can usually negotiate the “traditional” problems of preterm labor, toxemia and placenta-related bleeding with favorable outcomes for the mother and baby.
It is running the prenatal diagnosis gauntlet that gets tricky, especially if you are pro-life. The available tests range from alphafetal protein and multiple-marker screening to chorionic villus sampling and amniocentesis. The obstetric literature is replete with the latest studies and indications for various tests. While an argument can be made for the usefulness of prenatal diagnosis for couples who would not consider abortion, the thrust of prenatal diagnosis lies elsewhere.1 Seven out of ten women who have a fetus with a known chromosomal anomaly terminate their pregnancy with an elective abortion.2 For the chromosomally abnormal fetus the bounty has been set:
A gross estimate for detection of each case of fetal Down’s syndrome in our program is about 100,000 dollars. It was estimated in 1981 that the average health, education and residential costs for an individual with Down’s syndrome were 196,000 dollars. This did not include other costs such as loss of productivity of parents, counseling and social-work services, increased divorce rates and problems with siblings.3
A vegetable, a person? A human life or a lifelong burden? I explain to my patients that these tests pose not only medical questions, but philosophical and ethical questions as well. If the blood tests are abnormal, then what? If the amniocentesis shows Down’s syndrome, then what? If I choose to have an abortion, then what?
No longer can a woman journey through pregnancy with an ethos of “Let it be.” In modern obstetrical ethics, the examination of conscience is replaced by the examination of options. Morality is reduced to an exploration and exercise in personal autonomy. Will an ill-timed baby interfere with my career track? Can I have an abortion quietly and discreetly without my parents’ knowledge? Am I willing to risk a chance my baby will be mentally handicapped? In the portfolio of options, the fetal heartbeat becomes increasingly distant.
We as physicians become the priests of the new morality. Our role is to be objective and non-directive, presenting the options in all their neutrality. To the woman with a positive pregnancy test, we are careful to ask “Is this a planned pregnancy?” and “Have you considered all your options?” Choose your words carefully—“developing embryo” instead of baby, “previable” instead of living; at all costs avoid talking about the “Big A” in any graphic detail.
We preach in numbers—tables of age-related chromosomal anomalies, risk-benefit ratios of procedures, the “high” and “low” probabilities that define what is human. To the wary patient, we must be sure to note the “false negative” rate of any procedure, the chance that our tests would detect a less-than-perfect baby.
The march of statistics is frequently bewildering to the patient. Knowledge and numbers don’t always illuminate what is at the heart of the issue. As more than one patient has expressed to me: “Why all the fuss, Doctor, if I would never consider an abortion in the first place?”
Three miles into the run and I still think life is good. If I had Down’s syndrome, I could still breathe this air. Even with an extra chromosome, I could see the leaves quiver and smell the damp foliage.
Slowly I climb the last hill with the cascade of “then-whats” reaching a crescendo. As I look to the valley below and the sky above, I wonder “Then what happens to our souls?” What happens to the souls of the unborn and to the souls of us who turn the other way? In the fading light, where are they?
I am confused; the edges have frayed. The boundaries between life and death blur. The corridors once secure tremble beneath my feet . . . . I become the unborn, running this road out of town. Behind the gray-barked trees hide the abortionists, their poisoned arrows aimed at my imperfection.
The terrain is at once familiar and frightening. I too have touched the arrows. I’ve held the forceps and instruments—the cervix opening and the contents of the uterus pouring forth . . . in this life, there are no safe corridors.
Three days ago there was a clear heartbeat. Then a trickle of blood and stillness on the ultrasound screen. “A fetal demise, human reproduction is not perfect,” I explained to the mother. She fixated on the ultrasound screen, her eyes filled with anguish, and cried “My baby is dead.”
Driving from the hospital, the queasy feeling hits. I steel myself. The baby has died, the uterus needs to be emptied. I assure myself it is a task that I will do competently and compassionately.
The queasiness persists. In another city, a doctor drives to meet a woman whose womb tumbles with life. I know where he is going. I cannot stop him. The bounty is collected, the slayer poised, the arrows drawn in deadly, determined hands.
Gone is the usual banter of the operating room. In filtered quiet, I take the instruments deliberately—a number 12 dilator, tissue forceps, the vacuum apparatus, a sharp curette. Carefully I empty the uterus, directing the blood and fluid and flesh into a steel basin.
I’ve delivered death. I identify the parts submerged in blood: a forearm, a leg, part of the thorax attached to the vertebral column. A hand floats by palm up: perfect, fine, fingers spread like a star.
In the basin lies neither rhetoric or statistic. Abortion shakes me in the guts. Choice? Compassion? What words can sanitize the bits and pieces of a human staring at you? Do the sum of the parts make a whole? This baby, ripped apart, torn asunder—what we cannot recognize in life spills out in death.
Death, our own death. In the basin, we see our fragile reflection. We who’ve traversed this passage. This is not alien tissue in a strange land. We know our own.
Our own, despised and rejected, unknown and unwanted. Who shall name us? All that we are and shall be spilled into this steel cup.
I raise it off the table, the edges shimmer red and silver. Methodically, I examine the clots and fragments, my nerves beginning to betray me. I have a job to do. Standard abortion textbooks admonish the operator to find and identify all fetal parts.
Somewhere lies the missing calvarium . . . what a strange word. I remember my brothers hiding the last piece of a jigsaw puzzle, hoping to complete the picture.
A thousand points of death, a disassembled human being. The blood-red darkness climbing to the sky.
As I run, I pray . . . . Can we be cleansed?
- S. Clark, G. Devore, “Prenatal Diagnosis for Couples Who Would Not Consider Abortion,”
Obstetrics and Gynecology 1989, vol. 73, no. 6, pp. 1035-1037.
- 1. Haddow, G. Palomaki, et al., “Prenatal Screening for Down’s Syndrome with Use of
Maternal Serum Markers,” New England Journal of Medicine. 1992, no. 327, pp. 588-93.
- O. Philips, S. Elias, et al., “Maternal Serum Screening for Fetal Down Syndrome in Women
Less Than 35 Years of Age Using Alpha-Fetoprotein, HCG, and Unconjugated Estriol: A
Prospective 2-Year Study,” Obstetrics and Gynecology, 1992, vol. 80, no. 3, pp. 353-8.
—George Mulcaire-Jones, an obstetrician, practices family medicine in Montana. This reflection was originally published in the Spring 1995 issue of the Human Life Review.