From Spiked-Online.com Thursday 22 May 2008
Abortion in Britain: the debate ain’t over yet
Ann Furedi welcomes British MPs’ defence of the 24-week time limit, but says much more can be done to free up and streamline abortion services.
Following this week’s debate about abortion in the House of Commons, Ann Furedi of bpas – the leading provider of abortion services in the UK – says we now must debate how to make it easier for women to access abortion.
This week’s vote in the UK parliament to retain the 24-week upper gestational limit for most abortions was important for two reasons.
Firstly, because it retained the precedent that has existed since abortion was legalised in England and Wales in 1967 that the time limit is set by medical and scientific consensus on viability. Secondly, because MPs acknowledged why women need access to abortion services in the later weeks of the second trimester, and indicated that this would not change even if access to earlier abortion was improved.
There was much discussion on the floor of the House of Commons about ‘evidence’: evidence from august medical bodies about when severely premature infants can be kept alive, and evidence from abortion providers about the circumstances of their clients. There was little discussion about ‘principles’: whether abortion is ‘right’ or ‘wrong’, whether it is a ‘social good’ or a ‘social evil’.
For those of us who have watched the debates evolve over the decades, it was interesting to see how the limits of the discussion have shifted. In 1990, the best of the pro-choice placards and posters demanded that abortion should be available ‘as early as possible, as late as necessary’, suggesting that women’s need for abortion should be met irrespective of fetal viability (a principle that was adopted for women whose pregnancies were affected by a serious risk of severe abnormality). At the other end of the spectrum, the anti-abortion lobby argued that abortion was murder and should not be tolerated by civilised society.
During Tuesday’s debate, there was no consideration about whether a time limit is necessary and no argument about the need to outlaw abortions entirely. How curious to hear the most vociferous opponents of abortion accepting that abortion should be available to 12 weeks, and arguing that a reduction to 12 weeks would still allow the majority of procedures to take place. Did we really see that veteran anti-choice war-horse, Ann Widdecombe MP, walk into a division lobby in support of abortion in the first trimester? Tactics, tactics; it was all about tactics; it was all about what could be won.
Abortion politics in parliament today is about pragmatism more than principle. The anti-choice movement accepts that it cannot win support for an outright ban on abortion. The pro-choice movement accepts that politicians will set restrictions. Everything is about where the boundaries of provision are set. The discussion as the Human Fertilisation and Embryology Bill shuffles towards its Report stage and final vote will be focused on the ‘politics of the possible’. And there is much that should be possible.
The ‘progressive’ or ‘modernising’ amendments that have been discussed by the pro-choice movement are so moderate that they were recommended by a recent House of Commons Science and Technology Committee. The possible amendments that will receive serious consideration will not ‘liberalise’ the abortion law, in the sense of making it easier for women to have abortions in circumstances which would now be restricted. They are modest measures that would make the provision of services more straightforward and less bound by out-of-date bureaucracy.
The current requirement for two doctors to certify that a woman meets the legal grounds for abortion has been questioned even by many parliamentarians who wished for a lower gestational limit. The two-doctors rule is not a clinical assessment and not linked to obtaining consent, which happens later during a medical consultation. The requirement was seen as essential in the 1960s to underline the gravity of the abortion decision, and to provide reassurance to doctors who were concerned that abortion referrals might be challenged and who thus drew confidence from a colleague’s ‘second signature’.
But today, when abortion referral is so common and it is accepted by officials that the law can be interpreted to provide abortion when a pregnancy is unwanted – because it is accepted that an unwanted pregnancy is a threat to mental health – the certification requirements have become nothing more than a tick-box exercise. The doctors are not even required to see the woman – both can sign ‘unseen’ – making their assessment on the basis of recommendations made by a nurse or counsellor. Currently, it is difficult to sustain an argument for why two doctors need to certify rather than one. It is even difficult to argue that it should be a doctor that signs rather than a nurse or other trained professional. An amendment to get rid of the ‘two doctors’ requirement would eliminate some unnecessary bureaucracy that can sometimes delay treatment and which wastes clinicians’ valuable time.
Currently the law insists that only doctors registered with the General Medical Council can perform abortions. This requirement means that nurses can only assist and not take responsibility for carrying out procedures. This is frustrating for nurses denied the possibility of developing and practicing skills that are seen as a normal part of nursing care in other countries. Early aspiration abortion procedures are less complicated than many procedures routinely undertaken by nurses, and nurses already lead many early medical abortion services – doing everything except prescribe the drugs.
Even the Royal College of Nurses, not the most radical of institutions, is solidly behind a reform that would allow nurses to take responsibility for abortion care – a move that would make it possible to increase access to early abortion by increasing the number of appointments, and improve the quality of care.
Forty years ago, when the Abortion Act was passed, abortions were a more complicated medical procedure, usually requiring an overnight stay in hospital, and legislators were concerned to ensure that women received appropriate clinical care in properly equipped clinics. Memories of ‘backstreet’ abortions were recent, and the legislation was designed to ensure they were eliminated.
But today, an increasing number of pregnancies are terminated by medication: the abortion pill. This is a procedure that does not fit easily into a clinical environment, and it would be best if the medication used to bring on the woman’s ‘miscarriage’ were taken in the comfort and privacy of her own home, as happens in the US and many European countries. Yet the law, as it stands, means that women must receive the drugs at a licensed clinic and then travel home. In effect this undermines the quality of care that clinics can provide, as it means that women are at risk of starting to cramp and bleed while they are travelling. The current requirement for places using the abortion pill to be licensed by the secretary of state for health excludes facilities that could meet the technical requirements for early medical abortion provision, and consequently denies women more local, easily accessible services.
And then there is the issue of Northern Ireland, which was excluded from the provisions of the Abortion Act in 1967, meaning that a woman in Newcastle, County Down, is denied a procedure that is available to a woman in Newscastle-upon-Tyne, unless she meets the cost and emotional burden of travelling to a clinic in England.
The Report stage of the Human Fertilisation and Embryology Bill provides an opportunity for these modernisation measures to be considered in the context of the previous House of Commons vote that endorsed the current time limit. The House of Commons has clearly endorsed legal abortion up to 24 weeks gestation. When abortion is legal, it should be provided to the highest standards, by appropriately qualified staff, in an appropriately equipped environment. The law should surely ensure this and not frustrate it, as it does currently.
There is a longer and more complex debate to be had about the place of abortion in modern society. Right now, the HFE Bill provides an opportunity to deliver a quick fix on areas of the law that are clearly broken.
Ann Furedi is chief executive of the British Pregnancy Advisory Service, the leading provider of abortion services in the UK. bpas is holding a conference in June on the ethics, politics and practice of abortion. A small number of bursary places are available for people unable to obtain funding.