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FEATURE: Jonathan Gornall Where do we draw the line? BMJ 2007; 334: 285-289 [Full text]

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Rapid Responses published:

Human life and abortion

John. H Scotson   (10 February 2007)

Prejudiced Journalism

Caris Grimes   (10 February 2007)

Value laden slogans suggest bias

Adrian J Treloar   (10 February 2007)

The line needs to be drawn somewhere

Hans-Christian Raabe   (10 February 2007)

Politically incorrect terminology is emotive

David L. A. Crick   (10 February 2007)

Choose Life

John T Wenham   (11 February 2007)

Appeal for more honesty

Geoff Goodwin   (11 February 2007)

Science Applied to Abortion.

Margaret M Sealey   (11 February 2007)

Biased reporting

Mary C Walsh   (12 February 2007)

Abortion any time anywhere?

David M A Jackson   (12 February 2007)

Pro choice ? Pro death ?

Jon M Orrell   (12 February 2007)

Ethical incoherence

Anthony P Cole   (12 February 2007)

Abortion: Asking the Right Question

Michael G Peckitt   (13 February 2007)

Abortion: calculating the fetal age accurately

Christopher B Everett   (13 February 2007)

Pro-life does not equate to anti-choice

Elizabeth L Combeer   (13 February 2007)

Abortion Act.

Stephen. R. Brennan   (13 February 2007)

Time to erase the line?

Niall L Cox   (13 February 2007)

Condom splitting nonsense ...

Mark Struthers   (13 February 2007)

draw a line

maureen c. cash   (14 February 2007)

Shameful campaigning

John D Matthews   (14 February 2007)

Time to draw a line on abortion.

Gregory Gardner   (14 February 2007)

Abortion law: perpetual paradoxes, unending strife.

Alexander SD Spiers   (15 February 2007)

Abortion - a reproductive health choice

Toni Belfield   (15 February 2007)

The woman is more important than the fetus

David B Paintin   (15 February 2007)

Anti-abortion is the correct term and it's also anti-women

Marge Berer   (15 February 2007)

Never ending debate

James Currie   (16 February 2007)

What value any life?

John H Ainsworth   (19 February 2007)

The Start Line of Life

Greg P Tagney   (19 February 2007)

Naming of interest groups

mark g reed   (19 February 2007)

Comment on responses

Wendy D Savage   (21 February 2007)

True Choice

Anne M H Williams   (28 February 2007)

Neutral review or opinion for debate?

Stuart H McClelland   (28 February 2007)

Human life and abortion 10 February 2007
John. H Scotson, retired GP Retired home post code WA14 2AN Send response to journal: Re: Human life and abortion	In the abortion debate there is one vital question. When an abortion is performed what is being destroyed? The answer is a human being in utero. Considerations of viability, post abortion syndromes and so forth are important but they do not overshadow the one aspect of the case that a human life is eliminated when an abortion is performed whatever the degree of gestation. The Hippocratic Oath, The Fifth Commandment and the natural law proscribe deliberate human destruction. Abortion should play no part whatsoever in the practice of civilised medical practice Competing interests: Member of Life
Prejudiced Journalism 10 February 2007
Caris Grimes, SHO Surgery Addenbrookes Hospital, Cambridgeshire CB2 2QQ Send response to journal: Re: Prejudiced Journalism	Dear Editor I read the article on the abortion debate with great interest, not so much because of the subject, but because of the prejudiced way the material has been presented. I am surprised that a prestigious journal, such as the BMJ, allows such biased reporting. The use of emotive terms and phrases such as 'anti- choice campaigners', 'only 2500 [foetuses]'(only?), 'exposes the insincerity of the movement' sheds more heat than light to a complex and controversial subject. It would helpful, should the BMJ wish to publish such articles again, for there to be a balanced debate between the two sides. This is, after all, an ethical as well as a medical matter and this article, in my opinion, has done little to clarify or to move forward informed thinking on this subject. Competing interests: None declared
Value laden slogans suggest bias 10 February 2007
Adrian J Treloar, Consultant Memorial Hospital, London, SE18 3RZ Send response to journal: Re: Value laden slogans suggest bias	Gornall describes those who campaign in favour of abortion as "pro- choice". And yet he then describes those who are opposed to abortion as "anti-choice". If a slogan is required, then surely pro-life should be the term used. "Anti-choice" merely tells us that Gornall seeks to denegrate the pro -life movement. It is not even honest to characterise the pro-life movement as "anti-choice". Demands for women to have better information as to the purpose of their screening, the risks of screening, as well as demands that they are better informed about the psychological and physical sequelae of abortion (which include suicide and breast cancer) can only be described as helping women to make an informed choice. I hear of women who experience pressure from all sides to abort, they say they have been offered a true choice by those who seek to protect life. What choice is ever given to the child? By protecting unborn children from being killed, the ability of that children to make future choices is protected in a way, which is totally denied by the killing of unborn children. In the way Gornall uses it, "Pro-choice" is a slogan that values the right to choose to kill a child above all the other choices that mothers can make for her child. Anti-choice is a grave misportrayal of those who seek to defend life. There does seem to be wide agreement that there are too many abortions in the world. Why then denegrate organisations that seek to reduce their numbers? Better still, let's see some young children who might otherwise have been killed in their mothers womb. Competing interests: None declared
The line needs to be drawn somewhere 10 February 2007
Hans-Christian Raabe, General Practitioner Partington Health Centre, Partington, Manchester, M31 4FY Send response to journal: Re: The line needs to be drawn somewhere	The line needs to be drawn somewhere Gornall seems to brand all those who are concerned about abortion as ‘anti-choice’. However, while we may have a ‘choice’, it is usually forgotten that no choice has been offered to the foetus whether his or her life is being taken away. Abortion is a difficult and emotive subject and what I write should not be seen as criticism of women who felt that they had no choice but to go for a termination. However, Gornall seems to dismiss the increasing evidence linking abortion with adverse effect on women. Gornall’s – somewhat biased – comment ends with a quote by Professor Savage, who claims that the time has come "to look beyond just tinkering with the bill. Forty years after the law was changed, why shouldn't abortion be treated like any other operation, where the doctor gives you the information and you make an informed choice about whether you undergo surgery? We need to move the focus from the fetus to the woman." However - there is sufficient evidence to show that induced abortion is associated with 1. Increased mortality. A Finnish study found a nearly three-fold increase in total mortality after termination compared to carrying a pregnancy to term. Maternal deaths within 12 months of end of pregnancy (per 100,000 women) in Finnish population were: Births 28.2; Miscarriage 51.9 and induced abortions 83.1 (Gissler M, et al . Pregnancy-associated mortality after birth, spontaneous abortion, or induced abortion in Finland, 1987-2000. Am J Obstet Gynecol. 2004 Feb;190(2):422-7.) 2. Increased suicide rates. Finnish data find a six-fold increase in suicide rate after abortion Maternal suicide rate within 12 months of end of pregnancy (per 100,000 women): Births 5.9; Miscarriage 18.1 and induced abortions 34.7 (Gissler M, et al. Suicides after pregnancy in Finland 1987-1994. British Medical Journal 1996; 313; 1431-4.) 3. Increase in suicide attempts. Data from Wales (among a population of 408,000 women post abortion, post miscarriage and postnatal) showed a doubling of suicide attempts compared to women who delivered normally (Morgan CL et al. Suicides after Pregnancy. Mental health may deteriorate as a direct effect of induced abortion. BMJ 1997; 314: 902-3) It is not popular to admit this, but there are medical complications of abortion. While this is only anecdotal evidence, when I was working as SHO in obs and gynae, we regularly had women admitted as a result of abortion complications. Indeed, a number of studies from the UK, US, and New Zealand show complication rates after abortion between 5.8% and 17%. (Duthie SJ, et al. Morbidity after termination of pregnancy in first trimester. Genitourinary Medicine 1987; 63: 183-7. Major B, et al. Psychological responses of women after first trimester abortion. Archives of General Psychiatry 2000; 57: 777-84. Sykes P, Complications of terminations of pregnancy: a retrospective study of admissions to Christchurch Women’s hospital 1989 and 1990. New Zealand Medical Journal 1993; 106: 83-5.) A Canadian study finds there was a fourfold increase in hospitalisations for infections, and a nearly five times higher rate of hospitalisation for psychiatric events within three months of abortion. (Ostbye T, et al: Health services utilization after induced abortions in Ontario. American Journal of Medical Quality 2001 (May) 6; 99-106.) 4. Possible increase in breast cancer among high-risk groups. While it is controversial whether there is a link between abortion and breast cancer, one study examined the risk of developing breast cancer in a subgroup of women who had a combination of an abortion before age 18 together with a positive family history of breast cancer. It is very worrying, that all of the women in this group had developed breast cancer before the age of 45. In this study it is estimated that to terminate a pregnancy before age 18 probably leads to a doubling in the lifetime risk of developing breast cancer.. (Daling J, Malone KE, et al. Risk of breast cancer among young women: relationship to induced abortion. Journal of the National Cancer Institute. 1994; 86: 1584-92.) In this emotive debate, perhaps we should consider considering the statement by someone, who has been on 'both sides' of the debate, Dr Nathanson, an American Gynaecologist who – after running one of the largest abortion clinics in the US – changed his mind from ‘pro-choice’ to ‘pro-life’: “We must courageously face the fact – finally – that human life of a special order is being taken. (…) The fierce militants of the Women’s Liberation evade this issue and assert that the woman’s right to bear or not to bear children is her absolute right. (…) On the other hand the ferocious Right-to life legions proclaim no rights for the women and absolute rights for the fetus. (…) Somewhere in the vast philosophic plateau between the two implacably opposed camps- past the slogans, past the pamphlets, past even the demonstrations and the legislative threats – lies the infinitely agonizing truth. We are taking life, and the deliberate taking of life, even of a special order and under special circumstances, is an inexpressibly serious matter." (Bernard Nathanson. Deeper into Abortion. New England Journal of Medicine. 28 November 1974) After over 6 million abortions and essentially abortion on demand, is it not time for a mature national debate on this "inexpressibly serious matter"? Competing interests: None declared
Politically incorrect terminology is emotive 10 February 2007
David L. A. Crick, General Medical Practitioner HU6 7ER Send response to journal: Re: Politically incorrect terminology is emotive	It was a shame that the second sentence of Jonathan Gornall’s feature article contains the politically incorrect terminology which immediately reveals that this is not a neutral article. To call those who support abortion “anti-life” or even “pro-death” would be very inflammatory, but time & again the media use the terms “anti-abortion” and “anti-choice” for one side of those taking part in this debate, instead of “pro-life” or “pro-informed choice”. Showing the positive aspects is the politically correct way of things now-a-days – hence partially sighted & people with a learning disability rather than visually impaired & mentally handicapped. Why then, in this topic in which the author allows the “pro-choice” lobby to say that the argument is “being sentimentalised”, does he use “anti” rather than “pro” descriptions of those who appear to hold a different view from his own, immediately making the topic emotive? In addition there is an issue of denial by the pro-choice view in this article of the negative long term emotional effects on some women such as Professor Savage's statement “that abortion should be treated like any other operation”. This fails to take into account the increasing number of women accessing post abortion help (either in person, by phone or on-line) through organisations such as “Care Confidential” and CARE Centres Network’s “Pregnancy Crisis Centres”. As recently as 10 years ago literature from those in favour of abortion (e.g. British Pregnancy Advisory Service & Brook) denied that women had any emotional consequences at all from abortion but they have now amended their literature to show the reality that a number of women do indeed suffer emotional consequences following abortion, and for some this is long term, of which post abortion syndrome is at the extreme end. In many ways it is hardly surprising that there should be an emotional impact as women who suffer a “miscarriage” do not see it as a minor event but have an emotional reaction to the “loss of their child”. If abortion is just like any other operation why are so many women embarrassed to inform their GP at the time of abortion, or struggle to acknowledge it later, such as at antenatal booking. A “minor procedure with no emotional impact” should not induce this response. Dr. David Crick, General Medical Practitioner Pro Informed Choice Competing interests: Trustee of a CCN Crisis Pregnancy Centre (no financial interest)
Choose Life 11 February 2007
John T Wenham, GP Principal The Gill Medical Centre, Walkden, Manchester, M28 3DR Send response to journal: Re: Choose Life	HC Raabe summarises the medical evidence well in his response above. It is widely ignored by the pro-choice lobby. But then so are the central issues. Life is good. Most of us enjoy it. There are times we don't. As a GP I see a good number of people each week presenting with depression. Some of them are women with stories of regret about past decisions. They feel huge amounts of guilt and they wish they could turn the clock back. Women who miscarry also grieve, because they know they have lost something precious. But post-abortion distress is harder to deal with because the woman involved knows it was she who made the choice not to keep her baby. In a society where the only reason our population continues to rise is because immigrant families value children more than we do, we should be ashamed of our failure to counsel women appropriately when they present with unwanted pregnancy. They need support to come to terms with it, not a knee-jerk referral to a gynaecologist to "make things better". The fall-out from abortion should be a strong motivator for doctors to uphold the principle of informed consent. All the issues and options should be covered. But abortion is not just like "any other operation". Doctors err on the side of caution these days,quoting death rates for each type of operation performed. With abortion, it is always 100% - for the baby who wasn't allowed a choice. Competing interests: None declared
Appeal for more honesty 11 February 2007
Geoff Goodwin, Pastor Bethesda Chapel 0l25un Send response to journal: Re: Appeal for more honesty	Statistics - Six million four hundred thousand - If they were living people they would form a nation somewhat bigger than Scotland, if they were football supporters they would fill Old Trafford 84 times over, if they were large diamonds we would all kill each other to get our share. Some things are self evident and do not need lots of statistics to prove them. Today in England the destiny of a foetus is clearly understood by all; if it is wanted we will move heaven and earth to save and keep it but if it is unwanted it will go in the bin. The scientific argument - it is self evident, it is a simple fact that everyone who is reading these my words started their existence as a single cell. Nothing moral, nothing clever, incontrovertibly true - you and I started our lives as a single cell. I'm a single cell, leave me alone and I will mostly be born fine and healthy. The viability argument - I agree with 'Ellie Lee, a lecturer in social policy at Kent University' that this is a red herring. To link the pros and cons of abortion with, at how many weeks a baby will survive outside the womb, clouds the issue. Just leave me alone and I'll arrive more or less on time. The practice of feticide - I agree with Nadine Dorries MP that this is a barbaric practice akin to torture. I wonder how many more MPs would change their minds about this kind of abortion if Stuart Campbell's 4D ultrasound scanning showed what happened to the foetus during this process? Professor Savage's, "why shouldn't abortion be treated like any other operation?", argument - because every other operation we do leads to life but this one leads to death. No such thing as post-abortion syndrome argument - call it what you will but when someone comes into my church, looks me right in the face and says, "I've ...... my baby", post-abortion something is going on. As I write the news headlines are that Marie Stopes and Bpas are both acknowledging a record breaking increase in abortions due to women not taking proper contraceptive care. Two doctors will have signed for those abortions but I did not think that absence of contraception was a legal ground for abortion. When they found out they were pregnant with us, after the initial panic (I wonder what the statistics are for those of us who were the product of an 'accident'?) they made space and they found the money that was needed to have us as part of the human race. I really do think that we own it to our children to let them be born, it's not as if we didn't need them! Competing interests: I am a Bible believing Christian
Science Applied to Abortion. 11 February 2007
Margaret M Sealey, Retired consultant anaesthetist Queen Elizabeth Hospital, B15 2PR Send response to journal: Re: Science Applied to Abortion.	Science is the unbiased, objective consideration of evidence, and drawing honest conclusions from it. Why then do the 'Pro Choice' reject evidence of the humanity of the unborn and post abortion syndrome in the mothers? Such important matters requires full investigation and honest appraisal. Is it possible that they are letting fear and anger overwhelm them? The question of viability of the unborn is not the issue, implying as it does that the right to live depends on self sufficiency. Human beings throughout their lives, from conception, are dependent on each other. It is the humanity of the unborn that is at issue, and that of the newly conceived cannot be disputed. Ask those who work in fertility clinics: what are they implanting into a woman? A human being and a precious one at that; something that is recognisable as human, since it is perfectly possible to tell the difference between a human conceptus and say, that of a mouse. But even if viability was the issue, is it scientifically valid to extrapolate post natal follow up results from babies whom a pathological process has caused to be born prematurely - I am referring to the Nottingham EPICure study - to those (who would be) born quite normally? It is perfectly permissable to use objective evidence of the foetus in the womb and smiling, or dead, bruised and dismembered, to bring home the reality of abortion. Was it sentimental to use the distressing pictures of the little girl with burning napalm on her back to bring home the reality of the Viet-Nam war? Competing interests: None declared
Biased reporting 12 February 2007
Mary C Walsh, GP Principal 98 Wentloog Road Rumney Cardiff CF3 8XE Send response to journal: Re: Biased reporting	Whilst I welcome fresh debate on this subject I was appalled by the bias in this article. There are two camps; pro-choice and anti-choice. How about pro-life and anti-life or anti-death and pro-death? By referring to the pro-life view point all the way through as anti-choice, a negativity is projected that is hardly fair reporting. Competing interests: None declared
Abortion any time anywhere? 12 February 2007
David M A Jackson, Consultant Royal Gwent hospital, Cardiff Road Newport NP9 2UB Send response to journal: Re: Abortion any time anywhere?	It is sad how far the medical profession has changed in 40 years, epitomised by this article. The fetus has no rights, despite the fact that even a full term infant cannot survive without support, in all its forms, but suddenly it has rights. Infanticide is legal is a depressing inditement on the medical profession. This article is totally biased, throughout saying those apposed to killing of the fetus are anti-choice - a bizarre slant! Pro-choice usally means only one option - termination of pregnancy. There is certainly no other option discussed in this article. We should as a society be more tolerant of pregnancy and support adoption of a neonate rather than reverting to abortion as a solution or an extension of the contraception service Competing interests: None declared
Pro choice ? Pro death ? 12 February 2007
Jon M Orrell, GP Weymouth Dorset DT47BY Send response to journal: Re: Pro choice ? Pro death ?	Why do enquiries,such as Climbee, say the interests of the child are paramount when the national slaughter of innocents betray our real priorities and hedonism as a nation, revealing that the child is expendable and worthless. Prof.Savage forgets the unborn child is a genetically unique individual deserving care and respect not death and prejudice. The womb should be the safest place on earth, not a place of execution. Prof. Fitzgerald cannot face the obvious fact that a baby in ITU is identidal to a baby in the uterus at the same gestational age, as the consequences would demand changing actions and preserving life. Sentimentality is alleged and our nation's stance is curious. Soppy on animal cruelty but blind to human suffering. The language of this response may appear violent but this is in defense of the defenseless who have no voice of their own. The actions of the anti-life brigade reveal real violence despite a smokescreen of choice. What choice for the baby? Competing interests: Human being with a concern for fellow human beings
Ethical incoherence 12 February 2007
Anthony P Cole, consultant paediatrician worcestershire pct WR5 9RW Send response to journal: Re: Ethical incoherence	The Nuffield Council on Bioethics advised full resuscitation of pre term babies according to their gestational age. Other unborn babies of the same gestational age are being killed by intra uterine injection under the present abortion law. They say that babies of 24 weeks born alive should be given full resuscitation and intensive neonatal care. This gives rise to the probability that some will be killed on one ward by intra uterine injection, whilst in an adjacent ward, similar or even less mature babies are receiving full treatment. This is ethically incoherent. The abortion law draws a distinction between the viable and the non viable by setting the upper limit for almost all abortions at 26 weeks gestation. The threshold has already been changed once to reflect modern therapeutic realities and needs to be looked at again in the light of current developments in neonatal intensive care. There remains the moral question, which lies at the heart of the abortion debate:namely do unborn humans have moral equivalence with the born? Different views may be held, but it is hard to see why if they are equally viable Competing interests: None declared
Abortion: Asking the Right Question 13 February 2007
Michael G Peckitt, PhD Student in Philosophy University of Hull, c/o Philosophy Dept, Hull, East Yorkshire, HU6 7RX Send response to journal: Re: Abortion: Asking the Right Question	Mr.Gornall's article is timely reminder of an important debate. However, for me the pro-choice and anti-choice categories are unhelpful because they do not get to the heart of the matter. These are: Should a person be allowed to abort a fetus given a certain set of condition, or should they not be allowed to abort fetus. The labels do not help, fundamentally it is not 'should the baby live' but should I be allowed to terminate it. Answering this question, now that is a more difficult question, but lets find the right question. Competing interests: None declared
Abortion: calculating the fetal age accurately 13 February 2007
Christopher B Everett, Retired GP Alton Health Centre GU34 4HD Send response to journal: Re: Abortion: calculating the fetal age accurately	On the cover of this week’s journal you show an 'old-fashioned’ pregnancy calculator to which I could find no reference in the text. The traditional two disc obstetric rotary calculator is widely used by midwives and doctors in ante-natal clinics to assess the fetal age using the Last Menstrual Period [LMP]. However with the advent of Ultra- Sound examinations, this additional dating information could not be incorporated in the two disk calculator. This means that to assess the size of any discrepancy between the two results, the top disc has to be juggled between the two dates. In addition many such calculators have been a problem as they are cheap free-bees given out for advertising purposes and are varyingly inaccurate, especially the cardboard ones. By the addition of a third disc [for the U/S result] it is possible to show if the Ultra-Sound date is different from the LMP maturity. If there should be a significant difference, which might possibly affect the 23/24 week legal cut off point for abortions, the patient would benefit from a simple demonstration to understand the dating methods used. There may be no other way to do this. Made of high quality plastic and very accurate, such a device has proved to be popular with many clinicians and beneficial for both them and patients. It has been offered to Primary Care trusts for their clinical staff but they are not interested so the Obdsik3 is only available for individual purchase. As a clinical tool it is difficult to see why, if it is any good, it could not be provided by the NHS, as is other much more expensive equipment. Yours faithfully, C B Everett MB BS DObst RCOG Competing interests: GP Designer who has only marketed this calculator in order to introduce it into clinical use.
Pro-life does not equate to anti-choice 13 February 2007
Elizabeth L Combeer, Anaesthetic SpR Royal Surrey County Hospital, GU2 5XX Send response to journal: Re: Pro-life does not equate to anti-choice	To call pro-life campaigners "anti-choice" is as insulting as calling pro-choice campaigners "anti-life". Jonathan Gornall states that he has no competing interests in the abortion debate but can barely disguise his personal views in what is suggested to be a balanced presentation of the arguments. Competing interests: None declared
Abortion Act. 13 February 2007
Stephen. R. Brennan, Consultant Physician Northern General Hospital.Sheffield.S5 7AU Send response to journal: Re: Abortion Act.	Dear Sir, the article by Jonathan Gornall in the 10/2/07 BMJ is useful in keeping this important debate going, and demonstrating that the difference between the 2 camps, pro and anti-abortion, is vast. I agree that there is no moral sense in simply trying to reduce the upper age-limit. There are many doctors who still completely oppose abortion; it is wrong, and always will be, to deliberately kill another human being. Abortion is often described as the lesser of two evils, when, in fact, it is nearly always the greater of 2 evils. Future generations will look back at the 20th century Holocausts, and the medical profession will be castigated for its actions in Germany with the Handicapped & Jewish Holocaust, and in the UK with Abortion. Leaving behind the Hippocratic Tradition is destroying our profession. Yrs faithfully.Dr.Steve Brennan.MBBS.MRCS.FRCP. Competing interests: Master of Guild of Catholic Doctors.UK.
Time to erase the line? 13 February 2007
Niall L Cox, Consultant geriatrician Dewsbury and district hospital WF13 4HS Send response to journal: Re: Time to erase the line?	Sir As a longstanding anti-choicer, I commend Gornall on a balanced and informative article on abortion (1). There are a lot of eloquent words on both sides but it got me wondering if the abortion debate isn’t all a bit pointless. There is a fundamental disagreement between pro-choicers and pro-lifers. And that is the question of whether children can be treated differently depending on whether it’s before or after they’re born. The “right” answer to this seems to depend on what part of the world you’re in. Even within the mainly pro-choice United Kingdom, one nation (Northern Ireland) remains essentially pro-life. The point is that this argument will continue for the foreseeable future without a winner. Now, here’s an idea. What if we changed the focus to our main area of agreement: that women and children should be able to lead happy and fulfilling lives? What if pro-lifers and pro-choicers worked together for a better deal for pregnant women and the parents of young children? Does anyone really want any woman to have an abortion because she can’t afford to have a baby or because her job prospects will be wrecked? As a society, are we really doing enough to give women a real choice? How come a 36 year old medical consultant is able to have children with relatively little detrimental impact on finances or career compared to a 25 year old junior doctor or a 36 year old cleaner? What if maternity pay and leave was funded by the government rather than individual companies so that the cost is evenly distributed? What if….? The general consensus in Britain is that abortion is a necessary evil. Pro-lifers have spent a lot of time unsuccessfully trying to persuade the public that abortion is too evil to be necessary. It might be time to accept the prevailing view and instead work towards a society where it’s unnecessary to be so evil. And perhaps pro-choicers can join us? Then maybe we can all be truly pro-choice. Yours sincerely Niall Cox Consultant Geriatrician, Leeds, West Yorkshire LS8 2BS 1 Gornall J. Where do we draw the line? BMJ 2007; 334: 285 – 289 Competing interests: None declared
Condom splitting nonsense ... 13 February 2007
Mark Struthers, GP and prison medical officer Bedfordshire, UK mark.struthers@which.net Send response to journal: Re: Condom splitting nonsense ...	The all too common serial felons are particularly depressing. In these days of easy contraception, “if you don’t want to be pregnant, why are you?” is always on my mind when another young woman comes seeking a termination to her pregnancy. “Pro-choice usually means only one option – termination of pregnancy” says David Jackson – and “we should as a society be more tolerant of pregnancy and support adoption of a neonate rather than reverting to abortion as a solution or an extension of the contraception service.” [1] I agree, but we are a society which fights for freedom and democracy – and to kill who we choose – and it’s what the people want! I have been a GP for over 20 years and have, over the years, been a signatory to countless blue, green and white execution warrants. Before signing, I invariably raise the option of adoption – and the almost invariable choice is the death of an innocent. I sometimes wonder why I bother to offer the option or the choice. Society and the practice of medicine have indeed changed over the last 40 years. Perhaps abortion should no longer be free at the point of request – on the NHS. [1] Abortion any time anywhere? David M A Jackson (12 February 2007) Competing interests: I am a liberal secular fundamentalist intolerant of the hypocrisy of pro-life religionists.
draw a line 14 February 2007
maureen c. cash, retired OX14 1DA Send response to journal: Re: draw a line	When abortion was legalised in the sixties, it was at first highly restricted. Just as has happened in Portugal this past weekend. We know how over time restrictions are abandoned and abortion on demand becomes the norm. People want to draw the line somewhere to tighten the law somewhat and this has to be good. Perhaps the time is coming soon when we will view abortion as we do slavery now (in its time legally permitted) I look forward to that. Competing interests: None declared
Shameful campaigning 14 February 2007
John D Matthews, GP Principal Park Road Medical Practice, Wallsend NE28 7LP Send response to journal: Re: Shameful campaigning	This was a shameful article for a reputable journal such as the BMJ to produce. As has been pointed out by other respondents the choice of language was politically inflammatory and any confidence that this could be a rational discussion eroded. What are Jonathan Garnall's qualifications to speak on this subject, there is no indication of this in the article. His views may appropriately be published in a campaigning newspaper but surely not an academic journal. Or have I missed the point of the rebranded new look BMJ? Competing interests: None declared
Time to draw a line on abortion. 14 February 2007
Gregory Gardner, Associate General Practitioner Cape Hill Medical Centre, Raglan Rd., Smethwick B66 3NR Send response to journal: Re: Time to draw a line on abortion.	The Royal College of Obstetricians and Gynaecologists has recently suggested euthanasia for disabled newborn babies. It is therefore encouraging to read responses to Jonathan Gornall’s article about pre- natal killing, from colleagues in other branches of medicine who still have a functioning conscience. Women with crisis pregnancies need access to accurate information but who is most likely to be able to provide this? The private abortion sector accounts for the majority of abortions in the UK. They are in the business of selling abortion. It is not in their financial interest to either spend much time on counselling, or give women information about possible long term adverse consequences with the likelihood of turning potential customers away. A large amount of their income derives from repeat abortions. The pro-life community with its huge amount of experience in post-abortion counselling is uniquely placed to talk to women about the physical, emotional and relational harms of abortion. The record of the pro-life community is that it is pro-woman as well as pro-baby and it is impossible to be either alone. It should be remembered that it was pro-life doctors (well in advance of any RCOG guidelines) who persuaded the Rawlinson enquiry in 1994 to make administration of anti-chlamydial medication a standard part of abortion procedure.[1] Abortionists had been quite comfortable with the status quo and are still in denial about the growing evidence of abortion’s harm to women. From depression[2] and self harm, to substance abuse[3] and breast cancer,[4] and a long list of other problems, insufficient notice is being taken. Crucially the general public need to be educated that abortion is an act of violence which kills a baby. The BMJ has at least had the courage to publish a photograph of an aborted unborn child who obviously had been tortured to death. This is unusual as the media has a squeamishness about abortion which it doesn’t have about other forms of killing. 1. A report by the Commission of Inquiry into the Operation and Consequences of The Abortion Act. House of Lords 1994. 2. Reardon DC, Cougle JR. Depression and unintended pregnancy in the National Longitudinal Survey of Youth: a cohort study. Bmj 2002;324(7330):151-2. 3. Reardon DC, Ney PG. Abortion and subsequent substance abuse. Am J Drug Alcohol Abuse 2000;26(1):61-75. 4. Brind J. The abortion-breast cancer connection. Issues Law Med 2005;21(2):109-35. Competing interests: Financial supporter of several crisis pregnancy centres.
Abortion law: perpetual paradoxes, unending strife. 15 February 2007
Alexander SD Spiers, Professor of Medicine (Retired) N/A Send response to journal: Re: Abortion law: perpetual paradoxes, unending strife.	There can be few fields more complicated - nay Byzantine - than abortion and the laws that surround it. In this area medicine, religion, science, politics, ethics, feminism, the law, and commercial considerations meet and do battle. Some of the antagonists, notably the religious groups and the women's rights groups, are so totally convinced that their cause is correct, that there is little likelihood of agreement any time soon. The situation in Britain is bad, but when I was teaching in the United States, I found that there it is very much worse, principally because the population is much more religious than ours. The so-called Religious Right is adamantly opposed to abortion. They are also opposed to sex education and to making available contraceptive advice. This viewpoint is paradoxical, since the principal cause of abortions is unwanted pregnancies and education is the best way of preventing these.The religious groups believe that sex education might promote sexual activity and that abstinence from sex is the correct way to prevent unwanted pregnancies. Over six thousand years of human history testify to the fact that abstinence has never been popular or effective and the presence of six billion people on this planet confirms this. Sadly, the United States has lost two excellent Surgeon Generals because they advocated sex education. A further paradox, and a very dreadful one, is that a few members of the Right to Life movement will commit arson and even murder to prevent abortions. The burning down of abortion clinics and the shootings of abortion clinic doctors testify to their extremism. (Of interest, in Britain this kind of criminal activity seems to be confined to individuals who claim to support Animal rights - are animals more important than fetuses in British society?) Paradoxes abound on the American political scene. Traditional conservatives (please note the lower case "c") are opposed to abortion but in favour of capital punishment, whereas liberals (also lower case) oppose capital punishment but support women's rights to abortion. If anything, the latter view - sparing murderers but killing innocent fetuses - seems even more illogical than the former. In abortion, as with prostitution, there is a seemingly irreconcilable disagreement between the pragmatic and the moralistic viewpoints. History shows us that both abortion and prostitution have been, and will continue to be practised regardless of the law. The pragmatic - but also moral - stance on abortion was well expressed by President Clinton, when he said that abortion should be "legal, safe...and rare". Competing interests: None declared
Abortion - a reproductive health choice 15 February 2007
Toni Belfield, Director of Information fpa (Family Planning Association, Featherstone Street, London EC1Y 8QU Send response to journal: Re: Abortion - a reproductive health choice	Congratulations to the BMJ for addressing abortion. The article by Gornall and resulting correspondence continues to illustrate the strength of feeling around abortion and the polarised views it evokes. Wendy Savage is right to say the focus should be on women and we should robustly question why women are vilified for having an abortion - an appropriate, individual reproductive health choice in the event of an unplanned pregnancy. Sex and pregnancy takes two! Unplanned pregnancy is common - yes we have a wide range of contraceptive methods, but they are not perfect, they can fail and we as human beings can make mistakes. Supporting women (and men) to use contraceptive methods well and with confidence relies on services being available and professionals being trained to deliver them. Current disinvestment in contraceptive services, the lack of good sexual health training for profesionals, the resistance to providing good sex and relationships education from an early age and the inability to properly address the issues around sex and its consequences continues to indicate just how low a priority sexual health is really given in the UK. Competing interests: TB works for the fpa (Family Planning Association)
The woman is more important than the fetus 15 February 2007
David B Paintin, Emeritus Reader in Obstetrics & Gynaecology Imperial College School of Medicine (St Mary's), London W3 1PG Send response to journal: Re: The woman is more important than the fetus	The responses so far to Jonathan Glover's question "Where do we draw the line ?" focus on the immorality of destroying the fetus rather than the greater immorality of requiring women to continue an unwanted pregnancy. But these women, given a non-judgmental listener, make a compelling case for the termination of their pregnancies. It was by listening to distressed women that I became convinced that legal abortion should be available on request. My experience has led me to the following conclusions: 1 The need for legal abortion arises from the problems that women and men have in regulating their sexual behaviour. Many women remain very influenced by traditional stereotypes that include male dominance, the primacy of men's sexual, domestic and career needs and motherhood as the primary role of women. Women's use of contraception is often limited by the coercive behaviour of their partners and their low regard for her well being. Young people are still handicapped by lack of informed skill in the management of sexual relationships and in knowledge of the probability of conception, and the use of contraception. Failure of contraception for behavioural and technical reasons is, and is likely to remain, frequent. 2 Legal abortion avoids the very adverse consequences for the woman (and for society) of continuing an unwanted pregnancy. These may include the obligation to care for a child when she has no appropriate emotional and economic resources, the prolongation of a relationship that has already failed, interruption of education, loss of career opportunities, and lower total earnings and pension entitlement. 3 The woman has much greater ethical status than the fetus. This is recognised by the well-established principle in British law that the fetus is not a person and can be investigated or treated at any point in pregnancy only with the consent of the pregnant woman. This means than the woman has complete authority over her fetus throughout pregnancy — the fetus is part of her body and its possible viability if born is not relevant to the abortion issue. The woman confers the status of person on the fetus by her decision to continue the pregnancy and to give birth. The relationship with the fetus that the woman, her family and her health professionals develop during pregnancy provides a strong incentive for induced abortions to be obtained early – it is this growing relationship and not the law that results in about 90 per cent of abortions being obtained before 12 weeks and less than 2 per cent after 20 weeks. 4 There is no need for abortion to be regulated by law – all women are very reluctant to have their fetus destroyed and do so only for reasons they find compelling. It is an abuse of the rights of women that a law exists to limit their management of one of their internal organs. Old justifications for abortion law — the regulation of the sexual behaviour of women, the dangers of illegal abortion, the exploitation of women by illegal abortionists — are no longer relevant. The United Kingdom should follow the example of Canada and decriminalise abortion. David Paintin Competing interests: Member of the Abortion Law Reform Society (and its successor Abortion Rights) since 1963; a provider of legal abortion in the NHS from 1968 until retirement in 1990 (no private practice), trustee of the charities Pregnancy Advisory Service (1981 – 96) and British Pregnancy Advisory Service (1996 – 2003).
Anti-abortion is the correct term and it's also anti-women 15 February 2007
Marge Berer, Editor, Reproductive Health Matters 444 Highgate Studios, 53-79 Highgate Road, London NW5 1TL Send response to journal: Re: Anti-abortion is the correct term and it's also anti-women	I thank Jonathan Gornall for his excellent article. How sad to see, in the first letters in response to him, BMJ readers repeating so many thoroughly discredited, pseudo-scientific arguments and inaccurate data in order to oppose abortion, in spite of their medical qualifications. When will they face up to the proven negative public health consequences of making abortions illegal? When will they acknowledge that if a woman felt that having an abortion harmed her rather than helped her, or believed that having an abortion was not a necessity at the moment when she sought one, she would not have an abortion. When will they recognise that preventing unwanted pregnancy is something that every new generation needs to learn to do during the transition from adolescence to adulthood, sometimes through mistakes. Lastly, when will they acknowledge that the women who have had abortions are almost all the mothers of this world also who, when they do give birth to children, devote their entire lives to raising them. Yes, those of us who are pro-choice on abortion value women's lives first and foremost, and support women's right to choose motherhood voluntarily. We believe that that is the ethical position and we are proud to espouse it. Competing interests: None declared
Never ending debate 16 February 2007
James Currie, Consultant Gyneacologist Calgary Health Region Chronic Pain Centre, 2210-2nd Street SW, Calgary AB, T2S 3C3 Send response to journal: Re: Never ending debate	I'm disappointed at the majority of responses to this article. They mostly take us back to the question of whether abortion should be allowed in our society when that issue should have been settled 40 years ago. Dr Gornall does, however raise some important points, and the debate as to the maximum gestation for abortion is quite legitimate. Prof Paintin indicates rightly that abortion in Canada is effectively decriminalised. It is carefully regulated by each Provincial College of Physicians and Surgeons. Currently in Alberta abortion may be carried out up to 20 weeks on the request of a woman. Between 20 and 24 weeks it may be carried out in cases of major fetal abnormality incompatible with life, by referral to a multi-disciplinary clinic. I'm particularly offended by Dr Treloar and Dr Hans-Christian Rabbe in their suggestion of a link between abortion and breast cancer. For their information, they should refer to the report of the Collaborative Group on Hormonal Factors in Breast Cancer Lancet 363/9414, 27 March 2004 They can also in that article find the list of those bodies which endorse the report. I do not know of any reputable medical body which is not represented on that list. In my opinion, to continue to frighten women away from their choice is despicable and unethical. Competing interests: Former abortion provider at Calgary Health Region Gynaecology Out Patient Clinic
What value any life? 19 February 2007
John H Ainsworth, Retired Medical Practitioner (Home),SK9 6BR Send response to journal: Re: What value any life?	I was in general practice for 37 years, 33 of them in Wilmslow. Furthermore, for 25 of those 33 years, (1968 to 1993), I was Clinical Assistant/Hospital Practitioner at St. Mary's Maternity Hospital, Manchester, working in the Antenatal clinic. When a woman deliberately aborts the pregnancy she is carrying, it not only terminates the life of her child, but it damages her, often in a way that prevents her conceiving or if successful in conceiving, then carrying the pregnancy to term, not to mention the long term psychological consequences. Pro-choice supporters say that because it is the woman's body, she is entitled to make that choice, but they forget that the decision to terminate not only adversely affects the aborted child and its mother, but also the whole population; most of all the immediate relatives, who lose a brother or sister, an uncle or an aunt, a nephew/niece or a grandchild etc. The immediate neighbourhood loses a child, which would have needed to be educated; schools and higher education establishments close for lack of pupils or students. The easy availability of abortion and micro- abortifacient contraceptives have certainly contributed to the inversion of the demographic population triangle. Finally, how do we know that the child that is eliminated may have been a future, very valuable person in the country or even the world? What is to be done about it? Once life at one level is vulnerable, why not others? For example, what is the difference in the value of life of between unborn and newborn; Leonard Arthur terminated the life of a newborn infant with Down's Syndrome by giving it a drug contraindicated in children and was acquitted when taken to court. Now, with the passing of the Mental Capacity Bill (MCB) in 2005, people with Continuing Power of Attorney(CPA) can make legally binding healthcare decisions concerning the person over whom they have power of attorney and they are protected from prosecution, if they stand to inherit the residue of that person's estate. What is more, healthcare professionals can be criminalised if they act against the person with the CPA. Even the cruellest methods of terminating life are OK; when the Bill was going through Parliament, withdrawal of food and drink was supported; an amendment specifically tabled to prevent this was defeated. It was ironic that at the very time the MCB was being debated, the 60th anniversary of the liberation of Auschwitz was being celebrated; it was at Auschwitz that death by withdrawal of food and drink was used by the Nazis as an especially unpleasant way to kill the prisoners. I think that there is a direct link between violence that is enshrined on the statute book and the violent society in which we live, so building more prisons etc. is not the answer to the present problems, but rather repeal the laws that permit the destruction of human beings at all stages of human life, from conception to natural death. What has this to do with the question of where to draw the line with regard to abortion? I suggest that if it is considered appropriate to legalise abortion at any level, things will continue as now. The Hippocratic Oath is just that, an oath, something to be taken very seriously. Do the present final year medical students take it when they pass their finals? I suspect not; it is virtually impossible to practice medicine in this age without breaking it. I would like to take issue with Professor Wendy Savage’s comments; whereas I support her in the matter of the invasion of the woman’s privacy, it is most certainly not for political ends. It concerns far more where society is headed and why this topic is being raised again. Professor Maria Fitzgerald’s comments are puzzling too. Is she implying (in particular) that the fetus doesn’t experience pain at all, by quoting from David Mellor & colleagues study? Why then, when an amniocentesis is done, is it done with ultrasound guidance to avoid pricking the fetus, which usually responds with vigour if it is pricked during the procedure. Avoiding the placenta isn’t the only reason why ultrasound is used! Competing interests: Member of Life
The Start Line of Life 19 February 2007
Greg P Tagney, Design Co-ordinator for Kier Northern Kier Northern, Carlisle CA3 0JF Send response to journal: Re: The Start Line of Life	Having read Jonathan Gornall's article I am still as far away from agreeing with abortion as ever. Playing arround with the number of weeks still seems to me to be completely missing the point. If we accept that human life is something different to that of any other living organism known to man and as such cannot be terminated wilfully, then I fail to see why this priciple does not apply equally to the child in the womb. To use the argument of 'dependance' is spurious as no new born baby can survive without a high level of care and this requirement, merely to ensure sirvival, lasts for several years. The apparent ascertion that the child in the womb is just an unwanted growth within the mother that, like a cncer, should just be cut out and thrown away is not a concept that sits easy with me and I doubt it does with many others. Yet this is in fact what legal abortion sems to be saying. To me the acceptance of abortion means that human life has lost it's special status and therefore opens the debate as to who else we might like to be legally allowed to kill. I don't know what the answer is to help women who fall pregnant and feel they are unable to care for the child but I do know that that those of my aquaintence who have had abortions have seemed to suffer psycologically from the experience for the rest of their lies. The social stigma of being an unmarried mother barely exists within our society.I would like to see all pregnant women given a far higher satus. I would happily pay more tax to fund a comprehensive care system so that they suffered no loss of standard of living and if after the child was born they still felt unable to care for it then the child would be offered for adoption. Competing interests: None declared
Naming of interest groups 19 February 2007
mark g reed, gp, course organiser vts reading Send response to journal: Re: Naming of interest groups	Dear Sir, I thought the article by Jonathan Gornall was an interesting summary of the current political and societal attitudes to abortion. I also admired his subtle use of language to covertly imply that one position in this argument holds the moral high-ground. I am sure that most readers will have spotted it, but I feel it is necessary to point a few of his devices out anyway. The two extreme positions in the abortion debate are occupied by those who call themselves pro-choice (ie pro-abortion) and those who call themselves pro-life (ie anti-abortion). To apply the epithet "anti-choice" to the latter group is not only an insulting straw-man tactic but makes the article seem slightly childish. How objective would the article have seemed if he had described the two groups as pro-life and anti-life?! Many organisations apply this tactic in the hope that their detractors will seem to occupy the obviously wrong position; another interesting example is how the Voluntary Euthanasia Society has changed its name to "Dignity in Dying" implying anti-euthanasiasts are actually anti-dignity. Mr Gornall also used the term "propoganda" to describe pro-life arguments which is very strange in this context. Furthermore the tenor of the article implied that pro-lifers will stoop to anything, including bad research to stop abortions. Why would this possibly be so? If it is for moral reasons does he not think that such people might feel that such lying and deception were also morally wrong? Is it not possible that they feel there may be a variety of persuasive arguments why abortion is bad for women and society, not to mention the foetus? Arguments about physical and psychological sequelae need to be researched, not dismissed; if they are proven to be untrue then this will surely reassure pro-choicers. If there is any truth to them then surely the public need to know, so they can make informed decisions? Mark G Reed VTS Course Organiser Oxford Deanery Sessional GP Competing interests: None declared
Comment on responses 21 February 2007
Wendy D Savage, Honorary Professor Middlesex University NA Send response to journal: Re: Comment on responses	David Paintin has eloquently explained the position which those of us who are pro-choice hold and it is significant that he and I are part of the last generation of British doctors to have seen women who died from illegal abortions. Those who qualified since 1967 have not had that experience unless they have worked in the developing world as I did where the reality that women will take their lives in their own hands or accept the help of an unqualified person or witch doctor was brought home forcibly to me. My first published paper in 1968 was about septic abortions in Nairobi and during my 5 years in Africal I saw over 10 young women die from abortion. I do not think that those of us in the pro-choice movement are pro-abortion and most do see it as the best solution to a situation that we would prefer had not arisen. My own experience of interviewing women in New Zealand whom I had aborted was that what they regretted was the action that had led to the unplanned and unwanted pregnancy but not the abortion itself. The quality of the counselling and decision making makes an enormous difference to the way the woman feels about having made this difficult decision. If you look at the literature before 1968 it is clear that major feelings of guilt or regret did not occur if the abortion had been done in a situation where the woman felt supported whereas if it was done illegally or by punitive staff she may well have regrets afterwards. One of the respondents questioned whether one should treat abortion like any other operation but why not? If a woman receives clear information and understands the risks (albeit small) and makes her own decision as is done in any other surgery she is unlikely to regret her decision . Anyone who has listened to women knows that ultimately the woman makes the decision. However the need to get the signatures of two doctors may delay the woman and lead to later abortions and is unnecessary. We should follow the example of Canada where decriminilization has not led to a higher abortion rate than in the UK. One thing that bothers me are the statements of Prof Stuart Campbell highlighted by Jonathan Gornall which are emotive and unscientific but because he is a doctor are accepted as fact. This plays into the hands of our rightwing media with their anti women stance. Wendy D Savage retired Senior Lecturer in Obstetrics and Gynaecology and Honorary Professor Middlesex University Competing interests: Started an abortion serice in the public hospital in Gisborne New Zealand in 1973 and gave evidence to the Royal Commission on abortion contraception and sterilisation. Trustee of Pregnancy dvisory service from 1978 until it closed. Ran abortion service in Tower Hamlets and provided abortions from 1976-2000. Press officer for Doctors for a Womans Choice on Abortion from 1977 to date.
True Choice 28 February 2007
Anne M H Williams, GP Glasgow G12 0SG Send response to journal: Re: True Choice	I was very disappointed that the only letter(1) which was chosen for the printed version of the BMJ did not reflect the overwhelming views expressed in the electronic responses. Some people wish to dominate others, rather than think generously of them. This is an age old human weakness. If we want to allow freedom of choice, we need to allow life in the first place, so there can be a real choice. (1)Time to erase the line? Niall L Cox BMJ 2007;334:382, doi:10.1136/bmj.39128.715613.3 Competing interests: None declared
Neutral review or opinion for debate? 28 February 2007
Stuart H McClelland, Anaesthetic Research Fellow Nottingham University Hospitals NHS Trust, NG7 2UH Send response to journal: Re: Neutral review or opinion for debate?	I have watched as responses have been posted for the article about the abortion debate. There seems to be a widespread feeling that the article was not appropriately balanced for its place as a "Feature". In medical journals, it would be more usual to publish such a piece as an editorial, although typically this would be written by a clinician with some first hand knowledge of the topic, rather than a freelance journalist. Even in the BMJ, which now seems more like a magazine than a scientific journal, a more honest and transparent approach would be to publish it as a debate between two writers. If the aim really is to publish an independent review on a topic, then it is the editorial board's responsibility to ensure that this is what they get. It must have been obvious to them that the tone of this piece would provoke one side of the debate more than the other. As there has been no response from the editors on this issue, we do not know if that was their intention. I would ask that they do now consider this criticism and respond, as I feel they currently fail to clearly separate factual articles from opinion. As a scientific publication indexed by Medline, they have a responsibility to make this distinction. Perhaps it would be better if journalism was left to BMA News. Competing interests: None declared