OF all the choices confronting prospective parents during the next decade, those involving reproductive technology promise to be the most complicated. ``Many ethical dilemmas are coming up for the '90s with more sophisticated technology,'' says Dr. Brian Udell, a neonatologist at Broward General Medical Center in Fort Lauderdale, Fla. ``There will be a lot more babies who will survive.''
Ten years ago, he explains, the goal of neonatologists was to save three-pound babies. Today 85-to-90 percent of two-pound babies survive, along with 40 percent of one-pound babies. ``It may even go down to a 12-ounce baby or a 10-ounce baby that is survivable,'' he says.
But saving these tiny infants carries an enormous price tag. ``Babies who are born at 23 weeks can go through half-a-million dollars in their neonatal time,'' says Rebecca Heikenen, a neonatal nurse in Minneapolis. ``At what point do you draw the line and say we can't afford to do that? On the other hand, if it were my own child who could benefit from some expensive high-tech procedure, I would probably want everything done.''
Mrs. Heikenen and others who work in neonatal units also express concern about the quality of life for tiny infants who survive with grave physical problems.
Ten years ago, Dr. Udell explains, if a baby was born with major defects, doctors could talk to the parents and decide whether to continue treating the infant. Today, he says, ``I wouldn't even have that conversation with the parents. I have to do everything I can to save the baby. A downside of the current medical-legal climate and the right-to-life movement in some ways has been this inability for a mother and father to control their family's destiny.''
To avoid such heart-rending dilemmas, medical experts emphasize the importance of preventing premature births.
``The answer is to start changing our whole thinking,'' says Dr. Michael Katz, an associate professor of obstetrics, gynecology, and reproductive sciences at the University of California in San Francisco. ``For the last 25 years we have been working on making the intensive-care nursery a better womb. We add machinery, we add doctors. But we do very little to try to make the womb a better nursery. That's what I'm trying to focus on.''
For the '90s, other reproductive specialists will be focusing on the estimated 2.4 million US couples who cannot bear children because of infertility problems. For them, in-vitro fertilization and other forms of ``assisted reproduction'' offer new hope for conceiving a child of their own.
At the same time, these advances are changing the way men and women view procreation. ``The technology we're developing continues to substitute for one or another of the nurturing roles of pregnancy,'' says Barbara Katz Rothman, a professor of sociology at Baruch College in New York City, speaking at a conference on reproductive technology in Boston.
``The act of giving birth becomes increasingly unnecessary as doctors work on the surgical removal of babies, to the point where 1 in 5 American babies are born by Caesarean section. The nurturance of late pregnancy becomes unnecessary as neonatal intensive-care units develop the skills to maintain younger and younger babies. And the nurturing environment of the fallopian tubes has become replaceable as the nurturance of the glass dish, the in-vitro environment, develops.''
In the process, she continues, ``Mothers get reduced to backgrounds, to environments, to sites in which genetic material develops. But a pregnant woman is not a place, she is not a site, she is not a walking incubator. She is a person. She is engaged at a variety of levels in the process of baby-making. We act as if babies just unfold out of that little seed without interaction from the woman, without context.''
Adrienne Asch, a member of the New Jersey Bioethics Commission and another conference speaker, is also troubled by the bioengineering of birth. If parents try to control what they can control by using prenatal diagnosis, or a Nobel Prize sperm bank, or the perfect surrogate mother, she asks, ``How will they deal with the many unforeseen things that happen to all of us in all of our lives with the children we have that we can't control? If we work so hard before children are born to give the fantasy child the best chances for the fantasy life, what will our tolerance be for all the things we cannot tolerate?''
Ms. Asch concludes: ``Reproductive technologies are human issues and social issues, and we need women and men to think about them seriously.''