Batsheva Hershkovits, M.D.
“The priceless baby” is a concept
frequently encountered in gynecological practice. Does this concept exclude the
possibility of babies of limited value? Are some babies be of greater value
than others? Does the mere attempt to grade babies denigrate the ultimate value
of human life? In any event, the concept exists. “The priceless baby” is
usually a newborn whose birth requires heroic intervention at some point,
either at conception or in the course of pregnancy, in order to achieve the
safe birth of a healthy infant.
Couples with
difficulty in conceiving might require complic- ated tests to ascertain the
etiology of their infertility. Some of these tests involve certain risks
(hysterosalpingography or laparoscopy under general anesthesia for the woman;
testicular biopsy or ligation of distended veins resulting from varicocele for
men).
After
establishing a diagnosis, treatment often entails further risks such as the use
of large quantities of drugs to stimulate ovulation, which may irritate the
ovaries, or the extraction of ova for in-vitro fertilization, which requires
the use of an operation room and at least partial anesthesia.[1]
In leading
centers for in-vitro fertilization the success rate varies between 15 and 30%.[2] Pregnancy resulting from such a procedure must surely be specially
“valuable.” Furthermore, in these pregnancies Cesarean section is often
indicated[3] in order to spare the “priceless infant” the risks of
vaginal delivery although the mother’s risk of mortality is 21 times greater in
Cesarean sections than in regular deliveries.[4]
In view of this
let us consider whether the concept of “the priceless baby” has a valid role to
play in modern medicine.
Two clinical
cases exemplify the “price” to be paid for giving birth to babies in difficult
circumstances. In such a case the entire family is potentially effected by any
decisions regarding treatment.
A twenty-seven
year old married woman had two daughters. After her second birth she complained
of pain in her eyes and reduced visual acuity. Examination revealed severe
bilateral uveitis, with possible glaucoma, cataract, and detached retina which
could lead to blindness. The woman was treated with large doses of steroids,
which were reduced as the condition of her eyes improved. Due to the necessity
of such treatment, she was advised to avoid pregnancy. After one year of
treatment her eyes improved so much that she stopped taking medicine and became
pregnant.
After giving
birth to a healthy boy her inflammation worsened and she again required steroid
therapy for about a year. At the conclusion of this second round of steroids,
the patient stopped taking contraceptive measures and became pregnant a fourth
time. During this pregnancy the condition of both her eyes suddenly worsened
and she exhibited partial detachment of the right retina. An ophthalmologist
recommended immediate treatment with 80mg of prednisone, which constituted a
relatively high dose of steroids.
Her gynecologist
recommended lowering the steroid dose in order to allow normal fetal
development. But according to the consulting ophthalmologist lower doses of
steroids would lead to complete detachment of the retina and blindness.
Steroids may
have severe teratologic effects on all creatures.[5] In humans maintenance levels (20-40 mg) do not seem to lead to increased
birth defects.[6] But higher doses
may lead to death of the fetus and spontaneous abortion. Higher doses also
often lead to retardation of intrauterine growth (I.U.R.G). and abnormalities
in the fetal immune system.[7]
A thirty-two
year old woman, mother of four boys and two girls, gave birth to a fifth boy
with hypoplastic left heart syndrome. With this severe defect the newborn
cannot live more than a few weeks without complicated surgical intervention,
namely heart transplantation or multistage surgical procedures stretching over
the infant’s first two years of life.[8]
In neither
surgical option does the success rate exceed 15%.[9] Even following surgery the normal development of the infant is
unpredictable. Since such procedures are not performed in Israel, the family
would require massive financial resources in order to pay for surgery abroad.
This commonly involves absence of the parents from the family for an extended
period, which alone may lead to further emotional and social complications.
In principle
every effort should be made to save human life. In emotional terms, the sages
equated childlessness with death.[10] Thus, every
effort should be made to enable a couple to have children even when pregnancy
entails serious risks.
Every mother is aware of some of the dangers of childbirth. Men in general are willing to undergo testing procedures in order to enable them to bear children. In certain cases semen is frozen in order to enable men to procreate after radiation therapy.
Similarly, women
with certain medical conditions such as diseases of the liver,[11] kidney,[12] heart,[13] auto-immune system,[14] or cancer,[15] may be allowed to become pregnant if they receive special
treatment during pregnancy. Even after kidney[16] or liver transplantation,[17] every effort may
be made to allow for pregnancy.
But when the
couple already has children and has already fulfilled the mitzvah of “be
fruitful and multiply,” is it still proper to make great efforts to enable them
to have more children?
In Case A,
pregnancy is likely to lead to blindness of the mother. It is likely that many
women would be willing to risk possible blindness in order to become mothers.
But the woman in Case A already had children and would in the future have the
option of pregnancy without special risks. Given these circum- stances, should
she be allowed to become pregnant during steroid treatment?
Case B is more
difficult because the infant is already born. It is clear that if this infant
were the couple’s only chance to procreate, no effort would be spared to save
him even if the chances of success were very slim. But here the couple already
had healthy children, as well as the possibility of bearing more children in
the future. Is one obligated in such a case to spend vast resources which might
impoverish the family, or should one let nature take its course?
It is clear that
the concept of “the priceless baby” calls for careful evaluation. It is clear
that there are cases in which it is important and difficult to reach critical
decisions. These are cases in which the couple has a history of infertility,
and where the current pregnancy was achieved as the result of great efforts,
such as artificial insemination or in-vitro fertilization.
The concept is
similarly important in cases in which there is low probability of future
pregnancy, either because of the advanced age of the woman or the expected
death of one of the couple. In such cases the willingness to accept the risks
of pregnancy and birth or to engage resources above and beyond what halacha
requires are greater than usual. But, in cases such as these, it may be the
only opportunity of a couple to become parents.
Source: ASSIA
– Jewish Medical Ethics,
Vol. II, No. 2, May 1995, pp. 28-29
1.
Most centers for in-vitro fertilization follow clear criteria based on
age, number of children, the length of infertility, and any medical
contraindications.
3.
The rate of elective cesarean section following in-vitro fertilization is
double the rate in other pregnancies. The main indications for cesarean section
are multiple fetuses and “continued infertility.” see Varma, T.R., “Outcome of
pregnancy after infertility,” Acta Obstet Gynecol Scandin. 67(2)
155:1988.
5.
Gandelman, R. and Rosenthal, C., “Deleterious Effects of Prenatal
Prednisolone Exposure upon Morphological and Behavioral Development of Mice,” Teratology
24:293 1980.
6.
Berglund, F., et al., “Drug Use during Pregnancy and Breast
Feeding,” Acta Obstet Gynecol Scandin. 126:1984.
7.
Beitins, I.Z. et al., “The Transplacental Passage of Prednisone
and Prednisolone in pregnancy near Term,” Pediatric 81:936 1972.
8.
Deviri, A., et al., “Heart Transplantation in Hypoplastic Left
Heart Syndrome,” Ha-Refuah 114:621 1988.