ultralyd

Abortdebatten kommer!

Stortinget vedtar i mai å tilby alle gravide fosterdiagnostisk tidlig ultralyd. Vedtaket vil utløse en omfattende abortdebatt som først ender med partienes landsmøter våren 2021.

Nå er det klart at Sosialistisk Venstreparti (SV), Fremskrittspartiet (Frp) og Arbeiderpartiet (Ap) vil fremme et forslag om å tilby alle gravide et tilbud om tidlig ultralyd til alle gravide. Forslaget vil få flertall i Stortinget.

Anmodningsvedtak om tidlig ultralyd

Stortinget er demokratiets øverste organ. Stortinget vedtar lover og budsjett. Utarbeidelsen av lovverk skjer for det meste i departementene. Forslaget som Stortinget vedtar, blir et såkalt anmodningsvedtak, dvs. at Stortinget ber regjeringen utarbeide et lovforslag som sikrer alle gravide fosterdiagnostisk tidlig ultralyd. Når departementet har utarbeidet et slikt forslag, sendes forslaget fra regjeringen til Stortinget for behandling. I disse koronatider hvor det til stadighet kommer nye regler for helsetjenesten, så er nok kapasiteten i Helsedepartementets lovavdeling mer eller mindre sprengt. Mest trolig kommer det ikke et lovforslag i denne stortingsperioden.

Partienes landsmøter

Anmodningsvedtaket er viktig samtidig som det på sett og vis trolig er betydningsløst. Det er viktig i den forstand at det er første gang et stortingsflertall sier at «dette vil vi». Det er betydningsløst i den forstand at det er langt fra sikkert at anmodningen noen gang kommer. Før et eventuelt lovforslag fra regjeringen, har en hatt partienes landsmøter som vedtar partienes programmer. Kanskje en også har hatt stortingsvalg og fått en ny regjeringskonstellasjon og nye mulige flertall i Stortinget.

Anmodningsvedtaket er først og fremst en katalysator som setter hele abortloven under debatt frem mot partienes landsmøter. Vi snakker om NIPT-testen som er langt mer presis og enklere å utøve enn fosterdiagnostisk tidlig ultralyd. Det er allerede blitt fremmet forslag fra profilerte politikere om å heve grensen for selvbestemt abort til både 16. og 22. uke. Anmodningsvedtaket vil trolig havne i skyggen av de kommende abortlovsdiskusjonene.

Partienes syn på fosterdiagnostikk

Det at SV slutter seg til et anmodningsvedtak om å innføre tidlig ultralyd, er ingen oppsiktsvekkende sak. SV-landsmøtet vedtok å innføre et slikt tilbud allerede i 2013. Ap har stått på samme linje så lenge jeg kan huske. Frp har en rimelig liberalistisk holdning også på det etiske feltet. Siden 1990-tallet, da fosterdiagnostikken og sorteringsproblematikken var på dagsorden for første gang, har stadig flere partier beveget seg i retning av å åpne for mer fosterdiagnostikk. De fleste partiene fokuserer i stadig sterkere grad på kvinnens rett til å bestemme. Unntakene har vært partiet Rødt som, i det minste i perioder, har hatt et svært kategorisk syn på sorteringsproblematikken og de rasehygieniske siden av fosterdiagnostikken. Fosterdiagnostisk tidlig ultralyd har særlig til hensikt å avdekke Downs syndrom og andre trisomier. Partiet Rødt har markert seg mot en slik jakt på bestemte mennesker. KrF har vært minst like kategorisk, men ut i fra barnets rettsikkerhet og livets ukrenkelighet.

Det som er helt sikkert, er at fosterdiagnostikk, tidlig ultralyd og mere til, vil bli en stor sak i programarbeidet og på landsmøtene til de fleste partiene våren 2021.

Hvordan fremtidige lovendringer måtte bli, er langt mer avhengig av hva partiene bestemmer på sine landsmøter og valgresultatet ved stortingsvalget 2021 enn av anmodningsvedtaket.

Fosterdiagnostisk tidlig ultralyd

De fleste gravide har fått ultralydundersøkelser rundt uke 18. Da sveiper legen ultralydhodet over magen til den gravide og en får se barnet. Mange kjøper lignende undersøkelser fra privatpraktiserende leger og får med seg imponerende 3d-bilder av den kommende samfunnsborgeren. Slike ultralydundersøkelser må ikke forveksles med fosterdiagnostisk tidlig ultralyd som er en høyst spesialisert undersøkelse som kun utøves ved universitetssykehusene.

Har fosteret Down syndrom, Edward syndrom, Pataus syndrom eller andre trisomier, så vil det ofte vise seg i form av forstørret nakkefold i uke 11 til 14. Ved fosterdiagnostisk tidlig ultralyd, er siktemålet å sjekke størrelsen på nakkefolden, i tillegg til noen andre indikasjoner på trisomi, spesielt utviklingen av nesebenet.

Men fosteret er lite, nakkefolden er bitte liten og hevelsen enda mindre. Det å måle tverrsnitt er ingen enkel oppgave, tverrsnittet er nemlig svært avhengig av vinkelen som tverrsnittet måles i. Alle som har kuttet en banan opp i skiver har erfart dette. Skjæres skivene vinkelrett på bananen, så blir skivene sirkulære og tverrsnittet lite. Skjærer en mer på skrå, så blir skivene elliptiske og tverrsnittet blir større. Oppgaven med å måle nakkefolden rundt uke 12 i svangerskapet, er såpass krevende at de færreste fødselslegene ved universitetssykehusene har kompetanse til å gjennomføre fosterdiagnostiske tidlig ultralydundersøkelser.

Overlege Johan Arild Evang gjorde noen utregninger om metodens usikkerhet:

«Brukt på feil indikasjon, for eksempel hos kvinner uten spesiell risiko under 35 år, vil den [ultralydtesten] nesten bare gi falske positive prøver. Dersom en legger Kunnskapssenteret tall til grunn vil en hos en kvinne på 40 år få fem falske positive for hver sann positiv (Downs syndrom) mens hos en kvinne på 30 år vil få ti ganger så mange falske positive: 50 falske for hver sann.»

For når gravide på 40 år testes, så vil testen altså feilaktig vise at et foster har Downs syndrom eller andre trisomier i fem av seks tilfeller. Når den gravide er 30 år, så vil testen feilaktig vise at et foster har Downs syndrom eller andre trisomier i 50 av 51 tilfeller.

Når testen feiler mye mer blant yngre enn blant eldre gravide, så kommer det av at sannsynligheten for at barnet har trisomi, øker med morens alder.

Sikre svar er umulige å få med ultralyd, men med fostervannsprøve eller morkakeprøve, kan en få svar på om fosteret har trisomi eller ikke. Problemet med slike undersøkelser er at prøven skal skade fosteret eller medføre spontanabort.

Men uansett hvor sikker testen er, så er det ingen helsegevinst med tester for å avdekke trisomi. Oppdager en trisomi, så finnes heller ingen behandling. Den gravide kan ta abort, men om abort skal regnes som behandling, er et problematisk spørsmål.

Perspektiver i abortdebatten

Abortdebatten har vart lenger enn abortloven som er fra 1975. Frontene har vært steile og ulike grupper har argumentert ut i fra ulike synsvinkler og perspektiver. I forkant av abortloven, var et vesentlig argument å få slutt på illegale aborter som kunne skade kvinnen. Slike argumenter hører en ikke lenger i Norge, selv om argumentasjonen er like aktuell i andre land. Fosterdiagnostikken kom etter abortloven og fosterdiagnostikken har også utviklet seg. Nye teknologiske muligheter gir nye muligheter for lovgivning. Selv om argumentene har variert noe, så har de tre grunnleggende perspektivene i debatten vært de samme. De vil også forbli de samme i den kommende abortdebatten.

Kvinneperspektivet sier at det er kvinnen som bærer fosteret, det er kvinnens kropp og det er kvinnen som skal bestemme over kroppen sin. Mange vil også hevde at kvinnen har rett på tilgjengelig informasjon om barnet hun bærer. Den klareste rendyrkingen av kvinneperspektivet finner en i deler av kvinnebevegelsen.

Fosterperspektivet vektlegger at det ufødte liv også er liv som skal underlegges rettsvern. Dagens abortlov har innbakt en vekst i fosterets rettsværn frem mot fødsel. Frem til uke 12 er det kvinnen som bestemmer. Fra uke 12 til uke 18 skal kvinnens ønsker behandles av en nemnd. Etter uke 18 er det i hovedregelen ikke tillat med abort. Den klareste rendyrkingen av fosterperspektivet finner en deler av de religiøse miljøene. Den katolske kirke, betrakter f.eks. livet som hellig fra unnfangelsen.

Stigmatiserings- og sorteringsperspektivet er det fokuset som NFU har eksponert. Når staten bruker store ressurser på å avdekke Downs syndrom og andre trisomier for å gi den gravide mulighet til å ta abort, så sender det et klart signal: Verken mennesker med Downs syndrom eller andre trisomier er likeverdige andre mennesker. Gener har vi både før og etter vi er født. Hvis barnet med tre kromosm 21 oppleves som et problem i svangerskapet, så er det fordi barnet fryktes å bli et problem etter fødselen. Man kan ikke være rasist om dagen, men ikke om kvelden.

I Danmark står sorteringsideologien sterkt. Det fødes nesten ikke barn med Downs syndrom lenger. De få som fødes er stort sett resultat av svake tester, såkalte falske negative. Stigmatiseringen har gått såpass langt at pårørende møtes med argumentasjonen i etterspørselen etter tjenester. Pårørende har seg selv å takke. De kunne tatt abort og blitt mindre avhengig av det offentlige tjenestetilbudet.

Ekstremvarianten av av stigmatiseringsperspektivet finner en i vår eugeniske tradisjonen og blant nyttefilosofer i tradisjonen til Peter Singer som hevder at det moralsk kan forsvares å ta livet av fødte barn.

Balansen mellom abortdebattens dimensjoner

De fleste vil akseptere at hver av de tre dimensjonene har noe for seg. Innrømmer en det, så har en langt på veg innrømmet at en står overfor et sant dilemma: Beveger en abortlovgivningen i retning av en dimensjon, så vil en automatisk svekke minst en av de andre dimensjonene.

Vi kan f.eks. rendyrke kvinneperspektivet og gi den gravide all informasjon og all myndighet over fosteret. En slik situasjon vil fjerne fosterets rettsvern og bidra til omfattende sortering. En kan rendyrke fosterperspektivet og forby all abort, men da har vi automatisk eliminert kvinnens selvbestemmelse.

Anerkjenner en kvinneperspektivet, fosterperspektivet og stigmatiseringsperspektivet som reelle forhold som bør vektlegges, så står en overfor en svært krevende balansegang. Våren 2021 får vi vite hvilke partier som evner krevende balansegang og hvilke partier som vil sortere mest.

Jens Petter Gitlesen

21 april 2020

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