Examination of Witnesses (Questions 360-379)
RT HON
DAWN PRIMAROLO
MP, DR FIONA
ADSHEAD AND
PAULA COHEN
24 OCTOBER 2007
Q360 Dr Harris: Assuming that legal
advice is correct, my understanding is that it is unlawful in
this country to trial what happens in America, even to research
the safety, effectiveness and susceptibility under the current
law without class of place regulation being promulgated. Is that
also your understanding?
Dawn Primarolo: That is true.
Q361 Dr Harris: In 1990, the class
of place provision—which enables you, as the Department,
the Minister, to classify a woman's home as a class of place for
the specific purpose of taking Misoprostol, the second dose—was
given with a view, at some point in the future, to allowing research
or practice to take place in this country which takes place in
lots of other countries in the world safely, effectively and acceptably.
I am wondering why, 17 years later, no progress has been made
in doing that. Given that women already complete the termination
at home, why do they have to step in to take a pill or the pessary
in the hospital? Why has there not been an approved place regulation?
Dawn Primarolo: Because I think
the Department over the years has progressed very cautiously in
this area. It is the truth, you are quite right. In identifying
what can be done, because of the very strongly held views with
regard to abortion, the Department has been very cautious. It
has the pilots. Others have criticised that they are overly cautious
but, in trying to move to a position of having a clear protocol
with regard to class of place, there is no other answer that I
can give.
Q362 Chairman: That is perfectly
clear.
Dawn Primarolo: It is cautious.
Q363 Dr Harris: That is very clear,
but to clarify it further—and I am not arguing with you,
Minister, I am just saying that the reasons are reasons of sensitivity—there
have been no clinical or scientific reasons for thinking that
what happens in other countries would be a disaster in this country.
Dawn Primarolo: That is absolutely
true. We are being careful.
Q364 Chairman: That is an absolutely
fair and appropriate answer.
Dawn Primarolo: Given the views
held across the board on this subject.
Dr Harris: But not for medical or scientific
reasons.
Chairman: We have made that point.
Dr Harris: I have finished.
Chairman: You certainly have! Moving
on to Linda.
Q365 Linda Gilroy: On another area
where there is a fierce debate—although the Committee's
submissions overwhelmingly note, as you have already referred,
that the earlier an abortion is carried out the safer it is—does
the Government consider that women who ask for an early abortion
always fulfil the requirement that the continuance of pregnancy
would involve risk, greater than if the pregnancy were terminated,
of injury to the physical or mental health of the pregnant woman?
If so, should this language be dropped for abortions that take
place within the specified time limit? The risk of pregnancy is
always greater.
Dawn Primarolo: I have to say
I am uncomfortable with the arrangements as they are, given the
inconsistencies around this debate. My preference as a minister
is to ensure that we assist those who have taken a decision to
seek an early abortion and that we ensure that happens and that
they have access.
Q366 Linda Gilroy: Given those sensitivities
and the debates about the potential health risks, which become
quite significant the further on the pregnancy goes, they are
controversial. The level of risk is left with national bodies
at the moment but why does the Government's Chief Medical Officer
not assess the evidence and make judgments based on the balance
of evidence?
Dawn Primarolo: Because we think
that it is better left to the medical judgment as quite clearly
the arrangements in the sections of the qualifications of the
Act require.
Q367 Linda Gilroy: So you do not
think that the Department of Health has a duty in relation to
public health to do more to investigate and assess that evidence?
Dawn Primarolo: On balance, I
think we are in the right place.
Dr Adshead: Our policy is already,
as the Minister has already said, to promote abortion at the earliest
possible stage and in the last few years we have invested significantly,
over £8 million, in order to achieve that. Our statistics
show that there has been a significant shift to abortions under
ten weeks and, as the Minister has already said, the vast majority
are carried out under 13 weeks. We are aware obviously of the
evidence and we feel that the current Act is actually promoting
early abortion.
Q368 Linda Gilroy: But there are
gaps in the evidence, particularly in the one example that has
been drawn to our attention of studies that compare health outcomes
in women who have had an abortion and in women who have been refused
an abortion. Will the Government consider commissioning research
on the safety of abortions so that clinicians can offer better
advice to patients on that and other areas where there are gaps?
Dr Adshead: Currently, under medical
practice, if a doctor has a conscientious objection in terms of
carrying out an abortion themselves, they have to, under good
medical practice, ensure referral to another service, and from
our statistics that we have, as I have said, we feel that there
has been a significant shift to early abortion.
Q369 Linda Gilroy: But I think the
case that we are quoting is one where there just is not any research
currently available to demonstrate what the impact on a woman's
mental health is if she continues with the pregnancy.
Dr Adshead: Well, there have been
studies to look at the long-term psychological consequences, as
you will be aware, and some have done comparisons with continuing
with unwanted pregnancies and there is no overwhelming evidence
that there is long-term psychological damage from carrying out
abortions, but clearly what we are trying to do is ensure that
women who wish to proceed have access as soon as possible to services.
That is our policy because we want to promote safety and safety
would obviously include any possible psychological distress that
a woman might suffer, so our guidance and the guidance that we
have developed with colleges and others promotes early access
for women.
Q370 Graham Stringer: Is there any
way that a woman would know if her GP was a conscientious objector
before going in to see her doctor?
Dr Adshead: No, not as things
are, but the General Medical Council, in its Good Practice Guidance,
is absolutely clear that if a doctor feels that their own personal
views stand in the way of providing advice to the patient, they
have to declare that and they have to recommend to the woman that
there are alternatives.
Q371 Graham Stringer: But, Minister,
do you not think it would be helpful in moving abortions to an
earlier phase if the information was publicly available about
a doctor's personal view on these issues because it is a delay
factor?
Dawn Primarolo: Well, there is
not evidence in terms of we are using the figures of access to
early abortion. There is not sufficient evidence to indicate that
there is a delay tactic there and, to be frank, I think it is
difficult to see how that could be achieved given the requirements
on the doctor and how the consultation may proceed, so the doctor
concerned does have to say to the patient, "I can't proceed.
I have an objection", and make arrangements for referral
to another doctor and, if they are ethically opposed, they have
to follow the relevant professional guidance. Now, I am sure you
saw this evidence as well, the Marie Stopes International research,
that looked at over 7,000 GPs and something like 82% of them describe
themselves as pro-choice. It seems, therefore, firstly, is there
an issue here that needs to be addressed with regard to doctors
using a conscientious objection? We are not seeing that as an
issue in the evidence that we have. Secondly, if it was an issue,
how would we deal with it? It is very difficult given the interaction
with the requirements for the doctor to behave in accordance with
their own medical guidance, so I hear what you say, but I am not
sure how we could proceed on this. Are you suggesting a register?
Q372 Graham Stringer: Well, yes,
which would be publicly available because there is, I suppose,
an a priori case because, if you are going to have to see
your GP to find out that they are a conscientious objector, that
is a natural, inbuilt delay before the woman goes to another doctor,
and there is anecdotal evidence that some conscientious objectors
use the time of seeing the woman to delay the abortion, so I think
there are two routes of evidence there.
Dawn Primarolo: We would have
to raise that with the GMC, frankly, if that is what is being
suggested to us because it is about the guidance issued by the
GMC which is quite clear on how a doctor should behave under those
circumstances and, if it is being suggested that they are not,
that would be a matter for the GMC in terms of its guidelines
and the correct route would be to raise it with them. Presumably,
the GMC will be listening very carefully to the debates in Parliament.
Chairman: Listening to every word!
Q373 Linda Gilroy: There is a small,
extra question which I thought of earlier which Mr Stringer's
question has prompted me to think of again. Earlier, Minister,
you said, I think, that 89% of abortions were carried out within
what might be defined as an "early stage" and certainly
68% within 10 weeks. What does the Government then consider are
further steps that could be taken for the one in 10, the 10% of
abortions which are carried out beyond that point to try and ensure
that they are done sooner rather than later?
Dawn Primarolo: There has been
research in connection with why there is sometimes a delay, so
failure to recognise pregnancy, knowing where to go to get the
correct advice and I think under some circumstances, and we would
all understand this, the considerations that the woman herself
is undertaking before seeking advice, going through the issues
about what steps she wants to take. Now, the one where the Government
can have the most influence is to ensure that the information
is there to properly inform where to go once the woman has taken
the decision to seek an abortion and to make sure and work, as
Fiona has pointed out, in getting women quickly to that. That
would be the main way because both for the considerations of the
woman or failure to recognise pregnancy early enough, they are
about advice and making sure that is clear.
Chairman: There is one issue that I know
Robert wants to raise on the plus-24 weeks.
Q374 Mr Flello: One of the concerns
I have around the implications of a reduction of the time limit
from, say, 24 weeks to 20 weeks is that, rather than women deciding
to continue with the pregnancy or to present themselves for an
earlier termination, what might happen is that women will seek
other ways of having an abortion, so, in order to shed some light
on that, what is currently happening with women who seek an abortion
after 24 weeks? For example, are they going abroad and, if so,
is there any evidence on that? What is the situation?
Dr Adshead: As we know, under
the Act, if two doctors feel that there is, for example, a reason
why continuing with the pregnancy would put the woman or the child
at risk in terms of congenital abnormalities, then they are able
to advise that an abortion needs to be carried out beyond 24 weeks.
Q375 Mr Flello: Sure, but, if that
is not the case, what is happening at the moment with women who
discover late or it takes them some time to decide that they want
to have an abortion and they are at the point of 24 weeks? Is
there any evidence?
Dr Adshead: We do not have any
evidence of that, of what is happening that I am aware of.
Q376 Mrs Dorries: Actually the Chief
Medical Officer instigated an investigation into BPAS who are
actually referring women who are post-24 weeks to Spain for terminations,
and that is freely available on the web to be seen.
Dr Adshead: Yes, I mentioned that
earlier, when doctors had been asked if there had ever been any
circumstances in which we had carried out an independent review,
and you are absolutely right, the Chief Medical Officer did do
that. What he found was that in fact BPAS was acting within the
law.
Q377 Mrs Dorries: But they were not
carrying out the terminations themselves, they were giving women
the contact details of other hospitals where they had the terminations
carried out later in other countries, which is within the law,
but BPAS are advising women to go to other hospitals.
Dr Adshead: And we are absolutely
now trying, as I have already said, to promote early abortions.
Q378 Mrs Dorries: But do you not
think that there should be a strengthening of the law to stop
BPAS from referring women at 24 weeks plus to other hospitals
which will carry out the terminations?
Dr Adshead: That is a matter for
the law and they are acting within the law.
Dawn Primarolo: I think that one
of the issues as well to look at is the question, and I do not
know whether the Committee have looked at this and I certainly
asked for the figures on it, was looking at the question of abortions
as a percentage of conceptions and what the trends were and looking
at age as well because obviously one of the issues and continually
the case that is put is for—
Q379 Chairman: Sorry, but what is
this to do with plus-24?
Dawn Primarolo: Well, I think
that what we are trying to do, within the law in this country,
is ensure that we get women where they have taken the decision
on the grounds of right to early abortion and that is the provisions
that are made in this country within the law, that advice can
be given.
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