Testing, one, two

20 02 2012

Rick Santorum got one (kinda) right.

The bottom line is that a lot of prenatal tests are done to identify deformities in utero, and the customary procedure is to encourage abortions.

That is exactly why a lot of prenatal tests are done—to identify any possible problems—and, yes, if the problems are sufficiently grave, an abortion may follow.

I’d argue about the word “encourage”—doctors are unlikely to be so explicitly directive in their discussion of test results—but I wouldn’t doubt that a fair amount of pressure is brought to bear on the woman (and her partner) to decide quickly, not least because abortions become more complicated the later in the pregnancy they’re performed.

And in fact, prenatal testing, particularly amniocentesis — I’m not talking about general prenatal care—we’re talking about specifically prenatal testing, and specifically amniocentesis, which is a procedure that actually creates a risk of having a miscarriage when you have it, and is done for the purposes of identifying maladies in the womb. And which in many cases — in fact, most cases physicians recommend — particularly if there’s a problem — recommend abortion.

Again, this is less clear. “Non-directive counseling” is the watchword in genetics counseling, and while OB/GYN’s have not necessarily undergone such training, the mantra of let-the-patient-decide has pretty well seeped into the ethos of American medicine.

“Doctor’s orders” ain’t what they used to be: since the 1970s, patient autonomy has been elevated to one of the main principles of biomedical ethics, a principle reinforced by the legal system. Doctors may and do recommend a particular course of action, but having been imbued with the notion of respecting the ability of the patient to make her own decisions and mindful of the possibility of tort action if their recommended solution goes south, they are far more likely to dump information into the patient’s lap and say “your decision”.

Okay, that’s a bit severe, but it is the case that patients expect more information and that courts will hold a doctor liable if she withholds such information from them; failure to perform standard medical tests and inform the patient of the results can itself result in lawsuits.

This is the real dynamic behind the pressure—and oh, yes, there is pressure*—for pregnant women to undergo prenatal testing.  Blood tests and ultrasounds are routine in all pregnancies in the US, and amniocentesis is strongly recommended for high-risk pregnancies, a procedure which Santorum, correctly, notes puts the fetus at risk for miscarriage. To decline such tests is to open oneself to repeated (incredulous and/or hostile) questioning of that decision.

But here is where Santorum begins to go off track:

One of the things that you don’t know about ObamaCare in one of the mandates is they require free prenatal testing. Why? Because free prenatal testing ends up in more abortions and, therefore, less care that has to be done, because we cull the ranks of the disabled in our society. That too is part of ObamaCare — another hidden message as to what president Obama thinks of those who are less able than the elites who want to govern our country.

Let’s unpack this, shall we?

First, those who perform the test, those on whom the tests are performed, those who pay for the test,  and those who regulate insurance are not all the same person. The doctor orders the test because it is standard medical practice and because she agrees that this standard medical practice is, in fact good, insofar as it gives both her and her patient more information. The patient generally (although not always) wants this information, so she, too assents to the screenings.

Those who pay for the test do so as a result of pressure from doctors to pay for good medical care and because, yes, testing can lead to lower costs to the insurer down the road. These lower costs may result from treatments prior to birth to forestall greater problems after birth and, yes, from women deciding to terminate pregnancies which are at high risk of resulting in the birth of a child with a disability. Over 90 percent of fetuses which test positive for Trisomy 21, the chromosomal abnormality responsible for Down Syndrome, are terminated.

There was, in fact, a case in which an insurer told a couple that if they did not terminate an affected pregnancy, any medical expenses associated with the birth and the child would not be covered. The couple sued, and won. Given that many couples will chose voluntarily to end such pregnancies, however, such coercion is generally unnecessary.

Finally, there are the insurance regulators, who have to balance concerns of patients, doctors,  and insurance companies; given that there is little conflict between these different groups (although there may be with some individual patients and doctors) about the desirability of the tests themselves, encouraging or even mandating partial or full coverage of such tests is non-controversial.

This basic dynamic was set into play long before Barack Obama became president, and it is highly unlikely that the (equally highly unlikely) presidency of Rick Santorum would alter this in any way.

Oh, he might try to force insurers to drop coverage of prenatal care, but both Congress and the courts would be hostile (for a variety of reasons) to any such executive orders. The testing regime, for better and for worse, has become entrenched in American medicine.

Let us now consider the most offensive aspect of Santorum’s screed against screening: he doesn’t consider the role of the women (or couples) themselves. Once again, they are pure victims of a dark techno-liberal conspiracy, unable to make any decisions for themselves and unworthy of consideration as actors in their own lives. They must be protected from Obama, liberals, doctors, and, of course, themselves.

That is Santorum’s own not-so-hidden message to the rest of us: he doesn’t consider us able to make the most basic decisions about our own lives.

I hate the term “sheeple”, but it certainly seems as if that’s how Santorum, the would-be shepherd, views the American people.

~~~~~

*Questions regarding prenatal screening have long preoccupied those who work in bioethics; a good introduction to some of this work is Prenatal Testing and Disability Rights by Erik Parens and Adrienne Asch.

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4 responses

21 02 2012
dmf

the 2nd half of my link in the previous post is on the complications of genetic screenings and possible ethical aporias of responsibility

21 02 2012
22 02 2012
Folly's Antidote

Doctors have a responsibility to offer advice based on their experience, science and best practice, patients have the responsibility to listen, think about, possibly do some research themselves, ask questions and make decisions.

When I was offered prenatal testing, I simply asked, what decisions will I have to make if the outcome is positive or negative? Would the knowledge gained outweigh the risk to the baby or me and would I change my behaviour on the basis of that knowledge? If the answer was no, then I didn’t have the test. If the answer was yes, then I did. That was where I drew my line in the sand. So I chose to have tests for gestational diabetes and developmental ultrasounds amongst others and I chose not to test for trisomy 21. Others would choose differently and that is for them to do so.

I strongly resist partisan politics or religion inserting themselves into the equation except where a person’s individual religious belief is relevant to their decision-making. And I can’t even start on American religio-chauvenist-grandstanding politics or I will be here all day.

22 02 2012
absurdbeats

I was thinking of you when I wrote this, and I’ve mentioned your experience in my bioethics class—protecting your identity, of course!

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