Letters
Volume 165 Number 3
cian to oppose the current practice of abortion on demand? Steve Calvin, MD 5806 Oakland Ave. S., Minneapolis, MN 55417
REFERENCE 1. Callahan D. Religion and the secularization of bioethics. Hastings Cent Rep 1990 July/Aug 2-4.
Reply
To the Editors: Dr. Calvin uses a phrase that is used commonly in the abortion controversy but also has many meanings. "Abortion on demand" can mean that a physician is obligated to perform an abortion even if doing so, for whatever reason, violates the physician'S private conscience. We argue explicitly that there is no such ethical obligation. Moreover, we point out that religious traditions are a primary influence on the formation of private conscience. Thus we can in no way be understood to exclude altogether religious traditions from obstetric ethics. There is a second sense of "abortion on demand"a phrase we do not use because we find it uselessthat means that there can be no objections to abortion because the fetus never had moral status. We argue that the fetus does indeed sometimes have the moral status of being a patient. Hence we would reject "abortion on demand" in this second sense of the phrase. In answer to Dr. Calvin's question, we stated that, either for reasons of private conscience or when the fetus is a patient, any obstetrician should have grave moral reservations about "abortion on demand" in the above two senses. There is yet a third sense of "abortion on demand," namely, that pregnant women should be free to withhold, confer, or, having once conferred, withdraw the moral status of being a patient on the previable fetus. In effect, our article defends this sense of "abortion on demand," even while rejecting the previous senses of the phrase. Frank A. Chervenak, MD The New York Hospital-Cornell Medical Center, 525 East 68th St.-M713, New York, NY 10021
Laurence B. McCullough, PhD Center for Ethics, Medicine, and Public Issues, Departments of Medicine and Community Medicine, Baylor College of Medicine, 6550 Fannin, Houston, TX 77030
Examination of placentas by pathologists
To the Editors: The opinions expressed by Salafia and Vintzileos (Salafia CM, Vintzileos AM. Why all placentas should be examined by a pathologist in 1990. AM J OBSTET GYNECOL 1990;163:1282-93) represent wishful thinking regarding the ability of a pathologist's examination of the placenta to give meaningful information not better obtained by clinical means. In the comment section of their article they imply that examination of the placenta can "identify the exact cause" of an untoward outcome of pregnancy. How-
783
ever, numerous studies, including a major contribution among their own references, have emphasized the relative non specificity of pathologic examination, both gross and microscopic. 1 On the contrary, the experienced pathologist knows the disappointment of reporting, for example, severe chorioamnionitis by microscopy to a colleague, only to learn that the product of the suspect pregnancy was a bouncingly healthy neonate. Furthermore, their Table IV lists findings and their respective possible causes, for which one can easily suggest superior clinical or laboratory means to make the diagnosis. Finally, I find their cost-effectiveness argument quite unconvincing: To generate a charge of $2 million as prophylaxis against a possible $5 to $6 million lawsuit is not powerful leveraging. A cost of $225 per placenta for useless information is unconscionable in this time of diminished medical resources and merely buys the obstetrician a false sense of added security. Howard Goldman, MD Department of Pathology, Merrithew Memorial H~spital, 2500 Alhambra Ave., Martinez, CA 94553
REFERENCE 1. Fox H. Pathology of the placenta. In: Bennington JL, ed. Major problems in pathology. Philadelphia: WB Saunders, 1978 vol 7.
Reply
To the Editors: Unfortunately Dr. Goldman has missed our point. This is evident from his first paragraph. We did not represent placental pathologic examination to stand independent of, separate from, or as a substitute for clinical means of obstetric assessment. We instead emphasized that a pathologist requires clinical information to understand the relevance of placental lesions to outcome. Referencing a text does not require that we accept all its tenets, and we have significant disagreements with Dr. Fox in many areas. We are amazed that Dr. Goldman could be disappointed by reporting severe chorioamnionitis in the face of a "bouncingly healthy" neonate. Acute ascending infections may have a multiplicity of effects in the fetus-neonate that are remote from sepsis. The pathologist and the obstetrician should communicate on each case; the obstetrician should recognize that subclinical chorioamnionitis caused fetal distress, 1.2 which led to intervention and, thankfully, a healthy newborn. Only then will the pathologist recognize that chorioamnionitis may be clinically significant in the absence of infectious morbidity or mortality. Dr. Goldman apparently fails to consider that a healthy newborn does not of necessity grow up to be a neurologically normal child. As we cited, 85% of cases of mental retardation have no scientific or clinically based explanation." Experimental and clinical studies have shown that both acute intraamniotic infection and chronic villi tis representing a potential congenital viral infection can be related in a causal fash-
Volume 165 Number 3
cian to oppose the current practice of abortion on demand? Steve Calvin, MD 5806 Oakland Ave. S., Minneapolis, MN 55417
REFERENCE 1. Callahan D. Religion and the secularization of bioethics. Hastings Cent Rep 1990 July/Aug 2-4.
Reply
To the Editors: Dr. Calvin uses a phrase that is used commonly in the abortion controversy but also has many meanings. "Abortion on demand" can mean that a physician is obligated to perform an abortion even if doing so, for whatever reason, violates the physician'S private conscience. We argue explicitly that there is no such ethical obligation. Moreover, we point out that religious traditions are a primary influence on the formation of private conscience. Thus we can in no way be understood to exclude altogether religious traditions from obstetric ethics. There is a second sense of "abortion on demand"a phrase we do not use because we find it uselessthat means that there can be no objections to abortion because the fetus never had moral status. We argue that the fetus does indeed sometimes have the moral status of being a patient. Hence we would reject "abortion on demand" in this second sense of the phrase. In answer to Dr. Calvin's question, we stated that, either for reasons of private conscience or when the fetus is a patient, any obstetrician should have grave moral reservations about "abortion on demand" in the above two senses. There is yet a third sense of "abortion on demand," namely, that pregnant women should be free to withhold, confer, or, having once conferred, withdraw the moral status of being a patient on the previable fetus. In effect, our article defends this sense of "abortion on demand," even while rejecting the previous senses of the phrase. Frank A. Chervenak, MD The New York Hospital-Cornell Medical Center, 525 East 68th St.-M713, New York, NY 10021
Laurence B. McCullough, PhD Center for Ethics, Medicine, and Public Issues, Departments of Medicine and Community Medicine, Baylor College of Medicine, 6550 Fannin, Houston, TX 77030
Examination of placentas by pathologists
To the Editors: The opinions expressed by Salafia and Vintzileos (Salafia CM, Vintzileos AM. Why all placentas should be examined by a pathologist in 1990. AM J OBSTET GYNECOL 1990;163:1282-93) represent wishful thinking regarding the ability of a pathologist's examination of the placenta to give meaningful information not better obtained by clinical means. In the comment section of their article they imply that examination of the placenta can "identify the exact cause" of an untoward outcome of pregnancy. How-
783
ever, numerous studies, including a major contribution among their own references, have emphasized the relative non specificity of pathologic examination, both gross and microscopic. 1 On the contrary, the experienced pathologist knows the disappointment of reporting, for example, severe chorioamnionitis by microscopy to a colleague, only to learn that the product of the suspect pregnancy was a bouncingly healthy neonate. Furthermore, their Table IV lists findings and their respective possible causes, for which one can easily suggest superior clinical or laboratory means to make the diagnosis. Finally, I find their cost-effectiveness argument quite unconvincing: To generate a charge of $2 million as prophylaxis against a possible $5 to $6 million lawsuit is not powerful leveraging. A cost of $225 per placenta for useless information is unconscionable in this time of diminished medical resources and merely buys the obstetrician a false sense of added security. Howard Goldman, MD Department of Pathology, Merrithew Memorial H~spital, 2500 Alhambra Ave., Martinez, CA 94553
REFERENCE 1. Fox H. Pathology of the placenta. In: Bennington JL, ed. Major problems in pathology. Philadelphia: WB Saunders, 1978 vol 7.
Reply
To the Editors: Unfortunately Dr. Goldman has missed our point. This is evident from his first paragraph. We did not represent placental pathologic examination to stand independent of, separate from, or as a substitute for clinical means of obstetric assessment. We instead emphasized that a pathologist requires clinical information to understand the relevance of placental lesions to outcome. Referencing a text does not require that we accept all its tenets, and we have significant disagreements with Dr. Fox in many areas. We are amazed that Dr. Goldman could be disappointed by reporting severe chorioamnionitis in the face of a "bouncingly healthy" neonate. Acute ascending infections may have a multiplicity of effects in the fetus-neonate that are remote from sepsis. The pathologist and the obstetrician should communicate on each case; the obstetrician should recognize that subclinical chorioamnionitis caused fetal distress, 1.2 which led to intervention and, thankfully, a healthy newborn. Only then will the pathologist recognize that chorioamnionitis may be clinically significant in the absence of infectious morbidity or mortality. Dr. Goldman apparently fails to consider that a healthy newborn does not of necessity grow up to be a neurologically normal child. As we cited, 85% of cases of mental retardation have no scientific or clinically based explanation." Experimental and clinical studies have shown that both acute intraamniotic infection and chronic villi tis representing a potential congenital viral infection can be related in a causal fash-
