This article appears in the August 2003 edition of the Catholic Medical Quarterly
its implications for the abortion debate
Human dignity and responsible autonomy are two sides of the same coin. The one requires the other, generates and guarantees the other.
Responsible autonomy requires that I make responsible decisions - and I can do so only if I am adequately informed about what is at issue when I make them.
With its emphasis on transparency, accessibility, user-warnings, cooling-off periods, rights of appeal, etc our society would like to think that everything possible is being done to ensure that we are always able to make informed decisions about important issues in our lives. As far as medical matters are concerned, the new concern to ensure that the patient understands - as far as possible - what this or that medical procedure involves and what the hazards are, is always near the front of any doctor's (especially a surgeon's) mind; and the Patient's Charter has reiterated what is now routinely regarded as best practice.
So I have a right and a duty to make an informed decision when asked to consent to this or that medical/surgical procedure. But if that is so, the doctor has a duty to inform me about the risks.
That is clear enough. But it raises a big subsequent question. How demanding is the doctor's duty to be informed about the risk?
How familiar must he be with the literature on the subject, some of which may be obscure learned journals? More to the point, is he is a member of a medical College, how far may he accept what the latter says is the status questionis on this or that technical issue without going behind that statement to examine the literature himself? Can he simply say that the College's official pronouncements are enough to exonerate him of any further responsibility for ensuring that I am making an informed decision when I agree to this or that treatment on his advice?
This has especial urgency in the context of legal abortion.
Official doctrine uttered by the Royal College of Obstetricians and Gynaecologists is that there is really no such thing as post-abortion syndrome (PAS) and that the evidence of the abortion/breast cancer (ABC) link is 'inconclusive'. That is what the latest RCOG Guidelines for the Treatment of Women requesting Abortion (RCOG, 2000) say.
To take the ABC link first.
A meta-analysis of the literature on the subject from around the world published in 1996 by Professor Joel Brind of the City University of New York showed that 27 out of 33 studies in medical journals supported the link1. That is a substantial majority. The latest tally is 28 out of 37 - still a substantial majority. Furthermore, Brind has shown beyond all reasonable doubt that the major studies which deny the ABC link are so egregiously flawed as to be pretty well worthless. For example, he has shown that a large recorded-linked study of Danish women - which the RCOG regards as decisive evidence that the ABC link is a myth - omitted 60,000 abortion cases and included many recent ones, including thousands in their 'teens and early '20s who were far too young to have developed breast cancer. Hence its conclusions were unreliable.
Similarly Brind has shown that two studies from Oxford prove nothing. The first, on its own admission, included 'only a handful' of cases of induced abortion; the second, published in 2001, used records of only NHS abortions and could not always distinguish between the induced and the spontaneous. Since over 50% of abortions are done in the private sector and since it is generally agreed that spontaneous abortion does not carry an increased risk of breast cancer, the study is equally invalidated.
What this all means, therefore, is that there is objectively good reason for believing that induced abortion is an independent risk factor for breast cancer. That is not to deny, of course, that breast cancer - now the commonest form of disease among women - is multi-causal; nor (of course) is it to say that only women who have had abortions get breast cancer or that every woman who has an abortion will develop the disease. Rather, it is to say that there is a substantial body of medical opinion that the ABC link exists.
Furthermore, there is a biological explanation for the link: it is all about surging oestrogen levels in early pregnancy which cause a proliferation of undifferentiated breast cells. In a full-term pregnancy, these calls are eventually differentiated to secrete the mother's milk. But if the pregnancy is cut short before then, those cells remain undifferentiated and vulnerable to carcinogens.
So the majority of case-controlled studies, including some based on prospective medical records, points clearly to the ABC link. Few clearly challenge it. Furthermore, there is a clear explanation of how it 'works'. Finally, to complete the argument, there is now a major study which gives a decisive answer to those who say 'If the ABC link exists, show us a society which has had a lot of abortion and a concomitant increase in breast cancer'. The recent study by Patrick Carroll entitled Abortion and other pregnancy-related risk factors in female breast cancer showed that breast cancer rates have risen in Britain (as in Scotland, Sweden, Finland and the Czech Republic) exactly as one would have expected if induced abortion was a culprit.2 If Carroll's research had shown that breast cancer rates had not risen in Britain and elsewhere alongside abortion rates, the ABC link would have been seriously discredited.
There is also substantial evidence of three further things: that a full-term pregnancy, especially if followed by breast-feeding, gives protection against breast cancer in later life; that nulliparous abortion (ie where there has been no previous childbirth) elevates the risk of breast cancer; that a nulliparous abortion of a woman with a family history of breast cancer is especially dangerous. The RCOG and the cancer research agencies brush all this aside. The rise in breast cancer rates, we are assured, is due to delayed child bearing, lower parity, poor diet, obesity, female binge drinking, etc. Recently oral contraception has been blamed. There is no mention of abortion.
Similarly, the RCOG assures all gynaecologists that those who suffer from post-abortion trauma were already mentally ill before the operation and that any post-abortion suffering of women is outweighed by the damage allegedly done to others (and their children) who are denied abortion.
The RCOG bases these claims on a single survey of the literature by Dr. Paul Dagg, a Canadian psychiatrist, which appeared in 1991.3 But Dagg's findings are questionable. Many of the studies he collated had a follow-up time of only a few months (some only weeks) - and we all know that post-abortion syndrome can lie dormant for years and be 'triggered' by, for example, the menopause, the birth of a grandchild or even casual sight of a baby in a pram in a supermarket.
Worse, Dagg is now long out of date. In the last ten years there has been a huge outflow of writings - anecdotal and academic (ie case-controlled) - attesting to the damage which abortion can do to a woman's mental health.
It is really lamentable that the RCOG should brush aside the evidence for the ABC link and post-abortion syndrome. I am not asking them to state that they exist as a matter of certain fact; I am merely asking that they concede that there is a weighty body of evidence that they do and that they honestly warn their membership to this effect. At the same time they should publicly acknowledge the growing evidence that induced abortion is associated with increased risk of ectopic pregnancy, retained placenta and placenta praevia in subsequent pregnancy - and infertility.
But if the College fails to do so, how far are its fellows and members relieved of any duty to study the evidence for themselves? Can a senior gynaecologist be ignorant of or responsibly brush aside the studies indicating that abortion has serious physical sequelae, whereas full-term pregnancy has a protective effect? Since everyone seems to agree that raised levels of oestrogen are the prime cause of breast cancer and since it is common knowledge that those levels rise faster and higher in early pregnancy than at any other time (by 2000 per cent in the first trimester), can he ignore the obvious fact that there is at least a prima facie case that induced abortion is a risk factor for breast cancer? Can he agree with his College that the ABC evidence is not a risk factor for breast cancer? Can he agree with his College that the ABC evidence is 'inconclusive' - as stated in their Guidelines published in 2000 - even though Brind's meta analysis, which suggested that it was anything but inconclusive, was said to be methodologically sound and 'could not be disregarded'? If it was as reliable as that and if it showed that the ABC link was strongly supported by research from all over the world, how could the evidence be 'inconclusive'?
Finally, can our putative gynaecologist reasonably accept a single study published over a decade previously as a definitive verdict on post-abortion syndrome when easily accessible journals like the BMJ and the popular press have recently been carrying stories of how abortion can devastate women, how it pushes up female suicide rates, how it can wreck relationships, and so on?
The trouble, is that, if he/she does not dismiss all that evidence or does not accept the RCOG's bland assurances about PAS, it will be impossible to conclude in good faith that continuance of the pregnancy poses a greater threat to a woman's health than does abortion (the ground on which 95 per cent of abortions are done). On the other hand, if he/she does not know about the ABC and PAS literature and simply follows the RCOG's official line, the patient's chance of giving informed consent to the operation will be nil.
The RCOG says it is pro-choice. But in reality it is not. It is relentlessly pro-abortion, having been captured by the abortion industry. It does not want women to be told the whole truth and thus to be truly free to make their own informed choices. It is we pro-lifers who are truly pro-choice, i.e. pro-informed choice, which is the only real form of choice, and we are confident about how fully informed women and partners, doctors and nurses would exercise their responsible autonomy when faced with the challenge of a crisis pregnancy.
Ultimately it is impossible to give completely informed, honest consent to abortion, for a fully informed person will know two things:
that induced abortion can do terrible damage to women's minds, bodies and human relations, and that no moral distinction can be made between an unborn child and a born one.
The latter is a larger, more developed human being than the former, but not more human. A being is either human or it is not. If it is human it cannot be more human than it once was or others are - any more than one circle is more circular than another - and it can never be or have been anything but a human being. Thus abortion is always morally indistinguishable from infanticide or any other deliberate homicide. A fully-informed verdict on it must always be that it is both bad medicine and morally unacceptable.
Brind J, et al, 'Induced abortion as an independent risk factor for breast cancer; a comprehensive review and meta-analysis , Journal of Epidemiology and Community Health, 1996:50;481-96.
Carroll P, Abortion and other pregnancy-related risk factors in female breast cancer, 2001. This important correlational study using Government statistics for breast cancer and abortion rates since 1970 was undertaken for LIFE by the Pension and Population Research Institute. It cannot prove a causal link between abortion and breast cancer but it proves important confirmation of the studies which do.
Dagg P, 'The psychological sequelae of therapeutic abortion - denied and completed , American Journal of Psychiatry, 1991:148;578-85.
Professor J.J. Scarisbrick is National Chairman of LIFE