Abortion

Warning: This chapter contains information that will be disturbing for some people because abortion involves the killing of vulnerable human beings.

If any woman ever truly desires an abortion, I imagine it must be rare.

Shawn Carney, campaign director for 40 Days for Life, describes how awkward he felt during his first experience of praying outside an abortion clinic: …then a woman came out of the clinic, and I looked up and our eyes met. And she just kind of looked at me in utter despair and sadness, and I knew we were both sharing this moment, both knowing she had just aborted her child.[1]

Yet we know from the World Health Organization (WHO) that about one in 5 pregnancies worldwide end in abortion. That works out at around 42 million in 2003, down from nearly 46 million in 1995.[2] How can we explain this paradox? Why do so many women have abortions?

Pressure for easily available legal abortion grew as a result of easily available contraception, and the subsequent public perception that sex and child-bearing no longer had to go together. Once this idea caught hold, tolerance for enduring an unwanted pregnancy withered even when the pregnancy was due to contraceptive failure or a failure to use contraception at all. Legalization of abortion on demand was the predictable next step in the control of fertility—the so-called ‘right to choose’.[3]

What is abortion?

Abortion is the premature expulsion from the uterus of the products of conception. In technical terms, abortions may be spontaneous (meaning that they occur from natural causes—these are often called miscarriages) or induced, where someone deliberately causes the abortion. In this chapter, I am discussing induced abortion only—that is, the deliberate ending of a pregnancy so that it does not progress to birth. This is what I am referring to here when I use the word ‘abortion’. I think this is the common understanding of the word, and I am conscious that using the term for those suffering miscarriage can be offensive to some people.

History

Abortion has a long history, with evidence of its practice found in ancient Egyptian papyri.[4] In fact, while our society thinks quite differently about the killing of a child in the womb (which is legal and socially acceptable) from that of one who is already born (which is a shocking crime, particularly if committed by the parents), this was not the case in the Graeco-Roman world in the centuries leading up to the birth of Christ. During that time both abortion and infanticide (the killing of infants) were commonplace, with little differentiation between the two. There were some restrictions on each practice, but each was widely accepted nonetheless.

Infanticide involved the murder of abnormal, weak, or just plain unwanted infants, usually by drowning or suffocation. In Greece it was permitted, although in Athens a child was protected from the tenth day after birth and in Thebes infanticide was a capital offence. In Rome, infanticide of newborns was legal so long as the father approved.[5] Soranus of Ephesus, who practised medicine in Rome between 98 and 138 AD, gave instructions in his Gynecology on “how to recognize the newborn that is worth rearing”. He excluded the weak, premature and physically deformed.[6] Available evidence suggests that childhood death was not associated with the same formal recognition as the death of an adult.[7] The significance of this is not fully understood—it is hard to believe that parents at that time would feel significantly different from bereaved parents today.[8]

Of course, if the early Graeco Romans accepted the killing of infants then they were unlikely to give much consideration to an embryo in the womb. In early Roman law, according to Plutarch, Romulus permitted a husband to divorce his wife for using “medicine in regard to children”.[9] The Greek word for ‘medicine’, pharmakeia, can also be translated as ‘magic’ or ‘drugs’—terms that were interchangeable as far as the Graeco Romans were concerned. When used in relation to children, the term pharmakeia meant abortifacients (medicines that cause abortions)—although it was sometimes difficult to distinguish between those medicines that caused early abortions and those that were merely contraceptives (a difficulty that still exists today).

Abortion was tolerated and could be performed for similar purposes to infanticide (e.g. limiting family size), but there were also important differences. Obviously there was no prenatal screening, so abortions were never performed because of disability. Soranus approved of abortion for maternal health reasons, but not to hide pregnancies arising from adultery or to allow a woman to keep her figure. He describes two schools of thinking: those of his persuasion, and those who opposed abortion completely.[10] Like infanticide, legal abortion required the consent of the husband, with exile as punishment for the lawbreaker. In Greece, Aristotle approved of abortion as a means of population control in the crowded city-states but only “before sense and life have begun; what may or may not be lawfully done in these cases depends on the question of life and sensation”.[11] Abortion was certainly not easily available, according to these texts.

Another difference between infanticide and abortion lay in the implications for the expectant mother. Various methods of abortion were practiced in antiquity, but none were particularly safe for the woman involved. Maternal death occurred frequently. Known abortion techniques include a blow to the abdomen, vigorous movement, ‘womb-binding’ (tying a cloth tightly around the abdomen), abortion-inducing drugs that were either drunk or used as pessaries, and surgical techniques (which seem to have been a last resort—this is understandable in a time when sterilized instruments and effective anaesthesia were unknown).

From the first century, Roman writers began to criticize abortion. This is likely due not so much to Christian influence but to concern about declining birthrates amongst the Roman nobility.[12] The most significant Greek text opposing abortion is the oath attributed to the ancient Greek physician, Hippocrates (c460-377 BC). Still quoted by doctors today, it contains the promise: “I will not give a fatal draught to anyone if I am asked, nor will I suggest any such thing, Neither will I give a woman means to procure an abortion.”[13]

The reason for this opposition to abortion is unclear. It is unlikely to come from a belief that life begins at conception. In the Hippocratic Oath, abortifacients were described as ‘destructive’ (phthorion) rather than ‘deadly’ (thanasimon—the term used in the prohibition of assisted suicide in the same paragraph), so avoiding homicide was not the reason.[14] There are ancient references praising Hippocrates for identifying the need to protect “future life still in doubt”, but this does not necessarily mean the unborn infant was seen as a human person before birth.

Soranus explained in his Gynecology that some doctors were reluctant to prescribe abortifacients because “it is the specific task of medicine to guard and preserve what has been engendered by nature”.[15] This suggests a desire to promote maternal health and assist natural processes rather than cause ill health, which facilitating abortion would have done. Indeed, Soranus was the first to seek to develop effective contraceptives as an alternative to abortion, noting that “it is safer to prevent conception from taking place than to destroy the fetus”.[16]

Meanwhile in Jerusalem, the Jewish attitude to abortion and infanticide was clearly different from the Graeco-Roman attitude. The importance of children permeates the Old Testament. Population growth was seen as a blessing from God in response to his command to “Be fruitful and multiply and fill the earth and subdue it” (Gen 1:28). Israel’s genealogies in Genesis carefully trace the line of inheritance from Adam and Eve through to the twelve tribes of Israel. God’s promise to Abraham to make his offspring as numerous as the stars of heaven (Gen 15:5) was fulfilled by the time Israel arrived at the border of the Holy Land (Deut 1:10), and his promise to bless all families of the earth (Gen 12:3) is fulfilled at the beginning of the New Testament with the birth of Jesus Christ. We also know from the Scriptures that ‘deformed’ babies were allowed to live (Acts 3:2). So there is no evidence in the Bible of the Jews practicing abortion or infanticide in order to limit their families. Indeed, the promise for the man who feared the Lord was that “Your wife will be like a fruitful vine within your house; your children will be like olive shoots around your table” (Ps 128:3), and the ultimate blessing was to live to “see your children’s children” (Ps 128:6).

The Jews did, however, have infanticide forced upon them. While they were living as slaves in Egypt, Pharaoh attempted to control their numbers by telling their midwives to kill all male Hebrew children at birth (Exod 1:16). The Hebrews equated infanticide with homicide, so the midwives disobeyed Pharaoh out of their fear of God. Pharaoh then told his people to throw every newborn Hebrew boy into the river (v. 22). Infanticide was a terrible atrocity often committed by Israelite enemies, dashing little children to pieces and ripping open pregnant women (2 Kgs 8:12; Hos 13:16).

The only regular infanticide practiced by Jews was the sacrifice of children to pagan gods such as Molech (2 Kgs 23:10; Jer 32:35),[17] Baal (Jer 19:4-5) and others (2 Kgs 17:31). But it was prohibited in Mosaic Law (Lev 18:21, 20:2-5; Deut 18:10) and deemed an abomination by the prophets Jeremiah (32:35) and Ezekiel (23:36-9).[18]

For healthcare workers

The allegiance of the midwives in Exodus to God rather than to secular authority is an interesting lesson to us today. They were rewarded for their actions. I once had to resign from a job in a private hospital in London because I refused to assist in abortions—but then I got another job. I can’t remember if it paid better, but it was certainly more interesting. But even if God does not reward us in this lifetime, we know that he will in the life to come (Matt 5:11-12).

Awkward questions

Three Old Testament passages deserve a closer look at this point, because they raise seemingly awkward questions about God’s character when it comes to caring for children. The first is Leviticus 26, where God pronounces various punishments for disobedience to him. One of these is that “You shall eat the flesh of your sons, and you shall eat the flesh of your daughters” (v. 29). This curse is graphically repeated in Deuteronomy 28:53-57.[19] I expect many Israelites at the time would have had difficulty believing it would ever come to such a thing. But it did. During a siege in Samaria, a severe famine resulted in astronomical food prices. The Israelites were driven to desperate measures, including the murder and cannibalism of their own children (2 Kgs 6:24-29). What kind of God brings this on his own people?

But God didn’t bring this on the Israelites; they brought it on themselves. The passages in Leviticus 26 and Deuteronomy 28 are conditional—there is nothing inevitable about them. The whole point of these warnings was to alert Israel to the consequences of their behaviour so they could avoid punishment. Only persistent rebellion against God would bring about these awful outcomes. Yahweh had warned them—and now they were suffering under his judgement. Our choices matter.

Two more passages need mentioning. In Genesis 22, God commands Abraham to sacrifice his only son, Isaac—a command that Abraham seems willing to obey (although the angel of the Lord stops him at the very last minute and provides him with a ram as an alternative sacrifice). In Judges 11, the triumphant Israelite warrior Jephthah kills his only daughter to fulfil a vow he has made to the Lord.[20] And the faith of both men is commended in Hebrews 11. How can this be?

Moral law is not defied in either case, as the firstborn always belongs to the Lord (Exod 13:2). But both passages are difficult, and commentators differ in interpretation. Abraham’s story may represent the idea that one person’s sacrifice can benefit all people. Jephthah’s story may demonstrate that God is able to use Jephthah to fulfil his purposes despite Jephthah’s very poor understanding of God’s character (i.e. that unlike foreign gods, God does not delight in human sacrifice). The point of both stories for us is that these are examples of faith—complete trust—that may at times be very costly. This trust is what we are to emulate.

While there are no specific references to abortion in the Hebrew Scriptures, Jewish commentators have looked at Genesis 9:6 in the context of abortion. Two readings of the passage are possible depending on the meaning of the Hebrew preposition (either ‘by’ or ‘in’):

a)    Whoever sheds the blood of man, by a man shall that person’s blood be shed;

b)    Whoever sheds the blood of a man in a man, that man’s blood shall be shed.

Read as (b), the passage is a prohibition of abortion, classifying abortion as murder (a capital offence). The Talmud explains it thus: “Who is this ‘man in man’? It refers to the fetus in the mother’s womb.”[21] However, as bioethicist David Jones explains, the Jews thought the commandment referred only to the Gentiles because it was given to Noah (i.e. before God’s covenant with the Jewish people). And the standard Greek version of the Scriptures, the Septuagint (LXX), did not leave the anti-abortion interpretation open—so the Christians didn’t take any notice of it either.[22] Jones describes the tension in the Talmud view: while abortion was often seen as comparable to murder, at times there was less clarity (although it was always a serious crime against God). The only explicit permission for abortion found in the rabbinic tradition related to the forcible extraction of the infant to save the mother’s life.[23] In contrast, infanticide was clearly seen as murder from the moment of birth.

Jesus affirmed the importance of children demonstrated in the Old Testament. He likened the welcoming of children to the welcoming of Christ himself (Matt 18:5; Mark 9:36-7), rebuking his disciples for trying to keep them away (Matt 19:13-15; Mark 10:13-16; Luke 18:15-17). The terms used by Matthew, paidion and paidia (‘child’ and ‘children’), are used for children aged from earliest infancy to 12 years; while Luke uses the word brephē (‘babies’), the same Greek word he uses to refer to the unborn John the Baptist in Luke 1:41 and 44. The disciples may have thought children incapable of a relationship with Jesus, but these passages show us that even those we consider mentally incompetent (young children) were able to receive his blessing and were important to him. We should embrace them likewise.

Although there are no explicit references to abortion in the New Testament, the term pharmake-ia[-us] (use[r] of medicines that can cause abortions) does appear in lists of sinful acts (translated as ‘sorcery’ in Galatians 5:19-21 and ‘sorcerers’ in Revelation 21:8 and 22:15).

Church teachings

The early church attitude to abortion grew out of this background. It was initially influenced more by the Jewish tradition than by the surrounding pagan nations, but in the absence of direct biblical guidance it has developed over time, often in response to the surrounding culture.

The Didache is the earliest Christian text to mention abortion. Thought to have been written in the first century AD, it reflects the early ethical position: “You shall not kill a child by abortion nor kill it after it is born”.[24] Early Christians did not just oppose the practices of abortion and infanticide—they also provided practical alternatives. Rescuing orphans and foundlings (young children abandoned by their parents) was seen as a Christian duty. Parents seeking to abandon their babies often left them at churches, which took a major role in overseeing the care of abandoned children from at least the fourth century, often arranging for the foundlings to be brought up in Christian homes.

Over the next couple of centuries, records documenting this prohibition were plentiful as Christians—in particular Tertullian—sought to persuade the Roman authorities that Christianity did not undermine community morals and did not, as was spitefully rumoured, practice child sacrifice. Sadly, as is still the case, Christians then did not always practise what they preached. Many Christians were criticized for procuring abortions at the time. Because of this the church continued to emphasize the dehumanizing qualities of abortion, accusing those who obtained abortions of attacking not only the child but also the institution of marriage. Abortion was worse than murder because one’s own flesh and blood was involved. Athenagoras of Athens warned that the guilty would “have to give an account to God”.[25]

This occurred at a time when the early church was grappling with the threat of coming judgement, and with the ongoing repentance that Jesus demands of his people. While all sin is forgiven when a person first trusts Christ, the reality is that Christians keep on sinning. How was the church to handle ongoing sin in people who were washed clean by the blood of Christ? And so in order to deal with what was going on, yet without giving the impression that abortion was acceptable, the church allowed acts of penance as a means of forgiveness and reconciliation for those who had disobeyed. This way they were forgiven according to biblical direction (1 John 1:5-9), but at the same time Christian discipline was upheld.

The earliest record we have of the penance required for abortion comes from a church synod in Spain in 305 AD. A Christian who committed adultery, became pregnant and then had an abortion would not be allowed to receive communion again, even on her deathbed; and a woman preparing to become a Christian who committed the same sin would be barred from baptism until the end of her life.[26] These are very severe penalties, reflecting the seriousness with which abortion was viewed. This penalty was later reduced to ten years’ exclusion, after the Emperor Constantine made Christianity the state religion of Rome in 313 AD.[27] Pope Innocent I, commenting around 400 AD, stated that this revision was more tempered with mercy than the earlier penalty, but that “even the more severe practice of the past, by imposing penance, was offering a path of hope and salvation and not abandoning the repentant sinner altogether.”[28]

But the most authoritative statements, which still inform canon law in the Orthodox Church to this day, were those of the Sixth Ecumenical Council of Trullo in 692 (canons 2 and 91). These dictated that abortion was homicide, and that those giving drugs to procure an abortion were also guilty of murder.[29]

Modern abortion law

As early as the 13th century, English law prohibited abortion after the time of ‘quickening’.[30] But a revival of interest in Roman law during the Renaissance encouraged the Stoic view that the fetus became a legal person only after birth, and so by the beginning of the 19th century, the attitude of English law towards abortion had once again changed so that no charge of killing could arise until after the child was born. This meant that for British subjects and American citizens, abortion producing a live birth and subsequent death of the child was regarded as homicide, while abortion leading to stillbirth was a ‘great misprision’ (not homicide but still a very serious offence), especially after quickening. But the legal status of abortion prior to quickening was debated, although even where it was not a criminal offence, it was still considered unlawful. However, difficulty in prosecuting abortion cases led to a situation where the law failed to deter a growing trend.

In the 1800s, both England and the newly independent United States enacted statutes restricting abortion. Attitudes to abortion and legislative changes occurred at similar times and in similar ways in the United Kingdom, United States and Australia.

United Kingdom

The first legislative change was Lord Ellenborough’s Act of 1803, which made it a capital offence to administer poisons after quickening with the intention of causing abortion, once again giving legal significance to the unborn child. Subsequent laws gradually removed the reference to quickening and reduced the punishment for abortion to three years (1837). In 1861, the maximum term was raised to life imprisonment. In 1929, abortion of a viable fetus was specifically prohibited (to close a loophole). But though the acts of 1861 and 1929 remain in force, community desire to reduce illegal ‘backyard’ abortions (generally considered to be dangerous) was strong enough by 1966 to lead to radical abortion law reform.

Feminists in particular argued that abortion was inevitable because men kept pressuring women, making them pregnant when they could not manage a child. Since it was inevitable, the only practical solution to the risks of abortion was to make it safe and freely available. This led to a mental shift from seeing abortion as something that harmed a woman and her child, to something that was necessary to free a woman from difficult circumstances. At this point, the reframing of abortion as an act of compassion attracted some Christians to campaign for its legalization, which was a complete reversal of the traditional position of the church. This caused a split in the Christian lobby, as many Christians remained at the forefront of opposition to abortion. Note the problems caused when we determine matters by focusing only on our intentions (which in this case were good) rather than the morality of the act involved (terminating the life of an innocent unborn child).

The Abortion Act 1967 defines the statuary framework on which current mainland United Kingdom (England, Scotland and Wales but not Northern Ireland) abortion law is based. This legislation allows termination of pregnancy by registered medical practitioners under the following conditions:

  • when an abortion would cause less damage to a woman’s physical or mental health, or her child(ren)’s physical or mental health, than continuing with the pregnancy
  • when a woman’s health or life is gravely threatened by continuing with the pregnancy
  • when the fetus is likely to be born with severe physical or mental abnormalities.[31]

The abortion must be carried out in a hospital or specialized licensed clinic. Two doctors need to agree that the conditions are met except in the event of an emergency, when an abortion can be performed without a second doctor’s agreement.[32] The passing of the Human Fertilisation and Embryology Act 1990 reduced the abortion limit from 28 to 24 weeks on the grounds that 24 weeks was the current limit of viability (i.e. the earliest stage at which a child had survived outside the womb)—although it still allows abortions after 24 weeks if there is a grave risk to the life of the woman, evidence of severe abnormality, or risk of grave physical and mental injury to the woman.

Under these laws, the father of the child has no rights to give or refuse consent for abortion (coercion will be discussed below).

Today, at least one third of British women will have had an abortion by the time they reach the age of 45. Over 98% of induced abortions in Britain are undertaken because of risk to the mental or physical health of the woman or her children under the regulations listed above (common interpretations making it a conveniently broad category).[33] In 2008, 202,158 abortions were performed in England and Wales, representing 22.8% of all pregnancies. 91% of these abortions were funded by the NHS.[34]

United States

In the United States, abortion law is worked out state by state. Before 1820, the United States followed British common law (abortion after quickening was an offence). The first American abortion law was enacted in Connecticut in 1821, mirroring the common law example (and similarly, the reference to quickening was dropped later on grounds of being unscientific). In 1860, Connecticut introduced a law that clarified the woman’s liability and also banned advertising or provision of abortifacients. By 1880, there were anti-abortion statutes in most states.

While doctors in the United Kingdom had supported anti-abortion legislation, doctors in the United States were even more active. In 1857, an American physician called Horatio Robinson Storer launched a campaign to limit abortion. This led to an 1859 American Medical Association resolution opposing abortion on grounds that the role of the physician was concern for the life and health of both the mother and (especially) the unborn child.

Interestingly, at this stage the feminists were in favour of anti-abortion legislation. They saw women being oppressed by men who made them pregnant and then pressured them, or abandoned them, to the risk and guilt of abortion. Their concern was less for the unborn child than for the cause of the situation the woman found herself in. Most feminist spokeswomen called for prohibition of abortion, but also equality and respect for women and their right to refuse unwanted sexual advances. ‘Voluntary motherhood’ was advocated, primarily through sexual abstinence.

Several factors came together to bring about the abortion rights rhetoric of the 20th century. First was the emphasis on autonomy—the right to choose for oneself, which was developed in the writings of philosophers such as John Locke (1632-1704) and Jean Jacques Rousseau (1712-78). The American and French revolutions were also expressions of this idea of personal liberty. Second, the writings of English economist Thomas Malthus (1766-1834) popularized the idea that overpopulation led to poverty. Although he was personally against contraception and abortion, it was his idea that first led to the promotion of contraception and then, as I have already suggested, the corollary of abortion as society lost interest in tolerating unwanted pregnancy.

The first generation of birth-controllers included Marie Stopes.[35] It is interesting that her organization eventually promoted abortion (when contraception failed) not only for population control but also for ‘racial progress’—encouraging those with ‘superior’ qualities to breed and preventing the ‘inferior’ (i.e. mentally ill) from having children. Sterilization programs in several countries in the 1930s (Nazi Germany, Sweden and the United States) led to the practice of aborting children solely because they had some form of disability—echoing the Graeco-Roman practice of abandoning ‘defective’ children.[36]

In the 1920s a new feminist movement began with leaders such as Stella Browne, who promoted abortion as an element of women’s emancipation. Abortion was seen not as a violent act towards a mother and her unborn child, but as a social necessity for the liberation of women from poverty, unemployment, abandonment, physical and sexual abuse, exploitation and discrimination. Even though the slogan ‘Every child a wanted child’ was popular (coined by those in favour of abortion), in the big picture of abortion the humanity of the child was essentially disregarded. To deserve protection, a child had to be ‘wanted’. Those who spoke against this idea were criticized for not caring enough about the woman involved (and this is still the case, even now).

Illegal abortion by this time was not necessarily unsafe (due to the introduction of antibiotics and improved understanding of surgical techniques), but the risks fell primarily on poor women who could not pay good surgeons.

By the 1960s, the pro-abortion (pro-choice) movement was widespread, and some state legislatures began reforming abortion law. But it was the 1973 Supreme Court decision in Roe v. Wade that struck down anti-abortion legislation across the country, arguing that the Constitution contained a right to abortion.[37] This right to abortion is based on a right to privacy—the right to decide on matters that do not harm others—thereby implying that the embryo is not a human being with human rights. According to the ruling in this case, abortion cannot be restricted in the first trimester; second-trimester abortions can only be restricted on grounds of the mother’s health; and third-trimester abortions (after viability) can be allowed when necessary to preserve the mother’s life or health. Obviously, the definition of ‘health’ becomes quite important in defining the scope of the ruling. Another case decided at the same time, Doe v. Bolton, defined maternal health so broadly (“all factors—physical, emotional, psychological, familial, and the woman’s age—relevant to the wellbeing of the patient”)[38] that abortion became available essentially on demand. It is interesting that the anonymous ‘Jane Roe’ of Roe v. Wade, Norma McCorvey, has since become a Christian and deeply regrets taking part in the action. She has tried to get the decision overturned.[39]

Late-term abortions (partial-birth abortions) were prohibited in the Partial-Birth Abortion Ban Act of 2003, and this ruling was upheld in the 2007 Supreme Court decision Gonzalez v. Carhart.[40]

Despite the federal law, individual states can limit the practice of abortion, or create ‘trigger laws’ (laws that would make abortion illegal within the first and second trimesters, but could only take effect if Roe v. Wade were overturned by the United States Supreme Court). Indeed, there has been a recent increase in the number of state-based restrictions, including limitations on insurance coverage, targeted regulation of abortion clinics, ultrasound requirements, and mandatory counselling and waiting periods.

As in the United Kingdom, the father of the child has no rights to give or refuse consent to abortion.

Abortion remains a controversial subject in the United States. This should be the case, although I do not believe that violence in retaliation for the facilitation of abortion is ever justified. We are called to hate the sin and love the sinner (John 8:1-11).

Abortion statistics in the United States are collected by the government’s Centers for Disease Control and Prevention (CDC) and also by the Guttmacher Institute, which is Planned Parenthood’s special research affiliate monitoring trends in the abortion industry.[41] States report data voluntarily to the CDC for inclusion in its annual Abortion Surveillance Report. The CDC ordinarily develops its annual report on the basis of data received from 52 central health agencies (50 states plus New York City and the District of Columbia). The Guttmacher Institute gets its numbers from direct surveys of abortionists. There is no national requirement for data submission or reporting, so data—especially for the CDC—is incomplete. It is calculated that in 2008, 1.2 million American women obtained abortions, producing a rate of 19.6 abortions per 1,000 women of reproductive age. This is virtually unchanged from 2005, when the abortion rate was 19.4 abortions per 1,000 women 15-44 years. At current rates, around one third of American women will have an abortion in their lifetime.[42]

The racial distribution of abortion is interesting: the abortion rate for black women (33.9 per 1,000 women) is more than three times the rate for white women (10.8 per 1,000 women). The abortion rate for women of other races, including Hispanic and Native American, is 18.3 per 1,000 women.[43] I remember an anti-abortion campaign in New York in 2010 showing a picture of an African-American child and proclaiming that “the most dangerous place for an African-American is in the womb”. I heard soon after that the child model’s mother had asked for the advertisements to be removed, as she did not agree with the message of the poster. Sadly, it seems some people took it as a criticism of African-Americans instead of the way it was intended—as a show of concern for their children and a plea for the mothers to explore their options.[44]

The legal situation in Australia

Abortion law in Australia is decided on a state-by-state basis; laws across the country at the time of writing are quite inconsistent. Until 1901, when Australia became a federation, Australia followed the English law—specifically, the Offences Against the Person Act 1861, which prohibited abortion or supplying the means for abortion and carried a maximum penalty of life imprisonment. The wording of the Australian provisions establishing the crime of unlawful abortion, directly based on this Act, indicates that there will be circumstances in which involvement in an abortion is not unlawful, and therefore not a crime.

The legal test for when an abortion is not unlawful is different in each state and territory of Australia. Until the late 1960s and early 1970s, there were no Australian judicial or statutory explanations of when involvement in an abortion would constitute the crime of unlawful abortion, although the 1930s English case of R v. Bourne gave some guidance. In that case, regarding an abortion Dr Bourne performed for a 14-year-old girl who had been raped, the judge ruled that if “the probable consequence of the continuance of the pregnancy will be to make the woman a physical or mental wreck”, then an abortion represented “preserving the life of the woman” and was therefore lawful.[45] Justification for abortion was further extended by other cases to include preserving physical health (1948) and mental health (1958). Abortions for ‘therapeutic’ reasons therefore became more common, as these court cases broadened the definition so that it could pretty well cover any social or personal reason that might arise for avoiding pregnancy. This continues to be the case today.

At the time of writing, abortion has been decriminalized in the Australian Capital Territory, the Northern Territory and Victoria, but it remains a crime in the other states (however, there are ‘provisions’ so that if you are Australian you don’t need to travel far to get abortion on demand—and probably with a government rebate). Late-term abortion (abortion after 20 weeks) can involve laws regarding child destruction, which exist in some form in every state except Victoria.[46] For abortions performed from 20 weeks on, there is a legal requirement to register the birth even if the child is stillborn.

As in the United States and the United Kingdom, the father of the child has no rights regarding giving or withholding consent for abortion.

We don’t know the exact number of abortions performed each year in Australia because only South Australia collects detailed information. In the other states and territories, there is no official record of the abortion if the government (Medicare) rebate isn’t claimed and/or the procedure isn’t done in a public hospital. Research shows that this may be the case for up to one third of abortions.[47] According to the Australian Department of Health and Ageing, probably around 90,000 abortions are performed every year in Australia.[48] If 90,000 abortions are performed in Australia every year, this works out as one abortion for every 2.8 births.[49] One in three Australian women will have an abortion in their lifetime.

Ethics of abortion

So—legally—abortion is permissible in many countries. But ethics and law are not the same thing. While we would hope that ethics influence the laws we create, there is no longer much moral consensus in our pluralist community. As mentioned in chapter 5, this means it is not always your morality that is considered when laws are debated and enacted. And so it is possible for something to be legal but not ethically permissible for Christians.

To make it even more confusing, Christians today do not always agree on the matter of abortion. Some continue to argue that abortion represents the taking of a human life. Others see it as a compassionate response to a woman in a difficult situation—although this response has only been voiced since the middle of the 20th century. As we have already seen, until then the church had consistently opposed abortion.

The ethics of abortion have traditionally been argued from two opposing positions:

  • Pro-life: People who hold this position generally maintain that every person has a right to life. They argue that human fetuses and embryos are human persons and therefore have a right to life. Even though the mother has a right to decide what happens to her body, the child’s right to life is stronger than the right of its mother to control her body. It acknowledges the humanity of both the mother and the child and seeks to protect the lives of both whenever possible. This pro-life position is my position.
  • Pro-choice: Those who hold this view argue that a woman should have control over her body, which includes her fertility and the choice to continue or terminate a pregnancy. This entails the guarantee of reproductive rights, which include access to sexual education, contraception, fertility treatments, and safe and legal abortion. The humanity of the fetus is not necessarily denied, but it is seen as less important than the autonomy of the mother.

Websites abound that list the arguments for abortion with varying degrees of sophistication, but here is a summary of the main arguments in serious debate. I have also provided a response to each argument.[50]

1. Argument for a woman’s right over her own body

This argument says that a woman has a right to control her own body, so she has a right to undergo an abortion for any reason she chooses.

Response: First, the being within the pregnant woman’s body is not part of her body. It is a genetically distinct organism; it may have a different blood group from the mother, or a different gender. It has directed its own development since the time of fertilization. Although the being is attached to the mother from approximately ten days’ gestation onwards, it is not a part of the mother. Furthermore, there is no reason for the mother’s rights to automatically trump the fetus’s rights. Even if a right to control one’s body does exist, it is not an absolute right. Many laws exist to prevent us from using our bodies in any way we want (e.g. laws to restrict suicide). This first argument only works if you presume that the embryo is not a human being.

2. Argument from the danger of ‘backyard abortions’

This argument says that if abortion is made illegal, desperate women will still seek it anyway, and an unsafe ‘backyard abortion’ industry will re-emerge. Thus, legalized abortion is said to be necessary in order to prevent maternal deaths from backyard abortions.

Response: First, we might point out that this is not a valid argument if abortion is in fact the wrongful killing of a human being. That people will seek abortions anyway, and risk injury in doing so, is no justification for legalizing the practice—just as people will steal anyway, even though it is illegal, and often suffer injury, loss or imprisonment as a result.

More significantly, the evidence simply doesn’t support the myth of the dangerous backyard abortionist. The Australian Bureau of Statistics data shows that the maternal death rate from abortion fell significantly from approximately 100 deaths every year in the 1930s to one death in 1969, the year prior to the first legal abortion clinic opening in Australia. This improvement was mainly due to the introduction of antibiotics in the 1940s—a finding reflected in many countries.

A definitive 2012 study in Chile found that illegal abortion is not associated with increased maternal mortality.[51]

3. Argument from abortion being safer than childbirth

Based on the notion that we are never morally obliged to risk our own lives to save the life of another, this argument says that the pregnant woman has no moral obligation to carry her unborn offspring to term, regardless of whether or not it is fully human. And because abortion is statistically less dangerous than childbirth (as some claim), it is argued that a woman cannot be obliged to give birth to an unwanted child. This argument also implies that a mother’s obligations to her child are voluntary, not obligatory—that is, the mother has no special obligations towards her own child.

Response: Overall, is abortion safer than carrying a child to birth? This is not as easy to answer as you might think. Death caused by pregnancy (maternal mortality) is defined in the International Classification of Diseases (ICD-10) as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes”.[52] Because this definition captures both abortions and live births some countries pool the data, making it impossible to see the difference between the two groups. But a 2004 study looking at the population of Finland over 14 years found that the death rate of women following a birth (28.2/100,000) was lower than the death rate following an induced abortion (83.1/100,000), which suggests that childbirth may actually be safer than abortion.[53]

This argumentignores the idea of partiality—that there is a special relationship between mothers and their babies. Parents are indeed expected to perform self-sacrificing acts for their children even if not for anyone else. Furthermore, an obligation does not have to be voluntary to be binding. We assume that all children have a natural right to their parents’ care, which is demonstrated by laws requiring payment of child support and prohibiting child abuse.

If you recognize the humanity of the unborn child, it can be difficult to understand the commitment that some lobbyists have to protecting abortion rights. Yet the push continues. There have been attempts within the United Nations to register abortion as a basic human right (under the euphemism of ‘rights to sexual and reproductive health’), which would create an obligation for all member states. Pressure is being put to bear on countries that ‘deprive’ their citizens of this so-called human right. This has been countered by the launching of a document in 2011 called the San Jose Articles, which were written to clarify that there is no ‘right to abortion’ enshrined in international law. The document was signed by international experts in law, medicine and public policy.[54]

But there are also non-government organizations such as Amnesty International that while not promoting abortion as a human right in itself, nonetheless see its selected availability as necessary to address effectively the consequences of widespread sexual violence targeting women and girls. They want abortion to be available for the Mexican eight-year-old who is pregnant because she was raped. They also oppose the laws in countries such as El Salvador (whose constitution protects life from the time of conception without exception) that prevent a woman with an ectopic pregnancy (a life-threatening condition, and one of the few situations in which I believe abortion is morally justified) from receiving medical care.[55]

The WHO has reported that legal restrictions on abortion do not affect its frequency, but they do affect its safety. It found that 48% of all abortions worldwide are unsafe, accounting for 70,000 maternal deaths per year and leading to approximately 220,000 children losing their mothers to abortion-related death every year. The WHO provides examples of unsafe abortion methods, including drinking turpentine, bleach or tea made with livestock manure; placing foreign bodies such as a coat hanger or chicken bone into the uterus; and jumping from a roof.[56]

I give these facts not to argue the case for legal abortion but to explain why I can understand the anger that some women feel, even if we do not agree as to when abortion is ethically permissible. In this fallen world there will always be hard cases. While we need to maintain our own integrity, we also need to be careful how we judge those with whom we disagree.[57] We should also, however, rembmer that ‘hard cases make bad law’. Indeed, the Chile study has shown that it is education, not legal abortion, which will ultimately improve maternal health.[58]

The arguments I have summarized above obviously do not apply everywhere. Why does the push for abortion remain so strong in more developed countries? Is it really just about competing rights of mother and child? Or is there something else driving it?

Abortion is big business. The abortionist profits, as well as the owners of the clinics. The regular supply of fetal cells, tissue and organs has led, unintentionally, to the establishment of businesses that use this substrate to develop research, pharmaceutical products and cosmetics.[59]

While it is not clear whether abortion in the West is primarily a commercial enterprise or not, the ethical position that underlies the modern justification for continuing current laws will always be in conflict with the Christian position. Those who support the laws allowing easy access to abortion focus on a woman’s autonomy, equality and ‘right’ to self-determination. These will always be at odds with the position that respects human life at all its stages, and seeks to love God and one’s neighbour as oneself.

However we got here, though, current Western abortion laws—allowing what is essentially abortion on demand up to the time of delivery—are the most liberal that have ever existed in recorded human history.

The Christian position

Many books have been written on abortion, but the things I think we need to consider in order to think through the ethics of abortion include the following:

  • We need to consider what kind of thing the embryo/fetus is. Is it the kind of thing that it is wrong to kill?
  • We need to find out what happens during an abortion. What is intended as the end result? Is the death of the child deliberate or accidental?
  • We need to consider what makes a woman choose to have an abortion. Does the situation involved make a difference, ethically?
  • Finally, we need to decide how we make an ethical choice. Is abortion always wrong?

1. What kind of thing is a fetus? Is it the kind of thing that it is wrong to kill?

In chapters 2 and 3 I argued that the developing human in the womb deserves to be treated with respect and protected by the law from the time of fertilization (although this is not absolute—exceptions are discussed below). It is interesting to look at the human fetal development table in chapter 2 and realize that abortion is still legal for a normal baby in Australia at 20 weeks, in the United Kingdom at 24 weeks, and in the United States right up until birth. Look at how much development has already taken place at these gestations. Thankfully, the humanity of the developing child is no longer contested in informed ethical debate. With regard to the human embryo/fetus, it is no longer an argument of whether we are dealing with humans; it is now a matter of how we are going to treat them.

In the past, abortion debates focused on the ‘right to life’ of the unborn child. More recently, as awareness of the negative effects on the women involved has grown, it is the danger to the mother that has dominated community discussion. While this is an important consideration, for Christians the humanity of the unborn child will remain the major moral argument against abortion.

2. Abortion procedures: What does abortion involve?

Induced abortion is divided into medical abortion, where a drug is used to end the pregnancy, and surgical abortion, where instruments are used to remove the fetus from the womb. The procedure used depends on the stage of the pregnancy, the woman’s medical history and preferences, the clinical judgement and experience of the practitioner, and local availability of resources. Obviously the surgical method requires an operation, while the medical method may involve a few trips to the doctor.

Normally during pregnancy the cervix is tightly closed to keep the pregnancy in place. When labour starts, the cervix opens or ‘dilates‘ to allow the fetus through. Obviously the later in the pregnancy you are, the larger the fetus, and the more challenging it will be to get it out of the uterus through the cervix. Below is an outline of what is involved in each procedure. It does not contain full details of methods, side effects or complications. This information may distress some readers.

Medical abortion

RU-486 (mifepristone)

RU-486 was specifically designed to terminate a pregnancy. It is usually used in the first trimester, although in some places it is used throughout pregnancy. Up to 7-9 weeks gestation it may be possible to perform the abortion at home,[60] although after 9 weeks it would usually be done in a hospital. It is also known by its chemical name, mifepristone, and is usually used with misoprostol, a prostaglandin, in medical abortion. While its action is not fully understood, it is clear that mifepristone’s main action is blocking the chemical receptor sites normally used by the hormone progesterone in the uterus. This interrupts the functioning of the placenta so it produces less progesterone.[61] Progesterone is needed to sustain the pregnancy. Reduced levels of progesterone lead to degeneration of the endometrium (uterine lining), cervical softening and dilatation, and release of natural prostaglandins as well as an increase in the sensitivity of the uterus muscles to the contracting effects of prostaglandins. Mifepristone therefore indirectly causes the woman’s body to shut down the preparation of the uterus for the pregnancy and disrupts development of the embryo or fetus.[62]

As a result, in combination with misoprostol, labour is initiated and the developing embryo/fetus is expelled from the woman’s body with the uterine lining. Women are usually aware of when this occurs, and may recognize the fetus in the tissue discharge. Fetuses aborted after 20 weeks may show signs of life after abortion, and in a 2007 medical journal doctors were advised to consider giving intra-amniotic digoxin or potassium chloride into the fetal heart to stop it before the abortion begins and ensure the aborted child is dead on delivery.[63] According to the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), mifepristone plus misoprostol is the preferred regimen for medical abortion, and it seems to be the most common medical abortion in those places where it is legally available.[64] Its use in Australia is currently subject to approval of the Therapeutic Goods Administration.

For doctors

The WHO has approved the use of mifepristone 200 microgram tablets in combination with mifepristone “for termination of pregnancy (where legally permitted and culturally acceptable), on the Complementary List (added in 2005)”.[65] In 2011, the WHO approved the use of mifepristone for prevention of post-partum haemorrhage when oxytocin is not available.[66] This comes from good intentions, as post-partum haemorrhage is a significant cause of maternal death. However, there is concern that it may lead to self-administered abortions, especially since the organization that sought the drug’s approval, Gynuity Health Projects, has advocated the use of the drug without medical supervision.[67] Medical abortion without professional supervision can be dangerous.

Prostaglandins alone

Prostaglandins stimulate uterine contractions and soften the cervix. The procedure is similar to RU-486 use, with abortion occurring a couple of days after the administration of the drugs.

Methotrexate

Methotrexate can also be used with prostaglandins. Methotrexate is a drug used as chemotherapy for cancer or for treatment of immune disease. It was originally designed to attack fast-growing cells (like cancer cells) by blocking the folic acid that is needed for cell division. It works in abortion by inhibiting the rapid growth of the tissue that develops into the placenta (the trophoblast), which is the ‘support system’ for the embryo, providing oxygen and nutrients from the mother’s blood and disposing of waste. This in turn inhibits the implantation process and causes suppression of the hCG hormone, which is needed to sustain progesterone levels. Progesterone is needed to prevent breakdown of the uterine lining that is needed to support the pregnancy. The result of these effects is that within a few days or weeks of receiving the methotrexate injection, the placenta stops functioning and the embryo stops developing. Misoprostol causes the cervix to soften and the uterus to contract, resulting in the expulsion of the uterine contents.

Methotrexate can be used for treatment of ectopic pregnancy, which is ethically permissible.[68]

Surgical abortion

This type of abortion is more common than medical abortion, and is most often performed between 6-12 weeks gestation. It is used in conjunction with priming of the cervix (recommended for all abortions after 10 weeks or, in some places, where the woman is less than 18 years old). There are two common methods of priming the cervix. One method involves inserting a substance into the cervix that will absorb moisture and expand to open the cervix (usually a type of seaweed called laminaria, but synthetic osmotic dilators are also used). Alternatively, prostaglandins such as misoprostol or gemeprost are used, and there is evidence that mifepristone could also be used for this purpose.[69]

The procedures used in early abortion are also used for some other conditions, including treatment following spontaneous miscarriage. Use of the procedures for a non-abortion purpose is ethically permissible.[70]

Suction curettage/Vacuum curettage

This is the most common procedure, used in the first trimester and up to 14-15 weeks gestation. The procedure involves dilating the cervix by inserting metal rods of increasing size through the os (the opening in the cervix that leads to the uterus), and then inserting a plastic tube through the cervix into the uterus. The fetus and placenta are sucked out using a high-power vacuum. The walls of the uterus are then scraped with a curette to ensure that everything has been fully removed. The procedure is performed under local or general anaesthetic.

Manual vacuum aspiration

This method is less common and also used in the first trimester, especially before 7 weeks. A tube, narrower than the electric suction used in conventional curettage, is inserted into the uterus. The procedure lasts a bit longer and has a lower failure rate than suction curettage, but is otherwise quite similar. Interestingly, the American College of Obstetricians and Gynecologists (ACOG) call it ‘menstrual aspiration’, which makes it sound like you weren’t even really pregnant![71]

Dilation (dilatation) and curettage (D&C)

This method of abortion has been used since the late 19th century. It is used for gestation up to 12 weeks and is similar to suction curettage, except that instead of vacuuming the contents of the uterus, they are scraped out with a curette shaped like a loop. D&C requires heavy sedation or general anaesthesia and has higher risks of complication than suction procedures, so it is becoming less common as a method of abortion. According to the WHO, “D&C is an obsolete method of surgical abortion and should be replaced by vacuum aspiration and/or medical methods”.[72]

This procedure shouldn’t be confused with D&C used to treat other problems such as irregular menstrual bleeding and miscarriage.

Dilation and evacuation (D&E)

After 14-15 weeks, dilation and evacuation is often used. Cervical priming is recommended after 10 weeks. The cervix is dilated manually with rods and then instruments are used to crush and remove the fetus piecemeal. A combination of forceps, suction and curettage is often used. Sometimes the fetus will be delivered intact if sufficient cervical dilatation has occurred. Drugs that promote uterine contraction may be used. The procedure will be performed under local or general anaesthetic.[73]

Later second- and third-trimester abortions

Although medical abortion is available in the second trimester in some places, there is evidence that women prefer surgical abortion at this stage if they have a choice.[74] In later pregnancy, abortions are usually performed by inducing labour first. Several methods are used to commence labour. Inserting prostaglandins into the vagina is the most common method, and is generally preferred over instillation methods, which have largely been abandoned because of the risk of complications. Oxytocin (a hormone) is also sometimes given. As labour begins, the uterus contracts and the abortion usually occurs within 12-24 hours.

To avoid the accidental birth of a child who is old enough to survive outside the womb once it is born, and to shorten the time the abortion takes, the fetus is often killed with an injection of potassium into its heart with or without an injection of digoxin before the delivery. This causes a cardiac arrest (the fetus’s heart stops). Another method of ensuring fetal demise is an intra-amniotic injection of a small amount of hypertonic saline used in conjunction with vaginal prostaglandin.[75] The birth of a live child does sometimes occur,[76] testified to by mothers who heard their babies cry. One can only assume what happens next.

Gianna Jessen’s mother was seven-and-a-half months pregnant when it was decided to abort the fetus she was carrying. A saline solution was injected into Gianna’s mother’s womb, which doctors thought would kill the fetus within hours. This time, most unusually, the procedure failed and Gianna was born alive, thanks in part to a shocked nurse. She was so taken aback by Gianna’s live delivery that she summoned an ambulance to whisk her from the abortion clinic to the hospital…

Gianna, a committed Christian, is opposed to abortion. She has cerebral palsy as a direct result of the procedure carried out on her in the womb. The saline solution injected into the mother is to burn the baby, which gulps it in the womb, she said. But after being literally burned alive for 18 hours I was delivered live. It says on my records that I was born after a saline abortion.

I was not expected to be delivered live but fortunately for me the abortionist was not in the clinic when I arrived alive instead of dead…

Ann Furedi, chief executive of the British Pregnancy Advisory Service, said it was important to remember that late abortions, like that of Gianna’s mother, are uncommon. “These stories are extremely distressing. But the point we would always make is that these very late abortion at times when there is a potential for life are very few and far between.

“And there is very clear guidance to make sure this sort of thing does not happen.”[77]

Instillation abortion

This method of abortion was first developed in 1934 by Romanian obstetrician Eugen Aburel. It is most frequently used between 16-24 weeks gestation, when enough fluid has accumulated in the amniotic fluid sac surrounding the fetus to permit the technique. These days, this type of abortion technique is not commonly used due to complications for the mother. Instillation abortion is performed by first dilating the cervix, then inserting a needle through the abdomen or the vagina into the amniotic sac, which encloses the fetus in the womb. Amniotic fluid is withdrawn and replaced with a solution of chemicals such as hypertonic saline, hyperosmolar urea or prostaglandin (prostaglandins are usually given with a hyperosmolar agent). The fetus breathes in, swallowing the chemicals, which usually leads to death. Hypertonic saline also has a corrosive effect on the fetal tissues.[78] The chemicals induce uterine contractions, which precipitate labour and lead to expulsion of the fetus. Sometimes a dilation and curettage procedure will be necessary to remove any remaining tissue. According to the CDC, intrauterine instillation accounted for only 0.1% of reported abortions in the USA in 2007.[79]

Intact dilation and extraction

After 16 weeks gestation, abortions can be performed by intact dilation and extraction (IDX; also called intrauterine cranial decompression). Labour is induced and the cervix is primed to dilate, usually over the course of several days. Next, the doctor rotates the fetus to a breech position (head under the woman’s ribs). The body of the fetus is drawn out of the uterus feet first, until only the head remains inside the uterus. The doctor can then use an instrument to puncture the base of the skull, which collapses the fetal head. Typically the contents of the fetal head are then partially suctioned out, which results in the death of the fetus and reduces the size of the fetal head enough to allow it to pass through the cervix. (The baby may have been killed already by cardiac injection.) The dead and otherwise intact fetus is then removed from the woman’s body. IDX is sometimes called ‘partial-birth abortion’.

Hysterotomy and hysterectomy

Hysterotomy involves removing the fetus from the uterus using an approach through the abdominal wall. It is rarely used as the first method of abortion due to the increased risk to the mother. Hysterectomy involves removing the uterus itself. These two methods are sometimes used for late terminations if an abortion has failed and other methods such as D&E cannot be used due to an abnormality in the uterus. Hysterectomy is occasionally needed to control complications of abortion. These procedures would usually only be performed as a last resort.

Short-term complications of abortion

It is extraordinary to read in a 1989 article in the British Medical Journal that “early abortion is a safe operation and in most cases has no adverse sequelae, either mental or physical”.[80] Subsequent correspondence identified that the reason for this perceived lack of problems was a technicality (complications had to be officially reported within 7 days, and most were detected later). Still, this attitude has been pervasive in both medical and community circles. The reality is quite different, as many women have discovered to their dismay.

In any abortion, complications include pain, bleeding (occasionally requiring transfusion), infection and (rarely) uterine rupture. Both approaches (medical and surgical) may be accompanied by short-term emotional distress, and the continuation of the pregnancy is also listed as a possible ‘complication’. In addition to this, medical abortion can be associated with side effects of the medication used—side effects such as nausea, vomiting, diarrhoea, fever and chills. A minority of women will need surgery to complete the abortion. At least three deaths have occurred from mifepristone use for medical abortion.[81] In a surgical abortion, there may also be damage to the cervix or uterus itself; and any surgical procedure involves the risk of death, with mortality rate < 1 in 100,000.[82] The drugs used to start labour may cause side effects such as fever, nausea, vomiting, and diarrhoea, but less often than in medical abortions. The stage of pregnancy and the procedure used influence how often these problems occur, with fewer complications for earlier abortions.

Long-term complications of abortion

Future reproductive outcomes

Current research suggests that in countries where abortion is legal, it has no long-term effects on a woman’s reproduction with regard to future fertility or risk of ectopic pregnancy. There is a small risk of subsequent preterm delivery.[83] Results are mixed regarding whether abortion increases the future risk of placenta praevia or miscarriage.[84] More research is needed to clarify these risks.

Breast cancer

There has been much discussion regarding a link between breast cancer and induced abortion. Some early studies that suggested the possibility had technical errors; more recent research has established there is no causal relationship between abortion and an increased risk of breast cancer.[85]

Post-Abortion Syndrome

With regard to psychological problems following abortion, there has been ongoing debate for decades now regarding whether ‘Post-Abortion Syndrome’ (PAS) exists. PAS has become the term that describes a woman’s psychological response to abortion: long-lasting and recurring sadness, depression, anger or guilt; preoccupation with the aborted child and what it would have looked like; flashbacks of the abortion experience and nightmares related to it; low self-image, feelings of ‘craziness’, anxiety, discomfort being around babies; anniversaries of both the operation and the would-have-been birthdays noted each year.[86] Substance use, suicide and self-harm are also reported following abortion.[87] As a theory promoted by the anti-abortion movement, it has been viewed with skepticism by many commentators, especially because up until recently there was no strong evidence that abortion actually caused psychological problems. Studies on the topic generally showed that only a small number of women exhibited severe negative psychological responses to abortion, and it tended to be associated with psychological or other problems that were present before the abortion. Even when there was clear evidence of problems after abortion, causality was still questioned.[88] The usual conclusion was that it was due to the circumstances of the particular woman at the time of the abortion, rather than the abortion itself.[89]

This was always difficult to understand for those of us who had counselled women who relived the horror of the abortion years after it had occurred. We knew PAS existed, but the data did not measure up. Melinda Tankard Reist describes the hundreds of women “emotionally disabled by unrecognized and unrelieved grief” who have told her about their abortion experiences.[90] These women found the telling their stories cathartic, and she was encouraged to document this material:

So many feelings and emotions, locked in the secret hallways of my heart and mind! But it helps knowing that I’m not the only one going through all this. (Cassie)[91]

Still, many women feel they cannot share their pain with anyone:

I have paid the ultimate price. I have to live with myself… The worst part of the pain is there’s no-one to share it with… but… not a day goes by when I don’t think about it. I can’t believe I did it, I wish I could change everything and go back… I will never be forgiven for what I did. (Anonymous)[92]

While the existence of this disorder was denied, many women did not receive the help they needed to recover, emotionally or spiritually. And there was no reason for counsellors to warn women of the risk of post-abortion grief:

In 1998 an Australian woman sued her doctor for not warning her of the risk of depression she experienced after an abortion in 1990. It was settled out of court.[93]

Much confusion in the research was due to the polarization of those expressing the alternative views (either claiming that abortion always, or never, had psychological effects), and inadequate follow-up time (proponents argue it can take up to 10 years or even longer for PAS to manifest).[94] But also it was the result of a failure to separate two closely related questions:

  1. Is unwanted pregnancy terminated by abortion an adverse life event that leads to increased risks of mental health problems in those women exposed to the event?
  2. Are any adverse consequences of unwanted pregnancy terminated by abortion greater or lesser than the adverse consequences of unwanted pregnancy continued to birth?

A 2008 study has clarified the two and shown that mental disorder is 30% higher in those who have had abortions.[95] A further study in 2009 has shown that this is associated with a negative reaction to abortion, but not to whether the abortion was considered to be the right decision.[96] As the authors of both studies note, these findings are not consistent with either the pro-life position that abortion has devastating effects on women’s health, nor the pro-choice position that legal abortion is risk-free. Rather, it shows that unwanted pregnancy terminated by abortion is an event that causes significant distress in some, but not all, women. Even authors who are unhappy to agree with the results now acknowledge that some women do experience mental health problems following abortion, and that these experiences need to be “recognized, validated, and understood”.[97] Thankfully it is now recommended that women be warned of this possible complication.[98] Hopefully this will result in further research and the development of screening procedures to identify and help those affected.

It was also reported that unwanted pregnancy that was not terminated but proceeded to birth was not associated with a significant increase in mental health problems; and that abortion did not reduce the risks of mental health problems in women with unwanted pregnancy. This has important legal implications for those jurisdictions where legal abortion can be justified on the grounds that proceeding with the pregnancy represents a greater risk to a woman’s mental health than ending it (e.g. Britain, New Zealand and parts of Australia).

Since then, despite more studies that deny the mental health risk,[99] a 2011 meta-analysis of 22 published studies with data on 877,181 participants—163,381 of whom had experienced an abortion—found that women who had undergone an abortion had an 81% risk of increased mental health problems, and nearly 10% of those problems were directly attributable to abortion. The author of this study criticized the methods used by previous researchers who came to the opposite conclusion.[100] This raises the possibility that the law that was intended to reduce risks of mental health problems in women with unwanted pregnancy may in fact increase mental health risks. This suggests a need for further research and perhaps a need to review the legislation involved.

For doctors

The term ‘post-abortion syndrome’ was first used in 1981 by Vincent Rue, a psychologist and trauma specialist, during his testimony before American Congress. He used the term to describe post-traumatic stress disorder (PTSD) symptoms he had observed as a response to the stress of abortion. PAS was subsequently popularized and widely used by pro-life advocates to describe a broad range of adverse emotional reactions that they attribute to abortion (see above). Attempts have been made to have PAS defined as a form of PTSD. In order for abortion-related distress to be classified as PTSD in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), the abortion would need to be classified as a traumatic event experienced or witnessed by the woman “that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others” (criterion A1).[101] Currently there is no formal recognition of PAS as an actual diagnosis or condition, and it is not included in the DSM-IV-TR or in the WHO’s International Classification of Diseases (ICD-10) list of psychiatric conditions. Some pro-choice advocates have argued that efforts to popularize the term ‘post-abortion syndrome’ are simply a tactic used by pro-life advocates for political purposes. Research keywords for this topic include ‘abortion and mental health’, ‘psychological responses to abortion’, ‘emotional reactions to abortion’, and similar. The Royal College of Psychiatrists has recommended that women contemplating abortion should be advised of mental health risks.[102]

Psychological effects of medical abortion

I am not aware of any long-term studies on the psychological effects of medical (RU-486) abortion. There is anecdotal evidence of the shock women feel when they see their aborted child (possibly fully formed) in the toilet bowl or on the shower floor, leading to ongoing memories of their encounter. The abortion can happen at home if there is a delayed response to the prostaglandin given on day two. Also, counsellors often discuss how women feel more responsible for their abortion when they suffer over a longer period to achieve it. (Bleeding after mifepristone administration averages 9-15 days but can continue for up to around 70 days).[103] Some women say they feel it is right that they suffer. Time will tell what long-term psychological effects this has.

~

Despite the inherent dangers known to exist for the mother with elective abortion, these are not ethical objections (although the need to fully inform those contemplating abortion of possible complications is an ethical issue). The ethical basis for opposing abortion lies in the injustice done to the innocent child who is killed during the procedure.

Fathers hurt too

Australian novelist Peter Carey has written about the deep sadness he feels for his lost children—his grief over babies lost through abortion and subsequent miscarriages (due to damage to his first wife’s cervix during the abortion procedures); “children a long time dead”. He writes that he had been unable to give names to the lost children—his way of holding the grief at bay—and that he allowed their ashes to be placed in an unmarked niche in a wall. I wish only that we had honoured those children with a plaque, a name. I will always wish that, forever.[104]

The ‘atonement’ or ‘replacement’ child

This is the term for children born following an abortion, where the pregnancy is consciously chosen to compensate for the lost child. I needed to show the world I was a life-giver, not a baby killer, said Belinda, who had had four abortions.[105]

Fetal pain relief

In April 2010, the state of Nebraska in the United States banned abortions at and after 20 weeks. The Pain-Capable Unborn Child Protection Act is based on research that tells us fetuses can feel pain at 20 weeks, and possibly as early as 17 weeks. And according to the testimony of paediatrician Kanwaljeet Anand, who has been studying infant pain for 25 years, unborn infants may feel pain more keenly than those already born.[106] Abortion advocates are concerned that discussion of fetal analgesia ‘humanizes’ the fetus and is being used to oppose legal abortion.

The legislation is expected to be challenged in the courts, but meanwhile, it has inspired eight other states (Alabama, Idaho, Indiana, Georgia, Kansas, Ohio, Louisiana and Oklahoma) to also ban most abortions after five months.[107]

For doctors

The underlying research for this legislation has been challenged by researchers who suggest that the legislation is based on what is only a theory. A review article published in 2005 concluded that evidence regarding the capacity for fetalpain is limited but indicates that fetal perception of painis unlikely before the third trimester.[108] This conclusion was based on the presumption that conscious cortical processing is necessary for pain perception, and that EEG evidence suggests the necessary brain connections required for the fetal perception of pain (the establishment of the thalamocortical connections) do not exist before 29-30 weeks. A working party of the Royal College of Obstetricians and Gynaecologists (RCOG) reported in 2010 that intact nerve connections between the cortex and the periphery of the brain are not present before 24 weeks.[109]

However, while Kanwaljeet Anand acknowledges that the cerebral cortex is not fully developed in the fetus until late in gestation, he notes that what is up and running is a structure called the subplate zone, which some believe may be capable of processing pain signals. A kind of holding station for developing neurons that eventually merge into the mature cerebral cortex, the subplate zone becomes operational at about 17 weeks.[110] In other words, the fetus’s undeveloped state may not preclude it from feeling pain. In fact, its immature physiology may well make it more sensitive to pain, not less—the body’s mechanisms for inhibiting pain and making it more bearable do not become active until after birth.[111]

Anand’s findings are confirmed by Nicholas Fisk, fetal medicine specialist and director of the University of Queensland Centre for Clinical Research in Australia. He showed that the fetus mounts significant stress, hormonal and circulatory changes in response to invasive diagnostic and therapeutic procedures from 18-20 weeks.[112] He also showed that these changes are reduced once analgesia is given (he injected fentanyl into fetuses requiring blood transfusion).[113] Perinatal stress may have long-term neurodevelopmental implications.[114] Since it is possible that the fetus is aware of pain from around 20 weeks, he and co-researcher Vivette Glover have long suggested that we should err on the safe side and provide analgesia to fetuses during procedures and terminations from mid-gestation (since we can’t ask the patient if it hurts).[115]

David Mellor, the founding director of the Animal Welfare Science and Bioethics Center at Massey University in New Zealand, suggests that this does not take into account the special environment of the fetus. He found biochemicals produced by the placenta and fetus that have a sedating and even an anaesthetizing effect on the fetus (both equine and human).[116] Furthermore, some authors note that even if we can demonstrate the presence of anatomical structures responsible for pain impulses in fetuses, we cannot be sure that it means they perceive pain as we do.[117]

Anaesthesia has long been used for the fetus as well as the mother in intrauterine surgery by using drugs that cross the placenta. Parenteral opioids may alsobe administered to the fetus. Even though the practice commenced when withdrawal responses to noxious stimuli were observed, administration of anaesthesia and analgesia may serve purposes unrelated to reduction of fetal pain, includinginhibition of fetal movement, prevention of fetal hormonal stressresponses, and induction of uterine atony. It does not always reflect a belief that the fetus will experience pain during the procedure.[118]

So what of abortion? Is it valid to suggest that the fetus feels pain from 20 weeks and so requires pain relief in all procedures, including termination of pregnancy?

In 1997 the RCOG suggested that practitioners who undertake diagnostic or therapeutic surgical procedures upon the fetus at or after 24 weeks gestation consider the requirements for fetal analgesia and sedation; and that practitioners who undertake termination of pregnancy at 24 weeks or later should consider the requirements for feticide or fetal analgesia and sedation.[119]

The authors of the 2005 review disagree. They write that there is inadequate evidence available to assess the effectiveness of fetal anaesthetic or analgesictechniques. Similarly, limited or no data exist on the safetyof such techniques for pregnant women in the context of abortion. They note that general anaesthesia for the mother increases the risk of the abortion for the mother, as well as the cost.[120] It is not a straightforward issue of ‘erring on the safe side’, since some animal research suggests there may be a risk of long-term developmental damage to the fetus when given opioids.[121] I read of one commentator who dismissed the whole problem by saying that if it was risks for the future we were worrying about, it was simple in the case of abortion. An aborted fetus has no future.

The final word comes from a research review of fetal pain by the Medical Research Council in the United Kingdom.[122] Basically, we don’t really know when or how the fetus feels pain. But there is enough evidence to suspect there is a need for more attention to be given to how we treat developing humans. Does this mean the baby needs analgesia during childbirth, just like mum? I’m not sure. More research is needed.

~

There are no illustrations for this chapter. Those who would like more detail regarding how abortions are performed can use a search engine on the internet using the names of the procedures above. Be warned that this is an extremely unpleasant topic to research. The trauma personally experienced by abortion providers has been documented. Daleiden and Shields write:

Especially in abortions performed far enough along in gestation that the fetus is recognizably a tiny baby, this intimacy exacts an emotional toll, stirring sentiments for which doctors, nurses, and aides are sometimes unprepared. Most apparently have managed to reconcile their belief in the right to abortion with their revulsion at dying and dead fetuses, but a noteworthy number have found the conflict unbearable and have defected to the pro-life cause.[123]

One particularly famous abortion provider who changed his mind is Dr Bernard Nathanson, who by his own estimate performed more than 60,000 abortions, including one on his own child. After leaving his profession to spend time trying to repeal abortion laws in America, he produced a documentary called The Silent Scream (1984). It shows an actual abortion on ultrasound, where the 12-week-old fetus pathetically tries to escape the instrument that will terminate its life. Even now, this disturbing movie can be found on YouTube. Parental guidance is recommended.

It was seeing an abortion on ultrasound that made former Planned Parenthood clinic director Abby Johnson decide to change her allegiance. The image of a 13-week-old fetus reminded her of her own daughter’s ultrasound. Its futile twisting and struggling haunted her:

It wasn’t just tissue, just cells. That was a human baby—fighting for life! A battle that was lost in the blink of an eye.[124]

In summary, elective abortion involves the deliberate killing of a human embryo or fetus during termination of pregnancy. Obviously it will be a distressing and often painful procedure. This leads us to our next question.

3. What makes a woman choose to have an abortion? Does her situation make a difference, ethically?

What are the circumstances in which the decision is made to end a pregnancy? Most abortions are performed on healthy mothers and babies. However, unplanned pregnancy is not the simple cause of abortion. A significant number of women are ambivalent about their pregnancies and the abortion decision, and this ambivalence may last a long time.[125] I have certainly found this as a doctor—women, and less often men, who years afterwards can tell you what age their aborted child would have been had they lived. They wonder what the child would have looked like. A substantial number of women undergo abortion while being morally opposed to it. Their decisions are influenced by their circumstances and the people around them. Evidence suggests that most women consider abortion because they believe that they are not free to pursue motherhood, or because they lack the emotional and financial support they need to cope with a having a baby. Abortion is strongly associated with domestic violence and abuse of women.[126] Many women are unaware of the potential psychological harm associated with abortion, and afterwards express anger that they weren’t informed.

Even in the democratic West, it can be hard to access accurate abortion statistics. In Australia, currently the only state that collects information regarding the reasons for abortion is South Australia. For the year 2006 these were the official reasons given for elective (non-emergency) abortions:[127]

Reason given for abortion

Number

Percentage

Specified medical condition

16

0.3

Serious handicap of fetus

141

2.9

Mental health of woman

4,727

96.7

Pre-existing psychiatric disorder

4

0.1

Assault on person (e.g. rape or incest)

1

0.0

Total

4,889

100%

We see that the difficult cases—fetal abnormality and rape—motivate relatively few abortions compared with the vague ‘mental health of woman’ category. We won’t really know what is going on until more states start collecting detailed data. However, even now when you look more closely, the picture is not so straightforward. An Australian research project in 1995 asked 20 women what they considered while deciding to have an abortion (they were questioned at an abortion clinic).[128] The list of important factors, from most to least considered, is as follows:

  • pregnancy would jeopardize future
  • could not cope
  • my right to choose
  • know termination of pregnancy is safe and simple
  • can’t afford a baby
  • pregnancy has no real form yet
  • know other women who aborted and did well
  • don’t want others to know I’m pregnant
  • important others would suffer
  • would be a single mother
  • worried would not be a good mother
  • relationship unstable or new
  • partner could not cope, too young
  • not enough support
  • scared of childbirth
  • others say I should terminate
  • relationship at risk if continue
  • coped well with previous termination
  • health would suffer
  • don’t ever want (more) children
  • too old
  • result of forced sex
  • worried about health of pregnancy
  • not want others to know I had sex

It is obvious that lack of support, lack of confidence and coercion play an important part in the choice to abort. And this research was done by a group that supports abortion.

This is a topic that deserves much more attention than I can give it here, but suffice to say that abortion tends to be a difficult and distressing choice for most of the women involved. Indeed, many of these women would say they didn’t have a choice, because the option to keep the baby didn’t seem to exist for them. While pressure from male partners is known to play a significant part in choosing abortion,[129] fathers who want the child to live have no legal rights over the decision at all.

It is important to identify whether abortions are sometimes necessary to preserve a woman’s life and health.[130] There have been reports in the past that therapeutic abortion of wanted pregnancies has occurred to relieve severe morning sickness (hyperemesis gravidarum).[131] This was thought to be exacerbated by an unwillingness in physicians to prescribe drugs to stop nausea and vomiting in pregnancy (in case it would hurt the baby). This excuse has been firmly refuted in the literature.

Late-term abortions (over 20 weeks) are often justified on the basis of being necessary to preserve a woman’s life and health. However, the research suggests that most late-term abortions are just regular abortions performed late because of delayed diagnosis of pregnancy. The most common reasons are failure to recognize the pregnancy, and delays in arranging the abortion. Interestingly, a 2007 study found that 41% of women questioned had delayed the abortion due to indecision.[132] But regardless of why they are late, they are done for similar reasons to early abortions: relationship problems, young or old maternal age, education or financial concerns. Former abortionist Mary Davenport, of the American Association of Pro-Life Obstetricians and Gynaecologists, questions the necessity of late abortion on grounds of risk to maternal health:

The very fact that the baby of an ill mother is viable raises the question of why, indeed, it is necessary to perform an abortion to end the pregnancy. With any serious maternal health problem, termination of pregnancy can be accomplished by inducing labour or performing a caesarean section, saving both mother and baby.[133]

The point she is making is that in late-term abortion, the baby is often old enough to survive outside the womb (viable). If that is the case, why is the mother aborting? Why not just have an early delivery? Davenport describes the argument for late-term abortion on grounds of maternal health, particularly after viability, as a great deception.

However, there are some conditions where an abortion may be necessary to save a mother’s life. Sometimes the decision to end the pregnancy will be straightforward medically and ethically, although obviously still difficult emotionally. Consider these situations where the baby is not sufficiently mature to survive outside the womb:

  • Early ectopic pregnancy (‘tubal’ pregnancy) means the baby has started growing somewhere other than the uterus (usually the fallopian tube), which is inadequate to support the pregnancy. Internal bleeding is a common complication that can lead to death.
  • Severe eclampsia (high blood pressure) is another situation where the woman is at risk of dying if she does not receive treatment.

Sadly, treatment of these conditions at present involves termination of the pregnancy. This is not because the woman’s life is more valuable. It is ethically justified because the child has no chance of survival whether you try to save the mother’s life or not (it cannot survive outside the womb, and it cannot survive if it stays in the womb and the mother dies). The best outcome possible in this situation is that the mother’s life is preserved.

More complicated are the decisions where the woman’s health and the baby’s chances are more evenly balanced. Even in these conditions it may be possible to delay delivery until the baby is old enough to survive if the mother so desires. Each case will be judged on its own merits, but saving the mother’s life will be the priority for the obstetrician. If abortion is recommended, it is always worth getting a second opinion from a doctor who specializes in maternal fetal medicine.

For doctors

Maternal mortality is greater than 20% in the setting of late pregnancy for pulmonary hypertension (Eisenmenger’s syndrome), Marfan’s syndrome with aortic root involvement, complicated coarctation of the aorta, and, possibly, peripartum cardiomyopathy with residual dysfunction.[134] These conditions are rare. Their importance lies in the way they have been used to justify abortion on maternal morbidity grounds. While there is a long list of conditions that may occur during pregnancy and threaten the mother’s health, including preeclampsia, cancer and heart disease, it is always worth exploring whether treatment is possible while the pregnancy continues either to term or viability. Maternal fetal medicine specialists will be a great help in such situations.

There will occasionally be cases where a mother’s refusal of treatment for herself may lead to the child’s death, as it will be unsafe to deliver. Thankfully such cases are rare. This will be ethically challenging and will need to be reviewed on a case-by-case basis. In most Western countries, it is not possible to insist that a mentally competent patient is denied the right to refuse treatment.

As mentioned above, recent research shows that difficult situations such as fetal abnormality and rape motivate relatively few abortions. But abortion for fetal abnormality is a growing trend as we improve methods of detection.[135]

Abortion following IVF

About 80 British women abort their IVF babies every year. Apparently most are within weeks of the embryo transfer, after the mother has had a change of heart. 749 babies have been aborted in this setting over the 19 years in which statistics have been collected.[136]

Selective/fetal/pregnancy reduction

Selective reduction is a procedure used to ‘manage’ the problem of multiple gestation. It involves the termination of one or more, but not all, of the fetuses. This was originally done to increase the likelihood that the surviving child may develop in a healthy way, as risks (such as premature delivery) increase with every extra baby. It is now also done to spare parents the stress of having to look after twins.[137] The reduction procedure is generally carried out during the first trimester of pregnancy.The most common method is to inject potassium chloride into the fetal heart, which makes it stop beating. Generally, the fetal material is reabsorbed into the woman’s body. Miscarriage rate after the procedure (of the remaining child/ren) is around 5%-10%.[138]

While the motive for this intervention is a good one (wanting a healthy child), the action itself is not. This is how Gary justified it: You start thinking to yourself, Oh God, am I killing this child? But then he was told that it was not an abortion; it was a reduction. You’re reducing the pregnancy to make sure you have a greater chance of a healthy child, he told me. If you’re going to bring a child into this world, you have an obligation to take care of that child to the best of your abilities. See how easy it is to justify your actions just by changing terminology and focusing on consequences? This procedure is unethical for those who wish to protect life from the time of fertilization, as it involves the intentional killing of unborn children and perhaps the manslaughter of the children who are not targeted for death but are lost through miscarriage.

In November 2011, a tragedy occurred in Melbourne, Australia, which received worldwide news coverage. A woman who was pregnant with twins was told at 32 weeks that one of the twins had significant heart problems. She was advised to abort the child. The affected child would have had to have years of operations if he survived at all.

It was decided to abort the single twin by selective reduction. After a careful study of the two babies under ultrasound, the sonographer gave the healthy twin the lethal injection by mistake. When the mistake was noticed, the other twin was also aborted by emergency caesarean section.[139] The woman’s distress can only be imagined. However, it is interesting to reflect that only the death of the ‘wanted’ normal twin made the story newsworthy.[140]

4. How should Christians make ethical decisions about abortion?

Now that we have our information, what do we do with it? Is abortion always wrong? In chapter 5 we looked at a model for ethical Christian decision-making. We will now work through that model to examine the question of abortion.[141]

Motivation

Christians will be motivated by virtues like compassion, but unlike their pro-abortion neighbours, will act in ways that protect vulnerable human life as far as possible. It can be confusing to realize that those on both sides of the abortion debate share the motivation of compassion. How can this be? It is due to the meaning of ‘motivation’. Motivation will prompt us to act, but it will not inform the content of our actions.

Intention

In the context of abortion, our intentions will always be to protect the lives of both mother and child as far as is possible.

Action

Our actions will correspond with our intentions to protect human life. We will not disobey the guidance of Scripture in our attempts to reach our intended goal. In the case of abortion, we have seen that it involves the deliberate killing of an unborn child. Biblical commands represent absolute values; there are some things we should never do, whatever the consequences. By this argument most cases of abortion will be wrong—both performing the abortion as well as having it.

But what if our good intentions and actions lead to bad consequences? Consider this scenario: a mother develops a serious medical problem (e.g. acute heart failure) in the third trimester, and early labour is induced in an attempt to save the life of both mother and child. Despite every effort to save him, the baby dies because of complications of premature delivery. In this case the intention was morally good (to save both lives) and the action was morally acceptable (an appropriate medical intervention so the heart failure could be treated). But the outcome troubles us.

Consequences

We are judged only according to those things for which we are responsible, and not those things that are out of our control. If we aim for a good outcome—for example, in the case I just mentioned, a live mother and a premature but live infant—yet a bad outcome intervenes through circumstances beyond our control, we are not morally liable.

For doctors

This is not to say that we should not make the best prediction we can regarding the outcome; in medical scenarios we can usually make an educated guess regarding the impact of our intervention. But as humans we have limited foresight. (Though we would be negligent if we had made a treatment error and did not try to fix it as soon as possible.) I know that philosophers have spent time discussing whether we can know if good or bad outcomes are intended in medicine, but in my experience, doctors know what they are intending to achieve when they are treating patients. And God certainly knows our hearts (Rom 2:16).

Rights of conscience

In light of recent political activity around the world to remove the right of conscientious objection for doctors who oppose abortion, we also need to consider whether referring a patient for abortion is morally wrong for the Christian. For example, legislation passed in 2008 in the Australian state of Victoria decriminalized termination of pregnancy and removed the right of conscientious objection for doctors and nurses to avoid any involvement in the act of abortion.

Whether a doctor is morally complicit in an action will depend on several factors. Firstly, have you any role in the causation of the act? Is the woman’s desire for an abortion influenced by your role? It is easy to make sure you do not have a role in causation of the wrong act, by gently counselling the woman involved regarding alternatives to this path of action. Listen to her so that you understand her concerns. Direct her to explore the options, such as practical support for those who feel they cannot cope. If the child has a problem, the woman could speak to those who spend time with the disabled, such as support associations. They can explain what is available to help parents living with disabled children and what it actually looks like. Sometimes what we imagine is worse than what actually is the case. Allow time for your patient to reflect in ways that your colleagues do not allow time for. If the husband or partner is with her, include him in all your discussions. Even if the woman says she knows what is involved, it is necessary to check that her knowledge is correct in order to ensure proper informed consent.

Secondly, are you facilitating the morally wrong act directly? Are you making the abortion happen? This second question is interesting. By referring a woman for abortion are you helping her achieve her morally wrong aim? If you were the only possible referrer you may perhaps prevent the abortion by being obstructive, but in many cases a referral is not even formally required. However, agreeing immediately to her request may appear to give her choice some kind of legitimacy that may reinforce her decision—hence the benefit of taking the time to counsel. You may be the only person she meets who discusses the option of keeping the child. It would be tragic to miss the opportunity. Some healthcare workers believe that referral constitutes complicity and merely distances you from a morally wrong act rather than making you a value-neutral service provider. If you are convicted that referral does constitute complicity at this point, you should not go against your conscience (Rom 14:23).

Thirdly, does your action perpetuate the moral wrong? Does your referral increase the likelihood of it happening again? This is difficult to determine. With regard to refusal to refer, apart from the unlikely possibility of obstructing access to abortion (above), it is possible that by making a stand and sensitively explaining your point of view to the woman involved and others, you may persuade her to think differently about abortion in future. This may alter her behaviour. By going ahead and referring a patient for abortion at her request, as suggested above, you infer that this is a legitimate therapeutic pathway to take. This may also impact on future behaviour. Once again, we must each decide prayerfully what we believe is correct action.

But as I discuss this issue with those who work in this field, I realize it’s not so straightforward. Some Christians do not see referral for abortion as morally equivalent to performing the procedure themselves. They believe there are some moral arguments for referral. There are professional obligations to do good and not harm, to uphold ‘duty of care’ and ensure patient safety even if care is transferred to another doctor. You may have an ongoing relationship with the patient whether you like it or not, and you may not want to damage it. Remember that your non-Christian patients do not have the indwelling Holy Spirit who convicts them of sin (John 16:8-11), and we should not judge them.

In this case of referral, the doctor is motivated by care for the patient. If you have gently explored all options and the woman persists in her request, you may direct her ultimately to those who will perform a termination. And this you will grieve. But who knows what will happen as you continue on the path together, where you may have the opportunity to offer support in the aftermath of the termination; where you can help her make sure this never happens again. You do not necessarily condone her choice. Modern medical practice requires that we respect the autonomy of our mentally competent patients even when we do not agree with their choices.

This does not, however, mean that the patient has a right to make the doctor violate their conscience. There are ethical arguments both for and against referral, and committed Christians exist at both ends of the spectrum.

It is important that pro-life doctors work in the area of obstetrics to be salt and light in this specialty. There is also a need for all healthcare workers to show interest in public policy so that rights of conscience are not further eroded.

At times God may call us to take a stand against unjust laws and suffer the consequences. This will be between each individual and God. We must continue to pray for wisdom as modern medicine continues to move away from life-preserving Hippocratic medicine.

We have considered that the way to best live out kingdom values may be by being creative in considering what therapeutic options are available to us. This is easier to think through when we reflect on specific examples. Obviously when involved with anyone facing the challenges of an unwanted pregnancy, you will need considerable sensitivity in discussing the issues with them. In the following examples I will just discuss the basic approach.

Case 1: A university student requests abortion after finding out she is pregnant; it’s just not a good time for her to have a baby

In this case there is no medical indication for terminating the pregnancy.

However, if we are going to urge a woman to continue what may be an unwanted pregnancy, we will need to provide practical alternatives. There are three possible alternatives for a woman with an unwanted pregnancy: abortion, adoption, and keeping the baby.

It is easy to understand why some young women see abortion as a quick fix when they find themselves unexpectedly pregnant. It is often presented as an uncomplicated and safe procedure; a simple matter of removing the ‘tissue’ that is causing the problems and voilà—your life is back on track.

Do we need to encourage women to put their children up for adoption more often? There are always good families wanting to adopt. This option allows the mother to continue on her life journey without the responsibility of caring for a child. Interestingly, one reason women don’t give up their babies for adoption is that it would make them feel like a bad mother. Instead they choose abortion… which doesn’t?

However, in some places the pressure to keep the child despite the difficulties is the reason adoption is uncommon. This can vary according to peer pressure. Many workers in the adoption field saw the ‘Juno effect’ after a movie depicting a teen adopting out her baby became a hit. The social influences that have changed attitudes to adoption are complex.

However, if women are choosing abortion due to insufficient support, then being pro-life involves much more than being anti-abortion. If we really are serious about reducing the abortion rate then we need to show pregnant women a realistic, practical, reliable, available alternative to termination. The needs of a woman in this situation aren’t hard to work out. Apart from spiritual, emotional and psychological encouragement, it is possible she may need a place to stay if those close to her disagree with her choice. She may need other practical assistance—the single mother’s pension usually isn’t available until after the birth in those countries where it exists, and many women are unable to keep working until then. How will she manage to live with no income? This in itself is one reason some young women feel unable to cope with keeping the baby. They need clothes for the newborn, nursery furniture—all the paraphernalia of babies. This might be a good church project if there is a refuge for young pregnant girls near you. And everyone can do with a few meals dropped off when they have a new baby to manage.

Within the church we also need to think about creating an environment where single women are commended for keeping their babies and where single mothers are particularly supported. It has been suggested that the low rate of single mothers in our churches may not reflect sexual purity so much as the belief that proof you’ve been sexually active needs to be avoided at all costs. According to the Guttmacher Institute, two thirds of women in the United States who have abortions identify themselves as Christian.[142] We need to develop a culture where those brave repentant girls who take responsibility for an unborn child are forgiven for their mistakes and praised for their choice and given all the help a sister would expect from her family at such a time. Mary the mother of Jesus was a young unwed mother in a culture where it was far less acceptable than in ours.

Why is an unplanned pregnancy so often seen as a woman’s problem? Apart from the obvious reason, it is often because the child’s father refuses to stand by the mother. Christians need to take the lead in recognizing the importance of male responsibility and support, and commending those who live it out.

The take-home message is this: if we want to dissuade women from choosing abortion, we need to make sure there is a choice available, and one that they find out about before it is too late. The right to choose abortion has been won; the right to choose the opposite too often appears absent.

A national survey in the United States in 1991 found that of 65 babies abandoned at birth, eight died. In 1998 the number jumped to 105 abandoned babies, and 33 were found dead. As a result of increasing infant abandonment and infanticide, the majority of state legislatures have enacted safe haven laws. Beginning in Texas in 1999, ‘Baby Moses laws’ have been introduced as an incentive for mothers in crisis to safely relinquish their babies to designated locations where the babies are protected and provided with medical care until a permanent home is found. These laws generally allow the parent to remain anonymous and to be shielded from prosecution for abandonment or neglect in exchange for surrendering the baby to a safe haven.[143]

A service was introduced in Austria in 2001 that allows women to give birth in hospital secretly so the baby can be offered for adoption. The service allows the mother to give birth free of charge and without stating her identity. She can then disappear without fear of prosecution, and the child is kept safe for adoption. Another initiative in Austria that allows mothers to leave their babies in a ‘baby nest’ at hospitals was also introduced to prevent deaths among abandoned babies.[144]

Amritsar’s ‘cradle scheme’, as with many others in India, was established in 2008 to save unwanted babies. Mothers are able to anonymously leave newborns in a wicker basket at the Red Cross headquarters. In this part of northern India, gender discrimination has meant that the overwhelming majority of abandoned babies are girls. In some parts of the state, female babies are killed because they are considered by many to have lower economic, social and religious value than sons.[145]

For healthcare professionals

In many countries it is possible to arrange sessions of non-directive pregnancy support counselling by eligible practitioners for any woman concerned about a pregnancy. Partners may also attend. The provider may be a GP, psychologist, social worker or mental health nurse. In Australia there is a government (Medicare) rebate for such counselling. The organization Real Choices Australia can you put you in touch with local services. In the United Kingdom, organizations such as CareConfidential can provide support. In North America, there are many pro-life organizations such as Care Net, Heartbeat International and Birthright International. Healthcare professionals should familiarize themselves with the relevant organizations in their area so they can make suggestions if asked. Christians in the relevant professions should think about training for this kind of work. Training in counselling aims to prevent bias in the provision of information and facilitate the patient’s own decision-making rather than attempt to give them solutions.

Case 2: A 27-year-old woman wants an abortion for a pregnancy that is the result of a sexual assault

Rape is an extremely traumatic experience for women. Care of the woman in crisis needs to be multi-dimensional, and this cannot be fully addressed here.

The pregnancy rate following rape is unclear. While many authors cite around 5%, it is well known that rape is under-reported so it is very hard to know exactly. Certainly it is uncommon. However, that is no comfort to the rape victim who discovers she is pregnant.

In the case of rape, the wrongdoer is the rapist. He is the one who should be punished. The child conceived in the rape is innocent. While the woman involved has been wronged, abortion means that further injustice is perpetrated by punishing the innocent child. The Bible teaches the idea of personal accountability where punishment is concerned. In Deuteronomy 24:16 God commands that “Fathers shall not be put to death for their children, nor children put to death for their fathers; each is to die for his own sin”. Wronging the unborn child does not make right the violation of the mother.

Furthermore, rape does not change the moral significance of the unborn child, and therefore it is not a justification for abortion. The unborn child is still a human being made in the image of God who should not be killed (Exod 20:13).

There has been little research done on the effect of abortion after rape. There is no evidence that abortion helps the woman recover from her ordeal, and some evidence that it may have an overall negative effect.[146] One study found that none of the women subjects who continued a pregnancy following rape regretted their choice.[147] Obviously the woman who makes such a choice will need an enormous amount of spiritual, emotional and practical support. This is a challenge for the church.

Case 3: A 38-year-old woman is 11 weeks pregnant when she is found to have breast cancer; she is told her best chance of survival requires that she undergo chemotherapy after having an abortion

As mentioned previously, abortion on genuine grounds of maternal health is in reality a very small number. Most medical ‘indications’ for abortion (such as cancer and severe autoimmune disease) can be managed during pregnancy. In this actual case, chemotherapy (adriamycin and cytoxan) was given during pregnancy with no ill effects for the child and no increased cancer risk to the mother.

If the unborn child were viable at the stage where risk to maternal health developed, early induction of pregnancy or caesarean section would be appropriate. Should the fetus’s viability be in question when the mother’s life is at risk, it is still ethically appropriate to attempt early delivery as it means the mother’s life will be saved and an attempt is also made to save the baby. If the mother dies, the baby will not survive anyway. Occasionally the mother will be able to be kept alive on life support until viability is reached (e.g. with brain injury).

While this may sound straightforward, it is not always easy to determine viability. While babies have survived from as early as 22 weeks gestation, this is rare (which is why it gets into the news).[148] Survival rate at 23 weeks is 30%, at 24 weeks is 60% and at 25 weeks is 80%; and the survivors will most likely have substantial health problems and disability. It is not always a question of the gestation either. Survival among infants with a birth weight of less than 500g is rare. This is a difficult assessment that needs to be made on an individual basis.

Experienced Christian neonatologist Professor John Wyatt of the United Kingdom has watched many tiny frail bodies in his care struggle desperately for life. He has noted, “Treating babies with respect does not mean that we are obliged to provide intensive treatment in every conceivable condition, to attempt to prolong life even when there is no prospect of recovery”.[149] Those of us who care for the dying are familiar with the idea that we think in terms of whether a treatment is worthwhile—not whether a life is worthwhile. Every human life is precious. But as a baby’s chance of survival decreases, the importance of the health of the mother increases in our equation as we decide what needs to be done.

For doctors

Research suggests that improvements in survival and reductions in morbidity for babies born between 23-25 weeks may have reached a limit. The above figures come from tertiary nurseries in the United States and the United Kingdom, however mortality rates are known to vary among neonatal intensive care units even when similar care practices are in place. Local statistics are therefore preferred when counselling patients. Most units would resuscitate some babies at 23 weeks and most at 24 weeks, depending on the child’s condition at birth. Preterm infants are at risk for specific diseases related to the immaturity of the body’s organs and influenced by the cause and circumstances of the preterm birth. Basically, the frequency of short-term major morbidity increases as the gestational age decreases, especially under 30 weeks. Long-term problems such as chronic lung disease, cerebral palsy, vision and hearing impairment, and reduced cognitive and motor performance are especially increased in those born under 26 weeks. In a 2005 United Kingdom study, 78% of 308 survivors born at less than 25 weeks were followed and almost all of them had some kind of disability at the age of 6 years. Having said that, according to some experts, healthcare workers regularly overestimate the likelihood and severity of neurologic morbidity in preterm infants.[150] It is a difficult and distressing call to make, and expert opinion is recommended.

The take-home message is that maternal illness can often be treated while the pregnancy continues, and abortion should be the last resort. However, the woman in case 3 above had to shop around to find a doctor who was willing to treat her while she continued her pregnancy.

 

Case 4: Abortion for fetal abnormality

As previously mentioned, this is a growing trend in our community. For further discussion of this complex topic, see chapter 9.

According to Planned Parenthood, “everyone had the right to choose when or whether to have a child… every child should be wanted and loved, and… women should be in charge of their own destinies”.[151]

~

I have been discussing right and wrong from a Christian perspective. As we live in a world where elective abortion is almost universally socially acceptable, there will be many around us who will make choices with which we will not agree. While I advocate encouraging a couple to continue with a pregnancy they do not want, I am conscious that this is an act one cannot demand of another even if we think it is the right thing to do. And so my last suggestion is that whatever our friends or patients may decide, we endeavour to maintain our relationships with them so that we may be able to support them in the grief that ensues, and be witnesses to a loving God who forgives the repentant sinner.

I finish this chapter with the words of Pope John Paul II:

I would now like to say a special word to women who have had an abortion. The Church is aware of the many factors which may have influenced your decision, and she does not doubt that in many cases it was a painful and even shattering decision. The wound in your heart may not yet have healed. Certainly what happened was and remains terribly wrong. But do not give in to discouragement and do not lose hope. Try rather to understand what happened and face it honestly. If you have not already done so, give yourselves over with humility and trust to repentance.[152]


  1. S Carney, Campaign Director of 40 Days for Life, quoted in A Johnson and C Lambert, Unplanned, Tyndale, Carol Stream, 2010, p. 255. 
  2. Guttmacher Institute and World Health Organization (WHO), In Brief: Facts on Induced Abortion Worldwide, Guttmacher Institute and WHO, New York and Geneva, December 2009. 
  3. In her famous ‘A Defense of Abortion’ (Philosophy and Public Affairs, vol. 1, no. 1, Fall 1971, pp. 47-66), Judith Jarvis Thompson specifically denies parental responsibility for a child conceived accidentally. 
  4. JM Riddle, Contraception and Abortion from the Ancient World to the Renaissance, Harvard University Press, Cambridge, 1992, p. 8. 
  5. JT Noonan, Contraception, Mentor-Omega Press, New York, 1965, p. 112. 
  6. Soranus, Gynecology 2.6, trans. O Temkin et al., John Hopkins Press, Baltimore, 1991, pp. 79-80. 
  7. DA Jones, The Soul of the Embryo, Continuum, London, 2004, p. 36. 
  8. Academic theories suggesting that parental affection in previous times generally differed significantly from today are discussed in J Boswell, The Kindness of Strangers, University of Chicago Press, Chicago, 1988, pp. 36ff. While there are no doubt parents in every age who lack affection for their offspring, these theories are still controversial. 
  9. Noonan, op. cit., p. 41. 
  10. Soranus, Gynecology 1.19, op. cit., pp. 62ff. 
  11. Aristotle, Politics 7.16.1335b, in The Complete Works of Aristotle: The Revised Oxford Translation, vol. 2, ed. J Barnes, Princeton University Press, Princeton, 1984, p. 2119. 
  12. See my brief history of contraception in chapter 6. 
  13. GER Lloyd (ed.), J Chadwick and WN Mann (trans.), Hippocratic Writings, Penguin, London, 1978, p. 67. 
  14. Jones, op. cit., pp. 39-41. 
  15. Soranus, op. cit., p. 63. 
  16. ibid. 
  17. 2 Chronicles 28:3 and 33:6 also probably refer to the same practice. 
  18. The focus of the prohibition is that it represents idolatry, which is dishonouring to God (Deut 12:29-31). 
  19. See also Jeremiah 19:9; Lamentations 2:20; Ezekiel 5:10. 
  20. The vow is made when Jephthah says to the Lord, “If you will give the Ammonites into my hand, then whatever comes out from the door of my house to meet me when I return in peace from the Ammonites shall be the Lord’s, and I will offer it up for a burnt offering” (11:30). It was his daughter. 
  21. R Yishmael, Babylonian Talmud Sanhedrin 57b, cited in Jones, op. cit., p. 45. 
  22. Jones, op. cit., p. 46. For further further discussion of Old Testament Scripture addressing the moral status of the embryo, see chapter 3. 
  23. Misnah, Oholot 7.6, cited in Jones, op. cit., pp. 53-4. 
  24. Didache (or Teaching of the Twelve Apostles) 2.2, cited in Jones, op. cit., p. 57. 
  25. Athenagoras, A Plea for Christians 35:6, cited in Jones, op. cit., p. 60. 
  26. Council of Elvira, Canon 63 and Canon 68, cited in Jones, op. cit., p. 62. 
  27. Council of Ancrya, Canon 21, cited in Jones, op. cit., p. 63. 
  28. Innocent I, Letter to Exuperius, ibid. 
  29. A detailed history of the church’s attitude to abortion can be found in Jones, op. cit., chapters 5, 12 and 13. I highly recommend this book to those interested in the topic. 
  30. ‘Quickening’ is when the mother first feels the baby moving, usually beginning around 18-20 weeks gestation. This reference to quickening may reflect the medieval distinction between abortion before and after the soul was thought to enter the body. This in turn is a reference to Aristotle’s understanding of embryology. 
  31. This clause developed as a result of the thalidomide tragedy. The drug was developed in the 1950s for treatment of morning sickness, but was subsequently found to cause severe birth defects if taken during pregnancy. Over 10,000 children were born with congenital abnormalities, especially phocomelia (stunted limb growth). There was much public sympathy for those women affected. See BA Berkowitz, ‘Development and Regulation of Drugs’, in BG Katzung, S Masters and A Trevor (eds), Basic and Clinical Pharmacology, 11th edn, McGraw-Hill, New York, 2009, pp. 67-75. 
  32. The Royal College of Obstetricians and Gynaecologists recommended removing the requirement for the second authorization in their 2011 guidelines. 
  33. Royal College of Obstetricians and Gynaecologists (RCOG), The Care of Women Requesting Induced Abortion, Evidence-based Clinical Guideline no. 7, rev. edn, RCOG Press, London, November 2011. 
  34. Department of Health, Abortion Statistics, England and Wales: 2008, statistical bulletin 2009/01, Department of Health, London, May 2009. 
  35. Jones, op. cit., p. 203. Marie Stopes is now the company name of an international abortion provider. 
  36. More on this in chapter 8. 
  37. Roe v. Wade (1973) 410 US 113. 
  38. Doe v. Bolton (1973) 410 US 179 at 192. 
  39. C Overington, ‘Roe v Roe: a woman’s change of heart’, Sydney Morning Herald, 21 June 2003, p. 34. 
  40. Gonzales v. Carhart (2007) 550 US 124. 
  41. Planned Parenthood is the largest abortion provider in the United States. 
  42. Guttmacher Institute, In Brief: Facts on Induced Abortion in the United States, Guttmacher Institute, New York, August 2011. 
  43. K Pazol, SB Gamble, WY Parker, DA Cook, SB Zane, S Hamdan and Centers for Disease Control and Prevention (CDC), ‘Abortion Surveillance—United States, 2006’, MMWR Surveillance Summaries, vol. 58, no. SS-8, 27 November 2009, pp. 1-35. 
  44. J Swaine, ‘Anti-abortion billboard in New York sparks off furious row’, Telegraph, 24 February 2011. 
  45. R v. Bourne (1938) 3 All ER 615 at 619. 
  46. Child destruction is an unlawful intentional act causing the death of a child who is capable of being born alive. The law was introduced to criminalize the killing of a child during its birth, as this is technically neither abortion nor homicide. It therefore applies only to later terminations of pregnancy that are judged to be ‘unlawful’. 
  47. C Nickson, AMA Smith and JM Shelley, ‘Intention to claim a Medicare rebate among women receiving private Victorian pregnancy termination services’, Australia and New Zealand Journal of Public Health, vol. 28, no. 2, April 2004, pp. 120-3. 
  48. This was the estimate given by Senator Patterson in her response to Senator Boswell’s question in 2005. See Australia, Senate 2005, Debates, vol. S14, p. 69. A parliamentary review that year explained the impossibility of accurately assessing abortion numbers but noted the range of 70,000-100,000/year given in public debate. See Department of Parliamentary Services, How Many Abortions are There in Australia?, report prepared by A Pratt, A Biggs and L Buckmaster, Parliamentary Library Research Brief no. 9, 2004-05, Canberra, 14 February 2005. 
  49. According to the Australian Bureau of Statistics. This number does not include early abortions as a result of the ‘morning-after pill’ (see chapter 6). 
  50. This section is influenced by FJ Beckwith’s elegant response to the main arguments for abortion. See FJ Beckwith, ‘Personal Bodily Rights, Abortion, and Unplugging the Violinist’, International Philosophical Quarterly, vol. 32, no. 1, March 1992, pp. 105-18. 
  51. E Koch, J Thorp, M Bravo, S Gatica, CX Romero, H Aguilera and I Ahlers, ‘Women’s education level, maternal health facilities, abortion legislation and maternal deaths: A natural experiment in Chile from 1957 to 2007’, PLoS ONE, vol. 7, no. 5, 4 May 2012, e36613. 
  52. WHO, International Statistical Classification of Diseases and Related Health Problems, 10th revision, WHO, Geneva, 1992, cited in C Ronsmans and WJ Graham, ‘Maternal mortality: who, when, where, and why’, Lancet, vol. 368, no. 9542, 30 September 2006, p. 1190. 
  53. M Gissler, C Berg, MH Bouvier-Colle and P Buekens, ‘Pregnancy-associated mortality after birth, spontaneous abortion, or induced abortion in Finland, 1987-2000’, American Journal of Obstetrics and Gynecology, vol. 190, no. 2, February 2004, pp. 422-7. 
  54. This is an excellent initiative. My one concern is its failure to articulate the (admittedly rare) circumstance of abortion being necessary to preserve the life of the mother when the baby has no hope of survival (e.g. ectopic pregnancy). See San Jose Articles, San Jose, 25 March 2011 (viewed 23 November 2011): www.sanjosearticles.org 
  55. Amnesty International, ‘Protecting the human rights of women’, Human Rights Defender, vol. 19, no. 3, 21 September 2010, pp. 8-9. 
  56. Guttmacher Institute and WHO, In Brief: Facts on Induced Abortion Worldwide, loc. cit. 
  57. The WHO attributes the abortion problem to unintended pregnancy, which is a complex problem it is attempting to address. 
  58. Koch et al., loc. cit. 
  59. See appendix II for further details. 
  60. TD Ngo, MH Park, H Shakur and C Free, ‘Comparative effectiveness, safety and acceptability of medical abortion at home and in a clinic: a systematic review’, Bulletin of the World Health Organization, vol. 89, no. 5, May 2011, pp. 360-70. 
  61. Mifepristone-induced endometrial breakdown leads to trophoblast detachment, resulting in decreased production of human chorionic gonadotropin (hCG) and a withdrawal of support from the corpus luteum. Pregnancy is dependent on progesterone production by the corpus luteum for the first 9 weeks of gestation, until the placenta can take over. 
  62. MA Fritz and L Speroff, Clinical Gynecologic Endocrinology and Infertility, 7th edn, Lippincott Williams and Wilkins, Philadelphia, 2005, p. 852. 
  63. PC Ho, PD Blumenthal, K Gemzell-Danielsson, R Gómez Ponce de León, S Mittal and OS Tang, ‘Misoprostol for the termination of pregnancy with a live fetus at 13 to 26 weeks’, International Journal of Gynecology and Obstetrics, vol. 99, supp. 2, December 2007, pp. S178-81. 
  64. Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), Termination of Pregnancy, RANZCOG, Melbourne, November 2005. 
  65. WHO, Unedited Report of the 18th Expert Committee on the Selection and Use of Essential Medicines, WHO, Accra, 21-25 March 2011, p. 88. 
  66. ibid. 
  67. S Yanow, The Best Defense is a Good Offense: Misoprostol, Abortion, and the Law, report for Gynuity Health Projects and the Reproductive Health Technologies Project, New York, August 2009. 
  68. See ‘Ethics of abortion’ section, above. 
  69. RANZCOG, op. cit., p. 8. 
  70. See chapter 16. 
  71. ACOG, Induced Abortion, FAQ043, ACOG, Washington DC, October 2011 (viewed 16 November 2011): www.acog.org/~/media/For%20Patients/faq043.pdf 
  72. WHO, Safe Abortion: Technical and Policy Guidance for Health Systems, 2nd edn, WHO, Geneva, 2012, p. 31. 
  73. RANZCOG, op. cit., p. 14. 
  74. T Kelly, J Suddes, D Howel, J Hewison and S Robson, ‘Comparing medical versus surgical termination of pregnancy at 13-20 weeks of gestation: a randomised controlled trial’, BJOG: An International Journal of Obstetrics and Gynaecology, vol. 117, no. 12, November 2010, pp. 1512-20. 
  75. AH Goroll and AG Mulley, Primary Care Medicine, 6th edn, Lippincott Williams and Wilkins, Philadelphia, 2009, p. 893. 
  76. IL Craft and BD Musa, ‘Hypertonic solutions to induce abortion’, British Medical Journal, vol. 2, no. 5752, 3 April 1971, p. 49. 
  77. J Elliot, ‘I survived an abortion attempt’, BBC News, 6 December 2005 (viewed 25 October 2011): http://news.bbc.co.uk/2/hi/health/4500022.stm 
  78. RS Galen, P Chauhan, H Wietzner and C Navarro, ‘Fetal pathology and mechanism of fetal death in saline-induced abortion: A study of 143 gestations and critical review of the literature’, American Journal of Obstetrics and Gynecology, vol. 120, no. 3, 1974, p. 347. 
  79. K Pazol, SB Zane, WY Parker, LR Hall, SB Gamble, S Hamdan, C Berg, DA Cook and CDC, ‘Abortion Surveillance—United States, 2007’, MMWR Surveillance Summaries, vol. 60, no. SS-1, 25 February 2011, p. 24 (Table 11). 
  80. D Munday, C Francome and W Savage, ‘Twenty one years of legal abortion’, British Medical Journal, vol. 298, no. 6682, 6 May 1989, pp. 1231-4. 
  81. PG Stubblefield, S Carr-Ellis and L Borgatta, ‘Methods for induced abortion’, Obstetrics and Gynecology, vol. 104, no. 1, July 2004, pp. 174-85. 
  82. J Herndon, LT Strauss, S Whitehead, WY Parker, L Bartlett, S Zane and CDC, ‘Abortion surveillance—United States, 1998’, MMWR Surveillance Summaries, vol. 51, no. SS-3, 7 June 2002, pp. 1-32. 
  83. RCOG, op. cit., pp. 44-5. 
  84. RANZCOG, op. cit., p. 26. 
  85. RCOG, op. cit., pp. 42-3. 
  86. E Lee and A Gilchrist, ‘Abortion psychological sequelae: the debate and the research’, paper presented to the Pro-Choice Forum conference ‘Issues in pregnancy counselling: What do women need and want?’, Oxford, May 1997. 
  87. DM Fergusson, LJ Horwood and EM Ridder, ‘Abortion in young women and subsequent mental health’, Journal of Child Psychology and Psychiatry, vol. 47, no. 1, January 2006, pp. 16-24. 
  88. For example, Gissler et al., loc. cit. 
  89. This is the view held by RCOG and commentators such as Lee and Gilchrist, loc. cit. 
  90. M Tankard Reist, Giving Sorrow Words, Duffy and Snellgrove, Potts Point, 2000, p. 1. 
  91. Quoted in Tankard Reist, ibid., p. 4. 
  92. Quoted in Tankard Reist, ibid., p. 13. 
  93. S Vale, ‘GPs need to advise on risks of abortion’, Australian Doctor, 13 November 1998. 
  94. Women Hurt by Abortion, ‘Post-abortion syndrome. Does it exist?’ Australian Doctor, 4 September 1998, p. 32. 
  95. DM Fergusson, LJ Horwood and JM Boden, ‘Abortion and mental health disorders: evidence from a 30-year longitudinal study’, British Journal of Psychiatry, vol. 193, no. 6, December 2008, pp. 444-51. 
  96. DM Fergusson, LJ Horwood and JM Boden, ‘Reactions to abortion and subsequent mental health’, British Journal of Psychiatry, vol. 195, no. 5, November 2009, pp. 420-6. 
  97. B Major, M Appelbaum, L Beckman, MA Dutton, NF Russo and C West, ‘Abortion and mental health: evaluating the evidence’, American Psychologist, vol. 64, no. 9, December 2009, pp. 863-90. 
  98. RCOG, op. cit., p. 39. 
  99. National Collaborating Centre for Mental Health, Induced Abortion and Mental Health, Academy of Medical Royal Colleges, London, December 2011, cited in RCOG, op. cit., p. 99; Major et al., loc. cit. 
  100. PK Coleman, ‘Abortion and mental health: quantitative synthesis and analysis of research published 1995-2009’, British Journal of Psychiatry, vol. 199, no. 3, September 2011, pp. 180-6. 
  101. For full diagnostic criteria, see American Psychiatric Association, Diagnostic and Statistical Manual for Mental Disorders, 4th edn, text revision, American Psychiatric Association, Washington DC, 2000, pp. 467-8. 
  102. Royal College of Psychiatrists, Position Statement on Women’s Mental Health in Relation to Induced Abortion, Royal College of Psychiatrists, London, 14 March 2008. 
  103. RANZCOG, op. cit., p. 17. 
  104. P Carey, ‘My lasting wish’, Australian Magazine, 14-15 October 1994. 
  105. Quoted in Tankard Reist, op. cit., p. 42. 
  106. M Earley, ‘Seeing is believing: The humanity of the fetus’, radio program episode, Breakpoint, Breakpoint Prison Fellowship, Lansdowne, 27 April 2010. 
  107. More than 80 restrictions aimed at reducing access to abortion were approved in United States state legislatures in 2011. Other measures included expansion of counselling requirements and tougher regulations for clinics. See D Crary and T Ross, ‘More states crack down on late-term abortions’, Boston.com, 24 July 2011 (viewed 6 November 2011): http://articles.boston.com/2011-07-24/news/29810324_1_late-term-abortion-providers-ban-abortions 
  108. SJ Lee, HJP Ralston, EA Drey, JC Partridge and MA Rosen, ‘Fetal pain: A systematic multidisciplinary review of the evidence’, Journal of the American Medical Association, vol. 294, no. 8, 24/31 August 2005, pp. 947-54. 
  109. RCOG, Fetal Awareness, Report of a working party, RCOG Press, London, March 2010. 
  110. KJS Anand and PR Hickey, ‘Pain and its effects in the human neonate and fetus’, New England Journal of Medicine, vol. 317, no. 21, 19 November 1987, pp. 1321-9. 
  111. AM Paul, ‘The first ache’, Times Magazine, 10 February 2008. 
  112. RP Smith, R Gitau, V Glover and NM Fisk, ‘Pain and stress in the human fetus’, European Journal of Obstetrics and Gynecology and Reproductive Biology, vol. 92, no. 1, September 2000, pp. 161-5. 
  113. NM Fisk, R Gitau, JM Teixeira, X Giannakoulopoulos, AD Cameron and VA Glover, ‘Effect of direct fetal opioid analgesia on fetal hormonal and hemodynamic stress response to intrauterine needling’, Anesthesiology, vol. 95, no. 4, October 2001, pp. 828-35. 
  114. Anand and Hickey, loc. cit. 
  115. V Glover and NM Fisk, ‘Do fetuses feel pain? We don’t know; better to err on the safe side from mid-gestation’, British Medical Journal, vol. 313, no. 7060, 28 September 1996, p. 796. 
  116. DJ Mellor, TJ Diesch, AJ Gunn and L Bennet, ‘The importance of “awareness” for understanding fetal pain’, Brain Research Reviews, vol. 49, no. 3, November 2005, pp. 455-71. 
  117. Glover and Fisk, loc. cit. 
  118. Lee et al, ‘Fetal pain’, loc. cit. 
  119. Medical Research Council (MRC), Report of the MRC Expert Group on Fetal Pain, MRC, London, 28 August 2001, p. 1. 
  120. Lee et al, ‘Fetal pain’, loc. cit. 
  121. MRC, loc. cit. 
  122. MRC, loc. cit. 
  123. D Daleiden and JA Shields, ‘Mugged by ultrasound: Why so many abortion workers have turned pro-life’, Weekly Standard, vol. 15, no. 18, 25 January 2010. 
  124. Johnson and Lambert, op. cit., pp. 6-7. 
  125. S Ewing, Women and Abortion, Women’s Forum Australia, Brisbane, 2005. 
  126. ibid. 
  127. South Australia, Parliament 2000, Annual Report of the South Australian Abortion Reporting Committee 2007, Parl. Paper 90, Adelaide, p. 7. 
  128. S Allanson and J Ashbury, ‘The abortion decision: reasons and ambivalence’, Journal of Psychosomatic Obstetrics and Gynecology, vol. 16, no. 3, 1995, pp. 123-36. 
  129. AN Broen, T Moum, AS Bödtker and Ö Ekeberg, ‘Reasons for induced abortion and their relation to women’s emotional distress: A prospective, two-year follow-up study’, General Hospital Psychiatry, vol. 27, no. 1, January 2005, pp. 36-43. 
  130. This is the justification for abortion in the third trimester given by the United States Supreme Court in Roe v. Wade (1973). 
  131. P Mazzota, L Magee and G Koren, ‘Therapeutic abortions due to severe morning sickness: Unacceptable combination’, Canadian Family Physician, vol. 43, June 1997, pp. 1055-7. 
  132. R Ingham, E Lee, S Clements and N Stone, ‘Reasons for second-trimester abortions in England and Wales’, Reproductive Health Matters, vol. 16, no. 31, supp. 1, May 2008, pp. 18-29. 
  133. ML Davenport, Is Late-term Abortion Ever Necessary? American Association of Pro-Life Obstetricians and Gynecologists, Holland MI, June 2009 (viewed 6 November 2011): www.aaplog.org/american-issues-2/late-term-abortion/is-late-term-abortion-ever-necessary/ 
  134. TM Goodwin, ‘Medicalizing Abortion Decisions’, First Things, March 1996, pp. 33-6. This article discusses several case studies of women who were incorrectly told they needed abortions for medical indications. 
  135. See chapters 8 and 9. 
  136. M Davis, ‘IVF babies aborted’, Sunday Express, 26 June 2011. 
  137. R Padawer, ‘The two-minus-one pregnancy’, New York Times Magazine, 10 August 2011. 
  138. KL Armour and LC Callister, ‘Prevention of triplets and high order multiples: Trends in reproductive medicine’, Journal of Perinatal and Neonatal Nursing, vol. 19, no. 2, April/June 2005, pp. 103-11. See also A Antsaklis, AP Souka, G Daskalakis, N Papantoniou, P Koutra, Y Kavalakis and S Mesogitis, ‘Pregnancy outcome after multifetal pregnancy reduction’, Journal of Maternal-Fetal and Neonatal Medicine, vol. 16, no. 1, 2004, pp. 27-31. 
  139. S Drill, ‘Medical bungle at Royal Women’s Hospital kills healthy fetus’, Herald Sun, 24 November 2011. 
  140. For an alternative way to have managed this case, see case 1 in chapter 9. 
  141. Note that abortion was used as the example in chapter 5, so please revisit ‘Responding to alternative ethical theories’ in that chapter for a more detailed discussion. 
  142. Almost three quarters of women obtaining abortions in 2008 reported a religious affiliation. The largest proportion was Protestant (37%), and most of the rest said that they were Catholic (28%) or that they had no religious affiliation (27%). One in five abortion patients identified themselves as born-again, evangelical, charismatic or fundamentalist. See RK Jones, LB Finer and S Singh, Characteristics of US abortion patients, 2008, Guttmacher Institute, New York, May 2010. 
  143. US Department of Health and Human Services, Infant Safe Haven Laws: Summary of State Laws, Child Welfare Information Gateway, Washington DC, 2010. 
  144. Agence France Presse, ‘Service aids women in secret births, adoptions’, Australian Doctor, 8 June 2001. 
  145. M Wade, ‘India’s boy craze: From the cradle to a grave future’, Sydney Morning Herald, 23 October 2010. 
  146. Ewing, op cit., p. 12. 
  147. DC Reardon, J Makimaa and A Sobie (eds), Victims and Victors, Acorn Books, Brunswick, 2000. 
  148. A Florida IVF baby who was born at 21 weeks and 6 days survived and was released from hospital with an ‘excellent’ prognosis in February 2007. She overcame many medical problems to reach that point. See A Cable, ‘The tiniest survivor: How the “miracle” baby born two weeks before the legal abortion limit clung to life against all odds’, Daily Mail, 22 May 2008. 
  149. J Wyatt, Matters of Life and Death, 2nd edn, IVP, Leicester, 2009, p. 183. 
  150. JD Iams and R Romero, ‘Preterm Birth’, in SG Gabbe, JR Niebyl and JL Simpson (eds), Obstetrics, 5th edn, Churchill Livingstone, Philadelphia, 2007, pp. 668-712. 
  151. Johnson and Lambert, op. cit., p. 42. 
  152. Encyclical of John Paul II, Evangelium Vitae: On the Value and Inviolability of Human Life, Rome, 25 March 1995, paragraph 99. 

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