Selective self-determination

There is really only one covering word for the government's proposal for austerity in the use of ultrasound: double Moral. The differential treatment of women over and under 38 is a good illustration:

Norwegian women over the age of 38 are systematically offered fetal diagnostics. The disease cause (etiology) why this group is selected is that the risk of the fetus having Down syndrome or other abnormalities increases dramatically with the mother's age. the purpose with the examinations is to give the woman the opportunity for abortion – abortion. Down syndrome is thus today an accepted reason for having an abortion after 12 weeks – a late abortion.

The health authorities seem to believe that it is bra when women can detect Down syndrome on the fetus, and then abort the pregnancy.

At the same time, the government sees that if women were given – and used – this opportunity, children would not be born with Downs in Norway. And then we get a "sorting society", and we do not want that.

Therefore, the government has taken the simplest line: Close your eyes to the dilemma – try to ignore it. The problem is that it is neither the Minister of Health Dagfinn Høybråten nor other politicians who must ultimately try to ignore what is happening today. This is what midwives and other health professionals should do when they perform ultrasound examinations around the 18th week.

The government will in fact order the midwives not to look for signs of fetal abnormalities, such as undeveloped or weakly developed nasal bones – an indication that the child can have Downs. If the midwife would come to see it anyway, she should inform the mother in a gentle manner. Then the mother should be offered fetal diagnostics to finally determine if the child has Downs, with subsequent offers of pregnancy abortions.

The ethical dilemma faced by midwives is hardly the greatest in this matter, but no less insoluble for that reason. The midwives are, of course, competent to detect a number of fetal malformations during pregnancy, and it will be extremely difficult to try not to see these malformations. How the midwives will act is not good to say. Some of them may want to follow the ban on looking for nonconformities. Others will pretend that they just happen to notice the discrepancy, even if they have actually looked for it.

In the debate on tightening the use of ultrasound, there is great uncertainty both about what is the current practice today, and about what the government has actually proposed. Then an attempt at clarification may be necessary:

• Today, all pregnant women are routinely offered an ultrasound examination around the 18th week of pregnancy – that is, about six weeks after the deadline for self-determined abortion has expired. During the ultrasound examination, it is determined whether there is one or more fetuses, the location of the placenta, possibly the sex and a fixed date. In addition, it is common for the midwife to look for abnormalities in the fetus and other things that can create problems during pregnancy or birth. In addition to the routine examination, both the public and private health centers can offer ultrasound at another time. Ultrasound examinations are not regulated by law, apart from the fact that it is not permitted to provide information about gender until after the 12th week.
• The government has proposed that ultrasound be regulated by law – if purpose with the examination is to look for abnormalities or diseases of the fetus. Then it is defined as fetal diagnostics, similar to, for example, amniocentesis. And fetal diagnostics, only six approved institutions are allowed to perform. This means that midwives and other health personnel outside the six institutions are explicitly banned from conducting ultrasound examinations for the purpose of finding abnormalities in the fetus. All they are allowed to do is determine the term, the number of fetuses, the location of the placenta and any gender.
• If the health personnel still discover abnormalities in the fetus – even if they do not look for it – they should inform the woman as gently as possible, and then offer her fetal diagnostics.
• Today, women in certain risk groups are offered fetal diagnostics in addition to the usual pregnancy check-up with ultrasound. These can be women over the age of 38 or women with certain hereditary diseases. Who will be offered fetal diagnostics is decided by the doctor in consultation with the pregnant woman. Traditionally, fetal diagnostics has included methods such as amniocentesis and placenta testing. With the new law, it will cover all methods used to find abnormalities on the fetus: Amniocentesis, placenta test, blood tests and thus ultrasound where you look for abnormalities.
• Much of the debate about fetal diagnostics has been about children with Down syndrome. However, this is just one of several things you look for. Some of the abnormalities you look for are of such a nature that it is assumed that the fetus will die either in the mother's womb or shortly after birth. In these cases, the pregnant woman is offered an abortion. Other abnormalities are of such a nature that one can start medical treatment while the child is in the mother's womb, or prepare for a difficult birth. In other cases, there is little one can do beyond determining the discrepancy. The mother is then faced with the choice of whether or not to apply for an abortion.
• Up to and including the 12th week, pregnant women can have an abortion without having to apply for it. From the 12th to the 18th week, an abortion can be granted if serious social conditions warrant it, if there are serious abnormalities in the fetus or if the pregnancy involves danger to the mother's life. After the 18th week, an abortion can be granted if there is a danger to the mother's life, or if the fetus has abnormalities that are "incompatible with life". An application for an abortion after the 12th week is decided by a separate board of two doctors, with an appeals board of two doctors and most often a lawyer.
• The central point in the Government's proposal for austerity measures is that health personnel who do not work at one of the six approved institutions should be explicitly prohibited from looking for abnormalities in the fetus, regardless of when the examination is performed during pregnancy.

The government's hope is that a certain number of Down's fetuses will not be detected and removed, so that we can say that we do not have a sorting society. Besides, they can adorn themselves that we do not to be after fetuses with abnormalities to "sort" them out. Even if the health service is available in the "sorting" when the discrepancy is actually discovered.

From an ethical point of view, this attitude is of course double standards at its worst, because the crucial point is not whether we screen for malformations, but whether we open up for abortions at all close to the point where the fetus is fully developed and potentially viable with medical help.

There is reason to emphasize that it is a long step from an ordinary abortion performed before the 12th week, and the late abortions performed at Norwegian hospitals. From a purely medical point of view, it is even doubtful to refer to it as an "abortion", because what the women actually go through is an early birth. As a result of the provoked premature birth, the fetus dies in the mother's womb – in some cases the child is born alive, but dies after a short time. The women who undergo the birth are usually offered to see the child, and what they see leaves no doubt that it is a child, and not a lump of cells, that has come out. If an abortion procedure is a physical and mental strain, then a provoked premature birth is significantly worse.

The objections to allowing abortion so late in pregnancy are therefore justified. As doctors succeed in rescuing desired, premature babies earlier in the pregnancy, we are approaching a situation where many of the fetuses that are removed could actually have been kept alive after the abortion has been completed. It will present physicians with an impossible moral dilemma: their task, in addition to relieving and healing, is to save lives. That doctors should not give live-born children with Down's life-saving treatment, even if the birth is provoked with the intention of terminating the pregnancy, it is asked whether they can live with it in the long run.

If so, it burns a blue light for all late abortions that are not necessary to save the mother's life, or that are due to the fact that the malformations of the fetus are so great that the child will either be stillborn or will die shortly after birth. From an ethical perspective, it should be an important task to reduce the number of abortions late in pregnancy, either by not performing them, or by moving the time of the abortion to earlier in the pregnancy.

It is difficult to understand the Norwegian authorities differently than that Down's syndrome is "incompatible with life" – because the wording is difficult to read differently than that the child will die during pregnancy or shortly after birth. If the wording were to embrace further, it would have to say "incompatible with a good life", a "dignified life" or the like. But then one also had to decide whether life with Downs is good and / or worthy. And probably there are both – at least compared to the alternative: Non-life.

The real reason we allow these abortions is that it is perceived as immoral to force a woman to bear a child she does not think she is capable of caring for in a good way. It is the same reasoning that allows us to allow late abortions between the 12th and 18th week when strong social considerations warrant it, or that we allow abortions in general until the 12th week: The woman must decide for herself whether she is able to carry out the pregnancy , birth and at least a few decades as a parent. It is her choice, due to her own life situation.

Then it is of course crucial for such a decision what challenges she faces in the many years after the birth. If she has a healthy child without special needs, it is a different situation than if the child will require enormous attention throughout the upbringing – and perhaps also in the decades afterwards. A woman who is in a difficult social situation can consider it so that she will still be able to take care of a child – as long as the child is healthy and without extraordinary needs. But that she can not take responsibility for a child who requires large parental resources.

It is this confidence in women's own judgment that is the basis for our self-determined abortion in Norway. Until self-determined abortion was introduced, the prevailing view was that abortion could in many cases be legitimate, but that one could not rely on women's own judgment. Therefore, the case had to be submitted to a tribunal – a very humiliating experience for many women. Today we have kept the tribunal scheme after the 12th week – of course because an operation late in pregnancy is more problematic than an early operation. There is still reason to ask whether the women's judgment is declining throughout pregnancy.

Another way to go than the one the government has chosen would be to provide the women with as much information about the fetus as possible as early as possible, and leave the decision to terminate the pregnancy to the woman herself, even after the 12th week. A closer and more thorough follow-up of the pregnant woman before the 12th week could mean that more women who wanted to have an abortion – for whatever reason – could do so at an early stage.

The interesting thing is that medical technology points in the direction that certain abnormalities in the fetus can be detected ever earlier in the pregnancy. One example is indications that the fetus has Down syndrome. In Denmark, people have gone the exact opposite way of what we do in Norway. There, the health authorities have proposed that all pregnant women should be offered blood screening twice during pregnancy – around the 10th and 14th week – in addition to an ultrasound examination around the 12th week. A possible abortion can then be carried out many weeks earlier in the pregnancy.

The Danish model involves what Norwegian politicians do not want: A systematic screening to find fetuses with abnormalities – Downs is just one of them – so that the woman can decide whether she wants to carry the child or not. At the same time, you try to get the facts on the table as early as possible in the pregnancy – because you know that a late abortion is a greater burden for the woman.

The Danes have thus chosen a "sorting society", where children with Downs and other abnormalities are more or less systematically weeded out during pregnancy. The number of Down children born will be far less in Denmark than in Norway – given that Norwegian midwives follow the ban on looking for these discrepancies. At the same time, Danes to a greater extent avoid the ethical problem of late abortions up to the limit of when the fetuses can be saved.

The Danes also take seriously the women's need for thorough information about the condition of the fetus, and the women's right and ability to decide for themselves whether the child can be carried or not.

It is interesting to note that the party that can be the tongue in cheek in this case – the Socialist Left Party – has a completely different understanding of the government's bill than both the opposition (Labor Party and Progress Party) and the governing parties. SV's social politician Olav Gunnar Ballo rejects that women's opportunity to get information is cut. Instead, he is concerned with preventing a flora of private ultrasound services both late and early in pregnancy.

Ballo's concern about private fetal diagnostics could, however, be unfounded if Norway followed the Danish model, and offered pregnant women blood screening and ultrasound early in pregnancy. By then, worried women had stopped sending blood samples to foreign institutions they only knew via the internet.

One should not close one's eyes to the fact that such a line would mean that far more fetuses with abnormalities would be aborted, and there is every reason to question the help offered to families with disabled children. The attitude of the government, and SVs, is nevertheless based on a distrust of women's judgment and integrity, because they try to curb their opportunities to make an informed choice. The attitude is also unethical, because it cuts off the ability to make informed choices early in pregnancy.

But the attitude is also unethical in other areas: Much of the debate about ultrasound and fetal diagnostics has been about – like this article – Down syndrome. Then it is easy to overlook that fetal diagnostics is used to detect a number of other abnormalities and diseases in the fetus. Some abnormalities and diseases mean that the fetus will die either in the mother's womb or shortly after birth. It should be obvious that the pain of giving birth to a stillborn child is far greater than that of having an abortion procedure. Other abnormalities and diseases can be treated while the fetus is in the mother's womb. Not looking for these discrepancies as systematically and early as possible is morally unacceptable. A third factor is that giving birth to a sick or disabled child is probably easier for most people, if you are prepared for what is to come.

Given that we have a health minister from the anti-abortion party Christian People's Party, the government's line is not surprising. Far more disturbing is that SV is on the same line, and that they do not even seem to understand what they are involved in.

The social committee will submit its recommendation next Thursday. Then, in practice, it is SV that decides what matters most: society's need to adorn itself with double standards, or women's right to make an independent, informed choice.