Advances in medical technology have pushed the boundaries of fetal viability — a term for the point at which a fetus can survive outside the womb.
When the Supreme Court handed down the Roe v. Wade decision in 1973, doctors could support babies delivered as early as about 28 weeks. Now it’s 22 weeks.
The leaked draft opinion that would overturn Roe mentions “viability” dozens of times.
Dr. Rachel Fleishman works in a neonatal intensive care unit, or NICU, at Einstein Medical Center in Philadelphia. She wrote an essay for NBC about viability and what it’s like caring for very premature infants. Host Kimberly Adams asked her how it feels when her work is sometimes used in the abortion debate. The following is an edited transcript of that conversation.
Rachel Fleishman: It makes me feel like my role as a physician is to educate and empower people with the information and experiences that I see as a physician. But I worry that people who do not share those experiences may co-opt some of what we do to apply it to a discussion that is, in my mind, separate from the discussion that we are having in the NICU as we work with our patients and their parents.
Kimberly Adams: Because the term “viability” gets thrown around so much in this debate, what do you think people need to know about that word?
Fleishman: It is important to know that just because something is possible, medically speaking, with the application of advanced technology, does not necessarily mean that it is a) a guarantee of survival, that b), any parent may want the risks of long-term complications for their child in the face of uncertain survival and months of painful intensive care. And neonatal care is inconsistently available. Not every hospital has a NICU at all. And so, overgeneralizing from the experiences of one center where things can go remarkably well, to assume that that type of care is available in every hospital around the country is problematic.
Adams: What technology, what devices are involved in keeping baby born that early alive?
Fleishman: They generally all require a breathing tube that’s placed into the windpipe and then connected to a machine that can breathe in synchrony with the baby. They’re all housed in incubators. Those incubators, not only keep the babies warm, they also humidify the air. The skin is very fragile and not very good at holding moisture. And so by moistening the air around them, it helps prevent them from becoming severely dehydrated. So just the nursing care required to do something as basic as changing a diaper for these tiny babies is the thing that impresses me most.
Adams: How has the technology changed over time? How much advancement has there been in the last couple of decades?
Fleishman: So I was fortunate to work for a woman named Maria Delivoria-Papadopoulos. What she began in the ’60s and ’70s was placing babies on ventilators. She was among the first to do so. So even just the idea that that could be done was novel back when she was practicing. And over time, we have gotten better at not just supporting the breathing with invasive mechanical ventilators, but supporting babies in more gentle ways with application of devices that gets placed on the nose or around the nose, to help more gently inflate the lungs and allow babies to do more work of breathing.
Adams: What advice would you have for lawmakers faced with the term viability being used throughout this debate?
Fleishman: I want them to know that it’s complicated. I want them to know that neonatal care is not black and white. And that there is a lot of technology, a lot of heartache, a lot of exceptional hardworking nursing care and parental angst that is going on in NICUs, and to take the time to learn about it before they make decisions that may inadvertently impact the way that we in NICUs are doing our jobs to care for our patients and their families.
Related links: More insight from Kimberly Adams
Fleischman explained some of the efforts involved in taking care of those born at just 22 weeks both with ventilators and incubators. Her opinion piece for NBC describes the technical difficulty of keeping those patients alive and the difficult conversations she has with parents.
If you’re curious about some of the technology that’s still being developed in this field, The Washington Post has an article from December that focuses on some of those advances, like artificial wombs.
The Atlantic has a 2018 piece discussing what all this means for understanding viability. It includes insights from a doctor, a developmental biologist and an ethicist on how technology is shaping how we view personhood, and what role viability should even play in the abortion debate.
Finally, there’s a piece from the Associated Press that gets into the risks involved when infants are born extremely early, citing research showing that when it comes to babies born at 22 weeks, if doctors intervened to try to keep them alive, about 30% lived long enough to be sent home.
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