Imaging diagnosis and legal implications of brain injury in survivors following single intrauterine fetal demise from monochorionic twins - a review of the literature

Brain injury of the surviving twin from monochorionic pregnancies following intrauterine fetal demise during the second and third trimesters is a rare but severe complication. Monochorionicity and gestational age at the time of stillbirth seem to be decisive factors in terms of long-term neurologic outcome prediction for the survivor. Magnetic resonance imaging (MRI), diffusion weighted imaging (DWI) in particular, seem to bring the earliest and most accurate diagnosis. Ultrasound detection of brain damage is possible in later stages of fetal brain injury. It is essential to provide early diagnosis and multidisciplinary counsel to the parents to ensure informed decision making. For couples who choose to terminate pregnancy legislation related to late abortion might lead to further distress. Our paper aims to stress the importance of MRI DWI in the evaluation of surviving twins following single intrauterine fetal demise in monochorionic pregnancies and the delicate context of the medical professionals and parents facing this clinical situation, sometimes complicated by legal constraints.

The Curious Case of Thalidomide and the Absent Eugenic Clause in Canada's Amended Abortion Law of 1969

This essay traces the role of the drug thalidomide in the reform of Canadian abortion law during the late 1960s. Like elsewhere in the British Commonwealth, discussion of the "thalidomide disaster" of the early 1960s intensified leading up to the debates that culminated in the 1969 amendment to Canadian abortion law. Although thalidomide was a rallying point for advocates of eugenic abortion, a majority of Canadian MPs, unlike their British and Commonwealth counterparts, rejected this argument. Widespread public and political considerations of the thalidomide tragedy were thus unable to inspire support for a eugenic clause in Canada's new abortion law, in spite of the nation's infamous eugenic past.

Is a cleft lip and palate a serious "handicap"? Jepson v Chief Constable of West Mercia--a legal and ethical critique

This column considers the legal and ethical dimensions of the controversial case of Jepson v Chief Constable of West Mercia. The purpose of bringing legal proceedings was to judicially review the notion that a cleft lip and palate should be regarded as a serious "handicap" for the purposes of s 1(1)(d) of the Abortion Act 1967 (UK). The Column argues that while Parliament failed to provide a sufficiently precise definition of "seriously handicapped", it is clear that it never intended and positively rejected the notion that a cleft lip and palate was a serious enough condition to warrant the lawful termination of a pregnancy. In determining what constitutes a sufficiently serious disability, the column critiques the medical model of disability and proposes a remedy model in its place. Finally, it argues that an attentive and responsive moral framework is fundamental to any substantial narrative ethics, and it suggests that a life with a disability can generate meaningful stories and that when there is a network of support and relationships around the person living that life, that human life is not only viable but also, in its own way, fulfilling, even if not ordinary.

Law, reproduction, and disability: fatally 'handicapped'?

Although it provides the grounds for a numerically very small proportion of abortions performed in Great Britain each year, s.1(1)(d), the disability ground, raises considerable controversy. This controversy recently culminated in the Department of Health losing an appeal against an instruction from the Information Commission to publish more detailed statistics on abortions carried out on the grounds of foetal abnormality, particularly those that occur after 24 weeks' gestation. In this paper I criticise and reject the legitimacy of this controversial section and suggest possible alternative legislative approaches to the issues raised in 1(1)(d). The purpose of the paper is to use s.1(1)(d) as a catalyst for suggesting more dramatic changes to abortion law in Great Britain. The article concludes with a consideration of the significance of s.1(1)(d) in our wider framing of disability in the context of reproductive choices. Drawing from writing in disability studies I suggest that s.1(1)(d) problematically reifies the importance of the physical aspects of disability. It is also problematic because of the presumptive effect it could have on choices following prenatal screening. Many authors argue that the statistically small numbers of abortions carried out on grounds of foetal abnormality, particularly after 24 weeks' gestation, are disproportionate to the controversy it causes. I reject this on the basis of the impact that s.1(1)(d) has had on the regulation of reproductive choice in other areas; specifically preimplantation genetic diagnosis (PGD) under the Human Fertilisation and Embryology Act 2008. I conclude by arguing that s.1(1)(d) is a relic of an overly medicalised approach to disability and abortion.

[Eugenics' extension in the Spanish health care system through the prenatal diagnosis]

The wide implantation of strategies of sifted or prenatal selection close to laws that protect the destruction of the human life before the childbirth in the whole world, they are giving place to an increasing number of eugenic abortions. In Spain, the law 2/2010 of the sexual and reproductive health and voluntary interruption of pregnancy there has supposed the liberalization of the eugenic abortion without term limit. In we make concrete, the sanitary national and international policies of prenatal selection of Down's Syndrome, which they chase to facilitate the total or partial destruction before the childbirth of this human group, submitting it to a few particular conditions of existence during his prenatal life in those who will be an object of a series of technologies of selection, they might be qualified of genocidal policies if we consider the definition of genocide given by United Nations. In consequence, the sanitary agent who takes part without objection in the above mentioned programs promoted by the principal agents, meets turned into a necessary cooperator of the abortion who justifies itself in the supposition of "foetal risk". We can conclude that we are present at an eugenic drift of the prenatal diagnosis that is opposite to the ethical beginning of the medical profession.

Disability, ambivalence, and the law

In this Article, I advance a new frame through which to organize discourse on disability and the law: the notion of ambivalence. I make two claims, one descriptive and one normative. Descriptively, I argue that ambivalence pervades encounters with disability. Disability attracts because it is a force that makes us human and disability repels because it is a force that threatens our humanity. The tension between these sentiments is not easily tolerated and tends to prompt denials of ambivalence; we embrace a conscious view of disability that belies our mixed sentiments and we suppress reactions to disability that conflict with this conscious view. Normatively, I argue that the law should express and expose ambivalence about disability. When we deny ambivalence, I argue, we cannot account for our genuine sentiments and we cannot prevent suppressed sentiments from emerging, intensified, in harmful and unanticipated forms. To avoid these dangers, the law should prevent the embrace of unequivocal views of disability as valued, devalued, or neutral, and seek to expose ambivalence about disability to the public. This prescription calls into question the prevailing orthodoxies of disability law.

Prenatal diagnosis and abortion for congenital abnormalities: is it ethical to provide one without the other?

This target article considers the ethical implications of providing prenatal diagnosis (PND) and antenatal screening services to detect fetal abnormalities in jurisdictions that prohibit abortion for these conditions. This unusual health policy context is common in the Latin American region. Congenital conditions are often untreated or under-treated in developing countries due to limited health resources, leading many women/couples to prefer termination of affected pregnancies. Three potential harms derive from the provision of PND in the absence of legal and safe abortion for these conditions: psychological distress, unjust distribution of burdens between socio-economic classes, and financial burdens for families and society. We present Iran as a comparative case study where recognition of these ethical issues has led to the liberalization of abortion laws for fetuses with thalassemia. We argue that physicians, geneticists and policymakers have an ethical and professional duty of care to advocate for change in order to ameliorate these harms.

[Towards social eugenics. Ideology and bioethics in the construction of the social policy]

The social eugenics is the real face of the biomedical application of an ideological paradigm, self-styled like "progressive", that claims the radical transformation of the western society from laicist and utilitarians positions. This article tries to decipher the historical roots, the bioethical language and the political - social implications of this paradigm, which questions the essential dignity of any human life in benefit of "new rights", constructed ex professo. For it, it exposes three analytical dimensions of his "historical possibilities" (retrospective, perspective and Forward studies), taking as an example the role of the social Policy, and especially, the doctrinal and institutional paradoxes of the "Welfare state" in Spain.

RISK, MEDICINE AND WOMEN: A CASE STUDY ON PRENATAL GENETIC COUNSELLING IN BRAZIL

Genetic counselling is an important aspect of prenatal care in many developed countries. This tendency has also begun to emerge in Brazil, although few medical centres offer this service. Genetic counselling provides prenatal risk control through a process of individual decision-making based on medical information, in a context where diagnostic and therapeutic possibilities overlap. Detection of severe foetal anomalies can lead to a decision involving possible termination of pregnancy. This paper focuses on medical and legal consequences of the detection of severe foetal anomalies, mainly anencephaly and Down syndrome, and in light of the fact that abortion is illegal in Brazil. The discussion is based on the literature and empirical research at a high-complexity public hospital in Rio de Janeiro.

SELECTIVE ABORTION IN BRAZIL: THE ANENCEPHALY CASE

This paper discusses the Brazilian Supreme Court ruling on the case of anencephaly. In Brazil, abortion is a crime against the life of a fetus, and selective abortion of non-viable fetuses is prohibited. Following a paradigmatic case discussed by the Brazilian Supreme Court in 2004, the use of abortion was authorized in the case of a fetus with anencephaly. The objective of this paper is to analyze the ethical arguments of the case, in particular the strategy of avoiding the moral status of the fetus, the cornerstone thesis of the Catholic Church.

Awareness and attitude toward prenatal diagnosis of chromosomal abnormalities in patients with no access to legal termination of pregnancy

OBJECTIVE

To analyze variables affecting couples' decision making about prenatal cytogenetic diagnosis in patients with no access to legal termination of pregnancy (TOP).

METHODS

Patients undergoing invasive prenatal diagnosis were anonymously surveyed after counseling and before the procedure. The questionnaire enquired about sociodemographic features, medical history, knowledge of and attitudes toward genetic testing and TOP.

RESULTS

Two genetic units distributed 372 questionnaires. Mean maternal age was 36 +/- 4 years. Access to prenatal genetic counseling was mainly patient's own initiative, or 'self-referral'. Most self-referred patients (87%) considered that 'receiving accurate information' was the main issue. Eighty-one per cent of all couples knew that TOP because of fetal anomalies was not legal. In case of a serious anomaly, 68.2% of patients would contemplate TOP, in spite of the risk of being exposed to an unsafe abortion.

CONCLUSIONS

In many countries, prenatal genetic testing is offered, but TOP is not available. In the present study, although most of the couples who decided to undergo prenatal genetic testing were aware of this, they still chose to perform prenatal diagnosis. The main reason given was to obtain reliable information about fetal condition. Finally, if a fetal chromosomal abnormality were detected, most of them would consider TOP.

Parental decisions to abort or continue a pregnancy following prenatal diagnosis of chromosomal abnormalities in a setting where termination of pregnancy is not legally available

OBJECTIVE

To learn about parental decisions to abort or continue a pregnancy after prenatal diagnosis of chromosomal abnormalities among the population in Uruguay.

METHODS

Between 1982 and 2003, 14 656 amniocentesis and 2740 chorionic villus samplings were performed in a referral Genetic Unit. Chromosomal anomalies were found in 376 cases (2.16%) and included Down syndrome, aneuploidies in which a severe prognosis was expected, sex chromosome aneuploidy and aneuploidies with a low risk of an abnormal clinical phenotype. The couples that received abnormal results were contacted by phone and asked if they had continued or interrupted the pregnancy after the diagnosis and genetic counseling.

RESULTS

We contacted 207 couples (55%). When confronted with Down syndrome or an aneuploidy in which a severe prognosis was expected, 89% and 96% of patients, respectively, decided to terminate the pregnancy. When confronted with sex chromosome aneuploidy or aneuploidies with a low risk of an abnormal clinical phenotype, 79% and 90% of patients, respectively, decided to continue the pregnancy.

CONCLUSIONS

The present study shows that when faced with an anomaly such as Down syndrome and aneuploidies in which a severe prognosis was expected, most of the couples decided to terminate the pregnancy, although TOP is not legally available in Uruguay.

Thalassemia treatment and prevention in Uva Province, Sri Lanka: a public opinion survey

Due to its excessive cost thalassemia management is a major health care problem in Sri Lanka. The majority of doctors are using only desferrioxamine (DFO), in grossly inadequate doses mainly because of its unavailability. Deferiprone (L1), which is more affordable, is not used due to fear of toxicity, as previously reported. Arthropathy attributed to L1 has been observed in some patients, and has led to the discontinuation of the drug in all patients, without scientific rationale. The proposed thalassemia prevention project for Uva Province is based on prevention of marriages between carriers. This could be achieved by carrier screening and counseling of teenagers and adolescents well before they select their partners. In Sri Lanka, people find their marriage partners at their work place or universities, by themselves, or with the help of professional marriage brokers (they are called Kapuwa), through relatives and close friends. This process of finding a partner may also be helped by paper advertisements. However, in addition to the appearance and attitude of the prospective partner, the caste, social background and horoscope are major considerations in selecting a partner. Even when they select partners on their own at the work place or university, they keep these factors in the back of their minds to ensure social acceptance. Many relationships are given up due to objections and advice from parents when the caste or social background does not match. A horoscope is a written document that almost every child gets, written by a professional horoscope reader and depending on the time of birth. It is believed, according to the horoscope, that a person's attitudes, desires, future prospects of finding a suitable partner, could be predicted. It is rare to proceed with a marriage if the horoscope does not match. These customs are considered less seriously among educated people when they find their partner at the work place or university. The concept of thalassemia risk-free marriages advocates promotion of marriages where at least one partner is a non-carrier. Success of such a project could be monitored at the time of marriage. This opinion survey indicates that the public is motivated to promote carrier screening and the prevention of thalassemia.

Termination of pregnancy for fetal abnormality incompatible with life: women's experiences in Brazil

Fetal abnormality incompatible with life is a fact and the options for dealing with it are abortion or birth followed by death. This paper reports a qualitative study of the experience of ten women who had a pregnancy termination in a university hospital in Brazil for fetal abnormality incompatible with life. The women were interviewed approximately 40 days after the procedure. The experience was marked by strong emotions for the women, who had a terrible shock on learning of the diagnosis, which was given between 13 and 25 weeks into their pregnancies. They cried, and experienced fear, despair, anguish, a sense of uselessness and refusal to accept the situation. When they took the decision to terminate their pregnancies, the women experienced sadness, despair and guilt, and all these feelings caused them intense suffering. The killing of the fetus was the most difficult part of the termination for them. Nevertheless, afterwards they were satisfied with the decision taken and believed that it was the correct one, despite the anguish it caused. The inclusion of fetal abnormality incompatible with life in the Brazilian law on pregnancy termination would help to reduce women's suffering and contribute to the provision of supportive care by the health services.

Choosing between possible lives: legal and ethical issues in preimplantation genetic diagnosis

This article critically appraises the current legal scope of the principal applications of preimplantation genetic diagnosis (PGD). This relatively new technique, which is available to some parents undergoing in vitro fertilization (IVF) treatment, aims to ensure that a child is not born with a seemingly undesirable genetic condition. The question addressed here is whether there should be serious reasons to test for genetic conditions in embryos in order to be able to select between them. The Human Fertilisation and Embryology Authority and the Human Genetics Commission have decided that there should be such reasons by broadly aligning the criteria for PGD with those for selective abortion. This stance is critically explored, as are its implications for the possible use of PGD to select either against or for marginal features or for significant traits. The government is currently reviewing the legal scope and regulation of PGD.

Late pregnancy termination within a legislated medical environment

AIMS

To review the indications and outcomes for abortion beyond 20 weeks' gestation within an environment of legislated notifiable pregnancy termination.

METHODS

In Western Australia legislation allowing abortion > or = 20 weeks' gestation for serious maternal-fetal conditions was enacted in May 1998. Late abortions are only permitted in a single state institution and are notifiable by law. All pregnancy terminations > or = 20 weeks' gestation performed since this legislation were prospectively identified with the indications and outcomes reviewed.

RESULTS

During the study period, 219 women underwent abortion > or = 20 weeks' gestation, representing 0.5% of all abortions in the state. Comparison with 438 contemporanous medical abortions for fetal anomaly at 14-20 weeks' gestations was made. Misoprostol was the primary abortifacient for both. The median maternal age for termination at 14-20 weeks was 32 years (interquartile range (IQR) 27, 36) and 30 years (IQR 26, 34) at > or = 20 weeks' gestation (P < 0.001). There was no significant difference in maternal gravidity or parity. The principal indications for terminations > or = 20 weeks were: karyotypic (28.8%); cardiac anomalies (15.5%) and neural tube defects (11.9%). Cardiac anomalies represented 5.0% of fetal anomaly terminations at 14-20 weeks (P < 0.01). The median time for medical abortion was 15.4 h (IQR 11.5, 23.2) at 14-20 weeks' gestation compared with 18.3 h (IQR 13.3, 26.1) at gestations greater than 20 weeks (P < 0.001). A total of 13.2% of terminations were performed at gestations beyond 24 weeks.

CONCLUSIONS

Abortion > or = 20 weeks' gestation under medically regulated legislation is used primarily for serious fetal anomalies. The women are younger and the abortion duration is greater for late pregnancy termination compared with those conducted at earlier gestations. The majority of late terminations occur < 23 weeks' gestation and the incidence has remained stable since the legislation was enacted.

Declining sex ratio: role of society, technology and government regulation in Faridabad district, Haryana

BACKGROUND

A declining sex ratio at birth has been documented during censuses in India. The decline is especially more in the northern states of Haryana and Punjab. We attempted to assess the role of society (preference for a male child, awareness and acceptability of the practice of sex determination), technology (availability and affordability) and government regulation in the adverse ratio for girls in the Ballabgarh block of Haryana in northern India.

METHODS

The population (about 80 000) in the Ballabgarh block has been under constant demographic surveillance for the past 30 years and the data are stored electronically. This was used to determine the sex ratio at birth in the area since 1990. The data on availability of ultrasound machines was collected from the district authorities, as registration of these machines was made mandatory under the Prenatal Diagnostic Techniques Act, 1994. We interviewed 160 mothers and grandmothers to determine the awareness and acceptability of sex determination methods and practices.

RESULTS

The demographic data for the past 10 years showed a declining sex ratio-from 881 in 1990-91 to 833 in 2000-01. The data support the view that in the initial part of this period, ultrasound was used for sex determination of all-order births but subsequently was used more in higher-order births. Our interviews with the mothers and grandmothers of the area showed that the practice of sex determination is prevalent and the attitude of the society is ambivalent. The increased availability of ultrasound machines in the area in the past 10 years corresponded to the decline in sex ratio. When the government made the practice illegal, the sex ratio improved only to fall again as the law was not implemented. Later years saw a more stringent implementation of the law and the sex ratio improved again.

CONCLUSION

There is a 'demand' for sex determination technology and, therefore, this would continue to be 'supplied'. At most the 'supply' can be regulated. Social engineering efforts need to be targeted at reducing the demand if the sex ratio is to be improved.

Prenatal diagnosis--discrimination, deliverance or democracy?

Prenatal diagnosis utilizes invasive procedures such as amniocentesis, chorionic villus sampling, cord blood sampling and pre-implantation genetic diagnosis. These techniques can diagnose serious foetal illnesses and this therefore provides valuable information to couples, helping them to prepare for the birth of an affected child. It also affords women the freedom to decide whether to terminate a pregnancy. The selective termination of foetuses with serious disabilities does not represent disability discrimination because women and parents are actually rejecting the disability, rather than the foetus itself. More significantly, the choice to abort a foetus with a serious illness or disability is an intensely private and personal exercise that does not and cannot be reflective of a wider public morality. Exactly the same can be said of the choice to selectively abort foetuses based solely on their sex. The private choice of women in this respect does not amount to the social devaluation of women. Firstly, it is an erroneous assumption that women in Australia prefer male babies. Secondly, even if there is a preference for male babies, banning prenatal sex selection would be treating just one of many symptoms of sexism, rather than curing the primary causes. The moral right of all women to reproductive freedom is an embodiment of their equal value in society.