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  Defending abortion - in law and practice (cont.)

3. Abortion for fetal abnormality

Together with late abortion, another kind of abortion, where the procedure takes place because fetal abnormality of some kind is strongly suspected, has become increasingly contentious (17).  In 1967, when abortion was made legal in the UK, fetal abnormality was construed a 'good' reason for abortion. Today the opposite seems the case. This kind of abortion is now considered at best ethically difficult, at worst eugenic. The problematisation of abortion for abnormality can be discussed with reference to three groups, whose views have, to differing degrees, shaped the debate.

(a) The medical profession

Under British law, one exception to the general prohibition of abortion after 24 weeks gestation is where it is agreed that: 'there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped'.

The terms of this clause of the Abortion Act are in line with the way medical judgement is generally privileged in British abortion law. (In all instances, abortion is only legal if two medical practitioners agree that the woman meets one of the conditions for abortion specified in the Act, all of which are framed in medical terms). The clause that caters for abortion for abnormality is worded in an imprecise way. There is no specification of what is a 'substantial risk' or what is a 'serious abnormality'. This vagueness reflects the outlook of the medical profession at the time the Act was passed, which was reluctant to allow parliamentarians to interfere with matters of clinical judgement.

Today, by contrast, many in the medical profession are uncomfortable with the onus placed on them under the law to make judgements about whether a particular request for abortion meets the terms of the Abortion Act. Rather than wanting to 'play God', many doctors  would prefer it more specific guidelines were drawn up to guide them when they make decisions about whether a request for an abortion on the grounds of fetal abnormality is legal (18).

This has led to calls for the creation of lists, specifying which conditions are 'serious' and which are not. Some eminent professors have argued that abortion in the third trimester should be deemed ethically impermissible unless the fetus has an abnormality that can be diagnosed with certainty as leading to early death or cognitive developmental capacity, ruling out Down's syndrome or spina bifida as conditions warranting legal abortion.

Whilst restrictions on the range of conditions for which abortion is legally permissible may relieve doctors from the pressure of having to make difficult decisions, it is important to note the implication of such a measure regarding a woman's reasons for abortion. If only those conditions on a designated list are deemed sufficiently 'serious' to enable a woman to have an abortion, then other reasons, not included on such a list, are presumably deemed trivial in comparison. 

We have to be careful about suggesting that a woman's reasons for abortion are trivial. They may seem so to other people, but to her they may have a different meaning. A senior expert in fetal abnormality has commented about the distress he felt when presented with a request for abortion on the grounds that the fetus had a cleft palate. This expert made the point that he was horrified because he thought this to be a rather trivial abnormality - until he looked at the woman sitting in front of him and noticed she had a severe cleft palate herself. What he regarded as a quite trivial disability, this woman honestly regarded as being so serious that she was willing to put herself through the process of late abortion, and end what she already saw as the life of a child that she wanted (19).

(b) The disability rights movement

The movement for the rights of disabled people has become increasingly influential in recent years. With the completion of the mapping of the human genome, the prospect of the detection of a increasing number of genetic markers has generated a great deal of debate, which centres on the notion that 'eugenic' abortion may result. Many disability rights activists suggest that as knowledge increases about the human genome, it will bring with it attempts to 'screen out' embryos and fetuses whose genes are not 'perfect' (20).

The term eugenics is used very loosely, and often wrongly, in discussions of abortion and ante-natal screening today. Defined properly, eugenics is the view that society can be improved through the manipulation of genetic inheritance, and that social problems can be resolved biologically, largely through the control and shaping of human reproduction.

It could be argued that the abortion law in Britain, when first introduced, was motivated to some degree by a eugenic outlook. Some clauses in the Abortion Act were possibly motivated by a desire to tackle the social problems caused by poverty, deprivation and hardship by shaping people's reproductive patterns (i.e. making easier for them to limit family size), rather than by making greater social resources available to them.

But this was not the case with regard to the clause in the law about abortion for fetal abnormality, which was largely a response to the thalidomide tragedy, where the drug thalidomide was prescribed legally to thousands of pregnant women to alleviate the symptoms of morning sickness, but led to the birth of often severely disabled children. The clause was a response to a situation where women who feared they might give birth to such a child but were unable to prevent it within the terms of the law.

Regardless of the motivation of some of those who supported the legalisation of abortion in 1967, today it is definitely the case that abortion is not seen by doctors, policy makers, or women themselves, as an aspect of social engineering. The context for abortion today is one where its provision meets the request of a woman who no longer wants to be pregnant. That is the case when we are talking about the ending of unwanted pregnancies that have been conceived unintentionally, and is equally so where abortion for abnormality is at issue.

The overwhelming majority of women who discover that they are carrying a fetus affected by Down’s Syndrome currently choose to have an abortion. A study by ante-natal screening expert Professor Eva Alberman shows that just eight per cent of women who discover they are carrying a fetus affected by Down’s syndrome decide to continue the pregnancy (21).

It is not difficult to understand why women choose to abort abnormal pregnancies. Many women find that they feel differently about their condition when they find their baby would be born disabled. The discovery that the child is 'not normal' may challenge a woman's hopes and expectations about what her future family life will be.

A woman whose attitude to her pregnancy changes when she finds it is affected by an abnormality is not making a social or political statement about the abnormality, or about born people with that disability. She is making a statement about herself; what she feels she can cope with and what she wants.

To accept the notion that the views of some disability rights activists should be able influence abortion law or policy is to privilege the views of those who experience a condition over women who carry fetuses affected by it. Why should one individual’s experience of, say, spina bifida entitle that individual to a voice in the most personal decision a woman has to make?

 (c) The anti-abortion lobby

 The argument that abortion on the grounds of abnormality is eugenic has also been promoted, disingenuously, by those who oppose abortion in all circumstances.

The anti-choice organisation LIFE produces a leaflet called 'Pre-Birth Screening: Something Wrong With Baby?' This argues that '...to destroy a child because he or she is not perfect is especially unjust and elitist. Of course it is not always easy to cope, but eugenic abortion recreates and legitimises primitive phobias against mental and physical illness just when society seems to be making real progress in outgrowing them.' The leaflet asks '...are we not really sending a message to the disabled: you are inferior, you should never have been born?' (22).

The Society for the Protection of Unborn Children makes the point that '...abortion of the handicapped is both a reminder of the inhumanity of abortion, attacking the most vulnerable, those most in need of help, and an offence to the disabled, sending them the message that they are inferior and of less value than the able bodied' (23).

Does abortion for abnormality encourage discrimination against disabled people? No it does not, since it is possible to make a judgement or express an attitude towards a particular condition, without in any way imputing an attitude towards the value of people who suffer from that condition.

Most people would say they thought malaria was a bad thing, and that it would be better if people did not suffer from it. This does not mean they take a negative attitude towards people who suffer from that illness. The same applies with abortion for fetal abnormality. There is no reason to assume that a woman's choice not to bear a child which suffers from spina bifida or Down's syndrome implies she believes such people should not be born, or be supported. It simply implies that she does not wish to be a mother to one.

Issues relating to disability rights are completely different to those relating to abortion. At the heart of the issues of abortion (as the anti-choice lobby knows very well) is autonomy in reproductive decision-making, and, whether the fetus is abnormal or not, the ability for individuals to make such decisions must be primary. In a similar vein, the demand from some people with disabilities to be able to screen their pregnancies in such a way that a child with a disability results can also be defended on the same grounds. Since women, and their partners, disabled or not, have to live with the consequences of reproductive decisions, they must be able to make the decisions they perceive to be moral and appropriate.

Ultimately this is the issue which is at the heart of the abortion debate. However, the failure of anti-choice organisations to make a convincing argument against reproductive autonomy means they now try to duck the issue, and instead cloak their arguments in the language of disabled rights.

4. Is abortion a health risk?

(a) Physical health

Much evidence exists which attests to the low rate of risk to physical health associated with abortion. In 2000, the British Royal College of Obstetricians and Gynaecologists (RCOG) published an evidence-based guideline, The Care of Women Requesting Induced Abortion (24).

Based on systematic literature review, and synthesis of the best available research results, the guideline advises that women considering abortion should be given certain information on the possible complications of abortion. For example:

- Hemorrhage at the time of abortion is rare, occurring in around 1.5/1000 abortions overall. The rate is lower for early abortions (1.2/1000 at <13 weeks gestation and 8.5/1000 at >20 weeks).

- Uterine perforation at the time of surgical abortion is also rare. The incidence is of the order 1-4 per 1000 abortions.

- The rate of damage to the external cervical os (a small round opening at the lower part of the cervix) at the time of surgical abortion is no greater than 1 per cent.

- The rate for complications is lower when abortions are performed early in pregnancy by experienced clinicians.

- Genital tract infection of varying degrees of severity, including pelvic inflammatory disease, occurs in up to 10 per cent of cases. The risk is reduced when prophylactic antibiotics are given or when lower genital tract infection has been excluded by bacteriological screening.

Warren Hern, an American specialist in abortion services and author of the medical text, Abortion Practice, notes lower complication rates. In various published series, Hern reports a major complication rate (including haemorrage requiring transfusion) of 0.2 per cent (2 per 1000) in second trimester abortion from 15 - 34 menstrual weeks. His 30,000 first trimester patients have experienced a major complication rate of 0.01 percent with no uterine perforations. By contrast, patients carrying pregnancy to term in the United States routinely experience a caesarian rate of 25 - 30 per cent, a major complication rate more than a hundred times greater than second or third trimester abortion and more than 2500 times greater than that experienced by first trimester abortion patients (25).

Regardless of the evidence attesting to the safety of abortion, the idea that abortion constitutes a health risk remains the subject of debate. In particular, there has been some discussion in recent years that abortion leads to future infertility, breast cancer, or psychiatric illness. Women's concern about these conditions may have been heightened by claims made mainly by opponents of abortion.

The decreasing levels of support for opposition to all abortion has meant that anti-choice groups have developed a strategy that might be termed the 'feminisation' of anti-abortion argument. There has been a marked tendency for opponents of abortion to increasingly make their case on the grounds that abortion is bad for women's health. In this kind of argument, the apparent motivation for opposition to abortion stems for concern with women's well-being. Yet scientific evidence finds no support for these claims.

The RCOG reviewed available evidence about breast cancer for its guideline, and found that available evidence on an association between induced abortion and breast cancer is currently inconclusive. They noted, however, that the validity of the evidence gathered from studies which compare incidence of breast cancer in women who have and who have not had an abortion may be questionable, because of the reluctance of  women studied to reveal whether they had an abortion.

Studies based on national registers are less prone to inaccuracy because they do not rely on subject recall. Such studies have not shown any significant association between abortion and breast cancer. The guideline therefore states that when only those studies least susceptible to bias are included, the evidence suggests that induced abortion does not increase a woman's risk of breast cancer (26).

The RCOG guideline states that women with previous induced abortion appear to be at an increased risk of infertility in countries where abortion is illegal, but not in those where abortion is legal. It notes that published studies strongly suggest that infertility is not a consequence of induced abortion where there are no medical complications. British gynaecologist David Paintin has observed that, in so far as abortion and reduction in fertility are linked, a proportion of the one or two per thousand women who have serious abortion complications are likely to experience reduced fertility or inability to conceive again, but not in cases where there are no complications (27).

(b) Mental health

Assessments of the physical effects of abortion, and assessments of the relationship between abortion and a woman's emotional state, must be approached differently. The key to assessing the emotional impact of abortion on a woman’s emotional state is context-dependence. Where a discussion is to be had of women's emotional responses to abortion, attention must be focused on the social and personal situation in which abortion takes place. It therefore to makes no sense to contend that abortion has a particular, uniform mental health outcome.

Unfortunately, in much discussion of women's feelings about abortion, there is a general failure to contextualise the decision to abort a pregnancy. Many reports do not consider age, marital status, wantedness of pregnancy, gestational age, previous reproductive history, or sociocultural setting. These and other characteristics can have a substantial effect on a woman's motivation and may also influence the risk of negative psychological consequences.

The most extreme example of a de-contextualised approach to the relationship between abortion and emotion is the claim made by opponents of abortion that women suffer from 'Post Abortion Syndrome'. In this approach, rather than paying attention to the context in which abortion decisions are made, a woman's emotions after an abortion are pathologised as a form of mental illness.

Post Abortion Syndrome (PAS) was initially described by Rue in 1981, in United States Congressional Testimony, as a variant of post-traumatic stress disorder. He claimed that psychological stressors were capable of causing post-traumatic-stress disorder and that: 'Post-abortion Syndrome (PAS) is a specific type of post-traumatic stress disorder' (28). Subsequently, anti-abortion organisations in Britain adopted Rue's approach, and PAS has become a feature of anti-abortion arguments in British debate (29).

According to the American Psychiatric Association (APA), Post Traumatic Stress Disorder (PTSD) is a disabling condition '....following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury' (30). Likely stressors cited by APA as examples of PTSD include military combat, violent personal assault, terrorist attack, and being held hostage. Notwithstanding the substantial difficulties associated with the PTSD diagnosis in general (31), it is quite a stretch to claim abortion as a stressor likely to induce PTSD.

One criterion for PTSD is experiencing '...an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone' (32). Considering that around a third of British women will have an abortion at some point it can hardly be said that the abortion experience is outside the range of usual human experience. There has been no reported increase in public or private mental health services for women attributing their current psychological problems to abortion.

Many empirical studies have been conducted to investigate the emotional aftermath of abortion, and there is not space here to detail them all. In one example, reported in 1995 in the British Journal of Psychiatry, information was obtained about 13 261 British women, through volunteer GPs. This included age, marital status, social status and previous psychiatric and obstetric history. As a result, four comparison groups were obtained, of 6151 women who did not request abortion, 6410 who obtained an abortion, 379 who requested the operation but were refused and 37 who requested the abortion and changed their minds.

In this study, GPs were asked to record diagnoses of women they saw by grouping psychological or psychiatric disorders into three categories: major mental illness (including puerperal psychosis, schizophrenia, and manic depression), minor mental illness (depression, anxiety or other emotional disorders) and deliberate self-harm (drug overdoes, self cutting). Key findings reported were that in women with no past psychiatric histories there was no significant difference between comparison groups in rates of psychiatric illness; that women with a previous history of psychosis were more likely to experience a psychotic illness than those with no such history; and that termination of pregnancy did not appear to increase the risk (33).

In another, recent piece of research, Russo and Zierk reported findings from a US based 1992 study, which found that the wellbeing of 773 women, interviewed annually in a national sample of 5 295 women, was unrelated to their abortion experience eight years earlier. The study considered many factors that can influence a woman's emotional wellbeing, including education, employment, income, the presence of a spouse, and the number of children. Higher self-esteem was associated with having a higher income, more years of education, and fewer children.

Women who had experienced an abortion in fact had a statistically significant higher global self-esteem rating than women who had never had an abortion. This difference was even greater when comparing aborting women with women delivering unwanted pregnancies (who had the lowest self-esteem). Women who had experienced repeat abortions did not differ in self-esteem from women who had never had an abortion. In all, the evidence confirmed earlier findings that factors other than the abortion experience itself determine postabortion emotional status. Some women continually reconstruct and reinterpret past events in the light of subsequent experience and can be pressured into feeling guilt and shame long afterwards (34).

In the light of the substantial amount of evidence against the existence of Post Abortion Syndrome, it is perhaps surprising that the claim for PAS retains any credibility. In part the continued debate about whether or not there is such a syndrome can be explained by the confusing degree of variation in the 'symptoms' that are said to be associated with the putative condition.  As already noted, Rue claimed that PAS is a form of PTSD. As such it would constitute a severe psychiatric disorder. Yet if its occurrence could be measured on this basis, it would be found to be non-existent.

However, proponents of PAS tend to shift in their writings from a definition of the PAS 'symptoms' where the proposed comparison with PTSD is made clear, to a much broader collection of 'symptoms' that could perhaps more accurately be described as negative feelings (35).  Rue has listed a wide range of feelings, and forms of behavior that he argues might be evident in

women who have had an abortion. These include feelings of helplessness, hopelessness, sadness, sorrow, lowered self-esteem, distrust, regret, relationship disruption, communication impairment and/or restriction and self condemnation.

Associating this broad range of 'symptoms' with a diagnosis of PAS opens the door to claims that that large numbers of women may suffer from the syndrome. As the 'diagnostic criteria' for PAS become broader, it is easier to claim that many women may suffer from the 'syndrome'. A link between mild and severe psychological responses is generated: all become less serious versions of the same response. Feelings a woman might have after abortion, such as sadness or regret, are seen as a less serious version of a psychiatric disorder.

If an accurate assessment of the psychological effects of abortion is to be made, an approach which combines psychiatric illness with negative feeling is unacceptable. As Stotland argued in a 1992 Commentary in the Journal of the American Medical Association, a symptom or a feeling is not equivalent to a disease (36). Some women who undergo abortion experience feelings of sadness, regret and loss, but this does not mean they are suffering from an illness.

In sum, for the vast majority of women, an abortion of an unwanted pregnancy will be followed by a mixture of emotions, with a predominance of positive feelings and relief. The time of greatest stress is likely to be before the abortion decision is made.

Evidence from the research literature suggests that, in the aggregate, legal abortion of an unwanted pregnancy does not pose a psychological hazard for most women. They tend to cope successfully and go on with their lives. There is no credible evidence for the existence of a Post Abortion Syndrome.


Ann Furedi is director of communications at the British Pregnancy Advisory Service (BPAS).

Dr Ellie Lee is lecturer in sociology at the University of Southampton, UK, and co-ordinator of Pro-Choice Forum.

To order a hard copy of this paper in full, email spiked-central@spiked-online.com

References

(1) RCOG. 2000. The Care of Women Requesting Abortion, Evidence-based Guideline No. 7. RCOG Press: London.

(2) Furedi, Ann. 1997. The Causes of Unplanned Pregnancy, available at www.prochoiceforum.org.uk (Resources / Related Issues)

(3) MORI Consumer Survey of 1258 women aged 16 to 49, throughout the UK, conducted in March 1993 on behalf of Roussel Laboratories.

(4) Vessey et al. 1982. Efficacy of different contraceptive methods. Lancet 8276 :841-3; Wheble et al. 1987. 'Contraception: failure in practice. British Journal of Family Planning 13: 40-5; Ranjit et al. 2001. 'Contraceptive Failure in the First Two Years of Use: Differences Across Socioeconomic Subgroups'. Family Planning Perspectives 33 (1): 19-27.

(5)  Furedi, Ann. 1998. 'Wrong but the right thing to do: public opinion and abortion'. Lee E. (Ed.).  Abortion Law and Politics Today. Basingstoke: Macmillan Press.

(6) Sheldon, Sally. 1997. Beyond Control, Medical Power and Abortion Law (Chapter 6). London: Pluto Press.

(7) Office for National Statistics. 2000. Report: Legal Abortions in England and Wales 1999.  London: ONS.

(8) Easterbrook, Greg. 2000. 'What neither side wants you to know. Abortion and brain waves'. New Republic, 31 January. www.tnr.com/013100easterbrook013100.phpl

(9) Jackson, Emily. 2000. ' Abortion, Autonomy and Prenatal Diagnosis'. Social and Legal Studies

Vol. 9 (4) 467-94; Jackson, Emily. Ethics and British Abortion Law, available at www.prochoiceforum.co.uk (Resources / Abortion Law)

(10) George, Anne and Randall, Sarah. 1996. 'Late presentation for abortion. The British Journal of Family Planning 22: 12-15.

(11) Derbyshire, Stuart. 2000. The Science and Politics of Fetal Pain, available at www.prochoiceforum.co.uk (Commentaries)

(12) Rogers MC. 1992. 'Do the right thing: Pain relief in infants and children'. New England Journal of  Medicine 326: 55-56.

(13) Sheridan, Mary and Highfield, 2000. Roger. 'Can Late Abortions Cause Suffering in the Unborn Child'. Daily Telegraph. 11 October.

(14) Highfield, R. 2000. 'Babies may feel pain of abortion'. Daily Telegraph. 29 August;  Highfield, R. 2000. 'Brain scientist backs abortion pain relief call'. Daily Telegraph, 30 August; Meek, James. 2000. 'When does pain begin?'. The Guardian, 31 August; Macdonald, Victoria. 1998. 'Abortion doctors may give foetuses painkillers'. Daily Telegraph, 9 August.

(15) Derbyshire, Stuart. 1999. 'Locating the beginnings of pain'. Bioethics 13: 1-31; Derbyshire, Stuart. 2000. The Science and Politics of Fetal Pain, available at www.prochoiceforum.co.uk (Commentaries); Derbyshire Stuart. 1995. Comment: Do fetuses feel pain during abortion? Abortion Review 57: 1-2; Derbyshire, Stuart and Furedi, Ann. 1996. ''Fetal pain' is a misnomer'. British Medical Journal 313: 795.

(16) RCOG. 1997. Report of the Working Party on Fetal Pain. London: RCOG.

(17) Daniel, Caroline. 1996. 'Every baby a perfect baby?'. New Statesman. 2 August; Jackson, Emily. 2000. ' Abortion, Autonomy and Prenatal Diagnosis'. Social and Legal Studies Vol. 9 (4) 467-94. Various contributors. 1998. Ethics and Abortion for Fetal Abnormality, available at www.prochoiceforum.co.uk (Resources / Abortion and Disability).

(18) Chervenak, F. A., McCullough, L.B. and Campbell, S.. 1995. 'Is third trimester abortion justified?'British Journal of Obstetrics and Gynaecology 102 (June):434-5; Green, J.M. 1993. 'Obstetrician's views on prenatal diagnosis and termination of pregnancy: 1980 compared with 1993'. British Journal of Obstetrics and Gynaecology 102 (March): 228-232

(19) Personal correspondence to Ann Furedi.

(20) Shakespeare, Tom. 1998. 'Choice and Rights: Eugenics, Genetics and Disability Equality'. Disability and Society 13; Cunningham-Burley, Sarah. 1998. 'Understanding Disability'. Progress in Reproduction June (2): 10-11;  Deaf Worlds, Volume 13, Number 2, July 1997.

(21) Alberman, E. Mutton, D., Ide, R.G.. 1998. 'Trends in prenatal screening for and diagnosis of Down's syndrome: England and Wales, 1989-97'. British Medical Journal 317: 922-3.

(22) Life. Undated. 'Pre-Birth Screening: Something Wrong With Baby?'. Leamington Spa: Life.

(23) SPUC. Undated. 'Our aims, ethics and activities'. London: SPUC. 

(24) RCOG. 2000. The Care of Women Requesting Abortion, Evidence-based Guideline No. 7. RCOG Press: London.

(25) Hern, Warren. 2000. Personal Communication to Ellie Lee.

(26) RCOG. 2000. The Care of Women Requesting Abortion, Evidence-based Guideline No. 7. RCOG Press: London.

(27) Paintin, David. 1997. Twenty Questions About Abortion Answered. London: Birth Control Trust.

(28) Doherty, P. (ed.). 1995. Post-abortion syndrome: its wide ramifications. Dublin: Four Courts Press.

(29) Lee, E. 'Post-abortion syndrome: reinventing abortion as a social problem'. In Best, J. (Ed.). Spreading Social Problems: Studies in the Cross-National Diffusion of Social Problems Claims. Hawthorne, NY: Aldine de Gruyter (In Press).

(30) David, H. 1997. 'Post-Abortion Psychological Responses'. In Ketting, Evert and Smit, J. (eds). Abortion Matters: Proceedings of the 1996 Amsterdam Conference.

(31) Lee, Ellie. 2001. 'The Invention of PTSD'. Available at www.spiked-online.com

(32) APA. 1980. Diagnostic and Statistical Manual of Mental Disorders (III), American Psychiatric Association, Washington DC: 250-1)

(33) Gilchrist et al. 1995. 'Termination of Pregnancy and Psychiatric Morbidity'. British Journal of Psychiatry 167: 243-8.

(34) Russo, N. F. and Zierk, K. L. 1992. 'Abortion, childbearing and women's well-being. Professional Psychology: Research and Practice 23: 269-80.

(35) Lee, E. 'Post-abortion syndrome: reinventing abortion as a social problem'. In Best, J. (Ed.). Spreading Social Problems: Studies in the Cross-National Diffusion of Social Problems Claims. Hawthorne, NY: Aldine de Gruyter (In Press).

(36) Stotland, Nada L. 1992. 'The Myth of Abortion Trauma Syndrome'. Journal of the American Medical Association 268: 2078-9.

 
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