Unwanted pregnancy--medical and ethical dimensions

Globally, abortion mortality accounts for approximately 13% of all maternal mortality. Unsafe abortion procedures, untrained abortion providers, restrictive abortion laws and high maternal mortality and morbidity from abortion tend to occur together. Unplanned and unwanted pregnancies constitute a serious public health responsibility. While fertility has declined by half in developing countries, the motivation to control and space births has risen faster than the rate of contraceptive use. Preventing maternal mortality and morbidity from abortion in countries where these remain high is a matter of good public health policy and medical practice, and constitutes an important part of safe motherhood initiatives. A range of positive steps has been taken to reduce deaths and morbidity from abortion in a growing number of countries over the past 15 years. Making abortion legal is an essential prerequisite in making it safe. In this respect, changing the law does matter and assertions to the contrary are ill conceived and unsupported in practice. Although, in many countries, trends towards safer abortion have often occurred prior to or in the absence of changes in the law, legal changes need to take place if safety is to be sustained for all women. Religious laws may also require attention when legal change is being contemplated. There are three main ways of approaching this problem: liberalizing the existing law within the penal or criminal code; partially or fully legalizing abortion through a positive law or a court ruling; and decriminalising abortion by taking it out of the law. Women's health groups and other advocates, parliamentarians and health professionals, can work together to support the right of women not to die from unsafe abortions and to ensure they receive treatment for complications. Committed doctors can make a difference by providing treatment for abortion complications, interpreting the law in a liberal way and providing safe services where these are legal as well as training providers in the safest techniques to reduce mortality and morbidity. Although law, policy and women's rights are central to this issue, making abortions safe is above all a public health responsibility of governments. Moreover, reducing maternal mortality by making abortions safe is also an important part of the international commitment made in Cairo in 1994 at the ICPD and reaffirmed at the Cairo meeting in 1999.

Medical misadventures

Historical perspective of terminations of unwanted pregnancies in the UK. Moral and ethical considerations imposed by established church's teachings becoming increasingly in conflict with the wishes and expectations of a more secular society. Recognition that illegal abortion was, as a matter of fact available, at great risk to vulnerable girls and women. Eventually public demand and a radical and reforming government led to the current Statutory Framework. Statutory provisions: Offences against the Person Act 1861, Sections 58 and 59; Infant Life Preservation Act 1929 Section 1. Recognition of the limited flexibility allowed by the law in the original restrictive statutory framework. The direction to the jury in July 1938 by Macnaghten J in the case of R. v. Bourne [1939] 1 KB 687, where an eminent obstetrician was acquitted after carrying out an abortion on a young rape victim. Then the modern statutory provisions: Abortion Act 1967, amended by the Human Fertilisation and Embryology Act 1990. The statutory framework provides for healthcare professionals not to have to take part in terminations if they have a conscientious objection to doing so. While there are still fierce challenges from moral pressure groups when any changes in the detail of the law are proposed--such as reducing the maximum gestation period for a lawful termination--as a whole society seems to have accepted the current law. Issues affecting doctors who consider and provide terminations; current medico-legal problems relating to wanted pregnancies that have been lost by reason of clinical negligence, and unwanted children that have been born by reason of clinical negligence.

Abortion among adolescents

In most countries, adolescents' access to abortion is limited by restrictions on legal abortion. Abortion is legal in the United States, but many states require parental consent or notification. Legislation mandating parental consent has been justified by several assumptions, including high risk of psychological harm from abortion, adolescents' inability to make an adequately informed decision, and benefits of parental involvement. Empirical data raise questions about the first 2 assumptions: Studies suggest a relatively low risk associated with abortion, and adolescents seeking abortion appear to make an informed choice. Less is known about effects of parental involvement. The authors review available research and discuss policy debates over parental consent in the United States and the international context.

The legal aspects of the termination of unwanted pregnancies and the risks faced by the medical doctor: a UK perspective

Historical perspective of terminations of unwanted pregnancies in the UK. Moral and ethical considerations imposed by established church's teachings becoming increasingly in conflict with the wishes and expectations of a more secular society. Recognition that illegal abortion was, as a matter of fact available, at great risk to vulnerable girls and women. Eventually public demand and a radical and reforming government led to the current Statutory Framework. Statutory provisions: Offences against the Person Act 1861, Sections 58 and 59; Infant Life Preservation Act 1929 Section 1. Recognition of the limited flexibility allowed by the law in the original restrictive statutory framework. The direction to the jury in July 1938 by Macnaghten J in the case of R. v. Bourne [1939] 1 KB 687, where an eminent obstetrician was acquitted after carrying out an abortion on a young rape victim. Then the modern statutory provisions: Abortion Act 1967, amended by the Human Fertilisation and Embryology Act 1990. The statutory framework provides for healthcare professionals not to have to take part in terminations if they have a conscientious objection to doing so. While there are still fierce challenges from moral pressure groups when any changes in the detail of the law are proposed--such as reducing the maximum gestation period for a lawful termination--as a whole society seems to have accepted the current law. Issues affecting doctors who consider and provide terminations; current medico-legal problems relating to wanted pregnancies that have been lost by reason of clinical negligence, and unwanted children that have been born by reason of clinical negligence.

Prenatal care: revisions to SCHIP extend health care to "unborn children"

Effective November 1, 2002, the federal Department of Health and Human Services (DHHS) reclassified developing fetuses as “unborn children,” thereby providing health insurance benefits for prenatal care under the State Children's Health Insurance Program (SCHIP). By broadening the current definition of “child” —and thus expanding SCHIP insurance coverage — DHHS hopes to increase the number of low-income pregnant women who receive prenatal services. As noted by one commentator, the new rule represents the first time “any federal policy has defined childhood as beginning at conception.”

In an attempt to improve access to publicly funded health insurance for poor children not covered by Medicaid, Congress established SCHIP a 10-year, $40 billion program jointly funded by federal and state governments. Through a series of block grants, SCHIP allows states to either expand income-eligibility for their existing Medicaid program or to create a separate child health program to decrease the number of uninsured poor and near-poor children.

Abortion under Greek law: parental consent for a minor's abortion

As medical abortion becomes more widely used and available in Greece, several issues are emerging and require clarification. Health care providers often face a dilemma when dealing with an adolescent requesting abortion. Parents' consent is mandatory before delivering any kind of treatment to minors. However, as it appears in the case presented here, the circumstances are not always straightforward. A critical review of the Greek legal framework in relation to the current social context is attempted through an interesting case aiming to elicit potential defects of the law that should be addressed by the legislator.

Legal duties to respect abortion choices

This paper addresses legal protection of individual choices to obtain abortion services, to decline to perform abortions on grounds of religious objection, and to participate in these procedures. It considers legal duties to respect women as decision-makers in their own lives, including when they decide to continue pregnancy. The choice to decline participation in abortions is an aspect of religious freedom available to physicians, nurses, and, for instance, pharmacists, but not artificial legal persons such as hospital and clinic corporations. Refusal does not extend to ancillary functions such as serving meals, routine pre-operative and post-operative care of abortion patients or typing abortion referral letters. Physicians practising in proximate care must be trained in appropriate medical management of incomplete and threatened abortion even when they would refuse to apply such techniques to induce abortion.

Regulation of assisted reproductive technology: a case study of Japan

Most studies on the ethics and provision of assisted reproductive technologies (ART) have taken place in the context of the Judaeo-Christian culture of western developed countries. This study looks at ART, its provision and control, in an eastern developed country with a completely different cultural background; Japan. A necessarily brief description of the cultural context of religious belief, the family and reproduction in Japan is followed by a description of the development of ART in Japan together with an analysis of its provision and control.

Embryonic stem cell research: one small step for science or one giant leap back for mankind?

At the forefront of modern debate over the ethical use of biotechnology is embryonic stem cell research. In this poignant analysis of its legitimacy, the author examines the history of this research in light of the United States' policy favoring the protection of human beings over scientific progress. Stem cells, which can divide in culture to create specialized cells in the human body, possess significant potential for curing disease, particularly when taken from human embryos. However, as evidenced by the research atrocities committed under the Nazi regime, the benefits of human research do not come without a cost to humanity. Recognizing this, the later trial of these scientists produced the Nuremberg Code, a set of natural law principles guiding future research on humans that continues to influence health policy decisions. Drawing on this background, the author first considers the appropriate legal status for a human embryo. Biologically, the characteristics of a human embryo place it between human tissue and a constitutional person. Judicially, the answer is even less clear. The author analyzes case law in the context of abortion and in vitro fertilization, as well as classifications by the common law, state legislation, and the National Bioethics Advisory Commission, to conclude that a human embryo should be subject to the same legal and ethical restrictions as any other "human subject." Accordingly, the author argues that embryonic stem cell research violates the ethical standards and purposes of the Nuremberg Code and should be banned by federal legislation. Such a prohibition will fulfill the societal policy choice of protecting potential life and vulnerable human subjects.

A live issue and a moving target

US scientists have largely pioneered the field of human embryonic stem cell research, but the current political situation in the USA is not kind to their work

The value of life according to "law as a way to survive"

Law as a Way to Survive is a comprehensive evolution-theory orientated philosophy of law and state that is tested in this article on its pertinence and explanatory power for the following issues: animal rights, abortion, euthanasia and assisted suicide. These subjects are suitable as tests precisely because they are not those for which LWS or rival theories, with which it will be compared, and for which it was primarily developed for. It will be concluded that LWS is very superior in pertinence and explanatory power both because it is much less metaphysical and much more complex than its rivals.

[The right to be aborted]

This lecture deals with the difficult problem of so called "wrongful life". Two Court decisions have been issued recently in France and lead to a very ambiguous situation since they differ dramatically. In the "Perruche affair" where a diagnosis of rubella was not done, the parents prevented to get an interruption of pregnancy, and the child severely affected, the Court (Cour de Cassation, i.e. Supreme Court in charge of civil affairs) decided to compensate the child for "not having be aborted". In the "Quarez affair" where a diagnosis of Down syndrome was not done, the parents prevented to get an interruption of pregnancy, the Court (Conseil d'Etat, i.e. Supreme Court in charge of "administrative" affairs, affairs opposing individuals to state administration since the hospital in cause was belonging to the public sector) decided not to compensate directly the affected child. The consequences of these opposite decisions are analysed according to medical, legal, ethical and economic considerations.

Chinese moral perspectives on abortion and foetal life: an historical account

It is accepted wisdom that, at the present time as well as historically, the typical Chinese attitude toward abortion is very permissive or 'liberal'. It has been widely perceived that Chinese people usually do not consider abortion morally problematic and that they think a human life starts at birth. As part of a bigger research project on Chinese views and experiences of abortion, this article represents a revisionist historical account of Chinese moral perspectives on abortion and foetal life. By presenting Buddhist and Confucian views of abortion, traditional Chinese medical understandings of foetal life, the possible moral foundation of a 'conservative' Confucian position, and some historical features of abortion laws and policies in twentieth-century China, this paper shows that blanket assumptions that the Chinese view of abortion has always been permissive are historically unfounded. As in the present, there existed different and opposing views about abortion in history, and many Chinese, not only Buddhists but also Confucians, believed that deliberately terminating pregnancy is to destroy a human life which starts far earlier than at birth. The current dominant and official line on the subject does not necessarily accord with historical Chinese values and practices.

Children by choice: reproductive technologies and the boundaries of personal autonomy

Unlike other countries that regulate assisted reproduction, the US has largely left this field to the domain of professional self-regulation and market preferences. The reason lies both in the confused jurisprudence of reproductive liberty and the paralysing effect of the abortion debate on US politics. The debate surrounding cloning, however, has galvanized both activists and the government to revisit the question of regulation, and recent cases in the US Supreme Court suggest that if the political will to regulate this field is found, governmental authority to intervene in areas such as pre-implantation diagnosis, gamete donation and surrogacy might well be upheld, even in the face of constitutional challenges.

[Induced abortion--a doctor's point of view]

Traditionally, the medical community has sided against abortion. However, over the past century there has been a change in this stance. This paper will explore the position of the physician and the medical community in regards to abortion. From the physician's perspective, is there not a conflict between performing an abortion and the physician's duty to save life? Does the physician not feel some hypocrisy in working to save some fetuses and aborting others? The issue of abortion can also lead to the question of what the physician's obligations are; is he or she obligated to the woman and her best interests or to the principle of upholding life? Another discussion will be devoted to abortion in Israel and the factors affecting the decision making process of the "Abortion Committees". Members of these committees weigh issues that are not expressed forthrightly in the law, such as the social situation of the pregnant woman under consideration. Furthermore, the physician's outlook and even conscience can sway his or her decision in some cases. A review committee set up by the Ministry of Health found that in many cases in which abortion was permitted, there was no legal back up for the decision. That is to say, in some cases there was found to be no correlation between the decision and the legal guidelines set out. In light of this, the committee made a number of recommendations. One of these recommendations was that in cases that permission for an abortion was granted based on a reasonable concern for the welfare of the mother or fetus, this decision should be based on medical evidence that there was in fact danger to the mother or fetus.

[Is preimplantation diagnosis legal?--on the need for harmonizing legislation]

Whether PGD is already legally permitted in Germany today is a moot point. A guidelines draft of the Germany's Federal General Medical Council, the Bundesärztekammer, on pre-implantation genetic diagnostics that--like the earlier findings of the ethics commission of the German federal state of the Rhineland-Palatinate--assumed that the method is admissible, if certain clearly-defined indications are present and a rigorous testing procedure has been established, has given the discussion a new impetus. The discussion is in full swing, with calls by politicians for the legislator to pass a regulation mounting. Of late, though, constitutional objections have been raised against a positive-law regulation. Such a simple legal move to regulate PGD, it is claimed, would violate the constitutionally-guaranteed right to inviolable human dignity. Critics, however, point out that such an absolute inviolability does not exist. According to them, not only the verdicts by the German Federal Constitutional Court, the Bundesverfassungsgericht, on the reform of section 218 of the German Federal Penal Code (StGB)--the paragraph that specifies the conditions under which an abortion is not punished--that relativize (in terms of the indication model) one claim to existence with respect to another, but also the approval in terms of pharmaceutical and medicine-products law of nidation-blocking agents, serve to show this. If the condition of being a human being were made to coincide with the completion of the genetic code upon the completion of the process of fertilisation, then one tended to forget, the critics noted, that this attendant dignity was not properly "infused with life" unless nidation had been successful. Without nidation everything were fragmentary, the total protection of human dignity according to Article 1 Section 1 of the Federal Republic's Basic Law, Germany's constitution, notwithstanding. During every in vitro fertilisation embryo transfer is conditional upon a variety of factors the presence of which is not noted until after fertilisation has taken place. On the part of the embryos, too, certain conditions have to be met whose presence at the moment of fertilisation is not assured. Thus an embryo with, for instance, defects that can be visually detected will not be transferred. With regard to these facts too the opponents of pre-implantation genetic diagnostics must be challenged to answer the question of why an embryo with visually-detectable defects should undoubtedly be allowed to be discarded, but the act of searching for "internal" defects be banned. Thus the fact remains that the mere acceptance of the loss of created embryos does not make artificial insemination a punishable offense, as long as the motive for the act is to bring about pregnancy. To achieve legal security for the couples and the physicians involved the law on the protection of embryos should be changed. The new regulations should determine under which conditions PGD is permissible. As is already the case for other norms that apply to reproductive medicine, but also for the practice of abortion, these regulations should contain an analogous right of refusal for the professionals involved. The laws relating to the healing professions, to the professional chambers, as well as the regulations of the various German federal states (which together constitute the Federal Republic of Germany) that apply to the professions should be amended accordingly.

[Pregnancy termination in which the child would have been able to survive]

The reform of paragraph 218 (dealing with abortion) of the German Penal Code has caused the formerly embryopathic grounds for abortion to be subsumed within the medical grounds for abortion. This has led to the temporal limit on those cases in which a pregnancy is terminated on medical grounds due to foetal malformation to fall away. This state of affairs must be rated differently with respect to children with grave defects not able to survive and those with minor defects who would be able to survive. In the latter cases a regulation on a time limit or limits that took account of the ability of the unborn child to survive is called for. In addition, in the case of children that would have been able to survive feticide by injection of medication is recommended.

Induced abortion in Sri Lanka: who goes to providers for pregnancy termination?

The sociodemographic characteristics of abortion seekers and the reasons they give for procuring termination were studied in 356 clients selected from two abortion clinics in the city of Colombo. Nearly 80% were Buddhists and about 10% were Christians. Almost all had some formal education but only 20% were employed outside the home. Over 95% were currently married and at the peak of their childbearing age. More than one-half were aged 30 years or over, while adolescents only constituted about 3%. Fourteen per cent were nulliparous and about two-thirds had one or two living children at the time of obtaining the abortion. A significantly high proportion also had a very young child. In total, the 356 women had had 1130 pregnancies, and the mean rate of abortion was 42 per 100 pregnancies. Over one-quarter had had more than one abortion and about 10% had had three or more. Almost all abortions were performed within the first trimester with a mean gestation period of 6 weeks. About one-third of the clients were using some method of contraception at the time they became pregnant. The most common reasons cited for the present abortion were 'pregnancy too soon after previous delivery', 'no more children desired' or 'curtailment of opportunity for foreign employment'. Unmarried women constitute a special group of abortion seekers who have different needs and behave differently from married women. Their needs are not currently being met by reproductive health programmes in Sri Lanka, and it is important that they should be given special attention in the future. An interesting finding is that a significant minority of the abortion seekers answered negatively to the question regarding providing medical facilities for abortions without difficulty. This underscores the ambivalence many people have to abortion.