A new study that finds some extremely premature babies can survive outside the womb with aggressive medical intervention adds to the debate over viability, a complex medical concept that is not necessarily well-defined.
According to a sweeping review of thousands of infants who were born before 27 weeks of pregnancy, which was published this week in the New England Journal of Medicine, a very small number of babies born at 22 weeks were able to survive without major health problems after receiving state-of-the-art medical treatment. If their doctors or parents did not pursue treatment, there was no chance of survival at all.
Even with treatment, there’s no guarantee this early in a pregnancy. The vast majority of babies born at 22 weeks either died or suffered serious disabilities, like blindness, deafness, or cerebral palsy. (Medical experts agree that babies do best when they’re born at least four full months later, at 39 weeks.) But the fact that a tiny minority of 22-week-old preemies had a more promising outcome suggests that, in rare cases, babies may be able to survive outside the womb earlier than previously thought.
The finding — which is a testament to recent medical advances in the field of pediatrics — brings up a host of questions for medical professionals and family members who struggle to decide what to do when confronted with extremely premature babies who don’t have a high chance of survival. It also threatens to re-open a contentious political debate about the scope of legal abortion rights.
Up to this point, most medical professionals have been of the opinion that it’s not worth attempting any medical interventions for preemies born before the 23 week point. But Dr. Edward Bell, a pediatrics professor at the University of Iowa and the lead author of the new NEJM study, told the New York Times that his hospital now offers treatment to most 22-week-olds, with the understanding that may be possible for some of them to survive.
In Bell’s mind, the emerging research in the field suggests that 22 weeks could be considered a new definition of viability. “That’s what we think, but this is a pretty controversial area,” he told the Times. “I guess we would say that these babies deserve a chance.”
“Viability” is the vague standard that currently defines legal abortion; the Supreme Court stipulates that states may not restrict abortion before a fetus is viable outside of the womb. But Americans might be surprised to learn that “viability” doesn’t actually have a firm definition — and never has. Although many people use 24 weeks as a shorthand for talking about issues related to viability, there’s no line in the sand.
There are a couple common-sense reasons for that. First of all, it can be difficult to measure the exact gestation of a pregnancy. Some women have irregular menstrual cycles that make it more difficult to pinpoint the moment of conception, and some fetuses develop at different rates. Measurements like the size of the uterus, fetal heart tones, and ultrasound imaging can help doctors get really close. But it’s hard to have a definitive standard for viability when gestation isn’t an exact science.
On top of that, every pregnancy is different and his its own set of unique circumstances that contribute to the chances of survival for a premature infant. This field is complex, and brings up a host of ethical considerations, specifically because there are no uniform answers that are consistent across the board.
The research group Advancing New Standards in Reproductive Health (ANSIRH) explains it this way: “The potential for fetal survivability outside of the woman’s body differs for each pregnancy and can only be made by assessing the fetus as well as the pregnant woman. Factors that can affect potential viability include chromosomal abnormalities, the sex of the fetus, the conditions of a woman’s health, and the availability of sophisticated neonatology care.”
Different parents may make different decisions about the best course of action for their premature infant based on a host of factors, including health issues that may significantly lower their child’s quality of life even if they do survive after undergoing extensive treatment. Experts in neonatology agree that it’s impossible to craft a blanket policy about when treatment should be pursued. Despite medical advances that now help more preemies survive, the rates of serious disabilities afflicting these babies have remain unchanged. If a very premature baby can survive for a few weeks or a few months before passing away, for instance, does that still count as “viable”?
In that context, it could be more helpful to think of viability as an individualized medical prognosis, rather than as a specific point achieved after a certain number of weeks of pregnancy. “Viability is not an intrinsic property of the fetus because viability should be understood in terms of both biological and technological factors,” notes one study on the subject published in the Early Pregnancy journal.
All of the nuance surrounding viability doesn’t easily translate into crafting abortion policy. Indeed, anti-choice activists have already been testing the limits of the Supreme Court’s vague statute to narrow the window for legal abortion services. Arguing that fetuses start feeling pain at 20 weeks — and claiming that it’s possible for premature babies to survive at that point in pregnancy — conservative lawmakers have pushed for 20-week abortion bans on both a state and national level.
Although reproductive rights proponents argue that 20-week bans are blatantly unconstitutional, this policy has become increasingly popular. Nine states currently cut off access to abortion at 20 weeks based on the notion of fetal pain. If one of those laws makes it up to the Supreme Court, the justices may have to consider the complicated question of whether you can draw a line in the sand when it comes to viability.
The political debate over when to cut off abortion access is typically highly emotional, as abortion opponents argue that it’s barbaric to allow women to abort an unborn child who is fully formed and may even be able to feel pain. Evidence that some babies may be able to survive outside the womb earlier than doctors previously thought will likely fuel this line of argument.
But that rhetoric doesn’t necessarily reflect the reality of patients’ abortion decisions. The vast majority of abortions take place in the first trimester. Meanwhile, the people who have abortions after 20 weeks — at the point when Americans are grappling with ethical issues related to viability — are typically engaged with those same hard questions. Most late-term abortions occur because parents learn about serious fetal health issues that will make it very difficult for their unborn children to survive outside the womb; they’re forced to confront what “viability” really means for their own situation, and determine the most compassionate choice for their child.
“When people talk about fetal pain, it infuriates me, because that was our goal,” Mary O’Donnell, a Virginia resident who had a post-20-week abortion back in 2005, told ThinkProgress in a recent interview. “Our goal as parents was to avoid suffering on behalf of our child.”
Efforts to more rigidly define viability could prevent other parents from having the same options available to them that O’Donnell had. “Making a determination of the need for abortion when a woman is carrying a potentially viable fetus is a complex medical and ethical question that is best left to the woman and her physician,” ANSIRH researchers conclude. Nonetheless, the legal goal posts for viability have already started to move.