Book Review

Bioethics and the Fetus

N Engl J Med 1993; 329:512-513August 12, 1993

Article

Bioethics and the Fetus
(Biomedical Ethics Reviews 1991.) Edited by James M. Humber and Robert F. Almeder. 190 pp. Clifton, N.J., Humana Press, 1991. $39.50. ISBN: 0-89603-220-5

This book, part of the Biomedical Ethics series, consists of eight essays on moral and legal issues relating to the fetus. The first chapter, by Roger Dworkin, is alone worth the price of the book. Dworkin's text, “Every silver lining has a cloud,” expresses the theme of the book: successes in assisted forms of reproductive technology, prenatal diagnosis, and fetal treatment pose substantial ethical and legal issues that require public debate. But that debate has been limited by polarization on the issue of legal abortion and the political ascendancy of one extreme point of view.

Dworkin examines two current issues in which there is conflict between the rights of the mother and those of the fetus: whether pregnant women should be compelled to undergo treatment or forced cesarean section for the benefit of the fetus, and whether pregnant women may be compelled to cease behavior, such as drug use, that could injure the fetus. He convincingly demonstrates that the application of common sense and decency can result in the appropriate legal resolution of these vexing issues. He offers no mere weighing of pros and cons, but useful advice -- for example, that a competent woman should not be compelled to undergo cesarean section against her will, because the only way to do so would be to use physical violence against her, by tying her to the operating table, and that knowing this could happen, many women would avoid medical care altogether. One of Dworkin's concluding principles should be inscribed on the walls of hospitals and law courts: “Easy sloganeering unrelated to reality leads to fictions, self deception by the legal system and unsound results.”

A subsequent chapter considers who should determine the care of the fetus in the rare instance of its survival after late abortion. Another chapter discusses the case that determined the legal treatment of frozen embryos after a couple had divorced. The conclusion, that it is wrong to treat embryos as either children or property, offers a useful approach to the resolution of such conflicts. Still another chapter explores the case of a couple who undertook a pregnancy so that the infant could serve as a bone marrow donor for their older child, who had leukemia; it concludes that the couple's decision was ethical. Another chapter deals with the transplantation of fetal tissue to treat disease. It provides a good review of current knowledge and of the previous administration's decision to discourage such research despite the recommendation of an expert panel. The author proposes that research with fetal tissue can be considered under ethical guidelines that do not presuppose a position on the morality of abortion. In another chapter, Bonnicksen explores the techniques of treating the embryo, including zone drilling and gene therapy. She raises four key questions that she thinks should be answered by public debate before further clinical instances arise. Her intent is laudable, but this goal is unfortunately naive. Those working in these areas have avoided publicity because they have correctly perceived that their own government was against them. Perhaps now that the winds of national politics blow from a different direction, public debate can resume. This small book provides a calm and reasoned approach to many difficult issues. It deserves a wide readership.

Philip G. Stubblefield, M.D.
Maine Medical Center, Portland, ME 04102