Annals Publishes Essay on "Myth of Choice" for Woman With a Doomed Pregnancy

An anonymous essay, appearing Monday in Annals of Internal Medicine, captures the emotional, physical, and legal peril for both doctors and patients in states where restrictions on late-term abortion force all involved to wait for labor to start, even when an infant will not survive.

In the case described in the official journal of the American College of Physicians, a woman learns her pregnancy is doomed but must continue it against her wishes, because that is the law.

“The Myth of Choice” comes from a doctor who must tell a patient in the emergency department that the infant she carries, which she wanted very much, has no brain or skull, only a stem. The task is made worse by the fact that the patient speaks no English, and the doctor must relay this devastating news through an interpreter on a screen sandwiched between the pair.

“This condition has no survivors,” the doctor wrote.

Doctors Are Targets in Abortion Battle

The essay comes as 9 states have passed laws outlawing abortion after 6 to 8 weeks; these so-called “heartbeat” bills are designed to provoke challenges at the Supreme Court of the United States to Roe v Wade, which legalized abortion in 1972. The bills are all on hold, as lower-court judges have blocked them from taking effect. Protests rocked Missouri last week, before a federal circuit judge in St. Louis granted a temporary order that stopped the state’s only abortion clinic from losing its license at midnight Friday. A hearing is set for Tuesday.

Missouri is among the states to pass laws with no exceptions for rape or incest—most of the new wave of laws allow abortion only if there a threat to the mother’s life. Mississippi also allows an abortion if there is a threat to “a major bodily function,” and Louisiana’s law also includes an exception when the pregnancy is “medically futile.”

A law Kentucky passed in March is already being blocked. Mississippi’s law, signed May 21, was blocked 3 days later. Because Louisiana is in the same appellate circuit as Mississippi, that state’s law, signed May 30, is automatically on hold, too.

Several states have taken aim at doctors: Mississippi’s law would take a doctor’s license for a violation. Missouri would penalize doctors with up to 15 years in prison.

The Trump administration has also taken regulatory steps to curtail abortion. The American Medical Association (AMA) has warned that the loss of Title X funding for clinics that perform or make abortion referrals interferes with the doctor—patient relationship, and President Barbara McAneny, MD, has warned of the potential harm of new HHS “conscience” regulations that allow medical professionals to opt out of care that violates their religious beliefs. AMA joined Planned Parenthood in a lawsuit over the Title X funding change.

“Medically Futile”

In January, lawmakers in New York State received national attention when they revised their state law to allow abortion after 24 weeks if a physician determined the mother’s health was at risk or the fetus was not viable. It was designed to address cases like the one in the Annals essay.

The law has been presented differently to many opponents of abortion. It was portrayed as “infanticide” by President Donald Trump, among others, who said its purpose was to kill infants who survived an abortion procedure by denying them medical care.

In the case described in the Annals essay, no amount of medical care would save a child born without a brain. But the doctor references other cases, in which, “You’ve done this before, cared for women whose wishes were warped by politics. You’ve commanded millions of health care dollars on behalf of infants born with fatal diagnoses.”

In the case at hand, lack of a car had kept the mother from seeking care until she well past the point of having options. Upon learning that her infant would not survive, she was still forced to go home and make a return trip when she was ready to deliver. No obstetrician would manage her case until labor came naturally, the doctor wrote. “Nobody will do it. Not in this hospital. Not in this state.”

“And so, the mother goes home, pregnant and grieving.”

Providing Compassion

Journal editor Christine Laine, MD, MPH, FACP, said this was only the second time in nearly 10 years that Annals had published an anonymous commentary, and both cases were permitted for the same reason: to protect the identity of the patient. Laine said in an email that the decision was made by consensus after the commentary was submitted for the journal's "On Being a Doctor" section.

Beyond the use of resources for a pregnancy that cannot result an infant who survives, the doctor reflected on the harm that extending the pregnancy does to the mother’s health and well-being. “She will struggle with her gait for weeks, punctuating loss in the waddle of each step,” the doctor wrote.

“Sometimes the idea of choice is just a lie,” the essay concluded. “And sometimes all you can provide is compassion. Dignity in grief is the gift.”

Reference

Anonymous. The myth of choice. Ann Internal Med. 2019;170:809. doi: 10.7326/M19-1005.