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Health Care Ethics USA Raising Questions About Society's "Duty to Rescue" the Unborn Our society faces ethical questions today about both the extent of a mother's ethical obligation to save her unborn child and the difficulties society faces in determining its duty to intervene to rescue the unborn from those choices. It is the latter that is focused upon here, and four cases suggest the kinds of incidents in question. The first is that of Angela Carter, who refused a Caesarean section in 1987, as she lay dying of cancer. She had fought to remain pregnant, but at 26 weeks physicians felt the baby could no longer survive in her body. In 1999, a pregnant and intoxicated Deborah Zimmerman told a Wisconsin obstetrical nurse that if she was discharged from the hospital she would "just go home and keep drinking and drink myself to death—and I'm going to kill this thing [her unborn baby] because I don't want it anyway." In the third case, again in 1999, 29-year-old Angela Wolf tested positive for cocaine use throughout her pregnancy, unable to control her addiction. In the final case, Melissa Ann Rowland—a woman with a long history of mental illness—refused to undergo a C-section in January of 2004, in the last weeks of her pregnancy, even though doctors argued that it was necessary to save the lives of her unborn twins. How society should respond to these cases is especially challenging, both legally and ethically, in a nation where even late abortions are often legal. Principles Four moral principles come to mind in evaluating society's obligation in these cases. The first, respect for human life, is central to the debate, and concerns the essential nature of the parties involved. At one extreme are those who hold that each case involves only one human person, who has all the attendant legal rights of personhood, and who carries within her a fetus that bears only the potential of human personhood, thus having no legal rights. At the other end of the spectrum are those who argue that there are two fully human beings present, the mother and the unborn child, and that there is an ethical imperative to balance the rights of the two, even under law. The U.S. Supreme Court, however, has rejected any single theory of life, concluding in Roe v. Wade that a fetus is not a “person” under the 14th Amendment. This is the position of most pro-choice activists. The Catholic Church, on the other hand, turning its focus from the specific philosophical question of "personhood," teaches that even the smallest human embryo should be regarded not as a potential human being, but as a human being with potential. Part Four of The Ethical and Religious Directives points out that Catholic health care ministry witnesses to the sanctity of life "from the moment of conception" until death, and that the Church's defense of life specifically encompasses even the unborn. This position is widely embraced by pro-life activists. Between these positions one can find a wide range of views, as well as many persons who are at a loss about what to think. Even those who support the position of the Church are not always comfortable with the practical and ethical ramifications of deciding against pregnant mothers in all such cases. One concern that restrains them is the second ethical principle, that "like cases should be treated alike." It dictates, for example, that a person who commits a certain crime under certain circumstances should receive roughly the same sentence as another who commits the same crime under the same circumstances. The third moral principle is the "duty to rescue." Individual Americans almost never have a legal obligation to act as Good Samaritans, except through mandatory taxes that fund fire, police, welfare, and military services.1 The question here is whether there exists a moral obligation on the part of society to rescue a fetus from the womb of a mother who behaves in a manner that threatens its unborn life. This leads inexorably to the fourth relevant principle, autonomy, which has been critical to bioethical discussion since U.S. Supreme Court Justice Cardoza found in 1914 that "every human being of adult years and sound mind has a right to determine what shall be done with his own body."2 In the cases considered here, this brings us back to the competing views about who is involved; are there two human beings to consider or only one. When another human body is at stake, can a mother ethically be allowed to focus only on her own? Discussion Direct intervention to save the life of a fetus can be undertaken in two ways. The first requires the medical invasion of the mother's body, through C-section or fetal surgery, for example, while the second protects the fetus by restricting the mother's individual liberty. To date, this has meant her liberty to consume alcohol or use illegal drugs. Both kinds of intervention violate the mother's autonomy, but if one embraces the belief that both mother and fetus are fully human beings, then the mother's rights must be balanced against those of the fetus. Obvious questions arise about society's obligation to intervene as it does to save the life and protect the well-being of a born child. On the other hand, if it is held, as many pro-choice proponents believe, that only one human being exists, then the issue should be settled; the fetus is not a human being, and thus has no rights. It does not appear that much of U.S. society finds the issue to be so cut and dried. The four cases outlined here suggest the ethical and legal quandaries of the issue. In the cases of Angela Carter and Melissa Rowland, doctors sought to intervene, via C-section, without the mothers' consent. (Complicating these particular cases was the fact that Carter's judgment may have been impaired by impending death, and Rowland's by mental illness.) In Carter's case, a District of Columbia judge ordered the C-section, but an appellate court later decided that her refusal, supported by her surrogates, should have ended the discussion,3 despite the fact that doctors held surgery to be the child's sole chance to survive. When Rowland's son was stillborn after she belatedly acquiesced to surgery, she was arrested and charged with criminal homicide, and eventually accepted a plea to two counts of third-degree felony child endangerment. Angela Wolf was reported to authorities for violating state child abuse laws for her continued cocaine use, and ordered into treatment when lower courts ruled that her 36-week fetus met the definition of a child. The Wisconsin Supreme Court disagreed, finding that the legislature would have to have expressly included the word "fetus" for one to be considered a "child" under abuse laws. Deborah Zimmerman, who expressed a determination to kill her child, had a blood alcohol level of .302 (well above the legal limit of .10) when she gave birth, and her baby was born with a level of .199, and diagnosed with fetal alcohol syndrome. As a result, Wisconsin authorities filed attempted first-degree intentional homicide and first-degree reckless injury charges against her. In her appeal of the charges, Zimmerman's attorneys argued that her abuse of alcohol was directed toward her own body and the "fetus" she carried—and thus was by legal definition not against another "human being." The appeals court found that she was guilty of no crime, since "the term 'human being' was not intended to refer to an unborn child." Still, the matter has not been put to rest. The legal waters are churning, as society strives to do what may be impossible—to develop legislation that fully protects both maternal autonomy and fetal well-being. This leads to the logical inconsistency of rulings such as that of the Utah Supreme Court, that the state's criminal homicide statute applies to unborn children at all stages of development, yet exempts the killing of a fetus during an abortion. And while the decisions in Roe v. Wade—and in the cases of Angela Carter and Deborah Zimmerman as well—clearly state that the unborn are not human persons, and imply no ethical duty on anyone to rescue them, contradictory legislation has been passed. A new federal law signed by President Bush on April 1, 2004, makes it a separate and distinct federal crime to end the life of a fetus—defined as “a member of the species [H]omo sapiens, at any stage of development, who is carried in the womb”— during a violent attack on the mother.4 Here again, though, prosecution is specifically excluded when a legal abortion is performed. Pregnant women in South Dakota who abuse alcohol or other drugs now face involuntary detention in treatment facilities, and a law in Wisconsin allows juvenile court judges to intervene on behalf of the unborn to detain and restrict the liberty of such mothers. In 2003, Regina McKnight, a homeless drug addict with an IQ of 72, who abused cocaine during pregnancy and whose child was stillborn, lost a bid in the United States Supreme Court to reverse her conviction. She is now serving a 12-year prison sentence for homicide. Conclusion From both practical and ethical perspectives, determining where the line should ultimately be drawn is perplexing. If one agrees with the legal sanctions outlined in the cases discussed here, then at what point should they extend to other mothers with habits that jeopardize their fetuses? What about the pregnant CEO who refuses to reduce her work load, or the mother-to-be who undereats in an effort to maintain her trim figure? Should these women also be somehow detained? If their refusal to comply with medical advice leads to the premature birth and/or health problems or death of their fetuses, should they too be convicted of child abuse or murder? If not—if some mothers are allowed to risk the well-being of their fetuses, but others are not—the ethical dictate to treat likes in a like manner is violated. If a viable fetus is not rescue—and is thus allowed to die as the result of a mother who refuses medically indicated intervention—the principle of respect for human life is not upheld. On the other hand, if a competent mother is forced to submit to medical intervention without her consent, the principle of autonomy is violated. For those who believe that two human lives are at stake in these cases, serious reflection on these competing principles will continue to be a moral challenge. 
Ann K. Suziedelis, PhD
Suggested Readings For a formal, pro-choice, discussion of this issue, see Who Decides? A Reproductive Rights Issues Manual, The NARAL Foundation, pp. 62-67, at http://www.naral.org/publications/issue_manual.cfm. For a Catholic, pro-life perspective, see "Standing for the Unborn," a Statement of the Society of Jesus in the United States on Abortion, March 2003, at www.jesuit.org/images/docs/8V5ZWA.pdf. Questions For Discussion
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