Saturday, 17 November 2012

Life, Ethics & Independence I - Abortion

"Her name was Pauline, she lived in a tree."
Here's something cheery for a Saturday morning.
Most people stay away from this, but I don't because I'm a moron.
(Pic : WebMD [Foetus at 8 weeks gestation])
This is the first in a series looking at contentious issues surrounding science and health policy with regard independence – no doubt they'll be raised during Scotland's independence debate. I was going to post later this month, but due to debates about the abortion limit, and the news from Ireland this week, I decided to bring this forward.

Parts will probably go down like a rugby team of Frankie Boyles crash landing in the Andes and eating each other, but I'm not one to shy away from going where others fear to tread.

For now, I'll be looking at : abortion, vivisection & animal welfare, stem cells, genetic engineering (including GM crops) and euthanasia. Others could be added with time, but I'm spreading these out over a longer period. I'll also be looking at drugs policy separately, and in more detail, but not for a while yet.

I'm not trying to prove one way or another whether abortion is "right" or "wrong", just the reasoning behind it and the talking points. It's fair to point out that, although I consider non-emergency late-term abortions distasteful, I'm pro-abortion (I hate the labels "pro-life" and "pro-choice" as they're loaded terms).

I haven't included any gory pictures, though some of the content might be distressing for obvious reasons.

Defining abortion

Any foetal death is considered an abortion – whether that's natural (miscarriage) or medically induced (what most people consider an "abortion"). Most miscarriages occur before the 13th week of pregnancy, and any miscarriage after that is generally deemed a "stillbirth". Deaths of a live baby post-birth are called "neonatal deaths."

Most live births occur around the 40th week of pregnancy. Any birth before the 37th week is "clinically premature". Today, coincidentally, is World Prematurity Day. I'm great with timing, aren't I?

In 2011, of the 8,493 abortions in Wales carried out :
  • 90% were carried out before 13 weeks
  • 93% were funded by the NHS and the remainder (7%) privately
  • 67% were carried out in hospitals, with a further 26% by independent NHS contractors
  • The Welsh abortion rate (14.9 per 1,000 women aged 15-44) was lower than England (17.9)

Abortion : The biology

Time for a science lesson. For once this is an area where I can say I have some expertise in - which almost certainly means I'll get some of this wrong.

Firstly the ages. Gestational age means the age of the embryo/foetus from the mother's last menstruation (2 weeks before fertilisation). This is what the abortion limit, and the number of weeks I'm listing, is based on. Embryonic age is the age of the embryo/foetus from fertilisation. So if the abortion is carried out at 24 weeks, it means the foetus itself is 22 weeks old.

A life-size model of a human embryo
at 8-weeks gestation. Is this a person?
That's for you to decide.
(Pic : Digitaljournal)

There are two stages of prenatal development.

The first eight weeks of pregnancy is called embryogenesis. The embryo exists as a bundle of cells, which divide and gradually change into three layers which arrange themselves to form the body's core tissues and systems :
  • Endoderm – Digestive system, liver, pancreas, respiratory system, most glands
  • Mesoderm – Kidneys, cardiovascular system (including heart), dermis, connective tissues, musculo-skeletal system, genitalia
  • Ectoderm – Nervous system, hair, nails, eyes, enamel, pigmentation cells, epidermis

Embryonic stem cells have the potential to change into these three layers (pleuripotency), and subsequently, into cell lines which form specific tissues (multipotency). That's why they're considered a potentially valuable medical treatment.

Mammalian, bird and amphibian embryos have a lot in common with fish – a throwback to a common evolutionary ancestry. The eyes develop to the side of the head and move to the front, whilst many structures of the head develop from "gills" called pharyngeal arches.

The second stage – the foetal stage – is where the organs and tissues grow and develop to maturity.

It takes 9-11 weeks for a recognisable human face to develop, and you can tell the baby's sex from 13 weeks - though genitalia don't fully form until 15 weeks. It might have a face. It might have a heart and primitive lungs. But these aren't developed enough to enable it to survive outside the uterus - and the foetus itself would fit in your palm.

Comparisons between a chick embryo
and a human embryo.
(Pic : Berkeley University)

Most medical screenings take place within 12 weeks. However, you can't formally test for chromosomal abnormalities – like Down Syndrome – until after 15 weeks. Some scans can't be carried out until at least 18 weeks and a full foetal heart scan (cardiotocography) for example, can't be carried out until 24 weeks.

Alveoli form at around 21 weeks, but the lungs aren't mature enough to cope with gaseous exchange until 24-25 weeks.

Most scientists agree that a foetus doesn't feel pain until 24-26 weeks, while the foetus doesn't have the brain connections to relay sensory information (thalamus) until 28 weeks.

A "rough guide" to human gestation and foetal viability.
(Click to enlarge)

In terms of viability :
  • A baby born before 22 weeks wouldn't survive.
  • At 22-23 weeks, a baby only has a 10-30% chance of survival.
  • The chances of a baby surviving at 24 weeks is 50% (see this SW Argus article)
  • By 30 weeks, a foetus is 95%+ likely to survive if it were born there and then.

So there's a "zone of viability" between 21 weeks and 27 weeks.

Although mammalian embryos and foetuses aren't by definition parasites (as they're the same species), before this "zone of viability" they shares similar "mutualistic" biological behaviour:
  • A symbiotic (mutually supportive) relationship with the host (mother)
  • Reliance on the mother for basic life functions
  • It causes "upset" to the the mother's body
  • It exists at the consent of the mother's body (it can be biologically rejected)

But it's important to point out that a foetus does have some beneficial impact on the mother (offset by negatives). It improves reproductive fitness for example, and it's been suggested that pregnancy eases the symptoms of certain chronic conditions.

Abortion : The medical procedure


A fuller list of methods is available here, but I've simplified things.

For young embryos (up to 7 weeks), abortion is pharmaceutical – termed a "medical abortion". Drugs are used to induce a natural miscarriage. A vast majority of induced abortions in the UK are carried out this way.

Once you reach the foetal stage, surgical methods are used more often. For younger foetuses, in most cases, a vacuum is created in the uterus, which allows the doctor to remove the contents via medical tubing. This method is sometimes used as a therapy following miscarriages too.

More controversial, are intact dilation and extraction abortions, or "partial birth abortions." In this method, the doctor extracts the foetus legs-first, leaving the head inside the uterus (hence the term partial birth). Next, the head is - for want of a better description – "deflated", and the contents are mechanically extracted. In the UK, this method is only used when there's a threat to the mother's life, while it's been banned to varying degrees in the United States.

Abortions aren't riskless. Surgical abortions - in particular late-term abortions - are quite invasive medical procedures carried out under general anaesthetic. However, statistically, abortions are safer than childbirth.

Abortion : The public debate
Abortion's one of those "touchpaper" issues that provokes
strong opinions one way or another.
(Pic : Demotix)
Issues like abortion are rarely debated on science or medical reasons alone. There are several issues here that are hard to answer, or based on personal beliefs.

When does "life" start?


Most mainstream religions believe that life begins at conception, and is sacred (sanctity of life), with varying tolerances on abortion. Buddhists, Hindus and some Jewish sects believe abortion is "negative, but permissible" in varying circumstances. Muslims are allowed to abort in the first four months - for example, in cases of rape, deformation or a threat to the mother's life.

The picture with regard Christianity is more muddled. Even Catholic clergy generally accept "unintentional abortions" – for example, resulting from chemotherapy (principle of double effect). The general impression is that, unless the mother's life is threatened, abortion is immoral. Some liberal denominations take a more permissible stance, or no stance at all.

A blastocyst - one of the earliest
stages of embryogenesis.
Is this "alive"?
(Pic : IVF London)

Others will argue that a life doesn't become "a life" until it's autonomous as an individual and a definable person. This isn't so much a question of science, but one for philosophers and personal beliefs.

When does a foetus become a person?


Religions with the concept of a soul believe a person becomes a person when they receive one ("ensoulment"). This varies depending on which faith you follow. The first foetal movement ("quickening"), which occurs around 15 weeks, is the generally considered to be the point of ensoulment. Hindus believe it's around 7 months after conception.

It's important to note that, barring complications, every single embryo has the potential to become a person, but probably doesn't meet the definition of an autonomous "being" until late in prenatal development. It's "alive" without being "a life".

I don't, personally, believe that a foetus becomes a person until it has an excellent chance of survival outside of the uterus, and can/starts to respond to outside stimulus – including pain. Based on the biology, I would probably say the moment a foetus changes to a "being/person" is in that zone of 21-27 weeks.

Of course, you don't legally become a person until you're born and registered.

Is an embryo, or foetus, part of a mother's body?

As I noted earlier, mammalian embryos and foetuses have a mostly one-sided relationship with the mother. They aren't autonomous beings/persons until late in pregnancy, and are reliant on the mother and the environment of the uterus to survive.

Until that point - where a foetus changes from reliant-on-mother to "passenger" - you could argue that they are not separate from, but part of, the mother's body or at the very least living at the mother's pleasure.


Where that point is in pregnancy is the issue. It makes the difference (morally, and perhaps scientifically) between removing a non-viable foetus and infanticide.

Should women have freedom of choice over their own body?

It's solid medical ethics for a patient to have control over their treatment. Abortion is – however distasteful it might be to some - ultimately, a common or garden medical procedure.

I think we'd all agree that, whatever your views on abortion, if it's required, it has to be safe for the woman. We cannot, under any circumstances, go back to the days of backstreet coat hangers and knitting needles.

What counts as a valid reason to get an abortion?

Many consider the only valid grounds for abortion to be rape, incest or a medical threat to the mother's life.

As you might have heard, a mother recently died of septicaemia in the Republic of Ireland, after being denied an abortion during a miscarriage at 17 weeks, because the foetus' heart "was still beating". It's important to point out that it's unclear if an abortion would have saved her life – this is probably a case of malpractice - but it's likely the miscarried foetus caused the infection.

Under EU law, mother's have to be offered an abortion when their life is at risk. Irish political parties have chickened-out of legislating for abortion, which is usually governed (informally) by their widely-held Catholic faith, and therefore a political "no man's land". That means it's informally banned or informally legal under certain circumstances depending on interpretation. Since 1992, Irish women have been permitted to travel abroad to get an abortion. Obviously, if it's a medical emergency, you might not have that opportunity.

Should people be subject to the religious practises and beliefs of others?
(Pic : Via Flickr)

I think it's time a version of George Carlin's "eleventh commandment" (above) becomes EU law. Translating as : Only the faithful need to act and live by their religious beliefs as a matter of personal conscience – nobody else – especially if it's going to cost them their life.

Procreation between distant cousins is
less dangerous than closer relatives.
(Pic : Zimbio)

Incest/Inbreeding is genetically dangerous, and the criminal definition, in my opinion, should include first cousins. It would be wrong for the state to force an abortion - in any case - but it would, I imagine, be the sensible course of action. Distant relatives (removed, second and third cousins) is probably fine, if rather icky. It has nothing to do with wanting to elect heads of state with a chin and robust chromosomes.

Others might include serious birth defects. There are some truly heartbreaking ones that aren't picked up for several weeks of pregnancy. I don't need to go through them for reasons of taste, but personally, I think in some cases it's cruel NOT to have an abortion.

A minority might believe that carrying a baby with, for example, anencephaly (absence of most of the head and brain) to term is a "righteous thing to do". I was going to say something strong in response to that but decided against it. A decision like that has to be for the parents/mother alone.

You might also point to nations, widely considered "liberal", that have shorter abortion limits - 12 weeks for example. I believe this is because those nations have comprehensive, non abstinence-based sex education programmes, so well-informed women are less likely to find themselves with an unwanted pregnancy.


Some have the impression that abortion promotes promiscuity, implying that women can "run away from the consequences of their behaviour". I don't believe that's the case. For example, contraceptives are never 100% effective, and failures could lead to an unplanned pregnancy that wasn't picked up until it was too late.

I don't believe that a woman gets an abortion "just because she can". It's also important to note that abortion has no known proven impact on mental health. So, as long as abortion is legal, I don't believe there needs to be a reason, just a reasoned abortion limit.

What role should the father have in abortion decisions?


In cases of rape, there's no way you would be able to involve the father, and a crime has been committed – which should be the overriding consideration there.

Based on the principle that an embryo or foetus is part of the mother's body, it might logically follow that mothers should have exclusive authority. Making the decision as a couple – where applicable – should be considered good etiquette rather than a requirement.

Obviously there would be circumstances where a partner - as next of kin - or a medical professional, might have no choice but to authorise an abortion - an accident that left the mother unconscious for example.

"Sodomy is eco-friendly, and abortion is green." - Doug Stanhope

I might be slightly misanthropic, technocratic and utilitarian to a fault, but I'm not someone who thinks humans are a planetary cancer and nobody should have children ever. When I'm in a good mood anyway.

The above quote might be a crass way of putting it, but there's a point there. Every single new baby has an ongoing environmental, financial and social impact. There are ways you can minimise these impacts – not using disposable nappies for instance, or not having large families with no means to support them.

So, by removing themselves from the breeding pool (IVF exempted), not only have gay and lesbian communities contributed extensively to Welsh public life down the years, they're also helping to save the planet in more ways than one. More gays, fewer unwanted pregnancies, fewer abortions. Problem?

Gays are green - quite literally.
(Pic : New York Post)

There's a controversial study from the US, that theorised that legalised abortion resulted in falls in crime. The (summarised) argument being that unwanted children were not being brought up in dysfunctional/unstable households. That's not an unreasonable hypothesis, but it's worth reminding ourselves that correlation doesn't always imply causation. There were also concerns raised about the methodology, so take it with a pinch of salt.

Considering Wales' demographics, we should probably be encouraging more births. But those children have to be wanted and carefully planned for, not just by individuals and families but by governments too. It's one of the reasons politics exists.

So, once again, I think this comes down to comprehensive sex education, wider use and promotion of contraceptives....and recreational use of the mouth, cleavages, interestingly-named "aids", hands and the anus.

Abortion and independence

So, what abortion policy could an independent Wales have? Or even, what abortion policy could Wales have if it were devolved?

The issue was raised in the Senedd recently by Plaid's Health Spokesperson, Elin Jones (Plaid, Ceredigion),  following Jeremy Hunt's statement supporting a 12-week abortion limit. Nadine Dorries eating kangaroo anii and being buried in cockroaches is supposed to have something to do with the debate too....apparently. More on that at Plaid Wrecsam.

There are three separate issues that need to be addressed.

1. Sex Education


As in all health matters, prevention in the best cure.
(Pic : The Guardian)
This is worthy of a more detailed post another time, and I have addressed it in passing before. If you want the abortion rate (and limit) to come down, then there needs to be an overhaul of sex education and sexual health awareness to prevent unwanted pregnancies. You can either follow other examples, like the Dutch model, or come up with something appropriate to Wales.

Legislation could be passed making sex education "compulsory and comprehensive" in all Welsh schools, and include other related measures about provision and rights with regard sexual health services. Creating a fit-for-purpose sex education programme could be done in cooperation between local health boards, local governments (as education authorities), the Welsh Government and education professionals.

Labour suggested compulsory sex ed – at UK level - in 2010, but the Coalition dropped it, probably because of "outrage" about "exposing young children to filth" etc.

The Assembly might have the power to do something similar to this now – whether through statutory regulations or legislation. However, abortion itself is likely to remain reserved to Westminster – but there is the Northern Irish precedent (the most recent UK abortion laws don't apply there) and "Devo Max".

The ultimate tool of course, is the "i-word".

2. Abortion rights
  • Women should have the legal right to safe medically-induced abortions as part of a universal health care system, within a defined legal limit.
  • Abortion should be available "on request" without a reason being needed.
  • The state cannot "force" an abortion, but in situations where a mother's life is in danger, and she can't give consent for whatever reason, the next of kin would be able to authorise on her behalf.
  • Abortion counselling (pre and post) should be optional, but funded by the health service.
  • Abortion has to be an informed choice (procedures need to be fully explained to the patient).
  • Medical professionals (i.e GP) can refuse to authorise an elective/optional abortion based on personal objections, but if they do, they must immediately refer the patient to an alternative practitioner who would authorise it. They shouldn't be able object if the mother's life is in danger.
  • The requirement for a GP and abortion clinic doctor to sign a certificate authorising an abortion (ensuring legal requirements are observed) could remain.
  • Abortions should be classed as an "urgent non-emergency", and the administrative process should be as quick as possible. If a pregnancy is within a week of the abortion limit, then it should be (ideally) carried out the following day.

3. Abortion limits : Definitions and regulation
  • An embryo should be legally defined as a life state and not a person.
  • A foetus would "reach personhood" once they have a medically-proven greater than 50% chance of survival outside the uterus.

Abortion limits could/should be based on (roughly):
  • The point at which the majority of foetuses, if born naturally, are able to survive outside the uterus (viability).
  • When it's agreed, by medical evidence, that a foetus is able to feel pain.
  • Advances in medicine that enable a foetus to survive at increasingly earlier points.

Based on existing evidence, that would imply a minimum of 21 weeks and a maximum of 26 weeks. The 24-week abortion limit balances personhood, viability and reducing suffering on the mother and the baby perfectly. Limits should be reviewed at regular intervals to take advances in medical knowledge into account.

Abortions could be carried out beyond this point for reasons including:
  • The mother's life is in danger (as stipulated under EU law).
  • It's a result of/required for a medical procedure (i.e chemotherapy).
  • The foetus has died in the uterus/stillborn.
  • The foetus isn't expected to survive birth (i.e serious abnormality).

Abortions carried out for any other reason after the legal limit could be categorised as voluntary manslaughter.

Conclusion
It's unlikely Jeremy Hunt's 12 week limit (or Nadine Dorries' 20
week limit) will be debated in Westminster for some time.
(Pic : The Guardian)

I think it would be foolish for the UK Government to pile an abortion debate onto the problems they already have regarding Europe and various other things. I think those other matters have put the issue to bed (for now).

There might be a case for reducing the abortion limit by a few weeks, but I honestly don't see what the point would be. The current limit works fine, and most abortions are carried out quite early anyway. A 12 week limit (which Jeremy Hunt proposes) would be arbitrary – and not really standing up to any serious objective reasoning - without a guarantee that, at the very least, abortions that threatened a mother's life could still be carried out after that point.

It's still worth thinking about at a Welsh level should the powers be devolved (if Wales is going to run health, in principle it should be) and whether abortion and sexual health policy form a key part of the Welsh Government's commitment to "social justice".

I doubt many AMs would be pleased if the UK Government cut the abortion limit without consulting them.

5 comments:

  1. An excellent and well reasoned article, nothing here I can object too... I look forward to the next installment.

    ReplyDelete
  2. Thanks, Cibwr. Though as I said I'll be spreading these out over a longer period. So the other installments won't be for a while yet.

    ReplyDelete
  3. My small contribution to the public debate
    http://wrecsamplaid.blogspot.co.uk/2011/09/nadine-dorries-and-abortion-amendment.html

    ReplyDelete
  4. Thanks PG, I've added a link within the article.

    ReplyDelete
  5. Ha! I shouldn't laugh considering the topic but that pic is a bit cheeky. "Inbred" indeed.

    ReplyDelete

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