The exact numbers are not known and likely never will be, but somewhere between one-third and two-thirds of all “naturally” fertilized human eggs never develop into anything most people would recognize as human. In fact, the majority of those never-known pre-embryos come and go before their brief existence is even known to the woman who hosts them—she is most likely to experience only a late menstrual period, or more likely, nothing at all. For whatever reasons, spontaneous “wastage” of early fertilized eggs is extremely (to many people, astonishingly) common. But this is human biology, and maybe natural selection, in action. It just happens. There is little or no element of “choice” involved, and thus little controversy attached to this biological phenomenon.

When Maggie Hall died on March 3, 1999, CQ lost a valued friend and irreplaceable editorial consultant. Maggie, with her musician's gift for the sound of the written word, left her mark on every issue of the journal; and, with gratitude, this volume is dedicated to her memory. We asked Henrik Blum, Emeritus Professor in the School of Public Health, University of California, Berkeley, who worked with her over many years, to share some of his memories of Maggie.

When I was 19 years old, I fell crazily in love with a hometown girl. This was very surprising for both of us, as we had been acquainted since childhood but had never really noticed each other until a certain amount of maturing of mind and body took place. A second surprise, maybe inevitable in retrospect, came along a few months after we began spending virtually every possible hour in each others' arms. She called me from the university she was attending a few hours away and told me she was fairly certain she was pregnant.

Volumes have been written arguing the morality of abortion. A crucial premise in many of these arguments concerns the status of the fetus; specifically, that the fetus has or does not have a right to life. Opponents of abortion typically argue that fetuses are persons and hence have an inviolable right to life. Advocates of the right to abortion typically maintain that fetuses are not persons and hence have no right to life.

It is commonly taken for granted that abortion is necessarily impermissible if the fetus is a person with a right to life. In her influential essay “A Defense of Abortion,” Judith Jarvis Thomson offers what I will call the violinist example to show that merely having a right to life does not in and of itself give rise in the fetus to a right to use the mother's body. On Thomson's view, if the fetus has a right to use the mother's body that precludes terminating its life by means of an abortion, it is because the mother did something to give the fetus that right. Thus she concludes that the proposition that the fetus is a person does not imply that abortion is morally impermissible.

Judith Thomson argues that a fetus may have a right to life yet lack the right to use its mother's body to stay alive. According to Kenneth Einar Himma, Thomson's argument applies only to cases where the parties meet two conditions. First, they must “have a history of physical independence” and, second, they must be “autonomous moral agents, capable of incurring obligations.” Himma devises a case involving conjoined twins to show why the mother–fetus case does not meet these conditions.

This article will explore a pregnant woman's experience of relationship with the fetus, using a clinical case study in which abortion would have been clinically indicated because of severe fetal abnormality. Emphasizing the pregnant woman's actual experience in this case study helps to highlight inadequacies in how the debate about abortion is usually conducted.

Although the abortion debate continues to simmer in many places, the general issue of a woman's right to an abortion, at least in the Western democracies, is largely settled. In its place, the question of late-term abortion begins to assume a prominence only recently attributed to abortion itself. The advent of sophisticated fetal screening techniques makes possible detection of potentially severe fetal anomalies that in many cases are detected only late in the pregnancy, resulting in the need for late-term abortion.

Since the early 1970s, despite popular opposition, to control the rapid growth of population the Chinese government has been carrying out the strictest and most comprehensive family planning policy in the world. In addition to contraceptive methods and sterilization, artificial abortion—both surgical and nonsurgical—has been used as an important measure of birth control under the policy. Many women have been required, persuaded, and even forced by the authorities to abort fetuses no matter how much they want to give birth.

In the fall of 1996 I taught a course at Fudan University in Shanghai dealing with medical ethics in America. As part of the course we spent some time on the heated American debate about abortion. The reaction of Chinese students was revealing.

On the first page of this very timely paper the author quotes Linda Gordon: “Birth control has always been primarily an issue of politics, not of technology.” This statement provides a theme for response to Jing-Bao Nie's arguments. In reading this paper, I found myself reminded of two of George Orwell's insights: (1) When governments use euphemisms they are usually up to no good: “Such phraseology is needed if one wants to name things without calling up mental pictures of them” [e.g., the use of “remedial measure” for abortion]. “A mass of Latin words falls upon the facts like soft snow, blurring the outlines and covering up the details.” (2) Sexuality and the sexual act (I would add here reproduction—having children) can be a powerful tool of subversion and rebellion. One's sexuality (and reproductive ability) can be the last line of defense against repression or authority.

I would like to present the details of an actual case from my own experience over which I, along with the family, have agonized. I think this case brings into focus some of the unique issues in perinatal medicine where multiple patients, some real and some potential, can enter into a single decision. I hope that through this presentation others may gain insight into the complexities of applied ethics in perinatal medicine.

A woman presents to her physician with a newly diagnosed condition that in her considered and informed judgment requires an elective surgical procedure. The physician, after speaking with her, agrees that this is an acceptable option. The procedure in question is in fact one of the commonest surgeries performed on American women. The physician is also aware that although the procedure is deemed elective in this and in most cases, research has shown that the consequences of not providing the procedure when it is requested can be severe in terms of both physical and emotional sequelae—in fact, the woman's death can be a worst-case result when the procedure is denied. However, this senior physician is also aware that the procedure is controversial, and that ever fewer of his (now mostly younger) colleagues perform it, either because they are not appropriately trained, not so inclined, or fearful of becoming the target of vocal and even violent opponents of the procedure. In fact, he knew of seven American physician colleagues who had been slain in the past five years for providing this procedure, and of 16 more attempted slayings. Seeking an appropriate referral for this patient, the physician learns that she will have to travel hundreds of miles, involving considerable additional expense and delay—which itself can add to the complexity and risk of the procedure. Presented with this option, the patient expresses dismay but also her resigned commitment to follow through with this referral, and leaves the office in tears.

Kant postulates in The Metaphysics of Morals that we share a moral duty to sympathize actively in the suffering of another and to cultivate the virtue of compassion. More recently, Howard Brody has claimed that a good physician must maintain in her imagination “that separate vantage point from which the experience of the sufferer can be reinterpreted and reconnected to the broader context of culture and society.” What does it mean to take suffering seriously in the context of abortion? It means that a physician must listen to three rival versions of suffering: that of a woman who has inquired about an abortion, that of her fetus, and that of the community in which the woman lives. The professional duty that Brody ascribes specifically to physicians compounds the moral duty we all share to lessen suffering. Physicians differ importantly from nonphysicians, for suffering is their business.

These CQ Sources were compiled by Bette Anton.

The issue of the protection of communities in clinical research first arose 10 years ago in studies conducted in technologically developing countries by scientists from technologically developed nations. The question was, which ethical standards ought to apply, those of the Western investigators or local standards?

We were not surprised by the opinion piece written for the Cambridge Quarterly by George J. Agich, Ph.D., who chairs the Cleveland Clinic Foundation's bioethics department. Dr. Agich uses the article to attack those who criticized his institution's proposed non-heart-beating organ donor protocol. Because we reported on this controversy for 60 Minutes in April 1997, we wanted to set the record straight.

Frank Koughan and Walt Bogdanich's response to my article, “From Pittsburgh to Cleveland: NHBD Controversies and Bioethics,” reminds me of the Shakespearean line, “The lady protests too much, methinks.” My article was not about the specifics of the 60 Minutes April 13, 1997, story on NHBD at the Cleveland Clinic Foundation (CCF), even though the story formed the basis for the reflection. I did not attack the critics, though I do believe that bioethicists are accountable for their scholarly and public pronouncements. Although I do not see why the 60 Minutes' story should be treated with deference, my article was designed to raise questions for a primarily bioethics audience about the involvement of bioethicists in media coverage of bioethics topics. I am flattered that they took notice of my piece, but think their efforts to set the record straight only obfuscate matters further.

Muraskas et al. and Hefferman and Heilig present the painfully elusive ethical questions regarding decisionmaking in the care of the extremely low birth weight (ELBW) infants in the intensive care nursery. At what gestation or size do we resuscitate? Can we stop resuscitation after we have started? How much money is too much to spend? Is the distress of the parents of the ELBW infant, the anguish of their caregivers, and the moral and ethical uncertainty of the approach to these infants too much to pay? Who speaks for the neonate: the parent, nurse, attorney, or physician? Ideally these questions should have been answered 30 years ago when modern neonatology embarked on a journey from where it could not return. A new breed of physician, called “neonatologist,” seduced by the high-tech lure and the promise of saving lives previously unsavable pioneered a lucrative and life-saving technological revolution in the care of premature newborns. This rapid advancement in neonatology occurred a few years after the death of a premature infant named Patrick Kennedy in 1963. While the country mourned, medical scientists vowed that this would not happen again. First continuous positive airway pressure, then mechanical ventilation, changed medical care of premature newborns forever. It began an era of euphoria and excitement. Neonatologists raced to push to the edge of newborn viability. What was the youngest salvageable gestational age? What was the smallest that could be saved? Yes, we dreamed, and still do dream of artificial placentas. Ethical questions took a back seat in the search for the edge because the waters were uncharted and the tough questions could not be answered without experience. What was to be the cost in dollars and in anguish to save the Patrick Kennedys of the world? Triumphs led to grave concerns as we approached the edge. However, no advancement in neonatology has ever changed the ultimate questions.

In a recent issue of Cambridge Quarterly of Healthcare Ethics, Howard Brody and Lawrence Schneiderman offer contrasting opinions about how to apply the concept of “futility” in medicine. Brody holds that “futility cases” are those in which it is reasonably certain that a given intervention “will not work” when applied for the purpose of attaining a specific clinical goal. To determine which actions are futile, Brody prescribes a division of labor. Patients (or patient surrogates) are charged with choosing the goals of treatment while physicians are charged with determining whether specific treatments will be effective in achieving these goals. Though physicians do not choose specific goals, Brody thinks they have a prerogative to decide whether they can, in good conscience, aid in the achievement of specific patient goals. Let us use “positive validation” to denote choosing between alternative goals and “negative validation” to denote choices about whether one will assist in the pursuit of particular goals. Brody's position is essentially that patients are positive validators and that physicians are negative validators. Brody concludes that treatments that are effective in achieving patients' goals are not futile—even when physicians' personal or professional moral commitments prevent them from offering these treatments for the given purpose. “Futility” applies only where interventions won't “promote a goal that both agree is desirable.”