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DOI: 10.1111/1471-0528.12093 www.bjog.



Fatally awed?

Sir, My rst quick glance at Fatally awed? A review and ethical analysis of lethal congenital malformations (BJOG 2012;119:13021308) suggested that the two tables provide valuable information for women who have to decide whether to have a late termination or to continue the pregnancy and allow the neonate to die naturally. But when I reached the associated commentary in which Chervenak and McCullough congratulate the authors for asserting their professional responsibility to offer or recommend nonaggressive management, I realised that the authors presumed that abortion would not be ethical and that such pregnancies should continue: their concern is for the appropriate management of the affected infants. I hold the view that Chervenak and McCullough condemn as fallacious rights-based reductionism in obstetric ethics.1 In contrast to them, I regard the woman as having autonomy over her fetus up to the time when she decides to confer status on it as a person by giving birth. This is recognised in British law: the Abortion Act 1967 was amended in 1990 to allowed abortion at any gestation if there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped and, in 1998, the Court of Appeal conrmed a lower court ruling that a woman has a right to refuse caesarean section when this is recommended to protect either herself or her fetus from serious harm.2 Since 1990, in England and Wales, fetal abnormality has been the reason for relatively few terminations, with little change from year to year: in 2008, there were 1864 terminations performed up to 24 weeks of gestation and 124 later in pregnancy.3 Chervenak and McCullough believe that when a woman accepts obstetric care the viable fetus acquires independent status as a patient, so that, on rare occasions, it would be proper to coerce the woman into receiving treatment for which she has refused voluntary consent. The article in the current issue of BJOG is relevant in Britain only when the malformation is discovered for the rst time at delivery or

when the woman, aware of the malformation, has refused termination. &

1 Chervenak FA, McCullough lB, Brent RL. The professional responsibility model of obstetrical ethics: avoiding the perils of clashing rights. Am J Obstet Gynecol 2011;205:315.e15. 2 St. Georges Healthcare N.H.S. Trust v S [1998] 3 W.L.R. 936, 1998, Court of Appeal. 3 Abortion Statisics 2008. Dept of Health, 2009. [www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsStatistics/DH_099285]. Accessed 9 November 2012.

D Paintin
Emeritus Reader in Obstetrics & Gynaecology, Imperial College, London, UK
Accepted 4 October 2012.
DOI: 10.1111/1471-0528.12093

Fatally awed?

Authors Reply Sir, We thank Dr Paintin for his interest in our article.1,2 Paintins main concerns appear to relate to the views of Chervenak and McCullough in their accompanying commentary on the professional responsibility of obstetricians.3 Both responses appear to miss the central point that we argued: in counselling, language can corrupt both the inner logic of the clinicians decision-making process and the counselling of families facing difcult decisions. Paintin is wrong in characterising our argument as only relevant in the event of fetal abnormality undiagnosed at birth or when a decision has been made to continue the pregnancy. Our argument concerns the need for clarity in the language used in counselling. This applies whether the woman decides to terminate or continue the pregnancy and, if continuing, on what terms and with what goals.

2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2013 RCOG