SPECIAL ARTICLE * ARTICLE SPECIAL

Eugenic abortion: an ethical critique Malcolm N. Beck, MD, CM, FRCPC In 1967 the CMA officially approved abortions by physicians when there was "a substantial chance that the child would be born with grave mental or physical disability".' The stimulus for that revolution in the ethics of medical practice was the newly demonstrated causal association between maternal German measles in early pregnancy and severe physical and mental defects in the newborn.' I recall that there was surprisingly little debate about the resolution in the medical press or among members of the medical profession. Most of us thought that such a procedure would rarely be used. The policy still stands,2 but new technologic advances in ultrasonography, intrauterine techniques, karyotyping, biochemical analysis of amniotic fluid and molecular genetics have resulted in eugenic abortions becoming a regular occurrence in medical practice in Canada. Since 1967 few articles have addressed the rationale and indications for eugenic abortion, and even fewer have questioned whether eugenic abortion should be performed at all. The medical literature has betrayed a widespread, usually unstated assumption by the profession that fetal life should be terminated whenever a serious congenital abnormality is strongly suspected. It is now possible to diagnose relatively reliably 200 or more handicapping disorders. In Canada a surge in the use of such prenatal diagnostic techniques occurred in 1976 after the publication of three reports of international collaborative studies3-5 and one from the Medical Research Council of Canada.6 As early as 1983 Allanson and associates7 reported that 50% of older pregnant women in the Vancouver area "took advantage of the availability of amniocentesis". The indications now accepted for the prenatal investigation and diagnosis of genetic disorders have been established by the Society of Obstetricians and Gynaecologists of Canada;8 the most common indication by far is high maternal age, usually defined as over 35 years, at the expected date of delivery.

Physicians are not only accepting and sometimes promoting such investigative procedures but also are being increasingly pressed by older mothers and their partners to do them, mostly because of the fear of having a retarded child. The 16th postmenstrual week is the preferred time for amniocentesis. Since it takes 2 to 3 weeks for the laboratory analysis and reporting, the minimum time for the termination of fetal life is the 18th gestational week. Several authors have reported a mean gestational age of 20 weeks.6'9"'0 The issues raised by eugenic abortion should be distinguished carefully from those raised by the continuing debate on abortion as a matter of reproductive choice, determined by the "mother's own priorities and aspirations", the terminology used by the Supreme Court of Canada in the Morgentaler decision." Eugenic abortion deals with neither the pathos of an unplanned, unwelcome or forced pregnancy nor the personal matter of freedom of choice about what happens to one's body. Instead, it involves a deliberate, systematic search for those who may be unfit in mind or body, the primary intent being to terminate fetal life if such is found. If the fetus is thought to be "normal" the pregnancy is allowed to continue. Therefore, I prefer the more descriptive term "selective feticide", following Roberts and collaborators,'2 over the more common terms such as eugenic abortion, selective abortion and genetic abortion. My preference is supported by an awareness of the infrequently used, yet widely accepted, practice of selectively terminating the life of an "abnormal" twin in utero by exsanguination or injection of potassium chloride or a bolus of sterile air directly into its heart or umbilical vein and allowing the "normal" twin to develop to term. The dead twin is not "aborted" but, rather, is delivered at term as a fetus papyraceus.'3-'5 Selective feticide should not be equated with the reduction of multiple pregnancies associated with assisted ovulation and fertilization. Here the objec-

Dr. Beck practises child psychiatry in Charlottetown.

Reprint requests to: Dr. Malcolm N. Beck, 279 Richmond St., Charlottetown, PEI CIA IN8 CAN MED ASSOC J 1990; 143 (3)

tive is to create a maternal environment in which one or more of the fetuses can survive to viability and normality - a goal compatible with the traditional scope of medicine. 16,'7 Physicians should be concerned about the continuing welfare of their patients and the attitude of society toward them. Mentally handicapped people are not able to speak well for themselves; therefore, we who serve them must speak on their behalf, because it is unlikely that others will. Selective feticide is fraught with technical problems and clinical complications and may have severe psychologic effects on the mothers. It has ethical implications for physicians and some broader social implications. In addition, it may adversely affect the social identity of the medical profession.

Adverse effects of amniocentesis on the fetus Amniocentesis is not harmless. Early reports were divided on whether it caused fetal loss, but other, larger studies have demonstrated that uncomplicated amniocentesis in the second trimester has caused an increase in the mortality rate of healthy fetuses of 0.5% to 1.0% because of an increased rate of spontaneous abortion and a small but significant increase in the perinatal mortality rate.6,8- 10.1217-21 Also, after amniocentesis an increase of 0.4% above the expected rate of prenatal hemorrhage from placenta previa and abruptio placentae has been reported,'8 as has a threefold increase in the incidence of breathing problems in the normal newborn and of orthopedic problems, especially club foot and congenital dislocation of the hip.20,22 In a Canadian study Finnegan and colleagues23 found "needle marks" 6 months after birth on 6 of 91 infants whose mothers had undergone amniocentesis. Although the marks were only cosmetically important, they reviewed reports of single or rare instances of needle injury, such as exsanguination, cardiac puncture, puncture of the gut, ocular trauma, neurologic damage to a limb and gangrene of a

limb. False-positive and false-negative laboratory results do occur.24 The error rate of 0.3% in cytogenetic diagnosis reported in larger series is very low but of critical significance when the termination of life is involved.'0 Procedural mistakes by physicians, nurses, laboratory technicians and clerical staff occur despite the utmost care.'0 Furthermore, the procedures are not very effective in decreasing the rate of mental retardation. For example, the screening of mothers over 35 years of age prevents the birth of only 25% of the children expected to be born with Down's syndrome.25 The human cost for this supposed gain is very high: the number of cases of 182

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handicap prevented by these prenatal procedures is almost identical to the number of "normal" children sacrificed.26 27 Primum non nocere.

Adverse effects of selective feticide on the mother The degree of psychiatric illness caused by induced abortion of unwanted pregnancies may still be debatable.28 29 However, selective feticide and the related experiences create unusually high levels of stress for the mother30-32 and negatively affect the father33 and the siblings of the aborted fetus.34 The mothers are usually mature in their thoughtfulness and sensitivity, and their pregnancies are often planned, wanted and sometimes treasured events. For 4 months they have anticipated the healthy outcome of their pregnancy. Shortly after amniocentesis they experience quickening, with its consequent enhancement of maternal attachment and an increased awareness of the fetus as having a separate existence.3536 The interval of 2 to 4 weeks between amniocentesis and receipt of the laboratory results causes much anxiety and even denial of the pregnancy by the parents;37 this anxiety is not always relieved by good genetic counselling, which may even increase the mother's anxiety.38 When unwanted results are received the parents must make very difficult personal decisions based on concepts couched in terms that are foreign and often dreadful to them. The termination of a pregnancy through amnioinfusion techniques subjects the mother to distressing labour, which is often poorly attended by the medical and nursing caregivers.37 The stress is much less on the mother and the nurses if the abortion is done through dilatation and evacuation, which in skilled hands is the preferred procedure up to 20 weeks' gestation; however, this procedure is much more distasteful and stressful to the physician.3940 With the use of infusion techniques the dead fetus is easily recognizable as a tiny human being and may be seen by the mother after delivery. Physical complications after a second-trimester abortion for any reason are common4' and more frequent than would be acceptable in regular elective surgery. Castodot42 reported that in abortion after 16 weeks' gestation the rate of hemorrhage is over 10%, endometritis 10%, cervical laceration 3% and retained products of conception 32% to 46%. Grimes and Schulz,43 who reported the results of a collaborative study of 84 000 late induced abortions, found that abortion at 20 to 21 weeks resulted in a 12.4% risk of hemorrhage and a 7.7% risk of cervical laceration. The psychologic complications after delivery are also severe. Mothers who have undergone eugenic

abortion and have previously lost a child because of stillbirth or neonatal death have reported that the level of bereavement is equal; too often the intensity of the grief is not eased by the usually healing process of mourning.44,45 Normal grieving is confounded by the mother's mixed feelings of guilt and grief, her sense of relief about and responsibility for the abortion and the lack of awareness of the depth of her loss by the people close to her. There is no baby, no name, no photograph, no funeral, no grave.46 These negative psychologic consequences are not helped by the negative attitude of physicians to eugenic abortion, which is shown by the low rate of their attendance during the delivery39 and the lack of follow-up care given by physicians and public health nurses as compared with that given the same mothers after previous stillbirths or neonatal deaths.46 47 The few reports of follow-up of eugenic abortion have suggested that the rate of psychiatric complications is high.44-49 Lloyd and Laurence46 followed up 53 cases and, although the study was inadequately controlled, found that 78% of the women had acute grief reactions similar to those expected in any situation of major bereavement; 46% continued to suffer from clinically significant anxiety or depressive states up to 6 months after the abortion, and 10% required psychiatric treatment.

Ethical issues The central ethical issue in selective abortion is whether physicians should become involved in purely eugenic procedures that involve the termination of a human life. A cogent understanding of the proclivity of mankind to evil50 and the actions of the very sophisticated medical profession in Germany in the 1930s5-153 suggest that we should be very leery of such an involvement. The fears are not allayed by reports of the use of selective abortion techniques in India, administered on the basis of sex (Winnipeg Free Press, Aug. 28, 1982, and Times of India [Bombay ed], Oct. 17, 1985),54,55 or by evidence of a widespread acceptance of this practice among medical geneticists in the United States and Canada56 and the students of a supposedly conservative rural US college.57 Eugenic abortion is most often done at a gestational age that nearly approaches the age of fetal viability, even with good sequencing of procedures and reports. The dramatic advances in neonatology have resulted in the age of viability being changed to 24 weeks or even lower.58'59 At its 1988 meeting the CMA General Council accepted 20 weeks as the age of viability.2 However, in Britain the termination over a period of 6 months of 26 fetuses after 24 weeks' gestation was reported.606' Also, it has been

argued that the statutory age of viability not be lowered from 28 weeks because to do so might encourage legal infringement on the practice of late abortion of defective fetuses.31'60'62'63 What is technologically possible is not always right. Our ability to use these new techniques confronts us with the modem moral predicament posed by the Durants:64 Have we given ourselves more freedom than our intelligence can digest?

Broader social implications Vigorous public education efforts by the helping professions and voluntary organizations such as the Association for Community Living, formerly the Canadian Association for the Mentally Retarded, have done much to reduce the stigma borne by handicapped people. However, we should be concerned lest these gains be lost when most expectant mothers over 35 years of age and their husbands decide to have prenatal diagnostic studies done with the intent of terminating the life of their unborn child if a mental or physical defect is suspected. Such a reversal in public attitude could lessen the resolve of governments to fund adequate medical and other service programs for handicapped people and could diminish the impetus for public institutions to fund research into the disorders underlying mental and physical disability.65 It has been regularly argued in the medical literature that the economic burden of the lifelong care of retarded people provides adequate justification for genetic abortions.66-69 The economic load is real, but this argument is based on sociopolitical, not medical, premises (Audrey D. Cole: personal communication, 1985). Paradoxically, although the practice of eugenic abortion continues to grow, there is an increasing awareness that the fetus possesses an identity independent from its mother.70 This is prompted by increased public awareness of the success of prenatal fetal therapy71-73 and the procession of legal suits on behalf of children for "prematernal liability", "wrongful birth" and "wrongful life". Although a consensus on such suits has not been reached in the courts of the Commonwealth countries or the United States, physicians should be aware that a child can now sue his or her parents for giving them birth and win.74-76 New techniques, such as chorionic villus sampling, may lower the fetal age at which life can be terminated after prenatal laboratory diagnosis, but the risks of chorionic villus sampling are not yet confirmed as being acceptably low. Studies have shown the rate of fetal loss to be 0.7% to 2.7% higher than that associated with amniocentesis.71-8' When this is added to the increase of 0.5% to 1.0% in the CAN MED ASSOC J 1990; 143 (3)

and laboratories, in the silence of the womb and in the sterility of the operating theatres. In so doing the profession veils the awful reality of the means to attain such nonmedical, sociopolitical goals from public view and awareness. Physicians should not assume this death-dealing role. This great and historical, learned profession should not have thus allowed itself to become either the unwitting agent of public policy or the automatic servant of popular demand. Medicine must now raise the level of its internal debate about eugenic Selective abortion and the social role This could launch us on a process whereby abortion. of medicine our profession could return to its historical, distincThe medical profession has earned respect tive, ethical foundations. through its persistent exercise of traditional ethical values that lead physicians to abhor death and to work hard to maintain and restore health. If the References profession is to maintain credibility it must continue Transactions of the General Council at the One Hundredth to demonstrate concern for the preservation of the 1. Annual Meeting of the Canadian Medical Association, Quebec, lives of the sick and the weak. Eugenic abortion does June 9-10, 1967, CMA, Ottawa, 1967: 69 not fit this ideal; its practice endorses a principle of 2. Proceedings of the 121st Annual Meeting, Including the Transactions of the General Council, Vancouver, Aug 22-24, rejecting defect that gives a nonmedical (even 1988, CMA, Ottawa, 1988: 35-40 antimedical) priority to parental, familial and 3. Simpson NE, Dallaire L, Miller JR et al: Prenatal diagnosis of societal claims to well-being over those of the pergenetic disease in Canada: report of a collaborative study. son yet to be born.82 Can MedAssoc J 1976; 115: 739-748 In addition, eugenic abortion does not fall 4. MRC Working Party: An assessment of the hazards of Br J Obstet Gynaecol 1978; 85 (suppl II): 1-41 within the usual rigors of good medical practice. 5. amniocentesis. National Institute of Child Health and Human Development: Ordinarily physicians demand more clinical validaMid-trimester amniocentesis for prenatal diagnosis. Safety tion than that provided only through laboratory and accuracy. JAMA 1976; 236: 1471-1476 investigation and ultrasonography before they per- 6. Diagnosis of Genetic Disease by Amniocentesis During the Second Trimester of Pregnancy: a Canadian Study (rep 5), form procedures of grave importance to life. HowevMedical Research Council of Canada, Ottawa, 1977 er well conducted, karyotyping and biochemical 7. Allanson JE, McGillivray BC, Hall JG et al: Cytogenetic analysis of amniotic fluid do not possess the diagnosfindings in over 2000 amniocenteses. Can Med Assoc J 1983; 129: 846-850 tic validity derived from the direct examination of 8. Canadian recommendations for prenatal diagnosis of genetic physical and mental status corroborated by laboratodisorders. Bull Soc Obstet Gynaecol Can 1983; 5: 5 ry studies. Campbell83 argued persuasively that 9. Squire JA, Nauth L, Ridler MAC et al: Prenatal diagnosis and points of view denying protection to the fetus at any outcome of pregnancy in 2,036 women investigated by amniocentesis. Hum Genet 1982; 61: 215-222 stage are equally arguments for infanticide. If the Globus MS, Loughman WD, Epstein CJ et al: Prenatal premises underlying the practice of searching out the 10. genetic diagnosis in 3,000 amniocenteses. N Engl J Med 1979; unfit and terminating their lives before birth are 300: 157-163 judged to be reasonable, then clearer logic and firmer 11. Morgentaler, Smoling and Scott v The Queen, [1988] 1 SCR 30, at pp 141-143 resolve would lead to the conclusion that such 12. Roberts NS, Dunn LK, Weiner S et al: Mid-trimester amnitermination should occur after the delivery, when ocentesis: indications, technique, risks and potential for the diagnosis can be more exact and no increased prenatal diagnosis. J Reprod Med 1983; 28: 167-188 risk to the "normal" fetus is created. 13. Kerenyi TD, Chitkara U: Selective birth in twin pregnancy with discordancy for Down's syndrome. N Engl J Med 1981; The logical conclusion would be for the state to 304: 1525-1527 create a new bureaucratic position, filled by someone 14. Redwine FO, Hays PM: Selective birth. Semin Perinatol with a high level of technical training, to perform 1986; 10: 73-81 this task adequately. In the early 1970s Dr. John H. 15. Chitkara U, Berkowitz RL, Wilkins IA et al: Selective second-trimester termination of the anomalous fetus in twin Maloney, a widely respected senior colleague in my Obstet Gynecol 1989; 73: 690-694 home city, dubbed such an official "the provincial 16. pregnancies. foetal reduction. Lancet 1988; 2: 773-775 assassin". It is evident that our governments would 17. Selective Selective termination of pregnancy. Hastings Cent Rep 1988; not undertake a program as repugnant to the sensi18 (1): 21-22 bility of our citizenry as this. But, when physicians 18. Hanson FW, Tennant FR, Zorn EM et al: Analysis of 2136 genetic amniocenteses: experience of a single physician. Am J condone and actively participate in eugenic abortion Obstet Gynecol 1985; 152: 436-443 the medical profession must recognize that it is 19. O'Brien WF: Mid-trimester genetic amniocentesis, a review achieving these very ends in the secrecy of its offices of the fetal risks. JReprodMed 1984; 29: 59-63 rate of fetal vulnerability from amniocentesis the upper side of these figures would be unacceptable. Even if the low side is confirmed in current studies the core arguments against medical involvement in the procedures - the negative psychologic impact on mothers, their families and the handicapped and their questionable ethical, social and professional implications - remain unaffected and as convincing as ever.

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20. Cruikshank DP, Varner MW, Cruikshank JE et al: Midtrimester amniocentesis: an analysis of 923 cases with neonatal follow-up. Am J Obstet Gynecol 1983; 146: 204-21 1 21. Holzgrreve H, Ming P: Genetic aspects of fetal disease. Semin Perinatol 1989; 13: 260-277 22. Dick HM: Orthopedic problems. In Fanaroff AR, Martin RI (eds): Behrman's Neonatal-Perinatal Medicine: Disease of the Fetus and Infant, 2nd ed, Mosby, St Louis, 1977: 875-904 23. Finnegan JK, Quarrington BJ, Hughes HE et al: Infant outcome following mid-trimester amniocentesis: development and physical status at age six months. Br J Obstet Gynaecol 1985; 92: 1015-1023 24. Windsor EIT, Brown BS, Luther ER et al: Deceased co-twin as a cause of false positive amniotic fluid AFP and AChE. Prenat Diagn 1987; 7: 485-489 25. Bloom AD: Prenatal diagnosis: available alternatives. Hosp Pract [Of]] 1983; 18: 227, 229, 232-233 26. Leschot NJ, Verjaal M, Treffers PE. A critical analysis of 75 therapeutic abortions. Early Hum Dev 1985; 10: 287-293 27. Evans MI, Drugan A, Koppitche FC III et al: Genetic diagnosis in the first trimester: the norm for the 1990s. Am J Obstet Gynecol 1989; 160: 1332-1336 28. Doane BK, Quigley BG: Psychiatric aspects of therapeutic abortion. Can Med Assoc J 1981; 125: 427-432 29. David HP, Rasmussen NK, Holst E: Postpartum and postabortion psychotic reactions. Fam Plann Perspect 1981; 13: 88-92 30. Blumberg BD, Golbus MS, Hanson KH: The psychological sequelae of abortion performed for a genetic indication. Am J Obstet Gynecol 1975; 122: 799-808 31. Tumbull AC, MacKenzie IZ: Second-trimester amniocentesis and termination of pregnancy. Br Med Bull 1983; 39: 315321 32. Lazarus A, Stern R: Psychiatric aspects of pregnancy termination. Clin Obstet Gynaecol 1986; 13: 125-134 33. Rayburn WF, LaFerla JJ: Mid-gestational abortion for medical or genetic indications. Clin Obstet Gynaecol 1986; 13: 71 82 34. Furlong RM, Black RB: Pregnancy termination for genetic indications: the impact on families. Soc Work Health Care 1984; 10: 17-35 35. Brewer C: Induced abortion after feeling fetal movements: its causes and emotional consequences. J Biosoc Sci 1978; 10: 203-208 36. Sandelowski M: A case of conflicting paradigms: nursing and reproductive technology. ANS 1988; 10: 35-45 37. Brewster A: A patient's reaction to amniocentesis. Obstet Gynecol 1984; 64: 443-444 38. Verjaal M, Leschot NJ, Treffers PE: Women's experiences with second trimester prenatal diagnosis. Prenat Diagn 1982; 2:195-209 39. Kaltreider NB, Goldsmith S, Margolis AJ: The impact of mid-trimester abortion techniques on patients and staff. Am J Obstet Gynecol 1979; 125: 235-238 40. Lilford RJ, Johnson N: Surgical abortion at twenty weeks: Is morality determined solely by the outcome? J Med Ethics 1989; 15: 82-85 41. Stubblefield PG: Surgical techniques for uterine evacuation in first- and second-trimester abortion. Clin Obstet Gynaecol 1986; 13: 53-70 42. Castodot RG: Pregnancy termination: techniques, risks, and complications and their management. Fertil Steril 1986; 45: 5-17 43. Grimes DA, Schulz KF: Morbidity and mortality from second-trimester abortions. J Reprod Med 1985; 30: 505-514 44. Schmidt R, Priest RG: The effects of termination of pregnancy: a follow-up study of psychiatric referrals. Br J Med Psychol 1981; 54: 267-276 45. Rayburn WF, LaFerla JJ: Second-trimester pregnancy termination for genetic abnormalities. J Reprod Med 1982; 27: 584-588

46. Lloyd J, Laurence KM: Sequelae and support after termination of pregnancy for foetal malformation. Br Med J 1985; 290: 907-909 47. Kenyon S: Support after termination for fetal abnormality. Midwives Chron 1988; 102: 190-191 48. Donnai P, Charles N, Harris R: Attitudes of patients after "genetic" termination of pregnancy. Br Med J 1981; 282: 621-622 49. Jones OW, Penn NE, Shuchter S et al: Parental response to mid-trimester abortion following amniocentesis. Prenat Diagn 1984; 4: 249-256 50. Euthanasia Aiding Suicide and Cessation of Treatment (rep 20), Law Reform Commission of Canada, Ottawa, 1983: 1820 51. Slater ETO: German eugenics in practice. Eugen Rev 1936; 27: 285-295 52. Alexander L: Medical science under dictatorship. N Engi J Med 1949; 241: 39-47 53. Lifton RJ: The Nazi Doctors, Basic, New York, 1986: 417466 54. Jacob A: Consequences of the legalized abortion law in India. Presented at the World Congress on Law and Medicine, New Delhi, Feb 24, 1985 55. Wertz DC, Fletcher JC: Fatal knowledge? Prenatal diagnosis and sex selection. Hastings Cent Rep 1989; 19 (3): 21-27 56. Idem: Ethical problems in prenatal diagnosis: a cross-cultural survey of medical geneticists in 18 nations. Prenat Diagn 1989; 8:1-13 57. Feil RN, Largey GP, Miller M: Attitudes toward abortion as a means of sex selection. J Psychol 1984; 116: 269-272 58. Kitchen WH, Rickards AL, Ford GW et al: Outcome for live-born infants of 24-28 weeks' gestation: survival and sequelae at two years of age. In Abortion: Medical Progress and Social Implications (Ciba Foundation Symp 115), Pitman, London, 1985: 122-135 59. Dunn PM, Stirrat GM: Capable of being born alive. Lancet 1984; 1: 553-555 60. Alberman E, Kane W, Stanwell-Smith R: Congenital abnormalities in legal abortions at 20 weeks' gestation or later. Ibid: 1226-1228 61. Mundy D, Francome L, Savage W: Twenty-one years of legal abortion. Br Med J 1989; 298: 1231-1234, erratum 1367 62. Screening for foetal and genetic abnormality, conference report. Lancet 1987; 2: 1408 63. Late abortions and the law [E]. Br Med J 1988; 296: 446-447 64. Durant W, Durant A: The Lessons of History, S&S, New York, 1968 65. Motulsky AG, Murray J: Will prenatal diagnosis with selective abortion affect society's attitude toward the handicapped? Prog Clin Biol Res 1983; 128: 277-291 66. Sadovnick AD, Baird PA: A cost-benefit analysis of prenatal detection of Down's syndrome and neural tube defects in older mothers. Am JMed Genet 1981; 10: 367-378 67. Chapple JC, Dale R, Evans BG: The new genetics: Will it pay its way? Lancet 1987; 1: 1189-1192 68. President's Committee on Mental Retardation: Action for the Retarded: Recommendations to the President on Federal Programs, US Dept of Health, Education, and Welfare, Washington, 1973: 73-83 69. Tosi LL, Detsky AS, Roye DP et al: When does mass screening for open neural tube defects in low-risk pregnancies result in cost savings? Can Med Assoc J 1987; 136: 255-265 70. Callahan D: How technology is reframing the abortion debate. Hastings Cent Rep 1986; 16: 33-42 71. Queenan JT: Fetal therapeutics: present status and future prospects. Clin Obstet Gynaecol 1983; 26: 407-417 72. Adzick NS, Flake AW, Harrison MR: Recent advances in prenatal diagnosis and treatment. Pediatr Clin North Am 1985; 32: 1107-1117 73. Boothill PW, Nicolaides KH, Rodeck CH: Invasive techniques for prenatal diagnosis and therapy. J Perinat Med CAN MED ASSOC J 1990; 143 (3)

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1987; 15: 117-127 74. Shaw MW: To be or not to be? That is the question. Am J Hum Genet 1984; 36: 1-9 75. Gerber P, Pearn JH, Bell J: Prenatal cytogenetic diagnosis: some potential legal implications. Med J Aust 1985; 143: 8083 76. Fleisher LD: Wrongful births: When is there liability for prenatal injury? Am J Dis Child 1987; 141: 1260-1265 77. Modell B: Prenatal diagnosis. Chorionic villus sampling. Evaluating safety and efficacy. Lancet 1985; 1: 737-740 78. Multicentre randomised clinical trial of chorion villus sampling and amniocentesis: first report. Canadian Collaborative CVS-Amniocentesis Clinical Trial Group. Lancet 1989; 1:1-6

79. Wade RV, Young SR: Analysis of fetal loss after transcervical chorionic villus sampling - a review of 719 patients. Am J Obstet Gynecol 1989; 161: 513-518 80. Goldsmith MF: Trial appears to confirm safety of chorionic villus sampling procedure. JAMA 1988; 259: 3521-3522 81. Blakemore KJ: Prenatal diagnosis by chorionic villus sampling. Obstet Gynecol Clin North Am 1988; 15: 179-213 82. Lynch A: The amniocentesis-abortion-advocacy discontinuum. Presented to the 6th Congress of the International Association for the Scientific Study of Mental Deficiency, London, Ont, Aug 22-26, 1982 83. Campbell AV: Viability and the moral status of the foetus. In Abortion: Medical Progress and Social Implications (Ciba Foundation Symp 115), Pitman, London, 1985: 228-243

Conferences

Oct. 11 - 12, 1990: Histopathologic Diagnosis of Inflammatory and Neoplastic Skin Diseases: Assessment of Patterns and Silhouettes Halifax Sheraton Dr. Noreen Walsh, Department of Pathology, Victoria General Hospital, Rm. 721, D.J. MacKenzie Building, 1278 Tower Rd., Halifax, NS B3H 2Y9; (902) 428-3897

continuedfrom page 180 Sept. 30-Oct. 3, 1990: International Health Policy and Management Institute 7th Annual Conference "World Health Care in Transition" Hotel Berlin, Berlin, West Germany Darwin W. Schlag, Jr., c/o Laventhol & Horwarth, Ste. 1100, One City Centre, St. Louis, MO 63101; (314) 421-1710 Le 30 sept.-le 3 oct. 1990: 4e Congres international francophone de gerontologie Palais des congres, Montreal Les services de congres GEMS, 100-4260 Girouard, Montreal, PQ H4A 3C9; (514) 485-0855, telecopieur (514) 487-6725

Oct. 1-5, 1990: Canadian Society of Forensic Science Annual Conference Skyline Hotel, Ottawa Canadian Society of Forensic Science, 215-2660 Southvale Cres., Ottawa, Ont. Kl B 4W5; (613) 731-2096

Oct. 2-5, 1990: Canadian Association of Pediatric Hospitals Annual Conference Montreal Barry Rabinovitch, chairman, Organizing Committee, CAPH Conference '90, Montreal Children's Hospital, 2300 Tupper St., Montreal, PQ H3H 1 P3; (514) 934-4400 Oct. 10-12, 1990: Colloquium on Violence and the Elderly - Organizing Today for Tomorrow (cosponsored by Suirete du Quebec) Universite du Quebec, Montreal Transition House Association of Nova Scotia, 310-169 Provost St., New Glasgow, NS B2H 2P9; (902) 755-4878

Oct. 10-13, 1990: 5th National Conference on Perinatal Care and Prevention of Handicap: Promotion of Health Prevention of Handicap Ramada Renaissance Hotel, Saskatoon Saskatchewan Institute on Prevention of Handicaps, Box 81, University Hospital, Saskatoon, Sask. S7N OXO; (306) 966-2512 186

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Oct. 11-14, 1990: Canadian Pain Society (IASP Chapter) Annual Meeting London, Ont. Ms. Inese Kramins, Local Arrangements Committee, Department of Psychology, University of Western Ontario, London, Ont. N6A 5C2 Oct. 12-14, 1990: Freud and the History of Psychoanalysis Trinity College, University of Toronto Dr. Andrew Brink or Herma Joel, 300 Larkin Building, Trinity College, 6 Hoskin Ave., Toronto, Ont. M5S 1H8; (416) 978-8454 Oct. 13, 1990: Undersea and Hyperbaric Medical Society (Great Lakes chapter) 11th Annual Scientific Meeting Toronto General Hospital Dr. Rhonda Wilansky, Hyperbaric Department, CCRW G-821, 200 Elizabeth St., Toronto, Ont. M5G 2C4; (416) 340-4481, FAX (416) 340-3698 Oct. 14-18, 1990: Canadian Association of Radiologists 53rd Annual Meeting Pan Pacific and Vancouver Trade and Convention Centre Suzanne Charette, Canadian Association of Radiologists, 510-5101 Buchan St., Montreal, PQ H4P 2R9; (514) 738-3111 Oct. 16-20, 1990: Annual Joint Meeting of the Canadian Cardiovascular Society, the Canadian Council of Cardiovascular Nurses, the Heart and Stroke Foundation of Canada and the Canadian Society of Clinical Perfusionists World Trade and Convention Centre, Halifax Betty Fata, 645-375 Water St., Vancouver, BC V6B 5C6; (604) 681-5226, FAX (604) 681-2503

continued on page 193