Examination of Witnesses (Questions 246-259)
REV DR
JOHN FLEMING,
ANNE QUESNEY,
DR PETER
SAUNDERS AND
ANNE WEYMAN
17 OCTOBER 2007
Q246 Chairman: We welcome our second
panel to our inquiry this morning. Thank you all for coming. I
introduce you for the record: Rev Dr John Fleming, bioethics consultant
representing the Society for the Protection of Unborn Children;
Dr Peter Saunders, General Secretary of the Christian Medical
Fellowship; Anne Quesney, Director of Abortion Rights; and last
Anne Weyman OBE, the Chief Executive of Family Planning Association.
Welcome to you all. I am trying to be fairly strict in this inquiry.
We are looking at the science and how that has changed so that
we can inform any future changes to legislation. We expect there
will be amendments to the Tissue and Embryos Bill in the new Parliament.
That may or may not come about and, if it does, we hope that our
inquiry will be able to inform any debate on that matter. Dr Fleming,
how do you go about assessing the quality of evidence so that
you can form a view? What criteria do you use in assessing the
scientific evidence that is available? Is that a fair question?
Dr Fleming: It is a fair question.
The institute of which I am a member, Southern Cross Bioethics
Institute, has on its staff people who are scientifically qualified.
We are very careful in setting down certain criteria by which
we assess the evidence. We do not set ourselves apart from the
broader scientific community. We read the literature and we try
to be as objective and fair with that literature as we can be
because the establishing of scientific fact is a profoundly ethical
issue. That is, we have to sort out what is true from what is
untrue from what is controversial or controverted. For example,
you will find in our submission here on the question of the link
between breast cancer and abortion that our position is equivocal
in the sense that we are not persuaded that that is the case.
There may be some other groups that would and have taken a very
different view but we try to be as objective as we can without
fear or favour for any particular philosophical or ideological
view that we might hold.
Q247 Chairman: Would you not quote
anything unless it was peer reviewed, for instance?
Dr Fleming: We would cite stuff
that was not peer reviewed but we would take into account that
it is not peer reviewed. In other words, we are not going to exclude
anything in advance on the basis that the sole repositories of
all wisdom and knowledge are to be found in peer-reviewed journals,
prestigious as they are; there is a body of information that we
take into account as well. Where scientific data is concerned,
we balance that with the more rigorous standards that would obtain
in peer-reviewed journals.
Q248 Chairman: Anne Quesney, how
does your organisation evaluate the evidence? What are the criteria?
Anne Quesney: We try to be as
objective as possible by looking at historic evidence, by looking
at international evidence and scientific evidence to see really
what in the end we believe is in the best interest of women. To
give you an example, if you go back to the situation prior to
1967, for instance, it is very clear that women's health and women's
lives were not taken into account. I think it is very clear that
access to abortion has been of huge benefit to women. Looking
at scientific evidence across the board, I think it becomes very
clear that that is a recognised fact.
Q249 Chairman: In terms of evaluating
the evidence, again it would be peer reviewed mostly and where
it was not, you would make that clear?
Anne Quesney: We try to look at
a variety of reviews because I think you have to be critical in
the field that is so complex. A lot of the time we tend to have
a very scientific approach but in many ways abortion is also a
very practical issue for women. That also needs to be taken into
account.
Dr Saunders: I am here representing
the Alive & Kicking Alliance, which is 10 organisations, seven
of which have made written submissions. I am also here in my capacity
as General Secretary of the Christian Medical Fellowship, which
is an organisation with 5,000 UK doctors and 1,000 UK medical
students asmembers.
Q250 Chairman: In terms of the evidence—
Dr Saunders: As CMF, we are doctors
who are trained in assessing scientific evidence. We quote almost
exclusively peer-reviewed studies that have been published in
journals but, like John Fleming, we would take other evidence
into account if we felt that, although not yet peer reviewed and
published, it was making an important contribution to the debate.
Examples might be Ellie Lee's study from Southampton, EPICURE
II, or the study from University College Hospital London that
was reported earlier this week on neonatal survival rates and
presented at a medical conference. Generally, we are looking to
peer-reviewed studies but we do make some exceptions.
Q251 Chairman: If EPICURE II for
instance demonstrated, having been peer reviewed, that there was
no evidence to suggest that babies born at 23 weeks had any greater
chance of survival than they did a year ago or 10 years ago, would
you accept that?
Dr Saunders: If EPICURE II is
published in a peer-reviewed journal, then I think it becomes
part of the body evidence that one must consider in coming to
conclusions about the viability of neonates at the threshold of
life. We have quite serious reservations about the first EPICURE
study for two reasons. Firstly, we believe that it was a lowest
common denominator study that averages survival rates across a
whole range of different units, from centres of excellence to
regional hospitals; and, secondly, because we believe that EPICURE
is not just now providing evidence about neonatal survival but
has actually taken the position of a guideline in the sense, as
was reported in the Sunday Times last week, that some neonatologists
are simply not "trying hard enough" for babies at the
threshold because they believe that they will not survive. We
think that along with EPICURE, we need to take into account the
best studies from centres of excellence. One of the ones that
has been quoted this week and is in our own evidence is Hoekstra's
study from Minneapolis which showed survival rates for 22 weeks,
23 weeks and 24 weeks.[1]
Q252 Chairman: I am not getting into
that. I am trying to establish principally how you actually assess
your evidence. That is all I am trying to do at the moment. How
does the fpa assess their evidence? The point I am trying to get
at is: how do we get a level playing field for this committee
to decide on the evidence? It is important that we get your views
on this.
Anne Weyman: The whole rationale
behind fpa's work is the provision of information, particularly
to the public, which is based on the best evidence that is available.
That is on a whole range of topics: contraception, sexually-transmitted
infections, abortion, pregnancy choices and the different routes
women can take if they have an unintended pregnancy, and on planning
of pregnancy. There is a whole range of areas. It is a complex
task to assess the evidence. Obviously we work from published
studies. We also work very much with professionals who have great
expertise in the field. We have expert advisers whom we consult
when we are looking at evidence and putting forward information.
Obviously we want to go for the most reliable scientific evidence,
the peer-reviewed studies. Sometimes you have to look at other
information because you do not have a full range of information
from the peer-reviewed studies. That is the way that the professional
bodies also work when they produce guidance for professional practice.
You have a hierarchy and you have to assess the quality of that
evidence for any statements that you going to make and any views
that you are going to form.
Q253 Dr Harris: I think what our
inquiry is going to do is not recommend how people should vote
on changing the law. What we are going to try to do is say what
we think the evidence says in so far as the science, although
there will be other factors—feminism and the sanctity of
life—which other people will use to trump that sometimes,
perhaps frequently. That is why we are concentrating on the science
side of this. In so far as the science is concerned, just to follow
up what Mr Willis was saying, Dr Saunders, if you were trying
to judge the science of where viability was and EPICURE II was
published in a peer-reviewed journal and it suggested that viability
was still 24 weeks, if I can use that shorthand, would you give
that more credence in any way in your view on the narrow question
of where viability is, not where the upper time limit should be,
than an unpublished, un-peer-reviewed case study from one hospital,
like that you have cited from the Sunday Times? Would you
accept that there is a difference in quality there for that narrow
question?
Dr Saunders: EPICURE I has been
published in a peer-reviewed journal; EPICURE II has not. The
study referred to on Monday was presented at a scientific meeting
and gave figures for University College Hospital London. However,
there are a number of other peer-reviewed studies from centres
of excellence around the world.
Q254 Dr Harris: I am talking about
this country. I should have made that clear. I will put the question
again. For this country, for where viability is for women in this
country, in the narrow question of viability, talking theoretically
now since you have taken me down EPICURE I, if there was a peer-reviewed
published study that said 24 weeks was still the case and that
was across the country multi-centre, would you give that greater
weight than an individual non-peer-reviewed, non-journal published
report from one hospital, whether that is more or less?
Dr Saunders: I think that there
is a much bigger body of evidence than you are implying. I think
that any doctor coming to a conclusion—Could I finish, please?
Q255 Dr Harris: I would love you
to finish but I would really love you to answer my question, which
is not asking you to look at the evidence. I am asking you a theoretical
question. I am not asking you to search the world or your mind
for other studies. I am just asking: if there was a peer-reviewed
study that was national, that was published, would you give that
greater weight than an unpublished, non-peer-reviewed report from
a single hospital on the narrow question of viability? I have
asked this three times now.
Dr Saunders: Yes, I would but
I think when we are coming to conclusions about viability, it
would be quite inappropriate and irresponsible to ignore the vast
amount of international data about foetal viability from the very
best international centres and concentrate just on UK data that
has been very widely criticised.
Dr Harris: You have to understand that
we have your written evidence. You have made that point in your
written evidence. We just have to get through this oral session.
Chairman: Dr Harris, I am coming on to
viability in a minute.
Dr Harris: I want to ask several questions.
Lots of our submissions have selected papers, as it their right,
and interpreted them. Do you accept that there is a practice which
is to say: Let us have an independent body do the systematic review—not
ourselves, whether it is fpa, Abortion Rights or your organisations
with an agenda—that controls essentially for the instinct
just to select the argument on either side that supports it? Do
you think that is a legitimate thing to do? Do you think the Royal
College of Obstetricians and Gynaecologists is a reasonably independent
organisation that can look at the whole literature and not be
tempted? I put that to Dr Saunders and to Dr Fleming.
Q256 Chairman: Can you answer that
question as briefly as you can?
Dr Saunders: Yes, I do think there
should be independent panels which look objectively at all of
the studies that are available. I think there is a temptation
for people on both sides of this argument to cherry-pick the studies
that back up their position. I think that criticism could be made
of several of the written submissions that have been made. I have
serious reservations about the Royal College of Obstetrics and
Gynaecology guidance on abortion, firstly, because it was published
in September 2004.
Q257 Dr Harris: I was not asking
about the guidance but about whether they are independent enough
to set up a panel that would do it. Dr Fleming?
Rev Dr Fleming: Yes, I do think
in principle it is a good idea to have clearing houses where data
is assessed and has as objective an account as possible given
of the data because of the tendency of all organisations to cherry-pick
those studies which may support a pre-existing position. You mentioned
in your question about organisations with an agenda. With great
respect, I do not know of an organisation that does not have one
and if you do I would be very glad to know what it is. RCOG is
not what I would regard as a body that would be good for that.
I think it ought to be some sort of body which has clearly a representative
collection of individuals, where the various agendas, as you put
it, can rub against each other to some extent. If you are going
to be absolutely honest about this, not one of us here does not
have an agenda. If we accept that that is the case in all honesty
and we then say okay, how can we derive some kind of clearing-house
or houses which can look at the evidence in the best way possible—
Q258 Dr Harris: What comparative
group should we be using to distinguish between the health risks
of abortion versus covariate factors? In other words, if you are
looking at women who have had abortions, what is the best comparator
group? Is it all women? Is it women who are mothers? Is it women
with pregnancies that are wanted? Is it women who have unwanted
pregnancies but cannot get an abortion? Which do you think is
the right comparison?
Rev Dr Fleming: The answer is
all of those. I think any research worth its salt has got to take
account of the various conditions of the persons involved from
whom you are seeking information otherwise you are likely to come
to lopsided conclusions. I do not think that any reasonable research
can just simply ignore particular groups of women. If there is
a medical procedure being done on a group of women, presumably
with their full knowledge and consent, then any adverse outcomes
have to be measured against those who have not had such a procedure,
whatever the procedure might be and then you are going to have
to look at the sub-groups where there might be confounders which
you have to take into account.
Q259 Dr Harris: How do you take into
account confounders in choosing the right comparator group? How
does one deal with confounders? The suggestion is that it is best
to compare women who have abortions with women who have all the
same backgrounds and have unwanted pregnancies and where a higher
proportion of them have drugs misuse issues and domestic violence
issues and so forth but who cannot get abortions to see whether
the abortion itself has had an impact on that group of women.
Do you think that is powerful or do you think it is flawed?
Rev Dr Fleming: It depends on
the risks you are after. If you are after the psychological sequelae,
that might be the case. If you are after the physical risks to
the women of a particular medical procedure, that might not be
so appropriate. You really need to determine what are the risk
areas that you want to examine before you can decide how you are
going to do it.
1 Note from the Witness: As 32%, 66% and 81%
respectively. Back
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