O&G

Question 1

Is abortion legal?

Answer 1

Was illegal under the Offences Against the Person Act 1861 (England + Wales) and by common law in Scotland. Still by default illegal (don’t say ‘abortion is legal’) but it has been decriminalised in certain circumstances:

• Must be carried out within NHS or NHS approved facility
• Unless an emergency (in which case, no documentation), 2 registered medical practitioners (doctors), acting in good faith must sign off documents to indicate that an abortion is justified within the Abortion Act

Good faith: doctor not dishonest or negligent in forming opinion that there are lawful grounds for procedure

No legal rights for the fetus. HRA Article 2- Right to life does not extend to the fetus

No legal rights for the biological father (Biological fathers: if view fetus as separate entity may be seen differently, if viewed as part of mothers body father having rights about decision would be seen as control over her body)

Question 2

What does the abortion act say?

Answer 2

(1967) : amended by Human Fertilisation + Embryology Act 1990 (28 > 24)
1. Pregnancy has not exceeded 24 weeks + continuing pregnancy would involve risk, greater than if pregnancy were terminated, of injury to physical or mental health of the pregnant woman or any existing children of her family (most abortions; ‘social’)

Up to term:
2. That the termination is necessary to prevent grave permanent injury that the physical or mental health of the pregnant woman

3. That the continuance of the pregnancy would involve risk to life of pregnant woman, greater than if pregnancy were terminated
4. That there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped
   o Note: this criteria can be decided by any doctor doesn’t have to be O&G

Question 3

Criticisms of the abortion act?

Answer 3

Potentially disadvantaged if poor health literacy – ability to explain reasons why abortion is wanted and push forward to seek second opinion

Legal to terminate a pregnancy because of a woman’s social or financial circumstances (e.g. income, housing situation, her support network). The law bestows upon doctors a gatekeeping role in terms of deciding who may have an abortion. ‘Social abortion’ – the current criteria are supposed to be medical criteria. Do doctors have right to determine social criteria?

Lots of guidelines are open to interpretation: no right to abortion on demand illustrated in 3 ways. First, law makes very clear that the decision rests with 2 doctors, according to their own judgement about the impact of abortion vs childbirth on the woman’s physical or mental health. Second, on the question of the woman’s social circumstances, the law does not state that doctors ‘must’ take account of a woman’s environment, but that they ‘may’ do so. This means that doctors are not compelled to take these broader factors into account.

Last act: disablist act? RCOG: not practicable to give definition of serious disability – difficult to predict and should be based on discuss with parents
- ?Legal vs social law

Question 4

Termination on grounds of fetal sex?

Answer 4

‘Abortion on the grounds of fetal sex is illegal’

• DOH guidance 2014: abortion on the grounds of gender alone is illegal. Some people have campaigned for the law to be changed to include an explicit statement on this.

o Giving other reasons about how the sex of the baby will affect you makes it legal; X-linked recessive disease
o Doctors must know details of case in order to sign in good faith
- Telegraph sting > director of public prosecutions > GMC referral, 3 month suspension
- Directing to abortions abroad for fetal sex termination

Question 5

Arguments for TOP?

Answer 5

Women should have the right to choose what happens to their bodies (right of bodily integrity)

Autonomy of the mother outweighs the rights of the fetus/ fetus has no automatic right of use of a women’s body

Most people would choose to save the right of a woman over a fetus. Therefore women’s rights trump the rights/interests of a fetus

Mother is the patient and has ‘contract’ with doctor / duty of care;

In the best interests of the mother
> socio-economic factors
> ability to care for the baby

Question 6

Arguments against abortion?

Answer 6

Rights to the fetus & the sanctity of life
No moral difference between a fetus and a child
Morally significant point is conception: Wrong to kill a (innocent) human being, fetus is a (innocent) human being , therefore it is wrong to kill a fetus (abortion means murder)

• Religious/other reasons see life as from conception (pro-life arguments suggest that fetus have the right to life) 
• If the pregnancy was due to sexual assault (not their choice)
• May not in the best interests of the baby (medical reasons)

Question 7

What is the personhood argument?

Potentiality?

Answer 7

Only ‘persons’ can claim rights – therefore, what is a person?

• Someone who can make choices and is self-aware, conception of future and evaluate past experiences: foetus cannot claim right to life, but neither can patients in permanent vegetative states and neonates: but surely these patients are the ones requiring protection?
• Concept of potentiality: potential human being; wrong to kill potential human being. Foetus at later gestation has higher probability of becoming a person capable of independent life; however egg and sperm also have this potential – could be an argument against contraception – we don’t usually allocate rights + status according to potential
• When does moral status begin? Moral right at point of viability: however termination up to 24 weeks, some foetuses now surviving at 22 weeks?
  o Viability depends on technology so not ethical principle-differs depending on geography. If viability is at 6 months somewhere in the world is it ok to go there and have an abortion?)
  o If moral status starts at consciousness / pleasure / pain – how can we measure this? Social meanings? (Nadine Dorries – 21 weeks)
• Conception > nervous system > viability? More consensus for the gradualist approach (the further on in the pregnancy the more uncomfortable people feel)

Question 8

What is the notification system for abortions?

Issues with this

Answer 8

Abortion Notification to Chief Medical Officer (for statistics)

• HSA4: includes doctor + patient details; grounds for abortion type
• HSA1 kept on patient’s record for 3 years

Confidentiality GMC 2017: not absolute can be breached in following circumstances

• Patient consents
• Overall benefit to patient (when patient lacks capacity)
• Required by law
• Justifiable in public interest
• *Doctors have a statutory duty to report FGM (Young person under 18- may not be in their best interests), Some infectious diseases, Court request/GMC, Can breach a patients confidence in the interest of the public (public can mean just one person)

Issues: abortion not like a notifiable disease, why must they know the women’s names?

Question 9

Statistics on abortion?

Answer 9

2016 DOH abortion statistics
(A-E in statistics (A divided into 2 on forms))
- 190,406 abortions in 2016, slightly lower than in 2015 (191,014); (2017: 194,681)
• Rate was highest for women at the age of 22 

• 98% funded by NHS, 68% of these independent sector under NHS contract 

• 92% per cent under 13/40 

• 81% under 10/40 

• 2% under ground E (risk of serious handicap) 


Question 10

What is the law on abortion in NI / ROI?

Answer 10

Law in NI

• Medical abortions are legal up to 9 weeks; only if threat to the life of the woman or risk of serious adverse effect on her health, which is either long term or permanent
• Ireland 2018 referendum: ROI now legal up to 12 weeks

Question 11

What is conscientious objection?

Arguments against it?

Answer 11

Not wanting to do act as do not agree (fertility treatment, contraception, abortion)

Should be allowed to object to ANY procedure/Tx on basis of moral/religious reasons?
o Trained by public money
o Should act within our limitations
o More closely aligned the ethical values are to goals and values in medicine the more we might support the CO e.g. enhancing dignity, relieving suffering, saving life, respecting patient’s choices.
o Duty as a doctor outweighs one’s own beliefs: doesn’t comply with duty to put patient first (and act in their best interests) and harks back to paternalism.

Question 12

GMC Guidance on conscientious objection?

Answer 12

Good medical practice 2013

• You may choose to opt out of providing a particular procedure because of your personal beliefs and values
• As long as it does not result in direct or indirect discrimination against, or harassment of individual patients or groups of patients
• You must not refuse to treat a patient/group of patients because of your personal beliefs or views about them
• You must not refuse to Tx the health consequences of lifestyle choices to which you object because of your beliefs

BMA: Doctors should have the right to CO to participation in abortion, fertility treatment and withdrawal of life-sustaining treatment, where another doctor is willing to take over the patient’s care. Doctors should not claim a CO to particular patients or groups of patients

CO to treatment or procedure: Actions according to GMC guidelines

• Tell the patient that you do not provide the particular Tx or procedure, being careful not to cause distress, you may mention the reason for your objection (be careful not to imply judgement of the patient)
• Tell the patient they have the right to discuss their condition and make sure the patient can see another doctor who does not hold the same objection as you

Question 13

Outline CO in relation to abortion

Answer 13

• Doctors can conscientiously object* to abortion but they still have a duty to participate in Tx which is necessary to save the life or prevent grave permanent injury to a woman
• Any doctor/nurse with a CO must refer her to another doctor without delay
• Role of nurses in providing abortion services was examined by the supreme court which ruled that a nurse does not have the right to avoid supervising other nurses involved in abortion procedures (Supreme Court; must be ‘hands-on’ procedure)

Summary:
Doctors may practice medicine in accordance with their beliefs, provided that they act in accordance with relevant legislation and:
- Do not treat patients unfairly
- Do not deny patients access to appropriate medical treatment or services
- Do not cause distress

If any of these circumstances is likely to arise, we as doctors are to provide effective care, advice or support in line with Good medical practice, whatever their personal beliefs.

Question 14

Should women be held to account morally or legally if their lifestyles/activities cause potential harm to a fetus?

Answer 14

• Could argue fetus has interests but not rights, when to justify restricting woman’s liberty, removing children from parents for neglect – high threshold

Legal status is only acquired when child is born therefore unborn child has no rights until birth. Mother cannot be sued in negligence for harm caused in utero unless harm occurred as a result of a road traffic accident where insurance would fund a claim for compensation

Foetal alcohol syndrome case (court of appeal 2014): Section 23 Offence against the Person Act – unlawful to administer to any other person any noxious agent to inflict grievous bodily harm – foetus not believed to person at the time. If case won: suggests that foetus + mother as separate entities rather than part of mothers body – would also damage relationship between mother and healthcare professionals.

Congenital Disabilities (Civil Liability) Act 1976 – enables child once born to make a compensation claim for disabilities occurring before birth as a result of breach of duty owed to one of his parents

“Wrongful life” claim is one made by a child alleging that but for the negligence of doctor would not be born because mother was deprived of choice not to continue with pregnancy > English Law does not recognise claim for wrongful life as impossible to compare life of poor quality to no life at all

• Moral issues
• Women’s autonomy
• Cannot restrict a woman’s behaviour/activity without grey areas

Question 15

Screening in obstetrics?

Answer 15

Infections (HIV, Hep B, syphilis, ?rubella) and Rhesus
Anomaly screen 20-22 weeks (congenital defects)
Trisomy screening: T21, Edwards (high mortality at birth)  bonding with pregnancy and preparation
- *Harmony test-privately available (not 100% sensitive): ~99% look at book for more info

• Can be seen as a disablist argument- having down’s unacceptable by screening for it and is effectively eugenic

Question 16

What is PGD?

Answer 16

Pre-implantation Genetic Diagnosis: alternative to prenatal diagnosis: couple with genetic mutation could conceive naturally and choose termination if antenatal testing detects conditions; may not be acceptable choice to some couples; PGD preferable if consider foetus has greater moral value than embryo in vitro.

• HFEA: licences for condition which PGD can be used: must be sufficiently serious before licence granted – increasing numbers now that genetic mutation knowledge increasing
• Can be used for adult-onset conditions e.g. Huntington’s or lower penetrance late-onset conditions (BRCA1/2). Cannot be used to prefer selection of embryos which would develop serious disability or illness. Implantation of non-affected embryos eradicates mutation for future generations.
• HFEA 2008 amendment to 1990 Act: embryo testing acceptable where significant risk child born with or will develop serious illness / disability: consider degree of suffering, availability of affective treatment, degree of any intellectual impairment and social support available
• Destruction of embryos is morally contentious for those who consider life at fertilisation.

Question 17

What is assisted reproduction?

Answer 17

Ovarian stimulation, IVF, egg/sperm donation, IUI, PGD, surrogacy

• All regulated by Human Fertilization and Embryology Act 1990 (2008) – HEFA set up to license, monitor and collect data on procedures, license needed for any clinic involved in use, storage, disposal of gametes and embryos. 2012: 77 licensed clinics in UK.
• HFEA regulatory principles: equality, confidentiality, consent and guidance on assessing welfare of child to be born, safety and data transparency / research
• Section 3 Human Fertilization and Embryology Act: clinic must take into account ‘welfare of any child who may be born as a result of the licensed treatment provided by them and any other child who may be affected by that birth’ – in 2005 the HFEA published Tomorrow’s Children – more focused interpretation – provide Tx for those seeking it unless evidence that child born or existing child of family would face serious risk of medical, physical or psychological harm; consider previous convictions relating to harming children, chronic physical illness, mental health problems, drug/alcohol addiction, family history of inherited diseases (1990 – ‘Need for a father’ replaced by ‘supportive parenting’ which is defined as commitment to health, well-being and development of the child’

Question 18

Recommendations for treating infertility?

Answer 18

Infertility common (~7% having regular SI won’t conceive in 2 years). NICE: infertility Tx offered to individuals or couples with medical cause or UNEXPLAINED infertility after trying for 2 YEARS.
o <40 trying >2 years > 3 full IVF cycles
o 40-42: once cycle provided no previous cycles, no evidence of low ovarian reserve and aware of increased risks arising from pregnancy at this age
o Only recommended if BMI 19-30

• 40% of IVF cycles in 2012 were NHS funded
• CCGs: area specific criteria: some refuse in any circumstances ‘postcode lottery’ – common restrictions include ‘unexplained problems only, longer waiting times before Tx offered, more stringent age / BMI restrictions, smoking history, no partner must have another living child’

Question 19

What are the recommendations about donor anonymity?

Answer 19

HFEA 2004 – any child from gamete donation after April 2005 has the legal right to receive information about donor when they reach age 18. Includes identifying info e.g. name, DOB, physical characteristics and last known address > decrease in number of sperm donors. Does not apply in some European countries / USA – some self-funding couples go abroad.

Question 20

Is it everyones ‘right’ to have a baby?

Answer 20

Article 12 ECHR: ‘right to have a family’ but not absolute right – refusal to fund treatment where clinically less effective may be justifiable in light of limited resources?

• Resources- cost, access, ongoing health needs (same sex couples currently have to pay for fertility treatment on the NHS) – most CCGs do not cover cost of donor gametes irrespective of sexuality.
• 2008: HFEA: same-sex parents can be recognised as legal parents, any conceived after April 2009 both parents can be named on birth certificate and be entitled to PR as long civil partnership at time of conception, or child conceived via treatment at a licensed clinic; for lesbian couple non-biological mother listed as ‘parent’ rather than father – joint + equal PR.

Question 21

What is surrogacy - legal?

Answer 21

Woman carries baby for person unable to conceive/carry child – legal in the UK (Traditional: surrogate uses own eggs but sperm from intended father; host surrogacy where eggs and sperm from intended both implanted by IVF).

• No 3rd party involved commercially
• Advertising not allowed; but charities exist (Surrogacy UK and Childlessness overcome through Surrogacy – CTs). Contracts cannot be made; surrogacy agreement often drawn up between couple and surrogate but not legally recognised.
• Surrogate can only receive expenses; surrogate parents have equal rights to maternity leave
• Legal right to keep child even if not genetically related to them; person who gives birth has PR until 4 weeks after a court order – surrogate can change mind
  until parental order granted.

Question 22

Arguments against surrogacy?

Answer 22

• Commodification of babies
• Potential health risks of pregnancy / birth outweighing virtue of carrying baby for another woman
• Relatives may feel coerced into surrogacy by being unable to say no to a request from someone they love