After 50 years of legal abortion in Great Britain, calls grow for further liberalisation

Sally Howard sensitively and insightfully discusses the potential polemic surrounding the expansion and liberalisation of abortion legislation in the UK(1). As a profession, before we can responsibly support such a cause it is vitally important that we know why women seek abortions. The available data strongly suggests that a significant proportion of women undergo terminations due to poverty, this being one of the commonest reasons cited for requesting an abortion(2,3,4). In the USA the poorest 33% account for 75% of abortions(2,5,6) . In this context abortion cannot be considered to be a “choice” by any definition of the word. Addressing poverty may avoid a number of unwanted abortions. Liberalising legislation may result in abortion effectively being used as a solution to poverty, which is clearly undesirable. If abortion is a symptom of poverty criminalising vulnerable women is inappropriate but so too is the social “abortion on demand” model.

Howard persuasively argues that a shift in societal views of women and abortion since the 1967 Abortion Act drive the current will to emend legislation. However, since the act, a similar evolution has been observed in perceptions to disability and gender equality. The UK Equality Act 2010 prohibits discrimination on the ground of race, gender or disability. In spite of this according to the UK National Down Syndrome Cytogenetic Register, in 2013, 90% of foetuses with a prenatal diagnosis of Down's syndrome were terminated(7,8) . As a profession we need to be explicit and clear as to how we can reconcile championing disability rights and yet have no concerted response to these statistics, in the face of which we remain taciturn. The law argues that the foetus is not a life or alive until birth and hence cannot be subject to discrimination. However as doctors we know that this is medically antithetical or even absurd. In a similar vein, abortion cannot be presented as an unqualified victory for women’s rights. The World Health Organisation and UNICEF recognise that globally considerably more female foetuses are terminated than male, with in excess of 117 million “missing” girls globally as a consequence of sex-selective abortion(9). The United Nations has recently incorporated into its mission statement the objective to “eliminat[e].. all forms of violence against women”(10) . Our profession needs to urgently address the issue that the first act of violence against women is in utero and is fatal. We cannot espouse gender equality and yet support permissive legislation that facilitates this practise. Abortion is often seen as a totem of civil liberty and progress but clearly can be used as an instrument through which outmoded gender and disability prejudices are played.

Doctors have unique knowledge, experience and skills. With this comes influence and responsibility. We have an important role in the abortion debate. When we engage in the debate it is incumbent upon us to bring our peculiar skill-set which is science and medicine with humanity and humility. Our role is not to regurgitate the same political and legal arguments which have been circling for 50 years; nor is it to emote or moralise with anecdote. The anecdotes provided by Howard and Goldbeck-Wood are compelling(1,11) . However medicine no longer uses anecdotes to inform and control practice. People have questions specifically for doctors in the deliberation of the abortion debate, which pertain not to law or politics but to medicine. People want to know if the foetus is biologically and physiologically alive or not. The law argues that they are only alive after birth. However medicine gives a completely different truth, that once the haploid gametes unite to form a diploid zygote the human organism is alive. This is medicine. There is no magic or mystery to the inception of life, unless we seek to redefine the biological phenomenon. Further people want to know if the foetus feels pain. We need to consider the relevance of this to any putative time limits or methods of abortion. Finally people want to know why women, partners and families seek abortion, if for anything to know that they are not alone, irrespective of their motivation for requesting termination. If we fail to attend to these important and unanswered medical and epidemiological questions, as profession, we risk paradoxically further entrenching antiquated gender and disability prejudices or may merely create a world where abortion is a right but not a choice.

(1) Howard S After 50 years of legal abortion in Great Britain, calls grow for further liberalisation BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5278 (Published 23 November 2017)

(2) Uzoigwe CE. Socio-economics: Reduce inequality to reduce abortion. Nature. 2017 Apr 5;544(7648):35.

(3) Sedgh G, Bearak J, Singh S, Bankole A, Popinchalk A, Ganatra B, Rossier C, Gerdts C, Tunçalp Ö, Johnson BR Jr, Johnston HB, Alkema L.Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends. Lancet. 2016 Jul 16;388(10041):258-67

(4) Kirkman M, Rowe H, Hardiman A, Mallett S, Rosenthal D. Reasons women give for abortion: a review of the literature. Arch Womens Ment Health. 2009 Dec;12(6):365-78

(5) Jerman J, Jones RK and Onda T, Characteristics of U.S. Abortion Patients in 2014 and Changes Since 2008, New York: Guttmacher Institute, 2016, https://www.guttmacher.org/report/characteristics-us-abortion-patients-2014.

(6) https://www2.census.gov/programs-surveys/demo/tables/p60/252/pov_table5.pdf

(7) http://www.wolfson.qmul.ac.uk/images/files/pdf/annrep2013_FINAL.pdf

(8) https://www.nhs.uk/news/genetics-and-stem-cells/downs-syndrome-qa/

(9) http://www.unfpa.org/gender-biased-sex-selection

(10) García-Moreno C, Zimmerman C, Watts C.Calling for action on violence against women: is anyone listening? Lancet. 2017 Feb 4;389(10068):486-488

(11) Goldbeck-Wood S. Reflection is protection in abortion care-an essay by Sandy Goldbeck-Wood. BMJ. 2017 Nov 20;359:j5275.