Ethics

Five reasons for keeping the 2 doctor requirement

1. Abortion is illegal

In Britain abortion remains illegal, carrying up to a 14 year custodial sentence, except in those circumstances specified in the Abortion Act. The Offences Against the Person Act (1861) grants the unborn child legal protection, and doctors are only exempt from prosecution when they terminate a pregnancy within the terms of the 1967 Act.

The original intention of the 1967 Abortion Act, was to allow termination in 'hard cases' – rape, incest, foetal abnormality, and to prevent backstreet abortions. There was no intention to introduce abortion on demand. This legal framework remains relevant since it insists that all human life at all ages is significant and that a good reason is required to take life.

2. Abortion is not a 'normal' procedure

In Britain, for normal medical or surgical procedures only informed consent is required. However, a precedent exists for requiring two doctors' signatures in legally significant situations. For example, in detaining someone under the provisions of the Mental Health Act, two doctors must certify that a patient has a mental disorder and must be detained for their own safety and the safety of others. This is important as detaining an individual in hospital involves a serious breach of their human rights. Two doctors' signatures are also required on cremation forms.

Abortion is similar to the application of the Mental Health Act in that both involve overriding the human rights of another human being. It is therefore very appropriate that abortion forms require two signatures.

3. Private sector abortions allow potential for the commercial abuse of women

In 2007, of the 198,500 abortions that took place in England and Wales, 89% were NHS funded, of which 57% were carried out in the private sector.[1] This provides an incentive to breach the terms of the Act, in order to maximise the numbers of abortions carried out and therefore financial income. A properly implemented '2 doctor' rule, ideally with at least one of the doctors not being employed by the private sector institution, would ensure that women are not exploited.

4. The BMA does not support Harris's amendment

The BMA supports the abolition of the 2 doctor requirement only in the first trimester, a position that they justify on the grounds that first trimester abortions pose less risk to the mother's mental and physical health than full term pregnancy. This is itself controversial and at odds with the original intention of the Act. However the BMA does uphold the need for two signatures in the second trimester due to the higher risk to the woman's health. Though they may not be keen to say this openly, this remains BMA policy.[2]

5. Balancing risks is difficult

The BMA and RCOG maintain that first trimester abortion is automatically legal, as the risks of the procedure are always lower than the risks of continuing with the pregnancy.[3] [4] Therefore they argue that there is no chance that a doctor, signing a request for a first trimester abortion, could possibly be breaking the terms of the Abortion Act. Therefore there is no need for one to 'police' the other.

However, this statement is highly questionable. Evidence continues to accrue for the health risks of abortion. Furthermore, some studies suggest that certain patients are at higher risk of developing subsequent psychiatric problems than others. Particular risk factors include ambivalence about the decision, previous mental health problems, feeling coerced into aborting, and feeling rushed into the decision.[5]

The Royal College of Psychiatrists has said the following in its March 2008 position statement on abortion and mental health: '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. If a mental disorder or risk factors are identified, there should be a clearly identified care pathway whereby the mental health needs of the woman and her significant others may be met.'[6]

For patients with several of these risk factors, abortion may well pose a greater danger to their mental health than proceeding with the pregnancy. Thus there exists at least the possibility that many first trimester abortions do not fall within the grounds of the Act, and so the need for two doctors to police each other in ensuring the Act is properly applied remains.

Refuting arguments against the two doctor requirement

1. The two doctor rule delays abortions

This is an entirely theoretical objection. There is no proof that abortions are delayed by the 2 doctor rule. In Britain 89% of abortions occur before in the first trimester, proof according to Dawn Primarolo MP, health minister, that 'there is not a problem'.[7]

2. The two doctor rule is widely abused

This is certainly true – evidence was given to the Science and Technology Committee of various forms of abuse including signing whole batches of forms without seeing patients, faxing forms to other institutions when signatures were required or literally using a rubber stamp to sign forms more quickly. This evidence of abuse requires more stringent enforcement of the Act, not its removal. Examples of this principle would include gun control laws or safety legislation, where breaches are taken very seriously.

3. There are no other medical procedures requiring 2 signatures

This was argued for by the Royal College of Nursing.[8] Actually both use of the Mental Health Act and cremation law require two doctors assent.

4. In the first trimester abortion is always legal so no policing is required

See the answer to point 5 above. Judging risks is not always easy and it cannot be said with any certainty that all first trimester abortions meet the requirements of the Act.

Where we want to be:

The two doctor rule should not be thought of as an historical anachronism or a petty piece of bureaucracy. Rather it should be seen as signifying:

• That British law still respects and offers protection to unborn children
• That society treats abortion as a serious matter, not to be seen as like any other procedure
• That women need protecting from unscrupulous doctors who may benefit personally from breaking the terms of the 1967 Act

A properly enforced two-doctor requirement would serve as a safeguard for women and as a reminder of the seriousness of abortion.