Ultrasound technoloy boon or bane ?

By Manohar Agnani

A recent newspaper article reported that a brain dead pregnant woman on life support had passed the milestone in her pregnancy where doctors believed her baby could survive outside the womb, giving her family new hope. The family spokesperson said the baby is a girl and that Cecilia was a possible name the couple had discussed before her stroke.

As with all knowledge, ethical aspects have assumed an important criterion in the use and abuse of emerging technology. There have been regulatory procedures to limit the misuse of technology but rapid advances often make the regulatory process redundant. It is therefore necessary to periodically review such regulations. One such technology that needs to be examined is ultrasound. The ethical questions involved here are as grave as the questions weighed in the field of human cloning. The value of ultrasonography in healthcare facilities weighs heavily on its multi-functionality. It produces live images of muscle and soft tissue, enabling doctors to select the most useful sections for diagnosing and documenting changes. It shows the structure and function of internal organs and is a useful way to examine the musculoskeletal system to detect problems with muscles, ligaments, and joints. It also assists in identifying blockages, stenosis and other vascular abnormalities. Ian Donald and colleagues at the Glasgow Royal Maternity Hospital in Scotland conducted the first diagnostic procedures using ultrasonography. They applied these techniques to obstetrics to assess the growth of the foetus. As technical quality of scans further developed, it became possible to monitor pregnancy from start to finish and diagnose complications such as multiple pregnancy and foetal abnormalities. But the technology that came with a promise of wide-ranging benefits was soon abused as a tool to probe the foetus' sex and led to sex selective eliminations. In a country like India, where most of the population is still steeped in feudal mindsets, the obsession for a son has led to an adverse sex ratio and the situation has become alarming in some areas. In Madhya Pradesh's Morena district, the present child sex ratio stands at 837 (girls per 1,000 boys). To put an end to sex determination tests, the district authorities cancelled seven licences of ultrasound clinics and nursing homes that were suspected of carrying out the practice of sex selective elimination. But the order was set aside by state authorities and the clinics continued to function. Social activists then challenged the state's decision through public interest litigation (PIL) in the high court. The court stayed the state's move and re-imposed the ban, which was subsequently removed on the undertakings of the ultrasound centres and clinics. The clinics, in their replies, highlighted the benefits of sonography and what a boon it has been to mankind. The main argument put forward was that the petitioners might not know what ultrasound is and where it is used? They cited reports by the American Pregnancy Association and argued that ultrasound was indispensable for ascertaining congenital abnormalities and the health of the baby and the mother. They added that the petition deliberately emphasised only one aspect of ultrasonography - determination of foetal sex. The above argument is contrary to facts and opinion of experts. The economic aspect of sex determination tests is so overwhelming that the greed pushes back all considerations and caution is thrown to winds to make more money. The economics of the entire operation is revealed by Puneet Bedi, a doctor at Apollo Hospital in New Delhi, who is a votary of strong social values for the medical profession. He said: 'Ultrasound was invented in the 1950s for safe motherhood but it has not only killed millions of foetuses in India, it is also a leading cause of maternal mortality.' Since millions of foeticides occur every year in India, tens of thousands of doctors and nursing home owners are involved in it. The economics of the business, according to Bedi, is simple to understand. 'For every million foetuses killed, at least two million ultrasound examinations are done and one million abortions are performed. The revenue earned thus runs into at least Rs.5 billion (assuming that one sex determination and abortion costs Rs.5,000).' Coming to the cautionary warnings against ultrasound, a recent study by Pasko Rakic, chairman of the neurobiology department at Yale University School of Medicine says that exposure to ultrasound can affect foetal brain development. But it does not mean that the use of ultrasound on human foetuses for appropriate diagnostic and medical purposes be abandoned. Says Joshua Copel, president elect of the American Institute of Ultrasound Medicine: 'It's certainly helpful to know the anatomy of the foetus, but we should not be holding a transducer on the mom's abdomen for hours and hours!' Rakic's paper said that while the effects of ultrasound on the human brain development are not yet known, there are disorders thought to be the result of misplacement of brain cells during their development. As far as safety aspects are concerned, the risks of ultrasound during pregnancy are not fully known. Ultrasound has been possibly linked to miscarriages, lower birth weight, and pre-term labour. According to American Council of Gynaecologists, an ultrasound is not always accurate and it does not recommend its routine use. 'Ultrasound examination may disrupt normal brain development in unborn babies,' says Helle Kieler of Karolinska Institute, Stockholm. The expert urges mothers to avoid unnecessary ultrasonic scans but not cancel routine examinations. The World Health Organisation (WHO) too recommends prudence in ultrasound exposure to human subjects.

The Gokhale Institute of Politics and Economics at Pune had published a study of ultrasound clinics in Maharashtra. It showed that knowledge, financial resources and access are three factors which, when they come together, enhance the possibility of sex determination techniques and sex selective elimination being practiced. The study's finding clearly indicates the strong correlation between availability of sonography centres and decline in child sex ratio during 1991-2001. Demographer Ashish Bose had said: 'The unholy alliance between tradition (son preference) and technology (ultrasound) has played havoc in Indian society.' The above facts call for a reconsideration of the regulatory mechanism connected with ultrasound technology. More stringent regulations and awareness efforts at social grassroots level are urgently needed.