Ethics

Background information

According to the Abortion Act 1967[1] a legally induced abortion must be certified by two registered medical practitioners as justified under one or more of seven grounds A to G.[2] In 2007 98% of all abortions in England and Wales were performed under ground C, namely 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'. Of these, more than 99.5% were carried out on grounds of risk of injury to mental health.[3] In practice the mental health clause has been used by doctors as a catch-all for failed contraception, social inconvenience, unwanted pregnancy and emotional upset.

The Royal Colleges' historic positions

The Royal College of Psychiatrists has historically denied a link between abortion and mental health. A 1994 statement which had not, until very recently, been revised, stated: 'The Royal College of Psychiatrists finds that the risks to psychological health from the termination of pregnancy in the first trimester are much less than the risks associated with proceeding with a pregnancy which is clearly harming the mother's mental health. There is no evidence in such cases of an increased risk of major psychiatric disorder or of long-lasting psychological distress.'[4] It was on this basis that doctors justified signing abortion authorisations using the mental health clause.

The Royal College of Obstetricians and Gynaecologists' guidance on abortion and mental illness, to be 'given to women in order that they might give valid consent to abortion', reads as follows: '16.9 Psychological sequelae: some studies suggest that rates of psychiatric illness or self-harm are higher among women who have had an abortion compared with women who give birth and to non-pregnant women of similar age. It must be borne in mind that these findings do not imply a causal association and may reflect continuation of pre-existing conditions.'[5] There were no psychiatrists in the Guideline group which put the guidance together.

Medical dissent

On 27 October 2006, the 39th anniversary of the 1967 Abortion Act, The Times published a letter from 14 senior doctors, including eleven specialists in psychiatry and obstetrics/gynaecology, pointing out the growing evidence for a link between abortion and mental illness.[6] Research published in The Journal of Child Psychology and Psychiatry in January 2006 had shown that women who had had abortions had twice the level of mental health problems and three times the risk of major depressive illness as those who had given birth or never been pregnant.[7] The signatories called upon the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Psychiatrists (RCPsych) to bring their guidance on the link between abortion and mental health up to date.

Review of the position

The House of Commons Science and Technology Committee Report on Scientific Developments Relating to the Abortion Act 1967 concluded (29 October 2007) that 'there is no strong evidence which contradicts the wording of the current RCOG guidelines on the risk to mental health of induced abortion'. [8] The government in its response to the report (29 November 2007) said, 'We agree with the Committee's conclusions on this point' (para 24) but noted that the RCPsych was undertaking a literature review.[9] In February 2008 the RCPsych was asked by the Department of Health to update its statement on women's mental health in relation to abortion.[10] The RCPsych published their revised position on 14 March.[11]

The current position

The RCPsych's revised position statement significantly changes the College's previous 1994 position on the link between abortion and mental health in two ways.

1. The link between abortion and mental health problems

In 1994 the College held the view that there was 'no evidence… of an increased risk of major psychiatric disorder or of long-lasting psychological distress' following abortion. It now states that whilst 'the issue of whether or not induced abortion has harmful effects on women's mental health remains to be fully resolved' nonetheless that 'some studies identify a range of mental disorders following abortion'. It concludes that 'additional systematic reviews led by the Royal College of Psychiatrists into the relationship between abortion and mental health' should be carried out.

2. The psychiatric grounds for abortion

In 1994 the RCPsych found that 'the risks to psychological health from the termination of pregnancy in the first trimester are much less than the risks associated with proceeding with a pregnancy which is clearly harming the mother's mental health'. It now says that 'systematic reviews should consider whether there is evidence for psychiatric indications for abortion'.

It further recommends that 'healthcare professionals who assess or refer women who are requesting an abortion should assess for mental disorder and for risk factors that may be associated with its subsequent development' and that 'consent cannot be informed without the provision of adequate and appropriate information regarding the possible risks and benefits to physical and mental health'.

Relevance to the current debate and the HFE Bill

This new statement raises two important questions.

1. The psychiatric grounds for abortion

The Royal College of Psychiatrists is no longer confident that there are psychiatric indications for abortion. Instead it is calling for further systematic reviews to consider the evidence for such psychiatric indications. This raises the question whether a registered medical practitioner can any longer in good faith authorise an abortion under the mental health aspect of ground C of the Abortion Act 1967. Ground C asks the doctor to affirm 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'. Abortions that cannot be authorised under grounds in the Abortion Act are still unlawful under the Offences Against the Person Act.

2. The link between abortion and mental health problems

If some studies identify a range of mental disorders following abortion then women contemplating abortion should be entitled to have this information in order to be able to make a fully informed decision. The RCOG guidance on abortion (2004) should be amended accordingly.

BMA Motion

A motion currently being considered by the British Medical Association Annual Representative meeting on 10 July acknowledges that abortion can be a psychologically traumatic process for women, and urges the BMA to campaign for increased counselling and support for women before and after this procedure. This motion has been designated 'A' meaning that the chairman of the BMA Medical Ethics Committee has recommended it as likely to be non-controversial and acceptable without debate. He will formally move that it be accepted. This is in line with the recent recommendations of the Royal College of Psychiatrists and is being recommended in an EDM 1592[12] recently tabled by Angela Watkinson.

The amendments

The first restrictive amendment to the HFE Bill strengthens the mental health clause in order to prevent it being further abused. It stipulates that at least one of the registered medical practitioners must have suitable mental health training and expertise to enable a medical risk assessment to be made of the likely specific injury to mental health and the severity of that risk (excluding any risk normally attendant on childbirth), to ensure that only a serious and not a temporary, moderate or mild risk is taken into consideration. A second amendment asks that the risk to mental health of continuing a pregnancy must be other than 'that normally attendant on childbirth'.