Seabrook Island resident and guest columnist continues his series of blog posts on critical issues in the practice of modern medicine. —Tidelines Editors
Pregnancy and Concurrent Maternal Cancer
Last month, I wrote about modern revisions of the ancient Hippocratic Oath, and in closing that essay I mentioned that this month’s blog would delve into one of the most contentious of contemporary debates – abortion – an act specifically banned by the Oath. Abortion is the sine qua non of societal divide – a topic that bring up intense feelings and deep differences, none of which can be reconciled by this author. Since my areas of expertise are less cerebral, I will not presume to discuss the right or wrong of the subject, but will only touch on it as it pertains to the issues about which I usually write. Bottom line = pregnancy and cancer are not mutually exclusive; pregnant patients sometimes develop cancer, and cancer patients sometimes become pregnant. With the uncommon exception of serious surgical emergencies, the dilemma is unique in all of medicine. Thankfully the situation is encountered infrequently, but when it does happen, the oncologist’s responsibilities differ from that of the obstetrician – the latter has two primary patients.
One of the important themes in the core of my writings thusfar has been the importance of patients’ trust of their doctor because of that trust, an enormous responsibility is de facto bestowed on the physician. The physician must be careful to give advice that is totally unselfish and is in the best interest of the patient; that is to say, is based on beneficence. So while it is correct to be forthright in telling a patient what you would recommend for your own family, it is entirely inappropriate to exceed that in an attempt to convince the patient to breach her own moral code on something as important as the termination of a pregnancy. To paraphrase an old cliché: be careful what you recommend to people, they may do it. And once it is done, you own part of the consequences. Over many years of dealing with patients, I have come to realize that most cancer physicians don’t begin to realize how powerful their influence really is. Frightened patients are especially vulnerable, and when a trusted physician pushes in one direction, real power is in play. This is especially problematic in a pregnant woman who has cancer. There are conflicts within such a patient that are almost unimaginable. In a way, the primordial instincts of maternal protectiveness are juxtaposed to the equally primordial instinct for self-survival, and when one adds the woman’s sense of responsibility to her other children and her spouse, the dilemma can be paralytic. In this particular situation, parents and spouse are often unhelpful, since, understandably, their concern is more often than not skewed in favor of the mother. Thus, the trusted physician has extraordinary influence over a frightened patient, and it must never be exploited to promote values that are not beneficent. To do so is a form of betrayal.
A vigorous and often contentious debate continues within American society over the issue of whether an abortion is ever justified. Even though the United States Supreme Court has upheld a woman’s right to choose in Roe v Wade,2 there remains a large segment of the population that feels otherwise. In fact, a Gallup poll done in May 2009 reported that 51 percent of Americans polled call themselves pro-life (antiabortion) rather than pro-choice (mother’s choice) on the issue of abortion. An April 2009 Pew Research Center poll showed a softening of support for legalized abortion compared to the previous years of polling. People who said they support abortion in all or most cases dropped from 54 percent in 2008 to 46 percent in 2009. That the country is deeply divided over the legality of abortion is reflected by the fact that 23 percent of those polled in the Gallup study say it should never be legal and 22 percent say it should be legal under all circumstances.
As part of medical training, doctors are conditioned to sights and occurrences that repel lay people—autopsies, cadaver dissections, gruesome trauma, and so on—that type of conditioning goes with the territory and is unavoidable, even desirable. It is critical, however, that doctors not allow this state of societal desensitization to advance to the point of tolerance for that which is clearly wrong. As a means of lending realism to the possibility of insidiously crossing that line, one needs look no further than the shameful complicity of physicians with Nazi sadism in the 1930s and 1940s, when medical experimentation and murder were imposed on Gypsies, Jews, the disabled, the retarded, and others. Before that, during the 1920es in which the desensitization that resulted from the practice of eugenics, set the stage for the psychopathy of Nazism. As it pertains to the discussion of abortion in the United States, even though the pro-choice faction prefers not to discuss this issue in the same context as euthanasia and capital punishment, in fact the outcomes are the essentially the same. Attempting to justify any one of the three—abortion, euthanasia, or capital punishment—by minimizing the solemnity of the action is to wrap the issue in a type of intellectual delusion that diminishes the sanctity of life.
Importantly, the medical profession, however, must neither passively nor actively encourage further erosion of the value that our society assigns to human life. In saying this, I am reminded of the words of the British author, John Donne (1572–1631) that were put in a modern form by Ernest Hemingway, “Any man’s death diminishes me, because I am involved in Mankind; and therefore never send to know for whom the bell tolls; it tolls for thee.”1 I remind the reader that this author neither advocates nor opposes in this writing – instead it is meant to stimulate thought and discussion of this extraordinary topic.
When a pregnant woman develops cancer, or when a cancer patient who is under treatment becomes pregnant, those that advocate therapeutic abortion justify it because of their concern that the cancer treatment places the unborn child at risk of serious birth defects or mental damage or that optimal treatment of the mother is compromised by the pregnancy. This posture is abhorrent to many, however, and Roman Catholic doctrine unequivocally refutes it. Even though the issues of birth defects and fetal injuries from nuclear energy and anesthetic and chemotherapeutic agents are far more than theoretical, and are real possibilities with which the physician and the family must deal, the orthodox pro-life way of thinking contends that possible or even probable injury to a fetus does not legitimize its eradication. To protect victims from potential harm by killing them is counterintuitive. The very basic question in this line of thinking: Is there harm worse than death?
However, because pregnancy and cancer are not mutually exclusive, and when a pregnant woman develops cancer, or when a cancer patient becomes pregnant, heart-wrenching decisions are sometimes required. In this circumstance, there is no place for an indecisive cancer doctor. In such an undesirable situation, it is not enough for the doctor to say, “Here are your options, but I don’t have a recommendation—what you do, is up to you.” Of course, it is “up to you,” but in this situation a pregnant cancer patient is dominated by family and social influences, their own considerable fear of cancer, their preconditioning regarding the morality of abortion, and the hormonal instincts to protect the pregnancy that result from millions of years of evolution. For the cancer physician not to offer clear advice that might help a woman decide what to do is to shirk an important responsibility.
Despite the fact that the “right” or the “wrong” of the matter depends on personal beliefs of the patient, it is incumbent on the cancer physician to lead the discussion, and in the process of doing that, lend their own opinion on the matter. The hardest question for the physician is “Doctor, what would you advise if this occurred in your family. Would you recommend that the pregnancy be terminated if I were your daughter?” In other words, the physician should weigh in on the discussion, and above all, be able to answer the very fair question that I have just theorized. It is important to distinguish what I might recommend and what one of my daughters would actually do. As intelligent and independent individuals, they would, of course, decide that on their own.
My next essay will expand on this topic, and in order not to diminish the momentum of what is written here, I will put it forth sooner than usual.
—Roy B. Sessions, MD, FACS
Seabrook Island, SC
1. John Donne, quoted in preface of Ernest Hemingway, For Whom the Bell Tolls (New York: P.F. Collier and Son, 1940).
2. Roe v. Wade, 410 U.S. 113 (1973)