Examination of Witnesses (Questions 260-279)
REV DR
JOHN FLEMING,
ANNE QUESNEY,
DR PETER
SAUNDERS AND
ANNE WEYMAN
17 OCTOBER 2007
Q260 Dr Harris: You said yes for
psychological sequelae. In the memorandum from the Society for
the Protection of Unborn Children you say, at the top of page
8, "a major UK study did not identify a difference in total
psychiatric disorders between aborting women and those who carried
to term", and you give the reference as the 1995 Gilchrist
study. You then say, "The same study did however identify
an increase in deliberate self-harm, which includes substance
abuse." Are you aware that the full sentence of the Gilchrist
study says, " ... in women with no previous history of psychiatric
illness deliberate self-harm was more common in those who had
a termination"—which is what you are saying—"risk
ratio 1.7, or who were refused a termination, risk ratio 2.9"?
That is the group that you have agreed just now was the appropriate
group for psychological sequelae. Can you explain why you think
you missed out the second half of the sentence from the conclusions
of that study?
Rev Dr Fleming: I will have to
ask the researcher who wrote that part of the study for the answer
to the question. Was it number 34?
Q261 Dr Harris: Paragraph 34, reference
51.
Rev Dr Fleming: I will ask them.
Q262 Chris Mole: Chairman, it would
be interesting to hear some of the other answers from the other
witnesses to that question.
Dr Saunders: I think it is incredibly
important in research to eliminate confounding variables in order
to establish a proper causal connection. Every time I raise my
arm someone in China drops dead but that does not mean there is
a causal connection. In the same way, there are studies, for example,
that show a link between abortion and subsequent suicide in the
year following. It is a strong association which has been demonstrated
in linkage studies, but it is not yet established that there is
a causal relationship between abortion and suicide because when
you correct for all the confounding variables, such as socio-economic
status and so on, the connection is not as strong. However, if
you do correct for all the confounding variables and you find
that there is still a connection then it is strongly suggestive
of a causal relationship. An example of that would be one of the
most quoted studies this week the Ferguson study from Christchurch,
New Zealand linking abortion with subsequent mental health problems
in women, where they took great effort to remove all the confounding
variables and a pro-choice researcher was surprised at his findings
that the link still persisted.
Q263 Dr Harris: Do you accept that
the author said he recognised he could not adjust for the "wantedness"
of the pregnancy as the factor there?
Dr Saunders: Yes.
Q264 Dr Turner: Both pro-choice campaigners
and pro-life campaigners focus very heavily on the issue of viability
and this becomes conflated with the upper time limit for abortions.
I want to ask all of the panel what they feel is the connection
between the upper time limit on abortion and the gestational age
at which a live birth is considered viable?
Rev Dr Fleming: It depends entirely
on how you are going to ask this question. There is a factual
base on the question of viability. You then have to move from
that piece of information—let us suppose we could agree
on what that viability is, 24 weeks, 23, 22, 21, whatever, and
whether you can move from an "is" to an "ought",
which is an ethical question. All I have heard around the table
since I have been here pretty much is ethics and speaking as a
philosopher, everybody is moving from "is" to "ought".
The question is in itself a profoundly ethical question. As to
a connection between the upper time limit on abortion, that is
a piece of information and the gestational age at which a live
body is considered viable, I do not make much connection with
it at all. It seems to me that in principle there is no real difference
between what you do to a pre-viable infant or a viable infant.
Q265 Dr Turner: Before you finish
your opinion, you have stated the gestational age of viability
as an accepted fact or words to that effect. Do I take it that
you are content with the opinion, which others question, that
24 weeks is the generally accepted limit of viability?
Rev Dr Fleming: I accept that
it is a controverted question and I think there will be those
in a better position scientifically than me to answer that with
greater precision. I am simply saying that from the point of view
of abortion I think it is an irrelevant fact and your question
implies an ethical response because you are talking about a piece
of information, a fact that "is" and making it an "ought".
Any philosopher knows that is fundamentally ethical. In my view
the abortion issue does not turn on viability.
Q266 Dr Turner: But ethics are informed
by fact.
Rev Dr Fleming: Absolutely, but
that is my point, you are moving from "is" to "ought".
You are necessarily engaging in a philosophical enterprise.
Ms Quesney: I think the law in
Britain is based on a connection between the time limit and gestational
age. If you look at the last 17 years since that decision was
made to have a time limit for abortions of 24 weeks, there have
been very few changes in terms of foetal viability. One of the
issues we have not really talked about much at all is women and
their needs. This may not be purely scientific, but I think there
is a growing body of evidence which shows that there is a need
for the very few women who need to access abortions, for very
complex reasons, to be protected by law. As a society we really
need to make a choice about whether we need to protect the most
vulnerable people in our society.
Dr Saunders: This connection between
viability and the abortion law has its historical basis in the
Infant Life Preservation Act of 1929 which is still in force in
Britain, at least in England and Wales. The Infant Life Preservation
Act makes it a crime to procure an abortion involving a baby "capable
of being born alive", that is the basis. I would submit that
that is a different concept to viability, which has been the main
concern of this Committee. When we consider viability there is
a debate about when foetuses become viable based on the interpretation
of evidence, the alleged inadequacies of EPICure, other studies
from higher centres and so on which we will not go into further.
If we were to look back at the original intention of the law makers,
it was to make it illegal to procure an abortion for a baby "capable
of being born alive", that is why the 28 week limit was chosen
initially. It was modified in 1990 by the Human Fertilisation
and Embryology Act because foetal survival had improved with good
neonatal care. We would submit it has improved further in the
best centres. So we are in an anomalous situation at the moment
where, for example, the West Midlands region can publish in the
British Journal of Obstetrics and Gynaecology, looking
at the abortions anomaly between 1995 and 2004, as in the Pro-Life
Alliance's evidence here, that there were 102 babies born alive
after "botched abortions". Technically those are criminal
acts under the Infant Life Preservation Act. I think I would like
to question why the Committee is looking at the issue of viability
rather than the one that actually has legal significance, which
is capability of being born alive, which although similar is a
different concept.
Q267 Chairman: There is a fundamental
issue between viability and vitality. Do you make a difference
between the two or do you regard them as the same?
Dr Saunders: There is a difference
between a foetus capable of being born alive and, on the other
hand, a foetus that, with the best neonatal and intensive care,
is likely to live with or without handicap. I think that is a
distinction that this Committee has not yet made and it is an
important distinction in law.
Ms Weyman: I just wanted to make
a general comment first of all on this issue about the focus on
viability and the fact that this is something that has interested
both sets of organisations. My organisation is particularly interested
in a whole range of other issues that this Committee is discussing
and I would be disappointed if I am not able to comment on some
of those things, particularly around improving early access and
some of the things you were talking about in the earlier part
of the session. I think the first answer you had to this question
does rather reveal the important divide here in the discussion
around the time limit between those who are fundamentally opposed
to abortion in any circumstances and would like to have a time
limit really which is zero and therefore would push down the limit
and this difficult discussion around what is the appropriate time.
When I consider this issue, it seems to me that making any woman
continue with a pregnancy and have a child that she does not want
is always a terrible thing to do and has very bad effects on that
woman.
Q268 Chairman: We are not discussing
that. You were asked a question about viability.
Ms Weyman: I understand that.
I think the issue about the time limit is an issue about how you
reconcile the differing views and concerns about abortion and
the pressing needs of women. The discussion about viability is
obviously important in that because that is something that very
much matters to people and the discussion in society as we consider
what is a controversial issue. On the question that you raised
about vitality and viability and how you judge the fact that because
one baby may survive at a particular gestation against the needs
of women in that situation and the very few women—I think
we have to recognise that—who have abortions at that stage
of gestation, I think that that is where you are making judgments
which are based on the scientific evidence and how you evaluate
those different issues. Certainly our view as an organisation
based on the evidence, which much more expert people have given
to you on those scientific issues than I can and that you heard
on Monday particularly, is that the evidence still maintains that
24 weeks, when you take all that into account, is the compromise
that applies still today as it did when it was introduced.
Dr Spink: The figure was 3,000 last year
and that does not seem to me to be very few. Even one is too many.
Q269 Dr Turner: Thank you for those
answers which, as I anticipated, covered a range of views. The
one thing which all of you clearly felt extremely important was
the issue of viability. That was vital if you will pardon the
pun! What medical progress do you think has been made in recent
years in terms of improving the prospects for very pre-term babies,
and do these advances, if you accept that they are significant,
have an impact on upper time limits for abortions?
Rev Dr Fleming: There has clearly
been some improvement, that is undeniable from the literature.
As to whether or not there is anything there to justify playing
around with the time limits in the Abortion Act as it currently
is constituted, I am not persuaded. It seems to me that of all
of the issues we ought to be thinking about that is not really
at the top of my agenda. I would say that it is such a controversial
matter as to whether you move from 24 to 23 to 22 to 20. It seems
to me that there are more dangers raised in trying to go down
a pathway where there is as yet no clear answer to the question.
So I personally think that it would be better to leave aside playing
around with the number of weeks at this stage.
Ms Quesney: I think it is undeniable
that there has been some progress in medical techniques to keep
premature babies alive, but that should not stop us from distinguishing
between what is an unwanted and wanted pregnancy. Forcing a woman,
as Anne Weyman pointed out, to carry on with a pregnancy is something
that is of no benefit to society, to that woman or to her family.
One of the issues that was pointed out in the written evidence
is that in Holland for instance they have very clear guidelines
about not resuscitating prematurely born babies below 25 weeks.
It is probably a very pragmatic approach, but I think we should
probably take stock of what is happening internationally on this
issue as well.
Q270 Dr Turner: So you are not convinced
that the progress has meant that the gestational age of viability
has gone down?
Ms Quesney: I think there has
been progress in terms of keeping prematurely born babies alive.
The techniques that are being used in certain hospitals are enabling
those prematurely born babies to live but sometimes at great cost
to their personal health. I think what we need to take into account
as well is that prematurely born babies born alive at that stage
do not necessarily survive.
Q271 Mrs Dorries: What I interpret
your answer to be is that even though a baby may be viable and
that baby may be able to live if born, as far as you are concerned
viability has no bearing on whether or not an abortion takes place.
Do you believe an abortion should take place at any stage during
pregnancy?
Ms Quesney: I am quite comfortable
with the current time limit.
Q272 Mrs Dorries: So you think 24
weeks is the limit?
Ms Quesney: I think it is very
difficult for a woman to make a very, very complex decision about
whether or not to terminate a pregnancy at that stage or a woman
who has a very wanted pregnancy and is going into labour very
early.
Q273 Dr Turner: Dr Saunders?
Dr Saunders: The fact that there
have been massive advances in neonatal paediatrics leading to
the survival of infants at lower gestation is really undoubted.
That was reflected, first of all, in the fact that the HFE Act
changed the upper limit from 28 to 24 weeks. So there is no dispute
that between 1967 and 1990 there was massive change.
Q274 Dr Turner: Do you think there
has been significant change between 1990 and now, that is the
question?
Dr Saunders: I do. My wife worked
in neonatal paediatrics. In 1985 they had a 24-week old baby survive
in probably one of the top neonatal units in New Zealand. It was
so unusual that it became the subject of a grand round and all
the doctors came. Now in the best centres of excellence, like
Minneapolis, 81% of 24-weekers are surviving. At the risk of creating
boredom, we must distinguish between the kind of lowest common
denominator studies like EPICure which average across different
centres and do not take into account the postcode lottery of neonatal
care that exists in this country. When we do look at the centres
of excellence it is undoubted that at the very best centres there
has been a huge increase in the survival of infants at 23 and
24 weeks gestation between 1990 and 2007.
Q275 Dr Turner: Since you want to
focus on the centres of excellence, can you comment then on the
issues of vitality of those babies that survive given that the
number in the Epicure studies of those babies which have a degree
of handicap from mild to severe is extremely high? Can you comment
on that aspect of those that you consider show a greater survival
rate in the centres of excellence?
Dr Saunders: I would take issue
with the statement that the level of disability of early survivors
is unacceptably high. Even if you look at the EPICure figures
for 23 weeks, I think it was two out of 11 babies in that category,
which is just under 20%[2],
were in the severe disability category; others were moderately
disabled. I think then you are starting to verge on moral territory
where you are saying that babies with disabilities should be resuscitated,
which I do not think we should be doing in this inquiry. The figure
that is usually banded about by neonatal paediatricians is that
about 15-20% or so of early survivors will have a significant
degree of disability and a larger percentage than that will have
some disability and some will escape with no disability.
Q276 Dr Turner: Is your answer then that
in the centres of excellence the incidence of disability is not
different?
Dr Saunders: As far as I understand,
yes. What I understand from my neonatal colleagues is that the
percentage of babies surviving with disability at 24 weeks now
is pretty comparable to the percentage of babies that survived
with disability at 28 weeks 20 or so years ago. What has happened
with advances in neonatal paediatrics is that babies who would
have survived with severe disability are surviving with no disability,
others who would have died are surviving with moderate disability,
and some who had no hope are surviving with severe disability.
We are simply moving the line as neonatal paediatric care improves.
Ms Weyman: We have looked at the
evidence from the various different studies and also what the
expert bodies have been saying about this issue and we have been
looking at it for a long time and our view is that there has not
been such a significant change and therefore the present time
limit would be the appropriate one to continue with.
Q277 Dr Turner: There has been a
lot of publicity and a lot of emotive response certainly to 4D
images of babies in utero. What do you think that those
images actually tell us? Do we learn anything new from them?
Rev Dr Fleming: Very early on
in the days of the abortion debate people were told that the foetus
was a bundle of proplasm (?) and blood and I have many quotes
to that effect. What the images do is to give us information about
what it is that we are looking at. You have to add to that the
data about the developing human being and then after that you
move into the territory of philosophical reasoning, ie what do
you make of that information. I think ordinary people who respond
to the picture of an unborn child ought not to be dismissed as
responding emotively. We are human beings. I respond emotively
to a raft of things and which I am very well justified in responding
to. It does a disservice to the community that we all serve to
suggest that somehow or other people of the scientific or philosophical
dent of mind are more to be trusted and believed in abstracting
from an emotional response than ordinary people. Often times I
have found the responses of ordinary people to be far more instructive
to me than some of the nonsense I have heard from my fellow philosophers.
Q278 Dr Turner: Do these images actually
tell us anything concrete about the consciousness of a foetus,
its viability and all of those things?
Rev Dr Fleming: It tells ordinary
people this is a human being who is alive.
Q279 Dr Turner: But we knew that
anyway.
Rev Dr Fleming: We did not know
that anyway because the opposite was being said earlier in the
debate. I think the images have been effective for people who
have been told certain things and they see that that is not true.
2 Note from the Witness: When I checked these
remembered figures I realised I had quoted the percentages (2%
out of the 11% that survived) rather than the absolute numbers
(5 out of 22). The rounding off of percentages accounts for a
change from just under to just over 20%. Back
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