Is abortion worldwide becoming more restrictive?

BMJ 2012; 345 doi: (Published 4 December 2012)
Cite this as: BMJ 2012;345:e8161

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Ecological damage and depletion of non-renewable resources are proportional to population size [1,2]. Humankind can choose to control population growth by reducing the birth rate instead of increasing the death rate, as it has been usual throughout history. Possible solutions require new ethical principles: e.g. no population group should obtain advantages due to its numerical increase. Logically, those who have had more children should live in somewhat narrower conditions. Until now, birth control has been hampered by conflicting national and global interests: population growth has been deemed conductive to sovereignty and economic advance. However, the common interests of mankind have become obvious. Global birth control would require investment and administrative efforts; all simpler and less expensive solutions would be however less humane. As a source of financing, the revenues from fossil fuels could be used. Only by concentrating authority within a powerful international executive, based in the most developed parts of the world, can the vicious circus of international competition and conflicts be disrupted and priorities for addressing the overpopulation created.

With regard to birth control, the standpoints of all religions seem to be obsolete. Some Islamic laws are however constructive. According to the concepts of Ensoulment and La-haraj, abortion can be legal under certain conditions. Ensoulment takes place 16 weeks after fertilization [3]. In the Islamic Republic of Iran, permission of therapeutic abortions before the time of ensoulment is based on this principle. The rule of La-haraj says that Religion never imposes unbearable difficulties. Therefore, if the pregnancy causes such difficulties to a woman or her family, Islamic law allows the woman a termination of the pregnancy. The La-haraj concept is applicable to all kinds of hardship thus potentially justifying not only therapeutic abortions but also those related to social circumstances; it can be applied also to other domains of life to avoid excessive hardship. At the same time, certain Islamic principles are formally incongruent with legislation: "The law of equality is prescribed to you in cases of murder: the free for the free, the slave for the slave, the woman for the woman"; "As to the thief, male or female, cut off his or her hands"; "The recompense for an injury is an injury equal thereto" [4]. Furthermore, the commandment: "Take not for friends unbelievers" [4] might be conductive to self-isolation. Therefore, considering that all religious teachings apparently do not keep pace with the modern world, some of them should not be taken exactly to the letter.

Today, labour productivity is high, a few can cater for many, and more and more people get out of work. In the past, comparable conditions of relative overpopulation were terminated by wars or pestilence. This has not been happening for a long time, and we are waiting to see what happens, as if there had been nothing more to do. However, many things must be done to ensure life of billions: construction of irrigation facilities for drought-stricken lands, of thermonuclear, hydroelectric, solar, tidal and other power plants to reduce the consumption of fossil fuels, production of hydrogen as an energy carrier, and so forth. Scientific research should be activated, centrally planned to avoid parallelism, purged from commercial influences, scientific misconduct, and obscurantism. New pollutants, drugs, other chemical and physical factors should be tested in large-scale experiments to evaluate possible noxious effects. Such measures would provide occupation for many people. Not much is required for that: a globalized administration and English as the first or second language for everyone. Moreover, should the birth rate decline in future, it means that the workforce is at its maximum today: an opportunity to accomplish great projects. Therefore, propaganda should popularize the image of modest and hardworking people, which must become attractive for young generations. More details and references are in [5,6].

1. Desvaux M. The sustainability of human populations: How many people can live on earth? Significance 2007;4(3):102-7.

2. Van Niekerk JP de V. Humans - a threat to humanity. S Afr Med J 2008;98(3):163.

3. Ejtehadi F. Therapeutic Abortion in Iran; Role of Culture and Religion. BMJ Rapid Response of 9 December 2012.

4. Yusuf Ali A. The meaning of the Holy Qur’an. Beitsville, Maryland: Amana Publications, 2002.

5. Jargin SV. Ethical challenges in an age of overpopulation. S Afr Med J. 2010;100(11):694.

6. Jargin S. Demography and architecture in Ethiopia and elsewhere. Domus News of 05 June 2010

Competing interests: None declared

S. JARGIN, researcher

Peoples' Friendship University of Russia, Clementovski per 6-82; 115184 Moscow, Russia

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Fifty-six years ago abortion was legalised by the Soviet regime in Lithuania. Since then there have been an estimated two million abortions in the country, while currently there are a bit less then three million residents in the country. The phenemena without the causes for this high number of abortions having ever been tackled remain unresolved.

There are many reasons for abortions, whether they are financial or social problems, like insecure relationships. But particularly frequent are a lack of self-esteem, the inability to talk to one's partner or even total subjugation to that partner. The environment is of particular importance, and only too often society seems cold and indifferent towards the individual, and there is a lack of family love. These are factors that drive women to abortion: they have mothers and fathers and a man whom they love, but when they ask their close ones for help and advice these people turn their backs on them.

Termination of pregnancy is stigmatized both in society and psychiatry and is due to political and ethical debates. Therefore abortion may result in traumatized psyche as a complication. Trauma affecting a woman’s thoughts, feelings, dreams, fantasies, intentions, and relations change her attitude to life as such, to her nearest, also to the values and eventually to herself. The consequences occurring as uncontrolled chain reaction affect her family life, career and communication; they break her as personality and lead towards destruction. There is always a risk of suicide. In psychiatry, termination of pregnancy is very important as it can be a reason for developing psychopathology. The identified psychopathological symptoms meet the diagnostic criteria of post-traumatic stress disorder. Psychopathology is distinguished by its personal, spiritually painful and stigmatized character. During my psychiatric clinical practice I have met five hundred female patients suffering from this.

Competing interests: None declared

Palmira Rudaleviciene, Consultant Psychiatrist, Assoc. Professor

Vinius Mental Health Center, Mykolas Romeris University, Ateities 20. Vilnius, Lithuania

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If abortions are getting restricted, globally for whatever (religious or legal) reason, the only solution left is to prevent it. Use of contraception will prevent conception or implantation (e.g. oral contraceptives and Cu-T, respectively). In this modern era, Emergency Contraception, such as: the pill (e.g. Progesterone only Pill) and Copper-T insertion can be done within 72 hours and five days respectively of unprotected intercourse and can prevent unwanted pregnancy (and hence need for abortion) with an efficacy of 89% (1) and more (nearly 100%) respectively. Not only will an abortion be averted but also the morbidity and mortality associated with clandestinely performed abortions will be effectively prevented. And it will also decrease the burden on the Health Care System.



Competing interests: None declared

Neeru Gupta, Scientist E

Indian Council of Medical Research, Ansari Nagar, New Delhi-110029

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With great interest I read the article by Sophie Arie; “Is abortion worldwide becoming more restrictive” published in your journal I would like to explain the legality of abortion in the Islamic Republic of Iran.

Unfortunately, perhaps due to lack of knowledge, on the distribution map, quoted from the United Nations, Islamic Republic of Iran is labeled as an area in which abortion is prohibited altogether or only to save a woman’s life. Also the paragraph about abortion in Iran is not included in the printed version of BMJ.

As a physician who has practiced in Iran before joining the British health service I would like to clarify the indications and legality of abortion in Iran and to add some points regarding the matter.

Based on two Islamic laws, ensoulment and La-haraj, therapeutic abortion is legal in certain conditions. According to Islam, it is believed that the ensoulment takes place 16 weeks after fertilization and “La-haraj” is one of the Islamic rules that is relied upon by Shiite authorities to permit abortion before the time of ensoulment. The rule of La-haraj says that the religion never imposes unbearable difficulty to its believers. Therefore, if the pregnancy causes such a difficulty to a woman or her family, the Islamic law allows the woman to terminate her pregnancy, Major Thalassemia or bilateral polycystic kidney are good examples. Obviously this is the case before the time of ensoulment because this rule does not permit killing of an innocent soul.

The Forensic Medicine Organization (FMO) of Iran has issued a list of 29 fetal and 32 maternal indications for abortion. Request and consent of the mother would start the process and after approval of three specialist physicians and final acceptance by a legal medicine center, the procedure can take place.

To summarize, in the Islamic republic of Iran, based on Islamic rules, therapeutic abortion is allowed before the19th week of pregnancy if the mother's health is threatened, and also in cases of fetal abnormalities that makes it unviable after birth or causes difficulties for the mother to take care of the child after birth.

Competing interests: None declared

Farshid Ejtehadi, Surgical Registrar

Mid Yorkshire Hospitals NHS Trust, Pinderfields Hospital, Wakefield, WF1 4DG

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The title itself conveys that there is a growing restriction on abortion. But at the same time it must not end up with a loss of life because of religious or legal constraints. The very purpose of medicine is to save life and promote the health and well being of the individual being treated. It is very sad to hear about the loss of a life because of such restrictions.

It is a long debate about abortion which will never get universal agreement. It therefore depends upon the medical profession to have its say to decide about abortion. Abortion is not a method to restrict life but is a medical treatment to save the life of an endangered mother.

Competing interests: None declared

dhastagir s sheriff, Professor

Faculty of Medicine, Benghazi University, Benghazi, Libya

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It is truly good to hear that abortion is on the wane. As a recent op ed article in the New York Times said what we need are more babies. Ireland has a great track record in maternal health and has a minimal maternal death rate. It is twice to three times safer to give birth in Ireland than in the UK or USA. These jurisdictions have abortion and we do not so certainly abortion will not improve maternal well being.

The unfortunate case of the Indian woman who died from septicaemia has absolutely nothing to do with abortion as the facts will show when a full report is published. This unfortunate lady had septic threatened abortion and this carries its own morbidity and mortality even with the very best treatment. Evacuation of the products of conception was not an issue as it has not been an issue for the past 50 years and more in Ireland. The standard obstetric treatment for septic abortion is and has always been the practice in Ireland. There is no grey area where doctors don't know what to do. To my knowledge, there never has been litigation against doctors for aborting a foetus in such circumstances and there won't be because it is best practice. The media and vested interests whipped up a frenzy of heat and emotion around this case saying that the husband and patient asked several times for an abortion but were refused because "there is a foetal heart beating and this is a Catholic country and abortion is illegal" or words to that effect. The elephant in the room is that induction of labour/D and C in these circumstances (septic threatened abortion) is standard practice in Ireland and why this did not happen initially in this lady's case is unclear.

What is certain is that the above reasons proffered by the press are outrageous and amazing. Ireland is subject to lies and media confusion at the expense of the harrowing suffering of this lady and her husband, all to force the hand of the government to legislate for abortion. The European Court wants clarity around abortion here and the crystal clear transparency of the practice of the past 50 years speaks for itself. Women get the best maternity care in Ireland and abortion (that is the direct killing of the baby as opposed to the indirect when a procedure is needed to save the mother's life at the cost of the baby's life) is not needed as the facts show.

Competing interests: None declared

Eugene G Breen, Psychiatrist

Mater Misericordiae Hospital, Dublin., 62/63 Eccles St

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Thanks for writing such an informative article. I never realised that abortion is restricted to such an extent in developed countries as well. I think a women should be allowed to decide if she wants to continue the pregnancy or not. I agree when the abortion is due to sexual discrimination (eg:female foeticide in India) this should be illegal but otherwise abortion should be legalised. This will prevent illegal abortions and reduce the rates of maternal deaths.

Competing interests: None declared

Rakhi Singh Raghunath, Core medical trainee

Sheffield teaching hospitals NHS trust, 64 Olivet Road, Sheffield S8 8QS

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