Abortions

(Why so many posts over the last week? Because it's study week, of course.)

I have a stack of JAMAs piled up in our office. I haven't read them in months, but I can't bear to throw them away, either. It just seems so wasteful. I intend to figure out something to do with them, but that's last on my list of priorities right now. Anyway, last week I did pick one up and read the "A Piece of My Mind" feature. If I ever read anything in JAMA, it's that -- it's a reader-written essay on a topic of choice. They're always really well-written (a reminder that physicians are, on the whole, not only very intelligent but also well-rounded in life) and usually poignant. The one from this issue was particularly so. It was also relevant to the Supreme Court decision from last week. I don't have a good way of posting the full text, since it's a subscription service and I can't post a link to it, and I don't like the formatting of my blog a whole lot (the text column is too narrow, so it always looks like I'm writing a diatribe) but I don't have any better ideas, so here it is (at least I've provided the citation):

JAMA. Volume 297(13), 4 April 2007, p 1412
A Question of Faith [A Piece of My Mind]
Raghavan, Ramesh MD, PhD
Section Editor(s): Young, Roxanne K. Associate Editor. St Louis, Missouri

A 35-YEAR-OLD WOMAN PRESENTS IN AN EMERGENCY Department just as the day shift is coming on. She is in her 21st week of pregnancy and is carrying twins but is worried because she woke up with vague cramping sensations and noticed a bloody vaginal discharge. The ED attending performs a vaginal examination and determines that her cervix has dilated and that fetal membranes are bulging into the vaginal canal. The nurse straps a monitor to her abdomen, and all in the room stare at the screen pensively. The squiggly lines tell an ominous story—the uterus is contracting, and the fetuses, incapable of independent existence at this stage of their gestation, are slowly being expelled into the world.

Over the next two days, the power of modern pharmaceuticals is unleashed in an attempt to quiet her uterus and save the twins. In reality, this attempt is focused on the twin who is fully contained in the uterus, since the one who is almost inside the vagina has no realistic chance of achieving viability. The efforts are valiant—these twins were conceived after 10 years of marriage—and the desire is strong to salvage as much of this pregnancy as possible.

The body, so often the final arbiter of the endeavors of men and women of medicine, has other plans. The fetal membranes continue to prolapse. The hospital's maternal-fetal medicine team and the woman's personal obstetrician discuss the situation with the woman and her husband. The membranes of one twin will likely rupture in the next few days, and he will be delivered. There is the possibility of undertaking a rescue cerclage—a procedure where the placenta of the delivered twin is retained in the uterus and the cervix is sutured closed. But this buys them a week or two on average before infection sets in, and the other twin also needs to be delivered. There is a slim chance at a best-case scenario—a twin born at the cusp of viability, a million-dollar baby who will spend months in neonatal intensive care and will have considerable neurodevelopmental problems should he survive.

The woman and her husband discuss this through the night and decide that they do not want to take on the certainty of a uterine infection for a slender chance of a periviable baby. It makes more sense to them to evacuate the uterus before infection sets in, preserve the uterine environment for a future attempt at pregnancy, and begin the process of grieving over the loss of the twins. They request their obstetricians to induce labor.

And at this point their personal decision-making runs afoul of their hospital's policies.

Inducing labor before membranes have ruptured, or before there is a maternal indication such as infection, is technically an elective abortion. This hospital, like most hospitals in the metropolitan area in which they live, has a strict no-elective-abortion policy, which forbids her obstetricians from rupturing her membranes and initiating labor. Women who want elective abortions go to Planned Parenthood; the ones who want to deliver full-term babies go to hospitals; and so the woman and her husband are told they cannot exercise that option at this hospital. The two of them, recent transplants from California used to a less faith-based practice of medicine, are shocked by this. Nobody wants this pregnancy more than they, they argue. The sole reason they are doing this is because the risks outweigh the benefits. Does the hospital require emergence of a frank infection before intervention is permissible? Is this in keeping with the highest standards of practice in modern obstetrics? Her obstetricians are sympathetic but helpless. Finally, they come up with a plan. The sole hospital that does not have such an abortion policy is a university teaching hospital several miles away. Telephone calls are made, a direct admission is arranged, and the woman's husband drives her to the teaching hospital, where labor is induced. The twins are delivered the next day. They are stillborn.

You might wonder, reading this vignette, how I happen to know so many details about this case, or even whether this is a fictional teaching case that so bedevils medical students. The unfortunate truth is that this is real life: I am the husband in this story.

But the greater tragedy here, to my mind, is the straitjacket that a religious worldview imposes on the complexity inherent within clinical medicine. Our world sometimes presents us with situations that cannot be simplistically categorized as pro-choice or pro-life, and other patients across the nation will be faced with decisions like the ones we made on that fateful day.

This is why hospital policies that originate in religion rather than in science can be unhealthy and unsafe. Personal religious beliefs can and should guide the lives of clinicians of faith. The extent to which they guide a clinician's professional life is the clinician's personal matter, and I hope that clinicians will choose specialties and practice settings that ensure that patients receive needed care regardless of the clinician's religious beliefs. However, the extent to which these beliefs guide hospital policy is a matter of concern to all of us, whether we are patients or clinicians. The extent to which the US medical establishment succeeds in circumscribing the circle of influence of religion-based medicine will determine the quality of health care that physicians can offer their patients. Clearly, irrespective of what religion each of us belongs to, this is the very least that our patients deserve.

Ramesh Raghavan, MD, PhD

St Louis, Missouri

A PIECE OF MY MIND (Young RK, ed)

Then my friend adspar pointed me to this post, which relates a similar story. I know it takes extra effort to click on that link, but please do so.

I don't think there are two better examples of why medicine needs to be kept between physicians and patients. The government shouldn't be making decisions about what procedures should or should not be performed, and neither should insurance companies.