Memorandum 38
Submission from Dr Alex Bunn
SCIENTIFIC DEVELOPMENTS RELATING TO THE ABORTION
ACT 1967
REGARDING POINT
2:
"medical, scientific and social research
relevant to the impact of suggested law reforms to first trimester
abortions, such as: (b) the role played by the requirement for
two doctors' signatures".
EXECUTIVE SUMMARY
Abortion is an irreversible invasive procedure
with known long term consequences for health. The very least that
a woman contemplating an abortion should expect is balanced quality
information, and time for reflection. This is unlikely to be provided
by abortion providers, who have a vested interest in not deterring
a potential client, especially in the private sector. The requirement
for two doctors' signatures was originally meant to protect women
from such exploitation.
It is therefore a necessary safeguard that patients
are counselled thoroughly by an impartial third party to ensure
informed consent, without coercion. It is also necessary in order
to provide ongoing care in the community for those patients with
risk factors for adverse outcomes, which are likely to be neglected
in specialist centres. Both these functions are best provided
in primary care, which is a valuable check against consumerism
in British healthcare.
The requirement for two signatures was enshrined
in the 1967 legislation for good reason. The Act never made abortion
legal, but rather gave two independent doctors a defence against
prosecution. Recognising that abortion involves the taking of
human life, the legislators intended that, with the greatest care,
this should not be taken lightly.
Currently there is no agreed standard for abortion
counselling. This could be a great opportunity for parliament
to make a positive contribution by maximising the benefit of the
requirement for two medical consultations. A good parallel might
be the Fraser Guidelines, which governs how doctors ascertain
whether an underage girl can consent to family planning without
parental involvement. The Upper House's deliberation has brought
a minimum standard into medical practice which protects the vulnerable,
whilst retaining necessary freedoms for those who are in need.
These guidelines might contain agreed risks and benefits, a discussion
of alternatives with sources of help provided, and a built in
cooling off period in between consultations for reflection.
CONTENTS
1. Evidence for the physical harm of abortion.
2. Evidence for the psychological harm of
abortion.
3. The need for thorough counseling to ensure
informed consent.
4. The need for the involvement of GPs in
screening and ongoing care.
5. The case for requiring two doctors' signatures.
6. Objections anticipated:
(a) The requirement for two doctors' signatures
only delays the acquisition of a termination of pregnancy.
(b) Counselling and screening can be performed
by specialist services.
(c) Many patients are obstructed from obtaining
a termination due to conscientious objectors.
1. EVIDENCE FOR
THE PHYSICAL
HARM OF
ABORTION
There is not space to cover fully the increasing
evidence base for this observation but, I will mention a couple
of recent developments, as the case for close medical supervision
rests partly on the harm to be prevented.
Immediate post abortion complications, such
as infection, uterine perforation and haemorrhage, are thankfully
rare. However despite minimal media coverage, there is a very
real increased risk of miscarriages in future pregnancies following
abortions.[233]
There is a significant peer-reviewed literature suggesting a 30%
increased risk of breast cancer following abortion.[234],[235]
2. EVIDENCE FOR
THE PSYCHOLOGICAL
HARM OF
ABORTION
There is now substantial research which suggests
a significant risk of suicide,[236]
deliberate self-harm,[237]
,[238]
depression and low self esteem.[239]
The evidence is sometimes conflicting, which is why meta-analyses
(compilations and summaries of all the available data) are helpful
in quantifying the harm robustly. The aggregate data gives a figure
for harmful outcomes at 10%.[240]
It has also demonstrated the need for well constructed studies
which can differentiate between a direct effect of abortion and
confounding factors such as social class and previous mental health.
One rare such study has recently clarified the issue.
Research published in The Journal of Child Psychology
and Psychiatry in January[241]
has shown that even women without past mental health problems
are at risk of psychological ill-effects after abortion. Women
who had had abortions had twice the level of mental health problems
and three times the risk of major depressive illness as those
who had given birth or never been pregnant.
This research has prompted the American Psychological
Association to withdraw an official statement denying a link between
abortion and psychological harm.[242]
It also prompted eleven British consultants
in psychiatry and obstetrics to call upon the Royal Colleges of
Psychiatry and Obstetricians and Gynaecologists to revise their
guidelines,[243]
which have not been updated since 1993 and 2004 respectively.
This group included an Emeritus professor of obstetrics and a
previous president of the Royal College of Psychiatrists.
3. THE NEED
FOR THOROUGH
COUNSELING TO
ENSURE INFORMED
CONSENT
Anyone who conducts a medical procedure without
informed consent commits battery. The report by the Commission
of Inquiry into the Operation and Consequences of the Abortion
Act 1994 highlighted the fact that many women, despite seeing
two doctors, did not receive counselling that met the Department
of Health guidelines.[244]
Without adequate counselling, informed consent cannot be given.
The decision to remove the involvement of a second doctor can
only make this deficit worse. (Page 12 para 66)
The Commission also found that a number of women
who gave evidence stated that there was too much time pressure
already to make a rapid decision, even before a streamlined service
was considered (Page 12 para 69). With the increasing time pressures
of secondary and tertiary care, counselling in a non-directive
manner, ensuring all the alternative options are thoroughly explored,
will be further compromised. Secondary care (specialised abortion
services) has different priorities to primary care. The "bottom
line" is safe medical practice, and the avoidance of medical
complications, rather than facilitating a woman in crisis to make
a difficult and life changing decision.
For instance, the day case abortion service
proforma for counselling from Tower Hamlets, presented as best
practice to the Commission of enquiry, starts simply with the
words "You have decided to have an abortion ..." and
goes on to detail procedural details about anaesthetics, nail
varnish, valuables, clothing, blood tests, contraceptive advice,
when to return to work, discharge from hospital, follow up and
minor symptoms following the procedure such as pain, bleeding,
dizziness, infection. "Mixed feelings" was added to
the check list only several years after it was conceived, which
demonstrates that facilitating a choice between various options
was not a priority. This is the impression of many doctors, that
secondary care is an inappropriate environment to weigh up important
options in pressurised time scale.
Currently, each woman considering termination
of pregnancy first attends her own GP surgery, or a community
clinic. These places offer a wide range of services which are
not prejudiced to only one solution, which might include, if she
wishes mobilising the father or family, counselling services,
adoption agencies, housing options, and financial benefits. These
are stock in trade for a GP, but rarely utilised by secondary
care. General Practitioners are patient advocates who have a long-term
relationship with patients, often from a young age. They understand
the family background, subculture, previous choices and values,
financial situation, mental health profile and relationship status
of their patients, and are ideally placed to offer patient centred
counselling which takes into account the unique person sitting
before them.
The Commission noted that abortion is irreversible
with known long term consequences for health. They therefore recommended
a waiting period of at least one week before an abortion can be
performed, as well as a requirement to give advice on alternatives,
and services such as social security benefits, housing, information
on adoption etc. These are rarely discussed in secondary care,
and conceivably would obstruct a streamlined "one-stop shop"
approach. (Page 13 para 72)
A sample telephone survey conducted for the
commission highlighted the fact that only 3 out of a sample of
14 private clinics actually provided formal pre-abortion counselling.
This is a scandal that is unlikely to be remedied by the loosening
of procedures designed to ensure that patients are given the opportunity
to reflect on the options, and consider the consequences of what
is for many a momentous decision.
It may be that many doctors without psychiatric
training justify a mild paternalism on the grounds that an abortion
is in the patient's best interest if the pregnancy was unplanned.
However, witnesses representing the Royal College of Psychiatrists
also stated that "although the majority of abortions are
carried out on the grounds of danger to the mother's mental health
there is no psychiatric justification for abortion. Thus the commission
believes that to perform abortions on this ground is not only
questionable in terms of compliance with the law, but also puts
women at risk of suffering a psychiatric disturbance after abortion
without alleviating any psychiatric problems that already exist."
(Page 15)
It appears that according to psychiatric experts,
the justification for abortion on mental health grounds is a medical
myth. Rather, they warn that these patients are actually vulnerable
patients who may need protection from harm.
4. THE NEED
FOR THE
INVOLVEMENT OF
GPS IN
SCREENING AND
ONGOING CARE
Researchers from around the world found that
women are more likely to suffer psychologically from abortion
if they have certain risk factors:[245],[246]
,[247]
— poor emotional support;
— perceived pressure to have an abortion;
— underlying ambivalence, especially
if the decision is delayed;
— a partner who desired the pregnancy;
— previous miscarriage, stillbirth.
The psychiatrist who gave evidence to the commission
stated that a psychiatric assessment before an abortion was essential
in the following circumstances:
— all mid-trimester abortions.
— all women with a history of psychiatric
illness.
— women who felt coerced, or were ambivalent
about the decision to abort.
As these subtle factors about a patient's social,
psychological, spiritual and financial situations are far more
likely to be known by a patient's GP than by a specialist working
in secondary care, who has no long-term relationship with the
patient or their family. From many years of work in the NHS in
primary and secondary care, it is clear to me that the only knowledge
a specialist will have of a patient is that which the patient
volunteers when the clinician "takes a history".
In fact the only factors of the 11 above that
might be routinely covered by a standard clerking taught in hospital
practice are two: housing and formal psychiatric history. Housing
is usually only asked about in the elderly to ensure safe discharge
home. A patient may be asked about any previous "psychiatric
illness', but this is likely to signal that the doctor only wants
to know about severe mental illness under the care of a psychiatrist.
This is normally enough information for the purpose of assessing
a patient's reliability in giving a history, competence in giving
consent, and interactions with any drugs, prescribed or recreational.
The focus is less on ascertaining whether a patient is vulnerable
to the consequences of any medical procedure, which is rarely
as ethically and psychologically loaded as it is with abortion.
And specialist services are unable to provide the ongoing care
and support for those who have negative emotions in the years
following termination.
As a GP, I have certainly seen many patients
who have had terminations, who are still living with the fallout,
especially with secret sorrow and depression. These patients often
feel that they have no-one to turn to, but a GP is an advocate
who will stand by her from the positive pregnancy test, counselling,
referral and for ongoing care and support.
5. THE CASE
FOR REQUIRING
TWO DOCTORS'
SIGNATURES
So far I have argued on the basis of protecting
the patient's best interest, from direct harm and exploitation,
and for ongoing care in the community.
But it is also in the interests of society to
recognise that human life should not be taken lightly. A parallel
might be that two doctors currently are required to sign cremation
forms, partly as after cremation there is no body available upon
which to check cause of death, a factor which Harold Shipman exploited.
Even if this safeguard fails in preventing misdemeanour, it does
send a signal to doctors and society that we have a weighty obligation
to prevent unnecessary deaths. Likewise termination is not a service
like any other. It is not, in all good faith, usually offered
on medical grounds, except in the rarer cases of foetal abnormality,
which at present remains undefined. The requirement for two signatures
is a reminder that human life is being taken, quite unlike any
other medical procedure. Society therefore demands some objective
verification that is transparent, consistent, and above reproach.
Currently there is no agreed standard for abortion
counselling. This could be a great opportunity for parliament
to make a positive contribution by maximising the benefit of the
requirement for two medical consultations. A good parallel might
be the Fraser Guidelines, which governs how doctors ascertain
whether an underage girl can consent to family planning without
parental involvement. The Upper House's deliberation has brought
a minimum standard into medical practice which protects the vulnerable,
whist retaining necessary freedoms for those who are in need.
These guidelines might contain agreed risks and benefits, a discussion
of alternatives with sources of help provided, and a built in
cooling off period in between consultations for reflection.
6. OBJECTIONS
ANTICIPATED
A. The requirement for 2 doctors' signatures
only delays the acquisition of a termination of pregnancy
In fact, yearly abortion figures have tripled
since 1967 and continue to rise. The burden of proof should be
on those who wish to argue in the face of the evidence that abortion
is difficult to obtain. Women can already get early abortion more
easily than ever under the existing law and there is no reason
to liberalise further. In fact, much of the delay between conception
and termination occurs precisely because many women are ambivalent
about have an abortion, all the more reason to provide better
opportunities for counselling and reflection, rather than a conveyer
belt approach which precludes it.
Public opinion has also grown uneasy about the
increasing availability and volume of abortion in the UK. A recent
public opinion poll found that 81% of those who expressed an opinion
believe that ways should be found of reducing the 200,000 abortions
performed each year in Britain.[248]
It is encouraging to read that the Royal College
of Obstetricians and Gynaecologists does not support the removal
of the two doctor's requirement. Maggie Blott, of the RCOG, was
quoted by BBC online saying that scrapping the two-doctor rule
would be wrong:
"Some of the late abortions that are done
are not straightforward so having the built-in safety net of two
doctors is important, and you can't have one rule for them and
another for women who have early abortions".[249]
B. Counselling and screening can be performed
by specialist services
As stated above, the research suggests that
specialist services are not best placed to offer non-directive
counselling, that respects the patient's values, appreciates her
medical and mental health history, and has the time to allow reflection
and a wide range of alternatives. Without a requirement for an
independent referral, patients are less likely to receive adequate
counselling that ensures informed consent. Without informed consent,
patients are vulnerable to exploitation, battery, and the known
long-term harms of abortion.
C. Many patients are obstructed from obtaining
a termination due to conscientious objectors
Given that GPs usually provide one of the two
doctors signatures required before any abortion can legally proceed,
they are crucial to the smooth operation of the 1967 Abortion
Act. In mid June, Marie Stopes International published the results
of its survey into GP attitudes to abortion. The survey was the
first major investigation into the views GPs hold on abortion
for 26 years. Over 7,000 GPs were surveyed, a sample big enough
to make the results reliable. 82% of GPs describe themselves as
"pro-choice". Hence, there seems little reason to doubt
that patients requiring a first signature in the community would
be able to find a doctor to sign their form. In fact, in practice
it is not necessary to have a signed form from a GP, although
a GP is better placed to offer counselling and ongoing continuity
of care.
D. In practice, it is already the case that
only one doctor actually assesses the patient, the other signature
is a mere formality
This might be true, in which case all the more
reason to ensure that the current legislation is implemented in
a way that satisfies society that human life is not taken casually,
and that women in crisis get the support they need. One consultation
is not enough for such a momentous decision, and does not provide
sufficient guarantee of good practice for such a massive decision.
A time of reflection between consultations was recommended by
the previous Commission, and currently unenforced.
E. Requiring 2 signatures adds to the stress
a woman would have to endure in seeking an abortion
It is certainly a very distressing to decide
on whether to have an abortion. However, the recent medical evidence
shows that having a termination can cause more psychological pathology
in the long term, especially for women who are initially ambivalent.
Therefore it is even more incumbent on the medical profession
to ensure it is a decision that is informed, uncoerced and persistent
over time.
September 2007
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234
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