The Littlest Patients

September 20, 1999
Web posted at: 12:44 p.m. EDT (1644 GMT)

In this story: Turning one patient into two To wait or not to wait Changing the status of the fetus RELATED STORIES, SITES

In the ongoing search for earlier diagnosis and treatment of illness, the patient population keeps getting younger. In addition to assessing the health of fetuses through genetic testing and improved ultrasound, physicians are now perfecting techniques of fetal surgery to correct everything from congenital heart defects to cleft lips. But such treatments raise questions of when it is acceptable to carry out procedures that are risky to both fetus and mother, and how fetal surgery challenges our perspectives about when life begins.

What's your opinion?

Surgery on newborn babies carries certain risks, depending on the age and health of the child. If the same surgery is performed before the child is born, similar risks exist, as well as risk to the mother. In performing fetal surgery, the physician takes on an additional patient -- the mother -- and whatever benefit the surgery may provide must now be weighed against the risk not only to the fetus but to the mother as well.

Fetal surgery carries additional risks on top of the risks of similar surgery after the baby is born: a risk of premature delivery, and even additional risk of death or disability. To offset these risks, fetal surgery needs to offer substantial benefits over waiting. Health problems that threaten the life of the fetus will surely qualify (correcting a heart defect), as might surgeries to prevent disability (closing a neural tube defect), whereas cosmetic surgeries will be difficult to justify. Some parents may be willing to use fetal surgery for any of these reasons, and we must ask how far they should be allowed to go.

The availability of any new medical technique raises questions about which patients ought to be treated; but fetal surgery opens the door to an altogether new class of patients. No longer is birth the bright line before which only very limited direct medical care is possible. Fetal surgery may actually blur the distinction between babies and fetuses, and with it who has the right to decide about whether and when to treat.

Fetal surgery makes it possible to think of the fetus as a patient almost separate from its mother, with its own medical interests to be considered. Can these interests be separated from those of the mother, and if so, who should be making treatment decisions on behalf of the fetus? Up to now the mother has had sole decision-making authority, since nearly any treatment for the fetus could take place only by treating her at the same time. But fetal surgery offers a way to treat the fetus directly, and so challenges the mother's decision-making authority.

The opportunity to treat or remove threats to health before birth is so appealing that we will probably continue to forge ahead with fetal surgery. But since it also affects the health of the mother, there must be compelling reasons to justify not waiting until a baby is born for its treatment. Curing birth defects is now possible, and someday soon we may even see organ transplants on fetuses. But no matter how great the potential gain, forcing fetal surgery on a pregnant woman would be a setback at least as great as any advance the technology represents. The benefits of fetal surgery to its smallest patients may be great but will be unacceptable if its moral price is too high.