March 3, 2024

The zig-zag history of surgical treatment of spinal bifida

When is a clinical assessment ‘objective’?

A brief history of surgical treatment of spinal bifida in newborns in The Lancet raises interesting questions about the objectivity of medical judgements.

As the authors point out, spinal bifida is less common nowadays in developed countries for several reasons. The simple remedy of folic acid supplements has decreased its incidence and prenatal tests followed by abortion have decreased its prevalence.

However, when treatment became possible early last century, influential surgeons opposed it, partly for eugenic reasons. “In 1927, Edinburgh surgeon John Fraser, for instance, argued that many of the patients with spina bifida he had operated on were ‘evidently crippled in body or in mind or in both’, so that ‘as the records were gone through, one was tempted to say, “Cui bono [who benefits]?”’”.

In 1963 surgeons at Sheffield Hospital in the UK, including Robert Zachary and John Lorber, did a randomised control study on outcomes of post-natal surgery. They found that “neurological outcome improved after early surgical intervention, whereas the neurological condition of patients with no or delayed surgery further deteriorated”. Survival rates could be improved from 10% to 90%. They concluded that omitting surgery was “unethical”.

But Zachary – who had severe scoliosis himself – and Lorber diverged as time went on. In 1971 Lorber established a set of “objective” criteria for selective treatment. If any of these criteria existed in a newborn, he said, “no method of treatment could lead to an acceptable quality of life”.

Zachary vigorously opposed this. His position was that “disability was not the result of the physical or mental impairments per se, but of society's response to such impairments”. Furthermore, he noted that the babies could have survived if they had not been medicated to death.

The authors conclude: “In constructing his selective treatment policy, Lorber weaved [sic] an intricate web of facts and values, using scientific findings to make ‘objective’ clinical recommendations, while the problem essentially revolved around conflicting normative judgments.”

Michael Cook is editor of BioEdge  

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