Conclusions and recommendations
The aim of the Inquiry
1. In
this Report, we set out the key issues that have emerged and the
key questions MPs must ask themselves as they consider options
for changes in the law. Where we have felt it appropriate and
justified, we have drawn conclusions about what the science and
medical evidence currently before us tells us. We urge all MPs
to study the evidence we have taken and the conclusions we have
reached. (Paragraph 12)
2. Because we recognise
that what the science and medical evidence can tell us is only
one of many factors that are taken into account when legislating
on this issue, we have not made any recommendations as to how
MPs should vote on abortion law. (Paragraph 13)
Defining viability
3. Caution
needs to be applied to unpublished data but the least the Committee
is able to conclude is that we have not heard any evidence from
EPICure that survival rates below 24 weeks gestation have significantly
improved and we draw this to the attention of the House. (Paragraph
35)
4. We understand that
the EPICure 2 results will not be published for some time. It
is unfortunate that the published data may not be available in
time fully to inform debate in the House. We hope that the emerging
findings are published as soon as possible. (Paragraph 36)
Individual neonatal intensive care units and results
from abroad
5. We
reach the conclusion that the national and regional surveys of
outcomes for very premature neonates are the best basis for establishing
the limit of foetal viability. We draw this to the attention of
the House and invite members to consider our conclusions when
they consider the best basis for determining foetal viability.
(Paragraph 45)
6. Having considered
the evidence set out above, we reach the conclusion, shared by
the RCOG and the BMA, that while survival rates at 24 weeks and
over have improved they have not done so below that gestational
point. Put another way, we have seen no good evidence to suggest
that foetal viability has improved significantly since the abortion
time limit was last set, and seen some good evidence to suggest
that it has not. We draw this to the attention of the House and
invite Members and the Government to consider our conclusion when
deciding when a foetus becomes viable. (Paragraph 46)
7. We make no conclusion
on the legal upper limit for abortion but instead invite Members
of Parliament to consider the role played by foetal viability,
among other factors, in that decision and to consider our analysis.
(Paragraph 48)
Relevance to the upper gestational limit
8. We
conclude that, while the evidence suggests that foetuses have
physiological reactions to noxious stimuli, it does not indicate
that pain is consciously felt, especially not below the current
upper gestational limit of abortion. We further conclude that
these factors may be relevant to clinical practice but do not
appear to be relevant to the question of abortion law. (Paragraph
59)
9. We invite Members
of Parliament, when considering the role, if any, of questions
relating to pain, to clinical practice or abortion law, to consider
our conclusions. (Paragraph 60)
4D images and foetal consciousness
10. We
conclude that while new imaging techniques are useful tool in
diagnosis of foetal abnormality, there is no evidence they provide
any scientific insights on the question of foetal sentience. We
invite MPs to consider our analysis when approaching this issue.
(Paragraph 63)
Late presentation
11. We
believe that consideration of late presentation and the production
of guidance would be better enhanced by better collection of data
relating to the reasons why women present for late abortions and
how many women travel overseas for late abortions, and appropriate
analysis of such data, with due regard to the need to protect
the confidentiality of patients. (Paragraph 69)
12. We invite Members
of Parliament to consider what research has to say about the impact
that an alteration on the upper time limit would have on those
women who present late for abortions. (Paragraph 70)
Foetal abnormality
13. We
invite Members of Parliament, when considering whether a clarification
or a definition of 'seriously handicapped' is desirable and/or
feasible, to consider our conclusions. (Paragraph 80)
14. The Department
of Health should commission work to produce guidance that would
be clinically useful to doctors and patients, and look at who
is best placed to do so. (Paragraph 81)
15. We believe that
consideration of abortion for reason of foetal abnormality and
the production of guidance would be enhanced by better collection
of data relating to the reasons for abortion beyond 24 weeks for
foetal abnormality, and appropriate analysis of such data, with
due regard to the need to protect the confidentiality of patients.
(Paragraph 82)
Two doctors' signatures
16. We
were not presented with any good evidence that, at least in the
first trimester, the requirement for two doctors' signatures serves
to safeguard women or doctors in any meaningful way, or serves
any other useful purpose. We are concerned that the requirement
for two signatures may be causing delays in access to abortion
services. If a goal of public policy is to encourage early as
opposed to later abortion, we believe there is a strong case for
removing the requirement for two doctors' signatures. We would
like see the requirement for two doctors' signatures removed.
(Paragraph 99)
17. Members of Parliament,
when considering whether the requirement for two signatures safeguards
the interests of women and doctors or any other purpose, are invited
to consider our conclusions. (Paragraph 100)
Other causes of delay
18. We
urge the General Medical Council, while preserving the right of
doctors to conscientiously object and not to refer directly to
another doctor for an abortion unless it is an emergency, to make
clear that conscientious objectors should alert patients to the
fact that they do not consult on abortions and that if the issue
arises during a consultation that they have a duty immediately
to refer the patient to another doctor for the consultation. (Paragraph
102)
Increasing nurses' responsibilities
19. We
are satisfied that there is adequate evidence, particularly in
terms of the roles that nurses already play in service provision
and in terms of the international experience, to conclude the
following:
- that subject to usual training
and professional standards nurses (and midwives) could be permitted
to sign the HSA 1 form, for which they currently obtain consent,
and prescribe the necessary drugs, which they currently administer;
- that permitting nurses and midwives to sign the
HSA 1 form and prescribe the necessary drugs would not alter the
rates of failed and incomplete abortions, abdominal pain or uterine
cramping, nausea, vomiting, diarrhoea, vaginal bleeding or spotting,
or pelvic inflammatory disease that can be associated with EMA;
- that since most women go home after taking the
second pill, there is no direct involvement with either nurses
or doctors at this point. What is crucial is the ready availability
of appropriate care should a complication arise, and clear instructions
to women about what to do in the event of complications, something
that nurses routinely give;
- that subject to usual training and professional
standards nurses (and mid-wives) could be permitted to carry
out early surgical abortions; and
- that such practice would not compromise patient
safety or quality of care. (Paragraph 108.?)
20. We
recommend that when Members of Parliament consider whether the
statutory ban on anyone else than doctors carrying out abortion
should remain, they consider the evidence and conclusions in this
report. (Paragraph 109)
Places where abortions can be carried out
21. We
conclude that, subject to providers putting in place the appropriate
follow up arrangements, there is no evidence relating to safety,
effectiveness or patient acceptability that should serve to deter
Parliament passing regulations which would enable women who chose
to do so taking the second stage of early medical abortion at
home, or that should deter Parliament from amending the act to
exclude the second stage of early medical abortion from the definition
of "carrying out a termination". This would enable
a trial to take place. (Paragraph 123)
22. We invite Members
of Parliament to consider our conclusions when considering the
question of whether the 1967 Act should be amended or regulations
passed to enable the second stage of early medical abortion to
be self-administered in a woman's home. (Paragraph 124)
Mental health risks
23. In
view of the controversy on the risk to mental health of induced
abortion we recommend that the Royal College of Psychiatrists
update their 1994 report on this issue. (Paragraph 139)
24. We conclude that
there is no strong evidence which contradicts the wording of the
current RCOG guidelines on the risk to mental health of induced
abortion. (Paragraph 140)
Future reproductive outcomes
25. We
found no strong evidence of links between abortion and negative
future reproductive outcomes with the exception of a possible
link with future pre-term deliveries and miscarriages. We conclude
that there is no strong evidence which contradicts the wording
of the current RCOG guideline on the risk to future reproductive
health of induced abortion. (Paragraph 150)
Breast cancer
26. We
found no evidence which contradicts the wording of the RCOG guidelines
on the risk of breast cancer. (Paragraph 154)
Post abortion infection
27. We
did not receive any evidence which undermined the RCOG guidelines
on post abortion infection. (Paragraph 156)
Informed consent
28. We
therefore recommend to the Government and the National Institute
for Health and Clinical Excellence (NICE) that the clinical guidelines
on abortion provision, including health risks associated with
abortion, should ultimately be taken over by NICE. (Paragraph
160)
29. We further recommend
that the Government fund the RCOG or NICE to review the RCOG guidelines.
(Paragraph 161)
30. While we recognise
that obtaining informed consent is a process that is not always
best carried out through leaflets and checklists alone, we recommend
that abortion providers are required to ensure this information
is given to patients as part of the process of informed consent.
(Paragraph 163)
31. To ensure that
no patients are misled, we further recommend that the Government
consider ways of ensuring that all those claiming to offer pregnancy
counselling services make the guidelines available or indicate
clearly in their advertising that they do not support referral
for abortion. (Paragraph 164)
32. We recommend that
Members of Parliament, when considering the issue of health risks
in the context of clinical guidance and informed consent, consider
also our report and conclusions. (Paragraph 165)
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