On the history of fetal surgery. History is always important:
Fetal surgery was pioneered in the 1980s by Dr Michael Harrison ‘the father of fetal surgery’ at the University of San Francisco, California Children's Hospital. Since Harrison began his work, others have taken up the challenge, and fetal treatment centres are now in operation in Philadelphia, Boston, Cincinnati and Texas to name just a few. Fetal surgery has also become a reality in the UK. Figures given by Lord Darzi in a recent parliamentary debate indicate that 192 operations were performed on fetuses in the UK between 2006 and 2007.3
Fetal surgery and late-term abortion are interesting contrasts. One baby at 24 weeks could be the subject of a surgery as a patient, while another is terminated as a "product of conception."
The second issue I will discuss is the way that fetal surgery challenges autonomy-focussed approaches to medical ethics. Doyal and Ward4 suggest that women's autonomy may be threatened if fetuses are regarded as patients in their own right. Yet they, and a number of clinicians, suggest restricting access to fetal surgery on paternalistic grounds, which also present a threat to women's autonomy.
That's because autonomy as an absolute does not work. You can't isolate your own interests from that of everyone else's. At some point, your interests must be subliminated in at least some contexts. Feminists don't get that. They think men get to exercise absolute autonomy on all matters (which is false) so they think that they should, too.
About the reasons for fetal surgery:
The motivations for fetal surgery that I have discussed above apply to parents and clinicians, but what are the advantages, if any, for the fetus in being operated upon while still in utero?
There are some medical problems that, without surgery, will almost inevitably cause the death of the fetus before, or shortly after, birth. Among the conditions that might fall into this category are congenital diaphragmatic hernia, in which the abdominal organs protrude into the chest, impeding lung development.Teratomas that develop at the base of the coccyx are also highly risky for fetuses, as they can grow so large as to place a strain on the heart. When this has happened, surgery may be the only way of preserving the life of the fetus.
These benefits come at a cost to the mother. Open fetal surgery involves two Caesarean sections for the woman—the first at the time of the fetal intervention, the second at the time the baby is born. There is a risk of rupturing the uterus. Mothers will need to spend 5–7 days in hospital.20 Any future children will have to be delivered by Caesarean. Open fetal surgery very frequently involves premature labour and delivery—on average babies are born approximately 8 weeks after surgery. Mean gestational age at delivery according to one study was 32.5 weeks. The risks of endoscopic and percutaneous procedures are lower, but still significant.
So here's the big ethical dilemma:
Doyal and Ward argue that only the most serious conditions can justify fetal surgery. A similar stance is adopted by many of the clinicians involved in this kind of surgery. The risks imposed on women whose fetuses undergo surgery are thought to be justified only if the life of the fetus is in danger. This might seem to offer a relatively straightforward ethical blueprint for the management of fetal surgery. Other conditions—non-lethal tumours, for example, or cleft palate—could be addressed after the birth of the child without going through the mother, as it were. However, if we are to countenance fetal surgery at all, why should we restrict it to conditions that are life-threatening to the fetus? The obvious answer is: to protect mothers. Women should not have to undergo surgery unless it is absolutely necessary.
Yet who should be charged with making this judgement as to whether the risks to women are acceptable in balance against the benefits to the fetus? Should it be women themselves, or their clinicians? There are in fact some persuasive arguments in favour of fetal surgery for non-life-threatening conditions. If a problem has been identified by ultrasound, fetal surgery may offer the possibility of remedying the condition there and then without the need for postnatal intervention. Giving birth to a healthy child and taking it home straight away might seem more appealing than having a birth followed by surgery and uncertainty.
Still more significantly, the uterine environment promotes quicker healing with less scar tissue. Women may be eager to secure this benefit for their child even if its life is not at risk. When defects such as cleft palate or teratoma have been diagnosed prenatally, scarless fetal surgery will be a major advantage over postnatal treatment. It is plausible that some patients might want to spare their offspring the risk of disfiguring scars. This raises the question of whether the adult's willingness to undergo such procedures is sufficient justification to undertake them. It may be difficult to define the circumstances under which fetal surgery can take place without lapsing into paternalism: restricting patients' options for their own benefit, against their wishes.
So is a woman's autonomy absolute?
It appears not.
See, this is the thing that annoys me about these conflicts: it configures the situation as a power conflict: who decides?
Here's an idea: the woman and the doctor can both decide, and then each one act in consequence.
The doctor can decide fetal surgery is not right for his patient.
And the mother can decide fetal surgery is right for her and find another doctor.
What if the doctor is a woman? Is the mother entitled to take over the doctor's bodily autonomy and force her to perform a surgery she thinks ultimately is unethical?
This is why autonomy as an absolute does not work.
Only truth works.
And what about cases involving twin fetuses?
Is it ethically acceptable to impose the risks of surgery on someone who stands to derive no clinical benefit? Surely a large part of the answer depends on the ability to consent. A variation of this question has been explored by Paris and Harris in the context of operating on a twin in utero. Both twins are exposed to the risks of surgery. Therefore, they argue that both become patients. However, the healthy twin's interests are not served by being exposed to the risks of surgery. For this reason, they conclude that it would be unethical for doctors to operate in such circumstances. Seemingly, this argument could also apply to the mother of the fetus(es). In fetal surgery, mother and fetus become patients, and their interests might also seem to conflict in a similar way. Yet Paris and Harris do not rule out fetal surgery entirely, only in circumstances in which a healthy twin may be put at risk.
The difference here is that the mother has the ability to consent to the intervention, whereas the healthy twin does not, but Harris and Paris' recognition of fetuses as patients in their own right seems to raise some problems. Could a fetal patient's interests outweigh those of its mother? If so, women's autonomy and bodily integrity might be threatened by the development of fetal surgery. Doyal and Ward discuss the risk of coercion in this context, arguing that women's autonomy should be regarded as paramount, and surgery should only ever be performed with the mother's informed consent. The legal and moral status of the fetus, in their analysis, is kept within very restricted parameters—it may be ‘special’, but its interests are explicitly and necessarily subordinate to those of the mother.
Just as fetal surgery stretches the notion of what constitutes a patient, so the concept of informed consent seems to have become strangely distorted in this context. According to at least one practitioner: ‘There will be very few patients for whom it is an appropriate intervention […] We are going to deal with the unusual patient who can give an informed consent […] These patients are women who are carrying fetuses with life-threatening conditions.’ Here, in a strange inversion of what one might normally understand by the term, informed consent is deemed valid not by virtue of the wishes and understanding of the patient, but by virtue of the condition experienced by the fetus. Similarly odd ideas about consent and patient choice are implicit in the following quote: ‘The key to choosing appropriate patients for fetal intervention is to identify those that would not survive with postnatal therapy alone.’ Here again, it is not the mother who chooses whether to undergo the treatment. Rather, the medical establishment chooses her as an acceptable vehicle through which the treatment can be offered. It is no longer clear here just what role informed consent and respect for autonomy are playing in this undoubtedly complex ethical situation.
Showing once again that absolute autonomy does not work.
If the doctor thinks the risks will outweigh the benefits, what right does the mother have in demanding that he operate?
Which brings me to another subject.
Feminists like to treat abortion on demand as a right and insist that the medical establishment accommodates every single abortion request no matter how late in the pregnancy and for any reason. They insist that we must Trust Women.
But what happens if this principle is applied to fetal surgery? Do pregnant women have the right to expect fetal surgery on demand? Some feminists are arguing that C-sections should be on demand. Why not fetal surgery?
Some people might say this is unrealistic. Typically fetal surgeries are done for cancer or hernia or other very serious conditions. But that's not always the case. What about minor cleft palates or club feet? What if the case involves twins where the healthy fetus must subject to the risks?
Feminists require people to respect each woman's individual wisdom no matter how ridiculous it is, otherwise one is undermining female power. But the whole concept of absolute female supremacy in matters involving medical issues is stupid because sometimes the women in question are dumb. Stupidity does not always have to be respected, especially when it involves making someone else do something for you. If you want to do something stupid on your own, no one can stop you; but to make people do things they think are stupid, especially against their own beliefs is a form of tyranny.
But our author thinks this is problematic:
Our society expects and demands that pregnant women and mothers should be altruistic. Pregnancy itself is commonly regarded as a state in which what would normally be supererogatory becomes morally required. Pregnant women often behave in ways that in any other context would be deemed clearly supererogatory—perhaps even pathologically so. I have argued elsewhere that the demands placed on mothers and pregnant women are unreasonable and excessive. It is because of this that fetal surgery makes us uneasy, I would suggest. Expectations of maternal sacrifice in conjunction with new technological means of intervention have led us to an uncomfortable place.
How should we relieve this discomfort? The accepted view seems to be that we should erect a variety of barriers that constrain women's options within parameters that others have deemed reasonable. In short, a reversion to paternalism: it cannot be safely left to pregnant women to decide. This perpetuates and reinforces the idea that pregnant women are so extravagantly altruistic that their choices must be restricted in their own interests. In essence, because our ideas of maternal altruism do not fit into an autonomy-based ethics system, we are tempted to exclude pregnant women from their place in that system by a system of paternalistic restrictions. The paternalistic nature of these restrictions is often masked by their apparently clinical rationale. Laura Purdy has demonstrated the level to which paternalistic assumptions infiltrate arguments related to selective reduction—another facet of fetal surgery.
My beef is that the author assumes that pregnant women are altruistic because society expects them to be.
No, I would say that pregnant women are altruistic because it's hard-wired into women to care about their babies even to the point of being needlessly self-sacrificing.
But ultimately, the woman is her own person and even in a state of pregnancy, she doesn't completely lose her brain and can make a decision.
The only thing is that sometimes those decisions are unjustifiable. It doesn't necessarily have anything to do with pregnancy. Some women are just not that bright, lack logic or don't have a coherent and reality-based value system.
The author writes:
A better approach might be to look to the social world in which women's freedom to make choices is formed. It is a mistake here to suppose that non-pregnant women, and men, are perfectly free in their choices and decisions. Informed consent is always and necessarily constrained by social expectations and values.
Not entirely. People are quite capable of thinking outside the box.
And she concludes:
The spectacle of a woman undergoing open fetal surgery is undoubtedly disturbing. It illustrates in the most graphic way the collision of two highly problematical assumptions: first, that ever-greater surveillance of pregnancy is beneficial, or at least not harmful, and second, that pregnant women should sacrifice their bodily integrity for the welfare of their child.
Yeah, a feminist would say that fetal surgery and pregnancy surveillance is a bad thing. Naturally.