End of Prenatal Medical Care?

Marek R. Litmanowicz, Ph.D., specialist in prenatal testing

There are two aspects of the consequences of the Constitutional Tribunal’s judgment. The first boils down to answering the question: What will be allowed in theory and what will be possible in practice? Of course, prenatal tests have not been banned; any patient who is qualified for such diagnostics will be able to get tested within the National Health Fund (NFZ) system of services [100-percent reimbursed by the state].

We are talking about basic blood tests determining the likelihood of genetic defects in the fetus. Pregnancy Associated Plasma Protein A determines the probability of Patau syndrome, Edwards syndrome and, of course, Down syndrome. As part of NFZ services, you can also have an amniocentesis, for which you are referred after consulting a genetic clinic. Prenatal diagnostics also includes a biopsy of umbilical cord vessels in the case of suspected malformation, after gynecological consultation and ultrasound examination. This is also legal, but if the fetus dies as a result of such a procedure, the doctor might be accused of murder, given the judiciary apparatus’ current approach. The result will be this: Clinical facilities will officially declare their readiness to perform prenatal diagnostics; no one will renounce this in order to meet European standards. However, a large number of patients will not get tested; they Marek R. Litmanowicz, Ph.D will be afraid that even if the examination does not go well, there will be nothing to be done about it. In addition, many doctors, especially those who have signed the so-called conscience clause, will simply not inform patients about the possibility of getting tested or refer them for such tests.

Private diagnostics (no refund) is another option. More affluent patients will always be able to undergo prenatal diagnosis. Tests that extract data from a woman's blood to determine the fetus's karyotype currently cost about 2,000 zlotys. But we do not know whether, under the authorities’ future measures, such tests will remain legal; if not, prenatal diagnostics will cease to exist.

Aspect number two is the answer to the question: If a patient is informed that her fetus is seriously damaged, what then? The vast majority of defects detected by prenatal tests (not counting ultrasounds) are not lethal defects, and even finding obvious damage to the fetus will not be grounds for terminating the pregnancy. Even if the Polish president’s proposed amendment on lethal defects were to come into force, it is very difficult to specify and medically define them so that they can be unequivocally diagnosed. Doctors will find themselves under enormous pressure; so-called “defenders of life” will park their vans in front of every clinic that undertakes such testing, and they will call the doctors murderers.

Already with the current legislation, it has been difficult to perform legal forms of abortion, i.e. when the pregnancy was a result of rape or incest, or when the pregnancy threatened the life or health of the woman. As far as I know, all the hospitals in Podkarpackie province have already signed the above-mentioned conscience clause and a pregnancy cannot be legally terminated anywhere. Therefore, even during the time of the still valid “abortion compromise” from 1993, which is in fact a very restrictive law on the admissibility of abortion, it was often difficult to implement it. What will happen now is easy to guess.

Richer patients will get their prenatal diagnosis abroad. Here in Poland, we will observe not so much a lack of progress as simply a regression in the field of prenatal testing and therapy. Today in Poland, it is an area that is not inferior to world standards. Not only advanced research but also state-of-the-art therapies are being carried out, to mention decompression of hydrocephalus, renal decompression or really advanced, pioneering surgeries in which a sick fetus either undergoes endoscopic fetal surgery or is taken out of the uterus (while preserving the amniotic fluid), operated on, put back in, flooded with amniotic fluid and sealed with tissue glue. Such operations are only performed on fetuses that would otherwise have no chance of survival, but what doctor will undertake them once the law starts treating him or her like a killer if such a procedure fails?

Today in Poland we have a really high, European or even global standard of prenatal diagnostics. But there is a risk of a total crisis in this area if specialists withdraw from the profession for fear of not just professional but also legal consequences.

In countries such as Germany, France or the Netherlands, any doctor signing a document like the Polish “conscience clause” would lose their right to practice medicine the next day. The law of these countries clearly states that healthcare workers should be guided by science and medical knowledge, not by religion or any ideology. The situation in Poland is absurd: Dr. [Bolesław] Piecha [a member of the ruling Law and Justice (PiS) party], a gynecologist, speaks publicly about the “dignity of the embryo”; he pretends not to know that the cells responsible for thinking and consciousness develop around the 25th to 26th week of pregnancy. The embryo, which is undoubtedly human, therefore has no consciousness before then. Medically speaking, the stories disseminated by pro-life movements and recently, unfortunately, by public television, are fiction.