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The moving face of the fetus–the changing face of medicine

2006; Wiley; Volume: 28; Issue: 7 Linguagem: Inglês

10.1002/uog.3885

1469-0705

G. Gorincour, Sébastien Tassy, P. LeCoz,

Assisted Reproductive Technology and Twin Pregnancy

A recent preliminary study published in this Journal demonstrated the general feeling that ultrasound has a positive impact on maternal–fetal attachment, particularly in the first trimester1. It even suggested that it can help reduce maternal alcohol consumption, but that three-dimensional (3D) ultrasound does not offer enhanced benefits, leading us to the controversy surrounding the use of 4D ultrasound for non-medical purposes. Once in a while, the medical community reaches a global consensus, as it has done with its denunciation of such use of 4D ultrasound. The Food and Drug Administration2, the American College of Radiology3, the American Institute of Ultrasound in Medicine4, the American Medical Association5 and the French Academy of Medicine6 all support the position that fetal ultrasound should be performed only for medical purposes. Nevertheless, this consensus is obviously largely theoretical, and if you type ‘fetus 4D ultrasound’ into Google, you will get tens of thousands of hits. You will find many commercial websites with elaborate packages, offering, for example, (for US$ 250) a 30-min 4D ultrasound session, a videotape, color 3D photos, and announcement cards. The website of ‘limited medical ultrasound’ states that the package cannot ‘be substituted for a diagnostic or medically indicated ultrasound’. For the past 18 months in France (and for several years in the US and other countries), commercial centers have offered pregnant women high-cost non-diagnostic real-time images of their fetus. This ‘boutique’ fetal imaging raises both clinical and ethical issues. A criticism of routine medical fetal ultrasound could be that its emphasis is on fetal anatomy and well-being and that the emotional needs of the mother are either secondary or neglected. The companies offering boutique scans say they concentrate on imaging for purposes other than medical ones; indeed, they often require a medical ultrasound examination to have been performed before they agree to undertake a scan. At the end of last year, the French Academy of Medicine6 pointed out that any ultrasound examination (including fetal scans) performed outside a non-medical setting is illegal. The future will tell us if this French exception (in the US, Canada, and many other countries, ultrasound can be done by sonologists who are doctors or midwives, or by sonographers, i.e. technicians who work under the control of a doctor) will last, especially given the falling number of trained doctors there7. In French boutique centers, technicians perform the scan without doctors, because this situation is not (yet) forbidden by law! They have no guidelines, so do pretty much what they want because of this judicial vacuum. The Academy also discussed possible situations in which technicians might identify an anomaly. Is it better that unprepared technicians remain silent or give wrong information? Finally, and taking the lead from the US Food and Drug Administration2, the Academy emphasized the possible bioeffects of non-medical ultrasound scanning, which include cavitation and heating. Long-term outcomes in children exposed to prenatal ultrasound scans are, however, reassuring8. Earlier this year, Frank Chervenak and Laurence McCullough9 made a case for fetal imaging to be performed only by medical practitioners. First, they argued that the economic conflict of interest in boutique fetal imaging is obvious. Indeed, ‘the justification of gaining economic benefit from providing a clinically and ethically justified service collapses’ when the purpose is non-diagnostic, which suggests that boutique imaging would be highly unethical! Second, the names of the boutique imaging companies are misleading, in that they tend to personalize the unborn fetus and trigger emotions in the parents. In our experience, the first-trimester ultrasound image usually means the ‘start of life’ for parents; this picture becomes the first in the baby album. Real-time videoimages will add other ‘baby’ characteristics to the fetus. Today, whether you agree or not, a fetus is not legally a person, and we believe that restricting the use of the term ‘baby’ (which is used by almost all boutique fetal imaging companies) when referring to the unborn being would avoid affective confusion, and hence reduce the amount of suffering if the pregnancy course proved abnormal. It is noteworthy that this second item is all the more complicated as it is also in keeping with the recent anti-abortion laws in the US to protect the so called ‘unborn child’10. We have outlined previously how emotive words can alter the balance of a scientific debate11. Third, more than the name, 4D fetal images might affect the future relationship with the baby to come. There is a risk of increased moral confusion in the mother (and father) that might complicate already painful decision-making regarding the pregnancy. For example, the decision to terminate an abnormal pregnancy is likely to be influenced by the ‘normal’ image of their future baby, who already, in the parents' minds, belongs to the family. Autonomy demands that future parents must be fully informed that a 4D videotape of their beautiful fetus cannot rule out a severe malformation. The diagnostic rate of anomalies in the best centers doing routine fetal ultrasound is around 70%12, and boutique scans look only at the fetal face. Of course, no report can (and none will ever) be found in the literature of missed diagnosis in boutique scanning, partly because this practice is very recent, but more so because no official written report is provided after the scan. There is no clear answer to the debate on the non-medical use of ultrasound, and very recently, two preliminary studies13, 14 have suggested that the addition of 4D compared with conventional 2D ultrasound does not change significantly the perception that people have of their baby or their antenatal emotional attachment. We feel that it is important to point out that boutique fetal imaging has crept into medicine without any adequate informed debate within society, and without medical regulation. When medicine extends itself from care to commercial and not clinically essential services, such debate is a necessity. G. Gorincour*, S. Tassy*, P. LeCoz*, * Mediterranean Ethical Forum, La Timone Hospital, 264 rue saint Pierre, Marseille, BdR 13385, France