Abortion by telemedicine: an equitable option for Irish womenBMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2237 (Published 16 May 2017) Cite this as: BMJ 2017;357:j2237
All rapid responses
In their response (1) to the Editorial by Norman et al. (2) on our paper regarding the safety and effectiveness of abortion telemedicine (3), Dr. Uzoigwe and colleagues raise three concerns about the Women on Web (WoW) service.
The first is whether Women on Web (WoW) offers informed consent to women seeking telemedicine abortion. Dr. Uzoigwe and colleagues specify that in order to give informed consent “patients must have communicated to them all material risks of their abortion; in a manner that is intelligible”. These risks are clearly communicated to women not only via the information available on the website, but in an interactive format as they fill out the online consultation form. Moreover, once the consultation is approved, women receive further communication from the WoW helpdesk, including information about how the medications work, what to expect to see and feel, and the range of possible complications along with their respective risks. All women are able to ask further questions to the helpdesk and all will receive timely and medically accurate answers. Furthermore women can see and hear an animation on the website and YouTube with the information about the medical abortion as well as when to look for local health care. If Dr. Uzoigwe and colleagues are suggesting that women need to have this information read out to them by a doctor, rather than being able to read it , listen and see it for themselves, that idea seems at best paternalistic, and at worst offensive.
The second concern is that WoW recommends that anti-D is not needed for Rh-negative women. We have already addressed this issue in response to a previous letter co-authored by Dr. Uzoigwe (4).
Finally, Dr. Uzoigwe and colleagues suggest that WoW undermines the doctor-patient relationship because women who need to seek follow-up care are advised that they can say they had a miscarriage rather than a medical abortion. What they do not acknowledge, however, is the obvious fact that for Irish and Northern Irish women seeking advice following online telemedicine abortion, a normal doctor-patient relationship does not exist. A doctor may very well feel obliged to report women to the authorities and there are doctors that have actually done so, either out of fear of professional repercussions or lack of knowledge of the consequences, or because she or he disagrees with the decision to have an abortion. These possibilities all put women who pose no risk to themselves or others in danger. Until abortion is decriminalized and available like any other healthcare service in Ireland and Northern Ireland, the need for women to conceal their abortions will continue. It is not WoW that undermines the doctor-patient relationship. Instead it is the law of the land that does.
(1) Uzoigwe CE, Franco LCS, Campoy AS. Informed Consent and Telemedicine Abortion. BMJ. 2017 May 20. http://www.bmj.com/content/357/bmj.j2237/rr
(2) Norman WV, Dickens BM. Abortion by telemedicine: an equitable option for Irish women. BMJ 2017;357:j2237
(3) Aiken ARA, Digol I, Trussell J, Gomperts R. Self reported outcomes and adverse events after medical abortion through online telemedicine: population based study in the Republic of Ireland and Northern Ireland. BMJ. 2017 May 16;357:j2011
Competing interests: Gomperts and Digol are employed by Women on Web; Trussell is on the board of directors of Women on Web Foundation
Norman et al. provide an instructive synopsis of the work of Aiken et al(1,2). However the motives of telemedicine abortion providers cannot justify a permissive and uncritical assessment of their methods. Norman et al correctly identify women included in the study as representing a potentially vulnerable cohort. These circumstances cannot vitiate the need for the valid and informed consent process, to which women are entitled; consistent with the principles espoused in Montgomery vs Lanarkshire Healthcare Board (2015)(3). Patients must have communicated to them all material risks of their abortion; in a manner that is intelligible. A material risk is a risk to which a reasonabley prudent patient would attach significance(3). Hence the decision-making process is not paternalistic but shared and patient-centred. Exploration of the Women on Web website (www.womenonweb.org/en/i-need-an-abortion) must raise concern that women have not been adequately consented for their abortions. There is a "Q&A" drop down a la carte menu, with which patients may or may not necessarily engage, a fortiori given the emotive nature of the circumstances involved. For example the site advises against the need for anti-D as immunoprophylaxis to Rhesus alloimmunisation (https://www.womenonweb.org/en/page/1683/in-collection/6902/what-if-you-h...). Haemolytic disease of the new born, affecting subsequent children with a risk to the neonate's life, may constitute a material risk. This is all the more so given that Ireland has one of the highest prevalences of the Rhesus negative blood group in the world(4).
In the absence of informed consent, following Chester v Afshar (2005) in the UK, telemedicine providers would be liable for the complications that arose. In instances where the abortion did not termindate the pregnancy there would also potentially be liability for the unfortunate tort of wrongful birth.
The provider appears to counsel women to engage in behaviours which potentially undermine the doctor-patient relationship. For example they advise that women need not inform attending doctors that they have attempted medical abortion but rather that they have suffered a spontaneous miscarriage (https://www.womenonweb.org/en/page/1683/in-collection/6902/what-if-you-h... https://www.womenonweb.org/en/page/485/in-collection/6907/how-do-you-kno...). Further while correctly advising women to seek medical attention immediately, where they fear that a complication has arisen; WoW seem to add the caveat that where agents have been administered vaginally women "must check..to make sure that they are dissolved", with no further advice on how to proceed should they not have dissolved (https://www.womenonweb.org/en/page/1683/in-collection/6902/what-if-you-h...). The WoW objective is, in some ways, laudable in that they wish women to avoid prosecution. However practices which foster and breed mistrust between patients and healthcare professionals can only compromise the standard of care globally. There is a consensus that vulnerable and desperate women should not be criminalised. However difficult circumstances cannot arrogate to internet telemedicine providers the power to disregard fundamental rights of informed consent and autonomy.
(1) Norman WV, Dickens BM. Abortion by telemedicine: an equitable option for Irish women. BMJ. 2017 May 16;357:j2237.(
(2) Aiken ARA, Digol I, Trussell J, Gomperts R. Self reported outcomes and adverse events after medical abortion through online telemedicine: population based study in the Republic of Ireland and Northern Ireland. BMJ. 2017 May 16;357:j2011
(3) Chan SW, Tulloch E, Cooper ES, Smith A, Wojcik W, Norman JE.Montgomery and informed consent: where are we now? BMJ. 2017 May 12;357:j2224
(4) Bhutani VK, Zipursky A, Blencowe H, Khanna R, Sgro M, Ebbesen F, Bell J, Mori R, Slusher TM, Fahmy N, Paul VK, Du L, Okolo AA, de Almeida MF, Olusanya BO, Kumar P, Cousens S, Lawn JE.Neonatal hyperbilirubinemia and Rhesus disease of the newborn: incidence and impairment estimates for 2010 at regional and global levels.
Pediatr Res. 2013 Dec;74 Suppl 1:86-100. doi: 10.1038/pr.2013.208. web appendix www.nature.com/pr/journal/v74/n1s/extref/pr2013208x1.doc
(5) Sokol DK. "How can I avoid being sued?". BMJ. 2011 Dec 14;343:d7827
Competing interests: No competing interests