Week 7

Question 1

Termination of pregnancy in the UK

Answer 1

A medical procedure performed through pharmacologic or surgical means
-mifepristone-> misoprostol (can be done at home if <10 weeks)
-surgical- vacuum (<14 weeks) dilatation and evacuation >14wks
Provided on the NHS either directly or through affiliated clinics (eg BPAS)
Can self refer or GP referral
Regulated under the abortion act 1967

Question 2

Historical perspective

Answer 2

First reference to TOP is seen in the 13th century
-linked to teaching by the Christian church- abortion was permissible until ‘quickening’ (fetal movements being felt) at around 20 weeks
-parallels in other Abrahamic religions eg some Islamic schools hold that ensoulment happens on day 120 of pregnancy
In the early 19th century 1803 TOP before quickening became punishable by death
In 1837 TOP was made generally punishable by death
In 1861 offences against the person act : punishable by ‘lifetime penal servitude’
1929 infant life preservation act: illegal to kill a viable fetus (at that time fixed at 28 weeks) in all cases except when womans life was at risk

Question 3

Historical perspective 1929

Answer 3

At this time around 15% of maternal mortality was due to illegal ‘backstreet’ abortions
There was no welfare state and people could only afford to feed so many children
Infant mortality had plummeted since ~1750 (from around 25-30% to ~10% in 1930)
Women organised to mount a political campaign for safe access to abortion

Question 4

Historical perspective from 1938

Answer 4

1938: Dr Alex Bourne admitted performing an abortion for a suicidal 14 year old who had been gang raped. He went to trial and was acquitted on the grounds that the mothers life was at risk
1967: private members bill passed and the abortion act became law giving access to abortion on the NHS if “the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family”
Several attempts to overturn it including in 1974
1991: the human fertilisation and embryology bill: limit to 24 weeks

Question 5

The abortion act 1967

Answer 5

Medical termination of pregnancy:
-subject to the provisions of this section, a person shall not be guilty of an offence under the law relating to abortion when a pregnancy is terminated by a registered medical practitioner if 2 registered medical practitioners are of the opinion, formed in good faith
-a) that the pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated of injury to the physical or mental health of the pregnant woman or any existing children of her family
-b) that the termination is necessary to prevent grave permanent injury to the physical or mental health of the woman
-c)- that the continuance of the pregnancy would involve risk of life to pregnant woman greater than if pregnancy were terminated
-d)that there is substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped
In determining whether the continuance of a pregnancy would involve such risk of injury to health as mentioned account may be taken of the pregnant woman’s actual or reasonably foreseeable environment

Question 6

Termination of pregnancy UK

Answer 6

46% pregnancies in the UK are unplanned, ~1/60 women per year
200000 TOPs in the UK annually
There has been a recent increase associated with the COVID pandemic and difficulties accessing contraception and the cost of living crisis 214869 in England and wales 2021
57% of those terminating a pregnancy were already mothers
65% in a relationship
TOP continues to fall in those ages <18 with the biggest increase in patients aged 30-34
Around 1/3 women will terminate a pregnancy
Theres a significant societal taboo around TOP
Access to termination is under threat in a number of liberal democracies
In the UK there was a significant resistance to enabling access to TOP in Northern Ireland

Question 7

What is a life

Answer 7

Disagreement tends to centre on whether the embryo/fetus constitutes a life
-can we call a fetus life
-if so what rights are afforded to a life in this context

Question 8

Sanctity of life arguments

Answer 8

Ensoulment: life is sacred, initiated at conception, and of divine origin
Murder: this is an active process of ending a life and therefore murder
Divine will: ending a created life is interfering with divine will
The argument re: divine will is less commonly used in modern discourse you could argue cancer is divine will and so we shouldn’t treat
While ensoulment is often central to the beliefs of many anti-abortion groups its less often explicitly advanced as an argument
-European democracies have become more hostile over time to the religious beliefs of some governing the rights of all
Additional arguments eg that TOP is traumatic- not well supported by evidence
The dominant argument tends to be that a fetus should be classed as a life

Question 9

The abortion act- viewed through sanctity

Answer 9

Viewed through a sanctity lens the abortion act is permitting the destruction of one life for the benefit of another’s life up to 24 weeks gestation
The argument is that no one’s life should be forfeit to improve another’s
From a sanctity viewpoint the abortion act provides inadequate protection to the life of the fetus and sacrifices their rights

Question 10

What is a life legally

Answer 10

Legally a fetus has no rights or legal existence before birth
-the infant must be “born alive” and take its first breath in a “separate existence” before it has legal rights
Yet the law considers all terminations to be illegal unless the conditions of the abortion act are met
And if the conditions are not met (eg termination after 24 weeks) the charge of child destruction can be brought
Under the infant life preservation act 1929 child destruction is illegal unless to save the life of the mother
“An act causing a viable unborn child to die during the course of pregnancy or birth before it has an existence independent of its mother”

Question 11

What is a life humanism

Answer 11

Sanctity of life arguments are often bolstered by tethering them to humanist arguments about the value of the human being
Humanism does indeed advocate for the value of the human individual
-human happiness and suffering are real phenomena
-science and reason should be harnessed to optimise human flourishing
Humanism advocates for equality in the worth of human lives
-but it does not follow that humanism would value a fetus per se
Is it being homo Sapiens that conveys worth to a human life or is it humanity?
-humanist organisations are generally pro choice emphasising the quality of life of the existing (pregnant) human over any right to life of the foetus

Question 12

A clash of worldviews- naturalist (materialist)

Answer 12

The cells that constitute an embryo/fetus are alive. However they cannot survives independently -a life refers to a being that is capable of sustaining life
A pregnancy is not a life although it may result in one
If there is an argument for considering a fetus as a life it comes from its potential to be an independent life in the future
However if you believe that humans have a soul present from conception you will conceive of the fetus as life

Question 13

Theism and or spiritualism

Answer 13

A fetus has a soul therefore it is a life therefore it has these full complement of human rights including the right to life
The right to life supercedes all other rights

Question 14

Materialism

Answer 14

A fetus is more accurately seen as a pregnancy it may develop into a life but it is not one at present either legally or morally
A pregnancy is a process ongoing within a human body any rights and decisions about it rest only with the individual involved

Question 15

Potentiality

Answer 15

Moral status is not digital we have a spectrum
It’s possible to have a degree of moral concern for a fetus as a potential future person without affording them equal consideration to an existing person
This seems to be reflected in the legal position:
-while the fetus has no legal rights, it does not equate to ‘nothing’
Nor is moral status absolute- even if a being is afforded full moral status there can still be conflict with the rights and needs of others

Question 16

Rights in conflict

Answer 16

If the fetus is afforded a degree of moral concern via potentiality the pregnant adult has full concern as a person
It seems logical that this should outweigh our concern for a potential person
An individual with full personhood has the full complement of human rights and the right to self determination
This brings us to the notion of bodily autonomy

Question 17

The body as property

Answer 17

Historically this has often been stated as ones body being ones property
Ownership and jurisdiction over the self is at the core of modern democratic societies
-underpins principles related to self determination- consent, rights and freedoms
-legal responsibility for crimes committed
It one does not own oneself its not logical that one can own other things
Use of property without consent is trespass
Those who oppose abortion have advanced the argument that it would be immoral to refuse someone access to your property if their life were at stake; ergo the pregnancy must be “tolerated” on moral grounds
However this is a flawed analogy it is true that if one does not have absolute autonomy over ones own person property ceases to be a viable concept
But this does not mean that ones person is just property or should be treated in the same way as a house or car

Question 18

The body as more than property

Answer 18

The physical embodiment of a person is handled quite differently in law than a possession such as a house or car
Use of property without consent is trespass
Use of the person without consent is a much more serious crime:
-eg use of someone’s body for work without their consent is slavery
Use of the person without consent is not sanctioned for any reason even to save a life

Question 19

The abortion act through the lens of autonomy

Answer 19

From the perspective of autonomy even if a fetus is awarded full moral status- no person has the right to the use of the person of another without their consent
Withdrawal of that consent should be all that is required to end any pregnancy at any time

This would be the case even if pregnancy were not a risky process and even if labour were not dangerous and carried a high risk of lifelong complications
-the fact that pregnancy and childbirth involve a high risk of harm means we should have a high threshold for the quality of informed consent to continue it
The abortion act does not meet the demands of autonomy:
-it is up to 2 healthcare practitioner not the pregnant individual whether the procedure is permitted
-termination- withdrawal of consent for continuing the pregnancy is only available up to 24 weeks- after 24 weeks the pregnant individual has no bodily authority at all to remove the fetus

Question 20

Acknowledge the pachyderm

Answer 20

It’s not possible to consider the issue of termination of pregnancy ethically without considering it from the perspective of social justice
And historical persecution of women

Question 21

Women as property

Answer 21

Women were property owned by their husbands
Inheritance laws allowed males to monopolise most of society’s wealth
Laws were brought in throughout the 17th and 18th century to make it progressively harder for women to remain single earning their own living
-they were barred from professions and the majority of trades
-wages for female work were held artificially low at around 1/3 rates of males
Couverture laws legally subsumed a woman upon her marriage she was not a separate legal entity having no identity or legal status of her own:
-any wages she earned belonged to her husband
-she could only be educated and employed with his permission
-there was no concept of his trespass upon her person (eg marital rape, assault/domestic violence)
-contraception was basic and not widely available
-termination pregnancy was outlawed

Question 22

Women as property 2

Answer 22

“Marriage is the only actual bondage known to our law. There remain no legal slaves, expect the mistress of every house” John Stuart Mill and Harriet Taylor Mill
Termination is a tinderbox issue because of this history- the net effect of the legal subjugation of women was reproductive coercion - the removal from women of all choice over when, how often and with whom they reproduced
Limiting termination can easily be seen as part of the same agenda
Historically there does seem to be a basis to treat this as an issue of social justice

Question 23

Rawls- burdens and privileges

Answer 23

The production of the next generation of humans is a significant burden
This burden falls disproportionately on females
Biologically :
Pregnancies carries a high risk of significant detriment to health
-increased risk of DVT/PE
-immunosuppression, sepsis
-depression
-diabetes
-hypertension
-cardiomyopathy
Childbirth has an extremely high rate of complications:
-up to 85% vaginal births involve perineal trauma
-1/30 vaginal deliveries will have 3rd or 4th degree perineal tear
->1/10 will have an instrumental delivery- high risk injury, tear
-perineal infections
-haemorrhage
-caesarean risks- infection, wound dehiscence, bleeding
-VBAC-uterine rupture
-over 1/3 describe birth trauma ~5% develop PTSD
-1/3 will develop urinary incontinence
-long term effects uterine prolapse (up to 50% after vaginal delivery)
-23% experience postnatal depression

Question 24

Rawls- burdens and privileges social burden

Answer 24

Social burden of reproduction for females:
-females perform a disproportionate amount of childcare even when employed outside the home
-females see a significant wage drop after having children and are less likely to be promoted
-lifetime wage penalty of 45% for British women on average for having children

Question 25

Impact of the burdens

Answer 25

Burdens of childbearing and societal failure to equalise childcare burdens promote termination
2022- 60% of women undergoing termination cited inability to absorb childcare costs as the reason
It costs ~£175K to raise a child to adulthood in the UK
2022- only 44% of absent parents paid >90% child maintenance due with 37% paying nothing at all
60% of single parent families living in poverty would be lifted out if they were paid the money they were owed in child maintenance

Question 26

the abortion act viewed through social justice

Answer 26

From a social justice perspective the abortion act in limiting access and autonomy contributes to an already unfair situation
It is not tolerable that one demographic group should have complete bodily autonomy and another not
Should a fetus be disadvantaged because of this?

Question 27

What about the medical profession

Answer 27

In any other situation the only thing that can deny autonomous will to an individual regarding their healthcare is a lack of capacity
It is an incredibly hard position to advance that it would ever be in the best interests of someone who does not wish to be pregnant to continue to be so

Question 28

The RCOG

Answer 28

“Abortion care is an essential part of sexual and reproductive healthcare and the decision to have an abortion should be entirely up to the individual, without fear of prosecution”
Abortion here is seen as healthcare no different from seeking medical care to continue with a pregnancy

Question 29

The “rights gap”

Answer 29

But if it is healthcare why is it the decision of two HCPs instead of the patient
The legal situation does not meet the requirements of either position- it neither grants bodily autonomy to the pregnant nor rights to the fetus as a life nor social justice
Bodily autonomy is in reality at least partially suspended once pregnant
After 24 weeks the apparently non existent rights of the fetus effectively trump those of the pregnant patient

Question 30

Conscientious objection

Answer 30

Healthcare professionals have the right not to be involved in terminations of pregnancy if it countermands their personal beliefs
GMC: “you must treat patients fairly and with respect whatever their life choices and beliefs
You must explain to patients if you have a conscientious objection to a particular procedure. You must tell them about their right to see another doctor and make sure they have enough information to exercise that right. In providing this information you must not imply or express disapproval of the patient’s lifestyle, choices or beliefs. If it is not practical for a patient to arrange to see another doctor, you must make sure that arrangements are made for another suitably qualified colleague to take over your role.
You must not express your personal beliefs (including political, religious and moral beliefs) to patients in ways that exploit their vulnerability or are likely to cause them distress.”

Question 31

A settled state

Answer 31

The abortion act 1967 has stood although not unchallenged
However it does not decriminalise TOP rather it lays out conditions whereby its lawful to perform it
-it has always been argued that because the risks of pregnancy and delivery are in effect always higher than termination few TOPs are impossible to justify under this legislation
-at least 6 women in the UK have been prosecuted since 2022 for procuring an abortion outwith the conditions of the laws
-women have been investigated and threatened with prosecution after miscarriages
Reproductive rights groups advocate for TOP to be removed from the criminal code- for the right to TOP to be encoded as a right in law

Question 32

Settled state Heidi Crowther

Answer 32

Brought a case challenging the abortion act in 2021 arguing that permitting late term abortion for “serious handicap” amounted to discrimination against the disabled:
-a fetus with a ‘serious handicap’ was being handled less favourably than one without
-UNs committee on the rights of persons with disabilities:”concerned about perceptions in society that stigmatise persons with disabilities as living a life of less value than that of others and about the termination of pregnancy at any stage on the basis of fetal impairment”
She lost the case the judge ruling that there are many conditions which may be diagnosed only after 24 weeks and criminalisation would seriously curtail the choices of women and compound their trauma
However other disabled rights groups disagreed arguing that any ruling might endanger the rights of women to terminations or that antenatal screening was in itself discriminatory

Question 33

A settled state how serious is serious

Answer 33

In 2021 1.6% abortions carried out under Ground E
8.1% of these were at or over 24 weeks gestation:
-congential malformations
-disorders of the nervous system
-chromosomal abnormalities
-other conditions
A

Question 34

Eugenics

Answer 34

The study of how to improve the genetic fitness of the population through selective reproduction
Developed by sir Francis Galton who advocated ‘positive eugenics’ that those with desirable characteristics should procreate with those who shared them
Developed in California during 1920-30s
Adopted by the Nazis and used as justification for a range of medical torture and atrocities
This included forced sterilisation of disabled individuals those with epilepsy, cerebral palsy, mental health conditions, homosexuality
300000 were euthanised under an expanded program

Question 35

What counts as eugenics

Answer 35

Antenatal screening
Termination for serous handicap
IVF
Gene editing
Genetic counselling

Question 36

In vitro fertilisation

Answer 36

IVF involved the creation of embryos is a lab
The ‘best’ embryos are selected to be implanted into the patients womb at the correct time
Technology has developed to allow preimplantation screening for chromosomal abnormalities and even single-gene diseases (such as CF)
Affected embryos are discarded

Question 37

The human fertilisation and embryology act 1990 amended 2008

Answer 37

Testing for certain conditions (including chromosomal abnormalities and over 600 single-gene defects) is permitted in lab-created embryos
Centres are regulated and inspected by the HFEA and must apply for a license to perform each test
It is permitted to check the sex of embryos only where there is a family history of a sex-linked disease- sex selection for social reasons is illegal
Sperm separation for purposes of generating embryos of one sex rather than the other is also illegal
It is legal to tissue type an embryo so it will be compatible to donate umbilical stem cells to a sick sibling “saviour siblings”

Question 38

HFEA

Answer 38

Discarded or extra embryos can be used for stem cell research
Embryos can also be created expressly for this reason
Strict conditions:
-The research project is carried out in suitable premises
-The use of human embryos is necessary and the research fulfils at least one of the purposes set out in the Act:
—Increasing knowledge about serious disease or other serious conditions.
—Developing treatments for serious diseases or other serious medical conditions.
—Increasing knowledge about the causes of congenital diseases.
—Promoting the advances in the treatment of infertility.
— Increasing knowledge about the causes of miscarriages.
—Developing more efficient techniques of contraception.
—Developing methods for detecting gene, chromosome or mitochondrion abnormalities in embryos before implantation.
—Increasing knowledge about the development of embryos.
-The people donating their eggs, sperm or embryos for research provided consent to do so
-The embryos must not be allowed to develop in the laboratory beyond 14 days after fertilisation
-No embryo created or used in research can be transferred to a woman
-When a derived human embryonic stem cell line is fully characterised and cultured to ensure uniform
characteristics it is a condition of all Human Fertilisation and Embryology Authority research licences that the cell line is deposited in the UK Stem Cell Bank.

Question 39

Gene editing (CRISPR-Cas9)

Answer 39

It is plausible that gene editing techniques may soon be able to alter single genes within embryos- altering germline DNA in a way that would be passed on to future generations
At present this is illegal in the UK although one group in china reported that they successfully performed the procedure on twin girls born through IVF
Numerous ethical issues have been raised with the procedure:
-unknown future deleterious effects in the long term
-equality of access
-diminished resources for these diseases once rare
-increased stigma associated with such diseases
However some of these arguments could be applied to many forms of disease:
-eg we do not argue that we should not treat diabetes because it’ll lead to less resources once it is rare
-or that there will be more stigma if its rare/preventable

Question 40

Gene editing eugenics

Answer 40

Disabled rights activists see the same problem with gene editing as with embryo selection- it prevents people with disabilities being born therefore it is eugenics
They argue that this is based on assumptions about the quality of life of disabled people and a lack of value of diversity
However gene editing is different than embryo selection in important respects
It is the same individual who is ultimately born without the condition rather than a sibling selected because of the lack of it

Question 41

How much of medicine is eugenics

Answer 41

One of the problems with the ‘gene editing is eugenics’ argument is that a huge proportion of medicine is dedicated to preventing disability
Why make an arbitrary distinction between that caused by a single gene and that caused by many or the inherited vs acquired?
Eg. diabetes has genetic risk factors and could be considered a genetic disease - does that mean it is ‘eugenics’ to prevent the associated disability through treatment?
Thought experiment - two patients, one with a gene causing retinitis pigmentosa, one with diabetic retinopathy. Both will lead to blindness. Is genetic intervention to prevent blindness in one different than laser treatment in the other?