Termination of Pregnancy Statement by American College of Pediatricians

The Supreme Court, in Roe v. Wade, limited states' ability to regulate abortion in the first two trimesters strictly to issues of maternal health [1]. It therefore denied that a fetus might have interests equal to that of the mother. The organized pediatric community, to this day, has offered no comment to this interpretation, reportedly because the decision centered on the mother and not on a viable infant. (Of course 30 years ago even early third-trimester births raised questions about viability.) More recently, controversy has centered on late-term abortion and the procedures that are sometimes used at this stage. In its 1997 report [2], the AMA stated, Although third-trimester abortions can be performed to preserve the life or health of the mother, they are, in fact, generally not necessary for those purposes. Except in extraordinary circumstances, maternal health factors which demand termination of the pregnancy can be accommodated without sacrifice of the fetus, and the near certainty of the independent viability of the fetus argues for ending the pregnancy by appropriate delivery [3]. This issue has relevance for pediatricians since it involves infants whose viability is not questioned. Refusing to take a stand in support of the infant requires denying, at minimum, a tradition spanning over thirty years, maintaining the pediatricians responsibility for the infant from conception [4]. This indeed is a reason-for-being of the profession.

The issue is clear with respect to the viable fetus, as infants of the same gestational age are admitted to neonatal intensive care units routinely. Those infants receive, and their families demand, intensive medical efforts to preserve life, and society clearly approves. At this stage of viability (currently considered to be as early as 22 to 23 weeks gestation), termination of pregnancy does not automatically entail or imply termination of a fetus. Decisions regarding the care of a fetus in the termination of a pregnancy should always have ethical symmetry with that of a fetus prematurely delivered at the same stage. The Supreme Court has also supported the concept that such infants should be offered medical support. The Court (In Planned Parenthood of Kansas City vs. Ashcroft) upheld a law requiring that a second physician attend at the abortion of a viable fetus. The statute further required the physician to take all reasonable steps, in keeping with good medical practice, to preserve the life and health of the viable fetus, provided that such steps did not pose an increased risk to the life and health of the woman. The court found the second-physician requirement reasonably furthered the states compelling interest in protecting the lives of viable fetuses [5].

It is also unconscionable, therefore, to believe that we should avoid taking a position regarding the elective abortion of pre-viable fetuses, on grounds that there is a lack of consensus on this issue among pediatricians or in society at large. Human life, irrespective of stage of development, or condition, is inviolable and worth pediatric defense despite some contrary societal opinion. We may, therefore, as pediatricians, accept a civil Court s definition of viable fetus to mean capable of meaningful life outside the womb, albeit with artificial aid , as determined by the physician. Yet, we understand that this concept of viability is in no way a reflection on the moral worth of the fetus, but rather reflects only the limitations of what medicine has to offer. All infants, before and after successful delivery, are dependent on support and care from others for their continued existence. As such, they are no less valued as persons. In light of these considerations the American College of Pediatricians makes the following recommendations:

1) In recognition of the constitutional principles regarding the right to an abortion articulated by the Supreme Court in Roe v. Wade, but with higher regard for the advance of science and the values of medicine, we recommend that elective abortions not be performed. Although some abortions are said to be performed to preserve the life of the mother, they are in fact, rarely necessary for those purposes. Maternal health factors that are said to demand termination of the pregnancy can also be accommodated without sacrifice of the fetus. When there is possibility of independent viability of the fetus, we argue for ending the pregnancy by appropriate delivery.

2) All pre-term deliveries should be done with the health and safety of both mother and infant in mind, and, whenever possible, with a second physician present to safeguard the life and health of the fetus [6].

3) Decisions regarding the provision of life-sustaining medical treatment for the newly born infant should then proceed as for any other infant or child [7,8].

REFERENCES:

(1) Roe v. Wade, 410 V. S. 113 (1973)
(2) American Medical Association. Late Term Pregnancy Termination Techniques. Report of the Board of Trustees 26-A-97.
(3) American Academy of Pediatrics. Age Limits of Pediatrics. Policy Statement (RE8116). Pediatrics. 1972;49: 463.
(4) Textbook of Neonatal Resuscitation, American Academy of Pediatrics, Lesson 7-19, 2000.
(5) Planned Parenthood Association of Kansas City, MO v. Ashcroft, 462 V. S. 476 (1983).
(6) American Heart Association, International Liaison Committee on Resuscitation (ILCOR). Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 11: Neonatal Advances in Life Support. Circulation. 2000;102(Suppl I):I-343-I-357.
(7) American Academy of Pediatrics. Perinatal Care at the Threshold of Viability. Policy Statement (RE9541). Pediatrics. 1995;96:974-976.
(8) American Academy of Pediatrics. The Initiation or Withdrawal of Treatment for High-Risk Newborns. Policy Statement (RE9532). Pediatrics. 1995;96:362-363.

Addendum (Editor's Note):
This statement is intended to answer an ethical question. How should pediatricians approach and manage a viable fetus who might be unintentionally or inadvertently delivered alive in a late-term abortion attempt? The ethical question of whether a legal right to an abortion implies a right to the termination (death) of the viable or near-term fetus is still important; but in the course of producing this statement, the legal question has been addressed in part. In August 2002, Congress passed and the President signed the "Born Alive Infants Protection Act." This new law extends the same protections to any infant born alive, including those survivors of an abortion procedure.

Though the "Born Alive" law is a step in the right direction, it leaves unanswered the issue of the rights of the unborn. The pediatric community unfortunately has been influenced in policy development by personal perception of societal values and by existing civil law. Civil law cannot take the place of conscience or dictate moral norms. Societal standards must be characterized by a moral basis of respect for all and especially for the rights of the weakest and the most defenseless. The issue here is not viability but rather the inviolability of all human persons from conception to natural end. As pointed out by Paul Ramsey in 1975 (Ramsey P. Appendix, Research on the Fetus, National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, 1975), "The fetus is generally viable at all stages unless it is removed from its natural environment." As we know, the limits of viability have undergone considerable change over the past 30 years and it is anticipated this change will continue. A court, society or the medical profession cannot define humanhood on the basis of such arbitrary measures.

Pediatricians must advocate for all children, not just for those determined "viable." We should honor the advocacy proclaimed interestingly by the American Academy of Pediatrics in 1971, preceding Roe v. Wade by some thirteen months, to include pediatricians' responsibility for the child from conception through young adulthood. We must uphold scientific integrity. We must speak out against further "sacrifice of the fetus." The American College of Pediatricians shall not waiver from that commitment.

June 12,2003 

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