Intended for healthcare professionals

Feature Essay

Reflection is protection in abortion care—an essay by Sandy Goldbeck-Wood

BMJ 2017; 359 doi: (Published 20 November 2017) Cite this as: BMJ 2017;359:j5275
  1. Sandy Goldbeck-Wood, editor in chief, BMJ Sexual and Reproductive Health
  1. goldbeckwood{at}

Allowing the space for conscientious reflection is essential if harm is to be minimised—for professionals as well as for women, writes Sandy Goldbeck-Wood

Where I conduct abortions, all procedures are preceded by an exploratory conversation with women to establish that they are necessary. As well as ensuring compliance with the UK Abortion Act, we aim to allow space for ambivalence, invite reflection, and rule out coercion; a process that from the outset acknowledges the woman as the final arbiter of the likely balance of risks and benefits but that does not simply rubber stamp a request without a genuine effort to understand her situation.

I see this as protecting women from potential future harm caused by unexplored ambivalence—harm which occasionally reappears in psychosexual counselling as unresolvable guilt, impairing health and relationships. My hope is that without necessarily changing the decision, deeper reflection may result in greater resolution and integration, a better chance that a woman, whatever her decision, will be able to “move on.”

But the discussion also protects me, the surgeon. Despite my belief in properly delivered abortion as an ethical and evidence based part of women’s healthcare, there are moments when it is distasteful to carry out. I understand why, in addition to colleagues who have religious objections to abortion, some doctors experience a deep emotional unease or aesthetic aversion to the process. But meaning can protect against harm,1 and when performing an otherwise violent act, it really matters for your own sense of integrity that you genuinely believe that it is, on balance, necessary.

Haunted by a difficult case

I am still haunted by an abortion I performed recently and want to explore why it was so difficult. I have little doubt …

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