In the media everyone is pro-choice or pro-life. I am both
Opinion: A former master of the Coombe Hospital considers the complex decisions relating to abortion
Prof Chris Fitzpatrick: ‘Decisions that relate to the intentional ending of early human life do not neatly fit into a binary mode of thinking.’ Photograph: Aidan Crawley
On the many occasions that I have turned on the television to watch debates on the subject of abortion, I have almost invariably been able to predict what the various speakers will say. I have been able to do this even before they have said a single word, based on their previous pronouncements and/or their organisational affiliations.
What I have rarely, if ever, come across in any public discourse on this subject is anyone admitting that they were uncertain, confused or even that they had changed their minds. I have certainly never heard anyone say: “Yes, let us agree to disagree and to respect each other’s point of view”.
It seems that everyone who appears in the media is either firmly pro-choice or pro-life; nobody seems to live in the space in between.
However, outside in the real world, decisions that relate to the intentional ending of early human life do not neatly fit into a binary mode of thinking. Rather than being black and white, these decisions are more commonly grey, nuanced, complex.
Grey is not a colour that projects well on our high-definition screens, or that can be readily captured in a tweet or on a placard at a protest march, or for that matter in a text message sent by a party whip.
Nor does greyness, nuance or complexity fit in well with the reductionist biology of our constitution that offers equivalent protection to human life – be it made of a single cell, hundreds of millions or billions of cells, and the woman who carries such life inside her body.
As someone who grew up in the Ireland of president Eamon de Valera and archbishop John Charles Mc Quaid, I now look back, in the latter part of my career, on how I have changed my views over the years. They have changed from ones that were broadly in step with the march of an infallible Catholic dogma, to more fallible ones that I have tried to work out along the way, based on my experience of clinical practice and life itself.
So where do I stand then when it comes to termination of pregnancy? In raising one’s head above the parapet, one realises that one may be shot down. Many will disagree with these views. So be it. I would have disagreed with them myself – even a decade ago.
Threat to the life and health of a woman
When pregnancy poses a threat to the life of a woman, appropriate action needs to be taken to end the pregnancy, to save the mother. Long before recent legislation was passed, this was the standard of practice in this country.
Consideration, however, also needs to be given to termination of pregnancy if there is a significant threat to the health of the mother. Such decisions are more complex. What constitutes a significant threat to health? Women and doctors may differ in their interpretation of risk.
The distinction between threat to health and life may also be ambiguous and artificial. There needs to be sufficient clinical manoeuvrability within any new legislative framework to allow for these important considerations to be taken into account in the interests of women.
Rape and incest
For pregnancies resulting from rape and incest, termination of pregnancy should also be permitted. It is unconscionable that any woman, traumatised by these crimes, would be denied this.
Fatal foetal abnormalities
In cases of fatal congenital abnormalities – such as anencephaly or the developmental absence of both kidneys or a serious chromosomal abnormality such as Edward’s syndrome – if a mother requests that her baby be delivered sooner rather than later, this should be permitted so that mothers (and fathers) do not have to travel in the most distressing of circumstances outside of the State to be cared for.
Women who choose to continue with their pregnancies should be equally supported. In both instances this is the compassionate thing to do.
For women with a crisis pregnancy termination of pregnancy should be available in the first trimester within the context of a readily accessible comprehensive national crisis pregnancy service providing non-directive counselling, intervention (if chosen), and follow-up support.
At present Irish women wishing to have an early termination of pregnancy – because of the inherent delay in having to travel abroad and arrange their own medical care – are forced into the invidious position of having to undergo the trauma of late abortion in the UK or elsewhere.
Although the life of an embryo is different from that of a viable foetus, baby or adult, it is nonetheless a form of human life with its own intrinsic value and deserving of our respect.
The appearance of a foetal heartbeat in a tiny embryo will invariably elicit a response of excitement and joy from a woman who wants to be pregnant and so the termination of such a life in other circumstances in another woman must be recognised for what it is. I say this not to induce a sense of guilt, but rather to state the obvious seriousness of the decision.
The critical importance of health education in relation to sexual behaviour – relationships, consent, safety and contraception – should be emphasised when discussing crisis pregnancy in terms of prevention.
Serious non-fatal foetal abnormalities and Down syndrome
What if the foetus has a serious congenital abnormality that is associated with the prospect of long-term survival but with a significant risk of serious disability? These diagnoses are most often made at 18-20 weeks, the optimal time for ultrasound assessment.
Or what if the baby has Down syndrome? The recent availability of a screening test for Down syndrome by a blood test taken from the mother is allowing for earlier diagnosis, although the majority of diagnoses are not confirmed until after the first trimester.
Children born with Down syndrome and other serious conditions grow up to have meaningful lives, value their own self-worth and are loved and cherished.
As the mother of a 12-year-old son with Down syndrome, the actress Sally Phillips has recently challenged the introduction of the new screening technology by the NHS in the recently broadcast BBC documentary A World Without Down Syndrome.
Phillips asks: “What kind of society do we want to live in, and who do we think should be allowed live in it?” We all remember the national feel-good factor generated when Ireland hosted the Special Olympics in 2003.
In these contexts, my personal view is one of “pro-life”.
Decision-making about abortion is often complex and riddled with ethical inconsistencies and contradictions. The goalposts of foetal viability have also moved considerably – even during my career – from 28 weeks to 24 weeks and under.
How can one justify ending the life of a foetus at 22 weeks and yet do everything one possibly can to save the life of a baby at 24 weeks or 23 weeks? How can you terminate the life of foetus because he/she has a serious congenital abnormality and yet perform complex surgery on a baby with the same problem a few weeks later?
In Japan, babies as premature as 22 weeks are achieving long-term survival – although these cases are exceptional and are associated with high mortality rates and significant long-term disability.
Although Caesarean sections in the foetal interest are rarely, if ever, performed under 24 weeks in Ireland – or elsewhere – in circumstances where very early delivery is anticipated, issues of viability and medical intervention, including resuscitation, are discussed with mothers (and fathers) from 23 weeks onwards. This would appear to be the appropriate gestation at which to define viability – at the present time.
Advances in science
The development of an “artificial womb” within which to incubate extremely premature babies may sound futuristic, but is under active consideration by way of animal experiments at present. If realised this will represent a quantum leap in medicine.
Pre-implantation genetic diagnosis is now well established, and embryo gene-replacement and editing are now emerging technologies. Whatever we think now, we will have to rethink it again in the near future.
Screening and population eugenics
Accusations by some that universal antenatal screening for foetal abnormalities inevitably leads to some form or other of population eugenics may be the launching pad for some uncomfortable historical comparisons.
However wide of the mark and over-exaggerated such comparisons are, we must tread cautiously along pathways that lead to the fundamental reshaping of our humanity, both what we look like and how we view and value ourselves. Concerns need to be listened to and addressed, and the variable experiences of other jurisdictions need to be critically examined.
The views of doctors
Doctors, no matter how empathetic they are, are not automatons or technicians who can easily switch from providing IVF for one woman who desperately wants a baby, to terminating a pregnancy for another woman who desperately wants not to be pregnant – without questioning the underlying contradiction and some soul-searching.
In a world of consumerism and disposability, it is essential that early human life is not devalued to the status of a commodity. Even among those who have no moral objection to a more liberal abortion practice, many simply do not want to perform abortions, finding it counter-intuitive to what it means to them to be a doctor.
In Ireland doctors receive no formal training in relation to abortion. In certain jurisdictions there are problems recruiting experienced doctors in the public sector who have the appropriate technical competence.
When I worked in the US, many of my colleagues opted for subspecialties in obstetrics and gynaecology that would allow them to avoid the issue of abortion in their day-to-day practice.
For clinicians who conscientiously object to abortion (in some or all circumstances), their position must be respected and the interests and wellbeing of women protected by readily available alternative arrangements.
Clear and accurate medical information
As part of informed debate about abortion, there needs to be clear and accurate medical information made available – as with any therapeutic intervention – on how abortions are performed and the risks of various procedures. This must be done without resorting to sensationalism.
Not all abortions are the same; they may differ in terms of indication, stage of pregnancy and the technique used. As a society we must decide what we deem acceptable.
Drawing the line?
So where would I draw the line? In the much anticipated referendum, I will vote for the repeal of the 8th Amendment. After that I would support the liberalisation of legislation to include (a) a serious threat to a woman’s health (b) fatal foetal abnormalities (c) pregnancies arising from rape and incest and (d) crisis pregnancies in the first trimester.
These are my “pro-choice” views. I recognise that I have set down limitations and that there is an inherent arbitrariness in drawing lines of any sort. Naturally I respect the views of others on both sides of this position.
In making my mind up, I am also conscious of my gender – and would respectfully contend that it does not preclude having an equally valid opinion on this subject.
Women’s reproductive health: Church and State
When it comes to women’s reproductive health, ironies, ambiguities and inconsistencies abound. There was a time when the coil and post-coital contraception were not available in this state because they were viewed as abortifacients and a time before that again, within recent memory, when artificial contraception was not available.
Even the destiny of “surplus” in-vitro fertilised ova in the recent past in Ireland gave rise to medical practices that crossed into the realms of casuistry.
It is a tragic irony that the main thrust of moral opposition to abortion has come from a church that resolutely advocates to protect the rights of the embryo and foetus, and that yet has been culpable of the widespread systematic abuse of children as well as large-scale denials and cover-ups of these most egregious crimes.
Concerns that a removal of the constitutional protection afforded to the foetus will somehow erode our uniquely Irish Catholic tradition of cherishing all the children of the nation equally do not stack up. One needs only to reflect on what happened in Tuam mother and baby home – and in all the mother and baby homes, orphanages and industrial schools that were once dotted around the country – as well as the squalid conditions of poverty that many children live in today.
We must, however, listen respectfully and engage with those who raise concerns and learn from the experience of other jurisdictions that, perhaps, went too far in one direction or another.
It is another sad irony, worth repeating, however, that a century after striking out for self-determination and independence as a republic – we have been more than willing to leave it to the NHS and the private clinics of our erstwhile colonial masters to deal with the issue of abortion on our behalf.
It is perhaps easy to blame the church, the State, the medical profession and the legislature for passing the buck, but most of us have been happy to sit on the fence – a fence built to protect some mythical national moral high ground – and turn a blind eye to reality.
As a modern, mature 21st-century pluralist, secular republic, the time has surely come for us to take responsibility for the health and wellbeing of Irish women within the laws of the land and within the borders of our own country.
Prof Chris Fitzpatrick is a consultant obstetrician and gynaecologist, and former master, at the Coombe Women & Infants University Hospital, and is clinical professor at the School of Medicine & Medical Science, University College Dublin