Abortion

Before we start talking about abortion laws, let me tell you a story.

I was on a night shift in the department of OBGYN, and a patient comes in at 2 AM. She is in obvious pain and complaints of unbearable pelvic pressure. You can see that she is clearly in the early months of her pregnancy and you worry that she’s going to have a miscarriage. On examination, you see that it is a case of premature labor. Worse, the patient also has an incompetent cervical os. The fetal heart is viable and the fetal movements are good. You start noting down the detailed history. You find out that she is roughly 18weeks pregnant and this is her 3rd pregnancy, her previous two pregnancies ended early in the first trimester due to an incompetent os. So, this time around, she was extra careful and got a cerclage done as per her doctor’s suggestion. But, she started to experience abdominal cramps after dinner. She initially dismissed them but when the increased pressure made the sutures cut through the cervical epithelium, she hurried to the hospital. There is ballooning of amniotic membranes and it is too late for an intervention. She is going to give birth at 20weeks.

The labor is quick, and the fetus is born with a weak cry. There is spontaneous respiration and a heartbeat, and the baby weighs less than 170g.

This baby will live less than a few hours.  Even theoretically speaking, for the baby to survive, you’ll have to intubate (if the lungs are functional, but they usually are not), put in multiple IV lines (using what blood vessels?) for nutrition, dialysis, high doses of steroids, and broad-spectrum antibiotics. This would be followed by multiple surgeries and transplantations (where will you find appropriately sized organs?).

The parents will not be able to hold the baby. 

The baby will not be able to breathe on his own, eat on his own, or even open his eyes.

Now comes the ethical dilemma: Is it okay to subject an infant to everything mentioned above?

Now proceed to ask yourself the following questions:

Are there high chances of congenital anomalies? 

Are there high chances of developmental defects?

Will the baby require long term care?

Is the care affordable?

Will the baby have a normal childhood?

Is the baby going to be dependent for most of his life?

Will the quality of life be poor?

So, what is the most ethical thing to be done in this scenario?  Although the situation I described is not about abortion per se, I believe it highlights some relevant ethical dilemmas that individuals, policy-makers, and physicians should consider as they form their opinion on abortion and abortion policies.  Let’s look at both sides of the abortion issue from an aerial view:

Points in favor of pro-life:

• Fetus’ right to live: Fetus’ are considered living beings and therefore have the right to live. 
• Ethical dilemma: Abortion impedes a fetus’ right to live and therefore is not ethically acceptable.
• Religious views: The Catholic church has spoken against abortions. But, there are limited exceptions when the mother’s life is at risk. The specifics vary by church and country.
• Emotional impact on the mother: A mother may regret having an abortion later in life and may experience guilt.  
• Misuse of laws: With the relaxation of abortion laws and increased availability of safe procedures, instances of forced abortion have also risen. Laws have been misused to force women to undergo an abortion against their wishes. 
• Infertility following abortion: There is a wide belief that infertility issues arise after a woman has undergone an abortion. In reality, this is seen very rarely and is usually a consequence of complication-ridden surgical abortion.
• Error in medical diagnosis: Physicians err on the side of caution and suggest abortion when the mother’s life may be affected. There have been instances where the mothers have chosen to continue the pregnancy and both the baby and mother have survived childbirth.
• Sex-selective abortions: Asian countries are deeply patriarchal and a few have witnessed periods of sex-selective abortions and increased female infanticide. This has lead to an unbalanced sex ratio in the rural population and increased gender discrimination.

Safeguards

• Physician has the right to refuse participation: A physician can refuse to conduct any abortions if they’re morally or ethically opposed to the practice. Instead, they simply refer the patient to a different clinic. This is currently the case in the United States, providing the physician doesn’t try to sway the patient’s decision, and is ethically acceptable worldwide.
• Prior mental checkup: A physician may ask a patient requesting an abortion to get prior approval from a psychiatrist. Some hospitals already have this policy in place and most obstetricians assess a patient’s mental status during workup.  This is common practice in India and some hospitals and clinics in the United States.
• Approval from two physicians: To decrease misuse and screen mentally fit patients, approval from two physicians can be taken This also prevents the use of unsafe abortion practices.  Abortion policies vary state by state, but it is practiced by a few states.  This is stipulated in the law in India (MTP Act).
• Patient autonomy: Patients have the right to choose their plan of treatment. In cases where a fetus interferes with the mother’s ongoing treatment, if she chooses to forgo an abortion and discontinue treatment in favor of the pregnancy, her choice must be respected.
• Ban on sex-determining procedures: Most countries have banned gender-determination techniques during pregnancy. It is unlawful for physicians and healthcare personnel to reveal the gender of the baby during antenatal checkups.  This prevents abortion of babies based on sex.

Points in favor of pro-choice:

• Women’s rights: One of the most commonly asked questions is ‘don’t women have a say about their own bodies?’ This is becoming more and more controversial because most lawmakers are men and women are underrepresented in politics. 
• Quality of life: Babies born with birth defects, children born in poverty, children born to women with addiction issues have a poorer quality of life. They are also more likely to be subjected to neglect, abuse, and abandonment. 
• Religious views: Most religions have shown a flexible stance on abortion. Since Indic religions put more importance on the intentions behind one’s action and the consequences of those actions, they have mostly shown favorable views on it. Nonorthodox Christianity has similar views on abortion. They have nuanced opinions on the same and have no absolute view on it. Islam widely considers it acceptable to have an abortion in the early months of pregnancy and immoral as the pregnancy progresses.
• Congenital anomalies: There are many congenital diseases like Down’s syndrome, Turner’s syndrome, etc. that affect a child’s growth and development. They require long-term care and have a poorer quality of life.
• Humanitarian considerations: Victims of horrific sexual crimes of rape and incest need to be given appropriate consideration while making abortion laws. Furthermore, women and children are often targeted in armed conflicts and access to safe abortion practices becomes necessary.
• Threat to mother’s life: Abortion must be considered when a pregnancy threatens the mother’s life or interferes with her ongoing treatment. Personally speaking, in this scenario, I think I would choose to have an abortion. One of the main reasons behind my choice would be that pregnancy is not the only road to motherhood. Surrogacy and adoption are two amazing choices.
• Socioeconomic affordability: Children born with genetic and congenital defects often require long term care. They are dependent on other people for day-to-day activities. Not all families can afford that care.
• Contraceptive failure: All forms of contraceptives come with a certain degree of failure. Pregnancies that happen as a result of contraceptive failure are not planned. Do they deserve an option to discontinue the pregnancy?
• Mentally unfit mother: Parenting is a huge responsibility and requires a lot of time and effort. Some women are simply not mentally fit or prepared to be mothers. This comes even more apparent in mentally-challenged women and teenagers.
• Fall in unsafe abortion practices: History shows us that by making abortion services safe, available, and affordable, there is a decrease in the use of unsafe abortion practices. Unsafe abortion practices fail at best and kill at worst. 
• Unaffordability: An increasingly common scenario being seen in countries worldwide is unaffordability. Pregnancy and parenthood cost a lot of money. Most young families are facing a scenario where they can’t afford to have a child and to provide a child with a proper environment to grow up in.
• Individual liberty: Mother’s right to choose to continue or discontinue the pregnancy. This becomes extremely important in scenarios involving rape or incest. Some may consider all pregnancies a gift and choose to continue with the pregnancy, some would rather choose to move on from the trauma by discontinuing the pregnancy. Do they deserve a choice?

Conclusion:

Most discussions around abortion laws are centered around the argument of whether a fetus is a ‘living being who has the same rights as any other human’ or a ‘group of cells that should not be considered as a living person’. This discussion misses one very important point that we should be talking about: Viability. 

Abortion laws are not centered around the question of whether the fetus should be considered living or not. They’re made considering the viability of the fetus outside of a woman’s body. That is why, medically speaking, in the case of a non-viable fetus, we believe that the mother’s rights take precedence over the fetus’ rights. The fetus cannot live independently of the mother, so the mother’s rights are given priority.

It is illegal to abort a fetus in the third trimester and that is exactly as it should be. The fetus is then considered viable and can survive outside a woman’s body. At that point, the fetus and mother are considered independent of each other and have the same rights. It is absolutely unethical to harm the fetus in any way.

Similarly, forced abortions are inhumane, unethical, and must remain illegal. No healthcare personnel must ever subject a woman to forced abortion, regardless of what they think is in the best interest of the patient. The patient has autonomy over her body and it must be respected.

Let’s go back to the scenario mentioned in the beginning. It is not a typical example you are given when you talk about abortion laws. But that scenario is very real and forces you to consider both sides of the argument. On one hand, you have a living baby, but on the other hand, you have to consider that the baby can’t survive for longer than a few hours.

Should such fetuses have the same rights as an adult mother?

Now let’s consider different scenarios

Not all patients are the same. They are bound by different circumstances, they have different reasons behind their actions and they are not always forthcoming. A physician sees a very limited picture in a 20 min consultation. Ethically speaking, a physician must not influence a patient’s decision in any way and must remain neutral. So, here are a few examples of the type of patients you may encounter. Do you personally believe if any or all of these scenarios are enough justification for abortion?

1. A 12yr-year-old victim of incest. Is she physically, emotionally, and financially capable of continuing the pregnancy and being a mother? Is she mentally mature enough to make a choice on abortion?
2. The mother with addiction issues requests an abortion on her first visit at 20 weeks. She is unlikely to come back if you refuse.
3. A teen mother who comes in for an abortion at 6 weeks because she is too young to be a mother and instead wants to go to college and start a family when she’s older and financially stable.
4. A 26yr old pregnant woman with HELLP syndrome. It is a planned pregnancy but continuing the pregnancy may be fatal to her. 
5. A Catholic woman with an ectopic pregnancy.
6.  Parents of 3 children want to have an abortion because they can’t afford to raise another child and would rather focus on raising the children they have.
7. A 28yr old woman comes to the clinic for an abortion because the pregnancy resulted from contraception failure. While she is able to afford and care for a child, she made a decision to adopt children instead of having her own.
8. A financially stable woman with a high profile job wants an abortion because she doesn’t see herself as a mother and never wanted children.

Moving forward

When it comes to controversial topics, often we jump to quick or hastily-considered opinions.  It’s easy to say that abortion is always or never justified.  But there are many values and situations to take into consideration when determining policy or forming an opinion.  Sanctity of life matters, but quality of life also matters. Mother’s health, physical, emotional, mental, and spiritual health matters. Nuances matter. When it comes to abortion, regardless of your stance on the subject,  we must all respect individual choice and liberty.  We can never have all of the facts about a woman’s situation or the reasons behind her decisions. 

As a physician, you may not agree with a woman who chooses to continue a pregnancy, but it is their choice and it should be respected. Similarly, you may not agree with a woman who chooses to have an abortion, but it is their choice and it should be respected.  

Further reading:

1. A Defense of Abortion by Judith Jarvis Thomson (https://link.springer.com/chapter/10.1007/978-1-4684-2223-8_5)
2. Is abortion necessary for the life or health of the mother? By Wendy J Smith (https://www.liveaction.org/news/abortion-life-health-mother/?__cf_chl_jschl_tk__=3aa946955797c58b9e3f61540f8082bffb4a3c25-1606189694-0-Ad9xvoo71zIlMpWHQlYllnHpUtReLIZUIy1TEv7r4Vk1iK1La_7tFKV8AhRYK5WNccHhWKyM47uvsCbsjavwzWpWpV1Z-JqdTwndXRVYSS3bemIjeSi73OHWX8D-mfK8XoLs04UpVndtvaeWFR4CM8HcXgB57W7cpzf7Y_6HlWQF09zk_ayQ6ZTDkNew4-tBYBUA_hV1cdRTfyl9ZXdWO0T4N-JQTE9g7m9oiMkh_i-mqCUt6p0FD4tmlgB4_BmL-0LL0IaMzJO_u9L7XTKQIl4osERv_DmD1P6wa0wnfWwYFtM5MwcaZ2ZY9ciFqM75h3pXcyNjqeSv_8txN70ylybkBXstl1HH3Z6nJk5lcbPH)
3. Unsafe abortion: a preventable pandemic. (https://www.sciencedirect.com/science/article/abs/pii/S0140673606694816)
4. Abortion and infanticide by Michael Tooley (https://www.jstor.org/stable/2264919?seq=1)
5. Conceptualizing abortion stigma (https://www.tandfonline.com/doi/abs/10.1080/13691050902842741)