Catholic Medical Quarterly Volume 63(1) February  2013

Practical medical ethics
How can I advise a woman who comes to see me asking for an abortion?

Discussion From the Ethics committee of the CMA (UK)

The answer to this will always depend upon the patient, her circumstances and how well you know her. You will need to discuss the issues of her pregnancy, her feelings, worries and concerns about having a baby and you may need to think about the circumstances in which pregnancy occurred. It is important to check out how far she is into her pregnancy and how she feels about the baby. Some women, while shocked and unhappy about being pregnant, do in fact have mixed feelings and may well be able to recognise some positive feelings too. So an open, actively listening discussion is most often indicated.

It is then worth enquiring about the woman's general health and any medicines she has taken recently. Has she morning sickness? And has pregnancy been confirmed with a reliable pregnancy test. If not, she will need to have one arranged.

At this stage, while some women will acknowledge ambivalent feelings and a few will describe positive feelings, many will still wish to proceed with an abortion. If that is the case, it is important to make it perfectly clear with the patient that, because of a conscientious objection (as is your right under the Abortion Act you are not able to refer for an abortion. In doing this you need to help her understand that this is in no way a judgement on the patient, but merely a reflection of your professional duties and your ethical duties as a citizen. You should make it clear that she can choose to see a partner or another doctor or clinic and that you will not obstruct her wishes.

You may wish to advise the woman that while she is thinking about the decision and going through the referral and preparation for abortion, she should avoid all over the counter medicines other than paracetamol as, for example, the baby's organs, hands feet and fingers are starting to form. If the woman does change her mind she will not want to have taken a medicine that might lead to a deformity.

However, given that all women are likely to continue thinking about any procedure until that procedure is performed, you should also consider appropriate advice concerning the ensuing days. You may wish to advise the woman that while she is thinking about the decision and going through the referral and preparation for abortion, she should avoid all over the counter medicines other than paracetamol as, for example, the baby's organs, hands feet and fingers are starting to form. If the woman does change her mind she will not want to have taken a medicine that might lead to a deformity.

RCOG guidance sets out that women should be allowed to see the baby on scan if they wish. You may wish to discuss that too. Perhaps something like "if you do go forward for the abortion, you should be offered the choice of whether or not you can see the baby on the ultrasound scan. It’s OK either way, but you may want to have thought that through in advance"

You should also ensure that the woman knows that she can come back and ask anyone in the practice for further advice while she is thinking about her decision and after the abortion for whatever reason.

It will often be relevant to discuss the possible mental health sequelae of abortion. Mental disorders after abortion are common [1,2,3,] and may lead to persisting disabilities. Consent to medical procedures includes a requirement that common side effects and complications are discussed. According to the definitions of “common” (affecting more that 1 in 10) mental disorders after abortion are both common and disabling. Remember too that although the Academy of Royal Colleges did not conclude that abortion causes mental disorder (despite several studies showing statistically significant effects in some areas that this is so) they found no good evidence of benefit to women’s health from having an abortion [4]. Death following abortion is also more common [5].

Having discussed these things, you should also ensure that the woman knows that she can come back and ask anyone in the practice for further advice while she is thinking about her decision and after the abortion for whatever reason. While guidance from the Royal College of Obstetricians appears to be at variance with significant amounts of published literature in terms of mental disorders after abortion being rare, it is clear that women with a past history of mental health problems, those with a negative reaction to the abortion and those who are experiencing other stressful life events appear more likely to develop mental health problems. That being so, some women will require further emotional support or counselling and services should be available for such women, including the opportunity for self-referral [6]. Women will need to know how to go about seeking such help if they do suffer after abortion.

Perhaps most important of all, as set out in RCOG guidance, is the need to allow the woman time to think through the decision of whether to have the abortion or not. Most of all, during this time you will need to be tolerant. Because there are so many factors that can lead a woman to seek an abortion, it is unlikely that we will ever fully understand the whole of it. While we clearly judge killing to be wrong, we cannot in any way judge any woman who in crisis seeks an abortion.

The rights and duties of doctors with a conscientious objection to abortion

You are not required in conscience to make a referral to an abortion provider or to sign an abortion form and this is stated in UK law (and this is in line with GMC guidance.) At its 2008 meeting [7] the BMA reiterated doctors' moral and legal rights to opt out of abortions, embryo research, fertility treatment and the withdrawal of life-prolonging treatment. The BMA also affirmed that you may continue to counsel the patient with their consent.

The BMA does suggest that if a person cannot make arrangements to see another doctor you might have to facilitate this, but in truth, this is a very unlikely occurrence in women seeking abortion who have presented themselves already to a doctor making that request. In this rare situation one might refer to corroborate one’s own opinion to a doctor for a second opinion, with the strict proviso that it is your own opinion abortion is not indicated on legal and or moral grounds that you specify.

International law also sets out clear duties to do what is right and not to follow orders in doing what we believe to be wrong.

There is strong support for a right to conscientious objection in international law and historic ethical declarations. The right of conscience has been recognised as a fundamental human right in all of the post-Second World War international human rights instruments (Universal Declaration of Human Rights (1948), article 18; European Convention on Human Rights (1950), article 9; International Covenant on Civil and Political Rights (1966), article 18)

The International Code of Medical Ethics [8] of the World Medical Association (WMA) (1949) says that ‘a doctor must always maintain the highest standards of professional conduct’ and that it is unethical to ‘collaborate in any form of medical service in which the doctor does not have professional independence’ and goes on to say that “A doctor must always bear in mind the obligation of preserving human life from conception. Therapeutic abortion may only be performed if the conscience of the doctors and the national laws permit.”

The WMA Declaration of Geneva (1948) [9] (Physician’s Oath) states, ‘I will practise my profession with conscience and dignity… I will maintain the utmost respect for human life from the time of conception, even under threat, I will not use my medical knowledge contrary to the laws of humanity’

Article 18 of the Universal Declaration on Human Rights says: ‘Everyone has the right to freedom of thought, conscience and religion; this right includes freedom to change his religion or belief, and freedom, either alone or in community with others and in public or private, to manifest his religion or belief in teaching, practice, worship and observance.’

The European Commission has held in 1993 that a right to conscientious objection can be derived from article 18 of the International Covenant on Civil and Political Rights (ICCPR)

The Parliamentary Assembly of the Council of Europe (See ICCPR Article 8 and 18) supports the right to conscientious objection

Pope John Paul II having seen this from his first hand experience between 1940 and 1985 said: “Laws which authorise and promote abortion and euthanasia are therefore radically opposed not only to the good of the individual but also to the common good; as such they are completely lacking in juridical validity” [10]. The message is clear. We may not do what is wrong even if it is legal and our superiors tell us to. That is remarkably similar to our duties in many other fields. Examples would include our inability to participate in a legal execution, or perhaps, a forced abortion in China. Or inability to support discrimination in countries where some forms of discrimination are still legal.

This should encourage you to humbly accept a duty to do what is right, even though that may be very hard for you and risk difficulties in terms of career and engendering he opprobrium of other.

Can Catholics be involved in discussing abortion with patients?

We think that it is entirely right that doctors from all backgrounds and beliefs should be able to be involved in counselling women about abortion. The CMA thinks that there should be a clear separation of counselling (which should be available to all women considering abortion) from consent to the abortion and the abortion itself. In that case, the opportunity to discuss these issues when they first present is crucial.

Women must always be allowed time to think through these important issues and should not be denied the opportunity of consulting doctors who see more clearly the humanity of unborn children. We know of many cases where women have been really grateful for meeting a doctor who enabled them to think again. Cherished children brought into surgery to say “thank-you” speaks volumes. And we know of many more women who have sought out doctors who refuse to do abortions when seeking help to recover from the emotional harm suffered by abortion.

A simple sign stating “Dr X does not consult for family planning” may help.

We believe that patients do have a right to know the ethical position of a Catholic doctor. You may be able to ask receptionists to forewarn make appointments to see you. If in fact you do not prescribe the pill either, this may be easier to achieve, with a simple statement (or a poster near reception) that Dr X does not prescribe the contraceptive pill or fit coils, refer for abortions etc. a simple poster advising that Dr X does not consult for family planning may help. One good effect of this is that, in our experience, some women will then seek out Dr X for advice and support for other matters, including mental distress and mental illness arising after abortion. Those consultations can bring real benefit to some women.

But, in the end, you cannot participate in the process of killing a child. So you will have to detach yourself from the process of abortion going forward. In your work you will sometimes see, and must accept, that an unborn child will be or has been legally killed. As we have already said, judging that act is entirely separate from judging those who seek or provide abortion.