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ss triple helix - Easter 2010,  abortion requests: should we 'refer'?

abortion requests: should we 'refer'?

KEY POINTS
  • Christian GPs find handling abortion requests troublesome. CMF's recent publications on the subject are reviewed.
  • Jim Newmark began a new discussion about refusal to make a written referral to hospital: there are inevitable consequences to other doctors, whether Christian or not, now caught up in the issue.
  • Mark Houghton usually writes a referral letter but uses it to point out the probable illegality if an abortion were to be carried out. Rhona Knight seeks a shared understanding and negotiated management plan, in which evidence-based and values-based medicine both play an intrinsic part. Greg Gardner reviews law, the practice of providers, and the medical evidence and concludes it is entirely reasonable to decline a woman's request for referral.

Andrew Fergusson reviews GP members' attitudes to abortion requests

Over the years Triple Helix has considered the vexed question for GPs of handling abortion requests. In 2003 Liz Walker and Huw Morgan discussed 1 the following real life case: 'Jenny is 15 and thinks she may be pregnant. After talking and examining her you establish that she is around 20 weeks pregnant. She says she does not want to have the baby. She is scared to tell her parents and asks if you would tell her mother if she got her along to see you under false pretences.'

In 2008 Rachael Pickering who had edited that discussion used the Juniors' Forum to review professional aspects, (2) and the same edition contained an extensive and reassuring legal review. (3) The introduction to a 2009 CMF File 4 used the example of abortion to illustrate the right of conscientious objection:

'The right of conscientious objection is enshrined in medical law. For example the 1967 Abortion Act states that ...no person shall be under any duty, whether by contract or by any statutory or other legal requirement, to participate in any treatment authorised by this Act to which he has a conscientious objection.'

Each abortion consultation is stressful, and the troubled consciences of members continue to provoke them. This new year, another GP raised a further issue:

Jim Newmark (salaried, Bradford)

'I have been a Christian doctor for very nearly a third of a century. You would have thought I would have this issue just about sorted, but I do not. I remain confused. And just a touch irritated. This has nothing to do with those from whom conscientious objection has 'recently come under attack', nor with my secular acquaintances, friends, and patients. My take is from the perspective of a jobbing front-line Christian GP who personally has never (yet) signed a blue form, but does not object to making a written referral to the hospital.

I am puzzled by the objection to making a written referral to the hospital for a woman to undergo a termination of pregnancy. This is held to be reasonable in the light of the provision of the conscience clause…'

He went on to make the point that those who refuse to make a written referral ignore 'the inevitable consequences to other doctors, whether they are Christian or not, who are now consequently, and inevitably, caught up in the issue. Like the unborn child, they are ignored, a by-product of events out of their control...I think what has happened in Christian circles is that people have paid too much attention to the theoretical objections as a proxy for their "personal integrity", and have lost sight of the magnitude of the consequences… in the real world to others. And I have a sneaking suspicion that there is at least some element of one-upmanship in the sense that "by invoking my right of conscientious objection I am a better Christian than you".'

He summed up '...a doctor cannot un-know what he/she knows. In virtually all these situations in real, as opposed to theoretical, general practice, the doctor is a participant, albeit unwilling – end of story. I think that, too often, Christians use the conscientious objection clause without really thinking about what it means either for themselves or for others.'

The correspondence that followed stimulated a lively discussion at the Editorial Board, and it was agreed to canvass the views of some other GP members.

Mark Houghton (part time, Sheffield)

'I offer patients four things:

  • Respect – for the mother, baby, father and family
  • Review of knowledge to fill in the gaps about the fetus, social services, and so on
  • Regard for the law which does not permit abortion on demand
  • Referral as a last resort

The woman may arrive scared, angry, hurt and confused. I explore opportunities to find joy, because she is carrying a new person. A colleague of mine said to a woman: "You might be carrying the next Beethoven". Years afterwards she would bring the boy in, smiling, "Here is Beethoven"! Always seek trusted local counsellors and ultrasound scan.

In this area of terrible hurt and injustice we Christians need to decide our group strategy. We should leave patients free to choose their own path, fully informed of the threats to their life, health, conscience, fertility, and from the law. Jesus never stood in anyone's way but he did invoke the law.

We can choose non-cooperation and non-referral to stress a corrupt system into change – or we can combine to invoke the law. The UK Abortion Act is weak but exists to protect the woman and baby.

As a last resort the law offers hope for my little patient. And it may save her mother from death because abortion is more dangerous than a delivery. (5) If she is determined on abortion I write a detailed, referenced letter concluding "I find no grounds in law for this termination request. If it happens I would consider it illegal. The peer-reviewed evidence is below." Lawyers are eager to test this. If we all invoked the law and the medical evidence then change would be rapid.

Rhona Knight (portfolio, Leicester)

'My current approach to such consultations is to do what I aim to do in all consultations. I will take a history, clarifying the presenting problem and identifying the patient's ideas, concerns, thoughts, fears, and expectations and why they have them. I will explore external pressures compromising free choice. Having reached a shared understanding, I then hope to negotiate a management plan, in which evidence-based medicine and values-based medicine both play an intrinsic part.

I find myself at odds with the latest BMA position that "Doctors who have a conscientious objection to abortion…should make their views clear at the start of any consultation...should tell patients they had a right to see another doctor and, if appropriate, arrange for another doctor to take over the patient's care". (6) I am more inclined towards the GMC guidance (7) which, in acknowledging the potential of the physician's expression of personal beliefs to exploit the vulnerable patient, still gives the doctor permission to stay true to their moral beliefs.

The negotiated way forward, like each consultation, is unique. It may include time for reflection, or accessing other pregnancy support organisations, or bringing the patient back to see a colleague who would be happy to refer for abortion if this is what the patient chooses. In this overall approach, I hope I am making the care of the patients my first concern, demonstrating love for neighbour, born and unborn, while also working as part of a wider team who may have differing ethical beliefs.'

Greg Gardner (part time, Birmingham)

'The NHS commissions abortion services from two major and a number of smaller providers as well as its own hospital trusts. The two largest private providers are BPAS and Marie Stopes International which between them have a gross annual income of around £125 million. (8) Although having "charitable status" their profitability is huge, extending to their desire to fund advertising for their services on prime time TV. It is extremely rare for a woman to be refused an abortion by an abortion provider. Referral for a “second opinion” is in reality nothing of the sort. It is referral into a system which fast tracks pregnant women to one outcome only. Failure to screen women adequately for risk factors prior to abortion is negligent and failure to tell a woman if she does have risk factors for post-abortion injury is also negligent. Women need access to evidence and information – and time to think. Adherence to a proper standard of informed consent would go a long way to counter the paternalism and financial self-interest of the abortion industry.

There is no such thing as a legal right to abortion. The Abortion Act (1967 amended 1990) merely decriminalises abortion if certain criteria are satisfied. Among these are that the risk to the mother's physical or mental health would be greater if she continued with the pregnancy than if she had an abortion. Although a risk assessment has to be made in each case, there is enough evidence already of hidden and delayed maternal morbidity and mortality (9),(10),(11),(12) and this undermines the legal basis of virtually every abortion done in the UK.

How ethical is it for GPs to refer women into the abortion pathway? It depends on what your view is of complicity. At the very least it could be construed as endangering someone's life since this referral route almost always results in the death of the unborn child. Given that information conveyed to women prior to abortion is usually inadequate; given that most abortions done under clause C in the UK are illegal; given that putting a pregnant woman on to a referral pathway to an abortion provider endangers the life of the child; and given that there are issues surrounding complicity, it is entirely reasonable to decline a woman's request for referral to an abortion provider.

KEY POINTS
  • Christian GPs find handling abortion requests troublesome. CMF's recent publications on the subject are reviewed.
  • Jim Newmark began a new discussion about refusal to make a written referral to hospital: there are inevitable consequences to other doctors, whether Christian or not, now caught up in the issue.
  • Mark Houghton usually writes a referral letter but uses it to point out the probable illegality if an abortion were to be carried out. Rhona Knight seeks a shared understanding and negotiated management plan, in which evidence-based and values-based medicine both play an intrinsic part. Greg Gardner reviews law, the practice of providers, and the medical evidence and concludes it is entirely reasonable to decline a woman's request for referral.
References
  1. Walker L, Morgan H. Unplanned pregnancy: how I'd handle it. Triple Helix 2003
  2. Pickering R. Let's communicate about abortion. Triple Helix 2008; Summer:9
  3. Foster C. Conscience in the consultation. Triple Helix 2008; Summer:10-11
  4. Wyatt J. The doctor's conscience. CMF File 39, 2009
  5. Science and Technology Committee's Inquiry: Scientific developments relating to the Abortion Act 1967. Submission from Dr Chris Richards and Dr Mark Houghton, 2007
  6. British Medical Association ARM Report. Tell patients if you have objection to treatments, doctors urged. 14 July 2008.
  7. General Medical Council. Personal beliefs and medical practice - guidance for doctors. March 2008.
  8. www.charity-commission.gov.uk
  9. Reardon D et al. Deaths associated with pregnancy outcome: a record linkage study of low income women. South Med J 2002;95:834-41
  10. Gissler M et al. Injury deaths, suicides and homicides associated with pregnancy, Finland 1987-2000. Eur J Public Health 2005;15:459-63
  11. Brind J et al. Induced abortion as an independent risk factor for breast cancer: a comprehensive review and meta-analysis. J Epidemiol Community Health 1996;50:481-496
  12. www.afterabortion.org./reasmor.html
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