Fetal Heart Surgery - Controversial !

Dateline: 02/22/98

With the explosion of technology in cardiac surgery, it is difficult to point to one development and say "This is it, THIS is the most innovative advance in recent times". Over the past month, we have discussed the concept of minimally invasive heart surgery, and the use of this novel technique in treating coronary artery disease , heart valve disease and birth defects of the heart. For more information on minimally invasive surgery, visit the MICAS website. However, the concept of treating diseases of the heart even when the "child" is in the womb - fetal intervention - is perhaps the nearest to "IT".

Fetal Heart Surgery is an idea which has totally captured my imagination. It is at once bold and daring, exciting and scary. Is nothing sacred, forbidden, inaccessible any longer - even the fetus in its protective shell ? Not everyone, though, is as enthusiastic about it. Fetal surgery has strong detractors as well. So I thought of starting a forum to discuss this contentious issue.

What was merely a "fanciful figment of a fevered fanatic's fantasy" just a decade ago is now `frighteningly' near becoming reality. It is only a matter of time - and not much time too - before human fetal open-heart operations will be feasible with a fair chance of success. Many, many issues now become pertinent. I will discuss some of these here. It would be nice if you could suggest others as well.

This week, the issue is ....

IS THE FETUS "ALIVE" ?

Breathing is living; the onset of respiration is the beginning of life - J.Barcroft.

All of us are ALIVE. Yet when called upon to define the term "LIFE", how many of us can give a really unambiguous answer ? The dictionary defines life as "the state of being alive" or "the period between birth and death" or in an even more philosophical sense "the union of soul and body". None of these are however valid in a discussion on fetal "life".

Then we have the legal definitions. In India, where I live, for instance, the life of a fetus is dependent on its anticipated survival after delivery." Viability (of a fetus) is defined as the capacity of the fetus to lead a separate life after birth. A fetus attains viability after 210 days (7 months) of intra-uterine life. In law, a fetus delivered within this period is presumed NOT TO HAVE LIVED." In other countries, this period may differ, since premature infants are now being salvaged at increasingly smaller birth weights and shorter in-utero periods.

So here is the dilemma. How should we view efforts at fetal surgery - as attempts to save an undefined "life", or merely as "experiments" to repair anomalies in a defective fetus ?

The guiding principle for doctors has always been "I will maintain the utmost respect for human life from the time of conception.". This last, then, is alone enough justification to further explore the uncharted seas of fetal cardiac surgery. From the moment of conception, the fetus would be considered a "patient". Certainly it seems justified to think so, since the heart "beats" and the lungs "breathe" even as early as the 10th week in the womb.

We doctors strive to lengthen a life when doing so is felt to be in the patient's "best interests"... But we are still on shaky ground here. When so much is unknown about the outcome of fetal surgery, how can we be so sure that what we do will be in the patient's best interests ? Would it be better, if we just allow the pregnancy to continue to term under close supervision, and instead concentrate on improving our techniques to correct heart defects in the neonate after birth ?

This question can only be answered with time. When results of fetal intervention are available, they should be compared against the natural course of the heart defect without treatment. Only then can any "scientific" judgement be made about the superiority of one approach.

"The physician, who is also a philosopher, is like the Gods. There is no great difference
between medicine and philosophy because all the good qualities of a philosopher should
also be found in a physician - impartiality, zeal, modesty, judgement, knowledge of what
is useful and necessary, rejection of all that is wicked, a soul free of suspicion and
devotion to divinity. Where there is love of man, there is also love of art"
- Hippocrates

Everyone involved in this ground-breaking effort should keep this quotation in mind. Upon this pioneering lot falls the enormous burden of deciding between what is useful and necessary, as opposed to that which is harmful. May all assistance, divine and otherwise, bebestowed upon them to perform this task successfully !

Next week : Economic Impact of Fetal Heart Surgery.