I sincerely hope that common sense prevails and the Supreme Court throws this bill out. But if the South Dakota abortion is not overturned, I'm curious as to what the bill would mean in terms of the medicine involved.
Getting down to it: when may the physician act and stay within the law, when is action clearly illegal, and what - as often happens in medicine - lies in a gray area? All welcome to join in, and I'd especially like to hear from medical people or lawyers with information or speculation.
My speculation below the fold...
Caveat: I am not an OB-GYN. I can't imagine practicing in this situation; I'd hate to delay care for the patient while I figure out whether my recommendations and treatment are going to land me in jail.
First, the relevant parts of South Dakota House Bill 1215 :
No person may knowingly use or employ any instrument or procedure upon a pregnant woman with the specific intent of causing or abetting the termination of the life of an unborn human being.
Any violation of this section is a Class 5 felony.
And:
No licensed physician who performs a medical procedure designed or intended to prevent the death of a pregnant mother is guilty of violating section 2 of this Act. However, the physician shall make reasonable medical efforts under the circumstances to preserve both the life of the mother and the life of her unborn child in a manner consistent with conventional medical practice.
Medical treatment provided to the mother by a licensed physician which results in the accidental or unintentional injury or death to the unborn child is not a violation of this statute. .
So, where are the lines likely to be drawn?
1. Where "Preventing death" is clear:
I would expect toxemia, HELLP syndrome, and ectopic pregnancies to clearly fall into the "legal" category -
- Untreated ectopic pregnancy is almost always fatal to the mother. Some antiabortion proponents had no problem with how this was treated in the past, when doctors would remove the portion of the Fallopian tube that contained the embryo. By their reasoning, the diseased tube was removed, and the resultant death of the embryo was a regrettable side effect. Of course, the procedure left the woman with a missing section of tube, making it extremely unlikely that she'd be able to support a pregnancy on that side in the future. More recently treatment is methotrexate as the first choice, or if surgery is necessary, laparoscopic incision in the tube with suction of the embryo. Both of these leave a healthy tube afterward, but would clearly be seen as intentionally and directly causing pregnancy termination. However, without treatment, the woman will likely die. Although there are rare cases where the embryo implanted in the abdominal cavity, and surgery late in the pregnancy results in a live baby, more often, the fetus is dead or severely deformed.
- Toxemia, and the aptly named HELLP syndrome, are in a slightly different category in that they occur late enough in the pregnancy that the fetus has a chance to survive. In these cases the baby is delivered early to save the mother's life, and the baby may or may not survive. The abortion foes usually accept this, seeing it as not intended to cause the death of the fetus.
2. Some examples from the gray area (Gray to me, at least, perhaps not to an OBGYN or to the law):
- Pulmonary Hypertension - A journal article from 2005 follows 15 pregnancies in 14 women with pulmonary hypertension, and finds, "Despite the most modern treatment efforts, the maternal mortality was 36%." Is a one third chance of dying enough to satisfy the law's demand of "preventing the death of the mother?"
- Heart valve abnormality - these are divided into low, medium and high risk to the pregnant woman. When the cardiac disease is severe enough to permit only poor levels of daily function, these women have a 7% mortality rate in pregnancy, and a 30% rate of nonfatal complications. Is 7% enough for the law to recognize "preventing death?" If not, we know there will be a 30% rate of increased problems with the mothers' health.
A good discussion of heart disease and pregnancy for the medically inclined is
here.
3. What may fall in the "not legal" category:
- a common problem like diabetes. Most women with diabetes can be managed on insulin, but there is a 0.6% mortality rate - probably not enough for the law see this as "preventing death," possibly until it's rather late in the course of problems.
- compassionate issues, such as a fetus with anencephaly. This means there is no brain, and once born, the baby will die within hours to a few days. An ultrasound can usually diagnose this by 10 to 14 weeks. If there is no abortion permitted, the woman must carry a doomed, deformed child for the rest of the term - about six months.