The Ethics of Medical Homicide and Mutilation

by Austin O'Malley

In threatened abortion examination is to be avoided unless it is absolutely necessary for diagnosis, and then great gentleness is required so as not to excite uterine contractions. The woman is to rest in bed, not so much as raising her head to take a drink of water (which is given to her through a tube), and she is morally obliged to submit to this inconvenience. If she refuses she is accountable for the death of the fetus. If there is bleeding the foot of the bed should be elevated as in hemorrhage in typhoid fever. The routine practice is to quiet the woman and the uterine irritability with morphine and other opium derivatives. Children are readily overwhelmed by opium because their circulation is not sufficient to neutralize the deoxidizing effects of the drug up to safety. While the embryo is connected with the maternal circulation through the placenta the mother's circulation often safeguards the fetus from the effects of the opium. The danger to the child in such cases begins from the opium remaining in its circulation after the child has been separated from the mother. Often, however, fetuses in cases where scopolamine and morphine have been used on the mother during labor are born badly, and even fatally narcotized, despite the connection with the maternal circulation. Nevertheless, even if there is some real danger to the fetus from the use of morphine in a threatened abortion, the cautious use of this drug would be morally justifiable. Should the threatened abortion go on to actual abortion, the fetus will certainly be killed, but the use of morphine on the woman is the best and virtually the only means we have to avert a threatened abortion and so save the fetal life. The immediate double effect from the morally indifferent act of giving a dose of morphine is, on the good side, the saving of the fetal life, and on the other, the evil side, the danger of fetal narcosis, which is not at all certain to follow. Evidently, the good intended effect far overbalances the evil and somewhat hypothetical effect.

After about five days, if the bleeding ceases, the woman may be permitted to go back to her ordinary routine of life, but with extreme caution, and she must return to bed at the slightest show of blood. Morphine is used at the beginning to quiet the patient and the irritable uterus. If the cervix is eroded, applications of a 10 per cent. nitrate of silver solution are made. The bowels are kept locked for three days and a softening enema of olive-oil is used before emptying the bowel.

If the bleeding starts again every time the woman goes about her duties, the abortion may be inevitable. When the cervix is shortened and dilated so that the ovum is palpable and pieces of the decidua or ovum are expelled, the hemorrhage is more or less profuse, and especially if the bag of waters has ruptured and uterine contractions show, the abortion is deemed inevitable. In such a case the fetus may be alive, or it may be dead; and, again, conditions which show all the classic symptoms of inevitable abortion sometimes, though rarely, do not go on to abortion. It is extremely difficult, and often impossible, to tell whether an early fetus is dead or alive. A high, lasting fever sometimes kills the child; so do low blood-pressure, profuse hemorrhages, deoxidation of the blood in pneumonia, separation of the placenta, fatty degeneration of the placenta, and the severe infections—in such cases there is always strong probability that the child is dead when the abortion shows its symptoms. If the fetal tissues that appear indicate maceration, or if the discharge is fetid or purulent, the fetus is dead. Should the fetus be alive, tamponing the vagina to check the hemorrhage often separates the fetus from the uterus by the dissecting force of the blood dammed back, or in any case tamponing is almost certain to excite uterine contractions; thus there is an indirect killing of the fetus.

The treatment of inevitable abortion after the fifth month differs very much from the methods used in the early months. The prime principle is, never interfere until forced to do so. When the hemorrhage is dangerously profuse, so that the woman's life is endangered (an exceptional condition), the uterine cervix and the vagina must be tamponed with sterile gauze and cotton to check the bleeding, but this is a last resort. If the fetus is alive, or probably alive, nothing short of a necessity to save the woman's life by this means justifies the use of the tampon. De Lee advises the routine use of the tampon in threatened abortion, but this doctrine is erroneous medically and altogether false morally. If the physician knows the fetus is dead, he should, of course, tampon at once to get rid of the fetus. The tampon excites uterine contractions and causes destruction of a living fetus by dissecting it loose from the uterine wall through the dammed blood. Elevation of the foot of the bed and the use of morphine will, as a rule, check the bleeding.

When the woman is bleeding to the risk of her life, the tampon is put in to check the bleeding and so save her life. The double effect immediately following this indifferent act is on one side good, the saving of her life; on the other side evil, the killing of the fetus. The good effect is intended, the evil effect is reluctantly permitted. Such a procedure is morally licit.

Where a tampon must be put in, it is left in from sixteen to twenty-four hours, even if the temperature goes up. During this time there are painful contractions of the uterus, as a rule, and these are expulsive. No drug is to be given to allay these pains if the intention is to have a dead or viable fetus expelled. If the pains cease suddenly, this is usually a sign that the fetus has been expelled above the tampon. When the tampon is removed and the entire ovum is found, it is best for the ordinary physician not to meddle with the uterus in any manner. Some advise that the physician should go over the uterine lining with a half-sharp curette to make certain that nothing has been left behind, but this is dangerous advice to any one who is not an expert obstetrician. Should the temperature remain above 100 degrees, the uterus must be cleaned out, and flushing with uterine catheters is not enough: if the gloved finger cannot remove the secundines, the curette is needed.

If, when the tampon has been removed, no ovum is found and the cervix is still closed, another tampon is to be put in for another twenty-four hours, supposing the removal of the ovum is licit. Forcible dilatation of the cervix is always a dangerous operation, and should never be employed when avoidable. Steel dilators have ruptured the uterus and killed the patients again and again even when used by experts. Laminaria tents are not to be recommended; the tamponade is enough.

When the retained ovum cannot be removed by the finger or squeezed out, the free portion of the ovum is to be grasped by an ovum forceps and gently drawn out. The operator should be sure he has a part of the ovum in the forceps and not a part of the uterine wall. If he bites into the uterine wall (a common catastrophe), he may pull a hole in that wall, and then the woman will probably die unless the rent can be closed immediately after opening the belly. When the abdominal cavity has been opened in such an event, the uterus is also to be opened, cleansed, and sutured. This method is safer than curetting where there is a rent. If one is certain the gut has not been injured—and it is extremely difficult to be certain—vaginal anterior hysterotomy may be substituted. Sometimes perforations, when the uterus is not septic and the instruments are clean, are not dangerous. Rest in bed, ice-bags, ergot, and opium cure without operation.

Physicians who are called into an abortion case should always be certain that no one has attempted to pass sounds, curettes, or similar instruments, because a perforation may have been made by the meddler which will be charged to the second man himself.

If a uterus is flexed it is easy to poke a curette or like instrument through it at the bend, especially if the uterus is thin or friable from sepsis. Again, the placental site is raised, it feels rough, and the furrows in it lead one to think part of the placenta is still adherent, whereas all has been removed. Repeated scraping, due to this error, may dig a hole through the uterine wall. Perforation in a septic case is practically always fatal to the woman. The use of the curette supposes a special technic, and no physician should presume to try its use unless he has been carefully and practically instructed.