Counselling before and after ANT is crucial [20
]. It is suggested that, in an ideal counselling, the parents should be told that there is no 'right' decision to be made, and it should be made clear that whatever their decision is, it will be supported. They must also be clear about whether it is a screening test or a diagnostic test, and how accurate it is in their particular situation. They need to be aware of the risks involved to the pregnancy and the possible consequences of dealing with the information the test provides [21
]. Normally, medical professionals should not offer antenatal diagnosis, because it is known that it is very difficult for a woman to decline AND when offered [22
]. Instead, they should discuss the feasibility, accuracy and clear-cut details of any such tests, including the dangers of it.
Three pieces of information which women tend to cite as reasons for changing their minds about tests are;
- the level of risk they have for the condition in question;
- the miscarriage risk of the test being considered;
- the method of termination which would be offered if they chose to terminate the pregnancy following an abnormal result from the test in question [21
To provide this kind of ideal counselling, firstly there must be enough well-trained health care professionals. The units that provide these services must also provide suitable training opportunities and satisfy the expectations of users of ANT services.
Chadwick suggests that 'genetic counselling' includes the following kinds of activity:
a) advising adults, pre-conception, of the probability of their conceiving a child with a genetic disorder;
b) advising adults, post-conception, and as a result of some method of fetal screening, as to whether or not the fetus is suffering from a genetic disorder;
c) alerting them to the options open to them [23
Clearly, it is important to leave the final decision to the parents. Doctors are supposed to not impose their own moral attitudes upon their patients. If they find themselves disagreeing with the moral stance of their patients over these issues they should explain their situation and advise the patients to consult a clinical geneticist [24
However, it seems it does not work like this in practice. Because, making rules does not mean everything. The most important and difficult thing is applying them. And this depends on the development of public awareness and education [25
]. It is argued that the conflict of interests between providers and users of antenatal screening services is clearly reflected in the counselling process. At all stages of screening, counselling is systematically biased towards encouraging women to take up the tests and have an abortion if an abnormality is detected, rather than providing women with the information and support they require to make an informed choice and to avoid unnecessary distress [10
]. The Medical Research Council (MRC) stated in its report that: "Of the 112 women (including high risk women) interviewed after they had had an amniocentesis, 28 (24 per cent) were unaware that amniocentesis carried a risk of miscarriage, and 96 (86 per cent) were unaware of any other possible hazards. Of the 16 women aware of the possible risks to the newborn infant, 12 had obtained this information from sources other than the medical staff who had counselled them about amniocentesis" [14
]. There is literature available which is compatible with the MRC's report. For example: "Women undergoing routine antenatal screening are generally under-informed about the tests they are being offered and may subsequently undergo. For example, 39 per cent of women who had recently undergone maternal serum alphaprotein (MS-AFP) screening for open neural tube defects were unaware that they had even had the test" [26
Self-evidently, this is not an ideal situation for any health care service. Apart from the failure to provide enough information, the bias toward termination of pregnancy in the event of abnormality detection is another controversy in AND procedure. It is generally conceded by the medical profession that the primary aim of antenatal diagnosis is the detection, and subsequent abortion, of abnormal fetuses. Because of the procedural risks to the fetus and the lack of effective methods of fetal therapy for most malformations, antenatal diagnosis is a rational activity only if abortion is seen as an acceptable alternative [27
]. However, this kind of approach to prenatal diagnosis may be considered not only unfair, but also rather unethical, by some people.
In order to describe the feelings of parents who are pushed to have a termination, one needs to have experienced it. But it is not too hard to comprehend the difficulty for parents who decide not to terminate a pregnancy with a diagnosed fetal abnormality-they must face, as well as the distress of coping with a handicapped child, the mental and emotional struggle of defending their decision before health professionals [28
]. In an ideal ANT procedure, health care professionals are expected to strengthen their role as providers of support to the families for whom they care. They should provide moral support and practical help both to those who terminate fetuses at risk of malformation or disease and to those who choose not to do so. Furthermore, ANT providers in this field are expected to prevent any possibility that financial considerations might affect clinical behaviour. Angus Clarke, a clinical geneticist, makes a distinction between giving advice-a prescriptive activity, often subtly authoritarian when applied to the field of personal reproductive decisions-and the informing, supportive, and 'enabling' process of counselling [29
]. And he adds: "We do not tell people what to do but support them in reaching decisions, with the consequences of which they then have to live for the rest of their lives. We may have to inform clients about the disadvantages of their preferred course of action so that they can examine all options (such as a permanently handicapped child, or permanent remorse at a termination), but, when the decision is genuinely their own, the parents are much more likely to be able to live with it" [29
Another counselling issue related to ANT is that of directiveness. It has been argued that pre-test counselling should be non-directive since it is counsellee and not the counsellor whose entire future life may be affected by decisions made at the sessions. However, those present at the Third European Meeting on Psycho-social Aspects of Genetics (1992) voted by a narrow majority that non-directive genetic counselling was not achievable in practice. This is partly due to the fact that counsellors come to sessions with their own views about what they think they would do in the situation or what they think a responsible person should do. These views may be held consciously or unconsciously but they will influence the counsellors' choice of words in describing conditions, tests and probabilities, their facial expression, body language, and the order in which things are explained and the amount of time spent on different topics. For this reason non-directive counselling is thought to be an unattainable ideal. It is not because of a personal failure on the part of the genetic counsellor but as a direct result of the structure of the encounter between counsellor and client [30
]. Clarke argues that the counsellor's conscious or even unconscious motives are irrelevant; the offer and acceptance of genetic counselling has already set up a likely chain of events in everyone's mind [30
From all these discussions it becomes apparent that non-directive counselling is a myth. Today, counselling is directive, and its direction is towards having ANT and going to termination if something is wrong with the 'baby in the womb'. Let us now discuss (in terms of its benefits to different parties) the consequences of ANT.