I was the chief resident in pediatrics and covering my home hospital’s neonatal intensive care unit as the admitting physician when I got a phone call from my obstetrical colleague. She wanted to tell me that she had an impending delivery that would require my assistance in the delivery room. The infant would be an extremely premature, low birth weight infant that would likely require resuscitative efforts and, if surviving delivery, months of intensive care unit support. I appreciated the heads up because it allowed me to visit the parents in the obstetrical unit, introduce myself, and let them know what to expect in the next few hours. I was a little surprised, though, when I met them because even though their obstetrician had informed them of the vulnerability of their infant, they did not seem anxious or concerned. I started explaining some of the procedures that would likely be needed, such as ventilator support and intravenous access, when the father held his hand up to stop me. “We don’t need to know any of that,” he said, and he looked to his wife, who nodded in agreement. She then explained to me that the baby was going to be adopted. Arrangements had already been made through an agency because when she realized she was pregnant, she knew she didn’t want another child, but she didn’t “believe in abortion.” So, she carried the infant to delivery.
The infant did require resuscitation at delivery, and once we had a modicum of stability in the delivery room, the infant was rushed to the neonatal ICU. The infant remained in the ICU for almost six months and on life support for nearly three months. He developed most of the complications associated with extreme prematurity—chronic lung disease requiring a permanent breathing tube placed on the outside of his neck and into his windpipe, intracranial hemorrhages requiring a permanent shunt between his brain and his abdomen, a tube placed outside his belly and into his stomach to allow liquid feedings, and retinal hemorrhages that left him blind. At six months of age, he was moved from the neonatal ICU to the pediatric ICU. He would never leave an acute care setting because he required ongoing critical care that would not be available any other way. His life will be marked by frequent painful interventions such as mechanical ventilation, intravenous access, and life in a busy ICU with constant noise and light. He would never be part of a family, although pediatric ICU nurses would provide extraordinary, loving care. The chances of long-term survival were non-existent.
The parents left the hospital after two days and never looked back.
As a third-year medical student doing a clinical rotation in obstetrical medicine, I had a 19-year-old female admitted in active labor with her third baby. She required a C-section, mostly because her previous deliveries had also been via C-sections. As soon as she arrived in the delivery suite, she started begging everyone she saw to please help her get a tubal ligation (surgical sterilization) to prevent future pregnancies. She knew that the procedure could be performed easily at the time of the C-section because her obstetrician had given her that information at the time of her second pregnancy. But she was a Medicaid patient, and Medicaid would not pay for a tubal ligation until she was twenty-one. When she was told that she could only get the procedure if she paid for it out of pocket, she just stopped talking. I don’t know that I will ever forget the look of apathy and helplessness on her face. When the baby was delivered, she refused to look at her or hold her. It left such an impression on me that, days later, I retrieved her hospital chart to look over her history. Apparently, she had married at 16 with her first pregnancy, but she and her teenage husband had little family support and constantly teetered on the edge of a financial cliff. Neither had graduated high school, and both worked unskilled jobs. She had tried oral contraceptive methods but was intolerant of the meds. So now, we have impoverished teenagers parenting three babies and falling further and further into a social and financial abyss. All because their government-sponsored health care had restrictions that harmed them and their children. Learned helplessness that will become generational.
When I covered the neonatal ICU, my presence was required at all high-risk deliveries. Sometimes, I was called to spontaneous late-term miscarriages because even though the fetus would not be considered viable (able to survive outside the maternal womb), resuscitation might keep the fetus alive for a brief period. One of the standard procedures in this situation was to bring a scale into the delivery room. Resuscitation was not even attempted if the infant weighed less than 500 grams (about 17 ounces or equivalent to a package of butter). If the fetus weighed at least 501 grams, we would attempt resuscitation, which was often futile. What did this mean for the parents? If we did not attempt resuscitation, the fetus was considered a miscarriage. The hospital was responsible for the fetal remains. If we tried resuscitation and it was unsuccessful, it was an infant’s death. The parents were responsible for arranging for burial, including notifying a funeral home to pick up the infant’s body and arranging all ceremonies accompanying death.
This is true: No matter the law, women will continue to get abortions. And, as is often the case, women of privilege and wealth will find safe, hygienic methods. Women on the margins of society, poor and unsupported, will seek abortions in brutal conditions. They will allow strangers to poke knitting needles and wire hangers into their wombs and fill their uterus with Lysol, scalding-hot water, or lye. They will risk death to get an abortion, and many will die horrible deaths.
What do these stories mean? There are no easy answers—sometimes, there is not even a right answer. There are only fewer wrong answers. But it screams out to me that when the issues involve health care, the only participants in the dialogue should be the patient and their physician.
The most challenging part of my job as a pediatric physician was counseling the parents of a child in the process of dying. It never became a rote behavior; it was always an emotional struggle. And the dying process in an ICU is a surreal event because of ongoing life support to the lungs and the heart—the monitor beeps the cardiac rhythm, and the chest rises and falls with the ventilator. But one thing everyone—physicians, parents, supreme court justices—agree on is that brain death equals human death. We can keep hearts beating and lungs ventilating through artificial means, but death occurs if there is no brain wave activity. As the physician, I can terminate artificial life support with the declaration of death. Or, as one of my surgical colleagues once said, “When it’s obvious that God has his hands on your patient, then it’s time for us to take our hands off.”
The human fetus does not have brain wave activity until the sixth week of gestation. The fetus is receiving life support through the maternal body. If there is no brain wave activity in the fetus, is this not analogous to brain death in my patient? Why can’t life support be terminated in this situation? At what point do we want to insist that life has begun? At inception? At what point does death occur? When the body decomposes?
I don’t agree with all the nuances of anti-abortion laws that stress whether the pregnancy resulted from incest or rape or whether the mother’s health would be negatively impacted. Once life begins (initiation of brain wave activity), we are arguing only the merits of each life. That is a decision that MUST be between the mother and her physician in the same way that decisions about when to terminate life support in a dying or dead patient must be between the patient’s family and the physician.
And if there is no brain wave activity, there is no life.