Case commentary: absent fetal hand

This commentary refers to the article, Absent fetal hand: a case report, published in Australasian Journal of Ultrasound in Medicine May 2010 13 (2). This case raises difficult ethical issues about the use of medical imaging in pregnancy, including the role that a diagnosis of foetal disability or abnormality should play in decisions about late terminations. In Australia, late termination is typically understood as a termination of pregnancy after 20 weeks gestation, although this limit appears largely arbitrary. The gestational stage at which the termination occurs in this case is almost 20 weeks. Even just short of the 20-week mark, the case is troubling. In New South Wales, attempts to procure an abortion are dealt with in sections 82–84 of The Crimes Act 1900. The Act does not specify the criteria for unlawfulness, but recent interpretations have allowed that an abortion can be lawful if skilfully performed by a medical practitioner with the woman’s consent, where the practitioner holds an honest view that continuation of the pregnancy could endanger the woman’s mental or physical wellbeing. The grounds for such belief could be economic or social, as well as medical. Thus, unlike some states in Australia, the NSW law on abortion does not include explicit reference to foetal abnormality as grounds for termination. Presumably, though, it may be considered as contributing to the deleterious effect on the woman’s wellbeing if continuing the pregnancy. The law in New South Wales also differs from several other states in that it does not include the charge of child destruction, and makes no reference to foetal age. In ethics, the discussions of late terminations tend to revolve around a number of crucial issues. Perhaps least controversial of these is the idea that a termination is justified when continuing the pregnancy threatens the health of the woman; this is the notion of maternal interest. The related principle of autonomy suggests that a woman’s own values and interest in terminating or continuing a pregnancy should be paramount in determining the effect of a pregnancy on maternal interests. The role that foetal abnormality may play in justifying late term abortion is also increasingly controversial, especially with improvements in prenatal testing, such as through the use of ultrasound.