Examination of Witnesses (Questions 280-299)
REV DR
JOHN FLEMING,
ANNE QUESNEY,
DR PETER
SAUNDERS AND
ANNE WEYMAN
17 OCTOBER 2007
Q280 Dr Spink: Is it arbitrary and
misleading to consider vitality, looking at this upper age limit,
considering, of course, that almost all babies would have been
viable had they not been aborted?
Rev Dr Fleming: Absolutely. I
see considerations of viability and vitality as without moral
significance to the fundamental question that you are addressing.
There are many, many human beings who have become less vital because
of accidents that they have had into life beyond birth. If a committee
is purporting to say we are going to stick to the science then
you are moving into immediate moral territory once you raise the
eugenic question of whether or not a certain human being has too
many disabilities or too much disability to be allowed to be born.
Secondly, the viability question seems to me to be again supremely
irrelevant because by and large unborn children left to gestate
in the normal way will come to viability.
Q281 Dr Spink: They are all viable,
most of them.
Ms Quesney: I think, again, we
have to make a distinction between what happens when abortion
is illegal. I think everyone will remember what happened in this
country before 1967.
Q282 Dr Spink: I am asking about
the specific issue of viability. Is it misleading to look at viability
since almost all babies that are aborted would have been viable
had they not been aborted?
Ms Quesney: I think what is really
prevalent about this is women making decisions about their bodies,
about their futures, about their fertility and about their reproductive
lives. I think that is probably the key for abortion rights especially.
Let me just come back to those 4D pictures.
Q283 Dr Spink: We have moved on from
there.
Dr Saunders: My view is that the
law on this in this country is based on a moral or ethical presupposition
that the status of a human life is contingent upon its capacity
for communication, consciousness, self-awareness and so on. I
do not think that viability—I would agree with John Fleming—is
a morally relevant parameter. When we are moving to that position
and saying that it is all right to abort a foetus which does not
have this degree of self-awareness, consciousness and so on we
are moving out of science and into ethics.
Q284 Dr Spink: Let us put the morality
on one side and let us look at just the science. Do you accept
that the vast majority of those babies that were aborted were
viable had they not been aborted, from the science viewpoint?
Dr Saunders: You are absolutely
right that the vast majority of first trimester abortions would
have resulted in live babies had we not intervened.
Ms Weyman: I think it is a completely
irrelevant question to the debate. What we are talking about is
an issue for women about what happens to them when they are pregnant.
The beliefs that obviously some people have about life and when
life starts and how it should be regarded are not those that are
shared totally within our society. We live in a society in which
women are able, fortunately, to be able to make a choice.
Q285 Dr Spink: Did you mean it was
an irrelevant question or an inconvenient question?
Ms Weyman: No, I think it is irrelevant.
It may be a relevant one in your beliefs system, but that is not
the beliefs that are held by everybody in society about the question
of life and when life starts and the relative position of a woman
and a foetus. I realise we are not on the ethical issues, but
this question has been very much more about ethical questions.
Q286 Chairman: The whole issue of
viability as far as the Committee is concerned is that in 1990
the issue of late terminations was reduced from 28 weeks to 24
weeks on the basis of scientific evidence and viability. Whether
you agree with that or not—
Ms Weyman: I accept that.
Q287 Chairman: —that is what
the Royal College of Obstetricians advised the Government.
Ms Weyman: I answered the previous
question about that, which was about the viability question and
whether that has changed and we have expressed our views about
that.
Q288 Chairman: Dr Saunders, when
you talked about the Epicure study you mentioned, first of all,
about the lowest common denominator study and then you talked
about the average. Lowest common denominator study, was that really
what you meant to say? Which is right? Did it average the information
it received or did it in fact take the lowest common denominator?
Dr Saunders: I concede your point.
I think I am overstating the case by saying lowest common denominator.
It is an average we are talking about between the best centres
and the others.
Chairman: I really want to get on to
mental health.
Q289 Dr Iddon: Could I ask you each
to give your opinion on whether you believe that abortion increases
the risk of mental health and whether the restriction of access
to abortion also has an effect on a woman's mental health? Perhaps
you could also comment on any evidence of causal factors or confounding
factors.
Ms Weyman: As far as the evidence
is concerned affecting women's mental health, there is no evidence
to show that an abortion has an adverse effect on women's mental
health. Where there is a mental health outcome this is quite often
the result of previously existing circumstances and condition
of the woman. We do not have much current evidence about the impact
of abortions if women are denied abortions. However, the evidence
that does exist shows that that can have very severe consequences
for a woman if she is forced to continue with her pregnancy. Overall,
being able to make her own decision is in fact beneficial for
a woman and there is no evidence for there being any detriment.
Dr Saunders: There are a considerable
number of robust peer reviewed studies strongly suggesting that
women with a prior history of mental health problems are especially
vulnerable to further mental health problems following an abortion.
I do not think this is really disputed at all by anyone in psychiatry.
However, the question of whether women with no pre-existing mental
health problems are at greater risk from mental health problems
has been contentious. I think it would be fair to say, looking
at all the evidence, that the Ferguson study is the first methodologically
robust longitudinal study that has confirmed a link there. It
needs to be repeated in other areas to see if that link is confirmed.
I do think there is now robust evidence suggesting that link.[3]
Ms Quesney: Over the last 40 years
one in three women on average has had an abortion in this country.
If there were major psychological sequelae related to abortion
I think we would probably know about it. Most women would really
show some serious problems. There is a huge amount of taboo surrounding
abortion. It is an issue that women are not likely to talk about
and it is an issue that women are made to feel guilty about. I
think we also need to take that into account. Most of the women
that we would come across and most of the women generally are
women who feel an enormous sense of relief after being able to
access the abortion safely and that is a really important point.
Rev Dr Fleming: I agree with every
word that Dr Saunders said. I want to add to it my own research
which has been published in the last month in which we find—this
is a two-year study—that Australians generally are morally
opposed to abortion in almost all circumstances but they are pro-choice
at the same time. This deep conflict within the community is highly
suggestive of reasons why it would be that women who seek abortions
or feel that their situation is so oppressive to them that it
can only be relieved by an abortion at the same time will later
feel significant distress, anxiety, guilt and so on from the abortion.
It is not something that is heaped off on them by others but it
is a deep conflict within the human psyche, ie we want choice
yet we do not feel good about abortion. Just as in a deeply conflicted
society like Australia, if I was to replicate the study I have
done I think that would be found to be the case in Britain as
well.
Q290 Graham Stringer: Dr Saunders,
you gave a vivid explanation about the difference between cause
and correlation before. Can the panel tell us where there is established
cause between abortion and death following an abortion by the
woman, where there is an established relationship with breast
cancer, an ectopic pregnancy or infertility? In what areas has
causality been definitely established?
Dr Saunders: I think this relates
to the whole question of the safety of abortion. A lot of evidence
has quoted the Confidential Enquiry into Maternal Deaths as showing
that an abortion is safer than normal childbirth. The evidence
that would lead us to doubt that is, first of all, the evidence
about the link between abortion and mental health which I have
mentioned. Secondly, there is now very robust evidence linking
abortion with subsequent pre-term delivery, in particular in the
Thorpe Review of 2001, in the EPIPAGE multi-centre study in France
and in the EUROPOP multi-centre study in ten countries in Europe.
It is quoted by the FPA in their evidence and by Sam Rowlands
in his that a previous abortion raises your chance of having a
premature delivery by between 30 and 100%. If we are talking about
multiple abortions, there is a "dose" effect in that
the more abortions you have the more likely you are to have a
subsequent pre-term delivery and the more likely you are to have
a very pre-term infant. The data about breast cancer is far more
controversial. I would agree with John Fleming in that I think
the jury is still out. In our own submission on this we refer
to the RCOG guidance of September 2004. If you read not their
one line conclusion but actually the body of evidence within the
guidance, they reviewed two large analyses of all of the studies,
one by Wingo and one by Brind. In the Brind study, which shows
a link between abortion and breast cancer, they say in this guidance
it does not have methodological problems with it. I would commend
the Committee look at the criticisms of the 2004 Lancet study
from Oxford which contradicts Brind's findings and I commend that
the Committee look at Brind's own critique of this and also the
critique by Greg Gardner which you also have in the evidence before
you. Having said all that, at CMF we are still sitting on the
fence. We think women, in order to be properly informed, should
be told that the jury is still out, that there may be a link but
that more research is needed. There are two other issues. These
linkage studies from Finland and California which show a significant
association between abortion and death from suicide, homicide,
accidents and so on cannot be discounted. The final thing I would
say is that because the HSA1 form, which does have a space to
record complications, is filled in either at the time of the abortion,
shortly after or, as we have heard from Vincent Argent, beforehand
it will only record complications which occur within the immediate
time-frame of the abortion itself. A lot of publicity has been
given to the complications of haemorrhage, infection, subsequent
infertility and so on that happen after the form is sent in. There
was a case recently in London of a 14-year old girl who needed
a hysterectomy after an abortion and that will not appear in the
statistics simply because it will not appear on the HSA1 form.
So we have got reservations about the Confidential Enquiry into
Maternal Deaths for all of those reasons.
Q291 Graham Stringer: Do any of the
other witnesses believe in causality in any of these conditions?
Rev Dr Fleming: I am reminded
of the analogy with smoking. When I was a student at university
I regret to say that in the Sixties it was more association/correlation
between health outcomes and smoking and over time we moved from
association to causality. I think the submission that I am putting
before you here suggests that there are significant increased
risks of premature delivery. There are infections resulting from
abortion. On the breast cancer thing, as I have said before, the
jury is still out. I think it would be foolish not to imagine
that there is enough there to suggest, at least in some areas,
there is a connective relationship between abortions and outcomes.
Ms Quesney: There is always more
evidence needed to establish those links. If you make abortion
illegal, which is what some people are really trying to achieve,
then there will be huge amounts of women dying as there are around
the world. I think that is a very important point of consideration
for everyone.
Ms Weyman: We have obviously examined
the issues around the risks in our submission so I will not go
into that. Clearly it is important that we have good evidence
and on the basis of that evidence women are advised, but in the
end the situation for a woman is making the decision for her in
the circumstances she is in as to what she wants to do. The risks
for her associated with continuing with the pregnancy in the end,
if she chooses to have an abortion, are going to completely outweigh
any other risks, the extent to which they are proven and the hypothetical
risks that are also suggested as well. I think it is fundamentally
important that women should be given the best information that
is available so that they can make the decisions that they would
want to make and we know that that is what good services do and
we know that women choose to make the decision to have an abortion.
Q292 Mrs Dorries: We know that at
between 20 and 24 weeks a foetus is anaesthetised and yet we had
evidence on Monday from Dr Maria Fitzgerald saying that she believes
that a foetus does not feel pain until much later. Dr Saunders,
what is your take on foetal pain? At what point do you think the
foetus feels pain?
Dr Saunders: I have difficulties
with the evidence given by Maria Fitzgerald and that given by
Stuart Derbyshire in written form to the Committee over foetal
pain because I think there is a lot of disagreement between physiologists
who work in this area about when the foetus first feels pain.
Both Derbyshire and Fitzgerald work from the presupposition that
pain cannot be felt until cortical connections are established
between the thalamus and the cortex. That is highly contentious.
I would refer the Committee to a paper which is not in our evidence
because it was published this month by KJ Anand. It is a major
review of this whole issue in Seminars in Perinatology, October
2007 which makes this point very strongly that pain is in large
part a thalamic sensation and that we cannot draw conclusions
about whether or not foetuses feel pain from the presence or absence
of advanced thalamic cortical connections.
Q293 Dr Spink: But there is scientific
evidence from 4D imaging that foetuses smile and cry at 24 to
26 weeks, is there not? Would you agree with that?
Dr Saunders: We know a foetus
from a very early stage in pregnancy will withdraw from inoxious
stimulus. If you put a needle into a 22 weeker on a neonatal unit
it will cry. If we measure stress hormones like catecholamines
and cortisol, they are present at an earlier stage than 20 weeks.
The neural connections there to the thalamus are present at 19
to 20 weeks. So the jury is still out on this issue and I think
we should give the foetus the benefit of the doubt.
Q294 Chairman: Are you saying that
a quadriplegic feels pain when you stick a pin in their foot?
Dr Saunders: No, I am not saying
that, but I am saying—
Q295 Chairman: Is that not the reason
it does not feel pain, because there has been a severing of the
spinal cord?
Dr Saunders: With all due respect,
a quadriplegic will feel pain if you stick a needle into his face,
but we are talking about a lesion occurring in the spinal cord.
If you look at adults who have lesions in their sensory cortex—and
Anand goes into this—they still feel pain. Why is that?
It suggests that the cortex is not the only part of the brain
that is involved in conscious pain sensation. If that is true
for adults then surely we should be giving foetuses the benefit
of the doubt. Bertrand Russell once said that a fisherman told
him that fish had neither sense nor sensation but how he knew
that he could not tell him. I think we need to ask people like
Fitzgerald and Derbyshire how they can be absolutely sure. Given
that the RCOG itself recommends anaesthetics for babies being
operated on or for fetal surgery and late abortion—
Chairman: The evidence that Dr Fitzgerald
gave this Committee was very clear, she said she did not know;
that was her absolute starting point. There is a fundamental difference
there.
Dr Harris: I would like to move on to
areas where you have expertise rather than areas where you are
commenting on others' expertise.
Mrs Dorries: That is not a precedent.
Q296 Dr Harris: I would like Anne
Weyman to have the chance to comment about the issue of premises
and so forth, but before I do that I wanted to ask two short questions.
Firstly, just for my clarification, Dr Saunders, you quoted a
Greg Gardner as an authority in respect of his evidence. Is he
research active in this area?
Dr Saunders: Dr Harris, you and
I both know that any doctor with proper medical training can go
to peer reviewed journals and look at the evidence and draw conclusions
and that is the beauty of evidence-based medicine, it is that
a houseman, an FY1, can challenge a professor on the basis of
the written evidence.
Q297 Dr Harris: I just asked you
who Dr Gardner was.
Dr Saunders: He is not a researcher
in this area. He is someone who has looked at all the evidence.
I think your implication that someone who has not had hands-on
research experience in a certain area is not qualified to look
at the data—
Q298 Dr Harris: Let us try and find
some consensus. Conscientious objection is within our subject
area today. Would you agree with me that it is going to be necessary
for doctors and health professionals to have the right to conscientiously
object? Would you agree that that conscientious objection has
to include the right not to have to refer a patient for an abortion
so that someone else does it for you?
Dr Saunders: Chairman, is that
a question about the science? Should I answer it?
Q299 Chairman: I run this inquiry.
I am ruling that question out of order. I am going to finish with
one final question and it is really about the two doctors' signatures.
Why do you feel that two doctors' signatures are necessary for
a termination when they are not needed for any other medical procedure?
Rev Dr Fleming: I think you can
argue both ways on having one doctor's signature being sufficient
to refer. I think that the complication, if I may say, Chairman,
in relation to the abortion issue is that if an abortion is being
referred on the basis of a psychiatric condition you would think
it would be sensible for a psychiatrist to attest to that, that
would be the other signature. The initial referring doctor may
not have sufficient expertise for the reasons why the abortion
is being referred under law and it may therefore be thought very
prudent that there should be a second signatory and that the second
signatory should have expertise in the reasons why this referral
is being made.
3 Note from the Witness: with the Fergusson
Study. Back
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