April 17, 1998

Fetal surgery advances spur new ethical questions

Fetal surgery advances spur new ethical questions

Numerous ethical questions swirl around the subject of experimental fetal therapies.

Advances in diagnostic technology, as well as other fields such as genetic testing, are giving physicians the ability to diagnose potentially disastrous anomalies earlier than ever. This, in turn, is giving rise to a host of tough questions regarding possible treatment options.

Definitive answers are hard to come by, for that is the nature of ethical dilemmas. One national expert in the field believes that experience and communication are the keys.

"We have to balance what we can do ‹ what is possible ‹ and what the patients want us to do," said Dr. Mark I. Evans, Charlotte B. Failing Professor of Obstetrics and Gynecology, associate director of the Center for Molecular Medicine and Genetics and director of the Center for Fetal Diagnosis and Therapy at Wayne State University/Hutzel Hospital in Indiana.

"You have to talk to as many people as possible; there is safety in numbers. Good judgment comes from experience and experience comes from bad judgment."

Evans spoke at Vanderbilt University Medical Center's Ethics Spring Grand Rounds, sponsored by the Ethics Committee. His presentation was titled "Over the Cutting Edge: What are the Moral Boundaries for Experimental Fetal Therapies?"

Technology is rapidly increasing physicians' ability to detect serious anomalies long before birth. Experimental treatment options, and the relative success of those treatments, vary greatly. According to Evans, the first step is to determine what can be done when an anomaly is detected.

"You start with life-and-death issues, then move to quality-of-life issues. Then come some hard questions. Is the fetus an independent patient? Well, that depends on your perspective," Evans said. "I say the parents have the right to choose the course of treatment. I don't believe doctors have an obligation to the fetus that supersedes the rights of the parents.

"You have to consider the risk to the mother. And sometimes, to be honest, the zeal of the investigator can get in the way.

"Finally, just because a certain procedure can be done, should it be done? Not always. You really have to balance the good and bad sides of every situation," Evans said.

The advent of genetic testing is bringing these questions to the forefront. According to Evans, less than 10 percent of the abortions performed in the United States each year were done for genetic reasons.

"The more severe the anomaly, the more likely the pregnancy will be terminated, but we're not on a search and destroy mission," Evans said. "Fetal therapy is an emerging field, and it's forcing us to rethink how to handle patients who have babies with anomalies.

"We don't want to, with surgery and other fetal therapy techniques, deliver babies who will survive, but with disastrous consequences. We have the moral right to decide not to do that."

According to Evans, fetal therapy ‹ experimental and otherwise ‹ is a field that is technology-intensive and technology-dependent.

"I believe the ethical considerations of these situations change with technology also," Evans said. "However it is determined though, the bottom line always remains the same: How do I get the most good for my patient with the least amount of harm?"