Catholic Medical Quarterly Volume 64(4) November 2014
Honesty, Reverence and the Abortion Debate
Michael J Scott
This paper was delivered at the Royal Society of Medicine on November 29th 2013, as part of a symposium ‘Are There Mental Health Grounds for Abortion?’ organised by the Medical Ethics Alliance.
Ostensibly almost all abortions in the UK are performed on mental health grounds. But no reliable medico-legal examination has been conducted and these abortions are therefore dishonest and illegal. A dispassionate observer reviewing meta-analyses comparing the psychological effects of abortion versus continuing the pregnancy would conclude that there is no evidence that termination exerts a preventative mental health function.
Terminations in individual cases cannot therefore be justified by an appeal to the general benefits of termination. When considering the ‘best’ course of action in an individual case pronouncements either way are an exercise in unbridled clinical judgement, of saying more than can be known. The 1967 Abortion Act is largely located in an outdated mental health framework and needs major revision. Options for revision are discussed. However abortion is likely to continue to be a battle ground between primarily two opposing world views: secularists, who seek to preserve those ‘just like me’ and the religious who view born and unborn as children of the Father and therefore deserving of reverence. Both can at least unite in awe at the Universe and this may perhaps be a stepping stone to reverence.
The 1967 Abortion Act does not confer a right to abortion it simply excuses doctors from prosecution if they comply with the Act. For the most part this compliance takes the form of a doctor making a judgement that the continuance of the pregnancy would be more damaging to the woman’s mental health than if the pregnancy were terminated, Ground C. It is on this basis that 99% of the 180,000 abortions performed in the UK each year are justified. But are the mental health grounds for abortion spurious?
A Credibility Gap
The architects of the 1967 Abortion Act were adamant that abortion on demand was not being legislated, but given that a signatory to a termination may not have seen the woman, this is scarcely credible. Ms Furedi of the British Pregnancy Advisory Service is quoted in the Daily Telegraph of February 4th 2013 as saying that doctors are playing a ‘charade’ pretending that women have mental health grounds for abortions. There is a lack of honesty about the actual bases on which abortions are legitimated.
The 1967 Act Presumes a Reliable Medico-Legal Examination
Research on a new psychotropic medication or psychotherapy protocol is only possible if the diagnostic status of a person is reliably known. The efficacy of an intervention is judged on whether the diagnostic status of the patient has changed as a consequence of the medication/psychotherapy. Similarly in a medico-legal context a person’s compensation following traumatic injury will depend on their diagnostic status [see the Judicial Studies Board Guidelines (2006) ] and ultimately a Court may decide which of the opposing Expert Witnesses has conducted the most reliable assessment. A necessary but not sufficient condition for a reliable assessment is that the Clinician has asked questions about each of the symptoms that compose a diagnostic set and published thresholds are used to determine the presence or absence of a symptom i.e in the technical language information variance and criterion variance are controlled for [Scott and Sembi (2002)], (open ended interviews show very poor agreement with structured interviews). The signatories to a termination do not conduct an examination that has high reliability. Decisions cannot therefore be regarded as having taken place in ‘good faith’ as the Act requires.
Justification for Abortion in General on Mental Health Grounds
It can be argued that in general terminations promote a woman’s mental health and that therefore for any particular woman that seeks a termination it is likely to be advantageous compared to continuing the pregnancy. But a dispassionate observer reviewing the meta-analyses of comparative outcomes detailed in the British Journal of Psychiatry (Table One) would at least return the Scottish ‘not proven’ verdict with regards to the benefits of termination:
|Table One. Meta- Analyses: British Journal of Psychiatry|
|Coleman, P.K (2011) British Journal of Psychiatry. 199, 180-186 ‘ women who had undergone abortion experienced an 81% increased risk of mental health problems and nearly 10% of the incidence of mental health problems was shown to be attributable to abortion’|
|Kendall et al (2012) British Journal of Psychiatry. 200, 12-14 ‘Two recent meta-analyses claim that abortion leads to a deterioration in mental health. Previous reviews concluded that the mental health outcomes following an unwanted pregnancy are much the same whether the woman gives birth or terminates the pregnancy’|
|Ongoing debate between authors Brit J Psych, (2012) 200, 74-83.|
|Fergusson et al (2008) British Journal of Psychiatry, 193, 444-451, prospective study, prevalence of psych disorders up by 30% in women who had an abortion|
More recently Fergusson, Horwood and Boden writing in the Australian and New Zealand Journal of Psychiatry (2013) conducted a re-appraisal of the research evidence and concluded that there is no available evidence to suggest that abortion has therapeutic effects in reducing the mental health risks of unwanted or unintended pregnancy. Further, these authors conclude that there is suggestive evidence that abortions may be associated with small to moderate increases in risks to some mental health problems. The lack of evidence about the positive mental health consequences of abortion raises series doubts about the validity of current clinical practices in the UK (and Australia and New Zealand), where large numbers of abortions are currently being authorized on mental health grounds. It suggests that the 1967 Abortion Act is not fit for purpose, constructed in an era when the possible mental health benefits of a termination were taken for granted.
Unbridled Clinical Judgement
Evidence-based medicine puts boundaries on the exercise of clinical judgment. Whilst a doctor may form a judgment about which course of action, continuing the pregnancy or having a termination, might be most appropriate for a particular woman, pronouncing in either direction is saying more than we can know. Consider for example a woman who has a termination following a deleterious change in her partner’s behaviour because of excessive demands at him at work, and their relationship breaks up because he is opposed to the termination. On what body of evidence would one rely to say that from a mental health perspective one course of action is better than the other? It could be argued that Society ought to abandon the mental health pretexts for abortion and replace them with social criteria eg the social effects on the woman and her family, but these are more nebulous and incalculable than the mental health effects. There are no evidence based social criteria for determining in any particular pregnancy which is the better pathway; if doctors are involved in making such decisions they are straying outside of their area of expertise. In Ireland there are moves to legitimate abortion if the pregnant woman is suicidal. But in an individual case there is no way of knowing which will be the most appropriate course of action. Whilst there are risk factors for suicide eg previous suicide attempts, these operate at an actuarial level rather than an individual level; further those with previous mental health problems are also more likely to have an adverse mental health reaction to abortion. Decision-making by doctors in the Irish situation is highly likely to be an exercise in unbridled clinical judgement, though doubtless it will be presented otherwise.
Why Do Women Seek Terminations?
In the course of my medico-legal work I have reviewed thousands of GP records and not come across one case were a woman has explicitly sought a termination on the grounds of anticipated damage to her mental health. It appears rather that terminations are sought because of a perceived catastrophic impairment in an important role e.g partner, parent, employee. The decision to seek a termination will also be likely to be informed by role models e.g a respected Nurse in the TV drama Casualty had a termination, was upset by it but reported she did ‘the right thing’, and Society’s narrative about the unborn e.g Lady Grantham’s miscarriage in the TV drama ‘Downton Abbey’ was dismissed because it ‘would have been no bigger than a hamster’.
What Should the Societal Response Be To a Woman Seeking a Termination?
Society can take the view that any perceived role impairment is sufficient justification for a termination, but there are indications that this not the public will. For example The Secretary of State for Health, Mr Jeremy Hunt stated on September 5th 2013 that it is unacceptable for doctors to recommend a termination on the grounds that the unborn is not of the wanted gender. The implication is that Society does not want terminations to be on a par with a visit to the dentist, rather a minimum requirement is that any role impairment be grave and permanent. There may be a public consensus for altering legislation in this direction but they are difficult terms to operationalise and there may be a de facto return to mental health grounds. But given the findings on the mental health effects of an abortion it would seem appropriate for doctors to question the ‘catastrophising’ that may accompany the request for a termination, by asking whether the role impairment would be grave and whether it would be permanent, even notwithstanding changes in legislation. Given that the preventative mental health function of terminations has not been demonstrated it is difficult to justify its funding from the public purse. But it is important to ensure that there is evidence-based psychological treatment [ see for example Scott (2009)] for any woman with a mental health problem who may or may not be pregnant.
The Abortion Debate – a collision of worlds
There is a rough division in the abortion debate between the ‘religious’ and the ‘secularists’. The former take the view that born and unborn are children of God the ‘Father’ and all ‘siblings’ are deserving of equal respect (albeit that there are some disagreements about exactly when human life begins). The ‘secularists’ take the view that ‘rights’ should be accorded to ‘someone just like me’ i.e with personhood; there is clearly an evolutionary impetus to such a view. The conflict between the two sides becomes very acute when it comes to justification of the 1% of abortions that are performed after 24 weeks and up to birth on the grounds that the unborn has a serious physical/mental handicap. It seems that ‘never should the twain meet’, but both sides share a sense of awe at the Universe, both were probably inspired by performances at the Paralympics; perhaps talking about what both hold in common might be a stepping stone to reverence. Unfortunately, it seems at present with regards to the unborn it is a question of ‘out of sight out of mind’ but it does not have to stay that way. Unborn children are not a unique group, their powerlessness is a thread running through the lives of those with severe mental and physical difficulties. Whilst we may as a Society seek to protect the ‘vulnerable’, oftentimes they fall off the radar.
- Coleman, P.K (2011) Abortion and mental health: quantitative synthesis and analysis of research published , 1995-2009. British Journal of Psychiatry, 199, 180-186.
- Fergusson, D.M., Horwood, L.J and Boden, J.M (2008) Abortion and mental health disorders: evidence from a 30 year longitudinal study. British Journal of Psychiatry, 193, 444-451.
- Fergusson, D.M., Horwood, L.J and Boden, J.M (2013 Does abortion reduce the mental health risks of unwanted or unintended pregnancy? A re-appraisal of the evidence. Australian and New Zealand Journal of Psychiatry, 47, 819-827.
- Judicial Studies Board Guidelines for The Assessment of General Damages in Personal Injury Cases (2006) Oxford University Press.
- Kendall, T., Bird, V and Cantwell, R (2012) To meta-analyse or not to meta-analyse: abortion, birth and mental health. British Journal of Psychiatry, 200, 12-14.
- Scott, M.J (2009) Simply Effective Cognitive Behaviour Therapy: A Practitioners Guide London: Routledge.
- Scott, M.J and Sembi, S (2002) Unreliable assessment in civil litigation. The Psychologist, 15, 80-81.