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Dr. Amnio : UCLA’s Controversial New Chief of Obstetrics Takes Risks Others Won’t, Saves Babies Others Can’t

<i> Joy Horowitz is an ex-Times staff writer. She was once referred to Khalil Tabsh for prenatal tests. </i>

KHALIL TABSH was up all night delivering another baby and has just finished a 17-hour day, fueled only by cough drops and coffee. Now, wear ing green surgical scrubs, the newly appointed chief of obstetrics at the UCLA School of Medicine scrambles from his black Mercedes 560 SL and sweeps into the conference room 30 minutes late, like a man possessed. He is here, at Sherman Oaks Community Hospital, to discuss a case in which some lives must be ended to save others. And for Tabsh, the case is simple--a medical necessity--although he, perhaps more than anyone, still feels torn by it.

His 34-year-old patient has flown here from a small Midwestern town. For eight years, she has tried to conceive. Last year, she had a miscarriage. But in recent weeks, after in vitro fertilization, she had five embryos implanted in her womb and all five unexpectedly began to thrive. Now, the odds are not in her favor for a healthy pregnancy unless he uses his technical mastery: He must end the lives of three fetuses. Kill three to save two. That will allow this farmer’s wife to have the baby she so desperately wants. In fact, she can safely deliver twins, he reasons. If he does nothing, chances are that all five babies will either die or be born so premature that they’ll suffer brain damage and a host of other problems. The third option is to abort them all.

The audience Tabsh is trying to win over--a panel of doctors, lawyers and ethicists that compose the bioethics committee of the Los Angeles County Bar Assn.--is moved but not persuaded. Tabsh is not asking permission--the guidelines for doing such an experimental procedure are set by himself and a hospital research committee. But he does seem to be seeking approval, and he is certainly hoping for help in the struggle to balance what can be done, what the patient wants done and what should be done in cases like these.

Tonight, there is no consensus about the procedure in question, called selective termination or reduction of pregnancy, its safety and accuracy still unproved and its nomenclature a thinly veiled means of obscuring the emotional burdens of abortion.

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“Aren’t you playing a moral poker game with these fetuses?” one doctor asks.

“If we create human life with the knowledge that if there’s too many we can reduce their numbers, there’s an inherent disrespect in that,” another says. “We’ve got some doctors putting in extra babies only to turn to another doctor and ask him to get rid of a couple of them.”

“The future to me is bleak because I don’t know how this will be controlled,” says a third. “More and more people are pushing for aggressive fertility treatments. And we’re seeing more and more requests for selective reductions.”

Tabsh looks pained. “Patients with one baby with mental retardation--they suffer,” he says. The voice is Middle Eastern, the delivery brisk but gentle. “Can you imagine taking home five? But, you know, it’s very stressful on the person doing this procedure. I feel sick to my stomach every time I do this. It is not pleasant.”

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Tabsh is one of a handful of doctors across the country who is quietly pursuing selective termination. Technically, it is fairly straightforward--just a sidestep from amniocentesis. During the first trimester of pregnancy, when the fetuses are about 1 1/2 inches long, he watches them on a television monitor via ultrasound and selects those that, because of their position in the uterus, are most accessible. Still watching the monitor, he inserts a 22-gauge needle into the mother’s abdomen, through the uterus and into the chest cavity of the fetus and injects a lethal dose of potassium chloride. The heart stops and the fetus dies; in time, it is absorbed by the mother’s body.

“I’m pro-choice and I’m pro-life,” Tabsh tells the assembled group, thinking of the 20 times in the past two years that he has ended the lives of some fetuses to save others sharing a womb. “Knowing 20 of my patients have taken home healthy babies--this is why I do it.”

WHAT TABSH is wrestling with on this night is what he faces daily--a moral and ethical dissonance caused by what medical science enables him to do. That conflict defines his rapidly advancing branch of medicine--perinatology (literally, “around birth”), or maternal-fetal medicine. Perinatology turns on high-risk cases in which both mother and baby are the patients, not one or the other. It is the study of complicated pregnancies and of prenatal diagnosis, the wielding of tools such as ultrasound (also known as sonography) or amniocentesis or chorionic villi sampling, all of which allow one to “see” what is happening in the womb. Couples seek the new technology’s experts--a rare handful among whom Tabsh is prominent--to predict a pregnancy’s outcome and determine when to intervene to save a fetal life or end it, when to assure a successful pregnancy or terminate it.

It used to be that babies and pregnancy just happened. The doctor was there to monitor things, and he or she made an appearance at the decisive moment, intervening during the birth process, if at all. Even a decade ago, natural childbirth was the rage. Now, the laying of hands atop a pregnant belly seems to have been superseded by the laying on of ultrasound-conducting jelly, probing needles or fetal monitoring belts.

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High-risk pregnancies--involving mothers-to-be older than 35, couples with known genetic risks or a previous malformed child, women with medical problems or histories of miscarriage, and those whose tests indicate medical anomalies--can be monitored through technology unavailable a decade ago. Fetuses that would not have survived are born healthy now because doctors can judge when and how to deliver, and arrange for pediatric surgeons to be in the delivery room, ready to perform immediate procedures. Some surgical remedies can even be done in utero , although so far these are few and rarely indicated.

Doctors no longer simply ask, “Should we intervene in this pregnancy?” Instead, they focus on the questions of when and to what degree, particularly as the “high-risk” rubric seems to envelop a growing number of women. Even though the vast majority of pregnant women deliver healthy babies, more and more doctors are on the lookout for problems; peer pressure, malpractice fears and increasingly available technology are making intervention--from testing to selective termination--the norm rather than the exception. In the past 10 years, the number of women choosing prenatal testing has tripled.

Clinician, teacher, researcher, Khalil Mohammed-Ali Tabsh, 42, plows through this world like a combination high-tech wizard and the Lone Ranger.

“I’d place him among the top five or six people in the country in maternal-fetal medicine,” says Nicholas Assali, a founding father in the field of fetal physiology and recently retired professor of obstetrics from the UCLA medical school. “I’ll tell you this--he does not know what the word tired means.”

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Tabsh delivers about 100 babies and estimates that he performs about 1,000 ultrasounds and 500 amniocenteses annually, a high volume dictated by his specialty and his reputation. In addition, he is frequently called in as a consultant in emergency deliveries or complicated pregnancies at Santa Monica, Olive View, Northridge and UCLA hospitals. And he is continuing his research into the fetal lung development of twins and offering advanced training in high-risk obstetrics.

“He’s a Renaissance man,” says his boss, Roy Pitkin, chairman of obstetrics and gynecology at the UCLA School of Medicine, a highly respected figure in the field of maternal-fetal medicine who appointed Tabsh to the faculty in January. “Few people in this field are able to span the distance from research to teaching to patient care. And I must tell you, I don’t know that I’ve ever seen anyone with such devoted followers, from students to senior faculty colleagues. There is seemingly something charismatic about the guy.”

Tabsh, a master of the prenatal armamentarium, is considered a doctor of choice by patients and peers. Although many physicians perform ultrasound and amniocentesis, he is one of a select number of doctors authorized by the state to conduct the tests as part of its prenatal screening program, the only one of its kind in the nation. He was also one of the first doctors in Los Angeles to receive federal approval for pioneering the use of chorionic villi sampling, genetic testing of the placenta at nine to 11 weeks. For his part, Tabsh ascribes his talent to luck. “I’m good with my hands,” he says. Peers say his ability to extrapolate three-dimensional images from the fuzzy TV pictures produced during ultrasound is exceptional.

Tabsh’s technical skill often translates into an aggressive pursuit of the avant garde. He is something of an obstetrical cowboy, riding the wild frontier of medicine, experimenting with the uses of technology to save lives that would almost certainly be lost if he limited himself to traditional approaches. Medically acceptable protocols allow for such innovation; Tabsh develops possibilities that rules and guidelines will only later stretch to cover (see related story, opposite).

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Most obstetricians monitor a fetus’s condition with “non-stress” tests, stimulating the fetus and then asking the mother to report its response. But Tabsh applies a less commonly used but more sophisticated and invasive measure: He draws blood samples from the umbilical vein to determine how much oxygen is reaching the fetus.

Often, he will teach himself a procedure that he’s heard described, without ever having read about it in a medical journal or having seen it done. The controversial selective terminations are one such example. He had heard about colleagues performing the procedure in San Francisco and New York and decided to try it himself after discussing it with a doctor who’d pioneered the technique. “I talked to somebody who gave me an idea of how it could be done,” he says. “At that time, there was nothing published on the procedure. I thought of all the possible complications that could arise and saw the possible ways of preventing them.”

In another case he improvised a technique in response to a crisis. An ultrasound picture of twins showed that one was twice the size of the other. The smaller twin had started bleeding into his brother through a shared placenta, causing the larger twin to swell and making his heart pump harder than necessary. The deteriorating condition of the infants led Tabsh to deliver the smaller one by Cesarean section and leave the other in the womb. As it turned out, only the larger twin survived, though Tabsh had guessed that the Cesarean delivery would save the smaller child’s life and that the larger child was at greater risk. It was a never-before-attempted procedure. In fact, before performing the operation, Tabsh informed his patient that he had only practiced on sheep and other farm animals.

Colleagues regard all this with mixed feelings. While acknowledging that Tabsh is talented and energetic, some view his work with caution. “We’re not removing a fetus from the uterus and leaving one in,” says Dr. Lawrence Platt, professor of obstetrics and gynecology at USC, who questions Tabsh’s evaluation of the risks and benefits in deciding how to handle the twins’ problems.

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“He is a bit of a wild man when it comes to doing things,” says Dr. John Williams, formerly head of prenatal diagnosis at Cedars-Sinai Medical Center and now director of the privately run Prenatal Diagnostic Center in West Los Angeles. “If he sees something as being innovative, he pulls it off. Maybe he’s just ahead of his time.”

Tabsh is neither a politician nor a moral philosopher. His personal bent is to save every pregnancy he can. So he actively pursues “good outcomes.” He sees himself as a “fetal advocate,” even if, as in the case of a doomed multiple pregnancy, it means destroying presumably healthy fetuses to do so.

As obstetrical science moves closer to the ideal of guaranteeing every woman a perfect baby, Tabsh is viewed by many patients and doctors as a knight who will slay the dragon of uncertainty, replacing chance with choice; others say he is the dragon, a purveyor of runaway technology that has overtaken life’s greatest miracle. Still others, in a time of rising malpractice premiums (obstetricians pay the highest rates in California, with perinatologists at the top of the list), say he’s a saint; they’re grateful that he takes on cases that most doctors can’t or won’t handle. A few days with him offers a glimpse into the fastest of medical fast lanes.

TALL, BROAD-SHOULDERED, sometimes darkly preoccupied, Tabsh strides down UCLA Medical Center’s newly renovated hallways with a fierce intensity. After completing his obstetrics and gynecology residency at Yale Medical School in 1978, he came to UCLA for a two-year fellowship in perinatology and later received a tenured faculty appointment as associate professor. He looks at home here, having returned in January after three years in private practice.

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In some ways, Tabsh’s return to UCLA symbolizes the medical school’s commitment to revitalize its sagging obstetrical service, which had ceased to be a leader in the field. In recent years, morale there had plummeted, and, says Pitkin, the department of obstetrics and gynecology was marked by a general sense of unrest. Tabsh, for one, gave up his tenured position--a rare move in academia--to pursue a private practice in 1986. But now, in addition to $1.2 million in physical refurbishments for patient care, efforts are under way to expand research and training opportunities. Certainly, Tabsh’s being crowned with a full professorship by the university’s chancellor in January is a harbinger of change.

But at the moment, Tabsh’s concerns are far more immediate as he stands in his self-fashioned bullpen--between his patient, who is lying on an examining table, and his ultrasound machine. She is 32 weeks pregnant with twins and needs an amniocentesis immediately because she has started to go into premature labor.

This will not be a “tap” for genetic information but one to determine whether her babies’ lungs are mature enough for birth. If not, she might be given drugs to forestall labor or steroids to promote lung development. In any case, the amniotic fluid will be analyzed for surfactant, a type of fat secreted by well-developed lungs.

Tabsh is not one for easy chitchat. His bedside manner is efficient. His right hand traces the surface of her abdomen with a transducer, a wand-like device that emits high-frequency sound waves that project an image of her baby on the video monitor before him. With his left hand, he punches buttons and knobs, simultaneously stepping on a floor pedal, eyes narrowed on the monitor’s screen. Like a race-car driver, his body speaks of motion, swift and sure.

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“There is a membrane between them, though it’s thin,” he says, assessing the placement of the fetuses while pointing to a blip of light on the screen. The picture resembles a satellite-transmitted weather map. At the same time that he attends to the patient, he is also training two residents and an attending physician, none of whom was able to do the procedure the day before because of the babies’ positions in the uterus. Today, though, the babies have moved sufficiently to allow Tabsh to share his expertise with his colleagues.

“I’ll tell you everything we’re doing,” he says to the woman, who, like some of the patients in his varied practices, has received no prenatal care during her pregnancy. Now, tears stream down her face, though she says nothing, as her abdomen knots up in a ball during another contraction. A nurse holds her hand. “You won’t be surprised,” Tabsh says. “Try to relax. You’re doing fine.”

Watching the ultrasound machine, he guides a needle into the woman’s abdomen. “You’ll feel a little pressure now,” he says. Since one of the twins is floating, he must wait until it has stopped moving before he can extract amniotic fluid.

“It looks like strong, mature fluid,” he says, eyeing the vial he’s just filled from one twin’s sac. His patient smiles. But lab tests won’t be forthcoming for several hours. Explaining his every move, he shoots a blue-colored dye into the first twin’s sac to distinguish which fetus is which. Then, he does a second tap, this time guiding the plastic-gloved hands of a resident, who is placing the needle into the other twin’s sac.

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As it turns out, the twins’ lungs are mature. Although some doctors would have found the procedure unnecessary and simply allowed the woman’s labor to continue, Tabsh reasons that he’s seen too many preemies in the neonatal intensive care unit not to intervene this way. Two small, healthy babies are delivered that night.

But not all outcomes are so happy.

Back at his Northridge office, in a small building sandwiched between Northridge Community Hospital and a shopping center, Tabsh has a waiting room crammed with 12 patients waiting to see him for prenatal testing.

These patients are clearly nervous, flipping through magazines distractedly. Each is considered at risk of giving birth to an abnormal child, and many have been sent by a referring physician. Most have had simple blood tests to measure alpha-fetoprotein, or AFP, levels, yielding suspicious results. By California law, all patients less than 20 weeks pregnant must be offered the AFP test, and about half are choosing to have it.

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AFP is a protein produced by the fetus. If the AFP level is too high, it raises the specter of neural-tube defects, such as spina bifida, in which the lower end of the spinal chord fails to close properly, or anencephaly--literally, “no brain.” If AFP levels are low, there is a chance of a baby having Down’s syndrome or other chromosomal anomalies. On the other hand, suspicious AFP results might mean nothing more than that estimated gestational dates are wrong, or that twins are to be expected.

Tabsh’s follow-up examination--usually both ultrasound and amniocentesis--will confirm the suspicions or give these couples’ babies clean bills of health. If all is well, they could return for periodic ultrasound checkups; if it’s the bad news, they will be asked to make a choice--terminate or continue the pregnancy.

Although most women agree to undergo prenatal testing, they do so believing that they will be reassured. And 98% of the time, they are right. But when problems are detected, couples are often unprepared to decide.

One of the women in the waiting room is a petite 20-year-old, the youngest patient here. She is 18 weeks pregnant. When Tabsh turns on his white ACUSON model 128 real-time ultrasound machine to examine her, he winces. He immediately sees that there is no amniotic fluid around the baby. Cautiously, he tells her that there is a problem, even though she can see her baby kicking and waving on the screen. Soon, he realizes that the patient is leaking amniotic fluid. He asks her to meet him in his office down the hallway, past the bulletin board jammed with pictures of smiling babies.

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She sits in front of his desk, listening in shock and in tears. He tells her that he could not do an amniocentesis because of the lack of amniotic fluid around the baby. The baby is alive, he says. He could see nothing wrong with it, but its prognosis is extremely poor. Without amniotic fluid, the fetus cannot grow, its lungs cannot develop, and it will be grossly deformed.

“How bad?” she asks. He cannot say exactly. His tests can provide information, but they cannot always offer a crystal-clear understanding of what it means. She will need to discuss this with her doctor, he says. But given his experience with such situations, he says he would recommend terminating the pregnancy.

“I cannot kill my baby,” she says softly, walking out the door. In the days that follow, however, she will change her mind and opt for an abortion.

Tabsh drives back to UCLA. Down a dreary corridor and across from a series of doors with “Caution: Radioactive Materials” signs, his UCLA office is a nondescript space--a cubicle that, despite carpeting and a fresh coat of paint, remains virtually without personality. There are bookshelves, a desk, a chalkboard and not much else, save for the pictures of his four children--Ali, Dina, Kareem and Tarek.

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Because he is both an intensely focused technician and a doctor whose expertise helps parents make life-and-death decisions, Tabsh is like two people. One is controlled and flinty. The other is playful and emotional, a person whom all the technological wizardry belies. That person, the one with an aching empathy for patients, tends to be downplayed, perhaps to help him distance himself from the intense emotions that surround him. Even he overlooks that side of himself at times. But not always.

His next patient has driven from Santa Barbara to see him for a second opinion. She is a 32-year-old housewife who exudes much warmth. But she can barely conceal her grief at having lost a pregnancy for the second time. In 1987, she went into premature labor and delivered a 4-pound baby who died. In recent weeks, her fetus died during her fourth month of pregnancy.

Now, she must decide when, or if, she should try again--risking further heartbreak without any assurances of a healthy outcome. She has come for some simple blood tests and for basic information. She asks whether the demise of both fetuses was related. How could this happen again? Why?

This is the currency of Tabsh’s practice, the currency of loss. And of hope, too. He knows that he can provide courage to mothers who have suffered the trauma of a “bad outcome” or who, in years past, would never even have tried to become pregnant because of physical problems. But he also knows the limits of science, the reach of the heart.

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Doctors still do not know precisely what causes things to go wrong during pregnancy, or why. They have learned that certain factors can put women at higher risk--having children later in life and high blood pressure, for example--but they have no understanding of what brings those factors into play. And, in any case, many women who develop problems in pregnancy don’t fall into a known risk category.

Although the woman from Santa Barbara has a healthy child at home, she worries what another pregnancy will bring. There is talk of screening her for disease. But she’s determined to try again. And psychologically? How is she feeling, he asks.

“I’m OK as long as I don’t have to go to baby showers,” she says.

“You should not conceive in the next six months,” he advises. The tone is more comforting than patronizing. “The mourning process lasts about six months. Your body may be ready, but psychologically, it takes longer.”

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“I was hoping sooner,” she confides. “But that’s why I came here. I know you won’t miss anything, Dr. Tabsh.”

With that, he walks her to his door. And, awkwardly, he says goodby in a way that is at once professional and personal. Standing beside her, he places an arm over her shoulder and squeezes it. It’s his version of a hug.

TABSH IS a handsome, bespectacled man with dark, questioning eyes and black hair offset by a shock of gray up front. More often than not, he wears a white doctor’s coat that bears the name of a retired UCLA faculty member, which he covers with a strip of adhesive tape--a sign both of his quirky sense of humor and of his new-kid-on-the-block position at UCLA. At times, he looks more boyish than any graying man ought to look; at other times, especially when his glasses are off while he rubs his eyes, he looks monumentally tired.

Asked what prompted him to become a doctor, a half smile ducks across his face, and he replies: “My mother. She wanted a doctor in the family.”

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Brusque though polite, he grudgingly agreed to be interviewed for this article, and even then, scheduling time for a meeting proved almost impossible. The only time he would sit still long enough for an interview was when he had little choice--in an airplane on his way back from a meeting.

Those who know him best see him in starkly contrasting ways.

“People are misled by his outer core,” says his mentor, John C. Hobbins, professor of obstetrics at Yale University Medical School and a leader in the field of maternal-fetal medicine. “Inside the core, he’s a warm, loyal guy who can be quite a team player.”

“He’s not a team player,” counters Assali, another mentor. “He’s a loner and not an easy person to get to know.”

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To residents, who have a hard time figuring out when he’ll show up for rounds, he is a brilliant, if elusive, mystery man. To nurses, he’s a softie, who sometimes crouches in the corner of a room to pray before performing a delicate operation. To colleagues, he is diffident, at times arrogant, but always available and much respected, though many worry that he is spreading himself too thin. To patients, he is “Dr. Amnio” or Dr. Tabsh, pronounced TAB-ISH. His first name, Khalil, means lover in Arabic, and he says he wishes people could pronounce it correctly, with the guttural ch sound used in Hebrew. But since most cannot, he goes by K, just K.

A workaholic, he doesn’t smoke, drinks only on social occasions and takes vacations almost never. He would do without sleep, too, if he could, although he usually sleeps from 10 p.m. until 2 a.m., at which point he rises without an alarm clock and catches up on medical journal reading at his Pacific Palisades home. His wife complains that he’s so compulsive about documenting everything in patients’ charts that he often gets home at 5 a.m., only to rush out the door two hours later.

The last movie he saw, “The Godfather,” was in 1973. Reading novels, he says, is a waste of time because he “lacks the imagination” to appreciate them. The joke circulating around the medical school is how he and his wife, anesthesiologist Suha Murad, whom he met in medical school in Beirut, managed to produce four children, given his obsessive work habits.

Tabsh, son of a steel importer, was born in Lebanon and is a citizen of Saudi Arabia. But he says he plans to become an American citizen one day. He was born a Muslim, attended Protestant schools in Beirut and sends his children to Catholic school in Brentwood. He says he believes all religions teach the same thing: Do no harm.

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Educated at American University in Beirut, where he earned his bachelor’s degree and went to medical school, Tabsh left Lebanon in 1975, soon after the civil war broke out there, to attend Yale. Upon completing his residency in New Haven, he returned to Beirut--and lasted all of one week, finding it too unsafe to stay.

Although he still adheres to some patriarchal values of the Middle East, such as wanting his wife to be home with his children rather than working full time, he accepts a different reality. The couple’s conflicting work schedules preclude their spending much time together (two nannies take care of their children), but his wife says they at least talk on the telephone every night.

“The American way of communicating, we don’t have,” she adds. “K won’t come and tell me anything, especially about work. We survive with an understanding. An American woman would have divorced him a long time ago.”

THE DILEMMAS doctors like K Tabsh now face daily are inextricably linked to abortion. Prenatal diagnosis, after all, is the only type of medical diagnosis in which a possible result is intentional death. For that reason, abortion is a central issue. But Tabsh adamantly downplays its significance.

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“The aim of prenatal diagnosis is not abortion,” he says. “The aim is diagnosing malformations and abnormalities so patients can be prepared for a bad outcome, psychologically and physically.”

Deciding what to do in the case of a “bad outcome” is never easy, though some cases are more clear-cut than others. Sure candidates for abortion are the most severe abnormalities, such as anencephaly, or the disastrous, inherited metabolic and chromosomal diseases such as Tay-Sachs disease and Trisomy 13 and 18, in which an extra chromosome produces severe retardation and babies who frequently don’t live longer than one year.

But because prenatal screening cannot predict the severity of a defect such as Down’s syndrome, many couples are thrown into a moral quagmire. Some children with Down’s lead fairly normal, happy lives, and some suffer a lifetime of chronic disability, creating enormous hardship on their families. When faced with a diagnosis of Down’s, 91% of couples in California elect abortion, according to the most recent data compiled by the state Department of Health Services.

Tabsh’s position on abortion is clear: It is a patient’s right to decide. But sometimes that rhetoric gives way to his feelings about the grim realities of second-trimester abortions. “When you do a D and E (dilation and elimination), it’s a gross procedure,” he says. “You grab the baby and pull the baby out. You’re pulling arms and legs; the baby comes out in pieces. It’s a sickening procedure.”

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Personally, he does not perform abortions as part of his practice, except for selective terminations of multiple pregnancies--which usually involve far-less-developed fetuses. He distinguishes the two types of abortions, saying second-trimester procedures are used to end an unwanted pregnancy whereas his selective terminations are saving a desperately wanted infant.

But what of the patient who simply doesn’t want to carry twins? Or a couple that decides to terminate a triplet based on sex? His own ethics dictate that he will not reveal the sex of a fetus nor reduce healthy twins to singletons. And, like other doctors performing pregnancy reductions, he leaves the woman with twins whenever possible. He says he does it partly because it leaves a margin for error and partly because he wants to save every normal fetus that he can. Triplet pregnancies are in a gray area because medical data is scant. Tabsh has delivered some healthy triplets but has also seen many suffer from prematurity. Finally, the patient and her family must decide whether to choose abortion, he says.

“I don’t decide these things,” he explains. “If it were up to me, I’d probably decide against it. I’m just a technician.”

Tabsh follows one other ground rule before performing the procedure at Northridge Hospital, a UCLA-affiliated hospital. He has taken the unprecedented step of insisting that patients meet with the hospital ethics committee to ensure a fully informed consent.

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The first doctors who performed selective terminations did so during the second trimester to abort one of a pair of fetal twins afflicted with Down’s syndrome. Now, the stakes are changing. When the procedure is done to reduce the number of fetuses, it is done early in the pregnancy, before it is possible to detect genetic anomalies. That creates new worries.

After he terminated one fetus in a set of triplets not long ago, lab tests revealed that the aborted triplet had Down’s syndrome. It could have gone the other way. “I’m sure one day somebody’s going to terminate a normal baby and leave an abnormal one behind,” Tabsh says. “It’s one of the problems we face with this (procedure).”

For both patient and doctor, the moral ambiguity lingers long after an irreversible decision is made. And both find ways to live with the questions that will not be put to rest.

Debbie Embree, 33, a former patient of Tabsh’s who helped create a support group for patients facing such decisions, was carrying twins when Tabsh discovered that one of them was suffering from hydrocephalus at 23 weeks.

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If the affected twin continued to grow, Tabsh told her, it could stunt the growth of the healthy one. On the other hand, terminating the baby with hydrocephalus could traumatize the other and result in losing both babies. The legal cutoff for an abortion was days away, and she and her husband had to decide over the weekend whether to agree to a selective termination.

“We said to Dr. Tabsh, ‘Help us decide,’ ” she recalls. “He said, ‘You and your husband have to make the decision.’ And I really appreciate that. He doesn’t inflict moral values on patients.”

The Embrees elected termination for “Twin A.” “Twin B” was born just two weeks later, weighing in at a scant 1 pound, 15 ounces. She was named in honor of the physician who delivered her after ending the life of her sister. Erica Tabsh Embree is now a healthy 2-year-old.

Debbie Embree often warns people who are considering a termination that there is residual pain. “I’ll be at the mall now and see twins. I’ll get that trigger inside. It can hurt. That baby was mine and I grieved for her.”

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But when the time is right, she plans on telling her daughter about her start in life. And she will show her the ultrasound pictures, taken in utero, of twins who shared bloodlines.

Tabsh’s world is filled with the pain and joys of hundreds of parents like the Embrees. “Almost every day, you have to break bad news to one of these patients,” he says, drawing a deep breath. “It’s a catastrophe when you tell a patient: ‘Your baby has anomalies, and some of these anomalies are not compatible with life.’

“But sometimes, some come in with a problem and end up delivering a healthy baby. And that’s my reward.”

No doubt the sweetest reward came with the birth of one of his own children. When his wife was pregnant with their fourth child, the amniocentesis results were normal. But 24 weeks into her pregnancy, Tabsh turned on his ultrasound machine to take a peek. And what he saw worried him.

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It was a tiny bubble, later diagnosed as a bowel obstruction. But he knew the defect could be corrected surgically after delivery. The ultrasound exam allowed them to make arrangements with specialists for surgery soon after birth. Without it, Tarek, their Nintendo-loving 4-year-old, might not be alive today.

For Tabsh, it is reason enough to accept any moral conflict, to take the good with the bad.


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